Splinting programme for patients with burnt hand

Splintage is commonly used in conjunction with pressure therapy to tackle the contracted scars, make it supple and thus minimise dysfunction. A static or dynamic splint can provide valuable therapy that goes beyond any treatment session. The patient's active participation in the splint programme can facilitate early recovery. A good splinting design and wearing regime often depends on the therapist's understanding and integration of visco-elastic properties in soft tissues, maturation process of hypertrophic scars and mechanical principles in splinting. Different types of splints serve different functions at different stages of rehabilitation. A suitable and efficient application of splints can minimise most of the corrective surgical intervention and alleviate psychological trauma. This article attempts to highlight the clinical rationale and special considerations when applying different splintage on burns patients with upper limbs involvement.

Rehabilitation for distal radial fractures in adults

BACKGROUND

Fracture of the distal radius is a common clinical problem, particularly in older white women with osteoporosis.

OBJECTIVES

To examine the evidence for effectiveness of rehabilitation intervention(s) for adults with conservatively or surgically treated distal radial fractures.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Injuries Group specialised register (January 2002), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 4, 2001), the Cochrane Rehabilitation and Related Therapies Field database, MEDLINE (1966 to January 2002), EMBASE (1988 to 2001 Week 50), CINAHL (1982 to December Week 2 2001), Current Controlled Trials (December 2001), AMED, PEDro, conference proceedings and reference lists of articles.

SELECTION CRITERIA

Randomised or quasi-randomised clinical trials evaluating rehabilitation as part of the management of fractures of the distal radius sustained by skeletally mature patients. Rehabilitation interventions such as active and passive mobilisation exercises, and training for activities of daily living, could be used on their own or in combination, and be applied in various ways by various clinicians.

DATA COLLECTION AND ANALYSIS

All trials meeting the selection criteria were independently assessed by all three reviewers for methodological quality. Data were extracted independently by two reviewers. The trials were grouped into categories relating to the main comparisons, and to when the intervention(s) commenced (for example, during or after plaster cast immobilisation). Quantitative data are presented using relative risks or mean differences together with 95 per cent confidence limits.

MAIN RESULTS

Twelve trials, involving 601 mainly female and older patients, were included. Initial treatment was conservative, involving plaster cast immobilisation, in all but 20 patients whose fractures were fixed surgically. Though some trials were well conducted, others were methodologically compromised. No trial provided definitive evidence. Only very limited pooling of results from comparable trials was possible. During immobilisation, there was weak evidence of improved hand function in the short term, but not in the longer term, for early occupational therapy (1 trial), and of a lack of differences in outcome between supervised and unsupervised exercises (1 trial). Post-immobilisation, there was weak evidence of a lack of clinically significant differences in outcome in patients receiving formal rehabilitation therapy (3 trials), passive mobilisation (2 trials) or whirlpool immersion (1 trial) compared with no intervention. There was weak evidence of a short-term benefit of continuous passive motion (post external fixation) (1 trial), intermittent pneumatic compression (1 trial) and ultrasound (1 trial). There was weak evidence of better short-term hand function in patients given physiotherapy than in those given instructions for home exercises by a surgeon (1 trial).

REVIEWER'S CONCLUSIONS

The available evidence from randomised trials is insufficient to establish the relative effectiveness of the various interventions used in the rehabilitation of adults with fractures of the distal radius.

Changes in health status for persons with wrist or hand impairments receiving occupational therapy or physical therapy

OBJECTIVE

The purpose of this study was to describe changes of health status as perceived by clients with hand or wrist impairments who received rehabilitation in acute, orthopedic outpatient facilities from occupational therapy or physical therapy personnel.

METHOD

One thousand three hundred ninety-nine adults with wrist (n = 692) or hand (n = 707) impairments who were treated between July 1996 and June 1997 were selected from the Focus On Therapeutic Outcomes, Inc. (FOTO) national rehabilitation database. Each client completed a health status questionnaire on intake and discharge. Data consisted of number of outpatient visits, duration of treatment episode, and health status scores for six functional scales. Measures of intensity, global health status, global utilization, and client satisfaction were calculated. Outcomes were evaluated across occupational therapists and physical therapists.

RESULTS

Clients perceived improvement (p < .05) in their health status over the course of therapy. Number of visits and measures of health status and client satisfaction were similar across type of therapist. Episode duration was longer (p < .05) and intensity was less (p < .05) for clients seen by occupational therapists.

CONCLUSION

Clients receiving rehabilitation in acute orthopedic outpatient centers perceived improvement in their functional abilities and health and well-being (global health status and individual functional scales) over the time during which treatment was provided. Results confirm the responsiveness of the outcomes instrument to clinical change in the clients' perception of their health status over the course of therapy and support the use of health status as a measure of clinical outcome.

Self-reported disability following distal radius fractures: the influence of hand dominance

The purpose of this study was to record the spectrum of self-reported disability following distal radius fractures and to gauge for differences in hand dominance in the use of subjective outcome data. Items were generated through patient interviews, literature review, and peer consultation. Fifty-three items were evaluated by a group of 55 patients recovering from a fracture of the distal radius, which established the prevalence, mean severity score, and overall severity score (or impact) of each item as it related to physical function and social/emotional impact. Hand dominance, age, and gender were also recorded. The results confirm that many patients who sustain distal radius fractures experience substantial impairment across a spectrum of quality of life domains. Because patients who sustain a dominant wrist injury are likely to report greater functional impairment across a wider range of activities, they also possess a greater potential for improvement. The practical implication is that outcome studies for the treatment of distal radius fractures should take hand dominance into account.

Responsiveness of the short form-36, disability of the arm, shoulder, and hand questionnaire, patient-rated wrist evaluation, and physical impairment measurements in evaluating recovery after a distal radius fracture

We evaluated the responsiveness of patient questionnaires and physical testing in the assessment of recovery after distal radius fracture. Patients (n = 59) were assessed at their baseline clinic visit and again 3 and 6 months after injury. At each visit patients completed a short form-36, Disability of the Arm, Shoulder, and Hand questionnaire, and patient-rated wrist evaluation (PRWE). At 3 and 6 months grip strength, range of motion, and dexterity were analyzed. Standardized response means (SRM) and effects sizes were calculated to indicate responsiveness. The PRWE was the most responsive. Both the PRWE (SRM = 2.27) and the Disability of the Arm, Shoulder, and Hand (SRM = 2.01) questionnaire were more responsive than the short form-36 (SRM = 0.92). The physical component summary score of the short form-36 was similar to that of the physical component subscales. Questionnaires were highly responsive during the 0- to 3-month time period when physical testing could not be performed. Of the physical tests, grip strength was most responsive, followed by range of motion. Responsive patient-rating scales and physical performance evaluations can assist with outcome evaluation of patients with distal radius fracture.

From hand twister to mind twister: computer-aided treatment in traumatic wrist fracture

OBJECTIVE

The use of computers as a treatment modality in the occupational therapy hand clinic is, as yet, not common practice. A computer interface for wrist movements was developed, and a study to justify the application of such a device is presented.

METHOD

Forty-seven patients in a day hand clinic who had traumatic fracture of one hand with limitation of wrist mobility participated in the study. Participants were divided into two treatment groups: computer-aided treatment (high technology) and traditional brush machine treatment (low technology). A device was developed based on the brush machine in which the brush machine's mechanism was converted into a medial-lateral joystick. Right-to-left movements were digitally transformed for the use of a computer game. Participants were treated for 5 weeks, and outcome measures included range of motion (ROM), grip strength, edema, and level of interest.

RESULTS

Results showed significant improvement in ROM, grip strength, and edema across 5 weeks for all participants. Although no significant differences were found between the two groups in ROM, grip strength, and edema, the computer-aided group showed significantly more interest in treatment than did the brush machine group. Finally, the interaction between treatment group and the attitude toward computers was not significant.

CONCLUSIONS

These results indicate the potential for more interesting motor treatment and rehabilitation of the wrist through the use of computer games. The efficacy of using computers in occupational therapy clinics needs further investigation.

Three-dimensional dynamic external fixation of distal radial fractures. A prospective study

This prospective study describes the experience with a new dynamic external fixator which provides three degrees of freedom, while the centre of rotation of all these movements is located in the wrist. 44 patients with unstable fractures of the distal radius were included. During the period of dynamisation, with a median flexion of 30 degrees, extension of 18 degrees, radial deviation of 0 degree and ulnar deviation of 20 degrees the range of motion needed to perform activities of daily living was approached. In spite of early mobilisation reduction was maintained. The radiological result was excellent or good in 82% of the patients and the functional result was excellent or good in 92% of the cases. Pin track infections were noted rather frequently, possibly related to the interaction between the soft tissues and the fixator pins. Based on the experiences of the study the device needs further improvement.

The carpus: therapist's commentary

This paper presents an overview of therapy for the wrist after soft tissue reconstruction, arthroscopic debridement, arthroscopic ganglionectomy, total wrist arthrodesis, and vascularized bone grafts. Postoperative problems common to each of these procedures include stiffness, edema, scarring, decreased strength, and decreased use of the involved extremity. An understanding of the surgical procedure and its specific purpose is necessary for the hand therapist to formulate a plan of treatment and appropriate goals for rehabilitation. Treatment techniques and modalities for these procedures are reviewed, as well as the importance of patient education and activity modification.

Intra-articular fractures of the distal aspect of the radius

Intra-articular distal radius fractures are a heterogeneous group of injuries with different fracture patterns. The existing classification systems are helpful for describing the fractures but not for assessing their stability or for deciding which surgical approach to use. Patients who have a fracture with at least 1.0 mm of displacement of the articular surface may benefit from open surgical treatment. Improved diagnostic imaging with CT is helpful for fracture classification and surgical planning. The options for surgical treatment include limited open reduction and internal fixation, arthroscopically assisted internal fixation, and open reduction and internal fixation. The surgical approach is determined on the basis of the initial displacement of the fracture. Patients who have a displaced fracture of the volar rim may benefit from a volar approach; those who have a dorsally displaced fracture, from a dorsal approach; and those who have an impacted fracture such as a die-punch fracture, from a dorsal approach that provides better visualization of the articular surface. The long-term functional outcome is determined in part by the severity of the fracture as defined by the amount of comminution, the initial severity of displacement, and the number of fracture fragments. The accuracy of the reconstruction of the articular surface, with the goal of establishing congruency to within 1.0 mm, is also important in order to minimize the risk of late osteoarthrosis. Of all of the extra-articular parameters, restoration of the length of the radius is the most important for enhancing recovery of motion and grip strength and for preventing problems involving the distal radioulnar joint--the so-called forgotten joint in distal radial fractures.

Rehabilitation and use of protective devices in hand and wrist injuries

Hand and wrist injuries are common among athletes. Although the hand does not often bear weight and these injuries do not always sideline an athlete, careful attention must be paid when treating injuries of the hand and wrist. Rehabilitation is given for common injuries of the hand and wrist, including exercises and protective splints and braces. Details on how to fabricate a playing cast for athletes are also discussed.

Controlled active motion following primary flexor tendon repair: a prospective study over 9 years

One hundred and thirty patients with 339 divided flexor tendons affecting 208 fingers were studied prospectively between 1988 and 1996, to assess a regime of primary flexor tendon suture and active postoperative motion, combined with a modified Kleinert dynamic traction splint. The tendon suture technique used was a high-strength multistrand technique using a modified Kessler core and a Halsted peripheral stitch. The results were influenced by the zone in which the tendon was divided, by the physiotherapy and to a lesser extent by the grade of surgeon operating. Overall results by Strickland criteria were 92% excellent or good, 7% fair and 1% poor. There were 43 complications in 31 patients including five zone 2 ruptures (5.7%) and one further rupture in zone 5. This method of flexor tendon repair requires good physiotherapy and splint-making capability but gives good results with minimal need for further surgery.

The effect of low frequency, long-wave ultrasound therapy on joint mobility and rehabilitation after wrist fracture

Thirty-eight patients with dorsally-displaced distal fractures were prospectively studied to assess the clinical effects of low frequency ultrasound treatment, started immediately after plaster removal. Nineteen of the patients represented the control group and a double-blind protocol was followed. Assessment took place on the day of plaster removal and 2 and 8 weeks later. There was no significant difference in wrist motion and duration of follow-up between the treated and control patients.

Therapy after skeletal fixation in the hand and wrist

Skeletal fixation can be very beneficial to the recovery of wrist and hand function after a displaced fracture because it allows mobilization of soft tissues before the completion of fracture healing. The benefits of skeletal fixation can be greatly diminished, however, if excessive force causes the fixation to fail before fracture healing has occurred, infection occurs around the implant, or the patient develops reflex sympathetic dystrophy. Those complications, as well as others, are often caused by inappropriate or inadequate hand therapy. This article discusses the techniques needed to avoid many such complications while providing the best possible functional result for every patient.

The range of excursion of flexor tendons in Zone V: a comparison of active vs passive flexion mobilisation regimes

A number of early postoperative mobilisation regimes have been developed in an attempt to increase tendon excursion and gliding and thereby reduce formation of adhesions following repair of flexor tendons. Early active flexion mobilisation regimes are becoming more popular, and have replaced early passive flexion regimes in many centres. The aim of the present study was: (a) to determine the range of excursion of flexor tendons in Zone V, and (b) to compare the excursion ranges between active (Belfast) and passive (modified Duran) flexion mobilisation regimes postoperatively. This was done (a) in two cadavers, and (b) in two patients intraoperatively, and postoperatively at 10 days, 3 weeks and 6 weeks. With passive flexion, the mean tendon excursion in Zone V in cadavers was 1 mm for flexor digitorum superficialis (FDS), flexor digitorum profundus (FDP) and flexor pollicis longus (FPL) tendons respectively. With simulated active flexion, the mean tendon excursion was 14 mm, 10 mm and 11 mm respectively. The mean tendon excursion in clinical cases intraoperatively following passive flexion was 2 mm for FDS, FDP and FPL respectively; following simulated active flexion it was 10 mm, 11 mm and 11 mm for FDS, FDP and FPL respectively. On the tenth day following repair, the mean excursions of FDS, FDP and FPL were 1 mm, 4 mm and 4 mm on passive flexion as compared to 3 mm, 10 mm and 12 mm on active flexion respectively. Three weeks postoperatively, the mean excursions of FDS, FDP and FPL tendons were 1 mm, 2 mm and 1 mm on passive flexion as compared to 5 mm, 15 mm on active flexion respectively. Six weeks postoperatively, the mean excursions of FDS, FDP and FPL tendons were 9 mm, 7 mm and 4 mm on passive flexion as compared to 12 mm, 33 mm and 20 mm on active flexion respectively. These results demonstrate an increased excursion of repaired flexor tendons in Zone V following an active flexion mobilisation regime as compared to a passive flexion mobilisation regime.

Educational techniques used in occupational therapy treatment of cumulative trauma disorders of the elbow, wrist, and hand

OBJECTIVE

This study examined patient education techniques used by occupational therapists when treating cumulative trauma disorders (CTDs) of the elbow, wrist, and hand.

METHOD

A self-administered survey was sent to 232 registered occupational therapists whose primary area of practice was hand therapy. The questionnaire sought information about specific content areas and methods (i.e., media, format) used to educate patients about preventing the recurrence of CTDs in the elbow, wrist, and hand.

RESULTS

One hundred twenty-eight therapists responded to the survey. A majority of respondents (n = 116) reported that patient education content area consisted of anatomy of the joint, the CTD disease process, and job modification. Verbal instruction, illustrations, and pamphlets and handouts were the most frequently used forms of educational media. A majority of respondents (n = 111) also reported that individual interaction was the most common format of patient education.

CONCLUSION

The findings indicate that a majority of therapists use the same patient education techniques with regard to content areas, media, and format, regardless of the area being treated (i.e., elbow, wrist, hand). Furthermore, it appears that therapists with specialty training in CTDs more frequently include anatomy of the elbow, job modification, and proper body mechanics in the content of their patient education about the elbow.

Variability of short arm cast application: the influence of experience using fibreglass tape and QuickCast

A new short arm cast material which is heated to conform to the underlying limb was compared to conventional fibreglass tape. The time required for application, the pressures generated beneath the casts and the availability for digital motion were studied in three groups with varying lengths of casting experience. Results showed that the new immobilizer did not require additional time for application and provided similar interface pressures beneath the casts as compared to fibreglass tape. In addition, metacarpophalangeal joint motion was less restricted with the new casting experience. The shrinkable immobilizer thus offers an alternative to conventional fibreglass tape casts.

The role of arthroscopy in athletic injuries of the wrist

Arthroscopy has advanced our understanding of wrist dysfunction due to injuries sustained during participation in sports. Although the initial role of arthroscopy was primarily to facilitate diagnosis of specific injuries, technologic advances have allowed many of these entities to be managed arthroscopically. This minimally invasive surgery, which is used to treat cartilage lesions, ligament instability, synovitis, and other injuries, allows early and more specific diagnosis, satisfactory management, and early return to play or work. Arthroscopy should be considered a primary means of evaluation and management of athletic injuries of the wrist.

Medical management of pain for early motion in hand and wrist surgery

Pain control is a prerequisite to early motion. It can best be accomplished with a combination of drugs given around the clock, rather than on an as-needed basis.