10 F I S I O T E R A P I E D E S E M B E R 1 9 7 3 Fig. 6. Serial P laster. c i e n c y is a u t o m a t i c a l l y m a d e g o o d w i t h t i me . 6. S e r i a l p l a s t e r s : T h e p u r p o s e o f t h e s e is n o t t o g a i n r a n g e o f m o v e m e n t , b u t to r e t a i n t h e r a n g e g a i n e d b y t h e p h y s i o t h e r a p i s t d u r i n g t r e a t m e n t . T h e p l a s t e r s s h o u l d b e c o m f o r t a b l e a n d n o t h u r t t h e p a t i e n t . W y n n P a r r y ( 1973) s u g g e s t s w e a r i n g t h e s e p l a s t e r s b e t w e e n t r e a t m e n t s , b u t b e c a u s e t h i s m a y d i s c o u r a g e d a i l y a c t i v i t i e s t h e y a r e u s e d a s n i g h t s p l i n t s onl y. T h e s p l i n t s a r e m a d e f r o m p l a s t e r o f P a r i s a n d a r e p a d d e d . T h e y s t r e t c h f r o m b e l o w t h e e l b o w a c r o s s t h e v o l a r a s p e c t o f t h e w r i s t to b e y o n d t h e t i p s o f t h e t e r m i n a l p h a l a n g e s . G r o o v e s s h o u l d b e m a d e to a c c o m m o d a t e t he f i nge r s s e p a r a t e l y a n d r e i n f o r c e ­ m e n t w i t h t h e p l a s t i c s t i c k s o b t a i n e d f r o m t he m i d d l e o f t h e p l a s t e r b a n d a g e s is s o m e t i m e s n e c e s ­ s a r y ( Se e Fi g. 6). T h e s p l i n t is k e p t in p o s i t i o n by m e a n s o f a c r e p e b a n d a g e o r v e l c r o s t r i ps . 7. ft h a s b e e n f o u n d t h a t v e r y t i ght a d h e s i o n s a r o u n d t h e w r i s t s e l d o m b e n e f i t f r o m v e r y v i g o r o u s p h y s i o ­ t h e r a p y i.e. f r e q u e n t p a s s i v e s t r e t c h i n g , s e r i a l p l a s t e r s a n d f a r a d i s m u n d e r t e n s i o n . T h e t e n d o n s a d h e r e t i g h t l y t o e a c h o t h e r a n d t o t h e s u r r o u n d i n g s k i n a n d s c a r t i ss ue . P r o l o n g e d s t r e t c h i n g a n d h o l d - r c l a x t e c h n i q u e s t h u s d o l i t t l e t o l o o s e n a d h e s i o n s , b u t c a n l e a d t o n e c r o s i s o f t he t e n d o n s w h i c h b e c o m e t h r e a d l i k e a t t h e s i t e o f t h e a d h e s i o n t h r o u g h e x ­ c e s s i v e s t r e t c h i n g . I n f a c t , t h e a f o r e m e n t i o n e d p h y s i o ­ t h e r a p y t e c h n i q u e s m o b i l i z e t h e s c a r t i s s u e a t t h e cos t o f o v e r s t r e t c h i n g t he t e n d o n s . T e n o l y s i s a f t e r t h e a b o v e p h y s i o t h e r a p y t e c h n i q u e s h a s s h o w n t ha t t h e t e n d o n s a r e so s t r e t c h e d o u t t h a t t h e y a r e i n ­ e f f e c t i v e f o r i n n e r r a n g e m o v e m e n t s . W e a l s o k n o w t h a t a f t e r a p p l i c a t i o n o f t he s e d r a s t i c me a s u r e s , t e n d o n s m a y r u p t u r e m o r e ea s i l y. W i t h v e r y t i ght a d h e s i o n s , t h e bes t m e t h o d o f t r e a t m e n t is da i l y ( m o r e if n e c e s s a r y ) a p p l i c a t i o n o f u l t r a s o u n d , m a s ­ s a g e o v e r t h e s c a r t i ss ue, m i n i m a l p a s s i v e s t r e t c h a n d a s m u c h a c t i v e i n n e r r a n g e m o v e m e n t s a s pos ­ si bl e. If p r o g r e s s is u n s a t i s f a c t o r y , t h e p a t i e n t is r e f e r r e d b a c k t o t h e s u r g e o n f o r a t e n o l y s i s . 8. P a i n m a y l i mi t t h e a c h i e v e m e n t o f f ul l r a n g e of m o v e m e n t . P a s s i v e j o i n t m o b i l i z a t i o n t e c h n i q u e s , G r a d e III a c c o r d i n g t o M a i t l a n d , m a y t h e n b e used t o r e l i e v e t h e p a i n . T h e s e t e c h n i q u e s a r e a l s o a p p l i e d t o r e l i e v e a n y ' t r e a t m e n t p a i n ’ t h a t m a y o c c u r . 9. K a l t e n b o r n p a s s i v e j o i n t m o b i l i z i n g t e c h n i q u e s a r e n o t u s u a l l y n e c e s s a r y , b u t s i n c e p a t i e n t s a r e o f t e n u n r e l i a b l e a n d s t a y a w a y , a c e r t a i n a m o u n t o f j o i n t st i f f nes s is i n e v i t a b l e a n d t h e j o i n t s t i f f ness r e s p o n d s to t hi s f o r m o f t r e a t m e n t . St i ff M P j o i n t s , h o w e v e r , r e m a i n a n i g h t m a r e ! E v e n t h e m o s t v i g o r o u s t e c h ­ n i q u e s a r e o f t e n u n s u c c e s s f u l . T h e b e s t m e t h o d of t r e a t m e n t is, o f c o u r s e , p r e v e n t i o n o f t hi s st i ffness. B ibliography ^ 1. B y r n e , J. J. ( 1959): T h e H a n d : I t s A n a t o m y a n d D ise a se s . O x f o r d , B l a c k we l l Sc i e n t i f i c P u b l i c a t i o n s . 2. Bo y e s . J. H. ( 1964) : B u n n e l l ’s S u r g e r y o f th e H a n d . 4 t h Ed. P h i l a d e l p h i a . J. B. L i p p i n c o t t . 3. K a l t e n b o r n , F. H. ( 1974): M a n u a l T h e r a p y f o r th e E x t r e m i t y J o in ts . Os l o . O l a f N o r l i s B o k h a n d e l . 4. M a i t l a n d . G . D. ( 1977): P e r ip h e r a l M a n i p u la t i o n . 2nd Ed . L o n d o n . B u t t e r w o r t h s . PHYSIOTHERAPY IN A SPECIALISED HAND UNIT S U E H O L T , M. C . S . P . * D u r i n g t h e y e a r 1976. o v e r o n e t h o u s a n d n e w h a n d ca s e s a n d t h r e e t h o u s a n d r e p e a t ca s e s w e r e s e e n a t t he * S e n i o r P h y s i o t h e r a p i s t , G r o o t e S c h u u r H o s p i t a l , C a p e T o w n . H a n d U n i t o f G r o o t e S c h u u r H o s p i t a l . T h e m a j o r i t y o f t h e s e p a t i e n t s e i t h e r p a s s e d t h r o u g h t h e P h y s i o ­ t h e r a p y D e p a r t m e n t o r t h a t o f O c c u p a t i o n a l T h e r a p y . C l o s e t e a m w o r k is a n e s s e n t i a l f a c t o r in t hi s field. T h i s a r t i c l e a i m s a t d e s c r i b i n g t h e t r e a t m e n t g i v e n b y R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) D EC EM BE R 1978 P H Y S I O T H E R A P Y 11 the P h y s i o t h e r a p y D e p a r t m e n t . T h e c l a s s i f i c a t i o n of cases f r o m a p h y s i o t h e r a p e u t i c p o i n t o f v i e w is a s f o l l o ws : — T r a u m a F r a c t u r e s , d i s l o c a t i o n s , c r u s h i n j u r i e s . F i n g e r t i p i nj ur i e s , t r a u m a t i c a m p u t a t i o n s . C u t t e n d o n s . N e r v e lesions. I n f e c t i o n s j V f i s cc ll an eo u s C a r p a l t u n n e l s y n d r o m e , g a n g l i a . D u p u y t r e n ’s c o n t r a c ­ t u r e . b e n i g n g i a n t cell t u m o u r s a n d cyst s. S y st c m i c R h e u m a t o i d a r t h r i t i s , s y s t e m i c l u p u s e r y t h e m a t o s u s a n d g o u t C o n g e n i t a l T R A U M A F r a c t u r e s , d i s l o c a t i o n s , c r u s h i n j u r i e s )T h e g e n e r a l p r i n c i p l e o f t r e a t m e n t f o r all fr a c tu r e s e a r l y m o b i l i s a t i o n w i t h i m m e d i a t e r e d u c t i o n o f o e d e m a . S p l i n t a g e is us e d m i n i m a l l y . F r a c t u r e s o f t he p h a l a n g e s a r e s t r a p p e d t o t h e a d j a c e n t f i nger. A five c m c r epe b a n d a g e f o r m e t a c a r p a l f r a c t u r e s is suf f i ci ent , c a r e b e i n g t a k e n t o e n s u r e t h a t t h e m e t a c a r p a l j o i n t s a r e f r e e f o r m o b i l i s a t i o n . In t h e e v e n t o f a n u n s t a b l e f r a c t u r e a K i r s c h n e r w i r e m a y b e i n s e r t e d a n d if t hi s i n v o l v e s t h e j o i n t t h e m o b i l i s a t i o n m u s t b e l eft u n t i l l at er. H o w e v e r , f o r t h e m a j o r i t y o f f r a c t u r e s a n d c r u s h i n j u r i e s , t h e first a i m is t o r e d u c e o e d e m a a s q u i c k l y as p o s s i b l e , a s it m a y l e a d to a d h e s i o n s , p o o r b l o o d s u p p l y a n d l oss o f f u n c t i o n a l m o b i l i t y . T h e H o t Bo x , t h r o u g h w h i c h w a r m a i r is c i r c u l a t e d , has b e e n s p e c i a l l y d e s i g n e d s o t h a t t h e p a t i e n t c a n sit w i t h t h e h a n d a n d a r m e l e v a t e d . ( Se e Fi g. 1). In t hi s p o s i t i o n a s m u c h r a n g e o f a c t i v e m o v e m e n t a s p o s s i b l e is e n c o u r a g e d . T h i s is p r o g r e s s e d t o a s q u e e z i n g a n d p u m p i n g a c t i o n o n a r ol l o f s o r b o r u b b e r . In c a s e s w i t h s e v e r e o e d e m a a p a t i e n t c a n s p e n d u p to f o u r h o u r s w o r k i n g in t h e H o t Bo x , b o t h in t h e D e p a r t m e n t s o f P h y s i o t h e r a p y a n d O c c u p a t i o n a l T h e r a p y . It h a s b e e n f o u n d t h a t if e x e r c i s e s a r e s t a r t e d a s s o o n a s p o s s i b l e , o e d e m a is n o t a g r e a t p r o b l e m . If s w e l l i n g h a s b e e n p r e s e n t f o r o v e r 4 8 h o u r s it m a y b e c o m e c o n s o l i d a t e d a n d m i n i m i s e t h e fi nal r a n g e o f m o v e m e n t . A s s o o n a s o e d e m a is r e d u c e d , f u n c t i o n a l a c t i v i t y is s t r e s s e d b y a c t i v e a n d g e n t l e p a s s i v e m o v e m e n t s . A f t e r t h r e e w e e k s al l f i x a t i o n is r e m o v e d a n d t h e m a j o r i t y o f p a t i e n t s g a i n f ul l r a n g e o f m o v e m e n t w i t h i n s i x t o e i g h t w e e k s . D is lo c a tio n s o f t h e j o i n t s p r e s e n t g r e a t e r p r o b l e m s a n d m u s t b e i m m o b i l i s e d f o r a p p r o x i m a t e l y t w o t o t h r e e w e e k s . D u e to t h e d a m a g e t o t he c a p s u l e a n d s u r r o u n d i n g s t r u c t u r e s , t h e j o i n t s a r e o f t e n st i ff a n d it is e x t r e m e l y di f fi cul t t o r e g a i n full r a n g e . A g a i n , a c t i v e a n d p a s s i v e e x e r c i s c s a r e g i v e n a n d u l t r a s o u n d in w a t e r m a y b e u s e d a l t h o u g h its effi cacy is o p e n to q u e s t i o n . Ice b a t h s h a v e a l s o b e e n f o u n d to h e l p in i n c r e a s i n g r a n g e . ( W y n n P a r r y , C. B.. 1973). T r a u m a t i c a m p u t a t i o n s a n d m o r e p a r t i c u l a r l y f i n g e r t i p i n j u r i e s in c h i l d r e n a r e f a i r l y c o m m o n in t he W e s t e r n C a p e w h e n f i nge r s g e t c a u g h t in d o o r s d u e to t h e s t r o n g S o u t h E a s t e r l y w i n d . T r e a t m e n t is t h e s a m e , t o r e d u c e o e d e m a a n d r e g a i n full f u n c t i o n a l a c t i v i t y a s s o o n a s p o s s i b l e . C u t te n d o n s p r e s e n t a s u r g i c a l c h a l l e n g e . Br i e f l y t h e y a r e t r e a t e d b y p r i m a r y s u t u r e / r e p a i r , s e c o n d a r y s u t u r e / r e p a i r , t e n d o n g r a f t s o r i n s e r t i o n o f s i l a s t i c r o d s p r i o r to t e n d o n g r a f t i n g . If p r i m a r y r e p a i r is d o n e , t h e h a n d is i m m o b i l i s e d in p l a s t e r o f P a r i s f o r t h r e e we e k s . D u r i n g t h i s t i m e t h e o n l y t r e a t m e n t n e c e s s a r y is to t e a c h a n d s u p e r v i s e s h o u l d e r e l e v a t i o n e x e r c i s e s to p r e v e n t o e d e m a . A f t e r t h r e e w e e k s , t h e p l a s t e r is r e m o v e d a n d a c t i v e m o b i l i ­ s a t i o n is c o m m e n c e d . F o r a s e c o n d a r y r e p a i r , t h e s k i n is m e r e l y c l o s e d a f t e r t h e i n j u r y a n d t h e t e n d o n s wi l l b e r e p a i r e d a t a l a t e r s t a ge. In t hi s i n s t a n c e it is e s s e n t i a l t h a t t h e p h y s i o ­ t h e r a p i s t g a i n s a n d m a i n t a i n s F U L L p a s s i v e r a n g e o f all j o i n t s a n d e n c o u r a g e s t h e p a t i e n t t o k e e p t h e h a n d a n d ■> f i nge r s a s s u p p l e a s p o s s i b l e p r i o r t o t h e s e c o n d o p e r a - Sjl t i on. I m m o b i l i s a t i o n is a g a i n t h r e e w e e k s a n d a c t i v e Tl , m o v e m e n t c a n t h e n b e s t a r t e d . HJH O n e m u s t d i s t i n g u i s h b e t w e e n c u t e x t e n s o r t e n d o n s i J r a n d c ut f l e x o r t e n d o n s . T h e r e - e d u c a t i o n a n d m o b i l i s a - Fig. 1. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 12 F I S I O T E R A P I E tio n follow ing an extensor tendon re p a ir is straig h t­ forw ard. T h e p a tie n t strengthens up quickly, although a 5° to 10° extensor tendon lag m ay persist. T h e re-education follow ing a flexor tendon re p a ir is, how ever, m uch slow er an d m ore arduous. F ollow ing im m obilisation, i.e. fro m th e fo u rth week A C T IV E flexion an d extension, an d during the fifth week gentle passive flexion is allowed. F ro m th e sixth week, passive stretching into extension is started an d dynam ic splintage w orn a t n ig h t in o rd e r to increase the range o f extension. I t m u st be stressed th a t F L E X IO N is the fu n ctio n al m ovem ent o f th e hand an d it is m o re im p o r­ ta n t to regain th e m axim um possible range of flexion at th e expense of full extension. T his stage of the tendon re p a ir is vital and the p atien t should be p re ­ p ared to spend practically th e en tire day in the Physio­ th erap y and O ccupational T h erap y D epartm ents. Scarring an d adhesions m ay be form ing an d these m ust be kept to a m inim um . Passive range of flexion M U ST be o b tain ed and m aintained. A ctive m ovem ent should be encouraged continuously w ith the use o f sponge grips. Besides th e conventional m ethod o f heat, o u r D e p a rt­ m ent has also fo u n d ice baths to be effective in gaining a n increase in range both passive and active. A n ex p lan a­ tio n fo r this is uncertain, but it m ay b e due to the increased vasodilatation o f the vessels in the han d follow ing vasoconstriction. (W ynn P arry, C. B., 1973). U ltraso u n d an d scar massage are im p o rtan t in reducing tendon adherence. T h e effects o f u ltraso u n d have never been conclusively proved, but it has a p a rt to play providing dosages o f 1 - 2 W atts/cm 2, are used (W ynn P arry, C. B., 1973). T h is is applied eith er d irectly to the a rea o r thro u g h th e m edium o f 'w ater. I t should be used in conjunction w ith scar massage. D uring th is stage active m ovem ent is V IT A L L Y im p o r­ tant. If only o n e o r two fingers a re involved, it is of benefit to strap these to th e “good fingers” to help w ith flexion. In th e la te r stages of re-education resisted exercises can be given, such as p ro p rio cep tiv e n e u ro ­ m uscular facilitatio n techniques o r m anual la b o u r in th e w orkshops. T h ro u g h o u t the re-education process, m easurem ents should always be taken an d if th e result is a finger w hich can finally flex to w ithin 1 cm of p a lm a r crease, it can be considered successful. T en d o n grafts are usually determ ined by the level of th e lesion. F o r exam ple, in “ N o-m ans-land” suturing w ould p roduce excessive scarring an d hence no effective pull th ro u g h o f the tendons. T h e reh ab ilitatio n a fte r a g ra ft follow s the sam e p attern as fo r a d irect repair. In cases w here severe scarring is already present, silastic rods m ay be inserted so th a t a sheath can form p rio r to grafting. T h is is usually done in approxim ately th ree o r fo u r m onths. W ith this type o f patient, full passive m ovem ents m ust be m ain tain ed w hilst the rods a re in situ. N erve lesions are repaired by prim ary repair, secon­ dary re p a ir o r nerve grafts. T h e p h y sio th erap y treatm ent is p rin cip ally th e sam e as fo r tendon lesions. Im m e­ d iate p o st-o p erativ e instruction to reduce oedem a is given. I f it is a nerve cut at th e w rist th a t is repaired, then active m ovem ent o f th e fingers can begin im m e- . diately as f a r as the im m obilising plaster will allow. If tendons an d nerves are involved, a secondary nerve re p a ir is usually done by the tim e active m o b ilisatio n o f the tendons has already started. R e h a b ilita tio n o f the h an d follow s the sam e p attern , except th a t th e im m obilisation p erio d is six weeks. C om m only, e ith er th e m edian a n d /o r u ln a r nerve a re involved an d re ­ education should also involve retu rn in g sensation. T his is usually carried o u t by occupational therapy. If, how ever, th e rad ial nerve has been severed, this is su tu red an d th e p a tie n t w ears a lively sp lin t u n til the nerve grows dow n to the extensor muscles If n,- tendon transfers m ay be done. T h e re a fte r' r e , V S fa'K o f w rist, finger an d thum b extension w ould’ be " n e atinn INFECTIONS ecessarj T hese represent a large percentage o f hanH seen. T h e basic principles of treatm en t are i •Cascs d rain ag e an d excision o f anv sloueh: n r, n.Clsion d e s e m b e r 1978 ion, are - . r ----- va nvoiiucm are in d rain ag e an d excision o f any slough; no antih ?• given unless essential; freq u en t dressings a n n r ? -> duction of oedem a and m ovem ent are enconr ’ ru should b e stressed th a t th e rules regarding drps? 8Cd' 11 very strictly kept to in the H and U nit. D ry d S- ari: the m inim um o f bandaging an d specially h65-"1®'’' stockinette gloves and finger stalls to prevent CS'gn^ striction fro m tig h t bandaging, strapping or ti rc' are applied. T h e H o t B ox is used w ith the arm8aUZ|: han d in elevation to reduce swelling, passive ard m ents are given and active m ovem ent is enm„Inove' W hen the w ound is closed, it m ay be necessa 8Cd' soak th e h an d in w arm w ater mixed with a T *" Savlon. T h is helps to rem ove all the dead tissue ! the skin is then m assaged w ith lanolin cream R U l eith er fro m anim als, insects o r hum ans fall into 't i l category an d the treatm en t follow s the sam e principles MISCELANEOUS P atients w ith ganglia, carpal tunnel svndrnm„ D u p u y tre n ’s contracture, trigger finger, cysts etc ar' seen im m ediately post-operatively by the Physiotheranu D ep artm en t in o rd e r to give instructions to prevent oedem a and lack o f m obility. T h e p atient is instructed in the im portance o f doing elevation exercises of the Hand and shoulder (a m in im u m of 20 0 times per day) and to m ove the unaffected areas, such as metacarpal and interphalangeal joints. As a routine, the patient returns to th e D ep artm en t th e follow ing day fo r a check and this should b e all the treatm ent required. However w ith a release o f a D u p u y tre n ’s contracture, further passive stretching and treatm en t m ay be required, at the specific instruction o f the surgeon. SYSTEMIC CONDITIO NS A N D CONGENITAL H A N D DEFORM ITIES T hese are n o t com m on in this U n it and should be treated according to individual need. Splintage may be th e p red o m in an t issue in w hich case the Occupational T h erap y D ep artm en t w ill be p rim a rily responsible. CONCLUSION Tw o vital points emerge. F irstly, the patient, t h a t * T H E H A N D , should be treated as soon as possib™ before com plications have arisen. Secondly, the impor­ tance of team w ork cannot be stressed sufficiently enough. I t is no use w orking m erely as a physiotherapist in the isolation o f th e D epartm ent. One must be present at the clinics as a m em ber of the team, con­ sisting o f the surgeons, sister, occupational therapist and physiotherapist, as well as the social worker who is involved in placing the p atient w ith an injured hand in suitable em ploym ent. Acknowledgements M y thanks fo r the help in com piling this article arc due to D r. Cecil Bloch and D r. M artin Singer, surgeons attached to the H an d U n it o f G ro o te Schuur Hospital, to Mr. B. G. M oth, C h ief Physiotherapist of the P hysiotherapy D ep artm en t an d to D r. H . R e e v e - S a n d e r s , M edical Superintendent, G ro o te Schuur Hospital, f°r perm ission to publish th e article. References: W ynn P arry, C. B. (1973) C hapter 6 — Principles °[ R e h a b ilita tio n in R e h a b ilita tio n o f the Hand. B u ttc r- w orths, L ondon 3rd ed. pp. 243 - 270. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )