Hand function rehabilitation after Brachial artery revascularization surgery at elbow due to dog bite: A case report

INTRODUCTION

Dog bite injuries to the upper extremity can result in traumatic neurovascular and musculotendinous damage. 95.45% of dog bite cases were reported in tertiary care center of Bangalore Medical College and Research Institute, Bengaluru¹. Similar results were recorded in a study, stating dog was the most common (95.8%) biting animal,² The brachial artery is the most frequently injured artery in the upper extremity. Its injury accounts for approximately 28% of all vascular injuries^3,6,7,12. The median nerve courses with the brachial artery throughout its length. The radial and ulnar nerves are parallel portions of the brachial artery^11,13. Therefore, as in all upper extremity vascular injuries, there is a high incidence of associated nerve injuries with brachial artery injuries.

Case Report

A 56-year old house wife, right dominant, came to outpatient department (OPD) during September 2018 post right brachial revascularization surgery (May 2018). Surgery had been carried out as an emergency procedure due to a dog bite with the chief complaint of inability to move the right hand for day-to-day purposes. She reported to OPD after one month of physiotherapy intervention which was not specified. She had been given cock-up splint for 1-month post-surgery. She was diabetic and hypertensive and was on medication for past 10 years. Limb attitude at base line observation was, right shoulder slightly elevated, elbow flexed and wrist drop and ulnar deviation was prominent. Ulnar claw hand was noted and muscles of the hand were atrophied.

Investigations: NCV showed grade IV Sunderland classification of right radial nerve injury, grade II in ulnar and median nerve. Main Objective was to rehabilitate the hand function post Brachial revascularization surgery at elbow caused due to dog bite

Diagnostic Assessment

Outcome measures

1. Hand Dynamometer

2. Pinch Dynamometer

3. Manual Muscle Testing (MMT)

4. Range of Motion (ROM)

Duration of the Study: 12 weeks

Study design: Single case experimental study

Therapeutic Intervention

Written consent was obtained from the patient and patient was explained about the exercise protocol. Grip strength was measured by hand dynamometer, and pinch grip by pinch dynamometer. Range of motion of wrist joint, MMT was measured for wrist muscle strength.

Galvanic stimulation4 for 3 weeks was given followed by hand function exercise using hand exerciser unit was continued up-to 12th week of intervention.

Intervention details

1. Galvanic stimulation: 30 contraction/minute for Brachioradialis, Extensor Carpi Radialis Longus And Brevis, Extensor Digitorum, Extensor Carpi Ulnaris, Abductor Pollicis Longus Extensor Pollicis Longus and Brevis and Extensor Indicis for 5 days/week for 3 weeks. Progressed to 20 contraction/minute from 4th to 6th week. Galvanic stimulation was stopped after 6 weeks Fig.1).

2. Exercise: Passive range of motion and active assisted exercise was continued initial 3 weeks for 10 repetition/exercise for 3 session/day for 5 days /week. It was progressed to Hand exerciser unit exercise initiated with bimanual task, precision training, bimanual Velcro strap training, sorting the pebbles to various boxes 10 repetition/exercise for 3 sessions/day for 5 days /week. Variable practice was continued from 4th to 6th week beyond 6th week variable practice was continued and progressed to power gripper exercise for 15 repetition / session for 3 session /day for 5 days /week up to 12th week, the detailed description is given in the table and post assessment of outcome measures were measured(Fig.2).

Patient Perspective: Subject had regained hand function though the grip strength was not improved significantly, although the subject wanted to perform her day to day activities independently. subject was satisfied with the improvement after 12 weeks; subject did not take any medications or any health care services and her social functioning was normal.

RESULTS

Significant improvement in hand muscle strength of about 47% wrist extension, 45% radial deviation, there was improvement of ROM about 60% improvement in wrist extension. Though there was improvement in pinch grip 33.3% and grip strength 7.5% but was not marked improvement. Graph 1.1, 1.2, 1.3) 

Graph 1.1: The graph represents the graded grip strength improvement which represents weekly improvement to 1.5 kg by the end of the 12th week whereas pinch grip did not improve to the second session of assessment and pinch grip could increase upto 1 kg by the end of 12th week. Pinch grip 33.3% and grip strength 7.5% but was not marked improvement. Hand muscle strength of about 47% wrist extension, 45% radial deviators

Graph 1.2: Graph 1.2 Represents that muscle power of wrist flexors, ulnar deviation improved significantly and radial deviation improved to grade 2 only but the wrist extension improvement was significant by 12th week but initially by 6th week.

Graph 1.3: wrist extension and radial deviation was least improved post intervention. there was improvement of ROM ,60% improvement wrist extension.

DISCUSSION

Hand function was the primary concern for the subject and current clinical finding showed significant improvement in hand muscle strength of about 47% wrist extension, 45% radial deviators, there was improvement of ROM ,60% improvement wrist extension. Though there was improvement in pinch grip 33.3% and grip strength 7.5% but was not marked improvement. Galvanic stimulation was continued till the 6th week of intervention main aim of giving galvanic stimulation was to induce vasomotor effect. Galvanic stimulation is used to stimulate the muscle directly following the nerve injury 4,5,. Hand exercises were given with constant feedback of performance and knowledge of result, the exercises were progressed gradually by 6th week with variable practice which was continued throughout intervention. Hand exerciser unit is low cost project which can be used effectively in community for rehabilitation. constant motivation to the patient was given throughout the intervention. Future researches should consider focus on post vascular surgeries rehabilitation. Future research should also focus on psychological status of these subjects.

Brachial artery is the main artery of upper extremity any damage to the artery can deprive the blood supply to the muscle of the hand and injuries can also lead to nerve damage 8-10. Vascular injuries are very common and rehabilitation should focus on post vascular surgeries. There is scarcity of research post brachial artery vascular surgery rehabilitation. Long term rehabilitation is required post brachial artery surgeries and constant motivation is the key for success in rehabilitation.

CONCLUSION

Hand function improved significantly followed by hand rehabilitation there was marked improvement in ROM and strength post intervention although the grip strength and pinch grip had no marked improvement.

Conflict of interest: Nil