Wrist PPT 3 Soft Tissue Injuries of the Wrist and Hand PDF

SOFT TISSUE DIAGNOSIS OF THE HAND Sarah Maceda OTR/L CHT Tendon repair ■ Goal : Heal a tendon without Rupture or gap formation and to be able to have enough strength and excursion for ADLs ■ Normal tendon function needs free gliding without hindrance from surrounding tissues. Scar adhesions can oc...

SOFT TISSUE DIAGNOSIS OF THE HAND Sarah Maceda OTR/L CHT Tendon repair ■ Goal : Heal a tendon without Rupture or gap formation and to be able to have enough strength and excursion for ADLs ■ Normal tendon function needs free gliding without hindrance from surrounding tissues. Scar adhesions can occur easily due to close proximity if structures. ■ Tendon adhesions limit function and ROM of the digits ■ Normal gliding of the tissue encounters drag from surrounding tissues. Postoperatively the drag is increased by edema and bulk of sutures (more is not always better). If stressed too early the tendon may pull apart and rupture or Gap (weaken and elongate the tissue). Less than 2 mm of gapping is preferred. ■ Three types of Protocols, Immobilization, Early passive mobilization, early active mobilization (& Tenodesis). ■ Tendon nutrition comes from blood supply(Vincula ) and the synovial diffusion. Even if the vincula is damaged the synovial diffusion is important for healing . Important in Zone 2 Flexor tendon. ■ Brand: If living tissue is subject to slight tension for a long period of time the collagen fibers will be progressively absorbed and laid down again in modified bonding patterns. ■ Studies on animals show better healing of tendons with early mobilization and stress applied to tendon anastomoses. Day 3-5 is optimum. We want to achieve strong healing in the tendon and weak healing with surrounding tissue. Tendon Healing ■ Intrinsic healing: Tenocytes within the tendon Extrinsic healing: Healing stimulated by the synovial ■ fluid and inflammatory cells Forms scarring and adhesions ■ Local edema caused by healing = Increased resistance in flexor tendon movement ■ Based on experimental studies, Gelberman et al. found that 3-4 mm of excursion at a flexor tendon repair was necessary to stimulate the intrinsic repair site without creating significant repair-site deformation ■ Active tension of at least 300 g maybe necessary to effect 3 mm of true excursion in zone II ■ Many factors need to be considered. Moment arm at repair site, type of sutures, status of pully (venting), blood vessels, other structures damaged, amount of edema. WOF ■ Work of Flexion(WOF):summation of forces necessary to move the tendon along its excursion distance ■ – Edema factors ■ – Local edema contributes to 20-25% increase of total resistance to gliding of the flexor tendon ■ – Increase WOF 10-30% with prolonged edematous tissue Complications To Repairs ■ Rupture ■ Tethering of the extensor tendons ■ Adherence of the flexor tendon ■ Severe edema can cause restricted extensor tendon movement and secondary adhesions ■ Inadequate access to health care Flexor tendon repair ■ Early Passive motion 1977 – 1980s ■ 2 strand repairs ■ Modified Duran Program (Duran and Houser) ■ Objective: independent tendon gliding ■ 3-5mm tendon gliding intraoperative; less postop ■ Clinical research: 17-19 days negligible passive tendon gliding ■ Orthotic – wrist flex 30 deg , MP flex 70 .Ex every 2-3 hr 25 passive MP , PIP , Combined Flex and ext . Three weeks AROM ■ Kleinert Program ■ Orthosis – time-consuming to fabricate ■ Concerns with flexion contractures ■ Only use with N/C patients. Less popular Strength of healing Tendon Suture Techniques Movement towards Newer Protocols ■ Tendon Excursion is increased by the addition of wrist tenodesis. Synergistic wrist and MCP motion provide more effective excursion than wrist fixation ■ MCP extension and wrist extension with the IP joints in full flexion to provide effective excursion to the FDP. (modified tenodesis exercises) ■ Isolated DIP motion of at least 35deg may be necessary to effect 3-4 mm of differential glide of the FDP on the FDS and hook fist position also is critical in promoting differential glide within the digital ■ Improvements in surgical techniques to 4, 6 , and 8 strand repairs venting of pulleys. ■ four-strand core stitch repair with a running lock or horizontal mattress circumferential epitendinous stitch needed for tenodesis and early active exercises Indiana Protocol ■ the first published rehabilitation regimen to include synergistic motion and incorporate the exercise referred to as place and hold. 1993 ■ a hinged dorsal blocking orthosis is fabricated for exercise/strickland splint ■ place and hold sequence: passive digital flexion, wrist extension, active hold of the wrist and digit position for 5 seconds, and release to wrist flexion with digit extension Early Active Motion (EAM) ■ 2005 began ■ Studies only done for zone 2 flexor tendon. May not safely be applied to zone 1? ■ true active flexion as opposed to early passive or place and hold flexion. ■ Short Arch Motion through the available range others advocated initiating motion in the first 1/3 to midrange to avoid the higher levels of resistance encountered when making a composite fist. ■ Evans safe position orthotic wrist in 25-30 deg of flex . Dec MCP flex to 30 deg in order to decrease bias toward the proximal interphalangeal (PIP) joint and decrease work of flexion at the distal interphalangeal (DIP) joint ■ Newest protocols ( St John’s Protocol) splint becomes hand based at 2 weeks allowing full active ROM of the wrist Therapy considerations for EAM ■ Skilled surgeon, 4 strand or more repair ■ Venting of pulleys preferred ■ Favorable Considerations – Therapy ■ Limited edema – 5mm or less opposite digit P1 ■ Full passive flexion ■ Patient – “seemed reliable” ■ No pertinent medical history (delayed healing) Mayo Clinic Short Arc Active Flexion Protocol Peter Amadio, MD 4-strand and 6-strand repairs Modified Duran + Active . Each Week Move towards next finger down Saint John Protocol • Protocol Published 2016 . Saint John Hospital Canada. DR. Don Lalonde • WALANT – Wide Awake , Local Anesthetic, No Tourniquet. • Patient completes AROM in the operating room to ensure no gapping of tendon and proper gliding under pulley • Start therapy 3-5 days post op . Work on edema control and elevation first. Initial 2 ½ Weeks □DBO – forearm based; wrist 45⁰ ext. MP’s 30⁰ flexion & the IPs extended □PROM → short arc active flexion 1/3 – 1/2 fist. No forceful flexion. (day 4) □2 ½ to 4 Weeks □DBO reduced to hand based □↑ active flexion to 3/4 fist □4 – 6 Weeks □Gradually achieve full active flexion □6 Weeks – discontinue orthosis ■ “Although the literature continues to move toward progressive protocols with true active motion and decreased immobilization of the wrist, it is important to recognize that welldesigned intervention studies to support those regimens does not yet exist. Most studies Duran and Kleinert limited Ruptures but outcomes not as Favorable ■ Active full fist exercise protocols have higher rupture rate 5% ■ 50% of all ruptures are with the SF ■ Study : Place and Hold /Indiana 3% most other studies show none or 1-2% ■ Combined place and hold / SAM 1-2% ■ All place and hold and SAM or full fist show excellent to good outcomes Neiduski, R. L., & Powell, R. K. (2019). Flexor tendon rehabilitation in the 21st Century: A systematic review. Journal of Hand Therapy, 32(2), 165–174. https://doi.org/10.1016/j.jht.2018.06.001 Protocol Outcomes Zone 1 Flexor Tendon ■ Jersey Finger / closed avulsion injuries of the FDP ■ Can not Generalize the data and information from zone 2 protocols. Questions arise about strength of tendon to bone repairs. Kinematics, function of FDP, and small moment arm must be considered. ■ Evan’s Limited Extension Active Flexion (L.E.A.F) should be use due to the lack of research to show other EAM protocols can be generalized to zone 1 repairs. ■ Loss of DIP Flexion of 40 degrees of less is usually not acceptable for patient functionally. L.E.A.F Protocol Zone 1 ■ Orthotic wrist 30- 40 deg flexion, MPs 30 , PIPs 0, Dorsal DIP orthotic 40- 45 deg of flexion worn for first 2125 days. ■ Exercises: In dorsal orthotic: Passive DIP flex, Passive, hook, Passive Full, Passive MP flex with active IP ext, Place and hold FDS exercises, tenodesis. ■ 81% had good ROM (TAM 124-159). Other groups that 74% -58% . Average DIP flexion 47 degrees vs 25 Extensor Tendon Rehab ■ All tendons in the extensor system tolerate controlled Active motion except zone I, isolated wrist extensor tendons, and the musculotendinous juncture ■ zones III and IV do not require continuous immobilization for four to six weeks and will tolerate short arc motion (SAM) of 30 degrees in the initial weeks of healing ■ More ROM allowed in zones V-VII than previously allowed. ■ wrist position is critical in decreasing resistive forces from the antagonistic flexor system and is a factor in true tendon excursion gained with digital motion. ■ Evidence supports early active protocols. Limited studies found Extensor tendon ■ Extensor tendons in the finger are flat and intimate with the periosteum. Mattress sutures and Kessler repairs without epitendinous stitching are often used for zones II, III, and IV. This technique can only hold minimal force before failure. (840 Grams) Epitendinous repair only has shown better results ■ Shortening of the tendon when repaired or even a small amount of gapping at the repair site can lead to dysfunctions in ROM Zone I Extensor Tendon ■ Mallet Finger . Treated with a cast or orthotic 6 -8 weeks. DIP Must be supported at all times in extension or slight hyperextension ■ If injury more than 21 days old will need at least 8 Weeks . Wean from orthotic slowly ■ May need up to 10 weeks in the orthotic. ■ Boney mallet – 6 weeks only if less than 21 days . ■ Surgery not recommended /only for extreme Fractures. ■ If not treated will progress to swan neck deformity over time Zone III Closed tendon injuries ■ PIP Extension orthotic for 6-8 weeks ■ ORL Stretches ■ Wean from Orthotic ■ PIP must be at 0 degrees of extension full time Zone III & IV Extensor tendon Repair ■ Evans: SAM protocol Immediate SAM of 30deg at the PIP joint imposes approximately 300 g of internal tension to the central slip and 3.75 mm of excursion. ■ Resting orthotic DIP and PIP in 0 deg extension ■ 1st 3 weeks Exercise: Use of a template orthotic for exercise. Allow 30 deg of PIP flex to full extension . Wrist in 20 deg flex and MP in O deg ext. With lateral band repair DIP can be flexed to 30 degrees if PIP is held in extension . ■ Slowly increase AROM in weeks 3-6 if no Extensor lag . Zone IV- VII • Evans- treat the repaired EDC in these zones with dynamic splinting,. Considered Early passive motion (patients actively moving ) • Flexion Block 30-35deg of motion for the index and long digits and 40-45deg of motion for the ring and small digits effecting approximately 5 mm of excursion • Wean from orthotic by 6 weeks • Wrist ext 0 degrees ICAM Zones 4-7 extensor tendons ■ Immediate Controlled Active Motion Protocol. Howell 1980s . Used protocol for 25 years before article was published 2004. 142 patients. ■ More simple orthotic design than Dynamic orthotic. ■ Therapy starts 2-5 days Post OP. Static wrist orthosis with 2030 deg extension . Yoke splint incorporating all fingers . Holds involved digit 20 deg more ext than involved digit. ■ Phase 1 -0-21 days both orthotics worn. Phase 2- 22-35 days only the yoke orthotic unless median work performed . Phase 3 - 36-49 days no use of wrist orthotic. ICAM Orthotic CAM VS Relative motion only Fig. 1. (A) Orthoses used by the controlled active motion (CAM) group: (i) Daytime WHFO (wrist-hand-finger orthosis) with interphalangeal joints free. (ii) Nighttime static WHFO with additional interphalangeal joint extension paddle. (B) Orthoses used by the relative motion extension (RME) group: (i) Daytime RME static finger orthosis. (ii) Nighttime static WHFO. PIP Joint injuries ■ Most commonly injured joint of the hand ■ More complicated than a “sprain”. The spectrum of PIP joint injuries ranges from mild ligamentous sprains to unstable irreducible joint fracture-dislocations. ■ Hinge joint allows 100 degrees arch of motion ■ Condylar asymmetry produces 9 degrees supination during flexion ■ Stability provided by articular congruency and ligaments . Most important are the Radial and ulnar collateral ligaments and the Volar plate. ■ Proper collateral ligament (PCL) – eccentric origin on the lateral aspect of the proximal phalanx. Fibers then course volarly and distally and insert into the lateral tubercles of the middle phalanx. ■ Accessory collateral ligament (ACL)-from PCL to the volar plate. ■ Critical corner where all these structures converge at the middle phalanx ■ Function of the collateral ligaments: As the PIP flexes, tension increases on the PCLs as they stretch over the wider portion of the proximal phalanx . The ACls fold into synovial recesses and the volar plate migrates proximally to allow maximal joint flexion. ■ In extension the the ACL becomes taut and strong. The volar plate prevents hyperextension. Dislocation Mechanism of injury ■ Laterally directed dislocation forces. A, Laterally directed forces result in disruption of the collateral ligaments. Most commonly, this occurs at the origin of the ligaments at the proximal phalanx (1). B, Displacement that is more forceful leads to failure of the accessory collateral ligament (2), followed by failure of the volar plate at its insertion on the volar lip of the middle phalanx (3). The dotted line indicates the path of most common failure. Journal of Hand Therapy 2003 16, 117-128DOI: (10.1016/S0894-1130(03)80007-8) Journal oJour Hand Therapy Journal of Hand Therapy 2003 16, 117-128DOI: (10.1016/S0894-1130(03)80007-82003 16, 117-128DOI: (10.1016/S08941130(03)80007-8f Hand Therapy 2003 16, 117-128DOI: (10.1016/S0894-1130(03)80007-8) Bowers Classification ■ Grade I -asymmetric swelling and tenderness over the collateral ligament, without instability on stress testing. ■ Grade II -complete disruption of the collateral ligament, but the volar plate remains intact. These injuries are characterized by a stable active arc of motion and <20° of deviation with a firm end point on varus or valgus stress. ■ Grade III - total collateral ligament disruption and volar plate rupture. Clinically, this type of injury may exhibit subluxation or dislocation on active extension and >20° of joint laxity on varus/valgus stress without a solid end point. Treatment of Collateral ligament injury ■ Night time extension orthotic , day time buddy straps. ■ JHT July 2018 .67 patients treated . Prospective cohort . Buddy strapping and Tendon gliding exercises for grade 1-3 PIP collateral ligament injuries. ■ Discussion : Buddy strapping for PIP joint injuries led to satisfactory results with 77% recovery of grip strength, 84% recovery in ROM, and mean QuickDASH scores of 14 at 6 months. A decrease in grip strength was associated with an increase in age and injury severity at 6 months, and these 2 factors accounted for 22% of the variance in the grip strength. A decrease in ROM was associated with the delayed treatment, which accounted for 18% of the variance in ROM at 6 months. An increased disability was associated with delayed treatment, female gender, and radial digit injury at 3 months, and these 3 factors accounted for 37% of the variance in disability. At 6 months, only the delayed treatment remained an associated factor, which accounted for 20% variance in disability. Lateral dislocation with Fracture Lateral or rotatory forces on a proximal interphalangeal joint in slight flexion may result in unicondylar fractures of the proximal phalanx. fracture reduction and early motion, angulation at the joint, arthrofibrosis, and loss of motion are common complications. External reduction with open screw placement is the preferred treatment. mobilized actively between 30° and 60° arc of motion on the first postoperative day, with weekly increases in 10° increments. 6 weeks can begin PROM /gentle strengthening . Splint DC 8 weeks . Significant stiffness and PIP extensor tendon lag is a common problem with ORIF treatment . Minimally displaced FX can be treated with a traction splint for 6 weeks Dorsal Dislocation ■ PIP joint hyperextension, volar plate rupture, and dorsal dislocation with rupture of the collateral ligaments ■ Most treated with closed reduction and use of an orthotic and or buddy tape. Surgery only indicated when reduction is not possible. Eaton classification Dorsal Dislocation ■ Type I (hyperextension) injuries are defined by a partial volar plate avulsion with intact collateral ligaments. These injuries clinically do not exhibit hyperextension instability on active extension or passive hyperextension. ■ Type II (dorsal dislocation) injuries are characterized by total volar plate rupture and complete collateral ligament split. These injuries exhibit instability on active extension or hyperextension deformity on passive dorsally directed stress testing. ■ Type III (fracture-dislocation) injuries include a fracture of the insertion of the volar lip of the middle phalanx. Several classifications have been used to subcategorize this Eaton type III fracture-dislocation further Treatment for Dorsal Dislocation ■ Grade I – Treated with and ring splint (provides active flex and blocks extension and subluxation)preferred. Slight flexion till pain subsides. ■ Grade 2 & 3 - Ring splint in 20- 30 degrees of flexion . ■ Short phase of immobilization only 3 -5 days max . Volar dislocation ■ unilateral rupture of a collateral ligament and partial avulsion of the volar plate ,herniation of the head of the proximal phalanx through the extensor mechanism ■ rare injury and usually arises from a rotatory longitudinal force on a semiflexed digit. ■ No universally accepted classification of these injuries ■ Dorsal lip fracture (Boutonniere FX) . Rupture of the central slip insertion middle phalanx. ■ Treatment soft tissue extensor tendon injury6-8 weeks in a PIP extension orthotic. ■ Lip fractures – 4- 6 weeks in an extension orthotic ■ Perform ORL stretches MP Joints ■ Injured less frequently than PIP joints. ■ Metacarpal head is narrow dorsally and widens volarly ■ PCL – eccentric dorsal origin and tighten during flexion. Joint is lax during extension. Allows 30 digress of lateral deviation. ■ Test collateral ligaments in flexion. Point tenderness over ligament MCP Collateral Ligament Injuries ■ Forceful radial or ulnar stress to the MCP joint ■ Most common radial collateral ligament . ■ Treatment : Immobilization of MP joint in 50 degrees of flexion for 3 weeks. Buddy tape for 3-6 more weeks ■ more than 50 degrees of flexion will place the injured lig under max tension. MCP Dislocations ■ Dorsal dislocation Occurs with a hyperextension force to the digit. ■ Simple – 60-90 deg of hyperextension. Reduced with closed manipulation ■ Tx – dorsal extension blocking orthotic ■ Complex- irreducible dislocation . Caused by VP interposed dorsal to the metacarpal head. dimpling seen in the palm ■ Tx- surgical reduction . Orthotic in 50 degrees of MCP flexion ■ Volar dislocation rare Sagittal Band Injuries ■ Centralize the extensor tendon over the MCP joint and maintain them over the dorsum of the MCP. ■ Allows/ helps MCP extension to occur. ■ If Ruptured the extensor tendon will sublux to the opposite side of the MCP. ■ Most common LF with ulnar subluxation of the extensor tendon ■ Treated with a yoke orthosis for 6 weeks. Thumb MP joint ■ Collateral ligaments tight in flex , lax in extension. ■ Lateral movements 0-20 degrees with the MP in extension. ■ VP gives strong support. Dynamic stability –insertion of the thenar musculature through the sesamoid bones in the distal Volar plate. (APB, FPB, EPL,EPB,FPL ) Ulnar Collateral Ligament ■ 10 x more frequent than RCL injuries. ■ Forced radial deviation and hyperextension. ■ UCL is detached from its distal insertion on the proximal phalanx. ■ Stener’s lesion- UCL completely disrupted. Ligament displaces superficial to the adductor aponeurosis. This prevents the ligament from healing. MRI useful in diagnosis. Treatment ■ Nondisplaced stable avulsion, partial ligament- Hand based thumb spica cast 2-4 weeks, removable splint and begin A/AA ROM . Key pinch ok. Avoid tip pinch for 8 weeks. ■ Complete ligament disruption or displaced Fractures treated with ORIF. Cast 4 weeks. Begin gentle ROM . Avoid tip pinch for 8 weeks. Thumb spica orthotic for 2-6 weeks. Return to sport 10-2 weeks ■ Internal Brace from Arthrex – start ROM 7-10 days, orthotic as needed 4-6 weeks full activity. Trigger Digit ■ Fibroosseous tunnel formed by Metacarpal neck and A1 pully. FDS, FDP or both affected ■ symptomatic clicking or locking of a finger or the thumb. The etiology involves pathological thickening of the flexor sheath, the annular pulley system, and intrasubstance changes within the flexor ■ Felt as a palpable nodule, resulted in the inability of the affected digit to flex or extend smoothly. A person with TD may initially experience painless clicking of the digit during movements which may progress to painful triggering and locking. ■ 2.6% incidence in general population. Women more affected to men , 5 th and 6th generation. ■ Primary TD etiology is often idiopathic. Secondary TD can be caused by trauma (chronic trauma or repetitive strain) and is often found in association with other conditions such as diabetes mellitus, rheumatoid arthritis, carpal tunnel syndrome, and De Quervain’s tenosynovitis Conservative management ■ Poorer outcome with multiple digits . Symptoms more than 4-6 months . Presence of significant triggering . ■ CSI injection 50-94% effective . Diabeties 50% success rate . General population 72-90% ■ Several studies have evaluated the effectiveness of the MCPJblocking orthosis (MCPJ-BO), and the reported success rate range from 70% to 92.9%. ■ Randomized controlled study in JHT 2018 looked at immobilizing the PIP joint vs the MP joint . Wear 24hours a day for 8 weeks. 47% improved in PIP group one level on Green’s classification. MP group 40% improved. PIP joint was better tolerated, better cosmesis, and better compliance. Use for level 2-3 TD. Dupuytren’s Disease ■ Benign fibroproliferative disorder of the hand, characterized by nodules and cords of the palmar fascia. RF and SF usually affected the most . Surgery not recommended till MP or PIP Joint are at 30 degrees of flexion . ■ recurrence after palmar fasciotomy surgery may be as high as 60 percent. Extensive post operative care and therapy . PIPJ involvement has a higher rate of return than MPJ. ■ Current treatments are moving towards nonsurgical options such as needle fasciotomy and collagenase injections (XYLAFLEX). Journal of hand surgery study 2007 showed higher rates of return than Fasciotomy at 1 year follow up . ■ 2017 random study of 130 patient in the Journal of Plastic and Reconstructive study showed similar outcomes between Fasciotomy and XYLAFLEX for mild disease. Type I and II. Study only 1 year follow up not enough time. ■ Treatment post XYLAFLEX and Fasciotomy involves a custom static orthotic to wear at night for 4 months. Post surgical Treatment ■ Orthotic use for involved fingers only. Initiated 2-3 days post op/ continuous for 3 weeks and then at night for 6-8 months. ■ No tension techniques are considered superior to aggressive orthotic use and ROM. ■ Begin AROM day 2-3 Post op . PROM 3-4 weeks. Flair up usually occurs around week 2. Monitor for CRPS. Conservative Tx for Dupuytren’s ? ■ In the past studies that “stretch” the contracted tissues show no benefit. ■ Orthoses act on myofibroblasts and the contracted nodules of Dupuytren’s disease consist of myofibroblasts. ■ Myofibroblasts are activated contractile cells similar to those in scar tissue. In vitro experiments report that myofibroblasts are sensitive to mechanical traction but also to compression. ■ Randomized clinical trial on 30 patients in 2 groups. Used a compression orthotic (Hand based compression with silicone bed) or a tension orthotic. ■ Wore the orthotics 3 months 20 hours a day ■ Outcome Tension group TAE 32 deg, Compression 40 deg. ■ Both orthotics show reduction in Extension. Compression group was better tolerated and had increased extension. ■ Needs long term follow up study.