RECOMMENDED HAND SURGEON THERAPY ORDERS
- Edema control
- Patient education on prevention
- DIP mild hyperextension splinting for prolonged conservative management.
- Isolated active range of motion exercises, blocking and reverse blocking exercises for PIP
- Post-operative Massage with bacitracin until 48 hours after suture removal, then switch to vitamin E cream
- Tendon gliding exercises when allowed
- Begin strengthening exercises at 10-12 weeks after splinting has been discontinued
- Scar conformer splinting if scar is hypertrophic if applicable
- Progressive PROM stretches when applicable
- Strengthening if needed
REVIEW OF THERAPIST COSERVATIVE INTERVENTIONS FOR MALLET FINGER (ZONE 1 EXTENSOR TENDON INJURY)
Therapy for non-operative patient to include:
Full time splinting of DIP for 6-10 weeks in slight hyperextension or full extension if hyperextension is unobtainable (splinting for 6 weeks and then check for a lag. If no extension lag at DIP presents, you may order part time splint use and full night time splint use for an additional 4 weeks. If a slight extension lag persists, resume full time DIP splint use for an additional 4 weeks (total 10 weeks of splinting, day and night). Night extension splinting can be maintained for a total of 3-4 months if necessary to counterbalance flexion postures during the day.
- Prefab, alumo-foam, or custom splint fabrication by an Occupational Therapist or Physical Therapist / Hand Therapist. Custom splints may provide more proper fit and comfort, to immobilize DIP, but allow full PIP AROM. (see image below images with finger based splints)
- Patient should return 1x per week for splint checks and skin checks by therapist or surgeon, until week 6.
- Full AROM is initiated during week 1 to encourage PIP and MCP joint gliding.
- At week 6, Gentle AROM for DIP glide within reported pain free range and gradually progress through the next 2-4 weeks. (limit full composite flexion to prevent early overstretching)
- At week 8, initiate Tendon Gliding and Blocking exercises to encourage composite AROM within reported pain free range.
if no lag is present at DIP, otherwise, delay AROM exercises until 10 weeks at DIP. (see image below)
- Encourage towel wringing exercises with warm water to full functional use.
- Take breaks, ice x 10 minutes intermittently throughout the day.
- At 8-10 weeks, gentle PRE’s may be initiated.
REVIEW OF POST OPERATIVE BONY MALLET FINGER REPAIR
Early hand therapist assistance and intervention:
- At week 1, dressing assessment and changing with oil embedded dressings to keep the surgical site and pin site clean and dry. Check skin for signs of infection and educate patient.
- Edema control – encourage elevation, encourage early gentle finger ROM, watch for RSD/CRPS signs.
- At week 1, referral to an Occupational Therapist or Physical Therapist / Hand Therapist for protective splinting. Custom splint fabrication may provide the best pin protection from getting banged.
- At week 1, initiate full AROM for the PIP and MCP.
- Very light compressive sleeves for fingers and/or hand. Be aware of the tourniquet effect causing distal edema accumulation and restricted blood flow to the surgical site.
- Patient education – teach signs of infection, avoid maceration of surgical site, encourage a smoke free recovery, avoid excessive exercise to minimize scarring.
- At week 6, initiate gentle differential tendon glide of the FDS and FDP. Introduce tendon gliding exercises a few times per day to minimize stiffness from the splinting, with intermittent splinting as depicted in the conservative management section.
- At week 7, introduce gentle blocking exercises to improve both PIP and DIP flexion and reverse blocking exercises to improved finger PIP extension (see image)
- At week 8, progress to full unrestricted AROM of fingers, thumb and wrist while encouraging opposition to all fingers as well.
- At week 8-10, initiate light strengthening as tolerated with no pain above a reported 2/10 as they progress (gripper, putty, clips).
When Applicable:
- Scar management, scar massage with vitamin E oil / thick vitamin E cream in light circular motions with moderate pressure, 3-4 minutes twice daily.
- Education the patient to limit strengthening tasks, lifting and heavy use until 9-10 weeks post-op
- Encourage finger food tasks, in hand manipulation and coin stacking, and palm scratch exercises to optimize AROM and function. (when wound is fully healed)
- DIP blocking splint may be required to encourage differential glide of the FDP
- Encourage towel wringing exercises for incorporating fingers and wrist into HEP and functional re-integration.
- When available, find a Certified Hand Therapist to provide splinting
*Wound healing may be prolonged in diabetic patients and smokers
