Learning Objectives. Multi-Trauma and Complex Injuries. Systems (Tissues) Introduction. Vascular Structures &Considerations

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1 Multi-Trauma and Complex Injuries Nora Barrett, MS, OTR/L, CHT UC Irvine February 10, 2018 Learning Objectives Understand all systems involved and multisystem 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 Systems (Tissues) Therapist Hierarchy for Tissues Vascular Structures Skin Coverage Bone Stability Nerve Muscle/Tendon Tamai S. JHS, 1982, 7(6): Vascular Structures &Considerations 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

2 Inflammation vs. Infection Redness > extreme (mark area to track) Heat > increased temp Pain or swelling > sudden increase Debris > pus Odor Non-healing/new breakdown Exposed bone Managing Edema Elevation At what level? Active exercise Consider what is appropriate Compression Contraindicated with vessel repair until 6 weeks Physical agents MEM 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 Skin Coverage/Wound/Scar and Considerations 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%

3 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* 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 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 Pictures from boneandspine.com Common Flaps Pedicle Flaps Thenar Cross Finger 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 Sketches from boneandspine.com Groin

4 Scars Hypertrophic 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 4 th degree Circumferential burns Burn Treatment Biological Dressings/Wound Closures Edema Management Range of Motion Positioning Physical Agents Scar Management Pressure Therapy

5 Burn Orthosis Options Burns 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 Prosthesis 2. Passive 3. Body Power 4. External Power 5. Hybrid 6. Activity Specific Residual Limb Care Performed with complete amputations or fingertip injuries Stump wrapping for shaping and edema control Desensitization for stump hypersensitivity including massage, textures, vibration, particle immersion Pics from upperlimbprostheticsinfo.com

6 Nerves/Pain Pain 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 Sensory Hyperesthesia, allodynia Hyperalgesia, allodynia to light touch, movement, pressure Vasomotor Sudomotor/Edema Motor/Trophic Temperature/skin asymmetry/color changes/asymmetry Edema, hyperhidrosis, sweating changes asymmetry Decreased ROM, motor dysfunction, trophic changes Sign Temperature asymmetry, skin color changes Edema, sweating changes Decreased ROM, motor dysfunction, trophic changes

7 CRPS Criteria CRPS Treatment Visual Analog Scale > 3 cm McGill with greater than 3 words Temperature difference >0.4%C Volume difference > 6.5 % ROM limitation > 15% 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 wikipe Tendon/Muscle Orthosis Review Immobilization Orthoses Mobilization Orthoses Dynamic Static Progressive Serial Static Amount of Improvement Modified Weeks Test Orthosis 20* No orthosis 15* Static 10* Dynamic 0 5* Static Progressive 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

8 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, Bringing it all together ROM and ADL Picture from presenter Functional and Purposeful Activity Initiate non-resistive functional grasp and prehension activities as soon as able to encourage normalization of movement patterns Picture from presenter 11 Essential Hand Functions Replantation Who is appropriate? Thumb Multiple digits Metacarpal amputations Children Wrist or forearm level amputations Digit tips distal to FDS insertion orthobullets.com

9 Replantation Common order for replant: Clean wound Skeletal system/periosteum Extensor tendons Flexor tendons Nerves Artery Vein Skin Thumb Amputation Picture from presenter Thumb Replantation 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 Orthosis I Controlled Active Tenodesis Day 4-14 II Passive Intrinsic Minus Day 7-14 III Active Intrinsic Minus Day 14

10 EPM I: Controlled Active Tenodesis Early Protected Motion II: (Passive Intrinsic Minus/Hook) Begins 7-14 days after replant Continue PM I exercises Early Protected Motion III: Active table top/hook Patient progresses to place and hold, then to full active Add active gliding, isolated superficialis exercise Strengthen lumbricals and interossei in intrinsic plus position Replant Case Early Protected Motion 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 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

11 Acknowledgements Gary Solomon, MS, OTR/L, CHT Hannah Gift, OTR/L, CHT References Chan S & LaStayo P. (2003). Hand Therapy Management Following Mutilating Hand Injuries. In Hand Clinics, 19(1): 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): Colditz, J. Therapist s Management of the Stiff Hand. In Rehabilitation of the Hand and Upper Extremity, 6 th edition. Skirven, Osterman, Fedorczyk & Amadio. Elsevier/Mosby: Philadelphia Hannah S. (2011). Psychosocial issues after a traumatic hand injury: facilitating adjustment. In Journal of Hand Therapy, 24(2): Hay, D., Taras, J. & Yao, J. Vascular Disorders of the Upper Extremity. In Rehabilitation of the Hand and Upper Extremity, 6 th edition. Skirven, Osterman, Fedorczyk & Amadio. Elsevier/Mosby: Philadelphia 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), 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 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 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, 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): 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 Rizzo M. Complex Injuries of the Hand in Rehabilitation of the Hand and Upper Extremity, Sixth Edition. Skirven, Osterman, Fedorczyk & Amadio. Elsevier/Mosby: Philadelphia Silverman P., Willette-Green V & Petrilli J (1989). Early Protective Motion in Digital Revascularization and Replantation. In Journal of Hand Therapy, 2: Stanton, D., Pigott, R.. Orthotic Fabrication and Biomechanics. In Test Prep for the CHT Exam, 3 rd 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 Westlake K. & Byl N. (2013). Neural plasticity and implications for hand rehabilitation after neurological insult. In Journal of Hand Therapy, 26(2):