Postoperative Management of Flexor Tendon Injuries

POSTOPERATIVE MANAGEMENT OF FLEXOR TENDON INJURIES
Ahmad A. Fannoon, Hand Therapist
What are we learning?

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Fundamental tendon management. Flexor tendon anatomy, biomechanics, mechanism of nutrition & healing. Three approaches to tendon management, with protocols.
The Process of HTs treating FTIs

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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.
FUNDAMENTAL CONCEPTS
Part 1
Goal: a strong repair that glides freely

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

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Therefore, our goal for the tendon is: To heal without rupture or gap formation, with sufficient strength & excursion for daily activities
Evaluating tendon function

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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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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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Adherent tendons exhibits some excursion, however limited, the entire excursion may be taken up by flexion of a single joint.
PIP MCP DIP *AF Limited Composite flex. N/A Limited Composite ext. N/A Limited
FDP Adherent Adherent
Held passively in extension Left free
*AF: active flexion.

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The PIP can be extended completely when the wrist & MCP are flexed.

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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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When MCP & wrist extended, the PIP cant be extended, indicating adhesions in the palm, or at the level of MCP or proximal phalanx.
ROM restrictions problem solving

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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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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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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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Extend wrist and MCP and repeat PIP flexion.

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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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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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Tendon adhesions should restrictions in two directions.
cause
some
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.

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

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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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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

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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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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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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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ANATOMY
Part 2
Zones
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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

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Zones apply to the two finger flexors (FDS & FDP) and the single extrinsic thumb flexor (FPL).
Zone 5
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Musculotendinous junction in the distal third of the forearm.
Zone 4
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Carpal tunnel. Synovial sheaths. Lubrication. Nutrition. Protection. Carpal ligament.
Zone 3 & T3
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Ulnar & radial bursae. Lumbricals
Zone 2 & T2
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FDS insertion.
Separate digital synovial sheaths
Zone 2 & T2
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Digital synovial sheaths. Pulleys: annular & cruciate. Vinculi. Campers Chiasma
Zone 2 & T2 / APs

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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.
Zone 2 & T2 / CPs

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C1 located between A2 & A3 pulleys. C2 located between A3 & A4 pulley. C3 located between A4 & A5 pulley.
Zone 2 & T2
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Zone 2 Pulleys: A1-A3. C1-C2. Zone T2 Pulleys: A1. Oblique.
Zone 2 & T2
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The pulleys function as restraints or guides to the tendons. Without the pulleys, the tendon would pull away from bone with each muscle contraction.
Zone 2 & T2
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Research data revealed A2 & A4 pulleys are most important for achieving normal tendon function.
Zone 2 & T2
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Vinculia: folds of mesotenon carrying blood supply to flexor tendon (later).
Zone 2 & T2
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Zone 2 vincula: Vinculum longus & vinculum brevis to FDS. Vinculum longus to FDP.
Zone 2 & T2
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Chiasma of camper: space created by the FDS allowing FDP to go through.
Zone 1 & T1
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FDP insertion.
FDS insertion.
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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NUTRITION
Part 3
Nutrition
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Blood supply to the flexor tendon: Proximal vessels entering musculotendinous junction. at the
Less important sources
Distal vessels entering at the bony insertion of the tendon. Vessels in the surrounding tissues.
Most important source
Nutrition
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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.
Nutrition
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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.
Nutrition
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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.
Nutrition
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In zone 2 (relative avascularity), tendon nutrition comes from two sources: The blood supply.
Synovial diffusion.
Nutrition
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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?
Nutrition
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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!).
Nutrition
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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?.
Nutrition
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Why adhesions?
Bringing additional blood supply to the tendon necessary for the healing process. Limits tendon gliding.
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TENDON HEALING
Part 4
Tendon histology
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Tendon consists of connective tissue, & its 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

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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).
Factors influencing wound healing

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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.
The wound healers

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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

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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 fibroblasts. stimulates growth & migration of

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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.

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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).

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Continue Phase 3 The randomly oriented collagen fibers, under the influence of stress, is slowly replaced by newly formed collagen oriented along the long axis of the tendon, Thus providing tensile strength.
Nutrition needed for wound healing

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Calories to provide energy for wound healing. Carbohydrates for fibroblastic movement and leukocyte activity. Protein for fibroblast synthesis of collagen Vitamin A is needed in the inflammatory stage. Vitamin C for collagen synthesis. Zinc for collagen and protein synthesis. H2O to maintain hydration.
Adhesions in the 3rd stage

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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

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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

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1. 2. 3.
3 possible mechanisms of tendon healing are described in the literature: Extrinsic healing. Intrinsic healing. Combination of both.
Extrinsic healing
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Tendon has no active role in the healing process, whereas adhesions formation is vital to tendon healing. Adhesions provide blood supply & cells (fibroblasts) needed for tendon healing + limit tendon gliding.
Intrinsic healing
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Relies on the synovial fluid for nutrition & does not result in restricted motion of the tendon. The cells needed for tendon healing are supplied by the epitenon & endotenon itself.
Combination of intrinsic & extrinsic

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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

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Protected early mobilization repaired tendon function: Better tensile strength. Better excursion.
creates
better
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FACTORS AFFECTING HEALING & REHABILITATION
Part 5
Patient related factors

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Age: Number of vincula decreases as the patient grows older. Cell aging could lead to decreased healing capacity of tenocytes.

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General health & healing potential: Better health lead better healing. Lifestyles & dietary habits, e.g.: Cigarettes & Caffeine vasoconstriction. Healthy food & sport better blood supply & nutrition.

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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 motivation: Patient education is key. Adherence to home program is critical.

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Socioeconomic factors: No health insurance / no income / supporting a family but is unable to work? Unsupportive patients family? Living alone?
Injury- & surgery- related factors

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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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o o o
Level of injury: Zone 2 No Mans Land So many structures leading to adhesions: between FDP & FDS; between tendon & sheath; & between tendon & bony, vascular, & other soft tissue structures.

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Level of injury: Zone 2 No Mans 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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Level of injury: Zone 2 No Mans 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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Level of injury: Zone 3 Susceptible to adhesions to adjacent tendons, lumbricals, & interossei, & overlying fascia & skin.

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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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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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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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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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Type of injury: Partial laceration Partial laceration is better than complete laceration because vascularity generally will be better preserved. Should partial laceration be repaired? Tendon catches to the sheath Triggering/entrapment - rupture.

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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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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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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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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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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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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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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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Timing of repair: Shortening increase the risk of later flexion contractures.
Therapy- related factors

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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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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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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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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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Expertise: It is extremely vital to have a full understanding of rationale for treatment in tendon management.
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POSTOPERATIVE MANAGEMENT PROTOCOLS

Immobilization, early passive mobilization, & early active mobilization.
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ZONES 1 4 IMMOBILIZATION
Part 6
Rationale and indications

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Early mobilization protocols are appropriate for: Alert, motivated, patients who understand the exercise program & precautions.
Therefore, immobilization is indicated for:

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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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Significant soft tissue injury or concomitant crush injuries.
Immobilization protocol
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This protocol is based on that developed by Cifaldi Collins & Schwarze. This protocol includes several techniques & concepts applicable to all flexor tendon management, regardless of the approach used.
Early stage (from 0 to 3 or 4 weeks)

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o o o
Splint: Dorsal blocking splint (DBS): Wrist: 10 30 degrees of flexion. MCPs: 40 60 degrees of flexion. IPs: full extension. Worn 24 hours a day except for therapy visits 1-2 a week.

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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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Exercise 1: Literature shows that 3 days postoperative is the ideal time frame to initiate edema control. 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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Exercise 2: At home, patient perform ROM exercise to elbow & shoulder to prevent stiffness & weakness.

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Exercise 3: To protect the hand small joints from getting stiff, therapist removes the splint for gentle protected PROM as follows: Therapist holds adjacent joints in flexion while extending & flexing each joint.

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Exercise 4: After prolonged protection in MCP flexion, patient develops intrinsic tightness. Thus, protected intrinsic stretch is performed at therapy visits. Wrist flexed maximally while MPs are held in neutral & IPs are gently flexed passively.

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Intrinsic muscles pass volar to MPs & dorsal to IPs therefore they flex MPs & extend IPs.

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

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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. Gentle clockwise & counterclockwise massage with lotion.

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Exercise 6: Uncommonly, bulky & raised scars may develop. 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)

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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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Exercise 1: Passive exercise detailed in the previous stage.

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Exercise 2: With the wrist in 100 extension, the patient performs: 10 repetitions of passive digit flexion & extension, followed by; 10 repetitions of active differential tendon gliding exercises (DTGE).

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DTGE

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DTGE elicit max. total & differential flexor tendon glide at wrist/palm level. Straight fist: max. FDS glide in relation to surrounding tissue. Full fist: max. FDP glide in relation to surrounding tissue. Hook fist: max. differential gliding between FDS & FDP.

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1.
2.
3.
3 4 days after these exercises, tendon function is evaluated; Total the degrees of passive flexion at MP & IP joints = A. Total the degrees of active flexion at MP & IP joints = B. A B = Z.

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If Z > 500 then Patient is moved on to the next stage of therapy Else Patient continues with the current phase of therapy until 6 weeks after repair End if
Late stage (starting at 4 to 6 weeks)

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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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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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Exercises 1 & 2: Passive exercise & active differential tendon gliding exercise detailed in the previous stages.

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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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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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Blocking exercises can be dangerous for a newly healed tendon if not performed correctly; 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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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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Exercise 4: After 1 week of blocking exercises, if active flexion did not improve, the following exercises are added: Towel walking (flexing fingers individually in turn to gather a towel on a flat surface). Light pick-ups.

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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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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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Here is some tips to help you decide: Greater resistance more muscle contraction stretch tendon adhesions improve gliding. 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.

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Smoothly gliding tendon should not receive even light resistance until 7 8 weeks of repair. 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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Patients may overdo resistive exercise, this can: Provoke inflammation increased fibrosis & stiffness. Develop trigger. Therapist must warn patient & routinely palpate for triggering at the A1 pulley.

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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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o o o o o
Several techniques are available: Extension Splinting. Blocking exercises (with or without resistance). Differential tendon gliding. Friction massage. NMES. U/S.

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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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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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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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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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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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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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ZONES 1 TO 3 EARLY PASSIVE MOBILIZATION: MODIFIED DURAN
Part 7

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Early mobilization: Inhibits restrictive adhesions formation. Promotes intrinsic healing & synovial diffusion. Produces a stronger repair.

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Research found that measurable passive excursion occurs with passive IP flexion. Research also found a significant correlation between early passive IP flexion & later active flexion measured in long-term follow-up.
Duran & Houser

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A DBS is applied at surgery (wrist & MP flexed, IPs free or allowed to extend to neutral within the splint). The DBS allows passive flexion of fingers but limits extension beyond the limits of the splint.
Duran & Houser

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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)

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Splint: DBS, wrist in 200 of flexion & MP in a relaxed position of flexion.

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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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With MP & PIP flexed, the DIP is passively extended (moving the FDP repair distally away from the FDS repair). 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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Intermediate stage (from 4.5 to 7.5 or 8 weeks)

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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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Exercise 1: Active extension exercises begin within the limitations imposed by the wrist band.

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Exercise 2: At 5.5 weeks, Wrist band is removed. Active flexion is initiated. Blocking. FDS gliding. Differential tendon gliding fisting.
Late stage (staring at 7.5 to 8 weeks)

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Resisted flexion waits until 7.5 to 8 weeks. The programs is upgraded following the principles explained earlier in the immobilization protocols.
Surgical procedure
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A two-strand flexor tendon repair may be performed to initiate an early passive ROM program such as the Modified Duran Program.
3 days postoperation
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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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Fingersocks
CobanTM
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A DBS is fitted for continual wear: Wrist: 20 degrees flexion. MPs: 70 degrees flexion. IPs: full extension.
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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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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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If limited passive flexion is noted, a dynamic flexion assist may be added to the volar portion of the DBS.
10 14 days postoperation
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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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Otoform KTM
Rolyan 50/50TM
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The modified Duran passive exercises continued within the restrains of the DBS.
are
3 weeks postoperation
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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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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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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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The DBS is discontinued. AROM exercises described at 4 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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Passive extension exercises are initiated. Blocking, FDS gliding, differential tendon gliding fisting may be initiated. Blocking is not permitted to the little finger. 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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Dynamic extension splinting may be initiated if a PIP joint flexion contracture develops.
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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
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Patients may begin to use the involved hand in all activities of daily living.
14 16 weeks postoperation
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Heavy, weighted resistance to the hand & upper extremity is permitted after 14 16 weeks.
Considerations
186
The greatest achievements in ROM are obtained between 3 & 7 weeks. It is important to emphasize to the patient active participation in the therapy program during the crucial 4 weeks. Patient will continue to make gains though for up to 6 months by using their hand normally.
Considerations
187
Digital nerve repairs, in conjunction with flexor tendon repairs, may require positioning the PIP initially in 300 flexion & gradually increasing extension from 3 to 6 weeks. If the surgeon can report that the digital nerve was repaired with no tension this is ideal for allowing full passive excursion of the tendon.
Considerations
188
For PIP joint flexion contractures to the little finger, it is highly recommended to initiate an extension splint between exercise sessions & at night. There is a greater propensity for a flexion contracture to be difficult to resolve at the little finger, especially when laceration is located at the PIP volar plate.
189
ZONES 1 3 EARLY ACTIVE MOBILIZATION: TENODESIS PROGRAM
Part 8

190
Some of the best early passive mobilization results come when patients cheat & add a little active motion

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.

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.
Alert!
193
Early active mobilization is only appropriate if: Both therapist & surgeon possess skill & experience in tendon management. Therapist & surgeon communicate closely. The suture used was of adequate strength. The patient reliable & understands the program thoroughly.
Protocols
194
Several protocols are available: Coventry protocol. Active mobilization (Allen/Loma Linda). Active mobilization (Belfast & Sheffield). Active-hold/place-hold mobilization (Strickland / Cannon) / Tenodesis Program. Active-hold/place-hold mobilization (Silfverskoild & May). Active-hold/place-hold mobilization (Evans & Thompson) / guidelines, not a protocol.
Introduction
195
This protocol is an active-hold or place-hold active mobilization protocol. The digits are passively placed in flexion, & the patient then maintains the flexion with a gentle muscle contraction. Patients learn to use only minimal force by using biofeedback to monitor the strength of the contraction (< 10 mV on a Cyborg model).
Early stage (from 0 to 4 weeks)

196
Splints:
o o o
A DBS is fitted for continual wear: Wrist: 200 flexion. MCP: 650-700 flexion. IPs: full extension.

197
o o
Splints:
A tenodesis splint is fitted: A dynamic hinge serves as the wrist component. The hinge allows full wrist flexion & limits wrist extension to a max. of 300 extension. The MPs are positioned in 700 flexion & IPs in full extension (finger flexion is allowed).

198
DBS
Tenodesis Splint

199
Exercise 1: Every hour, patients perform the Strickland version of Modified Duran exercises: 25 repetitions of PROM to the PIP & DIP joints and the entire digit within the DBS.

200
Exercise 2: Following the Strickland version of Modified Duran exercises, the patient perform the tenodesis exercises within the tenodesis splint.

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).

202
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.

204
Exercise 1: The tenodesis exercises continue every 2 hours with 25 repetitions.

205
Exercise 2: Following the tenodesis exercises, 25 repetitions of active flexion & extension exercise for the wrist & digits (avoiding simultaneous wrist & digit extension).

206
Exercise 3: FDS gliding.

207
Exercise 4: At 5 6 weeks, blocking & hook fist may be initiated to improve tendon gliding.
Late stage (from 7 to 8 weeks)

208
Splint: The DBS is discontinued.

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.

210
10 12 weeks, patients may begin to use the involved hand in all activities of daily living.

211
Heavy, weighted resistance to the hand & upper extremity is permitted after 14 16 weeks.
212
ZONES 4 & 5: MOBILIZATION PROGRAM

Part 9
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.
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
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.
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.
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.
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.
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.
220
Unrestricted AROM exercises are performed to the wrist and digits. Emphasis is placed on isolated blocking of the FDS and FDP.
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.
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.
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.
224
Progressive strengthening may be upgraded to hand weights for the wrist.
10 12 weeks postoperative
225
During this time frame splinting can typically be discontinued. The patient may return to unrestricted use of the hand in all activity.
Considerations
226
Once active exercises are initiated at the 3 week point, it is critical to emphasize blocking exercises along with the composite active flexion exercises. If the patient is having difficulty recapturing active flexion, it is important to carefully monitor the ROM & encourage frequent therapy appointments in order to maximize flexion. The 3 to 7 weeks time frame is critical for maximizing tendon excursion.
Considerations
227
Concomitant median and/or ulnar nerve repairs at the wrist require special consideration. If the nerves have been repaired the wrist is initially placed in 300 of flexion and increased 100 of extension each week, during the 4th & 5th weeks.
Considerations
228
If the ulnar nerve has been repaired, it is important to block the MP joints of the ring and small finger from hyperextension and secondary clawing. the median nerve have been repaired, a night web spacer is recommended to avoid a potential web space contracture secondary to the denervation of the thenar muscles.
Considerations
229
If both nerves are repaired, the MP block should include all digits.
Considerations
230
It is important to emphasize scar management. It is not uncommon for the flexor tendons to become somewhat adherent to the skin and subcutaneous tissues. Performing scar retraction by securing a piece of Dycem just proximal to the repair site can be effective as the patient attempts to both flex &/or extend the digits.
Considerations
231
It is not uncommon for the patient to continue to regain active flexion for 6 months following the repairs.
232
Thank you
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Postoperative Management of Flexor Tendon Injuries

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Postoperative Management of Flexor Tendon Injuries

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POSTOPERATIVE MANAGEMENT OF FLEXOR TENDON INJURIES

Ahmad A. Fannoon, Hand Therapist

What are we learning?

The Process of HTs treating FTIs

Goal: a strong repair that glides freely

Goal: a strong repair that glides freely

Goal: a strong repair that glides freely

Goal: a strong repair that glides freely

Goal: a strong repair that glides freely

Goal: a strong repair that glides freely

Goal: a strong repair that glides freely

Goal: a strong repair that glides freely

Evaluating tendon function

Evaluating tendon function

Evaluating tendon function

FDP Adherent Adherent

Held passively in extension Left free

*AF: active flexion.

Evaluating tendon function

Evaluating tendon function

Evaluating tendon function

ROM restrictions problem solving

ROM restrictions problem solving

ROM restrictions problem solving

To check for this type of tightness:

ROM restrictions problem solving

Extend wrist and MCP and repeat PIP flexion.

ROM restrictions problem solving

ROM restrictions problem solving

ROM restrictions problem solving

Tendon adhesions should restrictions in two directions.

ROM restrictions problem solving

ROM restrictions problem solving

Joint related restrictions:

ROM restrictions problem solving

there was no adhesion,

Three Approaches to Tendon Management

Three Approaches to Tendon Management

Three Approaches to Tendon Management

Flexor tendon zones

Musculotendinous junction in the distal third of the forearm.

Carpal tunnel. Synovial sheaths. Lubrication. Nutrition. Protection. Carpal ligament.

Ulnar & radial bursae. Lumbricals

Separate digital synovial sheaths

Zone 2 & T2 / APs

Zone 2 & T2 / CPs

Zone 2 Pulleys: A1-A3. C1-C2. Zone T2 Pulleys: A1. Oblique.

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

Chiasma of camper: space created by the FDS allowing FDP to go through.

Most important source

Research studies found that:

Peacock one-wound concept

Factors influencing wound healing

The wound healers

Phases of tendon healing

Phase 1 Exudative or inflammatory phase

Phases of tendon healing

Phase 2 Fibroplasia phase

Tropocollagen are randomly oriented creating a network.

Phases of tendon healing

Phase 3 Remodeling phase

3 weeks 6 months or 1 year.

Phases of tendon healing