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Crush & De-Gloving Injury of the Hand

 

Allow me to introduce you to Bryce. Bryce is a wonderful family man and Electrician. He suffered a devastating injury which challenged him in many ways. His commitment to hand therapy and determination to regain full use of his hand meant that he achieved a result that far exceeded my expectations. He is a patient who has been the highlight of my career so far.

Bryce has requested that I tell his story with the hope that his experience may help someone else out there who has been in a similar situation and needs some inspiration or insight into what therapy may involve.

A year ago Bryce and his family were enjoying a fun day riding an off-road, open top 4 x 4 when the vehicle overturned. Bryce instinctively put out his left hand to protect himself but it was crushed between the the 4 x 4 and the gravel road, resulting in 6 hand fractures. Bryce panicked and withdrew his hand from underneath the bar causing a secondary degloving injury to the hand.He was rushed to Hospital where he spent 10 weeks having numerous operations to save his hand.

Fortunately Bryce was under the care of an excellent Plastic & Reconstructive Surgeon Dr Chetan Patel.

Dr Patel reconstructed the degloved left hand by performing a free tissue transfer using an antero-lateral thigh flap (ALT). The free tissue transfer provided cover for the exposed tendons, soft tissue and neuromuscular structures. An ALT permits more supple and pliable soft tissue cover when compared to skin grafts and makes it easier to perform secondary procedures such as tendon transfers and scar releases later on. A dermal substitute was used over the thumb area where no vital structures were exposed. Dermal substitutes provide a framework for blood vessels and dermal skin cells to remodel damaged skin, thereby facilitating adequate donor site recovery. A split skin graft was performed 21 days after the dermal substitute application.

When Bryce was referred to Hand Therapy 10 weeks after the injury, he had absolutely NO movement in his wrist, fingers or thumb. His wrist was fixed in a flexed position and had an85% functional impairment in his hand, including sensory loss due to nerve damage. His treatment plan was complicated by the fact that he lives 150 km from Hand Therapy Consulting. A round trip would take him 4 hours of travelling time in addition to therapy time. Bryce would need to attend hand therapy for at least a year in order to regain full hand function. He is the owner of a business and time away from work was an additional challenge.

Due to the geographical constraints I had to offer Bryce a treatment plan that would be both time and cost effective without compromising his treatment. In cases such as this a patient would have to attend therapy at least 3 times per week in order to make progress. We applied the Casting Motion to Mobilise Stiffness Technique as described by Judy Colditz OT/L, CHT, FAOTA . This technique uses plaster of paris to selectively immobilise mobile joints in an ideal position while constraining stiff joints so that they move in a desired direction.

Over 12 months, Bryce attended an average of 2 hand therapy appointments a month and achieved a full fist by 6 months. He currently has 35% functional impairment and has recently undergone an Opponens Plasty which will enable him to oppose his thumb to his middle finger and further improve his functional ability. His nerve function continues to improve.

I am extremely proud to present Bryce' results. We would not have been able to achieve this result with traditional therapy or without a patient who trusted the process. Well done Bryce!

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