Vita TU, Occupational Therapist and Project Manager
Sunshine Social Welfare Foundation
In previous articles, we talked about how crepe elastic bandage can be used to achieve simultaneous and continuous passive flexion stretching effect over scars on multiple joints of the fingers, as well as well for wrist flexion passive stretching. In this article, we will specifically discuss the considerations for use of crepe elastic bandage for wrist extension passive stretching.
What is the impact of scars on the volar side of wrist and hand?
When a burn is located on the volar side of the wrist and the hand, any joint covered by the scar risks being affected by extension limitation.
Compared to the dorsal side, skin on the palm of the hand is thicker and lighter in color. This is due to the specificity of cells that limit the production of melanin [1] and contribute to the thickening of the layers of the epidermis [2]. Because scars on the palm of the hand will not have obvious hyper or hypopigmentation, their hypertrophic growth may be easily overlooked. Severe hypertrophic scar growth may cause palmar scar contracture affecting extension of MP and IP joints, as well as thumb abduction and extension. This is commonly called “cupping hand.” The concavity of the hand’s transverse and longitudinal arches will also reinforce this tendency of cupping of the palm.
Normal wrist extension is 0 to 70 degrees, and is critical to functional performance of the hand during activities of daily living, like holding a pen for writing, holding utensils to eat, etc. The flexor and extensor muscles are situated in the forearm and run across the wrist to attach as flexor and extensor tendons in the hand. During wrist extension, wrist ligaments are stretched, and tension develops in the wrist and fingers flexor muscles, acting as pullies on tendons to move the fingers more easily, and create stability for precise movements. This tightness helps keep the wrist stable during extension. When scars extend over the volar side of the wrist, contracture will pull the wrist into flexion. Furthermore, the influence of gravity and the fact that flexor muscles are stronger than extensor muscles will further contribute to the development of flexion deformity.
This is why it’s important to pay attention to extension limitation caused by scars on the volar side of wrist and hand.
How to achieve passive extension stretching of wrist and hand?
Using a triangular wedge to wrap the wrist and hand with crepe elastic bandage can promote the simultaneous extension stretching of multiple joints of the wrist and hand.
There are three types of passive extension stretching that can be achieved with crepe elastic bandage: 1. Targeting wrist extension only; 2. Targeting wrist and finger extension; 3. Targeting wrist and thumb radial abduction.
If the patient’s pain tolerance threshold is low, or the scar is limited to the wrist, passive stretching can target only the wrist. However, we must still carefully monitor the extent to which scars will affect the thumb. Scars on the wrist may cause palmar contracture deformity, because the concave surface formed by the transverse palmar arch and the longitudinal palmar arch will aggravate the degree of scar contracture. Patients with burns on both the volar and dorsal sides of the hand may also experience this deformation if the scar contracture on the volar side is relatively strong. If the dorsal side of the thumb is burned, it may also be accompanied by hyperextension of the metacarpophalangeal joint of the thumb and flexion deformity of the interphalangeal joint.
If there is contracture on the palm surface, the CMC joint of the thumb will be in adduction. At this time, extension stretching for the wrist should be done and combined with radial abduction of the thumb, as shown in Figure 4. However, if the dorsal side of the thumb is burned and the metacarpophalangeal joint of the thumb is in hyperextension, as shown in Figure 6, we must avoid reinforcing MP hyperextension when wrapping the bandage, and the position of the bandage should be lower than the thumb MP joint.
If extension stretching of the wrist and fingers can be done at the same time, stretching of the scars on the ventral side can be enhanced. However, it should be noted that if the range of IP extension is too small, you may easily end up only strengthening MP extension and thus promote the development of claw hand. In this case, it would be more appropriate to first stretch only the wrist in extension.
References:
[1] Yamaguchi Y, Itami S, Watabe H, Yasumoto K, Abdel-Malek ZA, Kubo T, Rouzaud F, Tanemura A, Yoshikawa K, Hearing VJ. Mesenchymal-epithelial interactions in the skin: increased expression of dickkopf1 by palmoplantar fibroblasts inhibits melanocyte growth and differentiation. J Cell Biol. 2004 Apr 26;165(2):275-85.
[2] Julie Wiedemann, Allison C. Billi, Federico Bocci, Ghaidaa Kashgari, Enze Xing, Lam C. Tsoi, Leo Meller, William R. Swindell, Rachael Wasikowski, Xianying Xing, Feiyang Ma, Mehrnaz Gharaee-Kermani, J. Michelle Kahlenberg, Paul W. Harms, Emanual Maverakis, Qing Nie, Johann E. Gudjonsson, Bogi Andersen, Differential cell composition and split epidermal differentiation in human palm, sole, and hip skin, Cell Reports, Volume 42, Issue 1, 2023, 111994,