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Transcript of Physiotherapy Mgt of Infection in UL(160313) · sling suspension 8 Acute Phase Intervention –...
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Physiotherapy Management of Infection in Upper Limb
Raymond Tsang
13 March 2016
2
Hand Infection
In general, 3 phases for Assessment & Intervention for Physiotherapist:
• Acute Phase – acute inflammation & infection
• Post-Acute Phase – resolving inflammation & infection
• Post-Infection Phase – infection under control
3
Acute Phase
Assessment1. Acute Inflammation• Redness• Swelling• Temperature increase• Pain• Loss of function
4
Acute Phase
Assessment2. Wound Condition• 3-colour concept – red, yellow & black
wound• Any pus or abscess collection
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Acute Phase
Intervention – Aims & Methods1. To minimize exacerbation of
inflammation & infection• Rest/immobilization (boxing glove
bandaging)• Compression (boxing glove
bandaging)• Elevation
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Boxing Glove Bandaging
• Compression– venous return & oedema
• Reduction of inflammatory changes– rest– pain
• Facilitation of wound drainage
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Elevation with sling suspension
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Acute Phase
Intervention – Aims & Methods2. To prevent joint contracture• Rest/immobilization in intrinsic plus
position (position of immobilization)3. To drain pus and clean wound• Hibitane bath
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Acute Phase
Intervention – Aims & Methods3. To drain pus and clean wound• Saline irrigation for deep wound• Whirlpool therapy (past)
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Post-Acute Phase
Assessment1. Inflammation• Redness• Swelling• Temperature increase• Pain
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Post-Acute Phase
Assessment2. Wound Condition• More healthy wound condition (with
the use of antibiotics debridement)• Pus or abscess collection
3. Joint ROM & Soft Tissue Adhesions
12
Post-Acute Phase
Intervention – Aims & Methods
1. To prevent/improve finger joint stiffness & soft tissue contracture
• Gentle active passive finger mobilization exercises
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Post-Acute Phase
Intervention – Aims & Methods2. To prevent tendon adhesions &
improve tendon gliding• Tendon gliding exercises
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Post-Acute PhaseIntervention – Aims &
Methods3. To reduce residual
swelling• Pneumatic compression
therapy• Massage• Bandaging; Coban wrap• Advice on continuing &
appropriate elevation
15
Intermittent Pneumatic Compression
(Lowe et al, 2005)16
Post-Infection Phase
Assessment1. Joint ROM & Joint Stiffness2. Soft Tissue Adhesions/Scars3. Residual Swelling4. Muscle Strength5. Pain6. Function
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Post-Infection Phase
Intervention – Aims & Methods1. To improve finger joint ROM, stiffness
& soft tissue contracture• Active passive finger mobilization
exercises• Stretching
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Post-Infection PhaseIntervention – Aims & Methods2. To improve soft tissue adhesions/Scars• Massage• Ultrasound therapy3. To improve tendon gliding• Tendon gliding exercises4. To muscle strength• Muscle strengthening exercises
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Post-Infection Phase
Intervention – Aims & Methods5. To improve functions• Dexterity training• Work conditioning/simulation
programme
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Common Infection Cases• Paronychia – infection of space surrounding
eponychial fold
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Common Infection Cases• Felon – infection of closed space of volar
digital pulp
Septa22
Common Infection Cases• Felon
Treatment – Incision and drainage; appropriate antibiotics; open drainage of wound – saline gauze packing
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Common Infection Cases• Infective Tenosynovitis
(Tubiana et al, 1996) Incision & Continuous Drainage
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Common Infection Cases• Infective Tenosynovitis
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Special Infection Cases
• Mycobacterial Infections– Typical: Mycobacterium Tuberculosis– Atypical:
(Bhambri et al, 2009)
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M. Marinum
(Bhambri et al, 2009)
27(Cheung et al, 2010)
M. Marinum
28
Postoperative immobilization in boxing glove bandaging for 3 weeks
(Cheung et al, 2010)
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M. Marinum
Drug Treatment (QMH)(1) Standard regimen for previously untreated patient.• Ethambutol and rifampicin(2) For patient with relapse after treatment• Clarithromycin and minocycline and ethambutolDuration of treatment• 6 month in total or at least 2 more months after definite clinical
improvementDosage• Ethambutol 15mg/kg QD daily• Rifampicin 450mg (for BW ≤ 50kg) or 600mg (for BW > 50kg) QD
daily• Clarithromycin 500mg BD daily• Minocycline 100mg BD daily
29 30
Other Mycobacterial Infections
• Drug Treatment – multi-drug therapy, e.g.:– Isoniazid– Pyrazinamide– Rifampicin– Ethambutol (risk of blurred vision, red / green
colour blindness)– Clarithromycin– Minocycline (risk of pigmentation)– Amikacin (risk of vestibular & auditory damage)
• Monitoring of drug compliance and side effects by physiotherapist
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Mycobacterial Infections
• Monitoring of liver and renal functions, haemotological status (platelet, WBC, RBC counts)
32
Special Infection Cases
• Fungal Infections• Necrotising Fasciitis
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Fungal Infection• Scedosporium apiospermum infection
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Fungal Infection
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Fungal Infection
Management• Multiple surgical debridements + bone
graft + percutaneous K-wire fixation• Prolonged drug treatment –
Itraconazole• Physiotherapy & Occupational Therapy
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Necrotising Fasciitis• Type I – anaerobic bacteria and
streptococci other than serogroup A• Type II – group A Streptococci• Usually occurred in patients with
chronic debilitating diseases – diabetes, alcohol abuse, or renal insufficiency
(Cheung et al, 2009)
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Necrotising FasciitisManagement• Prompt diagnosis with radical
debridement amputation• Appropriate antibiotics• Rehabilitation – management of
sequelae
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Case 1
History• 88 year-old man• Slip & fell with sprained (R) Index
Finger• Consulted bonesetter• Developed swelling & pain for 3-4 days
before admission
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Case - Preop
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Case - Preop
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Case – I & D - Postop D4
C/ST: E. Coli, Streptococci; Bacteroides 42
Case - Physiotherapy
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Case – Postop D7(Osteolytic change at tuft of distal phalanx)
44
Case – Post-Amputation D1
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Case – Post-Amputation D20
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Case – Post-Amputation D29
AROM: (R) IF MPJ: 00-800; PIPJ: 00-500 (700)
Hand Grip: (R) 5kgf; (L) 9kgf
47
Case 2• Infection in an immunocompromised patient
48
Case 2• Infection in an immunocompromised patient
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Case 2• Infection in an immunocompromised patient
6 weeks later 50
Application ofBoxing Glove Bandaging
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•Wrist in neutral or slight extension
•MPJ ~ 900
•IPJ ~ 00
•Thumb in palmar abduction
Position of Immobilization
52
Position of Immobilization
MPJs
– Collateral ligaments taut in flexion
- Joint capsule & volar plate loose
(Tubiana et al, 1996)
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Position of Immobilization
IPJs – Joint capsule & volar plate are tight
(Tubiana et al, 1996)
54
Video on Boxing Glove Bandaging
55
Re-assessment after Application
• Check any subjective discomfort, e.g. too tight, throbbing sensation
• Observe capillary refill of nail bed or pulp
• Feel the resilience of bandaging for even pressure
56
Re-assessment when Boxing Glove Bandaging is removed
• Revise boxing glove bandaging when it is loosened
• Check any local pressure points (especially at PIPJs, wrist)
• Check any reduction in swelling or oedema– Wrinkles or creases
• Check position of finger joints
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References• Bhambri S, Bhambri A, Del Rosso JQ (2009) Atypical
mycobacterial cutaneous infections. Dermatologic Clinics 27: 63-73.
• Cheung JPY, Fung B, Tang WM, Ip WY (2009) A review of necrotising fasciitis in the extremities. Hong Kong Medical Journal 15: 44-52.
• Cheung JPY, Fung BKK, Ip WY (2010) Mycobacterium marinuminfection of the deep structures of the hand and wrist: 25 years of experience. Hong Kong Medical Journal 15: 211-216.
• Lowe E, Smith , Nolan TP (2005) Mechanical modalities: traction and intermittent pneumatic compression. In: Michlovitz SL, Nolan TP (Eds) Modalities for Therapeutic Interventions, Philadelphia: F.A. Davis, 165-181.
• To MKT, Ho PL, Ip WY (2005) Scedosporium apiospermumcausing septic arthritis of the hand in an immunocompetent patient. Hong Kong Journal of Orthopaedic Surgery 9: 73-78.
• Tubiana R, Thomine J-M, Mackin E (1996) Examination of the Hand and Wrist, 2nd ed, London: Martin Dunitz.