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Dr./ Mohamed rizk

Physical therapy protocol after pollicization surgery (Case study)

What is the pollicization surgery?


Pollicization is a plastic surgery technique in which a thumb is created from an existing finger. Typically this consists of surgically migrating the index finger to the position of the thumb in patients who are either born without a functional thumb (most common) or in patients who have lost their thumb traumatically and are not amenable to other preferred methods of thumb reconstruction such as toe-to-hand transfers.

How it is done?

During pollicization the index finger metacarpal bone is cut and the finger is rotated approximately 120 to 160 degrees and replaced at the base of the hand at the usual position of the thumb. The arteries and veins are left attached. If nerves and tendons are available from the previous thumb these are attached to provide sensation and movement to the new thumb ("neopollex"). If the thumb is congenitally absent other tendons from the migrated index finger may be shortened and rerouted to provide good movement.



The presence of an opposable thumb is considered important for manipulation of most objects in the physical world. Children born without thumbs often adapt to the condition very well with few limitations therefore the decision to proceed with pollicization lies with the child's parents with the recommendation of their surgeon. Persons who have grown to adulthood with functional thumbs and then lost a thumb find it highly beneficial to have a thumb reconstruction, not only from a functional but from a mental and emotional standpoint.

Case study..

A case of an adult admitted to the hospital after a gunshot.The bullet exploded the left thumb.A pollicization was done by replacing the left index finger to the thumb site.

This guy was 21 years old & working in a factory, so restoring the hand function is the main target.I started a physical therapy program depending on the problems he had.

Examination..

By looking to the movements, flextion is better than the extension, so extensor lag happened.
As a test for the function, he was asked to pick up a pen & write with the left hand (the affected hand) i found that he can grasp a pen but he can not control it to write.
Then he was asked to let it down but it was not easy to open his hand.

Some movements are missed like adduction & abduction .
And by examining the joints, PIP, DIP & MP i found PIP stiffness while the DIP has normal range of motion with passive movement test & lake of extension by active movement test.
But the MP joint i ignored testing it as this is not a real/normal joint.

The skin also play a very important role in the movement, as it gives more ranges to the joints to move further more so, paying attention to this factor is very important.
By examination, i found that the skin appears adherent on the dorsal surface & by testing its flexibility using my hand it was found rigid.

This adherence affecting the flexibility of the movement toward the flexion.

While the anterior surface is less adherence but still not permitting the normal flexibility.

No pain appear untill pressing on the metacarpophalangeal joint toward the flexion.

The program..

Exercises
Starting with strengthening exercises for the long flexors of the index and facilitating the extension using maximum resistance to the extensors to fire more fibers & neurons which improve the extension.

In addition , the functional exercises were done for improving the synchronization between all groups of the muscles and restore the function as quickly as possible.
Writing is very important as in this action we can get very specific feedback, as the action of writing linked with the perceptual & cognitive activities of the brain which improve the out put of the motor action.

Stretching exercises for the hand flexors, by opening the hand widely and extending the wrist to the middle range of wrist extension as we can not do full extension because the surgeon took a bone graft from the carpal bone.

Orthoses
As a way to overcome the extensor lag, using a splint to hold the DIP & PIP joints in extension for long time during the day.

Manual techniques
One of the big problems was the PIP stiffness that affecting the function of the transfered
finger so, mobilization techniques are used to increase the limited range of motion.


Now the movement became smoother and easier but the skin stiffness was limiting the movement so, for the stiff skin over the dorsal surface, myofacial release & massage were used.

Also both were donefor the anterior surface adding the vibrator machine, ultrasonic waves & short wave to them.

Electrotherapy
Ultrasonic waves was used as it creates micro-massage which break down the adhesions if used in form of pulsed waves.

Deep heating generated by the short wave which used in form of continuous waves helps in gaining the flexibility.In addition hot packs & sometimes paraffin wax.

Every session i was using the vibrator as the shaking waves generated by this machine have the ability to release the adhesion mechanically & generating the heat in those tissues as a result of the friction and the shaking action of the vibrator.

Using faradic stimulation in the form of titanic contraction was done to the extensors of the fingers to facilitate the extension by firing more muscle fibers and more neurons.

The results
For three months of rehabilitaion, he can touch the little finger with the tip of the index (the O position), the DIP restored a good range allowing the hand to restore most of its functions & the skin was flexible enough at the anterior surface while the dorsal surface did not achieve more results.
Extensor lag decreased but still appear there.He can use the left hand well in his job without any barrier.I advised him to keep exercising the fingers using tools like pinch grip or flexible ball.