PHYSIOTHERAPY IN A SPECIALISED HAND UNIT

ciency is au t oma t i ca l l y m a d e goo d wi th t ime. 6. Serial plas ters : T h e pu r po se o f these is not to gain r ange of mo ve me n t , but to re t a in the r ange gained by the phys i o t he r ap i s t d u r i n g t r ea t ment . T h e plas ters sh ou l d be c o mf o r t a b l e a nd not hur t the pat ient . W y n n P ar ry (1973) suggests wea r ing these plasters be tween t r ea tment s , but be c a us e this may d i sc ourage dai ly ac t ivi t i es they a r e used as n igh t spl ints only. T h e spl int s a r e m a d e f r o m plas ter o f Par i s a n d are padded . T h e y s t retch f rom be low the e lbow across the vo l ar aspect of the wr ist to b ey o nd the t ips of the t e r mina l phalanges . G r o o v e s shou l d be m a d e to a c c o m m o d a t e the fingers s epara t e ly a nd r e i n fo r ce ­ me n t wi th the plas t ic st icks o b t a i ne d f r o m the mi dd l e of the plas ter b andages is so me t i me s neces­ sa ry (See Fig. 6). T h e spl int is kept in pos i t i on by me a n s o f a crepe b an d a ge or velcro strips. 7. ft has been found that very t ight adhes i ons a r ou nd the wr i s t se ldom benef i t f rom very v igorous phys i o­ t he r ap y i.e. f r equent passive s t r e tching , serial plasters a n d f a ra d i sm u n d e r tens ion. T h e t endons ad he r e t ight ly to each o t h e r a n d to the s u r r ou n d i ng skin an d scar t issue. P r o l on g ed s t r e t ch ing and holdrc l ax t echn i ques thus do little to loosen adhes ions , but can l ead to necrosi s of the t endons which become th re a d l i ke at the si te of the adhes i on th ro ug h ex­ cessive s t retching. In fact , the a f o r e me n t i o ne d ph ys i o ­ ther apy t echn i ques mo b i l i z e the scar t issue at the cost of ove r s t re t ch i ng the t endons . Teno lys i s af t er the a b o ve phy s i o t he r ap y t echn iques has shown that the t endons a r e so s t r e tched out that they a r e in­ effect ive f o r i nner r ange movemen t s . W e also k n o w that a f t e r a p p l ica t ion o f these dras t i c measures , t endons m a y r up t u r e m o r e easi ly. Wi th very tight adhes ions , the best m e t h od of t r ea t men t is dai ly ( mo re if necessa ry) a p p l ica t ion of u l t ra sound , ma s ­ sage ove r the scar tissue, mi n i ma l passive stretch a nd as much ac t ive i nner r ange m o ve m e n t s as pos­ sible. If progress is unsa t i s fac tory , the pa t i ent is r e fe r red back to the su r geon for a tenolysis. 8. Pa in ma y l imi t the a c h i evemen t o f full r ange of mo ve me n t . Pass ive joint mob i l i za t ion t echniques , G r a d e III acco r d i ng to Ma i t l and , may then be used to rel ieve the pain. Th e se t echn i ques a r e also appl ied to rel ieve any ' t rea t men t p a i n ’ that may occur . 9. K a l t en b o r n passive joint mob i l i z i ng t echn i ques are not usua l ly necessary, but since pat i ent s are of ten unre l i ab l e an d stay away, a cer ta in a m o u n t o f joint stiffness is i nevi table and the joint st iffness r esponds to this f orm of t r ea tment . Stiff M P joints , however , r ema i n a n i gh t mare ! Even the mos t v i go r ous t ech­ n iques a r e o f t en unsuccessful . T h e best me t h o d of t rea t ment is, of course , p r even t ion of this stiffness.

the Physiotherapy Department. The classification of cases from a physiotherapeutic point of view is as follows:-

Systcmic
Rheumatoid arthritis, systemic lupus erythematosus and gout Congenital TRA U M A Fractures, dislocations, crush injuries

)
The general principle of treatment for all fra c tu r e s early mobilisation with immediate reduction of oedema. Splintage is used minimally. Fractures of the phalanges are strapped to the adjacent finger. A five cm crepe bandage for metacarpal fractures is sufficient, care being taken to ensure that the metacarpal joints are free for mobilisation. In the event of an unstable fracture a Kirschner wire may be inserted and if this involves the joint the mobilisation must be left until later. However, for the majority of fractures and crush injuries, the first aim is to reduce oedema as quickly as possible, as it may lead to adhesions, poor blood supply and loss of functional mobility.
The Hot Box, through which warm air is circulated, has been specially designed so that the patient can sit with the hand and arm elevated. (See Fig. 1). In this position as much range of active movement as possible is encouraged. This is progressed to a squeezing and pumping action on a roll of sorbo rubber. In cases with severe oedema a patient can spend up to four hours working in the Hot Box, both in the Departments of Physiotherapy and Occupational Therapy. It has been found that if exercises are started as soon as possible, oedema is not a great problem. If swelling has been present for over 48 hours it may become consolidated and minimise the final range of movement. As soon as oedema is reduced, functional activity is stressed by active and gentle passive movements. After three weeks all fixation is removed and the majority of patients gain full range of movement within six to eight weeks.
D islo c a tio n s of the joints present greater problems and must be immobilised for approximately two to three weeks. Due to the damage to the capsule and surrounding structures, the joints are often stiff and it is extremely difficult to regain full range. Again, active and passive exerciscs are given and ultrasound in water may be used although its efficacy is open to question. Ice baths have also been found to help in increasing range. (Wynn Parry, C. B.. 1973).
T r a u m a tic a m p u ta tio n s and more particularly finger tip injuries in children are fairly common in the Western Cape when fingers get caught in doors due to the strong South Easterly wind. Treatment is the same, to reduce oedema and regain full functional activity as soon as possible.
C u t te n d o n s present a surgical challenge. Briefly they are treated by primary suture/repair, secondary suture/ repair, tendon grafts or insertion of silastic rods prior to tendon grafting.
If primary repair is done, the hand is immobilised in plaster of Paris for three weeks. During this time the only treatment necessary is to teach and supervise shoulder elevation exercises to prevent oedema. After three weeks, the plaster is removed and active mobili sation is commenced.
For a secondary repair, the skin is merely closed after the injury and the tendons will be repaired at a later stage. In this instance it is essential that the physio therapist gains and maintains FULL passive range of all joints and encourages the patient to keep the hand and ■ > fingers as supple as possible prior to the second opera-Sjl tion. Immobilisation is again three weeks and active Tl, movement can then be started. HJH One must distinguish between cut extensor tendons iJrand cut flexor tendons. The re-education and mobilisa- Fig. 1.

Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2013.)
tion following an extensor tendon repair is straight forward. The patient strengthens up quickly, although a 5° to 10° extensor tendon lag m ay persist.
The re-education following a flexor tendon rep air is, however, much slower and m ore arduous. Following im m obilisation, i.e. from the fo urth week A CTIV E flexion and extension, and during the fifth week gentle passive flexion is allowed. F rom the sixth week, passive stretching into extension is started and dynamic splintage w orn at night in order to increase the range o f extension. It m ust be stressed th at F L E X IO N is the functional movem ent of the hand and it is m ore im por tant to regain the m axim um possible range of flexion at the expense of full extension. This stage of the tendon repair is vital and the patient should be pre pared to spend practically the entire day in the Physio therapy and O ccupational T herapy Departm ents. Scarring and adhesions may be form ing and these must be kept to a minim um. Passive range of flexion MUST be obtained and m aintained. Active movement should be encouraged continuously with the use of sponge grips.
Besides the conventional m ethod of heat, o ur D epart m ent has also found ice baths to be effective in gaining an increase in range both passive and active. A n explana tion fo r this is uncertain, but it may be due to the increased vasodilatation o f the vessels in the hand following vasoconstriction. (Wynn Parry, C. B., 1973).
U ltrasound and scar massage are im portant in reducing tendon adherence. T he effects of ultrasound have never been conclusively proved, but it has a p art to play providing dosages of 1 -2 W atts/cm 2, are used (Wynn Parry, C. B., 1973). T his is applied either directly to the area or through the medium o f 'water. It should be used in conjunction with scar massage. D uring this stage active m ovem ent is V ITA LLY im por tant. If only one o r two fingers are involved, it is of benefit to strap these to the "good fingers" to help with flexion. In the later stages of re-education resisted exercises can be given, such as proprioceptive neuro m uscular facilitation techniques o r m anual labour in the workshops. T hroughout the re-education process, m easurem ents should always be taken and if th e result is a finger w hich can finally flex to w ithin 1 cm of palm ar crease, it can be considered successful.
Tendon grafts are usually determined by the level of the lesion. F o r example, in " N o-m ans-land" suturing w ould produce excessive scarring and hence no effective pull through of the tendons. The rehabilitation after a graft follows the sam e pattern as fo r a direct repair.
In cases where severe scarring is already present, silastic rods may be inserted so th at a sheath can form p rio r to grafting. T his is usually done in approxim ately three o r fo u r months. W ith this type of patient, full passive movements must be m aintained whilst the rods are in situ.
N erve lesions are repaired by prim ary repair, secon dary rep air o r nerve grafts. The physiotherapy treatm ent is principally the same as for tendon lesions. Im m e diate post-operative instruction to reduce oedema is given. If it is a nerve cut at the w rist that is repaired, then active m ovem ent of the fingers can begin imme-. diately as fa r as the im mobilising plaster will allow. If tendons and nerves are involved, a secondary nerve rep air is usually done by the tim e active m obilisation of the tendons has already started. R ehabilitation of the hand follows the same pattern, except th at the im m obilisation period is six weeks. Commonly, either the m edian and/or u ln ar nerve are involved and re education should also involve returning sensation. This is usually carried out by occupational therapy. If, however, the radial nerve has been severed, this is sutured and the patient wears a lively splint until the nerve grows down to the extensor muscles If n,tendon transfers may be done. T h ereafter' r e ,V S fa'K o f wrist, finger and thum b extension would'be " n e atinn r -----va nvoiiucm are in drainage and excision of any slough; no antih ?• given unless essential; frequent dressings a n n r ? -> duction of oedema and m ovem ent are enconr ' ru should be stressed th at the rules regarding drps? 8Cd' 11 very strictly kept to in the Hand Unit. Dry d S -ari: the m inim um of bandaging and specially h65-"1® ''' stockinette gloves and finger stalls to prevent CS'gn^ striction from tight bandaging, strapping or ti rc' are applied. The H ot Box is used with the arm8aUZ|: hand in elevation to reduce swelling, passive ard ments are given and active movement is enm"Inove' W hen the wound is closed, it may be necessa 8Cd' soak the hand in w arm water mixed with a T *" Savlon. T his helps to remove all the dead tissue ! the skin is then massaged with lanolin cream R U l either from anim als, insects or humans fall into 'ti l category and the treatm ent follows the same principles

MISCELANEOUS
Patients with ganglia, carpal tunnel svndrnm" D upuytren's contracture, trigger finger, cysts etc ar' seen im m ediately post-operatively by the Physiotheranu D epartm ent in order to give instructions to prevent oedema and lack of mobility. The patient is instructed in the im portance o f doing elevation exercises of the Hand and shoulder (a m inim um of 200 times per day) and to move the unaffected areas, such as metacarpal and interphalangeal joints. As a routine, the patient returns to th e D epartm ent the following day for a check and this should be all the treatm ent required. However with a release o f a D upuytren's contracture, further passive stretching and treatm ent may be required, at the specific instruction of the surgeon.

SYSTEMIC CONDITIONS A N D CONGENITAL H A N D DEFORMITIES
These are not common in this U nit and should be treated according to individual need. Splintage may be the predom inant issue in which case the Occupational T herapy D epartm ent will be prim arily responsible.

CONCLUSION
Two vital points emerge. Firstly, the patient, th 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 work cannot be stressed sufficiently enough. It is no use working merely as a physiotherapist in the isolation of th e D epartm ent. One must be present at the clinics as a mem 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 patient with an injured hand in suitable employment.