Dressing

External Appearance

The type and amount of postoperative dressings used vary from one practice to another. However, all would agree that the overall appearance of the extremity should be clean and neat. The dressing itself should be dry and stain-free. Blood and plaster stains should be meticulously cleaned off the patient's nails, fingers and elbow creases or arm before the patient is transferred out of the operating theater. The dressing itself should appear neat with smooth, well-padded edges.

Position of Immobilization

Certain surgical procedures, such as flexor or extensor tendon repairs, dictate the position of joint immobilization after operation. In the absence of specific requirements, the ideal position for joint immobilization is called the position of safe immobilization. The wrist is positioned in 20–45 degrees of extension, the metacarpophalangeal (MCP) joints are flexed to 60–80 degrees, and the interphalangeal joints are extended 0–10 degrees.

Our hands are the end organs in a multilink chain that makes up our upper limb. The function of our fingers, being the most distal segments in the chain, is affected by position of proximal joints. Maximum grip strength is observed when wrists are in 35 degrees of extension and 7 degrees of ulnar deviation. Finger joints are easier to rehabilitate if immobilized with collateral ligaments under tension. Keeping the MCP joints maximally flexed uses the dorsal-volar diameter of the metacarpal head to maintain the collateral ligaments, which originate dorsal to the axis of rotation, in their full length. The proximal interphalangeal (PIP) joints are safely immobilized in extension. However, this is not because of the resting length of the main collateral ligaments. The PIP joint main collateral ligaments are at a constant tension throughout the range of motion. It is the accessory collateral ligaments, the dorsal fibers of the flexor sheath, and check rein ligaments of the PIP joints that shorten in flexion. One should also remember to keep the thumb widely abducted to prevent first webspace contracture.

Conforming Dressing

The many dressing techniques all have the common aim of forming a clean barrier between the wound and the environment, providing pain relief and minimizing postoperative swelling. This is achieved by a conforming (rather than compressive) dressing. A conforming dressing applies a uniform degree of pressure on the entire hand. It is snug enough to control capillary oozing and obliterate tissue cavities, but not constrictive enough to prevent venous return and cause swelling distally. A compressive bandage is not advised.

Immediately after surgery a plaster or resin slab is incorporated into the dressing to help maintain the position of safe immobilization. This provides support and pain relief to the injured hand. The slab and bandage form a single inseparable unit. It is placed on the cotton bandage with adequate padding and carefully molded, taking care to avoid forming pressure points that can further injure the patient. There should be enough padding to prevent the plaster or resin from sticking to the patient's skin, but not so much that it could hamper proper molding of the slab. Immobilization for pain relief should last only until the first wound inspection, unless it is required for other purposes because of the specific procedure performed. The use of a conforming dressing applies to succeeding dressing changes. If further immobilization is required, a new customized molded orthosis should be fabricated over a light dressing after the first wound inspection. One cannot expect the new dressing to faithfully reproduce the curves and contours of the first; hence the first slab should not be reused. The period of immobilization should not be prolonged more than necessary; any prolonged immobilization has serious consequences.