Early mobilisation of acute middle slip injuries

EARLY

MOBILISATION

OF

ACUTE

F. G. O’DWYER

MIDDLE

SLIP

INJURIES

and D. N. QUINTON

From the Ro_valInfirmary, Leicester After operative repair, the conventional management of open injuries to the middle slip of the extensor tendon involves prolonged immobilisation of the P.I.P. joint. We report our results using controlled mobilisation with a Capener splint after two weeks rigid splintage. In a series of 99 patients seen soon after injury, 88% had excellent or good results after six months. Poor results were more common in patients with complex joint injuries and in patients who did not comply with the treatment. We advocate early mobilisation following repair of the middle slip. Journal of Hand Surgery (British Volume, 1990) 15B: 404-406 It is important that all lacerations over the back of the P.I.P. joint are explored because there may be damage to the middle slip of the extensor tendon. Following repair of the middle slip, the conventional management has involved rigid splintage of the P.I.P. joint in extension for four to six weeks. Immobilisation is achieved either using a rigid splint (Doyle, 1988), a Kirschner wire or a combination of both (McFarlane and Hampole, 1973), followed by controlled mobilisation. Immobilisation is associated with the development of adhesions. Lindsay et al. (1960) showed that in flexor tendons, the development of adhesions at the site of repair may compromise the tendon repair. Gelberman et al. (1983) showed that adhesions that develop between the repaired tendon and the surrounding tissues are reduced by restricting the period of post-operative immobilisation. Verdan (1975) suggested that in this area of the finger, failure was seldom due to the giving way of the suture-line, but more often to the absence of sliding and the development of stiffness in extension. Indeed McFarlane and Hampole (1973) recommended reducing the period of absolute immobilisation in older patients to two weeks, to help them regain full flexion. As the aim of treatment is to restore extension while preserving a full range of motion, we decided to try early controlled mobilisation of the finger following operative repair of the middle slip. Material and methods All patients with extensor tendon injuries are dealt with in the accident and emergency department. Patients presenting with lacerations over the proximal phalanx and interphalangeal joint are explored in the minor operations theatre. Most wounds are explored within 24 hours. Patients receive pre-operative antibiotic cover. If more than 50% of the middle slip is divided, the tendon is repaired using a braided suture. The finger is then splinted in full extension, using a volar plaster slab. After ten to fourteen days, the sutures are removed and early controlled mobilisation begun using a spring coil dynamic P.I.P. extension splint (Capener), after suitable advice has been given to the patient. Patients are followed 404

up at two- to three-week intervals for up to eight weeks. If the patient has regained a full range of movement of their finger at eight weeks, he is discharged from the clinic with suitable instructions. For the purpose of this trial, patients were assessed at eight weeks and at a final review more than six weeks after injury. We used parameters similar to those used by Souter (1967) in assigning the patients into functional categories based on the flexion and extension of the involved finger (Table 1). Patients were considered to have a good result if they had an extension deficit of less than 20” and more than 80% of flexion at the P.I.P. joint and a distance of less than 2.5 ems. from the tip of the flexed finger to the distal palmar crease. Results 99 patients with middle slip injuries were treated in the department in the period from January 1987 to August 1989. 65 had complete division of the middle slip; the remainder had lacerations involving more than 50% of the tendon. The index or middle finger was affected in 64 patients. 90 of the patients were operated upon within 24 hours of sustaining their injury. The mean age was 32.5 years, with a range from 16 to 73 years. Most patients were young, 55 being aged between 16 and 30 years. Eight patients had their injuries complicated by an osteochondral fracture. One patient. h,ad a fracturesubluxation of the P.I.P. joint and two had skin loss over

Table l-Assessment Functional category

Excellent Good Fair Poor

of function Extensor loss at P.I.P. joint (degrees)

Distance from tip ofjexedjinger to distalpalmar crease (mms.)

Flexion at P.I.P. joint (% of normal)

Cl0 <20 <40 >40

120 <25 <40 >40

>90 280 >I5 17.5

THE

JOURNAL

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HAND

SURGERY

EARLY

MOBILISATION

OF ACUTE

SLIP INJURIES

the rigid splint and tore the repair and the last one, who had also partially-divided the lateral bands, would not mobilise his finger. Of the six patients who had a fair result, three had full extension of their finger but lacked full flexion. Three patients had sustained an osteochondral fracture. 22 patients did not wear the splint for the full period recommended, discarding their splint after two to four weeks. Interestingly these patients had no subsequent problems, although two were noted to be developing a boutonniere deformity. This was corrected by wearing a Capener splint and they had no sign of a deformity at eight weeks. As this was mainly a young population, we were interested to see how soon they were able to return to work. The mean time off work was 4.2 weeks (65 patients) with a range of 0 to 12 weeks.

the P.I.P. joint. None of these eight patients was in the excellent category at follow up. At follow-up of the 99 patients, 97 were assessed at eight weeks and 88 after more than six months. The average follow-up was at 15 months. There is no longterm record in 11 patients : two were lost to follow-up, one had a poor result and eight had a very good result at eight weeks. It is unlikely that these patients would significantly alter the results. The early results were excellent or good in 70% and fair or poor in 30% of patients. The long-term results were excellent ojr good in 88.6% and fair or poor in 11.4%. At eight weeks, 16 patients had an extension deficit of 20” or more: te:n of these improved over the course of time. Five patients had an extension deficit greater than 30” at eight weeks and all did poorly. Ten patients were unable to extend their finger fully at the long-term followup but four of these had extension deficits of less than 15”. All ten patients had some extensor deficit at eight weeks and no patient whose finger could fully straighten at eight weeks returned with a problem in extending the finger. 19 patients h,ad a flexion deficit of over 20” at eight weeks and this improved in 11 patients. 14 patients were unable to flex the finger fully when reviewed later: six had a deficit of less than 10”. In all nine patients improved from the good to excellent group and 18 patients improved from the poor or fair groups to the good or excellent groups. This left ten patients in the poor or fair group (Fig. 1). Of the patients who had a poor result at long-term follow-up, one patient had a fracture-subluxation of the P.I.P. joint, one developed a septic arthritis, one took off

Discussion

>

-12 ~

MIDDLE

~

Correct splintage is very important in the management of these injuries but there is disagreement about the duration of splintage required. Biddulph (1987) states that middle slip injuries need six weeks to heal and says that any compromise raises the failure rate. Immediate protected mobilisation of extensor tendons works well for repairs on the dorsum of the hand but not fingers (Allieu et al., 1988). Most authors recommend between four to six weeks splintage (Doyle, 1988; Froehlich et al., 1988). Our results show that patients with uncomplicated middle slip injuries do very well with early controlled mobilisation. We also found that the vast majority of patients continued to improve significantly after formal treatment had ceased (Fig. 1). Comparing ours with the only substantive series, Souter (1967) found that operative repair gave 50% of satisfactory results in mixed old and new injuries. We feel that following open injury the middle slip should be repaired. Like Souter, we found that poor results were more likely in patients who had complex injuries to the P.I.P. joint. Non-compliance in the early stages of treatment was also more likely to result in a poor result. We recommend that once the skin wound has healed, controlled mobilisation using a dynamic splint be started. Patients who have a full range of movement need not be reviewed after eight weeks. References

poor Fig.

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Improvement months.

in 88 patients

1SB No. 4 NOVEMBER

1990

followed-up

for more

than

six

ALLIEU. Y.. ASENCIO. G. and ROUZAUD. J. C. Protected Dassive mobilization after king of the extensor tendons of the hand. A survey of 120 cases. In: Tubiana R. (Ed.) The Hand. Philadelphia, W. B. Saunders, 1988: Vo13: 157-166. BIDDULPH, S. L. In: McFarlane R. M. (Ed.) Unsarisfacrorv Results in Hand Surgery. Edinburgh: Churchill Livingstone, 1987: 2%25?. DOYLE, J. R. Extensor Tendons-Acute Iniuries. In: Green. D. P.. (Ed.) Operatiue Hand Surgery, 2nd edn. Edinburgh, Churchill Livingstone; i9SSl Vol. 3: 2058-2060.

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F. G. O’DWYER FROEHLICH, J. A., AKELMAN, E. and HERNDON, J. H. (1988). Extensor Tendon Injuries at the Proximal Interphalangeal Joint. Hand Clinics, 4: 1: 25-37. GELBERMAN, R. H., VANDE BERG, J. S., LUNDBORG, G. N. and AKESON, W. H. (1983). Flexor Tendon Healing and Restoration of the Gliding Surface. An Ultrastructural Study in Dogs. Journal of Bone and Joint Surgery, 65A: 1: 70-80. LINDSAY, W. K., THOMPSON. H. G. and WALKER, F. G. (1960). Digital flexor tendons: an experimental study. Part II. The significance of a gap occurring at the line of suture. British Journal of Plastic Surgery, 13 : 1: l-9. McFARLANE, R. M. and HAMPOLE, M. K. (1973). Treatment of extensor tendon injuries of the hand. Canadian Journal of Surgery, 16: 366-375. SOUTER, W. A. (1967). The Boutonni&re deformity. A review of 101 patients with division of the central slio of the extensor exoansion of the fineers. Journal of Bone and Joint Surge&&, 49B: 4: 710-721. I

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AND

D. N. QUINTON VERDAN, C. E. Primary and Secondary Repair of Flexor and Extensor Tendon Injuries. In: Flynn J. E. (Ed.) Hand Surgery, 2nd edn. Baltimore, Williams and Wilkins, 1975: 148. WILSON, K., MOORE, M. J., RAYNER, C. R. and FENTON, 0. M. (1990). Extensor tendon repair: an animal model which allows immediate postoperative mobilization. Journal of Hand Surgery, 15B: 1: 74-78.

Accepted: 22 June 1990 Frank G. O’Dwyer FRCSI, Registrar in Accident and Emergency, The Accident and Emergency Department, SWW.

The Leicester Royal Inlinnary, Infirmary Square, Leicester, LEl

0 1990 The Britnh Society for Surgery of the Hand

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JOURNAL

OF HAND

SURGERY