donning and doffing it appropriately and concurrently maintaining postoperative restrictions. In these scenarios, it may be more feasible to use a static orthosis. In fact, researchers have noted similar outcomes in pain reduction, range of motion, and strength between clients treated with either a static orthosis or dynamic orthosis following PIP arthroplasty (Riggs et al., 2011). Furthermore, static orthoses are easier to fabricate and may be a better option for the During the first therapy visit, occurring from four to seven days following surgery, a dynamic PIP joint extension orthosis is fabricated to allow the client to flex the PIP joint to 30 degrees and allow the rubber band to return the joint to neutral. This limited movement allows time for healing of the extensor apparatus. When multiple fingers are involved, a dorsal forearm-based orthosis is fabricated that extends to the proximal phalanx, leaving the PIP joints free. A finger sling attached to monofilament and rubber bands is placed on the middle phalanx. To ensure that 30 degrees is maintained without additional flexion, a stop can be added to the monofilament as it crosses the outrigger to prevent additional movement of the joint. The client is instructed to complete 10 repetitions of flexion each waking hour. The goal of the orthosis is to provide proper protection and allow a limited arc of flexion from zero to 30 degrees at the PIP joint. less experienced therapist. Dynamic orthosis protocol Hyperextension of the PIP or extension lag (i.e., lack of full PIP extension) should be avoided, and therapy/orthosis should be adjusted immediately if either is present. Appropriate tensioning of the rubber bands, with close monitoring, minimizes development of these complications. If hyperextension is present, a small dorsal-based extension block can be secured over the PIP in a fashion similar to a gutter orthosis in order to block the PIP joint at 30 degrees or more, and active flexion to 60 degrees is then allowed. This creates a slight flexion contracture, which is more desirable than a nonfunctional hyperextended joint. Rotational deformities can occur and are treated with derotational slings affixed to an outrigger on the lateral sides of the orthosis. This traction helps avoid pronation or supination of the digits through the PIP joint (Gabay & Gabay, 2013). Lubahn and colleagues (2011) described an alternative to a dynamic orthosis, involving two static orthoses that are used as exercise templates to limit joint movement at the desired number of degrees (Figure 15). These are used throughout the day and preclude the need to create a dynamic orthosis that some clients find difficult to use. 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). 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).
Figure 15: Template for Limiting Active Flexion
Source: Erin Peterson 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 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).
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