Chapter 22: Rehabilitation of the Wrist, Hand, and Digits

INTRODUCTION

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 (ADLs). In the work setting, the hand is the most frequently injured part of the body.¹ Hand conditions can occur as a single injury, over time as in cumulative trauma, or due to disease process.

Treatment of hand conditions requires a comprehensive 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.),² for a complete discussion of evaluations and assessments. Patient-reported outcomes (PROs) should be considered a part of a thorough evaluation. The importance of PROs has been discussed extensively in the literature. PROs provide an opportunity for the patient to describe the impact of their health-related condition and use of PROs keep the patient central to their care.³ Various measurement tools have been developed for this purpose and the provider should use the most appropriate tool. 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.^4,5 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.^6,7 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. One 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 ...