Traumatic Injuries

Question 1

surgical procedures used to treat complex hand injuries - skin (3)

Answer 1

1. skin sutured in primary repair2. graft/flap placed for wound coverage3. skin left open for secondary closure

Question 2

surgical procedures used to treat complex hand injuries - tendons (2)

Answer 2

1. flexors/extensors repaired2. tendon grafts, transfers, tendon removal performed in prep for future graft (often w/ temporary spacer)

Question 3

surgical procedures used to treat complex hand injuries - nerves

Answer 3

nerves repaired with or without grafting

Question 4

surgical procedures used to treat complex hand injuries - blood vessels

Answer 4

veins and arteries repaired with or without grafting

Question 5

surgical procedures used to treat complex hand injuries - bone (3)

Answer 5

1. bone fixation performed 2. joint arthroplasty implant inserted where joint surfaces cannot be repaired3. joint fusion

Question 6

order of repair in traumatic hand injuries

Answer 6

1. bone fixation2. tendon (unless vascular status severely compromised)3. vascular and nerve repair4. skin

Question 7

general info needed from physician/surgeon (4)

Answer 7

1. what to hold and what to move2. what was injured, at what level, and what was repaired3. what type of injury4. what are expected outcomes/goals

Question 8

info needed from surgeon following surgical repairs (11)

Answer 8

1. structures repaired and how2. quality of repairs3. strength of repairs4. any tension on repairs5. tendon quality/repair site in relation to pulleys6. strength of any fracture fixation; presence of fusions; joint mobility; bone shortening7. any skin graft/flap precautions required8. any tissues/ROM to be protected9. any tissues with questionable viability that need to be watched10. anticipated time frames for progression11. any structures not repaired/plans for them

Question 9

types of bone fixations (7)

Answer 9

1. bone grafts2. fixators3. wires4. pins5. plates6. screws7. other devices

Question 10

bone injury precautions (2)

Answer 10

1. Avoid excess stress at the fracture or fusion site or pin site and watch for signs of infection.2. A joint next to a fracture may need to be moved to begin ROM protocols. Be aware of the location and type of fracture and the fixation and stability. Manually stabilize the bone during movement, and do not torque across the fracture site.

Question 11

ROM and bone injuries

Answer 11

if the surgeon established sufficient fracture fixation, ROM around fracture site may be initiated immediately, starting from midrange and progressing to full ROM as appropriate

Question 12

revascularizations precautions (11)

Answer 12

1. keep hand warm and avoid exposure to cold or sudden/extreme temperature change2. no eating/drinking anything vasoconstrictive (caffeine/chocolate)3. no smoking4. no compressive bandages until vascular status is stable5. prevent compression from orthosis material and straps6. constantly monitor color of the fingers with regards to capillary refill7. no cold treatments in acute phase8. do not use a whirlpool because it puts hand in dependent position9. do not use contrast baths10. mild heat may be used once vascularity has stabilized, but insensate hand does not have warning system for heat and cannot dissipate heat as well11. no extreme elevation (above level of heart)

Question 13

dusky (grayish) finger/hand

Answer 13

indicates severely diminished vascularity caused by arterial compromise

Question 14

purple colored finger/hand

Answer 14

indicates severely diminished vascularity caused by venous congestion

Question 15

exercise and revascularization

Answer 15

should be performed in a warm room away from AC vents with the dressing off so the OT can monitor color, capillary refill, and temperature

Question 16

nerve injury clinical reasoning (3)

Answer 16

1. important to educate client in care of hand2. after regained protective sensation, begin sensory reeducation3. be aware that not only do that have problems sensing temperature, but they also have problems dissipating heat as well

Question 17

positioning for replant or if both flexors and extensors are lacerated

Answer 17

position similar to one for flexor tendon injury*priority is given to flexors over extensors because flexion is more important for function

Question 18

edema

Answer 18

causes increased resistance with AROMlongstanding edema increases scar formation*compression may be used after vascular system stabilizes

Question 19

delayed mobilization protocol (DMP) for replants

Answer 19

used mostly for young children or clients who may not be fully cooperative

Question 20

DMP 0-3 weeks

Answer 20

no ROM

Question 21

DMP 3 weeks

Answer 21

AROM of involved structuresPROM of uninvolved structures

Question 22

DMP 4 weeks

Answer 22

NMESneuromuscular e-stim

Question 23

DMP 6 weeks

Answer 23

dynamic orthosisPROM of involved structuresinitiate use of hand for ADLs

Question 24

DMP 8-10 weeks

Answer 24

strengthening exercises

Question 25

early mobilization protocol for replants (EPM)

Answer 25

used for digital or hand replants characterized by stable fixation and a clean injury

Question 26

EPM 4-10 days

Answer 26

EPM IMP extension with wrist flexion*MP flexion with wrist extension

Question 27

EPM 7-14 days

Answer 27

EPM II passivecontinue EPM Ipassively move client’s fingers between “table”MP flexion with IP extension (intrinsic plus) and hook*MP extension and IP flexion (

Question 28

EPM 14-21 days

Answer 28

EPM II activecontinue EPM I and EPM II passivePlace and hold hook and table positionsprogress to active hook and tableisolated FDS tendon exercisesinterossei strengthening (intrinsic plus)*light functional activities

Question 29

EPM 28 days

Answer 29

increase wrist extension to full with flexed fingersprogress to full AROM and finger PROM*begin gentle blocking exercises

Question 30

EPM 6 weeks

Answer 30

NMESpassive stretching of involved structuresfull nonresistive use for ADLs (precautions for insensate hand)dynamic orthosis use

Question 31

EPM 8 weeks

Answer 31

*light strengthening exercises

Question 32

tendon repair precautions (3)

Answer 32

1. protect against a full active fist or full extension of the fingers2. avoid resistance from excessive co-contraction in early stages3. edema increases resistance during early ROM exercise so modify your approach if you encounter resistance

Question 33

fracture precautions (2)

Answer 33

1. avoid excess stress at fracture, fusion, or pin sites when mobilizing a complex injury2. if revascularization has been done in conjunction with fracture fixation, expect delayed healing or nonunion as a result of a decrease in the delivery of nutrients to the area

Question 34

nerve injury and repair precautions (4)

Answer 34

1. nerve injuries leave part of the hand insensate, so teach client to use caution with ADLs2. use caution with use of dynamic or static progressive orthoses and any other external compression because of the lack of a warning system for ischemia3. use heat and ice treatments cautiously4. remind the client that cold intolerance and pain after nerve injury is common for 2+ years

Question 35

incision, wound, and graft precautions (3)

Answer 35

1. make sure that dressings do not exert shear or mechanical stress on healing wounds2. prevent maceration while maintaining a moist wound bed3. avoid using cytotoxic chemicals on granulating wound tissue