April Part 2- Hand

[Kyle Feldman]

To go along with the Wrist post, I have added one for the hand

A 64 year old female presents to the clinic with one year history of right radial wrist and base of the thumb pain. Symptoms has gradually gotten worse over the last 3 months as she became the primary daycare provider for her granddaughter. Pain increased with lifting the child, holding pots cooking, and gardening. Recent radiographic imaging showed moderate degeneration of the thumb CMC joint and synovitis of her EPL.

Questions for thought
Would you consider treating only or an orthopedic referral and/or bracing for this patient? What would lead you to this clinical decision making?

Please discuss prognostic factors and management strategies for this patient.
Use these two articles as your guide

What experiences have you had with hand surgery? Have you seen patients post-op for the hand? How was the rehab and what were the outcomes?

Attachments:

You must be logged in to view attached files.

[awilson12]

Similar to wrist, I don’t have really any clinical experience with the hand to go off of. Drawing from my limited knowledge base and based on the J of Hand Therapy article it seems like there were good outcomes with patient specific splinting prescription, so I think it would be worthwhile to refer out to get that done since I don’t personally have the skill set to effectively help with this. In terms of referring to ortho I think this depends on the severity of pain and disability, the patients interest in pursuing other options, and/or progression with PT.

Using reasoning based off of other OA populations and the articles you provided management would likely include activity modification, joint mobilization, and mobility and strengthening in and around this region within appropriate pain levels. Potentially more severe levels of OA will not get as much benefit and relief, but it seems like (at least within the 4-6 week range) a combination of splinting, education, manual therapy, and exercise can provide the patient with pain relief and functional improvements.

I have had very few experiences with hand surgery- have only spent a couple of hours with our hand therapists doing pre and post-op consults through the UVA hand surgery center. I personally have not seen someone post-op and led them through rehab, so I have no experience to draw from to discuss outcomes in these patients. Would love to hear others experiences and take-aways if they have had experience with this!

[Taylor Blattenberger]

For this patient I don’t believe surgery would be a realistic option, at least in the short term. I have seen 4 people that have undergone the mini tightrope procedure (not the full way through, but at different points in rehab). When the rehab is completed I have noticed patients are typically satisfied, but the protocol is very restrictive, especially in the first few months. From my experience the protocol limits “excessive” gripping and lifting with the involved hand for at least 2 months allowing AROM only. With this woman needing to lift and care for her young granddaughter, this may not be feasible.

She would be much better off attempting conservative management. I think this case has the characteristics of an acute overuse injury as a new repetitive stressor is directly correlated with symptom onset and progression. I think bracing would be a great option for this patient to limit CMC movement, especially when she is doing more strenuous activity such as lifting her granddaughter and performing heavy ADLs.

[helenrshep]

Similar to Anna, I have very little experience with treating hands and haven’t ever seen anyone post op.

I would likely refer her for a splint/brace but then I feel comfortable continuing with physical therapy. Like Anna and Taylor mentioned, education about activity modification and strategies for picking up her granddaughter would be very beneficial in addition to manual therapy and exercise. I don’t think she needs a referral for surgery at this point as it has only been going on for 3 months and is associated with increased activity. I anticipate her doing well with conservative management through PT and bracing.

[Kyle Feldman]

Great points

Taylor you seem to have the most experience.
Have you seen anyone with hand pathology get local injections?

I ended up sending her to ortho for one directed at the EPL tendon and within 2 hours she was painfree and we were able to do all exercises next visit.

What concerns would you have with local injections near tendons?

[Author]

Posts