Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 42:
Hand Therapy
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  Patients with replanted fingers receive range-of-motion therapy according to protocols developed at the Davies Medical Center.5 These protocols, based on clinical and cadaver studies, attempt to provide early protected motion to both the extensor and flexor tendons while protecting the skeletal, vascular and neural repairs. The first phase of therapy, Early Protected Motion (EPM) I, begins on or about the fourth postoperative day and continues through the second postoperative week (Protocol I) (Figs. 42-4, 42-5). This program initiates metacarpal joint motion through tenodesis activated by active wrist flexion and extension. Range of motion is thus initiated without active pull of either finger flexors or extensors. Besides initiating motion, this protocol maintains metacarpophalangeal joint collateral ligament length and prevents wrist stiffness. While the Early Protected Motion (EPM) I protocol continues, EPM II begins between the tenth and fourteenth postoperative days (Figs. 4-26, 42-7). This protocol calls for individual joint motions performed while the other joints are maintained in an opposing direction. Specifically, metacarpophalangeal extension is achieved while the proximal and distal interphalangeal joints are maintained in flexion (simulating an intrinsic minus position). Metacarpophalangeal joint flexion is performed with the interphalangeal joints extended (an intrinsic plus position). The wrist is maintained in a neutral position. This protocol increases joint mobility and tendon excursion. Cadaver studies performed while these protocols were formulated demonstrated that the tendon excursion obtained by these isolated joint motions are 75% less than the excursion that occurs with composite motion. Stress on the extrinsic tendon repairs is therefore minimized. Intrinsic contractures are antagonized by these maneuvers. By the completion of postoperative week 2, and with successful initiation of passive EPM II, active EPM II therapy is introduced and progressed. The detailed steps of institution and progression of these protocols are outlined in the protocols appended to this chapter.

  Postoperative management of toe transfer patients is similar to the care of replant patients except that special attention must be directed toward the donor site (Protocols V and VI). Wound complications at the donor site may occur in as many as 30% of the cases,4 and particular care must be expended on dressing, positioning in dorsiflexion, and mobilizing the foot.

Postoperative care of microvascular tissue transfer must be highly individualized (Protocols VII and VIII). The physician and therapist must use all the details of the procedure (site of reconstruction, site of vessel repairs, skeletal defects, associated tendon, or nerve injury) to develop an individualized postoperative therapy plan.

FIG. 42-01. Xeroform is placed over the incision. Two-by-twos are placed between the fingers to avoid maceration.


FIG. 42-02. Fluffed four-by-eights are placed volar and dorsal to the wounds.


FIG. 42-03. Kerlix is applied loosely to avoid constriction.


FIG. 42-04. EPM I. The wrist is actively flexed, allowing the tenodesis action to extend the MP and IP joints.


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