postoperative management of flexor tendon injuries
DESCRIPTION
POSTOPERATIVE MANAGEMENT OF FLEXOR TENDON INJURIESTRANSCRIPT
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POSTOPERATIVE
MANAGEMENT OF FLEXOR
TENDON INJURIES
Ahmad A. Fannoon, Hand Therapist
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What are we learning?
Fundamental tendon
management.
Flexor tendon anatomy,
biomechanics, mechanism of
nutrition & healing.
Three approaches to tendon
management, with protocols.
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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.
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Part 1
FUNDAMENTAL CONCEPTS 4
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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.
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Goal: a strong repair that glides freely
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.
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Goal: a strong repair that glides freely
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.
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Goal: a strong repair that glides freely
Since the newly repaired tendon has a low strength
extra care must be taken to allow for this
increased resistance during all exercises.
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Goal: a strong repair that glides freely
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).
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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.
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Goal: a strong repair that glides freely
However, the dysfunctional effect of gaps has been
found less in repairs that have been mobilized
early.
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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”
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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).
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Evaluating tendon function
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.
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Evaluating tendon function
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
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Evaluating tendon function
The PIP can be
extended completely
when the wrist & MCP
are flexed.
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Evaluating tendon function
The PIP still can be
extended completely
when the wrist is
extended, but PIP
begin to flex,
reflecting some
tightness of FDP.
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Evaluating tendon function
When MCP & wrist
extended, the PIP can’t
be extended,
indicating adhesions in
the palm, or at the
level of MCP or
proximal phalanx.
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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.
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ROM restrictions problem solving
Muscle-tendon unit tightness of the opposing
muscles.
If PIP flexion is limited this could be due to tightness
of the long extensors.
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ROM restrictions problem solving
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.
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ROM restrictions problem solving
Extend wrist and MCP and repeat PIP flexion.
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ROM restrictions problem solving
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).
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ROM restrictions problem solving
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.
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ROM restrictions problem solving
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.
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ROM restrictions problem solving
They will also be unable to lengthen properly so
extension will also be limited.
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ROM restrictions problem solving
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.
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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.
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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.
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Three Approaches to Tendon Management
Early passive mobilization: these protocols involve
passively mobilizing the repair early (within first
week) either manually or by dynamic flexion
traction.
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Three Approaches to Tendon Management
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.
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Part 2
ANATOMY 32
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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.
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Flexor tendon zones
Zones apply
to the two
finger flexors
(FDS & FDP)
and the single
extrinsic
thumb flexor
(FPL).
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Zone 5
Musculotendinous
junction in the distal
third of the forearm.
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Zone 4
Carpal tunnel.
Synovial sheaths.
Lubrication.
Nutrition.
Protection.
Carpal ligament.
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Zone 3 & T3
Ulnar & radial bursae.
Lumbricals
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Zone 2 & T2
FDS insertion.
Separate digital
synovial sheaths
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Zone 2 & T2
Digital synovial
sheaths.
Pulleys: annular &
cruciate.
Vinculi.
Camper’s Chiasma
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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.
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Zone 2 & T2 / CPs
C1 – located between A2 & A3 pulleys.
C2 – located between A3 & A4 pulley.
C3 – located between A4 & A5 pulley.
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Zone 2 & T2
Zone 2 Pulleys:
A1-A3.
C1-C2.
Zone T2 Pulleys:
A1.
Oblique.
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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.
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Zone 2 & T2
Research data
revealed A2 & A4
pulleys are most
important for
achieving normal
tendon function.
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Zone 2 & T2
Vinculia: folds of
mesotenon carrying
blood supply to
flexor tendon (later).
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Zone 2 & T2
Zone 2 vincula:
Vinculum longus &
vinculum brevis to
FDS.
Vinculum longus to
FDP.
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Zone 2 & T2
Chiasma of camper:
space created by the
FDS allowing FDP to
go through.
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Zone 1 & T1
FDP insertion.
FDS insertion.
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Zone 1 & T1
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Zone 1 includes: A4,
C3, & A5.
Synovial sheaths end
in this zone.
Zones T1 includes FPL
insertion & A2.
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Part 3
NUTRITION 50
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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.
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Less important
sources
Most important
source
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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.
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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.
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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.
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Nutrition
In zone 2 (relative avascularity), tendon nutrition
comes from two sources:
The blood supply.
Synovial diffusion.
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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?
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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!).
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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?.
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Nutrition
Why adhesions?
Bringing additional blood supply to the tendon
necessary for the healing process.
Limits tendon gliding.
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Part 4
TENDON HEALING 60
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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.
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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).
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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.
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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.
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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
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Phases of tendon healing
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
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Phases of tendon healing
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
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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Combination of intrinsic & extrinsic 75
In actual practice, adhesions are seen to varying
degrees & the healing response is probably a
balance between intrinsic & extrinsic.
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Effect of motion on tendon healing 76
Protected early mobilization creates better
repaired tendon function:
Better tensile strength.
Better excursion.
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Part 5
FACTORS AFFECTING HEALING & REHABILITATION 77
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Patient related factors 78
Age:
Number of vincula
decreases as the patient
grows older.
Cell aging could lead to
decreased healing
capacity of tenocytes.
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Patient related factors 79
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.
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Patient related factors 80
Rate & Quality of scar formation:
Rapid & heavy scar formation highly limited
excursion.
Slow & light scar formation high risk or of
rupture.
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Patient related factors 81
Patient motivation:
Patient education is key.
Adherence to home program is critical.
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Patient related factors 82
Socioeconomic factors:
No health insurance / no
income / supporting a family
but is unable to work?
Unsupportive patient’s family?
Living alone?
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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.
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Injury- & surgery- related factors 84
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.
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Injury- & surgery- related factors 85
Level of injury: Zone 2 “No Man’s Land”
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.
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Injury- & surgery- related factors 86
Level of injury: Zone 2 “No Man’s Land”
Damage to pulleys compromise function.
Injury to vincula compromise nutrition.
Loss of few mms of tendon excursion
considerable functional deficit.
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Injury- & surgery- related factors 87
Level of injury: Zone 3
Susceptible to adhesions to adjacent tendons,
lumbricals, & interossei, & overlying fascia & skin.
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Injury- & surgery- related factors 88
Level of injury: Zone 4
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.
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Injury- & surgery- related factors 89
Level of injury: Zone 5
Commonly become markedly adherent to overlying
skin & fascia (generally are not problematic?).
Adhesions between tendon & paratenon (loose
connective tissue).
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Injury- & surgery- related factors 90
Level of injury: Zone 5
Adhesion formation is often very heavy!
Because of limited vascularity stimulates formation
of adhesions to supply nutrition to the healing
tendon.
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Injury- & surgery- related factors 91
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).
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Injury- & surgery- related factors 92
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.
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Injury- & surgery- related factors 93
Type of injury: Retracting tendon
Vincula may be ruptured or stretched impairing
vascularity.
Tendon retrieval may be traumatic to the tendon &
surrounding sheath.
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Injury- & surgery- related factors 94
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).
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Injury- & surgery- related factors 95
Sheath integrity: Pulleys
Injury to pulleys decrease mechanical advantage
of the tendon.
Injury to pulleys pumping mechanism (synovial
diffusion) is diminished.
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Injury- & surgery- related factors 96
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).
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Injury- & surgery- related factors 97
Surgical techniques:
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.
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Injury- & surgery- related factors 98
Surgical techniques:
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.
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Injury- & surgery- related factors 99
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.
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Injury- & surgery- related factors 100
Timing of repair:
Shortening increase the risk of later flexion
contractures.
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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.
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Therapy- related factors 102
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.
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Therapy- related factors 103
Technique:
Not every tendon injury can be treated with the
identical protocol.
The best approach is a combination of techniques
from various protocols.
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Therapy- related factors 104
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.
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Therapy- related factors 105
Expertise:
It is extremely vital to have a full understanding of
rationale for treatment in tendon management.
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Immobilization, early passive mobilization, & early active mobilization.
POSTOPERATIVE MANAGEMENT PROTOCOLS 106
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Part 6
ZONES 1 – 4 IMMOBILIZATION 107
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Rationale and indications 108
Early mobilization protocols are appropriate for:
Alert, motivated, patients who understand the
exercise program & precautions.
Therefore, immobilization is indicated for:
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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.
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Rationale and indications 110
Significant soft tissue injury or concomitant crush
injuries.
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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.
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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.
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Early stage (from 0 to 3 or 4 weeks) 113
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 .
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Early stage (from 0 to 3 or 4 weeks) 114
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Early stage (from 0 to 3 or 4 weeks) 115
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.
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Early stage (from 0 to 3 or 4 weeks) 116
Exercise 2:
At home, patient perform ROM exercise to elbow &
shoulder to prevent stiffness & weakness.
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Early stage (from 0 to 3 or 4 weeks) 117
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.
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Early stage (from 0 to 3 or 4 weeks) 118
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.
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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.
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Early stage (from 0 to 3 or 4 weeks) 120
Maximum
lengthening
of intrinsic
muscles is
achieved by
MP extension
& IP flexion
(intrinsic
minus)
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Early stage (from 0 to 3 or 4 weeks) 121
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.
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Early stage (from 0 to 3 or 4 weeks) 122
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).
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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.
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Intermediate stage (starting at 3 to 4 weeks) 124
Exercise 1:
Passive exercise detailed in the previous stage.
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Intermediate stage (starting at 3 to 4 weeks) 125
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).
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Intermediate stage (starting at 3 to 4 weeks) 126
DTGE
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Intermediate stage (starting at 3 to 4 weeks) 127
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.
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Intermediate stage (starting at 3 to 4 weeks) 128
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.
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Intermediate stage (starting at 3 to 4 weeks) 129
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
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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.
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Late stage (starting at 4 to 6 weeks) 131
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.
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Late stage (starting at 4 to 6 weeks) 132
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Late stage (starting at 4 to 6 weeks) 133
Exercises 1 & 2:
Passive exercise & active differential tendon gliding
exercise detailed in the previous stages.
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Late stage (starting at 4 to 6 weeks) 134
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.
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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.
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Late stage (starting at 4 to 6 weeks) 136
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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.
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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.
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Late stage (starting at 4 to 6 weeks) 139
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.
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Late stage (starting at 4 to 6 weeks) 140
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.
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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
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Late stage (starting at 4 to 6 weeks) 142
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.
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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.
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Late stage (starting at 4 to 6 weeks) 144
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.
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Late stage (starting at 4 to 6 weeks) 145
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.
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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.
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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.
MP & IP joints all could be placed at maximum
extension to stretch adhesions.
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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,
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)
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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.
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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.
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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.
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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.
The patient retracts the skin at the adhesion site
distally & actively makes differential tendon gliding
exercises.
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Part 7
ZONES 1 TO 3 EARLY PASSIVE MOBILIZATION: MODIFIED
DURAN 153
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Rationale and indications 154
Early mobilization:
Inhibits restrictive adhesions formation.
Promotes intrinsic healing & synovial diffusion.
Produces a stronger repair.
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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.
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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.
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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.
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Early stage (from 0 to 4.5 weeks) 158
Splint:
DBS, wrist in 200 of flexion & MP in a relaxed
position of flexion.
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Early stage (from 0 to 4.5 weeks) 159
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:
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Early stage (from 0 to 4.5 weeks) 160
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).
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Early stage (from 0 to 4.5 weeks) 161
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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.
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Intermediate stage (from 4.5 to 7.5 or 8 weeks) 163
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Intermediate stage (from 4.5 to 7.5 or 8 weeks) 164
Exercise 1:
Active extension exercises begin within the
limitations imposed by the wrist band.
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Intermediate stage (from 4.5 to 7.5 or 8 weeks) 165
Exercise 2:
At 5.5 weeks,
Wrist band is removed.
Active flexion is initiated.
Blocking.
FDS gliding.
Differential tendon gliding fisting.
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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.
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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.
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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.
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3 days postoperation 169
Fingersocks CobanTM
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3 days postoperation 170
A DBS is fitted for continual wear:
Wrist: 20 degrees flexion.
MPs: 70 degrees flexion.
IPs: full extension.
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3 days postoperation 171
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.
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3 days postoperation 172
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.
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3 days postoperation 173
If limited passive flexion is noted, a dynamic
flexion assist may be added to the volar portion
of the DBS.
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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.
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10 – 14 days postoperation 175
Otoform KTM Rolyan 50/50TM
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10 – 14 days postoperation 176
The modified Duran passive exercises are
continued within the restrains of the DBS.
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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.
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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.
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4½ weeks postoperation 179
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.
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5½ weeks postoperation 180
The DBS is discontinued.
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.
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6 weeks postoperation 181
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).
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6 weeks postoperation 182
Dynamic extension splinting may be initiated if a
PIP joint flexion contracture develops.
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8 weeks postoperation 183
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.
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10 – 12 weeks postoperation 184
Patients may begin to use the involved hand in all
activities of daily living.
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14 – 16 weeks postoperation 185
Heavy, weighted resistance to the hand & upper
extremity is permitted after 14 – 16 weeks.
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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.
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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.
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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.
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Part 8
ZONES 1 – 3 EARLY ACTIVE MOBILIZATION: TENODESIS
PROGRAM 189
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Rationale and indications 190
“Some of the best early passive mobilization
results come when patients cheat & add a little
active motion”
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Rationale and indications 191
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.
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Rationale and indications 192
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.
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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.
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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.
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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).
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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.
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Early stage (from 0 to 4 weeks) 197
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).
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Early stage (from 0 to 4 weeks) 198
DBS Tenodesis Splint
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Early stage (from 0 to 4 weeks) 199
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.
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Early stage (from 0 to 4 weeks) 200
Exercise 2:
Following the Strickland version of Modified Duran
exercises, the patient perform the tenodesis
exercises within the tenodesis splint.
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Early stage (from 0 to 4 weeks) 201
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).
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Early stage (from 0 to 4 weeks) 202
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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.
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Intermediate stage (from 4 to 7 or 8 weeks) 204
Exercise 1:
The tenodesis exercises continue every 2 hours with 25
repetitions.
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Intermediate stage (from 4 to 7 or 8 weeks) 205
Exercise 2:
Following the tenodesis exercises, 25 repetitions of
active flexion & extension exercise for the wrist & digits
(avoiding simultaneous wrist & digit extension).
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Intermediate stage (from 4 to 7 or 8 weeks) 206
Exercise 3:
FDS gliding.
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Intermediate stage (from 4 to 7 or 8 weeks) 207
Exercise 4:
At 5 – 6 weeks, blocking & hook fist may be initiated to
improve tendon gliding.
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Late stage (from 7 to 8 weeks) 208
Splint:
The DBS is discontinued.
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Late stage (from 7 to 8 weeks) 209
At 8 weeks, 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.
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Late stage (from 7 to 8 weeks) 210
10 – 12 weeks, patients may begin to use the
involved hand in all activities of daily living.
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Late stage (from 7 to 8 weeks) 211
Heavy, weighted resistance to the hand & upper
extremity is permitted after 14 – 16 weeks.
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Part 9
ZONES 4 & 5: MOBILIZATION PROGRAM 212
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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.
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3 – 5 days postoperative 214
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
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3 – 5 days postoperative 215
Within the restraints of the DBS, composite passive
flexion and extension are performed to the digits
25 repetitions, 3 to 4 times a day.
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10 – 14 days postoperative 216
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.
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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.
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3 weeks postoperative 218
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.
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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.
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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.
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6 weeks postoperative 221
The DBS is discontinued.
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.
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6 weeks postoperative 222
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.
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6 weeks postoperative 223
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.
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7 weeks postoperative 224
Progressive strengthening may be upgraded to
hand weights for the wrist.
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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.
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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.
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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.
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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.
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Considerations 229
If both nerves are repaired, the MP block should
include all digits.
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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.
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Considerations 231
It is not uncommon for the patient to continue to
regain active flexion for 6 months following the
repairs.
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The end
Thank you 232