Full-cycle rehabilitation strategy after hand trauma
hand injury
Hand trauma refers to all trauma beyond the wrist joint. Domestic clinical statistics show that in the orthopedic emergency department, hand trauma patients account for about 1/4 of the number of patients, and the incidence rate accounts for more than 1/3 of the total number of traumas. For manual workers in the construction industry, human factors (operations against regulations) account for more than 70%. In terms of injury types, cutting injuries and crush injuries are the most common. The dysfunction caused by hand trauma is the motor and sensory dysfunction caused by scar contracture, tendon adhesion, swelling, joint stiffness, muscle atrophy, tissue defect, and long-term non-healing of the wound, which brings serious inconvenience to work and life.
Functional rehabilitation in different periods after hand trauma is generally carried out in the following stages:
01 Preoperative period
Rehabilitation treatment before elective surgery creates better conditions for surgery and postoperative rehabilitation.
The main purpose of preoperative rehabilitation is to perform joint range of motion exercises and muscle strength exercises, partially loosen scars and adhesion tissues, and correct existing joint contractures and muscle atrophy as much as possible, so as to prevent postoperative functional recovery from being more difficult. In addition, preoperative functional exercise also facilitates early postoperative recovery. The key points of rehabilitation in the preoperative stage are joint immobilization, pain relief, swelling relief, promotion of wound healing, prevention of complications, avoidance of unreasonable force, and maintenance of soft tissue flexibility.
02 Early postoperative period
It is equivalent to a period of time after surgery until important tissues such as muscles, tendons, nerves, and bones heal. Necessary external fixation is often performed during this period. Starting rehabilitation treatment as early as possible on the 2nd and 3rd day after surgery can prevent joint and muscle dysfunction caused by surgery and postoperative fixation. The purpose of this phase of rehabilitation treatment:
1) Eliminate edema: Improper treatment of early edema will become the main cause of joint stiffness, so we must pay attention to the development of edema from the beginning of the injury to prevent local fiber proliferation and joint stiffness. The basic principles of treatment are: raising the affected limb, active movement and pressure on the affected part. Specific methods: ① After injury or surgery, the injured hand should be continuously elevated above the level of the heart; ② Slow and continuous planned isometric contraction is helpful for venous return, and patients can be counseled to do forearm and venous drainage 24 hours after the operation. Isometric contraction of the hand muscles. If the skin condition of the affected part permits, do a centripetal massage with the injured limb elevated during the interval of active contraction, and use the function of "muscle pump" to promote venous and lymphatic return. The freshly sutured muscle tendons are kept still. ③Compression treatment of the affected area usually uses an elastic bandage to wrap the finger from the fingertip to the root of the finger, and then release it. Repeat, several times a day. Elastic finger cots can be used for swelling of a single finger; ④ Physiotherapy: Use infrared, microwave, ultrashort wave, audio and other therapies to strengthen local blood circulation, enhance the permeability of blood vessel walls, and accelerate the absorption of exudate.
2) Prevent the mobility disturbance of the adjacent joints: the initial ROM exercise of the joints of the affected limbs that are not immobilized, the therapist performs passive joint activities within the range allowed by the patient's physique, and the activities should be painless or slightly painful. within the tolerable range. The technique is sustained, slow, and gentle, and each passive flexion and extension movement is held at the end for 6 to 10 seconds. Basic exercises include sliding and fisting movements of each tendon, rotational movements, etc., so that the superficial and deep flexors of the fingers can produce separate sliding.
3) Prevention of muscle atrophy: Except for the newly sutured muscles and tendons that must be kept still, all other muscles of the affected limb should start isometric or isotonic muscle exercises as soon as possible, and perform appropriate resistance exercises when possible. Electrical stimulation of paralyzed muscles begins early in the presence of peripheral nerve injury.
4) Get up early for activities, and do bed exercises when you have to lie in bed.
03 Mid postoperative period
The mid-term postoperative period starts from postoperative tissue healing and removal of external fixation to the time when hand function is basically recovered or cannot be further recovered. During this period, systematic range of motion exercises, muscle strength exercises, occupational therapy, and physical therapy should be carried out, and necessary braces should be used to maximize the recovery of hand functions. This period may last several months.
1) Severe joint flexion disorder can use sandbag pressurized traction method, starting from 0.25kg weight, adjust the traction angle, and gradually increase until the joints feel sore and tight. This method is effective for patients with flexion contracture of metacarpophalangeal joints. For patients with flexion disorder of the interphalangeal joints, the method of flexing the finger cuff splint can be used to perform flexion and pull-down respectively, with the fingertips facing the scaphoid tubercle.
2) For stiff joints, grade III and IV joint mobilization techniques can be used, such as stretching, squeezing, anteroposterior or posteroanterior sliding, radial-ulnar sliding, pronation and backward sliding between the two articular surfaces. Glide in each direction to the end of the joint's range of motion and feel tension in the soft tissues surrounding the joint.
3) Hypertrophic scars Ultrasound can separate collagen fiber bundles and soften and dissipate scar tissue. Audio frequency strip electrode, juxtaposition method, 20-30 minutes each time, once a day, one month as a course of treatment. It has a good effect on controlling scar itching or softening scar tissue. Massage from light to heavy techniques can soften scars and loosen adhesions. The frequency of massage should be slow, the intensity should be gentle, and the parts should be changed constantly to prevent scratching the skin or causing blisters. Commonly used techniques are rubbing, kneading, kneading, and strokes. Stretching the scar tissue with the joint as the fulcrum to make it produce continuous and slow passive movement is an effective method to extend the scar tissue.
4) Hyperesthesia refers to the increased sensitivity to stimuli of the general strength of the affected hand to the outside world. The basic principle of rehabilitation therapy is to gradually increase stimulation in sensitive areas. First rub the sensitive area with cotton, 5-10 times a day, 2-5 minutes each time. When the patient gets used to it, use cotton cloth or rough terry cloth to rub the sensitive area, and then use graded desensitization treatment: ① Take a whirlpool water bath for 15-30 minutes, start at a slow speed, then gradually speed up, and slowly adapt to the swirl of the water ; ②Apply Vaseline and massage in a circle for 10 minutes; ③Rub with towel knitted fabric for 10-30 minutes. After the affected part can tolerate the tactile stimulation, let the patient touch different materials, such as flour, yellow sand, rice grains, Small glass balls, etc.; ④ Vibrate the sensitive skin with an electric vibrator to consolidate the desensitization of the patient; ⑤ Tap the sensitive area with a pencil to increase tolerance.
5) Hypoesthesia For patients with hypoesthesia, sensory retraining can be carried out. After peripheral nerve damage, some abnormal sensations and sensory loss in some parts will appear. Allowing patients to learn the principles of sensory learning such as concentration, feedback, memory, and reinforcement can generate a new response mode in the brain and form a high degree of proprioceptive awareness. In the early stage, it is mainly tactile, positioning, and orientation training, and in the later stage, it is mainly discrimination training.
04 postoperative period
The postoperative period is quite a consolidation period for rehabilitation. At this time, the hand function has been better recovered, but it is necessary to continue to carry out necessary functional exercises to prevent the function from declining again, and to do appropriate fitness exercises.
If reoperation is required, the postoperative rehabilitation phases will be repeated in sequence.
