- Email: [email protected]
Balancing Contracture Management and function
[p~;~~
FORUM
J
Balancing Contracture Management and Function Proximal interphalangeal joint flexion contractures can be one of hand therapy's most challenging problems. The therapist must help the patient regain flexion and function while preventing the development of flexion contractures. The authors of this issue's Practice Forum offer a device that satisfies the challenge of contracture management and preservation of function.-PATRICIA BYRON, MA, OTR/L, PT, CHT, Practice Forum Editor
THE TREATMENT OF INTERPHALANGEAL JOINT FLEXION CONTRACTURES WITH REINFORCED LYCRA FINGER SLEEVES Sue Kennedy, BSc(Hons), DipCOT, SROT Fiona Peck, GradDipPhys, MCSP, SRP Judith Stone, DipEd Burns and Plastic Surgery Unit Withington Hospital Manchester United Kingdom Flexion contractures of the proximal interphalangeal joint are a well-recognized complication of hand surgery and trauma. Edema and its complications contribute to the initiation of the problem, and the weaker extensor apparatus is powerless to resist the subsequent shortening of the collateral ligaments and adhesion of the volar plate. Volar scarring frequently exacerbates the condition, and once established this contracture is notoriously difficult to manage. The aim of modern therapeutic regimens is to prevent the development of flexion deformity by edema control, therapeutic exercise, and the use of splinting. A variety of devices have been described, including static volar thermoplastic night splints, joint jacks, and dynamic splints using a three-point vector system. 1 - S Static splints are effective for night use, but gains in extension are often reversed by prolonged functional activities in the flexed posiThis paper is adapted from a presentation given by Sue Kennedy at the Fourth Congress of the International Federation of Societies for Hand Therapy in Vancouver, Canada, May 24-26, 1998. Correspondence and reprint requests to Sue Kennedy, BSc(Hons), DipCOT, SROT, Burns and Plastic Surgery Unit, Withington Hospital, Manchester, UK.
52
JOURNAL OF HAND THERAPY
tion during the day. Currently available dynamic splints often impede function and do not offer an acceptable level of cosmesis or comfort to the patient. At Withington Hospital during the last decade, custom-made Lycra finger sleeves have played a vital part in the management of hand injuries. In addition to their role in the management of edema and scarring, clinical experience has taught us that they also assist in the extension of the finger. The application of an extra layer of Lycra on the dorsum to reinforce the finger sleeve assists in the extension of the finger and allows the inclusion of polyester boning, which further enhances the effect on extension where necessary. The reinforced finger sleeve without boning is adequate in most cases of mild contracture.
Materials and Methods The finger sleeve is constructed by drawing around the affected finger and enlarging the pattern for the depth of the finger. (Figure 1). The pattern is cut out double on the fold of Lycra, together with a strip of Lycra of width equal to the finger tracing. The strip is then sewn into place and the longitudinal seam is sewn, with a zig-zag stitch. If the dorsal strip is to contain polyester boning, the proximal edge is turned under to retain it. The original pattern is further enlarged widthwise by approximately 1 mm on each side, to compensate for the loss of stretch caused by the addition of the boning. The cut ends of the boning need to be heat sealed. (Figure 2). Three finger sleeves are usually made and given to the patient, permitting the patient to change and launder them daily, which ensures recovery of stretch in the elastic fibers. The patient wears the finger sleeve constantly during the day, removing it only for hand hygiene and thus ensur-
ing a constant low-tension stretch for several hours at a time. At night, edema can be controlled with an unreinforced finger sleeve, and extension of the interphalangeal joints can be maintained with a static splint. We have used these reinforced Lycra finger sleeves for a variety of different conditions, including flexor tendon injury, acute boutonniere injury, extensor tendon injury, burns, Dupuytren surgery, and degloving injury. In many cases they have been introduced prophylactically and at the first sign of contracture. They are most effective in acute cases, where passive correction is still possible or where the flexion contracture is less than 30°. Their success in the treatment of more complex cases is demonstrated in the following case studies.
FIGURE 2. of Lycra.
The finger sleeve has a dorsal reinforcing strip
Case Study 1 A 25-year-old mUSICIan was referred to the Plastic Surgery Unit two years after a repair, performed elsewhere, of the flexor tendons of the right
little finger of her dominant hand. There was a severe contracture of all joints of the finger and no flexor tendon excursion. Extensive flexor tenolysis and arthrolysis were performed and full extension gained at all joints. Active and passive exercises commenced on the first day. A palmar gutter splint was worn at night to maintain extension of the little finger. Despite intensive therapy and splintage, the flexion contracture at the proximal interphalangeal joint recurred one month postoperatively. A passive correction was still possible, and at this stage the reinforced finger sleeve was introduced. This was worn full time in conjunction with conventional splintage at night, and within one month active extension to 20° was achieved along with a full range of active flexion. The finger sleeves were worn for a period of six months. During this time the patient reported that if the device was removed for long periods, the problem recurred. At six months, treatment was discontinued and the fixed flexion deformity has remained at 20°.
Case Study 2
::::::p ----- --
-~
FIGURE 1. To make a pattern for the finger sleeve, draw around the finger and enlarge the drawing to the depth of the finger.
A 58-year-old foreman trapped his left, nondominant hand in rollers, sustaining degloving injury to the little finger. There was extensive ' skin loss with exposed extensor tendon, but no bone injury. The treatment of choice was a groin flap, but reluctance on the part of the patient and previous hernia surgery prevented this. The finger was splitskin-grafted with a view to further surgery at a later date. Flexion contractures of the proximal and dorsal interphalangeal joints developed at an early stage, and healing was slow. Conventional splintage proved inadequate, and the proximal interphalan-
January-March 2000
53
eratively, and a gradual increase in extension was achieved over a period of 9 months. The patient subsequently returned to work with a 20° residual contracture at the proximal interphalangeal joint.
Discussion
FIGURE 3. Injecting fluid into the finger of a cadaver to simulate edema causes flexion of the proximal interphalangeal joint.
geal joint deteriorated to 45° of flexion. The dynamic Capener splint applied during the day caused pressure sores on the dorsum of the finger. The reinforced Lycra sleeve was applied over extra-thin Duoderm dressings at 2 months postop-
FIGURE 4.
54
The development of proximal interphalangeal joint contractures following hand trauma can be anticipated where edema and scarring are present in the finger. A cadaver experiment (Figure 3) has shown that when fluid is injected into the finger, the accumulation of fluid within the digit forces the digit into a position of proximal interphalangeal flexion, due mostly to the relative laxity of the dorsal skin. As the finger is "inflated" by fluid, the proximal interphalangeal joint flexes and correction of the flexed posture is facilitated by clearing the fluid. 6 It is clear that edema control is paramount in the prophylaxis of the contractures, and the Lycra finger sleeve is effective because it affords constant circumferential pressure. Several authors have expounded the concept of cylindrical splinting/ and in 1997 ClarkS published his investigation of the neoprene tube finger extension splint, confirming that constant tension with an upward force on the order of 500 grams would influence joint contracture. Our attempts to replicate measurements of force on the reinforced finger sleeve, using Clark's technique, have shown that forces vary with the resting tone of individual sub-
Application of the Lycra finger sleeve interrupts the normal cascade of flexion.
JOURNAL OF HAND THERAPY
jects. The observation that application of the finger sleeve interrupts the normal cascade of flexion in the digits (Figure 4) indicates that there is increased extension force against the flexor muscle in the resting position. Our device effects extension by means of dorsal reinforcement, encouraging straightening of the finger on relaxation of grip. In this way it provides a constant gentle stretch of the tissues as advocated by Brand in 19959 in his paper on joint stiffness and tissue growth. It is our clinical experience that night splintage using rigid thermoplastics alone is not sufficient to prevent or control particularly aggressive contractures, and that some patients require daytime splintage to provide constant stretch of the affected finger into extension. Patient compliance is promoted by virtue of cosmetic acceptability, comfort, and the fact that function is not compromised. The finger sleeves can be worn before wound healing is complete, over thin adhesive dressings, if necessary. They are easily applied, hygienic and washable, and inexpensive to make. In our opinion the reinforced Lycra sleeve can be used in the prevention and control of flexion contractures of the proximal interphalangeal joints, and in our unit they have proved to be a valuable addition to currently available treatment modalities in a variety of conditions.
References 1. Colditz Je. Spring-wire extension splinting of the proximal interphalangeal joint. In: Hunter JM, Mackin EJ, Callahan AD (eds). Rehabilitation of the Hand: Surgery and Therapy. 4th ed. St. Louis, Mo: Mosby, 1995:1617-29. 2. Fess EE. Principles and methods of splinting for mobilization of joints: In: Hunter JM, Mackin EJ, Callahan AD (eds). Rehabilitation of the Hand: Surgery and Therapy. 4th ed. St. Louis, Mo: Mosby, 1995:1589-98. 3. Prosser R. Splinting in the management of proximal interphalangeal joint flexion contractures. Aust J Physiother. 1995; 41:53-7. 4. Prosser R. Splinting in the management of proximal interphalangeal joint flexion contracture. J Hand Ther. 1996;9:37886. 5. Wu S-H. A belly gutter splint for proximal interphalangeal jOint contracture. Am J Occup Ther. 1991;45:839-42. 6. McGrouther DA. Factors influencing recovery. In: Burke PD, McGrouther DA, Smith PJ (eds). Principles of Hand Surgery. New York: Churchill Livingstone, 1990:18-9. 7. Bell-Krotoski JA. Plaster cylinder casting for contractures of the interphalangeal joints. In: Hunter JM, Mackin EJ, Callahan AD (eds). Rehabilitation of the Hand: Surgery and Therapy. 4th ed. St. Louis, Mo: Mosby, 1995:1609-16. 8. Clark EN. A preliminary investigation of the neoprene tube finger extension splint. J Hand Ther. 1997;10:213-21. 9. Brand PW. Mechanical factors in joint stiffness and tissue growth. J Hand Ther. 1995;8:91-6.
The Practice Forum editor invites contributions of clinically relevant, timely ideas for this column. Please send submissions to Patricia Byron, MA, OTR/L, PT, CHT, 1717 Ludwell Drive, Maple Glen, PA 19002.
January-March 2000
55
FORUM
J
Balancing Contracture Management and Function Proximal interphalangeal joint flexion contractures can be one of hand therapy's most challenging problems. The therapist must help the patient regain flexion and function while preventing the development of flexion contractures. The authors of this issue's Practice Forum offer a device that satisfies the challenge of contracture management and preservation of function.-PATRICIA BYRON, MA, OTR/L, PT, CHT, Practice Forum Editor
THE TREATMENT OF INTERPHALANGEAL JOINT FLEXION CONTRACTURES WITH REINFORCED LYCRA FINGER SLEEVES Sue Kennedy, BSc(Hons), DipCOT, SROT Fiona Peck, GradDipPhys, MCSP, SRP Judith Stone, DipEd Burns and Plastic Surgery Unit Withington Hospital Manchester United Kingdom Flexion contractures of the proximal interphalangeal joint are a well-recognized complication of hand surgery and trauma. Edema and its complications contribute to the initiation of the problem, and the weaker extensor apparatus is powerless to resist the subsequent shortening of the collateral ligaments and adhesion of the volar plate. Volar scarring frequently exacerbates the condition, and once established this contracture is notoriously difficult to manage. The aim of modern therapeutic regimens is to prevent the development of flexion deformity by edema control, therapeutic exercise, and the use of splinting. A variety of devices have been described, including static volar thermoplastic night splints, joint jacks, and dynamic splints using a three-point vector system. 1 - S Static splints are effective for night use, but gains in extension are often reversed by prolonged functional activities in the flexed posiThis paper is adapted from a presentation given by Sue Kennedy at the Fourth Congress of the International Federation of Societies for Hand Therapy in Vancouver, Canada, May 24-26, 1998. Correspondence and reprint requests to Sue Kennedy, BSc(Hons), DipCOT, SROT, Burns and Plastic Surgery Unit, Withington Hospital, Manchester, UK.
52
JOURNAL OF HAND THERAPY
tion during the day. Currently available dynamic splints often impede function and do not offer an acceptable level of cosmesis or comfort to the patient. At Withington Hospital during the last decade, custom-made Lycra finger sleeves have played a vital part in the management of hand injuries. In addition to their role in the management of edema and scarring, clinical experience has taught us that they also assist in the extension of the finger. The application of an extra layer of Lycra on the dorsum to reinforce the finger sleeve assists in the extension of the finger and allows the inclusion of polyester boning, which further enhances the effect on extension where necessary. The reinforced finger sleeve without boning is adequate in most cases of mild contracture.
Materials and Methods The finger sleeve is constructed by drawing around the affected finger and enlarging the pattern for the depth of the finger. (Figure 1). The pattern is cut out double on the fold of Lycra, together with a strip of Lycra of width equal to the finger tracing. The strip is then sewn into place and the longitudinal seam is sewn, with a zig-zag stitch. If the dorsal strip is to contain polyester boning, the proximal edge is turned under to retain it. The original pattern is further enlarged widthwise by approximately 1 mm on each side, to compensate for the loss of stretch caused by the addition of the boning. The cut ends of the boning need to be heat sealed. (Figure 2). Three finger sleeves are usually made and given to the patient, permitting the patient to change and launder them daily, which ensures recovery of stretch in the elastic fibers. The patient wears the finger sleeve constantly during the day, removing it only for hand hygiene and thus ensur-
ing a constant low-tension stretch for several hours at a time. At night, edema can be controlled with an unreinforced finger sleeve, and extension of the interphalangeal joints can be maintained with a static splint. We have used these reinforced Lycra finger sleeves for a variety of different conditions, including flexor tendon injury, acute boutonniere injury, extensor tendon injury, burns, Dupuytren surgery, and degloving injury. In many cases they have been introduced prophylactically and at the first sign of contracture. They are most effective in acute cases, where passive correction is still possible or where the flexion contracture is less than 30°. Their success in the treatment of more complex cases is demonstrated in the following case studies.
FIGURE 2. of Lycra.
The finger sleeve has a dorsal reinforcing strip
Case Study 1 A 25-year-old mUSICIan was referred to the Plastic Surgery Unit two years after a repair, performed elsewhere, of the flexor tendons of the right
little finger of her dominant hand. There was a severe contracture of all joints of the finger and no flexor tendon excursion. Extensive flexor tenolysis and arthrolysis were performed and full extension gained at all joints. Active and passive exercises commenced on the first day. A palmar gutter splint was worn at night to maintain extension of the little finger. Despite intensive therapy and splintage, the flexion contracture at the proximal interphalangeal joint recurred one month postoperatively. A passive correction was still possible, and at this stage the reinforced finger sleeve was introduced. This was worn full time in conjunction with conventional splintage at night, and within one month active extension to 20° was achieved along with a full range of active flexion. The finger sleeves were worn for a period of six months. During this time the patient reported that if the device was removed for long periods, the problem recurred. At six months, treatment was discontinued and the fixed flexion deformity has remained at 20°.
Case Study 2
::::::p ----- --
-~
FIGURE 1. To make a pattern for the finger sleeve, draw around the finger and enlarge the drawing to the depth of the finger.
A 58-year-old foreman trapped his left, nondominant hand in rollers, sustaining degloving injury to the little finger. There was extensive ' skin loss with exposed extensor tendon, but no bone injury. The treatment of choice was a groin flap, but reluctance on the part of the patient and previous hernia surgery prevented this. The finger was splitskin-grafted with a view to further surgery at a later date. Flexion contractures of the proximal and dorsal interphalangeal joints developed at an early stage, and healing was slow. Conventional splintage proved inadequate, and the proximal interphalan-
January-March 2000
53
eratively, and a gradual increase in extension was achieved over a period of 9 months. The patient subsequently returned to work with a 20° residual contracture at the proximal interphalangeal joint.
Discussion
FIGURE 3. Injecting fluid into the finger of a cadaver to simulate edema causes flexion of the proximal interphalangeal joint.
geal joint deteriorated to 45° of flexion. The dynamic Capener splint applied during the day caused pressure sores on the dorsum of the finger. The reinforced Lycra sleeve was applied over extra-thin Duoderm dressings at 2 months postop-
FIGURE 4.
54
The development of proximal interphalangeal joint contractures following hand trauma can be anticipated where edema and scarring are present in the finger. A cadaver experiment (Figure 3) has shown that when fluid is injected into the finger, the accumulation of fluid within the digit forces the digit into a position of proximal interphalangeal flexion, due mostly to the relative laxity of the dorsal skin. As the finger is "inflated" by fluid, the proximal interphalangeal joint flexes and correction of the flexed posture is facilitated by clearing the fluid. 6 It is clear that edema control is paramount in the prophylaxis of the contractures, and the Lycra finger sleeve is effective because it affords constant circumferential pressure. Several authors have expounded the concept of cylindrical splinting/ and in 1997 ClarkS published his investigation of the neoprene tube finger extension splint, confirming that constant tension with an upward force on the order of 500 grams would influence joint contracture. Our attempts to replicate measurements of force on the reinforced finger sleeve, using Clark's technique, have shown that forces vary with the resting tone of individual sub-
Application of the Lycra finger sleeve interrupts the normal cascade of flexion.
JOURNAL OF HAND THERAPY
jects. The observation that application of the finger sleeve interrupts the normal cascade of flexion in the digits (Figure 4) indicates that there is increased extension force against the flexor muscle in the resting position. Our device effects extension by means of dorsal reinforcement, encouraging straightening of the finger on relaxation of grip. In this way it provides a constant gentle stretch of the tissues as advocated by Brand in 19959 in his paper on joint stiffness and tissue growth. It is our clinical experience that night splintage using rigid thermoplastics alone is not sufficient to prevent or control particularly aggressive contractures, and that some patients require daytime splintage to provide constant stretch of the affected finger into extension. Patient compliance is promoted by virtue of cosmetic acceptability, comfort, and the fact that function is not compromised. The finger sleeves can be worn before wound healing is complete, over thin adhesive dressings, if necessary. They are easily applied, hygienic and washable, and inexpensive to make. In our opinion the reinforced Lycra sleeve can be used in the prevention and control of flexion contractures of the proximal interphalangeal joints, and in our unit they have proved to be a valuable addition to currently available treatment modalities in a variety of conditions.
References 1. Colditz Je. Spring-wire extension splinting of the proximal interphalangeal joint. In: Hunter JM, Mackin EJ, Callahan AD (eds). Rehabilitation of the Hand: Surgery and Therapy. 4th ed. St. Louis, Mo: Mosby, 1995:1617-29. 2. Fess EE. Principles and methods of splinting for mobilization of joints: In: Hunter JM, Mackin EJ, Callahan AD (eds). Rehabilitation of the Hand: Surgery and Therapy. 4th ed. St. Louis, Mo: Mosby, 1995:1589-98. 3. Prosser R. Splinting in the management of proximal interphalangeal joint flexion contractures. Aust J Physiother. 1995; 41:53-7. 4. Prosser R. Splinting in the management of proximal interphalangeal joint flexion contracture. J Hand Ther. 1996;9:37886. 5. Wu S-H. A belly gutter splint for proximal interphalangeal jOint contracture. Am J Occup Ther. 1991;45:839-42. 6. McGrouther DA. Factors influencing recovery. In: Burke PD, McGrouther DA, Smith PJ (eds). Principles of Hand Surgery. New York: Churchill Livingstone, 1990:18-9. 7. Bell-Krotoski JA. Plaster cylinder casting for contractures of the interphalangeal joints. In: Hunter JM, Mackin EJ, Callahan AD (eds). Rehabilitation of the Hand: Surgery and Therapy. 4th ed. St. Louis, Mo: Mosby, 1995:1609-16. 8. Clark EN. A preliminary investigation of the neoprene tube finger extension splint. J Hand Ther. 1997;10:213-21. 9. Brand PW. Mechanical factors in joint stiffness and tissue growth. J Hand Ther. 1995;8:91-6.
The Practice Forum editor invites contributions of clinically relevant, timely ideas for this column. Please send submissions to Patricia Byron, MA, OTR/L, PT, CHT, 1717 Ludwell Drive, Maple Glen, PA 19002.
January-March 2000
55