Multi-Trauma and Complex Injuries

Hannah Gift, OTR/L, CHT, COMT, CEAS

St. Louis, MOApril 27-29, 2018

Learning Objectives

• Understand all systems involved and multi-system approach to mutilating hand injuries

• Identify healing phases, considerations and relationships within each tissue system and between multiple systems

• Understand complex balance between tissue systems and appropriate advancement through healing phases

• Understand principles and phases of Early Protective Motion

Introduction

Trauma to multiple anatomic systems of the hand resulting in a varied and complex

clinical picture

Photos by Gary Soloman, Nora Barrett

Systems (Tissues) • Therapist Hierarchy for Tissues

Vascular

Skin Coverage

Bone Stability

Nerve

Muscle/TendonTamai S. JHS, 1982, 7(6): 549‐556. 

Vascular Structures &Considerations

Pictures provided by Nora Barrett 

Vascular Structures

• Arteries- carry blood AWAY from the heart• Compromise- pale or white (“dusky”), cold

feeling, slow capillary refill

• Veins- carry blood back to the heart• Compromise- blue or purple in color, edema,

rapid capillary refill

• Redness—> extreme (mark area to track)• Heat—> increased temp• Pain or swelling—> sudden increase• Debris—> pus• Odor• Non-healing/new breakdown• Exposed bone

Inflammation vs. Infection

Pictures provided by Nora Barrett 

• Elevation• At what level?

• Active exercise• Consider what is appropriate

• Compression• Contraindicated with vessel

repair until 6 weeks

• Physical agents

Managing Edema

Pictures provided by Nora Barrett 

Manual Edema Mobilization

• MEM vs. MLD• Steps

• Diaphragmatic breathing • “Clear” exercises • Light skin traction• Massage Elbow Lymph nodes• “Flow” exercises

Picture from Howard & Krishnagiri, 2001). 

Compartment Syndrome• 4 Ps:

• Pain (with passive stretch)• Paresthesias• Pallor• Pulselessness

• Compartments• Forearm- dorsal, volar, and mobile wad • Hand- interosseous, thenar, hypothenar, adductor

• Critical pressures: >30mm Hg, normal 8-10mm Hg

• Decompression

Pictures provided by Nora Barrett 

Skin Coverage/Wound/Scarand Considerations

Pictures provided by Nora Barrett 

Skin Coverage

• Types of Wound Closure • Primary Intention

• Secondary Intention

• Delayed Primary Closure

• Tensile Strength • Increases from day 5-30• By week 3: 15-20%• Healed wound 80%

Pictures provided by Nora Barrett 

Whirlpool Guidelines• Whirlpools may be utilized for cleansing and

debridement of superficial necrotic tissue

• May stimulate granulation tissue, soften necrotic tissue and increase circulation

• Temperature- goal is 94*

Photo from prohealthcareproducts.com

Skin Grafts • Indicated for skin or soft tissue

loss but good vascularity

• Split Thickness (STSG)• Viable in 3-5 days• LOW primary/HIGH secondary

contracture

• Full Thickness (FTSG)• Viable in 5-7 days• HIGH primary/LOW secondary

contracture

• Most common reason for failure?

• Hematoma

Meshed STSG

Sheet STSG

FTSG

Pictures provided by Nora Barrett 

Skin Flaps

• Indicated for wounds with limited blood supply or gliding structures are exposed

• Local Flaps • Comes from adjacent tissues

• Pedicle Flaps• Skin and sensate tissue is detached from site

and reattached to recipient site• Second surgery is required to separate

• Free Tissue Transfer

Common Flaps

• Local Flaps:• Moberg Advancement

• VY Advancement Flap

sketches from boneandspine.com

Common Flaps• Pedicle Flaps

Sketches from boneandspine.com

Thenar

Cross Finger

Groin

Pictures provided by Nora Barrett 

Common Flaps• Free Tissue Transfer

• Free groin flap, scapular flap, lateral arm flap, latissimus flap

• Used to cover much larger defects• Nerve and muscles can also be harvested to

regain motion

Pictures provided by Nora Barrett 

ScarsHypertrophic• Bulky, elevated above

skin

• Occur soon post injury

• Severity of injury determines scar

• Found in areas of motion

• Associated with wound tension and timing

• Will improve with therapy and flatten in 1-2 years

Scars

Keloid• Beyond original injury site

• 15X higher in darker pigments

• Occurs from superficial or deep injuries

• May occur within first month, year, or several years

• Medications, radiation, surgical excision

Scar Management • Controlled motion• Transverse Friction Massage

• Continuous Pressure Garments

• Silicone Gel Sheeting, Paper tape

• Scar molds

• Orthoses

• Physical agents

Burns

• Causes of Injury:• Cutaneous • Cold• Chemical• Electrical

• Common Complications: • Edema• Joint deformities• Sensory impairment • Restricted use of the hand• Compartment syndrome

Depth of Burns• Epidermal

• Sunburn

• Partial Thickness• Superficial• Deep

• Full Thickness

• 4th degree• Circumferential burns

Burn Treatment• Biological Dressings/Wound Closures • Edema Management

• Range of Motion • Positioning • Physical Agents

• Scar Management • Pressure Therapy

Burn Orthosis OptionsBurns • Most common deformities

• Thumb web space contracture• PIP joint flexion contracture • Boutonniere deformity• Swan neck• “Claw hand”• Burn syndactyly• Palmar cupping

Skeletal System Amputation Levels • Finger• Partial Hand• Wrist Disarticulation• Trans-Radial• Elbow Disarticulation• Trans Humeral• Shoulder Disarticulation• Forequarter• Bilateral

Prosthetic Basics

1. No Prosthesis2. Passive

3. Body Power4. External Power5. Hybrid

6. Activity Specific

Pics from upperlimbprostheticsinfo.com

Residual Limb Care

• Performed with complete amputations or fingertip injuries

• Stump wrapping for shaping and edema control

• Desensitization for stump hypersensitivity

www.rehabmart.com

Photo from ncmedical.com

Nerves/PainPain

• “An unpleasant sensory and emotional experience associated with actual or potential tissue damage.” IASP

• CRPS is characterized by severe pain, swelling, stiffness, discoloration, and decreased function in an entire extremity or single digit.

Types of CRPS

• Type I: • Previously RSD• Develops after noxious event• DOES NOT have an identifiable nerve lesion

• Type II: • Previously causalgia• INCLUDES Injury to peripheral nerve or branch

Types of CRPS

• Sympathetically Independent Pain (SIP)• Occurring in the initial onset of the syndrome

• Sympathetically Maintained Pain (SMP)• “A symptom of CRPS but not a clinical entity”• Occurs after a period of time

CRPS Criteria • Criteria: 1. Presence of an inciting noxious event or a

cause of immobilization 2. Continuing pain, allodynia, or hyperalgesia

with which pain is disproportionate to an inciting event

3. Evidence at some time of edema, changes in blood flow, or abnormal sudomotor activity

4. Excluding existence of other condition which would cause similar symptoms

CRPS Criteria Symptom Sign

Sensory Hyperesthesia, allodynia Hyperalgesia, allodynia to light touch, movement, pressure

Vasomotor Temperature/skin asymmetry/color changes/asymmetry

Temperature asymmetry, skin color changes

Sudomotor/Edema Edema, hyperhidrosis, sweating changes asymmetry

Edema, sweating changes

Motor/Trophic Decreased ROM, motor dysfunction, trophic changes

Decreased ROM, motor dysfunction, trophic changes

CRPS Criteria

• Visual Analog Scale > 3 cm • McGill with greater than 3 words

• Temperature difference >0.4%C• Volume difference > 6.5 %• ROM limitation > 15%

CRPS Treatment

• Stellate Blocks• “Horner’s Sign”

• Physical agents• TENS• Fluidotherapy/moist

heat• Contrast baths

• Therapeutic Neuroscience Education

• Graded exposure

• Graded motor imagery • Laterality• Imagery • Mirror visual feedback

• Desensitization • Increasing activity level

(including aerobic activity)

• Stress Loading

Picture from danmicglobal.com

Cortical Representation

Preserve Sensorimotor loops

• Begin immediately

• Persist ADLs

• Symmetrical activity

• Pressure

• Phone games/apps

• Mirror box, visualization

Picture from wikipedia

Tendon/Muscle

Orthosis Review • Immobilization Orthoses • Mobilization Orthoses

• Dynamic• Static Progressive• Serial Static Amount of 

ImprovementOrthosis

20* No orthosis

15* Static

10* Dynamic

0‐5* Static Progressive

Modified Weeks Test

Serial Casting • Used for PIP flexion contractures, muscle

tendon unit tightness and thumb web space widening

• Worn at all times, changed every 2-3 days

Photo provided by Hannah Gift

Casting Motion to Mobilize Stiffness (CMMS)

• Patterns of Stiffness• Loss of tenodesis• Intrinsic Plus

• Goals: • Mobilize stiff joints• Reduce edema• Revive cortical representation

• Benefits • Cost effective • Pain Free

Cast Position

• Intrinsic Minus Cast• Intrinsic Plus Cast

Pictures from Midgley, R. (2016). Case Report: The casting motion to mobilize stiffness technique for rehabilitation after a crush and degloving injury of the hand. In Journal of hand Therapy, 29, 323‐333. 

Bringing it all together

Functional and Purposeful ActivityInitiate non-resistive functional grasp and prehension

activities as soon as able to encourage normalization of movement patterns

ROM and ADL

11 Essential Hand Functions

Picture from presenter

Photo provided by Hannah Gift

Replantation• Who is appropriate?

• Thumb• Multiple digits• Metacarpal amputations• Children• Wrist or forearm level amputations• Digit tips distal to FDS insertion

orthobullets.com

Replantation • Common order for replant:

• Clean wound• Skeletal system/periosteum• Extensor tendons• Flexor tendons• Nerves• Artery• Vein• Skin

Thumb Amputation

Photos by Gary Soloman, Nora Barrett

Thumb Replantation

Photos by Gary Soloman, Nora Barrett

Early Protective Motion(Silverman, 1989)

Rationale: Early Protected Motion (EPM)

Differential glide of tendons• Joint movement• Protection to hand from composite

motion which may disrupt repairs• Give enough tendon gliding without

tension to prevent adhesions

EPM Phases

• I• Controlled Active Tenodesis • Day 4-14

• II• Passive Intrinsic Minus• Day 7-14

• III • Active Intrinsic Minus• Day 14

Orthosis

Photos by Gary Soloman, Nora Barrett

EPM I: Controlled Active Tenodesis

Photos by Gary Soloman, Nora Barrett

Early Protected Motion II: (Passive Intrinsic Minus/Hook)

• Begins 7-14 days after replant• Continue PM I exercises

Photos by Gary Soloman, Nora Barrett

• Patient progresses to place and hold, then to full active

• Add active gliding, isolated superficialis exercise• Strengthen lumbricals and interossei in intrinsic

plus position

Early Protected Motion III: Active table top/hook

Photos by Gary Soloman, Nora Barrett

• 4-5 weeks post-op: begin gradual wrist extension past neutral with digits flexed (toward composite)

• 4-6 weeks post-op: begin full composite flexion and extension (depends on tightness)

• Add NMES as indicated for adhesions• Passive stretch • Blocking exercises• Light functional exercises

Replant CaseEarly Protected Motion

Photos by Gary Soloman, Nora Barrett

Conclusions

• No specific protocols for therapeutic management of the mutilated hand

• Each component of the injury requires consideration during evaluation and treatment planning

• Therapeutic interventions must be considered in the total picture of the complex injury

Conclusions

• Psychosocial needs must be addressed• Communication with all team members is

essential• Therapist must have knowledge of normal

and pathologic healing of all injured tissues• Reconstruction is essentially a salvage

procedure to restore hand function, therefore therapeutic intervention should emphasize restoration of maximum function

Acknowledgements

• Gary Solomon, MS, OTR/L, CHT• Nora Barrett, MS, OTR/L, CHT

• Hannah Gift, OTR/L, CHT

• Chan S & LaStayo P. (2003). Hand Therapy Management Following Mutilating Hand Injuries. In Hand Clinics, 19(1):133-148.

• Chee, N. Complex Traumatic Injuries. In Test Prep for the CHT Exam, 3rd Edition.

• Chung K & Alderman A. (2002). Replantation of the Upper Extremity: Indications and Outcomes. In Journal of the American Society for Surgery of the Hand, 2(2):78-94.

• Colditz, J. Therapist’s Management of the Stiff Hand. In Rehabilitation of the Hand and Upper Extremity, 6th edition. Skirven, Osterman, Fedorczyk & Amadio. Elsevier/Mosby: Philadelphia 2011.

• Hannah S. (2011). Psychosocial issues after a traumatic hand injury: facilitating adjustment. In Journal of Hand Therapy, 24(2):95-103.

• Hay, D., Taras, J. & Yao, J. Vascular Disorders of the Upper Extremity. In Rehabilitation of the Hand and Upper Extremity, 6th edition. Skirven, Osterman, Fedorczyk & Amadio. Elsevier/Mosby: Philadelphia 2011.

• Howard, S. & Krishnagiri, S. (2001). The use of manual edema mobilization for the reduction of persistent edema in the upper limb. In Journal of Hand Therapy, 14(4), 291-301.

• Jones NF, Chang J & Kashani P. The Surgical and Rehabilitative Aspects of Replantation and Revascularization of the Hand. In Rehabilitation of the Hand and Upper Extremity, Sixth Edition. Skirven, Osterman, Fedorczyk & Amadio. Elsevier/Mosby: Philadelphia 2011.

• Levin LS. Management of Skin Grafts and Flaps in Rehabilitation of the Hand and Upper Extremity, Sixth Edition. Skirven, Osterman, Fedorczyk & Amadio. Elsevier/Mosby: Philadelphia 2011.

References

• McVeigh, K., Herman, M. & Laney, B. Wound Healing. In Test Prep for the CHT Exam, 3rd Edition.

• Midgley, R. (2016). Case Report: The casting motion to mobilize stiffness technique for rehabilitation after a crush and degloving injury of the hand. In Journal of hand Therapy, 29, 323-333.

• Monroe, B. Amputations and Prosthetics. In Test Prep for the CHT Exam, 3rd Edition.

• Neumeister M. & Brown R. (2003). Mutilating Hand Injuries: principles and management. In Hand Clinics 19(1): 1-15.

• Pettengill K. Therapist’s Management of the Complex Injury in Rehabilitation of the Hand and Upper Extremity, Sixth Edition. Skirven, Osterman, Fedorczyk & Amadio. Elsevier/Mosby: Philadelphia 2011.

• Rizzo M. Complex Injuries of the Hand in Rehabilitation of the Hand and Upper Extremity, Sixth Edition. Skirven, Osterman, Fedorczyk & Amadio. Elsevier/Mosby: Philadelphia 2011.

• Silverman P., Willette-Green V & Petrilli J (1989). Early Protective Motion in Digital Revascularization and Replantation. In Journal of Hand Therapy, 2:84-101.

• Stanton, D., Pigott, R.. Orthotic Fabrication and Biomechanics. In Test Prep for the CHT Exam, 3rd edition.

• Thurlow, M. & Anderson, P. Burns. In Test Prep for the CHT Exam, 3rd Edition.

• Villeco J. Edema: Therapist’s Management in Rehabilitation of the Hand and Upper Extremity, Sixth Edition. Skirven, Osterman, Fedorczyk & Amadio. Elsevier/Mosby: Philadelphia 2011.

• Westlake K. & Byl N. (2013). Neural plasticity and implications for hand rehabilitation after neurological insult. In Journal of Hand Therapy, 26(2):87-93.

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