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Early protected motion after extensor tendon repair
Early Protected Motion After Extensor Tendon Repair Carla A. Crosby, PT, CHT, Marwan A. Wehbe´, MD, Bryn Mawr, PA Thirty hands with 50 extensor tendon lacerations, excluding mallet finger injuries, were examined. They were treated with surgical repair followed by immediate motion which included a dynamic splinting and tendon mobilization program. The average follow-up period was 7 months (range, 8 weeks to 2 years). Forty-five of the 50 tendons regained full range of motion (average total active motion, 262°) within an average time of 9 weeks; the remaining 5 tendons had extension lags of ¶10°. All patients regained at least 93% of their predicted normal strength within 9 to 12 weeks and returned to their previous level of activity in an average of 10 weeks. These results, which include complex lacerations, are an improvement from previously published data. This is probably due to the addition of a tendon mobilization program to dynamic splinting following extensor tendon repair. (J Hand Surg 1999;24A:1061– 1070. Copyright © 1999 by the American Society for Surgery of the Hand.) Key words: Early motion, dynamic splinting, extensor tendons, tendon repair.
Extensor tendon rehabilitation has been addressed less in the literature than flexor tendon injuries. Traditionally, extensor tendon injuries have been treated with immobilization, although early motion programs for these injuries have been used for years by several surgeons and therapists. Most research on early motion after extensor tendon repair has focused on proximal injuries.1–17 Reports can be found describing the result of early motion after extensor tendon repair distal to the metacarpophalangeal (MP) joint level.1,4,7,10,12,14 –16 Allieu et al1 felt that proximal injuries (zones 4 –7) did better with early motion than distal injuries. Evans7 showed that both distal and proximal repairs can do well with early motion. Hung et al10 found poor results with dynamic splinting of distal lacerations, although RolphRoeming14 reported excellent results but in a small From the Pennsylvania Hand Center, Bryn Mawr, PA. Received for publication April 27, 1998; accepted in revised form May 17, 1999. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Marwan A. Wehbe´, MD, Pennsylvania Hand Center, Reprints Department, PO Box 241, Bryn Mawr, PA 19010. Copyright © 1999 by the American Society for Surgery of the Hand 0363-5023/99/24A05-0030$3.00/0
sample size. Saldana et al15 observed better results with dynamic splinting of zone 3 injuries, while Walsh et al’s16 results favored immobilization. O’Dwyer and Quinton12 recommended early motion following the repair of central slip lacerations after reviewing the results of 97 patients. The purpose of this study was to evaluate the results of dynamic splinting with the addition of an early tendon mobilization program after extensor tendon repair and to compare the results in all the various zones of injury. Mallet finger injuries (finger zones 1 and 2) were excluded as these injuries do not lend themselves to early motion.
Materials and Methods A retrospective descriptive study was conducted in which 30 consecutive patients were examined following extensor tendon repair in finger zones 3 through 7 and all thumb zones (including T1–T3) and zones 6 and 7. All patients were treated with early passive motion and dynamic splinting. Lacerations to the wrist extensors and all hands with fractures were excluded, yielding 50 extensor tendon lacerations. The laceration sites were classified by zone (Fig. 1) and extent of injury. The extent of the lacerations was classified as incomplete, complete, or complex. The Journal of Hand Surgery 1061
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Figure 1. Extensor tendon zones and location of the 50 tendon lacerations included in this study.
The latter refers to lacerations involving the extensor retinaculum, periosteum, or joint capsule in addition to the tendon, whether complete or incomplete. The 30 patients initially presented to the Pennsylvania Hand Center between January 1986 and September 1989 and were treated by the same team of surgeons and therapists. Patients were treated with the same protected early motion protocol following extensor tendon repair. Repairs were done within 1 day of injury with the exception of 5 tendons, which were repaired between 9 and 33 days after injury. The surgical repair was accomplished with mattress, figure-of-eight, or modified Kessler sutures, depending on the level of repair and the thickness of the tendon at that level. All tendons were immobilized 1 to 5 days after surgery (average, 4 days) after which dynamic splinting and a tendon mobilization protocol was started. The splint used for injuries proximal to and including the MP joint (zones 5–7; 33 tendons) was a dorsal forearm-based dynamic splint, positioning the wrist in 20° extension.18 Rubber band traction provided passive MP extension to the neutral position and allowed active fisting (Fig. 2). The use and degree of any MP flexion blocking was determined during surgery, depending on the strength of the repair and how far the repair glided free of tension. All flexion blocks consisted of a metal washer or rivet placed on the outrigger line to prevent full flexion (Fig. 2B). Flexion blocks at 30° to 60° were used in 9 of the 33 cases. All thumb extensor tendon lacerations required a forearm-based splint. The wrist was extended 20° and the thumb was held in extension with a rubber
band and sling. For lacerations proximal to the thumb MP level, rubber band traction held the MP joint in neutral while allowing full active thumb flexion across the palm (Fig. 3). In lacerations distal to the MP joint, that joint was blocked in the neutral position and rubber band traction allowed interphalangeal (IP) joint motion only. No flexion blocks were used for thumb repairs. When the injury was in zones 3 and 4 distal to the dorsal hood sagittal bands, a dorsal hand-based dynamic splint was used (Fig. 4). The splint held the MP joint in neutral while rubber band traction provided passive proximal interphalangeal (PIP) joint extension and full gentle hook fisting. Of the 9 tendon lacerations in zones 3 and 4, 3 required PIP flexion blocks of 30° to 45°. As noted above, the use and degree of the flexion block was determined during surgery based on how far the repair glided without tension. Hand-based splinting was not used for any thumb lacerations because the thumb sagittal bands are not substantial enough to protect a distal repair of the extensor pollicis longus tendon without the support of a forearm-based splint. Patients received therapy 2 to 5 times a week until strength was fully regained. Treatment included wound care, splint adjustments, and a tendon mobilization program. The tendon mobilization program was performed by holding the digits and wrist in maximal extension while passively ranging only 1 joint at a time (Fig. 5). For example, when the PIP joint was ranged passively, the wrist and the MP and distal interphalangeal (DIP) joints were held in maximal extension. Gentle gradual force was applied by the therapist until full range of motion was obtained or until pain or resistance was encountered.5 In zones 3 and 4, mobilization of the PIP joint was performed with the wrist and the MP and DIP joints in maximum extension, thus allowing enough slack at the central slip to prevent rupture. This was done only to the degree of the flexion block. The at-home program consisted of wearing the splint full-time and the patient making an active gentle fist 10 times every waking hour within the confines of the splint. The dynamic splint was used for an average of 4 weeks. Patients were weaned from the splint over a period of 3 days. On removal of the splint, active range of motion and tendon gliding exercises were started.19 If the tendon appeared to be gliding too easily, as reflected by a digit with full range of motion and no resistance, the splint was maintained approximately 1 or 2 weeks longer in case the tendon repair was healing slower than expected (ie, fewer adhesions
The Journal of Hand Surgery / Vol. 24A No. 5 September 1999 1063
Figure 2. (A) The forearm-based dynamic splint used for extensor tendon repairs proximal to the MP joint. (B) Active fisting and flexion is blocked with a washer (arrow).
and possible rupture). A graded strengthening program was also introduced after splint removal, with progression of resistive activities until full grip and pinch strength were achieved. Range of motion was measured with a goniometer at each visit by the same therapist and total active motion (TAM) was calculated.20 Extension lag was determined as active range of motion minus passive range of motion, considering the neutral position as the reference point (excluding hyperextension). Baseline grip and pinch measurements were taken 8 weeks after surgery. Grip strength was measured with a Jamar dynamometer (Asimow Engineering, Los Angeles, CA) and pinch strength was measured with a pinch meter
(B&L Engineering, Santa Fe, CA) for pulp-to-pulp and key pinch. The highest grip reading of the 5 Jamar levels was recorded as maximum grip strength. Pulp and key pinch measurements were averaged and this value was recorded for pinch strength. This was done because neither measurement reflects extensor tendon strength, but both are indicators of overall hand strength. Both grip and pinch readings were converted to a percentage of the uninjured hand’s maximum strength. Full grip or pinch strength was defined as the dominant hand being 10% greater than the nondominant hand in right-handed people and the same as the right hand in left-handed people.21,22 An edema and scar control program was used in
1064 Crosby and Wehbe´ / Early Motion After Extensor Tendon Repair
Figure 3. The forearm-based dynamic splint used for thumb lacerations proximal to the MP joint.
the majority of the patients. Edema control included elevation, Coban wrapping (3M, St Paul, MN), pressure garments, and/or retrograde massage. Scar control included friction massage, pressure pads, ultrasound, and/or steroid phoresis.23 Nineteen tendons required additional treatment to increase motion. Starting at an average of 3 weeks after surgery, 5
tendons in zone 3 and 3 in zone 5 needed a resting extension splint. Stiffness was encountered in 6 of the 8 tendons and the resting extension splint was used at night to prevent contractures. One patient complained of pain while wearing the night dynamic splint and was allowed to wear a resting extension splint to increase sleeping comfort while protecting
Figure 4. The hand-based dynamic splint used for finger extensor tendon repairs distal to the MP joint. Note the flexion block (arrow).
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Figure 5. The tendon mobilization program for the extensor tendons: ranging the (A) PIP joint and the (B) MP joint. Note the extension of all the other joints.
the repair. In another case an extension splint was used for protection at work since the patient was unable to work with the dynamic splint. Due to limited passive IP flexion, a flexion strap was used
starting at an average of 7 weeks after surgery in 8 tendons, including zones T1, T3, 3, 5, and 7. At 4 weeks after surgery a wrist continuous passive motion machine was used approximately 4 hours per
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Although insignificant, these lacerations also had slightly less TAM and an increase in time to return to full activity. Grip strength and the recovery time to reach full grip strength were essentially the same irrespective of extent of injury. Ruptures also were not related to extent of injury. The complex thumb injuries resulted in a lower TAM score compared with the less-severe injuries (Table 1). Patients with incomplete thumb lacerations took longer to regain pinch strength than those with more extensive injuries, yet returned to regular activities sooner. None of the thumb cases had any lags or complications. In all cases, hyperextension was within 10° of the opposite thumb. At the last follow-up visit, complex thumb injuries had 98% of predicted pinch power while incomplete and complete thumb injuries had 80% of pinch power. Tendon injuries were also compared by zone of laceration (Table 2). There were 11 tendon repairs distal to the MP joint (zones T1, 3, and 4) and 39 repairs proximal to the MP joint (zones T3, 5, 6, and 7). Thumb injuries showed no difference in outcome for extension lag, grip strength, and time to full recovery compared with other zones. Distal thumb lacerations, however, excelled in range of motion (TAM) scores. There also were no significant difference in outcome with regard to the various finger zones. Total active motion scores were nearly identical for all finger zones. At the last follow-up visit, all extension lags and slightly weaker grips were found in distal zones 3, 4 and 5 injuries. The extension lags were 5° to 10° at either the MP or PIP joint level. Complications were seen in the proximal group (zones 6 and 7), in which 2 tendon ruptures occurred requiring delayed repair and 1 of which
day to improve gliding of zone 7 tendons in 1 patient who had massive adhesions at the extensor retinaculum.
Results The 30 patients were between the ages of 8 and 81 years (average age, 32 years). Twenty-six were male and 4 were female. The dominant hand was injured in 12 patients. The patients were monitored an average of 7 months (range, 8 weeks to 2 years). Nineteen patients were routinely involved in strenuous activities or heavy labor and only 3 were limited to sedentary activities. One patient had a history of pseudogout with prominent arthritic deformities in both hands. The mechanism of injury included a jagged laceration and/or crushing injury in 23 patients, a sharp laceration in 5 patients, 1 tooth injury, and 1 closed rupture. Six patients had more than 1 ray involved: 2 rays in 4 patients, 3 rays in 1, and all 5 rays in 1. Fifty tendon lacerations in the 30 patients were the subject of this study (Fig. 1). The lacerations involved every finger and thumb extensor tendons. In the finger extensors there were 14 incomplete lacerations, 13 complete lacerations, and 15 complex lacerations (Table 1). There were 8 thumb extensor lacerations: 3 were incomplete, 1 was complete, and 4 were complex. Results also reflect comlete recovery after the 2 ruptured repairs and the 1 tenolysis, with the same protocol following each. Extent of injury in the fingers resulted in no significant difference in end result, especially between incomplete and complete lacerations (Table 1). The complex finger lacerations, however, did result in 4 extension lags and 1 tenolysis due to adhesions.
Table 1. Effect of Extent of Injury on Extensor Tendon Recovery Finger Lacerations
No. of tendons TAM* Extension lag (no. of tendons) Grip strength (%)† Pinch strength (%)† Time to full grip/pinch strength (wk) Time to return to activities (wk) No. of tendon ruptures No. of tenolysis cases
Thumb Lacerations
Incomplete
Complete
Complex
Incomplete
Complete
Complex
14 262 1 92 95 14 9 1 0
13 259 0 100 94 12 8 0 0
15 255 4 91 94 12 11 1 1
3 140 0 100 83 18 4 0 0
1 145 0 88 80 7 7 0 0
4 128 0 89 98 6 7 0 0
* Average TAM in a normal finger, 260°.20 Thumb TAM varies a great deal and an average value cannot be set. † Grip and pinch strength reported as percentage of expected (see text).
The Journal of Hand Surgery / Vol. 24A No. 5 September 1999 1067
Table 2. Effect of Zone of Injury on Extensor Tendon Recovery Zone of Injury
No. of tendons TAM* Extension lag (no. of tendons) Grip strength (%)§ Pinch strength (%)§ Time to full grip/pinch strength (wk) Time to return to activities (wk) No. of tendon ruptures No. of tenolysis cases
T1–2
T3
3–4
5
6
7
5–7
2 157 0 94 81 10 8 0 0
6 126 0 99 88 8 8 0 0
9 264 2† 90 99 11 9 0 0
18 260 3‡ 88 90 12 9 0 0
6 265 0 92 95 10 8 1 0
9 260 0 100 100 16 16 1 1
33 261 3 92 94 13 11 2 1
* Average TAM in a normal finger, 260°.20 Thumb TAM varies a great deal and an average value cannot be set. † One 5° PIP and 1 10° MP. ‡ One 5° PIP, 1 10° PIP, and 1 5° MP. § Grip and pinch strength reported as percentage of expected (see text).
required a subsequent tenolysis. Using the same therapy protocol, the final outcome of the tendon requiring tenolysis was full range of motion and normal grip strength. Zone 7 injuries involving the extensor retinaculum showed an increase in time to return to full activities and to reach maximum grip strength, yet final grip strength was 100% of normal. Forty-five of the 50 tendons under study regained full excursion in an average time of 9 weeks. The 5 tendons that did not regain full excursion had minimal extension lags at the MP or PIP joint: 3 had a 5° lag and 2 had a 10° lag (Table 2). There were no limitations in flexion, with all patients able to make a full fist. Average TAM was 264° for zones 3 and 4 and 261° for zones 5, 6, and 7. Average thumb TAM was 134°. All patients returned to unrestricted activities in an average of 10 weeks. Within approximately 12 weeks, all injured fingers regained over 90% of normal grip strength. The thumbs reached over 80% of maximum pinch strength within 9 weeks (Table 1). There were 3 complications requiring reoperation: 2 for repair of tendon rupture due to lack of patient compliance to the dynamic splinting program and 1 repeat surgery for tenolysis in 1 of those 2 tendons.
Discussion Flexor tendon repairs have received attention from hand surgeons and therapists for the past 20 years. Unfortunately, extensor tendons have suffered from benign neglect due to the assumption that they do well compared with the results of flexor tendon repairs.24,25 Research on extensor lacerations has yielded a wide spectrum of results. Hauge24 con-
cluded that extensor tendon repairs always do well; however, he did not measure loss of flexion after the repairs. At the other extreme, Kelly26 and Zander17 found that extensor tendon repairs did well only under ideal conditions and that they should be taken as seriously as flexor tendon injuries. Mallet fingers consist of a disruption of the terminal tendon in the fingers. This is a small tendon that lends itself poorly to surgical repair and is usually treated by full immobilization.26,27 The thumb terminal tendon (extensor pollicis longus insertion) is more substantial and can be repaired surgically; it was therefore included in this study. The MP joint level in the thumb and fingers is an important landmark because of the dorsal hood. The sagittal bands of the dorsal hood will prevent the finger extensor tendon from retracting proximally if the laceration is distal to them. This is also true of the thumb’s sagittal bands at the MP joint level. Therefore, like the fingers, the thumb MP joint level could be considered a T5 zone rather than a T3 zone, as it has been traditionally classified.6,8,20 When comparing end results of thumb laceration, it is very difficult to compare TAM scores since thumb range of motion varies greatly among individuals and even from one hand to the other in the same person. The sagittal bands also keep the tendon repair at minimal tension, especially in the fingers, where they are more substantial. Therefore, a hand-based splint can be used safely for finger lacerations. In addition, the extensor tendon excursion decreases as the tendon reaches its insertion distally. Flexion blocks are therefore more important for the distal injuries since there is less excursion to absorb the tensile tendon forces near the
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insertion. Surgical observation should determine the flexion blocks. Flexion blocks in this study were initially set at 30°. This is supported by Evans,7 who concluded that 30° of PIP active motion allows 3.75 mm of extensor digitorum communis excursion and provides the necessary amount of gliding to allow healing and avoid adhesions in zone 3– 4 repairs. Three weeks or more of immobilization followed by therapy traditionally has been the recommended treatment for extensor tendon repairs.28 –30 After the immobilization period, full range of motion was typically achieved after 2 months of therapy and further therapy was required to return to regular activities.28,29 Several studies have critically analyzed full immobilization in the treatment of extensor tendon lacerations.6,30 –35 Recommendations were made to immobilize and protect the repaired tendons for 10 days34 or up to 6 weeks.32 One study reported 90% complete recovery and return to work within 3 weeks of injury with surgical repair followed by 2 weeks of immobilization.31 Newport et al35 examined the long-term results of extensor tendon repair in 101 digits treated with traditional static splinting. Complex extensor tendon injuries included fracture, dislocation, joint capsule, and flexor tendon with 60% of cases having one of these types of injury. The exact number of fractures was not given. These complex injuries achieved 45% good to excellent results (,10° extension lag and ,20° loss of flexion) with TAM of 212°. Both simple injuries and those with the addition of a joint capsule injury only achieved 64% good to excellent results with TAM of 230°. Using Newport et al’s33 criteria, our lacerations resulted in 100% good to excellent results with TAM over 260° for both the complex and simple injuries. Lovett and McCalla30 found immobilized distal injuries to have serious gliding problems, observing a 50% loss of finger motion with just a 2-mm decrease in extensor tendon excursion. Weeks and Wray35 compared multiple studies and concluded that immobilization up to 2 weeks may be sufficient irrespective of zone of injury. Dynamic splinting following extensor tendon repair is becoming increasingly popular and is justified on the basis of electrophysiologic studies.11 Past reports have addressed its use for tendon injuries proximal to the MP joint.2,3,6 –10,13,17,36 More recent reports also address distal injuries.1,4,7,10,12,14 –16 Distal injuries did not do as well as proximal injuries according to Hung et al,10 with TAM of 188° for the distal lacerations and 229° for the proximal lacerations. Allieu et al1 had only 50% good results for
extensor zone 2 (mallet injury) and zone 3 lacerations, while 92% of injuries in zones 4 to 7 achieved good results with dynamic splinting. The use of a dynamic splint for zone 3 injuries was examined by Saldana et al15; however, PIP range of motion was not allowed until 1 month after extensor tendon repair. Rolph-Roeming14 used early controlled motion for 8 extensor tendon repairs with no ruptures, 90% TAM return, 93% or more of grip strength return, and extension lags of 4° in 2 patients. Eightyeight percent good to excellent results were reported by O’Dwyer and Quinton12 using a spring coil dynamic PIP extension split after 10 to 14 days of immobilization in 99 cases of central slip repair. This splint was used for 8 weeks or until full motion was achieved. The therapy program was not described and poor compliance was noted in 22 patients. It is pertinent to note that these splints are difficult to fit, uncomfortable due to pressure sores, resistant to active flexion, which varies from splint to splint, and jolt the finger back into extension once flexed. For zones 3 and 4, Evans7 proposed a system of immobilization and the use of a number of blocking splints that require a large amount of home instruction and good compliance. To assure that active range of motion was achieved, the injuries were immobilized and blocking exercises were performed intermittently. The results of Evans’7 study in 26 digits showed 5 to be excellent, 12 to be good, 7 to be fair, and 2 to be poor with no ruptures. This is a slight improvement compared with immobilized tendons, but falls far short of the results that can be achieved by adding tendon mobilization to dynamic splinting. All our distal injuries (zones 3 and 4) fell into the excellent category. The dynamic splint combined with the tendon mobilization program provided the gliding necessary for recovery and was easy for the patient to comply with and understand. It also can be speculated that some active range of motion is achieved due to the natural tendency to extend the digit along with the rubber band. No other study used tendon mobilization as part of the treatment protocol. Results of early motion and immobilization were compared in 3 reports.6,7,16 In Evans’6 1989 study, the patients were preselected for dynamic splinting by cooperativeness and good repair; the follow-up period was only 12 weeks. Under those conditions, the dynamically splinted tendons appeared to do better (TAM 240°) than the immobilized tendons (TAM 188°). It is unknown, however, if the immobilized tendons would not have improved further
The Journal of Hand Surgery / Vol. 24A No. 5 September 1999 1069
with a longer follow-up period. In her more recent publication involving proximal lacerations, Evans7 compared immobilization with early dynamic splinting with and without the use of active blocking exercises. She found that the addition of active motion improved results. It is interesting to note that in the dynamic splint, the PIP was held in neutral and the MP was blocked 30° to 40° in flexion for finger extensor lacerations. Thumb extensor laceration splints provided no MP motion with the IP blocked at 60°. This limits the excursion within the dynamic splint excessively and therefore may warrant the addition of active motion to improve results. Evans also described a partial mobilization program, but did not range the individual joints fully. Walsh et al16 compared 19 immobilized tendon lacerations with 12 tendon lacerations treated with early motion; thumb lacerations were excluded. Of the lacerations treated with early motion, 75% had a good/excellent result; the immobilized repairs did better, with an 82% good/excellent result. These investigators admitted that their sample size was not significant. Two other studies reported on the results of dynamic splinting after extensor tendon repair. The first included a neighboring finger in the splint9 and the other used dynamic splinting intermittently only.13 Both studies were limited to proximal injuries. When comparing our results from the proximal injuries (zones 5, 6, and 7) with the more distal injuries, it is apparent that both groups do especially well with dynamic splinting (Table 2). Two previously reported series excluded complex injuries and still did not obtain as good an outcome.2,10 Another study of 120 tendons included mallet fingers and follow-up data concerning 69 tendons.1 The results were good in only 56% of the complex injuries, which included 24 distal fractures. The noticeable difference between these 3 studies and our series is that we added a passive tendon mobilization program to the dynamic splinting. Zone 7 injuries are especially susceptible to thick, unyielding adhesions. Since the extensor tendons glide through narrow compartments and lay over the capsule of the wrist joint, differentiation of scar can be difficult, even with early motion, and is nearly impossible with immobilization. Bowstringing is also a potential problem. Adhesions and tenodesis can limit finger flexion with wrist flexion and finger extension with wrist extension.30,36 Our series included 9 zone 7 tendon repairs. These repairs had the most complications, with 3 tendons (1 patient) re-
quiring the special addition of continuous passive motion to increase gliding at the extensor retinaculum. The end results were excellent, nevertheless, with a TAM of 260°, no extension lags, and 100% return of grip and pinch strength. In spite of the great potential for adhesions at this level, early motion, including the tendon mobilization program, provided the gliding essential for a good recovery. In 1960, Young and Harmon37 introduced the idea of passive range of motion for the rehabilitation of flexor tendons. Subsequently, Duran and Houser38 developed an exercise program for flexor tendon repairs. A tendon mobilization program can also be applied to extensor tendon repairs.4,5 Our results show range of motion to be fully functional, extensor lags to be minimal, and return of nearly normal grip and pinch strength. Although the protocol presented was individualized with night extension splints, flexion straps, and continuous passive motion, the tendon mobilization program, which benefited all the patients, was the major factor contributing to our results. Our average finger TAM was 262° and our average thumb TAM was 134°. Comparitively, a multicenter study resulted in TAM scores of 240° for fingers and 116° for thumbs.6 That study included 32 patients, with complications in 1 patient requiring reoperation and extension lags of Ä30° at the MP joint in 4 other patients. Hand strength was not mentioned. This comparison supports the important art of hand therapy. Even though research protocols may need some modifications, major factors contributing to the final outcomes can still be determined. Another study had extensor lags of 5° to 15° in 5 of 52 patients treated with dynamic splinting.2 This compares favorably with our findings, with reoperation in 2 of their 30 patients and extensor lags of less than 10° at the MP joint. Both tendon ruptures were in patients who removed their splints at 6 and 19 days, respectively, after primary repair. This study excluded complex injuries by describing all lacerations as tidy wounds and did not measure range of motion in flexion. It should be noted that PIP extension lags must be measured when evaluating extensor tendon results because elongation or adhesions, even proximal to the MP joint, can result in loss of full extension at the PIP joint. Extension lag in a thumb, however, is not a reliable measure of success because most thumbs are capable of hyperextension at MP and IP joints. We can only theorize why incomplete extensor pollicis longus tendon lacerations took longer to regain full strength than finger extensors. It is possible
1070 Crosby and Wehbe´ / Early Motion After Extensor Tendon Repair
that they returned to regular activities earlier because their injuries were not taken as seriously as the more severe lacerations. An intensive rehabilitation program may not have been pursued. Such a program would obviously increase the cost of health care. A decision has to be made whether a full and complete recovery justifies such an expense, which is beyond the scope of this report.
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plex injury to the extensor tendons. J Hand Ther 1987;1: 38 – 41. Minamikawa Y, Peimer CA, Yamaguchi T, Banasiak NA, Kambe K, Sherwin FS. Wrist position and extensor tendon amplitude following repair. J Hand Surg 1992;17A:268 – 271. Wehbe´ MA. Tendon gliding exercises. J Occup Ther 1987; 41:164 –167. Kleinert HE, Verdan C. Report of the committee on tendon injuries. J Hand Surg 1983;8:794 –798. Crosby CA, Wehbe´ MA. Hand strength: normative values. J Hand Surg 1994;19A:665– 670. Petersen P, Petrick M, Connor H, Conklin D. Grip strength and hand dominance: challenging the 10% rule. Am J Occup Ther 1989;43:444 – 447. Griffin JE, Karselis T. Physical agents for physical therapists. Springfield, IL: Charles C. Thomas, 1980. Hauge MF. The results of tendon suture of the hand: a review of 500 patients. Acta Orthop Scand 1954;24:258 – 270. Miller H. Repair of severed tendons of the hand and wrist. Surg Gynecol Obstet 1942;75:693– 698. Kelly AP Jr. Primary tendon repairs: a study of 789 consecutive tendon severances. J Bone Joint Surg 1959;41A: 581–598. Brzezienski MA, Schneider LH. Extensor tendon injuries at the distal interphalangeal joint. Hand Clin 1995;11:373– 386. Doyle JR. Extensor tendons—acute injuries. In: Green DP, ed. Operative hand surgery. 2nd ed. Vol. 3. New York: Churchill Livingstone, 1988:2045–2069. Milford L. The hand. In: Edmonson AS, Crenshaw MD, ed. Campbell’s operative orthopaedics. St Louis: CV Mosby, 1980:152–153. Lovett WL, McCalla MA. Management and rehabilitation of extensor tendon injuries. Orthop Clin North Am 1983; 14:811– 826. Dargan EL. Management of extensor tendon injuries of the hand. Surg Gynecol Obstet 1969;128:1269 –1273. Kilgore ES, Graham WP. Tendons. In: The hand: surgical and non-surgical management. Philadelphia: Lea & Febiger 1977:162–210. Newport ML, Blair WF, Steyers CM Jr. Long-term results of extensor tendon repair. J Hand Surg 1990;15A:961–966. Stuart D. Duration of splinting after repair of extensor tendons in the hand: a clinical study. J Bone Joint Surg 1965;47B:72–79. Weeks PM, Wray RC. Restoration of tendon continuity. In: Management of acute hand injuries: a biologic approach. 2nd ed. St Louis: CV Mosby, 1978:292–325. Aulicino PL. Acute injuries of the extensor tendons proximal to the metacarpophalangeal joints. Hand Clin 1995; 11:403– 410. Young RES, Harmon JM. Repair of tendon injuries of the hand. Ann Surg 1960;151:562–566. Duran RJ, Houser RG. Controlled passive motion following flexor tendon repair in zones 2 and 3. In: American Academy of Orthopaedic Surgeons symposium on tendon surgery in the hand. St Louis: CV Mosby, 1975: 105–114.
Extensor tendon rehabilitation has been addressed less in the literature than flexor tendon injuries. Traditionally, extensor tendon injuries have been treated with immobilization, although early motion programs for these injuries have been used for years by several surgeons and therapists. Most research on early motion after extensor tendon repair has focused on proximal injuries.1–17 Reports can be found describing the result of early motion after extensor tendon repair distal to the metacarpophalangeal (MP) joint level.1,4,7,10,12,14 –16 Allieu et al1 felt that proximal injuries (zones 4 –7) did better with early motion than distal injuries. Evans7 showed that both distal and proximal repairs can do well with early motion. Hung et al10 found poor results with dynamic splinting of distal lacerations, although RolphRoeming14 reported excellent results but in a small From the Pennsylvania Hand Center, Bryn Mawr, PA. Received for publication April 27, 1998; accepted in revised form May 17, 1999. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Marwan A. Wehbe´, MD, Pennsylvania Hand Center, Reprints Department, PO Box 241, Bryn Mawr, PA 19010. Copyright © 1999 by the American Society for Surgery of the Hand 0363-5023/99/24A05-0030$3.00/0
sample size. Saldana et al15 observed better results with dynamic splinting of zone 3 injuries, while Walsh et al’s16 results favored immobilization. O’Dwyer and Quinton12 recommended early motion following the repair of central slip lacerations after reviewing the results of 97 patients. The purpose of this study was to evaluate the results of dynamic splinting with the addition of an early tendon mobilization program after extensor tendon repair and to compare the results in all the various zones of injury. Mallet finger injuries (finger zones 1 and 2) were excluded as these injuries do not lend themselves to early motion.
Materials and Methods A retrospective descriptive study was conducted in which 30 consecutive patients were examined following extensor tendon repair in finger zones 3 through 7 and all thumb zones (including T1–T3) and zones 6 and 7. All patients were treated with early passive motion and dynamic splinting. Lacerations to the wrist extensors and all hands with fractures were excluded, yielding 50 extensor tendon lacerations. The laceration sites were classified by zone (Fig. 1) and extent of injury. The extent of the lacerations was classified as incomplete, complete, or complex. The Journal of Hand Surgery 1061
1062 Crosby and Wehbe´ / Early Motion After Extensor Tendon Repair
Figure 1. Extensor tendon zones and location of the 50 tendon lacerations included in this study.
The latter refers to lacerations involving the extensor retinaculum, periosteum, or joint capsule in addition to the tendon, whether complete or incomplete. The 30 patients initially presented to the Pennsylvania Hand Center between January 1986 and September 1989 and were treated by the same team of surgeons and therapists. Patients were treated with the same protected early motion protocol following extensor tendon repair. Repairs were done within 1 day of injury with the exception of 5 tendons, which were repaired between 9 and 33 days after injury. The surgical repair was accomplished with mattress, figure-of-eight, or modified Kessler sutures, depending on the level of repair and the thickness of the tendon at that level. All tendons were immobilized 1 to 5 days after surgery (average, 4 days) after which dynamic splinting and a tendon mobilization protocol was started. The splint used for injuries proximal to and including the MP joint (zones 5–7; 33 tendons) was a dorsal forearm-based dynamic splint, positioning the wrist in 20° extension.18 Rubber band traction provided passive MP extension to the neutral position and allowed active fisting (Fig. 2). The use and degree of any MP flexion blocking was determined during surgery, depending on the strength of the repair and how far the repair glided free of tension. All flexion blocks consisted of a metal washer or rivet placed on the outrigger line to prevent full flexion (Fig. 2B). Flexion blocks at 30° to 60° were used in 9 of the 33 cases. All thumb extensor tendon lacerations required a forearm-based splint. The wrist was extended 20° and the thumb was held in extension with a rubber
band and sling. For lacerations proximal to the thumb MP level, rubber band traction held the MP joint in neutral while allowing full active thumb flexion across the palm (Fig. 3). In lacerations distal to the MP joint, that joint was blocked in the neutral position and rubber band traction allowed interphalangeal (IP) joint motion only. No flexion blocks were used for thumb repairs. When the injury was in zones 3 and 4 distal to the dorsal hood sagittal bands, a dorsal hand-based dynamic splint was used (Fig. 4). The splint held the MP joint in neutral while rubber band traction provided passive proximal interphalangeal (PIP) joint extension and full gentle hook fisting. Of the 9 tendon lacerations in zones 3 and 4, 3 required PIP flexion blocks of 30° to 45°. As noted above, the use and degree of the flexion block was determined during surgery based on how far the repair glided without tension. Hand-based splinting was not used for any thumb lacerations because the thumb sagittal bands are not substantial enough to protect a distal repair of the extensor pollicis longus tendon without the support of a forearm-based splint. Patients received therapy 2 to 5 times a week until strength was fully regained. Treatment included wound care, splint adjustments, and a tendon mobilization program. The tendon mobilization program was performed by holding the digits and wrist in maximal extension while passively ranging only 1 joint at a time (Fig. 5). For example, when the PIP joint was ranged passively, the wrist and the MP and distal interphalangeal (DIP) joints were held in maximal extension. Gentle gradual force was applied by the therapist until full range of motion was obtained or until pain or resistance was encountered.5 In zones 3 and 4, mobilization of the PIP joint was performed with the wrist and the MP and DIP joints in maximum extension, thus allowing enough slack at the central slip to prevent rupture. This was done only to the degree of the flexion block. The at-home program consisted of wearing the splint full-time and the patient making an active gentle fist 10 times every waking hour within the confines of the splint. The dynamic splint was used for an average of 4 weeks. Patients were weaned from the splint over a period of 3 days. On removal of the splint, active range of motion and tendon gliding exercises were started.19 If the tendon appeared to be gliding too easily, as reflected by a digit with full range of motion and no resistance, the splint was maintained approximately 1 or 2 weeks longer in case the tendon repair was healing slower than expected (ie, fewer adhesions
The Journal of Hand Surgery / Vol. 24A No. 5 September 1999 1063
Figure 2. (A) The forearm-based dynamic splint used for extensor tendon repairs proximal to the MP joint. (B) Active fisting and flexion is blocked with a washer (arrow).
and possible rupture). A graded strengthening program was also introduced after splint removal, with progression of resistive activities until full grip and pinch strength were achieved. Range of motion was measured with a goniometer at each visit by the same therapist and total active motion (TAM) was calculated.20 Extension lag was determined as active range of motion minus passive range of motion, considering the neutral position as the reference point (excluding hyperextension). Baseline grip and pinch measurements were taken 8 weeks after surgery. Grip strength was measured with a Jamar dynamometer (Asimow Engineering, Los Angeles, CA) and pinch strength was measured with a pinch meter
(B&L Engineering, Santa Fe, CA) for pulp-to-pulp and key pinch. The highest grip reading of the 5 Jamar levels was recorded as maximum grip strength. Pulp and key pinch measurements were averaged and this value was recorded for pinch strength. This was done because neither measurement reflects extensor tendon strength, but both are indicators of overall hand strength. Both grip and pinch readings were converted to a percentage of the uninjured hand’s maximum strength. Full grip or pinch strength was defined as the dominant hand being 10% greater than the nondominant hand in right-handed people and the same as the right hand in left-handed people.21,22 An edema and scar control program was used in
1064 Crosby and Wehbe´ / Early Motion After Extensor Tendon Repair
Figure 3. The forearm-based dynamic splint used for thumb lacerations proximal to the MP joint.
the majority of the patients. Edema control included elevation, Coban wrapping (3M, St Paul, MN), pressure garments, and/or retrograde massage. Scar control included friction massage, pressure pads, ultrasound, and/or steroid phoresis.23 Nineteen tendons required additional treatment to increase motion. Starting at an average of 3 weeks after surgery, 5
tendons in zone 3 and 3 in zone 5 needed a resting extension splint. Stiffness was encountered in 6 of the 8 tendons and the resting extension splint was used at night to prevent contractures. One patient complained of pain while wearing the night dynamic splint and was allowed to wear a resting extension splint to increase sleeping comfort while protecting
Figure 4. The hand-based dynamic splint used for finger extensor tendon repairs distal to the MP joint. Note the flexion block (arrow).
The Journal of Hand Surgery / Vol. 24A No. 5 September 1999 1065
Figure 5. The tendon mobilization program for the extensor tendons: ranging the (A) PIP joint and the (B) MP joint. Note the extension of all the other joints.
the repair. In another case an extension splint was used for protection at work since the patient was unable to work with the dynamic splint. Due to limited passive IP flexion, a flexion strap was used
starting at an average of 7 weeks after surgery in 8 tendons, including zones T1, T3, 3, 5, and 7. At 4 weeks after surgery a wrist continuous passive motion machine was used approximately 4 hours per
1066 Crosby and Wehbe´ / Early Motion After Extensor Tendon Repair
Although insignificant, these lacerations also had slightly less TAM and an increase in time to return to full activity. Grip strength and the recovery time to reach full grip strength were essentially the same irrespective of extent of injury. Ruptures also were not related to extent of injury. The complex thumb injuries resulted in a lower TAM score compared with the less-severe injuries (Table 1). Patients with incomplete thumb lacerations took longer to regain pinch strength than those with more extensive injuries, yet returned to regular activities sooner. None of the thumb cases had any lags or complications. In all cases, hyperextension was within 10° of the opposite thumb. At the last follow-up visit, complex thumb injuries had 98% of predicted pinch power while incomplete and complete thumb injuries had 80% of pinch power. Tendon injuries were also compared by zone of laceration (Table 2). There were 11 tendon repairs distal to the MP joint (zones T1, 3, and 4) and 39 repairs proximal to the MP joint (zones T3, 5, 6, and 7). Thumb injuries showed no difference in outcome for extension lag, grip strength, and time to full recovery compared with other zones. Distal thumb lacerations, however, excelled in range of motion (TAM) scores. There also were no significant difference in outcome with regard to the various finger zones. Total active motion scores were nearly identical for all finger zones. At the last follow-up visit, all extension lags and slightly weaker grips were found in distal zones 3, 4 and 5 injuries. The extension lags were 5° to 10° at either the MP or PIP joint level. Complications were seen in the proximal group (zones 6 and 7), in which 2 tendon ruptures occurred requiring delayed repair and 1 of which
day to improve gliding of zone 7 tendons in 1 patient who had massive adhesions at the extensor retinaculum.
Results The 30 patients were between the ages of 8 and 81 years (average age, 32 years). Twenty-six were male and 4 were female. The dominant hand was injured in 12 patients. The patients were monitored an average of 7 months (range, 8 weeks to 2 years). Nineteen patients were routinely involved in strenuous activities or heavy labor and only 3 were limited to sedentary activities. One patient had a history of pseudogout with prominent arthritic deformities in both hands. The mechanism of injury included a jagged laceration and/or crushing injury in 23 patients, a sharp laceration in 5 patients, 1 tooth injury, and 1 closed rupture. Six patients had more than 1 ray involved: 2 rays in 4 patients, 3 rays in 1, and all 5 rays in 1. Fifty tendon lacerations in the 30 patients were the subject of this study (Fig. 1). The lacerations involved every finger and thumb extensor tendons. In the finger extensors there were 14 incomplete lacerations, 13 complete lacerations, and 15 complex lacerations (Table 1). There were 8 thumb extensor lacerations: 3 were incomplete, 1 was complete, and 4 were complex. Results also reflect comlete recovery after the 2 ruptured repairs and the 1 tenolysis, with the same protocol following each. Extent of injury in the fingers resulted in no significant difference in end result, especially between incomplete and complete lacerations (Table 1). The complex finger lacerations, however, did result in 4 extension lags and 1 tenolysis due to adhesions.
Table 1. Effect of Extent of Injury on Extensor Tendon Recovery Finger Lacerations
No. of tendons TAM* Extension lag (no. of tendons) Grip strength (%)† Pinch strength (%)† Time to full grip/pinch strength (wk) Time to return to activities (wk) No. of tendon ruptures No. of tenolysis cases
Thumb Lacerations
Incomplete
Complete
Complex
Incomplete
Complete
Complex
14 262 1 92 95 14 9 1 0
13 259 0 100 94 12 8 0 0
15 255 4 91 94 12 11 1 1
3 140 0 100 83 18 4 0 0
1 145 0 88 80 7 7 0 0
4 128 0 89 98 6 7 0 0
* Average TAM in a normal finger, 260°.20 Thumb TAM varies a great deal and an average value cannot be set. † Grip and pinch strength reported as percentage of expected (see text).
The Journal of Hand Surgery / Vol. 24A No. 5 September 1999 1067
Table 2. Effect of Zone of Injury on Extensor Tendon Recovery Zone of Injury
No. of tendons TAM* Extension lag (no. of tendons) Grip strength (%)§ Pinch strength (%)§ Time to full grip/pinch strength (wk) Time to return to activities (wk) No. of tendon ruptures No. of tenolysis cases
T1–2
T3
3–4
5
6
7
5–7
2 157 0 94 81 10 8 0 0
6 126 0 99 88 8 8 0 0
9 264 2† 90 99 11 9 0 0
18 260 3‡ 88 90 12 9 0 0
6 265 0 92 95 10 8 1 0
9 260 0 100 100 16 16 1 1
33 261 3 92 94 13 11 2 1
* Average TAM in a normal finger, 260°.20 Thumb TAM varies a great deal and an average value cannot be set. † One 5° PIP and 1 10° MP. ‡ One 5° PIP, 1 10° PIP, and 1 5° MP. § Grip and pinch strength reported as percentage of expected (see text).
required a subsequent tenolysis. Using the same therapy protocol, the final outcome of the tendon requiring tenolysis was full range of motion and normal grip strength. Zone 7 injuries involving the extensor retinaculum showed an increase in time to return to full activities and to reach maximum grip strength, yet final grip strength was 100% of normal. Forty-five of the 50 tendons under study regained full excursion in an average time of 9 weeks. The 5 tendons that did not regain full excursion had minimal extension lags at the MP or PIP joint: 3 had a 5° lag and 2 had a 10° lag (Table 2). There were no limitations in flexion, with all patients able to make a full fist. Average TAM was 264° for zones 3 and 4 and 261° for zones 5, 6, and 7. Average thumb TAM was 134°. All patients returned to unrestricted activities in an average of 10 weeks. Within approximately 12 weeks, all injured fingers regained over 90% of normal grip strength. The thumbs reached over 80% of maximum pinch strength within 9 weeks (Table 1). There were 3 complications requiring reoperation: 2 for repair of tendon rupture due to lack of patient compliance to the dynamic splinting program and 1 repeat surgery for tenolysis in 1 of those 2 tendons.
Discussion Flexor tendon repairs have received attention from hand surgeons and therapists for the past 20 years. Unfortunately, extensor tendons have suffered from benign neglect due to the assumption that they do well compared with the results of flexor tendon repairs.24,25 Research on extensor lacerations has yielded a wide spectrum of results. Hauge24 con-
cluded that extensor tendon repairs always do well; however, he did not measure loss of flexion after the repairs. At the other extreme, Kelly26 and Zander17 found that extensor tendon repairs did well only under ideal conditions and that they should be taken as seriously as flexor tendon injuries. Mallet fingers consist of a disruption of the terminal tendon in the fingers. This is a small tendon that lends itself poorly to surgical repair and is usually treated by full immobilization.26,27 The thumb terminal tendon (extensor pollicis longus insertion) is more substantial and can be repaired surgically; it was therefore included in this study. The MP joint level in the thumb and fingers is an important landmark because of the dorsal hood. The sagittal bands of the dorsal hood will prevent the finger extensor tendon from retracting proximally if the laceration is distal to them. This is also true of the thumb’s sagittal bands at the MP joint level. Therefore, like the fingers, the thumb MP joint level could be considered a T5 zone rather than a T3 zone, as it has been traditionally classified.6,8,20 When comparing end results of thumb laceration, it is very difficult to compare TAM scores since thumb range of motion varies greatly among individuals and even from one hand to the other in the same person. The sagittal bands also keep the tendon repair at minimal tension, especially in the fingers, where they are more substantial. Therefore, a hand-based splint can be used safely for finger lacerations. In addition, the extensor tendon excursion decreases as the tendon reaches its insertion distally. Flexion blocks are therefore more important for the distal injuries since there is less excursion to absorb the tensile tendon forces near the
1068 Crosby and Wehbe´ / Early Motion After Extensor Tendon Repair
insertion. Surgical observation should determine the flexion blocks. Flexion blocks in this study were initially set at 30°. This is supported by Evans,7 who concluded that 30° of PIP active motion allows 3.75 mm of extensor digitorum communis excursion and provides the necessary amount of gliding to allow healing and avoid adhesions in zone 3– 4 repairs. Three weeks or more of immobilization followed by therapy traditionally has been the recommended treatment for extensor tendon repairs.28 –30 After the immobilization period, full range of motion was typically achieved after 2 months of therapy and further therapy was required to return to regular activities.28,29 Several studies have critically analyzed full immobilization in the treatment of extensor tendon lacerations.6,30 –35 Recommendations were made to immobilize and protect the repaired tendons for 10 days34 or up to 6 weeks.32 One study reported 90% complete recovery and return to work within 3 weeks of injury with surgical repair followed by 2 weeks of immobilization.31 Newport et al35 examined the long-term results of extensor tendon repair in 101 digits treated with traditional static splinting. Complex extensor tendon injuries included fracture, dislocation, joint capsule, and flexor tendon with 60% of cases having one of these types of injury. The exact number of fractures was not given. These complex injuries achieved 45% good to excellent results (,10° extension lag and ,20° loss of flexion) with TAM of 212°. Both simple injuries and those with the addition of a joint capsule injury only achieved 64% good to excellent results with TAM of 230°. Using Newport et al’s33 criteria, our lacerations resulted in 100% good to excellent results with TAM over 260° for both the complex and simple injuries. Lovett and McCalla30 found immobilized distal injuries to have serious gliding problems, observing a 50% loss of finger motion with just a 2-mm decrease in extensor tendon excursion. Weeks and Wray35 compared multiple studies and concluded that immobilization up to 2 weeks may be sufficient irrespective of zone of injury. Dynamic splinting following extensor tendon repair is becoming increasingly popular and is justified on the basis of electrophysiologic studies.11 Past reports have addressed its use for tendon injuries proximal to the MP joint.2,3,6 –10,13,17,36 More recent reports also address distal injuries.1,4,7,10,12,14 –16 Distal injuries did not do as well as proximal injuries according to Hung et al,10 with TAM of 188° for the distal lacerations and 229° for the proximal lacerations. Allieu et al1 had only 50% good results for
extensor zone 2 (mallet injury) and zone 3 lacerations, while 92% of injuries in zones 4 to 7 achieved good results with dynamic splinting. The use of a dynamic splint for zone 3 injuries was examined by Saldana et al15; however, PIP range of motion was not allowed until 1 month after extensor tendon repair. Rolph-Roeming14 used early controlled motion for 8 extensor tendon repairs with no ruptures, 90% TAM return, 93% or more of grip strength return, and extension lags of 4° in 2 patients. Eightyeight percent good to excellent results were reported by O’Dwyer and Quinton12 using a spring coil dynamic PIP extension split after 10 to 14 days of immobilization in 99 cases of central slip repair. This splint was used for 8 weeks or until full motion was achieved. The therapy program was not described and poor compliance was noted in 22 patients. It is pertinent to note that these splints are difficult to fit, uncomfortable due to pressure sores, resistant to active flexion, which varies from splint to splint, and jolt the finger back into extension once flexed. For zones 3 and 4, Evans7 proposed a system of immobilization and the use of a number of blocking splints that require a large amount of home instruction and good compliance. To assure that active range of motion was achieved, the injuries were immobilized and blocking exercises were performed intermittently. The results of Evans’7 study in 26 digits showed 5 to be excellent, 12 to be good, 7 to be fair, and 2 to be poor with no ruptures. This is a slight improvement compared with immobilized tendons, but falls far short of the results that can be achieved by adding tendon mobilization to dynamic splinting. All our distal injuries (zones 3 and 4) fell into the excellent category. The dynamic splint combined with the tendon mobilization program provided the gliding necessary for recovery and was easy for the patient to comply with and understand. It also can be speculated that some active range of motion is achieved due to the natural tendency to extend the digit along with the rubber band. No other study used tendon mobilization as part of the treatment protocol. Results of early motion and immobilization were compared in 3 reports.6,7,16 In Evans’6 1989 study, the patients were preselected for dynamic splinting by cooperativeness and good repair; the follow-up period was only 12 weeks. Under those conditions, the dynamically splinted tendons appeared to do better (TAM 240°) than the immobilized tendons (TAM 188°). It is unknown, however, if the immobilized tendons would not have improved further
The Journal of Hand Surgery / Vol. 24A No. 5 September 1999 1069
with a longer follow-up period. In her more recent publication involving proximal lacerations, Evans7 compared immobilization with early dynamic splinting with and without the use of active blocking exercises. She found that the addition of active motion improved results. It is interesting to note that in the dynamic splint, the PIP was held in neutral and the MP was blocked 30° to 40° in flexion for finger extensor lacerations. Thumb extensor laceration splints provided no MP motion with the IP blocked at 60°. This limits the excursion within the dynamic splint excessively and therefore may warrant the addition of active motion to improve results. Evans also described a partial mobilization program, but did not range the individual joints fully. Walsh et al16 compared 19 immobilized tendon lacerations with 12 tendon lacerations treated with early motion; thumb lacerations were excluded. Of the lacerations treated with early motion, 75% had a good/excellent result; the immobilized repairs did better, with an 82% good/excellent result. These investigators admitted that their sample size was not significant. Two other studies reported on the results of dynamic splinting after extensor tendon repair. The first included a neighboring finger in the splint9 and the other used dynamic splinting intermittently only.13 Both studies were limited to proximal injuries. When comparing our results from the proximal injuries (zones 5, 6, and 7) with the more distal injuries, it is apparent that both groups do especially well with dynamic splinting (Table 2). Two previously reported series excluded complex injuries and still did not obtain as good an outcome.2,10 Another study of 120 tendons included mallet fingers and follow-up data concerning 69 tendons.1 The results were good in only 56% of the complex injuries, which included 24 distal fractures. The noticeable difference between these 3 studies and our series is that we added a passive tendon mobilization program to the dynamic splinting. Zone 7 injuries are especially susceptible to thick, unyielding adhesions. Since the extensor tendons glide through narrow compartments and lay over the capsule of the wrist joint, differentiation of scar can be difficult, even with early motion, and is nearly impossible with immobilization. Bowstringing is also a potential problem. Adhesions and tenodesis can limit finger flexion with wrist flexion and finger extension with wrist extension.30,36 Our series included 9 zone 7 tendon repairs. These repairs had the most complications, with 3 tendons (1 patient) re-
quiring the special addition of continuous passive motion to increase gliding at the extensor retinaculum. The end results were excellent, nevertheless, with a TAM of 260°, no extension lags, and 100% return of grip and pinch strength. In spite of the great potential for adhesions at this level, early motion, including the tendon mobilization program, provided the gliding essential for a good recovery. In 1960, Young and Harmon37 introduced the idea of passive range of motion for the rehabilitation of flexor tendons. Subsequently, Duran and Houser38 developed an exercise program for flexor tendon repairs. A tendon mobilization program can also be applied to extensor tendon repairs.4,5 Our results show range of motion to be fully functional, extensor lags to be minimal, and return of nearly normal grip and pinch strength. Although the protocol presented was individualized with night extension splints, flexion straps, and continuous passive motion, the tendon mobilization program, which benefited all the patients, was the major factor contributing to our results. Our average finger TAM was 262° and our average thumb TAM was 134°. Comparitively, a multicenter study resulted in TAM scores of 240° for fingers and 116° for thumbs.6 That study included 32 patients, with complications in 1 patient requiring reoperation and extension lags of Ä30° at the MP joint in 4 other patients. Hand strength was not mentioned. This comparison supports the important art of hand therapy. Even though research protocols may need some modifications, major factors contributing to the final outcomes can still be determined. Another study had extensor lags of 5° to 15° in 5 of 52 patients treated with dynamic splinting.2 This compares favorably with our findings, with reoperation in 2 of their 30 patients and extensor lags of less than 10° at the MP joint. Both tendon ruptures were in patients who removed their splints at 6 and 19 days, respectively, after primary repair. This study excluded complex injuries by describing all lacerations as tidy wounds and did not measure range of motion in flexion. It should be noted that PIP extension lags must be measured when evaluating extensor tendon results because elongation or adhesions, even proximal to the MP joint, can result in loss of full extension at the PIP joint. Extension lag in a thumb, however, is not a reliable measure of success because most thumbs are capable of hyperextension at MP and IP joints. We can only theorize why incomplete extensor pollicis longus tendon lacerations took longer to regain full strength than finger extensors. It is possible
1070 Crosby and Wehbe´ / Early Motion After Extensor Tendon Repair
that they returned to regular activities earlier because their injuries were not taken as seriously as the more severe lacerations. An intensive rehabilitation program may not have been pursued. Such a program would obviously increase the cost of health care. A decision has to be made whether a full and complete recovery justifies such an expense, which is beyond the scope of this report.
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