Easy Hand Blast Injury Physiotherapy Exercise to Get back to job early

After the plastic surgery reconstruction of hand blast injury, the biggest challenge is to regain wrist and finger range of motion. Physiotherapy plays a crucial role in rehabilitating back the crackers blast in hand injury sufferer back to the job.

In this article, we will discuss everything related to hand injury due to blast. We will especially focus on physiotherapy treatment and exercises. But, let us start with this true case of a 28 years old male, that I dealt with at our physiotherapy centre.

Hand blast injury

A 28-year-old male with a postoperative case of hand blast injury came to our department for physiotherapy. Here’s the history of his injury. He was having fun with crackers when a firecracker accidentally blasted right on his hand. Immediately He was shifted to the local hospital by his friends and family member. The doctors ruled out any finger or wrist bone fracture, they performed primary debridement by primary closure.

It was a blast injury of the hand when a firecracker blasted on his hand. X-ray ruled out any involvement of the bone fracture. There was only involvement of the soft tissue. After stitch removal, he was referred to physiotherapy for postoperative physiotherapy.

The predominance of the hand in involvement in such injuries is due to accidental blast during hurling a bomb as well as the injury sustained when a person tries to shield himself from a bomb being hurled at him with his hands (1). A study finds that the most common causes of blast injuries are firecrackers, homemade bombs and bottle bombs.

The study also finds that the most common pattern of injury comprised of a first web space split with variable degrees of thenar muscle injury, dorsal dislocation of the CMC joint of the thumb, which was occasionally associated with 2^nd and 3^rd metacarpal injuries.

Treatment of blast hand injury

The key to management of blast injuries of the hand is early debridement and wound coverage. After the primary medical attention post-operative splinting in the functional position is important to prevent stiffness (1). Stiffness is common after blast injuries and can be countered by a properly instituted range of motion exercise program instituted as early as possible.

Let us move back to our case study, when he arrived at us (physiotherapy centre) his one hand was supported over the other. The affected hand was swollen, surgical wound was not completely healed. He was reluctant to do any movement on his fingers and wrist as it was painful and was under severe psychological stress. We took the case and carried out a thorough assessment and examination of the injured hand and his medical reports.

Inspection: On thoroughly inspecting we found a deep surgical wound on the palmar aspect of the hand beginning from the middle of the wrist and extending upward up to the 2nd web space (as in the figure below).

Examination: On further examination, we noted the following findings:

1. Unable to use hands for daily activities.
2. Swelling of hand in both the palmar and dorsal aspect.
3. Partially healed surgical wound.
4. Painful finger movement.
5. Painful wrist movement.

Rehabilitation after hand injury

Post-operatively the hand blast injury rehabilitation can be categorised into three-phase.  

1. Acute Phase
2. Sub-acute Phase
3. Rehabilitative Phase.

Acute phase

The acute phase is the initial stage after surgery and is characterised by the presence of swelling and pain. So aim of physiotherapy during the acute phase would be to control swelling (oedema) and pain management.

Swelling (oedema) control

a) Elevation: keep the hand in an elevated position while sleeping by using a pillow (see figure )

b) Movement: In an elevated position slight finger and wrist movement is started within a pain-free range.
c) Compression: Using crepe bandage or compressive garments optimum pressure is applied. 

Pain Control

• Heat therapy.
• Ultrasonic therapy: Its micro-massage effect is beneficial for both swelling and pain.
• Interferential therapy: It’s beneficial for pain and also for its stimulatory effect which contracts the muscle and helps relieve swelling.  

Strengthening of muscle around wrist and hand

During the acute phase, the slightest movement is painful. So for strengthening of the muscle Faradic Stimulation is given. It stimulates the muscle which contracts and relaxes the muscle as normal muscles do. Wrist extensors and finger extensor is mainly concentrated.

Sub-acute phase

Sub-acute phase is characterised by reduced acute pain and swelling. The surgical wound is healed and the surgical scar mark is left over. During this phase, the aim of physiotherapy would be

1. Gaining range of motion of wrist and finger joints.
2. Softening of scar mark.
3. Strengthening of muscle around wrist and fingers.
4. Taking care of swelling.  

Wrist range of motion exercise

Wrist stiffness is the commonest complication post-surgically. For this, we have to encourage wrist range of motion exercises as soon as the acute pain reduces. Wrist flexion-extension and radial-ulnar deviation motion are the two types of motion that occur in the wrist joint.

For this exercise, first, stabilise the forearm on the table. Now, for flexion-extension exercise, move the wrist joint forward and backwards as shown in the figure. For radial-ulnar deviation exercise simply move the wrist sideways in both right and left direction. Repeat this exercise a minimum of 20 to 30 times in a session, however, the more you do the better it is.

Finger range of motion exercise

For this, spread your fingers as wide as possible and bend your fingers so that your fingertips touch the top of your palm. Now, straighten your fingers again then again bend your fingers to touch the middle of your palm. Open your fingers wide.

Now bring your fingertips to touch the bottom of your palm. Then bring your thumb to touch each fingertip. Bring your thumb to touch different places on your palm. Do 3 sets twice a day.

Wrist stretching exercises

This is a stretching exercise for the wrist and our starting position would remain the same. Here we have to use our opposite hand and slightly put pressure at the end range of wrist flexion and extension. For example, to stretch the flexors, slightly extend the wrist and use the other hand to give pressure over the palm. 

Press and hold this position for a minimum of 30 seconds duration. Now repeat the same process by extending the wrist to stretch the flexor group of muscles.

c) Mobilisation of carpal bones, wrist joint, joints of the finger. This can only be done by a well-qualified Physiotherapist.

Softening of scar mark

Scar mark gets adhered to the lower structure and when the scar is not soft any stretching causes pain. Both factors together restrict joint movement. Therefore softening of scars is so important. Your physiotherapist will apply the following procedure for it.

1. DTMF (Deep Transverse Friction Massage) over the scar mark.
2. Ultrasonic Therapy.  
3. Strengthening: a) Resisted exercises. b) Grip strengthening exercise.

Pain

• Interferential Therapy.
• Heat therapy.  

Contrast bath for swelling

A contrast bath or alternate cold and hot bath is an effective way to manage hand and finger swelling. It is a process that involves dipping hands alternately in cold and hot water. We have already covered the exact method in one of our articles, How to Contrast Bath Therapy for Hand & Foot Swelling.

Do the contrast bath twice daily and you can find instant relief in swelling and pain.

Rehabilitation phase

In this phase, the patient is prepared for returning back to the work as before. According to their need, fine movement of the finger is taught particularly focusing on thumb movement. All the exercises which are done in the subacute phase are repeated but done more aggressively.

Reference:

1. Adhikari, S., Bandyopadhyay, T., Sarkar, T., & Saha, J. K. (2013). Blast injuries to the hand: Pathomechanics, patterns and treatment. Journal of emergencies, trauma, and shock, 6(1), 29–36. https://doi.org/10.4103/0974-2700.106322

Sunit. S. Ekka

Dr Sunit Sanjay Ekka is a physiotherapist in practice for the last 15 years. He has done his BPT from one of the premium Central Government physiotherapy colleges, ie, SVNIRTAR. The patient is his best teacher and whatever he gets to learn he loves to share it on his Youtube channel and blog.