Splints: Mobilization, Corrective Splintage, and Pressure Therapy for the Acutely Injured Hand

Abstract

The interplay of early active and passive mobilization helps reduce edema, encourages active tendon gliding, and prevents joint stiffness after injury and operative intervention of the hands. It also enhances tensile strength of the newly repaired tendons, soft tissues, or fractured site, minimizing scar adhesion. Corrective splintage and pressure garments contribute to an effective outcome.

I can touch my palm with my finger pulp again after splinting program and mobilization. I’d made it.Client

Appendices

The Case Study of John: Splinting Program for John’s Fractured and Dislocated Finger

Keywords

Corrective splintage, dislocation, fracture, protective splintage

Introduction

The theme of this case study concerns different functions of splintage and the importance of intermittent splinting and mobilization regime in a hand rehabilitation program for a person with finger fracture and dislocation during the initial 3 months after surgery.

The students’ task includes learning of:

• 1. The normal bone healing process

• 2. Different functions of splintage at different phase of rehabilitation

• 3. Importance of intermittent splinting and mobilization regime in the treatment of stiffening joints

As a starting point, students should use the following references to gather background information:

• 1. Brand PW (1995) The forces of dynamic splinting: 10 questions before applying a dynamic splint to the hand. In: Hunter JM, Mackin EJ, Callahan AD (eds) Rehabilitation of the hand: surgery and therapy, 4th edn. Mosby, St. Louis

• 2. Colditz JC (1995) Therapist’s management of the stiff hand. In: Hunter JM, Mackin EJ, Callahan AD (eds) Rehabilitation of the hand: surgery and therapy, 4th edn. Mosby, St. Louis

• 3. Flowers K, LaStayo P (1994) Effect of total end range time on improving passive range of motion. J Hand Ther 7(3):150–157

• 4. Freeland AE, Hardy MA, Singletary S (2003) Rehabilitation for proximal phalangeal fractures. J Hand Ther 16(2):129–142

• 5. Maitland GD (1977) Peripheral manipulation. Butterworth, London

• 6. Wong JMW (2002) Management of stiff hand: an occupational therapist perspective. Hand Surg 7(2):261–269

Overview of the Content

The major goal of the interventions is to maximize the full hand function of John, facilitating him to resume independence in performances in self-care, work, and leisure.

Learning Objectives

Students should learn from John’s rehabilitation process that finger joint suppleness is a prerequisite for smooth and strong tendon gliding and strength exertion; and intermittent splinting and mobilization regime is an effective way of therapeutic intervention in John’s rehabilitation.

Personal Data

John is a 24-year-old man, working as a computer technician. He lives with his family in public housing, and loves to play football with his friends during weekends.

Medical Diagnose and Progress

John was diagnosed to have fractured his right index finger after he slipped and fell during a football match. He landed on his right index finger when he collided with his teammate. There was a chip fracture over the ulnar base of middle phalanx with subluxed proximal interphalangeal joint (PIPJ), complicated by distal interphalangeal joint (DIPJ) dislocation, which was confirmed after x-ray. Surgery was done to immobilize John’s DIPJ.

Reason for Seeking Occupational Therapy

He was referred for occupational therapy for prescription of splinting and mobilization program immediate after the surgery (Fig. 18.14).

Fig. 18.14

X-ray on fracture index finger

During the initial assessment held on day 3 post operation, John was observed with moderately swollen right index finger with Kirschner wire (k-wire) fixation over the DIPJ. Moderate pain was reported over the PIPJ on gentle nonresistive motion. In order to start early protective motion to help reducing edema and prevent the development of joint stiffness, John was prescribed with a dorsal block hand-based splint to guard his finger motion. The dorsal block splint guided John’s index finger motion from a 30° extension block to full flexion. Meanwhile, he was put on a buddy strap between his affected index finger and middle finger to prevent any varus or valgus stress the PIPJ collaterals upon movement. He was also instructed on the proper mobilization regime and other measures for alleviating edema problem, including elevation and retrograde massage during the course of treatment. By that moment, John was well adapted by using his left hand assisting in all daily living activities, and his work duty was suspended for 2 weeks until his finger conditions became more stable (Figs. 18.15, 18.16).

Fig. 18.15

Dorsal block splint with buddy strap

Fig. 18.16

Buddy straps between index and middle finger to prevent any varus/valgus stress onto the PIPJ during movement

During the start of fourth week after surgery, k-wire was removed and John was suggested to wean off his dorsal block splint for free finger mobilization . The buddy strap protection continued until the end of sixth week. Pressure finger tubes were then prescribed to foster edema control. Free nonresistive finger mobilization was reinforced aiming at regaining his affected finger joint flexibility. John resumed his computer work after the removal of k-wire, and he was doing well in gradual reintegration of his right hand in mouse and keyboard manipulation. However, his return to football play was still suspended until the fracture healed completely (Fig. 18.17).

Fig. 18.17

Prescription of pressure finger tube

Steady progress was examined according to the results of weekly hand assessments, despite of the stiffening end-feel of both PIPJ and DIPJ upon manual manipulation. Up to the eighth week after surgery, the problem of joint stiffening persisted with flexion contracture over the PIPJ and extension contracture over the DIPJ were noted. Limited active and passive flexion ranges were measured over both finger joints. Hence, corrective splintage was incorporated into John’s daily treatment routine, including pressure therapy , active mobilization, and graded strengthening activities.

In view of the problem that John’s active range of index finger PIPJ extension/flexion could only achieve 30 lag/60°, during the eighth and ninth weeks, a flexion mitt was prescribed aiming at improving the passive ranges of interphalangeal joints (IPJs). It was used on top of a wrist neutral splint with a flexion volar block at the index finger in order to concentrate the stretching effect of the flexion mitt onto the PIPJ. The stretching effect from the flexion mitt could be upgraded every 5 min by tightening up when John adapted well after every 5-min trial. The wearing regime was 4–5 times a day during daytime, and every application should last for 15–20 minutes.. Gentle finger mobilization in extension and flexion follows every application of splint stretching in order to upgrade the tendon-gliding excursion over the improved joint flexibility (Fig. 18.18).

Fig. 18.18

Flexion mitt with wrist neutral splint. The volar flexion block of the splint at the MPJ level is molded to concentrate the stretching force from the flexion mitt onto the PIPJ. The force is further reinforced by the white strap wrapping around in horizontal direction

Another finger extension splint was provided for night use in order to correct flexion contracture developed over the PIPJ and to prevent it from further stiffening. John was reminded to have a warm soaking bath to his affected finger in the morning to ease his finger stiffnesswhich is usually felt in the morning. At the same time, John could mobilize his fingers in the warm bath to increase the suppleness of his finger joints(Fig. 18.19).

Fig. 18.19

Finger extension splint for night use to prevent further development of PIPJ flexion contracture

Passive stretching splintage was further upgraded afterwards when John made his progress. A handy flexion loop made of rubber band was prescribed, replacing the flexion mitt and with wrist splint. The flexion loop aimed at upgrading the stretching effect onto both PIPJ and DIPJ, restoring the full passive range of flexion. The night extension splint continued, and the flexibility of the PIPJ was improving according to the end-feel feedback from manual joint manipulation (Fig. 18.20).

Fig. 18.20

Flexion loop to restore full passive flexion ranges of PIPJ and DIPJ

Current Circumstances

At present, it was about 3 months after John’s surgery; he was so happy about his progress when he reported minimal pain on index finger exertion, and flexibility of joints improved as well. Swelling problem subsided well with skin folds easily visible again over his finger. Total active and passive motion of his injured index finger was already up 90 % of his unaffected side. Pincer strength was progressing, and his work duty and daily living tasks were being performed very well without any significant problem.

Occupational performance issues showed that John is now able to resume all of his functions without significant problem, except that he is still postponing his football practice to 3 more months later until the healing of his fracture becomes more consolidated.

The Students’ Report

The following guiding questions have been identified in developing possible solutions to John’s post finger fracture joint stiffness. These questions are generated from the available literature references and our clinical experiences.

• 1. What is the advantage of buddy taping a finger with a stable fracture to an adjacent uninvolved finger?

• 2. What is the role of a static splint on a finger with fracture?

• 3. What is the function of dynamic splint in collagen remodeling process?

• 4. Are there any alternatives for splinting such a fracture as John’s?