Hand Rehabilitation SIG

Carpal tunnel syndrome corresponds to compression of the median nerve located in the palm of the hand. This nerve provides sensation to the fingertips of the thumb, index, and middle fingers. It also provides motor innervation to certain muscles of the thumb. The carpal tunnel is an inextensible tunnel bounded by the carpal bones at the back and a thick ligament at the front. The median nerve passes through this inextensible canal accompanied by the 9 flexor tendons of the fingers. When the canal narrows, or if the tendon sheaths thicken, the nerve, which is compressed first, suffers, and symptoms appear. These symptoms are tingling or numbness, sometimes accompanied by pain in the thumb, index, and middle fingers, especially at night. In principle, the disorders only affect the fingers, but they can extend to the entire hand and arm.

The surgical treatment consists of sectioning the annular ligament of the carpus associated with neurolysis allowing the release of the median nerve.

Physiotherapy intervenes postoperatively and consists of scar massages, ultrasounds, and functional rehabilitation.

The goal is to avoid adhesions and to recover finger mobility as well as muscle strength.

Tenosynovitis is an inflammation of the tendon sheath. The origin can be infectious, rheumatic, or micro-traumatic.

The symptoms are well-localized pain during tendon movements with sometimes crepitation.

The medical treatment is immobilization, anti-inflammatories, and infiltrations.

Sometimes surgical intervention may be necessary to release the tendon (tenosynovectomy).

Physiotherapy intervenes before and during immobilization through physical agents and after surgical intervention through gentle and progressive functional rehabilitation to avoid tendon adhesions and accompanied by ultrasounds.

Tenosynovitis most often occurs at the level of the fingers.

This is a particular clinical form characterized by a more or less painful catching in the flexion-extension movements of the finger, the movement being slowed down halfway and ending abruptly as if driven by a spring.

Dupuytren's disease is a retractile fibrosis of the palmar aponeurosis of the hand (membrane located between the flexor tendons and the skin). It causes progressive and irreducible flexion of the fingers. The fibrosis transforms the palmar aponeurosis and leads to the formation of fibrous bands.

The origin of this disease is unknown, the only established fact is the existence of a genetic factor.

The symptoms are the appearance in the palm of the hand of one or more nodules located at the base of the 4th and/or 5th finger. Over time, the nodules lengthen and form longitudinal cords, and gradually an irreducible flexion of the fingers of the first two phalanges appears. In severe forms, the hand can close completely.

The treatment is surgical by percutaneous aponeurectomy or fasciotomy.

Physiotherapy intervenes after surgery through scar massage, functional rehabilitation, and ultrasounds.

Complex regional pain syndrome (CRPS) is a vasomotor and trophic pain syndrome resulting from an unknown neurovegetative disturbance and various causes. There are several synonyms to designate this disease: "Sudeck's disease", "reflex sympathetic dystrophy", "shoulder-hand syndrome".

The symptoms of CRPS are pain that causes functional impairment, trophic disorders with vasomotor disorders (edema, changes in skin temperature and appearance), as well as epiphyseal demineralization.

CRPS is rarely idiopathic but generally secondary and localized to the extremities of the limbs.

The causes can be:

• traumatic (50% of cases): surgery, fracture, sprain, dislocation, prolonged immobilization)
• neurological: hemiplegia, head trauma
• visceral: myocardial infarction, tumors
• medication-related
• metabolic: diabetes, hypothyroidism

Finally, there is an anxious-depressive and emotional background favorable to the appearance of algodystrophy, but its psychosomatic role should not be overestimated.

The evolution of the disease is generally favorable with complete recovery in a few months (6 to 24 months).

This evolution occurs in two phases:

• a hot or pseudo-inflammatory phase, characterized by severe pain and vasomotor disorders (heat, edema, shiny skin)
• an inconsistent cold phase, marked by the appearance of trophic disorders (cold limb, pale, smooth, and atrophic skin). There are sometimes capsulo-ligamentous retractions responsible for progressive joint stiffness

Treatment

There is no specific treatment for CRPS. It combines rest, adapted physiotherapy, and medications. It aims to reduce pain and preserve joint mobility.

Rest is indicated in the hot phase. For the lower limb, the suppression of weight-bearing is a crucial measure as long as pain persists. Immobilization should be avoided.

Physiotherapy

It must be cautious and well-conducted. It must be progressive and above all painless, because pain, in the hot phase, can worsen the disease.

In the hot phase, it uses cryotherapy, trigger points, analgesic electrotherapy, and cautious and painless mobilizations of the affected joint.

In the cold phase, capsulo-ligamentous stretching and active mobilization are added.