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Rehabilitation after fractures of the hand
REHABILITATION AFTER FRACTURES OF THE HAND TERRISKIRVEN, OTR/L CHT
Rehabilitation after a hand fracture begins during the early phases of fracture healing and continues until skeletal integrity and hand function are restored. The rehabilitation plan is tailored according to the stage of healing. The emphasis of therapy during the early reparative stage of healing is on edema control, pain management, preservation of motion at the uninvolved joints, protective splinting and positioning to prevent disruption of fracture healing, and to prevent joint contracture. The next phase of therapy begins when clinical healing is present and emphasizes the active mobilization of the joints immediately adjacent to the fracture that were incorporated in the cast or splint. Tendon gliding exercises are also stressed at this time to restore flexor and extensor tendon excursion. The final phase of therapy begins when the fracture is well healed. The focus of therapy at this time is the development of strength and hand function and the resumption of activities of daily living and work tasks. General rehabilitation techniques appropriate for all hand fractures include positioning and splinting, edema and pain control, joint and soft tissue mobilization techniques, and tendon gliding and strengthening exercises. KEY WORDS: prevention, early mobilization, edema control, protection
Rehabilitation after a hand fracture begins during the early phases of fracture healing and continues until skeletal integrity and hand function are restored. Typical problems after hand fracture include limited joint mobility and stiffness, tendon adherence, swelling, and decreased strength. The degree of limitation and disability relates to the severity of the fracture and the associated soft tissue injuries. Rehabilitation is directed toward the prevention and amelioration of these problems.
GENERAL CONSIDERATIONS One of the most important considerations in the rehabilitation of hand fractures is the stage of fracture healing. The timing of therapy depends on the stability of the fracture and the degree of healing. There are three phases of healing. The inflammatory phase begins during the first 24 hours after injury. It involves the migration of inflammatory cells to the area of the fracture and the resorption of dead bone by osteoclasts. The second phase begins by 3 to 4 days and is termed the reparative phase or stage of callus formation. Fibrocytes manufacture a collagen framework across the fracture site, and minerals are deposited along the framework. The resulting mass is called callus. Callus formation actively proceeds over the next 3 weeks, and during this time fracture stability develops. The third stage is termed the remodeling phase and involves the resorption of excess callus and change of the bone architecture in response to functional demands with the development of increased mechanical stability. Bone remodeling begins at 3 to 6 weeks and continues for months up to several years? Therapy is timed according to the stage of healing. The From The Philadelphia Hand Center, King of Prussia, PA. Address reprint requests to Terri Skirven, OTR/L CHT, Philadelphia Hand Center, 700 S Henderson Rd, Suite 200, King of Prussia, PA 19406. Copyright © 1997 by W.B. Saunders Company 1048-6666/97/0702-0005505.00/0 1 52
first stage of therapy can be termed the protective phase and corresponds to the inflammatory and early reparative stages of healing when motion may cause disruption at the fracture site and delay healing. The emphasis of therapy at this time is edema control, pain management, preservation of motion at the uninvolved joints, protective splinting, and positioning to prevent disruption of fracture healing and joint contracture. The second stage of therapy can be termed the active motion phase and corresponds to the reparative stage of healing when the fracture is determined by the physician to be clinically healed. This determination is based on the absence of pain and motion with palpation and stress of the fracture site. Clinical healing usually occurs by 3 to 4 weeks after fracture. The emphasis of therapy at this phase is the active mobilization of the joints immediately adjacent to the fracture that were incorporated in the cast or splint. Flexor and extensor tendon gliding exercises may begin at this time, and pain and edema control continue as needed. The protective splint is worn all the time except for exercise and bathing, to protect the healing fracture from disruption, which may occur through inadvertent injury or from the stresses of uncontrolled hand use. The final phase occurs when the fracture is well healed as determined by the surgeon and can withstand the stresses involved with passive and resisted motion and functional activity. The focus of therapy during this phase is the development of strength and hand function and continuation and upgrading of techniques directed toward the restoration of motion and tendon excursion. Protective splints are gradually discontinued as strength and motion returns. Another important consideration in the timing of therapy is the type of internal fixation used. The two types of fixation are stabilizing and rigid. 2 Stabilizing fixation holds the fracture fragments in place but not securely enough to be subjected to stress. An external splint or plaster cast is required. The splint typically incorporates Operative Techniques in Orthopaedics, Vol 7, No 2 (April), 1997: pp 152-160
Fig 1. Coban wrap is a compressive wrap applied to the digits and hand to control edema.
the joints immediately proximal and distal to the fracture and the adjacent digit(s). Rigid internal fixation restores skeletal integrity and allows active range of motion without risk of motion at the fracture site. Rigid fixation allows the initiation of motion almost immediately. Also important to keep in mind is that with an unstable or incompletely lhealed fracture, the pull of intrinsic and extrinsic muscles produce deforming stresses, and angulation can result. Angulation errors cause abnormal forces on the joints adjacent to the fracture according to Landsmeer's zigzag principle, and serious deformities may develop. The zigzag principle states that a multiarticulated structure such as the finger subjected to compression will buckle each joint in an opposite direction to form a zigzag configuration. 3 For example, with fracture-dislocation of the neck of the metacarpal in which the distal fragment is tilted anteriorly, the metacarpophalangeal (MCP) joint must hyperextend to achieve what appears to be neutral extension. The next joint, the proximal interphalangeal (PIP), has a compensatory loss of extensor forces, and an active extensor lag will result. If not controlled through careful positioning and exercise, a fixed PIP flexion contracture may develop. Anticipation of these deforming forces underlies the early phases of the rehabilitation program. Efforts are made to minimize these forces by avoiding uncontrolled motion that could cause angulation and by manual support of the fracture during initial efforts at active motion of the joints adjacent to the fracture. The rehabilitation program also must consider associated injuries and coordinate therapy protocols for the
Fig 2. A compressive glove used to control generalized hand edema. REHABILITATION AFTER HAND FRACTURES
Fig 3. String wrapping is applied distal to proximal and can be combined with retrograde massage to control digital edema.
injured structures. For example, with a combined skeletal and tendon injury, an early motion program for the tendon may produce deforming stresses at the fracture site; prolonged immobilization of the fracture may cause tendon adherence. The therapy protocols must be adapted and tailored to the requirements for protection, positioning, motion, and immobilization for the involved structures. GENERAL
THERAPY
TECHNIQUES
To a varying extent, all hand fractures are accompanied by swelling, pain, and restriction or inhibition of motion, and
Fig 4. The hand volumeter is used to measure hand size through water displacement. 153
Fig 5. The protective position for splinting involves MCP joint flexion and IP extension.
all require some level of protection and positioning to promote optimal healing. The following techniques and procedures are applicable to most hand fractures.
EDEMA CONTROL Unresolved hand edema leads to inhibition of motion, joint stiffness, pain, and deformity, and may involve not only the involved digit but the entire hand as well. Therefore, control of edema is a priority in the rehabilitation program. Edema control is initiated as soon as possible after fracture fixation. Patients are advised to elevate the involved extremity and hand above the level of the heart. External compression is a very effective means of edema control and can be applied in a variety of methods. Compressive wrapping can begin during the protective phase while the hand is in the cast or a protective splint. Coban is a self-adhering wrap that is used for this purpose and is applied in a distal to proximal direction starting at the fingertips. Once the cast or splint is removed, coban can be wrapped about the MCP joints and around the metacarpals to help control dorsal or palmar hand edema (Fig 1). The coban should not be wrapped tightly because this may exacerbate swelling. Coban can be left in place on the hand for long periods but should be removed for exercises. An alternative to compressive wrapping is the use of an elastic glove, which can be used to control generalized hand edema (Fig 2). String wrapping is another method of compression. String is wrapped about the involved digit from distal to proximal and is held for 5 minutes (Fig 3). During this time, retrograde massage can be performed. Flowers 4 found that combining massage and string wrapping was more effective than either technique alone. Once the string is removed, the patient performs range of motion exercises. Other methods used to control edema include the use of
Fig 6. Percutaneous pins used for fixation of a proximal phalanx fracture can be protected with a thermoplastic splint.
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Fig 7. Blocking exercises involves manual stabilization of the joint proximal to the joint targeted for exercise.
cold, galvanic stimulation and active digital exercises with the hand in the elevated position. Hand edema can be monitored with volumetric measurements (Fig 4). The hand volumeter uses water displacement to measure hand size and has been found accurate within 10 mL. 5 If swelling is confined to a single digit or joint, circumferential measurements are recorded.
PAIN M A N A G E M E N T Pain frequently accompanies the patient's efforts to move the involved joints of the hand. If pain limits the patient's ability to participate in the therapy program, pain control becomes a priority. The source of the pain must be determined and addressed accordingly. If pain is localized to the fracture site, it is important to determine Whether fracture healing or stability has been compromised. Pain frequently occurs during the initial efforts at moving the joints adjacent to the fracture and may be caused by the stressing of the periarticular soft tissues, which are frequently shortened and scarred. Oral analgesics and antiinflammatory medications, the use of transcutaneous electrical nerve stimulation, and modalities such as heat and cold are all helpful in controlling pain and may be used before, during, or after the exercise sessions. "No pain, no gain" is an inappropriate slogan for a hand
Fig 8. Blocking splints are made to stabilize the joints proximal to the target joint.
TERRI SKIRVEN
Fig 9. Extensor tendon gliding exercise is performed by extending the MCP joints with the IP joints flexed and the wrist in neutral position.
Fig 11. Exercise to isolate the flexor digitorum superficialis from the profundus; the adjacent digits are held in extension while PIP joint flexion is attempted.
therapy clinic. Certainly, pain and discomfort are expected as the patient begins to move joints compromised by swelling and stiffness. However, if pain exceeds the patient's level of tolerance and is out of their control, protective muscle guarding with inhibition of active motion results. Active motion exercises under the control of the patient and supervised and encouraged by the therapist are most appropriate, particularly during the early phases of the therapy program.
flexion contracture results. In general, the joints adjacent to the fracture site are immobilized as well as the adjacent finger. Splints are also fabricated to incorporate any percutaneous pins to prevent bumping or inadvertent snagging of pins (Fig 6).
PROTECTION AND POSITIONING After operative treatment of hand fractures, a custommade thermoplastic hand splint may be used to provide lightweight protection and positioning. The splint may be used during the early healing phases on a continuous basis and is worn inteITnittently once clinical healing has been achieved and active motion begins. The splint helps to insure immobilization of the fracture, provides protection for any percutaneous pins, and positions the involved joints and digits in a safe position to minimize the risk of joint contracture. The position of the splint in general should be in the safe, protective, or intrinsic plus position 6 (Fig 5). This position requires that the MCP joints be positioned in flexion because the collateral ligaments of the MCP joints are taut when the joint is flexed and cannot undergo shortening and contracture in this position. The interphalangeal (IP) joints are positioned in extension because if allowed to remain in a flexed position for long periods the volar plate and deep fascial supporting structures can undergo irreversible shortening, and a fixed
THERAPEUTIC EXERCISE Joint stiffness is a frequent and almost inevitable consequence after hand fracture, particularly of the joints adjacent to the fracture site. In some cases, stiffening and loss of motion of the more proximal joints of the involved upper extremity can occur as well. To prevent and minimize joint stiffness, therapeutic exercise is begun as early as possible. Active range of motion exercises can begin immediately for the unimmobilized joints. Patients are instructed to perform range of motion exercises of the shoulder and elbow to prevent stiffness and loss of motion. This is particularly important with the older patient with a diminished activity level. The joints adjacent to the fracture site are not moved until the fracture is judged to be clinically stable. If the fracture has been treated with rigid internal fixation, movement can start almost immediately. Exercises are initially performed actively without resistance. The fracture site can be manually stabilized by the therapist when moving the joints adjacent to the fracture. To isolate a particular joint during exercise, blocking exercises are performed. Blocking involves manual stabilization of the joint proximal to the target joint during active exercise (Fig 7). The proximal joint is usually positioned in a neutral position. Blocking splints can sometimes be
Fig 10. Flexor tendon gliding exercises. (A) Full fist; (B) straight fist. REHABILITATION AFTER HAND FRACTURES
155
Fig 12. Isolated flexor digitorum profundus exercise: The PIP joint is stabilized while DIP joint flexion is attempted.
helpful for the patient to use to perform the exercises on a home program basis and can be fabricated to block motion proximal and sometimes distal to the target joint (Fig 8). Flexor and extensor tendons can sometimes become adherent at the site of the fracture, limiting tendon excur-
sion. Tendon gliding exercises are performed to address this problem. Extensor tendon gliding is performed by extending the MCP joints with the IP joints flexed and the wrist in neutral (Fig 9). While maintaining MCP joint extension, the patient then extends the IP joints. Flexor tendon gliding has been described by Wehbe and Hunter. 7 Their program involves three basic hand positions. The full fist emphasizes maximum flexor digitorum profundus tendon glide; the straight fist requires maximum flexor digitorum superficialis tendon glide; and the hook fist involves maximum differential glide between the superficialis and profundus tendons (Fig 10). To isolate the flexor superficialis from the profundus, the adjacent digits are held in extension while the patient attempts to flex the PIP joint (Fig 11). To isolate the profundus from the superficialis, the PIP joint is held in extension while the patient attempts to flex the distal IP (DIP) joint (Fig 12). Later, once the fracture has been judged to be well healed and capable of withstanding increased stress, resistive and passive exercise can begin. Passive exercise must be performed within the pain tolerance of the patient. Overly aggressive passive exercise can cause inflammation, increased stiffness and pain, and limit progress. Strengthening exercises are typically performed with therapeutic putty, which can be graded in terms of resistance. Patients are instructed in exercises selected for their particular area of weakness. Flexion, extension, adduction, and abduction strengthening exercises can be performed using putty (Fig 13).
Fig 13. Putty exercises performed for (A) finger flexion; (B) finger extension; (C) abduction; (D) adduction.
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TERRI SKIRVEN
Fig 14. Splint used for metacarpal fractures includes the wrist and the MCP joints of the involved and the adjacent finger; buddy straps are used to control rotation. In all cases, patients are instructed in a home program that supplements the supervised therapy program. In some cases where limitations are minor, patients may be able to perform a home program with less frequent therapy visits. Range of motion measurements are taken on a regular basis to monitor progress and to determine the efficacy of the treatment program. Revisions are made to
Fig 16. Blocking exercises performed for PIP joint extension positions the MCP joint in flexion while PIP joint extension is attempted. the therapy program based on the patient's response to the therapy as well as on fracture healing.
SPECIFIC FRACTURES AND THERAPY CONSIDERATIONS Metacarpal Fractures Metacarpal fractures can occur at the base, the shaft, or the neck with the MCP joint surface involved~8 Base fractures usually involve the fourth or fifth metacarpals. Metacarpal shaft fractures can be transverse, oblique, or comminuted. Transverse fractures may angulate dorsally because of the
Fig 15. Dynamic flexion splint for limited MCP joint flexion. REHABILITATION AFTER HAND FRACTURES
Fig 17. (A) Blocking splint for PIP joint flexion positions the MCP joint in neutral; (B) blocking splint for PIP joint extension positions the MCP joint in flexion.
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Fig 18. Three-point extension splint used to correct PIP flexion contractures of 35 degrees or less,
forces of the long flexors and the interossei; oblique fractures are subject to shortening and malrotation; and comminuted fractures are often associated with significant soft tissue injury. Metacarpal neck fractures are the most common and result from a compression force such as a blow with a closed fist. These tend to angulate dorsally and are subject to the development of a claw deformity according to the zigzag principle as mentioned previously with MCP hyperextension and PIP flexion. Splinting for metacarpal fractures should incorporate support of the transverse and longitudinal arches and should be in the intrinsic plus position. The splint should include the wrist and the MCP joint of the involved metacarpal as well as the adjacent MCP joint. Buddy straps or rotational taping is used to control alignment and prevent overlapping of the digits (Fig 14). Common problems of metacarpal fractures include extensor tendon adherence and stiffness and limitation of the MCP joint. Extensor tendon gliding exercises are emphasized to promote tendon excursion. Friction scar massage is used in the case of adherent incision scars and can help to promote differentiation of the overlying scar from the tendon. Massage can be performed during efforts at active extensor tendon gliding. Stiffness and limited MCP joint flexion is also a frequent problem, and MCP joint exercises are emphasized. When performing exercises for the MCP joint, it is important to stabilize the wrist and corresponding carpometacarpal (CMC) joint to allow concentration of effort at the MCP joint. In some cases, IP joint flexion can be blocked as well to further concentrate forces at the MCP joint. When the fracture is well healed, dynamic splinting can be used to help restore MCP joint flexion if limitations persist. The dynamic splint must provide volar and dorsal
Fig 19. Dynamic PIP extension splint used for PIP flexion contractures of 35 degrees or more. 158
Fig 20. Dynamic splint used to increase PIP joint flexion.
support of the wrist and the CMC joint. Dynamic traction is applied with a finger cuff applied over the proximal phalanx and pulled to a volar attachment point (Fig 15). The tension of the dynamic traction is kept at level that can be tolerated for a prolonged period. Low-load prolonged stress to the shortened periarticular soft tissues has been found to be more effective than high-intensity brief stress in increasing tissue length. 9
Proximal Phalanx Fractures Proximal phalanx fractures can occur at the base, the midshaft, or the neck. Malalignments of proximal phalanx fractures can cause significant deformity. Fractures of the midshaft and base tend to angulate volarly secondary to pull of the interosseous muscles on the proximal fragment and the pull of the extensor mechanism of the distal fragment. With persistent angulation, the PIP joint flexes and can rapidly become fixed in a flexion contracture with edema and inflammatory reaction from the adjacent fracture. 10 Rotational errors can occur and are amplified at the fingertip with overlapping of the digits and compromise of function of the adjacent digits. The two major complications of proximal phalanx fractures include PIP flexion contracture and flexor tendon adherence at the site of fracture. Splinting for proximal phalanx fractures is in the safe position with particular attention paid to positioning the
Fig 21. Gutter splint with pin protection for distal phalanx fractures. TERRI SKIRVEN
limitations. With more significant limitations, a dynamic splint is most effective (Fig 20). Middle Phalanx Fractures
Fig 22. Blocking splint for DIP joint flexion stabilizes the PIP joint in extension.
PIP joint in extension to prevent the development of flexion contracture. The adjacent uninjured digit is included to control rotational alignment. The therapy program for proximal phalanx fractures emphasizes PIP joint range of motion exercises, and these are performed with stabilization of the proximal phalanx and the MCP joint. Tendon gliding exercises are performed as well. Extensor tendon gliding at the PIP joint level is performed by blocking the MCP joint in flexion during active efforts at PIP extension (Fig 16). Flexor tendon gliding exercises are performed as described previously. Blocking splints are sometimes very helpful to enhance the patient's efforts. The blocking splint for PIP extension positions the MCP joint in flexion. The blocking splint for flexion positions the MCP joint in neutral (Fig 17). Tendon gliding and blocking exercises can be combined with biofeedback and electrical stimulation to enhance the patient's active efforts. If limitations in PIP joint mobility persist, dynamic splinting may be used once the fracture is determined to be solidly healed. For a PIP flexion contracture that is 35 degrees or less, a three-point extension splint is recommended to restore extension (Fig 18). If the contracture is greater than 35 degrees, a dynamic PIP extension splint is required (Fig 19).11 If PIP joint flexion is limited, flexion straps or flexion loops are effective with mild to moderate
Fig 23. Dynamic DIP joint flexion splint used to overcome DIP joint stiffness and limited flexion after DIP joint fracture.
REHABILITATIONAFTER HANDFRACTURES
Middle phalanx fractures are less common. They can occur at the midshaft, base, or the neck, with the distal shaft the most frequent area affected. The flexor digitorum superficialis and the extensor tendon provide deforming forces. With a fracture of the neck, the pull of the superficialis causes volar angulation. With a fracture of the base, dorsal angulation results. Fractures of the middle third of the shaft can angulate either way. ~2 Problems common to middle phalanx fractures include stiffness of the PIP and DIP joints, PIP joint flexion contracture, and DIP joint extensor lag. Blocking exercises are begun as soon as the fracture is clinically healed. PIP joint range of motion is performed with the MCP and proximal phalanx supported. The middle phalanx and the PIP joint are supported during DIP joint range of motion. Flexion straps, loops, and dynamic splints are used when the fracture is fully healed and as needed. Distal Phalanx Fractures
The distal phalanx is the most frequently fractured bone in the hand, with the long and the thumb the most frequently involved digitsJ 3 These fractures usually result from crush injuries with comminution of bone. Fractures are classified as open or closed and occur at the tuft, shaft, or base. Unstable distal phalanx fractures require reduction and internal fixation and are protected while healing, usually with a gutter splint with pin protection with the PIP joint free (Fig 21). During healing, PIP and MCP joint range of motion exercises and pin site care are performed. After the pins are removed, usually at 3 to 4 weeks, DIP joint range of motion exercises are begun. Problems associated with distal phalanx fractures are DIP joint stiffness, pulp hypersensitivity, nail abnormality, numbness, and cold intolerance. For DIP joint stiffness, active range of motion exercises and blocking exercises begin as soon as the pins are removed. Blocking splints may be used, which stabilizes the PIP joint and permits DIP joint range of motion (Fig 22). Desensitization techniques are helpful and include massage, tapping, vibration, and rubbing with textures. Later, as healing permits, passive range of motion and flexion loops or dynamic splints can be used to restore DIP joint flexion (Fig 23). Putty exercises are used to develop tolerance for pinch pressure. Sensitivity may persist, and gel-lined sleeves may be helpful for use at work and during other activities (Fig 24).
Fig 24. Gel-lined digital sleeves are useful for hypersensitive fingertips after crush injuries of the distal phalanx.
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SUMMARY The rehabilitation p l a n after a h a n d fracture m u s t c o n s i d e r the stage of healing, the t y p e of internal fixation, potential d e f o r m i n g forces, a n d associated soft tissue injuries. C o m m o n p r o b l e m s after h a n d fractures i n c l u d e joint stiffness a n d limited mobility, e d e m a , pain, t e n d o n a d h e r e n c e , a n d d e c r e a s e d t e n d o n excursion, d e c r e a s e d strength, a n d limited function. G e n e r a l t e c h n i q u e s a p p r o p r i a t e for all h a n d fractures i n c l u d e p o s i t i o n i n g a n d splinting, e d e m a a n d p a i n control, t h e r a p e u t i c exercises, a n d s t r e n g t h e n i n g . The rehabilitation effort is i n t r o d u c e d early after fracture fixation a n d c o n t i n u e s until f u n c t i o n is restored.
REFERENCES 1. Beasley RW: Skeletal injuries, in Beasley RW: Hand Injuries. Philadelphia, PA, Saunders, 1981, p 168 2. Beasley RW: Skeletal injuries, in Beasley RW: Hand Injuries. Philadelphia, PA, Saunders, 1981
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3. Beasley RW: Skeletal injuries, in Beasley RW: Hand Injuries. Philadelphia, PA, Saunders, 1981, p 170 4. Flowers KR: String wrapping versus massage for reduction of digital volume. Phys Ther 68:57, 1988 5. Waylett-RendaU J, Seibly D: A study of the accuracy of a commercially available vohimeter. J Hand Ther 4:10,1991 6. Mannarino SL: Skeletal injuries, in Stanley BG, Tribuzi SM (eds): Concepts in Hand Rehabilitation. Philadelphia, PA, Davis, 1992, p 284 7. Wehbe M, Hunter J: Flexor tendon gliding in the hand. Part II. Differential gliding. J Hand Surg [Am] 10:575,1985 8. Meyer FN, Wilson RL: Management of nonarticular fractures of the hand, in Hunter J, Mackin E, Callahan A (eds): Rehabilitation of the Hand (ed 4). St. Louis, MO, Mosby, 1995, pp 367-372 9. Light KE: Low-load prolonged stretch versus high-load brief stretch in treating knee contractures. J Am Phys Ther 20:93, 1976 10. Beasley RW: Skeletal injuries, in Beasley RW: Hand Injuries. Philadelphia, PA, Saunders, 1981, pp 220-227 11. Fess EE, Philips CA: Splints acting on the fingers, in Fess EE, Philips CA: Hand Splinting. St. Louis, MO, Mosby, 1987, p 288 12. Beasley RW: Skeletal injuries, in Beasley RW: Hand Injuries. Philadelphia, PA, Saunders, 1981, p 217 13. Packer JW, Colditz JC: Bone injuries: Treatment and rehabilitation. Hand Clin 2:1, 88, 1986
TERRI SKIRVEN
Rehabilitation after a hand fracture begins during the early phases of fracture healing and continues until skeletal integrity and hand function are restored. The rehabilitation plan is tailored according to the stage of healing. The emphasis of therapy during the early reparative stage of healing is on edema control, pain management, preservation of motion at the uninvolved joints, protective splinting and positioning to prevent disruption of fracture healing, and to prevent joint contracture. The next phase of therapy begins when clinical healing is present and emphasizes the active mobilization of the joints immediately adjacent to the fracture that were incorporated in the cast or splint. Tendon gliding exercises are also stressed at this time to restore flexor and extensor tendon excursion. The final phase of therapy begins when the fracture is well healed. The focus of therapy at this time is the development of strength and hand function and the resumption of activities of daily living and work tasks. General rehabilitation techniques appropriate for all hand fractures include positioning and splinting, edema and pain control, joint and soft tissue mobilization techniques, and tendon gliding and strengthening exercises. KEY WORDS: prevention, early mobilization, edema control, protection
Rehabilitation after a hand fracture begins during the early phases of fracture healing and continues until skeletal integrity and hand function are restored. Typical problems after hand fracture include limited joint mobility and stiffness, tendon adherence, swelling, and decreased strength. The degree of limitation and disability relates to the severity of the fracture and the associated soft tissue injuries. Rehabilitation is directed toward the prevention and amelioration of these problems.
GENERAL CONSIDERATIONS One of the most important considerations in the rehabilitation of hand fractures is the stage of fracture healing. The timing of therapy depends on the stability of the fracture and the degree of healing. There are three phases of healing. The inflammatory phase begins during the first 24 hours after injury. It involves the migration of inflammatory cells to the area of the fracture and the resorption of dead bone by osteoclasts. The second phase begins by 3 to 4 days and is termed the reparative phase or stage of callus formation. Fibrocytes manufacture a collagen framework across the fracture site, and minerals are deposited along the framework. The resulting mass is called callus. Callus formation actively proceeds over the next 3 weeks, and during this time fracture stability develops. The third stage is termed the remodeling phase and involves the resorption of excess callus and change of the bone architecture in response to functional demands with the development of increased mechanical stability. Bone remodeling begins at 3 to 6 weeks and continues for months up to several years? Therapy is timed according to the stage of healing. The From The Philadelphia Hand Center, King of Prussia, PA. Address reprint requests to Terri Skirven, OTR/L CHT, Philadelphia Hand Center, 700 S Henderson Rd, Suite 200, King of Prussia, PA 19406. Copyright © 1997 by W.B. Saunders Company 1048-6666/97/0702-0005505.00/0 1 52
first stage of therapy can be termed the protective phase and corresponds to the inflammatory and early reparative stages of healing when motion may cause disruption at the fracture site and delay healing. The emphasis of therapy at this time is edema control, pain management, preservation of motion at the uninvolved joints, protective splinting, and positioning to prevent disruption of fracture healing and joint contracture. The second stage of therapy can be termed the active motion phase and corresponds to the reparative stage of healing when the fracture is determined by the physician to be clinically healed. This determination is based on the absence of pain and motion with palpation and stress of the fracture site. Clinical healing usually occurs by 3 to 4 weeks after fracture. The emphasis of therapy at this phase is the active mobilization of the joints immediately adjacent to the fracture that were incorporated in the cast or splint. Flexor and extensor tendon gliding exercises may begin at this time, and pain and edema control continue as needed. The protective splint is worn all the time except for exercise and bathing, to protect the healing fracture from disruption, which may occur through inadvertent injury or from the stresses of uncontrolled hand use. The final phase occurs when the fracture is well healed as determined by the surgeon and can withstand the stresses involved with passive and resisted motion and functional activity. The focus of therapy during this phase is the development of strength and hand function and continuation and upgrading of techniques directed toward the restoration of motion and tendon excursion. Protective splints are gradually discontinued as strength and motion returns. Another important consideration in the timing of therapy is the type of internal fixation used. The two types of fixation are stabilizing and rigid. 2 Stabilizing fixation holds the fracture fragments in place but not securely enough to be subjected to stress. An external splint or plaster cast is required. The splint typically incorporates Operative Techniques in Orthopaedics, Vol 7, No 2 (April), 1997: pp 152-160
Fig 1. Coban wrap is a compressive wrap applied to the digits and hand to control edema.
the joints immediately proximal and distal to the fracture and the adjacent digit(s). Rigid internal fixation restores skeletal integrity and allows active range of motion without risk of motion at the fracture site. Rigid fixation allows the initiation of motion almost immediately. Also important to keep in mind is that with an unstable or incompletely lhealed fracture, the pull of intrinsic and extrinsic muscles produce deforming stresses, and angulation can result. Angulation errors cause abnormal forces on the joints adjacent to the fracture according to Landsmeer's zigzag principle, and serious deformities may develop. The zigzag principle states that a multiarticulated structure such as the finger subjected to compression will buckle each joint in an opposite direction to form a zigzag configuration. 3 For example, with fracture-dislocation of the neck of the metacarpal in which the distal fragment is tilted anteriorly, the metacarpophalangeal (MCP) joint must hyperextend to achieve what appears to be neutral extension. The next joint, the proximal interphalangeal (PIP), has a compensatory loss of extensor forces, and an active extensor lag will result. If not controlled through careful positioning and exercise, a fixed PIP flexion contracture may develop. Anticipation of these deforming forces underlies the early phases of the rehabilitation program. Efforts are made to minimize these forces by avoiding uncontrolled motion that could cause angulation and by manual support of the fracture during initial efforts at active motion of the joints adjacent to the fracture. The rehabilitation program also must consider associated injuries and coordinate therapy protocols for the
Fig 2. A compressive glove used to control generalized hand edema. REHABILITATION AFTER HAND FRACTURES
Fig 3. String wrapping is applied distal to proximal and can be combined with retrograde massage to control digital edema.
injured structures. For example, with a combined skeletal and tendon injury, an early motion program for the tendon may produce deforming stresses at the fracture site; prolonged immobilization of the fracture may cause tendon adherence. The therapy protocols must be adapted and tailored to the requirements for protection, positioning, motion, and immobilization for the involved structures. GENERAL
THERAPY
TECHNIQUES
To a varying extent, all hand fractures are accompanied by swelling, pain, and restriction or inhibition of motion, and
Fig 4. The hand volumeter is used to measure hand size through water displacement. 153
Fig 5. The protective position for splinting involves MCP joint flexion and IP extension.
all require some level of protection and positioning to promote optimal healing. The following techniques and procedures are applicable to most hand fractures.
EDEMA CONTROL Unresolved hand edema leads to inhibition of motion, joint stiffness, pain, and deformity, and may involve not only the involved digit but the entire hand as well. Therefore, control of edema is a priority in the rehabilitation program. Edema control is initiated as soon as possible after fracture fixation. Patients are advised to elevate the involved extremity and hand above the level of the heart. External compression is a very effective means of edema control and can be applied in a variety of methods. Compressive wrapping can begin during the protective phase while the hand is in the cast or a protective splint. Coban is a self-adhering wrap that is used for this purpose and is applied in a distal to proximal direction starting at the fingertips. Once the cast or splint is removed, coban can be wrapped about the MCP joints and around the metacarpals to help control dorsal or palmar hand edema (Fig 1). The coban should not be wrapped tightly because this may exacerbate swelling. Coban can be left in place on the hand for long periods but should be removed for exercises. An alternative to compressive wrapping is the use of an elastic glove, which can be used to control generalized hand edema (Fig 2). String wrapping is another method of compression. String is wrapped about the involved digit from distal to proximal and is held for 5 minutes (Fig 3). During this time, retrograde massage can be performed. Flowers 4 found that combining massage and string wrapping was more effective than either technique alone. Once the string is removed, the patient performs range of motion exercises. Other methods used to control edema include the use of
Fig 6. Percutaneous pins used for fixation of a proximal phalanx fracture can be protected with a thermoplastic splint.
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Fig 7. Blocking exercises involves manual stabilization of the joint proximal to the joint targeted for exercise.
cold, galvanic stimulation and active digital exercises with the hand in the elevated position. Hand edema can be monitored with volumetric measurements (Fig 4). The hand volumeter uses water displacement to measure hand size and has been found accurate within 10 mL. 5 If swelling is confined to a single digit or joint, circumferential measurements are recorded.
PAIN M A N A G E M E N T Pain frequently accompanies the patient's efforts to move the involved joints of the hand. If pain limits the patient's ability to participate in the therapy program, pain control becomes a priority. The source of the pain must be determined and addressed accordingly. If pain is localized to the fracture site, it is important to determine Whether fracture healing or stability has been compromised. Pain frequently occurs during the initial efforts at moving the joints adjacent to the fracture and may be caused by the stressing of the periarticular soft tissues, which are frequently shortened and scarred. Oral analgesics and antiinflammatory medications, the use of transcutaneous electrical nerve stimulation, and modalities such as heat and cold are all helpful in controlling pain and may be used before, during, or after the exercise sessions. "No pain, no gain" is an inappropriate slogan for a hand
Fig 8. Blocking splints are made to stabilize the joints proximal to the target joint.
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Fig 9. Extensor tendon gliding exercise is performed by extending the MCP joints with the IP joints flexed and the wrist in neutral position.
Fig 11. Exercise to isolate the flexor digitorum superficialis from the profundus; the adjacent digits are held in extension while PIP joint flexion is attempted.
therapy clinic. Certainly, pain and discomfort are expected as the patient begins to move joints compromised by swelling and stiffness. However, if pain exceeds the patient's level of tolerance and is out of their control, protective muscle guarding with inhibition of active motion results. Active motion exercises under the control of the patient and supervised and encouraged by the therapist are most appropriate, particularly during the early phases of the therapy program.
flexion contracture results. In general, the joints adjacent to the fracture site are immobilized as well as the adjacent finger. Splints are also fabricated to incorporate any percutaneous pins to prevent bumping or inadvertent snagging of pins (Fig 6).
PROTECTION AND POSITIONING After operative treatment of hand fractures, a custommade thermoplastic hand splint may be used to provide lightweight protection and positioning. The splint may be used during the early healing phases on a continuous basis and is worn inteITnittently once clinical healing has been achieved and active motion begins. The splint helps to insure immobilization of the fracture, provides protection for any percutaneous pins, and positions the involved joints and digits in a safe position to minimize the risk of joint contracture. The position of the splint in general should be in the safe, protective, or intrinsic plus position 6 (Fig 5). This position requires that the MCP joints be positioned in flexion because the collateral ligaments of the MCP joints are taut when the joint is flexed and cannot undergo shortening and contracture in this position. The interphalangeal (IP) joints are positioned in extension because if allowed to remain in a flexed position for long periods the volar plate and deep fascial supporting structures can undergo irreversible shortening, and a fixed
THERAPEUTIC EXERCISE Joint stiffness is a frequent and almost inevitable consequence after hand fracture, particularly of the joints adjacent to the fracture site. In some cases, stiffening and loss of motion of the more proximal joints of the involved upper extremity can occur as well. To prevent and minimize joint stiffness, therapeutic exercise is begun as early as possible. Active range of motion exercises can begin immediately for the unimmobilized joints. Patients are instructed to perform range of motion exercises of the shoulder and elbow to prevent stiffness and loss of motion. This is particularly important with the older patient with a diminished activity level. The joints adjacent to the fracture site are not moved until the fracture is judged to be clinically stable. If the fracture has been treated with rigid internal fixation, movement can start almost immediately. Exercises are initially performed actively without resistance. The fracture site can be manually stabilized by the therapist when moving the joints adjacent to the fracture. To isolate a particular joint during exercise, blocking exercises are performed. Blocking involves manual stabilization of the joint proximal to the target joint during active exercise (Fig 7). The proximal joint is usually positioned in a neutral position. Blocking splints can sometimes be
Fig 10. Flexor tendon gliding exercises. (A) Full fist; (B) straight fist. REHABILITATION AFTER HAND FRACTURES
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Fig 12. Isolated flexor digitorum profundus exercise: The PIP joint is stabilized while DIP joint flexion is attempted.
helpful for the patient to use to perform the exercises on a home program basis and can be fabricated to block motion proximal and sometimes distal to the target joint (Fig 8). Flexor and extensor tendons can sometimes become adherent at the site of the fracture, limiting tendon excur-
sion. Tendon gliding exercises are performed to address this problem. Extensor tendon gliding is performed by extending the MCP joints with the IP joints flexed and the wrist in neutral (Fig 9). While maintaining MCP joint extension, the patient then extends the IP joints. Flexor tendon gliding has been described by Wehbe and Hunter. 7 Their program involves three basic hand positions. The full fist emphasizes maximum flexor digitorum profundus tendon glide; the straight fist requires maximum flexor digitorum superficialis tendon glide; and the hook fist involves maximum differential glide between the superficialis and profundus tendons (Fig 10). To isolate the flexor superficialis from the profundus, the adjacent digits are held in extension while the patient attempts to flex the PIP joint (Fig 11). To isolate the profundus from the superficialis, the PIP joint is held in extension while the patient attempts to flex the distal IP (DIP) joint (Fig 12). Later, once the fracture has been judged to be well healed and capable of withstanding increased stress, resistive and passive exercise can begin. Passive exercise must be performed within the pain tolerance of the patient. Overly aggressive passive exercise can cause inflammation, increased stiffness and pain, and limit progress. Strengthening exercises are typically performed with therapeutic putty, which can be graded in terms of resistance. Patients are instructed in exercises selected for their particular area of weakness. Flexion, extension, adduction, and abduction strengthening exercises can be performed using putty (Fig 13).
Fig 13. Putty exercises performed for (A) finger flexion; (B) finger extension; (C) abduction; (D) adduction.
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Fig 14. Splint used for metacarpal fractures includes the wrist and the MCP joints of the involved and the adjacent finger; buddy straps are used to control rotation. In all cases, patients are instructed in a home program that supplements the supervised therapy program. In some cases where limitations are minor, patients may be able to perform a home program with less frequent therapy visits. Range of motion measurements are taken on a regular basis to monitor progress and to determine the efficacy of the treatment program. Revisions are made to
Fig 16. Blocking exercises performed for PIP joint extension positions the MCP joint in flexion while PIP joint extension is attempted. the therapy program based on the patient's response to the therapy as well as on fracture healing.
SPECIFIC FRACTURES AND THERAPY CONSIDERATIONS Metacarpal Fractures Metacarpal fractures can occur at the base, the shaft, or the neck with the MCP joint surface involved~8 Base fractures usually involve the fourth or fifth metacarpals. Metacarpal shaft fractures can be transverse, oblique, or comminuted. Transverse fractures may angulate dorsally because of the
Fig 15. Dynamic flexion splint for limited MCP joint flexion. REHABILITATION AFTER HAND FRACTURES
Fig 17. (A) Blocking splint for PIP joint flexion positions the MCP joint in neutral; (B) blocking splint for PIP joint extension positions the MCP joint in flexion.
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Fig 18. Three-point extension splint used to correct PIP flexion contractures of 35 degrees or less,
forces of the long flexors and the interossei; oblique fractures are subject to shortening and malrotation; and comminuted fractures are often associated with significant soft tissue injury. Metacarpal neck fractures are the most common and result from a compression force such as a blow with a closed fist. These tend to angulate dorsally and are subject to the development of a claw deformity according to the zigzag principle as mentioned previously with MCP hyperextension and PIP flexion. Splinting for metacarpal fractures should incorporate support of the transverse and longitudinal arches and should be in the intrinsic plus position. The splint should include the wrist and the MCP joint of the involved metacarpal as well as the adjacent MCP joint. Buddy straps or rotational taping is used to control alignment and prevent overlapping of the digits (Fig 14). Common problems of metacarpal fractures include extensor tendon adherence and stiffness and limitation of the MCP joint. Extensor tendon gliding exercises are emphasized to promote tendon excursion. Friction scar massage is used in the case of adherent incision scars and can help to promote differentiation of the overlying scar from the tendon. Massage can be performed during efforts at active extensor tendon gliding. Stiffness and limited MCP joint flexion is also a frequent problem, and MCP joint exercises are emphasized. When performing exercises for the MCP joint, it is important to stabilize the wrist and corresponding carpometacarpal (CMC) joint to allow concentration of effort at the MCP joint. In some cases, IP joint flexion can be blocked as well to further concentrate forces at the MCP joint. When the fracture is well healed, dynamic splinting can be used to help restore MCP joint flexion if limitations persist. The dynamic splint must provide volar and dorsal
Fig 19. Dynamic PIP extension splint used for PIP flexion contractures of 35 degrees or more. 158
Fig 20. Dynamic splint used to increase PIP joint flexion.
support of the wrist and the CMC joint. Dynamic traction is applied with a finger cuff applied over the proximal phalanx and pulled to a volar attachment point (Fig 15). The tension of the dynamic traction is kept at level that can be tolerated for a prolonged period. Low-load prolonged stress to the shortened periarticular soft tissues has been found to be more effective than high-intensity brief stress in increasing tissue length. 9
Proximal Phalanx Fractures Proximal phalanx fractures can occur at the base, the midshaft, or the neck. Malalignments of proximal phalanx fractures can cause significant deformity. Fractures of the midshaft and base tend to angulate volarly secondary to pull of the interosseous muscles on the proximal fragment and the pull of the extensor mechanism of the distal fragment. With persistent angulation, the PIP joint flexes and can rapidly become fixed in a flexion contracture with edema and inflammatory reaction from the adjacent fracture. 10 Rotational errors can occur and are amplified at the fingertip with overlapping of the digits and compromise of function of the adjacent digits. The two major complications of proximal phalanx fractures include PIP flexion contracture and flexor tendon adherence at the site of fracture. Splinting for proximal phalanx fractures is in the safe position with particular attention paid to positioning the
Fig 21. Gutter splint with pin protection for distal phalanx fractures. TERRI SKIRVEN
limitations. With more significant limitations, a dynamic splint is most effective (Fig 20). Middle Phalanx Fractures
Fig 22. Blocking splint for DIP joint flexion stabilizes the PIP joint in extension.
PIP joint in extension to prevent the development of flexion contracture. The adjacent uninjured digit is included to control rotational alignment. The therapy program for proximal phalanx fractures emphasizes PIP joint range of motion exercises, and these are performed with stabilization of the proximal phalanx and the MCP joint. Tendon gliding exercises are performed as well. Extensor tendon gliding at the PIP joint level is performed by blocking the MCP joint in flexion during active efforts at PIP extension (Fig 16). Flexor tendon gliding exercises are performed as described previously. Blocking splints are sometimes very helpful to enhance the patient's efforts. The blocking splint for PIP extension positions the MCP joint in flexion. The blocking splint for flexion positions the MCP joint in neutral (Fig 17). Tendon gliding and blocking exercises can be combined with biofeedback and electrical stimulation to enhance the patient's active efforts. If limitations in PIP joint mobility persist, dynamic splinting may be used once the fracture is determined to be solidly healed. For a PIP flexion contracture that is 35 degrees or less, a three-point extension splint is recommended to restore extension (Fig 18). If the contracture is greater than 35 degrees, a dynamic PIP extension splint is required (Fig 19).11 If PIP joint flexion is limited, flexion straps or flexion loops are effective with mild to moderate
Fig 23. Dynamic DIP joint flexion splint used to overcome DIP joint stiffness and limited flexion after DIP joint fracture.
REHABILITATIONAFTER HANDFRACTURES
Middle phalanx fractures are less common. They can occur at the midshaft, base, or the neck, with the distal shaft the most frequent area affected. The flexor digitorum superficialis and the extensor tendon provide deforming forces. With a fracture of the neck, the pull of the superficialis causes volar angulation. With a fracture of the base, dorsal angulation results. Fractures of the middle third of the shaft can angulate either way. ~2 Problems common to middle phalanx fractures include stiffness of the PIP and DIP joints, PIP joint flexion contracture, and DIP joint extensor lag. Blocking exercises are begun as soon as the fracture is clinically healed. PIP joint range of motion is performed with the MCP and proximal phalanx supported. The middle phalanx and the PIP joint are supported during DIP joint range of motion. Flexion straps, loops, and dynamic splints are used when the fracture is fully healed and as needed. Distal Phalanx Fractures
The distal phalanx is the most frequently fractured bone in the hand, with the long and the thumb the most frequently involved digitsJ 3 These fractures usually result from crush injuries with comminution of bone. Fractures are classified as open or closed and occur at the tuft, shaft, or base. Unstable distal phalanx fractures require reduction and internal fixation and are protected while healing, usually with a gutter splint with pin protection with the PIP joint free (Fig 21). During healing, PIP and MCP joint range of motion exercises and pin site care are performed. After the pins are removed, usually at 3 to 4 weeks, DIP joint range of motion exercises are begun. Problems associated with distal phalanx fractures are DIP joint stiffness, pulp hypersensitivity, nail abnormality, numbness, and cold intolerance. For DIP joint stiffness, active range of motion exercises and blocking exercises begin as soon as the pins are removed. Blocking splints may be used, which stabilizes the PIP joint and permits DIP joint range of motion (Fig 22). Desensitization techniques are helpful and include massage, tapping, vibration, and rubbing with textures. Later, as healing permits, passive range of motion and flexion loops or dynamic splints can be used to restore DIP joint flexion (Fig 23). Putty exercises are used to develop tolerance for pinch pressure. Sensitivity may persist, and gel-lined sleeves may be helpful for use at work and during other activities (Fig 24).
Fig 24. Gel-lined digital sleeves are useful for hypersensitive fingertips after crush injuries of the distal phalanx.
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SUMMARY The rehabilitation p l a n after a h a n d fracture m u s t c o n s i d e r the stage of healing, the t y p e of internal fixation, potential d e f o r m i n g forces, a n d associated soft tissue injuries. C o m m o n p r o b l e m s after h a n d fractures i n c l u d e joint stiffness a n d limited mobility, e d e m a , pain, t e n d o n a d h e r e n c e , a n d d e c r e a s e d t e n d o n excursion, d e c r e a s e d strength, a n d limited function. G e n e r a l t e c h n i q u e s a p p r o p r i a t e for all h a n d fractures i n c l u d e p o s i t i o n i n g a n d splinting, e d e m a a n d p a i n control, t h e r a p e u t i c exercises, a n d s t r e n g t h e n i n g . The rehabilitation effort is i n t r o d u c e d early after fracture fixation a n d c o n t i n u e s until f u n c t i o n is restored.
REFERENCES 1. Beasley RW: Skeletal injuries, in Beasley RW: Hand Injuries. Philadelphia, PA, Saunders, 1981, p 168 2. Beasley RW: Skeletal injuries, in Beasley RW: Hand Injuries. Philadelphia, PA, Saunders, 1981
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3. Beasley RW: Skeletal injuries, in Beasley RW: Hand Injuries. Philadelphia, PA, Saunders, 1981, p 170 4. Flowers KR: String wrapping versus massage for reduction of digital volume. Phys Ther 68:57, 1988 5. Waylett-RendaU J, Seibly D: A study of the accuracy of a commercially available vohimeter. J Hand Ther 4:10,1991 6. Mannarino SL: Skeletal injuries, in Stanley BG, Tribuzi SM (eds): Concepts in Hand Rehabilitation. Philadelphia, PA, Davis, 1992, p 284 7. Wehbe M, Hunter J: Flexor tendon gliding in the hand. Part II. Differential gliding. J Hand Surg [Am] 10:575,1985 8. Meyer FN, Wilson RL: Management of nonarticular fractures of the hand, in Hunter J, Mackin E, Callahan A (eds): Rehabilitation of the Hand (ed 4). St. Louis, MO, Mosby, 1995, pp 367-372 9. Light KE: Low-load prolonged stretch versus high-load brief stretch in treating knee contractures. J Am Phys Ther 20:93, 1976 10. Beasley RW: Skeletal injuries, in Beasley RW: Hand Injuries. Philadelphia, PA, Saunders, 1981, pp 220-227 11. Fess EE, Philips CA: Splints acting on the fingers, in Fess EE, Philips CA: Hand Splinting. St. Louis, MO, Mosby, 1987, p 288 12. Beasley RW: Skeletal injuries, in Beasley RW: Hand Injuries. Philadelphia, PA, Saunders, 1981, p 217 13. Packer JW, Colditz JC: Bone injuries: Treatment and rehabilitation. Hand Clin 2:1, 88, 1986
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