POSTGRAD. MED. J. (I964), 40, 27I

THE IMPORTANCE AND PREVENTION OFOEDEMA OF THE HAND

T. L. BARCLAY, F.R.C.S.(ED.)Plastic Surgeon, Pinderfields Hospital, Wakefield

CEDEMA of the hand may follow severe trauma, oroperations, and will cause delay in return offunction, if it is allowed to persist. Other condi-tions, such as Sudeck's atrophy and arthritis, mayalso result in stiffness, but delayed resolution ofcedema is the commonest.

It follows that hand function will return morequickly and less time will be lost from work, ifcedema consequent upon injury or operation canbe minimized. A manual worker needs a powerfulgrip if he is to do his job with efficiency andsafety, and it is useless to expect a labourer toreturn to work until he has recovered a satisfactoryrange of pain-free movement.

It is therefore profitable to consider the commoncauses of post-operative (edema, and hence themeasures which will be the most effective in itsprevention.CausesThe common causes of cedema are:

I. Infection.Any local infection is accompanied by cedema.2. Trauma.Some degree of oedema will result from any

injury, surgical or accidental, however small. Itseems probable that the actual amount of oedemawill depend on three interrelated factors-thedegree of trauma, the physique of the patient, andthe length of time during which the hand isallowed to be dependent in the absence of function.A consideration of these factors affecting a

series of patients undergoing surgery for Dupuy-tren's contracture was reported by Barclay (1959).It appeared that there was a correlation between thepatient's physique and the amount of swellingwhich could be detected by plethysmographythree weeks later (i.e. when the dressings were

removed); the fatter (more endomorphic) thepatient, the more aedema would there be. Again,more swelling could be detected in patients whohad undergone a radical fasciectomy than in thosein whom the operation had been strictly localizedto the affected finger and the adjacent part of thepalm. No correlation was found with such otherfactors as the length of time the hand was ischaemicas a result of the tourniquet (up to 70 minutes) orto the type of dressing used. This work is so far

unconfirmed, but most surgeons who have todeal with hands would agree that fat men with fathands have more trouble in regaining full functionthan do thin men with thin hands.

3. Disuse in dependencyTissue fluid collecting under the influence of

gravity will not disperse without active movementof the part.Measures to Reduce (EdemaThe measures which can be taken to minimize

oedema are therefore:

I. Avoidance of infectionThe best safeguard against infection following

hand injury is the assurance of a good blood supply.Constricting dressings and bandages, haematomaformation giving rise to tension, and suturing awound with skin loss by dragging the edgestogether must all be avoided. The administrationof antibiotics may be indicated if the wound weresustained under conditions which made sepsis aparticular hazard, or when treatment has beendelayed (see 5 below), but attention to basicsurgical principles is usually far more important.

2. Avoidance of extra traumaThe greatest gentleness in handling tissues,

reducing and immobilizing fractures and inbandaging should be used.

3. Avoidance of unnecessary dissectionOperations for hand conditions such as Dupuy-

tren's contracture, tendon grafts and tendontransfers should be designed to avoid unnecessarydissection of tissue planes; the relevant structuresonly should be properly and gently exposed.

4. Avoidance of hamatomaHaematoma formation, apart from its own risks,

induces surrounding (edema; haemostasis is there-fore most important. At the completion of theprocedure the dressing must be designed to exertmild, even pressure over the whole area which hasbeen operated on (unless continuous suctiondrainage is being used). It is of cardinal importanceto avoid tight crepe bandages, firstly becauselateral compression of the hand allows a pool ofblood to collect in the hollow of the palm, andsecondly because it is not unknown for pressure

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272 FOSTGRADUATE MEDICAL JOURNAL May I964

FIG. i.--Adx anced localized Du?uytren's contractureb-fore o- ra.on.

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FIG. 2.-Operation completed by excision of diseasedtissue through longitudinal incision and closurewith Z-plasties.

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FIG. 3.-Hand elevated for return journey to ward.

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FIG. 4.-Elevation of hand continued for 48 hours.

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May I964 BARCLAY: The Importance and Prevention of (Edema of the Hand2

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FIG. 5.-Dressings remo-ed on fifth day and replacedby protective dressing allowing some movement.Note minimal swelling. Patient allowed home. FIG. 6.

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FIG. 7. FIG. 8.FIGS. 6, 7, 8.-Sixteenth day, following removal of sutures. Almost full extension and flexion has been regained.N.B.-This is a favourable case: a thin patient, a localized disease, and proper facilities for surgery and after-care.

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274 POSTGRADUATE MEDICAL JOURNAL May I964

necrosis of the thenar or hypothenar muscles tooccur if constriction is extreme; ischsemiccontractures of this kind are extremely difficult totreat, and must never be allowed to occur. Ajudicious combination of plaster slabs and gauzedressings is usually best.Mention of anti-inflammatory enzymes can be

made here. The best known of these, in thiscountry, is 'Chymar' (lyophilized chymotrypsin).Systemic administration of this substance isclaimed by the manufacturers to reduce cedemaformation following trauma. A favourablesubjective assessment, based on clinical impres-sion, has been reported by Moore (1959, I963),but several other authors (Calnan and Barr, 1960;Gall and Talbot, I962; Barclay, I960), using moreobjective methods such as the double-blind trial,or actual measurement of the amount of cedema,have failed to find a significant reduction ofcedema by the use of 'Chymar' in the recommendeddosage. The status of this treatment should beregarded at the present time as unestablished.The tendency to post-operative oozing will be

greatly diminished by elevation of the part in theimmediate post-operative period, and this is themost valuable single step in after-care, as discussedbelow.

5. Avoidance of dependencyThe hand should not be allowed to be dependent

until a reasonable degree of function has beenrestored. It is most important to elevate the handfrom the moment of completion of the operation,and elevation must be continued for 36 to 48hours, and sometimes much longer in severeinjuries and in burns (Figs. i to 8).

After the period of continuous elevation, itshould be impressed on the patient that de-pendency will do damage although actual highelevation may no longer be necessary.

It should be mentioned here that in somesevere crush injuries, and in some deep burns ofthe hands, it may be profitable to delay surgicalrepair for three to four days in order to dispersesome of the cedema by high elevation; this courseshould especially be considered if an abdominalflap repair is necessary, since when the hand isattached to the abdomen it is of necessity de-pendent. For this reason, as well as for others, apectoral flap is to be preferred to an abdominal

flap if the size and situation of the wound on thehand permit, since partial elevation will thus beachieved. Should the surgeon decide to delay therepair by reason of gross cedema, a course ofantibiotics should be started from the outset. Itis most unwise to withhold the repair for more thanfive days as infection will certainly supervenedespite precautions, and may convert a severeinjury into an irreparable one.

6. Avoidance offaulty immobilizationIf immobilization is necessary, the finger joints

should be held in such a position that even if somestiffness does develop the collateral ligaments arenot allowed to shorten. The best position for themetacarpo-phalangeal joints is in about 80° offlexion, as the attachments of the collateralligaments to the distal part of the metacarpal andthe proximal part of the proximal phalanx arefurthest apart at this angle. The interphalangealjoints should be in slight flexion only. In burnsof the hands it is particularly important to achievethis position both to protect the ligaments fromshortening and to decrease the danger of exposureof the extensor tendon which tends to occur overthe dorsum of the proximal interphalangeal jointif flexion is allowed at this point.

7. Avoidance offaulty physiotherapyMany patients, especially those with slim supple

hands will, if properly cared for, have littlestiffness following even quite extensive injuries,and can, if intelligent, be relied on to do their ownphysiotherapy.

Others require help in regaining function.While this is not the place for a discussion ofrehabilitation in general, it can nevertheless bestressed that in the main it is active movementsthat are to be encouraged and passive exercisesgiven by the physiotherapist must be very gentleif further damage is to be avoided; roughmanipulation may break down recent adhesions,but will by doing so give rise to more cedema.

Summary(Edema of the hand is an inevitable result of

injury or operation, but its degree and its deleter-ious consequences can be greatly minimized byproper attention to surgical principles at the timeof the operation, and proper after-care. The mostimportant single step is high elevation of the part.

REFERENCESBARCLAY, T. L. (1959): (Edema following Operation for Dupuytren's Contracture, Plast.- reconstr. Surg., 23, 348.-- (1960): Effect of 'Chymar' on Post-operative Swelling of the Hand, Brit. J. plast. Surg., x3, 253.MooRE, F. T. (1959): A Report on Seventy-Five Patients Treated with Chymar (Lyophilized Chymotrypsin), Ibid.,

II, 335-- (1963): Some Further Views on Alpha-Chymotrypsin in Facial Surgery, Ibid., x6, 387.GALL, W. J. and TALBOT, C. H. (1962): Chymotrypsin in the Reduction of Post-operative Bruising and (Edema,

Ibid., 15, 20.CALNAN, J., and BARR, A. (I960): The Prevention of Post-operative CEdema-Controlled Clinical Trial of Lyophilized

Chymotrypsin in Plastic Surgery, Brit. med. J3., ii, 261.

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