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Volume 2022 Issue 1
Rivista Orthopaedics

Role of Physiotherapist in the Rehabilitation of Hand Replantantion
Case Report

Rajani Cartor, M.1* & Divyavani, V.2

1Professor & Principal, VAPMS College of Physiotherapy, India
2Post Graduate student, VAPMS College of Physiotherapy, India

*Correspondence to: Dr. Rajani Cartor, M., Professor & Principal, VAPMS College of Physiotherapy, India.

Copyright © 2022 Dr. Rajani Cartor, M., et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 29 January 2022
Published: 15 March 2022

Keywords: Physiotherapy; Replantantion; Bones



Introduction
Replantation is the process of reattaching an amputated limb to the rest of the body using neurovascular and musculoskeletal tissues in order to restore function. Fingers, hands, forearms, arms, toes, feet, legs, ears, avulsed scalp, lips, penis, tongue, and other severed body parts have all been replanted. Malt and Meckhann successfully replanted a completely amputee human limb for the first time (1964). Thousands of damaged fingers and body parts have been successfully rescued since the first successful replantation of a human thumb by Komatsu & Tami in 1968.


After a traumatic amputation, the purpose of replantation is to restore the limb’s form and function. Returning circulation to the distal region isn’t enough to call it a success. The technical steps involved are:


Examination & dissesection of neurovascular structures.
Bones fixation
Muscle repair followed by microsurgical artery
Nerve
Skin closure


During the post-operative phase, the hand is splinted and the patient is continuously examined for circulation abnormalities in the fingers. Many criteria, including the relevance of the component, the level of harm, the predicted recovery of function, and the mechanism of injury, influence the choice to attempt salvage in such an accident.


• Good function can be obtained by replanting fingers distal to the flexor superficialis insertion hand at the wrist and the upper extremities at the distal forearm. In younger patients, the outcomes are more visible.


Anatomy
• Hand is the region of the upper limb distal to the wrist joint. It is sub divided into three parts.

Wrist
Metacarpus
digits


• The five digits consist of the laterally positioned thumb medial to the thumb, the four fingers- index, middle ring and little fingers.
• Hand has anterior surfaces: palm and dorsal surface: dorsum of hand [1].



Bones
Three groups of hand bones:


8 carpal bones wrist
5 metacarpals (1 to 5 metacarpals)
Phalanges bones of digits of thumb has only two remaining digits have three.


• The carpal bones and the metacarpals of the index, middle, ring and little fingers tend to function has a unit and form much of the bony frame work of the palm.


• The metacarpal of the thumb of functions independently and has increased flexibility at the carpo metacarpal joint to provide opposition of the thumb to the fingers.



A. Carpal Bones
• Small carpal bones of the wrist are arranged in two rows. They are proximal row & distal row, each consisting of 4 bones each.


• Proximal Row: From lateral to medial; viewed anteriorly this proximal row consists of the following:

boat shaped, scaphoid
crescent shaped, Lunate
3sided triquetrum
pea shaped pisiform


i. Pisiform:

• It is a sesamoid bone in the tendon of the flexor carpi ulnaris & articulates with the anterior of the triquetrum.


ii. Scaphoid:

• Has prominent tubercle on its lateral palmar surface i.e. is directed anteriorly.


• Distal Row: lateral to medial and when viewed anteriorly, the distal of the carpal bones consists of the following:

Trapezium bone
Trapezoid
Capitate
Hamate


i. Trapezium: It articulates with the metacarpal bone of the thumb and has a distinct tubercle on its palmar surface that projects anteriorly.


ii. Trapezoid:


iii. Capitate: The carpal bone which are larger i.e. capitates articulates with the base of 3rd metacarpal.


iv. Hamate The Hamate, which is positioned just lateral and distalled to the pisiform has a prominent hook on its palmer surface that projects anteriorly.


B. Metacarpals

• Each of the five metacarpals is related to one digit. The metacarpal is related to the thumb. Metacarpal 2 to 5 are related to the index, middle, ring and little fingers respectively. Each metacarpal consists of the base shaft and head.
• All the bases metacarpals articulate with the carpal bones in addition, the bases of the metacarpal bones of the fingers articulate with each other.
• All the heads of the metacarpals articulate with the proximal phalanges of the digits. The heads form the knuckles on the dorsal surface of hand when the fingers are flexed.


Phalanges:
• The phalanges are the bones of the digits. The thumb has a proximal and distal phalanx. The rest of the digits have 3 proximal middle and distal phalanx. Each phalanx has a base shaft and distal head.
• The base of each proximal phalanx articulates with the head of the related metacarpal bone. The head of each distal phalanx is non articular and flattened into crescent shaped palmar tuberosity which lies under the palmar pad at the end of the digits.


Functions
A) Prehension Handling [2]



B) Precision


Biomechanics

Prehension
Prehension actions of the hand entail grabbing or taking hold of an object between any two surfaces in the hand. The thumb is involved in the majority of Prehension tasks, but not all.

1. Prehension can be classified as either a power grasp or a weak grip (full hand Prehension). Each of these two groupings has subdivisions that define the grab even more.
2. A power grip is a powerful action that causes flexion in all of the finger joints. The thumb works as a stabiliser for the object held between the fingers and, most typically, the palm when it is utilised.
3. Precision handling, on the other hand, is the deft placing of an object between fingers or between the thumb and the finger.
4. There is no involvement of the palm. A power grip is the outcome of a series of actions that include:
a. opening the hand,
b. aligning the fingers,
c. bringing the fingers to the item, and
d. maintaining a static phase.


A. Power Grip
In a power grip, the fingers frequently work together to clamp down on and hold an object in the palm. The fingers assume a continuous flexion stance that varies in degree depending on the size, shape, and weight of the object.

• As the palmar arches form around the object, it is likely that the palm will contour to it.
• The thumb can adduct against the object or be detached from the object to act as an extra surface for the finger palm vice.
• When the thumb is used to clamp the object to the palm, it is usually adducted.
• Cylindrical grip, spherical grip, hook grip, and lateral prehension are all part of this category.


1. Cylindrical Grip: The flexors are virtually solely used in cylindrical grip to position the fingers around and maintain grasp on an object.

•The flexor digitorum profundus muscle performs the majority of the function in the fingers, particularly in the dynamic closing movement of the fingers.
• The flexor digitorum superficialis muscle assists in the static phase when the grip intensity requires more force.


2. Spherical Grip: Extensors are necessary for smooth and controlled opening of the hand and release of the object, as well as providing a balancing force for the flexors.

• When approaching and interacting with an object, open your hand. Extensor muscles such as the lumbrical, extensor digitorum communis, and thumb extrinsic muscles are used to open the hand during object approach and object release.


3. Hook Grip: Hook grip is a type of Prehension that has been refined. It’s in the power grip category because it has more power grip qualities than precise handling attributes. It’s mostly a finger-based function.

The thumb is never mentioned, even though the pain is present. Anyone who has carried a briefcase or books by his side or grabbed onto a commuter strap on a bus or rail can attest to this. Flexor digitorum profundus and flexor digitorum superficialis muscles supply the majority of the muscular actions.

• The flexor digitorum superficialis muscle may be sufficient if the load is carried further distally and distal flexion is required. The thumb extrinsic muscles in the hook grip hold the thumb in a moderate to full extension.


4. Lateral Prehension: Lateral Prehension is a type of grasp that is distinctive. Two adjacent fingers come into contact.

• The interossei muscles abduct and adduct the metacarpophalangeal joints concurrently.

• The extensor digitorum communis and lumbrical muscles are active to prolong the metacarpophalangeal joint abduction and adductions.


B. Precision Handling
Types of precision handling are pad-to-pad Prehension, tip-to-tip Prehension, and pad-to-side Prehension.


1. Pad-to-Pad Prehension: The pad, or pulp, of the thumb opposes the pad, or pulp, of the finger during prehension. The pad of each digit’s distal phalanx has the highest concentration of tactile corpuscles in the body.

• The volar and dorsal interossei muscles tend to function reciprocally during dynamic manipulation, rather than in the synergistic co-contraction pattern seen during power grip.
• The interossei muscles may co-contract again in a static yet firm pad to pad squeeze. Pad to pad with the thumb Carpometacarpal flexion, abduction, and rotation are held in prehension (opposition).


2. Tip-to-Tip Prehension: Although the muscle activity in tip to tip Prehension is essentially identical to that found in pad to pad Prehension, there are some significant differences.

• To achieve nearly full joint flexion in tip to tip prehension, the interphalangeal joints of the finger and thumb must have the range and muscle force to do so.


3. Pad to Side Prehension: Pad to side Prehension to the side, pad Because a key is grasped between the pad of the thumb and the side of the index finger, prehension is also called key grip (or lateral squeeze) [2].

• Pad to side Prehension is distinct from other types of precision handling. Handling solely in the sense that the thumb is adducted and rotated less.
• In comparison to tip to tip Prehension, the flexor pollicis brevis muscle activity increases while the opponens pollicis muscle activity decreases.
• The adductor pollicis muscle’s activity rises in comparison to either tip to tip or pad to pad Prehension. The thumb’s distal phalanx must be flexed somewhat.



Indications of Hand Replantation

Age: Below 55 yrs.

Indications Based on the Type of Finger
The severed thumb is the best sign of Replantation among all the fingers because the thumb is the most functionally important digit and good use of the replanted thumb is made regardless of the range of mobility and sensation recovery.

• A length as close to normal is just as important as feeling and mobility for a more functional thumb.
• As a result, even in adverse conditions, replantation of the thumb was attempted.
• All fingers are recommended for replantation in children since they have a unique capacity for regeneration and can expect continuing growth.
• The thumb is replanted first, followed by the opposing finger, in order to reclaim “pinch and grasp functions.”


Indication Based on Amputated Site
Amputation of the proximal region of the finger has traditionally been advised for replantation, although the recovery of functions has been poor.
• However, the closer the amputated level is to the tip of the finger, the less functional impairment the replanted finger will have.


Indications Based on the Number of Fingers
Multiple amputations of three or more digits would be the best indicator based on the number of digits amputated.

• When three or more fingers have been severed, the greatest effort should be placed into reattaching all digits, as each replanted digit may have some function impairment, and having even one extra finger would make a significant difference.


Indication Based on the Degree of the Finger
A clean cut amputation is a favourable indicator, but blunt amputations are more likely to be considered a replantation indication.
• Crush or harsh amputations necessitate severe shortening or tissue transplantation, and the survival rate falls.


Preservation of Amputated Fingers and Temporal Limits: Muscular tissue begins to degrade 5 hours after blood supply is cut off, and if significant amputations are replanted after this time, replantation toxaemia may ensue.

• In fingers without any muscle tissue, degeneration induced by a loss of blood supply develops slowly, allowing the finger to survive even when transplanted many hours after the damage.


Clear Cut Amputations
Duration of Amputations Not More Than
4-6 Hours.
Amputations Distal to the IP Joint Are Not Considered.


Contraindications

Severe vascular disorders
Mangled limb / crush injury
Segmental amputations
Prolonged ischemia time with large muscle content (>6hrs)
Disabling psychiatric illness
Medically unstable patient


Severe Contamination
• Life-threatening injuries
• Refusal to accept blood transfusions or blood products in cases of serious amputations
• Medical co-morbidities that can influence anaesthesia, healing, therapy, or ability to comply with care.


Surgical Management

Operative Management: At the same moment, two surgical teams are operating.

• One team identifies and marks the arteries, nerves, and tendons for easy identification for anastomoses later in the surgery, while the other works on the proximal part.

• The structures are then repaired in the following order:

1. The bones are shortened and fixed with screws/wires/plates, etc.
2. Repair of arteries
3. Repair of veins
4. Repair of nerves
5. Repair of tendon
6. Cover/ closure of the wound:

The repair of the nerves and tendons may be left to be done at a larger stage in some cases.


1. Bone Fixation:

• Bony fixing is completed fast without sacrificing stability. Replantation fractures are frequently transverse.
• If bone shortening is necessary, the lengths of the tendons, nerves, and arteries must be matched to guarantee adequate excursion during dynamic motions.
• Fixation is achieved using a mix of kirschner wires, screws, circumflage wires, or intermedullar plates.
• Plate fixation has several advantages, including no k-wire exit sites, more rigid fixation, and simpler early mobilisation post-operatively.
• Drawbacks include a longer operating time and the need for more bone stripping to expose the bone for plating.



2. Repair of Arteries: The both digital arteries are being repaired in every way possible. When only one artery needs to be repaired, the dominant artery gets priority.
• In the thumb and the rest of the fingers, the ulnar digital artery is prominent, with the exception of the tiny finger, where the radial artery is dominant.


3. Repair of Vein: Ideally, the number of vein repairs should be one more than the number of artery repairs.
• Tension-free primary repair can be accomplished by separating side branches or dissecting a vein long enough from the dorsum of a neighbouring digit.


4. Repair of Nerve: Adequate bone shortening enables for a tension-free nerve restoration in most cases.
• A graft harvested from the distal end of the posterior Interosseous nerve is useful in bridging short gaps, whereas a graft from the medial ante brachial cutaneous nerve is more suitable for longer defects.


5. Repair of Tendon: Excess tendon is exercised as a result of bone shortening.
• Tendon repair is done with care, using non-absorbable sutures to allow for early mobilisation and reduce adhesions.



6. Skin Closure: The skin flaps are lightly approximated with a few interrupted sutures after meticulous haemostasis is obtained.


Medical Management

1st Day:
• Low molecular -weight dextran 40 in 500cc of D5 -W is given over 6-24 hours.
• In patients with pulmonary problems, continuous intravenous
• Infusion at a lower
1. Aspirin (325mg, 1 by mouth 2times a day).
2. Thorazine (25mg, mouth 3times a day).
3. Antibiotics-cefazolin or a similar antibiotic is used for 3-5days.
4. Administer low-molecular-weight dextran 40and 500cc of D5-W at a rate of 10/ kg/ day for 3days to the paediatric patient.


5-10 Days:
• During this time, the initial difficulties were managed. Replantation failure due to vascular impairment is uncommon after that period. Arterial insufficiency due to thrombosis or vasoconstriction almost always necessitates a return to the operating room right away.
• Execute a plexus block, investigate the arterial anastomoses, remove the injured portion, and if necessary, perform vein grafting. In such cases, use heparin to keep the partial thromboplastin time 1.5 to 2.0 times normal.
• Insufficient venous outflow or venous thrombosis are both symptoms of venous congestion. Loosen all post-operative dressings at the first sign of venous congestion to reduce external constriction.
• A longitudinal Laceration into the digital pulp or loss of the nail plate can result in distal replantation with venous congestion. Applying heparinized saline drops to the nail bed and pulp may help with venous drainage. Leech therapy may be necessary if the venous outflow from the nail bed or drainage site is inactive but still present.
• Apply a medical leech to a finger or a congested location, shielding the remaining sites with the plastic wrapping. A leech cage can be made out of the plastic bag used to store intravenous bags. Tape the open end of the Plastic bag around the bulky post-operative dressing, then insert a leech through a vertical slit in the bag.

• However, for the leech to attach, arterial input must be present. If the leech fails not attach, the digit may have both arterial and venous insufficiency, necessitating prompt surgical exploration of the artery and Venous anastomoses for further rescue.
• If the patient’s look of the replanted part is acceptable, he or she may be discharged from the hospital.
• The patient’s dietary and environmental restrictions remain unchanged, and he is given aspirin (325mg) twice day for an additional week.


3 Weeks:
Examine the wound after removing the dressing. The granulating wounds on replanted digits are generally oedematous. Cleansing the wound with hydrogen peroxide and cauterising superfluous granulation tissue with silver nitrate are two wound care techniques. Fit the wrist with a splint in minor wrist flexion and MCP joint flexion to around 50 to 60 degrees and apply soft, non-adherent dressings. Begin with passive wrist flexion and MCP joint flexion, focusing on flexor tendon glide.


Rehabilitation Team
• Rehabilitation is not solely the responsibility of a few non-governmental organisations or the government. It is the obligation of the entire society of capable individuals.
• Rehabilitation’s goal is to transform a crippled person into a “differently abled” person.


Team Members

The Medical Team
Physiatrist

Other Team Members
a) Physical therapist
b) Occupational therapist
c) Rehabilitation nurse
d) Psychologist
e) Creative movement therapist/dance therapist/ play therapist
f) Social worker
g) Vocational counsellor
h) Placement officer


Physiotherapy Management
• Physiotherapy is crucial in the post-operative phase’s management. The foundation for early restoration of function after replantation is careful monitoring and precise procedures.


Pre-Operative Management: • The amputation stump is wrapped with saline-soaked gauze and raised [3].
• Stopping the bleeding may necessitate the use of a compression bandage.


Once the patient has been stabilised, all severed pieces are collected and preserved.

• The severed limbs are wrapped in saline-soaked gauze and placed in a dry, water-tight plastic bag, which is then placed on ice.
• The goal is to keep the portion cold to minimise the negative consequences of thermal ischemia while avoiding direct tissue contact with ice, which can lead to frostbite.
• Incomplete, nonviable amputations are wrapped in moist gauze, dressed, a simple splint made to minimise kinking, and ice packs are provided to the distal portion of the severed component.


Post Operative Management
Basic principles of the management include:
1. Prevention of infection
2. Prevention of circulatory failure and control of oedema
3. Prevention of deformity
4. Restoration of hand function.


1. Prevention of Infection: [4]
• In the acute phase Infection prevention and pain management are critical.
• Anti-inflammatories and antibiotics are administered.
• It’s possible that enzyme debridement and tangential excision are required.


2. Prevention of Circulatory Failure:
• Paleness, cold, and a loss of pulse are all signs and symptoms of circulatory failure that should be examined on a regular basis.
• Active exercises to the joints near the burn site and relaxed passive motions within the pain threshold help manage circulatory failure and avoid infection intervals.


3. Control of Oedema:
• Controlling oedema can be done by elevating the hand.
• Every hour, execute a slow and progressive active intrinsic muscle pumping activity.
• Active efforts are synchronised with high-voltage pulsed current.


4. Prevention of Deformity:
• The hand is immobilised in a plastic bag or splint at the ideal position of the hand from the start;
• Later, the splint is changed to a dynamic splint with built-in mechanism to allow scar tissue remodelling.


5. Restoration of the Hand Functioning:
• Whirlpool hydrotherapy is an incredibly useful and popular modality of treatment. It aids in wound debridement, improves circulation, maintains mobility, reduces oedema, and speeds up the healing process.


Stages of Management
Early Post Operative Management
• A thermoplastic volar resting orthosis is commonly used to retain the hand in a resting position while preventing joint contractures.
• To preserve the repair, proper posture of the limb is assured; the limb is checked for proper elevation, which does not place unnecessary stress on the operated part. Oedema and inflammation will be reduced as a result.
• It’s critical to keep a close eye on your fingertips for any changes in colour that could indicate circulatory insufficiency.
• Vigorous motions of other areas of the body and distant segments of the limb, when combined with suitable support for the replanted area, can help to increase circulation to the replanted area indirectly.


Phase of Restoration and Re-Education: (3-5 weeks)

After the dressings and the cast have been removed, this phase begins. The bandages are removed after 2 weeks for digit replantation and 4 weeks for more proximal locations.

1. With the wrist in slight dorsiflexion, the MCP joints in flexion, and the IP joints in slight flexion, a dynamic splint is applied.
2. It is critical to begin early mobilisation in a small range with relaxed passive stress.


Mobilisation Techniques

1. Tendon: After the immobilisation phase, mobilisation strategies are useful. Tendon gliding and tendon-blocking exercises are two types of mobilisation that can help with neuromuscular control and co-ordination.


a) Place-and-Hold Exercises: Place-and-hold exercises are a type of gentle muscle static/isometric exercise that is used during the post-operative period following tendon repair before active ROM is started, but when a minimal amount of stress on the repaired tendon and passive joint movement are beneficial for maintaining joint mobility and tendon excursion.

• A dorsal blocking splint or a tenodesis splint is frequently used after flexor tendon restoration. Passively place the IP joints in a slightly flexed posture with the MCP joints in flexion and have the patient hold the position independently for 5 seconds with a minimum static contraction of the finger flexors.
• If the patient is wearing a tenodesis splint, combine active wrist extension and place-and-hold finger flexion. Allow the patient to relax and passively flex the wrist and extend the digits.
• When the volar blocking splint can be removed for exercise following extensor tendon repair, passively position the joint in the repair zone in a neutral and then slightly extended position. After then, ask the patient to maintain the position. To avoid extensor lag, this stresses end-range extension.
• Have the patient practise the exercise with their uninjured hand or utilise biofeedback to learn how to hold the position with the least amount of power.


b) Flexor Tendon- Gliding Exercises: Flexor tendon gliding exercises are meant to keep or improve free gliding between the FDP and FDS tendons, as well as between the tendons and bones in the wrist, hand, and fingers. During tendon gliding exercises, the fingers can be moved into five different positions: table-top position; straight hand; hook fist; complete fist.

• Hook (claw) Fist Position
• Full Fist
• Straight Fist (sublimis fist)
• Thumb Flexion



c) Extensor Tendon-Gliding Exercises: Teach the patient to passively flex the MCP and IP joints of one finger with the opposite hand while actively maintaining extension of the other fingers. If the patient is having trouble, start by placing the concerned hand on a table with the palm IP. Passively stretch one of the digits to stabilise three to four fingers against the table. Then have the patient try to aggressively keep their fingers against the table while passively flexing one of their digits.

• Begin by having the patient actively retain the fingers in extension with the fingers spread out, and then have them actively flex each finger in turn while the others stay extended.
• Ask the patient to flex the middle and ring fingers while keeping the index and little fingers extended. This promotes extensor indicis and extensor digitorum communis control in isolation.


d) Flexor Tendon - Blocking Exercises: Flexor tendon blocking exercises are not recommended. They need neuromuscular control of particular joint motions in addition to developing gliding of the tendons with respect to the sheaths and connected bones. As a result, they make use of the flexibility developed through flexor tendon gliding workouts. As the tissues heal and can handle resistance, progress to manual resistance.

• Isolated MCP flexion (Lumbrical and palmar interossei): Only have the patient flex one digit’s MCP joint. If required, use the other hand to stabilise the remainder of the fingers in extension against the table.
• PIP Flexion (flexor digitorum superficialis): Stabilize the proximal phalanx of one digit with the opposite hand, and bend only the PIP joint of that digit while keeping the DIP joint stretched and the rest of the fingers extended. If the patient is having trouble doing so, use the opposite hand to hold the other digits in extension.
• DIP Flexion (flexor digitorum profundus): Instruct the patient to flex only the distal phalanx. With the opposite hand, stabilise the middle phalanx of one digit. Increase the range of MCP and PIP flexion until the patient loses DIP motion; stabilise in this posture and have the patient try DIP flexion.
• Full Fist: The patient should be able to create a full fist once full independent tendon-gliding is available. Adding resistance to the exercises indicated above can help you progress.



e) Exercises to Reduce an Extensor Lag: Extensor lag occurs when a person has full passive range of extension but cannot actively move the joint through the full range of extension. Extensor lag can be caused by weakness, but it’s most commonly caused by adhesions that hinder the tendons from gliding as the muscles contract.


f) Isolated MCP Extension: Change the patient’s fist from full to hook. If the patient is having trouble keeping the IP joints flexed, have him or her wrap their fingers around the pencil while extending the MCP joint. While performing MCP extension, begin with flexion and extension of the wrist.

• Isolated PIP and DIP Extension: Intrinsic and extrinsic muscle (extensor digitorum communis) control are required for interphalangeal joint extension. Stabilize the MCP joint in flexion as the patient tries IP extension, progressing from full fist to tabletop posture, for the most effective lumbrical participation. With the PIP or DIP joint partially flexed over the edge of a table (or block), go to stabilising the palm of the hand on the edge. Extend the phalanx in question across the range of motion.

• Terminal-Range Extension of IP Joints: Stabilize the entire hand, palm side down on a flat surface, and have the patient stretch the affected phalanx into hyperextension to progress to the terminal range. Place a pencil or block under the proximal phalanx or middle phalanx to increase the range of motion of the PIP or DIP joint.


2. Scar Tissue: Scar tissue adhesions can form where there is inflammation and immobilisation during the healing process after a trauma or surgery, preventing the tendon from gliding.

• The application of friction massage directly to the adhesion is one technique for mobilising sticky scar tissue. Active and passive stretching techniques, as well as tendon gliding procedures, are all used in conjunction with this. Hold the tendon in a prolonged posture and massage perpendicular to the tendon and longitudinally in proximal and distal directions using your thumb, index, or middle finger.


a) To mobilise the long finger flexor tendons: Adhesions between the flexor tendons and their sheaths, or between tendons and the underlying bones, prevent tendon gliding in both directions, so the joints distal to the scar do not flex when the muscle contracts.

• If there are no capsular constraints, passive movements into flexion of the joints distal to the adhering scar are possible. Due to the inability of the tendon to glide distally, full range of motion of the joints distal to the scar is not achievable, either actively or passively.
• Begin the stretching routine by passively moving the tendon in a distal direction by extending the finger joint as far as possible and holding for a sustained period of time to allow for creep.
• Next, use active contraction of the flexor muscle to create a stretch force against the adhesion in a proximal direction using the same patterns of movement as the tendon-gliding exercises.
• If the active and passive stretching techniques outlined above do not relieve the adhesion, extend the MCP and IP joints as far as possible and stabilise them. While holding the tendon in its stretched position, provide friction massage with your thumb or finger at the region of the adhesion. Apply a longitudinal stretch force across the tendon, both proximally and distally, to massage the tendon.
• After friction massage, have the patient repeat the flexor tendon-gliding exercise to make use of any improved mobility.
To Mobilise the Extensor Tendons and the Extensor Mechanism: Muscle activity is not communicated through the mechanism to extend the joint or joints distal to the limitation if the extensor tendons or extensor mechanism have restricted mobility due to adhesions. Extensor lag is the loss of active extension when there is full passive extension without free gliding.
• Stretch the adhesion in a distal direction, then have the patient actively extend the joint and apply proximal strain on the scar.
• Apply friction massage to the adhesion location while keeping the tendon taut by holding the joint at its flexion limit. Apply friction massage across the fibres in a distal and proximal direction, and have the patient contract the extensors to help with the mobilisation effort.
• Extensor tendon gliding activities should be performed after these mobilisation procedures have been completed.


1. Joint Mobilisation:
A) Carpometacarpal and Intermetacarpal Joints of Digits (II-V)
I. Carpometacarpal Distraction:
Stabilisation and Hand Placement: Use the thumb and index finger of one hand to stabilise the appropriate carpal. Grab the proximal end of a metacarpal with your hand.
Mobilising Force: Apply traction to the metacarpal in the long axis to mobilise it.


II. Carpometacarpal and Intermetacarpal: Volar Glide.
Indication: To improve the mobility of the hand’s arch.
Stabilisation and Hand Placement: With one hand’s thumb and index finger, stabilise the carpals; with the other, put the thenar eminence along the dorsal face of the metacarpals to provide mobilisation force.
Mobilising Force: Glide the metacarpal volar ward’s proximal section. See also the cupping and flattening the arch of the hand stretching technique.


• Carpometacarpal Joint of the Thumb: A saddle joint is the CMC of the thumb. The proximal metacarpal has convex abduction/adduction, while the trapezium is concave. The proximal metacarpal is concave for flexion and extension, while the trapezium is convex.

Resting Position: Between flexion and extension, as well as abduction and adduction, the resting posture is in the middle.
• Stabilisation: Use the hand closest to the patient to hold the trapezium in place.
Treatment Plan: The trapezium is treated for abduction and adduction, as well as flexion and extension, in the proximal metacarpal.


I. CarpoMetacarpal Distraction (Thumb)
Indication: Testing, initial therapy, pain management, and overall mobility are all part of the process.
Patient Position: The patient is positioned on the treatment table with his forearm and hand resting on it.
Hand Placement: Use the hand that is closest to the patient to fixate the trapezium. Wrap your fingers around the patient’s metacarpal.
Mobilising Force: To separate the coupled forces, apply long action forces.


II. Carpometacarpal Glides (Thumb)
• Indications:
▪ Ulnar glide to increase flexion.
▪ Radial glides to increase extension.
▪ Dorsal glide to increase abduction.
▪ Volar glide to increase adduction.

Patient Position and Hand Placement: Either grip the trapezium directly or wrap your fingers around the distal row of carpals to stabilise it. Place the thenar eminence of your other hand on the side opposite the desired glide against the base of the patient’s first metacarpal. The thenar eminence’s surface is on the radial side of the metacarpal, causing ulnar glide.
Mobilising Force: Apply force to the metacarpal using your thenar eminence. To align the force, change your body position.


B) Metacarpophalangeal and Interphalangeal Joint of the Finger: The proximal end of the proximal articulating surface is always concave, whereas the distal end is always convex.
Resting Position: All joints are in flexion in the resting position.
Treatment Plane: The distal articulating surface is where the treatment plane is located.
Stabilisation: Place the forearm and hand on the treatment table and use one hand’s fingers to secure the proximal articulating surface.


I. Metacarpophalangeal and Interphalangeal Distraction

Indications: Initial therapy evaluation, pain management, and overall mobility.
Hand Placement: Wrap the fingers and thumb of your other hand around the distal bone near to the joint with your proximal hand to stabilise the proximal bone.
Mobilising Force: To separate the joint surface, use long axis traction.


II. Metacarpophalangeal & Interphalangeal Glides & Progression

Indications:
▪ volar glide to increase flexion
▪ Dorsal glide to increase extension.
▪ Radial or ulnar glide (depending on finger) to increase abduction or adduction.
Mobilising Force: The glide force is applied by the thumb or thenar eminence against the proximal end of the bone to be moved. Progress by taking the joint to the end of its available range and applying slight distraction and the glide force. Rotation may be added prior to applying the gliding force [5].


Splints

Splinting aids in tissue repair and tendons co-optation by weak transplanted hands, as well as providing a foundation for joint contracture prevention.
• The splint can be made dynamic by focusing on MP joint flexion and extension to direct the movements. This encourages tendon gliding and early motions.
• The splint protects the flexor tendons, which can withstand tension because they heal faster than the extensor tendons. As in aiding hand, the hand should be exposed to early functional restoration initially, then primary.
• On the fourth postoperative week, we begin using a dorsal blocking or anti-claw orthosis with thumb opposition.


Dynamic Splints
1) Dynamic Wrist Flexion-Extension Splint: It enables for wrist flexion and extension, as well as the ability to keep any of these movements fixed inside a certain range. It is recommended to help with wrist ROM after flexor or extensor tendon repair or wrist arthroplasty.
2) Metacarpophalangeal Joint Flexion-Extension Splint:
• Depending on the aim, this splint can be both supportive and resistive to flexion and extension movements. This is accomplished by applying a 90-degree angle to the outrigger’s effective pull at the proximal phalanges. Following MCP arthroplasty, soft tissue injury, or extensor tendon repair, it is recommended.
3) Proximal Interphalangeal Joint Flexion -Extension Splint:
• Immobilization of the proximal phalanx is required to localise movements at the proximal interphalangeal joint. As needed, the outrigger rubber band is modified to offer dynamic help and controlled resistance to the middle phalanx.
• This splint is recommended after a PIP joint arthroplasty or as a lower-profile splint after tendon repair.
4) Finger Trapper or Buddy System Splint:
• The active force of one digit is used to mobilise the joints of the neighbouring digit in this basic but unusual dynamic splint. This is recommended as a therapeutic aid for increasing range of motion. It’s employed after a soft-tissue injury, joint disease, or a phalanx fracture, as well as in people who are afraid of pain.
5) Dynamic Thumb Splint:
• A low-profile dynamic thumb splint can be made to hold the thumb in opposition while maintaining web space. By properly setting the outrigger with a rubber hand, it is possible to mobilise the MCP or IP joints of the thumb.
6) Specially Fabricated Controlled Movement Dynamic Splints.



Exercises
The exercise should be progressed to gain more range and strength of the involved joints [6].

1. ROM Exercises:
a) Hand
Straighten your fingers and thumb, and make sure all of your joints are in good working order.
• Make a fist with your fingers contacting the base of your palm at your wrist, then the middle of your palm, and finally the upper palm near your fingers.
• Separate your fingers and bring them back together again.
• Make a fist.
• Squeeze a bottle between your fingers to spread it out.
• Stretch your thumb sideways away from your palm, keeping your hand flat. Stretch your thumb away from your palm, as if you were holding a can of soda, or wrap it around a large jar in the same way.
• Apply pressure to the tips of each finger and the base of the little finger with your thumb.


b) Wrist
• Bend forearm up while keeping palm flat on table or chair (hand push up).
• Place palms together and elevate forearms in the air, stretching the wrists upside down.
• Place forearm on table, palm up, with handoff edge; place dumbbell weight in palm for stretch.
• Wrist should be moved from side to side.
• Make big circles with your wrist.
• Keep your back hand on the table and bend your forearm towards you.
• Bring the backs of your hands together and bend your forearms down, stretching the tops of your wrists.


2. Strenghtening Activities




• Therapy putty
• hand helper/hand grip squeezers
• stacking cones
• nuts and bolts
• bend fingers against resistance of sand bag weights hung on IV poles
• turn faucets & door knobs
• open bottles and jars
• use tools such as hammers & pliers


1. Coordination/Dextrity Activities




• Dealing & playing cards
• pegboard
• lacing activities
• Shooting marbles, playing jacks, etc.
• cutting with scissors
• tearing tape
• turning pages
• crafts-painting, drawing, ceramics, making models
• typing


D) Sensory Re-education:
• Sensory education is a method for retraining or stimulating atypical sensory pathways.


1. Quick Phasic Withdrawal:
• If the stimulus is transient and unpleasant in nature, it will elicit a short-term protective response; stimuli like as pain, temperature, fast movement, and light touch are likely to elicit these responses via activating free nerve endings.


Stimulus: pain
- Cold 1 sweep with ice cubes
- Light touch brushing / stroking.


Response:
a) Extensor surface stimulus causes flexion withdrawal;
b) Flexor surface stimulus causes flexion withdrawal from extension.


2. Prolonged Icing:
• The goal of this approach is to reduce body temperature during a fever or inflammation by inhibiting hyper tonicity or discomfort.


Stimulus:
-ice cubes: reticular activating system
-Ice chips and wet towel
-Bucket of ice water
-Ice pack
-Immersion


Response: muscle inhibition


3. High Intensity Icing/Repetetive Icing:
• To facilitate, an ice cube is massaged for 3-5 seconds in a rapid sweep motion over the muscle belly.
• This approach can also provide unpredictably unpressurized outcomes. Although the phasic withdrawal pattern generates a response, the phenomenon causes the muscle that has been stimulated to drop its resting potential.


4. Neutral Warmth:
• When utilised as an isolation intervention, a 3-4 minute tepid bath can achieve the same outcomes as a 15 minute entire body wrapping therapy.


Stimulus: Airbag splints
Wrapping entire body with towel
Light clothing (tight, jerseys)
Tepid water / shower.


Response: The area where the heat is administered is inhibited.


5. Light Touch, Rapid Stroking: Many treatment tools, such as position, balance in space perception task, become available after the individual can differentiate light touch path for discriminatory learning protection.


Stimulus: An identified dermatome/myotome interaction region was given a light intermittent tactile stimulus.


6. Maintained Stimulus/Pressure: By blocking other inputs from entering the system, it will successfully create inhibition. To normalise skin responses, it is administered to hypersensitive areas.

Stimulus: a) slow rubbing the target area with towel.
b) Wearing spandine clothing.

Response: Sensory receptor adaptation &decrease in afferent firing.


7. Stretch: All sensory input systems that are stretch receptors in muscle and herghten motor pool are quick stretch and maintained stretch. It increases the sensitivity of an agonist and decreases the excitation of antagonistic muscle stretch information, which is delivered to higher brain centres for sensory integration and awareness.


Methods to apply stretch:

• The power of the hands and their individual muscles to stretch the manual weight system.
• Suspension workouts, such as pillats.
• The patient’s own weight in relation to gravity.
• A sophisticated robotic system


8. Tapping: The stimulation of tapping tendons is largely non-discriminatory.


• It determines a muscle’s degree of stretch sensitivity, and the response is a rapid muscle contraction, however tapping the muscle belly is pref


9. Electrical Stimulation:
It is an outstanding muscle spindle facilitatory technique that uses a combination of voluntary movement, proprioceptive sensory feedback electrical stimulation, and power assisted FES therapy to help improve defective sensory motor integration.


10. Vibration: They are two methods:

A) Hand held vibration: The purpose of hand-held vibration is to help Ia receptors enhance agonistic contracture in hypotonic contracture and block hypertonic agonist.

B) Total Body Vibration: Postural tone and balance vibrators registering 100-125HZ are used to assist total body vibration. Hand vibrations powered by a battery work at a frequency of 50-90Hz, which has a lower inhibitory impact on normal muscle than 75Hz. High frequency vibration (100-300HZ) elicits a reflex response called tonic vibratory response in muscles/tendons, although frequencies more than 150HZ are harmful to skin and cause pain and discomfort.


11. Inhibitory Pressure: Constant mechanical force, such as cones, pads, and orthokinetic cuffs, is inhibiting. When administered over the longitudinal sections of a tendon, it was effective. The application of pressure to a bony prominence has a modulatory impact.


Modalities
1. Electrical Muscle Stimulation:
• Pain relief, oedema reduction, muscular strengthening, and wound healing are all benefits of electrical stimulation.
• Nerve and muscle stimulating currents are frequently helpful in the treatment of any illness in which the patient’s voluntary control of skeletal muscle has been compromised.
• Electrical stimulation stimulates the affected muscle, resulting in active joint range of motion in the absence of voluntary muscle control.
• This will help the patient until he or she regains voluntary muscle control. Monopolar or bipolar alternating currents, as well as direct currents, help to efficiently manage the difficulties that arise in patients who have been thermally wounded.
• Muscle elasticity is preserved when bipolar or monopolar direct current muscle stimulation is used before muscle reinnervation.
• After a diagnosis of denervation has been established, electrical muscle stimulation is usually started as soon as possible.
• Electrical stimulation at a high enough level to elicit a visible contraction of the affected muscle for two or more sessions per day is useful.
• Alternating current that is bipolar, pulsed, or surged helps to reduce oedema and promote joint range of motion.
• The patient is positioned to help with oedema reduction, with electrodes applied to the skin near the oedematous area. To expand joint range of motion, pulsed or surged alternating current is utilised to loosen stuck tendons or dissolve calcium deposits.
• The extremity is stretched to its maximum length and all proximal joints are stabilised while utilising electrical stimulation to increase range of motion.
• The current’s intensity should be high enough to elicit a noticeable contraction in the agonistic muscle or muscular group involved in the adherence.
• For muscle re-education and functional range of motion, an alternating current at a high enough intensity to elicit a muscle contraction through the greater part of the available range of motion is recommended.
• To successfully depolarize the underlying nerve, a greater intensity current is required. As a result, there is a danger of tissue damage, especially when using direct current for an extended period of time. Because of the lower skin resistance to the current and the patient’s apparent ability, electrical stimulation should be avoided over recently healed areas or recent grafts.



2. Transcutaneous Electrical Stimulation: In various sorts of impaired people, transcutaneous electrical nerve stimulation [TENS] has been utilised in physical therapy to control both acute and chronic pain.
• It’s suspected that low-frequency TENS aids the release of endogenous opiates, which have an analgesic effect similar to morphine.
• Low frequency TENS tends to provide relief to those with dull, persistent, and less localised pain.
• Stimulators typically have two or four electrodes positioned in the myotonal or dermatomal distribution, with electrode pairs administered in a crisscross or linear pattern across the painful area. However, the conductive gel and electrode tape required to apply some surface electrodes irritate newly healed skin and can’t be utilised on open areas. Skin irritation can occasionally be solved with disposable, self-adherent electrodes. Most TENS machines include a number of different stimulus parameters that can be changed.
• Depending on the patient’s tolerance, pain kind, and desired outcomes, changes in pulse width, stimulation rate, and intensity can be made.



3. Biofeedback: Biofeedback is an effective therapy for muscle relaxation and re-education, as well as addressing neurological impairments, improving wound healing, encouraging normal mobility, and boosting general patient relaxation.
• When the patient’s goal is to either increase motor activity or attain muscular relaxation, the electromyographic biofeedback unit should be considered as a medium.
• Three electrodes, two active and one ground, are placed on the patient’s skin over the appropriate muscle belly with electrode gel and tape to use the biofeedback.
• Increases in skin temperature indicate that thermal biofeedback can be utilised to boost peripheral blood flow. Instructing the patient on how to elevate his peripheral body skin temperature relieves muscle and joint pain and speeds tissue recovery.
• The movement of metabolites and electrolytes down the adrenergic neurons that innervate skin blood vessels has been postulated to be stimulated by thermal biofeedback with relaxation.
• The metabolic process is changed, which improves neuronal excitability, synaptic transmission, and muscle cell function. This device gives auditory and visual feedback when the skin temperature changes.



4. Paraffin and Sustained Stretching: Paraffin, which offers superficial heat and lubrication, is best applied to healed scars before physical activities, in conjunction with static stretching.
• After considerable healing has occurred, the combination of paraffin and sustained stretch is usually started late in the acute period of rehabilitation and is usually continued throughout the patient’s rehabilitation.
• When a painful and constricting scar impairs joint range of motion, paraffin is recommended. If you don’t want to use commercially available premixed paraffin, a mixture of two and a half ounces of mineral oil and one pound of paraffin can be used instead.
• Paraffin is kept at a temperature of 51.7-54.4 degrees Celsius on a regular basis. Paraffin should not be used on recently healed, fragile, or insensitive skin.
• Dip the hands, elbows, and feet in paraffin 8 to 10 times or until they are thoroughly coated, then cover with plastic and wrap in a towel or elastic bandage to prevent heat loss. Maintaining the stretch posture is made easier with the use of sandbag weights, splints, and restraining ties.
• The average paraffin treatment time is 20 minutes.



5. Fluidotherapy: When looking for a thermotherapeutic agent to relieve pain or improve range of motion in a body part, especially a foot or hand, the fluidotherapy unit should be explored.
• Fluidotherapy combines the benefits of massage with the ability to exercise while administering heat to a specific body region. Some of the larger apartments feature a separate entrance for the therapist, who can assist the patient with vigorous exercise.
• A dry whirlpool of finely divided solid particles suspended in a heated air steam has the qualities of a liquid, and the temperature can be adjusted between 95 and 130 degrees Fahrenheit.
• Because the unit’s solid particle medium is selfsterilizing, it can be utilised to treat a wide range of diagnoses without risk of infection or contamination. During a 20-minute treatment, this device provides greater heat to the body portion than a paraffin or hydrotherapy dip approach.
• The body part is placed horizontally into the medium to utilise the device, which reduces the likelihood of the part swelling. Treatment can be sustained with this technique by shielding small open regions. Any form of surface heat is a contraindication for fluidotherapy.



6. Ultrasound: Ultrasound is a vibrating energy with a frequency that is too high to stimulate the human ear’s sensory receptors.
• Therapeutic ultrasound is delivered via direct touch or submerged methods at intensities of no more than three watts per square centimetre.
• For small areas with irregularly shaped surfaces, such as fingers and ankles, ultrasonography under water is recommended.
• Ultrasound’s thermal and non-thermal effects, as well as its depth of penetration, make it an effective modality for treating a wide range of physical problems in thermally wounded patients.
• Ultrasound is an excellent method for reducing pain associated with peripheral neuropathies or neuronal pain following amputation because of its physiological action.
• When pain is caused by increased connective tissue proliferation, such as in severe scarring, polypeptides absorb ultrasonic energy and cause these bonds to relax, resulting in a reduction in painful feelings.
• If the therapist applies cold massage to the affected scar tissue before applying ultrasound, the patient typically gets a significant reduction in pain.
• Using a continuous movement approach with the ultrasound head raises the temperature of the underlying muscle tissue by 1-2 degrees Celsius.
• Increased blood flow to the area is facilitated by an increase in tissue temperature, resulting in reduced pain and tissue relaxation.
• Ultrasound enhances the suppleness of tendon, muscle, connective fascia, and most scar tissue, allowing for an improvement in range of motion.
• The effects of increased blood flow to the area can persist up to an hour following a five-minute exposure to ultrasound. Ultrasound is recommended for enhancing joint range of motion in people who have had bursitis or tendinitis for a long time.
• The increase in range of motion could be attributed to calcium deposits being absorbed or the ligamentous tissues being more supple.




Late Phase of Restoration
• We use a variety of tools, including weights, wall pulleys, ergometers, and thera-bands.
• Transcutaneous electrical stimulation is used to help with muscle re-education and pain control. for pain management.
• At this level, all grades of joint manipulation and mobilisation techniques, as well as PNF techniques, are safe and effective if force and resistance are carefully controlled.
• Job-specific functional training should be provided.
• By 16-20 weeks, the transplanted hand should have acceptable function again.


Special Tests
A) “Seddon’s” Coin Test:
The patient, whose eyes must be closed, is given a coin and asked to identify it. If he has a median nerve lesion, he must not cheat by pushing the coin towards an area of normally sentient skin. I believe this test is now of historic interest, except that coin identification is included in the object recognition test [7].


B) Porter’s “Letter Test”:
In 1966, Porter, 36 then an Orthopaedic Registrar at King Edward VII Hospital in Sheffield, England, described a “simple objective test for fingertip sensation which is believed to be a more accurate index of tactile sensation and is less time-consuming than the conventional tests.” Porter uses metal typesetting letters, H, 0, U, V, Y of approximately 1.0 X 0.8 cm in size with the letters standing out in relief. The patient “runs his fingertip over the surface as a blind person would read Braille. Five letters are examined unhurriedly in one hand, and the patient then applies the letters himself to the pulp under test. Incorrect identification or failure to identify the letter after 30 seconds is recorded as an error, and a score is obtained out of five [7].


C) Wrinkle Test:
It is common knowledge that our fingertips become wrinkled like prunes when we bathe. In 1973, O’Rain37 observed that denervated skin lost this ability. An attempt to study this phenomenon in patients with nerve injury and nerve compression, comparing wrinkling with classic two-point discrimination and Ninhydrin, has been reported (Fig. 6.9).38 Patients with complete nerve injury had no wrinkling, no two point discrimination, and no sweating. Patients with nerve compression had no correlation among the sestets, that is, two-point discrimination was abnormal (greater than 15 mm), wrinkling was normal (in five of the eight patients), and ninhydrin staining was variable (normal in 3/8 and near normal in 5/8). I do not believe this test has clinical value [7].


Scales to Assess the Hand Functions
A Comprehensive Functional Score System in Hand Transplantation
Marco Lanzetta, Palmina Petruzzo
In 2002, a worldwide registry [8] was created to provide a basis for cooperation by all teams Performing hand transplantations: International Registry on Hand and Composite Tissue transplantation (IRHCTT); www.handregistry.com. When gathering data for the presentation of a comprehensive report by the registry at the 2002Hand and Composite Tissue Allograft meeting in Italy, it was evident that we needed to adopt a common functional score system, as none of the existing ones could be adapted due to the fact that they were used mainly for evaluating results of hand/limb replantation [3,9,10] or disability due to single or multiple disorders of the upper limb [4,5,6]. The unique nature of hand transplantation requires evaluation of a general and complex outcome. It must include specific parameters, such as cosmetic appearance, colour, size and shape matching with the contra lateral hand (in case of a single hand); psychological and social effects of the procedure; and the result as a whole. The main purpose of this score is to allow evaluation of cosmetic and functional results as well as to take into account “what really happened to the patient” following hand transplantation, assessing his or her psychological outcome, social behaviour, work status, satisfaction, body image and well being (Table 1). The importance of body image must specifically be taken into consideration; usually,


The Hand Transplantation Score System (HTSS) as Adopted by the International Registry of Hand and Composite Tissue Transplantation
The score system is based on a value of 100points, which involve six items with different Weight: appearance (15), sensibility (20), movement (20), psychological and social acceptance (15), daily activities and work status (15), patient satisfaction and general well-being (15). A total result of 81-100 points is graded as an excellent outcome, 61-80 as good, 31-60 as fair and 0-30as poor. The new scoring system is easy to use, and correlation with the Disabilities of the Arm, Shoulder and Hand (DASH) score [11], which was designed to measure upper-limb disability and symptoms, is excellent. This scoring system has good test-retest reliability and responsiveness. Furthermore, it allows measurement of the “ability and the performances” of the grafted patients instead of measuring the disabilities of proximal or distal parts of upper extremities (Table 1). In Table 2, the score of all European patients is reported. It is important to note that the recipients present a different follow-up, ranging from 2 to 6 years.






Dash
The DASH (Disabilities of the Arm, Shoulder, and Hand) questionnaire has been developed to measure disability and symptoms related to upper extremity musculoskeletal disorders, thus eliminating the need for separate questionnaires for the shoulder, wrist, or elbow. The 30-item questionnaire includes 21 physical function items, 6 symptom items, and 3 social/role function items. There are also two optional 4-item modules: one intended for athletes and musicians, and the other for working populations.
Disability/symptom score At least 27 of the 30 items must be completed for a score to be calculated. The assigned values for all completed responses are simply summed and averaged, producing a score out of five. This value is then transformed to a score out of 100 by subtracting one and multiplying by 25.This transformation is done to make the score easier to compare to other measures scaled on a 0-100 scale. A higher score indicates greater disability. Optional modules (sport/music or work) Each optional module consists of four items, which may or may not be used by individuals because of the nature of the questions. The goal of the optional modules is to identify the specific difficulties that professional athletes/performing artists or other groups of workers might experience but which may not affect their activities of daily living and consequently may go “undetected” in the 30-item portion of the DASH. The same procedure described above is followed to calculate the optional four-item module score. All four questions must be answered in order to calculate the score. Simply add up the assigned values for each response and divide by four (number of items); subtract one and multiply by 25 to get a score out of 100. Missing Items If more than 10 percent of the items (that is, more than three items) are left blank by the respondent, you will not be able to calculate a DASH disability/symptom score. By this same rule (that is, no more than 10 percent of the items can be left blank), no missing values can be tolerated in the high-performance sports/ performing arts or work module because the module consists of only four items. This missing data “rule” applies to both the original and revised scoring methods. DASH disability/symptom score = [(sum of n responses) - 1] x 25, where n is equal to the number of completed responses.




Case Studies

Case-1:
A 16 year old female patient with crushed injury of right index finger with PIP joint dislocation. I got this case at Ankapalli at “Usha prime” hospital and I have done the follow up for 3 months. The injury occurred due to accidental pulling of the right hand into washing machine on 5th may, 2018. Past` medical history showed no contraindications for replantation history showed no contraindications for replantation. Deformity of the right hand index finger present with decreased pulsations. An open reduction was accomplished and bone fixation was done with Kirschner wires. Primary skin closure was accomplished upon discharge from the hospital the finger was vascularly intact with good capillary refill and the wound was healing well. After 1week of immobilisation, the cast was removed and rehabilitation programme was started. Joint mobilisation and active ROM exercises were taught to the patient to be carried out at home. During the 4th week of post-replantation the pin was removed from the finger following an X-ray to determine the extent of bony healing. Active range of motion measures were taken and gentle AROM, as well as grade-1 mobilisation was begun. Light precision activities are initiated to encourage AROM. At 5 weeks of post-replantation the wounds were healed. The patient was instructed how to use her hand regarding particular functions. Writing practice, buttoning, holding a key, picking up objects were encouraged for functional use.




Case -2:
The patient was a 30 year old male, status post closed oblique fracture of the proximal phalanx digit 3 and replantation of digit 2 at the proximal phalanx of the right dominant hand. The injury occurred when the patient caught his hand in a machine at work. Past medical history showed no contraindications for replantation.


A closed reduction was accomplished with digit 3. Digit 2sustained a relatively clean cut around the finger just distal to the MCP joint. The fracture was fixated with cross k-wires. Radial and ulnar digital nerves were repaired. Two venous anastomoses were performed with two vein grafts to repair the digital arteries. The flexor digitorum profundus tendon was repaired. Primary skin closure was accomplished. Upon discharge from the hospital the finger was vascularly intact with good capillary refill, and the wound was healing well. Repeat X-rays showed both fractures to be non-displaced and non-angulated. After 3 weeks of immobilisation, the cast was removed and the patient started therapy. Sutures were in place, cross k-wires were protruding from the patient skin, and small open areas were present around the replantation site. The wound was debrided following a whirlpool treatment. The patient was issued written instructions in wound care and how to bandage his hand. A protective splint was fabricated, positioning the wrist in neutral, with MCPs flexed and IPs extended. Written instructions on care, wearing time, and precautions were reviewed and issued to the patient. Whirlpool and debridement were continued until the wounds were healed. The wrist, thumb, and digits 3 through 5 were stiff from being caste so joint mobilisation was begun and active ROM exercises were taught to the patient, to be carried out at home. Exacting stabilising was utilised during gentle grade 1 mobilisation of MCP, PIP, and DIP joints of digit 3. Minimal movement was noted at the digit 3 PIP. Gentle active movement was encouraged at this joint.


During the 4th week post-replantation, the pin was removed from digit 2, following an X-ray to determine the extent of bony healing. Active range of motion measures were taken, and gentle AROM, as well as grade 1 mobilisation with exact stabilisation, was begun at the PIP and DIP joints of digit 2. Light Prehension activities were begun, alternating each digit with the thumb to encourage AROM.


At 5th week post-replantation, the wounds were healed. Oedema was evaluated and a coban wrap issued to decrease the oedema in digits 2 and 3 as well as an isotoner glove to be worn overnight to decrease the minimal oedema present in the entire hand. Passive range of motion was evaluated, and gentle PROM exercises were begun. A flexion assist splint was fabricated to increase passive flexion of all the joints of digits 2 and 3. Bunnell blocks to increase active PIP flexion of digits 2 and 3 were also fabricated. An ADL evaluation revealed that the patient had difficulty eating and cutting meat with the involved hand, so built-up handled utensils were issued to encourage the patient to begin using the impaired hand. He had difficulty with many bilateral tasks, and was instructed as to how he could use what function he had in the involved hand to complete these tasks. Writing practice was begun to further encourage functional use.


Once oedema subsided somewhat, a sensory evaluation was completed, which revealed moving touch to be grossly intact but localisation to be absent. Hot-cold and deep touch were absent, rendering digit2 essentially anaesthetic sensation elsewhere in the hand was intact.


At approximately 6weeks post-replantation, the fracture sites were healed sufficiently to withstand stress. The hand function test and manual muscle test were administered, as well as dynamometer and pinch-meter readings to access strength. More aggressive passive stretching was tolerated, and resistive hand strengthening exercises were begun. MCP joint ROM was normal in digits 2 and 3, so an MCP block was added to the dynamic flexion splint so that the flexion forces would be concentrated at the PIP joint and DIP joint. Heavy resistive activities were gradually added, particularly those involving to use, as this was part of his job requirement. He was being followed by a vocational counsellor throughout this outpatient status and until he returned to work.


At the time of discharge, gross grasp measured 36lb, palmar pinch 5lb, and lateral pinch 8lb. Sensation improved significantly, with 7mm of moving two point discrimination on the radial and ulnar aspects of digit 2. Active range of motion was normal throughout the hand, with the exception of digit 2PIP joint, which measured 15-60 degrees of motion and digit 3 PIP joint which measured 0-95degrees.


A follow-up evaluation 1½ years post-replantation reveals the following status; PROM of digit 2PIP joint improved to 5 to 80 degrees, AROM 5 to70degrees. PROM of digit 3 PIP joint measures 0-100 degrees and AROM 0 to 90degrees.Gross grasp is now 52lb, compared to 75lb on the left palmar pinch is 25lb, and lateral pinch is 20lb.Palmar and lateral pinch are now equal to that of the left hand. Sensation shows significant improvement and is now considered normal, with 3mm of moving two-point discrimination in the autonomous zones of the digital nerves to digit 2-5mm of static two point discrimination. The patient is independent in activities of daily living, (i.e., dressing, eating, hygiene, and variety of simple home tasks.) He cannot sustain an activity that requires power gripping or heavy resistance, due to pain in the involved digits. As a result, although he has returned to work, his job has been modified to eliminate these types of tasks. The patient experiences hypersensitivity to cold, although appears to be less sensitive 1 ½ years post-replantation than he was upon discharge from an active therapy program.


Review Literature

1) Rehabilitation Following Hand Transplantation
Ericka Bueno, Marie-Jose Benjamin, Geoffroy Sisk, Christian E. Sampson, Matthew Carty, Julian J. Pribaz,Bohdan Pomahac, and Simon G. TalbotHand (N Y). 2014 Mar; 9(1): 9-15. Published online 2013 Oct 18.


The BWH Therapy Protocol
The Brigham and Women’s Hospital (BWH) Hand Transplantation Team’s post-hand transplant rehabilitation protocol is presented here. The protocol must be modified to address each transplant recipient’s unique needs. It builds on universally used modalities of hand rehabilitation such as splinting, oedema and scar management, and range of motion exercises, activities of daily living training, electrical stimulation, cognitive training and strengthening. The BWH hand transplant rehabilitation protocol consists of four phases with distinct goals, frequency, and modalities. (1) Pre-operative: functional assessments are completed and goals and expectations of transplantation are established. (2) Initial post-operative (post-operative weeks 1-2): hand protection, minimization of swelling, education, and discharge. (3) Intermediate (post-operative weeks 2-8): therapy aims to prevent and/or decrease scar adhesion, increase tensile strength, flexibility and function, and prevent joint contractures. (4) Late (from 8 weeks forward): maximization of function and strength, and transition to routine activities. The frequency of rehabilitation therapy decreases gradually from the initial to late phases. Rehabilitation therapy after hand transplantation follows a progressive increase in activity in parallel with wound healing and nerve regeneration. Careful documentation of progress and outcomes is essential to demonstrate the utility of interventions and to optimize therapy protocols.


2) Multivariate Analysis of Factors Influencing the Functional Recovery after Finger Replantation or Revascularization
Dr. Haw‐Yen Chiu M.D. Shyh‐Jou Shieh M.D. Hsiu‐Yun Hsu O.T. First published: 1995 https://doi.org/10.1002/micr.1920161010


A multivariate statistical analysis was utilized to study the influence of the four preoperative (age, mechanism of injury, level of injury, and type of amputation) and one postoperative (rehabilitation) variables on the functional recovery of the replanted or revascularized finger. Statistically significant differences are summarized as follows. The young age groups have a better functional recovery due to better sensory recovery than the old age group. The crush injury groups have a better functional recovery, with better scores in motion and patient satisfaction, than the avulsion injury group. The middle phalange injury groups have a better functional recovery, with better score in motion and sensation than the proximal phalange injury group. There is no statistically significant difference in functional recovery between the revascularized and replanted fingers, but there is a significantly better sensory recovery in the revascularized finger. The rehabilitation group has a better functional recovery, with better score in motion, subjective symptoms, and patient satisfaction, than the non rehabilitation group. © 1995 Wiley‐Liss, Inc.


3) Major Limb, Hand, and Digital Replantation
World Journal of Surgery January 1979, Volume 3, Issue 1, pp 17-28| Cite as Authors: Takehiko Susumu Tamai, Yoshihide Hori, Yoshitaka Tatsumi, Hisao Okuda, Hisao Okuda, Yoshiya Nakamura, Hiroshi Sakamoto, Takita


Successful replantation of an amputated extremity depends mainly upon the accurate repair of blood vessels, but the final goal must be complete restoration of function. Before a decision to replant is made, the extent of tissue damage, the patient’s age and general condition, sex, occupation, and the patient’s wishes regarding replantation are evaluated. All tissues that influence survival of the replanted part and its ultimate function must be repaired primarily. An operating microscope should always be used for the vascular and nerve repairs, especially in digital replantation. Good postoperative management is the final key for successful replantation, and includes prevention of thrombosis and adequate rehabilitation.


Rehabilitation is begun on the first post-operative day, but several reconstructive operations may be necessary on the replanted part to achieve improved function.


4) Replantation of Hand Multi-Level Severances with 17 Segments
Author links open overlay panelJian-XiHouShu-QiangXieHua-FengZhangQi-QiangDongMing-WuZhangZhao-SenWuHong-XinWang


https://doi.org/10.1016/j.injury.2014.03.005Get rights and content


The patient was 18-year-old female with multi-level severances due to cutting injury. During the surgery, we adopted unifying coordination and grouping surgery. Moreover, we tried to improve the quality of vascular anastomosis with various measures and shorten operative time. Postoperatively, we closely observed the patient to effectively prevent and treat vascular crises. Furthermore, we acquired utmost hand function recovery through enhancing functional rehabilitation exercise. The case was followed- up regularly. As a result, the replanting palm and all fingers survived successfully. At 5-year follow-up, the Prehension function of the hand was restored and the patient was capable of general labour and normal activity with the replanted hand. Postoperative functional rehabilitation exercise can restore utmost hand function. Upper-extremity limb loss has a significant psycho-social impact on the individual, in terms of both aesthetic and functional aspects. While amputees can be fitted with mechanical prosthesis and advances in upper-limb prostheses will offer more options for amputees, they cannot fully duplicate the intricate actions of a native hand. Hand transplantation aims to provide a hand that looks more natural than prosthesis, and which restores some sensation and movement. Hand transplantation is a complex operation (can take up to 16 hours -- twice the time of the average heart transplantation); but is not as difficult as a hand replantation because the latter usually involves severely damaged tissues. When performing a hand transplant, surgeons first fix the bone, and then repair tendons, arteries, nerves and veins. Postsurgery complications can include poor circulation, infections and rejection. Before the operation, psychological assessment is needed of a patient’s motivation and likely compliance with post-operative rehabilitation and immuno-suppressive medication. Following the procedure the limb may be immobilized in a plaster splint for a number of weeks. The patient should undergo intensive rehabilitation, including physiotherapy, occupational therapy and possibly electro-stimulation for best restoration of function.


5) Cognitive Re-Education and Early Functional Mobilisation in Hand Therapy after Bilateral Hand Transplantation and Heterotopic Hand Replantation--Two Case Reports.


Piza-Katzer H, et al. Acta Neurochir Suppl. 2007.

The main challenge for a successful hand therapy after heterotopic hand replantation is the re-education of patients’ sensory and motor perception.


The case of a 28-year-old patient is described. After resection of a tumour and amputation of the elbow, tendons of the hand had to be joined to only three muscles of the upper arms. Elbow extension and flexion had to be trained to control the wrist, fingers,and thumb movements. In a similar way, the main focus after orthotropic hand transplantation lies on retraining the wrist, finger, and thumb functions. This is illustrated by a second case of a patient who had lived for 5 years with myoelectric prostheses on both lower arms and had forgotten these functions. The final aim in both cases was regaining of daily living and working skills. The therapy was started with fitting supporting thermoplastic splints. Early motioned passive and passive-assistive active mobilization prevented tendons adherences and initiated hand-functions. An intense sensory remaining programme and cognitive therapeutic exercises ensured the sensory and motoric activation of the referring cortical hand aerials. At conclusion of therapy it can be said that both patients have fully taken up their professional duties again and that they are able to manage successfully their activities of daily living on their own.


6) Evaluation of the Effectiveness of Sensory Re-Education Following Digital Replantation and Revascularization

Shyh‐Jou Shieh M.D., Haw‐Yen Chiu M.D., Jing‐ Wei Lee M.D., Hsiu‐Yun Hsu B.S.

First published: 1995

Sensory recovery following digital replantation plays an important role in the restoration of hand function. Twelve patients with twenty‐four replanted or revascularized digits were randomly selected to enter a program of sensory re-education, and another 15 patients with 22 replanted or revascularized digits were selected as controls who did not receive sensory re-education. The period of sensory re-education was 18.83 weeks on average, and the mean follow‐up time was 11.94 months. The group that received sensory re-education significantly improved to a better degree of moving two‐point discrimination and Semmes‐Weinstein threshold level by both univariate and multiple regression analysis. We suggest that sensory re -education should be an integral part of the postoperative rehabilitation protocol following digital replantation and revascularization. © 1995 Wiley‐Liss, Inc.


7) Sensory Recovery in Replanted Digits and Transplanted Toes: A Review.

Dellon AL. J Reconstr Microsurg. 1986.

A review of replanted digits has indicated that excellent sensory function can be recovered in replants that are distal, in which the mechanism of injury has been a sharp cut, in which the patient’s age is young, and in cases where the patient receives postoperative sensory re-education. Future improvements in recovery of sensation in replanted digits may come from increased use of nerve grafting in those digits that have been crushed or avulsed, and by instituting routine sensory re-education in the postoperative period.


8) Fingertip Replantation After Amputation: Report of 32 Fingers.

Ren GH, et al. Di Yi Jun Yi Da Xue Bao. 2004.


To describe the surgical techniques and our experiences in finger tip replantation after amputation. On the basis of examination of the anatomic features and the degree of fingertip vascular injury, 32 amputated fingertips in 26 cases were replanted, and flexible revascularization procedures of both artery and vein anastomoses, artery-only anastomosis, arterialized vein and arteriovenous anastomosis were adopted. All the replanted fingertips were trained with comprehensive rehabilitation program. Fingertip replantation after amputation can achieve not only high survival rate but also satisfactory appearance and functions as long as appropriate operative procedures are adopted with comprehensive rehabilitation therapy.


PMID: 15321773 [Indexed for MEDLINE]


9. Functional Outcomes after Bilateral Hand Transplantation: A 3.5-Year Comprehensive Follow-Up
Since the first successful hand transplantation in 1998, 72 patients have been operated on for unilateral/bilateral hand transplantation across 13 countries.


This article reports functional outcomes in a patient with bilateral hand transplants at a mid-forearm level with serial follow-ups over 3.5 years. Different parameters used to study the functional outcomes include the Disabilities of the Arm, Shoulder, and Hand score, the Carroll test, the Hand Transplant Score System, the Short Form-36 Health Survey, and routine occupational therapy measures. Various task-oriented outcomes were also assigned to provide milestones to the recovery. The patient had a Disabilities of the Arm, Shoulder, and Hand score of 40, a Carroll test score of 48 (right) and 49 (left), and a Hand Transplant Score System score of 58 (right) and 57.5 (left) at 3.5-year follow-up. Interestingly, his objective scores did not change significantly during the follow-up, but he continued to function quite independently and is subjectively pleased with his outcomes. Multiple functional outcome measures provide an objective way to follow patients who have undergone hand transplantation. The authors propose a series of measures to elucidate subtleties in functional gains. However, use of this series in isolation may belie subjectively good results. They also propose a series of milestones in the recovery to give a better real-world explanation of progress.


10) Management of Hand and Finger Injuries
The role of hand therapists in treating sports-related injuries of the upper limb has evolved over the past century. Effective treatment and application of physical modalities depend on accurate diagnosis and appreciation of the cause of injury. Rehabilitation protocols and progression must be based primarily on the physiologic responses of tissue to injury and on an understanding of the wound healing processes of various tissues. Thus, in acute injuries clinical evaluation should focus on the effect of the injury since the degree and nature of tissue disruption have more impact on therapy than the cause of the injury. Conversely, in overuse injuries the intrinsic and extrinsic causes should be considered to eventually achieve effective treatment.


11) Human Hand Allograft: Report on First 6 Months

Prof, MD Email the author Prof Jean-Michel Dubernard

Volume 353, No. 9161, p1315-1320, 17 April 1999

On Sept 23, 1998, we transplanted the right distal forearm and hand of a brain-dead man aged 41 years on to a man aged 48 years who had had traumatic amputation of the distal third of his right forearm. The donor’s arm was irrigated with UW organ preservation solution at 4°C, amputated 5 cm above the elbow, and transported in a cool container. We dissected the donor limb and the recipient’s arm simultaneously to identify anatomical structures. Appropriate lengths of viable structures were matched.


Transplantation involved bone fixation, arterial and venous anastomoses (ischemic time 12·5 h), nerve sutures, joining of muscles and tendons, and skin closure. Immunosuppressant included antithymocyte globulins, tacrolimus, mycophenolic acid, and prednisone. Maintenance therapy included tacrolimus, mycophenolic acid, and prednisone. Followup included routine post-transplant laboratory tests, skin biopsies, intensive physiotherapy, and psychological support. The initial postoperative course was uneventful. No surgical complications were seen surgery. These signs disappeared after prednisone dose was increased (from 20mg/day to 40mg/day) and topical application of immunosuppressive creams (tacrolimus, clobetasol). Intensive physiotherapy led to satisfactory progress of motor function. Sensory progress (Tinel’s sign) was excellent and reached the wrist crease (20cm) on day 100 for the median and ulnar nerves, and at least 24 cm to the palm by 6 months when deep pressure, but not light touch sensation, could be felt at the mid palm.


12) Functional Results of the First Human Double-Hand Transplantation

Jean Michel Dubernard, MD, PhD,* Palmina Petruzzo, MD,† Marco Lanzetta, MD,‡ Helen Parmentier, PT, CHT,§Xavier Martin, MD,* Marwan Dawahra, MD,* Nadey S Hakim, MD, PhD,¶ and Earl Owen, MD║


Ann Surg. 2003 Jul; 238(1): 128–1362 The recipient was a 33-year-old man with bilateral amputation. Surgery included procurement of the upper extremities from a multiorgan cadaveric donor, preparation of the graft and recipient’s stumps; then, bone fixation, arterial and venous anastomoses, nerve sutures, joining of tendons and muscles and skin closure. Rehabilitation program included physiotherapy, electro stimulation and occupational therapy. Immunosuppressive protocol included tacrolimus, Prednisone and mycophenolate mofetil and, for induction, antithymocyte globulins and then CD25 monoclonal antibody were added. Sensorimotor recovery tests and functional magnetic resonance imaging (fMRI) were performed to assess functional return and cortical reorganization. All the results were classified according to Ipsen’s classification.


13) Rehabilitation of Patients After Finger Replantation
The aim of the present study was to assess results of rehabilitation of patients after finger replantation. The study examined 160 fingers amputated and replanted at various levels between 2000 and 2013 at the clinic. Mean patient age was 29.4 years. Mean follow-up time was 23 months. Rehabilitation of fingers began between postoperative fourth and eighth week and continued until the 24th week. Range of motion of affected hand, return to daily activities, aesthetic appearance, and patient satisfaction were assessed according to Tamai criteria. Functional results according to Tamai criteria were perfect in 36 patients, good in 54 patients, average in 27 patients, and poor in 18 patients. Post-operative rehabilitation of replanted fingers should begin as soon as possible. During the rehabilitation period, physiotherapist, surgeon, and patient must work in close cooperation. Functional results of patients who adjust to the rehabilitation program, home practice, and splint usage are better.


14) Rehabilitation (including early active motion) and Excellent Functional Outcome:
Wendy Young, Mahendra Daya, Pragashnie Naidoo, Vicki Hofmann UKZN, Durban, Westville, KZN, South Africa

This presentation discusses the rehabilitation and excellent functional outcome of a young man who sustained a complete avulsion amputation of his dominant upper limb in Zone 5. His hand was replanted with 2cm bone shortening and he was referred to Occupational Therapy for early controlled active motion on day six. This is a retrospective case study. Patient had 65 sessions of Occupational Therapy in the first year which included, but was not limited to, early active and passive range of motion, many custom moulded orthosis, functional retraining and sensory re-education No additional reconstructive procedures were performed. At one year post, he had excellent range of motion, with almost full flexion and extension of the digits, ability to oppose thumb to all fingers, good intrinsic return, 32% power grip strength, protective sensation and mildly impaired co-ordination (30 seconds on 9 Hole Peg Test). He had achieved an excellent result according to Chen’s criteria, with the exception of only partial sensory recovery. Subjectively, the patient was highly satisfied and was managing well at work. This begs the question: “should we consider a re-look at current replantation protocols that often start active range of motion at four weeks post surgery?” Many centers use this 2011 replantation protocol. Whereas, early active motion at 5-7 days post, has been previously described by Papanastasiou in 2002. The author recommends a prospective trial be done in view of greater bone shortening with early active motion.


15) Therapy After Injury to the Hand
Dorf E, Blue C, Smith BP, Koman LA.

Surgical and nonsurgical management of upper extremity disorders benefits from the collaboration of a therapist, the treating physician, and the patient. Hand therapy plays a role in many aspects of treatment, and patients with upper extremity injuries may spend considerably more time with a therapist than with a surgeon. Hand therapists coordinate oedema control; pain management; minimization of joint contractures; maximization of tendon gliding, strengthening, and work hardening; counselling; and ongoing diagnostic evaluation. Modalities used to manage hand injuries include ultrasound, splinting, Fluidotherapy (Chattanooga Group, Chattanooga, TN), cryotherapy, various electrical modalities, phonophoresis, and iontophoresis.


16) Sensory Recovery Following Digital Replantation
Laurence T. Glickman M.D., Susan E. Mackinnon M.D.
First published: 1990

The recovery of sensibility following digital replantation is essential in the restoration of hand function. We reviewed 12 series of digital replantation between 1977 and 1989. Three hundred sixty‐seven fingers and 87 thumbs were successfully replanted. Mean age was 32.5 years. Mean followup was 33.5 months. Mean static two‐point discrimination (S2PD) was 9.3 mm in clean thumbs vs. 12.1 mm in crush/avulsion thumb replantation. Mean S2PD was 8 mm in clean fingers vs. 15 mm in crush/avulsion finger replantation. Overall mean S2PD was 11 mm in thumb and 12 mm in finger replantation. Sixty‐one percent of replanted thumbs and 54% of replanted fingers regained useful S2PD (<15 mm or ≥ S3 +). Factors that influenced digital sensibility following replantation included patient’s age, level and mechanism of injury, digital blood flow, cold intolerance, and postoperative sensory re-education. Recovery of sensibility in the replanted digit is comparable to simple nerve repair and to nerve grafting techniques. Further emphasis should be on elucidating the mechanism of cold intolerance, which was a significant complaint for most replanted digits. The universal practice of postoperative sensory re-education will continue to improve digital sensibility following replantation [12,13].


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