(A) Nerve injury
1.Median nerve injury
(1) Fixation and application of orthoses: After repair, the wrist joint is fixed in the flexed position (to the palm) for 3 to 4 weeks. 4 to 6 weeks later, the wrist joint is gradually extended to the normal position. After 12 weeks, the index finger and middle finger IP joints were actively extended with a power orthosis. The thumb “tiger mouth” contracture can be corrected with a static orthosis.
(2) Work activities: Due to the loss of stability of the thumb and the loss of palmar abduction of the thumb, the force grip is affected, so that the patient’s “tiger mouth” grip is limited and he cannot grip large objects, such as bottles, bowls and cups. Therefore, in the early stage of treatment, activities that involve the entire upper extremity should be considered when selecting work activities. As functional progress is restored, multi-point grasping of large caliber objects and two-point grasping should become the focus of occupational therapy.
(3) Sensory remodeling: Due to the loss of sensory function, patients with median nerve injury can show clumsy movements in fetching and holding objects. Sensory remodeling training can be used to restore their function, and vision can also be used to protect the sensory loss area.
(4) Aids: Finger writing aids and grip aids (e.g., “C” handle) can be used to help with writing and cup-holding activities, prevent first finger web contracture, and maintain finger grip function.
(5) Surgery: If there is no hope for nerve recovery, functional reconstruction can be considered b permanent paralysis of the greater interosseous muscle, and if the thumb cannot be palmarized, thumb-to-palmar tendon transfer can restore the function of the thumb.
2, ulnar nerve injury
(1) Fixation and application of orthosis: After the injury of “claw-shaped hand”, orthosis can be used to fix the MP joint in the flexion position for 3–4 weeks to prevent the MP joint from hyperextension and the IP joint from flexion. 4 weeks later, functional training can be implemented gradually.
(2) Work activities: ulnar nerve injury can lead to the loss of ulnar innervation of the thumb adductor muscle, loss of hand stability, strength and coordination, the patient cannot grasp larger objects, cannot complete the lateral pinching action, such as holding keys, tapping the keyboard and grasping bottles and other activities are limited. The types of work activities to be selected are more varied, such as.
① Improving gripping ability and gripping strength.
② improvement of finger coordination.
③ Improving finger dexterity.
④ Work-based work activity training. The work activities should include such movement elements as cylindrical grip, lateral thumb pinch and counterpalm, IP joint extension, finger inversion and abduction.
(3) Sensory remodeling: When the ulnar nerve is injured, the ulnar side hemi-skin sensation of the little finger and ring finger is lost, and writing movements cannot be completed. Sensory reeducation can be implemented, and visual substitution can also be used to protect the area of skin sensory loss at the ulnar margin of the hand.
(4) Surgery: for those who have no possibility of self-recovery of the nerve, surgery can be considered to reconstruct the intrinsic muscle function.
3.Radial nerve injury
(1) Fixation and application of orthoses: In radial nerve injury, the patient cannot simultaneously extend the wrist, knuckle and abduct the thumb to the radial side. Therefore, a wrist orthosis should be used to maintain the wrist in extension, the metacarpophalangeal joint straightened, and the thumb externally fixed for 3-4 weeks. Prevent overdrawing of the extensor muscles to assist in the grasping and relaxing function of the hand. Static orthoses or powered wrists can be used
extension orthoses to correct wrist deformities and promote MP joint extension for 04 weeks before gradually implementing functional training.
(2) Operational activities: After 4 weeks, gradually train the wrist and IP joint muscles through activities, including.
(i) being able to keep the wrist joint stable while performing grasping.
(ii) simultaneous extension of the wrist joint and fingers.
③ Improving hand coordination and enhancing muscle strength.
④ Training for work-based operational activities.
(3) Sensory remodeling: In radial nerve injury, dorsal sensory deficits of the radial side and one and a half or two and a half fingers on the radial side of the affected hand can be implemented for sensory reeducation, and visual substitution can also be used to protect the area of sensory loss in the skin of the radial margin of the hand.
(4) Surgery: if necessary, wrist extension, thumb extension, finger extension functional reconstruction surgery can be performed.
4, combined with nerve injury clinically more median nerve injury combined with ulnar nerve injury, late injury can appear “ape hand” deformity, all palm skin sensory loss, all fingers end dorsal and thumb dorsal skin sensory loss. A power orthosis can be used to extend the fingers and improve function, and sensory re-education can improve the patient’s sensory impairment.
(B) Hand fracture
Treatment of hand fractures begins with fixation of the fracture site so that the fracture can grow safely without deformity; other uninjured areas should also be kept mobile to avoid stiffness or atrophy.
The treatment is generally divided into two phases: the early phase (fixation phase) and the later phase (recovery phase) after the fracture. The duration of fracture fixation varies depending on the location and extent of the injury.
1.Metacarpal fracture
(1) Fixation and application of orthoses: braking and fixation within 3 to 6 weeks after injury. Fractures of the metacarpal bone can easily lead to bone rotation deformity and angular deformity, and the fracture site must be fixed. Orthoses can be used to immobilize the affected area, maintaining the wrist joint in 15 degrees – 20 degrees of extension and the MP joint in 70 degrees of flexion, and IP is generally not fixed to prevent deformity.
(2) Operational activities: only the healthy finger can be moved passively within 1 week after the injury. 1 week later, the healthy finger can be moved actively, and the DIP and PIP joints of the injured finger can be moved passively. at this time, the therapist can design therapeutic activities to allow the patient to move the uninjured parts, such as the fingers, wrist, elbow and shoulder, to reduce metacarpophalangeal joint contracture and stiffness 06 weeks later, the MP joint of the injured finger can start to move, first passively and then actively Training, without inducing pain, gentle and active flexion of the interphalangeal and metacarpophalangeal joints to obtain a good grip. This is followed by training in hand grip strength, finger extension, finger dexterity and working ability.
(3) Sensory remodeling: In case of combined nerve injury, sensory remodeling training can be implemented.
(4) Surgery: In case of comminuted fracture or angular deformity, surgery must be performed before rehabilitation.
2.Finger bone fracture
(1) Fixation and application of orthoses: There are extensor and flexor muscles in the finger, so the injured area is susceptible to muscle traction and deformity. Fixation of the initial fracture site is the key to prevent deformity: after resetting the fracture of the proximal phalanx, the MP joint should be flexed 45 degrees and the PIP joint should be flexed 90 degrees and fixed for 4-6 weeks; after resetting the fracture of the middle phalanx, the DIP joint should be flexed 30 degrees and fixed to the palmar side; the DIP joint should be fixed to the dorsal side in the straight position for 4-6 weeks; after resetting the fracture of the terminal phalanx, the PIP joint should be flexed 90 degrees and the DIP joint should be fixed to the straight position for 4-6 weeks. The DIP joint was fixed in the straight position for 4-6 weeks.
(2) Operational activities: The therapeutic activities after finger fracture are similar to those of metacarpal fracture, and the healthy finger starts active activities on the 3rd to 5th postoperative day.
The third to fifth postoperative day, the healthy finger begins to move actively, in conjunction with the MP joint, to the extent that the injured finger is not involved in the fixation. At this time, the therapist can design therapeutic activities for the patient to
The therapist can design therapeutic activities for the patient to actively move the uninjured part of the finger, wrist, elbow, and shoulder, such as grasping, dribbling, and maintaining finger dexterity of the healthy finger.
The therapist can design activities that allow the patient to initiate movement of the uninjured area, such as finger, wrist, elbow and shoulder grasping activities, dribbling activities and finger dexterity activities to maintain the healthy finger. After removal of immobilization and satisfactory fracture healing, interphalangeal joint flexion and extension exercises should be performed for the injured finger. The activities designed by the therapist should emphasize achieving the maximum range of motion of each joint possible.
(3) Sensory remodeling: Desensitization training is required for finger fractures combined with allergies.
(4) Surgery: If there is a comminuted fracture, bone rotation deformity or angular deformity, surgery is necessary before rehabilitation.
3.Basal fracture of the metacarpal of the thumb
(1) Fixation and application of orthoses: There are 2 types of fractures. Type 1 thumb metacarpal base fractures that do not pass through the joint are fixed with orthoses for 3 to 6 weeks after repositioning. Type 2 thumb metacarpal base fractures that pass through the joint (Bennett fracture) are easy to reset but difficult to fix, and often require surgical incision for internal fixation and removal of fixation after 3 to 6 weeks.
(2) Operational activities: During the fixation period, the active and passive movements of the remaining healthy fingers of the injured hand are the main activities. After the edema and pain are controlled, the flexion and extension movements of the interphalangeal joint can be performed with the assistance of the injured hand with the healthy hand. Each activity is suitable for local pain-free and fatigue-free. After the immobilization is removed, the thumb abduction, adduction, palmar and flexion-extension exercises should be strengthened. The training is gradual from passive to active activities. The therapist should design activities that follow.
① promotion of thumb-to-finger and palm-to-palm grip function.
(ii) Promoting thumb extension movements.
③ Improve hand coordination and enhance muscle strength.
(C) Joint dislocation
PIP joint dislocation can be caused by traumatic violence, hyperextension of the finger joints and lateral external force. Dislocation can be palmar, dorsal and lateral. Joint dislocations are often associated with soft tissue injuries. Dislocations can sometimes be accompanied by fractures. The treatment of fracture dislocation depends on the size of the fracture and may be surgical if necessary.
1.Dorsal dislocation of PIP joint This dislocation is more common and often results in hyperextension deformity of PIP joint, which is caused by hyperextension injury. dorsal dislocation of PIP joint may mainly injure the base of middle phalanx and surrounding soft tissues, and there may be small bone fragment avulsion. After dislocation, due to the increased tension of the dorsal tendon membrane and lateral bundle of the finger, the PIP joint may be hyperextended and the DIP joint may be slightly flexed and deformed, which may lead to a “goose neck” deformity over time.
(1) Fixation and application of orthoses: After early repositioning, fix the PIP and DIP joints in flexion at 20 degrees to 30 degrees for about 3 weeks. 3-6 weeks, use the dorsal block orthoses to limit the PIP joint hyperextension and train the DIP joint in active flexion within the limits of the injured finger. 6 weeks later, remove the fixation to train the DIP and PIP joints in free flexion and extension. If flexion contracture develops after PIP joint fixation, it is necessary to correct it gradually by pulling the joint with a power orthosis to assist extension. Surgical correction is performed if necessary.
(2) Operational activities: 3 to 5 days after the injury is fixed, the healthy finger can perform active movements. 1 to 3 weeks, the DIP and PIP joints of the injured finger can move in passive flexion. 3 to 6 weeks, the DIP and PIP joints of the injured finger can actively move in active flexion within the limits, at which time the therapist can design therapeutic activities for the patient to perform grip training to reduce metacarpophalangeal joint contracture and stiffness. 6 weeks later, the Gradually train the extension activities of the injured finger IP joint, followed by muscle strength, finger dexterity and work ability training.
2.Lateral dislocation of the PIP joint is caused by external forces that partially rupture the unilateral collateral ligament of the PIP joint and the attachment point of the metacarpal plate.
(1) Fixation and application of orthosis: After early repositioning, the PIP joint is fixed at 20 degrees of flexion for about 2 weeks. 3-5 weeks, the injured finger is fixed together with the neighboring finger, and active flexion of the PIP joint is performed under the protection of a dorsal blocking orthosis. 5 weeks later, the fixation can be removed for PIP joint extension activities. However, if the PIP joint shows instability under the action of lateral external force, it should be fixed for another 3 weeks.
(2) Operational activities: 3 to 5 days after the injury is fixed, the injured finger can perform active movements. 3 to 5 weeks later, the injured finger and the adjacent finger can perform active flexion movements of the PIP joint. After removal of the fixation, gradually train the extension activities of the PIP joint of the injured finger, followed by muscle strength, finger dexterity and work ability training.
3, PIP joint palmar dislocation clinically, . Metacarpal dislocation is less common. When the PIP joint is dislocated palmarly under the action of external force, the head of the proximal phalanx is incompletely or completely protruded into the cleft of the extensor tendon, which may be accompanied by a tear of the central tendon bundle of the extensor tendon. In the late stage, a “buttonhole” deformity may be formed.
(1) Fixation and application of orthosis: After repositioning, use the PIP joint extension orthosis for 4-6 weeks to ensure healing of the extensor tendon.
Thereafter, the fixation was removed after 2 weeks of joint function restoration training while using the PIP joint hyperflexion restriction orthosis intermittently.
(2) Operational activities: After removal of the extension orthosis, active PIP joint flexion and extension training is required. During the first 2 weeks of training, the PIP joint hyperflexion limiting orthosis can be used in between training sessions, such as at night. During the training, the therapist mostly designs the extension activities of the PIP joint of the injured finger, followed by the training of muscle strength, finger dexterity and working ability.
4.MP joint dislocation MP joint dislocation usually occurs in the MP joint of the index finger or little finger, which is rare in clinical practice. However, when the MP joint is dislocated, surgery is required because the soft tissue is easily embedded in the joint space. After 3 weeks of postoperative fixation, MP joint extension training can be performed.
(D) Ligament injury
1.Lateral interphalangeal ligament injury
(1) Application of fixation and orthosis: the incidence of PIP joint is the highest among joint ligament injuries, and the radial side is more than the ulnar side, resulting in the loss of joint stability. Therefore, when the lateral collateral ligament is partially torn, fixation must be used. The PIP joint of the injured finger is immobilized for 2 weeks at 15 degrees to 20 degrees of flexion. After the pain and edema are controlled, if the lateral compression test examination, when compared with the healthy side, reveals that the PIP joint of the injured finger is unstable, the adjacent finger needs to be combined and fixed for 2 to 3 weeks.
(2) Operational activities: After fixation in the flexion position, active PIP joint flexion and extension training must be performed. The therapist mostly designs activities related to PIP joint extension of the injured finger, followed by training of muscle strength, finger dexterity and working ability.
(3) Surgery: If the lateral collateral ligament is completely ruptured, then early surgical repair is required to suture the torn tissue and fix it immediately after surgery.
2.Lateral collateral ligament injury of MP joint
(1) Fixation and application of orthoses: Radial collateral ligament injuries of the MP joint from the index finger to the little finger are more common. Most due to finger poking or lateral strikes caused by MP joint hyperextension, so the MP joint needs to be fixed at 45 degrees – 50 degrees of flexion for 2 to 3 weeks, and needs to be fixed from the PIP joint to the middle of the forearm.
(2) Operational activities: Active MP joint flexion and extension training should be started immediately after the release of immobilization. The therapist designs activities to first improve MP joint extension activity, followed by muscle strength training, and finally to improve ADL and work capacity.
3, thumb MP joint lateral collateral ligament injury thumb MP joint lateral collateral ligament injury is mostly seen on the ulnar side. Under the action of external force, the thumb ulnar side of the proximal phalanx is stressed and the tension of the medial collateral ligament of the metacarpophalangeal joint is increased, resulting in ligament injury.
(1) Fixation and application of orthoses: After surgery or repositioning, the MP joint of the thumb needs to be fixed in the flexed position for 5 to 6 weeks, and the fixation should preferably include the carpal joint.
(2) Operational activities: Active motor training of the MP joint of the thumb starts immediately after the end of joint immobilization. It takes about 12 weeks to recover from a lateral collateral ligament injury of the thumb to reach a stable state. Therefore, the therapist primarily designs activities related to extension of the MP joint of the thumb early on, gradually increasing the muscle strength training and finally improving the ADL and working ability.
(3) Surgery: When the lateral collateral ligament is ruptured, early surgical repair is required to suture the torn tissue and immobilize it immediately after surgery.