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 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.
CASE STUDY 1: NONSURGICAL
Mrs. Hernandez is a 62-year-old female with a diagnosis of left dominant hand thumb CMC osteoarthritis. Mrs. Hernandez is employed as an office manager of a busy orthopedist office and in her free time enjoys crocheting scarves; cooking; and playing with her grandchildren, ages two and four. Mrs. Hernandez was referred to rehabilitation for treatment of her left hand because she has reported increasing pain and decreasing functional abilities with work, leisure, and ADL activities. The therapist administered the Manual Ability Measure-20 (MAM-20) to determine the extent of Mrs. Hernandez’s functional deficits. She scored a 58/80 and reported pain as an 8 on a 0 to 10 visual analog scale (Chen & Bode, 2010). During visual examination, the therapist noted enlargement of the CMC joint with a squared appearance at the base of the thumb. AROM measurements of the MCP and IP joints indicated full ROM in flexion and extension, with no deformities of these joints. Thumb palmar abduction, however, was found to be 40 degrees in comparison to 60 degrees on the right hand, indicating early adduction contracture. Strength measurements using dynamometer and pinch meter were:
Left
Right 79 lb
Gross grasp Lateral pinch
40 lb
5 lb 15 lb 3 lb 13 lb
Three-jaw chuck
Pincer grasp 6 lb The therapist created a treatment plan to address the concerns of Mrs. Hernandez, which included pain; decreased ADL, work, and leisure functions; weakness (secondary to pain); and early adduction contracture. Treatment included: 3 lb ● Fabrication and provision of a custom short-thumb spica orthosis with C-bar to prevent adduction contracture; an instruction sheet for care and use was provided. ● Instruction in joint protection techniques and adapted techniques for ADL. ● Recommendation, due to pain associated with writing at her job, that Mrs. Hernandez complete work on a tablet computer using a stylus, which was adapted to increase circumference and thereby reduce pinching and force application to the CMC joint.
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Book Code: PTOH1324
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