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POSTOPERATIVE MANAGEMENT OF FLEXOR TENDON INJURIES Ahmad A. Fannoon, Hand Therapist

POSTOPERATIVE

MANAGEMENT OF FLEXOR

TENDON INJURIES

Ahmad A. Fannoon, Hand Therapist

What are we learning?

2

Fundamental tendon

management.

Flexor tendon anatomy, biomechanics, mechanism of

nutrition & healing.

Three approaches to tendon

management, with protocols.

anatomy, biomechanics, mechanism of nutrition & healing.  Three approaches to tendon management, with protocols.

3

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.

4 FUNDAMENTAL CONCEPTS

Part 1

Goal: a strong repair that glides freely

5

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.

Goal: a strong repair that glides freely

6

In the hand, so many structures lie in a constricted space scar adhesions between adjacent

a constricted space  scar adhesions between adjacent structures can occur easily after injury or surgery.

structures can occur easily after injury or surgery. Tendon-adjacent-tissue & intertendinous adhesions can seriously limit excursion & decrease function.

Goal: a strong repair that glides freely

7

Normally,

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.

of

tendon

encounters

certain

a

amount

Goal: a strong repair that glides freely

8

Since the newly repaired tendon has a low strength extra care must be taken to allow for this

tendon has a low strength  extra care must be taken to allow for this increased

increased resistance during all exercises.

Goal: a strong repair that glides freely

9

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).

For

repaired

tendon

to

function

a

10

Goal: a strong repair that glides freely

The gap maybe filled with scar leading to:

Weaker repair.

Increased adhesion formation.

Longer tendon.

An elongated tendon requires greater excursion to function normally.

11

Goal: a strong repair that glides freely

However, the dysfunctional effect of gaps has been found less in repairs that have been mobilized

early.

12

Goal: a strong repair that glides freely

Therefore, our goal for the tendon is:

“To heal without rupture or gap formation, with

sufficient strength & excursion for daily activities”

13

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).

14

Evaluating tendon function

If passive flexion greatly exceeds active flexion, the tendon is not functioning adequately:

active flexion, the tendon is not functioning adequately:  The tendon may have ruptured or elongated,
active flexion, the tendon is not functioning adequately:  The tendon may have ruptured or elongated,

The tendon may have ruptured or elongated, or it may be adherent.

the tendon is not functioning adequately:  The tendon may have ruptured or elongated, or it

15

Evaluating tendon function

Adherent tendons exhibits some excursion, however limited, the entire excursion may be taken up by

flexion of a single joint.

FDP

PIP

MCP

DIP

Composite

Composite

flex.

ext.

Adherent

Held passively in extension

*AF 

*AF

N/A

N/A

Adherent

Left free

Limited

Limited

Limited

*AF: active flexion.

Evaluating tendon function

16

The PIP can be extended completely

when the wrist & MCP are flexed.

Evaluating tendon function 16  The PIP can be extended completely when the wrist & MCP

Evaluating tendon function

17

The PIP still can be extended completely

when the wrist is extended, but PIP

begin to flex,

reflecting some

tightness of FDP.

PIP still can be extended completely when the wrist is extended, but PIP begin to flex,

Evaluating tendon function

18

When MCP & wrist

extended, the PIP can’t

be extended, indicating adhesions in

the palm, or at the

level of MCP or

proximal phalanx.

wrist extended, the PIP can’t be extended, indicating adhesions in the palm, or at the level

ROM restrictions problem solving

19

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.

ROM restrictions problem solving

20

Muscle-tendon

muscles.

unit

tightness

of

the

opposing

If PIP flexion is limited this could be due to tightness

of the long extensors.

unit tightness of the opposing  If PIP flexion is limited this could be due to

ROM restrictions problem solving

21

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.

to tightness of the opposing muscle group, ROM will increase when the muscle tendon unit is

ROM restrictions problem solving

22

Extend wrist and MCP and repeat PIP flexion.

ROM restrictions problem solving 22  Extend wrist and MCP and repeat PIP flexion.

ROM restrictions problem solving

23

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).

 produce the movement. If PIP flexion is minimal, perform a MMT on the finger flexors

ROM restrictions problem solving

24

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.

you are testing or the muscle belly to determine if tension is being produced, specially if

ROM restrictions problem solving

25

Tendon

adhesions

should

cause

some

restrictions in two directions.

ROM

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.

before they cross the PIP joint they will not be effective flexors of the PIP joint

ROM restrictions problem solving

26

They will also be unable to lengthen properly so extension will also be limited.

ROM restrictions problem solving 26  They will also be unable to lengthen properly so extension

ROM restrictions problem solving

27

Joint related restrictions:

If

restriction is likely due to a tight joint capsule or

the

of

the

other

problems

noted

none

are

tight ligaments or boney block to movement.

due to a tight joint capsule or the of the other problems noted none are tight

28

ROM restrictions problem solving

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.



Three Approaches to Tendon Management

29

Three Approaches to Tendon Management 29  Immobilization : these protocols call for complete immobilization of

Immobilization: these protocols call for complete

immobilization of the tendon repair, generally 3 to

4 weeks, before beginning active & passive mobilization.

complete immobilization of the tendon repair, generally 3 to 4 weeks, before beginning active & passive

Three Approaches to Tendon Management

30

Three Approaches to Tendon Management 30  Early passive mobilization : these protocols involve passively mobilizing
Three Approaches to Tendon Management 30  Early passive mobilization : these protocols involve passively mobilizing

Early passive mobilization: these protocols involve passively mobilizing the repair early (within first

week) either manually or by dynamic flexion traction.

involve passively mobilizing the repair early (within first week) either manually or by dynamic flexion traction.

Three Approaches to Tendon Management

31

Three Approaches to Tendon Management 31  Early active mobilization : these protocols mobilize the repair

Early active mobilization: these protocols mobilize

31  Early active mobilization : these protocols mobilize the repair (within few days of repair)

the repair (within few days of repair) through active

contraction of the involved flexor, with caution & within carefully prescribed limits.

days of repair) through active contraction of the involved flexor, with caution & within carefully prescribed

32 ANATOMY

Part 2

33

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.

Flexor tendon zones

34

Zones apply to the two finger flexors (FDS & FDP) and the single extrinsic thumb flexor (FPL).

Flexor tendon zones 34 Zones apply to the two finger flexors (FDS & FDP) and the

35

Zone 5

Musculotendinous

junction in the distal

third of the forearm.

36

Zone 4

Carpal tunnel.

Synovial sheaths.

Lubrication.

Nutrition.

Protection.

Carpal ligament.

Zone 4  Carpal tunnel.  Synovial sheaths.  Lubrication.  Nutrition.  Protection.  Carpal

37

Zone 3 & T3

Ulnar & radial bursae.

Lumbricals

37 Zone 3 & T3  Ulnar & radial bursae.  Lumbricals

Zone 2 & T2

38

FDS insertion.

Zone 2 & T2 38 FDS insertion. Separate digital synovial sheaths

Separate digital synovial sheaths

Zone 2 & T2 38 FDS insertion. Separate digital synovial sheaths

39

Zone 2 & T2

Digital synovial

sheaths.

Pulleys: annular & cruciate.

Vinculi.

Camper’s Chiasma

Zone 2 & T2  Digital synovial sheaths.  Pulleys: annular & cruciate.  Vinculi. 

40

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.

part of proximal phalanx.  A4 – lies centrally on middle phalanx.  A5 – lies
part of proximal phalanx.  A4 – lies centrally on middle phalanx.  A5 – lies

Zone 2 & T2 / CPs

41

C1 located between A2 & A3 pulleys. C2 located between A3 & A4 pulley.

C3 located between

A4 & A5 pulley.

A2 & A3 pulleys.  C2 – located between A3 & A4 pulley.  C3 –

42

Zone 2 & T2

Zone 2 Pulleys:

A1-A3.

C1-C2.

Zone T2 Pulleys:

A1.

Oblique.

42 Zone 2 & T2  Zone 2 Pulleys:  A1-A3.  C1-C2.  Zone T2

43

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.

or guides to the tendons.  Without the pulleys, the tendon would pull away from bone

44

Zone 2 & T2

Research data

revealed A2 & A4

pulleys are most important for achieving normal tendon function.

45

Zone 2 & T2

Vinculia: folds of mesotenon carrying blood supply to flexor tendon (later).

Zone 2 & T2

46

Zone 2 vincula:

Vinculum longus &

vinculum brevis to

FDS.

Vinculum longus to FDP.

Zone 2 & T2 46  Zone 2 vincula:  Vinculum longus & vinculum brevis to

Zone 2 & T2

47

Chiasma of camper:

space created by the

FDS allowing FDP to go through.

Zone 2 & T2 47  Chiasma of camper: space created by the FDS allowing FDP

Zone 1 & T1

48

FDP insertion.

Zone 1 & T1 48 FDP insertion. FDS insertion.

FDS insertion.

Zone 1 & T1 48 FDP insertion. FDS insertion.

Zone 1 & T1

49

Zone 1 includes: A4,

C3, & A5.

Synovial sheaths end

in this zone.

Zones T1 includes FPL

insertion & A2.

Zone 1 includes: A4, C3, & A5.  Synovial sheaths end in this zone.  Zones

50 NUTRITION

Part 3

51

Nutrition

Blood supply to the flexor tendon:

Proximal

vessels

entering

at

musculotendinous junction.

the

Distal vessels entering at the bony insertion of the tendon.

Vessels in the surrounding tissues.

Less important sources

Most important

source

Nutrition

52

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.

53

Nutrition

The small vessels entering the vincula originate from 4 transverse communicating arteries, which branch

from the two digital arteries.

vessels communicate with the

intratendinous vessels that lie longitudinally within

the tendon & originate in the palm.

The

vincular

54

Nutrition

These longitudinally oriented vessels are located in the dorsal half of each tendon, leaving the volar side

in the dorsal half of each tendon, leaving the volar side of the tendon relatively avascular

of the tendon relatively avascular.

Areas of relative avascularity between the segmental vincular blood supply have been described as watershedor critical tendon zones.

between the segmental vincular blood supply have been described as “ watershed ” or critical tendon

Nutrition

55

In zone 2 (relative avascularity), tendon nutrition comes from two sources:

The blood supply.

Synovial diffusion.

Nutrition

56

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? 
Pumping Mechanism?

57

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

high pressure against the pulleys during active flexion of the fingers ( synovial diffusion in articular

articular cartilage!).

58

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

in the tendon watershed areas, the balance is disturbed & excessive adhesion formation is seen, why

formation is seen, why adhesions?.

in the tendon watershed areas, the balance is disturbed & excessive adhesion formation is seen, why

Nutrition

59

Why adhesions?

Bringing additional blood supply to the tendon necessary for the healing process.

Limits tendon gliding.

60 TENDON HEALING

Part 4

61

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.

Peacock one-wound concept

62

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

involved tissue layers together (skin, subcutaneous

formed involved tissue layers together (skin, subcutaneous will glue all in the first 3 weeks tissue,

will glue all

in

the

first

3

weeks

tissue, & underlying tissue).

63

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.

64

The wound healers

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

65

Phases of tendon healing 65  Phase 1 “ Exudative or inflammatory phase”  0 –

Phase 1 Exudative or inflammatory phase”

65  Phase 1 “ Exudative or inflammatory phase”  0 – 5 days.  Tensile

0 5 days.

Tensile strengths of the immobilized tendon repair

diminishes in the first 3-5 days.

Influx of leukocytes & macrophages.

Macrophages

stimulates

growth

fibroblasts.

&

migration

of

Phases of tendon healing

66

Phases of tendon healing 66  Phase 2 “ Fibroplasia phase”  5 – 21 days.

Phase 2 Fibroplasia phase”

of tendon healing 66  Phase 2 “ Fibroplasia phase”  5 – 21 days. 

5 21 days.

Fibroblasts migrates to the wound & produce

tropocollagen (triple-helix molecule with little tensile

strength).

Tropocollagen are randomly oriented creating a

network.

Phases of tendon healing

67

Phases of tendon healing 67  Phase 3 “Remodeling phase”  3 weeks – 6 months

Phase 3 “Remodeling phase”

of tendon healing 67  Phase 3 “Remodeling phase”  3 weeks – 6 months or

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).

Phases of tendon healing

68

Phases of tendon healing 68  Continue Phase 3 …  The randomly oriented collagen fibers,

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.

69

Nutrition needed for wound healing

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.

H 2 O to maintain hydration.

Adhesions in the 3 rd 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

described in the literature:

1. Extrinsic healing.

2. Intrinsic healing.

3. Combination of both.

healing

are

73

Extrinsic healing

Tendon has no active role in the healing process,

whereas adhesions formation is vital

healing.

to tendon

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.

75

Combination of intrinsic & extrinsic

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

repaired tendon function:

Better tensile strength.

Better excursion.

creates

better

77 FACTORS AFFECTING HEALING & REHABILITATION

Part 5

Patient related factors

78

 Age:
 Age:

Number of vincula

decreases as the patient grows older.

Cell aging could lead to decreased healing

capacity of tenocytes.

of vincula decreases as the patient grows older.  Cell aging could lead to decreased healing

Patient related factors

79

Patient related factors 79  General health & healing potential :  Better health lead better

General health & healing potential:

factors 79  General health & healing potential :  Better health lead better healing. 

Better health lead better healing.

Lifestyles & dietary habits, e.g.:

o

Cigarettes & Caffeine

vasoconstriction.

o

Healthy food & sport better blood supply & nutrition.

& Caffeine  vasoconstriction. o Healthy food & sport  better blood supply & nutrition.

Patient related factors

80

Patient related factors 80  Rate & Quality of scar formation :  Rapid & heavy

Rate & Quality of scar formation:

factors 80  Rate & Quality of scar formation :  Rapid & heavy scar formation

Rapid & heavy scar formation highly limited excursion.

Slow &

rupture.

light

scar formation high risk

or

of

Patient related factors

81

Patient related factors 81  Patient motivation :  Patient education is key.  Adherence to

Patient motivation:

Patient related factors 81  Patient motivation :  Patient education is key.  Adherence to

Patient education is key.

Adherence to home program is critical.

Patient related factors

82

 Socioeconomic factors:
 Socioeconomic factors:

No health insurance / no

income / supporting a family but is unable to work?

Unsupportive patient’s family?

Living alone?

/ no income / supporting a family but is unable to work?  Unsupportive patient’s family?

Injury- & surgery- related factors

83

Injury- & surgery- related factors 83  Level of injury : Zone 1  Tendon has

Level of injury: Zone 1

surgery- related factors 83  Level of injury : Zone 1  Tendon has a small

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

Loss of

even small amount of

excursion can be

functionally limiting.

Prone to adhesions

to

the

A 4

&

A 5

weakening of the repair.

pulley &

Injury- & surgery- related factors

84

Injury- & surgery- related factors 84  Level of injury : Zone 2 “No Man’s Land”

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

84  Level of injury : Zone 2 “No Man’s Land”  So many structures leading

So many structures leading to adhesions:

o

between FDP & FDS;

o

between tendon & sheath; &

o

between tendon & bony, vascular, & other soft tissue structures.

Injury- & surgery- related factors

85

Injury- & surgery- related factors 85  Level of injury : Zone 2 “No Man’s Land”

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

85  Level of injury : Zone 2 “No Man’s Land”  If repair is delayed

If repair is delayed or if injured while finger is

 If repair is delayed or if injured while finger is flexing  Tendon retracts 
 If repair is delayed or if injured while finger is flexing  Tendon retracts 

flexing Tendon retracts The tendon must be retrieved Intraoperative trauma.

The tendon must be retrieved  Intraoperative trauma.  repair is delayed  Tendon may shorten

repair is delayed Tendon may shorten Tendon repaired under tension.

If

 Intraoperative trauma.  repair is delayed  Tendon may shorten  Tendon repaired under tension.

Injury- & surgery- related factors

86

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

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

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

Damage to pulleys compromise function. Injury to vincula compromise nutrition.

 Injury to vincula  compromise nutrition.  Loss of few mms of tendon excursion considerable

Loss

of

few

mms

of

tendon

excursion

considerable functional deficit.



Injury- & surgery- related factors

87

Injury- & surgery- related factors 87  Level of injury : Zone 3  Susceptible to

Level of injury: Zone 3

surgery- related factors 87  Level of injury : Zone 3  Susceptible to adhesions to

Susceptible

to

adhesions

to

adjacent

tendons,

lumbricals, & interossei, & overlying fascia & skin.

Injury- & surgery- related factors

88

Injury- & surgery- related factors 88  Level of injury : Zone 4  At risk

Level of injury: Zone 4

surgery- related factors 88  Level of injury : Zone 4  At risk for adhesions

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.

Injury- & surgery- related factors

89

Injury- & surgery- related factors 89  Level of injury : Zone 5  Commonly become

Level of injury: Zone 5 Commonly become markedly adherent to overlying skin & fascia (generally are not problematic?).

skin & fascia (generally are not problematic?).  Adhesions between tendon connective tissue). &

Adhesions

between

tendon

connective tissue).

&

paratenon

(loose

Injury- & surgery- related factors

90

Injury- & surgery- related factors 90  Level of injury : Zone 5  Adhesion formation

Level of injury: Zone 5

surgery- related factors 90  Level of injury : Zone 5  Adhesion formation is often

Adhesion formation is often very heavy!

Because of limited vascularity stimulates formation of adhesions to supply nutrition to the healing tendon.

Injury- & surgery- related factors

91

Injury- & surgery- related factors 91  Type of injury : Crush or blunt injuries 

Type of injury: Crush or blunt injuries

factors 91  Type of injury : Crush or blunt injuries  Infection may prolong the

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).

Injury- & surgery- related factors

92

Injury- & surgery- related factors 92  Type of injury : Partial laceration  Partial laceration
Injury- & surgery- related factors 92  Type of injury : Partial laceration  Partial laceration

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.

Injury- & surgery- related factors

93

 Type of injury : Retracting tendon

Type of injury: Retracting tendon

related factors 93  Type of injury : Retracting tendon  Vincula may be ruptured or

Vincula may be ruptured or stretched impairing

 Vincula may be ruptured or stretched  impairing vascularity.  Tendon retrieval may be traumatic

vascularity.

Tendon retrieval may be traumatic to the tendon & surrounding sheath.

Injury- & surgery- related factors

94

Injury- & surgery- related factors 94  Type of injury : Finger position when injured 

Type of injury: Finger position when injured

94  Type of injury : Finger position when injured  A given point on the

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).

Injury- & surgery- related factors

95

Injury- & surgery- related factors 95   Sheath integrity : Pulleys Injury to pulleys 
Injury- & surgery- related factors 95   Sheath integrity : Pulleys Injury to pulleys 

Sheath integrity: Pulleys

Injury to pulleys decrease mechanical advantage

of the tendon.

 decrease mechanical advantage of the tendon.  Injury to pulleys  pumping mechanism (synovial

Injury to pulleys pumping mechanism (synovial diffusion) is diminished.

Injury- & surgery- related factors

96

Injury- & surgery- related factors 96  Surgical techniques : tissue     Intraoperative

Surgical techniques:

tissue

related factors 96  Surgical techniques : tissue     Intraoperative increased adhesions. trauma
 


Intraoperative

increased

adhesions.

trauma

hematoma

inflammatory

increased

response

Therefore, tissue must be handled delicately (even marks of the forceps on the epitenon can trigger

adhesion formation).

Injury- & surgery- related factors

97

Injury- & surgery- related factors 97  Surgical techniques :  Suture may strangulate the intratendinous

Surgical techniques:

& surgery- related factors 97  Surgical techniques :  Suture may strangulate the intratendinous vessels

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.

Injury- & surgery- related factors

98

Injury- & surgery- related factors 98  Surgical techniques :  Strong mobilization.  Strength of

Surgical techniques:

& surgery- related factors 98  Surgical techniques :  Strong mobilization.  Strength of the

Strong

mobilization. Strength of the suture is proportional to the number of strands crossing the repair. Bulky sutures added resistance to the tendon drag.

early

sutures

give

the

chance

for

Injury- & surgery- related factors

99

Delayed repair 
Delayed
repair

Timing of repair:

factors 99 Delayed repair   Timing of repair : scar to surrounding tissue & must

scar to

surrounding tissue & must be dissected free before

tendon

ends

will

repair.

be dissected free before tendon ends will   repair. Delayed repair  the entire musculotendinous

Delayed repair the entire musculotendinous unit shortens tension on the repair higher risk of

 the entire musculotendinous unit shortens  tension on the repair  higher risk of gapping
 the entire musculotendinous unit shortens  tension on the repair  higher risk of gapping

gapping or rupture.

Injury- & surgery- related factors

100

Injury- & surgery- related factors 100  Timing of repair :  Shortening  contractures. increase

Timing of repair:

& surgery- related factors 100  Timing of repair :  Shortening  contractures. increase the

Shortening contractures.

increase the risk of

later flexion

Therapy- related factors

101

 Timing:
 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.

Therapy- related factors

102

 Timing:
 Timing:

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

In severely

postoperative dressing.

Therapy- related factors

103

 Technique:
 Technique:

Not every tendon injury can be treated with the

identical protocol.

The best approach is a combination of techniques from various protocols.

Therapy- related factors

104

 Expertise:
 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.

Therapy- related factors

105

 Expertise:
 Expertise:
Therapy- related factors 105  Expertise:  It is extremely vital to have a full understanding

It is extremely vital to have a full understanding of rationale for treatment in tendon management.

106 POSTOPERATIVE MANAGEMENT PROTOCOLS

Immobilization, early passive mobilization, & early active mobilization.

107 ZONES 1 4 IMMOBILIZATION

Part 6

Rationale and indications

108

Early mobilization protocols are appropriate for:

Alert,

motivated,

patients

who

understand

the

exercise program & precautions.

patients who understand the exercise program & precautions. Therefore, immobilization is indicated for: 

Therefore, immobilization is indicated for:

Rationale and indications

109

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.

Rationale and indications

110

Significant soft tissue injury or concomitant crush injuries.

111

Immobilization protocol

111 Immobilization protocol  This protocol is based on that developed by Cifaldi Collins & Schwarze

This protocol is based on that developed by Cifaldi Collins & Schwarze.

on that developed by Cifaldi Collins & Schwarze .  This protocol includes several techniques &

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:
 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.

113

Early stage (from 0 to 3 or 4 weeks)

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 .

Early stage (from 0 to 3 or 4 weeks)

Early stage (from 0 to 3 or 4 weeks) 114
Early stage (from 0 to 3 or 4 weeks) 114

114

Early stage (from 0 to 3 or 4 weeks)

115

Early stage (from 0 to 3 or 4 weeks) 115  Exercise 1 :  Literature

Exercise 1:

Early stage (from 0 to 3 or 4 weeks) 115  Exercise 1 :  Literature

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.

Early stage (from 0 to 3 or 4 weeks)

116

Early stage (from 0 to 3 or 4 weeks) 116  Exercise 2 :  At

Exercise 2:

Early stage (from 0 to 3 or 4 weeks) 116  Exercise 2 :  At

At home, patient perform ROM exercise to elbow & shoulder to prevent stiffness & weakness.

Early stage (from 0 to 3 or 4 weeks)

117

Early stage (from 0 to 3 or 4 weeks) 117  Exercise 3 :  To

Exercise 3:

Early stage (from 0 to 3 or 4 weeks) 117  Exercise 3 :  To

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.

Early stage (from 0 to 3 or 4 weeks)

118

Early stage (from 0 to 3 or 4 weeks) 118  Exercise 4 :  After

Exercise 4:

Early stage (from 0 to 3 or 4 weeks) 118  Exercise 4 :  After

After prolonged protection in MCP flexion, patient develops intrinsic tightness. Thus, protected intrinsic stretch is performed at therapy visits.

flexed maximally while MPs are held in

o Wrist

neutral & IPs are gently flexed passively.

Early stage (from 0 to 3 or 4 weeks)

119

Intrinsic muscles pass

volar to MPs

& dorsal to

IPs therefore

they flex MPs

& extend IPs.

4 weeks) 119 Intrinsic muscles pass volar to MPs & dorsal to IPs therefore they flex

Early stage (from 0 to 3 or 4 weeks)

120

Maximum

lengthening

of intrinsic muscles is achieved by

MP extension

& IP flexion

(intrinsic

minus)

120 Maximum lengthening of intrinsic muscles is achieved by MP extension & IP flexion (intrinsic minus)

Early stage (from 0 to 3 or 4 weeks)

121

Early stage (from 0 to 3 or 4 weeks) 121  Exercise 5 :  Sutures

Exercise 5:

Early stage (from 0 to 3 or 4 weeks) 121  Exercise 5 :  Sutures

Sutures

after

surgery, within 48 hours of suture removal, scar massage would help control skin & tendon adhesions.

usually

removed

10-14

days

are

o Gentle clockwise & counterclockwise massage with lotion.

Early stage (from 0 to 3 or 4 weeks)

122

Early stage (from 0 to 3 or 4 weeks) 122  Exercise 6 :  Uncommonly,

Exercise 6:

Early stage (from 0 to 3 or 4 weeks) 122  Exercise 6 :  Uncommonly,

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:
 Splint:

The DBS is modified to bring the wrist to neutral.

Patient exercise.

is taught to remove

the splint

hourly for

Intermediate stage (starting at 3 to 4 weeks)

124

Intermediate stage (starting at 3 to 4 weeks) 124  Exercise 1 :  Passive exercise

Exercise 1:

Intermediate stage (starting at 3 to 4 weeks) 124  Exercise 1 :  Passive exercise

Passive exercise detailed in the previous stage.

Intermediate stage (starting at 3 to 4 weeks)

125

Intermediate stage (starting at 3 to 4 weeks) 125  Exercise 2 :  With the

Exercise 2:

stage (starting at 3 to 4 weeks) 125  Exercise 2 :  With the wrist

With the wrist in 10 0 extension, the patient performs:

o

10 repetitions of passive digit flexion & extension,

followed by;

o

10 repetitions of active differential tendon gliding exercises (DTGE).

126

Intermediate stage (starting at 3 to 4 weeks)

DTGE

127

Intermediate stage (starting at 3 to 4 weeks)

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

to

surrounding tissue. o Full fist: max. FDP glide in relation to surrounding tissue. o Hook fist: max. differential gliding between FDS & FDP.

o Straight

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

FDS

glide

in

relation

max.

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

128

Intermediate stage (starting at 3 to 4 weeks)

3 4 days after these exercises, tendon function is evaluated;

Total the degrees of passive flexion at MP & IP joints = A.

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

1.

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

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

2.

3. A – B = Z.
3. A – B = Z.

Intermediate stage (starting at 3 to 4 weeks)

129

Intermediate stage (starting at 3 to 4 weeks) 129 If Z > 50 0 then Patient

If Z > 50 0 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: 
 Splint:

The DBS is discontinued.

4 to 6 weeks) 130  Splint:  The DBS is discontinued. If extrinsic flexor tightness

If extrinsic flexor tightness is noted, a forearm-based

If extrinsic flexor tightness is noted, a forearm-based  palmar night splint is fitted, holding wrist

palmar night splint is fitted, holding wrist & fingers in

max. comfortable extension, splint is then serially adjusted to accommodate for any improvement in

extension.

Late stage (starting at 4 to 6 weeks)

131

Late stage (starting at 4 to 6 weeks) 131  Within 1 week, if improvement is

Within 1 week, if improvement is not noted, dynamic

 Within 1 week, if improvement is not noted, dynamic or static progressive extension splint may

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

if PIP flexion contracture is developed (not uncommon in zone 2 injuries), serial cylinder casting may

may be needed.

Late stage (starting at 4 to 6 weeks)

132

Late stage (starting at 4 to 6 weeks) 132
Late stage (starting at 4 to 6 weeks) 132

Late stage (starting at 4 to 6 weeks)

133

Late stage (starting at 4 to 6 weeks) 133  Exercises 1 & 2 : 

Exercises 1 & 2:

(starting at 4 to 6 weeks) 133  Exercises 1 & 2 :  Passive exercise

Passive exercise & active differential tendon gliding exercise detailed in the previous stages.

Late stage (starting at 4 to 6 weeks)

134

Late stage (starting at 4 to 6 weeks) 134  Exercise 3 :  Gentle blocking

Exercise 3:

Late stage (starting at 4 to 6 weeks) 134  Exercise 3 :  Gentle blocking

Gentle blocking exercises for isolated FDP & FDS glide (4-6 times a day for 10 repetitions).

Isolated

in

extension, thus preventing FDS glide, while FDP

functions alone to flex the DIP joint.

FDP

gliding:

MP

&

PIP

joints

held

Late stage (starting at 4 to 6 weeks)

135

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.

Late stage (starting at 4 to 6 weeks)

136

Late stage (starting at 4 to 6 weeks) 136

Late stage (starting at 4 to 6 weeks)

137

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.

Late stage (starting at 4 to 6 weeks)

138

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.

Late stage (starting at 4 to 6 weeks)

139

Late stage (starting at 4 to 6 weeks) 139  Exercise 4 :  After 1

Exercise 4:

Late stage (starting at 4 to 6 weeks) 139  Exercise 4 :  After 1

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.

Late stage (starting at 4 to 6 weeks)

140

o Gentle putty squeeze;  No more than 10 repetitions with the lightest putty. 1
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.

Late stage (starting at 4 to 6 weeks)

141

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

Late stage (starting at 4 to 6 weeks)

142

o

o

o

Here is some tips to help you decide:

Here is some tips to help you decide:

Greater resistance more muscle contraction

stretch tendon adhesions improve gliding.

 stretch tendon adhesions  improve gliding. Excessive resistance may rupture a tendon even as late

Excessive resistance may rupture a tendon even as late as 3 months after repair.

The more adherent the tendon, the safer it is to apply resistance to glide.

Late stage (starting at 4 to 6 weeks)

143

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.

Late stage (starting at 4 to 6 weeks)

144

Patients may overdo resistive exercise, this can:

o Provoke

stiffness. o Develop trigger. Therapist must warn patient & routinely palpate for triggering at the A 1 pulley.

&



inflammation

increased

fibrosis

Late stage (starting at 4 to 6 weeks)

145

Late stage (starting at 4 to 6 weeks) 145  Treating adhesion problems : allow greater

Treating adhesion problems:

allow greater

glide,

145  Treating adhesion problems : allow greater glide, To the aim is to gradually 
145  Treating adhesion problems : allow greater glide, To the aim is to gradually 

To

the aim

is to gradually

: allow greater glide, To the aim is to gradually  lengthen adhesions not to break
: allow greater glide, To the aim is to gradually  lengthen adhesions not to break

lengthen adhesions not to break them, breaking adhesions is an internal trauma that will lead to

greater fibrosis & more adhesions.

Late stage (starting at 4 to 6 weeks)

146

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.

Late stage (starting at 4 to 6 weeks)

147

E.g., in case of extensive FDP & FDS adhesions of 3 fingers in zones 2 through 4.

all could be placed at maximum

MP

&

IP joints

extension to stretch adhesions.

Late stage (starting at 4 to 6 weeks)

148

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,

addressed with

frequent blocking, putty scarping, or sustained grip activities.

limitations

in

flexion

could

be

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

Late stage (starting at 4 to 6 weeks)

149

E.g., if FDS tendons are adherent! DIP extension splint may be worn during active & resistive exercise to aid in eliciting FDS gliding.

Late stage (starting at 4 to 6 weeks)

150

NMES may be used to provoke a stronger muscle contraction.

This would be appropriate within 1 week of initiating resisted exercise.

Late stage (starting at 4 to 6 weeks)

151

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.

Late stage (starting at 4 to 6 weeks)

152

Scar retraction is also another technique. The therapist retracts the skin at the adhesion site proximally & passively extends fingers.

retracts the skin at the adhesion site

The patient

distally & actively makes differential tendon gliding

exercises.

ZONES 1 TO 3 EARLY PASSIVE MOBILIZATION: MODIFIED

153 DURAN

Part 7

Rationale and indications

154

Early mobilization:

Inhibits restrictive adhesions formation.

Promotes intrinsic healing & synovial diffusion.

Produces a stronger repair.

Rationale and indications

155

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.

156

Duran & Houser

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.

157

Duran & Houser

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: 
Splint:
Early stage (from 0 to 4.5 weeks) 158 Splint:   DBS, wrist in 20 0

DBS, wrist in 20 0 of flexion & MP in a relaxed position of flexion.

Early stage (from 0 to 4.5 weeks)

159

Exercise 1: 
Exercise 1:
Early stage (from 0 to 4.5 weeks) 159 Exercise 1:   Duran & Houser found

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:

Early stage (from 0 to 4.5 weeks)

160

Early stage (from 0 to 4.5 weeks) 160 o With MP & PIP flexed, the DIP

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).

Early stage (from 0 to 4.5 weeks)

161

Early stage (from 0 to 4.5 weeks) 161
Early stage (from 0 to 4.5 weeks) 161

Intermediate stage (from 4.5 to 7.5 or 8 weeks)

162

Splint: 
Splint:
stage (from 4.5 to 7.5 or 8 weeks) 162 Splint:   After 4.5 weeks, the

After 4.5 weeks, the splint is replaced with a wrist

band to which a rubber band traction is attached.

Intermediate stage (from 4.5 to 7.5 or 8 weeks)

163

Intermediate stage (from 4.5 to 7.5 or 8 weeks) 163
Intermediate stage (from 4.5 to 7.5 or 8 weeks) 163

Intermediate stage (from 4.5 to 7.5 or 8 weeks)

164

Exercise 1: 
Exercise 1:

Active

extension

exercises

begin

limitations imposed by the wrist band.

within the
within
the

Intermediate stage (from 4.5 to 7.5 or 8 weeks)

165

Exercise 2: 
Exercise 2:

At 5.5 weeks,

Wrist band is removed.

Active flexion is initiated.

Blocking.

FDS gliding.

Differential tendon gliding fisting.

flexion is initiated.  Blocking.  FDS gliding.  Differential tendon gliding fisting.

Late stage (staring at 7.5 to 8 weeks)

166

Late stage (staring at 7.5 to 8 weeks) 166  Resisted flexion waits until 7.5 to

Resisted flexion waits until 7.5 to 8 weeks.

The programs is upgraded following the principles

explained earlier in the immobilization protocols.

167

Surgical procedure

A

two-strand

flexor

tendon

repair

may be
may
be

performed to initiate an early passive ROM

program such as the Modified Duran Program.

168

3 days postoperation

168 3 days postoperation  The bulky compressive dressing is removed.  A light compressive dressing

The bulky compressive dressing is removed.

A light compressive dressing is applied to the hand

& forearm along with digital level fingersocks or Coban TM .

3 days postoperation

169

Fingersocks
Fingersocks
3 days postoperation 169 Fingersocks Coban T M

Coban TM

3 days postoperation 169 Fingersocks Coban T M

3 days postoperation

170

A DBS is fitted for continual wear:

Wrist: 20 degrees flexion.

MPs: 70 degrees flexion.

IPs: full extension.

is fitted for continual wear:  Wrist: 20 degrees flexion.  MPs: 70 degrees flexion. 

171

3 days postoperation

171 3 days postoperation  Modified Duran exercise program is initiated within the restrains of the

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. digit.

of

composite flex. & ext. of the entire

172

3 days postoperation

172 3 days postoperation  It is important to place equal emphasis on the passive extension

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.

173

3 days postoperation

173 3 days postoperation  If limited passive flexion is noted, a dynamic flexion assist may

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

10 – 14 days postoperation 174  Within 48 hours following suture removal scar massage with

Within 48 hours following suture removal scar massage with lotion may be initiated, along with Elastomer TM , Otoform K TM , or Rolyan 50/50 TM .

10 14 days postoperation

175

Otoform K TM
Otoform K TM
10 – 14 days postoperation 175 Otoform K TM Rolyan 50/50 T M

Rolyan 50/50 TM

10 – 14 days postoperation 175 Otoform K TM Rolyan 50/50 T M

10 14 days postoperation

176

10 – 14 days postoperation 176  The continued within the restrains of the DBS. modified

The

continued within the restrains of the DBS.

modified

Duran

passive

exercises

are

3½ weeks postoperation

177

The

modified

Duran

passive

3½ weeks postoperation 177  The modified Duran passive exercises are continued within the restrains of

exercises

are

continued within the restrains of the DBS. Active exercise within the DBS may be initiated.

178

4 weeks postoperation

178 4 weeks postoperation  NMES may be added to the therapy program after the patient

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.

4½ weeks postoperation

179

4½ weeks postoperation 179  The DBS is removed every 1-2 hours to begin AROM exercises

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.

5½ weeks postoperation

180

The DBS is discontinued.

AROM

exercises

described

continued.

at

weeks are
weeks
are

Patient education is vital:

at 4½ weeks are  Patient education is vital:  A tight sustained fist with or

A tight sustained fist with or without weighted resistance greatly increase the risk of rupture

during the early healing of the flexor tendon

repair.

181

6 weeks postoperation

Passive extension exercises are initiated.

Blocking, FDS gliding, differential tendon gliding

 Blocking, FDS gliding, differential tendon gliding  fisting may be initiated. Blocking is not permitted


fisting may be initiated.

Blocking is not permitted to the little finger.
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).

182

6 weeks postoperation

182 6 weeks postoperation  Dynamic extension splinting may be initiated if a PIP joint flexion

Dynamic extension splinting may be initiated if a

PIP joint flexion contracture develops.

183

8 weeks postoperation

183 8 weeks postoperation  Resisted flexion may be initiated.  The programs is upgraded following

Resisted flexion may be initiated.

The programs is upgraded following the principles

explained earlier in the immobilization protocols.

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

10 12 weeks postoperation

184

10 – 12 weeks postoperation 184  Patients may begin to use the involved hand in

Patients may begin to use the involved hand in all

activities of daily living.

14 16 weeks postoperation

185

14 – 16 weeks postoperation 185  Heavy, weighted resistance to the hand & upper extremity

Heavy, weighted resistance to the hand & upper

extremity is permitted after 14 16 weeks.

186

Considerations

186 Considerations  The greatest achievements in ROM are obtained between 3 ½ & 7 ½

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.

187

Considerations

187 Considerations  Digital nerve repairs, in conjunction with flexor tendon repairs, may require positioning

Digital nerve repairs, in conjunction with flexor

tendon repairs, may require positioning the PIP

initially in 30 0 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.

188

Considerations

188 Considerations  For PIP joint flexion contractures to the little finger, it is highly recommended

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.

ZONES 1 3 EARLY ACTIVE MOBILIZATION: TENODESIS

189 PROGRAM

Part 8

Rationale and indications

190<