REHABILITATION AFTER FRACTURES

OF THE HAND
TERRISKIRVEN, OTR/L CHT

Rehabilitation after a hand fracture begins during the early phases of fracture healing and continues until skeletal
integrity and hand function are restored. The rehabilitation plan is tailored according to the stage of healing. The
emphasis of therapy during the early reparative stage of healing is on edema control, pain management, preservation
of motion at the uninvolved joints, protective splinting and positioning to prevent disruption of fracture healing, and
to prevent joint contracture. The next phase of therapy begins when clinical healing is present and emphasizes the
active mobilization of the joints immediately adjacent to the fracture that were incorporated in the cast or splint.
Tendon gliding exercises are also stressed at this time to restore flexor and extensor tendon excursion. The final phase
of therapy begins when the fracture is well healed. The focus of therapy at this time is the development of strength
and hand function and the resumption of activities of daily living and work tasks. General rehabilitation techniques
appropriate for all hand fractures include positioning and splinting, edema and pain control, joint and soft tissue
mobilization techniques, and tendon gliding and strengthening exercises.
KEY WORDS: prevention, early mobilization, edema control, protection

Rehabilitation after a hand fracture begins during the
early phases of fracture healing and continues until skel-
etal integrity and hand function are restored. Typical
problems after hand fracture include limited joint mobility
and stiffness, tendon adherence, swelling, and decreased
strength. The degree of limitation and disability relates to
the severity of the fracture and the associated soft tissue
injuries. Rehabilitation is directed toward the prevention
and amelioration of these problems.
GENERAL CONSIDERATIONS
One of the most important considerations in the rehabilita-
tion of hand fractures is the stage of fracture healing. The
timing of therapy depends on the stability of the fracture
and the degree of healing. There are three phases of
healing. The inflammatory phase begins during the first 24
hours after injury. It involves the migration of inflamma-
tory cells to the area of the fracture and the resorption of
dead bone by osteoclasts. The second phase begins by 3 to
4 days and is termed the reparative phase or stage of callus
formation. Fibrocytes manufacture a collagen framework
across the fracture site, and minerals are deposited along
the framework. The resulting mass is called callus. Callus
formation actively proceeds over the next 3 weeks, and
during this time fracture stability develops. The third stage
is termed the remodeling phase and involves the resorp-
tion of excess callus and change of the bone architecture in
response to functional demands with the development of
increased mechanical stability. Bone remodeling begins at 3
to 6 weeks and continues for months up to several years?
Therapy is timed according to the stage of healing. The
From The Philadelphia Hand Center, King of Prussia, PA.
Address reprint requests to Terri Skirven, OTR/L CHT, Philadelphia
Hand Center, 700 S Henderson Rd, Suite 200, King of Prussia, PA 19406.
Copyright © 1997 by W.B. Saunders Company
1048-6666/97/0702-0005505.00/0
first stage of therapy can be termed the protective phase
and corresponds to the inflammatory and early reparative
stages of healing when motion may cause disruption at the
fracture site and delay healing. The emphasis of therapy at
this time is edema control, pain management, preservation
of motion at the uninvolved joints, protective splinting,
and positioning to prevent disruption of fracture healing
and joint contracture.
The second stage of therapy can be termed the active
motion phase and corresponds to the reparative stage of
healing when the fracture is determined by the physician
to be clinically healed. This determination is based on the
absence of pain and motion with palpation and stress of
the fracture site. Clinical healing usually occurs by 3 to 4
weeks after fracture. The emphasis of therapy at this phase
is the active mobilization of the joints immediately adja-
cent to the fracture that were incorporated in the cast or
splint. Flexor and extensor tendon gliding exercises may
begin at this time, and pain and edema control continue as
needed. The protective splint is worn all the time except for
exercise and bathing, to protect the healing fracture from
disruption, which may occur through inadvertent injury or
from the stresses of uncontrolled hand use.
The final phase occurs when the fracture is well healed
as determined by the surgeon and can withstand the
stresses involved with passive and resisted motion and
functional activity. The focus of therapy during this phase
is the development of strength and hand function and
continuation and upgrading of techniques directed toward
the restoration of motion and tendon excursion. Protective
splints are gradually discontinued as strength and motion
returns. Another important consideration in the timing of
therapy is the type of internal fixation used. The two types
of fixation are stabilizing and rigid. 2 Stabilizing fixation
holds the fracture fragments in place but not securely
enough to be subjected to stress. An external splint or
plaster cast is required. The splint typically incorporates

1 52 Operative Techniques in Orthopaedics, Vol 7, No 2 (April), 1997: pp 152-160

Fig 1. Coban wrap is a compressive wrap applied to the
digits and hand to control edema.

the joints immediately proximal and distal to the fracture

and the adjacent digit(s). Rigid internal fixation restores
skeletal integrity and allows active range of motion with-
Fig 3. String wrapping is applied distal to proximal and can
out risk of motion at the fracture site. Rigid fixation allows be combined with retrograde massage to control digital
the initiation of motion almost immediately. edema.
Also important to keep in mind is that with an unstable
or incompletely lhealed fracture, the pull of intrinsic and injured structures. For example, with a combined skeletal
extrinsic muscles produce deforming stresses, and angula- and tendon injury, an early motion program for the tendon
tion can result. Angulation errors cause abnormal forces on may produce deforming stresses at the fracture site; pro-
the joints adjacent to the fracture according to Landsmeer's longed immobilization of the fracture may cause tendon
zigzag principle, and serious deformities may develop. adherence. The therapy protocols must be adapted and
The zigzag principle states that a multiarticulated structure tailored to the requirements for protection, positioning,
such as the finger subjected to compression will buckle motion, and immobilization for the involved structures.
each joint in an opposite direction to form a zigzag
configuration. 3 For example, with fracture-dislocation of
GENERAL THERAPY TECHNIQUES
the neck of the metacarpal in which the distal fragment is
tilted anteriorly, the metacarpophalangeal (MCP) joint To a varying extent, all hand fractures are accompanied by
must hyperextend to achieve what appears to be neutral swelling, pain, and restriction or inhibition of motion, and
extension. The next joint, the proximal interphalangeal
(PIP), has a compensatory loss of extensor forces, and an
active extensor lag will result. If not controlled through
careful positioning and exercise, a fixed PIP flexion contrac-
ture may develop. Anticipation of these deforming forces
underlies the early phases of the rehabilitation program.
Efforts are made to minimize these forces by avoiding
uncontrolled motion that could cause angulation and by
manual support of the fracture during initial efforts at
active motion of the joints adjacent to the fracture.
The rehabilitation program also must consider associ-
ated injuries and coordinate therapy protocols for the

Fig 2. A compressive glove used to control generalized hand Fig 4. The hand volumeter is used to measure hand size
edema. through water displacement.

REHABILITATION AFTER HAND FRACTURES 153

Fig 5. The protective position for splinting involves MCP
joint flexion and IP extension.
all require some level of protection and positioning to
promote optimal healing. The following techniques and
procedures are applicable to most hand fractures.
EDEMA CONTROL
Unresolved hand edema leads to inhibition of motion, joint
stiffness, pain, and deformity, and may involve not only
the involved digit but the entire hand as well. Therefore,
control of edema is a priority in the rehabilitation program.
Edema control is initiated as soon as possible after fracture
fixation. Patients are advised to elevate the involved
extremity and hand above the level of the heart. External
compression is a very effective means of edema control and
can be applied in a variety of methods.
Compressive wrapping can begin during the protective
phase while the hand is in the cast or a protective splint.
Coban is a self-adhering wrap that is used for this purpose
and is applied in a distal to proximal direction starting at
the fingertips. Once the cast or splint is removed, coban can
be wrapped about the MCP joints and around the metacar-
pals to help control dorsal or palmar hand edema (Fig 1).
The coban should not be wrapped tightly because this may
exacerbate swelling. Coban can be left in place on the hand
for long periods but should be removed for exercises. An
alternative to compressive wrapping is the use of an elastic
glove, which can be used to control generalized hand
edema (Fig 2).
String wrapping is another method of compression.
String is wrapped about the involved digit from distal to
proximal and is held for 5 minutes (Fig 3). During this time,
retrograde massage can be performed. Flowers 4 found that
combining massage and string wrapping was more effec-
tive than either technique alone. Once the string is re-
moved, the patient performs range of motion exercises.
Other methods used to control edema include the use of
Fig 6. Percutaneous pins used for fixation of a proximal
phalanx fracture can be protected with a thermoplastic splint.
154
Fig 7. Blocking exercises involves manual stabilization of
the joint proximal to the joint targeted for exercise.
cold, galvanic stimulation and active digital exercises with
the hand in the elevated position.
Hand edema can be monitored with volumetric measure-
ments (Fig 4). The hand volumeter uses water displace-
ment to measure hand size and has been found accurate
within 10 mL. 5 If swelling is confined to a single digit or
joint, circumferential measurements are recorded.
PAIN M A N A G E M E N T
Pain frequently accompanies the patient's efforts to move
the involved joints of the hand. If pain limits the patient's
ability to participate in the therapy program, pain control
becomes a priority. The source of the pain must be
determined and addressed accordingly. If pain is localized
to the fracture site, it is important to determine Whether
fracture healing or stability has been compromised. Pain
frequently occurs during the initial efforts at moving the
joints adjacent to the fracture and may be caused by the
stressing of the periarticular soft tissues, which are fre-
quently shortened and scarred. Oral analgesics and antiin-
flammatory medications, the use of transcutaneous electri-
cal nerve stimulation, and modalities such as heat and cold
are all helpful in controlling pain and may be used before,
during, or after the exercise sessions.
"No pain, no gain" is an inappropriate slogan for a hand
Fig 8. Blocking splints are made to stabilize the joints
proximal to the target joint.
TERRI SKIRVEN
Fig 9. Extensor tendon gliding exercise is performed by
extending the MCP joints with the IP joints flexed and the
wrist in neutral position.
therapy clinic. Certainly, pain and discomfort are expected
as the patient begins to move joints compromised by
swelling and stiffness. However, if pain exceeds the pa-
tient's level of tolerance and is out of their control,
protective muscle guarding with inhibition of active mo-
tion results. Active motion exercises under the control of
the patient and supervised and encouraged by the thera-
pist are most appropriate, particularly during the early
phases of the therapy program.
PROTECTION AND POSITIONING
After operative treatment of hand fractures, a custom-
made thermoplastic hand splint may be used to provide
lightweight protection and positioning. The splint may be
used during the early healing phases on a continuous basis
and is worn inteITnittently once clinical healing has been
achieved and active motion begins. The splint helps to
insure immobilization of the fracture, provides protection
for any percutaneous pins, and positions the involved
joints and digits in a safe position to minimize the risk of
joint contracture. The position of the splint in general
should be in the safe, protective, or intrinsic plus position 6
(Fig 5). This position requires that the MCP joints be
positioned in flexion because the collateral ligaments of the
MCP joints are taut when the joint is flexed and cannot
undergo shortening and contracture in this position. The
interphalangeal (IP) joints are positioned in extension
because if allowed to remain in a flexed position for long
periods the volar plate and deep fascial supporting struc-
tures can undergo irreversible shortening, and a fixed
Fig 10. Flexor tendon gliding exercises. (A) Full fist; (B) straight fist.
REHABILITATION AFTER HAND FRACTURES
Fig 11. Exercise to isolate the flexor digitorum superficialis
from the profundus; the adjacent digits are held in extension
while PIP joint flexion is attempted.
flexion contracture results. In general, the joints adjacent to
the fracture site are immobilized as well as the adjacent
finger. Splints are also fabricated to incorporate any percu-
taneous pins to prevent bumping or inadvertent snagging
of pins (Fig 6).
THERAPEUTIC EXERCISE
Joint stiffness is a frequent and almost inevitable conse-
quence after hand fracture, particularly of the joints adja-
cent to the fracture site. In some cases, stiffening and loss of
motion of the more proximal joints of the involved upper
extremity can occur as well. To prevent and minimize joint
stiffness, therapeutic exercise is begun as early as possible.
Active range of motion exercises can begin immediately
for the unimmobilized joints. Patients are instructed to
perform range of motion exercises of the shoulder and
elbow to prevent stiffness and loss of motion. This is
particularly important with the older patient with a dimin-
ished activity level. The joints adjacent to the fracture site
are not moved until the fracture is judged to be clinically
stable. If the fracture has been treated with rigid internal
fixation, movement can start almost immediately.
Exercises are initially performed actively without resis-
tance. The fracture site can be manually stabilized by the
therapist when moving the joints adjacent to the fracture.
To isolate a particular joint during exercise, blocking
exercises are performed. Blocking involves manual stabili-
zation of the joint proximal to the target joint during active
exercise (Fig 7). The proximal joint is usually positioned in
a neutral position. Blocking splints can sometimes be
155

Fig 12. Isolated flexor digitorum profundus exercise: The PIP
joint is stabilized while DIP joint flexion is attempted.
helpful for the patient to use to perform the exercises on a
home program basis and can be fabricated to block motion
proximal and sometimes distal to the target joint (Fig 8).
Flexor and extensor tendons can sometimes become
adherent at the site of the fracture, limiting tendon excur-
Fig 13. Putty exercises performed for (A) finger flexion; (B) finger extension; (C) abduction; (D) adduction.
156
sion. Tendon gliding exercises are performed to address
this problem. Extensor tendon gliding is performed by
extending the MCP joints with the IP joints flexed and the
wrist in neutral (Fig 9). While maintaining MCP joint
extension, the patient then extends the IP joints. Flexor
tendon gliding has been described by Wehbe and Hunter. 7
Their program involves three basic hand positions. The full
fist emphasizes maximum flexor digitorum profundus
tendon glide; the straight fist requires maximum flexor
digitorum superficialis tendon glide; and the hook fist
involves maximum differential glide between the superfi-
cialis and profundus tendons (Fig 10). To isolate the flexor
superficialis from the profundus, the adjacent digits are
held in extension while the patient attempts to flex the PIP
joint (Fig 11). To isolate the profundus from the superficia-
lis, the PIP joint is held in extension while the patient
attempts to flex the distal IP (DIP) joint (Fig 12).
Later, once the fracture has been judged to be well
healed and capable of withstanding increased stress, resis-
tive and passive exercise can begin. Passive exercise must
be performed within the pain tolerance of the patient.
Overly aggressive passive exercise can cause inflamma-
tion, increased stiffness and pain, and limit progress.
Strengthening exercises are typically performed with
therapeutic putty, which can be graded in terms of resis-
tance. Patients are instructed in exercises selected for their
particular area of weakness. Flexion, extension, adduction,
and abduction strengthening exercises can be performed
using putty (Fig 13).
TERRI SKIRVEN
Fig 14. Splint used for metacarpal fractures includes the
wrist and the MCP joints of the involved and the adjacent
finger; buddy straps are used to control rotation.
In all cases, patients are instructed in a home program
that supplements the supervised therapy program. In
some cases where limitations are minor, patients may be
able to perform a home program with less frequent therapy
visits. Range of motion measurements are taken on a
regular basis to monitor progress and to determine the
efficacy of the treatment program. Revisions are made to
Fig 15. Dynamic flexion splint for limited MCP joint flexion.
REHABILITATION AFTER HAND FRACTURES
Fig 16. Blocking exercises performed for PIP joint extension
positions the MCP joint in flexion while PIP joint extension is
attempted.
the therapy program based on the patient's response to the
therapy as well as on fracture healing.
SPECIFIC FRACTURES AND THERAPY
CONSIDERATIONS
Metacarpal Fractures
Metacarpal fractures can occur at the base, the shaft, or the
neck with the MCP joint surface involved~8 Base fractures
usually involve the fourth or fifth metacarpals. Metacarpal
shaft fractures can be transverse, oblique, or comminuted.
Transverse fractures may angulate dorsally because of the
Fig 17. (A) Blocking splint for PIP joint flexion positions the
MCP joint in neutral; (B) blocking splint for PIP joint exten-
sion positions the MCP joint in flexion.
157
Fig 18. Three-point extension splint used to correct PIP
flexion contractures of 35 degrees or less,
Fig 20. Dynamic splint used to increase PIP joint flexion.
forces of the long flexors and the interossei; oblique
fractures are subject to shortening and malrotation; and support of the wrist and the CMC joint. Dynamic traction
comminuted fractures are often associated with significant is applied with a finger cuff applied over the proximal
soft tissue injury. Metacarpal neck fractures are the most phalanx and pulled to a volar attachment point (Fig 15).
common and result from a compression force such as a The tension of the dynamic traction is kept at level that can
blow with a closed fist. These tend to angulate dorsally and be tolerated for a prolonged period. Low-load prolonged
are subject to the development of a claw deformity accord- stress to the shortened periarticular soft tissues has been
ing to the zigzag principle as mentioned previously with found to be more effective than high-intensity brief stress
MCP hyperextension and PIP flexion. in increasing tissue length. 9
Splinting for metacarpal fractures should incorporate
support of the transverse and longitudinal arches and Proximal Phalanx Fractures
should be in the intrinsic plus position. The splint should
Proximal phalanx fractures can occur at the base, the
include the wrist and the MCP joint of the involved
midshaft, or the neck. Malalignments of proximal phalanx
metacarpal as well as the adjacent MCP joint. Buddy straps
fractures can cause significant deformity. Fractures of the
or rotational taping is used to control alignment and
midshaft and base tend to angulate volarly secondary to
prevent overlapping of the digits (Fig 14).
pull of the interosseous muscles on the proximal fragment
Common problems of metacarpal fractures include exten-
and the pull of the extensor mechanism of the distal
sor tendon adherence and stiffness and limitation of the
fragment. With persistent angulation, the PIP joint flexes
MCP joint. Extensor tendon gliding exercises are empha-
and can rapidly become fixed in a flexion contracture with
sized to promote tendon excursion. Friction scar massage
edema and inflammatory reaction from the adjacent frac-
is used in the case of adherent incision scars and can help
ture. 10
to promote differentiation of the overlying scar from the
Rotational errors can occur and are amplified at the
tendon. Massage can be performed during efforts at active
fingertip with overlapping of the digits and compromise of
extensor tendon gliding. Stiffness and limited MCP joint
function of the adjacent digits. The two major complica-
flexion is also a frequent problem, and MCP joint exercises
tions of proximal phalanx fractures include PIP flexion
are emphasized. When performing exercises for the MCP
contracture and flexor tendon adherence at the site of
joint, it is important to stabilize the wrist and correspond-
fracture.
ing carpometacarpal (CMC) joint to allow concentration of
Splinting for proximal phalanx fractures is in the safe
effort at the MCP joint. In some cases, IP joint flexion can be
position with particular attention paid to positioning the
blocked as well to further concentrate forces at the MCP
joint.
When the fracture is well healed, dynamic splinting can
be used to help restore MCP joint flexion if limitations
persist. The dynamic splint must provide volar and dorsal

Fig 19. Dynamic PIP extension splint used for PIP flexion Fig 21. Gutter splint with pin protection for distal phalanx
contractures of 35 degrees or more. fractures.

158 TERRI SKIRVEN


Fig 22. Blocking splint for DIP joint flexion stabilizes the PIP
joint in extension.
PIP joint in extension to prevent the development of
flexion contracture. The adjacent uninjured digit is in-
cluded to control rotational alignment.
The therapy program for proximal phalanx fractures
emphasizes PIP joint range of motion exercises, and these
are performed with stabilization of the proximal phalanx
and the MCP joint. Tendon gliding exercises are performed
as well. Extensor tendon gliding at the PIP joint level is
performed by blocking the MCP joint in flexion during
active efforts at PIP extension (Fig 16). Flexor tendon
gliding exercises are performed as described previously.
Blocking splints are sometimes very helpful to enhance the
patient's efforts.
The blocking splint for PIP extension positions the MCP
joint in flexion. The blocking splint for flexion positions the
MCP joint in neutral (Fig 17). Tendon gliding and blocking
exercises can be combined with biofeedback and electrical
stimulation to enhance the patient's active efforts.
If limitations in PIP joint mobility persist, dynamic
splinting may be used once the fracture is determined to be
solidly healed. For a PIP flexion contracture that is 35
degrees or less, a three-point extension splint is recom-
mended to restore extension (Fig 18). If the contracture is
greater than 35 degrees, a dynamic PIP extension splint is
required (Fig 19).11 If PIP joint flexion is limited, flexion
straps or flexion loops are effective with mild to moderate
Fig 23. Dynamic DIP joint flexion splint used to overcome
DIP joint stiffness and limited flexion after DIP joint fracture.
REHABILITATIONAFTER HANDFRACTURES
limitations. With more significant limitations, a dynamic
splint is most effective (Fig 20).
Middle Phalanx Fractures
Middle phalanx fractures are less common. They can occur
at the midshaft, base, or the neck, with the distal shaft the
most frequent area affected. The flexor digitorum superfi-
cialis and the extensor tendon provide deforming forces.
With a fracture of the neck, the pull of the superficialis
causes volar angulation. With a fracture of the base, dorsal
angulation results. Fractures of the middle third of the
shaft can angulate either way. ~2
Problems common to middle phalanx fractures include
stiffness of the PIP and DIP joints, PIP joint flexion
contracture, and DIP joint extensor lag. Blocking exercises
are begun as soon as the fracture is clinically healed. PIP
joint range of motion is performed with the MCP and
proximal phalanx supported. The middle phalanx and the
PIP joint are supported during DIP joint range of motion.
Flexion straps, loops, and dynamic splints are used when
the fracture is fully healed and as needed.
Distal Phalanx Fractures
The distal phalanx is the most frequently fractured bone in
the hand, with the long and the thumb the most frequently
involved digitsJ 3 These fractures usually result from crush
injuries with comminution of bone. Fractures are classified
as open or closed and occur at the tuft, shaft, or base.
Unstable distal phalanx fractures require reduction and
internal fixation and are protected while healing, usually
with a gutter splint with pin protection with the PIP joint
free (Fig 21). During healing, PIP and MCP joint range of
motion exercises and pin site care are performed. After the
pins are removed, usually at 3 to 4 weeks, DIP joint range
of motion exercises are begun. Problems associated with
distal phalanx fractures are DIP joint stiffness, pulp hyper-
sensitivity, nail abnormality, numbness, and cold intoler-
ance. For DIP joint stiffness, active range of motion exer-
cises and blocking exercises begin as soon as the pins are
removed. Blocking splints may be used, which stabilizes
the PIP joint and permits DIP joint range of motion (Fig 22).
Desensitization techniques are helpful and include mas-
sage, tapping, vibration, and rubbing with textures. Later,
as healing permits, passive range of motion and flexion
loops or dynamic splints can be used to restore DIP joint
flexion (Fig 23). Putty exercises are used to develop
tolerance for pinch pressure. Sensitivity may persist, and
gel-lined sleeves may be helpful for use at work and
during other activities (Fig 24).
Fig 24. Gel-lined digital sleeves are useful for hypersensitive
fingertips after crush injuries of the distal phalanx.
159
SUMMARY
The rehabilitation p l a n after a h a n d fracture m u s t c o n s i d e r
the stage of healing, the t y p e of internal fixation, potential
d e f o r m i n g forces, a n d associated soft tissue injuries. C o m -
m o n p r o b l e m s after h a n d fractures i n c l u d e joint stiffness
a n d limited mobility, e d e m a , pain, t e n d o n a d h e r e n c e , a n d
d e c r e a s e d t e n d o n excursion, d e c r e a s e d strength, a n d lim-
ited function. G e n e r a l t e c h n i q u e s a p p r o p r i a t e for all h a n d
fractures i n c l u d e p o s i t i o n i n g a n d splinting, e d e m a a n d
p a i n control, t h e r a p e u t i c exercises, a n d s t r e n g t h e n i n g . The
rehabilitation effort is i n t r o d u c e d early after fracture fixa-
tion a n d c o n t i n u e s until f u n c t i o n is restored.
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TERRI SKIRVEN