cartilage is removed from the middle phalanx. The angle of hyperflexion is reduced, and the ends of the bones are brought together (Leibovic, 2007). The PIP joint is placed in a flexed position, making it more functional for the client during grasping activities, yet not so flexed as to impair release. According to Leibovic (2007), the following degrees of flexion are appropriate, based on the digit being fused: Index finger PIP 20 to 25 degrees Long finger PIP 30 degrees Ring finger PIP 40 degrees Small finger PIP 40 to 50 degrees Joint fusion is achieved in several ways, depending on the choice of the surgeon. Longitudinal and oblique Kirschner wires (K-wires) can be used, or alternatively, Herbert screws or small dorsal plates (particularly if bone loss is present) are options (Figure 17). Following closure of the joint capsule and skin, the joint is placed in a surgical dressing. Figure 17: Arthrodesis of Distal Interphalangeal Joint
The orthosis is fabricated at the first therapy session, occurring three to five days postop, and is worn between exercise sessions and during sleep hours. Specific active and passive ROM exercises are initiated four times a day, including isolated flexion blocking to the PIP and DIP; short arc composite active flexion; full arc active extension; straight fist; and reverse blocking, which involves active extension of the PIP while maintaining MCP flexion. Composite flexion exercises should be avoided to minimize risk of an extensor lag. Isolated active and passive PIP joint flexion exercises should be performed instead, ensuring the MCP remains in extension. Typical ROM following a PIP arthroplasty is only 25/75 degrees, so care should be taken to conduct exercises with respect to that range (Cannon, 2020). At 10 to 14 days postsurgery, the client can begin composite active flexion, isolated PIP passive flexion, and full active and passive extension exercises every two hours. If passive flexion of the PIP is less than 70 degrees and the extensor lag is less than 20 degrees at this time, then a custom-fabricated dynamic flexion orthosis for the PIP only may be used for 30- to 60-minute sessions, four to six times a day (Cannon, 2020). Use of the dynamic flexion orthosis should be limited or discontinued if the extensor lag increases. It is important during this time to balance flexion and extension gains and minimize risk of an extensor lag as much as possible. At three weeks postsurgery, the hand-based extension orthosis can be discontinued, and a static digital gutter orthosis (Figure 16) is worn instead, keeping the PIP and DIP in max extension (Cannon, 2020). The therapist should continue to monitor the extensor lag and decrease flexion exercises if the lag increases. Figure 16: Volar Digital Gutter Orthosis
Note: OA “X-ray of distal interphalangeal joint arthrodesis, left hand” by Jmarchn, used under Creative Commons license BY-SA 3.0. Within two weeks following surgery, the client is referred to therapy for fabrication of orthoses, as well as education on orthosis use and care (Leibovic, 2007). DIP joint arthrodesis Fusion of the DIP joint occurs similarly to the PIP joint and is typically the only viable solution to painful arthritis of this joint. Although DIP arthroplasty (i.e., replacement) procedures are possible, the DIP joints are typically unstable and become damaged easily (Rongières, 2013). Following surgical exposure of the joint using an H-shaped incision, the ligaments and terminal tendon are retracted and preserved. The DIP joint is taken apart and the joint surface is removed. The bone ends are made congruous (either flat or cup in cone) and set in a slightly flexed position (zero to 15 degrees). It is better to err on the side of too much extension than too much flexion with DIP joints. In addition, it is important to ensure that the joints align vertically without rotation. Although some surgeons prefer a type of fusion that is unfixed but allows for slight movement (i.e.,
Source: Erin Peterson At eight weeks postsurgery , the client should begin slowly weaning from the digital gutter extension orthosis and fully discontinue wear over the next four weeks. When out of the orthosis, the affected digit should be buddy taped/strapped to the adjacent digit to provide protection against lateral stress (Cannon, 2020). Gentle strengthening can also be initiated during this time if there is no extensor lag. Any orthoses should be discontinued at 12 to 14 weeks postsurgery; however, buddy taping/strapping may continue until week 16, especially for heavy activities, to avoid any lateral stress to the PIP joint (Cannon, 2020). PIP joint arthrodesis As stated previously, depending on the needs of the client, a joint fusion accomplishes the goals of reducing pain and preserving function that is diminished by pain. When fusing the PIP joint, the joint is placed in maximum flexion by the surgeon, who then removes the distal end of the proximal phalanx, creating a volar slope. The articular
EliteLearning.com/Physical-Therapy
Page 151
Powered by FlippingBook