December 4, 2019
Chronic post-traumatic deformity of the distal radial and distal ulnar, with remodeling of the distal radius with proximal migration of the proximal carpal bones most prominent the lunate, along with chronic dorsal dislocation of the distal ulnar. Severe degeneration of the first CMC joint. Madelung deformity that led to rupture of extensor tendons.
Patient: a piano teacher, depressed that she wont be able to play the piano and teach it to little kids.
Procedures performed: Left wrist distal ulnar resection; Distal ulnar stabilization with distal-based slip of extensor carpi ulnaris tendon; Left middle finger extensor tendon repair Left index finger to ring finger; Extensor digitorum communis tendon transfer side to side Left small finger to left middle finger extensor tendon transfer at zone VII.
Piano playing requires independent movement of the finger, both extension and flexion. With the side to side transfers we weren’t sure if patient would be able do achieve that and go back to playing piano. She would be functional but piano playing may be difficult.
Also, given the short stature and weak digits especially of the small finger which was now transferred to the middle finger even extension of middle digit seemed difficult.
Patient was seen 3 weeks post op with a pain rating ranging from 2 – 10/10 and a DASH score of 92.5 in a forearm based splint. Patient had difficulty rotating the forearm as well
Protected finger ROM was initiated with the wrist in full extension and as tolerated forearm rotation.
At 5 weeks we noticed middle finger adhesion and inability of the patient to lift the finger up. She stated that the finger feel dead just like before the surgery.
Gentle active wrist flexion was initiated with putty rolling, wristcizer, gentle active forearm rotation. However, we were unable to get the middle finger extension. Even wrist flexion was minimal due to adhesion. We were unable to elicit any finger extension with wrist extension.
At 6 weeks post op we fabricated a relative motion splint to protect the middle finger in extension to be worn 23/7 with the soft wrap all the time, and discharged the forearm based splint.
We had the middle and pinky up in relative extension compared to the index and ring (Pt. not wearing it accurately here The splint was made at P1 not at PIP joint)
We added intrinsic squeeze exercises, and scar management techniques were enhanced including scar suction pump.
Patient was educated that scar tissue will relax and to not push the fingers/ wrist in extreme and aggressive flexion for fear of gaping and that finger and wrist extension were more important than flexion as flexion will be normal over time.
We werent sure if we could even give the patient the reassurance that she will be able to extend the finger especially the middle finger completely let alone play the piano with the little finger controlling the middle finger and index controlling the ring and have the pan to play the octaves.
Graded putty extension along with the velcro board and wrist isotonics which were some of the exercises used to bring about full extension of the finger.
Once we were able to get her pain in control and relatively good ROM in the fingers we discharged the patient to return to her home in Dallas.
Patient sent us the video and her results 5 months out. https://www.linkedin.com/embeds/publishingEmbed.html?articleId=9008944072214494021
Well, this was a pleasant surprise to receive this image and video
Pt. not only was able to regain full extension but was able to independently extend finger and play the piano.
We believe timing of relative motion aided in the recovery resulting in full extension of the finger along with strengthening exercises to the middle finger in extension