Managment of Complex Hand Injuries

Acute Phase Healing

• often prolonged

• edema may be extensive

• epithelization (fresh, fragile skin)

Static orthosis for acute phase healing

• immobilization intent

• rest, support, protection and position to prevent deformity

Protected positioning acute phase healing

• restrictive intent

• dorsal blocking orthoses used with replants, flexor tendon repairs, and/or nerve repairs

Intermediate phase healing

• all injured structures heal in same manner

• one wound with one scar

• structures may become adherent in scar

• extensive scarring, soft tissue loss, and edema lead to joint fibrosis and soft tissue tightness.

therapy during intermediate phase healing

• control edema

• scar management

• minimize stiffness

When is mobilization initiated in intermediate phase healing?

once healing structures have enough tensile strength

What does an orthoses need to address during intermediate phase healing?

• MCP extension

• PIP flexion/extension

• 1st web space

Late phase healing

• vigorous scar management to reorient collagen in scar to allow ROM

• many techniques used to elongate scar adhesions

• apply low-load prolonged contributing to loss of motion

Purpose of orthosis during late phase healing

provide support or improve functional use of hand such as anti-claw orthosis or opponens device

Assessment of complex hand injuries

• medical history review

• identity damage and repair to each system

• specific diagnosis

  • standard sensorimotor battery

skin integrity in complex hand injuries

• skin/soft tissue loss

• amputations

• medical treatments

• special procedures

Wound assessment

• location

• skin loss, type of closure

• open wounds

• surrounding tissues

• exudate

• wound bed

• grafts and flaps

• signs of infection

exudate

color, odor, and consistency

wound bed

necrotic tissue, granulation tissue, epithelial budding, vital structures exposed

grafts and flaps

• adherence

• drainage

  • vascularity and viability

dusky and gray grafts

restricted arterial flowp

purplish graft

restricted venous outflow

signs of infection

redness, warmth, pain, edema, drainage, and/or odor

scar assessment

• location and size

• textural changes

• vascularity

• sensibility

• motion impairment

• document with photography

vascular assessment

• vessels repaired or not repaired

• tension or repaired structures

• vascular patency

• edema

assessment of edema

• visual inspection

• palpation

• circumference

• volumeter

s

skeletal assessment

• fractures, osteotomies, and joint implants

• type of fixation

• skeletal shortening will affect muscle and tendon function

muscle-tendon assessment

• repairs

• implants

• tension on repairs

• balance of repairs

• poor tendon quality

  • suture type/technique

assessment of motion

evaluate non-involved structures

measure involved hand only as permitted

physical examination

differential diagnosis to determine cause of restricted motion

joint contracture, capsule tightness

check A/PROM

Adhesion ROM

PROM>AROM

strength assessment

Initiated when cleared by MD and when healing structures can tolerate applied tension

nervous system assessment

gross assessment

specific assessment

pain

6-8 weeks post-injury → reveals status of nerve damage

Acute wound care

• performed in a neutral temperature room, away from vents

• bandages removed carefully to avoid shearing forces

• dressing should be applied distal to proximal

• dressings should be changed daily

• wounds with well approximated margines only require light, dry dressings

Pin site care

• monitor for signs of infection

pain management in acute wound care

• thermal agents have limited use

• heat discouraged

• cold may provide analgesia and control edema with hand elevated above heart level

• Electrical stimulation

• Thermal agents contraindicated if protective sensation is not intact

Edema control in acute wound care

• monitor for signs of acute inflammation due to therapeutic exercises or functional use

• elevation

• compression

• active exercise

• cryotherapy

When should hand elevation not be used?

in the case of vessel repairs

What should be done to the hand for vessel repairs?

hand should be positioned at heart level

When should compression garments not be used?

for vessel repairs in the first 6 weeks

Range of motion in acute wound care

• AROM/PROM to uninvolved joints

• PROM/AROM to involved joints as permitted depending on structures involvement

What should be initiated first regarding ROM?

• non-resistive grasp and prehension activities as soon as able to encourage normalization of movement patterns

• passive stretching exercises to structures contributing to loss of motion

  • tendon gliding and blocking exercises

Strengthening in acute wound care

resistive gripping exercises at multiple angles to enhance tendon gliding

strengthening for involved hand as tolerated

aerobic exercise to minimize deconditioning

resistive exercise of uninvolved extremities

Sensory re-education

techniques to retrain sensory pathways or stimulate unused pathways

perform exercises 2 to 4 times a day for 10 minutes in a quiet room

desensitization techniques

textures, vibrations, massage, fluidotherapy, particle, immersion

What is the indication for starting sensory reeducation?

• can feel red monofilament

• can feel vibration

Compensation for sensory loss

• use vision

• use unaffected side to test temperatures

• use unaffected side with sharp objects

• use built up handles on the affected side

• change positions frequently

• use cushions to protect bone areas

• do not apply excessive forces

• observe and care for skin

Scar management

controlled motion = controlled collagen synthesis

generally begin 24hrs after surture removal

massage

compression garments/devices

serial use of orthoses/casting

scar management techniques should be vigrous in later stages

c

care of residual limbs

performed with amputations and fingertip injuries

wrapping for shaping and edema control

desensitization

mutilating hand injuries

trauma to multiple anatomic systems resulting in varied clinical picture

mechanisms of mutilating hand injuries

motor vehicle accidents, machinery-related accidents, explosions, gun shots

Multiple system involvement

• each system may be in a different phase of healing

  • directs courst of treatment

patient considerations

• encouraging

• explain complexity

• explain need for treatment

• be realistic in expectation

• goal is functional ROM and use of hand

goals for the mutilated hand

• ROM

• maximal functional use

• aesthetically acceptable

• Maximal PROM

• maximize strength

• normalize movement patterns in hand