FIG. 42-05

FIG. 42-06. EPM II, tabletop (intrinsic plus position). Wrist is in neutral, MP joints are flexed, and IP joints are extended.

FIG. 42-07. EPM II, claw position (intrinsic minus position). Wrist is in neutral, MP joints extended to neutral, and IP joints flexed.

Intermediate Care (Time of Hospital Discharge to 6 Postoperative Weeks)

After discharge, the replant patient is seen 3 to 5 days a week in therapy. Dressing changes, suture removal, x-ray follow-up leading to fixation removal, splinting, and increasing mobilization are all important aspects of management throughout this period. Following the assurance of vascular and skeletal integrity, passive and active mobilization are given the highest priorities.

The toe transfer patient receives the same attention. Additionally, dangling and crutch-walking of the donor extremity are introduced after secure soft tissue healing.

Flap care during the period primarily consists of protection of the operative site, dressing care, and mobilization of the patient as much as possible without compromising the flap.

Late Therapy (6 Postoperative Weeks to Discharge)

This period functionally commences when all wounds are healed, all skeletal problems are resolved, and the patient is ready to progress to his final result. Several specific therapy techniques and modalities useful to all microsurgical patients can be introduced and progressed during this period.

Aggressive edema control is directed toward reduction of swelling and stiffness and thus enhancement of motion. Gentle compression, using Ace wraps (for the lower extremity, Figs. 42-8 and 42-9) or Coban (for the upper extremity, Fig. 42-10), may be cautiously initiated as early as 3 to 5 weeks postoperatively in uncomplicated patients. Gentle retrograde massage can also be initiated coincidentally. As the patient demonstrates tolerance for these treatments, they can be prolonged. At 8 weeks postoperatively, a tailored compression garment can be considered.

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