Physical Therapy Rehabilitation for Hand Replantation: A Case Report

From total trauma patients with road traffic accidents and machines as the most typical modes of injury, Hand injury accounts for 5.5%. Hand injuries are common in developing countries such as India due to the recent increase in industrialization and motorization. In 2001, the Registrar General of India showed that 82.2% of the employed population works in unregulated sectors like manufacturing, retail trade, agriculture, etc, while only 17.8% works in an organized sector. This lack of safety measures has been well documented as an independent risk factor of occupational injuries. The patients studied for hand injuires had a mean age of 28 years. Whereas a study done in North India evidenced a mean age of 31.13 years of population with hand injuries. Most of the categories affected by hand injury as found in North India were agricultural workers (27.86%), labourers (23%), Students (23%), and service class (9.84%).¹  Injuries proximal to the carpus, from a major traumatic amputation of the upper limb, which is a rare but life-altering event. According to the survey of National Trauma Databank, 0.09% of persons hospitalized after trauma sustained a major upper limb amputation¹ and 34,000 people are living with a major amputation in the metropolitan cities.² Formulation of strategies for limb management, limb salvage and rehabilitation for such patients can be done by knowing the causes and patterns of trauma-related amputations.³ Trauma-related amputations are more in the developing countries, while peripheral vascular disease and diabetes are the leading cause of amputation in developed countries.³ The prevalence rate of amputees is estimated to be 0.62 per 1000 population of India as per the national report in 1981.³ Machine injury and workplace accidents mostly lead to upper limb amputations. Generally, a smaller zone of injury, usually from a sharp amputation, results in a more successful replantation. ² Moreover, any formal data concerning its incidence and change over the last decade are not available online and in any published literature. ³ When a traumatic upper limb amputation takes place, definitive treatment must be emphasized on providing the patient with the maximum level of function possible. ² Replantation is as a surgical procedure of reconstruction of neurovascular and musculoskeletal structures, seeking the recovery of an amputee segment of the body. ⁴ Traumatic limb amputation is considered to be a sudden and emotionally devastating posture and a catastrophic type of injury. ⁴ Late functional outcomes between major upper extremity amputation and replantation at an average of 7.3 years post injury, was compared by Graham and his colleagues. In their study, the Functional outcomes were determined using the Carroll Standardized Evaluation and Integrated Limb Function, which assessed a person’s ability to perform simple and complex tasks. 22 major upper limb replantation were compared with 22 similar level amputees with prostheses, and it was found that the functional abilities of the replantation group were significantly better than the prosthesis group.² Advances in modern microsurgical technology and a clearer understanding of tissue healing in response to trauma has resulted in a reasonably predictable success rate with replantation of an amputated limb. Using the most common parameter, survival of the replanted extremity, the success or failure of this procedure has been evaluated, which has been reported to between 80% and 94%. ⁴ A well-structured rehabilitation program is essential for proper functioning of the replanted hand. So, this case report aims at exploring a rehabilitation program for a replanted hand.

HISTORY

A 21-year-old right-handed male patient sustained an injury when his dominant hand was caught in a cutting machine, he was cleaning. A bandage was applied and he was brought to the hospital where he arrived within 1 hour of injury in an unconscious state. His right forearm was bandaged and tunicate was applied as the forearm showed evidence of crush injury, (fig 1). The patient was then sent to Sancheti Hospital, Pune with an amputated hand in a polythene bag placed inside a plastic box filled with ice.  Hand replantation was performed on the amputated part by an orthopedic hand surgeon. After one month, tendon repair and skin grafting procedures were done with a gap of one month respectively. Postoperatively patient received only 4 physiotherapy sessions once a week, as accessibility was an issue, almost 5 months after surgery the patient visited a tertiary care hospital in Ahmednagar and was referred to the physiotherapy department with complaints of pain around the suture site with severe stiffness in the wrist and fingers. The patient reported a desire to do activities of daily living for independent living status. The patient provided informed consent for the retrospective review and subsequent professional presentation of his treatment case.