- Discussion:
- initial postop plaster splint holds the wrist in 20 deg flexion, MP joints in at least 60 deg flexion, and digits should be held in extension inorder to avoid contractures;
- motion is begun after a few days, once it is clear that the wounds are healing well;
- early motion is started to decrease tendon adhesions & to improve digit motion;
- active extension and passive flexion of the tendons are begun within 24hrs;
- a 4 strand core suture w/ a locked running epitendinous repair should allow light active tendon motion;
- typically 10 times per hour;
- between these sessions of hourly exercises and while the pt is asleep IP joints of fingers & thumb are maintained in extension by rubber band traction;
-
tendon excursion:
- 9 cm of tendon excursion may occur w/ simultaneous wrist and finger flexion, where as only 2.5 cm of tendon excursion occurs w/ isolated digital motion;
- FDS Motion: flex PIP joint w/ the adjacent joints held in extension;
- FDP Motion: immobilize the PIP joint and flex the DIP joint;
- Kleinert Splint:
- combines dorsal extension block w/ rubber-band traction proximal to wrist;
- this passively flexes the fingers, and the patient actively extends within the limits of the splint;
- originally, included a nylon loop placed thru the nail, and around the nail is placed a rubber band;
- rubber band is inserted into the dressing (via paper clip), over distal radius;
- this passively flexes fingers, & pt actively extends w/ in limits of the splint;
- originally, rubber bands were applied for only 1-2 hrs / day, inorder to avoid finger flexion contractures;
- Brooke Army Hospital Splint:
- uses rubber band traction to passively flex the fingers, but traction is thru pulley at distal palmar crease, which increases passive flexion at the IP joint;
- during active extension exercises, pt is instructed to hold MP joint in flexed position and then to extend fully IP joints;
- full excursion of IP joints is obtained while tendon is protected;
-
modified splint:
- wrist and MP joints are held flexed (20 deg short of full flexion);
- straps are placed at forearm, wrist, MP joints;
- rubber band and nylon suture extend from nail to MP joint strap to the forearm strap;
- when performing active extension exercises, the patient holds the MP joint in flexion;
- it is important the the patient concentrate on fully extending the PIP joint (inorder to avoid contracture);
- patient should perform hourly active extension exercises;
- Passive Motion: (used in conjunction w/ Kleinert or Brooks splint)
- patient needs to perform twice daily passive motion inorder to achieve full extension and flexion;
- passive motion should also focus on individual ROM of the DIP and PIP joints, in order to maximize the excursion of the FDP and FDS, respectively;
- some surgeons insist that the patient be seen everyday for 2 weeks to ensure compliance;
- passive motion should continue beyond 2 weeks if the patient lacks full active extension;
- Medications:
- three meds have been shown to decrease adhesions in animal studies;
-
ibuprofen, beta amino propionitrile, and
steroids;
- Effects of Time on Tendon Healing:
- strength duration curve show that healing is weak at 21 days, but of sufficient strength to tolerate active contraction of muscle;
- at 6 weeks, external elastic traction can be applied if force is not excessive;
- some surgeons allow gentle active ROM at 6 weeks;
- at 3 months, moderate stress can be applied to the flexor tendon in both flexion and extension;
- at 8 months, full tensile strength has been recovered;
Influences of the protected passive mobilization interval on flexor tendon healing. A prospective randomized clinical study.
Effects of constant mechanical tension on the healing of rabbit flexor tendons.
Tendon excursions after flexor tendon repair in zone. II: Results with a new controlled-motion program.
The correlation between controlled range of motion with dynamic traction and results after flexor tendon repair in zone II.
Early postoperative mobilization of flexor tendon injuries using a modification of the Kleinert technique.
The rupture rate of acute flexor tendon repairs mobilized by the controlled active motion regimen.
Flexor tendon repair in zone 2 followed by controlled active mobilisation.
Early active mobilisation following flexor tendon repair in zone 2
A combined regimen of controlled motion following flexor tendon repair in "No Man's Land." Plastic and Reconstructive Surgery, Vol 79, No 3. March, 1987.
