EASY Hand Fast Track Framework For OT's
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Well, welcome everybody. Thank you so much for giving me this opportunity to talk to you guys this morning. Like I said, I'm, My name is Wong. I run my own private practice in Miami and I also run and teach online through hand therapy secrets.com. I'm just gonna go [00:01:00] over the objectives today. . So really go over some, a quick anatomy and then share with you a framework that I use not only in my clinic, but with my students.
And I call it the fast track framework. And one of the reasons why I call it the fast track framework is that a lot of times we as therapists, regardless of whether you're. Just getting started in hand therapy, you're doing pretty well, or you're a certified hand therapist with many years of experience is that sometimes we get cases that come to us and we don't have the prescription, we don't have the op note.
You know, not everyone works with the surgeon, next to the surgeon has access to the surgeon a hundred percent of the time or have access to like hospital records. And I'm saying that because I used. Work in the hospital and I had records that I could access like x-rays and reports and stuff like that.
And then I left there and went, worked for a private clinic right across the hall from the hand surgeon and I had access to. I had [00:02:00] access to him, I had access to all the records from his staff. And so, you know, in that sense, you can gather a lot of information when you get those type of patients that come in before they come in, so you can know exactly what to do nowadays.
You know, I work in a private practice and I don't have that luxury of just knowing always exactly what's coming through the pipeline. And I think that what happens is a lot of people who are practicing are in the same boat, right? And so I developed this framework to help, you know, regardless of whether you're new, you've been practicing for a while or you're an expert this framework so that it can help.
Think through cases easier even if you don't know like exactly what's going on, and you can think through those cases no matter when that patient comes into you. If we're fortunate and they're fortunate, we get them in pretty fast, right? We get them in pretty quick and we get them in [00:03:00] like right after injury or post-surgery.
But in this day and age, people are more skeptical. They wait, they're just not sure. Let's face it. There's so much information out there right now that people are just confused, you know? What to decide or what to do with all that information. 20, 30 years ago, there was no information, so we're on the other swing of it.
But this framework really just allows us to, to dive in and make decisions and help our patients really at the end of the day, make decisions about coming into therapy and getting the results that they're hoping for. So I'm gonna go through that and then we're gonna go through some some cases that I.
And how I just progressed them through the protocols and how to progress them towards the end goal that they wanted. And then I'm gonna also include in the talk just recommended orthosis versus plaster casting. . All right. So, oh, thank you for turning your picture on. I like to see [00:04:00] faces, so if you wanna put your face on, I wanna see faces cuz that allows me to know who I'm talking to and am I boring you or is it, am I on point
And if you're confused, I can tell . All right. So feel free to turn your camera on so I can see some faces and I can interact with you. So, like you guys do an amazing job. There's 74, you know, over 70 people on this call, which is really accredited to this association for putting on such a great platform for you guys to join.
Not just locally in your area, but for those who are joining outside of the area, kudos to this association. All right, so I'm gonna go over just a general anatomy and this is what I do with my. I am super low tech. I'm gonna see if I can pin myself. I just pinned you. Hold on. So I just wanna make sure that for all the attendees, like on your screen, you should be able to see her real big.
And [00:05:00] then all everybody else should be at the top screen smaller, but with video, Is that right? Thumb up. Oh, perfect. Great. I usually do this for my own lecture, so I'm like, wait, I'm not pinned And then you might not be able to see so. . I'm real low tech because you know the way I like to teach my own student.
It's just to help them have an understanding as well. And then this is, this works great for patients as well. I love explaining to patients what's going on with them and in a very simplified way so that they have a buy-in. If they have buy-in to the fact that they understand what's going on.
They understand how they can get results by coming into you as a, as an expert. They're gonna keep. And it's not gonna matter about money or time. They're gonna come in because they want the results that you are gonna give them. So when I think about the hands, I think about I'd essentially just [00:06:00] draw blocks, right?
So this is P three P two. and then P one, right? And I think about like where potentially the fractures can be. And then we know that we have ligaments right here. We have collateral ligaments on the side of , P one, P two, and those ligaments are always tight. It doesn't matter if you're an extension, if you're inflection, they're always tight.
And this is one of the reasons why they're always the problem. Child of the hand. You can break your big knuckle, you can break your little knuckle, and you'll still have problems with your p . And then we have coming on the flexor side. So if you're looking at this, and this is your, anterior view, and the other side is your posterior view.
You know that your flexor tendons are here. And it attaches to the proximal end of P two that allows you to flex that p i [00:07:00] p. And then you have your profundus that comes and attaches and allows d i p flexion and also helps with p i p flexion and MP flexion. And then you have. on the anterior side as well, your volar plate.
So here's where I would essentially draw that volar plate. Now you can do the same and we could take a look at it from the side view,
right? The side view and here would be your volar plate, and this would be your flexors, right? Here are your flexors. . And then of course you have your sensors yeah, like all your sensor hood. So I'm just gonna draw it simply like this. So it's always something to keep in mind in terms of anatomy when you think about [00:08:00] different various hand injuries.
Today I'm gonna speak specifically about fractures just because our. So many different types. You can have tendon lacerations and stuff like that. I'm gonna speak on more fractures of the hand, and of course, what are the types of injuries when it pertains to fractures you can have or of the fingers in the hand.
You can have fractures, you can have dislocations, and you can have fractured dislocations. And the way I always explain it with my patients are fractures. At least you can see where the bone is broken. , right? When you can see where the bone is broken, they almost have a little comfort right feeling because they can see that it's broken and potentially they could, you know, do the surgery to fix it so they, it's something that they can see, right?
Dislocations are a lot harder because they're the soft tissue aspect and you can't really see. . [00:09:00] Sometimes people talk about, Look, let's do an mri, but the structures are, honestly, they're so small you can't see it. And what are you gonna do with that information anyway? MRIs are usually done because you need to see something so that you can potentially do surgery.
Usually with dislocations especially with the sprain, strained ones, you can't really do. , you know, it's really just about reducing the pain and doing the therapy. And then there's fractured dislocations. And the way I explained that is, you know, it was bad enough that you had a fracture, but now you have two particular problems.
You have a bony problem and you have a soft tissue problem. And one of the reasons why I like to go over a little bit of that anatomy is because it allows for you to understand. Based on the injuries. So today I have a case where she actually broke the p i p, she broke P one and it was an [00:10:00] interarticular fracture, so it went through the joint and it was displaced enough and it was so bad.
She had a fracture and a dis. . So when you take a look, when you get cases that come in and you don't always know what's been going on one way, especially if they've had surgery, one way to look and see what might be going on is just by looking at their scars, right? Just by looking at their scars, you may be able to determine and then guide your questions in a way that.
You get the answers from your patients if you cannot get them from the doctor's office fast enough, right? So we have the two types of injuries. You have, your fractures, your dislocations, and then your fracture dislocations. So think about, let's think about the types of treatment now for those types of injuries.
All right? Let's think about those types of. Those types of injuries. [00:11:00] So for example, for your, let's do types of treatment, so we can chunk them up into different buckets of treatment, right? You can have your conservative treatment,
you can have conservative treatment and in conservative treatment, what are you thinking that they're, you know, that usually. Usually entails casting or splitting, right? They're very similar in the sense that they just want to immobilize you. They just want to immobilize you. So let's say you have a p, you have a p three fracture and or a p a two fracture.
A P one fracture. If it's anywhere between the P I P or [00:12:00] the D I P, they're going to potentially try to, I just immobilize you through using splints. They can be an aluminum splint that a doctor puts on. It could be cons like a prefab, such as a stack splint that someone puts on. Or it could be essentially plaster casting or a custom fitted orthosis with thermo class.
Right? So that's a type of treatment that can occur. And then if you have a fracture or a fractured dislocation, that is severe enough and the severity is if it's into the articular cartilage, if it's displaced a certain amount, or if it's into multiple pieces, multiple fragments, then you're gonna most likely see a surgical component.
Right? And when you think about surgery, , what types of surgeries are you considering that the doctor's going to be doing? So depending on the location of that [00:13:00] fracture, you might see an o, rif F you might see pins, right? What else? You might also see from that? From that from that anatomy portion you might see ligament.
All right. You might see some ligament repairs and it, of course, it depends on the case. Does anyone have any cases that they're currently treating right now that sounds at all similar? Do you have a finger fracture? Finger dislocation? They're one of the toughest ones. Just because what generally happens to the p I.
what generally happened to the P I P Ps tend to get stuck, right? They get stuck and they get and they like to get stuck in the middle. They don't want, you know, they get stuck in the middle. And actually, I always say that each of [00:14:00] our fingers tends to have their own personality and attitude. So, the index fingers, if you have a fracture there, index fingers like to say.
Right. Who's with me who sees this? I always say that index fingers like to stay straight. And that's because you can get around your life without using it. So then people are like, Oh my God, it's so stuff so sucks straight. Right. And I just can't bend it. . But even in that extended position, you're going to see a little bit of a flexion contracture cuz p they like to stay in the middle, right?
And then in all these other fingers, they like to be in a more flex position. And the further you go along the finger, especially to the small finger, you're gonna see more flexion. Am. . So ideally we do not want more than 30 degrees, right? But ideally, we want it to be as straight as possible. I don't know [00:15:00] about you, but I'm a very, what I call a loosey-goosey person.
I have lots of joint play, and if I broke my finger and knock on wood, I always say, if I broke my finger, I would want to get as much motion back as possible, even that hyper extension so that I. Feel loose and my joints can have that flexibility. So they all have their little attitudes with this being the most straight in extension and this one being the most flex.
So if anyone has cases like that, let me know. We can talk about it cuz I'm gonna share the case that I had with you that had the same problem and it was my favorite. The middle finger . Which likes to say in that 30 degrees, you know? But what happens if you have a fracture here it's always going to make your d i p very stiff.
Why? If you go back to [00:16:00] anatomy, if your tendons are not gliding very well, then your profundus will not glide very well if you are not able to move. Guess. , your extens hood won't like to move either. So you have your central tendon, but then you also have your terminal tendon. And then of course you have the, all the bands on the side.
So you have your your lateral bands, your l, your what's it, what is it called? Oblique, right? Macular ligaments. So all those things, everything gets tight, and nothing is, , right? So then we have to think, well, what are we gonna do in order to be able to help them? And this is where I like to use my fast track framework, right?
So if you have cases that come in and you're just not really sure, and you're just not really sure about like where they're going to get started or what you're allowed to do with them [00:17:00] based on their injury, this framework, which I call my fast track f. Fast Track
framework allows you to go through all the, I guess like areas and pieces that you could potentially work on. Right. And we have bones, we. muscles and tendons. And the reason why I stick them together is because the muscles attach a tendon and it's from the movement of the muscles.
Muscles only get long and only get short is what allows our tendons to glide, right? Especially in the hand. And then we have our ligaments. And our ligaments are what holds bone to bone and gives us that stability and that structure all. and then we have nerve. in the hand. We have digital [00:18:00] nerves, and if we're just sticking to like fractures and dislocations, they're technically not injured.
But let's face it, the structures of the hand are so small that sometimes they're. They're irritated, right? They're being crushed or tethered down. And so when people come in really stiff and they tell you that they have like a numbing sensation or they just feel like numb and tight all the time, it's probably cuz it's tethering, dawn and nerves.
And then we have our skin and fascia. So this essentially is the framework that I go through and I go through with my students. I go through it with my, my, my patients. And it's a great way to explain to somebody what you're allowed to do and what you're not allowed to do. So let's think about when your case came in particularly, and they, and you don't have any [00:19:00] information.
And so my woman, she came in and just looking at her. She had little scars on the side and she had pins, so she had little pin holes from the actual pin, and she was actually able to tell me that she had pins. And when I spoke to her, I knew okay. , she most likely had a fracture, which she knew she had a fracture, but I just wasn't sure.
Did she have a dislocation as well? And so it was, in looking at her scars that I was able to say, you know, it looks like you had a fracture, but was your finger in a certain did it look like it was bent in the opposite direction or whatever, where you potentially had a dislocation as well. And she goes, I think.
I think so. And so that just allows me to know, okay, how fast can I go? Or how can I explain to her how slow she's going to need to go or how slow the [00:20:00] progress is going to take? Because if you just had a fracture and it was nice and simple, you might be able to go a little bit faster, right? Your progress might be a little faster, but you have a fractured dislocation that compounds your injury.
And so I'm able to explain to her, listen. You had two pot, you had two problems, not just one. So we still have a particular protocol we can follow, but just to let you know, don't get frustrated. Don't get frustrated if you're not seeing your fingers. Move as fast as you would like to. I don't know about you, but every single patient that comes in wants to be better.
Yesterday I've had. I want it to be better. Yes. You know what? As a matter of fact, I didn't even want the injury to start with. Right? So most of them are gonna feel that kind of way. And when you start working with your patients, it's I find it so helpful to be able to talk to them in this way that.
Simplifies everything, but also [00:21:00] shows them that we are the experts as occupational therapists, a certified hand therapist to know we're gonna be able to help you and get results. But you do your portion, I'm gonna do my portion, and together when we work together, we're gonna get the best possible results for you.
Right. So I know that there's a fracture and I know that if she came in at a particular time, I'm allowed to move her. So what do we know about bone healing? Right. Bones start to, you know, to heal, show signs of clinical healing. Around, you know, four to six weeks, right? Actually before two to four weeks.
And then it continues to heal and you have that clinical and you can start moving them more about four to four to six weeks. And then around eight weeks it's a lot more solid. So you can start doing a lot more passive range, motion, a lot more like strengthening over a period of time until you get to 12 weeks and around 12 weeks.
Then you can go. You have [00:22:00] no precautions. The bone should be healed. Now, obviously that depends on the fact that the bones are aligned and they're showing those clinical signs of healing, right? Sometimes your fractures could be so large and so far displaced that it takes so much to, to fill in the gap.
Alright? So she had surgery though. So if she had surgery, that tells me that they essentially put her back together, pinned her to stay stable, and by the time she came in to me, she was four weeks along. So what does that tell me? Her bones, you have a certain amount of stability. , right? So, hey Victoria, based on when you're coming in, you're four weeks now your pins are out and so the doctor won't remove your pins unless you are showing signs of a great healing and you're allowed to remove those pins and start gentle active range of motion, right?
So [00:23:00] gentle act, arrange emotion is for here. But what about all the other joints that are not? I know because you're P one and your your other fingers or your other bones are not broken, I'm actually allowed to move them and make sure that they're moving. Luckily for her, she was just, if a p p i p and d I p, her mps looked really good, right?
What do I know about muscles and tendons? Well, muscles and tendons. Like I said, the tendons have to be able to glide. The flexors pull, but in order for the flexors to pull, the extensors have to give. And in order to extend our extensors, especially here in the p i p and the D R P, they tend to be small.
They tend to be weak, so they have to actually work against how strong the flexors are to pull them. . Right? And they're so weak that sometimes we have to put them in certain positions like the MP into a flex position [00:24:00] so that the p i p can have a chance to go into extension from our intrinsic muscles, right?
Our intrinsic muscles are the muscles that allow us to flex the mps and extend the I. And if you've had surgery, everything is locked down for four weeks, you haven't moved. Right? And that was necessary for your bones, your fractures to be stabilized and healed. And now we're allowed to start moving everything.
Ligaments, right? Ligaments. Well, you had a dislocation potentially repaired those ligaments and so, after a ligament repair, what happens? You wanna stiffen them up and then after about four to six weeks, you want to start to move them. Well, p ps like I said, your collateral ligaments are tight in both directions.
So if they did the surgical procedure to stabilize those ligaments, and you've been immobilized for four weeks now [00:25:00] we're technically allowed to start moving. And ligaments, we wanna be careful because we wanna pay attention to pain. We wanna make sure that you can move. But in a relative, and I say relative because p ps are always painful, relative PainFREE emotion pain-free way, but where they feel stable.
You know, the ligaments in the p i p they're taught all the time. They're strong, so they do give stability. It's not the same. I mean, ligaments or ligaments, they work the same, but it's not exactly the same as if you compare ligaments to other parts. But in the p I p they get tight very fast.
And so it's solid. I'm technically at four weeks, I'm technically allowed to start. Right. And then don't forget that the P I p, I mean the d i P here, which it has not been moving, is technically not hurt. So you can actually move the d I P so much more, so much faster, even though it hurts [00:26:00] like the dickens.
Right? But how do you get patients to buy into the fact that they're allowed to move even though. Well, we can explain it like this, We can explain it to them, like that actually wasn't hurt. It was just hurt. You know, As a second order consequence, as a consequence of this one, not moving, but we're technically allowed to move it right now.
Nerves, if you didn't cut anything, the nerves weren't injured, and that means you're allowed to move. You're allow. You know, to extend your fingers, you're allowed to curl your fingers down and you're allowed to move. Now, skin and fasc is really funny because it's sometimes can be the forgotten structure.
But if you haven't moved in a really long time and you've had surgery, and there we have such little. , little itty bitty structures in our fingers, and there's really not that much meat. So if you think about it, you need. It's the only place you [00:27:00] want wrinkles, right? It's in your hands and fingers. It's the only place.
So when I don't see wrinkles, that tells me that you're really swollen. That tells me that when you have swelling and you have swelling for a really long time that swelling hardens and turns into essentially scar tissue. And so the faster we can move it, the faster we can move your fingers, but the more we can move your skin around.
is what's gonna allow us to get better movement with less pain faster. Right, And this is the easiest part that they could help you with because they're with their hands and fingers all the time. And you know, there, there is this thing where, I don't know about you guys, but I always learned it when I first came outta school, which was like retrograde massage, right?
Retro from the top to the bottom, From the top to the bottom. That's all you do. And that might be great for when you have the edematous [00:28:00] finger and hand and stuff like that. After a while that doesn't necessarily work as well. So one of the things that I like to do is I like to make sure that I go in the direction that actually helps them.
So I go if I massage you going down, does that help you? Does I, if I massage going up, does that feel better? So I pick the direction. They pick the direction that feels the best, and then that's the direction that we move into. And believe it or not, sometimes it's very distal. Why? Because if you pull everything distal, it's been so tight this whole time.
If you pull it distal, If you pull it and pull it, do that about 10 to 20 repetitions. And then when you go in the opposite direction, ask them, Did that feel easier and better? And then try to move because all you're doing is you're trying to move the skin and what's below the skin, the extensor hood.
The flexors, the ligaments. [00:29:00] And if we got that to move in one direction and you're able to bend your fingers a little bit easier, a little bit smoother then that's telling you that you could do that at home too, right? And that's gonna get you better motion. So skin goes all the way around. Remember, skin and scars don't just go in one direction, they go in multiple directions.
So don't be scared to try and do some rotation. So the ligaments, the muscles pull us into flexion extension but we have passive rotation. So sometimes just moving that around. And I do the same thing. I have a yummy side and a yucky side, and if I roll into the yummy side and I can go below the area and above the area, I go at the area too.
But you can go and you can rotate the , the P one area, you're moving all those muscles and all those tissues. You go in one direction and you go into the [00:30:00] other direction, which direction feels the best, and you just go in the direction that feels the best and then you go and you test it against your range of motion.
Any questions on that?
Any questions at all? No, that was good. I mean, I'm just listening to you on the skin fashion. I. That is some, something that was missing, you know, in a lot of the textbooks, but as we find out, there's more and more involvement from the fashion, from the skin. Sure. And so, there's a comment by Elise.
It's great so far. Yeah. Feel free to join as a panelist. Turn on your video talk. You know, we welcome that. So when you were talking about the weakest sensors, it just made me think that so many of my finger fracture, you know, proximal. Especially 10 to or middle failings too. They can't get their active extension back, especially if they've been pinned.
Right. So that's really hard. I put them in relative, a relative motion so that they can get this, but even if I [00:31:00] do that, it's still, Do you have any. Tricks, tips on that? Yes. So, I was gonna just go into that. So thank you so much for your question. So one of the things that I talk a lot about with my patients is setting expectations.
Especially after talking to them around what's going on and what's safe for them to do, Right. I start telling them that even though, cuz everyone wants flexion, they come in, they're like, I can't make a fist. I'm trying so hard. And they squeeze their fingers together. But I always tell them, Hey listen, I know that getting your.
Into flexion or into a full fist is really important. But if we work on getting your finger really straight, we can actually get into that full fist faster and less pain. And here's why. We go back to our anatomy and our structures and we think through our framework, the bones, right? Which is also really, if you think about it, it's your.[00:32:00]
Right? So the joint now has been immobilized for a really long time. The ligaments are really tight. The muscles and tendons are really tight. Nothing has been moving. If I can get you going into extension, if I can get you going into extension, look what happens. I feel like I was gifted with freaky fingers, so I can really demonstrate to you.
What actually really happens, right? If you go into extension, look what you stretch. You stretch your flexors, you stretch your volar plate, and the volar plate is a ligament and it needs to be stretched so that when it goes into flexion, it can actually glide out of the way, so you can get better Flex.
right? So what happens, it's not just the tissues, but where the ligaments all create a capsule. So if your capsule is really tight, [00:33:00] then your muscles can pull and pull all it wants. It will not go anywhere. So what do you need to do first? You need to get passive extension. When you get passive extension, then you can go into better flexion, get pass, and.
Extension, even though it hurts, feels better than flexion. Ask your patients. When I push you into, there's a sharpness to that pain. But when you go into extension, even though there's pain, there's like this pain that compresses a joint and they feel like you're going to burst them, right? It's just a tightness.
You go into that extension, you are going to then, The extensor tendons, right? And they're gonna be able to go back into better flexion. So when my patients, Victoria, I'm gonna show you her pictures, but I actually told her we gotta work on [00:34:00] extension, we gotta work on extension, we gotta work on extension.
You all. The only exercise you need to do is stretch the hell out of that joint in between and just do extension if you can do. Then when you come in, we can progress and we can progress and then you can add a little bit more. But it's, I usually give my patients one to two things to do, and that's it.
They're not therapists. They do not want to be therapists. And if we can simplify it for them, we'll get better results for them. They'll get better results for themselves. So I work a lot on extension first, and I set that expectation and you're going to see that they're gonna harp on flexion.
I'm gonna get, we're gonna get there. We're just, we gotta get on extension first and then we'll get flexion. That doesn't mean I don't work on flexion when they're there. I do. I'll just start and end on extension. And I also like to go into [00:35:00] composite extension, which is then to take the whole risk back too, because then you stretch the whole superficialis and profundus tendons.
Someone had their hand. I think yes, we have Misha with her hand raised, and we also have a question from the audience. Sure. Tell me, Hi Juan. My question is about the splinting in between and then it's night. How long do you recommend it and how far to the palm new go? Okay, so I, with this particular case, and I do this with actual several of my cases I only splint the p i p if this is where it's fractured.
So go back to your fundamentals of splinting, splint, only the joint that you need to splint and don't splint anything else. Right. So I get that p i p as straight as possible and I'll make a finger gutter. Or one thing that I really love is doing, like using a really thin [00:36:00] material and doing a circumferential.
And the reason why I was so confronted was really nice is because it's easier to put on and it can give you some compression. And if you splint only the p i p during the day, they can block and they can do blocking better, right? Blocking done wrong won't get you results. Blocking done right will get you better results.
Getting the profundus moving, that means getting this p i p as straight as possible. So I recommend after. After the
the stability of the bone. You don't have to wear it all the time. So one thing, and you want to promote function, right? So one splint that I like to to use is that circumferential finger gutter. And I'll wear that at night. And it's all the time at night, right? And then during the day, you just need to work on flexing it.
I mean, you need to work on extending it and then using it function. I love a relative motion orthosis, but the [00:37:00] relative motion orthosis when the finger is really stiff, doesn't always help. So it's not that you can't use it, you have to pick when and when it's gonna be the most effective for you to use it.
So I wouldn't necessarily start at the beginning, but as they start getting better and better motion, I'll use it. Now there's. Two two ways to put it. And it depends on what you want more of, right? So if you're looking you need that extension, then you would put them in the relative motion or where the top is on the dorsal aspect of the finger, and they're gonna work on getting extension.
or if they're really locking that flexion, you're gonna put it so it's on the lower aspect. And so you're gonna work on getting more flexion. I used, did I use this for her? I did not use this for her, for Victoria, and all I did was I had her every night stretch her finger and then wear that splint and [00:38:00] then just do a ton of blocking at first.
In order to keep that. P i p from falling into more and more flexion. I had her wear it throughout the day. I had to wear it throughout the day for about two weeks, and then I reduced it down to only at night. And then she kept with that night orthosis. And then about a month into it I put it into even more extension so that she could wear it at night.
And the way I did it was I used coband wrapping as well, so that it would give that compression to reduce the. That's the splinting that I would use. You can also on a really stiff finger, I actually like plaster casting, and there's two ways that you could use plaster casting . You can use plaster casting if it's more of a soft tissue issue.
I'll show you Brian's case. He had a fracture to the D I P area, but he had [00:39:00] grafting all right here. So his p i P flexion, like severe flexion contracture was more of a soft tissue issue than it was a. A joint issue because of the scarring from the graft. And he was so sensitive there. I actually casted him here at the d i p.
So I worked on extension, casted him into as much extension as possible. If I can eliminate one joint, then he's gonna move the other, and that's what helped get him the extension and the flexion that he needed. So let me see if I can share my screen just to show you guys some of the picture.
Of their improvement. So this is this is Victoria's finger fractured. You can see how it's an interarticular fracture and it's completely dislocate. I mean, displaced, right? And this is her flex.[00:40:00] Right at the doctor's office. By the time she came in, she was at 30 degrees flexion contracture, and she only had about 50 degrees of flexion.
So she total of 20 degrees of motion. And then the d i p had no motion. And this is how she started with her motion. Let's see. Can you guys see, Ella? You can see. Yeah. Yeah. Looks great. Great. Perfect. So that's how much motion she had, and this is how much motion she has. She's done. We got her. Show us how your middle finger used to look like.
I. Like this, like that. . I used to joke all the time that her finger was tuck it all do that. Oh my God. You're like, Yay. Yay. That great. All right, that's good. Find my own voice. Annoying[00:41:00] . So I didn't have any pictures of Brian before, but I just wanted to share this. What, Why can't I open it there? So, I don't know if you could see, whoops, but he had an amputation of the index finger, and he had a fracture here, but lost a lot of tissue.
So he had a graft put in, but he had an infection, so the first graft didn't take, and so they had to do another one. So when he came in, hypersensitive. Didn't want anyone to touch him, couldn't take any pictures. This was really, it was in 60 degrees of flexion where we just could not extend him. And he was just so sensitive.
He thought everything was gonna bust open, and this is him now. So he still has some [00:42:00] issues with the D I P, but he actually has really great motion with him. He's the one that. , because of his sensitivity and fear of putting anything around the P I decided to use what's called a quick cast, which is a rolling brand.
I cannot find that anywhere y'all. Y'all hand therapists help a girl out. If you have seen it, let me know. But it's a rolling brand, it's called Quick Cast, and it's so great for mallet fingers and stuff like that. So, he was so anxious that I was like, Okay, I can't do plaster cast with him. I couldn't splint him.
but I needed to show progress first for him, but also for the surgeon, right? And so I worked a lot on extension, just passive extension, cuz that joint was stiff. So I worked on a [00:43:00] lot of extension and I, he allowed me to quick cast him. He wore that. And immediately from one, you know, Usually I follow up every other day.
So he had it, he had, and the great thing about quick casting is you can actually take it off if like you get claustrophobic or there's some problem. So I quick casted him on a Monday and when he came in on Wednesday, he was like, This really helped me, right? Because all of this here was just soft. So if you take a look at the the framework, it's just gonna allow you to help you critically think through and figure out what is their actual problem, and then make decisions around what are you gonna do for treatment.
Because there's a lot that we can do for treatment. Obviously, if they're swollen, work on edema if they have scar, work on scar, if they have range motion stuff, work on range emotion stuff. But how do we do all those things, right? Grip strength is never a concern of mine. And the reason why is if you don't [00:44:00] have range of motion, if you have pain, how are you gonna have any strength?
Let's get that other stuff. I mean, obvious. It's a necessary objective measurement that we have to take, but it's not anything that I focus on. I don't focus on it with my patients. I don't have them focus on it. And I say, You know, as soon as we get the joints feeling soft, the tendons moving, right, going, lying, going short, and the ligaments loose in every direction and the skin and fascia flowing, you're gonna have great motion.
Do I ever use buddy straps in these cases? Later on I use buddy straps if I'm trying to get someone to remember to use their fingers in a certain way. I use buddy straps if they're not my favor, but I do use them if I'm trying to get them to get more. , you know, if they're not remembering. So it's a great one for your index finger [00:45:00] to be buddied to your long finger so that your long finger can remind your index finger to move.
It's not the best always in the small finger and the ring finger, but. It depends on your case, but I do use them when I deem that it's appropriate. But we have a lot of tools in our toolboxes. Any ideas for deviated P ips? So with Victoria, she looked like she had a deviated two, and sometimes deviated DV did.
A structural problem. So if you broke, it's, I always say, you know, Humpty Dumpty fell, You know, shout into all the kingsmen and all the kings are, try to put Humpty Dumpty back together again. So if you broke your joint so bad that there's a certain amount of displacement, then that's. It's deviated and you can't necessarily do anything about it.
But if you've, you're very well aligned, then your deviation might be from[00:46:00] a ligament or a tendon skin imbalance. And one of the things that I like to do is I will actually rotate. So I will shift, look at my fingers shifting for you guys. , I will shift it back into place. So sometimes if you imagine your joint.
You imagine your joint like this and your scar and your tendons are just a little off center. It's pulling your joint like this. So if you put them back in alignment and get them to move, you can realign your tendons and your ligaments and stuff like that. So if I see that they're a little maline, instead of just pushing them, I will distract.
And place back in. And then in that position, I will get them to block. And that can help with deviated p ips. I will also work on that. Remember I was talking to you guys about the scan rotation. Go to the yummy side. [00:47:00] Go to the yummy side. So go to the yummy side like this, really by six. After a ligament issue, you're allowed to really start moving them.
You've got to start moving them and know that there's no fear in it because they're painful and their bodies will not let you just, rupture their ligaments, right? If they're unstable to begin with, then that's a different problem.
right? So if they're un, if they're unstable to begin what they should have been immobilized from the get. and most of them, you as hand therapists, we don't always see them from the beginning. So they've been immobilized for like way too long by the time they come to us. So it's really just about getting emotion.
Is that helpful? Any other questions? Did I I think those are all, you took up the questions in the chat. That's great. One question from q and a was, do you use any [00:48:00] STM. To help with finger motion. So I stm the like myofascial tools? Yeah. The mild, Yeah. Okay. I was just making sure I was on the right thing.
You know, I have them, I personally. Don't love them. I had a client call, he's a chiro and he had a flexor tendon injury and he's got all this massive scarring and he was like asking me like, Do you use this, and this? Do you use ultrasound? Do you e some I have those thingss, but the best tools that you're gonna come for on my hands, they're built in and done the right way with a certain amount of firm.
Can get you the results that you're hoping for. But can you use them? Absolutely. Actually I had Allison Taylor here. Was it Allison? Taylor was here a couple months ago, and she brought up the tongue scraper. So I actually brought, I bought it for my therapist and she. . So I [00:49:00] think it's a personal preference whether you like to use tools or don't like to use tools.
I like to use them very, you know, particular cases, but I like the feel of my fingers because I can feel when I can feel the direction of the scar adhesion. So when I was talking about Victoria, she had scars here and. And I could feel like if I went in one direction, I could feel it stuck. And I don't think that I could feel it as well if I was using a tool.
But people love them and find that they're very useful. So I think there's no harm in them. So play around . Yeah. That's a personal preference thing. Yeah. Yeah. But people love them and I say, Go for it. a, a scar tissue. So, so I do using the tools for bigger scars. I do using it for [00:50:00] bigger scars.
I just find that in the fingers. It's not like I don't love it. We have cup. I try to get all the latest tools that all the big kids are talking about. But you know, I'm look at me on this whiteboard for you guys. I'm a simple girl. You can use cupping scar tissue stuff, the extractor in the finger.
I don't find it as like beneficial. I personally, I like to use paper tape. I love paper tape. You guys use paper tape? I can use paper tape And do, I usually do a double crisscross and I. With the tape, I can pull on it even more and I can go in different directions. And it was funny cuz I was working on her scar in extension it was like to go into extension first and then I was, I put her and I was holding her in that flex position and I was pulling up her skin cuz what's tight?
[00:51:00] The extensor part. So if I pull it to put it on some slack, it's going to, So I was pulling and I was just like, we were talking smack about stuff and all of a sudden I hear that and that was from the scar giving like satisfaction. And then we open and she's Oh yeah, it's straighter, it's moving.
You know? So I love tools, I have tools, but I don't know when it comes to the fingers. Nothing is just better than your own little fingers going to town.
any other questions? Was that helpful? Oh yeah, for sure. Was that helpful to Yeah, I'm getting feedback. That is really nice to have the interactive piece.
Hey, thanks for listening to Hoang's world podcast. If you are brand new to the hand therapy world, head over to my website, www . Hand therapy secrets.com, where you can get started with [00:52:00] some of our free guides and paid programs for both OTs and PTs diving into the world of hand therapy. Or if you've been listening for a while watching on our YouTube channel and you think you could benefit from developing and moving your career further along in hand therapy, reach out to me and my team at info @ Hand therapy.secrets.com and tell us exactly what you're looking for, By the way, if you know someone who could benefit from today's show, please share.
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