Case Presentation:

Alleged industrial injury,

bil total hand amputation
MUHAMMAD MUIZZUDDIN BIN ABD RAZAK
2019409168
UiTM CAWANGAN PULAU PINANG KAMPUS
BERTAM
 table of Content

1 2 3
ANATOMY OF HANDS TRAUMATIC CASE PRESENT
AMPUTATION
1. Anatomy of HanDs

physiopedia, 2021
Joint Type Movt
Carpometacarpal joint Saddle Flexion-extension;
(thumb) Abduction-adduction;
circumduction; opposition

Carpometacarpal joint Ellipsoidal Flexion-extension

(fingers)

Metacarpophalangea Ellipsoidal Flexion, extension,

l joints abduction, adduction,
circumduction

Interphalangeal Hinge Flexion (lots) Extension

(minimal)

physiopedia, 2021
physiopedia, 2021
2. Traumatic Amputation
• Traumatic amputation is the loss
of a body part, usually a finger,
toe, arm, or leg, that occurs as
the result of an accident or
injury.

hopkins, 2019
AETIOLOGY
• Motor vehicle accidents, including car collisions, truck wrecks, and
motorcycle accidents
• Industrial accidents, including workplace, factory, and construction
accidents
• Agricultural accidents, including lawn mower accidents
• Fireworks, explosives, and firearm accidents, including military-related
injuries
• Electrocution accidents
• Ring traction accidents
• Car door and building accidents
Clinical presentation
• in complete amputation ussualy
body part or limbs are devided
from the body

• In a partial amputation, some

soft-tissue connection remains.
Doctor Management
• RECONSTRUCTION
• osteomyoplastic reconstruction
• full-thickness skin grafting

• initial stabilization and bleeding

control
• infection control
• prosthetic
Physio management
• pain management
• regaining function
• adapting new environment
3. CASE • 1st visit
PRESENTATION • d.o.ax : 11/5/2022
Subjective Assessment
• Name : Mr G Pt .complaint
• D.O.Ax: 11/5/2022
• Age : 64 years old - still has difficulty to hold small or
• MRN: SP000846.. heavy object
• Gender : Male
- stiff & inability to clench both
hands
• Dr diagnosis : Alleged Industrial
Injury, bil total hand amputation

• Dr mx : post we+wb+K wire &

replantation of bil hands
Body Chart
- Healed scar
- no pain
• Current hx + mx
• Alleged industrial injury while working. Accidently cut by metal cutter
while trying to remove wooden block. He was sustained total cut at
bilateral hand. No LOC. He was then brought immediately to HSAH.
Then, being transfer to HSB for emergency replantation within 6 hours.

• Past hx + mx
• had h/o cut at his Rt little, ring & middle finger, cause him had difficulty
to flex the fingers

• Past med/surgical hx + mx

• hyperlipidimia - dx at age 59y/o

Family and social hx

• Occupation + NOJ : Currently unemployed - use to work at wood factory

• Married / single : Married, blessed with 3 children
• Hobby : no specific hobby, just sitt around house
• Type house and toilet : single story, sitting toilet
• D.Hand : Rt hand
• Smoking status: No
• Alcohol consumption : occasionaly, usually on celebration
Functional Activity
• eating : able to do; using spoon
• dressing : able to do ; had difficulty to button shirt.
• open door knobs : able to do;
• riding MB : able to ride MB not for a long period; (< 30mins)

Pt Goals : - to be able to fully clench hand

- able to do ADL independently
OBJECTIVE ASSESSMENT
G/O :
• a mesomorph middle aged indian man came to dept independently;
• both his hand in clawed position
L/O :
• swan neck deformity like appearance
• horizontal scar around both hands
• no redness or swelling at both hand
PALPATION
• no swelling, tenderness or warmth at both hands
• fully healed scars
 ROM
Right Left
Finger Joint Active Passive OP Active Passive OP
Thumb MCP 10 - 30 10 - PFROM 15 - 30 15 - 35 HARD
IP 30 - 60 30 - 70 HARD 10 - 70 10 - PFROM
HARD MCP 0 - 60 0 - 80 HARD 0 - 60 0 - 80 HARD
INDEX PIP AFROM - 10 - 70 10 - PFROM
DIP 0 - 35 0 - 35 HARD 30 - 50 30 - 70 HARD
MIDDLE MCP 0 - 30 0 - 80 HARD 0 - 60 0 - PFROM
PIP 60 - 80 60 - PFROM 10 - 80 10 - PFROM
DIP 40 - 75 40 - 75 HARD 10 - 55 10 - 70 HARD
RING MCP 0 - 60 0 - 75 HARD 0 - 40 0 - 65 HARD
PIP 25 - 80 25 - PFROM AFROM
DIP 30 - 70 30 - 70 HARD 40 - 40 40 - 40 HARD
LITTLE MCP 20 - 35 20 - 60 HARD 0 - 20 0 - 20 HARD
PIP 55 - 60 55 - PFROM HARD 30 - 70 30 - PFROM
DIP 60 -60 60 - 60 HARD 30 - 45 30 - 75 HARD
Interpretation Reduce ROM over bil hands d/t jt stiffness & ms tightness
PULP TO PULP
Right hands

Index Middle Ring Little

- - 1cm 2.5cm

Left hands

Index Middle Ring Little

- 3cm 2cm 2.5cm

unable to fully reach each finger on both hand d/t jt stiffness

PALMAR CREASE
Right hands
Index Middle Ring Little
3cm 2.5 3.5cm 2cm

Left hands
Index Middle Ring Little
4cm 5cm 4cm 3cm
Unable to fully grip bil hand d/t jt stiffness
 GRIP STRENGTH (w/in range)

Right hand 8.1 kg Left hand 3.7kg

interpretation : poor grip strength on both hands d/t not fully ROM
ANALYSIS
IMPAIRMENT FUNCTIONAL LIMITATIONS PARTICIPATION RESTRICTION

 Unable to fully grip bil hand d/t  difficult to hold or pick up small  disturb ADL
jt stiffness object
 Reduce ROM over bil hands d/t  difficult to button up shirt
jt stiffness & ms tightness
 poor grip strength on both
hands d/t not fully ROM
SHORT TERM GOALS
• To improve pt’s ROM over bil hand w/in 2 sessions.
• To improve grip strength over bil hand w/in 1 month.
• to able grip hands w/in 2 month.

LONG TERM GOALS

• To optimise ADL independently as much as possible with minimise
disabilities.
PLAN OF TREATMENTS
• STM
• JT. MOBILIZATION
• STRETCHING EXS
• STRENGTHENING EXS
• HEP
• PT EDU
Intervention
INTERVENTION PROCEDURE EVALUATION
WAX BATH Wax bath; both hands; 7 dipped ; pt felt comfortable and claim felt
20mins stiffness reduced
Manual therapy Pt sitt (chair); hand rest on table; pt able to follow the exs given
(passive stretching) therapist tract each finger; stretch
it; flex and extend; hold 10s; each
finger.

Hand putty exs Pt sitt (chair); use theraputty green pt able to do the exs given
color; do gripping; pinching &
twisting; use both hands; 10mins
Gripping exs Pt sitt (chair); use digiflex green
(digi flex) color; do gripping exs; hold 5-8s;
10x each hands
INTERVENTION PROCEDURE EVALUATION
HEP • do passive stretching exs for pt understand the advice given
both hands; fingers & wrist
• do gripping exs using towel or
elastic ball; hold 10s; 10x each
hands
Pt edu • advice pt to continue exs at
home
• advice pt to dipped both hands
in warm water; 5 mins
REVIEW
ASSESSMENT TREATMENT

Pt c/o Thermal Therapy

Grip strength Stretching Exs
Pulp to Pulp Gripping Exs
Palmar Crease
• 2nd visit
• d.o.ax : 8/6/2022
Subjective Assessment
• Pt c/o :
Pt had no new active complain
OBJECTIVE ASSESSMENTS
G/O :
• a mesomorph middle aged indian man came to dept independently;
• both his hand in clawed position
L/O :
• swan neck deformity like appearance
• horizontal scar around both hands
• no redness or swelling at both hand
PALPATION
• no swelling, tenderness or warmth at both hands
• fully healed scars
GRIP STRENGTH

Right hand 8.2 kg Left hand 4.1kg

interpretation : Improved left hand grip strength by 0.4kg
PULP TO PULP
Right hands

Index Middle Ring Little

- - 1cm 2.5cm

Left hands

Index Middle Ring Little

- 2cm 1cm 2.5cm

reduce distance in pulp to pulp over Left middle & ring finger
PALMAR CREASE
Right hands

Index Middle Ring Little

3.5cm 2.5cm 3.5cm 2cm

Left hands

Index Middle Ring Little

3.5cm 4cm 4cm 3cm

Improved distance in palmar crease over Right index & Left index and middle finger
ANALYSIS
• Improved left hand grip strength by 0.4kg
• Reduced distance in pulp to pulp over Left middle & ring finger
• Reduced distance in palmar crease over Right index & Left index and
middle finger
INTERVENTION
INTERVENTION PROCEDURE EVALUATION
WAX BATH Wax bath; both hands; 7 dipped ; 20mins pt felt comfortable and claim felt
stiffness reduced
Manual therapy Pt sitt (chair); hand rest on table; hold pt able to follow the exs given
(PNF stretching) relax; therapist ext finger MCP & PIP jt and
hold; 30s; stretch extensor digitorum ms;
hold 15s; each finger; both hands.

Hand putty exs Pt sitt (chair); use theraputty green color; pt able to do the exs given
do gripping; pinching & twisting; use both
hands; 10mins
Gripping exs Pt sitt (chair); use digiflex green color; do
(digi flex) gripping exs; hold 5-8s; 10x each hands
INTERVENTION PROCEDURE EVALUATION
HEP • do passive stretching exs for pt understand the advice given
both hands; fingers & wrist
• do gripping exs using towel or
elastic ball; hold 10s; 10x each
hands
Pt edu • advice pt to continue exs at
home
• advice pt to dipped both hands
in warm water; 5 mins
REVIEW
ASSESSMENT TREATMENT

Pt c/o Thermal Therapy

Grip strength Stretching Exs
Pulp to Pulp Gripping Exs
Palmar Crease
EVIDENCE BASED
Intervention Authors/ sources
PNF stretching to increase ROM Hindle, K., Whitcomb, T., Briggs, W., & Hong,
J. (2012). Proprioceptive Neuromuscular
Facilitation (PNF): Its Mechanisms and Effects
on Range of Motion and Muscular
Function. Journal of Human
Kinetics, 31(2012), 105–113.
https://doi.org/10.2478/v10078-012-0011-y
‌
(Hindle et al., 2012)
Results/ statements
PNF is a stretching technique utilized to
increase ROM and flexibility. PNF increases
ROM by increasing the length of the muscle
and increasing neuromuscular efficiency. PNF
stretching has been found to increase ROM in
trained, as well as untrained, individuals.
CONCLUSION
• Traumatic amputation is one of the severe condition and almost
impossible for pt to regain it’s normal form
• hand is very complex; containing 27 bones; 4 types of joint & 34
muscles act on the hand
• the aim to treat the pt was to achieve their ability to grip their hands.
REFERENCES
Amputation. Johns Hopkins Medicine. (2021, August 8). Retrieved June 11, 2022, from
https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/amputation
Common traumatic amputations. MBM Justice. (2021, June 23). Retrieved June 11, 2022, from
https://www.mbmjustice.com/blog/common-types-of-traumatic-amputation/
MediLexicon International. (n.d.). Cut-Off Finger: First Aid, treatment, and recovery. Medical News
Today. Retrieved June 11, 2022, from https://www.medicalnewstoday.com/articles/cut-off-
finger#treatment
U.S. National Library of Medicine. (n.d.). Traumatic amputation: Medlineplus medical
encyclopedia. MedlinePlus. Retrieved June 11, 2022, from
https://medlineplus.gov/ency/article/000006.htm#:~:text=Traumatic%20amputation%20is%20the
%20loss,of%20an%20accident%20or%20injury.
Wrist and hand. Physiopedia. (n.d.). Retrieved June 11, 2022, from https://www.physio-
pedia.com/Wrist_and_Hand#:~:text=The%20joints%20formed%20between%20the,as%20two
%20single%20synovial%20joints.