week 23 Flexor_tendon_Injuries-_SHEENA_2010_part_1

Flexor Tendon Injuries

Restoring hand function after flexor tendon injuries continues to be one of the greatest challenges.

Related stiffness, scarring and functional impairment persist on frustrating the most experienced hand

surgeons and therapist.

Rehabilitation Goals

Promote an opportune environment for strong repair to support normal forces acting on the tendon in normal hand use

– Excessive stress in early healing may lead to rupture or attenuation

• Attenuation: tendons that are pulled apart with a gap filled with scar

Rehabilitation Goals Facilitate tendon gliding without adherence

to adjacent tissues

Rehabilitation Goals Facilitate tendon gliding without adherence

to adjacent tissue– Specific amplitude of excursion required to flex

the digit completely and with power• Active composite wrist and digital flexion required 9

cm of flexor excursion

– Adhesions to surrounding structures limit tendon function

Significant Anatomy Flexor Tendons

– Flexor digitorum superficialis

– Flexor digitorum profundus

– Flexor pollicis longus

Significant Anatomy FDS

– Origin• Humeroulnar head from the

medial epicondyle and coronary process of the ulna

• Radial head arises from proximal shaft of radius

– Insertion• Middle phalanx of each digit

– Innervation• Solely median nerve

• FDS to small finger absent in 21% of population

Tendon Healing

Phases of Healing– Inflammatory Days 1-21

• Proliferation or cells on outer edge of tendon which migrate into the tendon by day 7.

• Increased vascular proliferation in tendon occurs• Day 9- repair is as strong as the original suturing

and continues to increase.• Strength increases rapidly when tendon is stressed.• Collagen synthesis begins and quantity of collagen

stabilizes by 3 weeks

Tendon Healing Fibroplasia Phase Days 22-42

– Tensile strength increases– Able to withstand AROM at 3-4 weeks

Scar Maturation Days 43-84– Collagen synthesis reaches its max after 4

weeks however; stays active.– Active collagen synthesis allows us to

lengthen, weaken, or break adhesions over time. We are able to create a more elongated and better gliding scar.

– 5-6 weeks repair can withstand light resist.– 7-9 weeks repair can withstand heavy resist

Tendon Healing Factors affecting adhesion formation:

• Pre-op condition of tendon• Involvement of one or both tendons• Location of injury• Condition of surrounding structures• Trauma from surgical procedures• Tendon ischemia- injury to vincula• Gapping at repair site (poor repair; too much

stress on repair site)• Double tendon injuries • Patient Factors ie: age, health, scar formation,

motivation, socioeconomic factors

Tendon Healing

Controlled mobilization programs– tendons probably heal by a

combination of extrinsic and intrinsic cellular activity- the more intrinsic healing that occurs; the less peritendinous adhesions

– Early Passive Mobilization– Early Active Mobilization

Tendon Repairs Primary repair within 24 hours Delayed primary repair

– Between 24 hours and 3 weeks– Delayed by MD due to contamination

or loss of skin coverage Secondary repair

– More then 3 weeks after injury• May be extensive scarring and

muscle contracture as well as retraction of tendon ends, may require tendon grafting

Primary tendon graft• Unable to perform end to end repair

so tendon in replaced with a graft from palm to fingertip. Treatment proceeds according to Zone II guidelines which follow only delay all exercises by 1-2 weeks.

Flexor Tendon Suture Techniques

Approaches to Rehabilitation

Immobilization

Early passive mobilization

Early active mobilization

Approaches to Rehabilitation

Considerations in choice of approach:– Pt. compliance– Surgeon preference– Type of injury– Location and zone of injury– Strength of repair

Approaches to Rehabilitation

Phases of all post-op tendon protocols– Phase I

• Day 1 to Week 3-4• Tendon immobilized or

mobilized in controlled way• Includes inflammatory and

fibroplasia phases of wound healing

• Repair is at its weakest

Approaches to Rehabilitation

Phase II: Intermediate Phase– Week 4– Increase stress on tendon– Mobilize for the first time, or

decrease protection during mobilization

– Includes scar maturation phases of wound healing

Approaches to Rehabilitation

Phase III: Late Stage– Week 6-8 – Repair can withstand

resistance– Continued scar

maturation

Factors Affecting Healing and Rehab

Patient Related Factors– Age

• Decreased vinicula with ageing

– General health• Lifestyles and dietary habits can adversely

affect healing.– Cigarette smoker and coffee drinker= delayed

healing secondary to vasoconstrictive effect.

– Scar Formation rate/quality– Patient Motivation– Socioeconomic factors

Factors Affecting Healing and Rehab

Injury and Surgery-related Factors– Location of Injury

• Zone V– Tendon may adhere to overlying skin and fascia; not usually a

problem• Zone IV

– Tendons may adhere to synovial sheaths, each other and structures lying within the carpal tunnel

• Zone III– Tendons may adhere to adjacent tendons, lumbricals, interossei and

to overlying fascia and skin• Zone II

– Adhesions likely between:• FDP and FDS• Tendon and Sheath• Tendon and boney tissue• Tendon and vascualr tissue• Tendon and other soft tissue structures

• Zone I– Possible adhesions to A4 or A5 pulley repair or attenuation of the

repair• Tendon only has a normal excursion of 5-7 mm in this zone, so

small loss of excursion may be functionally limiting

Factors Affecting Healing and Rehab

Injury and Surgery-related Factors (cont.)– Type of Injury

• Crush or blunt injury• Complete vs. partial laceration• Infections• Vascularity (integrity of vinicula)

– Sheath Integrity– Surgical Technique– Timing of Repair

• The longer the tendon repair is delayed the tendon can scar down to surrounding tissues.

Factors Affecting Healing and Rehab

Therapy related factors– Timing

• Early stage is protective stage- repair is at its weakest

• Early mobilization protocol must begin therapy ASAP (24-48 hrs strengthens the repair)

• Immobilized tendon lose strength initially

– Technique• *not every tendon injury can be treated with the

identical protocol

– Expertise• Therapist skill level

Wound and Scar Care/Edema Control

Healing- sutured wound– Adaptic and Kling wrap dressing

• Changed each visit– Sutures removed 2-3 weeks– Suture line debrided with scissors and forceps

at 21 days post-op Edema Control

– Overhead elevation – Coban wrap at 1-2 weeks per MD– Finger sock; isotoner glove or digisleeve as

edema stabilizers– Increased edema = increased resistance to

tendon glide and can have an effect on safety of performing early active motion exercises

Wound and Scar Care/Edema Control

Scar care- external – 3-4 weeks initiate scar massage– Instruct on desensitization when initiating scar massage via

different textures– Scar pad at 3-4 weeks to be worn up to 23 hours for the first

2 months, then at night up to 6 months• CVS: curad scar therapy pads

Scar care- internal – Ultrasound can be used to soften scar at 8 weeks (10-12

weeks after tendon graft)– Passive stretching into extension at 6-7 weeks

• If tendon is exposed to excessive stress during early stages; tendon ends may pull apart and scar will fill the gap.

– Active exercises• Fisting• Blocking

– Scar mobilization at 4-6 weeks• Extractor• Deep myofascial release• Skin friction with active tendon glide

Approaches to Rehabilitation Immobilization

– Complete immobilization of tendon repair for 3-4 weeks

– Indicated for children < 10 years of age, or pt’s that are unable to perform complex rehab protocols

• Cognitive deficits

• Unwilling patients

– Begin active and passive motions at 4 weeks

Immobilization Early Stage: 0 – 3 or 4 weeks

– Splint• Dorsal Forearm-based blocking splint/cast

– Wrist in 10-30 degrees of flexion– MP joints in 40-60 degrees of flexion– IP joints in full extension

• Worn 24 hours/day except for therapy visits 1-2 x/week– Exercise

• AROM exercises to all uninvolved joints to prevent stiffness• Therapist provides gentle protected PROM

– Adjacent joints are held in flexion while flexing and extending each joint

– Protected intrinsic stretch exercises – Scar healing

• Cleaning of skin • Massage once sutures are removed and incision is healed

– Assists with skin and tendon adhesions• Elastomer or pressure dressings

– to flatten bulky scars

Immobilization

Intermediate Stage- starting at 3-4 weeks– Splint

• Modified to bring wrist to neutral (0 degrees)• Removed hourly for exercises

– Exercises• Passive digit flexion and extension with wrist in 10

degrees of extension performed 10 x’s• Active differential tendon gliding 10 x’s• Tenodesis exercises increasing excursion attained

(Cifdaldi Collins and Schwarze protocol)

Immobilization Late Stage: starting 4-6 weeks

– Splint is discontinued• If flexor muscle-tendon shortening

becomes a problem- nighttime extension splint may be fabricated and adjusted for continued improvements in extension

• If after 1 week improvement is noticed Dynamic or static progressive extension splint are introduced- gentle tension initially

• PIP contractures may require serial casting in zone 2 injuries

– Exercises• Blocking exercises for isolated FDP and

FDS glide– 10 repetitions 4-6 times/day

• Towel walking introduced after 1 week if active flexion not improved

• Sustained grip activities after 1 more week

• Heavy lifting not introduced until 10-12 weeks

Tendon Gliding Three ways of

making a fist– Hook

• Maximum differential glide b/w FDS and FDP

– Straight Fist• Maximum FDS

glide

– Full Fist• Maximum FDP

glide

Tendon Gliding Determine Tendon Gliding

– Compare active and passive flexion– Measurements should be taken for DIP (block

PIP in neutral) and PIP (block MP in neutral) – If measurements are 10 degrees of each other

assume tendon is gliding well– If measurements are >15 degrees different

(passive exceeds active) assume tendon is not gliding well and adhesions are restricting glide

Tendon Gliding Determine if soft tissue is shortened or adherent

– Compare measurements of a joint’s passive extension with adjacent joint first in flexion and then in extension

– Joints measured depends on site of injury Zone 3-5 measure MP extension with wrist flexed

and extended Zone 2-3 measure PIP extension with MP flexed

and extended Zone 1-2 measure DIP extension with PIP flexed

and extended – If measurements are the same the loss is a joint

problem– If measurements are different the loss is due to

adhesion or shortening of the tendon• (MP extension improves when wrist is flexed)• (PIP extension improves with MP’s flexed)• (DIP extension improves with PIP flexed)

JOINT TIGHTNESS NOT ASSOCIATED WITH TENDON SHORTENING

Considerations Patient education on rupture capabilities

throughout stages is crucial When to increase amount of resistance and

functional use is not easy- there is no rules. Understanding of tendon healing and ability to

evaluate tendon function precisely is important for progression through stages.

Ruptures can occur even as late as 3 months. More adherent the tendon the safer it is to apply

resistance to glide. Smoothly gliding tendon resistance applied with

extreme caution Trigger finger may develop through excessive

repetitive gripping/squeezing- Therapist to routinely palpate A1 pulley for triggering

Treating Adhesion Problems Restrictive adhesions are the most common

complication after immobilization of the repaired flexor tendon

Goal is to lengthen adhesion not break it! Treatment

– Dynamic extension splint– Frequent blocking, putty scraping, sustained grip

activities – NMES– US with stretch or active tendon glide– Massage

Early Passive Mobilization Produces superior results because early mobilization inhibits

restrictive adhesion formation, promotes intrinsic healing and synovial diffusion.

2 basic types of protocols– Kleinert - Rubber band traction within DBS– Duran and Houser- Passive exercise with DBS

Forearm based Dorsal blocking splint (DBS) applied at surgery– Wrist and MP joints blocked in flexion

• Places tendons on slack– IP joints are left free

• And may extend to neutral within the splint

Thermoplastic splint 1-2 weeks– Passive flexion of fingers does not allow extension beyond

limits of the splint– Dynamic traction maintains fingers in flexion to further relax the

tendon & prevents active flexion

Early Passive Mobilization Dynamic traction of Splint

– Rubber bands– Elastic threads– Sprints

Traction applied to fingernail– Placing a suture through the

nail in surgery– Gluing to fingernail

• Dress hook• Velcro• Soft leather• Moleskin• Rubber band

Early Passive Mobilization– Passively mobilize tendon repair

within first 24 hours to 1 week.– Indicated for delayed referral to

therapy > 1 week– Passive mobilization by

therapist, pt and/or dynamic flexion traction

– Passive flexion pushes tendon proximally; limited active or passive extension pulls the tendon distally

– Begin active motion at 4 weeks

Kleinert vs. Duran 0-3 days post op

– DBS– Remove compressive

dressings from fingers and allow passive flexion to palm within DBS

– Rubber band on involved digit attached to volar forearm

0-3 days post op– DBS with velcro

straps

Kleinert vs. Duran First 3 weeks

Patient encouraged to actively extend the finger and allow elastic band to passively flex digit

10x’s each hour

First 4 ½ weeks 8 reps full passive flexion

and extension of PIP joint 8 reps of full passive flexion

and extension of DIP joint 8 reps of passive flexion and

extension of in a composite manner to MCP, PIP and DIP joints

Do passive motions to the uninvolved digits to prevent stiffness

Remove velcro straps for the above exercises on hourly basis

Kleinert vs. Duran 3-6 Weeks

DBS removed Pt’s hand is maintained

in a wrist band with rubber band traction (full active extension of IP and MCP joints against rubber band with wrist in neutral

Active digital flexion is still not permitted

4 ½ Weeks Continue with 1-4 ½ week

exercises 10 reps of active flexion of

wrist with digits flexed followed by extension of wrist and digits

10 reps of composite active flexion and extension MCP, PIP and DIP joints (bend/straighten)

Exercises are performed once every hour throughout the day with DBS worn b/w exercises and at night

Kleinert vs. Duran Change of protocol

at 6 weeks 5 ½ Weeks DBS no longer used tx

plan changes:– 12 reps of active flexion

of wrist with digits flexed, followed with active extension of wrist and digits

– 12 reps of composite active digital flexion and extension

– 12 reps of blocking exercises for PIP joint (5 sec hold)

– 12 reps of blocking exercises for DIP joint (5 sec hold)

Kleinert vs. Duran 6 Weeks

Wrist band removed and active flexion can commence and tendon gliding exercises or blocking

6 Weeks Revisions:

– Passive extension of wrist and digits is allowed

– Splinting: full extension gutter or extension resting pan may be initiated

– Active and passive range of motion exercises and blocking exercises are permitted on an hourly basis

Kleinert vs. Duran 8-10 Weeks

– Progressive strengthening is initiated starting with mild resistive exercises followed by sustained grip

3 Months– Heavy resistive

exercises and return to heavy labor activities

8 Weeks– Progressive strength

building may be initiated

10 Weeks– Aggressive use of

hand with sports or heavy lifting is allowed

Early Active Mobilization Key Points

– Actively mobilize the tendon within first 24 hrs to 3 days post-op

– Only appropriate if both therapist and surgeon possess skill and experience in tendon management, communicate closely with one another and suture utilized is adequate in strength.

– Indicated for physically and cognitively competent patients

– Most aggressive approach

Active contraction of the injured flexor muscle within strict precautions– Pulling the tendon proximally should

produce better glide

Early Active Mobilization Early Stage: 0-4 or 6 weeks

– Postoperative cast• Wrist in 20 degrees flexion• MP joints at 89-90 degree of flexion• IP joints in full extension• Extends 2 cm beyond fingertips to prevent use of hand• Radial plaster wing wraps proximal to the thumb around wrist to

prevent migration distally

– Exercises• Zone 2 initiated 48 hrs post surgery• Zone 3 initiated 24hrs post surgery• Full passive flexion, active flexion and active extension

– All digits 2 repetitions every 4 hours

Goal 1st week= full passive flexion, full active extension, and active flexion to 30 degrees at PIP, 5-10 degrees at DIP.

4th week= 80-90 degrees active flexion at PIP, 50-60 degrees at DIP,

Early Active Mobilization Intermediate Stage: 4-6 weeks

– Splint • Discontinued at 4 weeks if

tendon glide is poor• Discontinued 5 weeks for most

patients• Discontinued 6 weeks for

patients with unusually good tendon gliding. (full fist within first 2 weeks of repair)

• 3 weeks post discontinuation of splints is when flexion contractures are addressed with finger based dynamic extension splints

– Exercise• Protective passive IP extension

w/ MCP in flexion• 6 weeks- tendon gliding, heavier

hand use at 8 weeks and 12 weeks full function

Active-hold/place-hold mobilization

By Strickland/Cannon– “active-hold” – “passive-place active mobilization”

• Digits are passively placed in flexion and patient attempts to maintain flexion for gentle muscle contraction

Active-hold; Passive-place 0-4 weeks

– 2 splints are utilized• Dorsal blocking splint w/20 degrees of flexion & MP

joints at 50 degrees• Exercise splint with hinged wrist, allowing full wrist

flexion with extension limited to 30 degrees. Full digit flexion and IP extension are allowed with MP extension limited to 60 degrees.

• Utilized for distal FPL repairs (zone T1) allowing IP extension to only 25 degrees to prevent deformation and problems with glide deep to the A2 pulley

– Exercise• Hourly 15 repetitions of PROM to PIP and DIP joints

and the entire digit in DBS• 25 repetitions of place –hold digit flexion in the

tenodesis splint

Active-hold; Passive-place

Intermediate Stage (4 weeks to 7-8 weeks)– Discontinue tenodesis splint. DBS worn

except for tenodesis exercises– Exercises

• Tenodesis exercises 25x every 2 hrs• Active flexion and extension 25 repetitions

avoiding simultaneous wrist and digit extension

• Week 5 or 6- blocking and hook fist added

Active-hold; Passive-place

Late Stage (starting at 7 or 8 weeks)– Splint discontinued– Exercise

• PRE’s, • ADL’s- gradually no restrictions at 14

weeks• FPL is moved more aggressively with

theraputty (7 weeks)

Tenolysis Surgical procedure to excise adhesions that limit flexor

tendon glide Original diagnosis

– Repair– Graft– Incomplete laceration– Crush– Fractures– Healed infections

Indications– Unable to achieve full gliding limiting range of motion– Progress plateaus– Flexor tendon intact– Passive flexion markedly exceeds active flexion– Restriction of passive motion into extension– Limitation of active motion relative to age, occupational

needs, and individual desires of patient

Tenolysis

After surgery– New adhesions will form– Begin active motion a.s.a.p.– Controlled stress to ensure that new

adhesions are long & elastic to allow tendon glide

– Initiate therapy within 12 hours– Tendon rupture is still a risk

Tenolysis Rehabilitation Daily treatment for first 7-10 days Post-Op eval

– Wound assessment– Pain– Edema– AROM– PROM- caution! Tendon is weak and vulnerable to rupture– Sensory testing

Edema Control– Elevation– Gentle coban wrap– CPM with hourly active exercise

Pain Control– TENS– Medication

Splinting– If patient had good extension but limited flexion pre-op

• Dorsal resting splint for 2 weeks with wrist at 30 degrees of flexion and MP, IP joints in balance flexion

– If transverse carpal ligament was released wrist in 10-20 degrees of extension for the first 2-3 weeks

Tenolysis Rehabilitation Phase I (week 1)

– Achieve/maintain A/PROM achieved in surgery

– Decrease pain– Control edema

Phase II (week 2-3)– Facilitate wound healing– Promote scar mobility– Maintain AROM– Continue edema control– Encourage functional hand use of involved

hand in light ADL’s

Tenolysis Rehabilitation Phase III (Weeks 4-6)

– AROM equivalent or greater than achieved in surgery– Increased hand strength– Eliminate residual edema

Phase IV (weeks 7 onward)– Return to work (8-12 wks post-op)– Work hardening– Job simulation– Maximize strength

References Hand Rehabilitation Foundation (March 18-21 2006) Surgery and Rehabilitation of the Hand

Conference Concurrent Sessions: Flexor Tendon Management Hospital for Special Surgery Rehabilitation Department. (October 25-26 2002) course. Elbow,

Wrist & Hand Injuries: Surgical and Therapeutic Management Hunter; Mackin & Callahan (2002). Rehabilitation of the Hand and Upper Extremity. St. Louis,

MO; Mosby, Inc. McGrouther, D.A.; Colditz, J.C.& Harris, J.M. (2001) Interactive Hand; Primal Pictures Roholt, P.K. (2001) Clinical Specialty Education: Hands on Tendon Trauma course: Flexor &

Extensor Tendon Injuries Steinberg, D.R. (1997) Flexor Tendon Lacerations in the Hand retrieved November 30, 2002 from

the World Wide Web. http://www.uphs.upenn.edu/ortho/oj/1997/oj10sp97p5.html Schneider, R.M.; (Sept 17-18, 2005) An Introduction to Hand Therapy course. Sethi, S; (December 4, 2002) Flexor Tendon Injuries presentation for Seton Hall University School

of Graduate Medical Education: Advanced Hand Seminar Skolnik, D.; (Fall Semester 2002) Advanced Hand Seminar; Seton Hall University: School of

Graduate Medical Education, South Orange, NJ The Hand Rehabilitation Center of Indiana (2001). Diagnosis and Treatment Manual for

Physicians and Therapist: Upper Extremity Rehabilitation; Fourth Edidtion. Orthoteers; Flexor Tendon Injuries of the Hand retrieved Novermber 30, 2002 from the World Wide

Web. http://orthoteers.co.uk/Nrujp~ij33lm/Orthhandtendoninj.htm Wehebe’, M. & Hunter, J.M.; (1985) Flexor Tendon Gliding in The Hand; Part I. In vivo excursions.

The Journal of Hand Surgery, 10A, No. 4, 570-579.