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Upper Extremities
Common Upper Extremity Deformities:
• Internal Rotation of the Shoulder
• Extension of Flexion Contractures of the Elbow
• Flexion Contractures of the Wrists
• Thumb in Palm
• Extension or Flexion Contractures of Individual Fingers
Courses of Treatment:
Therapy
O/T should begin as soon as possible to increase passive range of motion. This can be done through a clinic or at home with your local Early Intervention. Either way you should be taught stretches to do at home with your child. Here are some common stretches to try. Always speak to your O/T or Child's Doctor before starting any kind of new routine.
Stretches
Thumb: This is hard when your baby is very tiny. Put your thumb in the palm of your child's hand and push outward on the thumb at the base of the hand. Be very careful not to just push on the thumb itself because you can dislocate the thumb at the joint that connects it to the hand.
Fingers: If in flexion, straighten out each finger and hold. If in extension, gently curl finger. Be very careful and do not go beyond your child's limits. Do not force anything or you can break their little bones.
Wrists: This is also a very hard stretch on very tiny babies that are very stiff. Place your thumb under the center of you child's wrist and push upward while bracing the top of their wrist with your middle finger straight across.
Elbows: Be sure you find the elbow joint and are bending in the correct direction. This may sometimes require rotating the arm externally a little bit. Bend the elbow very slowly and gently. As with any other stretch be very aware of how your child is feeling. You know the difference between the annoyed whimper and the cringe of pain. Don't go any further than your child will tolerate.
Shoulders: This can vary a lot depending on the actual quality and condition of your child's shoulder joint. I would consult an O/T before doing any kind of shoulder stretches.
Stretches no matter what kind are very important and should be done at least 6 to 8 times a day. A lot of parents do stretches at every diaper change. It makes 1 less thing to remember!
Splinting
Splinting for wrists should be started as early as possible to take advantage of the infant's flexibility. In remote areas splinting is used less often than therapy but the sustained stretch at night and 3/4 of the day up to about age 2 will gain the best results. Some doctors believe splints can restrict movement and sometimes become more cumbersome than helpful. Though not always effective, splints provide a sustained stretch. They are most often prescribed for over-night wear. Most often they are wrist splints used to slowly stretch the wrists out of flexion.
There are many types:
Benik: Soft neoprene splints with a metal bar that can be manipulated to give different amounts of stretch
Custom Made Splints: These are fabricated by an O/T or Orthotist. They are usually made with the same material as AFO's and can be custom made to your child's hands. They are secured most often with velcro straps.
Elbow splints are prescribed less often. There are not any commercially manufactured wrist splints that are small enough for children. Often an O/T or Orthotist can fabricate these using the thermoplastic splinting material for wrist splints (similar to that used in AFO's). They then attach velcro and a rubber band that connects to a wrist splint and they provide a sustained stretch while child is relaxed. When the child wants to they can extend their arms it just takes work for them to do so. The other down side to this is that it actually strengthens the muscle that extends the arms, by giving the child the option to extend their arms if they push out. Though this does not usually outweigh the benefits. A static elbow trough-like splint for night and nap use may gain better results than the dynamic one described.
Surgery
Often with children who have little passive elbow flexion, surgery is recommended. Doctors often recommend an elbow release (tricepsplasty) surgery between 8 months and a year but may be delayed to assure that the child is up and walking before changing the power of straight elbows. This is a surgery done by releasing the tight fibrous structures in the elbow that constrict movement. After that if is child still does not develop any active flexion or enough functional passive flexion doctors may recommend a muscle transfer to give elbow flexion (bending). This depends on the quality of the donor muscles as well. Common muscles used are the pecs (pectoralis major) and a muscle from the back, Latissimus dorsi. Most doctors will not perform this surgery on children under 4 or 5, because the child needs to participate in the therapy following the surgery to re-train the muscle motion, wear splints to protect the transfer, etc. Every doctor is different in how aggressively they treat upper extremity problems. Some doctors do not believe this surgery is effective at all and may not offer this as an option to their patients. There are also several hand surgeries that can be performed. For children with a serious flexion contracture in their wrists a small triangular wedge of bone (wedge osteotomy) can be removed to bring the wrist to a more neutral resting position. There are also surgeries for thumb-in-palm, if extremely severe, and various finger surgeries.
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