|Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.|
| A thumb web space splint is often necessary. Consider splinting once vascular status has stabilized, wounds are healed, and joints are stable and can tolerate stress.
Pulsed ultrasound is administered if adhesions are present.
6 TO 8 WEEKS
Discontinue use of protective splint. Continue light functional activities.
Begin light, resistive activities and progressive strengthening exercises as tolerated. When patient achieves protective sensation, begin sensor re-education program.
PROTOCOL III: HAND REPLANTATION
Immediately postoperatively, elevate on pillows. Keep the extremity warm using a heating pad.
DAY 2 TO 7
The first postoperative dressing change is performed by the physician. After this, the therapist is responsible for twice-daily dressing changes and monitoring of wounds during treatment sessions.
A protective positioning splint is frequently constructed early in the postoperative period to optimize wrist and hand positioning. Choice of volar or dorsal splint depends on wound location, anastomosis site, tension of repairs, and presence of wrist fixation. If the wrist is not pinned, it is positioned in neutral or in slight flexion. Digits are positioned in the intrinsic plus position as tolerated (Fig. 42-16).
Passive EPM II (position described under DIGIT REPLANTATION, EPM II) to thumb and finger MP and IP joints is begun in the first postoperative week after discontinuation of anticoagulant therapy. In the event that the wrist joint did not require bony fixation, consult physician and consider passive EPM I (as described under DIGITAL REPLANTATION). All passive motion is limited by tension on nerve, tendon and vascular repairs.
FIG. 42-16. Dorsal protective splint (with detachable CPM unit) to include thumb and digits. The midportion of the splint is held on by bias stockinette to avoid pressure over the volar muscle flap.
Retrograde massage to digits and palm is initiated. Elbow and shoulder range of motion are evaluated and included in therapy as indicated. Wrist and forearm motions are contraindicated.
DAY 14 TO 21
Active assistive range of motion is begun in protected position. Because of deinnervated intrinsics, the therapist assists MP flexion while the patient actively extends the IP joints. The therapist then assists MP extension while the patient actively flexes the IP joints.
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