Diagrama entrópico (T-S)

1. Early diagnosis and prevention of wound complications, e.g. removal of sutures from any area of skin with poor circulation.

2. Treatment of oedema.

3. Maintenance of surgical correction.

4. Scar management.

5. Restoration of flexion range and hand function.

112 The Hand: Fundamentals of Therapy

Monitoring of the hand

The appearance and condition of the hand is monitored closely during the first few weeks after surgery as changes in hand circulation and oedema can be quite marked from one therapy session to the next. The therapist should remain alert to any signs that may herald the onset of chronic regional pain syndrome. These signs include:

1. Oedema that worsens rather than improves during the course of the day.

2. Pain that progressively worsens rather than eases.

3. Lack of progress in regaining flexibility (in the absence of arthritic changes).

4. Autonomic signs such as excessive sweating or mottling of the skin.

Occasionally following surgery, the patient will present with a ‘flare’ reaction which can have a similar appearance to CRPS. It is distinguished from this condition by the fact that it is usually confined to the area of surgery, rather than the whole hand, and tends to settle within a few days.

Refer to the chapter on ‘Chronic regional pain syndrome’ for management.

Wound care

The hand therapy programme is commenced 2 to 3 days following surgery. Ideally, the patient is seen at least 2 to 3 times a week for the first fortnight.

If skin grafting has been carried out, exercise is deferred for 7 to 10 days during which time the hand usually remains in its postoperative plaster.

Patients who have undergone regional fasciect-omy will have had primary closure of their wounds. Dressings should be renewed at each treatment session so that the wound can be assessed for any signs of infection or haematoma.

The replacement dressing should be minimal so that exercises can be performed in an unimpeded manner.

When the open-palm technique is used, the wound can be soaked once or twice a day for 5 min in a solution of warm water (1200 ml) to which 20 g of salt has been added. This is prepared by boiling the water, adding the salt and allowing the solution to cool until tepid. The patient is encour-aged to perform gentle active exercises while the wound is soaking (Fietti and Mackin, 1995).

Following this procedure, the wound is redressed

with a non-adherent dressing, e.g. Adaptic), layer of gauze and a layer or two of bandage or Tubigrip stockinette.

Treatment of oedema

Because surgery for Dupuytren’s disease is often quite extensive, postoperative hand oedema should be anticipated. Persisting oedema can result in fibrosis of the joints and soft tissues which leads inevitably to stiffness. Oedema can be managed by:

1. Elevation (for at least the 1st postoperative week).

2. Ice therapy.

3. Commencement of early active exercise in the absence of grafting.

4. Compression wrap, e.g. gentle application of a crepe bandage, Coban wrap or Tubigrip support for palmar or dorsal hand swelling. When applying Coban wrap to the digits, tension should be negligible and application is in a distal to proximal direction.

If hand swelling persists beyond wound healing, a lycra compression glove is applied (Fig. 9.8). The patient should be fitted with the appropriate size to avoid compromising circulation. The glove should fit snugly but should not cause throbbing or numbness. It should be pointed out to the patient that active flexion exercises are a little more

‘challenging’ to perform with the glove in place due to the gentle extension force exerted by the elasticity in the material. If flexion range is

Figure 9.8. Where hand oedema persists beyond the wound healing stage, a lycra compression glove is applied. Silicone scar gel can be used beneath the compression glove.

significantly restricted, removal of the glove prior to exercise may be advisable. Many patients are able to demonstrate improved flexion range while wearing the glove because the support it provides can reduce discomfort during exercise.

Maintenance of surgical correction

The postoperative splint is most important in maintaining the extension range achieved at sur-gery. The plaster applied in theatre is replaced with a thermoplastic splint on the 3rd day. This splint is usually a static one and can be applied either on the volar or dorsal aspect of the hand and forearm. The splint should extend from just distal to the fingertips to two thirds along the forearm and extend mid-laterally on the ulnar and radial aspects of the forearm (Fig. 9.9).

To accommodate a comfortable finger extension range in the immediate postoperative phase, it is sometimes necessary to place the wrist into slight flexion to avoid undue tension on the palmar tissues. The splint is worn continuously for the first 3 to 4 weeks, being removed only for dressing changes and 2-hourly exercise sessions. After this time, the splint is left off for increasing periods throughout the day so that flexion range can be regained.

Where there has been correction of a single digit contracture or where correction has been localized to the PIP joint, a dorsal hand-based outrigger splint can be fitted (Rives et al., 1992). This dynamic splint has the advantage of allowing active motion while the splint is being worn.

Wearing of the splint at night is continued for 6 months after surgery (Fig. 9.10).

Scar management

When the wound has healed, usually between 10 to 14 days, oil massage is commenced. This serves to desensitize as well as soften the scar. If there are areas of diminished sensation, the patient is given advice regarding protection from injury.

Grafted areas are massaged very lightly at first to avoid blistering of the skin. The linear scar resulting from the open-palm technique is usually minimal, requiring little or no therapy intervention.

To assist scar resolution, adhesive silicone gel (Cica-Care) is applied to the scar and used in conjunction with the extension splint. It can be held in place with a compression glove or a layer of Tubigrip. The gel is used only on clean, dry and oil-free skin. The gel is washed on a daily basis and is left off the skin for at least 4 h each day to avoid skin maceration. On the first day, the skin is checked every few hours for irritation or signs of allergy which are rare. When present, allergy usually manifests as small red dots.

Although the gel is quite costly, one piece is usually sufficient for the duration of scar treatment which is generally 4 to 6 weeks.

Regaining movement

All joints proximal to the hand should be exercised regularly throughout the day to prevent stiffness.

Figure 9.9. Surgical correction is maintained with a static volar extension splint. To avoid placing undue tension on the palmar tissues following surgery, the wrist may need to be placed in slight flexion.

Figure 9.10. A dorsal hand-based outrigger can be used to maintain correction following a single digit PIP joint release. This splint has the advantage of allowing active PIP joint flexion against the rubber band traction.

114 The Hand: Fundamentals of Therapy

This applies particularly to the shoulder joint of the older patient.

Gentle passive and active wrist and finger movements are commenced on the 2nd post-operative day unless there has been skin grafting, in which case movement of the grafted area is delayed for 7 to 10 days. Movements should not cause pain and they should be performed with the hand is slight elevation to assist resolution of oedema.

Each digit is exercised individually with the therapist passively flexing the digit at the MCP, PIP and DIP joints simultaneously until maximum passive flexion is achieved without undue dis-comfort. This position is held for a short time (30–60 s) after which the patient actively extends the digit. When reasonable passive flexion range has been achieved, 10 active stabilized IP joint flexion exercises are practised. Individual finger exercises are followed by 10 global flexion (or fist-making) exercises.

Because patients with Dupuytren’s disease tend to be in the older age group and because surgery is frequently quite extensive, the propensity toward

stiffness is great. Exercise sessions should there-fore be repeated at least 2-hourly during the early postoperative phase.

As soon as allowed (usually after the 1st postoperative week), warm water soaks are com-menced. A mild cleansing agent can be added to the water. The effectiveness of these soaks cannot be overemphasized. The advantages include:

1. Debridement of the wound.

2. Reduction of pain.

3. Increased movement.

Soaking the hand in warm soapy water has a soothing effect and helps facilitate movement. This is particularly the case in colder weather. Squeez-ing a soft sponge improves mobility and helps to reduce hand swelling. Where interphalangeal joints are quite stiff, the fingers are gently bandaged into flexion for 15-min periods several times a day. For extra effectiveness, this manoeuvre should be combined with the warm water soaks. An IP joint flexion strap will help gain the final degrees of flexion range (Fig. 9.11).

Some patients regain flexion range quite quickly. Others must persevere with their home programmes for several months before regaining a flexion range that is consistent with good function.

The patient should be informed that grip strength can take many months to return and that activity levels should be gradually increased commensu-rate with improvement.

References

Belusa, L., Buck-Gramcko, D. and Partecke, B. D. (1997).

Results of interphalangeal joint arthrolysis in patients with Dupuytren’s disease. Handchir. Mikrochir. Plast. Chir., 29, 158–63.

Fietti Jr., V. G. and Mackin, E. J. (1995). Open-palm technique in Dupuytren’s disease. In Rehabilitation of the Hand:

Surgery and Therapy (J. M. Hunter, E. J. Mackin and A. D.

Callahan, eds) pp. 995–1006, Mosby.

Hueston, J. T. (1984a). Dermofasciectomy for Dupuytren’s disease. Bull Hosp. Joint Dis. Orthop. Inst., 44, 224.

Hueston, J. T. (1984b). ‘Firebreak grafts’ in Dupuytren’s contracture. Aust. N. Z. J. Surg., 54, 277–81.

Hurst, L. C. and Badalamente, M. (1990). Associated diseases.

In Dupuytren’s Disease. Biology and Treatment. The Hand and Upper Limb Series (R. M. McFarlane, D. A. McGrouther and M. H. Flint, eds) pp. 253–60, Churchill Livingstone.

Luck, J. V. (1959). Dupuytren’s contracture: A new concept of the pathogenesis correlated with surgical management.

J. Bone Joint Surg., 41A, 635–64.

Figure 9.11. To help overcome interphalangeal joint stiffness, the fingers can be bandaged into flexion several times a day for a period of 10 to 15 minutes.

The effect of this stretching manoeuvre is augmented if the hand is immersed in warm water.

McCash, C. R. (1964). The open palm technique in Dupuytren’s contracture. Br. J. Plast. Surg., 17, 271.

McFarlane, R. M. and Botz, J. S. (1990). The results of treatment. In Dupuytren’s Disease. Biology and Treatment.

The Hand and Upper Limb Series. Vol. 5 (R. M. McFarlane, D. A. McGrouther and M. H. Flint, eds) pp. 387–412, Churchill Livingstone.

Meagher, S. W. (1990). Manual work and industrial injury: A personal commentary. In Dupuytren’s Disease. Biology and Treatment. The Hand and Upper Limb Series. Vol. 5 (R. M.

McFarlane, D. A. McGrouther and M. H. Flint, eds) pp. 261–

4, Churchill Livingstone.

Prosser, R. and Conolly, W. B. (1996). Complications following surgical treatment for Dupuytren’s contracture. J. Hand Ther., 9, 344–8.

Rives, K., Gelberman, R., Smith, B. and Carney, K. (1992).

Severe contractures of the proximal interphalangeal joint in Dupuytren’s disease. Results of a prospective trial of operative correction and dynamic extension splinting.

J. Hand Surg., 17A, 1153–9.

Umlas, M. E., Bischoff, R. J. and Gelberman, R. H. (1994).

Predictors of neurovascular displacement in hands with Dupuytren’s contracture. J. Hand Surg., 19B, 664–6.

Further reading

Andrew, J. G., Andrew, S. M., Ash, A. and Turner, B. (1991).

An investigation into the role of inflammatory cells in Dupuytren’s disease. J. Hand Surg., 16B, 267–71.

Breed, C. M. and Smith, P. J. (1996). A comparison of methods of treatment of PIP contractures in Dupuytren’s disease.

J. Hand Surg., 21B, 246–51.

Foucher, G., Cornil, C. and Lenoble, E. (1992). Open palm technique for Dupuytren’s disease. A five-year follow-up.

Ann. Chir. Main Memb. Super., 11, 362–6.

Hall, P. N., Fitzgerald, A., Sterne, G. D. and Logan, A. M.

(1997). Skin replacement in Dupuytren’s disease. J. Hand Surg., 22, 193–7.

Hueston, J. T. (1963). Dupuytren’s contracture. E & S Livingstone.

Lanzetta, M. and Morrison, W. A. (1996). Dupuytren’s disease occurring after a surgical injury of the hand. J. Hand Surg., 21B, 481–3.

McFarlane, R. M. (1991). Dupuytren’s disease: relation to work and injury. J. Hand Surg., 16A, 775.

McFarlane, R. M. and MacDermid, J. C. (1995). Dupuytren’s disease. In Rehabilitation of the Hand: Surgery and Therapy (J. M. Hunter, E. J. Mackin and A. D. Callahan, eds) pp. 981–94, Mosby.

McGrouther, D. A. (1999). Dupuytren’s contracture. In Green’s Operative Hand Surgery (D. P. Green, R. N. Hotchkiss and W. C. Pederson, eds) pp. 563–91, Churchill Livingstone.

Moermans, J. P. (1996). Long-term results after segmental aponeurectomy for Dupuytren’s disease. J. Hand Surg., 21B, 797–800.

Schneider, L. H. (1991). The open palm technique. Hand Clin., 7, 723.

Skoog, T. (1967). The transverse elements of the palmar aponeurosis in Dupuytren’s contracture. Scand. J. Plast.

Surg. 1, 51–63.

Starkweather, K. D., Lattuga, S., Hurst, L. C., et al. (1996).

Collagenase in the treatment of Dupuytren’s disease: An in vitro study. J. Hand Surg., 21A, 490–5.

Tonkin, M. A., Burke, F. D. and Varian, J. P. W. (1984).

Dupuytren’s contracture: A comparative study of fasciectomy and dermofasciectomy in one hundred patients. J. Hand Surg., 9B, 156–62.

Weinzweig, N., Culver, J. E. and Fleegler, E. J. (1996). Severe contractures of the proximal interphalangeal joint in Dupuyt-ren’s disease: Combined fasciectomy with capsuloliga-mentous release versus fasciectomy alone. Plast. Reconstr.

Surg., 97, 560–6.

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