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A-1172 PIP problems after trauma and surgery, pearls and tricks for success
Gwendolyn van Strien, The Netherlands
Friday, June 15, 2018 · 10:52 a.m. · 11m 35s
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my own yes alright i'm gonna give you some tips and tricks on the
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p. l. p. problems that we see from a therapist point of view
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um and i'm gonna start with putting this picture up why is it so difficult to get
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good results with these p. i. p. joints all tip number one is gonna be for
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is based on the bach uh by bowers the i.
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p. joints and i wish that nobody in this
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room would ever a mobile i. c. p. a. p. joint again in thirty degrees of flexion
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um this isn't a graph that shows the lateral till to the p. l. p. joint going from hyper extension to flexion
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and as you can see there's the line that sets shows all the comments intact
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as you can see them hyper extension to about ten degrees of
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flexion um or yeah selection uh that that the ligaments are
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tight then between ten and sixty they're not so tight then going from sixty on to more functions they're tight again
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so if you start a mobile rising in thirty degrees where it's maximal slack then
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if they contract then you will have a hard time going to it either
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total function or total extension so you're building and basically a problem by a mob lies in them in thirty degrees
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so you should do it in zero two maybe ten and you could do it
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in sixty plus but of course that's not an option for other reasons
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so is this new no it's not in nineteen eighty nine already
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uh steven cobble showed that he get his palmer plate
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in zero degrees for ten days and then you get body tape in exercise and everything
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but his bowler played injuries had all good to excellent results so you can do the zero degrees but still
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it's a clinical decision you have to make a choice and regarding the the first two speakers too
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it's not always the same sometimes you have these patients yes and extend their fingers these are farmers on the north holland
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and they say well this is my extension ends like yeah a little bit more he said no this is it
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and they'll have a slightly flexed figure you also have the hyper lacks population the asians and the young kids
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so you have to make a decision based on what you're seeing and sometimes you want
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to prevent this faction contractor and don't do the thirty degrees so zero ways my
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perfect or zero maybe ten but sometimes you wanna create a small print
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a fashion contractor with young kids and these asian a population
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okay that number to uh the problem is that we always seem to end up
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with this flexion contractor and even if it was straight on your operating
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table or if we um all lies it in perfect zero purpose for six
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weeks we end up with these p. l. p. afflictions contractors haunting at
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so what is the problem i know i call this the cortex effect if just at this stage p.
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i. p. joint is and you're moving your hand if you have a stiff p. l. p. joint
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then we know that if you move around you'll have a change of your movement patterns based on the
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article white what all into two thousand eleven where he showed if you can mobile i stay hand
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within seventy two hours you're cortex will have changed except in new motor pattern that will be your new normal
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and a stiff joints nothing else then that animal blessed p. l. p. joint
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so don't underestimate this cortex effect because they will start moving with hyper
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extension after m. c. p. joints and they will not have any p.
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i. p. extension so you see this happening and that's not good
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if you use relative motion flexion then you can see you can break the pattern
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of that hypertension and because the exercise all day without even thinking best
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that thing is on there they don't even notice it at a certain point in more but all the time you'll have affective p. i. p. extension
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you often don't even need additional therapy they just move around and because it's not in
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their way they can flex and do everything they will not take the splint off
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so they will keep using it for a long time because this guidance of not doing the hyper
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extension of the l. p. joint needs to be done for a long period of time
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why is our normal exercise not working every hours
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tend to our ten times your extension exercise adds up to what is it
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twelve times five minutes that's an hour day the rest of the day
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this is what happens they're using their hands and they're mostly using p. l. p. flexion that is what we do
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we rarely extend our fingers and if we do you don't control the extension table to the hyper extension
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so all those hours are also exercises so they're working
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towards the uh p. l. p. flexion contractors themselves
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so i'll not so often but sometimes flexion is also hard again and again it
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can be the cortex effect because if you look at these pictures and
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observe your patient when they're moving you'll see that the n. p. joint will
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start going down for that that should be compared to the other fingers
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and that's because the intrinsic start taking over the moving the finger as a complete unit and the f.
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t. p. and f. e. s. will have a hard time to been the i. p. joint
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so what do you do well you can't first to your surgery and loosen up the p. l. p. joint but then the bad news
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is they will still use that normal pattern that is different from
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the actual correct patent bills to move from the intern six
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so to avoid this you should don't do any forceful feasting where you see this happening now the i. p. in a lot of m. p.
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um but you could do things with um doing a very easy
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uh exercise where you actually put the finger on the palm
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and you mark the palm for the patient and you just slide and scratched the pomp taking
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your finger away from that line and if you do that they'll have no forceful
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a function but they will have the p. i. p. and the t. i. p. moving the correct way without the m. p. flexion
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a similarly this is like a banana block but we use these things all
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the time you all holding him up right now um this is
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great from exercising p. i. p. m. d. a. p. motion it blocked dislike of an l. block and the great thing about this is
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that every time you grab your phone you have to do five times pulling around that that age and how many
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repetitions you think these people make i mean the young kids will do like three hundred times a day
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so that's a great little trick to get people to move there and their
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p. l. p. and the i. p. without flexing the n. p. joint
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of course you can also use devoted motion extension they will be using their
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hands normally and all the time the wrong pattern will be blocked
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tip number three the relative motion for five to seven zone five to seven is well known but
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we use it now like the forms because that already for zone three and distal zones for
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how does this work handles video from doctor merit he made essential slip injury
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and on the could they're responding on the e. d. c. while
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there's a relative motion flexion spent on for the index finger antique fingers
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extending their their goes it's nicely extending no problem at all
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next he will take off the splints so the extension would go unchecked
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and within one or two or three pulls on t. v. c. u. c. to hyper extension
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coming and you see to put near developing so this is relative motion explained not try
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to explain it because you didn't do it so there's still a lot to learn about
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this but what we think that happens is that when you plot the hyper extension
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then the extension forces shuttle through to level bands and if you have those
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connections there they will created dorsal pull on the lateral bands coming up
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substantial is still possible to the remaining part of the extent for mechanism now this is theory
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and we also have to admit that it doesn't always work when does it what it
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not work it's because the extent to make his way too much damage people not work well
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obviously but also when you don't have a free p. i. p. joint you need
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passive p. i. p. extension if you don't have that or at least twenty degrees of
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flexion contractor those leather bands will not go up of course they won't go up
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so all the best test is the pencil test i think it's better than the l. some test or reversed you put it in
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there you test the extension and if it works then you're splint will work if it doesn't work go for something else
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so if your work with your central slip by using relative motion function because they can make a
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full fest domes to say the protocol doesn't work because you can use multiple protocols in one
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if you use the shorter commotion in combination with the relative motion flexion split
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the gold one is the relative motion flexion the blue one clicks on
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it has a little block that you can put down into flexion so you can slowly
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increase flexion over time so using two protocols easy to do and it's very stable
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and one little thing about relative motion flexion again i don't care if you use it all day all night
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you have to have an extension split and probably for six to twelve months because all night they sleep
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usually with the first set sixty hours of flexion you don't want that so give them a night split in extension
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and my last tip and this is more thing that i think we should learn a lot more about extends or mechanism
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the influence of the finger position on the extensive mechanism is what we're
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talking about with this will tell relative motion flexion a protocol
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and in two thousand seventeen docket bill got off a that did the first study probably he thought
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because he said it was the first study where you look at the forces
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indexed answer mechanism in different finger positions and he said in his article
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that that had never been done and it's rarely done because i've been looking for articles to find it they usually test these forces
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indexed answer mechanism in extension so basically get data from those studies
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do not work for us because we're looking at fingers inflection
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and all kinds of postures so these data need to be figured out with more in need more research
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although i did find one in two thousand and eight uh some locally
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can he looked at different positions and with and be flexion he
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found in d. that did there was decreases of slip
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forces of the central slip into terminal slip so there's changes in that extends or mechanism as you move around
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and the last one is not so much for the extension but for flexion because extension mechanism also is
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a a sort of a ligament against flexion if you
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have the uh contracted for accents or mechanism
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no phone sweeten in this is two thousand eighteen he looked at the palmer the lateral bands any
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set if you do just p. i. p. flexion base like down a little bit palm really
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if you do p. l. p. n. b. i. p. function combined they go
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down even further for that you need widening of the extends or mechanism
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so if you are planning your surgeries on the door some of the p. l. p. joint
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and you know that palmer light and is widening fixing extensive mechanism is important for flexion
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then we should planner extends attendance and p. i. p. reconstruction techniques with this in mind there
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is a whitening necessary to get flexion so just hiking up those lateral bands and
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each attaching them might not be a great idea if you also wanna have flexion we
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wanna have both extension inflection basically functions a lot more interesting than x. full extension
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alright so uh i hope i make clear that we as therapists but the
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surgeons also attention to detail how they move and what's going on there
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gives always gets better outcomes so you have to be really nit picky about everything in there
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and the last thing i want to say is that it takes a lot of time for
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p. l. p. joint to settle and my experiences twelve months so i was to
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my patients for six to twelve months have to weirder splints to have to work on
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