hand reconstruction surgery for restore the function and appearance of hand.&restore the static and dynamic hand function.

1. HAND RECONSTRUCTION
SURGERY & PT
MANAGMENT
PRESENTED BY~ SARVANSHI KHALORA

2. CONTENTS
#ANATOMY OF HAND
#WHAT IS HAND RECONSTRUCTION SURGERY?
#INDICATION OF HAND RECONSTRUCTION SURGERY
#SURGERY
.SKIN GRAFT
.FLAPS
.TENDON REPAIR
.TENDON TRANSFER
.TENDON GRAFT
.CLOSED REDUCTION & FIXATION

3. CONT…..
.FASCIOTOMY
.NERVE REPAIR
.SURGICAL DRAINAGE OR DEBRIDEMENT
.JOINT REPLACEMENT
.REPLANTATION
.JOINT STABILIZATION(ARTHRODESIS) IN FUNCTIONAL
POSITION
#COMPLICATION
 #PT MANAGEMENT
PROTOCOLS OF PT MANAGEMENT

4. ANATOMY OF HAND
HANDS ARE AMONG THE MOST DELICATE STRUCTURE IN THE HUMAN
BODY, FILLED WITH A COMPLEX NETWORK OF FINE BONES ,TENDONS
& BLOOD VESSELS.
THE HAND IS DESIGNED FOR:
(1) FOR GRASPING
(2) FOR PRECISE MOVEMENTS
(3)FOR SERVING AS A TACTILE ORGAN

5. BONES of HAND
.The human hand has 27 bones.
~8 carpal bone
~5 metacarpal bone
~14 phalanges

7. MUSCLES OF HAND
• INTRINSIC MUSCLES OF HAND ~
• (1) a) three muscles of thenar eminence
• ~abductor pollicis brevis
• ~flexor pollicic brevis
• ~opponens pollicis
• b) one adductor of thumb: adductor pollicis

8. Cont…
• (2) four hypothenar muscles
• ~palmaris brevis
• ~abductor digiti minimi
• ~flexor digiti minimi
• ~opponens digiti minimi
• (3) four lumbricals
• (4)four palmar interossei
• (5)four dorsal interossei

10. FOUR LUMBRICALS

11. FOUR PALMAR INTEROSSEI

12. FOUR DORSAL INTEROSSEI

13. EXTENSOR MUSCLES OF HAND~

15. JOINTS OF HAND

16. NERVE SUPPLY OF HAND

17. BLOOD SUPPLY OF HAND

18. WHAT IS HAND RECONSTRUCTION SURGERY?
• RECONSTRUTIVE SURGERY is all about repairing people & restoring function.
• It is performed to repair &reshape bodily structures affected by birth defect, developmental
abnormalities ,trauma injuries ,infection, tumours & disease.
• PLASTIC SURGERY OF
HAND ~CHIROPLASTY
.

19. INDICATION OF HAND RECONSTRUCTION
SURGERY
• #CONGENITAL DEFECT OR DEFORMITY
• Radial club hand
• Ulnar club hand
• Syndactyly
• Polydactyly
• #TRAUMATIC CRUSH INJURIES
• #BLOOD VESSELES DAMAGE
• #CARPAL TUNNEL SYNDROME
• #CUBITAL TUNNEL SYNDROME
• #NERVE DAMAGE~RADIAL NERVE=WRIST DROP
• ~ULNAR NERVE=ULNAR CLAW HAND
• ~MEDIAN NERVE=MEDIAL CLAW HAND &SIMIAN HAND OR MONKEY THUMB
• #FRACTURE
• #ARTHRITIS

20. CONT….
• #RHEUMATOID ARTHRITIS
• ~Intrinsic plus deformity
• ~swan neck deformity
• ~boutonniere deformity
• ~ulnar drift
• ~opera glass hand
• #TRIGGER FINGER RELEASE
• #GANGLION REMOVAL
• #DUPUYTREN’S CONTRACTURE
• #BURN
• #INFECTIOUS DISEASE
• #TUMOUR
• #LEPROSY

21. RECONSTRUCTION SURJERY
• [A] SKIN GRAFTING- It is transfer of skin from one area(donor area) to the required
defective area(recipient area).
It is an autograft.
• TYPES~
(1)PARTIAL THICKNESS GRAFT[SPLIT-THICKNESS SKIN GRAFT—SSG] also called as THIERSCH GRAFT.
(2)FULL THICKNESS GRAFT[WOLFE GRAFT]

23. CONT….
• (1)PARTIAL THICKNESS GRAFT~ removal of full epidermis + of the dermis from
the donor area.
• INDICATION~
WELL-GRANULATED ULCER
CLEAN WOUND OR DEFECT WHICH CAN NOT APPOSED
AFTER SURGERY TO COVER&CLOSE THE DEFECT CREATED.
FOR EXAMPLE;
• -after wide excision in malignancy
• -after mastectomy
• -after wide excision in squamous cell carcinoma

24. Cont…
• CONTRAINDICATIONS~SSG can not be done over bone ,tendone, cartilage, joint.
• DISADVANTAGES OF SSG~
 Contracture of graft
 seroma and haematoma formation will prevent graft take up.
 Infection
 loss of hair growth, blunting of sensation
 dry, scaling of skin due to nonfunctioning of sebaceous gland
 graft failure
• ADVANTAGE~
o technically easier
o wide area of recipient can be coverd
o graft taken up is better
o donor area heals on its own

25. Cont…
• (2) FULL THICKNESS GRAFT-
It include both epidermis+full dermis.
It is used over the face, eyelid, hands, fingers and over the joints.
• COMMON SITE OF DONOR AREA~
.post-auricular area
.supraclavicular area
.groin crease area
• ADVANTAGES~
colour match is good .especially for face
no contracture(unlike ssg)
sensation,function of sebaceous glands,hair follicles are retained better compared to SSG
functional and cosmetic results are better.

26. Cont..
• DISADVANTAGES~
 it can be used only for small areas.
 wider donor area has to be covered with SSG to close the defect.
• OTHER GRAFTS~
 .tendon graft
 .bone graft
 .nerve graft
 .venous graft
 .corneal graft
 .combined graft(allograft +autograft)

27. FLAPS
• [B] FLAPS~ it is transfer of donor tissue with its blood supply to
the recipient area.
• PARTS OF FLAPS~
BASE
PEDICLE
TIP OF FLAP
• INDICATIONS~
To cover the wider,deeper defects.
To cover over bone,tendon, cartilage
If skin graft repeatedly fails.

28. FLAP

29. CLASSIFICATION OF FLAPS
(A)BROADLY CLASSIFIED
(a)PEDICLED FLAPS
PEDICLE OR THE BASE
REMAINS ATTACHED TO THE
DONOR SITE DURING ITS
TRANSFER TO THE
RECIPIENT AREA.
(b)FREE FLAPS
THESE ARE COMPLETETY
DETACHED FROM THE DONOR
AREA BEFORE BEING
TRANSFERRED TO THE RECIEPENT
AREA
(B) BASED ON THE
COMPOSITION
*SKIN FLAP
*FASCIOCUTANEOUS FLAP
*MUSCLE FLAP
*MYOCUTANEOUS FLAP
*ADIPOFACIAL FLAP
*OSTEOCUTANEOUS FLAP

30. CONT…
• ADVANTAGES OF FLAPS~
good blood supply ,good take up.
gives bulk ,texture , colour to the area
allow required movements in the recipient area.
cosmetically better.
• DISADVANTAGES OF FLAPS~
Long-term hospitalization
Infection
Kinking ,rotation and flap necrosis
Staged procedure

31. TENDON REPAIR
• (C) TENDON REPAIR~
1. PRIMARY REPAIR~IS done within 24 hours.
2. DELAYED REPAIR~within a week after 24 hours.
3. SECONDARY REPAIR~anytime after one week.
• TYPES OF SUTURING THE TENDON ~
1. KESSLER METHOD.Here knot comes in the cut part of the tendon.
2. GOLDNER METHOD.HERE KNOT COMES AWAY FROM THE CUT ENDS OF THE TENDON.
• COMPLICATION~
 .INFECTION
 .ADHESION
.STIFFNESS AND FAILURE

32. TENDON TRANSFER
• (D) TENDON TRANSFER~ TENDON TRANSFER IS A
SURGICAL PROCESS WHICH INVOLVE’ DETECHMENT OF A
FUNCTIONAL TENDON DISTALLY FROM IT’S INSERTION,
REATACHED IT TO A NEW DISTAL ATTACHMENT OF A
PARALYSED MUSCLE OR INJURED TENDON.
# function of the transferred tendon should be maintained by other
tendon.

34. Cont..
• INDICATION
restore function to a paralysed muscle ,as a result of peripheral nerve
injury or spinal cord injury.
to restore function after close tendon rupture or open injury to a tendone.
Restore balance to a hand deform from neurological condition.
Poliomyelitis
deformity condition like rheumatoid arthritis.

35. Cont…
• BASIC PRINCIPLE OF TENDON TRANSFER~
1. Straight line of pull.
2. Expendable donor.
3. Adequate strength.
4. Correction of contracture.
5. One tendon one function.
6. Ampluted of motion.
7. Synergism of motion.
8. Tissue equilibrium.

36. Cont..
• Common tendon transfer~
1. To restore wrist extension ; PRONATOR TERES (supplied by the median
nerve) is transferred to the EXTENSOR CARPI RADIALIS LONGUS
AND BREVIS (in a radial nerve lesion).
2. To restore finger extension at MP joints ; FLEXOR CARPI ULNARIS is
divided into four and five slips and transferred dorsally into four fingers
(radial nerve lesion between the spiral groove &the lateral epicondyle)
3. To restore thumb extension and abduction ; the muscle PALMARIS
LONGUS is transferred to EXTENSOR POLLICIS LONGUS or
ABDUCTOR POLLICIS LONGUS.

37. TENDON GRAFT
• (E) TENDON GRAFT~ when tendon suturing or transfer is not possible
because of inadequate length, tendon of a muscle which is not of
much help functionally, is taken as a graft to obtain required length.
• COMMON GRAFT USED ARE~~
1. Palmaris tendon in forearm
2. Extensor carpi radialis brevis [ECRB] is lengthened using tendon graft to transfer to lumbrical
canal in claw hand.

38. CLOSED REDUCTION &FIXATION
• (F) CLOSED REDUCTION & FIXATION~ this may be
used when there is a bone fracture ,or broken bone, in part
of the hand, including the fingers.
Realigns the broken bone ,and then hold it in place,or
immobilizes it, while it heals.
Immobilization can be done with internal fixateres, such as
with wires, rods, screw, nails ,splints and cast.

40. NERVE REPAIR~
• (G) NERVE REPAIR~ IN EARLY STAGE OF NERVE INJURY.
(1) NERVESUTURE[NEURORRHAPHY& NERVE GRAFTING]~
1. Epineural repair.
2. Fascicular repair.
3. Both epineural & perineural repair.
4. Nerve grafting.
5. Decompression of the nerve.
(2)NEUROLYSIS~ when the continuity of the nerve is well maintained but it
conductivity is hampered due to its entrapment with the scar formation ,
fibrosis, excessive callus formation.

41. FASCIOTOMY
• (H) FASCIOTOMY~ this procedure is done to help treat
compartment syndrome.
This painful condition occur when there is swelling &increased
pressure in a small space or compartment ,in the body specially
in hand.
It may cause severe pain and muscle weakness.
Fasciotomy , prevent any further damage and decrease in
function of the affected hand.

43. (I) SURGICAL DRAINAGE AND DEBRIDEMENT
• HAND INFECTION ARE COMMON.
• If there is sore or abscess in the hand , surgical drainage may help remove
any pus.
• If the infection or wound is severe, debridement me be used to clean dead
and contaminated tissue from the wound.

44. (J)JOINT REPLACEMENT
• ALSO CALLED ARTHROPLASTY.
• USED IN CASE OF SEVERE HAND ARTHRITIS.
• IT INVOLVES REPLACING A JOINT THAT HAS BEEN DESTROYRD BY ARTHRITIS , WITH AN
ARTIFICIAL JOINT.

45. (K) REPLANTATION
• This type of surgery reattaches a body part , such as a finger ,hand,
or toe, which has been completely cut or severed from the body

46. (L) JOINT ARTHRODESIS
• This procedure involves fusion of a joint which has been damage/destroyed due to
disease/trauma beyond repair or reconstruction with marked instability, severe pain and
functional handicap.
• INDICATION~
1. Infection ,eg. Tuberculosis.
2. Paralytic condition ; for flail joint.
3. Malignancy.
4. Degenerative condition.
5. To correct deformity
6. Miscellaneous ; it is also indicated after failure of a total joint replacement.

47. PHYSIOTHERAPY MANAGEMENT
• GOALS~
1. TO CONTROL PAIN.
2. TO CONTROL ORDEMA.
3. TO RESTORE BOTH THE STATIC AND DYNAMIC HAND FUNCTIONS TO THE FULLEST POSSIBLE EXTENT WITH
LEAST DISCOMFORT
• ASSESSMENT~
a) Range of motion
b) Oedema
c) Muscle performance
d) Sensation
e) Dexterity(skill of using hand)
f) Functional and physical capacity
g) Functional sensibility

48. CONT…
• WOUND HEALING~THE PROCESS OF WOUND HEALING
FOLLOWING INJURY OR SURGERY MUST BE UNDERSTOOD CLEARLY TO
ADOPT PERCISIVE THERAPY.
• THE WOUND HEALING HAS THREE STAGES.
A. INFLAMMATORY PHASE.
B. FIBROPLASIA PHASE.
C. REMODELING PHASE.

50. CONT….
• SPLINTS~ basically 2 types-
A. Static splints~ provide rest and stability.
B. Dynamic splints~ resist and strengthen the weak movement and movement re-education.
 STATIC SPLINTS~
1) Anti-swan neck splints.
2) Anti-boutonnier splint.
3) Opponens splint.
4) Safe position splints.
5) Factional position splints(same as safe positional splint)
6) Wrist cock-up splints.

52. Cont….
DYNAMIC SPLINTS~
1) Dynamic wrist flexion extension splint
2) Metacarpophalangeal joint flexion-extension splint
3) Proximal interphalangeal joint flexion-extension splint
4) Finger trapper or buddy system splint
5) Dynamic thumb splint

53. Cont….
• PHYSITHERAPY TREATMENT~
IMMOBILIZATION
EXERCISE PROGRESSION~
a) Exercise: maximum protection phase
b) Exercise: moderate protection phase.
c) Exercise: minimum protection/ return to function phase.

54. Cont….
• IMMOBILIZATION~ the duration ,type , and position of immobilization must be
considered
A. DURATION~ when prolonged immobilization (3 to 4 week) necessary , the repaired
tendon is continuously immobilized after surgery for up to 5 days while the bulky
compression dressing is kept in place[ this allow some time for postoperative
edema to decrease.
B. TYPE OR METHOD OF IMMOBILIZATION~ if motion of operated part is delayed for 3
to 4 weeks- a cast or static splints provides the immobilization.
 early controlled motion require the different type of splint.
C. POSITION OF IMMOBILIZATION ~ depend upon condition or affected part of hand.

55. Cont..
• EXERCISE PROGRESSION~
1) EXERCISE: MAX PROTCTION PHASE ~ the priorities of rehabilitation are
pain & edema control & protection of reconstructed part, followed by
carefully controlled mobility of operated areas to prevent adherence of
healing tissue.
 while the operated hand or part is immobilized, perform active ROM of
all necessary joints.
Re –establish mobility & control of the repaired part
Passive ROM of operated hand or part.
HEATING(HOT PACK) BEFORE EXERCISE.

56. Cont…
2)Exercise: Moderate protection phase~
 continue of increase ROM or restore ROM of the operated joint.
 isometric exercise against light resistance.
Stretching exercise of hand
Heating (hot pack) before exercise.
Place & hold exercise.

57. Cont…
3) Exercise :minimum protection / return to function phase~
 resistance exercise to improve strength and endurance
Dexterity exercise & use of the hand for light functional activities.
Protective splinting is discontinued, but intermittent splinting may
be necessary ,if the patient has a contracture.
Active ROM.