Upon completion of this chapter the student should be able to demonstrate the following competencies and proficiencies concerning rehabilitation of the wrist and hand:
Describe the anatomy and function of the triangular fibrocartilage complex in the wrist
Describe the implications on range of motion when the normal articular surface alignment is not restored on wrist fracture reduction
Describe the anatomy of the carpal tunnel and the possible role of the lumbricales in carpal tunnel syndrome
Explain why the musculotendinous system causing finger interphalangeal joint extension is now called dorsal mechanism instead of extensor mechanism
Know which nerve is considered the nerve of fine movements, and describe this nerve's course of innervation into the hand
Explain why a radial collateral ligament rupture at the first metacarpophalangeal joint can be a functionally debilitating injury if not recognized and treated appropriately
The hand and wrist structures are prone to both traumatic and overuse conditions just like the rest of the body; however, there are additional challenges to the rehabilitation process. As with any physiological structures in the human body, "normal function" requires coordinated events that involve having the correct amount of soft tissue extensibility, muscle strength, stabilizing factors, and neurological function. After an injury, optimal function can only be regained if the rehabilitation process addresses all these facets of volitional motion. The hand and wrist area has the added complication of having multiple structures crossing multiple joints. Excessive scarring in these areas can limit motion and thus prevent optimal function. It is imperative, then, that the clinician consider the process of connective tissue healing and formulate a rehabilitation plan around the phase of wound healing and not follow a "cookbook approach." A "cookbook approach" can give good guidelines for care but could cause more scarring if the treatment was not appropriate for the connective tissue healing present.
CONNECTIVE TISSUE HEALING
Connective tissue, which is what makes up cartilage, ligaments, tendons, nerve, and muscle, has the ability to repair but not with replacement of the original structure. Connective tissue heals with scarring, and three phases of healing occur. An important concept about these phases is that there is a "cascade of healing." According to Merriam-Webster Dictionary, a cascade is "something arranged, or occurring in a series or in a succession of stages so that each stage derives from or acts upon the product of the preceding." These phases of healing also follow each other and must continue the cascade to completion. The phases are the inflammatory phase, the fibroblastic phase, and the remodeling phase. These phases can vary in their duration and more than one phase can exist in a wound area. The significance in the rehabilitation process is that the rehabilitation plan needs to consider the phase of healing the wound is in. In accordance with the cascade process, if a wound is put ...