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Post operative care following flexor tendon grafts
Post Operative Care Following Flexor Tendon GraJts--Raoul Tubiana
POST OPERATIVE
CARE FOLLOWING
FLEXOR
TENDON
GRAFTS
R A O U L T U B I A N A , Paris In this paper our current post-operative treatment following flexor tendon grafts is outlined. DRESSING
The dressing is applied at the end of the operation and should be soft, compressive and elastic. It should include the wrist and all the fingers and is reinforced by a dorsal plaster splint. IMMOBILISATION
It is now accepted that a tendon graft should be immobilised for at least three weeks. This is necessary not only to avoid tension on the suture but also to allow for revascularisation which is so important. Thus one can allow early passive movement in a position of relaxation after flexor tendon repair in cases where the blood supply has not been significantly reduced, and this is why modern techniques favour preservation of both flexor tendons when possible. When the superficial tendon has been removed or stripped, the blood supply is compromised and the repaired profundus should be considered and treated as a graft. The position of immobilisation is that of relaxed tension which differs from that of the "position of function" and also from that adopted to gauge the graft tension at the time of suture. The position of relaxed tension is also a "position of protection" but being unphysiological cannot be maintained too long. The "position of protection" is accomplished by relaxation at the wrist, metacarpophalangeal, proximal and distal interphalangeal joints. At the wrist the amount of flexion will depend on the age of the patient. Young adults will tolerate 35 ° to 40 ° without deleterious consequences while in older patients no more than 20 ° is allowed. The metacarpophalangeal joints are the only ones that may be put in full flexion since the capsule and collateral ligaments are fully extended in that position and 80 ° is therefore desirable. On the other hand the capsule and collaterals have similar tension throughout the range of movement in the proximal interphalangeal joints except at the very extremes. For the sake of the extensor tendons full flexion should be avoided and a position of moderate flexion at about 40 ° is suggested. For the distal interphalangeal joints where recovery of extension is most difficult, no flexion is allowed. FURTHER TREATMENT
The hand is maintained in elevation for forty-eight hours and the patient remains in hospital for three to four days. Small, limited movements within the dressing are permitted. The splint is removed at three weeks but contraction against resistance is not allowed since the risk of rupture of the repairs, especially the distal one, remains for several weeks. Thus the pull-out wire is preserved for four weeks and not removed with the plaster. PHYSIOTHERAPY
Physiotherapy commences at the time of removal of the plaster and the programme should be carefully supervised by the surgeon. Co-operation between 152
The H a n d - - V o l . 6
No. 2
1974
Post Operative Care Following Flexor Tendon G r a f t s - - R a o u l Tubiana
the surgeon, physiotherapist and patient is indispensable for a good result. The surgeon must see the patient weekly for the first month and then monthly until recovery is complete. It is important to remember the principles of physiotherapy necessary for rehabilitation following tendon grafts. One must first recover:
1. 2. 3. 4. 5.
Passive flexion then active flexion without resistance then active extension then passive extension and finally active flexion against resistance. FIRST W E E K OF R E - E D U C A T I O N
The programme of the first week after removal of the plaster, i.e. the fourth week after surgery, begins by working on passive flexion in all joints. It would be unwise to try to recover full passive extension but one must not allow contractures to develop at the interphalangeal joints that will be difficult to correct later. To accomplish this, increased passive flexion of the wrist and metacarpophalangeal joints is carried out while passively extending the distal interphalangeal joints and moving the proximal interphalangeal joints between 30 ° and 90 ° of flexion. At this stage one must not extend the proximal interphalangeal joints completely even with the metacarpo-interphalangeal joints flexed, in order to avoid the production of a swan-neck deformity which is so easy in the absence of the superficial flexor. During this same period one must try to obtain a small amount of active flexion at the proximal interphalangeal joints with the metacarpophalangeal joint held in extension. This flexion is at first difficult to obtain being inhibited by fear, uneasiness and misunderstanding of instructions. It is helpful to have the patient contract the neighbouring digits and the corresponding digits of the other hand at the same time. SECOND W E E K OF R E - E D U C A T I O N
During the second week the pull-out wire is removed. Active contractions at all the proximal interphalangeal joints are continued without resistance. Extension at this joint is progressively increased, again without attempting full extension. At the distal interphalangeal joins passive movements of flexion and extension are continued, complete extension being obtained with the metacarpophalangeal and proximal interphalangeal joints flexed. T H I R D W E E K OF R E - E D U C A T I O N
In the third week active flexion of the distal interphalangeal joints begins, the proximal ones being held in extension. The recovery of active flexion of proximal interphalangeal joints also continues. Then, progressively, one encourages active flexion of all the interphalangeal joints simultaneously while restricting flexion at the metaearpophalangeal joints. This avoids improper action of the intrinsics which once established is very difficult to overcome. At this stage one must guard against the incorrect use of the extensor system which may keep the grafted finger extended when the others are flexing. The active role played by the lumbrical in this syndrome, as evidenced by Athol Parkes (1970, 1971), is well kno~vn,~ but the defect is seen even in the absence of lumbricals. It is a protective reflex in which the patient contracts the extensors The H a n d - - V o l . 6
No. 2
1974
153
Post Operative Care Following Flexor Tendon Gra]ts--Raoul Tubiana
when the injured flexors are used. The surgeon and physiotherapist will require patience and all their persuasive powers, and the patient's co-operation is indispensable. At times a local anaesthetic block of the ulnar nerve at the wrist will suppress flexion of the metacarpophalangeal joints by the interossei temporarily and allow the patient to appreciate the action of the graft. At the same time splints or serial corrective plasters used between periods of exercise will obtain full extension of all joints as shown by Wynn Parry (1973). F O U R T H W E E K OF R E - E D U C A T I O N
In the fourth week, flexion and extension exercises against resistance are begun. Extension, both active and passive, should now be complete. Occupational therapy at this stage is very useful, being adapted to each case according to the sensation of the digit. It benefits the patient to make a partial return to work at two months, even if flexion is still incomplete as is always the case. The intensive phase of re-education in a Centre is now complete and the patient must continue his exercises on his own being checked weekly at the Centre, and seen monthly by the surgeon. REFERENCES
PARKES, A. R. (1970) The "Lumbrical Plus" Finger. The Hand, 2: 164-165. PARKES, A. R. (1971) The "Lumbrical Plus" Finger. Journal of Bone and Joint Surgery, 53B: 236-239. WYNN PARRY, C. B. (1973) Rehabilitation of the Hand. Third Edition, London, Butterworths.
154
The Hand--Vol. 6
No. 2
1974
POST OPERATIVE
CARE FOLLOWING
FLEXOR
TENDON
GRAFTS
R A O U L T U B I A N A , Paris In this paper our current post-operative treatment following flexor tendon grafts is outlined. DRESSING
The dressing is applied at the end of the operation and should be soft, compressive and elastic. It should include the wrist and all the fingers and is reinforced by a dorsal plaster splint. IMMOBILISATION
It is now accepted that a tendon graft should be immobilised for at least three weeks. This is necessary not only to avoid tension on the suture but also to allow for revascularisation which is so important. Thus one can allow early passive movement in a position of relaxation after flexor tendon repair in cases where the blood supply has not been significantly reduced, and this is why modern techniques favour preservation of both flexor tendons when possible. When the superficial tendon has been removed or stripped, the blood supply is compromised and the repaired profundus should be considered and treated as a graft. The position of immobilisation is that of relaxed tension which differs from that of the "position of function" and also from that adopted to gauge the graft tension at the time of suture. The position of relaxed tension is also a "position of protection" but being unphysiological cannot be maintained too long. The "position of protection" is accomplished by relaxation at the wrist, metacarpophalangeal, proximal and distal interphalangeal joints. At the wrist the amount of flexion will depend on the age of the patient. Young adults will tolerate 35 ° to 40 ° without deleterious consequences while in older patients no more than 20 ° is allowed. The metacarpophalangeal joints are the only ones that may be put in full flexion since the capsule and collateral ligaments are fully extended in that position and 80 ° is therefore desirable. On the other hand the capsule and collaterals have similar tension throughout the range of movement in the proximal interphalangeal joints except at the very extremes. For the sake of the extensor tendons full flexion should be avoided and a position of moderate flexion at about 40 ° is suggested. For the distal interphalangeal joints where recovery of extension is most difficult, no flexion is allowed. FURTHER TREATMENT
The hand is maintained in elevation for forty-eight hours and the patient remains in hospital for three to four days. Small, limited movements within the dressing are permitted. The splint is removed at three weeks but contraction against resistance is not allowed since the risk of rupture of the repairs, especially the distal one, remains for several weeks. Thus the pull-out wire is preserved for four weeks and not removed with the plaster. PHYSIOTHERAPY
Physiotherapy commences at the time of removal of the plaster and the programme should be carefully supervised by the surgeon. Co-operation between 152
The H a n d - - V o l . 6
No. 2
1974
Post Operative Care Following Flexor Tendon G r a f t s - - R a o u l Tubiana
the surgeon, physiotherapist and patient is indispensable for a good result. The surgeon must see the patient weekly for the first month and then monthly until recovery is complete. It is important to remember the principles of physiotherapy necessary for rehabilitation following tendon grafts. One must first recover:
1. 2. 3. 4. 5.
Passive flexion then active flexion without resistance then active extension then passive extension and finally active flexion against resistance. FIRST W E E K OF R E - E D U C A T I O N
The programme of the first week after removal of the plaster, i.e. the fourth week after surgery, begins by working on passive flexion in all joints. It would be unwise to try to recover full passive extension but one must not allow contractures to develop at the interphalangeal joints that will be difficult to correct later. To accomplish this, increased passive flexion of the wrist and metacarpophalangeal joints is carried out while passively extending the distal interphalangeal joints and moving the proximal interphalangeal joints between 30 ° and 90 ° of flexion. At this stage one must not extend the proximal interphalangeal joints completely even with the metacarpo-interphalangeal joints flexed, in order to avoid the production of a swan-neck deformity which is so easy in the absence of the superficial flexor. During this same period one must try to obtain a small amount of active flexion at the proximal interphalangeal joints with the metacarpophalangeal joint held in extension. This flexion is at first difficult to obtain being inhibited by fear, uneasiness and misunderstanding of instructions. It is helpful to have the patient contract the neighbouring digits and the corresponding digits of the other hand at the same time. SECOND W E E K OF R E - E D U C A T I O N
During the second week the pull-out wire is removed. Active contractions at all the proximal interphalangeal joints are continued without resistance. Extension at this joint is progressively increased, again without attempting full extension. At the distal interphalangeal joins passive movements of flexion and extension are continued, complete extension being obtained with the metacarpophalangeal and proximal interphalangeal joints flexed. T H I R D W E E K OF R E - E D U C A T I O N
In the third week active flexion of the distal interphalangeal joints begins, the proximal ones being held in extension. The recovery of active flexion of proximal interphalangeal joints also continues. Then, progressively, one encourages active flexion of all the interphalangeal joints simultaneously while restricting flexion at the metaearpophalangeal joints. This avoids improper action of the intrinsics which once established is very difficult to overcome. At this stage one must guard against the incorrect use of the extensor system which may keep the grafted finger extended when the others are flexing. The active role played by the lumbrical in this syndrome, as evidenced by Athol Parkes (1970, 1971), is well kno~vn,~ but the defect is seen even in the absence of lumbricals. It is a protective reflex in which the patient contracts the extensors The H a n d - - V o l . 6
No. 2
1974
153
Post Operative Care Following Flexor Tendon Gra]ts--Raoul Tubiana
when the injured flexors are used. The surgeon and physiotherapist will require patience and all their persuasive powers, and the patient's co-operation is indispensable. At times a local anaesthetic block of the ulnar nerve at the wrist will suppress flexion of the metacarpophalangeal joints by the interossei temporarily and allow the patient to appreciate the action of the graft. At the same time splints or serial corrective plasters used between periods of exercise will obtain full extension of all joints as shown by Wynn Parry (1973). F O U R T H W E E K OF R E - E D U C A T I O N
In the fourth week, flexion and extension exercises against resistance are begun. Extension, both active and passive, should now be complete. Occupational therapy at this stage is very useful, being adapted to each case according to the sensation of the digit. It benefits the patient to make a partial return to work at two months, even if flexion is still incomplete as is always the case. The intensive phase of re-education in a Centre is now complete and the patient must continue his exercises on his own being checked weekly at the Centre, and seen monthly by the surgeon. REFERENCES
PARKES, A. R. (1970) The "Lumbrical Plus" Finger. The Hand, 2: 164-165. PARKES, A. R. (1971) The "Lumbrical Plus" Finger. Journal of Bone and Joint Surgery, 53B: 236-239. WYNN PARRY, C. B. (1973) Rehabilitation of the Hand. Third Edition, London, Butterworths.
154
The Hand--Vol. 6
No. 2
1974