6 F I S I O T E R A P I E DESEMBER 1975 o ften incom plete. T h e trau m atic B outonniere lesion: In this case the in ju ry is to th e m iddle slip o f th e extensor tendon in ­ serted into the m iddle p h alan x o n its dorsal aspect. W hen this occurs the trian g u lar ligam ent u n itin g two lateral tendons p rio r to th e ir fusion is also disrupted and th e p ro x im al interphalangeal jo in t (P.I.P.), because o f the absence of a n extensor, progresses in to flexion. T his process is slow and due to gradual v olar displace­ m ent o f the lateral bands over th e area o f th e P.I.P. jo in t u n til they now act as flexors ra th e r than extensors o f this joint. As th e P .I.P. jo in t proceeds in to flexion, so the distal interphalangeal (D .I.P.) jo in t assum es a p o sitio n o f extension as a result of the increased pull of th e displaced lateral bands on th e ir eventual in sertio n into th e term in al phalanx. T h e lesion m ay be grouped into m o b ile and fixed versions. In th e m obile version, the P.I.P. jo in t is still m obile and m ay be passively placed into full extension. In the fixed version, th e P.I.P. jo in t is no longer able to be m oved passively into extension. I. T reatm ent o f the m obile version: This injury should b e treated aggressively w hilst still in th e m obile phase, a n d eith er efficiently splinted, o r surgically corrected and splinted. Splintage m ust be m ain tain ed fo r six weeks. A n efficient sp lin t is one w hich holds the P.I.P. jo in t in extension, w hilst allow ing flexion and extension a t th e D .I.P. joint. T h is action tends to close th e gap in the tria n g u la r ligam ent and to p rom ote healing and m ay be used as a conservative m ethod o f treatm ent. In the a u th o r’s o pinion, surgical correction is effective and a m ore satisfactory result is o b tain ed in th at the correction is anatom ical. T h e P .I.P. jo in t is transfixed w ith a K irsch n er w ire w hich ensures adequate healing A fter six weeks th e w ire is rem oved and active m obile zation is comm enced. It often takes up to two m onths f o r th e finger to be com pletely m obilized. 2. T reatm ent o f the fix e d version: T h e fixed type ;s very difficult to tre a t and attem pts m ust be m ade to m obilize th e finger before op eratio n . V arious form s of d ynam ic finger splints are used and all are effective if correctly designed and correctly applied. N o surgery should be attem pted u n til correction is obtained, if correction has to be obtained by surgical means, the end result is often extrem ely disap p o in tin g and the prognosis o f arthrodesis o f the P .I.P. jo in t is a distinct possibility. Bibliography: Weeks, P. M., C hristie W ray, R., (1973). M anagem ent y t A cu te H a n d Injuries, C. V. M osby C om pany, S-* Louis. R ank, B. K ., W akefield, A. R ., H ueston, J. T ., (1973). Surgery o f R epair as A p p lie d to H a n d Injuries, 4th Ed., C hurchill Livingstone, E dinburgh and London. Boyes, J. H ., personal com m unication. K leinert, H . E., personal com m unication. THE PHYSIOTHERAPY OF FLEXOR TENDON INJURIES TO THE HAND J. D U PLESSIS, B.Sc. in P h y sio th erap y (Stell.)* O f th e 92 n o n -E u ro p ean and 32 E u ro p ean hand patients referred to o u r D e p a rtm e n t fo r Physiotherapy during th e six m onth period Ja n u a ry to June 1978, 31% and 34% respectively had suffered flexor tendon in ­ juries, w ith o r w ith o u t nerve and blood vessel involve­ m ent. T hese form ed th e m ajo rity o f o u tp a t ie n t s , since any o th e r single type o f hand in ju ry am ounted to under 10% o f the total n u m b er o f patients treated. T h e causative factors w ill n o t be discussed, b u t this article w ill be confined to th e d escription o f phy sio ­ th erap y treatm en t o f flexor tendon injuries follow ing the types o f surgical re p a ir described in the preceding article by L. K . P retorius. G en eral considerations to be tak en in to account when treatin g ten d o n injuries are: (1) age; (2) infection; (3) associated injuries e.g. nerves, fractures; (4) m en tality of p atients; (5) occupation. Y oung patients n orm ally do very well, b u t w ith elderly patients o r p atien ts w hose in ju ry has been com plicated by sepsis, treatm en t m ust be carried o u t very carefully and m ay have to be m odified to su it the needs o f a p articu lar patient. P H Y SIO TH ER APY FOLLOW ING T H E BUN NE L L - TYPE R EPA IR W ITH BUT T O N (Zone I - II) T h e han d and fo rearm are placed in a plaster back- * P hysiotherapist, T ygerberg H o sp ital, P arow vallei. slab w ith the w rist in slight flexion and th e m etacarpo­ phalangeal (M P) joints in at least 90° flexion. A cling bandage fits into th e palm , keeping th e fingers in a p o sitio n o f semi-flexion. 0 - 2 weeks: N o m o b ilizatio n is carried o u t save fo r th e slig.vj active extension and flexion o f the fingers allowed by-' the p laster o f P aris (PO P) and cling bandages re­ spectively. 2 - 4 weeks: A t this stage, the cling bandage is rem oved and active extension o f the fingers to the lim it of th e plaster slab is perform ed. M ore flexion is now possible b u t no resistance is allowed. Specific passive physiological flexion and extension are given to th e in dividual inter­ phalangeal (IP) joints, w hilst keeping the relevant M P and o th er IP joints in as m uch flexion as possible w hen doing the extension. A t no tim e m ust any stretch be afforded th e tendon and each passive m ovem ent must be localized to th a t p a rtic u la r joint. I t is advisable to be conservative w ith passive m ovem ent a t th is stage. (See F ig 1.1 and 1.2.) 4 - 6 weeks: T he plaster slab is rem oved w hilst th e suture and b u tto n are retained. G entle m obilizing oil massage is applied to th e scar on the finger. N o passive stretch is as yet applied to th e lim ited joints. O ne now aim s fo r R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) pgCEMBER 1978 P H Y S I O T H E R A P Y 7 Fig. 1.1. Passive flexion and extension o f P .I.P. jo in t m ain tain in g M .P. and D .I.P . jo in t flexion. Fig. 1.2. P assive flexion and extension o f D .I.P . jo in t m ain tain in g M .P . and P .I.P . jo in t flexion. further active flexion through th e in n er range w ith o u t giving resistance, although m in im al resistance m ay be given to th e distal phalanges. T h is is purely to act as a guide fo r the m ovem ent required. I f patients have difficulty in flexing the distal interphalangeal (D IP) 'oints, strong resistance m ay be given to flexion of )e unaffected fingers. Since flexor d ig ito ru m profundus YFDP) has a mass action, this will also encourage the injured finger to m ove (See F ig. 2). F req u en cy o f treatm ent: D aily treatm en t is im p rac­ tical since the p atien ts are all o ut-patients. P rovided the p atien t is m otivated and understands the need fo r exercising a t hom e betw een sessions and th e ph y sio ­ therapist is satisfied th a t he w ill n o t overexercise, tr e a t­ m ent is given th ree tim es per week. 6 weeks onw ards: T h is will be discussed u n d e r th e corresponding p erio d after th e K leinert-type o f postoperative treatm ent, since treatm ent p rinciples are sim ilar. T H E K L E IN E R T -T Y P E O F P O S T O P E R A T IV E R E G IM E 0 - 2 weeks: Im m ediately postoperatively, o r a few days afte r suturing, elastics are inserted th ro u g h th e nails a t the finger tip s and attached by m eans o f a plaster to the forearm , keeping the fingers in semi-flexion. Exercise is comm enced im m ediately the elastics are applied. Patients a re encouraged to do active finger extension against the elastics up to the lim it o f the PO P. T hey then relax th e extensors and le t th e tension o n th e elastics pull th e fingers back into flexion. Since no active flexion is allow ed as yet, careful p a tie n t in stru ctio n is essential. T h e M P and IP jo in ts m ust, how ever, be k ept m obile. T his is achieved by p utting the M P joints in as m uch flexion as possible fo r extension o f the I P joints and then doing full range passive physiological m ovem ents o f the IP joints individually (Fig. 3.1 and 3.2). W ith injuries in Z one III an d IV , th ere is a strong likelihood o f adhesions form ing betw een the tendons and scar tissue. I t th erefo re helps to extend and relax fingers individually, thus allow ing th e tendons to glide p ast each other. F req u en cy o f treatm ent: T reatm en t is given th ree tim es per week depending on the co-operation o f th e p a tie n t and th e m o b ility of th e fingers. 2 - 4 weeks: T reatm en t is continued as above, bu t the p atien t m ay now be asked to flex his fingers fro m th e relaxed semi-flexed position. T h is is m erely to test the tendons fo r fu nctional ability. 4 - 6 weeks: T h e surgeon usually decides to rem ove the plaster slab, b u t retains the elastics fo r a fu rth e r two weeks. 1. F o r treatm en t p urposes only, th e elastics m ay now R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 8 F I S I O T E R A P I E DESEMBER 1978 F ig. 3.1. P assive P.I.P . joint flexion m aining M .P. joint flexion. be rem oved. A soap an d oil m assage w ith th e arm in elevation is given to rem ove the dead skin and increase th e blo o d flow, keeping the w rist and fingers flexed. 2. G en tle m assage, using olive oil, is given over the scar tissue to increase tissue m obility. 3. A low dose o f u ltra so u n d (lW /c m 2 pulsed fo r 5 m inutes) is given over th e scar, ag ain to im prove tissue m obility. 4. Passive a n d active m ovem ents now include sim ul­ taneous extension o f P IP a n d D IP joints, w hilst re­ tain in g M P flexion. 5. A ctive finger flexion is p erm itted . W e find th a t a softly inflated p lastic b a ll/tu b e is useful, fo r it provides th e re q u ire d am o u n t o f resistance needed to guide the m ovem ent. P atien ts m ay experience difficulty in p erfo rm in g active flexion w hich m ay be overcom e by: 5.1. D e m o n stra tio n an d e x p lan a tio n o f fu n ctio n on th e unaffected hand, 5.2 A p p lic a tio n o f strong resistance to uninvolved fingers o f th e in ju re d h a n d w hilst encouraging c o n tractio n o f su tu red tendons by giving m inimal resistance to flexion o f th e in ju re d finger p u rely as a guide fo r m ovem ent. 6. I f b o th F D P an d F D S tendons to th e sam e finger have been su tu red , then it is im p o rta n t to elicit the specific fu n ctio n s o f these tend on s i.e. flexion of D IP jo in t and th en flexion o f P IP jo in t w hilst D IP jo in t rem ains extended. Surgically, if b o th tendons to a finger are severed, one is o fte n sacrificed. 7. W rist m o b ilizatio n is started, using passive jo in t m o b iliz a tio n tech n iq u es according to M a itla n d and K alten b o rn . T h ese techniques a re m odified fo r each p a rtic u la r p a tie n t’s need; all th e fingers a re alw ays m ain tain ed in flexion d u rin g m o b ilizatio n . 6 w eeks on w ard s (fo r b o th types o f suture): T h e tendons should now be strong enough fo r the ph y sio th erap ist to go ah ead an d achieve full jo in t m o b ilizatio n o f b o th th e w rist an d fingers. T h e p a tie n t is also referred fo r o ccu p atio n al th erap y a t th is stage fo r fu nctional re-education in th e finer h an d skills. A im s o f p h y sio th e ra p y a re to: 1. G a in full activ e use o f the individual fingers. 2. G a in full fu n c tio n a l sim ultaneous use o f all the fingers i.e. th e h an d as a w hole. 3. L oosen adhesions. 4. M obilize scar tissue. 5. M o b ilize joints. 6. E n su re th e fullest possible fu n c tio n a l use o f th e hand. I f th ere is n o lik elih o o d o f fu rth e r im prove­ F ig. 3.2. P assive D .I.P . joint flexion and extension maintaining M .P. joint flexion. m ent, the necessary referrals to the occupation;^ th e ra p ist a n d /o r w ork p lacem ent officer should L'J m ade. TECHNIQ UES 1. W ax baths. 2. Scar tissue massage. 3. P ro p rio cep tiv e n eu ro m u scu la r fa c ilita tio n (PNF) 3.1 H o ld -relax techniques 3.2 R ep eated contractions 3.3 R h y th m ic stabilizations. 4. U ltraso u n d 5. Passive m anual stretching o f jo in t structures and tw o-joint muscles. 6. S erial plasters. 7. F a ra d ism u n d er tension (occasionally necessary where w rist adhesions persist) 8. Passive jo in t m obilizing techniques according to M a itla n d an d K a lte n b o rn fo r p erip h eral joints. 9. H om e exercise p rogram m e. ! ’ Specific p o in ts w ith regard to techniques 1 - 8 : 1. W ax b ath s are useful b efo re treatm en t as a means o f softening scar tissue an d relaxing the hand. P atien ts are instructed how to use the w ax bath a n d do th is on th e ir ow n w hilst th e physiotherapist treats o th er patients. 2. M assage: In Z one I very lig h t m obilizing massage is given to th e affected finger w ith the arm kept is elevation. In Z ones I I - V, circu lar lig h t to dej] fric tio n massage is given. O live oil is used as tm lu b ricatin g m edium . I f it is too slippery, the oil m ay be ru b b ed off fo r the latter p a rt o f 'th e massage. T h e p o sitio n of arm elevation for,- treatm ent is im p o rta n t (See F ig. 4). N o t only will this facilitate the red u ctio n o f an y swelling b u t also th e relaxation o f the p a tie n t so necessary fo r th e execution of passive m ovem ents. R em em ber also th a t the super­ ficial c ircu latio n o f the hand is easily occluded. II is th u s im p o rta n t th a t any pressure exerted by the p h y sio th e ra p ist’s fingers d u rin g m assage, passive m ovem ents and P N F techniques should be relieved freq u en tly d u rin g th e execution o f these techniques. 3. P N F : fo r all treatm ents, th e p a tie n t is best placed supine. T h e elbow is flexed against resistance to 90°. T h e p h y sio th erap ist then uses h e r free hand to a p p ly the specific techniques m entioned above, all o f w hich produce very satisfacto ry results. Rhythmic stab ilizatio n s can be done w ith one h an d by using th e fingers and palm s as a ltern ate resisting surfaces. A t a la te r stage in treatm ent, full arm P N F tech­ n iq u es are used. S traig h t arm techniques achieve b e tte r results w ith F D P sutures, w hilst patterns R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) DECEMBER 1978 P H Y S I O T H E R A P Y 9 Fij>. 4. T reatm en t in elevation. w i t h e l b o w f l e xi on f a c i l i t a t e b e t t e r F D S f u n c t i o n . 4. U l t r a s o u n d is g i v e n w i t h i n c r e a s n i g i n t e n s i t i e s , 0. 5 - 2 W / c n r c o n t i n u o u s o r 1 , 5 - 3 W / c n r p u l s e d . F o r s u t u r e s in Z o n e 1 a n d II it is b e s t g i v e n u n d e r w a t e r w h e r e p o s s i b l e . U l t r a s o u n d a n d m a s s a g e o f t e n p r o d u c e t h e b e s t m o b i l i z a t i o n o f a d h e s i o n s . 5. P a s s i v e s t r e t c h i n g : T h i s m u s t b e c a r e f u l l y e x e c u t e d a t first a n d t h e f o r c e i n c r e a s e d g r a d u a l l y . P a t i e n t s c a n d o t h e i r o w n p a s s i v e s t r e t c h i n g a t h o m e f r o m t h e e i g h t h w e e k o n w a r d s b y p l a c i n g t h e flat h a n d o n a s m o o t h , h a r d s u r f a c e ( t a b l e ) a n d u s i n g t h e o t h e r h a n d t o p r e v e n t t h e I P o r M P j o i n t s f r o m b o w - s t r i n g i n g ’, g r a d u a l l y b r i n g i n g L ip t h e w r i s t to a m o r e e x t e n d e d p o s i t i o n b y b r i n g i n g t h e b o d y w e i g h t m o r e v e r t i c a l l y o v e r t h e h a n d ( Fi g . 5). W i t h s o m e F D P s u t u r e s in Z o n e 1, a c e r t a i n e x t e n s o r l a g is p e r m i s s i b l e , s i n c e a s h o r t p o r t i o n o f t he t e n d o n is s a c r i f i c e d d u r i n g t h e o p e r a t i o n . T h i s defi- R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 10 F I S I O T E R A P I E D E S E M B E R 1 9 7 3 Fig. 6. Serial P laster. c i e n c y is a u t o m a t i c a l l y m a d e g o o d w i t h t i me . 6. S e r i a l p l a s t e r s : T h e p u r p o s e o f t h e s e is n o t t o g a i n r a n g e o f m o v e m e n t , b u t to r e t a i n t h e r a n g e g a i n e d b y t h e p h y s i o t h e r a p i s t d u r i n g t r e a t m e n t . T h e p l a s t e r s s h o u l d b e c o m f o r t a b l e a n d n o t h u r t t h e p a t i e n t . W y n n P a r r y ( 1973) s u g g e s t s w e a r i n g t h e s e p l a s t e r s b e t w e e n t r e a t m e n t s , b u t b e c a u s e t h i s m a y d i s c o u r a g e d a i l y a c t i v i t i e s t h e y a r e u s e d a s n i g h t s p l i n t s onl y. T h e s p l i n t s a r e m a d e f r o m p l a s t e r o f P a r i s a n d a r e p a d d e d . T h e y s t r e t c h f r o m b e l o w t h e e l b o w a c r o s s t h e v o l a r a s p e c t o f t h e w r i s t to b e y o n d t h e t i p s o f t h e t e r m i n a l p h a l a n g e s . G r o o v e s s h o u l d b e m a d e to a c c o m m o d a t e t he f i nge r s s e p a r a t e l y a n d r e i n f o r c e ­ m e n t w i t h t h e p l a s t i c s t i c k s o b t a i n e d f r o m t he m i d d l e o f t h e p l a s t e r b a n d a g e s is s o m e t i m e s n e c e s ­ s a r y ( Se e Fi g. 6). T h e s p l i n t is k e p t in p o s i t i o n by m e a n s o f a c r e p e b a n d a g e o r v e l c r o s t r i ps . 7. ft h a s b e e n f o u n d t h a t v e r y t i ght a d h e s i o n s a r o u n d t h e w r i s t s e l d o m b e n e f i t f r o m v e r y v i g o r o u s p h y s i o ­ t h e r a p y i.e. f r e q u e n t p a s s i v e s t r e t c h i n g , s e r i a l p l a s t e r s a n d f a r a d i s m u n d e r t e n s i o n . T h e t e n d o n s a d h e r e t i g h t l y t o e a c h o t h e r a n d t o t h e s u r r o u n d i n g s k i n a n d s c a r t i ss ue . P r o l o n g e d s t r e t c h i n g a n d h o l d - r c l a x t e c h n i q u e s t h u s d o l i t t l e t o l o o s e n a d h e s i o n s , b u t c a n l e a d t o n e c r o s i s o f t he t e n d o n s w h i c h b e c o m e t h r e a d l i k e a t t h e s i t e o f t h e a d h e s i o n t h r o u g h e x ­ c e s s i v e s t r e t c h i n g . I n f a c t , t h e a f o r e m e n t i o n e d p h y s i o ­ t h e r a p y t e c h n i q u e s m o b i l i z e t h e s c a r t i s s u e a t t h e cos t o f o v e r s t r e t c h i n g t he t e n d o n s . T e n o l y s i s a f t e r t h e a b o v e p h y s i o t h e r a p y t e c h n i q u e s h a s s h o w n t ha t t h e t e n d o n s a r e so s t r e t c h e d o u t t h a t t h e y a r e i n ­ e f f e c t i v e f o r i n n e r r a n g e m o v e m e n t s . W e a l s o k n o w t h a t a f t e r a p p l i c a t i o n o f t he s e d r a s t i c me a s u r e s , t e n d o n s m a y r u p t u r e m o r e ea s i l y. W i t h v e r y t i ght a d h e s i o n s , t h e bes t m e t h o d o f t r e a t m e n t is da i l y ( m o r e if n e c e s s a r y ) a p p l i c a t i o n o f u l t r a s o u n d , m a s ­ s a g e o v e r t h e s c a r t i ss ue, m i n i m a l p a s s i v e s t r e t c h a n d a s m u c h a c t i v e i n n e r r a n g e m o v e m e n t s a s pos ­ si bl e. If p r o g r e s s is u n s a t i s f a c t o r y , t h e p a t i e n t is r e f e r r e d b a c k t o t h e s u r g e o n f o r a t e n o l y s i s . 8. P a i n m a y l i mi t t h e a c h i e v e m e n t o f f ul l r a n g e of m o v e m e n t . P a s s i v e j o i n t m o b i l i z a t i o n t e c h n i q u e s , G r a d e III a c c o r d i n g t o M a i t l a n d , m a y t h e n b e used t o r e l i e v e t h e p a i n . T h e s e t e c h n i q u e s a r e a l s o a p p l i e d t o r e l i e v e a n y ' t r e a t m e n t p a i n ’ t h a t m a y o c c u r . 9. K a l t e n b o r n p a s s i v e j o i n t m o b i l i z i n g t e c h n i q u e s a r e n o t u s u a l l y n e c e s s a r y , b u t s i n c e p a t i e n t s a r e o f t e n u n r e l i a b l e a n d s t a y a w a y , a c e r t a i n a m o u n t o f j o i n t st i f f nes s is i n e v i t a b l e a n d t h e j o i n t s t i f f ness r e s p o n d s to t hi s f o r m o f t r e a t m e n t . St i ff M P j o i n t s , h o w e v e r , r e m a i n a n i g h t m a r e ! E v e n t h e m o s t v i g o r o u s t e c h ­ n i q u e s a r e o f t e n u n s u c c e s s f u l . T h e b e s t m e t h o d of t r e a t m e n t is, o f c o u r s e , p r e v e n t i o n o f t hi s st i ffness. B ibliography ^ 1. B y r n e , J. J. ( 1959): T h e H a n d : I t s A n a t o m y a n d D ise a se s . O x f o r d , B l a c k we l l Sc i e n t i f i c P u b l i c a t i o n s . 2. Bo y e s . J. H. ( 1964) : B u n n e l l ’s S u r g e r y o f th e H a n d . 4 t h Ed. P h i l a d e l p h i a . J. B. L i p p i n c o t t . 3. K a l t e n b o r n , F. H. ( 1974): M a n u a l T h e r a p y f o r th e E x t r e m i t y J o in ts . Os l o . O l a f N o r l i s B o k h a n d e l . 4. M a i t l a n d . G . D. ( 1977): P e r ip h e r a l M a n i p u la t i o n . 2nd Ed . L o n d o n . B u t t e r w o r t h s . PHYSIOTHERAPY IN A SPECIALISED HAND UNIT S U E H O L T , M. C . S . P . * D u r i n g t h e y e a r 1976. o v e r o n e t h o u s a n d n e w h a n d ca s e s a n d t h r e e t h o u s a n d r e p e a t ca s e s w e r e s e e n a t t he * S e n i o r P h y s i o t h e r a p i s t , G r o o t e S c h u u r H o s p i t a l , C a p e T o w n . H a n d U n i t o f G r o o t e S c h u u r H o s p i t a l . T h e m a j o r i t y o f t h e s e p a t i e n t s e i t h e r p a s s e d t h r o u g h t h e P h y s i o ­ t h e r a p y D e p a r t m e n t o r t h a t o f O c c u p a t i o n a l T h e r a p y . C l o s e t e a m w o r k is a n e s s e n t i a l f a c t o r in t hi s field. T h i s a r t i c l e a i m s a t d e s c r i b i n g t h e t r e a t m e n t g i v e n b y R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )