New York Physical Therapy Ebook Continuing Education

Surgical management and postsurgical therapeutic intervention Over the years, many surgical approaches to treatment of arthritis of the CMC joint and other hand joints have been tried and discarded, or improved on. Current approaches to OA of the CMC joint include arthroplasty and arthrodesis. Arthroplasty

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- fabricated 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 interphalangeal 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 possible to avoid stretching the LRTI; therefore, PROM of the CMC is not recommended. 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 substance 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. Desensitization 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 fasteners (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. Following 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 circulatory 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 container 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 interphalangeal 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

is the reconstruction of a diseased or destroyed joint, and arthrodesis refers to joint fusion in which two (or more) bones that articulate to form the diseased area are connected through either a bone graft or fixation device such as interosseous wiring. Carpometacarpal joint arthroplasty While silicone implants are commonly used for PIP joint arthroplasty procedures, they are not recommended for CMC arthroplasty (Lubahn et al., 2011). Due to repeated stress demands placed on the thumb CMC during daily use and the wide range of mobility of the joint, silicone implants often fragment after several years of use, leading to silicone synovitis, which necessitates removal of the implant. Instead, surgeons have utilized multiple excisional techniques for the damaged CMC joint with varying anatomical nuances. In general, excision of the affected bone regardless of the technique has been shown to improve function in most clients (Lubahn et al., 2011). Complications for some clients still exist, however, and surgeons continue to find new options to restore the thumb CMC (Lubahn et al., 2011). The most widely used excision and arthroplasty technique for the thumb CMC is the ligament reconstruction tendon interposition (LRTI) procedure. In general, the trapezium is completely removed, and a tendon or partial tendon is harvested from the client and used as a soft tissue interpositional athroplasty, taking the place of the trapezium (Cannon, 2020). Donor tendons include all or part of the flexor carpi radialis (FCR), abductor pollicis longus (APL), or (rarely) the extensor carpi radialis brevis (ECRB; Badia, 2011). Depending on the donor tendons used, clients may have decreased wrist flexion strength or other complications (Duerinckx & Verstreken, 2022). Outcomes are generally good following LRTI procedures, but rehabilitation can be long and painful (Badia, 2011). Due to this, surgeons are continually researching other methods of restoring the thumb CMC joint, including use of prosthetics. Various brands and types of prosthetics can be used for the thumb CMC joint depending on the surgeon’s preference and the needs of the client (Holme et al., 2021). In a systematic review, overall 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 portion of time educating the client on prognosis and any permanent differences or limitations in hand function depending on the surgical 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 function, 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 surgery. Clients might also have undergone tenodesis (i.e., anchoring 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

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Book Code: PTNY1024

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