Fig. 15.1
The Pyramid of Progressive Forces. Rehabilitation exercises generally begin at the base, where stress on tendons will be least. Stress increases as the exercises move up the pyramid, with resistive, isolated joint motion at the pinnacle (Used with permission from Groth [3])
The Pyramid of Progressive Force provides a systematic method to determine progression of therapeutic exercises designed to provide the appropriate level of force to the healing flexor tendon to achieve tendon glide with the minimal amount of force needed to affect the desired excursion. When adhesions preventing tendon glide occur during rehabilitation, this presents clinically as a plateau or decrease in range of motion. Exercises in the pyramid represent a series of specific rehabilitation levels arranged according to the amount of load being placed on the healing tendon in order to affect excursion of the tendon through the wound site.
This approach differs from traditional, time-regimented protocols in that the tendon excursion or “glide” dictates the advancement of the exercises based on patient’s response to the exercises. Initial exercises begin with those that provide the lowest level of force to the tendon repair and progress only as needed to gain the desired tendon excursion. Protected passive motion of the digit promotes distal excursion of the tendon, whereas passive wrist extension promotes proximal tendon excursion. These glides provide the lowest level of force to achieve tendon excursion while remaining within the tensile strength of the repair. If the patient demonstrates improving range of motion to this level of load application, they should remain at the existing level of exercise force. If the patient’s tendon excursion is not responsive to the load application at that level, the exercises should be progressed upward to the next level on the pyramid.
Wound Care
Following replantation, the most common types of wounds that may be encountered by the treatment team include closed incisions, open wounds, abrasions, and skin grafts. It is important to know how each of these is managed to ensure that proper dressing care is provided during hand therapy sessions.
Incisions and Abrasions
Closed incisions will be sutured and have bulky postoperative dressings, which may be taken down as soon as postoperative day one as reepithelialization of the wound typically occurs in the first 24 h. Dressings should be changed daily or as needed. Incisions and abrasions may be cleaned with soap and water, though submersion of the hand should be avoided.
Skin Grafts
Skin grafts are used to cover soft tissue defects once the concern for gross contamination is eliminated. Skin grafts may either be full thickness (epidermis and dermis) or partial thickness (epidermis and part of the dermis) and may be meshed in order to increase surface area, prevent fluid collection, and aid in graft contouring (Fig. 15.2a, b). Skin grafts heal by way of diffusion (imbibition) from the underlying wound bed and from alignment of existing vessels (inosculation) and ingrowth of new blood vessels (angiogenesis). The critical time for this to occur is in the first 5 days where a pressure dressing is kept in place (bolster or vacuum-assisted dressing). Occasionally, when the graft rests directly on top of venous outflow from the replanted digit, no compressive dressing will be applied. In this setting, great care must be taken during dressing changes at therapeutic visits so as not to disturb the skin graft.
Fig. 15.2
(a) The appearance of a full-thickness skin graft over a replanted thumb as observed during the first dressing change at postoperative day 3. (b) The same graft and thumb at 3 months postoperatively
Factors that result in early graft failure include seroma, hematoma, and graft shear. Shearing forces are the most important for the therapist to consider, and caution should be particularly observed when designing and securing a custom orthosis. Ideally, any orthotic used within the first 1–2 weeks following skin graft placement should either avoid contact with the graft or, alternatively, have a wide distribution of pressure over the entire area.
Assessment of initial graft take should be made 5–10 days following the graft. Skin graft take is always assessed in follow-up with the hand surgeon, and dressings should be left in place during initial therapy sessions. If a graft has not successfully taken within this time frame, it is unlikely to ever take. Indicators of skin graft take include a graft that is adherent to the underlying wound bed with no necrosis and color matching of the skin surrounding the original donor site. In the event of graft loss, local wound care should be instituted with nonadherent dressings and antibiotic ointment to prevent desiccation of the deep tissue, allowing for granulation and secondary healing.
Neural and Vascular Monitoring
Sensation should be assessed as soon as feasible, and patient education regarding sensory precautions should be initiated early in the process. Clearly, more proximal levels of replantation will require longer periods of time to demonstrate any sensory return to the fingertip. Sensory testing should include Semmes-Weinstein monofilament testing to determine quality of sensation. Other tests, such as moving and static two-point discrimination, may be used; however, the discrimination of return of sensation is likely to be less accurate than monofilament testing (Fig. 15.3).
Fig. 15.3
Semmes-Weinstein filament (SWF) testing. Pressure is applied with the tip of the filament until the filament bends into a “C” shape. The finest filament that can be sensed in this fashion defines sensibility by SWF criteria
Management of the vascular status of the replant largely consists of monitoring, avoidance of stressors that might increase sympathetic tone, and avoidance of compression. The patient should be instructed to avoid temperature extremes as well as to monitor circulation by observing the color and capillary refill of the replanted part. When instructing the patient in placement or removal of the orthotic, the therapist should stress the importance of avoiding placement of retaining straps across inflow or outflow vessels and should carefully instruct the patient in the appropriate level of tension to be placed on the retaining straps.
Edema
The problematic issue of significant and persistent edema almost always accompanies major trauma. Because persistent edema increases tissue resistance and limits the progression of both active and passive range of motion postoperatively, effective edema management strategies are paramount to all rehabilitation protocols. Edema management techniques include elevation, icing, active ROM, and light compression [4]. Interventions such as icing and compression in the setting of replantation may be contraindicated due to poor sensation and fresh vascular reconstructions. Thus, elevation is the treatment of choice at the initial posttrauma and postsurgical phase.
Depending on patient tolerance and the level of the replant, manual lymph drainage (MLD) may provide an early technique to decompress the hand and fingers. In order to perform MLD, light surface massage should be performed starting proximally at the shoulder near the site where the lymphatics drain into the subclavian system. The massage should move distally along the arm and forearm to just proximal to the level of replantation. Efficacy of this procedure in decreasing hand/wrist edema in the setting of external fixation of distal radius fractures has been shown [5].
Kinesthetic taping is another modality that has shown promise in treating posttraumatic edema as well as edema related to venous stasis [6, 7]. Known often by the brand name of Kinesio® Tex (Kinesio Precut, Albuquerque, NM) taping, the procedure appears to improve edema by providing increased mobilization of fluids through the lymphatic system. Although more research regarding efficacy in the upper limb is needed, we have had good success in reducing edema with this method in a wide range of hand and wrist injuries complicated by swelling. One advantage appears to be that taping does not restrict circulation in any way when correctly applied. Sensitivity to adhesives is a contraindication to using Kinesio tape.
Scar Management
Scar management may begin as soon as the wound has sufficiently healed. The therapist may apply light compression wraps and begin retrograde massage if vascularity allows. Adjunctive therapy to manage scar restrictions may include the use of ultrasound, a modality frequently employed in multiple scar conditions. Silicone gel sheeting (Fig. 15.4a, b) or elastomer putty products (Fig. 15.5) may be helpful with scar maturation by maintaining hydration of the new collagen tissue. These topical treatments are primarily useful for improving the clinical appearance of the scar rather than addressing any contribution of the scar to the function of the underlying structures [8]. Scar support, through linear, longitudinal taping or compression garments, shows some promise in preventing scar hypertrophy [9]. Compression garments for scars should only be implemented only after vascular perfusion has been firmly established.
Fig. 15.4
Silicone gel sheeting may be useful in managing cutaneous scar healing. Appropriately sized segments may be cut from larger, over-the-counter sheets (a) or self-adherent patches (b) may be used
Fig. 15.5
Elastomer putty allows scar compression and maintains cutaneous moisture. Advantages include the ease of molding the putty into virtually any configuration and the ability to place the elastomer mold into a compression garment
Rehabilitation by Level of Replantation
Digital Replantation
Initial Protected Active and Passive Motion (Days 3–21)
Rehabilitation following digital replantation (flexor zones 1 and 2) should begin as early as possible after postoperative day 3. Early motion of the involved digit prior to this time is not recommended due to postoperative pain and inflammation [10–12]. This short delay does not affect outcomes, as the risk of adhesion formation in the very early postoperative period is low, since collagen formation does not typically begin until day 3.
Prior to initiating therapy, the bulky surgical dressings should be removed to allow for the fitting of a custom orthosis. An assessment of the wound can be done at this time with any concerns being relayed to the surgical team. A dorsal blocking orthosis is then fabricated, placing the wrist in neutral, the metacarpophalangeal (MCP) joints in approximately 60–70° of flexion, and the interphalangeal (IP) joints in full extension (Fig. 15.6). These positions may be modified depending on any repairs requiring primary arthrodesis of finger joints. If the injury is to the fingertip only, a finger-based splint may be fabricated (Fig. 15.7).
Fig. 15.6
Dorsal block splinting (orthosis). A standard for protection of flexor tendon repairs, the orthotic should be fabricated with finger position determined in consultation with the surgical team so that excessive stress is not placed on either extensor or flexor tendon repairs
Fig. 15.7
Distal replants may occasionally be protected solely by a finger-based orthotic
Early motion of the replanted digit may begin 3–5 days after surgery. Therapist-directed passive range of motion is helpful in order to “warm up” the tissues and decrease overall tissue resistance due to edema and immobility [12]. The patient is instructed to passively flex and extend the DIP joint and the PIP joints in turn for several repetitions within the dorsal blocking orthosis (Figs. 15.8 and 15.9). These passive ROM exercises also serve to promote distal glide of the tendons.
Fig. 15.8
PROM distal glide exercises for the DIPJ. Passive flexion of the DIPJ is performed using the unaffected hand to feel light resistance, then extended to the limit of the splint
Fig. 15.9
PROM distal glide exercises for the PIPJ. Passive flexion of the PIPJ is performed using the unaffected hand to feel light resistance, then extended to the limit of the splint
Tenodesis exercises promote proximal glide of the flexor tendons. These exercises are performed in a limited range of motion and begin with gravity-assisted passive wrist flexion, resulting in finger extension (Fig. 15.10a, b) followed by active wrist extension, which produces finger flexion (Fig. 15.11a, b). The dorsal block orthosis should be used initially for these maneuvers; however, the patient can gradually progress to limited PROM out of the orthosis.
Fig. 15.10
Passive tenodesis exercises for tendon glide begin in the orthotic (a) and gradually progress to similar maneuvers outside of protection. (b) Wrist flexion, either actively or by gravity, results in passive extension of the fingers
Fig. 15.11
Active wrist extension results in passive finger flexion. Exercises begin in the orthotic (a) and continue after orthotic removal (b)
The initiation of active ROM requires discussion with the surgical team. When approved, early active motion may be performed by flexing the digits to midrange using a submaximal effort [11] to no more than approximately 45° at each of the three finger joints (MCP, PIP, and DIP). Full active flexion is not advised as it could increase tension at the repair and risk rupture. Full active extension is allowed within the constraints of the orthotic. Exercises should be performed four times a day. Additionally, active range of motion of uninvolved structures, including the elbow and shoulder, should be encouraged to maintain mobility for function.
When the patient is 2.5 weeks out from surgery, the thermoplastic dorsal blocking orthosis may be modified to extend the wrist to 20–30°. Therapeutic exercises continue to emphasize both active and passive finger flexion. Passive ROM for distal glide of the tendon should continue prior to active motion exercises. Active flexion up to two-thirds of full range is encouraged with continuation of submaximal effort so that it is resistance free. Active flexion into the final one-third of full range of motion results in resistance which is 5–10 times that of the previous two-thirds and consequently carries a greater risk of tendon rupture [10,11]. If any resistance to active flexion is encountered, gentle passive motion into the end ROM may be implemented. Awareness of resistance in both the flexors and extensors should be continuously monitored; when new resistance is encountered at a point that provided smooth glide at prior sessions, formation of adhesions may be suspected. Resistance at the end points of motion, especially full flexion, may represent tightness or shortening of the extensor repair. While adhesions may prompt a move up the pyramid of exercises in order to prevent progression, attempting to force past a shortened tendon will likely only lead to gap or rupture.
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