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A Unique Patient Case
228 Plays10 days ago
Hand Therapy Academy welcomes Megan, who shares a unique patient case. Tune in to hear her practical tips and innovative strategies you can apply in your own practice.
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Transcript
Introduction to Megan Welchman and her recent certification
00:00:04
Miranda Materi
Hello, I'm Miranda.
00:00:05
Megan
Megan Welchman, And i'm megan and we're hand therapy academy. Megan
00:00:08
Miranda Materi
Well, welcome, Megan. We have Megan here with us. She is a hand therapist at um one of our hand therapy our outpatient hand therapy practices in the Phoenix metro area. She has been a therapist for four years and last year became a certified hand therapist. So welcome, Megan.
00:00:24
Megan
Thank you for having me.
00:00:25
Miranda Materi
Yeah, we're excited to talk about some
Case Study: Partial Finger Amputation and Reattachment
00:00:27
Miranda Materi
cases. So first, Megan is going to be presenting a case and kind of just going through the treatment plan and what was all involved.
00:00:35
Megan
Yeah, so we had a patient. He works in like refrigeration and maintenance for schools and cooling systems. And he had his ring finger. um We say partial amputation, but really it was everything except the dorsal skin.
00:00:50
Megan
And they actually reattached it in surgery. And then they pinned his PIP joint. for about six to eight weeks. I think they decided to leave it a couple extra weeks and then they took it out at eight weeks and they repaired all the flexor and extensor tendons and everything, but we couldn't really start a typical flexor or extensor tendon rehab protocol because we weren't allowed to do anything with the PAP joint.
00:01:15
Megan
um Even after he got the pin out, they were really cautious about mobilizing the PAP joint. We could only do active motion So for a few weeks, we were really focusing on how stiff and swollen his hand was and getting the long finger and the small finger moving, which were very stiff.
00:01:32
Megan
And then finally, we were allowed to start kind of putting more pressure on the ring finger and really just cranking as hard as we could to get everything moving passively so that we could prepare for...
00:01:44
Megan
his next surgeries.
Surgical Interventions and Challenges
00:01:47
Megan
So they did an extensor tenolysis and a capsulotomy to the ring finger PAP joint. They were supposed to do a flexor tenolysis in the same surgery, but because of the blood flow restrictions from his reattachment, they decided to do them separately, which I think was better because we didn't have full passive flexion. We had passive extension.
00:02:07
Megan
So he came in, we started stretching him the day after surgery every day for two weeks. And we've gotten him to now full passive flexion of the ring finger.
00:02:16
Miranda Materi
Oh, that's amazing.
00:02:18
Megan
Yeah, it was awesome. The capsulotomy, it helped a lot. He's gotten so much more motion.
00:02:23
Miranda Materi
Wow. Oh, cool.
00:02:24
Megan
Yeah.
00:02:24
Miranda Materi
So almost a good thing that they couldn't do the flexor tenolysis.
00:02:25
Megan
Yeah.
00:02:28
Megan
That's what I said. As soon as he came in, he was like, oh, they had to split up the surgery. And I was like, honestly, i think that's great because he didn't have full passive. So what were we going to get actively if it was such a stiff joint?
00:02:39
Miranda Materi
Yeah.
00:02:40
Megan
So I think it's great because we're able to really stretch the finger and get the passive mobility before he goes in for the flexor tenolysis.
00:02:47
Miranda Materi
And then what's his active extension like?
00:02:50
Megan
His active extension is getting better, but not... great in my opinion. i think partially because the patient cares more about flexion.
00:03:00
Miranda Materi
Yeah.
00:03:00
Megan
So every time he comes in, i'm like, we got to be doing our place and holds. We got to be doing our reverse joint blocking. Let's add in some resisted rubber bands. And he's like, yeah, yeah, yeah. But look how I can stretch it.
00:03:12
Miranda Materi
How much extension does he have?
00:03:14
Megan
Um, let pull it up real quick. I know he has good MCP extension.
00:03:19
Miranda Materi
or about.
00:03:24
Megan
Oh, what in the world is pulling up their own patient?
00:03:26
Miranda Materi
Yeah. So while you're pulling it up, I was just thinking, so in terms of going into extension, you know, I think that's like a little bit tricky, especially for like new grads is like how, like you really have to isolate the central slip,
Techniques for Enhancing Finger Extension
00:03:39
Miranda Materi
right?
00:03:39
Megan
Mm-hmm.
00:03:40
Miranda Materi
Or you're going to be getting the lumber calls involved in the extension as well. So what would you say is like some your favorite things to isolate? the central slip over the intrinsics doing the work of extension.
00:03:54
Megan
um I like to, so for him, sometimes when we block him in full MCP flexion, it's not really, it doesn't feel like it's activating. So I'll kind of block him like partway so that the MCP isn't fully taking over the extension when we're doing joint blocking. It's still forcing pull on the PIP joint, but he doesn't have the intrinsics ability to just like take over in an intrinsic plus position.
00:04:20
Miranda Materi
Oh,
00:04:21
Megan
And then I have him doing um resisted rubber band. I really like that for putting the rubber band on the fingertips so that it doesn't really help if you only extend your MCPs, you have to extend everything together.
00:04:28
Miranda Materi
okay.
00:04:34
Miranda Materi
Right, because you have to take out the EDC.
00:04:35
Megan
but
00:04:37
Miranda Materi
Yeah, that makes sense.
00:04:39
Megan
Yeah, that's what we've been doing the most. um He's actually due for progress not soon. So we don't have a ton of measurements other than right after.
00:04:50
Megan
um
00:04:52
Miranda Materi
That's okay.
00:04:52
Megan
sorry
00:04:52
Miranda Materi
I was just kind of curious about, I were like, what do you think when you eyeball it?
00:04:54
Megan
but like
00:04:55
Miranda Materi
Like, how is it?
00:04:56
Megan
When I eyeball it, personally, I'd like him to be having more considering we're a couple weeks out from the tenolysis. His MCP extension is good, but I would say he's still got at least a 30 to 40 degree lag at the PIP and then some lag at the DIP as well.
00:05:12
Miranda Materi
And then what about doing, or have you thought about doing an RMO for him to get the extension?
00:05:18
Megan
Actually, no, we haven't. Now that his scar is all healed up, that might be a good thing to put him in during the day while he's working.
00:05:26
Miranda Materi
Yeah, that's kind of a nice one because they have to use it.
00:05:27
Megan
That's a good idea. Yeah, it is.
00:05:30
Miranda Materi
They use it all day and then.
00:05:31
Megan
Forces him and then he can take it off and stretch. That's a good idea. Yeah. I'll have to get that approved.
00:05:35
Miranda Materi
Yeah, I like that. Okay, what else are you doing for extension? Anything else? and
00:05:39
Megan
um I added in towel walking and then we'll progress to, I like using the Velcro board for extension, focusing on making them like push that towel.
00:05:45
Miranda Materi
That's a good one.
00:05:48
Megan
And we added a weight to the towel. So it's like a little harder to pull and push.
00:05:53
Miranda Materi
Oh, that's a good idea. I didn't think about adding a weight to the towel.
00:05:56
Megan
Yeah. I watched another therapist do it and i was like, I like it.
00:05:59
Miranda Materi
i That's a good trick.
00:06:01
Megan
ah That's a good trick. make A little higher level.
00:06:02
Miranda Materi
That's a really good trick. Yeah, no, that's all especially for pulling in. i think for pushing out, that'd be hard. But once you pull in, that'd be great.
Replantation Debate: Function vs. Finger Type
00:06:11
Megan
Mm-hmm.
00:06:11
Miranda Materi
ah My other question for you, i think, and this is something that's what often debatable, is if you should replant the digit or not, right? Like, is it worth going through all the steps in the work?
00:06:22
Miranda Materi
And I think it depends on how good of an outcome you get. But ah a lot of times I've seen where they just opt to not replant the digit.
00:06:30
Megan
Yeah, and I think this patient was close to that. That's what he thought they were going to do was not replant it. And then um the surgeon, from my understanding, the surgeon was like, wait, we can do this and opted to replant it. And I think, you know, this patient in particular, he is really grateful to have his finger. But I think sometimes like the amount of pain we're having to put him in because it's so it's still so painful for him.
00:06:53
Miranda Materi
Right.
00:06:53
Megan
to stretch and like his scar is so sensitive, even though we're doing everything we need to be doing with like desensitization and textures and vibration, it like is really sensitive and painful.
00:06:53
Miranda Materi
Right. It's not
00:07:05
Megan
So I think you do have to weigh that. Like, does a person want to go through eight months of rehab, especially if there's multi-staged surgery that each time they have to reheal from all of that pain and all the scar tissue and everything?
00:07:12
Miranda Materi
right
00:07:18
Miranda Materi
right so easy And then does it depend on the digit, right? Like if it's your index finger, do you just like not like, I think if it was my index finger, I'd probably choose not to reap to reapplant it.
00:07:30
Megan
Yeah, i think I think it does depend on the finger. Because that ring finger, especially with his job, I think that like using tools and stuff, it is going to be kind of important for grasping things and not dropping things. But I feel like an index finger or even a long finger, if they can do like more of a ray amputation with it, it might not be worth it.
00:07:46
Miranda Materi
Yeah.
00:07:49
Megan
Depending on when you want to get back to work, how important it is to you.
00:07:53
Miranda Materi
Right, because I mean, in theory, you could go back to work much sooner if it wasn't replanted, you know?
00:07:58
Megan
Yeah.
00:07:59
Miranda Materi
Yeah. And if they did a ray where they could move the small finger over.
00:08:03
Megan
Mm-hmm.
00:08:04
Miranda Materi
Yeah.
00:08:04
Megan
But he is, i think, going to have some some use of it. I will say when we hadn't done the teenolisis, we were doing a lot, a lot of strengthening, a lot of remobilization, a
Post-Surgery Improvements and Future Considerations
00:08:15
Megan
lot of scar work.
00:08:15
Megan
And I was like, don't, I think this ring finger might just be in the way. Like it was starting to look like it wasn't really going to be helpful.
00:08:19
Miranda Materi
Yeah.
00:08:21
Megan
So I'm really surprised by and grateful for the outcome we've gotten with the capsulotomy because otherwise, I think it would be a case where it's like, is this really more functional if he can't move the ring finger and it's just there?
00:08:34
Miranda Materi
Yeah, that's true. And it's good that, you know, at least he has the opportunity to to to work at it and see. I guess you could always go to amputation later, which I've seen where they've replanted it and it didn't work out. And then, you know, nine months later, they're getting it amputated. So, and I think that's like almost harder in a lot of ways, but.
00:08:52
Megan
Right, because then you've tried for so long and then you have to get amputated and keep going to therapy for the amputation. I feel like it just extends out the process.
00:08:59
Miranda Materi
Yeah, it does. Interesting topic.
00:09:00
Megan
But, yeah.
00:09:02
Miranda Materi
Okay, Megan, well, thank you for sharing that case.
00:09:04
Megan
You're welcome.
Conclusion and Call for Listener Engagement
00:09:05
Miranda Materi
Yeah. So if you want more info, if you want to share your own cases, please email us info at hand therapy academy or, um, reach out to us on Instagram at hand therapy academy.