in moderately resistive daily activities such as vacuuming, laundering clothes (e.g., picking up garments one or two at a time), washing dishes, and preparing simple meals using the operated hand. Between weeks 12 and 14 pos-surgery, and when wrist arthrodesis is established, the surgeon discontinues the orthosis. The client is instructed to resume normal activities and can begin a work-conditioning program if indicated (Cannon, 2020). Partial wrist arthrodesis Many types of partial wrist fusions exist. Partial wrist fusion allows continued motion of the wrist because hardware and bone grafts do not cross the radio-carpal joint. Partial wrist fusion is indicated for a painful wrist that cannot tolerate weighted resistance and, as with the PRC and total wrist arthrodesis, is performed to restore pain-free motion, restore intercarpal stability, and increase functional use (Dewing et al., 2012). Most recent literature concerning treatment of SLAC and SNAC wrist focuses on four-corner arthrodesis rather than PRC. Various partial wrist fusions are performed, but the most common pattern is scaphoidectomy and four-corner fusion. This involves removing the scaphoid bone (which is arthritic) and fusing the lunate, capitate, hamate, and triquetral bones. The fusion is necessary to stop the remaining parts of the wrist from collapsing once the scaphoid has been removed. Joint motion is preserved at the base of the thumb and between the lunate and the distal radius. The bones to be fused are held together using various types of hardware, including a four- pronged metal staple (Shah & Stern, 2013). As with total wrist arthrodesis, the client is secured in a postsurgical cast following the procedure and is referred for therapy within 10 days to begin rehabilitation (Cannon, 2020). Therapeutic intervention following partial wrist arthrodesis At two weeks postsurgery, the client is fitted at the surgeon’s office with a short arm cast or thumb spica cast (for radial-sided fusions). Referral to PT/OT also occurs at this time, with the goal of preserving and increasing the motion of surrounding joints, including the elbow, MCPs, and IPs (Cannon, 2020). Motion is impossible in supination and pronation because of the cast and should not be forced. The therapist also explores areas of occupational dysfunction experienced by the client due to stiffness of the surgical wrist. As needed, the therapist recommends adaptive techniques or devices to enhance functional abilities. Between 10 and 12 weeks postsurgery, the cast is removed and the therapist provides either a wrist immobilization orthosis (Figure 23) or a thumb spica orthosis (Figure 21) to be worn between exercise sessions and at night. The client is instructed in AROM exercises for the wrist that take place during 10-minute sessions each hour. Since a partial wrist fusion does not cross the distal radio-carpal joint, the return of some mobility of the wrist joint is expected. Scar control can also be initiated using massage and silicone gel sheets as indicated. At 12 to 14 weeks postsurgery, PROM can be initiated at the wrist. The expectation for motion following a partial wrist fusion is approximately 50% of normal range (Cannon, 2020). Forces that achieve normal arcs of movement should not be attempted. If significant limitations exist, dynamic mobilization can be initiated and monitored for excessive force or acquisition. Progressive strengthening can also begin during this phase for both the hand and the wrist. The client can also return to normal daily activities either with or without wrist orthosis protection, depending on required forces and pain. Pain should be avoided when the client is completing strengthening, dynamic mobilization, or functional tasks (Cannon, 2020). Once the client is established with their home program and is able to complete desired daily activities, therapy and dynamic mobilization are discontinued.
Figure 24: X-ray: Total Wrist Fusion
Note : “X-ray showing arthrodesis of right wrist” by TheFriendliest, used under Creative Commons license BY-SA 4.0 / Cropped from original. During fusion, the wrist is placed in 10 degrees of wrist extension to allow positioning of the hand needed for power gripping. Although the best wrist position for power gripping is 35 degrees of extension, that angle interferes with occupational engagement. A position of 5 to 10 degrees of ulnar deviation is also set (Shah & Stern, 2013). Following surgery, the client is placed in a postsurgical cast and referred to therapy after approximately 10 days to 2 weeks. Therapeutic intervention following total wrist arthrodesis Following total wrist fusion, the client’s wrist is immobilized in a cast for as long as six weeks. During that time, the client is referred to therapy for edema control and ROM of the noninvolved joints. Specific attention must be paid to the extensor indicis, the extensor digitorum, and the extensor pollicis longus tendons because they can become adhered with a scar that develops from the long dorsal incision required to access the joint and apply the plate during the fusion. Gentle functional activities that encourage excursion and gliding of these tendons should be initiated (Cannon, 2020). The therapist can use neuromuscular electrical stimulation if they are well versed in its application, indications, and contraindications. One- handed techniques and adaptive equipment ideas should be shared with the client to foster ADL function during this time of healing. Between six and ten weeks, when consolidation is progressing, the cast is removed and the therapist fits the client with a bivalve thermoplastic orthosis (Cannon, 2020). Scar massage can be started along with heat modalities to increase scar extensibility. Modalities such as ultrasound (Knight & Draper, 2013), hot packs, and dry whirlpool can be beneficial if the therapist is skilled in their use and they are used in preparation for function (AOTA, 2020). Taping or dynamic mobilization of fingers can be used to increase flexion if scar adhesions or disuse contractures are present (Cannon, 2020). At week eight postsurgery, progressive strengthening of the hand can be initiated while the client is using the wrist orthosis. No resistance to supination and pronation should be applied because the torsional load could negatively impact the fusion (Cannon, 2020). The therapist encourages the client to engage
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