Dupuytren’s Contracture

Introduction Dupuytren’s contracture is a thickening of deep tissue (fascia) which passes from the palm into the fingers. Shortening of this tissue causes “bands” which pull the fingers into the palm. The cause of this is unknown but it tends to run in families. The condition is progressive and the only treatment is surgery. If untreated, the fingers will be gradually pulled into the palm. Fasciectomy Your Dupuytren’s contracture will be corrected by removal of the abnormal fascia and relaxation of the overlying skin. The entire wound is stitched up in a zigzag manner which lengthens it but occasionally, a segment of the wound in the palm is not stitched, being left open to heal by itself (open-palm technique). Dermofasciectomy In some situations it is necessary to also remove the overlying skin if it is affected by the disease or previous operation. Amputation Very rare in unoperated cases but may be preferred in a finger in which the bands have returned many times and where there has been previous nerve and vessel damage. Post-Operative Care  Hand elevation is important to prevent swelling and stiffness of the fingers. Remember not to walk with your hand dangling, or to sit with your hand held in your lap.  You will be initially placed in a bulky dressing consisting of gauze, plaster of paris and tensor bandage to rest the hand. The dressing will be removed after 3-5 days and then be left open at this stage, if possible, to allow mobilization of the fingers. The open-palm technique usually requires dressing to be applied to the palm for 2-3 weeks while mobilization is performed in the usual way.  At this time, you will see a hand therapist who will fit you with a splint and give you specific exercises to perform. The splint is to be worn at night for 6-12 weeks to keep the finger straight. During the day, the hand should be exercised and you should perform normal light activities. You may require ongoing therapy for range of motion and strengthening.  Your stitches will be removed one to two weeks after the operation. Following this the scar will be somewhat firm to touch and tender. This can be helped by firmly massaging the area with moisturizing cream. At this stage it is safe to get the hand wet in the bath or shower. The scar and the surrounding skin often become very dry and will be more comfortable if a moisturizer is applied, including the scar itself.  A Hand Therapist will see you for scar management. It is often not possible to fully straighten fingers that are very bent at the time of the operation, particularly if much of the bend occurs in the middle joint of the finger. This can sometimes be improved with splinting and exercise later after the operation. Duputren’s contracture can return either at the site of surgery or else where in the hand.  You can usually drive a car a couple of weeks as long as you are comfortable and have regained good finger movements. Timing of your return to work is variable according to your occupation and this should be discussed. Please call the Office or your Family Doctor if:  The prescribed medication does not provide adequate pain relief  The dressing/cast is too tight or uncomfortable  Numbness persists  You have a fever Risks of Surgery Nerve Damage The nerves running to the fingers can be damaged during the surgery and cause numbness in part of the finger. This complication is unusual in unoperated areas but becomes more common during repeat operations. If this occurs the nerve would be repaired immediately, if possible. Infection Any operation can be followed by redness and tenderness which may indicate infection. Do not apply antiseptics. It would be treated with antibiotics.

Your Hand Therapist and You - Working together to help you return to work

Your doctor or surgeon has referred you to a hand therapist to help you: • Recover from your workplace injury • Return to work as soon as you can safely do so • Prevent a similar injury from happening again. During your first visit, your hand therapist will: • Ask questions about your work • Assess your injury and, if necessary, start treatment to help your recovery • Explain what you can expect during your treatments • Explain your role in recovery • Plan with you how and when you will be able to return to work Why is your hand therapist asking questions about your work? Your hand therapist needs to know the kinds of activities you do at work and the way your workplace is set up so he or she can: • Understand how your injury affects your ability to work • Advise on when and how you can safely return to your regular or modified work • Advise you on how to prevent a similar injury from reoccurring How will your hand therapist assess your injury? Your hand therapist will ask you questions about how your injury occurred and the limitations the injury is causing. He or she will examine the injured part of your body. If your hand therapist treatments are required, your hand therapist will begin right away. What may your hand therapist treatments include? • Exercise – specific exercises to increase mobility and strength; doing the exercises recommended by your hand therapist is very important to your recovery. • Control inflammation – such as ice, ultrasound, and laser. • Control of pain – such as ice, heat, mild electrical stimulation, and stretching. • Manual therapy – a “hands on” approach to improve mobility • Education – to help prevent a similar or future injury and control pain. • Home program – exercises that you can do on your own. Your hand therapist will explain how many treatments you are likely to need and how often you need to attend the clinic. You will discuss a target date for being able to return to work safely. The hand therapist is available to answer any questions regarding your treatment. Before going to back to work, you must notify your doctor, who may wish to see you. What are your responsibilities during recovery? Much of your recovery is up to you. Your hand therapist will show you how to do the exercises that will help you regain your strength and flexibility. Learning how to do the exercises correctly, then doing them at home as recommended by your hand therapist, is important. Remain as active as you can during your recovery. This will help your recovery and get you back to your regular job as soon as possible. Your hand therapist will provide guidance regarding the types of activities that are beneficial. Keep in touch with your employer and be willing to do tasks that your hand therapist, doctor, and employer agree you are able to safely do. If you cannot return to your regular job, WorkSafe BC will contact your employer to see if there is suitable work. When will you be able to return to work? Your hand therapist and your doctor will both discuss with you when you might be able to return to work. Here are some possibilities: • Your return to your regular job as soon as you are able to do so safely • You return to your job with temporary modifications in your hours of work, the tasks you do, and/or the way you do your tasks for a defined period of time Your hand therapist may recommend that you return to work before you feel you are fully recovered. The type of activities that you do at work may contribute to a faster recovery. If necessary, you will continue your hand therapist treatment for a brief period after you return to work. Return to work is good recovery Return-to-work programs are based on the idea that many injured workers can safely perform work during their recovery period and doing so provides emotional and physical benefits which can help in recovery. WorkSafe BC nurse advisors are here to help you return to work and recover from your injury. What is a nurse advisor? A nurse advisor is a registered nurse with additional training and education focused on recovery and return-to-work planning. The nurse advisor does not handle claim entitlement issues. How can the nurse advisor help you? The nurse advisor may contact you to assist with developing a return-to-work plan. In doing so the nurse advisor may: • Collobarate with you and your physician, employer and health care provider • Organize, start, and monitor a return-to-work plan • Support you throughout the recovery process Other important questions for you and your hand therapist to discuss Who pays for your hand therapist treatments • If you have reported your injury to your employer and WorkSafe BC, you will have a claim number. • If WorkSafe BC accepts your claim then WorkSafe BC will pay your hand therapist directly. YOU DO NOT HAVE TO PAY ANY COSTS • If your claim is not accepted, you are responsible for the full cost of your hand therapist care • If your claim is pending on the date of your initial visit and then not accepted, your hand therapist will directly bill WorkSafe BC for the initial visit only and reimburse you any money paid for this visit. What if you have not started a claim with WorkSafe BC? Call WorkSafe BC at one of the following numbers: General claim or entitlement inquiries Lower Mainland 604-231-8888 You will be given a claim number, which you can give to your hand therapist. Keep these numbers close at hand so you can call if you have any questions about your claim. What if you have not returned to work as you and your hand therapist planned? If you have not returned to work as planned, WorkSafe BC will work with your doctor and physiotherapist to confirm a future treatment plan. While receiving hand therapist treatment, how often should you go to your doctor? Go to your doctor if: • Your condition changes significantly • Your physiotherapist recommends a visit • Your doctor recommends a visit Your doctor is not required to send progress reports to WorkSafe BC for you to continue receiving compensation payment. If you have had a workplace injury, call one of our offices to book an appointment for your initial assessment.

Trevor

Trevor, Thank you for making time in your schedule to craft a note for my doctor regarding my hands. I appreciate it very much, for it, I hope will further inform my doctor of the state of the bio-mechanics of my hands. I hope he will repair what needs same. Gratefully, Nancy P.S. Every day, I do your exercises (the ones possible to do).

Introduction to Pain

No-one really wants pain. Once you have it you want to get rid of it. This is understandable because pain is unpleasant. But the unpleasantness of pain is the very thing that makes it so effective and an essential part of life. Pain protects you, it alerts you to danger, often before you are injured or injured badly. It makes you move differently, think differently and behave differently, which also makes it vital for healing. It is usually really sensible to hurt. Wikipedia describes Pain as: " Pain is an unpleasant sensation often associated with damage to the body. It is the feeling common to such experiences as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone" and is caused by activation of specialized pain-signaling nerve fibers or by damage or disease affecting the somatosensory nervous system." www.handtherapycenters.com

Mallet Finger

The extensor tendon of the finger can become injured, usually through a sudden forced flexion of the distal interphalangeal joint (DIP), for example, when a ball hits the tip of a finger.

The common presentation of this injury is an individual who can not straighten (extend) the DIP joint of a finger. There may or may not be associated pain and swelling at the DIP joint. In fact, it is not uncommon for a person to remark how they didn’t know the finger had been injured until it was noticed that it could not be fully straightened.

On x-ray, there may be an associated avulsion fracture where the terminal extensor tendon joins onto the distal phalanx, known as a “bony mallet”. When there is no fracture, it is referred to as a “soft tissue mallet”.

The accepted treatment for either a bony or soft tissue mallet injury is positioning of the DIP joint of the finger in slight hyper-extension for a minimum of 6 uninterrupted weeks, but optimally 8 weeks uninterrupted. This is best achieved through provision of a custom fitted thermoplastic splint. Although the “stax splints” are readily available, the fit is often not acceptable, not extending the DIP joint sufficiently, or interfering with full PIP joint motion. The alumifoam splints can position the DIP more carefully, but can create skin maceration from excess moisture collection.

The Certified Hand Therapists at the Hand Therapy Centres (www.handtherapycentres.com) treat many clients with mallet injuries. Evidence shows that the following needs to be in place to result in the best outcome from this injury:
1. If patients are sufficiently educated about their injury they will be more likely to comply with the exacting splinting regime.
2. Custom splints need to be comfortable, adequately position the finger and allow for the individual to participate in work and leisure activities.
3. Finally, monitoring of the patient while they are weaning out of the splint minimizes the risk of the extensor lag from re-occurring.


Secondary complications of poor management include:
• Swan neck deformity;
• Continued pain;
• Patient unhappy with range of motion;

The best results occur when treatment is started promptly, within a few days of injury. However, full functional range of motion of the DIP has been restored in some patients even when treatment has been delayed for several months.

On average, patients attend three sessions for treatment of mallet finger injuries, (once for the initial splinting and patient education; at 6 or 8 weeks of splinting to start the weaning process and final visit during the end of the weaning process to ensure an excellent outcome). The total cost of these visits is reimbursable from most extended care insurance plans.

If you have any questions in regards to the treatment of Terminal Extensor Injuries, pleas feel free to contact us and speak to one of our Certified Hand Therapists.

Thank You Very Much

I'd like to thank you guys for taking me under your wing for the past 5 weeks. It's been a great learning experience in an incredibly interesting field. I'm sure I've seen some things I will never get a chance to witness again. But also, I've learned from the experts in the field how to manage some of the more common upper limb injuries I'll be sure to come across again. It was a challenging and rewarding placement, so I appreciate all of your time, effort and patience which helped make it so good. All the best to everyone on the team.

Joe
July 2011

What is CMC Arthritis

In the thumb, the most common area of arthritis is at the base of the thumb, known as the CMC joint. Symptoms may include swelling, pain, redness, “crepitus” or creaking, and enlargement of the joint.

As the process progresses, the muscles may eventually overpower the weakening joint, pulling the thumb into the palm. This will decrease the ability to pinch, greatly affecting the function of the hand.

There are many hand therapy options including education, acute symptom control, chronic pain management, joint protection techniques, personalized exercises, and customized splinting. The combination of splinting, and learning management techniques will make a significant difference in functional levels.

A steroid injection to the joint may be recommended.

For badly damaged joints, remarkable surgeries are now offered which can rebuild the CMC joint. Therapy is offered following joint replacement surgery to protect the thumb during healing and to safely begin moving and strengthening.

www.handtherapycentres.com