Vol. 23 Issue 6
Amputations of the Hand
Helping your patient cope with the physical andpsychological ramifications of loss
It is almost incomprehensible to literally lose a part of yourself. Guided by billions of synapses, our brain has mapped out a body image for us that aids in awareness of body parts and how they function within our personal space.
Accidents are often the cause of amputations; however, digit/hand amputations may be congenital, or they may be performed electively as a result of severe and irreparable circulatory compromise, infection, tumor and/or isolated digit stiffness, which may place the patient at risk for further injury.
Once healing is sufficient, the therapy that follows walks the thin line between rehabilitative and compensatory, depending upon the circumstances precursory to loss of hand function and the subsequent surgical repair.1,2
As the fictional Oscar Goldman once declared, "We can rebuild him. We have the technology." Today, those once-fictional words are becoming an emerging reality. A surgeon may restore hand function after amputation or congenital anomaly via procedures such as:
Replantation. Replantation of the amputated part back onto the hand or arm may include multiple repairs to damaged structures, including crucial vascular structures.
Primary repair. This involves smoothing out the terminal end of the bone and suturing of the wound. Advancement flaps or skin grafting may be necessary in order to provide adequate coverage. Advancement flaps, such as a VY flap, may be obtained from the injured finger itself; or from a donor site, such as an adjacent finger (cross finger flap or thenar flap).
Revision amputation. A revision amputation of the stump includes removing irreparably damaged soft tissue and shortening/smoothing out the remaining bone to produce a stump that will heal satisfactorily, as well as re-anchoring tendon insertion sites, which originally were distal to the amputation.
Reconstruction procedures. Reconstruction procedures such as pollicization of the index to take the place of the thumb, great toe to thumb transfer, or deepening the first web space to compensate for a partial thumb amputation, may be considered for congenital loss, or as a follow-up surgery to transfer function after acute loss.1,2,3,5
While general guidelines exist for hand therapy following repair to hand/digit amputations, therapy is initiated and progresses based solely on the surgeon's orders. This is due to the crucial factors affecting healing, and to the many variables affecting the type of repair following complex injuries. According to Rehabilitation of the Hand, the physician may order hand therapy 5-14 days post operative digit/thumb replantation, and 2-7 days post operative hand replantation.
The initial goal is to protect injured and repaired structures: vasculature, nerves, tendons, bones and ligaments. Typical protocols begin with splinting the hand and employ protective exercises specific to the level and location of the injury, timed with the rate of healing.2,3
The surgeon may order hand therapy to commence 3-5 days after conservative or simple surgical procedures. Therapy begins with a focus on wound care, edema management and gentle ROM, while protecting re-sutured tendons.3
More comprehensive surgical procedures involving flaps, skin grafts, reconstruction or replantation will necessitate a longer waiting period to begin dressing changes and progress therapy. Splints are generally fabricated after the post-operative dressing is changed. The subsequent exercises are based on early protective motion protocols, avoiding tension to healing repairs.
Digit replantation exercises usually begin with passive ROM wrist flexion to elicit tenodesis digit extension, and active ROM wrist extension to elicit tenodesis digit flexion.
Thumb replantation exercises often begin with active/passive ROM wrist flexion to 10-15º, and extension to neutral; CMC (carpometacarpal) passive ROM if tension is avoided to repair sites; and MCP (metacarpophalangeal)/IP (interphalangeal) passive ROM flexion and MCP/IP active ROM extension no further than the limit of the dorsal protective splint.
Hand replantation exercises usually -begin with passive finger flexion and extension, proceeding no further than the dorsal protective splint allows.3
ROM, massage, desensitization and strengthening will need to be progressed gradually, and according to the surgeon's orders, due to the greater risk of complications of the graft lifting or vascular compromise to the replanted/reconstructed part. Seemingly benign treatments, such as dressing changes, elevation and retrograde massage, have the potential to cause vasospasm. This may cause failure or rejection of the replanted/reconstructed part if treatments are poorly timed or done in an overly aggressive manner. Monitor vascular patency by observing capillary refill, temperature and color of the skin and fingernail.1-3
Eventually, retraining of the hand in ADL should focus on occupation-based activities, as well as therapeutic exercise, considering the altered level of hand function that the patient may experience due to reconstruction, amputation, nerve damage or the use of a prosthesis. The patient must be taught compensatory strategies and movements.
Hypersensitivity and cold intolerance tend to be a hallmark of fingertip crush and amputation injuries. Once healing is complete, start the patient on a gentle desensitization hierarchy of light to coarse textures. Progress activities from having the patient tap their finger on a towel placed on a table, to tapping on the table directly. Digicaps, which have a durable gel liner, may be placed over the affected tip to promote function in cases where the patient is experiencing extreme and disabling hypersensitivity.2,3
Conversely, it is important to perform a thorough sensory evaluation, once healing is complete, and initiate sensory re-education activities as needed. Sensory loss, especially to the thumb, has the potential to be just as disabling as ROM and strength deficits. Utilize activities that promote localization of light touch and stereognosis, the ability to identify objects by touch.
Progress from gently rubbing coarse to light textures on intact skin of the affected part, or use particle desensitization, having the patient use his hand to sift through a container of popcorn kernels or other material. Step up the program by placing safe objects, such as small balls or large coins, in the container to promote stereognosis.2,3
Once healing has progressed enough to commence strengthening, exercises may need to focus on strengthening muscles to initiate functions that they did not primarily initiate prior to the injury. For example, in absence of the index finger, the thumb will be required to oppose the middle finger or other remaining fingers, necessitating stronger interossei to those digits.
Scar management should play an important part in your therapy plan of care once the wound has healed, with a longer waiting period after grafting. It is important to reduce the risk of restricting adhesions and painful neuromas, which sometimes develop as masses of scar tissue around a nerve. Also of importance is cosmesis, the aesthetic appeal of the hand. Strategies such as scar massage and silicone gel sheeting are important, with an added benefit–compressive wraps used to keep silicone gel sheeting in place, often for night wearing, can also be used to reduce edema and to shape the stump. Use caution after vascular repairs, replantation and reconstruction, so as not to restrict blood flow.1-3
Phantom limb pain/phantom limb sensation may resolve as the brain goes through the time-consuming process of reorganization; however, the patient's physician may suggest other treatments to address painful symptoms, including antidepressants, spinal cord stimulation, stump desensitization and virtual reality exercises.4
Prostheses may be provided for cosmetic appeal and compensatory function when the scope of disability or cosmetic distraction is significant and replantation or reconstruction is not feasible. This may be due to expected poor prognosis for healing or poor condition for replantation of the amputated part. Not all patients are receptive to the use of a prosthesis due to comfort -issues and perceived inconvenience.3
Prosthetic training focuses on the use of the prosthetic part in relation to the body, the use of the controls on the prosthesis and the manner in which to don/doff the apparatus. Types of prostheses include static/cosmetic, mechanical and myoelectric. Recent advancements in technology have produced more efficient prostheseslighter in weight and with more sensitive controls.
We must also consider preventing further injury by discussing safety issues with the patient, which may entail reorientation to their previous employment conditions, as applicable. This is especially important if the patient is to return to working around heavy machinery.
It takes a team to treat a patient, including the surgeon, the primary hand therapist and the patient himself. Depending on the patient's needs, the team may also include:
A physical therapist to perform gait training statuspost great toe to thumb transfer;
A prosthetist to fabricate and provide initial prosthetic training;
A counselor to help the patient cope with grieving, accepting altered function, change in appearance or change in life roles; and
A vocational counselor, if the patient needs to find another type of suitable employment.
An amputation of the hand or any portion thereof represents a physical loss, requiring both physical and psychological adjustments. The loss of hand function is palpable, affecting ADL, employment and overall life satisfaction.
Many variables are important regarding the patient's ability to cope with his injury and the follow-up treatments, but one thing remains a constant: Each member of the patient's rehabilitation team must provide encouragement and truly listen to the patient's concerns and goals, in order to provide quality, compassionate care.
References available at www.advanceweb.com/OT or upon request.
Amy Roux, OTR/L, CHT, has worked as an occupational therapist at University of Massachusetts–Leominster Hospital since 1993 and became a certified hand therapist in 2001. She has worked with patients ranging in age from 3 months to 104.
Each Finger Represents a Percentage and Type of Hand Function.2
Thumb (40 percent). The "pillar of the hand" provides an opposable surface forthe other fingers, thereby promoting dexterity activities. Accurate sensation is also of the utmost importance.
Index (20 percent). Enables 2-point, 3-point and lateral pinch.
Middle (20 percent). Stronger and longer than the index, provides power to 3-point pinch and gripping.
Ring (10 percent). Participates with thelittle finger in palmar grip. It is the weakest finger and its loss represents the smallest functional deficit.
Little (10 percent). Provides width and power to the hand during spherical andcylindrical grip due to the extreme mobilityof the MCP and the strength of the opponens digiti minimi, flexors, abductorand adductor muscles.