die klinik für handchirurgie - southampton hand course
TRANSCRIPT
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Klinik für
Handchirurgie
Central Slip Rehabilitation
Natascha Weihs Cert. Hand Therapist DAHTH
Dept. of Hand Surgery - Bad Neustadt / Saale
10th Wessex Instructional Hand Course For Surgeons And
Therapists
15th May 2015
Chilworth Manor, Southampton
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• 1995 Establishment of the association
• 620 members
• Member of „European Federation of
Societies for Hand Therapy“ (EFSHT)
and „International Federation of
Societies for Hand Therapists“ (IFSHT)
• Cooperation partner of
German Society of Hand Surgery (DGH)
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Annual Congress DGH and
DAHTH
www.dahth.de
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Rehabilitation after extensor tendon
injuries at the PIP joint
• Problem
– Immobilization
• Adhesions
– Mobilization
• Insuffinciency of
Ext.Tendon
• Risk of rupture
Skylla und Charybdis
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Post-treatment methods after
extendor tendons injuries
• Immobilization
• Dynamic mobilization
– passive stretching
– active bending
– „reversed Kleinert-regime“
• Active Mobilization
– SAM (Early active Short Arc
Motion ) protocol
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Extension of the PIP- joint
Extrinsic muscles Intrinsic muscles
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Dorsal aponeurosis
Dorsal aponeurosis
Intrinsic Extensors
Extrinsic Extensors
Pars lateralis des Tr.
intermedius
Pars medialis des Tr. lateralis
Lamina triangularis
aus Schmidt, Lanz
Lamina intertendinea
Ligg. retinaculare obliquum and
transversum (Landsmeer)
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Anatomy worse 8-10 weeks small, 3mm static
Post-tre
atm
ent p
rincip
le
Tendon s
lidin
g a
mplitu
de
Imm
obiliz
atio
n p
erio
d
Blo
od flo
w
better 4-6 weeks big, 40mm dynamic
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The higher the glide
amplitude, the greater the
restriction of movement
because of adhesions
Extrinsic
Extensors
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Zones
zone 1+2
Verdan
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Special features of the zone 3 and 4
Wide contact zone
between bone and
tendon Schmidt H.-M., Lanz U.
(2003)
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Indications
• Fresh isolated injuries of the zones 3 and 4
• Fresh combined injuries of the zones 3 and 4, mobilization according to the SAM- protocol, associated injuries permitting
• Reconstructions of the extensor tendons of the zones 3 and 4
• Surgically treated bony avulsions of the Tractus intermedius
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Zone 3 Closed injuries
-> difficult to diagnose
Clinical evidence test:
Incomplete PIP joint extension
„Table edge test“
MRI?
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Zone 3 Mechanism of injury:
- Closed injuries
- Open violation
- Defect injury
Clinical evidence:
Lack of PIP joint extension
In older injuries the
development of a
boutonniere deformity is
possible
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Therapy:
- with fresh closed injuries
- with boutonnaire deformity without contracture
8 weeks PIP joint in extension with
free DIP joint
Zone 3
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Zone 4
• Usually incomplete transection after
laceration injuries
• Often only slight extension deficit
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= standardized treatment concept
Follow-up treatment zone 3 and 4
Evans R.B.-1995
Quelle: www.indianriverhandrehab.com
SAM – Protocol
Short Arc Motion
Central slip
Lateral bands
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Aims
• Protection of the tendon suture
• Avoiding of tendon adhesions
by allowing of the early active mobilization in
a small, slowly increasing range of motion
• Prevention of PIP- contractures
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Requirements
• Good patient compliance
• Willingness to attend regular
follow-up appointments
• No associated injuries early post-
operative treatment contraindecated
• pre-operative: passive extension of
PIP joint
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Splint treatment
1 resting splint 2 exercise splints
- Starts from the 2nd post-operative day
- Over a period of 6 weeks
- Using 3 different splints
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Resting splint
Purpose: maintain the PIP- and DIP joint in 0°
extension to protect the suture
Wearing time: full-time, remove for exercice only
6 weeks day and night
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Exercise splint 1 – Blocking
• PIP- joint at 30° Flex – (weekly increase 10°!)
• DIP-joint at 20-25° Flex
– Exercise frequency • 20x / waking hour
– Position to train • wrist in 30° flexion
• MP-joint at 0°
Evans R.B., Early short arc motion for the repaired central slip. J Hand Surg 1994, 19A: 991 - 997
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Exercise splint 2 – Immobilization
• PIP at 0°
– Blocking • DIP at 30 – 35° Flex,
But only when lateral bands were repaired
• Otherwise DIP – joint free
– Exercise frequency • 20x / waking hour
– Position to train • Wrist at 30° Flexion
• MP-joint at 0°
Evans R.B., Early short arc motion for the repaired central slip. J Hand Surg 1994, 19A: 991 -
997
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SAM – increase movement
• Reducing the blocking for the
flexion of the PIP-joint
– Up to 40° after 2 weeks
– Up to 50° after 3 weeks
Requirement:
Full active extension of the PIP- joint
• Exercise splints worn for 4 weeks
• Exercises without resistance,
starting position: wrist 30° flexion, MP joint in extension
• Resting splint worn in full-time in exercise-free time for 6
weeks
Evans RB, Thompson DE (1993) !
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SAM-Protocol
!! Often no further treatment necessary !!
After 6 weeks:
• Mobilization multi-joint
• Enhance tendon gliding
• Work for full fist-circuit
• Conserving the extension
• Stress only after 12 weeks
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Result after 6 weeks
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After 2 weeks… if needed
alternativ scheme
Dynamic splint when not reaching a full active
extension at the PIP- joint
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Conclusion
SAM – Protocol
is a convincing concept
• Consideration:
– High compliance of the patient and
– Special expertise of the therapy team and
– Monitoring with regular and frequent follow-
up appointments are
absolutely necessary!
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World congress
2019 in Berlin
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Thank you