Hand Rehabilitation in Occupational Therapy

Jane Bear Lehman, Florence S Cromwell

• Publisher: Routledge
• Year: 2012
• ISBN:
  9781136552274
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

This practical book presents the latest and most effective occupational therapy methods and theories designed for treating patients with decreased hand function. The growing incidence of hand injuries in recent years has challenged occupational therapists to develop innovations in hand care. Now, with this authoritative resource, you can greatly enhance your practice skills and ability to plan effective treatment programs. The contributors provide clear examinations of such topics as wound and scar tissue management, the treatment of Colles fracture, and pre- and post-operative approaches to therapy, among many other pertinent areas.

Wound Management in Hand Therapy

Cecelia Holt Skotak, OTR Susan M. Stockdell, OTR

SUMMARY. Competent wound management is critical to successful rehabilitation of the injured hand. The occupational therapist who treats patients with such injuries must know what is involved and how various treatment procedures and activities impact healing. This paper will review the physiology of wound healing, present a framework for evaluation of the wounded hand and provide practical suggestions for treatment.

PART I: PHYSIOLOGY

Occupational therapists have specialized training to recognize physiological and psychological responses to injury or disease, as well as the potential for these responses to impede a person's function. Therapists who treat patients with hand injuries must understand the skin's structure and physiological phases of wound healing and be able to recognize deviation from the expected course of events as well as potential complications. This guides the therapist in treatment planning and facilitates appropriate communication with the other professionals involved in the patient's care.

Skin is comprised of epithelial and connective tissue. Epithelial tissue lines the body's cavities and organs as well as forms the exterior surface or the epidermis of the body. Connective tissue or the dermis provides the integral, deep mechanical support for both anchoring and binding.¹

Several layers of dead epithelial cells form the top outer layer of the epidermis; these cells are constantly sloughed and then replaced by new cells produced in the bottom layer through mitosis which then migrate to the superficial layer.¹ The dermis is composed of collagen fibers as well as elastic and reticular fibers. Blood vessels, lymph vessels, hair roots, nerves, and portions of the sweat and sebaceous glands are all located in the dermis.

Epithelial Tissue Healing

In wounds which involve the epidermal layer of the skin, such as first and second degree burns or abrasions, healing occurs in a simplified manner. The abrasion-type wound is initially filled with clotted blood and necrotic debris which eventually dehydrate to form a scab. In first or second degree burns, the dead epidermis remains on the wound or is elevated by a collection of fluid between the layers of the epidermis, thus forming a blister.¹

In either case, the bottom layer of epithelial cells as well as those cells at the wound margins migrate into the wound, multiply by mitosis to resurface the wound, and then differentiate into mature epidermal cells. Once the wound is filled in, the migrated cells undergo mitosis to thicken the new epithelial layer. Upon completion of this process when there is a new surface to the wound, the scab sloughs off. If there is bacterial invasion at any stage, the superficial wound may be converted into a deeper wound.¹,²

Connective Tissue Healing

The healing process is more complicated when an injury involves both layers of the skin and possibly even subcutaneous structures. This is frequently the case in hand injuries. Crush injuries, avulsion, lacerations, third degree burns, and surgical incisions are examples of such wounds. Wounds are classified by the type of wound closure which is based on the degree of: host tissue injury, contamination by living organisms, and presence of foreign bodies.³

WOUND CLOSURE CLASSIFICATION

Primary closure. The wound is closed immediately provided that host tissue injury, contamination, and the presence of foreign bodies are minimal. The physician takes into consideration the mechanism of injury (e.g., a clean unused kitchen knife laceration to a clean hand) when making this decision. Healing of this type of wound is the most expedient.⁴

Delayed primary closure. The wound is not closed initially to allow for further debridement and/or to minimize the risk of infection.³ The physician elects to complete closure when there appears to be no risk of infection.

Secondary intention healing. Again based on the mechanism of injury, the physician decides that surgical wound closure is contraindicated because the degree of host tissue injury, contamination, and presence of foreign body is too great thus the wound is allowed to close spontaneously (e.g., farmyard equipment injury, high pressure paint gun injury). This is also utilized in elective surgery in which there is a great deal of host tissue injury, such as Dupuytren's contracture excision.³

Treatment planning is augmented when the therapist also considers the nature/mechanism of each patient's specific hand injury and how these factors will effect the physiological course of events (see Table 1).

Wound Healing in Primary Closure

When connective tissue is injured, there are three phases of wound healing: inflammation, fibroplasia, and scar maturation. These phases will be discussed separately but in actuality occur as a continuum.

TABLE 1 NATURE/MECHANISM AND EXAMPLES OF INJURY

Consider which type of wound closure might be utilized and how healing would vary for different injuries.

Nature/Mechanism of Injury	Example of Injury
Amputation	skill saw, lawn mower
Crush	punch press
Avulsion	ring or rope avulsion
Laceration	clean kitchen knife, pork slaughterhouse knife
Puncture	nail gun
Thermal-heat/cold	burn, frostbite
Chemical	hydrofluoric acid
Electrical	entrance and exit wound
Explosive	gun shot wound, fireworks
High Pressure Injection	paint gun
Mutilating	wringer/roller, corn picker

Inflammation

Inflammation is a vascular and cellular response to tissue trauma, the purpose of which is to dispose of necrotic tissue, foreign material, and bacteria, thus preparing the wound for repair. It is nonspecific to the type of trauma whether thermal, mechanical, or bacterial and will be present in any damaged tissue.² The clinical signs of an acute inflammatory response are redness, local heat, swelling, pain, and loss of function.⁴ During the first 5-10 minutes following an injury, constriction of the local vasculature occurs. Simultaneously, the vessel walls become lined with leukocytes, erythrocytes, and platelets.⁵

Active vasodilation follows, with increased blood flow and increased permeability of the small venules. It is possible that the vasodilation is induced by a local histamine action, which may explain a patient's complaints of the wound “itching.” The endothelial cells, which swell and “round up,” form separations between the cells, allowing plasma containing electrolytes and macromolecules to enter the site of injury.² Edema caused by this interstitial fluid will be present, as will redness and local heat caused by the increased circulation. Pain is thought to be caused by pressure on nerve endings, chemical mediators, increased neural sensitivity, or a combination of these factors. Lymphatic channels at the injury site are occluded by fibrin plugs which arise from the plasma. This occlusion prevents drainage of fluid from the area, thus localizing the inflammatory reaction.⁵

White blood cells (leukocytes) leave the vessels, concentrate at the injury site, and engage in phagocytosis of foreign substance. Ingested bacteria are partially digested by the leukocytes. As the leukocytes die, intracellular enzymes and debris are released into the wound to become part of the wound exudate or pus. Exudate can develop in the absence of bacterial contamination—without the wound being “infected” —but this interferes with healing. The enzymes contain protease and collagenase which solubilize connective tissue; consequently the wound must be kept clean in order to expedite completion of the inflammatory response.

Fibroplasia

During the first 24 hours of primary intention healing, the line of incision fills with clotted blood, and the wound is sealed. During the second day, reepithelization of the surface and bridging of the dermal cleft occur. The blood clot provides a structural scaffold along which the epithelial cells migrate. There are small tongue-like processes of cells protruding into the wound from the epithelial margins; these connect within 24 hours so that there is a surface covering of epithelium. Initially, the epithelium is very thin, but with proliferation of cells, it becomes several layers thick. Migratory fibroblasts (which have evolved from undifferentiated mesenchymal cells) move into the wound, proliferate and synthesize scar. Components of the ground substance of connective tissue are synthesized initially, and later, collagen is formed. At this time,⁵ granulation tissue (a highly vascularized tissue containing fibroblasts, capillary networks and other infiltrating cells) can be microscopically recognized in a wound which is healing by primary intention.²,⁶

By the fourth to fifth day, the wound space is filled with a highly vascularized, loose, fibroblastic connective tissue in which scattered collagen fibrils are present. Wound contraction begins to take place at this time through the movement of myofibroblasts from the periphery towards the center of the wound. By the fourth day, the wound has approximately one tenth of one percent of its ultimate strength.⁷

By the seventh day, the wound is covered by epidermis of near normal thickness. During the second week of healing, there is ongoing proliferation of fibroblasts and production of collagen. The collagen molecules are initially held together by weak physical forces and by hydrogen bonds. As the fibrils mature, the weak forces are replaced by covalent bonds (strongest type of chemical bond) to produce strong flexible fibers. At this point, the scar has increased vascularization as the capillaries are formed through endothelial budding. The fibrin scaffold has disappeared, and the inflammatory reaction should be completely subsided. Only the sutures and the epithelial bridge provide the wound with tensile strength. Carefully sutured wounds have approximately 70 percent of the strength of normal skin. If the sutures are removed on the seventh postoperative day, the wound alone has only 5-10 percent of the strength of normal skin.⁵

By the end of the second week, the basic scar structure is present, and with the accumulation of collagen, the tensile strength and rigidity of the scar increases. The vascular channels become compressed, and blanching of the scar begins. As a sufficient quantity of collagen is produced, the number of fibroblasts decreases. The synthesis of collagen is dependent on an adequate supply of nutrients (i.e., amino acids and vitamin C).⁵,⁷ All of the sutures may be removed by this time and the wound is prepared for the next stage: scar maturation.

Scar Maturation

Function of the hand is dependent on the gliding of strong, dense connective tissues (i.e., tendon, bone, muscle, skin, and fascia) upon each other, thus allowing the great combination of movement, stability and strength necessary for everyday activities.⁸ However, these tissues can be “cemented” together by the scarring process, thus preventing this gliding.

Scar tissue formed during fibroplasia is an enlarged, dense, protein structure comprised of collagen. The collagen fibers are randomly oriented and highly soluble; initially the union created is fragile. The maturation process (or chang...

Table of contents

• Cover Page
• Half Title page
• Series page
• Title Page
• Copyright Page
• Contents
• About the Editor
• From the Editor's Desk
• In This Issue
• Hand Rehabilitation and Occupational Therapy: Implications for Practice
• Wound Management in Hand Therapy
• Clinical Management of Scar Tissue
• Concepts and Current Trends in Hand Splinting
• Dexterity as a Valid Measure of Hand Function: A Pilot Study
• Proposal for Splinting the Adult Hemiplegic Hand to Promote Function
• EMG Biofeedback Training to Promote Hand Function in a Cerebral Palsied Child with Hemiplegia
• Occupational Therapy and the Treatment of the Colles'Fracture
• Pre and Post Operative Occupational Therapy for a Toe to Hand Transplantation
• Pre- and Postsurgical Approaches to the Treatment of the Adult with Hemiplegia Having Motor Balancing Surgery of the Upper Extremity
• Occupational Therapy Management of Tendon Transfers in Persons with Spinal Cord Injury Quadriplegia
• Practice Watch: Things to Think About
• Books Reviews