REHABILITATION OF FINGERTIP INJURIES

 

Hands are one of the most intricate parts of the human body. There are so many structures that can be damaged from injury and when these structures are injured the ability of the hand to perform grasping, reaching, manipulating and touching can become impaired. Simple activities such as writing, tying your shoes, opening your car door or holding your toddlers hand can become impossible. Unfortunately because our hands are always moving, reaching grasping and releasing they are exposed to many dangers. Injuries that can occur are fractures, lacerations, crush injuries and amputation.

Fingertip injuries account for 10% of all accidents in the United States that are referred to emergency rooms. Hand injuries are frequently the result of job injuries and account for 11-14% of on the job injuries.

After an injury to the fingertip has occurred the patient will evaluated by a hand surgeon. The surgeon will determine what type of injury has occurred and what structures are involved. He will then develop a plan of care which may involve surgery to repair damaged nerves, tendons, arteries or bone or he may determine that the injury can be treated conservatively which may consist of wound care and/or splinting to help the damaged structures heal. The hand surgeon will determine if surgery is required, if not he/she will refer the patient to a hand therapist for conservative care in order to restore function to the hand.

Upon referral to a hand therapist the physician orders will be reviewed to determine the exact diagnosis and any specific protocols the physician wants the hand therapist to follow. A detailed history will be taken and an evaluation will be performed. The evaluation will take into consideration information such as the wound appearance and healing, swelling, scar tissue formation, scar mobility, range of motion, sensation, strength and function. Once the evaluation is complete a treatment plan will be developed based on the diagnosis.

TENDON INJURIES:

Tendon injuries at the tip of the finger may include the extensor tendon which would result in a MALLET FINGER. A mallet finger is a disruption of the terminal extensor tendon secondary to laceration, rupture or avulsion. Conservative treatment of a mallet finger would include splint fabrication of the distal phalanx for 6-8 weeks. The therapist would fabricate a splint positioning the distal phalanx in 15 degrees of hyperextension. The patient would be instructed to wear the splint continuously except for hygiene. The patient would be taught how to perform skin care without letting the distal phalanx flex. At 7 weeks the patient begins to wean out of the splint under the therapists directions and supervision. As long as the distal interphalangeal joint (DIP), remains between 0-5 degrees of extension, the time the splint is worn continues to be reduced. The patient continues to use the splint at night. At 8 weeks gentle strengthening is added and at 9 weeks all splinting is discontinued

Surgical management of the mallet finger would consist of wound care, fabrication of a tip protector, scar management, and edema control. Active and passive range of motion is initiated according to the protocol. The patient will continue to use the splint for up to 9 weeks and at night up to 12 weeks.

Injuries to the volar surface of the fingertip can result in injury to the flexor digitorum profudus. Injury to this tendon can be due to an avulsion injury, a.k.a. FOOTBALL JERSEY FINGER, or a laceration. Treatment is usually surgical, followed by fabrication of a dorsal blocking splint to protect the tendon repair, edema control, scar management, and specific exercises to be performed several times a day within the restraints of the splint.

FINGERTIP FRACTURES:

Some people think that a broken finger is a minor injury, but without proper treatment it can result in significant loss of normal hand function. These injuries may be treated surgically or conservatively. These patients are often referred to a hand therapist for splint fabrication which can be a static splint to be used for protection or a static progressive splint to help regain range of motion. Swelling needs to be addressed as soon as possible, as swelling acts like glue and can cause the tendons to adhere down to the bone as it is healing. Some of the fixation techniques that the hand surgeons are currently using allow the therapist to get the patients moving much faster, which ultimately shortens the patient’s rehabilitation.

AMPUTATIONS:

The occurrence of fingertip amputations has dropped 50% over the past twenty years although they still occur too frequently both on and off the job. Areas that need to be addressed by the hand therapist for these patients include would care, stump reshaping, edema control, sensation, dexterity, strength, sensation and range of motion of the digit. Sensation to the digit may be lost from the injury and the patient may require sensory retraining, or the nerve may be hypersensitive which requires the patient to undergo a desensitization program. One area that is often overlooked is the patient’s body image and how they are emotionally dealing with their injury, such as such as an amputation. Information on cosmetic prosthetics should be reviewed with these patients, as patients are usually unaware that a single digit cosmetic prosthesis is available.

FINGERTIP CRUSH INJURIES;

Crush injuries can result in a fracture, a nail bed laceration or something more severe such as an amputation. Once the patient is referred to the hand therapist the patient will be treated for all the secondary symptoms that occur with crush injuries, such as swelling, scarring, the need for protective or static progressive splinting, sensory reeducation, desensitization or strengthening. One area that needs to be monitored closely with these patients is the development of Chronic Regional Pain Syndrome or CRPS. This is a condition that occurs when the body responds to the injury with an abnormal pain “reflex” that can cause continuous pain. Stiffness can affect the whole extremity. Hand therapists are trained to identify the signs and symptoms of this condition. The earlier CRPS is diagnosed and treatment begun by the physician and therapist, the better the prognosis. In some cases the physician may refer the patient to a pain specialist and in conjunction with the pain specialist the therapist will begin the patient on a scrub and carry program, which consists of compression and distraction of the joints of the upper extremity which helps to stimulate the patients own endorphins which helps break the pain cycle.

A certified hand therapist is an integral part of the rehabilitation program for patients with a variety of fingertip injuries, due to their knowledge and expertise in treating these types of conditions.

Certified hand therapists specialize in the treatment of many conditions of the elbow, wrist and hand. A certified hand therapist is an occupational or physical therapist who has at least 5 years experience as an occupational or physical therapist, two years directly in the treatment of hand therapy, has passed a national certification examination, and maintains at least 80 hours of continuing education units every five year period. Accelerated Rehabilitation Centers offers hand therapy in many of our Chicago and Suburban locations.

Lori Risner OTR/L, CHT graduated from the University of Illinois at Chicago in 1987 with a Bachelor of Science degree in Occupational Therapy. She has been a Certified Hand therapist (CHT) since 1992. Lori joined Accelerated Rehabilitation Centers in June of 2000 and currently treats patients at Accelerated on the Northwest Side of Chicago (Norridge ) and in Barrington . You may reach Lori at 708-583-9500, or 847-381-0372.

REFERENCES:

1. Hunter, J., Mackin, E. And, Callahan, A: Rehabilitation of the Hand: Surgery and Therapy Volume 11.

2. Diagnosis and Treatment Manual for Physicians and Therapists: Upper extremity Rehabilitation: The Hand Rehabilitation Center of Indiana.

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