postoperative management of flexor tendon injuries

POSTOPERATIVE

MANAGEMENT OF FLEXOR

TENDON INJURIES

Ahmad A. Fannoon, Hand Therapist

What are we learning?

Fundamental tendon

management.

Flexor tendon anatomy,

biomechanics, mechanism of

nutrition & healing.

Three approaches to tendon

management, with protocols.

2

The Process of HTs treating FTIs

Surgeon refers patient with surgery details, HT:

Substantially prepared (anatomy, physiology, biomechanics, normal

& pathological healing of tendon & other tissues)

Evaluates tendon (palpation, observation, & measurement)

Questions patient & surgeon for more details.

With surgeon consultation, selects the appropriate therapeutic approach & modifies.

3

Part 1

FUNDAMENTAL CONCEPTS 4

Goal: a strong repair that glides freely

For a tendon function; free gliding without

hindrance from surrounding tissues is required.

A certain amplitude of excursion with adequate

power are required for each tendon to glide & flex

a digit.

5


In the hand, so many structures lie in a constricted

space scar adhesions between adjacent

structures can occur easily after injury or surgery.

Tendon-adjacent-tissue & intertendinous adhesions

can seriously limit excursion & decrease function.

6


Normally, tendon encounters a certain amount of resistance when it glides.

First weeks after repair, the resistance is increased considerably by:

Normal posttraumatic/postoperative edema.

Lacerated tissues.

Extra bulk of sutures.

Newly forming scar.

7


Since the newly repaired tendon has a low strength

extra care must be taken to allow for this

increased resistance during all exercises.

8


For a repaired tendon to function adequately

during ADLs & others; it requires an unobstructed

gliding & enough strength.

Repaired tendon if stressed excessively during

early phases of healing may rupture or the tendon

ends may pull apart (creating a gap).

9


The gap maybe filled with scar leading to:

Weaker repair.

Increased adhesion formation.

Longer tendon.

An elongated tendon requires greater excursion to

function normally.

10


However, the dysfunctional effect of gaps has been

found less in repairs that have been mobilized

early.

11


Therefore, our goal for the tendon is:

“To heal without rupture or gap formation, with

sufficient strength & excursion for daily activities”

12

Evaluating tendon function

To plan effective therapy, tendon function should be

evaluated in several ways:

AROM

PROM

Palpation along the course of the tendon (detecting

impediments).

13


If passive flexion greatly exceeds active flexion, the

tendon is not functioning adequately:

The tendon may have ruptured or elongated, or it

may be adherent.

14


Adherent tendons exhibits some excursion, however

limited, the entire excursion may be taken up by

flexion of a single joint.

*AF: active flexion.

FDP PIP MCP DIP Composite

flex.

Composite

ext.

Adherent Held passively in extension *AF N/A N/A

Adherent Left free Limited Limited Limited

15


The PIP can be

extended completely

when the wrist & MCP

are flexed.

16


The PIP still can be

extended completely

when the wrist is

extended, but PIP

begin to flex,

reflecting some

tightness of FDP.

17


When MCP & wrist

extended, the PIP can’t

be extended,

indicating adhesions in

the palm, or at the

level of MCP or

proximal phalanx.

18

ROM restrictions problem solving

Problem solving of finger motion restrictions seems

necessary to be explained at this point.

ROM restrictions in the hand can be grouped into

four major categories.

19


Muscle-tendon unit tightness of the opposing

muscles.

If PIP flexion is limited this could be due to tightness

of the long extensors.

20


To check for this type of tightness:

Place the suspected tight muscle-tendon unit on slack at

a proximal joint and repeat the measurement.

If the restriction was due to tightness of the opposing

muscle group, ROM will increase when the muscle

tendon unit is on slack at a proximal joint.

21


Extend wrist and MCP and repeat PIP flexion.

22


Extreme weakness of the muscles that should

produce the movement.

If PIP flexion is minimal, perform a MMT on the

finger flexors (manually resist PIP flexion).

23


Also it is a good idea to palpate the tendon of the

muscle you are testing or the muscle belly to

determine if tension is being produced, specially if

no movement is noted.

24


Tendon adhesions should cause some ROM

restrictions in two directions.

If the FDS and FDP tendons are adherent before

they cross the PIP joint they will not be effective

flexors of the PIP joint and flexion will be limited.

25


They will also be unable to lengthen properly so

extension will also be limited.

26


Joint related restrictions:

If none of the other problems are noted the

restriction is likely due to a tight joint capsule or

tight ligaments or boney block to movement.

27


For our PIP joint,

if the FDS and FDP were not tight or adherent and

the fingers’ flexors were of normal strength and

there was no adhesion,

then the lack of extension is likely due to a joint problem.

28

Three Approaches to Tendon Management

Immobilization: these protocols call for complete

immobilization of the tendon repair, generally 3 to

4 weeks, before beginning active & passive

mobilization.

29


Early passive mobilization: these protocols involve

passively mobilizing the repair early (within first

week) either manually or by dynamic flexion

traction.

30


Early active mobilization: these protocols mobilize

the repair (within few days of repair) through active

contraction of the involved flexor, with caution &

within carefully prescribed limits.

31

Part 2

ANATOMY 32

Zones

The flexor tendons commonly are described

according to the zones defined by the International

Federation of Societies for Surgery of the Hand

(IFSSH) committee on tendon injuries.

33

Flexor tendon zones

Zones apply

to the two

finger flexors

(FDS & FDP)

and the single

extrinsic

thumb flexor

(FPL).

34

Zone 5

Musculotendinous

junction in the distal

third of the forearm.

35

Zone 4

Carpal tunnel.

Synovial sheaths.

Lubrication.

Nutrition.

Protection.

Carpal ligament.

36

Zone 3 & T3

Ulnar & radial bursae.

Lumbricals

37

Zone 2 & T2

FDS insertion.

Separate digital

synovial sheaths

38

Zone 2 & T2

Digital synovial

sheaths.

Pulleys: annular &

cruciate.

Vinculi.

Camper’s Chiasma

39

Zone 2 & T2 / APs

A1 – lies at head of metacarpal.

A2 – lies at midshaft of proximal phalanx.

A3 – lies at distal part of proximal phalanx.

A4 – lies centrally on middle phalanx.

A5 – lies at base of distal phalanx.

40

Zone 2 & T2 / CPs

C1 – located between A2 & A3 pulleys.

C2 – located between A3 & A4 pulley.

C3 – located between A4 & A5 pulley.

41

Zone 2 & T2

Zone 2 Pulleys:

A1-A3.

C1-C2.

Zone T2 Pulleys:

A1.

Oblique.

42

Zone 2 & T2

The pulleys function as restraints or guides to the tendons.

Without the pulleys, the tendon would pull away from bone with each muscle contraction.

43

Zone 2 & T2

Research data

revealed A2 & A4

pulleys are most

important for

achieving normal

tendon function.

44

Zone 2 & T2

Vinculia: folds of

mesotenon carrying

blood supply to

flexor tendon (later).

45

Zone 2 & T2

Zone 2 vincula:

Vinculum longus &

vinculum brevis to

FDS.

Vinculum longus to

FDP.

46

Zone 2 & T2

Chiasma of camper:

space created by the

FDS allowing FDP to

go through.

47

Zone 1 & T1

FDP insertion.

FDS insertion.

48

Zone 1 & T1

49

Zone 1 includes: A4,

C3, & A5.

Synovial sheaths end

in this zone.

Zones T1 includes FPL

insertion & A2.

Part 3

NUTRITION 50

Nutrition

Blood supply to the flexor tendon:

Proximal vessels entering at the

musculotendinous junction.

Distal vessels entering at the bony

insertion of the tendon.

Vessels in the surrounding tissues.

51

Less important

sources

Most important

source

Nutrition

In the forearm & the palm; abundance of vessels

enter the tendon at random form the surrounding

tissues.

Within the pulley system; small vessels (originating

from surrounding tissue) enter the tendons through

the vincula.

52

Nutrition

The small vessels entering the vincula originate from

4 transverse communicating arteries, which branch

from the two digital arteries.

The vincular vessels communicate with the

intratendinous vessels that lie longitudinally within

the tendon & originate in the palm.

53

Nutrition

These longitudinally oriented vessels are located in

the dorsal half of each tendon, leaving the volar side

of the tendon relatively avascular.

Areas of relative avascularity between the segmental

vincular blood supply have been described as

“watershed” or critical tendon zones.

54

Nutrition

In zone 2 (relative avascularity), tendon nutrition

comes from two sources:

The blood supply.

Synovial diffusion.

55

Nutrition

Research studies found that:

“Under certain conditions synovial fluid can provide the

essential nutrition for tendon & the elements necessary

for healing after tendon injury, even if detached from

blood supply”

Pumping Mechanism?

56

Nutrition

Pumping Mechanism:

Synovial fluid is “forced” into the tendon under

influence of high pressure against the pulleys during

active flexion of the fingers (synovial diffusion in

articular cartilage!).

57

Nutrition

A delicate balance between the 2 nutritional

pathways is found within the tendon.

When injury occurs in the tendon watershed areas,

the balance is disturbed & excessive adhesion

formation is seen, why adhesions?.

58

Nutrition

Why adhesions?

Bringing additional blood supply to the tendon

necessary for the healing process.

Limits tendon gliding.

59

Part 4

TENDON HEALING 60

Tendon histology

Tendon consists of connective tissue, & it’s function is

to link muscle to bone.

It is made up of collagen bundles, with only small

amount of proteoglycans & elastic fibers.

The collagen bundles are longitudinally oriented

parallel bundles surrounded by epitenon.

61

Peacock one-wound concept

In the first few days after a repair, the wound is

filled with a cicatrix, consisting of ground substance

& many types of cells.

Scar formed in the first 3 weeks will glue all

involved tissue layers together (skin, subcutaneous

tissue, & underlying tissue).

62

Factors influencing wound healing

In general, age, overall health and nutritional status will impact the wound healing process.

Wound healing will be delayed if the patient has poor circulation, diabetes, anemia, COPD etc.

Tobacco use will also delay wound healing by decreasing available hemoglobin.

Caffeine and stress cause vasoconstriction.

Steroid medication suppresses the normal immune system.

63

The wound healers 64

Platelets: pile up after initial blood vessel damage and help stop bleeding.

Fibrin: protein strand added to platelets to help stop bleeding.

Histamine: active once bleeding is controlled to produce vasodilatation of

non injured capillaries.

Macrophage: “Pac Man” cell that helps clean up non viable tissue.

Fibroblast: cell that produces collagen.

Collagen: triple helix protein strand that imparts strength to the wound.

Phases of tendon healing

Phase 1 “Exudative or inflammatory phase”

0 – 5 days.

Tensile strengths of the immobilized tendon repair

diminishes in the first 3-5 days.

Influx of leukocytes & macrophages.

Macrophages stimulates growth & migration of

fibroblasts.

65


Phase 2 “Fibroplasia phase”

5 – 21 days.

Fibroblasts migrates to the wound & produce

tropocollagen (triple-helix molecule with little tensile

strength).

Tropocollagen are randomly oriented creating a

network.

66


Phase 3 “Remodeling phase”

3 weeks – 6 months or 1 year.

Tropocollagen weak hydrogen bonds are replaced

by stronger cross-links between the 3 strands of the

helix (collagen matures).

67

Phases of tendon healing 68

Continue Phase 3…

The randomly oriented collagen fibers, under the

influence of stress, is slowly replaced by newly

formed collagen oriented along the long axis of the

tendon,

Thus providing tensile strength.

Nutrition needed for wound healing 69

Calories to provide energy for wound healing.

Carbohydrates for fibroblastic movement and leukocyte

activity.

Protein for fibroblast synthesis of collagen

Vitamin A is needed in the inflammatory stage.

Vitamin C for collagen synthesis.

Zinc for collagen and protein synthesis.

H2O to maintain hydration.

Adhesions in the 3rd stage 70

The randomly oriented fibers of the scar between

tendon & surrounding tissues must be loose & filmy

to regain gliding function.

When adhesion-bound tendon gains motion, it is

usually not because adhesions are broken, but

rather because they are lengthened or changed

under the influence of stress.

Differential wound healing 71

Week healing is needed between tendon &

surrounding tissue recover free gliding.

Strong healing is needed between the tendon ends

to transmit muscle power.

Extrinsic versus intrinsic healing 72

3 possible mechanisms of tendon healing are

described in the literature:

1. Extrinsic healing.

2. Intrinsic healing.

3. Combination of both.

Extrinsic healing 73

Tendon has no active role in the healing process,

whereas adhesions formation is vital to tendon

healing.

Adhesions provide blood supply & cells (fibroblasts)

needed for tendon healing + limit tendon gliding.

Intrinsic healing 74

Relies on the synovial fluid for nutrition & does not

result in restricted motion of the tendon.

The cells needed for tendon healing are supplied

by the epitenon & endotenon itself.

Combination of intrinsic & extrinsic 75

In actual practice, adhesions are seen to varying

degrees & the healing response is probably a

balance between intrinsic & extrinsic.

Effect of motion on tendon healing 76

Protected early mobilization creates better

repaired tendon function:

Better tensile strength.

Better excursion.

Part 5

FACTORS AFFECTING HEALING & REHABILITATION 77

Patient related factors 78

Age:

Number of vincula

decreases as the patient

grows older.

Cell aging could lead to

decreased healing

capacity of tenocytes.


General health & healing potential:

Better health lead better healing.

Lifestyles & dietary habits, e.g.:

o Cigarettes & Caffeine

vasoconstriction.

o Healthy food & sport better

blood supply & nutrition.


Rate & Quality of scar formation:

Rapid & heavy scar formation highly limited

excursion.

Slow & light scar formation high risk or of

rupture.


Patient motivation:

Patient education is key.

Adherence to home program is critical.


Socioeconomic factors:

No health insurance / no

income / supporting a family

but is unable to work?

Unsupportive patient’s family?

Living alone?

Injury- & surgery- related factors 83

Level of injury: Zone 1

Tendon has a small excursion (5-7 mm).

Loss of even small amount of excursion can be

functionally limiting.

Prone to adhesions to the A4 & A5 pulley &

weakening of the repair.


Level of injury: Zone 2 “No Man’s Land”

So many structures leading to adhesions:

o between FDP & FDS;

o between tendon & sheath; &

o between tendon & bony, vascular, & other soft tissue

structures.



If repair is delayed or if injured while finger is

flexing Tendon retracts The tendon must be

retrieved Intraoperative trauma.

If repair is delayed Tendon may shorten

Tendon repaired under tension.



Damage to pulleys compromise function.

Injury to vincula compromise nutrition.

Loss of few mms of tendon excursion

considerable functional deficit.



Susceptible to adhesions to adjacent tendons,

lumbricals, & interossei, & overlying fascia & skin.



At risk for adhesions to synovial sheaths, to each

other, and to the other structures lying within the

constricted carpal tunnel space.

Intertendinous adhesions will limit differential glide

severely limit hand function.



Commonly become markedly adherent to overlying

skin & fascia (generally are not problematic?).

Adhesions between tendon & paratenon (loose

connective tissue).



Adhesion formation is often very heavy!

Because of limited vascularity stimulates formation

of adhesions to supply nutrition to the healing

tendon.


Type of injury: Crush or blunt injuries

Infection may prolong the inflammatory phase.

Cause more associated injuries to surrounding tissues

more scar formation.

Commonly involve vascular injury (vincula) impair

healing.

Treatment is modified if adjacent injured tissue must be

protected (fractures / nerve injuries).


Type of injury: Partial laceration

Partial laceration is better than complete laceration because vascularity generally will be better preserved.

Should partial laceration be repaired?

o Tendon catches to the sheath - Triggering/entrapment - rupture.


Type of injury: Retracting tendon

Vincula may be ruptured or stretched impairing

vascularity.

Tendon retrieval may be traumatic to the tendon &

surrounding sheath.


Type of injury: Finger position when injured

A given point on the tendon glides proximally during flexion & distally during extension.

E.g.: Test tube broken in hand (fingers flexed), lacerated FDS & FDP, when the digit extends the distal portion of the tendon may be pulled distally 3 - 4 cm (depending on the level of injury).


Sheath integrity: Pulleys

Injury to pulleys decrease mechanical advantage

of the tendon.

Injury to pulleys pumping mechanism (synovial

diffusion) is diminished.


Surgical techniques:

Intraoperative tissue trauma hematoma

increased inflammatory response increased

adhesions.

Therefore, tissue must be handled delicately (even

marks of the forceps on the epitenon can trigger

adhesion formation).



Suture may strangulate the intratendinous vessels &

provoke adhesion formation.

Suture is often placed in the relatively avascular

volar aspect of the tendon to avoid damage to the

dorsally placed intratendinous vessels.



Strong sutures give the chance for early

mobilization.

Strength of the suture is proportional to the number

of strands crossing the repair.

Bulky sutures added resistance to the tendon drag.


Timing of repair:

Delayed repair tendon ends will scar to

surrounding tissue & must be dissected free before

repair.

Delayed repair the entire musculotendinous unit

shortens tension on the repair higher risk of

gapping or rupture.


Timing of repair:

Shortening increase the risk of later flexion

contractures.

Therapy- related factors 101

Timing:

An immobilized tendon loses strength initially, whereas early mobilization strengthens the repair.

If mobilization begins at 1 week after repair, the repair will already have weakened enough to be greatly at risk of rupture or deformation. Adhesions also would have begun to form.


Timing:

In severely edematous digit, starting early

mobilization on the day of the surgery would be

dangerous.

Inflammation & edema will reduce within around 3

days of rest & elevation in the bulky compressive

postoperative dressing.


Technique:

Not every tendon injury can be treated with the

identical protocol.

The best approach is a combination of techniques

from various protocols.


Expertise:

No therapist should undertake a treatment program

without sufficient preparation, experience, & any

supervision needed.

Many therapists attempt to use protocols that they

simply do not understand.


Expertise:

It is extremely vital to have a full understanding of

rationale for treatment in tendon management.

Immobilization, early passive mobilization, & early active mobilization.

POSTOPERATIVE MANAGEMENT PROTOCOLS 106

Part 6

ZONES 1 – 4 IMMOBILIZATION 107

Rationale and indications 108

Early mobilization protocols are appropriate for:

Alert, motivated, patients who understand the

exercise program & precautions.

Therefore, immobilization is indicated for:


Patients younger than 10 years.

Patients with cognitive deficit.

Patients who are unable (for any clear reason) / unwilling to participate in a complex rehabilitation program.

Patients who are overzealous or ignore precautions when first allowed to move the tendon.


Significant soft tissue injury or concomitant crush

injuries.

Immobilization protocol 111

This protocol is based on that developed by Cifaldi

Collins & Schwarze.

This protocol includes several techniques & concepts

applicable to all flexor tendon management,

regardless of the approach used.

Early stage (from 0 to 3 or 4 weeks) 112

Splint:

Dorsal blocking splint (DBS):

o Wrist: 10 – 30 degrees of flexion.

o MCPs: 40 – 60 degrees of flexion.

o IPs: full extension.

Worn 24 hours a day except for therapy visits 1-2 a

week.


At therapy visits, when splint is removed for exercise,

therapist should inspect & cleanse patients skin &

splint.

Hydrogen peroxide is used in cleansing skin even

when there is an open wound.

Sterile cotton swab may be used to cleanse the splint

material .


Exercise 1:

Literature shows that 3 days postoperative is the

ideal time frame to initiate edema control.

o Significant edema can often be managed with

elevation and digital level light compressive dressing

on a periodic basis during the day and/or night.


Exercise 2:

At home, patient perform ROM exercise to elbow &

shoulder to prevent stiffness & weakness.


Exercise 3:

To protect the hand small joints from getting stiff,

therapist removes the splint for gentle protected

PROM as follows:

o Therapist holds adjacent joints in flexion while

extending & flexing each joint.


Exercise 4:

After prolonged protection in MCP flexion, patient

develops intrinsic tightness. Thus, protected intrinsic

stretch is performed at therapy visits.

o Wrist flexed maximally while MPs are held in

neutral & IPs are gently flexed passively.


Intrinsic

muscles pass

volar to MPs

& dorsal to

IPs therefore

they flex MPs

& extend IPs.


Maximum

lengthening

of intrinsic

muscles is

achieved by

MP extension

& IP flexion

(intrinsic

minus)


Exercise 5:

Sutures are usually removed 10-14 days after

surgery, within 48 hours of suture removal, scar

massage would help control skin & tendon adhesions.

o Gentle clockwise & counterclockwise massage with

lotion.


Exercise 6:

Uncommonly, bulky & raised scars may develop.

o Elastomer or other pressure dressing are helpful in

flattening these scars (generally, should be used only

at night to avoid restricting mobility during the day).

Intermediate stage (starting at 3 to 4 weeks) 123

Splint:

The DBS is modified to bring the wrist to neutral.

Patient is taught to remove the splint hourly for

exercise.


Exercise 1:

Passive exercise detailed in the previous stage.


Exercise 2:

With the wrist in 100 extension, the patient performs:

o 10 repetitions of passive digit flexion & extension,

followed by;

o 10 repetitions of active differential tendon gliding

exercises (DTGE).


DTGE


DTGE elicit max. total & differential flexor tendon glide at wrist/palm level.

o Straight fist: max. FDS glide in relation to surrounding tissue.

o Full fist: max. FDP glide in relation to surrounding tissue.

o Hook fist: max. differential gliding between FDS & FDP.


3 – 4 days after these exercises, tendon function is

evaluated;

1. Total the degrees of passive flexion at MP & IP

joints = A.

2. Total the degrees of active flexion at MP & IP joints

= B.

3. A – B = Z.


If Z > 500 then

Patient is moved on to the next stage of therapy

Else

Patient continues with the current phase of therapy until

6 weeks after repair

End if

Late stage (starting at 4 to 6 weeks) 130

Splint:

The DBS is discontinued.

If extrinsic flexor tightness is noted, a forearm-based

palmar night splint is fitted, holding wrist & fingers in

max. comfortable extension, splint is then serially

adjusted to accommodate for any improvement in

extension.


Within 1 week, if improvement is not noted, dynamic

or static progressive extension splint may be used

(very gentle tension initially).

Later, if PIP flexion contracture is developed (not

uncommon in zone 2 injuries), serial cylinder casting

may be needed.


Exercises 1 & 2:

Passive exercise & active differential tendon gliding

exercise detailed in the previous stages.


Exercise 3:

Gentle blocking exercises for isolated FDP & FDS

glide (4-6 times a day for 10 repetitions).

Isolated FDP gliding: MP & PIP joints held in

extension, thus preventing FDS glide, while FDP

functions alone to flex the DIP joint.


Isolated FDS gliding: the adjacent fingers held in full

extension, thus holding FDP tendons at their full

length & making it impossible for them to assist as

the FDS flexes the PIP joint.


Blocking exercises can be dangerous for a newly

healed tendon if not performed correctly;

o Blocking exercise may become a strongly resisted

exercise if the patient does not concentrate on

flexing only the DIP, but instead fights the fingers

holding the PIP in extension.


o If the hand is still edematous and/or the patient has

a difficulty resisting the temptation to exercise too

vigorously, then:

Delay blocking exercises until 2 – 3 weeks later,

when the tendon repair is stronger.

Note: try demonstration on your own hand or on

his/her intact hand.


Exercise 4:

After 1 week of blocking exercises, if active flexion

did not improve, the following exercises are added:

o Towel walking (flexing fingers individually in turn to

gather a towel on a flat surface).

o Light pick-ups.


o Gentle putty squeeze;

No more than 10 repetitions with the lightest putty.

1 weeks later, sustained grip may be added,

followed by light resistance grip exerciser, putty

scarping, & use of heavier putty.


The patient is also may be instructed to begin lifting

heavier objects at home (e.g., a quart of milk).

“It is not easy to decide when to increase the amount

of resistance. There are no rules!” Hunter


Here is some tips to help you decide:

o Greater resistance more muscle contraction

stretch tendon adhesions improve gliding.

o Excessive resistance may rupture a tendon even as

late as 3 months after repair.

o The more adherent the tendon, the safer it is to

apply resistance to glide.


o Smoothly gliding tendon should not receive even light

resistance until 7 – 8 weeks of repair.

o Most tendons are not ready for heavy resistance

(e.g., heavy putty) and manual labor job simulation

until 10 – 12 weeks.


Patients may overdo resistive exercise, this can:

o Provoke inflammation increased fibrosis &

stiffness.

o Develop trigger.

Therapist must warn patient & routinely palpate for

triggering at the A1 pulley.


Treating adhesion problems:

To allow greater glide, the aim is to gradually

lengthen adhesions not to break them, breaking

adhesions is an internal trauma that will lead to

greater fibrosis & more adhesions.


Several techniques are available:

o Extension Splinting.

o Blocking exercises (with or without resistance).

o Differential tendon gliding.

o Friction massage.

o NMES.

o U/S.


E.g., in case of extensive FDP & FDS adhesions of 3

fingers in zones 2 through 4.

MP & IP joints all could be placed at maximum

extension to stretch adhesions.


E.g., in a case of a single FDP tendon repair

adherent only in the distal portion of zone 2.

Finger-based dynamic splint or cylinder cast,

limitations in flexion could be addressed with

frequent blocking, putty scarping, or sustained grip

activities.

(Gripping a small cylinder 10 times a day for 10-30 seconds)


E.g., if FDS tendons are adherent!

DIP extension splint may be worn during active &

resistive exercise to aid in eliciting FDS gliding.


NMES may be used to provoke a stronger muscle

contraction.

This would be appropriate within 1 week of initiating

resisted exercise.


U/S may provide deep heat combined with stretch

or active tendon gliding to stretch adhesions.

Superficial & deep scar respond well to soft tissue

mobilization techniques such as cross-frictional

massage.


Scar retraction is also another technique.

The therapist retracts the skin at the adhesion site

proximally & passively extends fingers.

The patient retracts the skin at the adhesion site

distally & actively makes differential tendon gliding

exercises.

Part 7

ZONES 1 TO 3 EARLY PASSIVE MOBILIZATION: MODIFIED

DURAN 153


Early mobilization:

Inhibits restrictive adhesions formation.

Promotes intrinsic healing & synovial diffusion.

Produces a stronger repair.


Research found that measurable passive excursion

occurs with passive IP flexion.

Research also found a significant correlation

between early passive IP flexion & later active

flexion measured in long-term follow-up.

Duran & Houser 156

A DBS is applied at surgery (wrist & MP flexed,

IPs free or allowed to extend to neutral within the

splint).

The DBS allows passive flexion of fingers but limits

extension beyond the limits of the splint.

Duran & Houser 157

Dynamic traction is added to maintain the fingers

in flexion to further relax the tendon.

Dynamic traction is provided by rubber bands or

similar elastic materials.

The traction is applied to the finger nail either by

placing a suture through the nail in surgery or by

gluing to the finger nail a nail hook.

Early stage (from 0 to 4.5 weeks) 158

Splint:

DBS, wrist in 200 of flexion & MP in a relaxed

position of flexion.


Exercise 1:

Duran & Houser found that 3 – 5 mm of glide was

sufficient to prevent formation of firm tendon

adhesions. Therefore, they designed the following

exercise to be performed 6 – 8 repetitions twice a

day:


o With MP & PIP flexed, the DIP is passively

extended (moving the FDP repair distally away

from the FDS repair).

o With the MP & DIP flexed, the PIP is passively

extended (moving the FDP & FDS repairs distally

away from site of repair & surrounding tissues).

Intermediate stage (from 4.5 to 7.5 or 8 weeks) 162

Splint:

After 4.5 weeks, the splint is replaced with a wrist

band to which a rubber band traction is attached.


Exercise 1:

Active extension exercises begin within the

limitations imposed by the wrist band.


Exercise 2:

At 5.5 weeks,

Wrist band is removed.

Active flexion is initiated.

Blocking.

FDS gliding.

Differential tendon gliding fisting.

Late stage (staring at 7.5 to 8 weeks) 166

Resisted flexion waits until 7.5 to 8 weeks.

The programs is upgraded following the principles

explained earlier in the immobilization protocols.

Surgical procedure 167

A two-strand flexor tendon repair may be

performed to initiate an early passive ROM

program such as the Modified Duran Program.

3 days postoperation 168

The bulky compressive dressing is removed.

A light compressive dressing is applied to the hand

& forearm along with digital level fingersocks or

CobanTM.


Fingersocks CobanTM


A DBS is fitted for continual wear:

Wrist: 20 degrees flexion.

MPs: 70 degrees flexion.

IPs: full extension.


Modified Duran exercise program is initiated

within the restrains of the DBS each two hours

throughout the day:

25 rep. of passive flex. & ext. of the PIP joint.

25 rep. of passive flex. & ext. of the DIP joint.

25 rep. of composite flex. & ext. of the entire

digit.


It is important to place equal emphasis on the passive extension & the passive flexion.

It is through the effort of passive extension that allows the tendon to glide distal from the repair site.

It is equally important to ensure a tight composite passive flexion to the distal palmar flexion crease to maximize tendon excursion.


If limited passive flexion is noted, a dynamic

flexion assist may be added to the volar portion

of the DBS.

10 – 14 days postoperation 174

Within 48 hours following suture removal scar

massage with lotion may be initiated, along with

ElastomerTM, Otoform KTM, or Rolyan 50/50TM.


Otoform KTM Rolyan 50/50TM


The modified Duran passive exercises are

continued within the restrains of the DBS.

3½ weeks postoperation 177

The modified Duran passive exercises are

continued within the restrains of the DBS.

Active exercise within the DBS may be initiated.

4 weeks postoperation 178

NMES may be added to the therapy program

after the patient has been performing active

flexion exercises for 3 – 5 days.

U/S deep heat may be added to therapy if a

dense scar is present &/or limited tendon

excursion is a concern.


The DBS is removed every 1-2 hours to begin

AROM exercises outside the splint:

Wrist & finger flexion followed by wrist & finger

extension.

Composite fist followed by MP extension with IPs

flexed, followed by IP extension.

Composite fist with wrist extension & flexion.



AROM exercises described at 4½ weeks are continued.

Patient education is vital:

A tight sustained fist with or without weighted resistance greatly increase the risk of rupture during the early healing of the flexor tendon repair.


Passive extension exercises are initiated.

Blocking, FDS gliding, differential tendon gliding

fisting may be initiated.

Blocking is not permitted to the little finger.

o By experience of many hand therapists, blocking the

PIP & in particular, the DIP is at relatively at high

risk for rupture (no exception).


Dynamic extension splinting may be initiated if a

PIP joint flexion contracture develops.


Resisted flexion may be initiated.



Note: no heavy use of the hand is allowed at this

time.

10 – 12 weeks postoperation 184

Patients may begin to use the involved hand in all

activities of daily living.

14 – 16 weeks postoperation 185

Heavy, weighted resistance to the hand & upper

extremity is permitted after 14 – 16 weeks.

Considerations 186

The greatest achievements in ROM are obtained

between 3 ½ & 7 ½ weeks.

It is important to emphasize to the patient active

participation in the therapy program during the

crucial 4 weeks.

o Patient will continue to make gains though for up to

6 months by using their hand normally.

Considerations 187

Digital nerve repairs, in conjunction with flexor

tendon repairs, may require positioning the PIP

initially in 300 flexion & gradually increasing

extension from 3 to 6 weeks.

If the surgeon can report that the digital nerve was

repaired with no tension this is ideal for allowing full

passive excursion of the tendon.

Considerations 188

For PIP joint flexion contractures to the little finger, it is highly recommended to initiate an extension splint between exercise sessions & at night.

There is a greater propensity for a flexion contracture to be difficult to resolve at the little finger, especially when laceration is located at the PIP volar plate.

Part 8

ZONES 1 – 3 EARLY ACTIVE MOBILIZATION: TENODESIS

PROGRAM 189


“Some of the best early passive mobilization

results come when patients cheat & add a little

active motion”


The early motion program permits tendon excursion believed to be sufficient to prevent dense peritendinous adhesions from blocking tendon gliding.

In all likelihood, without early motion the flexor tendon would become severely adherent to surrounding tissues.

The early motion favorably influences the orientation of the collagen fibers along the tendon.


By permitting joints flexion & extension, this helps

minimize the likelihood of joints contractures by

allowing the collateral ligament some degree of

stretch.

AROM decreases edema and maintains soft tissue

elasticity.

Alert! 193

Early active mobilization is only appropriate if:

Both therapist & surgeon possess skill & experience

in tendon management.

Therapist & surgeon communicate closely.

The suture used was of adequate strength.

The patient reliable & understands the program

thoroughly.

Protocols 194

Several protocols are available:

Coventry protocol.

Active mobilization (Allen/Loma Linda).

Active mobilization (Belfast & Sheffield).

Active-hold/place-hold mobilization (Strickland / Cannon) / Tenodesis Program.

Active-hold/place-hold mobilization (Silfverskoild & May).

Active-hold/place-hold mobilization (Evans & Thompson) / guidelines, not a protocol.

Introduction 195

This protocol is an “active-hold” or “place-hold active mobilization” protocol.

The digits are passively placed in flexion, & the patient then maintains the flexion with a gentle muscle contraction.

o Patients learn to use only minimal force by using biofeedback to monitor the strength of the contraction (< 10 mV on a Cyborg model).

Early stage (from 0 to 4 weeks) 196

Splints:

A DBS is fitted for continual wear:

o Wrist: 200 flexion.

o MCP: 650-700 flexion.

o IPs: full extension.


Splints:

A tenodesis splint is fitted:

o A dynamic hinge serves as the wrist component.

o The hinge allows full wrist flexion & limits wrist

extension to a max. of 300 extension.

o The MPs are positioned in 700 flexion & IPs in full

extension (finger flexion is allowed).


DBS Tenodesis Splint


Exercise 1:

Every hour, patients perform the Strickland version

of Modified Duran exercises:

o 25 repetitions of PROM to the PIP & DIP joints and

the entire digit within the DBS.


Exercise 2:

Following the Strickland version of Modified Duran

exercises, the patient perform the tenodesis

exercises within the tenodesis splint.


The tenodesis exercises:

Passive composite flexion of the digits simultaneous with

wrist extension is performed.

Once in this position, the patient actively attempts to

maintain a fist with a gentle muscle contraction for 5

seconds.

Then, relaxing the wrist & letting it drop into flexion

(which will lead to finger extension).

Intermediate stage (from 4 to 7 or 8 weeks) 203

Splint:

The tenodesis splint is discontinued.

Patient still wear the DBS except for tenodesis exercises.


Exercise 1:

The tenodesis exercises continue every 2 hours with 25

repetitions.


Exercise 2:

Following the tenodesis exercises, 25 repetitions of

active flexion & extension exercise for the wrist & digits

(avoiding simultaneous wrist & digit extension).


Exercise 3:

FDS gliding.


Exercise 4:

At 5 – 6 weeks, blocking & hook fist may be initiated to

improve tendon gliding.

Late stage (from 7 to 8 weeks) 208

Splint:



At 8 weeks, resisted flexion may be initiated.



Note: no heavy use of the hand is allowed at this

time.


10 – 12 weeks, patients may begin to use the

involved hand in all activities of daily living.


Heavy, weighted resistance to the hand & upper

extremity is permitted after 14 – 16 weeks.

Part 9

ZONES 4 & 5: MOBILIZATION PROGRAM 212

3 – 5 days postoperative 213

The bulky compressive dressing is removed.

A light compressive dressing is applied to the hand

and forearm, along with digital level fingersocks or

Coban.


A DBS is fitted for continual wear. The wrist and

hand are positioned as follows:

Wrist: 30° of palmar flexion

MP's: 70° flexion

IP's: full extension


Within the restraints of the DBS, composite passive

flexion and extension are performed to the digits

25 repetitions, 3 to 4 times a day.


Within 48 hours following suture removal, scar

mobilization techniques may be initiated.

This may include scar massage with lotion and

Rolyan 50/50, Otoform K, or Elastomer.

The patient continues with composite PROM

exercises within the dorsal blocking splint.

3 weeks postoperative 217

The DBS is continued at all times.

AROM exercises are initiated within the restraints of the DBS.

A wrist and MP block splint may be fitted on the volar side of the DBS to be used to isolate the PIP and DIP joints with active flexion.

Gentle blocking exercises may be initiated to the PIP and DIP joints at 4 weeks.


NMES may be initiated within 3 to 5 days following

initiation of AROM exercises.

U/S may be initiated with the goal of enhancing the

elasticity of the underlying peritendinous adhesions

to promote tendon excursion.

4½ weeks postoperative 219

The DBS is worn between exercise sessions and at

night.

Note: If there is an associated nerve repair at the

wrist level, exercises are continued within the

restraints of the dorsal blocking splint.

4½ weeks postoperative 220

Unrestricted AROM exercises are performed to the

wrist and digits.

Emphasis is placed on isolated blocking of the FDS

and FDP.



A full extension resting pan splint or a long dorsal

outrigger with lumbrical bar may be initiated if

extrinsic flexor tightness is present.

Note: It is not atypical to require some form of

static or dynamic splinting to resolve extrinsic flexor

tightness.


Unrestricted active and PROM exercises are

emphasized.

Passive extension of the wrist and digits is initiated.

Exercises emphasizing differential tendon gliding of

the FDS and FDP are encouraged.


Progressive strengthening may be initiated with

putty and a hand exerciser.

Patient education is important.

The patient should be advised to avoid heavy

lifting or use the hand with a tight, sustained grip.


Progressive strengthening may be upgraded to

hand weights for the wrist.

10 – 12 weeks postoperative 225

During this time frame splinting can typically be

discontinued.

The patient may return to unrestricted use of the

hand in all activity.

Considerations 226

Once active exercises are initiated at the 3 week point, it is critical to emphasize blocking exercises along with the composite active flexion exercises.

If the patient is having difficulty recapturing active flexion, it is important to carefully monitor the ROM & encourage frequent therapy appointments in order to maximize flexion.

The 3 to 7 weeks time frame is critical for maximizing tendon excursion.

Considerations 227

Concomitant median and/or ulnar nerve repairs at

the wrist require special consideration.

If the nerves have been repaired the wrist is initially

placed in 300 of flexion and increased 100 of

extension each week, during the 4th & 5th weeks.

Considerations 228

If the ulnar nerve has been repaired, it is important to block the MP joints of the ring and small finger from hyperextension and secondary clawing.

the median nerve have been repaired, a night web spacer is recommended to avoid a potential web space contracture secondary to the denervation of the thenar muscles.

Considerations 229

If both nerves are repaired, the MP block should

include all digits.

Considerations 230

It is important to emphasize scar management.

It is not uncommon for the flexor tendons to become somewhat adherent to the skin and subcutaneous tissues.

Performing scar retraction by securing a piece of Dycem just proximal to the repair site can be effective as the patient attempts to both flex &/or extend the digits.

Considerations 231

It is not uncommon for the patient to continue to

regain active flexion for 6 months following the

repairs.

The end

Thank you 232

postoperative management of flexor tendon injuries

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