The first hand rehabilitation case - my left hand

1. Injury and rehabilitation

My left wrist was broken in Christmas Eve 2009 and the diagnosis was a fracture of ulna and radial bone, S52.6. 

Since the fracture was splintery, it was operated in another hospital 11 days later.
One bone got a titanium plate and two K-spikes were placed in the second. The plaster cast was quite long, it went over the knuckles, and the given the exercise program was minimal. 

When, two and half weeks later the plaster cast was replaced the doctor noticed that the spikes had pressed the skin. I didn't like the new, lighter cast, made with a tight tubular bandage, two plaster slabs and elastic bandages, which felt like a too tight ribbing, and caused swelling and problems in fingers.  Altogether, the hand was in a cast during seven weeks.

In February 2010, when finally the cast and the spikes were removed, the little finger was bent. I asked the doctor whether the spikes were placed through the tendon, because I felt tension in the tendon of the little finger. The answer was: NO.

After the removal of the cast, physiotherapists gave me instruction for mobilization of the hand and fingers. There were some wrist stretches (see chapter 5.); and one ineffective stretching instruction for bent finger. Effective stretching instructions for fingers and finger splints were missing completely.

Hand in the evening,
March 2010

Hand in the morning,
March 2010

In March 2010, one month after the removal of the cast, I met the surgeon for the first time after the wrist surgical operation. Because of the wrong plaster cast and/or long time spent in plaster cast, or some internal injury, and the lack of proper rehabilitation, my hand looked like this, fingers extended.
The finger were slightly less bent in the morning, but the during the day the fingers crooked again, and I had a feeling of a cramp. The wrist was also stiffened after a long period in plaster cast.
I showed the pictures that I had taken the night before and the same morning to the surgeon and I got an appointment to occupational therapists the following week.
The surgeon didn't know stretching or finger splints and in her opinion the deficiency in bending was a bigger problem than deficiency in stretching straight. Therefore, I got first a wrist support, which kept the wrist in back position and straps, which were pulled over the fingers and knuckles, in order to make the knuckles and fingers to bend more.

Crooked fingers, May 2010

In April 2010, 2 months after the removal of the plaster cast, I got the first customized thermoplastic splint for the night, which was supposed to straighten the fingers. The splint was very stiff, and there were two straps for the fingers, one for the index and the middle finger and a second for the ring and the little finger. Since the straps ran the over the PIP joints, the splint straightened only the index and middle finger, where the PIP joints were alongside and less bent. The common strap for the ring and the little finger did not get the stretching done, because the PIP joints were out of align and the fingers were more hooked.

In May 2010 my fingers were bent and already so stiff, that when I pressed the hands together, the fingertips of my little, ring and middle finger turned upwards. I do not recommend this exercise, it can produce a permanent hyperextension in the fingers. This picture was taken in Djerba, Tunisia.

In June 2010, four months after the removal of the cast, I met the surgeon for a second time. In this meeting her opinion was, that only my little finger needs a surgical repair, not the two others which were also bent. In the statement she also confirmed, that the bending of the fingers was no caused by Dupuytren's contracture.
On the same day, I got a new splint, with separated straps for the ring and little finger. The splint was a perfect fit, but the material was thinner and more flexible than in the first one, and after a while, my fingers were even more bent.

Bend to fist
before operation

Spring splints

In July 2010, six months after the surgery I met a physiotherapist outside the hospital and she made a recommendation for finger splints with a spring, and with them the bend of the fingers improved; three weeks later I got the middle finger to touch the bottom of the palm, for the first time after the operation.

I used the splints for half an hour at a time and three times a day. Because the splints could not be kept in adjacent fingers, one stretching treatment took one hour. Since I got the spring splints six months after the surgery, they did not straighten the fingers anyway.

August 2010

In August 2010, six months after the removal of the plaster cast, my left hand looked like this, fingers extended as straight as possible.

August 2010

The PIP joints were more and more bended, and so stiff that it was impossible to stretch the fingers straighter.
The extension deficiency in the little finger was 70 degrees, in the ring finger 60 degrees and in the middle finger 40 degrees.
The knuckle of my little finger (pinkie) had "disappeared" and the PIP-joint was sore.

It was the time to change the doctor and the hospital (private clinic).

Finger and knuckles surgery:

In this surgery, in September 2010, the tendons of the three fingers and two knuckles were cleaned. I was very surprised, that I didn't need any painkillers after this operation. According to the surgeon, the extension deficiency would be maximum 20 degrees after the operation.


After the surgery, the hand was in plaster cast for one week and then started a new rehabilitation.
I met the physiotherapist and the occupational therapist immediately after the removal of the plaster cast, and got workout instructions and a customized thermoplastic splint for the night. PIP joints were still a little bent, from the old memory; I also experienced a feeling of a cramp in the hand.

Finger Surgery was very well done, and the biggest surprise was, that I didn’t need any painkillers after the operation.
However, the rehabilitation was still a problem: the splint for the night did not fit, even after two corrections. Also the proper stretching instructions were missing from the workout program. I continued to use my old spring splints, but the physiotherapist's opinion was that they were wrong size. There were no better size available in the clinic, and no ring splints either.

In December 2010, almost one year after the injury, I found the ring splints by change in a shop, and got from a person with a crooked finger the right stretching instructions (straightening stretch); two weeks later I could put a ring in my ring finger. The hospitals didn't have ring splints available, and didn't even know them.

Spring splints can be found in hospitals, but selection can be very small, so that the correct size may not be found.  If you know that splints are also available in shops, outside the hospital, you can try on different models and find the best suited.

Bend to fist 3 weeks

after operation

Rehabilitation is also a tool discipline and bad equipment does not give good result. Equally important are the correct instructions. I got the right instructions for the straightening of the fingers by accident, in a store, but not from the hospitals.
However, there are lots of things that can be done at home and which do not cost anything, or just a little.

Bent PIP joints need for rehabilitation: stretching, splints, hand exercises and massage, on a daily basis. Rehabilitation should also begin immediately, since if it starts too late, it does not produce expected results, and then the only solution is a new surgery. Even repeated surgeries do not help, if the correct rehabilitation is missing, and the result can be worse. I'm convinced that with the right stretching instructions after the removal of the plaster cast, the finger operation could have been avoided.

More information:
https://kirja.elisa.fi/ekirja/rehabilitation-after-plaster-cast-home-2-hand-rehabilitation-cases

2. Hand rehabilitation schedule was the following

Hand rehab is an endurance discipline, it can take a long time, specially when you get older. I was 64 years old when I broke my wrist.

Since the fracture was splintery, it was operated 11 days later, the 5th january 2010.

In February 2010, the cast and the K-spikes were removed.

In August 2010, six months after the removal of the plaster cast, the PIP joints were more and more bended, and so stiff that it was impossible to stretch the fingers straight or bend them to fist.

In September 2010, the tendons of the three fingers and two knuckles were cleaned in another operation.

Wrist

After 7 weeks in plaster cast, my wrist was stiff. I got mobilization exercises from the physiotherapist but the stiffness disappeared slowly. I was more worried about my fingers.

In May 2010, three and half months after the plaster cast was taken away, I went for one week in a spa in Djerba / Tunisia.  Because I had complications after the operation, I got every day half an hour personal physiotherapy in warm seawater pool.

The physiotherapy was very good, with the help of water gymnastic, the flexibility of my wrist increased much more in one week than with mobilization exercises during the three preceding month.

Little finger and knuckle position

before finger operation

After my return home, I continued for a while swimming and water gymnastic in a warm water pool in Helsinki, and therefore I purchased some tools, for ex HipperSmile.

Knuckles

I got the first flexion straps in March 2010, but they were uncomfortable to use and I didn’t like them.

I got an other splint in August 2010, this time with flexion loops (the picture), but because I got it too late, it wasn't any help.

After the finger surgery in September 2010, I started to use a splint for the knuckles again. It was quite uncomfortable; some loops were too small and thus laborious to put in the fingers. The stretch of the loops was too strong, and I had to take the splint away from the hand after a 15-minute use.

Approximately one month after the finger surgery, I started stretching the knuckles with HipperSmile and a PE foam disc, and 6 months after the finger surgery the knuckles bent well.

Later, I found the right way to stretch knuckles against without any splint, and I continue to do the stretching in order to maintain the result.

Little finger knuckle 6 months 

after finger operation

Little finger knuckle 3 weeks
after finger operation

Incomplete extension of the fingers 

In February 2010, when the plaster cast was taken away, the little finger was crooked.

Hand in August 2010

In August 2010, already three fingers were crooked: middle finger, ring finger and little finger, they were also so stiff, that an operation was the only possibility. Fingers were operated in September 2010.

In November 2010, after I had modified the customized thermoplastic splint, the middle finger straightened so that I could put a ring in it.

The ring and little finger were more severe cases. Two months after the operation, they started to look crooked again.

In December 2010, when the finger operation was 10 weeks away, I found ring splints in a shop and I got the right stretching instructions from a person with a bent finger, and a couple of weeks later I got a ring to go in the ring finger. I started with size No 9 in the ring finger, and size No 7 in the little finger.

In January 2011, the swelling had decreased so much that I had to change splints to a smaller size, No. 8 to ring finger and No. 6 to little finger, and I used them also during the night.

I used the splints for about 6 months, and the ring finger stabilized after some months.

Then I stopped the use of ring splints, even thought I didn't get my pinkie completely straight and the thickened PIP joint accentuated it.

The result wasn't permanent, in December 2011, about 6 months after I stopped the use of the ring splint, the little finger began to look more bent again, so I started to use the ring splint again.

In January 2012, I noticed that the PIP joint had gradually become thinner and my little finger could accommodate a smaller size, No. 5, which also fitted better, without customization.

I have already seen results, because now I have kept the ring splint during the night, and done the straightening stretch several times during the day, stretching the fingers between knuckles and PIP-joints, instead of stretching the PIP-joint. This seem to be a good combination.

I still use the ring splint No 5 every day, as night splint, and this way I can maintain the result.

http://www.3pointproducts.com/WhereToBuy-Oval-8-Finger-Splints/

Stiffness and incomplete bending of the fingers

Fingers bent, September 2010

Through trial and error I found the right way to bend and extend my fingers with bend/extend stretching, and the bending began to improve.

Fingers bent, February 2012

10 months after finger surgery fingers bended and extended well, and I could touch the lines of the palm with fingertips.

In my case, these instructions worked so well that the finger surgery doctor was surprised in the annual inspection of the hand in September 2011.

Stiffness in the hand is lost very slowly; it can take up to two years.

Swelling and thickening of joints

After the wrist operation, the back of my hand was swollen, but most of the swelling decreased after about four months.

The PIP-joints thickened in the finger surgery, especially the PIP joint of the little finger, which thinned slowly, taking 15 months. 

In the ring and middle finger the PIP-joints returned to the normal size after one year.

3. Pain

I didn't have much pain in my hand, but I used painkillers after the wrist operation. After the finger operation I didn't take them, because I didn't feel any pain.

Acupuncture can help in case of pain, but if there are no results during the 5 first sessions, there is no reason to continue it.

More information concerning pain relieving: http://orthoinfo.aaos.org/menus/treatment.cfm

Managing Pain With Medications After Orthopaedic Surgery

4. Summary of the rehabilitation 

Wrong plaster cast, too tight tubular bandage and wrong rehabilitation, as well as too late started use of the splints or  wrong splints,  and too late started or wrong stretching may create entirely new, different problems.

Straightening of the fingers is easiest during the first few weeks, and after 4 months it is very difficult to achieve any results, if the fingers are stiffened. However, a skillful physiotherapist will be able to show short-term results.

If you feel that your fingers are completely stiff, it's time to go see (another) doctor.

Rehabilitation is, a know-how, an equipment and an endurance discipline, this rehabilitation has gone for more than two years. With right instructions for stretching and right splints, the rehabilitation could have been considerably faster. You may know that you need splints and stretching, but if the know how is missing, things can go wrong.

Hits:

• If I had not found a shop (Health Care shop, Mannerheimintie 69, 00250 Helsinki) ring splints and received from a person with a crooked finger better stretching instructions (straightening stretch), the ring and little finger would have stayed more crooked.

Misses:

• Both hospitals missed the best rehabilitation time. In the first hospital they first observed the situation, and I got the first splint 6 weeks after the plaster cast was removed, and this splint was supposed to bend my fingers even more. The first splint for the straightening of the fingers was made 2 weeks later, but it didn't work well. After the finger operation, I got the first splint immediately after the removal of the plaster cast, but the splint wasn't good and the best rehabilitation time was used for reparations, without result.
• Both hospitals missed the knowledge about splints. Hospitals didn't know the ring splints at all, and many of the splints I got, were unsuitable for the case, or with bad ergonomics.
• Both hospitals missed the stretching instructions for fingers. They had correct instructions only for the wrist. The instructions I got for the fingers gave only temporary results and delayed the rehab.

In my experience, the most important things in the rehabilitation of the hand are:

1. The fastest possible start

The best results are obtained during the first weeks. The later the treatment is started, the more time will be needed to get results, and it is less certain to get good results.

2. Stretching

Proper and regular stretching keeps the fingers and knuckles flexible, straighten the fingers, and help also stiff fingers to bend more. This happens only when the stretching is done the right way and early enough, and in this case the first results should be visible in two weeks. 
If not, the instructions may be incorrect or the stretching exercises are done too late, when the hand or fingers are already stiffened.

You may get from hospitals stretching instructions for bent fingers giving only short-term results. In that case, the only long term result can be a new surgery.

3. Splints

In addition to stretching, splints, which help to keep the right stretch for longer periods, may be needed. The splint should be appropriate for the case, well fitting and ergonomic. Improper splint or bad fit do not give good results.

4. Mobilization exercises

To exercise the hand with versatile but slowly made movements is also important. Too fast, or one-sided movements, can lead to entirely new problems in the case of a stiff hand or bent fingers.

5. Maintenance training

Daily: 

I use the ring splint in my pinkie during the night, with fingerless woolen gloves

I start the day by bending the fingers properly, and keeping them bent for 20 seconds, then I extend the fingers straight.

Thereafter I stretch knuckles against the mattress.

I also do strength training using 2 kg weights, and have noticed positive results. It reduces the stiffness.

Regularly:

I do the straightening stretch, and stretch the first phalange of the fingers against a table for 10 sec, especially the little finger.

I do bend / extend stretching and keep both stretching for 10 sec.

These stretching maintain the flexibility of the hand and fingers, and keep the fingers straight.

When necessary:

I squeeze the foam disc to keep the stiffness away.

I do stretching wide apart.

I do scar massage to the scar of the knuckles.

There can be backtracking, if you have stopped to exercise your hand or if it has been exposed to cold. Then there is no help other than exercise more for a few days, do the slow bend / extend stretching, and keep the stretching for 10 seconds. Do also squeezing, if you feel tightness in the hand.

The heating of the hand and massage of the fingers can relax your hand.

Stretching of the knuckles may also help.

I have a feeling, that I shall continue the stretching program the rest of my life, otherwise my hand may stiffen again. And I know, that it will help.

6. Situation 4 years later, in 2014

 Four years after the finger operation (September 2010) I still use the ring splint as night splint in my left pinkie.

I do regularly the bend / extend stretch, because it keeps the stiffness away from my hand.

My middle finger tend to bend a little again, but because it is still flexible, I do straightening stretch from time to time.

In case you have questions or comments ( in English or in French), you can send also an email: lpuranen(at)elisanet.fi