Prior to rehabilitation, the therapist should be familiar with the medical history and surgical procedure. Emphasis should be placed on understanding the date of surgery, the type of injury (e.g., crush contusion, avulsion, or cut), the planes of various tissue injuries, bone fixation, and wound closure. The rehabilitation after amputation reimplantation is roughly divided into 3 stages: early, middle and late. Wang Bo, Department of Rehabilitation, Songwon Hospital of Traditional Chinese Medicine
11.1 Early stage rehabilitation (0-4 weeks)
11.1.1 0 to 1 week after surgery Anti-spasticity, anti-coagulation and anti-inflammatory treatment are given clinically to ensure the survival of the reimplanted limb (finger). Rehabilitation is not intervened at this time.
11.1.2 2~4 weeks after surgery The purpose of rehabilitation is to cooperate with clinical prevention of infection, promote blood circulation, maintain smooth flow of repaired blood vessels and accelerate wound healing of repaired tissues. For example, ultrashort wave electrotherapy:It has the effect of promoting deep vasodilation, improving blood circulation, preventing small vein thrombosis and inhibiting bacterial growth. It can accelerate the edema decreasing and control the infection. However, for the fracture end fixed with fine steel pins, the ultrashort wave dose should be strictly controlled in the heat-free range to avoid burns due to metal overheating. Ultraviolet irradiation:When the postoperative wound infection has exudate, local irradiation with ultraviolet light is available. UV has a bactericidal effect, which can control infection in superficial areas and promote wound healing. Infrared irradiation: It can make superficial blood vessels dilate, promote exudate absorption and keep the wound surface dry. The patient has loss of sensation in the limbs, so pay attention to prevent burns. Exercise therapy: For the unbraked joints, the therapist will help to do slight extension and flexion exercises. The patient is instructed to do active exercises for the shoulder and elbow joints to avoid affecting the range of motion of other joints due to long-term braking. Educate the patient’s awareness of self-protection: educate the patient that the replanted limb (finger) should be kept warm to avoid vasospasm caused by cold; not to consume caffeinated liquid to avoid vasoconstriction; not to smoke because nicotine in cigarette will reduce the oxygen content in blood and endanger the blood supply of the replanted limb; elevate the injured limb to keep it at the heart level to reduce the occurrence of edema.
11.2 Medium-term rehabilitation (5-8 weeks) Medium-term rehabilitation is started after the hand is released from braking, with the aim of controlling edema and preventing joint stiffness and tendon adhesions. Active exercise: practice finger extension, flexion, finger hooking, fist clenching and other movements. The movements should be gentle so as not to strain the repaired tissues, and the therapist should properly instruct the patient on the exercises. Teach the patient the technique of compensating for loss of sensation in the injured limb by using vision to compensate for the loss of skin sensation.
11.3 Post-rehabilitation (9-12 weeks) By this time, the fracture has healed and the muscles, nerves and blood vessels have healed firmly. Passive activities and resistance exercises are available. The focus is on continued edema reduction, scar management, active joint mobility exercises, functional activity training (e.g., activities of daily living), and sensory retraining.
11.3.1 Physical therapy Commonly used are ultrasound therapy and audio therapy to soften the scar. Before performing active and passive joint movements, local wax therapy is used to soften the stiff scar and joint, which is beneficial to the functional exercise of the injured hand.
11.3.2 Joint mobility exercises Active movement: active movement of the joint in all directions. The movement should be smooth and gentle, and then moderate force when the maximum amplitude is reached, so that the joint area feels tension or mild soreness. Passive exercise: perform passive stretching activities: this method has a strong stretching force, but the technique should be gentle, in order to cause tension or soreness in the joint. Do not use violence or cause significant pain to avoid new trauma. Splinting: There are two types of static and power splints. The purpose of using splints is: to correct and prevent deformity; to improve function.
11.3.3 Muscle strength and endurance exercises Graded resistance training from light to heavy may be used. The principle of promoting muscle recovery is to contract the muscle to its maximum capacity to induce moderate fatigue, followed by appropriate rest to allow the muscle to recover and develop its form and function in recovery and subsequent overload recovery.
11.3.4 Sensory retraining Refer to the relevant section in the Techniques of Rehabilitation Therapy.
11.3.5 Occupational therapy When there is some recovery of joint mobility and muscle strength, various activities of daily living and functional activities can be started in time. Please refer to the relevant part of “Occupational Therapy”.
12 Rehabilitation of ischemic muscle contracture of the forearm
According to the different rehabilitation treatment and prognosis, we divide ischemic muscle contracture into three types: light type: deep (or) superficial flexor contracture, unable to extend the wrist and fingers at the same time, only when the wrist is flexed, can actively or passively extend the fingers; or when the wrist is flexed, can actively or passively extend the wrist, generally no skin sensory disorder, and the prognosis is better. Moderate type: contracture of deep and superficial finger flexors, long thumb flexors, wrist flexors and pronator teres, or contracture of intrinsic hand muscles, with skin sensory disturbance in the median nerve sensory distribution. Severe type: contracture of forearm flexors, extensors and intrinsic hand muscles, loss of movement and sensation, generally poor prognosis.
12.1 Treatment
12.1.1 Before rehabilitation Firstly, control the wound infection and promote wound healing can be treated with a combination of ultrashort wave, ultraviolet light and drug exchange.
12.1.2 Intensive thermal therapy According to the different degrees of ischemic lesions and etiology, intensive thermal therapy, which is 2 to 4 times larger than conventional treatment, is used. Ultrashort wave, plate electrode, forearm to hand opposed, microcaloric, 15min/time, 1～2 times/d. Wave spectrum: forearm to hand, distance 15cm, 20min/time,1～2 times/d. Wax therapy: disc wax, about 40°, 30min/time, 1～2 times/d, site for forearm and hand. Low and medium frequency electrotherapy. Electrical stimulation: electrodes 4cm×5cm, placed on the flexor side of the forearm. Frequency 10Hz, wave width 100ms, 20min/time, 1 time/d. Audio: electrodes 8cm×1.5cm, placed on both sides of the scar, parallel to each other, 20min/time, 1 time/d.
12.1.3 Exercise therapy Massage:Immediately after wax therapy, massage was performed. Massage the forearm flexors with kneading method, the technique should be gentle, but also with certain force, avoid using rough technique or causing pain. Passive movement:When the muscles are denervated or the joints are stiff, in order to maintain the range of motion of the joints, passive movement is performed on the joints of the hands and wrists, and stretching activities are performed on the contracted muscles. Active movement: When the nerve gradually recovers, you should seize the opportunity to train active or active-assisted activities of the hand, such as flexion and extension of interphalangeal joints, metacarpophalangeal joints, thumb abduction, opposable fingers, finger abduction and induction, wrist flexion and extension, forearm rotation and elbow flexion and extension activities. Muscle training: Use the wall puller to train the forearm flexors. The weight starts from 2 kg, 20-50 strokes/time, 2 times/d. Hold 2 pounds of small mute, wrist flexion, wrist extension, elbow flexion training, 15-30 strokes/time, 2 times/d. Hand squeeze play dough, training finger flexors and intrinsic hand muscles, 30-50 strokes/time, 2 times/d. The intensity of muscle strength training should be appropriate for the patient to feel mild fatigue. Homework therapy: daily life training, such as button tying, brushing teeth and washing face, holding a spoon, holding chopsticks, etc. Functional training, such as writing, screwing, typing, weaving, etc. Sensory training: using the rubber end of a pencil, gently and repeatedly touching the skin of the fingers from the proximal to the distal end; identifying objects of different shapes and textures, respectively, with eyes open ~ eyes closed, adding various objects to sand or rice grains to make them picked up, respectively, with eyes open ~ eyes closed. The use of splint support is mainly used for heavy or medium-sized patients. The purpose is to retract contracted muscles, maintain flexor length, and correct deformities. An angle-adjustable wrist brace can be made and placed on the palmar side of the forearm. The angle is continuously adjusted to maintain flexor length as function is restored. To correct flexor and thumb adduction deformities, splints for finger extension and thumb abduction can be fabricated.
12.2 Role and significance of rehabilitation therapy The necrotic degeneration of fibers that occurs after muscle ischemia is not always a reversible change. In milder cases, necrotic muscle fibers can be removed by phagocytes and then replaced by regeneration of new muscle fibers from nearby viable muscles. Clinically, it has been observed that within 48h after the onset of ischemic contracture, if not treated appropriately, the contracture gradually worsens and reaches its most severe level after a few weeks. After a few months, the contracture may recover again. Intensive heat therapy can dilate blood vessels, increase blood flow, improve muscle nutrition, eliminate edema, and promote nerve recovery. Low and medium frequency electrotherapy can stimulate the injured nerve muscle, reduce or prevent muscle atrophy, promote nerve recovery, soften the purpura and loosen the adhesions. Exercise therapy can pull and stretch the contracted muscles and ligament joint capsule, so that part of the fibrous degenerated muscle tissue under the action of stress collagen fiber elasticity increases, blood circulation improves, so that the remaining muscle cells restore vitality and function. It can also maintain joint mobility and prevent muscle atrophy. Active and passive exercises can promote lymphatic and venous return, eliminate edema, enhance muscle strength and minimize purpura adhesions. Occupational therapy is to train the flexibility and coordination of the fingers. Therefore, timely and effective rehabilitation can promote the regression of the pathological process to the good side and reduce the occurrence of complications. Stabilization of ischemic muscle contracture takes about six months. Thus, observation for 6 to 12 months is generally required before deciding on surgical treatment. However, observation is not the same as passive waiting, some clinicians do not know enough about rehabilitation, so many patients lose the opportunity of early treatment, resulting in hand function does not recover properly, resulting in disability, this lesson is worth noting.
The treatment of severe ischemic muscle contracture is based on functional reconstruction. For such patients, rehabilitation treatment is to prepare for elective surgery, such as improving local soft tissue conditions and passively moving the stiff joints to make the joint mobility meet the needs of functional reconstruction, which can improve the effect of surgery.
13 Hand burn rehabilitation
The complications after hand burn are: local trauma inflammation, swelling, strange itching and pigmentation changes at the site of implant and skin donor area, joint stiffness, MP joint extension contracture, PIP joint flexion contracture, finger web, especially thumb web contracture, hyperplastic scar, nail bed damage and severe psychological trauma. Rehabilitation is broadly divided into two phases: early (burn treatment period) and late (healing period or late surgery period). Early rehabilitation focuses on clinical control of inflammation, promotion of wound healing, reduction of edema, and maintenance of proper hand position. The goals of late rehabilitation are to reduce tissue scarring and adhesions as well as contracture deformities, increase joint mobility, and minimize hand dysfunction. In order to prevent joint deformity and restore optimal hand function, early activity and swelling control are very important aspects, provided that medical conditions allow.
13.1 Early Rehabilitation
13.1.1 Protective Position The hand splint is maintained at 30° of wrist extension and 70° to 90° of MP flexion. the PIP and DIP are held in the straight position, thumb to palm position, and the extensor tendon device is protected. The splint had to be worn for the rest of the time except for active exercises.
13.1.2 Pre-implant mobility exercises Passive joint movements or complete fist clenching movements were prohibited. Individual active ~ assisted movements were performed for each finger. Exercises: extension/flexion of the MP joint in the PIP and DIP extension position; extension/flexion of the PIP joint in the MP and DIP extension position; extension/flexion of the DIP in the MP and PIP extension position; extension/flexion of the MP joint of the thumb in the IP extension position; extension/flexion of the IP of the thumb in the MP extension position; thumb-to-finger exercises. The above exercises eliminate the stretching of the extensor tendon apparatus without affecting the movement of the joints.
13.1.3 Treatment of local traumatic inflammation Ultrashort wave: acute phase of inflammation with no heat, opposed, 10 min. gap: low power 1 to 2 cm, high power 3 to 5 cm. subacute and chronic phase with micro heat, opposed, 10 to 15 min. if the infection is in deep layers, ultrashort wave is preferred, but the dose should be strictly controlled. UV: for superficial trauma infection, use medium-wave UV with a wavelength of 280-320 μm. 1 to 2 erythematic amounts are used for fresh trauma to promote epithelial growth; 3 erythematic amounts are used for the acute phase of inflammation to promote limited absorption of inflammation; 4 erythematic amounts are used for septic trauma to induce necrotic tissue to fall off as soon as possible. Combined use of ultrashort wave and UV light is more effective for controlling traumatic inflammation and reducing swelling. However, ultrashort wave should be done first, followed by UV; conversely, ultrashort wave will affect the erythema volume of UV.
13.1.4 Reduction of edema Due to pain and edema, the injured person tends to place the hand in a “comfortable” position, but this comfortable position tends to cause palmar flexion and radial deviation of the wrist, extension of the MP joint, flexion of the interphalangeal joint, and thumb inversion deformity. Therefore, at the beginning of treatment, the affected limb was elevated to facilitate swelling reduction, and the hand was immobilized with a hand splint.
13.2 Post-treatment rehabilitation After the wound heals (or skin graft), the new skin fibers are thin and brittle, easily producing blisters and requiring care. Non-irritating skin care agents can be applied to keep the new skin lubricated, soft and elastic. If blisters appear, sterile gauze can be used to cover the wound until it is dry. After the new skin is stabilized, it can be massaged to loosen tissue adhesions. To avoid damage to joint ligaments or tearing of scar fibers, passive activities need to be gentle and slow. The newborn skin is delicate and tender, and sensation has not yet been restored, so heat therapy should be used with caution to avoid burns. Encourage the injured person to use the affected hand for activities of daily living and functional activities. Activity exercises focus on flexion and extension of the MP joint PIP, and DIP joint, thumb abduction, and opposable finger function. Gradually, full range of motion, muscle strength, endurance, dexterity and coordination of the joints are trained. In addition, skin sensory training is performed.
13.2.1 Hyperplastic scar management
13.2.1.1 Compression therapy It takes 12 to 18 months for trauma healing scars to mature, and approximately 70% to 80% of burns will produce hyperplastic scarring. All wounds involving dermal layer burns, including those with skin grafts, should be given compression therapy. The rationale may be that continuous application of pressure similar to capillary pressure of 3.3 kPa will cause the collagen fibers to rearrange. Compression therapy methods include elastic bandages, compression gloves, etc. Compression therapy needs to be continuous and should be worn every day except for grooming and hygiene. Compression gloves should be worn for 12 to 18 months until the scar matures. The gloves need to be remeasured every 3 months. The gloves should be worn inside and outside backwards so that the sutures do not compress the skin. There must be close contact between the skin of the hand and the glove, especially at the finger web area. The skin on the back of the hand is prone to abrasion and should wait for the wound to heal before wearing gloves. Otherwise, the wound will not heal easily.
13.2.1.2 Audioelectric therapy has a good effect of softening the scar and improving tissue nutrition, as well as relieving itching and pain. 1 time/d, 30 min each time, 20 times for a course of treatment.
13.2.2 Management of contracture Contracture is the result of shortening of the connective tissue of the muscles, tendons and joint capsule spanning or surrounding the joint. Prevention of contracture is primarily a matter of performing full range of motion as early as possible, maintaining proper position and splinting support. The casualty should begin activity as soon as conditions permit. If the casualty is reluctant to move actively, gentle active to assisted movement can be given. Any passive movement should not be excessive, otherwise it will aggravate the existing injury, edema and bleeding causing further joint restriction. We generally take active to assisted movement. This is because it helps to maintain muscle strength and normal movement patterns. Instruct the injured person to perform the exercises as described below. Each exercise should be performed to achieve maximum range of joint motion, 3 times/d, 30 min each time. finger extension, abduction and adduction, full range of motion of the thumb and wrist joint; thumb to finger; MP joint flexion and extension in the interphalangeal joint extension position; and interphalangeal joint flexion and extension in the MP joint extension position. Note: Avoid excessive fist clenching and passive flexion of the PIP joint in deep hand burns to avoid damage to the extensor tendons. If the entire upper extremity is burned, the upper extremity should be elevated, with the shoulder joint maintained in a 90° position and the elbow joint in a straight position. Simple hand burns should not neglect other joint activities of the upper extremity. The elderly should pay particular attention to prevent stiffness of the shoulder and elbow joints. The forearm is rotated forward and backward.
The correct position is the direction to counteract the contracture, and the appropriate position is taken depending on the burn site. For example, for simple dorsal hand burns, the wrist joint should be placed in palmar flexion position; for simple palmar burns, the wrist joint should be placed in dorsal extension; for full hand burns, the wrist joint should be placed in slight dorsal extension, and the MP joint should be flexed 80° to 90° so that the lateral collateral ligament is maintained in the longest position, which can prevent MP joint hyperextension deformity, and the interphalangeal joint should be straightened to avoid tendon injury and thumb external booth. Contractures may persist for months after wound healing, and the importance of long-term distraction activities should be made clear to the injured patient and should be followed up regularly for discharged patients. (Continued)