Hand rehabilitation after Extensor tendon

injury repair By:

Dr.Mohammed Abd AlhusseinPlastic surgeon

Baghdad university -Alkindy college of medicine

• Hand rehabilitation after extensor tendon repair differ according to injury zone .

• There are many protocols e.g. immobilization

Passive or active mobilization .Most currently used protocols are

combination of these protocols.

Injury zones

Zone I Injuries• Injuries to the distal end of the

extensor tendon mechanism in zone I are also known as mallet finger injuries

• Splinting remains the hallmark of treatment for most mallet finger injuries, especially closed injuries without subluxation of the distal phalanx.

•The mallet finger splint is best customized. To increase patient compliance and avoid the complication of tissue maceration and necrosis.•The DIP joint should be placed into slight hyperextension.•The PIP joint is left free, and immediate range-of-motion exercising of this and all other joints is continued. •All patients should be continuously splinted for 6 to 8 weeks. •After 6 to 8 weeks, the splint is removed. If there is no extensor lag, the patient is progressed to night splinting for an additional 2 weeks, after which the splint is discontinued.•If extensor lag remains, the patient is again splinted for another 6 weeks or until the extensor lag has resolved. •The patient may then need controlled active flexion exercises to regain DIP flexion.

Stack splint.

Aluminum splint.

Zone 2 Extensor Tendon Injuries

• Zone II injuries, which occur at the level of the middle phalanx of the fingers or proximal phalanx of the thumb.

• For complete tendon lacerations requiring repair, splinting protocols are similar to those for zone I mallet finger injuries.

Zone III Injuries• Zone III injuries, which occur over

the PIP joints, consist of disruption of the central slip from the base of the middle phalanx.

• In both closed injuries and postprocedure repaired central slip injuries:

• the finger is placed into a splint with the PIP joint extended and the DIP joint left free.

• At 3 weeks, the patient is placed into a spring-loaded splint, which

• allows for active PIP flexion and passive extension. The splint is worn at all times up to 8 weeks .

• Night splinting and active and passive range-of-motion

exercises are instituted between 8 and 11 weeks after the

operation.

Zone IV Injuries• the hand Immobilized in wrist

extension ,MCP joint flexion IP joint extended for 4 weeks .

• Early, controlled, active or passive range-of-motion protocols indicated in a properly selected patient only.

• Thumb zone 4 tendon large enough that can be repaired by core suture so Early, controlled, active or passive range-of-motion protocols can be initiated.

Zone V Injuries• Involve tendon laceration alone or

with sagital band laceration which could be open laceration or closed rupture.

• If tendon laceration alone which repaired by core suture then splinting the hand in wrist extension MCP joint 30 degree flexion the IPJ. Allowed for active motion .

• early motion rehabilitation can be used in selected patient with dynamic extension splinting within the limits defined at surgery.

Sagittal band injuries• Open sagital band injury repaired by

mattress suture then buddy splinting to adjacent finger for 3 weeks which allow gentle mobilization.

• closed Sagittal band injuries that do not cause EDC subluxation may be treated with “buddy taping” to an adjacent digit for 4 weeks.

• Closed Sagittal band injuries with EDC subluxation that are seen within 3 weeks of injury may be treated non operatively.

• An MP joint flexion block splint, or “sagittal band” splint, may be used to limit MP joint flexion of the involved finger.

• The splint is applied to hold the injured MP joint in 25 to 35 degrees of hyperextension compared with the adjacent MP joints. It is recommended that the splint be worn full-time for 8 weeks.

• Active motion of the MP and IP joints is permitted with the splint in place.

sagittal band splint

buddy taping

Zone 6 and 7 Injuries• Postoperatively, either static or dynamic

splinting may be employed. • Static splinting involves wrist extension of 30

to 45 degrees, MP joints at neutral to 15 degrees of flexion, and IP joints free for active range of motion.

• Dynamic splinting involves wrist extension, dynamic rubber band MP joint extension, and Active MP joint flexion to the level of repair tension determined at the time of surgery.

Zones VIII/IX • Adequate repair of muscles and tendons can

be very difficult in this area. Sutures of muscle fibers alone have virtually no tensile strength. Therefore an effort should be made to suture tendons or fascial layers instead of muscle fibers alone.

• these sutures are usually not strong enough for dynamic postoperative treatment protocols and immobilization for 3–4 weeks should be initiated postoperatively.

Standard rehabilitation in zones VI through IX injury

• Following tendon repair inpatients are placed in a static volar splint with the wrist in 30 degrees of extension, the MCP joints in 0 to 15 degrees of flexion, and the interphalangeal (IP) joints in full extension.

• The splint is worn at all times and no active or passive motion is allowed at the fingers.

• While wearing the splint, the patient may start passive MCP hyperextension exercises.

• Between 3 and 6 weeks, the patient is placed into a dynamic splint with the wrist in 30 degrees extension, the MCP is in increasing flexion, and the IP joints are held in full dynamic extension by the splint.

• Guarded active flexion is begun at the IP joints, using a volar guard to block the amount of flexion allowed.

• The static splint should be worn at night.

• Between 6 and 8 weeks, the patient may begin exercises, consisting of active digital flexion with the wrist in extension and active finger extension, out of the splint.

• Wrist flexion and extension are also begun with the fingers in a relaxed, extended posture.

• At 8 to 12 weeks postrepair, the patient is slowly weaned from the splints. Full range of motion is allowed with the avoidance of simultaneous finger and wrist flexion.

• The patient should also start light grip-strength activities.

• At 12 weeks postoperative, the patient is allowed to flex both the fingers and thewrist.

• These protocols may be advanced more quickly in the compliant patient.

Dynamic splinting• It can be used early from 2nd

postoperative day in zone 4,5,6,7 when early mobilization protocol used.

• It should be started later after 3rd week when static splint protocol used.

• It should be started later after 3rd week in zone 8,9.

• It used to the end of 8 weeks.• 10 movement in hour in a day time.

Dynamic splint for early motion of extensor tendon injuries.

Suture technique in different zones

Controlled active mobilization

• involves active joint extension.• limiting joint flexion with a palmar

splint to allow MP joint flexion to about 30 degrees.

• it is called (“short arc motion”) which used in zone III–V only.

Controlled active mobilization

• For the protocol, three finger splints are required. • The affected digit is immobilized between training sessions

in an extension split in 0° extension of the DIP and PIP joints.• At every waking hour, the splint is removed and a controlled

active motion protocol is followed.• First a splint is put on to block flexion of the PIP joint at 30°

and flexion of the DIP at 20–25°. After 20 repetitions of active and passive motion within the defined limits,

• a third splint is put on that stabilizes the PIP joint in 0° extension while sparing the DIP joint. The patient then actively extends and flexes the DIP joint 20 times.

• During the second and third week of the protocol, flexion of the PIP joint is increased to 40° and 50°

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