How controlled stress affects healing tissues

Treatment of wrist stiffness through posture orthosis and active exercise: A case report

Introduction

Wrist fractures, particularly the distal radius, can result in significant stiffness and hand dysfunction if not mobilized early. The variable immobilization period post-fracture depends on fracture type, location, stability, and surgical intervention. Inadequate early mobilization typically leads to structured stiffness, influenced by patient health, injury mechanism, joint surface involvement, associated tissue injuries, and patient motivation.

Case presentation

A 64-year-old female in good health suffered a distal radius fracture, treated with open reduction and internal fixation. A modified treatment plan, including custom orthosis and active wrist exercises, was initiated after the standard immobilization phase to enhance the range of motion while accommodating the patient's daily activities.

Clinical discussion

The patient underwent 15 evaluations of active range of motion (AROM) using a goniometer, guided by the American Society of Hand Therapists. A Tissue Composition Analysis (TCA) was performed to guide the orthosis-treatment choice. Despite consistent improvement shown in AROM, it was inconclusive whether the modified treatment contributed significantly beyond the standard approach.

Conclusions

While the patient's AROM improved, the treatment's effect on this single case cannot definitively confirm the efficacy of the modified approach. A more extensive study is necessary to evaluate the conservative treatment strategy's validity for such fractures in high-demand patients, considering the biomechanical complexity of the injury and the patient's professional needs.

Clinical outcomes after primary repair for thumb ulnar collateral ligament ruptures: a systematic review and meta-analysis

There is no consensus on the best surgical technique for treating thumb ulnar collateral ligament (UCL) ruptures. This systematic review and meta-analysis investigates which primary repair technique and postoperative immobilization protocol result in the best clinical outcomes. A literature search was conducted in Embase, Medline ALL Ovid, Web of Science Core Selection and Cochrane Central Register of Controlled Trials. Pain, stability, tip pinch strength, key pinch strength, grip strength, return to work and metacarpophalangeal joint range of motion were collected as postoperative outcomes. In total, 29 studies were included. All surgical techniques resulted in satisfactory clinical outcomes, with no significant differences between bone anchor reinsertion, suture fixation, K-wire fixation and a combination of techniques. K-wire immobilization resulted in worse postoperative pain, but similar stability compared to immobilization without a K-wire. Clinical outcomes after thumb UCL repair are excellent, with no differences in clinical outcomes noted among surgical techniques.

How controlled motion alters the biophysical properties of musculoskeletal tissue architecture

INTRODUCTION

Movement is fundamental to the normal behaviour of the hand, not only for day-to-day activity, but also for fundamental processes like development, tissue homeostasis and repair. Controlled motion is a concept that hand therapists apply to their patients daily for functional gains, yet the scientific understanding of how this works is poorly understood.

PURPOSE OF THE ARTICLE

To review the biology of the tissues in the hand that respond to movement and provide a basic science understanding of how it can be manipulated to facilitate better functionThe review outlines the concept of controlled motion and actions across the scales of tissue architecture, highlighting the the role of movement forces in tissue development, homeostasis and repair. The biophysical behaviour of mechanosensitve tissues of the hand such as skin, tendon, bone and cartilage are discussed.

CONCLUSION

Controlled motion during early healing is a form of controlled stress and can be harnessed to generate appropriate reparative tissues. Understanding the temporal and spatial biology of tissue repair allows therapists to tailor therapies that allow optimal recovery based around progressive biophysical stimuli by movement.

Overhead arm positioning in the rehabilitation of elbow dislocations: An in vitro biomechanical study

STUDY DESIGN

In vitro biomechanical study.

INTRODUCTION

Elbow stiffness is a common complication following elbow dislocation. Overhead exercises have been proposed to initiate early motion to reduce stiffness through employing gravity to stabilize the elbow. The implications of this position with regard to elbow kinematics after dislocation have not been reported.

PURPOSE OF THE STUDY

To determine the influence of the overhead position on elbow stability following combined medial and lateral collateral ligament (MCL and LCL) injuries.

METHODS

Passive and simulated active extension were performed on 11 cadaveric elbows with the arm in the overhead, dependent, and horizontal positions and with the forearm in pronation, neutral, and supination. Internal-external rotation (IER) and varus-valgus angulation (VVA) of the ulnohumeral joint were assessed for the intact elbow and after simulated MCL-LCL injury. Repeated-measures analyses of variance were conducted to analyze the effects of elbow state, arm position, forearm rotation, and extension angle.

RESULTS

During passive extension with the arm overhead, the pronated position resulted in more internal rotation than supination (-2.6 ± 0.7°, P = .03). There was no effect of forearm rotation on VVA. The overhead position increased internal rotation relative to the dependent position when the forearm was neutral (-8.5 ± 2.5°, P = .04) and relative to the horizontal position when the forearm was supinated (-12.7 ± 2.2°, P= .02). During active extension, pronation increased valgus angle compared to the neutral (+1.2 ± 0.3°, P= .04) and supinated (+1.5 ± 0.4°, P= .03) positions, but did not affect IER. There was no difference between active and passive motion with the arm overhead (P > .05).

DISCUSSION

Movement of the injured elbow in the overhead position most closely replicated kinematics of the intact elbow compared to the other arm positions.

CONCLUSIONS

Overhead elbow extension results in similar kinematics between an intact elbow and an elbow with MCL and LCL tears. As such, therapists might consider early motion in this position to reduce the risk of elbow stiffness after dislocation.

Does Use of a Night Extension Orthosis Improve Outcomes in Patients With Dupuytren Contracture Treated With Injectable Collagenase?

Purpose

Current prescribing information for the treatment of patients with Dupuytren contracture with injectable collagenase Clostridium histolyticum (CCH) recommends use of a night extension orthosis for 4 months after treatment. The present study examines whether this treatment improves the outcomes.

Methods

Adult patients with Dupuytren contracture treated with CCH during the study period were eligible for inclusion. The patients were randomized to orthosis or no orthosis groups and were stratified based on the severity of contracture prior to randomization. The orthosis group was fitted postmanipulation with a hand-based custom orthosis that held the treated finger in maximal comfortable extension, and the patients were instructed to wear the orthosis at night for 3 months. The patients were assessed at 7–10 days, 30 days, and 90 days postmanipulation. Orthosis compliance was measured with a survey. The primary outcome measure was improvement in total active extension (TAE), defined as the sum of active metacarpophalangeal (MCP), proximal interphalangeal, and distal interphalangeal joint extension in the treated finger at 90 days after treatment. Secondary outcomes included total active flexion (TAF), Michigan Hand Questionnaire scores, patient satisfaction, and clinical success.

Results

Twenty-six patients completed the study, 12 in the orthosis group and 14 in the no orthosis group. The majority of contractures (90%) were primarily through the MCP joint. The patients in both the groups demonstrated significant improvements in TAE at 90-day follow-up (orthosis P = .002, no orthosis P = .001) . The difference in improvement in the median TAE between the 2 groups was not significant (P = .40). There were no significant differences between groups for TAE, TAF, Michigan Hand Questionnaire scores, patient satisfaction, or clinical success at any of the time points assessed (P > .05).

Conclusions

In patients with Dupuytren contracture with primarily MCP joint involvement, providing an orthosis after treatment with CCH may not offer a short-term benefit compared with CCH treatment alone in terms of TAE, TAF, or patient-reported outcome measures.

Type of study/level of evidence

Therapeutic I.

The effects of rehabilitation on the outcomes of surgically treated acute and chronic thumb metacarpophalangeal ulnar collateral ligament ruptures

The aim of this study was to compare the outcome of patients who received rehabilitation to those who did not receive it after surgical treatment of acute and chronic tears of the ulnar collateral ligament (UCL) of the thumb. Forty-two patients with an acute UCL injury repaired with two soft mini-anchors to bone insertion sites, and 40 patients with a chronic UCL injury reconstructed with autografts were involved in this study. The patients were divided two subgroups depending on rehabilitation. Patient characteristics were not significantly different between the two groups and subgroups. Range of motion, grip strength and pinch strength were evaluated. There was no significant change in terms of grip and pinch strength in patients with acute UCL injury who received rehabilitation after surgical treatment. However, significantly better results were achieved in flexion, extension, ulnar and radial deviation. There was no significant change in pinch strength in patients with chronic UCL reconstructions, but significantly better results were achieved in grip strength, flexion, extension, ulnar and radial deviation. A rigid MCP splint in patients with acute and chronic UCL tears is effective in preventing early ligament insufficiency.

Static progressive stretch orthosis-consensus modality to treat knee stiffness-rationale and literature review

The current literature supports static progressive stretch (SPS) orthoses as the consensus modality to treat joint stiffness as an adjunct to manual therapy. Over 50 published studies prove the efficacy and safety of this modality as an adjunct to therapy to improve range of motion (ROM) as well as decrease stiffness and pain. Data from a large prospective study on SPS effectiveness identified a 90% improvement in ROM, 84% reduction in stiffness and swelling, 70% reduction in pain, and no reports of complications or injury. Another 13 studies evaluating patients with knee stiffness have shown excellent results with SPS, and a reduced need for manipulation under anesthesia or additional surgeries. The bidirectional SPS device allows for ROM therapy in both flexion and extension, uses short, 5-minute incremental stretches for up to a 30-minute session applied 1 to 3 times per day for 8 weeks, though treatment might be needed for longer durations (8 to 12 weeks) in cases with chronic stiffness/contracture, to improve motion and significantly reduces need for manipulation or surgery for treatment of knee fibrosis. Earlier application of SPS therapy, even immediately postoperative following corrective surgery for motion loss, can greatly improve the results for patients who have limitations in knee motion.

Night Orthosis After Surgical Correction of Dupuytren Contractures: A Systematic Review

PURPOSE

To determine the role of night orthosis use after surgical correction of Dupuytren contracture.

METHODS

We searched MEDLINE, EMBASE, CINAHL, AMED, OTSeeker, and CENTRAL for articles published from inception of the databases to August 2015. Assessment was undertaken by 2 independent reviewers (O.A.S. and S.A.). Methodological quality of randomized controlled trials was assessed using the Cochrane risk of bias tool and the Newcastle-Ottawa instrument.

RESULTS

Seven studies met the standard for inclusion in this review. A total of 659 patients across these 7 studies were included in the analysis, with follow-up ranging from 3 to 72 months. None of the included studies assessed recurrence. The analysis revealed no significant improvement in range of motion of hand joints for patients who received a static night orthosis after Dupuytren surgery compared with patients without an orthosis. Similarly, no differences were found in patient-reported functional status across the 2 groups.

CONCLUSIONS

The current literature does not appear to support the use of static night orthosis in addition to hand therapy after surgical correction of Dupuytren contracture.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Case Report: The casting motion to mobilize stiffness technique for rehabilitation after a crush and degloving injury of the hand

STUDY DESIGN

Case report.

INTRODUCTION

This case report describes the use of the casting motion to mobilize stiffness (CMMS) technique in the management of a crush and degloving injury of the hand. The patient was unable to attend multiple hand therapy sessions due to geographic constraints. The CMMS technique involved the application of a nonremovable plaster of paris cast that selectively immobilizes proximal joints in an ideal position while constraining distal joints to direct desired motion over a long period. This uses active motion only. Traditional hand therapy techniques or modalities are not used. This treatment approach was beneficial to the patient as a minimum of 2 appointments per month were needed to regain functional hand use.

PURPOSE OF THE STUDY

To document the use of the CMMS technique as an effective treatment approach in the management of a crush and degloving injury of the hand.

METHODS

The CMMS technique was applied to the patient's left (nondominant) hand 8 weeks after injury. The technique's aim was to improve the 30° flexion deformity of the left wrist and flexion contractures of the index, middle, and ring fingers with a total active motion of 0°. Orthotic devices and traditional therapy were applied once joint stiffness was resolved, and a normal pattern of motion was reinstated.

RESULTS

At 6 months, substantial improvement was noted in wrist as well as metacarpophalangeal and interphalangeal joints. Total active motion exceeded 170° in all fingers excellent functional outcome resulted as measured with the upper limb functional index short form-10. The upper limb functional index increased from 0% to 55% of preinjury status (or capacity) over the 18 months of therapy.

DISCUSSION

Brief immobilization through casting causes certain functional losses, but these are temporary and reversible.

CONCLUSION

Finger stiffness, edema, and tissue fibrosis were successfully managed with the CMMS technique without the need for attendance at multiple hand therapy sessions.

LEVEL OF EVIDENCE

Level V.

Quantifying the Ponseti method

The Ponseti method is the accepted treatment of idiopathic clubfoot. Although the method of manipulating the baby feet is described in great detail, current study aimed to investigate the magnitude and course of the applied forces in order to optimise the treatment of clubfoot. An instrumented clubfoot model was constructed with force sensors on the location of the first metatarsal (FM) and the talar neck (TN) and treated with the Ponseti method by 17 practitioners. Applied forces on FM and TN were measured during manipulation (4.2N; 12N), during casting (3.2N; 3.5N) and after casting (2.9N; 2.2N). The forces during manipulation were significantly higher than during casting on TN (p<0.001) but not on FM (p=0.129). No 'correct' amount of force could be determined and inter-practitioner variability was measured to be 70%. The resulting pressure of the cast on the clubfoot model as measured directly after casting was significantly higher than local tissue perfusion. The results of this study suggest potential for the optimisation of the application of the Ponseti method.

A Study of the Effect of Night Extension SpLintage on Post Fasciectomy Dupuytren's Patients

This retrospective study examined the effect of night extension splinting on finger joint range of motion, pain, grip strength and hand function in post-fasciectomy Dupuytren's patients. In a group of 31 subjects, divided into those that had worn a night extension splint for the first three months of their rehabilitation and those that had never worn a night extension splint, assessment outcomes were collected retrospectively from the records at the subject's first assessment and at three months postoperatively. Statistical analysis between the two groups demonstrated that night extension splinting at three months post-fasciectomy for these subjects did not aid the maintenance of finger joint extension and reduced the rate of hand function resumption. However, night splintage did not cause a reduction in finger joint flexion. Night extension splinting for these subjects did not affect the recovery of hand grip strength nor did it affect the resolution of pain.

Routine use of night extension splintage did not achieve the aim of maintaining finger joint range of extension in these subjects. However, it would be inappropriate to apply these findings to the general population of Dupuytren's patients or alter any treatment regimes on the basis of these results due to the limitations of the study and the small sample size. It is suggested that more individual treatment programmes are appropriate rather than the routine regimes. A further prospective randomised controlled study with a larger sample size would be necessary to re-evaluate these findings.

Conservative management of elbow dislocations with an overhead motion protocol

PURPOSE

To report the results of using an overhead motion protocol in 27 patients and to assess final range of motion and incidence of persistent instability in this cohort.

METHODS

A total of 27 patients were included who sustained a simple elbow dislocation and were treated nonsurgically with an overhead motion protocol designed to convert gravity from a distracting to a stabilizing force. Motion was initiated within 1 week of injury and average follow-up was 29 months. Final arc of motion and prevalence of instability were the primary outcomes measures.

RESULTS

Final mean arc of extension to flexion was from 6° to 137°, and of pronation to supination was from 87° to 86°. No recurrent instability was observed in this cohort and all patients were fully functional and without limitations at latest follow-up.

CONCLUSIONS

The overhead motion protocol was a reliable rehabilitation program after elbow dislocation that allowed for controlled early motion by placing the elbow in an inherently stable position. Prompt initiation of motion in a protected position can optimize final motion and satisfaction outcomes, and when done in a mechanically advantageous position it can potentially limit the risk of recurrent instability.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Efficacy of Static Progressive Splinting in the Management of Metacarpophalangeal Joint Stiffness: A Pilot Clinical Trial

Objective

To evaluate the efficacy of a static progressive metacarpophalangeal (MCP) joint flexion splint in managing MCP joint stiffness in patients suffering from traumatized hands.

Methods

A total of 31 patients with stiff MCP joints (n = 116) were recruited for this prospective study. A static progressive MCP flexion splint was designed to manage the MCP joint stiffness of traumatized hands, which is a common problem after surgery. The values of the initial and final passive range of motion (PROM) and active range of motion (AROM) were compared. In addition, the Disabilities of the Arm, Shoulder, and Hand (DASH) scores before and after surgery were also compared. Spearman correlation matrix was used to determine the relationship of the DASH score with PROM and AROM separately.

Results

The PROM increased from 23.47 ± 16.26 degrees to 59.01 ± 14.75 degrees after treatment, and the difference between the initial and final PROM is 35.54 ± 16.92 degrees (t = 22.63, p < .001, df = 115). The AROM also significantly increased from 10.29 ± 10.67 degrees to 25.03 ± 18.25 degrees, with a mean difference of 14.74 ± 15.40 degrees (t = 10.31, p < .001, df = 115). The DASH score improved from 40.71 ± 13.22 to 24.26 ± 11.33 (t = 7.00, p < .001, df = 30), which indicates a significant negative correlation with the AROM of MCP joints following treatment.

Conclusion

The static progressive MCP flexion splint promotes both physical and functional outcomes. The increased AROM of the MCP joints improves the functional outcomes in patients with traumatized hands.

Proximal interphalangeal joint dislocations and treatment: an evolutionary process

Background

Proximal interphalangeal joint (PIPJ) dislocations represent a significant proportion of hand clinic visits and typically require frequent follow-ups for clinical assessment, orthotic adjustments, and physiotherapy. There are a large number of treatment options available for PIPJ dislocations, yet no prospective or controlled studies have been carried out, largely due to the diversity of the various types of injuries.

Methods

We retrospectively reviewed all the PIPJ dislocations in our institution over a five-year period and directly compared the different splinting techniques that we have used over this time frame.

Results

There were a total of 77 dislocations of the PIPJ (57 men and 20 women) that were included in our study. We found that our management has shifted gradually from complete immobilisation to controlled early mobilisation with figure-of-eight splints. Following treatment, the range of motion of the PIPJ in the figure-of-eight group was significantly greater than that in the other three methods (P<0.05) used. There were significantly fewer hospital visits in the figure-of-eight splint group than in the other treatment groups.

Conclusions

The treatment of PIPJ dislocations has undergone a significant evolution in our experience. Early controlled mobilisation has become increasingly important, and therefore, splints have had to be adapted to allow for this. The figure-of-eight splint has yielded excellent results in our experience. It should be considered for all PIPJ dislocations, but careful patient selection is required to achieve optimum results.

Superimposed electrical stimulation improves mobility of pre-stiff thumbs after ulnar collateral ligament injury of the metacarpophalangeal joint: a randomized study

OBJECTIVE

This study aimed at testing the ability of the superimposed electrical stimulation technique to restore the mobility of pre-stiff thumbs after operative repair for rupture of the ulnar collateral ligament.

MATERIAL AND METHODS

Eight patients demonstrating a pre-stiff metacarpophalangeal joint were involved in two rehabilitation sessions of a counterbalanced design. In the voluntary contraction session, they performed 20min of repeated active flexions of the impaired metacarpophalangeal joint. In the superimposed electrical stimulation session, they performed 20min of percutaneous neuromuscular electrical stimulations which were superimposed to voluntary flexion.

RESULTS

Mean active range of motion improvement from pre- to post-session was significantly greater in the superimposed electrical stimulation condition compared to the voluntary contraction condition (11±5 deg versus 3±4 deg; P<0.01).

CONCLUSION

Superimposing electrical stimulation to voluntary contractions is an efficient technique to improve active range of motion of the pre-stiff metacarpophalangeal joint of the thumb.

The effect of night extension orthoses following surgical release of Dupuytren contracture: a single-center, randomized, controlled trial

PURPOSE

To clarify the efficacy and detrimental effects of orthoses used to maintain finger extension following surgical release of Dupuytren contracture.

METHODS

We conducted a single-center, randomized, controlled trial to investigate the effect of night extension orthoses on finger range of motion and hand function for 3 months following surgical release of Dupuytren contracture. We also wanted to determine how well finger extension was maintained in the total sample. We randomized 56 patients to receive a night extension orthosis plus hand therapy (n = 26) or hand therapy alone (n = 30). The primary outcome was total active extension of the operated fingers (°). Secondary outcomes were total active flexion of the operated fingers (°), active distal palmar crease (cm), grip strength (kg), and self-reported hand function using the Disabilities of the Arm, Shoulder, and Hand questionnaire (0-100 scale).

RESULTS

There were no statistically significant differences between the no-orthosis and orthosis groups for total active extension or for any of the secondary outcomes. Between the first postoperative measure and 3 months after surgery, 62% of little fingers had maintained or improved total active extension.

CONCLUSIONS

The use of a night extension orthosis in combination with standard hand therapy has no greater effect on maintaining finger extension than hand therapy alone in the 3 months following surgical release of Dupuytren contracture. Our results indicate that the practice of providing every patient with a night extension orthosis following surgical release of Dupuytren contracture may not be justified except for cases in which extension loss occurs after surgery. Our results also challenge clinicians to research ways of maintaining finger extension in a greater number of patients.

Implementation, testing and pilot clinical evaluation of superelastic splints that decrease joint stiffness

The present work aims at demonstrating that a customised choice of shape memory alloy (SMA) composition, thermo-mechanical treatment and shaping can lead to effective rehabilitation devices applicable to sub-acute and chronic spastic paresis in paediatric patients. SMA pseudoelasticity is regarded as a means to implement a corrective action on posture without hindering residual voluntary or reflex mobility of the affected limb. Specific hinges containing NiTi or NiTiNb elements were designed and constructed to transfer pseudoelastic recovery force to fitted splints for the elbow or the ankle joint. The devices were mechanically tested and showed complete stability after 20-100 cycles, and unchanged characteristics after 1000 full-range deflections. Repositioning splints equipped with patient-specific pseudoelastic hinges were prescribed to 25 individuals (aged 7.75 ± 5.40 years) with mild to severe spastic tetraparesis. Clinical and instrumental evaluations were carried out during crossover trials with traditional and pseudoelastic splints. The sequence of treatment steps was randomized for each subject. The results show that, compared to fixed-angle braces, pseudoelastic devices decrease passive joint stiffness while providing the same control on limb posture. Dynamic pseudoelastic braces are therefore an innovative treatment for spastic paresis, which may reduce joint stiffness.

Nonoperative treatment of PIPJ flexion contractures associated with Dupuytren's disease

Post-surgical outcomes in patients with Dupuytren's disease causing flexion contractures of the proximal interphalangeal joint can be inconsistent and are often associated with protracted rehabilitation, reduced flexion, recurrence of the contracture, and patient dissatisfaction. An alternative treatment option, comprised of splinting and soft tissue mobilization techniques, was introduced to stabilize early contractures of the proximal interphalangeal joint in the hopes of delaying or obviating surgery. Over the course of approximately 12.6 months (± 7.8), thirteen patients were followed at the hand clinic at Hotel Dieu Hospital in Kingston. One patient was unable to complete the course of therapy. Of the remaining patients, analysis showed significant improvement in active proximal interphalangeal joint extension of approximately 14.6° (SD: ± 5.1°; range: 5-25°) over the course of the treatment (p < .05). Nighttime static extension splinting and soft tissue mobilization techniques appear to delay and possibly prevent the need for surgery in individuals with flexion contractures of the proximal interphalangeal joint due to Dupuytren's disease.

A critical review of the evidence on the use of videotapes or DVD to promote patient compliance with home programmes

PURPOSE

The purpose of this paper is to critically review published research in order to evaluate the evidence surrounding the provision of video or DVD technology to promote patient compliance with home exercise or health programmes.

METHOD

A literature search of the MEDLINE, CINAHL and Cochrane databases was undertaken. Critical appraisal of selected studies was undertaken using a previously validated tool. Inclusion criteria were: research related to DVD or videotape technology to improve compliance; published in peer-reviewed journals and full-text English language articles. Compliance was the main outcome measure.

RESULTS

Eleven eligible studies were reviewed. All but one, which used a before-after design, were randomised controlled trials. Study quality tended medium to high in the critical appraisal scoring system, but an overall low quality on the Jadad score for randomisation; with only one study from 11 scoring well on both these measures. Research into the use of video or DVD showed mainly positive effects on compliance; however, methodological issues limit clinical applicability.

CONCLUSIONS

Future well-designed randomised controlled trials with adequate sample sizes and reliable outcome measures will provide clearer evidence into the effectiveness of this technology in improving home exercise or health programme compliance, particularly for rural and remote populations.

Use of casting motion to mobilize stiffness to regain digital flexion following Dupuytren's fasciectomy

Background

A priority in hand therapy following Dupuytren's fasciectomy is to regain and maintain extension of the proximal interphalangeal joint (PIPJ). Historically this has been achieved through the application of mechanical stress to the affected digit with splinting and exercise. However, loss of a normal pattern of digital flexion in both the operated and non-operated digits is a common complication.

Method

Four patients who underwent a Dupuytren's fasciectomy presented with persistent digital stiffness and a poor pattern of motion of the operated hand following traditional therapy. The casting motion to mobilize stiffness (CMMS) technique was therefore applied. The type of cast applied, duration of casting, duration of sessions and cast exercises are described.

Results

All patients regained digital flexion and an improved pattern of motion through the use of the CMMS technique without compromising PIPJ extension.

Conclusion

This small case series demonstrates the use of the CMMS technique to regain digital flexion and a normal pattern of motion when traditional treatment fails to achieve the desired outcomes following Dupuytren's fasciectomy. The use of the CMMS technique was beneficial in these patients and provides a means to regain digital flexion without the loss of PIPJ extension and is successful even when traditional therapy has failed.

Changes in impairment and function after static progressive splinting for stiffness after distal radius fracture

The purpose of this study was to describe changes in range of motion, grip strength, and function in subjects treated with static progressive splinting for stiffness after distal radius fracture. A retrospective review was conducted on 25 patients; outcomes reviewed included wrist/forearm motion, grip strength and Disability of the Arm, Shoulder, and Hand (DASH) scores. The Wilcoxon-Signed Rank test was used to assess differences between pre-/postsplinting outcome measurements. Spearman correlation coefficients were calculated for the DASH scores with each of the other measurements. Wrist extension and flexion improved 18.6 (p<0.0001) and 11.4 degrees (p<0.0001), respectively. Forearm pronation and supination improved 20.0 (p<0.0001) and 14.5 degrees (p<0.0001), respectively. Grip strength improved 24.5 pounds (p=0.0012). The median DASH score improved from 43 to 19 (p>0.0001). DASH scores demonstrated a significant negative correlation with wrist extension (r=-0.50, p=0.011) and forearm supination (r=-0.47, p=0.02). Increased wrist extension and supination correlated with better functional outcome as reflected by the DASH scores.

Which Splint? Dynamic versus Static Progressive Splinting to Mobilise Stiff Joints in the Hand

Mobilising splinting is a common tool used by hand therapists to improve movement in stiff joints, by holding them at the end of available range of motion (ROM) under light tension, for extended periods of time. Both dynamic and static progressive splints are classified as mobilising splints. Many clinicians believe that static progressive splints are more effective than dynamic splints for improving ROM in particularly stiff joints. This paper reviews the limited available research evidence behind the assumptions that currently guide splint choice in clinical practice. Joint stiffness theory and the visco-elastic nature of the soft tissue response to stress are also revised. A rationale for the use of dynamic splints in preference to static progressive splints to mobilise the chronically stiff joint is presented. The need for further research, ideally in the form of a randomised controlled clinical trial, is highlighted.

Clinical effectiveness of post-operative splinting after surgical release of Dupuytren's contracture: a systematic review

BACKGROUND

Splinting after contracture release for Dupuytren's disease of the hand is widely advocated. The purpose of this systematic review was to evaluate the quantity and quality of evidence regarding the effectiveness of splinting in the post-surgical management of Dupuytren's contractures.

METHODS

Studies were identified by searching the electronic databases Medline, AMED, CINAHL and EMBASE. Studies were included if they met the following inclusion criteria: prospective or retrospective, experimental, quasi-experimental or observational studies investigating the effectiveness of static or dynamic splints worn day and/or night-time for at least 6 weeks after surgery and reporting either individual joint or composite finger range of motion and/or hand function. The methodological quality of the selected articles was independently assessed by the two authors using the guidelines for evaluating the quality of intervention studies developed by McDermid.

RESULTS

Four studies, with sample sizes ranging from 23 to 268, met the inclusion criteria for the systematic review. Designs included retrospective case review, prospective observational and one controlled trial without randomisation. Interventions included dynamic and static splinting with a mean follow-up ranging from 9 weeks to 2 years. Pooling of results was not possible due to the heterogeneity of interventions (splint type, duration and wearing regimen) and the way outcomes were reported.

CONCLUSION

There is empirical evidence to support the use of low load prolonged stretch through splinting after hand surgery and trauma, however only a few studies have investigated this specifically in Dupuytren's contracture. The low level evidence regarding the effect of post-operative static and dynamic splints on final extension deficit in severe PIP joint contracture (>40 degrees ) is equivocal, as is the effect of patient adherence on outcome. Whilst total active extension deficit improved in some patients wearing a splint there were also deficits in composite finger flexion and hand function. The lack of data on the magnitude of this effect makes it difficult to interpret whether this is of clinical significance. There is a need for well designed controlled trials with proper randomisation to evaluate the short-term and long-term effectiveness of splinting following Dupuytren's surgery.

Radial head fractures--advanced techniques in surgical management and rehabilitation

Radial head fractures are the most common fractures in the elbow, and the treatment of nondisplaced fractures is often straightforward. However, radial head fractures with concurrent injury to the elbow stabilizers may require complex treatment and therapy that are targeted at specifically restoring elbow stability. This treatment of complex radial head fractures has recently improved because of long-term follow-up studies, increased biomechanical research on elbow stability, and improved surgical techniques. With an open line of communication between the surgeon and the therapist, an appropriate therapy plan can be initiated to protect both simple and complex injuries. The therapist should have knowledge of specific tissue healing and treatment techniques, and the patient must be educated in possible outcomes, safe arcs of motions, positioning, and proper splint use. This article summarizes current advanced techniques in the surgical management and rehabilitation of radial head fractures. Comprehensive protocols for decision making and treatment are introduced for both simple and complex radial head fractures.

Lateral elbow instability: nonoperative, operative, and postoperative management

The purpose of this article is to present a treatment approach that has been found to be effective in the early management of lateral elbow instability. Anatomy and joint mechanics related to stability of the elbow are reviewed. Operative and nonoperative treatment is outlined followed by a description of an innovative paradigm for the rehabilitation of elbow instability. Progression of the rehabilitation program as the elbow achieves greater stability is discussed. The authors hope that therapists and surgeons will find this method beneficial in beginning early range of motion for the unstable elbow, thus minimizing joint stiffness while preserving stability at the elbow joint.

Early controlled mobilization of potentially unstable extra-articular hand fractures

This article presents early controlled mobilization options for potentially unstable, nondisplaced, nonarticular hand fractures. Early controlled mobilization of tissues surrounding a healing fracture has the potential to enhance the quality and rate of fracture healing and a person's functional recovery. The options discussed protect the integrity of the fracture alignment, while permitting safe, pain-free protected motion of joints adjacent to the fracture. Traditionally, healing fractures are thought of as clinically stable or unstable. If clinically unstable, the fracture often is considered unable to tolerate unrestricted active motion during the initial stages of healing. This article offers an alternative perspective, in which clinicians can consider the clinical factors that can be controlled to allow for early protected motion of the regional tissues surrounding a potentially unstable hand fracture. These additional clinical options offer an alternative to acute fracture immobilization and help progress the rehabilitation of hand fracture patients.

Physiological and biomechanical principles in splinting the traumatised hands

The aim of this article is to review the biological sequence of wound repair and the rationale of using splintage to modify the healing process. Appropriate use of splintage and controlled stress can prevent adhesion and periarticular fibrosis. Splinting prescribed at appropriate timing and methods will enhance wound healing and tissue remodelling. In reverse, it will cause permanent damage to the tissues.