- Discussion:
- initial postop plaster splint holds the wrist in 20 degree flexion, MP joints in at least 60 degree 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 24 hrs;
- 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;
- references:
- Effects of Nonsteroidal Anti-Inflammatory Drugs on Flexor Tendon Adhesion
- 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.
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."
Ultrasonographic Assessment of Flexor Tendon Mobilization: Effect of Different Protocols on Tendon Excursion