Clinicians › Hand

Immobilization and Therapy

Hand immobilization & therapy: principles of splinting, adherence challenges, and rehabilitation protocols post-injury/surgery.

82 citationsUpdated Oct 2026

Overview

Immobilization remains the most effective treatment for acute orthopaedic problems, whereas surgical intervention is often necessary for chronic conditions but yields less predictably corrective results [1]. The optimal duration of immobilization varies significantly by injury type and patient population. For adults with distal radial fractures treated with open reduction and internal fixation, immobilization periods of 1 and 3 weeks produced superior short-term outcomes for function, range of motion, and pain compared with 6 weeks [3]. Similarly, nonoperatively treated proximal humeral fractures can be successfully managed with a short immobilization period of 1 week without compromising patient independence [4], as no significant differences in pain or functionality were found between 1-week and 3-week immobilization regimens [13]. In contrast, for small finger metacarpal neck fractures with limited deformity, there is no evidence that any specific form or duration of immobilization is superior, and data remain insufficient to determine the best treatment for fractures with substantial angulation [5]. Regarding rotator cuff tears, 8 weeks of immobilization did not yield a higher healing rate for medium-sized tears compared with 4 weeks [15]. For displaced scaphoid waist fractures (≤ 2 mm), initial cast immobilization followed by early fixation of nonunion is supported by five-year follow-up findings [24]. In toddler fractures, those without radiological evidence of fracture are more likely to be managed without immobilization [2].

Device selection and mobilization protocols further refine management. The Miami breakout cast provides a safe and effective alternative to standard cast immobilization in carefully selected patients [6], while polyurethane allows for rigid immobilization combined with intermittent mobilization and can be constructed on the patient in less than 30 minutes [7]. The clamshell splint with otoform lining has proven equally effective for other conditions requiring immobilization [8]. For closed mallet fingers, cast immobilization seems slightly more effective than the traditional self-removal orthotic approach, probably due to its greater capacity to reduce edema [16]. Orthoses are usually part of the hand therapy protocol after corrective procedures for Dupuytren disease, though it is recommended to provide them based on individual patient needs rather than routinely due to a lack of strong evidence [30].

Mobilization strategies influence functional recovery. Outcomes were equivalent for passive mobilization with place and hold and active motion therapy groups after flexor tendon repair [12]. Following tendon transfer for claw deformity correction, immediate mobilization offers reduced morbidity and improved total active range of digit flexion compared to immobilization [14]. The immediate active motion protocol is safe and has similar outcomes compared with immobilization, with the added advantages of earlier pain relief and quicker restoration of hand function [19]. While evidence from a limited number of small studies suggests short-term benefit for early mobilization after tendon transfers, findings for longer-term outcomes remain inconclusive [18]. The author recommends the use of moon socks for patients with residual extensor lag or those at risk of developing a lag following the immobilization period [10]. For children, immobilization for the first four weeks following flexor tendon repair remains the most clearly articulated and supported rehabilitative option [98]. Patients likely should not be cleared for driving if they are using a longarm immobilization device [9].

Anatomy & Pathophysiology

Osseous and Articular Architecture

The skeleton of the hand and wrist comprises 27 bones, 19 of which are long bones [36]. The hand skeleton is organized into five rays, each forming a polyarticulated chain of metacarpals and phalanges [36]. The wrist possesses three axes of movement, including pronation and supination from the forearm, permitting the hand to assume any spatial configuration [36]. Regarding metacarpal length, the thumb metacarpal is the shortest, while the index metacarpal is the longest [36]. The proximal and middle phalanges of the middle and ring fingers are longer than those of the index finger [36]. The transverse axis of the palm is oblique, forming an acute angle of approximately 75 degrees with the longitudinal axis [36]. Epiphyseal plates are located at the proximal ends of the phalanges and the first metacarpal, and at the distal ends of the other metacarpals [36].

The metacarpophalangeal joints serve as the keystones of the longitudinal arches of the hand [64]. The volar plates act as thick anterior glenoid capsules that prevent hyperextension at the metacarpophalangeal joints [64]. The ring metacarpal exhibits about 10 degrees of mobility in flexion and extension, whereas the fifth metacarpal has a range of flexion–extension of approximately 20 degrees [64]. The articulations of the hand form functional groups arranged in kinetic chains, where the position of each articulation depends on the equilibrium of forces and the position of the immediately proximal articulation [69].

Soft Tissue and Musculotendinous Anatomy

Control of digital posture requires a complex balance of extrinsic and intrinsic muscle forces [35]. Extrinsic extensors traverse six distinct fibroosseous retinacular compartments at the wrist level [35]. The first extensor compartment contains the abductor pollicis longus and the extensor pollicis brevis [35]. The second extensor compartment contains the extensor carpi radialis longus and the extensor carpi radialis brevis [35]. The third compartment contains the extensor pollicis longus, which turns abruptly radialward about Lister tubercle [35]. The fourth extensor compartment contains the extensor indicis proprius lying deep to the four tendons of the extensor digitorum communis [35]. The fifth compartment contains the extensor digiti quinti [35]. The sixth compartment contains the extensor carpi ulnaris tendon [35]. The extensor digitorum communis tendons of the middle, ring, and little fingers are tethered together by juncturae tendinum over the dorsum of the hand proximal to the metacarpophalangeal joint [35].

Sagittal band fibers insert onto the volar proximal phalanx and onto the lateral borders of the volar plate [35]. These bands form a sling that allows proximal extrinsic extensor tension to be transmitted to the proximal phalanx, permitting metacarpophalangeal joint extension without a tendinous insertion onto the proximal phalanx [35]. The extrinsic finger flexors are the flexor digitorum profundus and the flexor digitorum superficialis [35]. The flexor digitorum profundus inserts on the proximal volar aspect of the distal phalanx [35]. The flexor digitorum superficialis inserts via radial and ulnar slips into the proximal metaphysis of the middle phalanx [68]. The fibroosseous tunnel, or digital flexor sheath, consists of annular pulleys that provide mechanical stability and cruciate pulleys that provide flexibility [68]. The A2 and A4 pulleys are the most essential in maintaining the mechanical advantage of the flexor tendons [68]. The tenosynovium lining the fibroosseous tunnel supplies nutrition and lubrication to the poorly vascularized flexor tendons [68]. Within the flexor tendon sheath, tendon vascularity is supplied via the vincula system, specifically the vinculum longus and brevis [68].

There are seven interosseous muscles in the hand: four dorsal and three volar [61]. The dorsal interossei are abductors, while the volar interossei are adductors [61]. The middle finger has two dorsal interossei and no volar interossei because the central axis of the hand lies within it [61]. The deep head of each dorsal interosseous muscle forms a lateral tendon, or lateral band, at the level of the metacarpophalangeal joint [61]. Transverse fibers arch dorsally from each lateral band to join over the dorsum of the finger, flexing the proximal phalanx [61]. Oblique fibers from the lateral bands insert onto the lateral tubercles at the base of the middle phalanx to extend the proximal interphalangeal joint [61]. The lateral bands are joined by the lateral slips of the extensor tendon to form the conjoined lateral band, which unites to form the terminal tendon inserting at the base of the distal phalanx [61]. The volar interossei do not insert onto the proximal phalanx [61]. The abductor digiti quinti and flexor digiti quinti brevis are structurally and functionally similar to the superficial and deep heads of the dorsal interossei, respectively [61]. The opponens digiti quinti arises from the pisohamate ligament and the hook of the hamate and inserts onto the ulnar side of the diaphysis of the fifth metacarpal [61].

The checkrein ligaments extend from the proximal volar plate and anchor it to the proximal phalanx, serving to prevent hyperextension [11]. Bony adhesions of the volar plate or contracture of the checkrein ligaments can result in diminished range of motion and flexion contracture [11]. The collateral ligaments are primarily responsible for radial and ulnar stability [11]. The proper collateral ligaments originate from the head of the proximal phalanx and insert into the middle phalanx [11]. The accessory collateral ligaments arise from the proximal phalanx and insert onto the volar plate and flexor sheath [11]. Because the accessory collateral ligaments do not insert into the middle phalanx, they remain lax in full flexion, rendering them susceptible to fibrosis and contracture if immobilized [11].

The superficial palmar fascia covers a triangular area of the central palm, with four central bands extending distally toward each of the fingers [71]. There is no central band of the superficial palmar fascia for the thumb [71]. The digital neurovascular structures are surrounded by a diffuse network of thin transverse oblique fibers, with dorsal fibers called Cleland ligament and palmar fibers called Grayson ligament [71]. A subdermal fascial layer borders the periphery of the web spaces, forming the distal first web space ligament between thumb and index in continuity with the natatory ligament [71].

Cutaneous Anatomy

The dorsal skin is thin, with a horny layer only 0.02 mm thick, and possesses a normal pilosebaceous system [70]. It has loose connections with deeper planes, allowing free gliding and full flexion at the digital joints [70]. Flexion of the fingers produces a significant lengthening of the dorsal skin, with an average increase of 3 cm in the middle finger from extension to full flexion [70]. Flexion at the metacarpophalangeal joint alone requires an average skin lengthening of 1.25 cm [70]. The dorsal and palmar areas of skin are independent due to a system of adhesions that anchors their common boundary to the underlying plane [70]. The dorsal covering of the interphalangeal articulations forms a unique cutaneous unit characterized by a considerable excess of skin when the digits are in extension [60].

The palmar integument is subdivided into two separate zones by the oppositional crease of the thumb [60]. The skin of the radial portion of the palm covers the thenar eminence and is the mobile portion [60]. The skin of the ulnar and distal portion of the palm covers the hypothenar eminence and has poor mobility [60]. The central triangular part of the palm has fixed, poorly vascularized skin covering almost directly the superficial palmar aponeurosis [60]. When a digit is completely flexed, the integument of adjacent phalanges comes into contact in the zones of the flexion creases, establishing areas of cutaneous contact in the form of a diamond [60]. The sides of the diamond-shaped cutaneous contact zones do not undergo variations in length during movements of flexion and extension [60]. The dorsal slope of the web spaces has a gradual incline and its supple skin is not adherent to the subjacent region [60]. The palmar surface of the web spaces is flat and precipitously interrupted, with skin densely adherent to the commissural skeleton [60].

Pathophysiology of Immobilization

Soon after injury, edema fluid and blood accumulate within and around tendons, ligaments, sheaths, and the articular space, resulting in swelling that mechanically limits joint motion [11]. The swollen, injured hand tends to assume a characteristic posture with the metacarpophalangeal joint extended and the interphalangeal joints flexed 30 to 40 degrees to maximize joint space and reduce pressure and discomfort [11]. Prolonged immobilization of the proximal interphalangeal joint in a flexed posture can cause contracture [11]. Mechanisms of contracture from prolonged immobilization include secondary contracture of the skin envelope and joint capsule [11]. Immobilization is usually the most effective treatment of acute problems, whereas surgery is often necessary for chronic conditions but results are much less predictably corrective [1].

Immobilization of the distal interphalangeal joint of any finger reduces the overall grip strength of the hand, with the effect becoming progressively more pronounced from the index to the little fingers [45]. Joint contracture is typically due to a combination of soft tissue contracture of the ligaments around a joint and the joint capsule itself [57]. Animal studies on immobilized limbs have demonstrated proliferation of fibrofatty connective tissue within the joint space, adhesions between synovial folds, adherence of fibrofatty connective tissue to cartilage surfaces, atrophy of cartilage, ulcerations at points of cartilage-cartilage contact, disorganizations of cellular and fibrillary ligament alignment, and regional osteoporosis [57]. Immobilized joints adapt to their new position by modifying the length of some compartments of the synovial intima [57]. Adhesions of synovial villi rather than a proliferation of pannus are shown in immobilized joints [57].

Muscle atrophy quickly ensues in response to immobilization or disuse due to reduced protein synthesis and hormonal contributions [74]. Muscle atrophy, loss of extensibility, and loss of force production are more pronounced in muscle immobilized without tension than in muscle immobilized under stretch [74]. When muscles are stretched in immobilization, the loss of strength is partially compensated for by the growth in length with formation of new sarcomeres and contractile proteins [74]. Stretched muscle produces less tension from stretch and maintains its extensibility [74]. Adaptive shortening refers to the loss of soft-tissue extensibility of tissues investing a joint in response to the decrease in demand for joint motion [148]. Adaptive shortening of connective tissues supporting a joint has been demonstrated in the presence of joint trauma followed by cast immobilization [148]. The mechanism of restriction in adaptive shortening describes an increase in "crosslink formation" between adjacent collagen fibers [148]. Decreased connective tissue extensibility in cast-immobilized specimens results from increased collagen synthesis in immobilized tissues [148]. Prolonged external immobilization of seemingly normal joints promotes progressive contracture of capsular and periarticular structures, resulting in encroachment of the joint space by fibrofatty connective tissue [148].

Immobilization alters the muscle/tendon ratio while causing muscle atrophy, weakness, and loss of elasticity [23]. There is a lack of accurate, reproducible, and noninvasive methods to demonstrate changes in human articular cartilage after a given period of immobilization [23]. Damage to cartilage from immobilization can range from mild and recoverable to severe [23]. The ulnar 2 digits play a significant role in overall grip strength of the entire hand [97]. There were significant differences in hand force between the injured and uninjured hands after completion of hand rehabilitation for all injury groups [91]. Grip strength is generally decreased compared with the contralateral side in carpal instability [131].

Classification

ASHT Splint Classification System (SCS): This system defines splints according to their function rather than their configuration or the presence of specific components [102]. By focusing on function, the SCS allows similarly performing splints to be grouped together [102].

Slade et al. External Fixation Classification: Slade et al. differentiated methods of external fixation into those that compress, neutralize, or distract [54]. This classification may be useful for future evaluations and comparisons between methods [54]. In the management of intra-articular fractures and fracture dislocations in the hand, dynamic constructs were far more common than static constructs [54].

Doyle Classification of Mallet Injuries: This classification categorizes mallet injuries into distinct types based on injury mechanism and pathology. Type I is defined as a closed injury with or without bony avulsion [134]. Type II involves an open injury, characterized by a laceration at or around the DIP joint, or an open injury accompanied by loss of skin and substance of the extensor tendon [134]. Type IV-A refers to a growth plate fracture in pediatric patients [134]. Type IV-B describes a fracture fragment involving 20%-50% of the articular surface in adults [134]. Type IV-C describes a fracture fragment involving > 50% of the articular surface in adults [134].

Other Considerations: Frozen shoulder may be classified as primary (idiopathic) or secondary, with the latter being related to injury or other diagnosis [140]. The condition follows a pattern consisting of three phases. The first is the painful phase, also known as the ‘freezing phase’ [140]. The second is the stiff or ‘frozen’ phase, during which active and passive ROM, especially in the external rotation and elevation planes, are restricted [140].

Clinical Presentation

The swollen, injured hand assumes a characteristic posture with the metacarpophalangeal joint extended and the interphalangeal joints flexed 30 to 40 degrees [11]. This positioning serves to maximize joint space and reduce pressure and discomfort [11]. Soon after injury, edema fluid and blood accumulate within and around the tendons, ligaments, sheaths, and articular space of the joint [11]. This accumulation results in swelling that mechanically limits joint motion [11].

Accurate diagnosis and management of hand and carpal fractures and dislocations are predicated on a thorough physical examination and appropriate imaging to limit joint stiffness while preserving mobility and function [33]. The collateral ligaments are primarily responsible for radial and ulnar stability of the joint [11]. Because the accessory collateral ligaments do not insert into the middle phalanx, they remain lax in full flexion and are susceptible to fibrosis and contracture if immobilized [11]. Mechanisms for proximal interphalangeal joint contracture include secondary contracture of the skin envelope and joint capsule [11].

Immobilization of the distal interphalangeal joint of any finger reduces the overall grip strength of the hand [45]. This reduction in grip strength becomes progressively more pronounced from the index to the little fingers [45]. Additionally, immobilization of the shoulder in an orthosis for 2 days leads to significantly reduced activity levels in young, healthy volunteers [29].

The safe position for hand immobilization is broadly defined as mild-to-moderate metacarpophalangeal joint flexion that is sufficiently safe and maximizes patient comfort [25]. This position is distinct from the traditional intrinsic plus position [25]. Splintage of the hand must be in the position of safe immobilization, with knuckle joints flexed at least 70 degrees, finger joints straight, and the thumb abducted [80]. In this position, ligaments are at full stretch so that movement can be regained with physiotherapy if they become adherent [80]. Splintage must be kept to a minimum, such that if only one finger is injured, it alone should be splinted [80].

Investigations

Physical Examination: A careful physical examination is essential to direct care and future testing if indicated, as diagnostic tests such as imaging and serum laboratory studies can be expensive, time consuming, and often nonspecific [34]. Patients with no radiological evidence of fracture are more likely to be managed without immobilisation [2].

Plain Radiography: Radiographic follow-up during splinting appears to be necessary for bony mallet finger [110]. In patients with displaced distal radius fractures, better final radiological and objective physical results were associated with a better patient-perceived outcome, as measured by the DASH score [139].

CT: Scaphoid waist fractures which appear to be undisplaced and united on a week 4 CT scan will unite, and may not need to be immobilised in a plaster cast for more than 4 weeks [55].

MRI: MRI is probably most useful in identifying additional pathology such as flexor tendon bowstringing in Dupuytren’s disease [75]. MRI may be helpful in providing a quantitative noninvasive measure of cellularity of affected areas, which is an index of biologic activity, but this potential staging tool has not been investigated yet on a large scale [75].

Doppler: An 8-MHz Doppler tone assessment may be used to identify superficially displaced neurovascular bundles when Dupuytren cords lie beneath soft fleshy prominences, but false-negatives are possible [75].

Other Considerations: The recommendation that adult patients with a fracture of the waist of the scaphoid which is displaced by ≤ 2 mm should be treated initially with immobilization in a cast, followed by early fixation of a nonunion, is further corroborated by findings from the Scaphoid Waist Internal Fixation for Fractures Trial [24].

Treatment

Non-Operative

Conservative management is the primary treatment pathway for a wide spectrum of upper and lower extremity injuries, with immobilization duration tailored to the specific fracture pattern and anatomical site. For nonoperatively treated proximal humeral fractures, a short immobilization period of one week is sufficient to avoid compromising patient independence, as no significant differences in pain or functionality were found compared to three weeks of immobilization [4] [13]. In the hand, there is no evidence that any specific form or duration of immobilization is superior for small finger metacarpal neck fractures with limited deformity, while data remain insufficient to determine the best treatment for those with substantial angulation [5]. Similarly, immobilization offers no advantage over symptomatic treatment for fractures of the base of the fifth metatarsal when judged by patient-reported outcomes [20]. For adult scaphoid waist fractures displaced by ≤ 2 mm, initial immobilization in a cast is recommended, followed by early fixation if nonunion develops, a strategy corroborated by five-year follow-up findings [24].

In the lower extremity, conservative treatment utilizing cylinder cast immobilization and bracing is a recommendable method for isolated acute posterior cruciate ligament injuries [26]. For osteochondritis dissecans lesions of the knee, nonoperative management may include restricted weight bearing and immobilization, such as cylinder casts or bracing, to protect healing tissue [28]. Allowing 4 to 6 weeks of non-weight bearing decreases compressive forces on the knee and provides rest from weight-bearing stress in patients with tibiofemoral joint lesions [28]. Conversely, isolated patellofemoral joint lesions are typically permitted to progress weight bearing and mobilization earlier in rehabilitation due to the absence of compressive forces on the lesion site during these activities [28]. Elbow immobilization has demonstrated positive effects on healing, enabling early return to sports and complete healing in conservative treatment for stable osteochondritis dissecans of the elbow before epiphyseal closure [87].

For pediatric and specific adult fractures, nonoperative management is effective in appropriately selected cases. A non-surgical, conservative protocol is suitable for patients with isolated proximal phalangeal fractures without uncorrectable finger rotation or fracture angulation exceeding 25 degrees in the sagittal plane or 10 degrees in the coronal plane following closed reduction [94]. Nonoperative management of completely displaced distal radial fractures in appropriately selected children results in excellent outcomes without exposing the patient to surgical risks [96]. However, treatment may need to be individualized for patients with displaced pediatric finger fractures, as absolute conclusions cannot be made for these specific cases [49]. After acceptable closed reduction of intra-articular distal radial fractures, patients randomized to the nonoperative group continued cast immobilization for 4 to 5 weeks [103].

For femoral shaft fractures, conservative treatment is rarely considered in contemporary practice due to the problems of prolonged immobility of 10–14 weeks [81]. Traction should be applied as soon as possible at the scene of injury and before transport, with a Thomas splint or derivation thereof being critical to reduce blood loss, ease transfer, and reduce pain [81]. Main indications for the use of traction in femoral shaft fractures include fractures in children, contraindications to anaesthesia, and lack of suitable skill or facilities for internal fixation [81].

High-risk stress fractures require immediate intervention to avoid progression. Treatment decision making should be based on radiographic findings with less consideration given to symptom severity [79]. The immediate goal is to avoid progression and achieve healing, typically requiring either complete elimination of loading of the site or surgical stabilization [79]. Patients with stress injuries in high-risk locations may require immediate immobilization and/or restriction from weight-bearing activities with close monitoring [79]. If an incomplete fracture is present on plain films with evidence of fracture on MRI or CT in a high-risk location, immobilization and strict non-weight bearing is indicated [79]. Worsening symptoms or radiographic evidence of fracture progression despite nonoperative treatment is an indication for surgical fixation of high-risk stress fractures [79]. All complete fractures at high-risk sites should receive serious consideration for surgical treatment [79].

Operative

Indications: Surgical intervention is indicated when nonoperative management fails or when specific anatomical criteria are met. For intra-articular distal radial fractures, immediate postoperative mobilization of the wrist was allowed in the operative group following volar plate fixation [103]. During the first 6 weeks following this fixation, weight-bearing exercises were not allowed [103]. Surgical fixation is indicated for high-risk stress fractures if worsening symptoms or radiographic evidence of fracture progression occurs despite nonoperative treatment [79]. Additionally, all complete fractures at high-risk sites should receive serious consideration for surgical treatment [79].

Adjuncts: The halo traction apparatus is a safe and effective method of traction and immobilization for the cervical and upper thoracic spine [40].

Other Considerations: Conservative management for carpal tunnel syndrome has shown improvement in symptoms and function [32]. Although used in practice, evidence for the use of relative motion orthosis for non-surgical management of adult and pediatric trigger finger is absent [47]. The efficacy of splinting for rheumatoid arthritis remains in question [39]. A case series tracked a comprehensive intervention based on a holistic activities of daily living framework that considered the nuances of individual complexities of immobilization following hand trauma [21]. Conservative treatment improves efficacy by reducing surgical indications for the cervico-thoracobrachial crossing syndrome [100].

Mobilization and Therapy Protocols: Early active short arc motion following central slip repair produces improved range of motion with shorter treatment time compared with static immobilization, though success depends on attention to splinting details and patient compliance [89]. For complete divisions of extensor tendons in Zones 5 and 6, good and excellent results were achieved in 95% and 98% of cases following dynamic outrigger mobilization [93]. Similarly, good and excellent results were achieved in 93% and 95% of cases using palmar blocking splint mobilization for these injuries [93]. In contrast, the 56% excellent and good results of the passive motion group were statistically significant (P < 0.005) when compared to the 12% in the immobilized group for digital function following flexor tendon repair in Zone II [46].

Positioning and Device Selection: The safe position for hand immobilization should be broadly defined as mild-to-moderate metacarpophalangeal joint flexion that is sufficiently safe and maximizes patient comfort, rather than the traditional intrinsic plus position [25]. A short, moulded metacarpal cast is used in the non-surgical management of metacarpal shaft fractures with an unacceptable apex dorsal angular deformity greater than 10 degrees [51].

Orthokinetic Orthosis: The term orthokinetic orthosis describes a dynamic orthosis that does not use nonelastic, rigid components and that applies no extraneous modulating mechanical force or constraint [117]. The construction of orthokinetic orthoses is intended to obviate negative sequelae of muscle disuse through immobilization [117]. The preferred materials of construction are flexible rubber- or spandex-reinforced elastic bandage materials [117]. Fabrication of the orthokinetic cuff uses the continuous foldover process, which results in a cuff-shaped orthosis with a continuous inner surface [117]. The orthokinetic orthosis should provide well-fitting, snug, but nonconstricting contact with the patient's skin overlying the targeted musculatures [117]. The orthokinetic cuff consists of a fully elastic area termed the active field A and a relatively inelastic area with residual elasticity termed the inactive field I [117]. The active field A is placed in contact with the skin areas overlying the paretic agonist musculature, and the inactive field I overlying the antagonist musculatures [117].

Pathophysiology of Immobilization: Mechanisms by which prolonged immobilization of the proximal interphalangeal joint causes contracture include secondary contracture of the skin envelope and joint capsule [11]. The checkrein ligaments extend from the proximal volar plate and anchor it to the proximal phalanx, also serving to prevent hyperextension [11]. The collateral ligaments are primarily responsible for radial and ulnar stability of the proximal interphalangeal joint [11]. Soon after injury occurs, edema fluid and blood tend to accumulate within and around the tendons, ligaments, sheaths, and articular space of the joint, resulting in swelling of the digits and hand that mechanically limits joint motion [11]. The swollen, injured hand tends to assume a characteristic posture with the metacarpophalangeal joint extended and the interphalangeal joints flexed 30 to 40 degrees, serving to maximize joint space and reduce pressure and discomfort [11].

Complications

Joint Stiffness and Contracture

Prolonged immobilization of the proximal interphalangeal joint (PIPJ) in a flexed posture causes contracture [11]. The mechanisms underlying PIPJ contracture include secondary contracture of the skin envelope and joint capsule [11]. Accessory collateral ligaments are susceptible to fibrosis and contracture during immobilization because they remain lax in full flexion [11]. In a rat model, the increase in joint stiffness caused by immobilizing an injured and repaired shoulder was transient [48]. This transient increase in joint stiffness does not outweigh the long-term benefits of immobilization on improved tendon to bone healing [48]. The casting motion to mobilize stiffness (CMMS) technique is used to manage joint stiffness resulting from crush and degloving injuries of the hand [145].

Tissue Degeneration and Atrophy

Immobilization alters the muscle/tendon ratio, causing muscle atrophy, weakness, and loss of elasticity [23]. It also contributes to edema, tissue inflammation, atrophy, adhesions, and injury [23]. Mid-frequency electrical muscle stimulation during immobilization may prevent early deltoid muscle atrophy after arthroscopic rotator cuff repair [50]. This stimulation may also promote early strength recovery after arthroscopic rotator cuff repair [50]. The long-term impact of mid-frequency electrical muscle stimulation on functional outcomes after rotator cuff repair remains unclear [50].

Functional Limitations and Activity Reduction

Patients using a longarm immobilization device likely should not be cleared for driving [9].

Treatment Efficacy and Outcomes

Immobilization was not successful in controlling pain and recurrence of instability in patients with midcarpal instability [56]. Immobilization periods of 1 and 3 weeks produced superior short-term outcomes compared with 6 weeks of immobilization for function, range of motion, and pain after open reduction and internal fixation of distal radial fractures [3]. Proximal humeral fractures treated conservatively can be immobilized for one week without significant differences in pain or functionality compared to three weeks of immobilization [4, 13]. Immediate mobilization following tendon transfer for claw deformity correction has the added benefits of reduced morbidity and improved total active range of digit flexion compared to immobilization [14]. The immediate active motion protocol after tendon transfer for claw deformity is safe and has similar outcomes compared with immobilization, with the added advantage of earlier pain relief and quicker restoration of hand function [19]. Outcomes were equivalent for passive mobilization with place and hold versus active motion therapy after flexor tendon repair [12]. Cast immobilization for closed mallet fingers seems to be slightly more effective than the traditional self-removal orthotic approach, probably due to its greater capacity to reduce edema [16]. Large variations exist in the duration of immobilization following common hand surgery procedures [53]. Immediate immobilization following proximal row carpectomy is unnecessary, and early rehabilitation is of the essence [22]. Undisplaced scaphoid waist fractures that appear united on a week 4 CT scan may not need to be immobilized in a plaster cast for more than 4 weeks [55]. The three 'figure of eight' suture technique allows safe early active mobilization in children aged 5–10 years for finger zone II flexor tendon repair, provided the wrist is immobilized in 30° of flexion and pulleys are vented proximal to the repair site [137]. The Miami breakout cast provides a safe and effective alternative to standard cast immobilization in carefully selected patients [6]. Polyurethane hand splints allow for rigid immobilization combined with intermittent mobilization and can be constructed on the patient in less than 30 minutes [7]. The halo traction apparatus is a safe and effective method of traction and immobilization for the cervical and upper thoracic spine [40]. In a cohort of toddler fractures, those with no radiological evidence of fracture are more likely to be managed without immobilization [2].

Recovery

Rehabilitation protocol: Management of nonoperatively treated proximal humeral fractures utilizes a short immobilization period of 1 week to avoid compromising patient independence for an overly extended period [4]. Following proximal row carpectomy, immediate immobilisation is unnecessary, and early rehabilitation is essential [22]. For tendon transfer procedures correcting claw deformity, immediate mobilization provides reduced morbidity and improved total active range of digit flexion compared to immobilization [14]. This immediate active motion protocol is safe, yields similar outcomes to immobilization, and offers advantages of earlier pain relief and quicker restoration of hand function [19]. While evidence supports short-term benefit for early mobilization after hand tendon transfers, findings for longer-term outcomes remain inconclusive [18]. In the context of acute Jones fractures, early surgical treatment results in a shorter time to clinical union and allows patients to return to sports and activities of daily living faster than with cast treatment [58].

Other Considerations: Prolonged immobilization of the proximal interphalangeal joint in a flexed posture can cause contracture through mechanisms including secondary contracture of the skin envelope and joint capsule [11]. Conversely, the increase in joint stiffness caused by immobilizing an injured and repaired shoulder is transient and does not outweigh the long-term benefits of immobilization on improved tendon to bone healing [48]. Mid-frequency electrical muscle stimulation during immobilization may prevent early deltoid muscle atrophy and promote early strength recovery after arthroscopic rotator cuff repair, though its long-term impact on functional outcomes remains unclear [50]. Regarding orthotic management, moon socks are recommended for patients with residual extensor lag or those at risk of developing a lag following the immobilization period [10]. The duration of orthotic use is significantly associated with the extent of contracture resolution in the stiff proximal interphalangeal joint [147]. Continuous passive motion following tenolysis did not result in a reduction in treatment time from date of injury to discharge from therapy [150]. Orthotic considerations for dense connective tissue and articular cartilage include minimizing immobilization and facilitating natural mechanisms of tissue nutrition through movement [23].

Key Evidence

• [L5] Immobilization is usually the most effective treatment of acute problems, whereas surgery is often necessary for chronic conditions but results are much less predictably corrective. [1] (10.1016/j.hcl.2013.03.003)
• [L4] In this cohort, those with no radiological evidence of fracture are more likely to be managed without immobilisation. [2] (10.1016/j.injury.2024.111566)
• [L1] Immobilization periods of 1 and 3 weeks produced superior short-term outcomes compared with 6 weeks of immobilization for function, range of motion, and pain. [3] (10.2106/jbjs.17.00912)
• [L2] These fractures can be successfully managed with a short immobilization period of 1 week in order to not compromise patients' independence for an overly extended period. [4] (10.2106/jbjs.20.02137)
• [L2] There is no evidence that any specific form or duration of immobilization is superior for fractures with limited deformity, and there are insufficient data to determine the best treatment for fractures with substantial angulation. [5] (10.1016/j.jhsa.2009.06.015)
• [L5] In carefully selected patients we believe the Miami breakout cast provides a safe and effective alternative to the current standard of care in cast immobilization. [6] (10.1177/1753193411419440)
• [L5] It allows for rigid immobilization combined with intermittent mobilization and can be constructed on the patient in less than 30 minutes. [7] (10.1016/s0894-1130(12)80334-6)
• [L5] The splint has proven equally effective for other conditions requiring immobilization. [8] (10.1016/s0894-1130(97)80046-4)
• [L4] Patients likely should not be cleared for driving if they are using a longarm immobilization device. [9] (10.1016/j.jhsa.2014.04.037)
• [L5] The author recommends its use for patients with residual extensor lag or those at risk of developing a lag following the immobilization period. [10] (10.1197/j.jht.2006.04.016)
• [L5] [11] (10.1016/j.hcl.2017.12.012)
• [L1] The outcomes were equivalent for both the mobilization groups. [12] (10.1016/j.jhsa.2021.11.031)
• [L2] The immobilization of PHF that are treated conservatively can be reduced to one week, as no significant differences were found with regards to pain nor to functionality of the patients, whether they are immobilized for one week or for three. [13] (10.1016/j.jse.2021.03.018)
• [L2] Immediate mobilization has the added benefits of reduced morbidity and improved total active range of digit flexion compared to immobilization. [14] (10.1016/j.jhsa.2007.10.012)
• [L1] Eight weeks of immobilization did not yield a higher rate of healing of medium-sized rotator cuff tears compared with four weeks of immobilization. [15] (10.2106/jbjs.l.01741)
• [L1] Cast immobilization seems to be slightly more effective than the traditional approach probably for its greater capacity to reduce edema. [16] (10.1016/j.jht.2013.01.004)
• [L2] Based on a limited number of small studies, there is evidence of short-term benefit for early mobilization, but inconclusive findings for longer-term outcomes. [18] (10.1016/j.jht.2012.06.006)
• [L1] The immediate active motion protocol is safe and has similar outcomes compared with immobilization, with the added advantage of earlier pain relief and quicker restoration of hand function. [19] (10.1016/j.jhsa.2008.11.014)
• [L1] Immobilisation is no better than symptomatic treatment in the management of a fracture of the base of the fifth metatarsal when judged by PROMs. [20] (10.1302/0301-620x.98b6.36329)
• [L4] This case series tracked a comprehensive intervention based on a holistic activities of daily living framework that considered the nuances of individual complexities of immobilization following hand trauma. [21] (10.1016/j.jht.2017.10.002)
• [L4] This study shows that immediate immobilisation following PRC is unnecessary, and that early rehabilitation is of the essence. [22] (10.1016/j.otsr.2010.02.011)
• [L5] [23] (10.1016/j.jht.2011.12.002)
• [L1] The recommendation that adult patients with a fracture of the waist of the scaphoid which is displaced by ≤ 2 mm should be treated initially with immobilization in a cast, followed by early fixation of a nonunion, is further corroborated by these findings. [24] (10.1302/0301-620x.108b1.bjj-2025-0122.r1)
• [L5] The safe position for hand immobilization should be broadly defined as mild-to-moderate MP joint flexion that is sufficiently safe and maximizes patient comfort, rather than the traditional intrinsic plus position. [25] (10.1177/1753193419873899)
• [L4] Conservative treatment utilizing cylinder cast immobilization and brace may be one of the recommendable treatment methods in an isolated and acute PCL injury. [26] (10.1007/s00167-008-0531-0)
• [Paper] [28] (10.1016/j.csm.2014.01.001)
• [L4] Results of this study show that even in young, healthy volunteers immobilization of the shoulder in an orthosis for 2 days leads to significantly reduced activity levels. [29] (10.1186/s12891-020-3133-8)
• [L5] Orthoses are usually part of the hand therapy protocol after corrective procedures despite lack of strong evidence, and it is recommended to provide them based on individual patient needs rather than routinely. [30] (10.1016/j.hcl.2018.03.008)
• [L1] Patients who underwent conservative management for CTS showed improvement in symptoms and function. [32] (10.1016/j.jht.2018.01.004)
• [L4] The efficacy of splinting remains in question. [39] (10.1197/j.jht.2007.08.002)
• [L4] Immobilization of the distal interphalangeal joint of any finger reduces the overall grip strength of the hand, with the effect becoming progressively more pronounced from the index to the little fingers. [45] (10.1177/1753193418765068)
• [L3] The 56% excellent and good results of the passive motion group were statistically significant (P < 0.005) when compared to the 12% in the immobilized group. [46] (10.1016/s0363-5023(80)80101-8)
• [L1] Although used in practice, evidence for the use of relative motion orthosis is absent. [47] (10.1016/j.jht.2023.05.016)
• [L5] This study demonstrated that the increase in joint stiffness caused by immobilizing an injured and repaired shoulder was transient and, therefore, does not outweigh the long-term benefits of immobilization on improved tendon to bone healing. [48] (10.1016/j.jse.2007.08.004)
• [L1] Treatment may need to be individualized for patients with displaced fractures as absolute conclusions cannot be made for these specific cases. [49] (10.1177/1753193418822692)
• [L3] However, its long-term impact on functional outcomes remains unclear and warrants further investigation. [50] (10.1002/ksa.70303)
• [L4] [51] (10.1177/17531934211024579)
• [L4] This study supports the hypothesis that large variations exist in the duration of immobilization following common hand surgery procedures. [53] (10.1177/1558944715617221)
• [L3] [54] (10.1016/j.jht.2016.04.001)
• [L3] Scaphoid waist fractures which appear to be undisplaced and united on a week 4 CT scan will unite, and may not need to be immobilised in a plaster cast for more than 4 weeks. [55] (10.1177/1753193409105189)
• [L4] Immobilization was not successful in controlling pain and recurrence of instability in patients with MCI. [56] (10.1016/j.jhsa.2017.11.002)
• [L5] [57] (10.1016/j.hcl.2018.06.011)
• [L1] Early surgical treatment results in a shorter time to clinical union and allows patients to return to sports and activities of daily living faster than with cast treatment. [58] (10.1177/0363546504272262)
• [L3] Elbow immobilization had positive effects on healing and enabled both an early return to sports and complete healing. [87] (10.1016/j.jse.2022.01.148)
• [L4] Early active short arc motion following central slip repair produces improved range of motion with shorter treatment time compared with static immobilization, though success depends on attention to splinting details and patient compliance. [89] (10.1016/j.jhsa.2010.10.007)
• [L4] There were significant differences in hand force between the injured and uninjured hands after completion of hand rehabilitation for all injury groups. [91] (10.1177/1558944716660555ko)
• [L1] Good and excellent results were achieved in 95 and 98% of cases following dynamic outrigger mobilization and 93 and 95% of cases using palmar blocking splint mobilization. [93] (10.1054/jhsb.1999.0356)
• [L4] A non-surgical, conservative protocol can be used for patients with isolated proximal phalangeal fractures without uncorrectable finger rotation or fracture angulation exceeding 25 degrees in the sagittal plane or 10 degrees in the coronal plane following closed reduction. [94] (10.1177/1753193419881086)
• [L3] Nonoperative management of completely displaced distal radial fractures in appropriately selected cases results in excellent outcomes without exposing the child to the risks of surgery. [96] (10.1302/0301-620x.103b.bjj-2020-1740.r1)
• [L4] The ulnar 2 digits play a significant role in overall grip strength of the entire hand. [97] (10.1197/j.jht.2006.07.009)
• [L5] Immobilization for the first four weeks following flexor tendon repair in children remains the most clearly articulated and supported rehabilitative option. [98] (10.1016/j.jht.2014.12.002)
• [L5] It improves the efficacy of conservative treatment by reducing surgical indications. [100] (10.1016/s1297-3203(00)73483-4)
• [Paper] The ASHT Splint Classification System (SCS) provides a consistent language that defines splints according to their function rather than their configuration or presence of certain components, allowing similarly performing splints to be grouped together. [102] (10.1016/s0894-1130(12)80337-1)
• [L1] [103] (10.2106/jbjs.20.01344)
• [L1] Radiographic follow-up during splinting appears to be necessary. [110] (10.1177/1753193420917567)
• [L5] [117] (10.1016/s0894-1130(12)80350-4)
• [L4] Grip strength is generally decreased compared with the contralateral side. [131] (10.1197/j.jht.2007.04.006)
• [L4] [134] (10.1016/j.jhsa.2018.03.037)
• [L4] The three 'figure of eight' technique is strong enough to allow safe early active mobilization in children between 5–10 years as long as the wrist is immobilized in 30° of flexion and pulleys are vented proximal to the repair site. [137] (10.1177/1753193410395837)
• [L3] Better final radiological and objective physical results were associated with a better patient-perceived outcome, as measured by the DASH score, in this patient group. [139] (10.1197/j.jht.2007.06.001)
• [L3] [140] (10.1177/1758573217693974)
• [Case_report] [145] (10.1016/j.jht.2016.03.013)
• [L2] The duration of orthotic use (weeks of treatment) is significantly associated with the extent of contracture resolution. [147] (10.1016/j.jht.2011.09.006)
• [L5] [148] (10.1016/s0894-1130(12)80060-3)
• [L4] Furthermore, there was no reduction in treatment time from date of injury to discharge from therapy. [150] (10.1197/j.jht.2006.07.014)

See Also

• Flexor tendon repair
• Dislocations
• Mallet Finger
• Finger Fractures
• Trigger Finger

References

[1] Diagnosis and Treatment of Finger Deformities Following Injuries to the Extensor Tendon Mechanism. Hand Clinics. 2013. DOI: 10.1016/j.hcl.2013.03.003

[2] Toddler fractures immobilisation and complications: A retrospective review. Injury. 2024. DOI: 10.1016/j.injury.2024.111566

[3] A Comparison of the Effect of One, Three, or Six Weeks of Immobilization on Function and Pain After Open Reduction and Internal Fixation of Distal Radial Fractures in Adults. Journal of Bone and Joint Surgery. 2018. DOI: 10.2106/jbjs.17.00912

[4] One Versus 3-Week Immobilization Period for Nonoperatively Treated Proximal Humeral Fractures. Journal of Bone and Joint Surgery. 2021. DOI: 10.2106/jbjs.20.02137

[5] Small Finger Metacarpal Neck Fractures. The Journal of Hand Surgery. 2009. DOI: 10.1016/j.jhsa.2009.06.015

[6] The Miami breakout cast: a method for applying a removable cast. Journal of Hand Surgery (European Volume). 2011. DOI: 10.1177/1753193411419440

[7] The Use of a Polyurethane in Hand Splinting. Journal of Hand Therapy. 1993. DOI: 10.1016/s0894-1130(12)80334-6

[8] The clamshell splint with otoform lining. Journal of Hand Therapy. 1997. DOI: 10.1016/s0894-1130(97)80046-4

[9] Driving With Upper Extremity Immobilization: A Comprehensive Review. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2014.04.037

[10] Moon Socks for Mallets. Journal of Hand Therapy. 2006. DOI: 10.1197/j.jht.2006.04.016

[11] Treatment of Proximal Interphalangeal Joint Contracture. Hand Clinics. 2018. DOI: 10.1016/j.hcl.2017.12.012

[12] Passive Mobilization With Place and Hold Versus Active Motion Therapy After Flexor Tendon Repair: A Randomized Trial. The Journal of Hand Surgery. 2022. DOI: 10.1016/j.jhsa.2021.11.031

[13] One or Three-Weeks Immobilization Period in Proximal Humeral Fractures Conservatively Treated. Prospective Randomized Study. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2021.03.018

[14] Immediate Postoperative Active Mobilization Versus Immobilization Following Tendon Transfer for Claw Deformity Correction in the Hand. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2007.10.012

[15] Effect of Immobilization without Passive Exercise After Rotator Cuff Repair. Journal of Bone and Joint Surgery. 2014. DOI: 10.2106/jbjs.l.01741

[16] Effectiveness of cast immobilization in comparison to the gold-standard self-removal orthotic intervention for closed mallet fingers: A randomized clinical trial. Journal of Hand Therapy. 2013. DOI: 10.1016/j.jht.2013.01.004

[18] The effectiveness of early mobilization after tendon transfers in the hand: A systematic review. Journal of Hand Therapy. 2013. DOI: 10.1016/j.jht.2012.06.006

[19] A Randomized Clinical Trial Comparing Immediate Active Motion With Immobilization After Tendon Transfer for Claw Deformity. The Journal of Hand Surgery. 2009. DOI: 10.1016/j.jhsa.2008.11.014

[20] Symptomatic treatment or cast immobilisation for avulsion fractures of the base of the fifth metatarsal. The Bone & Joint Journal. 2016. DOI: 10.1302/0301-620x.98b6.36329

[21] Unilateral hand training on functional performance in patients with upper extremity trauma. Journal of Hand Therapy. 2019. DOI: 10.1016/j.jht.2017.10.002

[22] Proximal row carpectomy: Is early postoperative mobilisation the right rehabilitation protocol?. Orthopaedics & Traumatology: Surgery & Research. 2010. DOI: 10.1016/j.otsr.2010.02.011

[23] Orthotic Considerations for Dense Connective Tissue and Articular Cartilage—The Need for Optimal Movement and Stress. Journal of Hand Therapy. 2012. DOI: 10.1016/j.jht.2011.12.002

[24] Clinical effectiveness of early surgical fixation versus cast immobilization for adults with a scaphoid waist fracture: five-year follow-up of the Scaphoid Waist Internal Fixation for Fractures Trial. The Bone & Joint Journal. 2026. DOI: 10.1302/0301-620x.108b1.bjj-2025-0122.r1

[25] On the safe position for hand immobilization. Journal of Hand Surgery (European Volume). 2019. DOI: 10.1177/1753193419873899

[26] Active non‐operative treatment of acute isolated posterior cruciate ligament injury with cylinder cast immobilization. Knee Surgery, Sports Traumatology, Arthroscopy. 2008. DOI: 10.1007/s00167-008-0531-0

[28] Physical Therapy Management of Patients with Osteochondritis Dissecans. Clinics in Sports Medicine. 2014. DOI: 10.1016/j.csm.2014.01.001

[29] How shoulder immobilization influences daily physical activity – an accelerometer based preliminary study. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-3133-8

[30] The Role of Hand Therapy in Dupuytren Disease. Hand Clinics. 2018. DOI: 10.1016/j.hcl.2018.03.008

[32] Short-term clinical outcome of orthosis alone vs combination of orthosis, nerve, and tendon gliding exercises and ultrasound therapy for treatment of carpal tunnel syndrome. Journal of Hand Therapy. 2019. DOI: 10.1016/j.jht.2018.01.004

[33] Chapter 29 Hand/Carpal Fractures and Dislocations. 2021.

[34] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy, Evaluation, Clinical Examination, and Imaging > Evaluation and Clinical Examination: Current Concepts.

[35] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 9Hand Surgery > Image DISORDERS OF THE MUSCULATURE OF THE HAND.

[36] Exam Of The Hand Wrist 2Ed. 1.1 SKELETON OF THE HAND > The osseous skeleton.

[39] Efficacy_of_Custom_Versus_Prefabricated_Splinting_in_Clients_With_Rheumatoid_Art_S0894113007001391. Journal of Hand Therapy. 2007. DOI: 10.1197/j.jht.2007.08.002

[40] The halo. A spinal skeletal traction fixation device.. The Journal of bone and joint surgery. American volume. 1968.

[45] Effect of immobilization of the distal interphalangeal joint of fingers on grip strength. Journal of Hand Surgery (European Volume). 2018. DOI: 10.1177/1753193418765068

[46] Digital function following flexor tendon repair in Zone II: A comparison of immobilization and controlled passive motion techniques. The Journal of Hand Surgery. 1980. DOI: 10.1016/s0363-5023(80)80101-8

[47] Orthotic intervention options to non-surgically manage adult and pediatric trigger finger: A systematic review. Journal of Hand Therapy. 2023. DOI: 10.1016/j.jht.2023.05.016

[48] After rotator cuff repair, stiffness—but not the loss in range of motion—increased transiently for immobilized shoulders in a rat model. Journal of Shoulder and Elbow Surgery. 2008. DOI: 10.1016/j.jse.2007.08.004

[49] Buddy taping versus splint immobilization for paediatric finger fractures: a randomized controlled trial. Journal of Hand Surgery (European Volume). 2019. DOI: 10.1177/1753193418822692

[50] Mid‐frequency electrical muscle stimulation during immobilization may prevent early deltoid muscle atrophy and promote early strength recovery after arthroscopic rotator cuff repair. Knee Surgery, Sports Traumatology, Arthroscopy. 2026. DOI: 10.1002/ksa.70303

[51] A 4-year study of the use of the short metacarpal cast in the management of metacarpal shaft fractures. Journal of Hand Surgery (European Volume). 2021. DOI: 10.1177/17531934211024579

[53] Variations in Postoperative Immobilization Following Common Hand Surgery Procedures. HAND. 2016. DOI: 10.1177/1558944715617221

[54] A scoping review of applications and outcomes of traction orthoses and constructs for the management of intra-articular fractures and fracture dislocations in the hand. Journal of Hand Therapy. 2016. DOI: 10.1016/j.jht.2016.04.001

[55] Undisplaced scaphoid waist fractures: is 4 weeks’ immobilisation in a below-elbow cast sufficient if a week 4 CT scan suggests fracture union?. Journal of Hand Surgery (European Volume). 2009. DOI: 10.1177/1753193409105189

[56] Dorsal Wrist Plication for Midcarpal Instability. The Journal of Hand Surgery. 2018. DOI: 10.1016/j.jhsa.2017.11.002

[57] Management of Joint Contractures in the Spastic Upper Extremity. Hand Clinics. 2018. DOI: 10.1016/j.hcl.2018.06.011

[58] Early Screw Fixation versus Casting in the Treatment of Acute Jones Fractures. The American Journal of Sports Medicine. 2005. DOI: 10.1177/0363546504272262

[60] Exam Of The Hand Wrist 2Ed. Functional cutaneous units.

[61] Green S Operative Hand Surgery. Interosseous and Hypothenar Muscles.

[64] Exam Of The Hand Wrist 2Ed. The arches of the hand > The metacarpal arch.

[68] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 9Hand Surgery > FLEXOR TENDON INJURY.

[69] Exam Of The Hand Wrist 2Ed. 1.3 MOVEMENTS OF THE HAND AND WRIST > Gliding mechanisms.

[70] Exam Of The Hand Wrist 2Ed. The dorsal skin.

[71] Green S Operative Hand Surgery. PERTINENT ANATOMY.

[74] Orthopaedic Basic Science Fifth Edition Print Ebook. Biology and Mechanics of the Skeletal Extracellular Matrix > Immobilization.

[75] Dupuytren S Disease And Related Hyperproliferative Disorders. 54. The Future of Dupuytren’s Research and Treatment > 54.4 Mechanical Measurements and Procedures > 54.4.4 Imaging.

[79] Rockwood And Green S Fractures In Adults. 21: Psychosocial Aspects of Recovery After Trauma > Management of High-Risk Stress Fractures.

[80] Apley And Solomon S Concise System Of Orthopaedics And Trauma. PRINCIPLES OF TREATMENT.

[81] Apley And Solomon S Concise System Of Orthopaedics And Trauma. Complications > Treatment.

[87] Conservative treatment for stable osteochondritis dissecans of the elbow before epiphyseal closure: effectiveness of elbow immobilization for healing. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2022.01.148

[89] Early Active Short Arc Motion Following Central Slip Repair. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2010.10.007

[91] Residual Grip and Pinch Strength Deficits After Completion of Hand Rehabilitation. HAND. 2016. DOI: 10.1177/1558944716660555ko

[93] A Comparison of Dynamic Extension Splinting and Controlled Active Mobilization of Complete Divisions of Extensor Tendons in Zones 5 and 6. Journal of Hand Surgery. 2000. DOI: 10.1054/jhsb.1999.0356

[94] Non-surgical management of isolated proximal phalangeal fractures with immediate mobilization. Journal of Hand Surgery (European Volume). 2019. DOI: 10.1177/1753193419881086

[96] Treatment of completely displaced distal radial fractures with a straight plaster or manipulation under anaesthesia. The Bone & Joint Journal. 2021. DOI: 10.1302/0301-620x.103b.bjj-2020-1740.r1

[97] Contribution of the Ulnar Digits to Overall Grip Strength. Journal of Hand Therapy. 2006. DOI: 10.1197/j.jht.2006.07.009

[98] Flexor tendon injuries in children: Rehabilitative options and confounding factors. Journal of Hand Therapy. 2015. DOI: 10.1016/j.jht.2014.12.002

[100] Réflexions sur la rééducation du syndrome de la traversée cervico-thoracobrachiale. Chirurgie de la Main. 2000. DOI: 10.1016/s1297-3203(00)73483-4

[102] The Need for a Consistent International Language In Hand Rehabilitation. Journal of Hand Therapy. 1993. DOI: 10.1016/s0894-1130(12)80337-1

[103] Volar Plate Fixation Versus Cast Immobilization in Acceptably Reduced Intra-Articular Distal Radial Fractures. Journal of Bone and Joint Surgery. 2021. DOI: 10.2106/jbjs.20.01344

[110] Splinting versus extension-block pinning of bony mallet finger: a randomized clinical trial. Journal of Hand Surgery (European Volume). 2020. DOI: 10.1177/1753193420917567

[117] Rehabilitation of a Post-stroke Patient with Upper Extremity Hemiparetic Movement Dysfunctions by Orthokinetic Orthoses. Journal of Hand Therapy. 1992. DOI: 10.1016/s0894-1130(12)80350-4

[131] Current Practice in the Diagnosis and Treatment of Carpal Instability—Results of a Survey of Australian Hand Therapists. Journal of Hand Therapy. 2007. DOI: 10.1197/j.jht.2007.04.006

[134] Outcomes of Splinting in Pediatric Mallet Finger. The Journal of Hand Surgery. 2018. DOI: 10.1016/j.jhsa.2018.03.037

[137] Finger zone II flexor tendon repair in children (5–10 years of age) using three ‘figure of eight’ sutures followed by immediate active mobilization. Journal of Hand Surgery (European Volume). 2011. DOI: 10.1177/1753193410395837

[139] Patient-perceived Outcome after Displaced Distal Radius Fractures. Journal of Hand Therapy. 2007. DOI: 10.1197/j.jht.2007.06.001

[140] Management of post-traumatic stiffness of the shoulder following upper limb trauma with manipulation under anaesthetic. Shoulder & Elbow. 2017. DOI: 10.1177/1758573217693974

[145] Case Report: The casting motion to mobilize stiffness technique for rehabilitation after a crush and degloving injury of the hand. Journal of Hand Therapy. 2016. DOI: 10.1016/j.jht.2016.03.013

[147] The Long-term Relationship between Duration of Treatment and Contracture Resolution Using Dynamic Orthotic Devices for the Stiff Proximal Interphalangeal Joint: A Prospective Cohort Study. Journal of Hand Therapy. 2012. DOI: 10.1016/j.jht.2011.09.006

[148] Soft-tissue Mobilization Techniques for the Hand Therapist. Journal of Hand Therapy. 1994. DOI: 10.1016/s0894-1130(12)80060-3

[150] Continuous Passive Motion following Tenolysis in Hand Therapy Patients: A Retrospective Study. Journal of Hand Therapy. 2006. DOI: 10.1197/j.jht.2006.07.014