Surgical management and postsurgical therapeutic intervention Several types of surgery can be executed based on the medical diagnosis and mechanics of the joint/bone breakdown resulting from OA. Each procedure has its own postsurgical therapy protocol. This section outlines the protocols for therapy following proximal row carpectomy and partial- and total-wrist arthroplasty. Proximal row carpectomy
thermoplastic orthosis. If tendon gliding and excursion (i.e., the ability for tendons to travel freely through their sheaths) have been impacted by dorsal hand scarring and are causing difficulties with finger flexion and extension, the therapist can initiate neuromuscular electrical stimulation (NMES), an electrical modality that stimulates the muscle fibers to create a contraction, thereby assisting with application of internal force (i.e., pressure) to the scar adhesions surrounding the tendons. Light activities that target and encourage flexion and extension of the fingers should be suggested not only to encourage movement of the hand but also to provide an opportunity for light protected strengthening and affirmation that the surgical intervention will lead to newfound, pain-free function. At five weeks postsurgery, active-assisted ROM can be initiated to the forearm and wrist as long as exercises remain pain-free. It is important to respect the client’s pain and never force recovery of motion (Cannon, 2020). Orthosis wear should be continued during resistive activity and sleeping but can be removed for light activities such as eating, reading, typing, writing, and watching television. At six weeks postsurgery, PROM geared toward increasing ROM can be initiated (Cannon, 2020). At eight weeks postsurgery, with wrist joint flexion limited to less than 30 degrees, a dynamic wrist flexion orthosis can be used. However, 30–35 degrees of wrist flexion is functional, and the wrist should not be pushed to gain more motion than that into flexion. The wrist immobilization orthosis can be mostly discontinued except for heavy activities that involve resistance or torque to the hand or wrist. Progressive strengthening can commence if the client has only low pain. Strengthening can be accomplished with therapy putty and wrist weights, beginning with the least resistive and lightest, and eventually working toward those with more resistance (Cannon, 2020). The client can also begin to use the hand in occupations that are mildly resistive and done in a controlled manner. For example, brushing teeth and using the hand for bathing, eating, and preparing light meals are appropriate. Working in the garden using tools or completing carpentry activities is inappropriate at this time, but these activities are added to a client’s regimen within the next few weeks. No activity should be completed if it causes discomfort. Between 10 and 12 weeks postsurgery, the resting orthosis should be fully discontinued. Dynamic mobilization should be stopped at 12 weeks unless gains continue and more than 30 degrees of flexion is not being sought (Cannon, 2020). The client can be instructed to resume all normal activities. For those involved in heavy work, a workplace assessment will determine the amount of force that their job places on the wrist and whether a protective circumferential wrist orthosis should be provided. This intervention significantly reduces the client’s pain and allows them more functional use despite an expected permanent decrease in strength and motion. Total wrist arthrodesis The ultimate salvage for any motion-preserving procedure is total arthrodesis (i.e., fusion). This procedure involves fusing all wrist bones, leaving the rotating joint between the radius and the ulna to preserve supination and pronation (Figure 24). Indications for total wrist fusion include a painful or unstable wrist due to collapse of the carpus, Kienbock’s disease, or SLAC wrist. According to Cannon (2020), to create total wrist fusion, the surgeon makes a dorsal incision extending along the third metacarpal to the distal third of the radius. The dorsal wrist capsule is exposed and incised. The proximal row of carpal bones and distal radius are removed, and the dorsal surface of the third metacarpal is shaved to expose cancellous bone. A cancellous bone graft from the iliac or other viable donor site, including possible use of removed carpal bone, is placed in the defect with a plate that extends to the radius along the third metacarpal (Shah & Stern, 2013).
Proximal row carpectomy (PRC) is a surgical treatment for severe arthritis of the wrist. The procedure involves removing the first row of wrist bones and relying on the remaining bones for movement. In comparison to other forms of joint fusion, PRC is a simple procedure that does not require permanent immobilization of the wrist or placement of indwelling hardware. Rehabilitation following the procedure is straightforward and progresses quickly because no bone healing is required. PRC is appropriate for moderate and early-stage SLAC and SNAC wrists when the articular surfaces of the head of the capitate, and the lunate facet of the distal radius, have not been destroyed (Wall & Stern, 2013). The radioscaphocapitate ligament must also be intact to prevent postoperative ulnar shifting of the carpus. The procedure is effective in cases of Kienbock’s disease with carpal collapse (Cannon, 2020; Wall & Stern, 2013). Good results have been achieved with PRC, which provides most clients with total, pain-free, active motion in flexion and extension of 72 degrees (Cannon, 2020). Average grip strength following PRC varies. Several studies suggest average grip strength is 71% to 79% compared to the contralateral noninvolved hand (Bednar et al., 2011), and other studies show that as much as 91% to 100% of grip strength is regained, but this might take up to a year to achieve (Wall & Stern, 2013.) Therapeutic intervention following proximal row carpectomy According to Cannon (2020), approximately 10 to 14 days following removal of the proximal carpal row, the client is fitted with a short arm cast in the surgeon’s office. If there are no concerns for client compliance, the client can instead use a custom-fabricated and clamshell design forearm-based wrist immobilization orthosis. The orthosis is worn full time, with removal only for careful hygiene. A referral for therapy is made, during which active and passive ROM exercises are initiated to the shoulder, elbow, digits, and thumb. These movements are safe because the healing wrist is immobilized securely in the circumferential cast or orthosis. In addition to ROM, edema control methods such as retrograde massage, positioning, and compression garments can be provided as needed to the forearm and hand. At three weeks postsurgery, and while the client is still wearing the orthosis or cast, AROM exercises for the forearm can begin. It is important for clients to only perform short arc motion initially, then progress to mid arc, followed by full arc over the course of a week (Cannon, 2020). At four weeks postsurgery, the cast is removed and AROM wrist exercises can begin with the forearm in neutral (Cannon, 2020). By keeping the forearm in neutral or pronated, the distal end of the radius rests more proximally and puts less strain on the healing wrist (Cannon, 2020). The thermoplastic wrist immobilization orthosis (Figure 23) is fabricated at this time (if the client was in the cast prior) or continued. Clients are instructed to wear it full time, removing it only for hygiene and exercises. This orthosis offers rest and protects the healing wrist. It enables the client to engage in ADL that are too forceful for an unprotected joint. For example, while wearing the orthosis, the client can complete dressing activities and household tasks such as light meal preparation and light sweeping. The client should be educated on activities that are appropriate for this period and instructed to wait until additional healing occurs before attempting others. Scar-control techniques, including massage elastomer pressure inserts and silicone gel sheets, can be started as needed at four weeks, or sooner if the client was using the
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