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Early Active Range of Motion Rehabilitation Protocol for Spaghetti Wrist Injury
Christopher Robert Howell, M.D.1, Greg Pitts, OTD, OTR/L, CHT2 and Maureen O'Shaughnessy, MD1, (1)University of Kentucky, Lexington, KY, (2)Commonwealth Hand and Physical Therapy, Lexington, KY

Hypothesis:
Good outcomes with hand replantation therapeutic protocol inspired us to employ this approach for "spaghetti wrist" injuries, i.e. complex volar wrist injuries with involvement of Zone IV and V flexor tendons, vessels, and nerves. Our hypothesis is that the use of dynamic crane orthotic for initiation of early active motion leads to improvement in both objective and subjective outcomes without increased risk of wound healing complications or rupture of neurovascular or tendinous repairs.

Methods:
Retrospective review was performed of patients treated with early active motion protocol following repair of volar wrist injury with damage sustained to the median and/or ulnar nerve, and multiple Zone V flexor tendons. Patients were treated in an outpatient hand therapy clinic with early introduction of a dynamic crane orthotic as previously described in the hand replantation literature. Clinical and demographic data were recorded. Pre- and post-rehabilitation outcomes including QuickDASH and Global Rating of Change (GRoC) score, Purdue peg board testing and grip strength were measured. Complications including regional sympathetic dystrophy, wound healing issues, tendon ruptures or need for revisional surgery were recorded.

Results:
Twenty nine patients with average age at time of injury of 38 years were included. Average follow up with a certified hand therapist was 21 visits. Pre- and post-assessment data yielded positive changes in QuickDASH scores from 76 to 26 and GRoC score from 5.01 on average at completion of therapy. Post-assessment grip strength indicated a percent difference in grip strength between hands to be 10.2% for males and 1.86% in females. One patient required an un-related return to the OR for median neurolysis. No complications, specifically no tendon ruptures or wound healing issues, were encountered.

Conclusion:
Early low-load and high-excursion therapy protocol as described in hand replantation literature yields promising results in patients following repair of Zone IV and V tendon, vessel and nerve injuries. No tendon ruptures were encountered in our cohort with use of this therapy protocol. Self-reported outcome measures and objective clinical outcomes are promising at early follow up. The significance of these results may indicate the utility of employing the early active range of motion protocol for patients suffering from spaghetti wrist injuries in the future with regularity.


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