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Hand Therapy Consulting regularly shares current news and information on hand therapy practices from around the world, including information on common hand problems, trends in hand therapy exercises and treatment as well as updates and announcements on our own research and activities.

                                           INITIAL X-RAY                                                                             FINAL X-RAY

Mechanism of Injury:

In October 2015, Chris sustained a crush injury to his right index finger, resulting in an open comminuted fracture of the  middle phalanx. There was no nail bed damage, vascular compromise or nerve damage. Chris was taken to Sandton Clinic and was seen by Dr Juan Marin, Orthopaedic Surgeon. Dr Marin informed Chris that the fracture would need to be fixated with K Wires. Chris would not give consent to the use of K Wires or Plate & Screw Fixation as he wanted to return to sporting activities as soon as possible.

Noval Surgical Procedure:

Dr Marin was aware of the use of a figure of eight tension band suture to stabilise nail bed and distal phalangeal fractures (Memon, 2012, Patanker, 2007, Bristol & Verchere, 2007 and Bindra, 1997) but these sutures were placed dorsally over the skin and nail bed injury. The multi-fragment fracture of the middle phalanx required reduction and internal fixation. Therefore Dr Marin adapted the previously described technique to provide internal fracture fixation by using a K Wire to drill diagonally across the middle phalanx in both directions. A figure-of eight tension band using Fiber Wire 2 was then threaded through the holes drilled by the K wire to internally fixate the fracture.

Hand Therapy:

Chris was referred to Hand Therapy 2 weeks after surgery. An orthosis was applied dorsally to the right index finger to provide support and pain relief. In the absence of K wires, early active mobilisation of the index finger PIP and DIP joints could be performed. Treatment included wound and scar management, active and passive mobilisation of the right index finger and strength re-training. Chris attended 12 hand therapy appointments over a period of 4 months.

Outcome:

Chris can achieve a composite fist, but is unable to make a tight fist die to the scar tissue that is present over the dorsum of the DIPJ. He has regained full functional use of the hand. Grip and pinch strength are normal in the right hand when compared to the left. Chris is very satisfied with the outcome of the intervention and is grateful that his hand surgeon respected his wish to not have K wire fixation and rather applied an innovative technique.

The technique was successful and should be considered in the future management of comminuted fractures of the finger.

 

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!

As the world celebrates the first double hand transplant performed by Philadelphia Hand Surgeon Dr Scott Levin on an 8 year old boy, HTC remembers the pioneering surgeon Dr Martin Singer who performed the first hand reattachment in Africa after a man severed his hand in an industrial accident. The operation was successful, but sadly the patient was furious about the operation as he was no longer entitled to receive a disability grant. The man shook his hand vigorously, inflicting so much damage that the hand had to be amputated. A devastating reality of a man who came from a poor socio-economical background. A stark contrast from the joy and excitement such pioneering surgery has brought to 8 year old Zion in Philadelphia. Zion lost his hands and feet due to an infection and has become the world's youngest patient to receive a double hand transplant.

Dr Singer formed the first Hand Unit at Groote Schuur Hospital in Cape Town in 1966. The Orthopaedic Department refused to accept there was a need for a dedicated Hand Unit or specialist Hand Surgeon insisted that Dr Singer resign from the Orthopaedic Surgery and join the General Surgery department. He was not deterred and proceeded to demonstrate true leadership and vision when he invited Plastic Surgeons to be a part of the team.

Dr Singer was the 12th Hand Surgeon in the world to receive the Pioneer of Hand Surgery Award from the International Federation of Societies for Surgery of the Hand in Budapest.

The passion and vision of surgeons such as Singer and Levin makes me feel incredibly proud to be a hand therapist and to be a part of the global hand surgery and therapy community that makes a difference in people's lives.

 

http://www.nbcnews.com/health/kids-health/boy-8-gets-double-hand-transplant-surgical-first-n399811

 

 

  • DeQuervainsFT                                                                                                                                                                                ©Donald Sammut 2015

'My experience of De Quervain pain was debilitating. Every time I picked up my 5 month old baby, flexed my right wrist, or used my thumb, I experienced sharp unbearable shooting pain.

The culprits were poor positioning during breastfeeding, and texting with my thumb whilst nursing my baby.

I saw my hand therapist Robyn Midgley 3 times a week for 4 weeks, where she used ultrasound, massage, an ice probe, and a heated bean bag.

I wore a combined wrist and thumb immobilisation splint for 6 weeks and used flexadrin pain relieving cream daily. The splint made mothering my son a little tricky, but I just had to accept help for that relatively short time frame.

I am delighted to say that my wrist is 100% cured, without the need for any cortisone injections or more invasive surgical treatment.' Charisse Plumb

New mom's frequently contact me for assistance with wrist and thumb pain which develops soon after their baby is born. The pain usually begins as a sharp pain, which they tend to ignore. After 3-6 months, the pain in the wrist and thumb usually becomes excruciating and they find it difficult to handle and care for their baby.

These mom's have a condition known as De Quervain's disease. De Quervain's disease is a stenosing tendonopathy or 'strangling' of two of the thumb tendons (APL & APB) that bring the thumb away from the hand. These tendons lie together in a common sheath in the fisrt dorsal compartment of the wrist.

Is it an inflammatory condition?

Contrary to what is believed, the APL & APB tendons in De Quervain’s Disease are normal and do not possess inflammatory cells. However, the fibro-osseous channel has been found to be diminished during cross section of the compartment and fibrotic thickening of the extensor retinaculum is present. In addition, angiogenesis (increased vascularity) is present in diseased tissue.

What causes De Quervain's Disease?

While De Quervain’s Disease is most often linked with over-use injuries, the cause of de Quervains remains unknown. Recent evidence suggests that Prolactin levels (hormone secreted during pregnancy) may increase the risk of developing the disease. The disease is also seen in new fathers, drummers, golfers, racket sports and following trauma such as a direct blow to the tendons.

When experiencing thumb or wrist pain it is important to see a Hand Specialist so that other causes of wrist pain such as a fracture, Osteoarthritis, nerve irritation or Carpal Tunnel Syndrome can be ruled out.

What are the signs & Symptoms:

  • Pain and swelling near the base of the thumb.
  • Tenderness above the wrist when touched.
  • The pain may appear suddenly or may increase gradually over time. Moving the thumb and wrist may aggravate the pain.
  • Difficulty with gripping, pinching, squeezing or moving the wrist from side to side, such as when waving.
  • Difficulty with lifting or carrying a baby or an object.
  • Restriction or “sticking” sensation in the thumb or wrist with movement.

What tests will be performed?

De Quervain's disease can be diagnosed during a clinical examination without the need for specialist investigations. The Finklestein test is a provocative test that is commonly used to confirm the diagnosis.

What can new mom's do to prevent De Quervain's Disease?

  • Avoid placing your thumb in an 'L' shaped position when lifting the baby. Rather scoop the baby up by placing your hand palm up on its bottom with your wrist and thumb in a neutral position.
  • Be aware of your wrist posture when bottle feeding your baby. Your wrist and thumb must rest in a comfortable, neutral position.
  • Be aware of your breast feeding position. Various breast feeding positions could put strain on a mother's wrist, especially when inflammation is already present. Use a pillow for support and ensure that the full weight of baby's head isn't resting in your hand.
  • Rest your wrist & thumbWhenever possible, have your partner lift and carry the baby to give your wrist some time to heal. Limit smartphone use whenever possible.
  • Avoid repetitive motions. Do not perform constant motions such as chopping, gardening, drumming, knitting, cleaning, sports motions or texting without sufficient rest periods or stretches.
  • Be aware, adapt and avoid: Be aware of any activity that aggravates the symptoms so that those activities can be avoided or adapted. 
  • Be smart: Purchase ready-peeled vegetables and adapt the way that you use your hands and thumb to perform daily activities. For example if you are reaching and grasping for an item, rather than use your thumb of one hand for support, exclude the thumb by using the palms and fingers of both hands for support.
  • Seek help: Contact a Hand Therapist as soon as possible.

 

Special thanks to Dr Donald Sammut FRCS,FRCS, (Plast.) Consultant Hand Surgeon for his permitting the use of his drawing of a specialist performing the Finklestein test; a provocative test used to clinically diagnose the presence of De Quervain's Disease (www.donaldsammut.com).

 

 

 

 

 

 

 

'Pain used to be the name of my game before I met Robyn Midgley.  My journey started with the diagnosis of Hypermobility Syndrome, which mostly affected my hands.   I lived with it my whole life and had to have numerous surgeries including partial bone fusions and carpal tunnel releases in order to maintain hand function. Recently, after having a ganglion removed, I was diagnosed with base of thumb arthritis. Being a keen guitar player, and mother of twins, this was devastating news, since the two greatest joys of my life caused me a lot of physical pain.  And then I met Robyn, who made me splints for both hands, which, miraculously, took away the pain.  Since wearing the splints I am able to play guitar and pick up my kids, pain free.  I believe that if I had met Robyn before the operation to remove the ganglions, it wouldn’t have been necessary, and the after effects of any operation could have been avoided.  Be that as it may, Robyn and the splints changed my life.  All I can say is, thank you, oh, and, wait before you operate….  There might be another option.'

Retha Buys, June 2015

Arthritis at the base of the thumb (CMC Joint) can be very disabling as a result of the pain that is experienced during functional use of the hand.

Therapists and surgeons frequently recommend splinting as part of conservative treatment. Early stabilization of the thumb CMC joint with a small CMC immobilization splint prevents further degeneration of the joint and the subsequent need for surgery.

Patient compliance with splinting will be poor if too many joints are immobilised, if hand function is limited and if pain is not reduced.

An effective splint must:

  1. Prevent motion of the thumb metacarpal in relation to the finger metacarpals.
  2. Prevent tilting of the first metacarpal during pinch
  3. Permit unrestricted thumb metacarpal and wrist joint motion.

Attention to detail during construction is required for the splint to be successful in controlling thumb CMC pain. The splint must not impair pinching or the handling of objects. When the splint is correctly designed and moulded, patients report an immediate elimination or reduction of thumb CMC pain with pinch.

Unlike most splints applied to joints, this CMC splint cannot be worn too long or too much. The problem at the thumb CMC joint is one of excessive motion. It is believed that the splint can be worn long enough for the joint to "stiffen" and subsequently have greater stability.

Reference: Colditz J, The Biomechanics of a Thumb Carpometacarpal Immobilization Splint: Design and Fitting J HAND THER. 2000, 13:228-235.

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