Rehabilitation of the Hand & Upper Limb

407 Pages·77.748 MB·English

by  Edited by, Rosemary Prosser, MSc BApSc CHT, and W. Bruce Conolly, AM FRCS FRACS FACS (Eds.)

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Contributors
Editors Judith DavidsonBAppSc(OT)MAppSc(Ergon)
OccupationalTherapist,
RosemaryProsser
Prince ofWalesHospital,
CHTMSc(Hand&UpperLimb)PGDSport5c&ExBAppSc(Phty) Randwick,Sydney,Australia
Director,
SydneyHandTherapy& RehabilitationCentre;
VictoriaFramptonMCSPSRP
ConsultantHandTherapist,
HandTherapist, Private Practitioner,Canterbury;
StLuke'sHospitalHandUnit,
HandTherapyAdvisorto EastKent Hospitals
Sydney,Australia
Trust,Kent,UK
WBruceConollyAMFRCSFRACSFACS KarenGinnPhDBScGradDip(Manips)
Associate ProfessorofHandSurgery,
SeniorLecturer,
UniversityofNewSouthWales;
SchoolofBiomedicalSciences(Anatomy),
ClinicalAssociate Professor,
UniversityofSydney,
DeparhnentofSurgery,
Lidcombe, Sydney,Australia
UniversityofSydney;
StaffSurgeon,SydneyHospitalHandUnit; ClaudiaRGschwindMDFRACSFMH(Switzerland)
Director, Hand& MicrosurgeryUnit,
OverseasHandSurgery& Rehabilitation Projects, RoyalNorthShorePrivateHospital,
StLuke'sandSydneyHospitalHandUnits, Sydney,Australia
Sydney,Australia
TImothyJHerbertFRCSFRACS
EmeritusConsultant,
Contributors
SydneyandStLuke'sHospitalHand Units,
Jill AllenGradDip(Phty) Sydney,Australia
Physiotherapist,Principal,PrivatePractice
(Specialising in theShoulder1991-2001), Jeffery HughesMBBSFRACS(Ortho)FAOrthA
Chatswood,Sydney,Australia OrthopaedicSurgeon,PrivatePractice,
Chatswood,Sydney,Australia
CraigAllinghamBAppSc(Phty)GDSport5c
CertMens'Health Elaine juzlGDPhysMCSP
Sports Physiotherapist;Director,Physiocare; ClinicalSpecialist in HandTherapy,
AdjuctSenior Lecturer, Wellington Hospital;
SchoolofPhysiotherapyandExerciseScience, Partner,
GriffithUniversity, NESHandTherapyTraining;
Queensland,Australia London,UK
vIII CONTRIBUTORS
SandraKay MClinSc(Hand&UpperLimb)BAppSc(Phty) Lisa NewellBAppSc(Phty)
HandPhysiotherapist, PrivatePractitioner,
Physiotherapy Department, NorthShorePrivateHospital,
RoyalAdelaideHospital, StLeonards,Sydney,Australia
Australia
MarkMJPerkoMBBSFRACS
Paul LaStayo PhDPTCHT OrthopaedicSurgeon,
AssistantProfessor, NorthSydneyOrthopaedic&
DepartmentofPhysical Therapy, Sports Medicine Centre,
NorthernArizonaUniversity, Sydney,Australia
Flagstaff,AZ,USA
MichaelJSandowBMBSFRACS
AnnetteLeveridgeDipCOTSROT HeadofService,HandandUpperLimbService,
PrivatePractitioner, DepartmentofOrthopaedicSurgery and Trauma,
OccupationalTherapySpecialist, RoyalAdelaideHospital,
HandTherapyand Bums; Australia
previouslyHeadofOccupationalTherapyService,
MountVernonHospital,UK
PeterScougallMBBSFRACS(Ortho)FAOrthA
ConsultantHand& WristSurgeon,
AmeliaLucas MHlthSc(OrthoManips) SydneyandStLuke'sHospitalHand Units,
Practice Principal,Cabramatta,Sydney;
Sydney,Australia
previouslySeniorAcademicAssociate,
CSU/AAOMTpost-graduateMastersDegree,
DavidH SonnabendMDBSc(Med)FRACS
CharlesSturtUniversity,
ProfessorofOrthopaedicandTraumaticSurgery,
WaggaWagga,Australia
UniversityofSydneyand
RoyalNorthShore Hospital,
Jenny McConnellMBiomedEngGradDip(Manips) Sydney,Australia
BAppSc(Phty)
Physiotherapist,PrivatePractice,
AnneWajon CHTMAppSc(Phty)BAppSc(Phty)
Mosman, Sydney,Australia
Director,HandTherapyatHornsby,
Hornsby, Australia
DeirdreMcGheeBAppSc(Phty)DipTCM(China)MATMS
Physiotherapist,PrivatePractice;
Lecturer, DouglassWheenMBBSFRACS
Director,StLuke'sHospitalHand Unit;
UniversityofWollongong,
ConsultantHand Surgeon,
Wollongong, Australia
SydneyHospitalHandUnit,
Sydney,Australia
James AMasson MBBS(Hons)FRACS
Director,
SydneyHospitalHandUnit, MaureenWilliamsAUABA
Sydney,Australia Physiotherapist,NorthShore PrivateSuites,
StLeonards,Sydney,Australia
BryceMMeadsBHBMBChBFRACS(Orth)
ConsultantHandSurgeon, JudithWiltonMSPGDHlthScBAppSc(OT)
SydneyandStLuke'sHospitalHandUnits, Director,HandRehabilitationSpecialists,
Sydney,Australia WestPerth,WesternAustralia,Australia
Preface
Theoutcomeforany patientwithadisorderofthe Although there have been great advances
hand or upper extremity depends on the mutual in surgery, e.g. tissue transplantation based on
understandingand cooperationofthe three main microsurgerytechniques,and greatimprovements
parties concerned: the patient, the surgeon and inmany handtherapytechniques, thebasicprinci
the therapist. ples of hand surgery and hand therapy remain:
The surgeon must know the indications and thorough assessment/examination, accurate diag
rationale for, and results of surgery, as well as nosisand appropriatetreatmentofeachindividual
both the physiotherapy and occupational ther patientand theirproblem.
apy aspects of hand therapy. The therapist, like Manyyearsago,theeditorswere invitedtopro
wise, must know the indications and rationale duce a text on the rehabilitation of the hand and
for,and results ofhand therapy,as well as those upperlimbthatwouldbeapplicable intheclinical
ofsurgical treatments. The patientmusthave an situation.This resultingbook is forsurgeons and
understandingofhis orherpathologyandhis or therapists at all levels of experience and training
her role in its management, along with the roles whomightbe treatingpatients with adisorder of
ofthe surgeonand therapist. their handorupperlimb.
RP,WBC,2003
Acknowledgements
Wewouldliketoexpressourthanksto:DrBarbara supportovermany yearsgoes to all members of
Grunseit, Director of Clinical Services, StLuke's St Luke's and Sydney Hospital Hand Units and
HospitalComplexand the Board ofthathospital Sydney HandTherapyandRehabilitation Centre.
for making available the Hand Unit office staff; We would like to convey our appreciation to
Pam Morris, St Luke's Hospital Hand Unit ourcontributingauthors, all ofwhom are recog
secretary for her assistance in the preparationof nised by theircolleagues as experts in their par
the manuscript,handlingofcorrespondenceand ticularfield.
proofreading;andMrDavidRobinson,StLuke's Finally, we thank Caroline Makepeace, who
Hospital Hand Unit Medical Photographer, for initiated the project, and Zoe Youd,Heidi Allen,
producingmanyofthe photographsand coordi David Burin and Derek Robertson who have
nating the illustrations. Appreciation for their helpedbringthis booktofruition.
RP,WBC,2003
1
CHAPTERCONTENTS
A. Woundandtissue healing 1
Woundhealing 1 Introduction
Factorsaffectingwoundhealing 3
Abnormalscars 4
B. Therapyprinciples andmodalities 5
Treatmentofthepatient 5
Treatmentrationale 6
Assessment 7
A. WOUND ANDTISSUE HEALING
James AMasson
WOUND HEALING
Wound healingisa complex continuumofphys
iological, biochemical, cellular, molecular and
immunological responses to tissue injury, regu
lated by growth factors and cytokines released
fromthewounditself(Fig.1.1).Theaimofwound
healing is to restore structural and functional
integrity to the damaged tissues. Traditionally,
wound healing has been divided into three
phases- theinflammatoryphase,theproliferative
phaseandthe remodellingphase' (Fig.1.2).
Inflammatory phase
Theinflammatoryphasecommencesuponinjury
and lasts for approximately 72 hours. The first
eventin tissue injury is disruption ofblood ves
sels, followed by a brief period of vasoconstric
tion andplateletdegranulation. This initiatesthe
clotting cascade, ending in the production of a
fibrinclot.Activated plateletsalsoinitiatetheplas
minogen,complementandkinin cascades, result
ing in vasodilatation and increased small vessel
permeability, giving rise to tissue oedema. The
activated plateletproducesmany growth factors
whichare chemotacticand mitogenic forinflam
matorycells,suchasneutrophilsandmonocytes,
the latter transforming into macrophages.v'
The increased vessel permeability allows these
2 INTRODUCTION
neutrophils and monocytes to pass out between the first6hoursand reach apeakat 24-48 hours.
theendothelialcellsby aprocessofdiapedesis. Wound healingcan stillprogressnormally in the
In the initial stages of healing, the inflamma absence ofneutrophils.Macrophagesfirstappear
tory cellseliminatebacteriaanddebrisbyphago 48 hours after injury and remain in the wound
cytosis. Neutrophils arrive in the wound within until healing is complete. The macrophages are
also responsible for recruiting the mesenchymal
cells,whichsignalthetransitiontotheproliferative
phase.Theyarethemostimportantcellsinampli
fyingandsustainingthewoundhealingprocess.'
T lymphocytes appear around the fifth day and
play a part in the regulation of macrophage
activities. They also secrete lymphokines, which
affect endothelial cell behaviour and fibroblast
recruitmentandproliferation."
Proliferative (fibroblastic) phase
The next phase of wound healing, also known
as the granulation phase, commences 3-4 days
aftertheinitialinjuryandlastsapproximately2-4
weeks.Themacrophages,whichappearedduring
the initial inflammatoryphase,continuetomove
intothewound.Theysecretecytokinesand growth
factors which attract fibroblasts and new blood
vessels. The fibroblasts lay down a loose matrix
Figure1.1 Overview ofhealing.(Reproduced withkind
of fibronectin, hyaluronic acid and collagen into
permission fromHuntTK:Basicprinciples ofwoundhealing.
JTrauma30(12Suppl):S124, 1990.) which the blood vessels grow.This composite of
Figure1.2 Generaltimeframeofthewound healingprocess.(Reproduced
fromHomDB:Thewoundhealingresponsetograftedtissue.Otolaryngol Clin
North Am27:14, 1994.)
WOUNDANDTISSUEHEALING 3
fibroblasts, macrophages and new capillaries is
knownas 'granulationtissue'.
Within hours of injury, epithelial cells at the
periphery of the wound and in residual dermal
epithelialappendagesrestoreepidermalcontinu
ity through the processesofmobilisation,migra
tion, mitosis and cellular differentiation. During
mobilisation,thecellsimmediatelyadjacenttothe
wound edge enlarge, flatten, detach from neigh
bouringcellsand flowawayfromthem.Migration
continues until cells touch one another, produ
cingcontactinhibition.Epithelialmitosis actually
begins within hours of injury, but intensifies
Days Weeks Months
during the proliferative phase. Fixed basal cells
away from the wound edge multiply to replace FIgure1.3 Thethreephases ofwound healing, showing
thephasesofrepairandthegainintensile strength in
the migrating cells, and the cells that have
eachperiod.(Reproduced withpermission fromBoscheinen
migratedalsomultiply.Oncethewoundhasbeen MorrinJ,ConollyWB:Thehand:fundamentals oftherapy.
bridgedbyacompletelayerofepithelialcells,the Oxford:Butterworth-Heinemann,2000.)
cells differentiate from basal cells through the
various stages of differentiated keratinocytes to number of myofibroblasts within the wound?
produceastratumcorneum. Wound contractioncan be used to advantage by
thesurgeonand therapist,e.g.infingertip wounds
or the open palm technique in Dupuytren's con
Remodelling (maturation) phase
tracture. The final resultofthe healing process is
During the final phase ofwound healing, which a mature scar, which may take up to 18months
begins about 3 weeks after the injury and lasts from the time ofthe initial injury.The increase in
for several months, the extracellular matrix is wound tensile strength that takes place during
reorganised.Bothcollagensynthesisanddegrad the fibroblastic phasecorresponds tothe increas
ation are increased, so there isno netincrease in ing levels of collagen within the wound.f The
collagencontent.Thetypeillcollagenwhichwas tensile strength of a wound never reaches the
secretedinitiallyisgraduallyreplacedby mature pre-injury state, and probably plateaus at about
type Icollagen, whichishighlycross-linked and 80% of normal at approximately 60 days after
reoriented in response to mechanical stress. injury" (Fig.1.3).
There is an overall reduction in cell numbers
(fibroblasts and macrophages) and a decrease in
FACTORS AFFECTING WOUND
tissue vascularity.
HEALING
Wound contraction is an active, essential part
of the repair process which begins around the Therearemanyfactorswhichcanhave anadverse
fifthdayandlasts for2weeks. Aspecialisedtype affect on wound healing. Only those of clinical
offibroblastwithinthewound,themyofibroblast, relevance to the hand surgeon and therapist will
providesthecontractileforce,"Themyofibroblast be discussed here.
differs fromthe normalfibroblastinhavingsome
ultrastructuralsimilaritiestosmoothmusclecells.
Oxygen
Myofibroblasts are present throughout the
wound, not just at the periphery, so that the Various steps in the wound healing process are
entire granulating surface of the wound acts as particularly oxygen-sensitive: namely, collagen
a contractile organ. There isa direct relationship synthesis, angiogenesis and epithelialisation.!"
between the rate of wound contraction and the Therefore,thecommonestreason that woundsfail
4 INTRODUCTION
to heal is an inadequate tissue oxygen tension. glycosylated and competes with oxygen. In the
This may resultfrom insufficientdebridementof initialinflammatoryphase,the whitecellsofdia
atraumaticwound,leavingnecrotictissuebehind; betics have a decreased ability to phagocytose
unsatisfactory vascularity of tissues; tightsutur and killbacteria.P
ing or postoperative swelling,producingwound
tension; wound infection, which may compete
ABNORMAL SCARS
for the availableoxygen; or anaemia,withinsuf
ficient haemoglobin to transfer the available
Whenexcessive accumulationofcollagenoccurs
oxygen.
from increased collagen synthesis or decreased
collagenbreakdownduringthe proliferativeand
Infection remodelling phases of wound healing, a hyper
trophicscar or keloid mayresult."
Infection decreasestheoxygenlevelinthe tissues Hypertrophic scars are limited to the confines
and increases the breakdown of collagen. Italso oftheinitialinjury,whereaskeloidsextendbeyond
impairsangiogenesisandepithelialisation.l' theoriginalwound.Hypertrophicscarsare much
more common than keloids. In fact, the hand is
quite a privileged site in terms of occurrence of
Age
true keloids. Hypertrophic scars are not infre
Withincreasingage,the phasesofwoundhealing quently seen in the palmar skin, whereas true
take longer,andthe rate ofcellularmultiplication keloidsrarelyare.Thesamecannotbesaid forthe
isslower. Tissues ofelderlypatients are also less dorsumof the hand or the volarand dorsal fore
resistanttoischaemia. arm skin, especially in predisposed individuals,
i.e. young dark-skinned or Asian individuals.
Keloids seem to be hormone-sensitive, often
Smoking
worsening during pregnancy and resolving
followingmenopause.
Nicotine causes sympathetically induced vaso
constriction, producinglocalised tissue ischaemia,
and decreased oxygen delivery. Smoke also
Management
contains carbon monoxide, which binds with
haemoglobin to form carboxyhaemoglobin. The Surgery is rarely indicated in the management
oxygen molecules then have to compete for free of hypertrophic scars or keloids. Unless the
haemoglobinmoleculesfor transport. abnormalscar followed adefinedcomplication
e.g. wound infection, haematoma, dehiscence
further attempts at surgical correction will often
Steroids
only worsen the situation. Therefore, all non
Steroids arrest the inflammatory process. They surgical modalities should be exhausted before
inhibit wound macrophages and interfere with surgery is considered. Many modalities have
collagen formation, angiogenesis and wound been used experimentally and clinically. Once
contraction.12 again, onlythose ofclinicalrelevancein the hand
patientwill bediscussed.
Diabetes mellitus
Pressure
Patients with diabetes mellitus have decreased
oxygen delivery to the tissues due to stiff red Itisthoughtthatpressuredecreasestissue metab
bloodcellsandincreasedbloodviscosity,making olism and increases collagen breakdown by
it more difficult for the corpuscles to negotiate increasingthe activityofcollagenase.ISThecolla
the capillaries. Their haemoglobin also becomes genaseenzymeisheat-sensitive, withits activity
THERAPYPRINCIPLESANDMODALITIES 5
increasing lOOO-fold for every degreecentigrade siliconeoilwhichbleedsfrom the gel,orperhaps
increase in temperature. Therefore, the local the occlusive effectofthe dressing.16,17
warming produced by a pressure garment may
have its effect partially by this mechanism.
Intraleslonal steroids
However, as with all conservative measures,
treatment should persist for at least 6 months Intralesionalinjection of steroidspreventsexces
and, inburnspatients,often forupto2years. sive collagendeposition, and allows collagenase
to correct the imbalance in collagen metabolism.
Injectionmaybecombinedwithexcision.Import
Silicone gel
ant side effects are local hypopigmentation
The exact mechanism of action of silicone gel is (which can be quite distressing in dark-skinned
not known.Itmayberelatedtosomeeffectofthe individuals),skin atrophyand telangiectasiae.
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techniques, anunderstandingofthepatient'sabil
B. THERAPY PRINCIPLES AND ity and motivation to participate in the therapy
MODALITIES programme,andhavingthe appropriate therapy
skills,materialsandequipmentavailable.
Rosemary Prosser
TREATMENT OFTHE PATIENT
Hand therapy, occupationaltherapyandphysio
therapy require a knowledge of science and an Itis essential to understand the impact of upper
appreciation of humanity. One needs a logical limb dysfunction on each patient's ability to
scientificbasis in order to problem solve and set work, play sport, perform hobbies or general
appropriate treatment goals. Developing treat activities ofdaily living (ADL).Aseach patientis
ment strategies requires a knowledge ofvarious an individual, the response will be different and