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The effect of intermittent pneumatic compression on the hand after fasciectomy
The Effect o f Intermittent Pneumatic Compression on the Hand after Fasciectomy E. Z. Hazarika, M. T. N. Knight and A. Frazer-Mooclie
THE EFFECT OF INTERMITTENT PNEUMATIC COMPRESSION ON THE HAND AFTER FASCIECTOMY E. Z. HAZARIKA, M. T. N. KNIGHT, London and A. FRAZER-MOODIE, Bristol SUMMARY Thirty-nine patients undergoing surgery for Dupuytren's contracture were included in a fully randomised, matched, prospective trial to evaluate the effect of intermittent compression on the post-operative hand. The study revealed a definite improvement in the treated, over the control patients. There was a distinct decrease in oedema with almost immediate return to normal hand function in the group treated by compression. Other benefits accrued from the earlier subsidence of pain in treated hands requiring reduced or no analgesia and from the earlier expression of fluid discharge from the w o u n d thus preventing h a e m a t o m a formation and the consequent ills.
INTRODUCTION It is universally agreed that post-operative oedema of the hand is undesirable. Following surgery, the smooth functioning of the tendons in their sheaths is at stake and is of the utmost importance to the success of the operation. Many methods of managing the hand both during operation and postoperatively have been proposed to prevent oedema and to eliminate the possibility of haematoma formation. These have particularly relied on various modes of splinting and bandaging, on the open palm technique (McCash 1964), and on elevation of the hand (Ward 1976; Ward 1977; Beltran 1976; Noble 1976). The use of a tourniquet during the operation is said to produce increased postoperative oedema as shown in the study undertaken by Ward (1976). Many surgeons have abandoned the use of a tourniquet and now use the elevated hand table which they have found gives an adequately bloodless field while reducing post-operative oedema. However, to many surgeons the tourniquet is still a necessary evil, affording the required operating conditions while followed unavoidably by the increased oedema. All the patients in this study were operated upon using a tourniquet. The trial attempts to show the effects of pneumatic intermittent compression on the hand following fasciectomy. MATERIALS AND METHODS From amongst the thirty-nine patients included in the trial, eleven closely matched pairs were obtained. There were twenty-two hands from twenty-one patients with previously untreated Dupuytren's contracture. The trial was prospective, fully randomised and the patients matched for the nature and degree of involvement, the extent and ease, or otherwise, of operative dissection, type of incision, tourniquet time and other salient features including the age, sex and build of the patient. The patients ranged between forty-six and seventy-six years of age and there were four female and seventeen male patients.
E. Z. Hazarika,Departmentof Surgery,RoyalPostgraduateMedicalSchool,LondonW120HS. The Hand-- Volume 11
No. 3
1979
309
The Effect o f lntermittent Pneumatic Compression on the Hand after Fasciectomy E. Z. Hazarika, M. T. N. Knight and A. Frazer-Moodie
Fig. 1. The apparatus in use with the hand within the Compress garment showing the fingers in extension and flexion.
The operation carried out in every case was limited fasciectomy and all but two patients had transverse incisions. The wounds were closed post-operatively using black silk sutures. The hands were allocated to control~ and treated groups by random selection. One patient's left hand served as control to her treated right hand both having undergone fasciectomy. The hands from both groups underwent similar surgery under similar operating conditions. There was no difference in the mean length of tourniquet time between the two groups. Post-operatively, the control hands were managed in the Classical " b o x i n g - g l o v e " dressing and roller towel elevation. The treated hands were loosely dressed with a small strip of gauze over the wound and introduced into the compression garment (Fig. 1) immediately on completion of the operation. The garment comprises a forearm length glove with a bulbous expansion around the hand. There is an inner lining and outer layer, both transparent polyvinyl chloride and, into the space between the two is fed air under pressure from an electrically driven p u m p (Fig. 2). A ringed " p l u g " has been fitted in a safer3 exit valve should the need arise for rapid deflation. The hand is remarkably free to move within the glove at the height of compression (Figs. la and b) and is easily observable through the transparent material. This factor is especially useful to the physiotherapist during periods of exercise. In both groups, finger movement was encouraged as soon as practicable on return to the ward from the operating theatre. Formal physiotherapy sessions also took place equally in the two groups. The electric p u m p (Fig. 2) which constitutes the driving force of the pneumatic intermittent compression is small (6 inches square and 2V2 inches high), neat and compact making it easily portable. Separate outlet ports make it possible to use the same machine for two garments in the same or in two patients. The cycle is of four minutes duration equally divided between inflation and deflation with a fifteen second change-over period. Inflation is held at a constant pressure once the required m a x i m u m is reached. Pressure to be exerted on the hand within the glove is 310
The H a n d - - Volume 11
No. 3
1979
The Effect o f lnterm#tent Pneumatic Compression on the Hand after Fasciectomy E. Z. Hazarika, M. T. N. Knight and A. Frazer-Moodie
Fig. 2. Flowtron Apparatus.
regulated at the pump by a knob which spans a range between 30 to 80 mmHg. The patient is given a demonstration in the use of the garment pre-operatively. Postoperatively, compression is started at low pressure gradually increasing to the maximum pressure compatible with comfort as the patient gains confidence. A switch on the front o f the machine can turn it on or o f f without manipulating the plug in the wall socket. A red warning light on the facing indicates a leak in the closed circuit of compressed air. The treated patients wore the compression garment almost continuously for between two and six days post-operatively (with one exception) at variable pressure settings between 30 and 80 mmHg. The apparatus was disconnected when necessary, for example during meals and ablutions and sometimes during sleep. Measurement of hand volumes was carried out pre-operatively on admission after the technique of Eccles (1956) wherein the hand, with fingers extended, is immersed in fluid contained in a transparent tank at room temperature. The middle finger is flanked by two vertical extensions from the base. This ensures a constant position of the hand at every measurement. The displaced fluid collects, via a syphon, in a measuring cylinder from which the reading is obtained. All twenty-two hands were measured similarly on the seventh post-operative day. Apart from hand volume measurements, observations on wound discharge and dressing saturation were recorded on each of the first seven post-operative days. Pain and the dispensing of analgesics were similarly recorded. The presence or absence of haematoma in the wound was noted. The Hand-- Volume 11
No. 3
1979
311
The Effect o f lntermittent Pneumatic Compression on the Hand after Fasciectomy E. Z. Hazarika, M. T. N. Knight and A. Frazer-Moodie
TABLE 1 COMPARISON OF MEAN PRE- A N D POST-OPERATIVE H A N D VOLUMES IN TREATED AND CONTROL GROUPS OF PATIENTS
Group
No. in Group
Mean Pre-op. Hand vol. (mls)
Mean Post-op. Hand vol. (mls)
Mean diff. (mls)
Treated
11
447.36
453.18
5.82
SEM " t " df
p
3.68 4.15 20 <<0.001
Control
11
445.63
478.81
33.18
5.47
Following discharge, observations on at least one follow-up appointment were recorded. The physiotherapist's report of progress was noted in every case. RESULTS
The most outstanding feature of the results obtained is the difference in hand volumes post-operatively between the treated and control groups (Table 1). One patient, allocated to the treated group, declined to use the pneumatic intermittent compression after less than one day. However, he has been retained in the treated group of the trial and is the only one of the group in which postoperative hand volume is greater than the pre-operative by 9 mls. As already mentioned, one patient had a bilateral, simultaneous fasciectomy and both hands were included in the trial, the right one being treated by pneumatic intermittent compression, the left serving as control. Her right hand was the more severely involved in Dupuytren's disease than was her control left hand. All other factors being comparable, there is a post-operative difference in hand volumes, the control hand being greater by 19 mls. Another interesting fact that comes to light in this trial is the relationship between the duration of time that the tourniquet was worn and the post-operative oedema. As seen in Table 2, tourniquet time has not affected the post-operative hand volume in either group. Analysis of the physiotherapist's report on each patient shows a reduction in" post-operative pain and an earlier resumption of normal hand movements in the group wearing the compression device over the control patients. Maceration of the skin which may occur in the hand within the confines of the garment poses no problem and quickly disappears once the operated hand is extricated and exposed to air. There was a larger amount of serosanguinous discharge in the immediate postoperative period in the treated group but this reduced rapidly and soon ceased. Discharge in the control patients was small and spread over a longer period. Pain being less in the treated group, fewer analgesics were used. Six patients had small, detectable h a e m a t o m a s on the second post-operative day: five o f these belonged to the control group and one was f r o m the treated group. The period of time over which compression is applied after the first twenty-four hours and the exerting pressure to which the machine is set does not appear to have any significant effect on post-operative oedema. 312
The Hand--Volume 11
No. 3
1979
The Effect o f lntermittent Pneumatic Compression on the Hand after Fasciectomy E. Z. Hazarika, M. T. N. Knight and A. Frazer-Moodie
TABLE 2 SHOWING THE CORRELATION COEFFICIENT BETWEEN THE D U R A T I O N OF TOURNIQUET A N D H A N D VOLUME IN TREATED A N D CONTROL GROUPS
Group
No.
Treated Control
11 11
Correlation Coefficient (r) .3128 .0089
Significance p = ))0.05 p = ))0.05
DISCUSSION
Almost a hundred and fifty years ago Dupuytren (1832) laid down his principles of surgical treatment: he emphasised transverse skin crease incisions; division of the offending fascial bands and the need to leave the wound unsutured allowing it to heal by granulation while splinted in extension. McIndoe's (1958) radical excision of the palmar fascia was replaced by limited palmar fasciectomy due to the inherant post-operative complications. The open palm technique first described by Dupuytren is again being advocated (McCash 1964) on the grounds that free drainage of the wound prevents h a e m a t o m a formation and finger oedema. The absence of pain and of tension sutures allows commencement of finger exercises on the second (Beltran 1976), twelfth or nineteenth (Noble 1976) post-operative day. Complete healing is obtained in an average of three weeks and the final scar quality is excellent. From the results of the study herein presented, all this may be achieved by the use of pneumatic intermittent compression with finger exercises commencing on the first post-operative day, if not on the day of operation. The cumbersome classical "Boxing-glove" dressing is dispensed with and there is no need for elevation further than placing the limb on a pillow at the patient's side. Study of the relationship between Dupuytren's contracture and injury has shown a similar change within the palmar tissues caused by varied injuries such as a local penetrating wound, a burn, a hyperextension injury, Colles' fracture, an ulnar nerve lesion, and a dislocated shoulder. This suggests a "final c o m m o n p a t h w a y " in the pathogenesis of Dupuytren's contracture, possibly related to a phase of local oedema (Plewes 1956; Hueston 1975). It seems a matter of utmost importance, therefore, to do all within our power to prevent or control oedema in the hand especially following surgery for Dupuytren's contracture. The malady is known for its recurrence with the passage of time and though in this trial, the follow-up is too short for any comment on this aspect, it would be very worthwhile to carry out long term observations in order to note a difference, if any, in recurrence rate and pattern in treated and control groups. Also no attempt has been made here towards precise assessment o f hand function and reliance has been placed on the observations of a senior physiotherapist with long experience. This is another aspect worth studying. In this small series no infection occurred but it is reasonable to suppose that the early expression of fluid discharge from the wound would obviate or at least render less likely such a complication. The Hand-- Volume 11
No. 3
1979
313
The Effect o f Intermittent Pneumatic Compression on the Hand after Fasciectomy E. Z. Hazarika, M. T. N. Knight and A. Frazer-Moodie
The pneumatic intermittent compression device has a wide range of uses. By modifying the basic tubular structure of the garment, it is adaptable to various parts of the body, for example, the lower limb, the hip after surgery in that area, the breasts and the face. In this study Dupuytren's contracture has been used as a model for studying the effect of intermittent compression but it seems that the hand, after any surgery, is likely to benefit from it. Its use in other fields such as burns and the control of hypertrophic scars and keloids is perhaps also worth investigating. CONCLUSION
A statistically significant reduction in post-operative hand volume occurred in patients after the use of pneumatic intermittent compression. Post-operative pain was markedly reduced in treated patients compared with matched controls. This, probably coupled with the absence of post-operative oedema and haematoma enabled the patient to have immediate, unhampered hand movement. Although the results of long-term hand function are not available, it may be reasonable to suppose that benefit might accrue from the use Of the intermittent compression device judging from the short-term results. The device is suitable for use after any kind of hand surgery besides Dupuytren's contracture release. ACKNOWLEDGEMENTS
We are indebted to Professor D. G. Melrose and Mr. R. W. Hiles for their help and encouragement: to the Department of Health and Social Security for funding the project and to Ward Sister B. C. Clooney and Mrs. M. Hales, Senior Physiotherapist at Frenchay Hospital, Bristol for their generous help. The entire apparatus is available at approximately s Dallow Road, Luton, Beds., LU1 1XE.
from Flowtron-Aire Limited, Bilton Way,
REFERENCES
ECCLES, M. V. (1956) Hand Volumetrics. British Journal of Physical Medicine, 19: 5-8. BELTRAN, J. E., J1MENO-URBAN, F. and YUNTA, A. (1976) The Open Palm and Digit Technique in the Treatment of Dupuytren's Contracture. The Hand, 8: 73-77. DUPUYTREN, G. (1832) Lecons Orales de Clinique Chirurgicale, Faites a l'H6tel Dieu de Paris, 1: 1, Paris, Bailli6re. HUESTON, J. T. (1975) Dupuytren's Contracture: Selection for Surgery. British Journal of Hospital Medicine, 13: 361-370. LEADING ARTICLE (1976) Dupuytren's Contracture. British Medical Journal, 2: 719. McCASH, C. R. (1964) The Open Palm Technique in Dupuytren's Contracture. British Journal of Plastic Surgery, 17:271-280. MclNDOE, Sir A, and BEARL; R. L. B. (1958) The Surgical Management of Dupuytrens's Contracture. American Journal of Surgery, 95: 197-203. NOBLE, J. and HARRISON, D. H. (1976) Open Palm Technique for Dupuytren's Contracture. The Hand, 8: 272-278. PLEWES, L. W. (1956) Sudeck's Atrophy in the Hand. The Journal of Bone and Joint Surgery, 38B: 195-203. WARD, C. M. (1976) Oedema of the Hand after Fasciectomy with or without Tourniquet. The Hand, 8: 179-185. WARD, C. M. (1977) Vacuum Splintage of the Hand. The Hand, 9: 71-75.
314
The Hand-- Volume 11
No. 3
1979
THE EFFECT OF INTERMITTENT PNEUMATIC COMPRESSION ON THE HAND AFTER FASCIECTOMY E. Z. HAZARIKA, M. T. N. KNIGHT, London and A. FRAZER-MOODIE, Bristol SUMMARY Thirty-nine patients undergoing surgery for Dupuytren's contracture were included in a fully randomised, matched, prospective trial to evaluate the effect of intermittent compression on the post-operative hand. The study revealed a definite improvement in the treated, over the control patients. There was a distinct decrease in oedema with almost immediate return to normal hand function in the group treated by compression. Other benefits accrued from the earlier subsidence of pain in treated hands requiring reduced or no analgesia and from the earlier expression of fluid discharge from the w o u n d thus preventing h a e m a t o m a formation and the consequent ills.
INTRODUCTION It is universally agreed that post-operative oedema of the hand is undesirable. Following surgery, the smooth functioning of the tendons in their sheaths is at stake and is of the utmost importance to the success of the operation. Many methods of managing the hand both during operation and postoperatively have been proposed to prevent oedema and to eliminate the possibility of haematoma formation. These have particularly relied on various modes of splinting and bandaging, on the open palm technique (McCash 1964), and on elevation of the hand (Ward 1976; Ward 1977; Beltran 1976; Noble 1976). The use of a tourniquet during the operation is said to produce increased postoperative oedema as shown in the study undertaken by Ward (1976). Many surgeons have abandoned the use of a tourniquet and now use the elevated hand table which they have found gives an adequately bloodless field while reducing post-operative oedema. However, to many surgeons the tourniquet is still a necessary evil, affording the required operating conditions while followed unavoidably by the increased oedema. All the patients in this study were operated upon using a tourniquet. The trial attempts to show the effects of pneumatic intermittent compression on the hand following fasciectomy. MATERIALS AND METHODS From amongst the thirty-nine patients included in the trial, eleven closely matched pairs were obtained. There were twenty-two hands from twenty-one patients with previously untreated Dupuytren's contracture. The trial was prospective, fully randomised and the patients matched for the nature and degree of involvement, the extent and ease, or otherwise, of operative dissection, type of incision, tourniquet time and other salient features including the age, sex and build of the patient. The patients ranged between forty-six and seventy-six years of age and there were four female and seventeen male patients.
E. Z. Hazarika,Departmentof Surgery,RoyalPostgraduateMedicalSchool,LondonW120HS. The Hand-- Volume 11
No. 3
1979
309
The Effect o f lntermittent Pneumatic Compression on the Hand after Fasciectomy E. Z. Hazarika, M. T. N. Knight and A. Frazer-Moodie
Fig. 1. The apparatus in use with the hand within the Compress garment showing the fingers in extension and flexion.
The operation carried out in every case was limited fasciectomy and all but two patients had transverse incisions. The wounds were closed post-operatively using black silk sutures. The hands were allocated to control~ and treated groups by random selection. One patient's left hand served as control to her treated right hand both having undergone fasciectomy. The hands from both groups underwent similar surgery under similar operating conditions. There was no difference in the mean length of tourniquet time between the two groups. Post-operatively, the control hands were managed in the Classical " b o x i n g - g l o v e " dressing and roller towel elevation. The treated hands were loosely dressed with a small strip of gauze over the wound and introduced into the compression garment (Fig. 1) immediately on completion of the operation. The garment comprises a forearm length glove with a bulbous expansion around the hand. There is an inner lining and outer layer, both transparent polyvinyl chloride and, into the space between the two is fed air under pressure from an electrically driven p u m p (Fig. 2). A ringed " p l u g " has been fitted in a safer3 exit valve should the need arise for rapid deflation. The hand is remarkably free to move within the glove at the height of compression (Figs. la and b) and is easily observable through the transparent material. This factor is especially useful to the physiotherapist during periods of exercise. In both groups, finger movement was encouraged as soon as practicable on return to the ward from the operating theatre. Formal physiotherapy sessions also took place equally in the two groups. The electric p u m p (Fig. 2) which constitutes the driving force of the pneumatic intermittent compression is small (6 inches square and 2V2 inches high), neat and compact making it easily portable. Separate outlet ports make it possible to use the same machine for two garments in the same or in two patients. The cycle is of four minutes duration equally divided between inflation and deflation with a fifteen second change-over period. Inflation is held at a constant pressure once the required m a x i m u m is reached. Pressure to be exerted on the hand within the glove is 310
The H a n d - - Volume 11
No. 3
1979
The Effect o f lnterm#tent Pneumatic Compression on the Hand after Fasciectomy E. Z. Hazarika, M. T. N. Knight and A. Frazer-Moodie
Fig. 2. Flowtron Apparatus.
regulated at the pump by a knob which spans a range between 30 to 80 mmHg. The patient is given a demonstration in the use of the garment pre-operatively. Postoperatively, compression is started at low pressure gradually increasing to the maximum pressure compatible with comfort as the patient gains confidence. A switch on the front o f the machine can turn it on or o f f without manipulating the plug in the wall socket. A red warning light on the facing indicates a leak in the closed circuit of compressed air. The treated patients wore the compression garment almost continuously for between two and six days post-operatively (with one exception) at variable pressure settings between 30 and 80 mmHg. The apparatus was disconnected when necessary, for example during meals and ablutions and sometimes during sleep. Measurement of hand volumes was carried out pre-operatively on admission after the technique of Eccles (1956) wherein the hand, with fingers extended, is immersed in fluid contained in a transparent tank at room temperature. The middle finger is flanked by two vertical extensions from the base. This ensures a constant position of the hand at every measurement. The displaced fluid collects, via a syphon, in a measuring cylinder from which the reading is obtained. All twenty-two hands were measured similarly on the seventh post-operative day. Apart from hand volume measurements, observations on wound discharge and dressing saturation were recorded on each of the first seven post-operative days. Pain and the dispensing of analgesics were similarly recorded. The presence or absence of haematoma in the wound was noted. The Hand-- Volume 11
No. 3
1979
311
The Effect o f lntermittent Pneumatic Compression on the Hand after Fasciectomy E. Z. Hazarika, M. T. N. Knight and A. Frazer-Moodie
TABLE 1 COMPARISON OF MEAN PRE- A N D POST-OPERATIVE H A N D VOLUMES IN TREATED AND CONTROL GROUPS OF PATIENTS
Group
No. in Group
Mean Pre-op. Hand vol. (mls)
Mean Post-op. Hand vol. (mls)
Mean diff. (mls)
Treated
11
447.36
453.18
5.82
SEM " t " df
p
3.68 4.15 20 <<0.001
Control
11
445.63
478.81
33.18
5.47
Following discharge, observations on at least one follow-up appointment were recorded. The physiotherapist's report of progress was noted in every case. RESULTS
The most outstanding feature of the results obtained is the difference in hand volumes post-operatively between the treated and control groups (Table 1). One patient, allocated to the treated group, declined to use the pneumatic intermittent compression after less than one day. However, he has been retained in the treated group of the trial and is the only one of the group in which postoperative hand volume is greater than the pre-operative by 9 mls. As already mentioned, one patient had a bilateral, simultaneous fasciectomy and both hands were included in the trial, the right one being treated by pneumatic intermittent compression, the left serving as control. Her right hand was the more severely involved in Dupuytren's disease than was her control left hand. All other factors being comparable, there is a post-operative difference in hand volumes, the control hand being greater by 19 mls. Another interesting fact that comes to light in this trial is the relationship between the duration of time that the tourniquet was worn and the post-operative oedema. As seen in Table 2, tourniquet time has not affected the post-operative hand volume in either group. Analysis of the physiotherapist's report on each patient shows a reduction in" post-operative pain and an earlier resumption of normal hand movements in the group wearing the compression device over the control patients. Maceration of the skin which may occur in the hand within the confines of the garment poses no problem and quickly disappears once the operated hand is extricated and exposed to air. There was a larger amount of serosanguinous discharge in the immediate postoperative period in the treated group but this reduced rapidly and soon ceased. Discharge in the control patients was small and spread over a longer period. Pain being less in the treated group, fewer analgesics were used. Six patients had small, detectable h a e m a t o m a s on the second post-operative day: five o f these belonged to the control group and one was f r o m the treated group. The period of time over which compression is applied after the first twenty-four hours and the exerting pressure to which the machine is set does not appear to have any significant effect on post-operative oedema. 312
The Hand--Volume 11
No. 3
1979
The Effect o f lntermittent Pneumatic Compression on the Hand after Fasciectomy E. Z. Hazarika, M. T. N. Knight and A. Frazer-Moodie
TABLE 2 SHOWING THE CORRELATION COEFFICIENT BETWEEN THE D U R A T I O N OF TOURNIQUET A N D H A N D VOLUME IN TREATED A N D CONTROL GROUPS
Group
No.
Treated Control
11 11
Correlation Coefficient (r) .3128 .0089
Significance p = ))0.05 p = ))0.05
DISCUSSION
Almost a hundred and fifty years ago Dupuytren (1832) laid down his principles of surgical treatment: he emphasised transverse skin crease incisions; division of the offending fascial bands and the need to leave the wound unsutured allowing it to heal by granulation while splinted in extension. McIndoe's (1958) radical excision of the palmar fascia was replaced by limited palmar fasciectomy due to the inherant post-operative complications. The open palm technique first described by Dupuytren is again being advocated (McCash 1964) on the grounds that free drainage of the wound prevents h a e m a t o m a formation and finger oedema. The absence of pain and of tension sutures allows commencement of finger exercises on the second (Beltran 1976), twelfth or nineteenth (Noble 1976) post-operative day. Complete healing is obtained in an average of three weeks and the final scar quality is excellent. From the results of the study herein presented, all this may be achieved by the use of pneumatic intermittent compression with finger exercises commencing on the first post-operative day, if not on the day of operation. The cumbersome classical "Boxing-glove" dressing is dispensed with and there is no need for elevation further than placing the limb on a pillow at the patient's side. Study of the relationship between Dupuytren's contracture and injury has shown a similar change within the palmar tissues caused by varied injuries such as a local penetrating wound, a burn, a hyperextension injury, Colles' fracture, an ulnar nerve lesion, and a dislocated shoulder. This suggests a "final c o m m o n p a t h w a y " in the pathogenesis of Dupuytren's contracture, possibly related to a phase of local oedema (Plewes 1956; Hueston 1975). It seems a matter of utmost importance, therefore, to do all within our power to prevent or control oedema in the hand especially following surgery for Dupuytren's contracture. The malady is known for its recurrence with the passage of time and though in this trial, the follow-up is too short for any comment on this aspect, it would be very worthwhile to carry out long term observations in order to note a difference, if any, in recurrence rate and pattern in treated and control groups. Also no attempt has been made here towards precise assessment o f hand function and reliance has been placed on the observations of a senior physiotherapist with long experience. This is another aspect worth studying. In this small series no infection occurred but it is reasonable to suppose that the early expression of fluid discharge from the wound would obviate or at least render less likely such a complication. The Hand-- Volume 11
No. 3
1979
313
The Effect o f Intermittent Pneumatic Compression on the Hand after Fasciectomy E. Z. Hazarika, M. T. N. Knight and A. Frazer-Moodie
The pneumatic intermittent compression device has a wide range of uses. By modifying the basic tubular structure of the garment, it is adaptable to various parts of the body, for example, the lower limb, the hip after surgery in that area, the breasts and the face. In this study Dupuytren's contracture has been used as a model for studying the effect of intermittent compression but it seems that the hand, after any surgery, is likely to benefit from it. Its use in other fields such as burns and the control of hypertrophic scars and keloids is perhaps also worth investigating. CONCLUSION
A statistically significant reduction in post-operative hand volume occurred in patients after the use of pneumatic intermittent compression. Post-operative pain was markedly reduced in treated patients compared with matched controls. This, probably coupled with the absence of post-operative oedema and haematoma enabled the patient to have immediate, unhampered hand movement. Although the results of long-term hand function are not available, it may be reasonable to suppose that benefit might accrue from the use Of the intermittent compression device judging from the short-term results. The device is suitable for use after any kind of hand surgery besides Dupuytren's contracture release. ACKNOWLEDGEMENTS
We are indebted to Professor D. G. Melrose and Mr. R. W. Hiles for their help and encouragement: to the Department of Health and Social Security for funding the project and to Ward Sister B. C. Clooney and Mrs. M. Hales, Senior Physiotherapist at Frenchay Hospital, Bristol for their generous help. The entire apparatus is available at approximately s Dallow Road, Luton, Beds., LU1 1XE.
from Flowtron-Aire Limited, Bilton Way,
REFERENCES
ECCLES, M. V. (1956) Hand Volumetrics. British Journal of Physical Medicine, 19: 5-8. BELTRAN, J. E., J1MENO-URBAN, F. and YUNTA, A. (1976) The Open Palm and Digit Technique in the Treatment of Dupuytren's Contracture. The Hand, 8: 73-77. DUPUYTREN, G. (1832) Lecons Orales de Clinique Chirurgicale, Faites a l'H6tel Dieu de Paris, 1: 1, Paris, Bailli6re. HUESTON, J. T. (1975) Dupuytren's Contracture: Selection for Surgery. British Journal of Hospital Medicine, 13: 361-370. LEADING ARTICLE (1976) Dupuytren's Contracture. British Medical Journal, 2: 719. McCASH, C. R. (1964) The Open Palm Technique in Dupuytren's Contracture. British Journal of Plastic Surgery, 17:271-280. MclNDOE, Sir A, and BEARL; R. L. B. (1958) The Surgical Management of Dupuytrens's Contracture. American Journal of Surgery, 95: 197-203. NOBLE, J. and HARRISON, D. H. (1976) Open Palm Technique for Dupuytren's Contracture. The Hand, 8: 272-278. PLEWES, L. W. (1956) Sudeck's Atrophy in the Hand. The Journal of Bone and Joint Surgery, 38B: 195-203. WARD, C. M. (1976) Oedema of the Hand after Fasciectomy with or without Tourniquet. The Hand, 8: 179-185. WARD, C. M. (1977) Vacuum Splintage of the Hand. The Hand, 9: 71-75.
314
The Hand-- Volume 11
No. 3
1979