口腔癌患者的復健治療
肌腱轉移(Tendon Transfer)
伸肌肌腱(Postoperative Management of Extensor Tendon Repair)
屈肌肌腱修復的手部復健
手指再植病患術後之復健活動
鬆筋手術(Tenolysis)

口腔癌患者的復健治療


長庚醫院整形外科肢體重建中心

復健不等於運動
復健是讓病人在最短的時間內恢復最大的功能

口腔癌病患的復健治療

口腔癌病患的問題一般約可分為
     口腔
     頸部
     肩膀
    
供應皮瓣處(donor site)

口腔張合有問題時會造成下列之困擾
     牙齒咀嚼食物的能力受損
     口腔衛生很難保持,清潔工作有死角
     需要進行牙科治療時,會有實際上的困難

口腔張合有問題時會造成下列之困擾
     影響患者說話的能力
     影響患者臉部的表情生動活潑度
     患者無法使用活動假牙或無法裝置永久性假牙

頭頸部腫瘤---臉頰及牙齦腫瘤
口腔問題的特性

     嘴巴開合幅度較舌部腫瘤患者差---口腔衛生、牙科矯治等工作比較困難 

頭頸部腫瘤---臉頰及牙齦腫瘤
口腔問題的特性

     外表有時比較不雅觀,患者傾向戴口罩出門---影響社交功能

頭頸部腫瘤---臉頰及牙齦腫瘤
口腔問題復健之應注意事項

     軟組織之按摩---除了外側要保持柔軟、口腔內側之按摩也要加強

頭頸部腫瘤---臉頰及牙齦腫瘤
口腔問題復健之應注意事項

     軟組織延展性---必須注意一年

頭頸部腫瘤---臉頰及牙齦腫瘤
口腔問題復健之應注意事項

     多練習嘟嘴巴往內吸口水的動作---避免或改善流口水的困擾 

頭頸部腫瘤---舌部腫瘤
口腔問題的特性

     舌頭動作比較會受影響---吃東西、吞嚥功能受影響,營養的攝取要特別注意

頭頸部腫瘤---舌部腫瘤
口腔問題的特性

     外表雖然不受影響,但吃東西不方便---影響社交功能,有些患者影響工作能力 

頭頸部腫瘤---舌部腫瘤
口腔問題復健之應注意事項

舌頭的按摩---不要怕麻煩,可以用手、可以用壓舌板、可以用鐵湯匙,儘可能保持重建皮瓣的柔軟

頭頸部腫瘤---舌部腫瘤
口腔問題復健之應注意事項

     軟組織延展性---必須注意一年

頭頸部腫瘤---舌部腫瘤
口腔問題復健之應注意事項

     多練習舌頭上下左右各方向的動作---避免或改善口齒不清的困擾

口腔問題復健運動及治療方法
Rehabilitation  復健運動
 Trismus appliances  矯治工具
 

口腔問題復健運動
  每1--2小時按摩臉頰部位可以使咀嚼肌肉放鬆,顳頷關節韌帶鬆弛,比較容易將關節拉開  按摩後主動將嘴巴打開到最大幅度,停留10秒,重複10次,每天最少練習10回合千萬不要一次運動過度,而久久才做一次
  按摩後也可以頭稍微抬高,將手扣住下巴,輕輕向下壓,保持此姿勢5分鐘力量不要太大、太猛,不要刻意搖晃,保持拉開嘴巴的姿勢的時間盡量久一點
 

口腔問題的矯治工具
     紗布
     壓舌板
     不袗張口器
 

嘴巴打不開施予物理治療
應注意事項

 熱敷、薰蒸氣、超音波、泡熱水、紅外線等物理治療方法固然可以增加組織的延展性,相對的也可能提高腫瘤的復發機率,基於病患的安全考量是絕對禁止的
 

頸部、肩膀動作有問題時
會造成下列困擾

      頭痛
      頸部、肩膀酸痛、影響睡眠
      社交生活受影響
 

頸部、肩膀動作有問題時
復健運動及治療方法
     病患的教育
     
復健治療
 

頸部、肩膀動作有問題時
復健運動及治療方法
    病患的教育
  找出問題
  睡覺姿勢
  家居生活

頸部、肩膀動作有問題時
復健運動及治療方法
    病患的教育
 –
找出問題
針對家居生活及睡覺時的姿勢,糾正不對的姿勢、觀念及習慣,而不是
       一味叫病人做運動,因為這樣不切實際

 –
睡覺姿勢:患者常因擔心傷口裂開,睡覺姿勢緊張僵硬,一覺醒來頸部及肩膀都很
       僵硬,可以在後頸部和身體的其他部位,加上枕頭支撐,避免某些部位懸
       空。

 –
家居生活:病人靜坐時的姿勢不宜彎腰駝背,必須時應該加一個腰墊,一方面給予腰
        部肌肉支撐的力量,另一方面矯正姿勢。

 頸部動作有問題時
復健運動及治療方法
     復健治療
    拉筋運動
    腹式呼吸
    居家運動
    治療儀器

 頸部、肩膀動作有問題時
 復健運動及治療方法
     復健治療
  拉筋運動

  拉筋運動對病人的急性症狀很有用,剛開始拉筋應該從15秒開始,避免誘發症狀,拉筋強度也應從弱到強,過度拉扯沒有好處只有壞處。

  腹式呼吸

    不好的呼吸習慣會增加某些肌肉的不當使用,所以要調整呼吸習慣。

  居家運動
  
提醒大家必須常做頸部及肩膀的運動, 才是根本解決之道

 頸部、肩膀動作有問題時
 復健運動及治療方法

 口腔癌患者
頸部、肩膀之照護

     擺位

  越舒服的姿勢,就是越危險的姿勢
 不要因為怕傷口裂開,而錯誤的擺位會造成嚴重的後遺症

     運動方法:
 
每小時做關節彎曲運動十次

  每小時做關節伸展運動十次
  每次動作必須停留十秒;不可以太快
 

供應皮瓣區的種類
  一般常用的皮瓣,大致上分四種

    1
 前臂皮瓣
    2
 腓骨皮瓣
    3
 大腿前外側皮瓣
    4
 上臂皮瓣
 

供應皮瓣區的照護及復健---前臂皮瓣取皮瓣區的照護
支架保護

  •
   顯微手術完畢後,一般會植皮將傷口復合,無論是哪一種植皮手術,都必須以石膏或塑膠支架固定手腕、手指約1~2個星期,完全不動,2星期之後,可將支架修改成只固定手腕,再戴2個星期,所以總計4個星期

復健運動
l
     手術完第2天~2星期

    手腕及手指固定不動,以免影響植皮手術的存活

l
     手術完2星期  ~  4星期

   加強手指握拳、伸直,以及手指靈活度的訓練

l
     手術完4星期~半年

    加強屈肌肌腱的延展性,定時做拉筋運動,加強疤痕的按摩,清醒時每小 時做5分鐘,必須長達半年以上

 彈性的護具
  一方面保護一方面壓疤痕
  病人居家要常常作祈禱的動作 

腓骨皮瓣取皮瓣區的照護
支架保護

 •
   顯微手術完畢後,一般會植皮將傷口復合,無論是哪一種植皮手術,都必須以石膏或塑膠支架固定腳踝、腳趾約1~2個星期,完全不動,2星期之後,支架可改成睡覺及白天休息時間穿戴,再戴4個星期,所以總計6個星期
 

腓骨皮瓣取後必須穿戴保護性副木前後6星期

腓骨皮瓣取皮瓣區的照護
復健運動

手術後第二天-----四個星期

 患側必須24小時穿戴支架,腳踝保持90度,腳趾[尤其是大腳趾]完全伸直的姿勢,儘量抬高,絕對不可以踩地走路。傷口如果癒合,每小時按壓疤痕5分鐘

手術後五星期-----六個星期

 每小時按壓疤痕5分鐘。腳踝及腳趾做向上翹和向下彎的運動也是每小時各10次,運動時動 
 作做到最大關節活動度、速度要慢
。仍然不可以踩地走路。

 腳踝及腳指盡量向下壓

  腳踝
CPM機器幫助病人增加關節活動度

 家屬或治療師可以常常將腳踝及腳指向腳背方向推腳趾及腳踝拉筋的動作

手術後七星期-----三個月

 可以開始踩地走路,剛開始練習走路速度放慢,時間不可太久。

腓骨皮瓣取皮瓣區的照護
復健運動

手術後二星期-----六個月

 為保護小腿肌肉及預防長期腫脹,必須用4吋彈性繃帶自腳掌向心方向纏繞,期間共半年左右。

 小腿繃帶要綁半年

大腿前外側皮瓣取皮瓣區的照護
復健運動

手術後第二天-----四個星期

 開完刀至少2個星期避免下床走路,2個星期之後可以下床走路,但必須注意不可以走太久,而且大腿一定要綁上彈性繃帶

手術後五星期-----六個月

 傷口拆線後,加強疤痕的按摩,清醒時每小時做5分鐘,建議患者練習膝蓋打直及彎曲的運動,每小時10次,彈性繃帶建議要綁半年,以保護大腿肌肉,避免產生任何後遺症。

 

肌腱轉移(Tendon Transfer)

 

Definition
 A tendon is transected and reinserted into a bone or another tendon. The innervation and blood supply of its muscle are preserved.

 Tendon transfer for shoulder reconstruction
  
~L'Episcopo procedure
   Teres major & Latissimus Dorsi
   ~Modified L'Episcopo procedure
   detached insertion of L.D. & T.M.
   plasterolateraly pass down through humerus
  attached to origin of lateral head of biceps

Indications for tendon transfer
~Substitution for function or paralyzed muscle
~Restoration of balance to a deformed hand
~Replacement of rupture or avused tendons or muscles

Reconstruction of paralyzed muscle function
~Neurorrhaphy
~Tendon trasfer
~Neurorrhaphy and Tendon trasfer

Basic requirements before tendon transfer
~Good skeletal stability
~Adequate joint mobility
~Supple soft tissue
~Good donor strength
~Good donor excursion
~Patient's education

Principles of tendon transfer
~Correction of deformity
~Adequate donor strength
~Adequate amplitude of excursion
~Adequate integrity

Adequate Integrity
A tendon transfer should have only one function

Early tendon transfer
~act as internal splint
~within 3 months

Conventional tendon transfer
~3 months after the time of expected recovery in traumatic nerve lesion

Method of donor selection
~What works
~What's available
~What's needed
~Matching
~Alternatives
~Staging

Preoperative management
~Strengthen the donor muscle
~Obtain full passive R.O.M
~Encourge scar massage
~Evaluate the patient

Postoperative management
~According to
-----surgical technique
-----tissue healing process

Conclusion
~encourage positives factors
-----balance, strength, mobility
~minimize nagative factors
-----stiffness, deformity

Low radial nerve palsy
~posterior interosseous nerve (motor )
*ECRB
*EIP
*EPL *EPB
*EDC *ECU
*EDM *Supinator
~superficial redial nerve (sensory )

High radial nerve palsy
~P.I.O. nerve innervated muscles
~triceps
~brachioradials
~ECRL

Low median nerve palsy
~APB
~FPB
~Opponens pollicis
~Lumbrical I , II

High median nerve palsy
~APB , FPB , OP , Lumbrical I , II
~FPL
~FDS
~FCR
~PL
~PT
~FDP II , III

Extensor tendon transfer
~Protective splint
*Wrist -----45 degrees extention
*MPJs -----full extention
*IPJs ----- full extention
*Thumb--- full extention &abduction

Extensor tendon transfer
~Protective stage (1st day ~4th wk)
~Active motion stage (5th wk ~6th wk)
~A.D.L. training stage (7th wk ~8th wk)
~Prevocation training stage (8thwk~ )

Opponensplasty ---Pulley Reconstruction
~Parallel to APB
~More longitudinal direction More powerful abduction
~More transverse direction More stable pinch

Opponensplasty ---Postoperative management
~Protective stage (1st day ~4th wk )
*splint : wrist 20 degrees flexion thumb opposition
*immobilization
*massage

Opponensplasty --- Postoperative management
~Active Motion Stage (5th~6th wk )
*gentle active exercise
*edema control
*scar massage
*continuation splinting between exercise

Opponensplasty ---Postoperative management
~A.D.L. training stage (7th~8th wk )
*muscle power strengthening
*R.O.M. improvement
*scar massage
*daily living activities design

Opponensplasty ---Postoperative management
~Prevocational training stage (8thwk~ )
*muscle power strengthening
*R.O.M. improvement
*coordination & dexterity training

High median nerve palsy
~Inability to oppose the thumb
~Inability to flex IP of the thumb
~Inability to flex IPs of the index (and middle) fingers

High median nerve palsy --- operative techniques
~Burkhalter 1974
~Brand 1975
~Golder 1974

High median nerve palsy --- postoperative management
~Controlled mobilizationstage (1st day ~4th wk )
~Active motion stage (5th ~ 6th wk )
~A.D.L. training stage (7th ~ 8th wk )
~Prevocational training (8th wk ~ )

Reconstruction of low ulnar nerve palsy
~Lasso procedure ( Zancolli 1974 )
*FDS IV ----- loops around A1 pulley
----- inserts back on itself
*Splint ----- dorsal block splint
wrist --20 degrees flexion
MPJ --50 degrees flexion
IPJ --extention

Reconstruction of low ulnar nerve palsy
~Lasso procedure ( Zancolli 1974 )
*Exercise program
A. 1st day ~ 3rd wk : passive R.O.M. for IP joints
B. 3rd wk ~6th wk : passive & active exercise for MPJ & IPJ ( within the splint )

Reconstruction of low ulnar nerve palsy
~Lasso procedure ( Zancolli 1974 )
*Exercise program
C. 6th wk : DC the splint . Apply the anticlaw hand splint
D. 12th wk : DC the anticlaw hand splint

Reconstruction of low ulnar nerve palsy
~Brand procedure ( Brand 1954 )
*Volar route
ECRL -----through carpal tunnel
-----lateral band
*Dorsal route
ECRB ----- through intermetacarpal space
----- lateral band

Reconstruction of low ulnar nerve palsy
~Splint
*Wrist : 45!Cextention
*MPJ : 60!Cflexion
*IPJ : extention

Reconstruction of low ulnar nerve palsy
~Exercise program
A. 1st day ~ 4th wk ----- immobilization
B. 4th wk ~ 6th wk ----- active motion
C. 6th wk ~12th wk ----- DC the splint apply the anticlaw hand splint
D. 12th wk ~ ----- DC the anticlaw hand splint

Tendon tranefer for shoulder reconstruction
~L'Episcopo procedure
shoulder -- shoulder spica cast
70 degrees abduction
45 degrees external rotation
20 degrees forward flexion

Tendon tranefer for shoulder reconstruction
~Chuang's procedure
L.D.-- to -- humerus for deltoid function
T.M. -- to -- lateral humerus for external ratation

Tendon tranefer for shoulder reconstruction
~Chuang's procedure
*postoperative protocol
A. Protective stage (1st day ~ 6th wk )
B. Active motion stage ( 7th wk ~ 8th wk )
C.Strengthening stage ( 9th wk ~ )

Chuang's procedure
~Protective stage (1st day ~ 6th wk )
*Splint ----- shoulder spica cast
90!Cabduction
60!Cexternal rotation
*Immobilization

Chuang's procedure
~Active motion stage (7th wk ~ 8th wk )
*Gentle active motion
*Gentle passive R.O.M.
*Scar massage
*Changing splint to 45!Cabduction

Chuang's procedure
~Strengthening stage ( 9th wk ~ )
* strengthening the muscle power
* improvement of R.O.M.
* D.C. the splint

Elbow reconstruction
Flexion is more important than Extention

Steindler flexor plasty
~Indication : normal function of finger flexors ( pronator group )
~Method :
A. detached origin of flexor group
B. attached at more proximal part of humerus
~Effect : flexion wrist & fingers !÷ achieving elbow flexion

Modified Steindler flexorplasty
~detached origin of flexor
~elbow in 130!C
~attached to anterior aspect of humerus

Conclusion
~Good communication with surgeon
~Good rehabilitation program
~Cooperative and well-informed patient
Make a successful result of tendon transfer

 

伸肌肌腱(Postoperative Management of Extensor Tendon Repair)

 

Extensor System Anatomy--Tendon System
Extensor System Anatomy--Zones of Injury

Tendon Healing Phase
~Exudative phase
 - 0~4 days Inflammatory response
~Fibroblastic phase
 - 5~21 days Collagen synthesis
~Remodeling phase
 - 3wk~6mo/1yr Scar remodeling

History Review
~A study of the dynamic anatomy of extensor tendons and implication for treatment :
 - Dynamic extensor tendon splint with elstic traction slings
 - Palmar blocking limited MP flexion in the arc of motion Evans RB , Burkhalter J Hand Surgery
      1986 ; 11A:774
~Early dynamic splinting of extensor tendons :
 - Dynamic splint for MP flexion 70° , PIP flexion 70° , DIP flexion 50°
 - Full extension in 77 / 82 , no rupture Browne EI , J Hand Surgery 1989 ; 14A:72
~A comparison of results of extensor tendon repair followed by early controlled mobilization versus
  static immobilization :
    - Faster recovery and return to work , better functional results and avoidance of secondary
      procedure in dynamic extension splint protocol Chow JA , J Hand Surgery 1989 ; 14A:72
~Early controlled mobilization with dynamic splinting for treatment of extensor tendons injuries :
   - Injury distal to the MP joint had Poor results than those proximal Hung LK , J Hand Surgery 1990;
     15A:251
~Long - term results of extensor tendons repair : Newport ML , J Hand Surgery 1990; 15A:961
~Wrist position and extensor tendons amplitude following repair :
    - NO tension after extensor tendon repairs with full flexion of the digits when the wrist in 45° of
      extension Minamikawa , J Hand Surgery 1992; 17A:268
~Postoperative management of extensor tendon repairs in Zone V, VI, and VII :
  - Levame type , dorsal steel leaf blade spring protective splint for Zone V, VI
  - Tom splint for Zone VII Thomas D , Moutet F J Hand Therapy 1996 ; 9(4):309-14
~Immediate active short arc motion following extensor tendon repair :
 - Active SAM with minimal tension and wrist tenodesis programs
 - Safe and effective for Zones III, IV, V, VI, VII, T IV, TV Evans RB , Hand Clinics 1995 ;
   11(3):483-512

Three components for Successful Extensor tendon rehabilitation
o Skilled surgeon
o Skilled hand therapist
o Cooperative patients

Extensor Tendon Repair
 Zone I and Zone II (DIP and Mid-Phalanx)
   o Possible Deformity :Mallet Finger
   o Major Types :
   o 1.Closed terminal tendon complete or incomplete rupture
   o 2. Terminal tendon rupture combined articular avulsion fracture

Extensor Tendon Repair
 
Zone I and Zone II (DIP and Mid-Phalanx)
  0 ~ 6 weeks
    o Splint 1. custom made ( dorsal or volar )
        2. stax splint ( commercial avalible )
    o Keep DIP extension 0 or hyperextension
    o PIP joint free

Extensor Tendon Repair
 Zone I and Zone II (DIP and Mid-Phalanx)
  0 ~ 6 weeks
    o Exercise Program
   - DIP joint :Full immobilization
     Not allow DIP flexion
     When the splint is removed
  - PIP joint and other unaffected joints:Active / Passive ROM

Extensor Tendon Repair
 Zone I and Zone II (DIP and Mid-Phalanx)
  6 ~ 8 weeks
   o Splint 1. Protective splint ( dorsal or volar )
       2. Blocking splint ( block PIP flexion when DIP flexion exercise )

Extensor Tendon Repair
 Zone I and Zone II (DIP and Mid-Phalanx)
   6 ~ 8 weeks
    o Exercise Program
  - Allow DIP 20 ~ 25 flexion 1st week.Increased to 35 flexion 2nd week
  - If extension lag occurred , 2 more weeks immobilization

Extensor Tendon Repair
 Zone I and Zone II (DIP and Mid-Phalanx)
  8 ~ 12 weeks
   o Splint 1. Night splint ( keep DIP extension )
       2.Template splint ( gradual progression flexion of DIP starting at 20 ~ 25 )

Extensor Tendon Repair
 Zone I and Zone II (DIP and Mid-Phalanx)
8 ~ 12 weeks
o Exercise Program - Gradually progress to composite. active/passive flexion/extension
         - If extension lag occurred , 2 more weeks immobilization

Extensor Tendon Repair
 Zone I and Zone II (DIP and Mid-Phalanx)
  12 weeks
   o Splint : Night splint discontinued - as long as no extensor lag

Extensor Tendon Repair
 Zone I and Zone II (DIP and Mid-Phalanx)
  12 weeks
   o Exercise Program - Beginning resistive exercise. active/passive flexion/extension
           - ADL progressed to normal

Extensor Tendon Repair
 Zone III and Zone IV (PIP and Proximal-Phalanx)
  o Possible Deformity :Traumatic Boutonnier Finger
   - 1. Acute :within 6 weeks of injury Central slip rupture, ORL tight﹝-﹞
   - 2. Chronic :longer than 6 weeks Central slip rupture, ORL tight﹝+﹞

Extensor Tendon Repair
 Zone III and Zone IV (PIP and Proximal-Phalanx)
   o Major Types :1. Closed :Forced flexion on active extended PIP joint
          2. Open :laceration wound deep to central slip rupture
Extensor Tendon Repair
 Zone III and Zone IV (PIP and Proximal-Phalanx)
   0 ~ 6 weeks
    o Splint : Volar static gutter splint
           1. Lateral band involved-PIP,DIP immobilize
           2. Lateral band uninvolved -PIP immobilize only
   o Keep PIP extension 0 or hyperextension
   o MP joint free

Extensor Tendon Repair
 Zone III and Zone IV (PIP and Proximal-Phalanx)
   0 ~ 6 weeks
    o Exercise Program ( 1 )
       - PIP joint :Full immobilization Not allow PIP flexion When the splint is removed
       - MP joint and other unaffected joints: Active / Passive ROM

Extensor Tendon Repair
 Zone III and Zone IV (PIP and Proximal-Phalanx)
   0 ~ 6 weeks
     o Exercise Program ( 2 )
       - If lateral band uninvolved encourage DIP flexion , but make sure PIP joint in extension position

Extensor Tendon Repair
Zone III and Zone IV (PIP and Proximal-Phalanx)
6 ~ 8 weeks
o Splint 1. Protective splint ( volar static gutter )
    2.Dynamic extension splint ( as feedback during PIP flexion exercise )

Extensor Tendon Repair
Zone III and Zone IV (PIP and Proximal-Phalanx)
6 ~ 8 weeks
o Exercise Program
- Gradually increase PIP 30 flexion 1st week
Increased to 5 flexion per treatment session
- Monitor whether extension lag presence
- Monitor whether ORL tightness presence

Extensor Tendon Repair
Zone III and Zone IV (PIP and Proximal-Phalanx)
8 ~ 12 weeks
o Splint 1. Night splint ( keep PIP extension )
    2.Template splint ( gradual progression flexion of PIP starting at 30 )

Extensor Tendon Repair
Zone III and Zone IV (PIP and Proximal-Phalanx)
8 ~ 12 weeks
o Exercise Program - Gradually progress to composite active/passive flexion/extension
- If extension lag occurred , 2 more weeks immobilization

Extensor Tendon Repair
Zone III and Zone IV (PIP and Proximal-Phalanx)
12 weeks
o Splint : Night splint discontinued - as long as no extensor lag

Extensor Tendon Repair
Zone III and Zone IV (PIP and Proximal-Phalanx)
12 weeks
o Exercise Program - Beginning resistive exercise active/passive flexion/extension
- ADL progressed to normal

Extensor Tendon Repair
Zone V ~ Zone VII (Proximal to MP joint)
0 ~ 4 weeks
o Splint 1. Static volar splint
    2. dynamic splint
o Keep wrist extension 40 ~ 45 , MP extension
o If wrist extensor repair only, immobilize wrist only

Extensor Tendon Repair
Zone V ~ Zone VII (Proximal to MP joint)
0 ~ 4 weeks
o Exercise Program
- Wrist joint :Full immobilization
Not allow wrist drop
When the splint is removed
- PIP joints and MP joints: ROM exercise under therapist supervise

Extensor Tendon Repair
Zone V ~ Zone VII (Proximal to MP joint)
4 ~ 6 weeks
o Splint 1. Static volar splint
    2. dynamic splint ( flexion/extension)
o Keep wrist extension 40 ~ 45 , MP extension when rest and night time
o Dynamic splint to resolve joint stiffness

Extensor Tendon Repair
Zone V ~ Zone VII (Proximal to MP joint)
4 ~ 6 weeks
o Exercise Program
- Wrist joint :60 ~ 0 extension , gravity eliminated
Radial / Ulnar deviation : 50% ROM
- PIP joints and MP joints: Full fist when wrist extension

Extensor Tendon Repair
Zone V ~ Zone VII (Proximal to MP joint)
6 ~ 12 weeks
o Splint 1. Protective splint discontinued
    2. staticic splint as night splint , if extension lag presence
    3.dynamic splint if necessary

Extensor Tendon Repair
Zone V ~ Zone VII (Proximal to MP joint)
6 ~ 12 weeks
o Exercise Program
- Wrist joint :Full ROM exercise
Radial / Ulnar deviation : 100% ROM
- PIP joints and MP joints:
composite wrist,MP,IP joints extension
composite wrist,MP,IP joints flexion

屈肌肌腱修復的手部復健


長庚醫院整形外科肢體重建中心

Flexor System Anatomy
Tendon System
Flexor System Anatomy Pully System
Flexor System Anatomy Zones of Injury
Flexor System Anatomy
Tendon Nutrition and Blood Supply

Tendon Healing Phase
o Exudative phase
- 0~4 days Inflammatory response
o Fibroblastic phase
- 5~21 days Collagen synthesis
o Remodeling phase
- 3wk~6mo/1yr Scar remodeling

Tendon Healing Theory
o Extrinsic theory:
Healing rely on cellular ingrowth and vascular supply through adhesion
Potenza 1962
o Intrinsic theory :
Tendon healing cell needed supplied by epitenon and endotenon itself
Lunborg , Manske , 1976~1978

Tendon Healing Theory
o Combined Extrinsic and Intrinsic theory :
Tendon Healing rely on either extrinsic or intrinsic mechanism
Mason , Shearon , 1932
Flynn , Graham , 1965

History Review
o 1573 Ambroise Pare
- Performed one of the first end to end suture of a tendon
o 1882 Heuck
- Performed the first tendon graft with good results
o 1918 Bunnel
- Described his operative philosophy: atraumatic technique , sterile field , preservation of pullys and suture technique
Suggested postoperative care of 3 weeks immobilization
o 1934 Bunnel
- Coined the term " no - man's land "
o 1967 Klienert et al
- Reported good results with early motion following primary repair
o 1973 Klienert et al
- Described the dynamic traction splint used in postoperative tendon repair allowing active extension of the digits
o 1975 Duran and Houser
- Stated " 3~5 mm " of passive extension motion prevent firm adherence of repaired tendon within the digit sheath
o 1980 Strickland
- Concluded that early protected motion has superior results when compared to immobilization following Zone II repair
o 1982 Gelberman et al
- Confirmed " Wolff's Law of connective tissue " with their study of canine tendon
o 1989 Klienert et al
- Developed the PFT brace to achieve maximum DIP & PIP joint flexion and to provide a constant tension of 65 grams of force on the injured digit
o Double loop locking suture :
a technique of tendon repair for early active mobilization

Lee H , J. Hand Surgery
1990 ; 15A:945
o Post flexor tendon repair motion protocol :
- Hinge Splint for tenodesis active flexion motion
- Dorsal Protective Splint as conventional splint
Cannon N , Indiana Hand Center
Newsletter 1993 ; 1:13
o Flexor tendon repair :
- Indinana Method

Strickland JW , Indiana Hand Center
Newsletter 1993 ; 1:1-12

Factors affecting
tendon repair outcome

o Patient factors
- age , health , motivation , scar formation
cooperation
o Injury factors
- level , type , pully integrity
o Surgical factors
- technique , resection of tendon sheath

Postsurgery 2nd day ~ 4 weeks
(Inflammatory and Fibroblastic Phase)

o Protective Splint
- wrist at 30° ~ 40° flexion
- MP joints 50° ~ 70° flexion
- IP joints extended

Postsurgery 2nd day ~ 4 weeks
(Inflammatory and Fibroblastic Phase)

o Edema control
- elevation position
- coban wrap
- cold pack
- retrograde massage

Postsurgery 2nd day ~ 4 weeks
(Inflammatory and Fibroblastic Phase)

o Early controlled mobilization regimen
( combined Klienert and Duran method )
- 10 repetition every waking hours in Splint
- every repetition
o passive flexion all MP and IP joints until fingertip touch distal palmar flexion crease , then hold 10 sec.
o active extension all MP and IP joints until fingertip touch dorsal protective splint , then hold 10 sec.

Postsurgery 2nd day ~ 4 weeks
(Inflammatory and Fibroblastic Phase)

o Patient education
- Explain the severance of injury and prognosis
- ADL recommendation , one hand activity training
- Prevocational consultation
- Referral

Postsurgery 4 weeks ~ 6 weeks
(Remodeling Phase)

o Protective Splint
- wrist at neutral position
- MP joints 0° extension
- IP joints extended

Postsurgery 4 weeks ~ 6 weeks
(Remodeling Phase)

o scar management
- scar massage 5 to 10 min. every waking
- coban wrap but removed during exercise
- elastomer / otoform
- ultrasound

Postsurgery 4 weeks ~ 6 weeks
(Remodeling Phase)

o Early controlled mobilization regimen
( combined Klienert and Duran method )
- 10 repetition every waking hours on Table
- every repetition
o affected hand active flexion all MP and IP joints as hard as possible , then hold 10 sec.
o Affected hand active extension all MP and IP joints as hard as possible , then hold 10 sec.without stretch

Postsurgery 6 weeks ~ 12 weeks
(Remodeling Phase)

o Protective Splint
- discontinue
o Dynamic Splint
- If necessary
o Serial splinting as night splint

Postsurgery 6 weeks ~ 12 weeks
(Remodeling Phase)

o scar management
- scar massage 5 to 10 min. every waking
- coban wrap but removed during exercise
- elastomer / otoform
- ultrasound
similar to postsurgery 4 weeks ~ 6 weeks

Postsurgery 6 weeks ~ 12 weeks
(Remodeling Phase)

o Early controlled mobilization regimen
( combined Klienert and Duran method )
- tendon gliding exercise
- strengthening exercise
- endurance training
- modalities

Modalities for enhancing
tendon gliding

o Functional Electrical Stimulus ( FES )
o Transcutaneous Nerve Stimulus ( TENS )
o Electromyographic Biofeedback
Postsurgery 6 weeks ~ 12 weeks
(Remodeling Phase)
o Patient education
- Explain the prognosis
- Light ADL consultation and training
- Prevocational consultation and training
- Home program

Complication

o PIP contratures
+ Splinting in IP extension
+ Detect contractures early
+ Increase MP flexion in splint
+ Dynamic corrective splinting after 6~8
weeks


Complication

o Tendon adhesion
+ Scar management
+ FES used after 5 weeks
+ Ultrasound started at 4 weeks

Complication

o Pully Repair and Bowstringing
+ Pully rings for 4~6 months
+ Manual pressure at pully location during
active flexion

Complication

o Gapping and tendon ruptures
+ Determine patient reliability and
cooperation
+ Adapt protocol for patients with good
early tendon glide
+ ADL recommendation to avoid sudden
stretch
+ Gradual increase of demand on the repair
, job simulation

手指再植病患術後之復健活動


Historical Review

o 1962
- Ronald Malt , the first successful replantation of a major limb
- Chen , in China , the first successful hand replantation General Principles

o Mechanism of injury
- Cutting
- Crushing
- Degloving
- Avulsed
o Warm Ischemia Time

o Cold Ischemia Time

General Principles

o Availability of transportation

o Extent of other injuries

o General health and age of the patient


General Principles

o Desires of the patient

o Availability of a skilled replantation team

o Indication and contraindication

Rehabilitation program poses a " challenge "
For both the treating hand therapist and the patient


Why ?
The Reason is

o All 5 systems involved , including
- Skeletal
- Vascular
- Tendon
- Nerve
- Skin
o Healing mechanism and time frame of each system differ

If 95% patients benefit but 5% patients suffer from rehabilitation
We go ahead !

Successful replantation outcome depends on
Surgeon and nurse
Hand therapist
Compliant patient

It's our responsibility

o Education the patient and family about
- The condition of replantated part
- Surgical repair
- Rehabilitation process
- Expectation of outcome
- Precaution


手指再植患者之術後治療
o 0 ~ 7 天
- 患者需24小時平躺,患側上肢不可活動
- 家屬可幫患者按摩肩膀及上臂之肌肉,以預防患者因長期固定同一姿勢,或是過度緊張,而
  導致肌肉痙攣

手指再植患者之術後治療
o 7 ~ 10 天
- 如果斷肢情況穩定,則給予保護性支架,以作患者開始下床活動之準備
- 肩膀及手肘視情況可以給予和緩之伸展運動,以預防肩膀及手肘之關節僵硬攣縮

手指再植患者之術後治療
o 7 ~ 10 天
- 運用tenodesis的原理,開始早期的保護性的控制運動
- 受傷的手指不要做彎曲、伸直的動作,沒有受傷的手指可以在患者不痛的範圍下,開始和緩
  的主動彎曲及伸直動作

手指再植患者之術後治療
o 7 ~ 10 天
- 疼痛的處理:視情況給予患者經皮神經電刺激(低週波)止痛,電流劑量不可太高,避免引
  起肌肉之收縮
- 嚴格禁止冰敷、熱敷、紅外線等各項冷、熱治療方法,避免溫度急遽變化造成血管負荷

Modalities
Transcutaneous Electrical Nerve Stimulus

手指再植患者之術後治療
o 10 ~ 14 天
- 繼續運用tenodesis的原理,進行早期保護性的控制運動,手腕掌側彎曲時作手指伸展的運
  動,手腕背側彎曲時作手指握拳的運動
- 開始未受傷手指的肌腱滑動運動(tendon gliding exercise)

手指再植患者之術後治療
o 10 ~ 14 天
- 未受傷手指的肌腱滑動運動(tendon gliding exercise)包括
o 鷹爪功姿勢:手腕自然,將掌指(MP)關節擺成伸直角度,指(IP)關節需呈彎曲狀
o 蛇形刁手姿勢:手腕自然,將掌指(MP)關節擺成彎曲角度,指(IP)關節需呈伸直狀

手指再植患者之術後治療
o 14 ~ 28 天
- 受傷手指的肌腱滑動運動(tendon gliding exercise)包括
o 鷹爪功姿勢:手腕自然,將掌指(MP)關節擺成伸直角度,指(IP)關節需呈彎曲狀
o 蛇形刁手姿勢:手腕自然,將掌指(MP)關節擺成彎曲角度,指(IP)關節需呈伸直狀
o 視情況是否穩定而定,不可過度勉強

手指再植患者之術後治療
o 14 ~ 28 天
- 其他應注意事項
o 消腫
o 傷口及疤痕的處理
o 檢視手腕、手肘、肩膀之肌腱及韌帶是否有拉、扭傷
o 修改副木,以符合手部消腫後之情況

手指再植患者術後治療( 14~28天)
o 消腫的方法
- 坐姿或站姿時,手部抬高高度必須高於心臟,絕對不可以長時間佩戴三角巾
- 和緩的向心方向按摩
o 禁止冰敷、熱敷

手指再植患者術後治療( 14~28天)
o 傷口及疤痕的處理
- 受傷後14~28 天,若傷口未癒合
→教導患者清洗傷口及其他未受傷部位之 方法,如有必要須與主治醫師聯繫
- 受傷後14~28 天,若傷口已拆線癒合
→教導患者每小時和緩的按壓疤痕5 分鐘
手指再植患者術後治療( 14~28天)
o 檢視手腕、手肘、肩膀之肌腱及韌帶是否有拉、扭傷
o 修改副木,以符合手部消腫後之情況

手指再植患者之術後治療
o 4~6星期
- 慢慢增加手腕背側彎曲及掌側彎曲的角度
- 開始作超音波
- 開始作功能性電刺激
- 手指開始綁消腫繃帶(COBAN wrap)


postoperatively modalities
Ultrasound

Modalities
Functional Electrical Stimulus

手指再植患者之術後治療
o 4~6星期
- 開始手腕和手指可以同時一起做伸直或彎曲的動作
- 開始使用副木和矽膠處理關節僵硬攣縮、肌腱粘黏的問題


Exercise program
Wrist and finger flexion followed by wrist and finger extension

手指再植患者之術後治療

o 4~6星期
- 加強手指各關節的主動及被動性關節活動度
- 開始各種種類的肌腱滑動運動
- 日常生活仍然不宜使用受傷的手


Exercise program
Composite fist ==>intrinsic minus position
==>extending the digits

Exercise program
PIP and DIP joints blocking exercise
Exercise program
PIP joint isolated blocking exercise

手指再植患者之術後治療
o 6~8星期
- 白天可以不穿戴保護性副木
- 晚上穿戴矯治畸形的副木
- 受傷的手可以開始作一些不需用力的日常生活活動


手指再植患者之術後治療
o 8~12星期
- 加強屈肌和伸肌的拉筋運動
- 加強訓練受傷的手的肌力和耐力
- 強調患者居家時主動性運動,預防前臂肌肉廢用性萎縮

postoperatively modalities
Electromyographic Biofeedback

手指再植患者之術後治療
o 8~12星期
- 加強感覺功能,包括減敏感訓練及感覺再教育
- 加強手指之靈活度
- 加強手部之協調性

手指再植患者之術後治療
o 12~ 星期
- 職業諮詢及評估
- 職能訓練
- 轉介及社會資源的運用

Complication

o PIP contractures
" Detect contractures early
" Splinting in IP extension
" Increase MP flexion in splint
" Dynamic corrective splinting after 6~8 weeks

Complication

o Pully Repair and Bowstringing
" Pully rings for 4~6 months
" Manual pressure at pully location during
active flexion

Complication

o Gapping and tendon ruptures
" Determine patient reliability and cooperation
" Adapt protocol for patients with good early tendon glide
" ADL recommendation to avoid sudden stretch
" Gradual increase of demand on the repair , job simulation

Complication

o Bony mal-union or non-union
" Protective controlled exercise program
" Corrective splinting

Complication

o PIP or DIP Extension lag
" Night splint to keep PIP or DIP in entension
" Blocking exercise
 

 

鬆筋手術(Tenolysis)


Tenolysis Literature Review
o First reported by Bunnel in 1918
o 1960s , Brooks , Peacock , Rank , experienced high rupture rate

Indications for Tenolysis

o A high motivated patient ( 11 years )
o maximum passive flexion / extension
of the involved digit(s)
o quiescent , supple soft tissues
o a strong motor unit proximally in the
forearm Therapeutic Consideration-Preoperatively

o Evaluation of relevant information include initial injury mechanism and medical history
o Review patient history include : previous infection , tendon rupture , grafts , wound problem , poor general health

Therapeutic Consideration-During Surgery
Obtain following surgical information

- extent of the dissection
- whether additional procedure ( e.g, capsulectomy , pully reconstruction , neurolysis , tendon rod )
- quality of tendon(s)
- result achieved actively or passively

Therapeutic Consideration-Postoperatively

o Medical Management
- bulking compressive dressing
- elevated position
- pain management
V oral or parenteral medication
V TENS
V marcaine catheters

Therapeutic Consideration-Postoperatively

o Hand therapy
- exercise program
- splinting
- scar management
- strengthening exercise
- modalities

Exercise program

Wrist and finger flexion followed by wrist and finger extension

Exercise program

Composite fist ==>intrinsic minus position
==>extending the digits

Exercise program

PIP and DIP joints blocking exercise

Exercise program

PIP joint isolated blocking exercise

Exercise program

o Light ADL initiated after 4 weeks after surgery
o Be careful of activities
- put on pants
- scratching
- opening door

Therapeutic Consideration-Postoperatively

o Hand therapy
- exercise program
- splinting
- scar management
- strengthening exercise
- modalities

Splinting

Static extension splint as night splint to prevent flexion contracture

Splinting

Dynamic splint to enhance supple passive flexion

Therapeutic Consideration-Postoperatively

o Hand therapy
- exercise program
- splinting
- scar management
- strengthening exercise
- modalities

Scar management

o Scar massage after wound healing
o elastomer / otoform
o scar retraction technique

Therapeutic Consideration-Postoperatively

o Hand therapy
- exercise program
- splinting
- scar management
- strengthening exercise
- modalities

Strengthening exercise

Initiated from 6~8 weeks after surgery
But delayed until 10~12 weeks in replantated fingers
o Progressive resistance exercise
o activity
- hand exerciser
- putty

Therapeutic Consideration-Postoperatively

o Hand therapy
- exercise program
- splinting
- scar management
- strengthening exercise
- modalities

Modalities

Functional Electrical Stimulus

Modalities

Transcutaneous Electrical Nerve Stimulus

Modalities

Continuous Passive Motion

Tenolysis postoperatively modalities
Electromyographic Biofeedback

Tenolysis postoperatively modalities
Ultrasound

Tenolysis postoperatively frayed tendon
Place and Hold Exercise

Tenolysis surgery
grading scale

o Excellent : normal flexion and extension
o Good : marked improvement ability to flex within 1cm of the distal palmar flexion
crease
o Fair : mild improvement flexion and extension dificit
o Poor : no improvement
Worse : tendon rupture or amputation

以上所有資料來源:長庚醫院肢體重建中心 連淑惠小姐