Traumatic Hand Injury Involving Multiple Structures



Traumatic Hand Injury Involving Multiple Structures


Paige E. Kurtz


Traumatic hand injuries can be both the most daunting and the most rewarding conditions that hand therapists treat. Deciding where to start with a new evaluation can be intimidating for a therapist; however, once therapy is underway, and throughout the rehabilitation process, the experience of participating in a client’s recovery can be remarkable and rewarding. Being part of the progress from initial evaluation to final status and good function is truly gratifying.


The systems approach is the easiest way to evaluate, prioritize, and treat traumatic and complex injuries. Consider each individual system involved; then, for each system, determine the stage of the injury and how it can best be treated in light of necessary precautions. This approach makes it much easier to choose the correct interventions for each system according to its stage. Systems that should be considered include the skin (wound/graft), tendons (flexors, extensors, or both), nerves, blood vessels (veins and arteries), and bones (fractures, fusions, and joint surfaces). Pain and edema are additional considerations.


Plan ahead throughout the course of therapy. If future surgery is to be expected, incorporate that fact into the goals of therapy and treatment planning. For example, if tenolysis or tendon grafting is likely, maximize passive range of motion (PROM); if tendon transfer is expected, maximize the strength of potential donor muscles. During the process, continually educate your clients about what may be coming next and how current treatments will benefit them in the long run.


Most traumatic hand injuries involve many different structures and systems. The most extreme and complex injuries require a replant; that is, an amputated finger, hand, or arm is reattached surgically to re-establish viability and function. Not all traumatic hand injuries involve a replant or revascularization (a surgical procedure to repair severed arteries or veins to restore blood supply to a limb). However, the precautions and the decision-making and treatment processes are similar across the spectrum of these injuries.



image Clinical Pearl


Keep in mind that the goal of rehabilitation after a traumatic injury is not to regain a completely normal hand, but rather to regain maximal function with minimal pain.


As soon as possible, determine the reasonable functional outcome, given the extent and location of the injury; keep in mind that a client can be functional with less than “normal” range of motion (ROM). At this point, work with your client to set reasonable goals and expectations for both of you. Often, one of the most important parts of therapy is managing expectations and providing psychosocial support.


Precaution. Achieving a pain-free hand with functional prehension, grip, and grasp is better than pushing to gain a few more degrees of ROM while jeopardizing stability. It usually is not worth risking the possibility of increasing pain and edema and reducing the chance of long-term success.


Clients’ satisfaction with their outcome is related to their expectations, as explained by the surgeon before surgery and reinforced by the therapist after surgery.1



Anatomy


Traumatic, multisystem injuries can involve many different structures from the surface of the skin through to the bone. Complex injuries, including replants and revascularizations, may occur at any level of the extremity, from the upper arm to the fingertips. To treat these injuries successfully, therapists must have a thorough working knowledge of the anatomy involved. They must know the locations and workings of veins and arteries; the stages of wound healing; the anatomy and healing processes of tendons, ligaments, and bone; and the biomechanics and interrelationships of these tissues and structures during functional movement.


The therapist first must understand the mechanics of a “normal” (that is, uninjured) hand, because this provides the basis for maximizing the client’s hand function after surgery. If you understand the implications of the injury and the surgery, you will be better able to set realistic goals and formulate a good treatment plan. Decision making is related to healing times and sequences and may depend on the surgery performed. Some structures may need to be protected while others must be mobilized early in therapy; this can be difficult to manage. Treatment of the traumatic hand injury can become a balancing act, requiring you to determine which joints to move and which structures to protect, and when stability is more important than mobility. Some stress on healing structures is good because it stimulates healing, but too much stress can cause a loss of stability. How aggressively to push the therapy depends on the skills and knowledge of the physician and therapist, as well as the ultimate goals and expectations.


The therapist must know what tissues were disrupted and to what extent, the effect of different types of injuries on different tissues, and what surgical procedures were performed to repair those tissues. The position of the hand at the time of injury may affect which structures were injured and at which level (that is, the anatomic location of injury). The therapist must take into account the effect of the injury on surrounding, uninjured structures and attend to those uninjured structures throughout the extremity (for example, the shoulder or elbow) to prevent additional loss of function.


Anatomically, consider the functional implications of the anatomy and the injury. Moran and Berger2 have described seven basic maneuvers that constitute basic hand function; these include three types of pinch and four types of grasp. These can be further categorized into two primary functional uses of the hand: pinch between the thumb and finger (or fingers) and grip. Pinch is affected by a radial side hand injury, which influences prehension and fine motor coordination. Grip is affected by an ulnar side hand injury, which diminishes composite grip and stability. Keep these functional movements in mind when planning treatment and devising exercises and activities.3



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Finger flexors offer more function than extensors. However, in ADLs, wrist extension generally is more useful than wrist flexion. The importance of the thumb’s contribution to overall hand function cannot be ignored; thus, maintaining a good web space and opposition is critical. It is imperative to work for a strong, stable wrist; without it, finger function and grip strength will be impaired. Keep in mind also that regaining functional use of the hand is very difficult without functional sensibility.



Diagnosis and Pathology


Traumatic hand injuries can be caused by many types of force, from sharp lacerations to crush injuries. The mechanism of injury (for example, tearing, crushing, cutting, or twisting forces) and the cleanliness of the wound are important pathologic factors. A closed crush injury may show little visible damage but may involve fractures or ischemia as a result of extensive damage to internal structures.


Primary treatment typically is performed in the emergency department, ideally with immediate referral to a hand specialist and replant team. The hand surgeon evaluates the injury with regard to what can and cannot be salvaged and restored to good function. Many systems and algorithms are available to aid problem solving and prioritization in the emergency department and operating room. Generally, the thumb, if salvageable, is always replanted as a priority. With multiple-digit amputations, the surgeon tries to replant as many as practical. Replants are nearly always attempted at any level in children. Incomplete amputations are also treated with maximum aggressiveness.3 Box 37-1 lists surgical procedures used to treat complex hand injuries.



BOX 37-1   Surgical Procedures Used To Treat Complex Hand Injuries


Skin









BOX 37-2   Information Needed From the Physician


Therapists should make sure they obtain the following information from the client’s physician or surgeon:



With Surgical Repairs





Timelines and Healing


Operative Treatment


Most or all involved structures are repaired surgically, depending on the timing of surgery and the extent of injury. The hand surgeon evaluates which structures can be repaired and which cannot be salvaged and therefore must be amputated or considered for later surgical interventions. Irrigation and debridement are performed first to remove contaminants and nonviable tissue.


The order of repair generally begins with stabilization of the injury. Blood flow and fracture stabilization are most critical, and these guide the surgeon’s planning. Typically, bony injuries are fixed first, using techniques that are expedient but that also allow early ROM. Bone shortening may be done to allow for easier end-to-end repair of other structures. This ultimately can affect biomechanics, possibly resulting in compromised ROM and strength.


Tendon repairs often are performed next, unless the vascular status is severely compromised. When both flexors and extensors are involved, the surgeon tries to restore balance between the two, giving priority to functional flexion. Generally, vascular and nerve repairs are performed next, and then skin coverage is addressed.


The initial goal of the surgeon is to restore the framework that allows the client and therapist to work toward a good functional outcome with a reasonably strong structure, optimal skeletal alignment and joint mobility, vascular flow, and the potential for functional tendon balance and glide. If the injury is extremely complex, scar, tendon and nerve grafts, joint contractures, and other deficits may be addressed by further surgeries.


Many of the involved systems may be in different stages of healing after surgery. For example, a finger fracture may have good stability because of stable internal fixation, but an overlying skin graft or infection may delay wound healing. The systems approach can be very helpful for such cases.


Prioritize the systems during the initial evaluation. There is no specific hierarchy of systems; however, without healing in some systems, no further healing occurs in any of the others. The general order of importance is as follows:



The goals and priorities early in therapy (0 to about 3 weeks after surgery, the acute phase) are to manage and protect repairs, prevent joint stiffness in all uninvolved joints, control edema, manage the wound, manage pain, educate the client, and provide psychosocial support. As the client progresses into the intermediate phase (3 to 6 weeks after surgery), therapy focuses more on increasing ROM of involved structures, managing scarring, continuing wound care and protection, and initiating functional use of the involved extremity. Later phases focus on building and maximizing ROM, endurance, strength, and function.



image Questions to Discuss with the Physician


Whenever possible, obtain a copy of the operative report. Make sure you and the physician have the same understanding of treatment goals and expectations; do not hesitate to ask for clarification when needed (Box 37-2). Other important questions include the following:



Therapists spend considerable time developing a rapport with their clients, which means that clients sometimes are more likely to report problems and concerns to the therapist than to the physician. Also, therapists see clients more regularly and often are more likely to notice subtle changes that indicate potential problems.



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Do not be afraid to confer with the physician in a timely manner on any information that appears to be important regarding the client’s status, complaints, or problems.



image What to Say to Clients



About the Injury


Try to give clients perspective about their injury and realistic goals for the outcome. Teach them that a good outcome is about getting enough movement to use the hand to regain independence in normal everyday tasks but will not necessarily mean “normal” ROM. “I am not going to worry about getting your hand back to normal, we are going to focus on you being able to use your hand for as many normal things as possible.” Work to develop a partnership: “I’m the coach, but you have to do the practices. We will work together to get you the best use of your hand. If you do not do your exercises consistently at home, there is nothing we can do a few times a week here in therapy that will make up for it.”


Discuss the ramifications of not complying with contraindications and precautions: “If you are not careful about doing the exercises as I show you or you do not wear your orthosis, it could mean your hand will not heal as it should. If something goes wrong, it could even mean you’ll need another surgery to fix your hand again.”


Clients come to rely on their therapists for information, and they often ask questions they are afraid to ask the physician. Do not hesitate to refer the client to the physician for questions you cannot answer.


Clients often are more compliant with therapy and achieve better outcomes when the underlying anatomy and the healing process are explained to them in common terms. Try to explain what the client is attempting to achieve with specific exercises, using terms the client can understand. Provide basic information on how the flexors and extensors work and explain that many of the muscles that move the fingers originate near the elbow. When possible, use models, pictures, or drawings to show specific anatomic features. Explain how the normal anatomy was affected by the injury and what outcome the client should expect. If future surgery is likely, make sure the client understands that and incorporate it into the goals of therapy.




About Exercises


Most clients are afraid to move any part of the hand immediately after surgery, especially if they feel pain, have swelling or open wounds, or if they can see pins sticking out of the hand. The therapist must stress the importance of movement despite these problems: “You will not hurt your hand if you do the exercises just as I showed you. If you do not do the exercises, getting good movement back will be more difficult. We cannot wait for the swelling to go away, the pins to come out, or the wound to heal before we start moving your fingers. By that time, your fingers will be really stiff, and it will hurt more to move them.” Make sure the client understands that “more” exercises are not necessarily better, and that they should follow your directions on how often to exercise and how many repetitions to perform as closely as possible.



Evaluation Tips




• The initial evaluation may be mostly “hands off” because of the client’s pain and fear and, often, the need to establish trust and rapport at this time. Before seeing the client, gather all information available on the type of injury and the treatment to this point, especially the operative reports. The initial evaluation may be a time to gain trust and establish ground rules, to do an overview assessment of the status of various systems, and to perform necessary aspects of therapy (for example, wound care and orthosis fabrication).


• When you begin an evaluation, consider comorbidities and overall health status. Ask whether the client is a smoker or diabetic or has any other health problems. These can delay healing in all systems.


• Make sure to ask about support systems, including friends and family. Monitor clients’ behavior toward the injured hand: Are they able to look at the hand, or do they treat it as if it belonged to someone else or as if they would like to get rid of it? To achieve a good outcome, the client must develop “ownership” of the injured hand and take some responsibility for recovery.


• Visually inspect the following:



• Check ROM at uninvolved joints (for example, shoulder and elbow)


See Chapters 5 and 13for more detailed information.



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At the initial evaluation, obtaining specific measurements is not as important as making a global assessment of the client’s status, and establishing a baseline for treatment planning.



Diagnosis-Specific Information that Affects Clinical Reasoning


The following sections present a general discussion of the critical areas to evaluate for each system, precautions and contraindications, and healing guidelines and timelines. More detailed information on specific systems is available in the relevant chapter in this text.



Bone Injury: Fracture


With a complex injury, all surrounding and unaffected joints should be moved immediately, if possible, depending on the type and location of fracture and the type of fixation. Beginning ROM exercises as soon as the physician permits helps enhance fracture healing. During the evaluation, consider precautions, the type of fixation, and the expected stability of structures. The surgeon may have elected to shorten bony structures at the time of fixation. This may allow for a cleaner, more stable fixation, and it facilitates end-to-end repair of tendons, nerves, and blood vessels in the area; however, it also may greatly alter the mechanics of musculotendinous units in the arm and hand.


Surgical fixation may be achieved with pins and Kirschner wires, joint implants, plates and screws, interosseous wiring, or even joint fusion (Fig. 37-1). An important goal of surgery is to achieve as much stability as possible, creating the framework for movement in rehabilitation.6,7


image
FIGURE 37-1 X-ray film showing amputation and internal fixation.

Precaution. Avoid excess stress at the fracture or fusion site or pin site and watch for signs of infection.


If revascularizations were done in conjunction with fracture fixation, the chance of delayed healing or nonunion is greater because of a decrease in the delivery of nutrients to the area.


Precaution. A joint next to a fracture may need to be moved to begin ROM protocols. If this is the case, be aware of the location and type of fracture and the fixation and stability. Manually stabilize the bone during movement, and do not torque across the fracture site.


If the surgeon has established sufficient fracture fixation, ROM around a fracture site may be initiated immediately, starting from the midrange and progressing to full ROM as appropriate, observing precautions for tendons, nerves, and vascular structures.8


See Chapters 25 and 27 for further indications, contraindications, and typical timelines for healing.



Revascularization: Arteries and Veins


Revascularizations and replants often are categorized together as the most complex injuries because injury to an artery or vein (or both) with revascularization affects peripheral blood flow, which in turn affects the potential for survival of nearly every other structure in the hand. In complicated cases, surgeons may not repair both arteries into a digit; the digit therefore has decreased vascularity because of the repair and because it has only one functioning artery.4,7 After surgery, these clients are placed in a “hot” (for example, 75° F to 80° F) room in the hospital to help increase peripheral circulation. Keep in mind that the decreased circulation after arterial repair affects the healing rate of the wound, tendon, and fracture in an extremity because of the decrease in peripheral circulation and delivery of nutrients to the area.


If possible, have the client exercise with the dressing off so that you can observe the vascular status. Ideally, therapy should be performed in a comfortable, warm room, away from air conditioner vents. While working with the client, monitor the color, capillary refill, and temperature in the injured hand.


Precaution. A dusky (grayish) finger or hand indicates severely diminished vascularity caused by arterial compromise; a purple color suggests venous congestion. Alert the referring physician if you note either a dusky or purple appearance. Either of these could signify distress for the finger, which could lead to failure of the replant.10


A major precaution with revascularizations is to avoid anything that challenges the weakened peripheral vascular system. The client must not eat or drink anything vasoconstrictive, such as caffeine and chocolate. Smoking is prohibited, because it causes severe vasoconstriction, reduces peripheral circulation, and affects the blood’s ability to carry oxygen.9 Compressive bandages (for example, elastic stockinette, tape, or gloves) should not be used for 3 to 8 weeks, until the vascular status has stabilized. Monitor for compression caused by orthotic material and straps. Constantly check the color of the fingers with regard to capillary refill.


Another precaution to keep in mind is to avoid using cold treatments in the acute phase (3 to 6 weeks or longer after surgery). If the injury occurs during the winter, advise the client to keep the hand warm with a mitten, an oven mitt, or a scarf for both comfort and safety. Many experts recommend avoiding the use of a whirlpool, because it puts the hand in a dependent position; if a whirlpool is used, it must be run at neutral temperature.5,11 Contrast baths should also be avoided, because they may cause vasospasm followed by vasoconstriction. Mild heat may be used 4 to 8 weeks after surgery, once vascularity has stabilized. However, keep in mind that the insensate hand does not have a warning system to let the client know when a substance is too hot; it also cannot dissipate heat as well (that is, the tissue burns more easily). Although elevation is a good way to reduce edema, excessive elevation challenges the vascular system. The hand therefore should not be held significantly above the level of the heart, because this puts stress on the newly repaired arteries and can cause failure.5


Specific treatment considerations require positional protection of artery and vein repairs similar to that for flexor tendons (that is, an orthosis with the wrist and fingers flexed, such as a flexor tendon dorsal protective orthosis), because neurovascular bundles generally are volarly located (see Chapter 30). If the bone was not shortened, the physician may need to use vein grafts to ensure adequate circulation without putting tension on the system. If tension is unavoidable, precautions must be observed, such as more flexed positioning in the orthosis and in therapy. If no other injuries or complications are involved, vascular structures can be moved soon after surgery. If tendon injuries or fractures occur in the same digit, follow the highest level of precautions to protect these structures appropriately.



Nerve Injury: Laceration and Repair


Like vascular injuries, nerve injuries often occur with flexor tendon injuries. In such cases, treat according to the appropriate flexor tendon protocol. Tension on the nerve guides decision making on protocols. As with tendon injuries, establishing early gliding is essential.


A nerve injury leaves part of the hand insensate. This is not a significant problem in the early phase of therapy, while the client is continually wearing the orthosis. However, it becomes a concern when the client begins to perform activities of daily living (ADLs) out of the orthosis.


Precaution. The client must be taught to take care with ADLs (for example, heat, sharp objects); the eyes must be used as a sensory guide for the nerves. The therapist must use caution with use of a dynamic or static progressive orthosis and any other external compression, as well as heat and ice, because of the lack of a warning system for ischemia.


A client with decreased sensibility may be unable to tell whether the temperature of a substance is excessively hot or cold.


A full sensibility evaluation is not necessary immediately after a traumatic hand injury. Because it takes some time for the repaired nerves to reinnervate an area, a cursory screening is practical at the initial evaluation to detect areas of sensory deficit. A full sensibility evaluation rarely is worthwhile earlier than 1 month after surgery. Follow-up re-evaluations should be performed approximately once a month thereafter, because nerves regrow slowly from the injury site to the distal fingertips


After the client has regained protective sensation, begin sensory reeducation to teach the brain to recognize signals from the peripheral nerves.5 Start with constant pressure and moving touch. Begin with the client’s eyes open and progress to eyes closed; vary between the involved and uninvolved side or area. Desensitization exercises should be performed for hypersensitivity.



image Clinical Pearl


Remember that sensitivity to and intolerance of cold are common for up to 2 years after a nerve injury and sometimes longer.9,19

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Sep 9, 2016 | Posted by in MANUAL THERAPIST | Comments Off on Traumatic Hand Injury Involving Multiple Structures

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