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Boney vs Soft Tissue Mal-rotation
20 Plays14 minutes ago
This week, Delaney chats with Miranda on Hand Therapy Academy about what sets bony and soft tissue malrotation apart. Their discussion is full of real-world advice and clinical pearls for hand therapists.
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Transcript
Introduction to Hand Therapy Academy
00:00:06
Miranda Materi
Hello, I'm Miranda.
00:00:07
Delaney Wright
And I'm Delaney and we are Hand Therapy Academy.
00:00:10
Miranda Materi
All right, welcome
Causes of Finger Malalignment
00:00:11
Miranda Materi
Delaney. Today we're gonna be talking about um when you have a malalignment or a rotation in the finger either from a soft tissue injury or maybe from ah fracture that um wasn't able to be reduced quite right or um maybe it was treated conservatively like why they occur in those types of things.
00:00:11
Delaney Wright
Thank you so much.
00:00:33
Delaney Wright
Yeah, super
Differences Between Bony and Soft Tissue Malalignment
00:00:34
Delaney Wright
interesting. um Can you, do you mind talking a little bit, Miranda, about what the difference is between a soft tissue and a bony malalignment malrotation?
00:00:41
Miranda Materi
Yeah, so a bony malalignment can happen i really out after any type of fracture. it could be a proximal phalanx or a metacarpal fracture, or those are things that I've seen it most commonly happen with.
00:00:54
Miranda Materi
And typically what will happen is the patient will break their finger or break their hand, and then sometimes they're either pinned or plated, or maybe they have an intramedullary nail put in.
00:01:09
Miranda Materi
and or they're treated conservatively in a cast. And if these are not set just perfectly, um and they can look perfect too, like they they you could look at them on x-ray and they have the pins in and everything looks aligned perfectly.
00:01:22
Miranda Materi
But then in therapy, you're starting to have them move and you notice that their fingers are scissoring. So that would be ah bony malalignment. So it's usually typically after the bone has started to heal.
00:01:35
Miranda Materi
and then the fingers are not in alignment and that's no bueno or not good, right? Because with a bony malalignment therapy cannot fix that, and right? But if there's a malalignment due to a tissue injury, um it could be from swelling, it could be from ligament injury or something like that. And then that's something that
Treatments for Soft Tissue Malalignment
00:01:56
Miranda Materi
therapy can help with. We can do malrotation taping, you know, there's some K-tape, there's an article that was written about K-taping and aligning the fingers, or by like reducing the swelling and treating the reason for the malrotation.
00:02:11
Miranda Materi
So soft tissue therapy can help for a bony malalignment, it cannot. But I will say that sometimes with the bony malalignments, um it could be magnified or made worse by the swelling. So even though we're not necessarily going to derotate that finger, right, we're not going to change the bony structure of it, we can reduce the swelling, which can help improve the malrotation a little bit if if that's adding to the reason for the malrotation.
Case Study: Surgical Intervention for Bony Malalignment
00:02:43
Miranda Materi
Does that make sense?
00:02:43
Delaney Wright
OK, yeah, that makes total sense.
00:02:46
Miranda Materi
Yeah.
00:02:46
Delaney Wright
on With the bony ones, if it is like if the swelling is under control and it's just rotating, um are your patients like commonly in like a lot of pain or is it just that it's like an like a that's just like bothering them?
00:03:00
Miranda Materi
yeah Yeah, I would say each case is unique. You know, the most recent one I can think of is someone that had their small finger. It was a small finger proximal phalanx injury. And the small finger was rotated out.
00:03:13
Miranda Materi
So it was rotated away from the palm and out. So she was always getting a caught on everything.
00:03:17
Delaney Wright
Okay.
00:03:20
Miranda Materi
So it was painful from that aspect. um And so for her, she had initially she had pins put in and it was by this was before I saw her. So it was by a provider in another part of the valley. She had pins put in.
00:03:37
Miranda Materi
And for whatever reason, when she went to make her fist or maybe something happened when she was in her brace or her cast where the fracture kind of got malaligned and she ended up having that significant malrotation. So she had to go back in, have another surgery where the surgeon actually cut, it was her proximal phalanx. So he actually cut her proximal phalanx.
00:03:59
Miranda Materi
twisted it, and then put an intramedullary nail in it. So the advantage of the intramedullary nail was that we could start moving it right away. And he woke her up. um I had the advantage of going in on and watching the surgery, which was really helpful because he woke her up during the surgery and had her moving her fingers into a fist.
00:04:18
Miranda Materi
So we could check the alignment before actually moving her off the operating room table. So he could say, oh, that was good. Or, oh, we need to adjust it just a little bit.
00:04:29
Delaney Wright
That's awesome.
00:04:30
Miranda Materi
Yeah, that was really awesome.
00:04:32
Delaney Wright
And at what point do you kind of refer them back for surgery if they're like coming to see you?
00:04:39
Miranda Materi
Yeah, I mean, it's, so you know, ultimately, with that patient, when she was so, so malrotated, it was like, okay, well, let's go back. I say sooner than later, right? Because that's really a certain that's a decision that needs to be made by the patient and the surgeon, because you know, the the surgeon is the one that's going to be doing it, the patient is going to be the one that's and tolerating and enduring it.
Communicating Malrotation Issues to Doctors
00:04:57
Miranda Materi
Not that our opinions don't Matters much, but i think the sooner the better.
00:04:59
Miranda Materi
And if the surgeon wants to wait a bit of time and let the patient go through that inflammatory process before cutting them open again, that's understandable. But if they want to do it sooner, then, you know, that's really kind of up to them and the patient too, right?
00:05:12
Delaney Wright
Yeah. Better outcomes.
00:05:14
Miranda Materi
So each patient has unique circumstances.
00:05:15
Delaney Wright
Yeah.
00:05:17
Delaney Wright
Exactly.
00:05:18
Miranda Materi
Yeah. So I think the sooner, the sooner, the better.
00:05:18
Delaney Wright
That makes sense.
00:05:21
Delaney Wright
Okay. That makes sense.
00:05:23
Miranda Materi
And then sometimes patients will ask me like, or people ask me, well, how do you tell the doctor that the finger is malrotated?
00:05:23
Delaney Wright
um
00:05:29
Miranda Materi
And you're like, well, when they're making a fist, you see scissoring.
00:05:32
Delaney Wright
Yeah.
00:05:32
Miranda Materi
But
00:05:33
Delaney Wright
Yeah. It's obvious. It's there.
00:05:36
Miranda Materi
yeah but sometimes I've had have patients that have had malrotations that go to the doctor and the doctor looks at the x-rays and looks at their hands, but doesn't have them move.
00:05:44
Delaney Wright
Oh, good to know.
00:05:45
Miranda Materi
You know, so then you don't see the scissoring. So then you're making sure you're educating your patient. Like, make sure when you go in, you know, you show them that you're having, you're making a fist and what happens to your fingers.
00:05:56
Delaney Wright
Because you would think it would be kind of obvious, like, hey, this is happening. But yeah, if they're just looking at the hand just like that, then
00:06:02
Miranda Materi
Right. Because sometimes they're fast. They're in and out fast. They have three to four minutes. Maybe
Intervention Techniques for Soft Tissue Malalignment
00:06:06
Miranda Materi
they're distracted by a surgery that they're going to, you know, and the x-rays look good. So and yeah.
00:06:10
Delaney Wright
Yeah. So you're good. Send you on your way.
00:06:14
Miranda Materi
Good. See you later.
00:06:14
Delaney Wright
Yeah. um So for the soft tissue one, what are your like go-to interventions and how do you feel like they do in therapy? Yeah.
00:06:24
Miranda Materi
um I think they do pretty well. You know, usually it's like a minor thing. And the first thing I'm doing is working to get rid of their swelling and having them do their tendon glides. Because typically if it's caused by swelling, that's easy, right? You take care of, i mean, sometimes it's not easy, but you get rid of the swelling. So some of my favorite things for swelling are you know, doing overhead hand pumps or what we say, like reaching for the star and looking at the star. So doing those typical edema measurement exercises, maybe we're giving them edema glove, maybe an edema sock, and really just providing education on how to manage the swelling and then to not over traumatize the area where we're causing more inflammation.
00:07:04
Delaney Wright
Yeah, that makes sense. So keep it like really like light and just gentle, pain-free range of motion initially.
00:07:07
Miranda Materi
Yeah.
00:07:10
Miranda Materi
right. And I guess I'm not saying something very obvious and that's to do body taping.
00:07:16
Delaney Wright
Yeah, that makes sense.
00:07:18
Miranda Materi
And um I was thinking of something else when we were talking to or something that I saw in, I think the journal hand therapy. And this was maybe like four or five years ago. And they were talking about if you have a patient that has like a ring finger metacarpal or ring finger proximal phalanx fracture,
00:07:37
Miranda Materi
And that how sometimes when we're splinting them, if we only splint to the small finger, you know, we like put them together, then that actually can kind of lead to the bony malalignment, especially if you're pulling the ring finger over to buddy it with the small finger.
00:07:54
Miranda Materi
So they were advocating, so for ring finger fracture or metacarpal fracture to actually include the long finger. So then it's like the ring finger is centralized between the two digits.
00:08:05
Delaney Wright
Oh, that's super interesting.
00:08:07
Miranda Materi
Yeah, and then it would be the same thing if it's like a long finger fracture, you know, you would include the index in the ring just because you help keep things in alignment. Or if you're not going to include both adjacent digits to just make sure you have good alignment.
00:08:20
Miranda Materi
So sometimes that means putting a pad between the ring and small finger or something that helps maintain that alignment and then that you're being very careful to not pull um that fracture into a radial or ulnar direction.
00:08:32
Miranda Materi
Yeah.
00:08:33
Delaney Wright
Okay.
Conclusion and Contact Information
00:08:34
Delaney Wright
Interesting. interesting Very interesting.
00:08:36
Miranda Materi
Yep. right. So that's pretty much anything else.
00:08:38
Delaney Wright
Wow.
00:08:40
Delaney Wright
I don't think so. No, I think you covered it all.
00:08:42
Miranda Materi
Okay. Okay, cool. I'm sure I missed something. But um so anyways, for more information, or if you have questions, or you want to share a case, please email us info at hand therapy academy or our social media, which is at hand therapy academy.