Introduction rehabilitation centre, SRU for hand rehabilitation following

 Introduction

Rheumatoid Arthritis (RA) is an autoimmune condition which primarily affects
the synovium of the joints. It is characterized by soft tissue laxity, joint
erosion, and deformities which happen as a result of inflamed synovial tissue1.Extensor
tendon ruptures are often associated with rheumatoid arthritis. Extensor tendon
injuries are not as common as flexor tendon injuries but if not treated properly
might lead to substantial loss of hand function2.  This condition is best treated with surgical
exploration and repair of the ruptured tendons, followed by hand therapy.
Rehabilitation following an extensor tendon injury helps to improve range of
motion, strength and hand function. Here, we present a case of extensor tendon
repair with extensor indicis (EI) transfer to extensor digitorum communis (EDC)
along with resection of distal ulna. We discuss its presentation, physiotherapy
assessment and management.

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Case presentation and Rehabilitation

The patient is a
45-year-old right-handed woman referred to rehabilitation centre, SRU for hand
rehabilitation   following right Upper limb EDC exploration and
repair with EI transfer to EDC along with distal ulnar resection . The patient is
a known case of Rheumatoid Arthritis for past 20 years on treatment. The
patient chief complaint was inability to extend ring finger and little finger since
4 months. A hand surgeon’s referral was sought and was operated on 4.8.2017.A right
Upper limb  extensor tendon exploration
and repair with distal ulnar resection at the level of the wrist joint (zone 7).On surgical exploration  it was found that EDC of ring and little
finger was completely ruptured. EIP was intact, but thinned out. Proximal and
Distal cut ends of EDC was identified. Distal end of EDC, middle and finger
sutured with EDC of index and middle finger. EIP transected and transferred to
EDC. Through the same incision distal ulnar periostium also elevated.
Subluxated ulnar excision . Ulnar styloid left intact. Periostium
reapproximated. Functional POP applied.

Postoperative period was uneventful
and patient discharged in stable condition. Patient had undergone B/L TKR in
2002 and hysterectomy in 2016. The  patient was evaluated for range of motion,
grip strength pinch strength and hand function. The examination was performed
on 3rd, 6th and 12th week.

 

PHYSICAL THERAPY TREATMENT AND SPLINTING

  

The patient received physiotherapy program (
immobilization method) as per the guidelines   provided by Hunter JM, Mackin EJ, and Callahan
AD. The Physical therapy  treatment was
divided into three phases

The first phase: During the
first three weeks wound care was performed by hand surgeon, management of edema
and exercise were advised by physiotherapist. Exercises were applied using
Hunters Protocol. A volar splint (POP)was
applied by the surgeon  with wrist in 40-45
degrees extension, 0 to 20 degrees of MP flexion, and 0 degrees or IP flexion. The POP
cast extended upto the level of DIP joints. DIP joint protective ROM exercises were given. After a week POP was
reapplied. Sutures were removed after 15 days and POP reapllied from below
elbow upto MCP joints. Protected ROM exercises to MCP, PIP and DIP joints were
started. These
exercises were given to prevent tendons adhesions. at the end of 3 weeks, the
POP was removed and a thermoplastic splint which maintained the wrist in 40 degrees
extension , MCP in 70 degree flexion and IP in neutral position was provide. Since
the extensor tendon injury was associated with DRUJ disruption following
surgery the patient presented with extensor lag of 20 degrees and it was graded
as fair using dragon’s criteria.

 

The second
phase: From 3-6
weeks we continued with the same exercises as phase I .Active MCP exercises
were added to treat extensor lag and added exercises “press and hold”which were
replaced with tendon gliding and grip strength exercises using a hock position.
In week 6 we also started with abduction and adduction of fingers, Individual finger extension, Isolated EDC extension and
opposition of the pollicis divide to the other fingers and active exercise for
radio-carpal joint, composite MCP and IP flexion with wrist extension were
started

 

The third phase: In week 8-12, the patients continued with described
exercises as above and  Mild progressive strengthening including wrist flexion/
extension, forearm pronation/supination, smile ball, putty clay exercise ,
pegboard  exercises were performed.

 

All exercises were
performed every 2 hours a day (1 set, 10 repetitions).The patient was
instructed to continue the home-based exercise programme, which was modified
and intensified at that point.

 

RESULTS

Range
of motion(ROM): Standard goniometric measurement of
fingers and wrist were performed using a standard goniometer .Total range of
motion of the digits(TROM) , ROM of wrist and radio-ulnar joint was measured at
the beginning  of 4th   and at
the end of 8th and 12th week and was tabulated. Range of
motion was reduced at assessment- 1 and gradually improved at subsequent assessments.
During 1st assessment it was observed that the ROM of the digits was
very minimal. This was due to the presence of POP for initial 3 weeks and hence
ROM exercises was not possible and hence the rehab program was modified
according to the medical management. An extensor lag of 20 degrees was present
in middle finger, but during phase 2 and phase 3 the extensor lag improved due
to  splinting and isolated EDC activation
exercises. wrist ROM and radio-ulnar  ROM
improved steadily in phase 2 and 3.

 

AROM

Wrist
Flex

Wrist
Ext

R.dev

U. dev

Sup

Prn

4rd  week

0~10

10

0

10

   10

           50

6th  week

50

10

10

20

10

70

12th  week

50

30

10

25

30

80

TROM

1
 

2nd
 

3rd

4th
 

5th
 

4rd  week

70

50

40

40

40

6th  week

140

220

230

200

160

12th  week

140

240

250

220

190

 

 

Assessment of strength: grip strength was measured using sphygmomanometer
and pinch strength using a pinch meter at 8th and 12th
week. There was an improvement in both measurements. The results are shown in
the table

 

Pinch Strength

Tip  pinch

Lateral pinch

Palmar pinch

Grip
Strength

Right

left

Right

left

Right

left

Right

Left

8th
 week

3kg

6kg

2kg

5kg

3.5 kg

7kg

 

   

12th  week

4 kg

6kg

4 kg

5kg

5 kg

7kg

 

 

 

Measurement of hand function: measurement of hand function was assessed
using DASH scale. There was improvement in scores denoting improved hand
function

DASH

Score

6th  week

38

12th  week

18

 

DISCUSSION

The challenge in
rehabilitation of surgical repaired extensor tendon with tendon transfer is to
find balance between protection of repaired site and prevention of adhesion,
movements constrains. There are various protocols in managing tendon repair
namely 1) immobilization 2) early controlled mobilization 3) Early active
mobilization. All these protocols are variably used for rehabilitation of
flexor tendon. Recently they are gradually integrated in to the treatment of
extensor tendon. Even though  now a days
early controlled mobilization and early active mobilization are frequently used
we followed immobilization method as selecting the protocol depends upon
experience of the Hand surgeon and Hand Therapist. Studies support that three
month post operative, no difference was found between the different
rehabilitation programmes. Immobilization protocol prove to be useful in
managing extensor tendon rehabilitation as there was a considerable improvement
in ROM, hand function

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