secured with self-adherence wrap can be used during certain activities to protect the PIPs. At this and earlier phases, the therapist is instrumental in assisting clients in understanding their limitations and the limitations of their new joints, and providing adaptive equipment or techniques to ensure that clients can engage in desired activities without risk to new joints. Static orthosis protocol If the physician orders a static orthosis following surgery or a dynamic orthosis is not indicated, a custom- fabricated, hand- based extension orthosis is used on the affected digit. Care should be taken to ensure there is lateral support to the PIP joint for neutral alignment, and this may include a neighboring digit if necessary. If multiple digits were repaired, a forearm-based orthosis should be used to provide additional support (Cannon, 2020). The orthosis is fabricated at the first therapy session, occurring three to five days postop, and is worn between exercise sessions and during sleep hours. Specific active and passive ROM exercises are initiated four times a day, including isolated flexion blocking to the PIP and DIP; short arc composite active flexion; full arc active extension; straight fist; and reverse blocking, which involves active extension of the PIP while maintaining MCP flexion. Composite flexion exercises should be avoided to minimize risk of an extensor lag. Isolated active and passive PIP joint flexion exercises should be performed instead, ensuring the MCP remains in extension. Typical ROM following a PIP arthroplasty is only 25/75 degrees, so care should be taken to conduct exercises with respect to that range (Cannon, 2020). At 10 to 14 days postsurgery, the client can begin composite active flexion, isolated PIP passive flexion, and full active and passive extension exercises every two hours. If passive flexion of the PIP is less than 70 degrees and the extensor lag is less than 20 degrees at this time, then a custom-fabricated dynamic flexion orthosis for the PIP only may be used for 30- to 60-minute sessions, four to six times a day (Cannon, 2020). Use of the dynamic flexion orthosis should be limited or discontinued if the extensor lag increases. It is important during this time to balance flexion and extension gains and minimize risk of an extensor lag as much as possible. At three weeks postsurgery, the hand-based extension orthosis can be discontinued, and a static digital gutter orthosis (Figure 16) is worn instead, keeping the PIP and DIP in max extension (Cannon, 2020). The therapist should continue to monitor the extensor lag and decrease flexion exercises if the lag increases. Figure 16: Volar Digital Gutter Orthosis
During the same postoperative visit, a static resting pan orthosis is fabricated for night wear and for times when a break from the dynamic orthosis is required. The static orthosis is forearm based, with the wrist in approximately 15 degrees of extension, the MCP joints in 20 degrees of flexion, and the PIP/DIP joints in full extension (Gabay & Gabay, 2013; Lubahn et al., 2011). Figure 15: Template for Limiting Active Flexion
Source: Erin Peterson At two weeks postsurgery, flexion of the PIP can be increased to allow 45 degrees in the dynamic orthosis or static templates only if active extension of the PIP is noted and no extension lag is present. If active flexion is less than 30 degrees and full PIP extension is maintained, dynamic traction during exercises (in the case of dynamic orthoses) can be removed and active assistive ROM can be initiated. During these exercises, the MCP should be maintained in blocked flexion (Gabay & Gabay, 2013). During the third postoperative week, the dynamic orthosis can be discontinued, and active flexion can be allowed with buddy taping to adjacent digits to 60 degrees. Buddy taping allows gentle force to be applied in flexion and protects from lateral deviations and rotation. At six weeks postsurgery, flexion should be allowed to 75 degrees, ensuring that extension remains at zero degrees. Seventy-five degrees of active flexion is the maximum amount of motion that should be sought following this procedure. A pain- free state is also of great importance in marking a successful arthroplasty. At three months, the client is usually allowed to return to typical daily activities, but these should be initiated only as tolerated. Joints with arthroplasties are more delicate than natural joints, and care should be taken not to place undue lateral pressure of excessive flexion forces on them (Gabay & Gabay, 2013; Lubahn et al., 2011). If needed for protection, a small gutter orthosis
Source: Erin Peterson At eight weeks postsurgery , the client should begin slowly weaning from the digital gutter extension orthosis and fully discontinue wear over the next four weeks. When out of the orthosis, the affected digit should be buddy taped/strapped to the adjacent digit to provide protection against lateral stress
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Book Code: PTNY1024
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