«THE PREVENTION OF DEFORMITY IN THE SEVERELY PARALYSED HAND By D. J. E. CHESHIRE, M.B., B. S., D.Phys.Med. and GLENYS ROWE, Dip.Occ.Ther.* Spinal ...»
THE PREVENTION OF DEFORMITY IN THE
SEVERELY PARALYSED HAND
By D. J. E. CHESHIRE, M.B., B. S., D.Phys.Med. and
GLENYS ROWE, Dip.Occ.Ther.*
Spinal Injuries Centre, Austin Hospital, Heidelberg, Victoria, Australia
THE human hand represents the highest attainment in bio-mechanical sophistica
tion, but it is much more than an organ of grasp and manipulation; it is also an
organ of self-expression, an extension of speech and of personality. Furthermore, the hand is usually exposed to the sight of every casual observer. When creating a rehabilitation programme for a patient with a severely paralysed hand, it is fundamental that due emphasis shall be given both to the physical and to the psychological components of rehabilitation. There is no more important feature in this programme than to prevent a hand deformity which may both impair physical efficiency and be a potent factor in the development of psycho-social maladjustment, especially if the paralysis of the hand is only one part of a major compound disability, such as tetraplegia.
These hand deformities, characteristically the claw hand, the flipper hand and the intrinsic minus hand, can be prevented, but the techniques in general use have been found to be inadequate.
Mechanism of Deformity. Both the frequency and the importance of the potential deformities of the paralysed hand demand that all possible steps be taken to prevent them, but this prevention itself depends on understanding the mechanisms which may produce modifications in the length or the elasticity of soft tissues. The causes of deformity in the paralysed limb are poorly understood.
Writings between I9 I I and 1954 variously attributed deformity in poliomyelitis to oedema in a paralysed limb, shortening of active unopposed muscles, fibrosis in paralysed muscles, adhesions between muscles and their sheaths, stretching of paralysed muscles, failure to stretch paralysed muscles, injudicious splintage, failure to splint, muscle imbalance, posture, gravity and collagen deposition of unknown cause (Jones, I9 I I; Lovett, 1922; Ghormley & Allen, 1949; Bennett, 1952; Seddon, 1954).
Study of approximately 250 patients with cervical spinal paralysis has led to the conclusion that, other things being equal, the tetraplegic who is most liable to develop hand deformity is the patient who develops oedema of the hand, or is a middle-aged manual worker with fibrotic hands, and most difficult of all, has fibrotic hands and develops oedema.
This opinion was strengthened by a recent paper in which Sharrard (1967) described the mechanisms of paralytic deformity. In summary, he stated that there are three mechanisms which can produce modifications in the length or
elasticity of soft tissues. These are:
Present Address: Occupational Therapy School of Victoria, 623 Swanston Street, * Melbourne.
PREVENTION OF DEFORMITY IN THE SEVERELY PARALYSED HAND 49
1. Acute Neurological Contracture. In acute paralytic conditions, loss of elasticity and shortening may develop in tendons, fasciae, intermuscular septa, joint capsules and ligaments in which collagen is deposited. If length can be maintained by stretching the soft tissues during the acute phase, deformity can be prevented; otherwise the deposited collagen becomes converted into strong fibrous tissue and a fixed deformity results.
The factors responsible for the rapid deposition of collagen in acute neuro logical contracture are not known.
2. Postural Contracture. If a paralysed limb is kept immobi1ised, or if full passive movements are not performed, deformity may develop. If there be also oedema, collagen is deposited in the oedema fluid and leads to contractures and adhesions.
The daily maintenance of a full range of passive movements, and the effective use of measures to prevent oedema will be sufficient to prevent the development of deformity.
3. Deformity from Muscle Imbalance. This deformity differs in several ways from those already described. It does not occur in any limb with normal muscles;
it does not develop in a flail limb; and it is seen much more often in children than in adults. In the context of the tetraplegic hand, this type of deformity is perhaps best shown in the intrinsic minus hand. Treatment is essentially a long-term problem and corrective splints may be required indefinitely.
In both acute neurological contractures and postural contractures, the con tracture is caused by the conversion of deposited collagen into fibrous tissue. This collagen is deposited in oedema fluid. Hence, to prevent oedema is an essential step in the prevention of deformity in the severely paralysed hand.
To prevent deformity in the paralysed hand, three criteria must be rigidly
I. A full range of passive movement must be preserved in all joints.
2. In between physiotherapy treatments the hand must be supported in a position which maintains the length of the soft tissues, particularly the collateral ligaments of the metacarpo-phalangeal and interphalangeal joints, and the muscles of the adductor web.
3. A technique must be developed which will minimise the development of oedema in the paralysed hand.
The 'Boxing Glove' Splint. In 1965, as these ideas concerning the impor tance of oedema in the genesis of hand deformities were developing, one of us (D. J. E. Cheshire) attended a lecture by Professor J. 1. P. James on the subject of Hand Injuries. In this lecture, James laid great emphasis on the importance of immobilising the injured hand in a position of maximum soft tissue length and of minimising oedema. He described a technique of compression bandaging which he called the 'Boxing Glove' bandage.
A few weeks later, a 17-year-old boy was admitted to the Centre two hours after having fallen from a moving train, sustaining a vertical compression fracture of the fifth cervical vertebra with tetraplegia and multiple injuries which included fractures of the second, third, fourth and fifth metacarpals of the right hand. The left upper limb was uninjured. With James' lecture in mind, the right hand was treated by maintaining the re-aligned metacarpals over a palmar pad of cotton wool with the metacarpo-phalangeal joints flexed to 90° and with about 20° of D 50 PARAPLEGIA flexion at the interphalangeal joints. A 'boxing glove' compression bandage was then applied to minimise oedema. Despite inability to perform passive movements of the hand during the time of metacarpal immobilisation, it was observed, at the end of six weeks, that there was less oedema and thickening of the right, and injured hand than there was of the uninjured left hand, which had been treated by the then routine technique of maintenance of the anatomical 'position of function' on a palm roll and twice daily passive movements of all joints. It was also observed that the patient rapidly regained a full range of movement at the metacarpo phalangeal joints of the right hand, but had developed some extension contracture at these joints on the left side and the restoration of the full range was significantly delayed.
This case illustrates two fundamental points upon which our ideas are based:
1. Palm rolls, as usually used, place the metacarpo-phalangeal joints in 45° of flexion, or less (fig. I). It is granted that this is the 'position of function', but it is also a position in which severe functional contracture can develop at the meta carpo-phalangeal joints. The study of the anatomy of the metacarpo-phalangeal and interphalangeal joints, as recently published by Kuczynski (1968), is the basis upon which James (1968) teaches that, because the collateral ligaments of the metacarpo-phalangeal joints are at their maximum tension at 90° flexion, it is only by immobilising the hand in that position that one may ensure that the chances of contracture in these ligaments are minimised (fig. 2).
2. Previous techniques did not prevent oedema of the paralysed hand, and the significance of oedema, in terms of future contractures, is such that a method for its prevention had to be developed.
Such is the derivation of the use of the 'boxing glove' splint in the prevention of deformity in the severely paralysed hand.
Method of Application of 'Boxing Glove' Splint. 1. Hand Position. The wrist is placed at 45° of dorsi-flexion, the second to fifth metacarpo-phalangeal joints are placed at an angle as near to 90° as possible, and the interphalangeal joints are placed at 20-30° of flexion. The thumb is placed in a partially opposed position with the adductor web on full stretch and the pad of the thumb vertically beneath the pads of the second and third fingers. One is thus already starting to think about the position for a thumb-finger tenodesis grip.
2. The Palmar Pad. As the 'boxing glove' technique evolved it became appa rent that the usual palm roll was too large in diameter to permit flexion of the metacarpo-phalangeal joints beyond 45°. In order to immobilise the hand in the optimum position which is described above, it is necessary to abandon the concept of a palm roll and to make a palm pad for each individual hand. For accurate shaping, cheapness and availability of material, and, not least, because of the absence of sensation in the hand, a simple cotton-wool pad is preferred. Time and experiment is needed to ensure that the pad is of the correct size and shape (figs.
3 A and B).
3. A Wrist Cock-up Splint. When considering the problem of preventing deformity in the severely paralysed hand it is also necessary to prevent a flexion contracture at the wrist, and to prevent interference with the re-education of a weak extensor carpi-radialis through the over-stretching of this muscle in the early post-accident phase. In many patients it is therefore wise to incorporate a light 5I
PREVENTION OF DEFORMITY IN THE SEVERELY PARALYSED HAND
wrist cock-up splint into the boxing glove splint. A combined wrist cock-up splint and palmar bar can be made in an appropriate plastic material by the occupational therapist who is treating the patient (figs. 4 A, B, c).
4. Prevention of Pressure. In any technique of compression bandaging, and particularly when the part being bandaged is anaesthetic, it is essential to take all possible steps to avoid the patient's developing the effects of pressure. A thick layer of cotton-wool laid over the dorsum of the hand and forearm not only prevents this pressure, but also ensures even and effective compression (fig. 5).
FIG. 3 A,The palmar pad of cotton-wool. B, positioning of the hand prior to bandaging. There is approximately 90' flexion at the second metacarpo-phalangeal joint.
5. The Application of the Compression Bandage. The compression bandage is completed with two 3-inch (7·6-cm.) crepe bandages. The bandage is applied in the traditional manner of a stump bandage (fig. 6).
Of particular importance in the prevention of oedema of the dorsum of the hand are those sections of the bandage which pass longitudinally along the forearm and over the dorsum of the hand.
6. Elevation. Further to minimise the development of postural oedema, it is wise, when possible, to elevate the hand relative to the shoulder, by placing the arm upon a pillow.