Case Presentation. Musculoskeletal Module.

UCP/AL/11/193Perera W.V.A.I.Allied Health Sciences UnitFaculty of MedicineUniversity of Colombo

Subjective examination.• Age:- 61 years• Gender:- Male• Occupation:- Electrician• Family position:- Father of three children• Present complain:- Can’t extend 4th and 5th fingers in right hand• History of pc:- RTA, while travelling on the bike a three-wheeler

has come towards right side and stopped. Suddenly his R hand directly blow on the side frame of the three-wheeler.

• Mechanism:- RTA, direct blow of R 4th & 5th digits, closed fracture in the 5th proximal phalanx, open subluxation in the 4th PIP joint.

• History of surgery:- Surgical intervention in the 5th proximal inter phalanx.

• Pain scale:- NPS; 3• No tenderness, no numbness, no any other uncomfortable

sensations.• Past medical history:- HT+, DM+, Cho+, under medications for

above conditions as well as CHD.

Objective examination

• Observation. Deformity in 4th & 5th IP joints (Boutonnière, due to post

traumatic condition) Swelling around joints, and tendon sheath. Muscle wasting especially in thenar, hypothenar muscles,

interossei and extrinsic muscles. Skin condition (colour is much darker, temperature is

normal)

• Palpation. Dorsal surface; Anatomic snuff box, carpal bones,

metacarpal bones & phalanges. Anterior surface; Pulses, tendons(L-M), palmar fascia and

intrinsic muscles, skin flexion creases, & arches, skin is more rough than the surrounding skin.

Stiffed and swollen around PIP joints in 4th and 5th digits.

Cntd,• Examination. Active movements; Elbow, wrist, MCP, PIP and DIP joints in

the R. Passive movements; Elbow, wrist, MCP, PIP and DIP joints in

the R. Resisted isometric movements; Elbow, wrist, MCP, PIP and

DIP joints. Functional Assessment (Grip) Extrinsic and intrinsic hand muscle strength scales (MRC) Radiographic findings; Subluxation of the 4th PIP joint and

simple oblique fracture in the 5th proximal phalanx of the R side.

• Special tests. Ligamentous instability test for the fingers. Test for tight retinacular (Collateral) ligaments. Test for Extensor Hood Rupture. Phalen's (Wrist Flexion) Test.

Physiotherapy diagnosis.

• According to the examination,

Active, passive, resisted isometric movements in elbow, wrist, MCP, & IP (thumb & index finger) were almost normal.

But, active, passive, resisted isometric movements were restricted in MCP, PIP, & DIP joints of 3rd, 4th, & 5th digits.

Power grip was less with compare to other types of grips, due to affected ulnar portion.

Making fist is normal, but expansion of it abnormal extension lags in 4th, & 5th PIP joints.

Extrinsic hand muscles is in grade 5, but intrinsic hand muscles is in grade 4. (According to MRC scale). Atrophy of these muscles also revealed that disuse of the right hand often.

Cntd,• According to the special tests, Ligamentous instability test for the fingers was negative to all

five digits. Test for tight retinacular (Collateral) ligaments also negative to

all five digits. Test for extensor hood rupture was positive in 4th and 5th digits.

Which indicate that, Boutonniere Deformity has being occurred. Phalen's (Wrist Flexion) test was negative and there were no

any sings of carpal tunnel syndrome.Physiotherapy diagnosis is impairments and functional

limitations may occur from the lack of motion and muscle contraction, including:

Decreased ROM and decreased joint play with firm end- feel and pain on overpressure. Tendon adhesions. This is a significant complication if there was any inflammation in a tendon or its sheath. Decreased muscle performance including muscle weak- ness, weak grip strength, decreased flexibility, decreased muscle endurance, and rupture in the extensor hood of 4th & 5th digits.

Treatment plan and justification• Short term goals. Pain management- o Gentle grade I or II distraction and oscillation techniques

10 minutes, twice a day, for 3-4 weeks, may inhibit pain and move synovial fluid for nutrition in the involved joints.

o Applying Infrared therapy :20 minutes,3 times a week, for 3-4 weeks. Superficial heat ,causes vasodilation reducing muscle ischaemia, this relieve muscle spasm, reducing pain(counter irritation),prior to exercises.

o Applying an electric stimulation to the extrinsic hand muscles.

Maintain Joint and Tendon Mobility and Muscle Integrity-o Passive, assistive, or active ROM- It is important to move

the joints as tolerated because immobility of the hand quickly leads to muscle imbalance and contracture formation.

Cntd,• Tendon-gliding exercises- Have the patient perform full

motion in the uninvolved joints and as much motion as possible in the involved joints to prevent adhesions between the long tendons or between the tendons and their synovial sheaths.

• Increase Joint Play and Accessory Motions-o Joint mobilization techniques- Apply grade III sustained or

grade IV oscillation techniques to stretch the capsules to all wrist, hand and digits.

o Self-mobilization.• Increasing the ROM in all joints of the R hand.o Passive, assistive, or active ROM exercises.• Resistance exercise for regain the muscle performance.o Resistance exercises for all the elbow, wrist, hand and finger

movements.

All the above exercises are done twice a day(morning and evening), 10 repetitions for 2 weeks.

Cntd,

• Long term goals.• Regain the neutral position to the 4th and 5th PIP joints.

(Neutralized the extension lag)-o Static splinting to the 4th and 5th PIP joints. Wears a volar

static (resting splint), which holds the wrist in 15° of extension and the fingers in full or almost full extension.

• Patient education.o Educating the patient about all the exercises as well as the

importance of being an active participant of the exercise programme for the rehabilitation.

Outcome measurements of the intervention.

Motion Session; 01 (°) Session; 02 (°)

Flexion 150 150

Extension 0 0

Pronation 80 80

Supination 90 90

Elbow joint.

Wrist joint.

Motion Session; 01 (°) Session; 02 (°)

Flexion 80 80

Extension 70 70

Ulnar deviation 30 30

Radial deviation 20 20

Hand

Joint Motion Thumb 2,3 digits

4th digit 5th digit

S1° S2° S1° S2° S1° S2° S1° S2°

CMC Flexion 13 15 - - - - - -

Extension

18 20 - - - - - -

Abduction

68 70 - - - - - -

MCP Flexion 48 50 87 90 80 83 82 85

Extension

0 0 43 45 20 21 20 21

Abduction

- - 24 25 20 22 22 23

Adduction

- - 0 0 0 0 0 0

IP Flexion 48 80 93 95 21 25 42 45

Extension

17 20 0 0 0 0 0 0

Value of the NPS was 01 in the previous session.

Thank You