The client should also begin scar control techniques with scar massage and begin to use a custom elastomer-based cover or silicone gel sheet for the scar. Elastomer is a silicone-based sub- stance that is molded to a scar to provide well-dispersed pressure for prevention of hypertrophic scarring. When used in concert with a secondary device such as spandex (e.g., Lycra) gloves, the elastomer-based covering ensures that pressure over the scar is distributed evenly. In comparison to other scars, those from CMC arthroplasty surgeries tend to be hypersensitive and might require desensitization techniques in addition to scar massage. Desensi- tization can be accomplished by instructing the client to rub the area gently with materials of increasingly rough texture, starting with satin fabric and ending with sandpaper or hook-and-loop fas- teners (e.g., Velcro). Edema control techniques, if needed, should be initiated at this time in the form of retrograde massage and nylon/spandex glove wear. Retrograde massage can be administered by the therapist and shown to the client for independent edema control. Follow - ing application of a mineral-oil-based, nonscented hand lotion or cream, the fingers and wrist are stroked gently from fingertips to forearm for approximately 10 minutes. This technique not only enhances circulation and pushes interstitial fluid into the circula- tory system but also warms the hand in preparation for motion and function. Additionally, at the six-week mark, the client can be given light therapeutic tasks such as penny or foam square pick-ups and transferring rice or popcorn kernels (unpopped) from one contain- er to another. Activities such as simple crafts and light writing can also be initiated within limits of pain tolerance and according to client desires. Following a session of exercise and activity chosen for enhancing motion in the stiff postsurgical thumb, ice packs can be applied to control discomfort and swelling or inflammation. The thumb spica orthosis should be worn during daily activities for protection between exercise sessions and at night. At eight weeks postsurgery, extension contractures of MCP or in- terphalangeal joints (that have not been fused) can be treated with dynamic orthoses or passive manual stretching. Regaining a normative balance of the tendon and ligament system of the thumb is of paramount importance in preventing further defor- mities and enhancing function. Care should be taken not to ap- ply these forces to newly reconstructed CMC joints (Bielefeld & Neumann, 2011). Clients will discover renewed interest in some daily activities that were avoided due to pain, and should be encouraged to participate in desired activities within pain limita- tions. Scar control, edema control, and ice should be continued as needed. During the ninth and tenth postoperative weeks, the thumb or- thosis can be discontinued if the client is reporting less pain, the joint is stable, and the surgeon approves. Optional dynamic or- thoses can be continued or discontinued according to the client’s progress. Light strengthening exercises can be initiated at this time. Increases in resistance should be introduced gradually and according to pain tolerance. During this time, therapy can be dis- continued, but prior to the final visit, the client should be instruct- ed in joint protection techniques to ensure the pain-free status of the CMC and prevent disruption of the joint. (See Appendix A.) posture that can result in a dorsal intercalated segment instabil- ity deformity. Both conditions lead to OA of the radioscaphoid articulation and eventual midcarpal collapse (Shah & Stern, 2013). Kienbock’s disease involves breakdown of the lunate resulting from trauma of that bone. Active adults age 20 to 40 years are most likely to report the disease. Kienbock’s disease might involve both wrists, but is primarily a unilateral joint condition. Although an exact etiology for the condition has not been determined, re- petitive trauma of the wrist is the suspected cause (Dewing et al., 2012). Individuals such as carpenters and roofers, who spend a great deal of time bearing weight on extended wrists when using heavy tools, tend to have higher incidences of Kienbock’s disease
of the client (Holme et al., 2021). In a systematic review, over - all outcomes were good regardless of the type of implant, but researchers discovered failure rates ranged from 2.6% to 19.9% (Holme et al., 2021). Failures included loosening or dislocation of the implant, which necessitated revision, often by performing an LRTI (Badia, 2011; Holme et al., 2021). It is crucial that therapists be aware of the type of arthroplasty used and associated restrictions and precautions as outlined by the surgeon so that they can follow the appropriate rehabilitation protocol. Additionally, therapists usually spend a significant por- tion of time educating the client on prognosis and any permanent differences or limitations in hand function depending on the surgi- cal approach used. For example, it is common for clients to not be able to flatten their hand after an LRTI due to the position of the reconstruction and the need to maintain stability of the CMC (Cannon, 2020). While this may not have a large effect on func- tion, clients are often very concerned about this, which can lead to increased anxiety regarding recovery. Therapeutic intervention following carpometacarpal joint arthroplasty Clients who have undergone the LRTI procedure most typically require pinning of the CMC joint for added stability following sur- gery. Clients might also have undergone tenodesis (i.e., anchor- ing a tendon to a bone) or arthrodesis (i.e., fusion) of the MCP or interphalangeal joints to create stability in the case of hyperflexion or hyperextension deformities. Pinning for stability is in addition to the postsurgical plaster cast dressing applied by a surgeon. As a result, therapy is typically not initiated until a minimum of four to six weeks following surgery, when the pins are removed. Some surgeons, however, might refer a client earlier for the provision of a thermoplastic thumb spica orthosis that can be donned and doffed for dressing changes if needed and that is lighter weight and water resistant. This early therapy visit offers an opportunity for the OT to assist a client in completing desired ADL and other activities using one-handed techniques or adaptive equipment. When the surgeon dictates that mobility can occur (typically four to six weeks postsurgery), the client is fitted with a custom-fabri- cated thumb spica orthosis or has the size of a previous orthosis adjusted. The orthosis is a traditional thumb spica that involves the wrist and thumb MCP joint, and possibly the interphalange- al joint. The orthosis provides protection and pain control while tissue healing continues and motion is initiated. During the first therapy visit, regardless of when that occurs, the client must be instructed on how to maintain participation in desired activities using adaptations and modifications as needed. At this time, the client is instructed to begin active or gentle passive ROM to the wrist three to four times a day (Cannon, 2020). While stabilizing the thumb CMC joint with the other hand, clients can also begin AROM of the thumb MCP and IP (Cannon, 2020). One week after beginning wrist, thumb MCP, and thumb IP AROM exercises, clients can begin AROM to the thumb CMC, focusing on composite thumb flexion and extension, palmar abduction, thumb circumduction, and opposition to each finger (Cannon, 2020). It is important to maintain as much CMC stability as pos- sible to avoid stretching the LRTI; therefore, PROM of the CMC is not recommended. Several conditions are commonly associated with OA of the wrist and hand. An overview is provided here, followed by discussions of conservative medical management, surgical management, and occupational therapy interventions. Scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) are the two most common patterns of posttraumatic wrist arthritis. Both conditions lead to abnormal joint kinematics because of changes in the orientation of the lu- nate due to changes to the scaphoid. Change can occur as a result of rheumatoid arthritis, calcium pyrophosphate dehydrate depo - sition disease, neurogenic disease, or nonunion of the scaphoid (Shah & Stern, 2013). Over time, the lunate assumes an extended
WRIST OSTEOARTHRITIS
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Book Code: PTCA2624
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