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Physical Rehabilitation Medicine/Physical therapy after broken finger

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QUESTION: About 8 weeks ago I shattered the distal portion of my middle finger. This required reduction and external fixation, which was in place for 6 weeks. I recently got the hardware removed, and about to go into occupational therapy. The affected finger is mostly frozen straight (the distal joint won't move at all, and the next joint medial to that I can force a few millimeters before it just won't move any farther). My questions are:

    1.  What can I do to accelerate regaining movement?
    2.  How much pain is too much? Can I cause further injury by forcing the joint to move with my other hand?
    3.  Is there an injection, maybe cortisone, that can be used to free the joint up quicker?
    4.  How long before it's back to "normal"?

Thanks in advance for any insight you can give. Odd that something small like a finger can be so impactful to your life, but wow -- I've had to give up nearly everything that I enjoy doing!

Mike

ANSWER: Ouch...you aren't going to like the answer Mike.  You don't see much external fixation anymore.  That's kinda old school for the most part as internal fixation has largely taken that procedure over for digit fractures.  The only external fixator I've seen on a finger in quite a while was a spring fixator for the PIP joint.  Other than that it's old news.  

Ok, 6 weeks is WAY too long to be immobilized for a finger.  But if it's external fixation that's to be expected.  You are probably set up for what's called a tenolysis.  Look it up.  Also the joint will be stiff which throws another wrench in the works.  Don't force the finger...period.  You will stretch out the extensor mechanism of the finger.  Look it up too.  The central slip will attenuate and you will lose extension of the finger, likely forever.  It's VERY difficult to get extension back once the slip is stretched out.

1.  Heat via paraffin bath, active ROM.  No passive.
2.  A "stretch" is ok, pain is not.  You will make the joint swell and cause more scar tissue.
3.  No
4.  A long time.  You'll see changes in the finger for over a year.

In sum, you are looking at more surgery in the long run.  You need a board certified hand surgeon.  Nothing against your current surgeon but this is very delicate stuff.  Go to www.assh.org.  Also, call around to different therapy places and ask who's the best.  That exact question.  If you have to go to a larger city then do it.  I've had people drive 3 hours, 2-3 times per week to see me.  It's extremely important.

You're looking at a tenolysis with or without a joint capsule release.  For this type of thing you definitely need a certified hand therapist to care for you.  Go to www.asht.org to find one.  Most of them don't know what they're doing so do your homework.  

Keep in touch but be patient.  It's going to be a long road.  Stay in touch and continue to email and ask questions.  Don't be afraid to take videos and email them or post them on here.

---------- FOLLOW-UP ----------

QUESTION: Thanks for your candid answer.  (I'm also a registered expert on this site for real estate, so I know all about having to give bad news sometimes). Wow, that certainly isn't encouraging.  I'm still an avid baseball player, tennis enthusiast, and play drums in several bands. None of which I can do again until this finger gets healed.

My health plan is through Kaiser so I have to use them. My surgeon wasn't an ortho, he's a plastic surgeon who apparently does a lot of hand stuff, but who knows. He says he used external fixation after reduction because (1) the finger was shattered in too small of pieces that was his only option and (2) he wanted to minimize risk of infection. He also says it had to be immobilized that long for that bone to heal (which he's not sure is complete yet).

My first occupational therapy session was yesterday,  and not a lot of fun. I was given a lot of exercises to do, both passive and active, to the middle joint (PIP?). They still don't want me to work the distal joint until confirmation thatthe bone has healed sufficiently.

how sure are you about tenolysis in my case? I looked that up which appears to involve tendon damage, which my surgeon says didn't occur. He also claims I should regain. Movement just fine, although probably over several months. I'm just trying to get an understanding of when I should punt and go in a different direction since I have to get this healed. If there's anything I can send to help make a better determination,  please ask.

thanks again.

Answer
Like I said, that's not always the case so it may be just your luck that the bone was severely fractured.  With that said, be very careful with passive ROM of the PIP joint.  Most therapists believe that if you push it then you get movement.  Which is true however most don't give much concern to the tendon.  I'm assuming the incision is directly on top of the finger...correct me if I'm wrong.  That's important.

Tenolysis is likely needed.  6 weeks immobilized is a VERY long time.  I could be wrong but I've been doing this since 98' and I've seen a lot.  Your surgeon probably doesn't want to get you down but it's likely needed.  Tendon "damage" isn't the problem.  It's tendon adhesion to surrounding tissue.  Scar tissue will stick to anything...such as bone, tendon, connective tissue, nerve, etc.  Anything.  

If you'd like to email me directly you can do so at bneville093@gmail.com or call me at (859)509-4164 to follow the case.  I'll do whatever I can to help.

The passive ROM on the PIP joint is dangerous for a number of reasons that probably need a lengthy explanation.  It's important to know where the incision is so first tell me that.

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Brian Neville, OTR/L, CWCE

Expertise

I can answer questions about both conservative and post-operative rehabilitation for UPPER extremity injuries. These include but are not limited to: fractures, tendon repairs, tendon transfers, nerve repairs, lacerations, tenolysis procedures, TFCC injuries, repetitive motion disorders, reconstructive procedures. I have an advanced knowledge of UPPER extremity anatomy and industrial rehabilitation. I have extensive splinting skills for injuries to the upper extremity. Although not a physician or a surgeon I have worked closely with world renowned upper extremity specialists for over 10 years. I can give general information on what some of the most common upper extremity surgeries involve. I can reference those procedures as well. PLEASE DON'T ASK ME QUESTIONS ABOUT ANYTHING OTHER THAN THE NECK, SHOULDER, ARM/HAND. I'M NOT QUALIFIED AND KNOW ABSOLUTELY ZERO ABOUT BACKS/HIPS/KNEES/ANKLES/ETC. THANK YOU!!!

Experience

10+ years working closely with orthopedic and hand surgeons and their patients. I have treated patients with small lacerations to major reconstructive procedures. My knowledge base includes both conservative and post-operative rehab protocols and care for upper extremity injuries. I have treated patients all the way from day 1 post-op to return-to-work status.

Organizations
Kentucky Occupational Therapy Association American Society of Hand Therapy National Nurses in Business Association Roy Matheson and Associates

Publications
RSD article

Education/Credentials
Occupational Therapist former Certified Hand Therapist (license currently inactive) Deep Physical Agent Modalities Instructor Certified Work Capacity Evaluator

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