Rehabilitation

What should I expect as I recover?


The process of healing is much the same for all tissues. The gap between torn or broken tissue fills with blood; the blood clots; blood vessels gradually grow into the clot bringing scar-forming cells; the volume that was clot becomes scar. Where bone is involved there is a further development where some of the scar cells transform into bone cells and lay down bone mineral. This stiffens the scar and turns it into bone. It takes about six weeks for enough bone mineral to be laid down for x-rays to show it.

This early healing bone is called bridging callus. When bridging callus appears, the bone is usually strong enough to keep the healing fracture in place but not strong enough for normal forces to be applied across the fracture. The tissue consolidates gradually and becomes more and more like normal bone and stronger and stronger. By three months the repair is 80% as strong as normal and that is enough to allow most normal activities. Putting near-normal forces through the fracture stimulates the bone to get stronger. The process of strengthening continues for up to 18 months post fracture.

Although each case is different and you should be guided by your surgeon, as a rough guide the splints, casts or pins through the skin are maintained until there is bridging callus, usually about six weeks. After they are taken off there is usually another six-week period of protected exercise - you won't be able to do all your normal activities but will concentrate on recovering range of motion of the hand and fingers. After three months you may be able to do heavier things and build up strength and endurance. The timing of return to work and to sports activity depends so much on the fracture, your individual healing and the type of activity, that it is not possible to make a general statement. You would be quite lucky to be able to do this at three months post injury.

There are two other important results of the healing process. The healing tissue is usually bigger than the bone and forms a lump which is often noticeable. Although this lump may get smaller with time, it is permanent. In most cases it does not cause symptoms.

The other significant side-effect is scar formation. The bruising and swelling associated with a fracture is actually blood clot. This clot may spread widely into other tissues - especially the tendons and the tendon sheaths. Blood clot can eventually turn into scar tissue. If the tendons move while the blood clot is still relatively fresh, the clot will stretch or disappear. Any eventual scar will be thin and not interfere with tendon function. If the hand is splinted so the tendons cannot move, then scar will form in all the tissues that remain static (muscle, tendon and ligament). This scar tissue may be strong enough to tether the tendons down to the bone or to the sides of the tendon sheath.

Ligament tissue tends to contract, further limiting movement at joints and muscle can be scarred down as well. It then becomes necessary but very difficult to stretch the scar tissue to allow normal function of the tendons. For this reason one of the aims of treatment is to stabilize the bones well enough that you can move the tendons and curl the fingers early on in the process - before the blood clot turns to scar.

In most cases there is some residual stiffness after the hand has been taken out of the splints. You and your hand therapist then have to work on identifying which areas are scarred down and then working at those areas to stretch them. Fresh scar tissue has quite a rich nerve supply so it hurts to stretch it. You may find yourself often muttering "There is a difference between hurt and harm!" as you work to recover normal function. The longer it takes to get the fingers to move fully - straighten right out and curl into the palm - the more likely it is that you will have some permanent stiffness.

The bones of the hand usually heal and in most cases your hand function does return to normal. The commonest long term problem would be loss of full range of motion - stiffness. If a joint has been damaged there is an increased risk of wear-and-tear arthritis in the future. If there was extensive damage to the muscles, tendons or nerves of the hand as part of the injury, then the long term outlook may be affected more by that part of the injury than the fracture.