Chapter 22

### Objectives

After completion of this chapter, the physical therapist should be able to do the following:

• Discuss key concepts of functional anatomy and biomechanics involved in the normal wrist and hand.

• Relate biomechanics and tissue-healing principles to the rehabilitation of various wrist and hand conditions.

• Discuss criteria for progression of the rehabilitation program for specific hand and wrist conditions.

• Describe the rationale for specific orthotic techniques in the management of selected wrist and hand conditions.

### Functional Anatomy and Biomechanics

The hand is an intricate balance of muscles, tendons, and joints working in unison. This balance combines mobility, stability, and dexterity allowing the hand to perform a multitude of activities. Any disruption of this balance as a result of an injury or condition can greatly alter the ability of the hand to perform activities of daily living (ADL). At work, the hand is the most frequently injured part of the body.79 Hand conditions can occur as a single injury, over time as in cumulative trauma, or because of a disease process.

Treatment of hand conditions requires a complete history and evaluation. These evaluations can include subjective and objective assessments that assist the physician and therapist in determining the specific hand dysfunction. A diagnosis of “hand pain” or “wrist pain” does the client a disservice and may lend itself to treatment that is not specific to the condition. The reader is referred to the text, Rehabilitation of the Hand and Upper Extremity (6th ed.),72 for a complete discussion of evaluations and assessments.

Treatment of the hand is based on the phases of wound healing. Initially, the inflammatory phase usually lasts 3 to 5 days. It is typically a time of vascular dilation and edema.62,89 The extremity is often immobilized during this phase. For example, following a surgery, a bulky dressing can provide immobilization during this phase. This phase can be prolonged in cases of overactive patients or aggressive therapy. Diabetes or specific medications can prolong this and other phases of wound healing. The second phase is the fibroplasia phase, which typically lasts from 5 to 21 days.62,89 During this phase, the fibroblasts lay down collagen in a random network. Depending on the specific diagnosis, special protected motion exercises may be allowed during this phase. An example of this is treatment of a newly repaired flexor tendon, which generally begins with passive range of motion (PROM) in a protective orthosis during this phase to avoid stress on or rupture of the repair.62

The third phase is the maturation phase that usually begins at 3 weeks. It continues for several months. Here the randomly oriented collagen matures and develops strength with intermolecular crosslinking.62,89 Adhesions also form during this phase. Some treatment protocols are often progressed during this phase. Care should be taken to use caution during the application of ...

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