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Flexor Tendon Injuries
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Flexor Tendon Injuries S. Brent Brotzman, MD | Steven R. Novotny, MD
IMPORTANT POINTS FOR REHABILITATION AFTER FLEXOR TENDON LACERATION AND REPAIR • The goal of the tendon repair is to coapt the severed ends without bunching or leaving a gap (Fig. 1.1). • Repaired tendons subjected to appropriate early motion stress will increase in strength more rapidly and develop fewer adhesions than immobilized repairs. • Flexor rehabilitation protocols must take into account the typical tensile stresses on normally repaired flexor tendon tendons (Bezuhly et al. 2007). Passive motion: 500–750 g (4.9–13 N) Light grip: 1500–2250 g (14.7–22 N) Strong grip: 5000–7500 g (49–73.5 N) Tip pinch, index flexor digitorum profundus (FDP): 9000– 13,500 g (88.2–132.3 N) • Initially rather strong, the flexor tendon repair strength decreases significantly between days 5 and 21 (Bezuhly et al. 2007). • The tendon is weakest during this time period because of minimal tensile strength. Strength increases quickly when controlled stress is applied in proportion to increasing tensile strength. Stressed tendons heal faster, gain strength faster, and have fewer adhesions. Tensile strength generally begins gradually increasing at 3 weeks. Generally, blocking exercises are initiated 1 week after active range of motion (ROM) excursion (5 weeks postoperative) (Baskies 2008). • The A2 and A4 pulleys are the most important to the mechanical function of the finger. Loss of a substantial portion of either may diminish digital motion and power or lead to flexion contractures of the interphalangeal (IP) joints. • The flexor digitorum superficialis (FDS) tendons lie on the palmar side of the FDP until they enter the A1 entrance of the digital sheath. The FDS then splits (at Champer’s chiasma) and terminates into the proximal half of the middle phalanx. • Flexor tendon excursion of as much as 9 cm is required to produce composite wrist and digital flexion. Excursion of only 2.5 cm is required for full digital flexion when the wrist is stabilized in the neutral position. • Tendons in the hand have both intrinsic and extrinsic capabilities for healing. • Factors that influence the formation of excursion-restricting adhesions around repaired flexor tendons include the following: Amount of initial trauma to the tendon and its sheath Tendon ischemia Tendon immobilization Gapping at the repair site Disruption of the vincula (blood supply), which decreases the recovery of the tendon (Fig. 1.2) • Delayed primary repair results (within the first 10 days) are equal to or better than immediate repair of the flexor tendon. 2
• Immediate (primary) repair is contraindicated in patients with any of the following: Severe multiple tissue injuries to the fingers or palm Wound contamination Significant skin loss over the flexor tendons
REHABILITATION RATIONALE AND BASIC PRINCIPLES OF TREATMENT AFTER FLEXOR TENDON REPAIR Timing The timing of flexor tendon repair influences the rehabilitation and outcome of flexor tendon injuries. • Primary repair is done within the first 12 to 24 hours after injury. • Delayed primary repair is done within the first 10 days after injury. • If primary repair is not done, delayed primary repair should be done as soon as there is evidence of wound healing without infection. • Secondary repair is done 10 and 14 days after injury. • Late secondary repair is done more than 4 weeks after injury. After 4 weeks it is extremely difficult to deliver the flexor tendon through the digital sheath, which usually becomes extensively scarred. However, clinical situations in which the tendon repair is of secondary importance often make late repair necessary, especially for patients with massive crush injuries, inadequate soft tissue coverage, grossly contaminated or infected wounds, multiple fractures, or untreated injuries. If the sheath is not scarred or destroyed, single-stage tendon grafting, direct repair, or tendon transfer can be done. If extensive disturbance and scarring have occurred, two-stage tendon grafting with a silicone (Hunter) rod should be performed. Before tendons can be secondarily repaired, these requirements must be met: • Joints must be supple and have useful passive range of motion (PROM) (Boyes grade 1 or 2, Table 1.1). Restoration of PROM is aggressively obtained with rehabilitation before secondary repair is done. • Skin coverage must be adequate. • The surrounding tissue in which the tendon is expected to glide must be relatively free of scar tissue. • Wound erythema and swelling must be minimal or absent. • Fractures must have been securely fixed or healed with adequate alignment. • Sensation in the involved digit must be undamaged or restored, or it should be possible to repair damaged nerves at the time of tendon repair directly or with nerve grafts. • The critical A2 and A4 pulleys must be present or have been reconstructed. Secondary repair is delayed until these are reconstructed. During reconstruction, Hunter (silicone) rods are useful to maintain the lumen of the tendon sheath while the grafted pulleys are healing.
1 Flexor Tendon Injuries Extending skin incision line
3
Passive DIP joint flexion
Distal FDS/FDP stumps Cruciate-synovial sheath flap
Approximation of distal and proximal stumps
Proximal FDS/FDP stumps
Tendon repair
Laceration of zone ll Skin flaps
Wound repair
Tube attachment
A
B
C
D
Fig. 1.1 Author’s technique of flexor tendon repair in zone 2. A, Knife laceration through zone 2 with the digit in full flexion. The distal stumps retract distal to the skin incision with digital extension. B, Radial and ulnar extending incisions are used to allow wide exposure of the flexor tendon system. Note appearance of the flexor tendon system of the involved fingers after the reflection of skin flaps. The laceration occurred through the C1 cruciate area. Note the proximal and distal position of the flexor tendon stumps. Reflection of small flaps (“windows”) in the cruciate-synovial sheath allows the distal flexor tendon stumps to be delivered into the wound by passive flexion of the distal interphalangeal (DIP) joint. The profundus and the superficialis stumps are retrieved proximal to the wound by passive flexion of the DIP joint. The profundus and superficialis stumps are retrieved proximal to the sheath by the use of a small catheter or infant feeding gastrostomy tube. C, The proximal flexor tendon stumps are maintained at the repair site by means of a transversely placed small-gauge hypodermic needle, allowing repair of the FDS slips without extension. D, Completed repair of both FDS and FDP tendons is shown with the DIP joint in full flexion. Extension of the DIP joint delivers the repair under the intact distal flexor tendon sheath. Wound repair is done at the conclusion of the procedure. Proper palmar digital artery
TABLE
1.1
VBP VLP VBS VLS Superficialis tendon Profundus tendon Fig. 1.2 Blood supply to the flexor tendons within the digital sheath. The segmental vascular supply to the flexor tendons is by means of the long and short vincular connections. The vinculum brevis superficialis (VBS) and the vinculum brevis profundus (VBP) consist of small triangular mesenteries near the insertion of the FDS and FDP tendons, respectively. The vinculum longum to the superficialis tendon (VLS) arises from the floor of the digital sheath of the proximal phalanx. The vinculum longum to the profundus tendon (VLP) arises from the superficialis at the level of the proximal interphalangeal (PIP) joint. The cut-away view depicts the relative avascularity of the palmar side of the flexor tendons in zones 1 and 2 as compared with the richer blood supply on the dorsal side, which connects with the vincula.
Anatomy The anatomic zone of injury of the flexor tendons influences the outcome and rehabilitation of these injuries. The hand is divided into five distinct flexor zones (Fig. 1.3): • Zone 1—from the insertion of the profundus tendon at the distal phalanx to just distal to the insertion of the sublimus • Zone 2—Bunnell’s “no-man’s land”: the critical area of pulleys between the insertion of the sublimus and the distal palmar crease
Boyes’ Preoperative Classification
Grade
Preoperative Condition
1
Good: minimal scar with mobile joints and no trophic changes Cicatrix: heavy skin scarring from injury or previous surgery; deep scarring from failed primary repair or infection Joint damage: injury to the joint with restricted range of motion Nerve damage: injury to the digital nerves resulting in trophic changes in the finger Multiple damage: involvement of multiple fingers with a combination of the above problems
2 3 4 5
• Zone 3—“area of lumbrical origin”: from the beginning of the pulleys (A1) to the distal margin of the transverse carpal ligament • Zone 4—area covered by the transverse carpal ligament • Zone 5—area proximal to the transverse carpal ligament As a rule, repairs to tendons injured outside the flexor sheath have much better results than repairs to tendons injured inside the sheath (zone 2). It is essential that the A2 and A4 pulleys (Fig. 1.4) be preserved to prevent bowstringing. In the thumb, the A1 and oblique pulleys are the most important. The thumb lacks vincula for blood supply.
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SECTION 1 Hand and Wrist Injuries
Distal to FDS tendon l l
l l
ll No man’s land
l
ll ll Lumbrical origin
lll lV
lll lV
Carpal tunnel V Muscle-tendon V junction
Fig. 1.3 The flexor system has been divided into five zones or levels for the purpose of discussion and treatment. Zone 2, which lies within the fibro-osseous sheath, has been called “no man’s land” because it was once believed that primary repair should not be done in this zone.
A5 C3 A4
Distal transverse digital artery Intermediate transverse digital artery
C2 A3
Proximal transverse digital artery
C1 A2
A1
Branch to viniculum longus Proper palmar digital artery Common digital artery Flexor tendon
Fig. 1.4 The fibrous retinacular sheath starts at the neck of the metacarpal and ends at the distal phalanx. Condensations of the sheath form the flexor pulleys, which can be identified as five heavier annular bands and three filmy cruciform ligaments (see text).
Tendon Healing The exact mechanism of tendon healing is still unknown. Healing probably occurs through a combination of extrinsic and intrinsic processes. Extrinsic healing depends on the formation of adhesions between the tendon and the surrounding tissue, providing a blood supply and fibroblasts, but unfortunately it
also prevents the tendon from gliding. Intrinsic healing relies on synovial fluid for nutrition and occurs only between the tendon ends. Flexor tendons in the distal sheath have a dual source of nutrition via the vincular system and synovial diffusion. Diffusion appears to be more important than perfusion in the digital sheath (Green 1993). Several factors have been reported to affect tendon healing: • Age—The number of vincula (blood supply) decreases with age. • General health—Cigarettes, caffeine, and poor general health delay healing. The patient should refrain from ingesting caffeine and smoking cigarettes during the first 4 to 6 weeks after repair. • Scar formation—The remodeling phase is not as effective in patients who produce heavy keloid or scar. • Motivation and compliance—Motivation and the ability to follow the postoperative rehabilitation regimen are critical factors in outcome. • Level of injury—Zone 2 injuries are more apt to form limiting adhesions from the tendon to the surrounding tissue. In zone 4, where the flexor tendons lie in close proximity to each other, injuries tend to form tendon-to-tendon adhesions, limiting differential glide. • Trauma and extent of injury—Crushing or blunt injuries promote more scar formation and cause more vascular trauma, impairing function and healing. Infection also impedes the healing process. • Pulley integrity—Pulley repair is important in restoring mechanical advantage (especially A2 and A4) and maintaining tendon nutrition through synovial diffusion. • Surgical technique—Improper handling of tissues (such as forceps marks on the tendon) and excessive postoperative hematoma formation trigger adhesion formation. The two most frequent causes for failure of primary tendon repairs are formation of adhesions and rupture of the repaired tendon. Through experimental and clinical observation, Duran and Houser (1975) determined that tendon glide of 3 to 5 mm is sufficient to prevent motion-limiting tendon adhesions. Exercises are thus designed to achieve this motion.
Treatment of Flexor Tendon Lacerations Partial laceration involving less than 25% of the tendon substance can be treated by beveling the cut edges. Lacerations between 25% and 50% can be repaired with 6-0 running nylon suture in the epitenon. Lacerations involving more than 50% should be considered complete and should be repaired with a core suture and an epitenon suture. No level 1 studies have determined superiority of one suture method or material, although a number of studies have compared different suture configurations and materials. Most studies indicate that the number of strands crossing the repair site and the number of locking loops directly affect the strength of the repair, with six- and eight-strand repairs generally shown to be stronger than four-strand or two-strand repairs; however, the increased number of strands also increases bulk and resistance to glide. Several four-strand repair techniques appear to provide adequate strength for early motion. The following discussion is mainly for zone 2 flexor tendon lacrations. The other zones are repaired similarly, but the peculiarities of zone 2 tendon repairs will be emphasized. I still
1 Flexor Tendon Injuries
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prefer a standard Brunner type incision instead of a midaxial. My exposure and opening of the tendon sheath depends on the location of its laceration and the quality of the traumatized sheath. If the laceration is through the A2 pulley, I will make controlled sheath incisions distal or proximal to the pulley. If the pulley is cut asymmetrically, I have vented the pulley for a better exposure. I prefer to work through distally based triangular openings if possible, believing the repaired sheath apex will allow enhanced gliding for the tendon anastomosis, as opposed to the transversely sutured sheath flap. Rectangular flaps for larger exposure are sometimes needed. When retrieving a tendon from the palm, I have no qualms about excising the A1 pulley for enhanced visualization. I place my core sutures approximately 1 cm from the laceration (Cao et al. 2006). The proximal core sutures are captured with a 26-gauge looped steel wire as a passer, causing minimal trauma to the native sheath. I try not to use hypodermic needles, Keith needles, or a manufactured tendon approximator unless needed, to minimize epitendon trauma. A skilled assistant can often tension the proximal stump with traction on one set of core sutures. The core sutures should be placed dorsal as opposed to volar (Aoki et al. 1996), the running epitendon suture must have reasonable depth (Daio et al. 1996), and I repair the sheath whenever possible (Tang and Xie 2001). Tendons lacerated sharply without need of débridement are repaired as described in Pike, Boyer and Gelberman’s 2010 publication. Not surprisingly, many patients have significantly traumatized tendon edges in need of débridement. I use the ASSI Peripheral Nerve and Tendon Cutting Set (ASSI, Westbury, NY) to restore quality tendon edges. In this scenario I am more likely to use basic science principles (Zhao et al. 2002; Paillard et al. 2002; Xu and Tang 2003) and débride one slip of the superficialis tendon.
should not be advanced more than 1 cm to avoid the quadregia effect (a complication of a single digit with limited motion causing limitation of excursion and, thus, the motion of the uninvolved digits). Citing complications in 15 of 23 patients with pull-out wire (button-over-nail) repairs, 10 of which were directly related to the technique, Kang et al. (2008) questioned its continued use. Complications of the pull-out wire technique included nail deformities, fixed flexion deformities of the distal interphalangeal (DIP) joint, infection, and prolonged hypersensitivity. A more recent technique for FDP lacerations is the use of braided polyester/monofilament polyethylene composite (FiberWire, Arthrex, Naples, FL) and suture anchors rather than pullout wires (Matsuzaki et al. 2008; McCallister et al. 2006). Reports of outcomes currently are too few to determine if this technique will allow earlier active motion than standard techniques.
Teno Fix Repair
Rehabilitation After Flexor Tendon Repair
A stainless-steel tendon repair device (Teno Fix, Ortheon Medical, Columbus, OH) was reported to result in lower flexor tendon rupture rates after repair and similar functional outcomes when compared with conventional repair in a randomized, multicenter study, particularly in patients who were noncompliant with the rehabilitation protocol (Su et al. 2005, 2006). Active flexion was allowed at 4 weeks postoperatively. Solomon et al. (unpublished research) developed an “accelerated active” rehabilitation program to be used after Teno Fix repairs: Active digital flexion and extension maximum-attainable to the palm are started on the first day with the goal of full flexion at 2 weeks postoperatively. The anticipated risks with this protocol are forced passive extension, especially of the wrist and finger (e.g., fall on outstretched hand), and resisted flexion, potentially causing gapping or rupture of the repair. The possibility of a more rapid return of function, or at least being more forgiving of rehabilitation mistakes, adds some potential attractiveness to the use of Teno Fix for flexor tendon repairs. At least one research group (Wolfe 2007) noted no benefit of using the Teno Fix system compared to the sutures techniques they used. What one doesn’t know is the cost to the consumer of the product. Is the product cost worth the benefit? Kubat (2010) describes a case report with multiple tendon involvement and proposes that, at least with his patient, the savings of operative time and its associated expense may make using this product more palatable. FDP lacerations can be repaired directly or advanced and reinserted into the distal phalanx with a pull-out wire, but they
The rehabilitation protocol chosen (Rehabilitation Protocols 1.1 and 1.2) depends on the timing of the repair (delayed primary or secondary), the location of the injury (zones 1 through 5), and the compliance of the patient (early mobilization for patients who are compliant and delayed mobilization for patients who are noncompliant and children younger than 7 years of age). A survey of 80 patients with flexor and extensor tendon repairs determined that two thirds were nonadherent to their splinting regimen, removing their splints for bathing and dressing (Sandford et al. 2008). In a comparison of early active mobilization and standard Kleinert splintage, Yen et al. 2008 found at an average 4-month follow-up (3 to 7 months) that those in the early active mobilization group had 90% of normal grip strength, pinch, and range of motion compared to 50%, 40%, and 40%, respectively, in those with Kleinert splinting. Sueoka and LaStayo (2008) devised an algorithm for zone 2 flexor tendon rehabilitation that uses a single clinical sign— the lag sign—to determine the progression of therapy and the need to modify existing protocols for individual patients. They defined “lag” as PROM—AROM (active ROM) ≥15 degrees and consider it a sign of tendon adherence and impairment of gliding. Rehabilitation begins with an established passive ROM Protocol (Duran), which is followed for 3.5 weeks before the presence or absence of a lag is evaluated. The presence or absence of lag is then evaluated at the patient’s weekly or twiceweekly visits, and progression of therapy is modified if a lag sign is present (Rehabilitation Protocol 1.3).
Bloodless Surgery A current topic of interest is bloodless awake surgery for more complex hand problems. I refer the reader to a recent publication by Lalonde and Martin (2013). I firmly believe in the science and employ it when appropriate. However, some patients refuse to proceed under local anesthesia. Vasculopaths, such as those with Buerger’s disease, may not be appropriate candidates. Lastly, repairing extensor tendons, an easier proposition, can still be challenging when the patient involuntarily contracts muscles as the proximal tendon stump is pulled distally for repair. A posterior interosseous nerve block is easy to perform to prevent inadvertent muscle pull; a proximal median nerve block in the antecubital fossa is a little different. Gaining the skill to use an ultrasound or having an anesthesiologist perform the block if needed could be difficult.
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SECTION 1 Hand and Wrist Injuries
REHABILITATION PROTOCOL 1.1 Rehabilitation Protocol After Immediate or Delayed Primary Repair of Flexor Tendon Injury: Modified Duran Protocol Marissa Pontillo, PT, DPT, SCS • Active wrist extension to neutral only • Functional electrical stimulation (FES) with the splint on
Postoperative Day 1 to Week 4.5 • Keep dressing on until Day 5 postoperative. • At Day 5: replace with light dressing and edema control prn. • Patient is fitted with dorsal blocking splint (DBS) fashioned in: • 20 degrees wrist flexion. • 45 degrees MCP flexion. • Full PIP, DIP in neutral • Hood of splint extends to fingertips • Controlled passive motion twice daily within constraints of splint: • 8 repetitions of passive flexion and active extension of the PIP joint
A
5.5 Weeks • Continue passive exercises. • Discontinue use of DBS. • Exercises are performed hourly: 12 repetitions of PIP blocking • 12 repetitions of DIP blocking • 12 repetitions of composite active flexion and extension • May start PROM into flexion with overpressure
B
Passive flexion and extension exercises of the proximal interphalangeal (PIP) joint in a dorsal blocking splint (DBS). A, Passive flexion of PIP joint. B, The finger being extended from flexed position.
• 8 repetitions of passive flexion and active extension of the DIP joint • 8 repetitions of active composite flexion and extension of the DIP and PIP joints with the wrist and MCP joints supported in flexion
4.5 Weeks • Continue passive exercises as needed. • Removal of DBS every 2 hours to perform 10 repetitions of each active flexion and extension of the wrist and of the digits • May start intrinsic minus (hook fist) position and/or tendon gliding exercises
6 Weeks • Initiate passive extension for the wrist and digits. 8 Weeks • Initiate gentle strengthening. • Putty, ball squeezes • Towel walking with fingers • No lifting or heavy use of the hand 10–12 Weeks • Return to previous level of activity, including work and sport activities.
REHABILITATION PROTOCOL 1.2 Indianapolis Protocol (“Active Hold Program”) • Indicated for patients with four-strand Tajima and horizontal mattress repair with peripheral epitendinous suture • Patient who is motivated and compliant • Two splints are used: the traditional dorsal blocking splint (with the wrist at 20 to 30 degrees of flexion, MCP joints in 50 degrees of flexion, and IP joints in neutral) and the Strickland tenodesis splint. The latter splint allows full wrist flexion and 30 degrees of dorsiflexion, while digits have full ROM, and MCP joints are restricted to a 60-degree extension. • For the first 1 to 3 weeks, the modified Duran protocol is used. The patient performs repetitions of flexion and extension to the PIP and DIP joints and to the whole finger 15 times per hour. Exercise is restrained by the dorsal splint. Then, the Strickland hinged wrist splint is applied. The patient passively flexes the digits while extending the wrist. The patient then gently contracts the digits in the palm and holds for 5 seconds.
• At 4 weeks, the patient exercises 25 times every 2 hours without any splint. A dorsal blocking splint is worn between exercises until the sixth week. The digits are passively flexed while the wrist extends. Light muscle contraction is held for 5 seconds, and the wrist drops into flexion, causing digit extension through tenodesis. The patient begins active flexion and extension of the digits and wrist. Simultaneous digit and wrist extension is not allowed. • After 5 to 14 weeks, the IP joints are flexed while the MCP joints are extended, and then the IP is extended. • After 6 weeks, blocking exercises commence if digital flexion is more than 3 cm from the distal palmar flexion crease. No blocking is applied to the small finger FDP tendon. • At 7 weeks, passive extension exercises are begun. • After 8 weeks, progressive gradual strengthening is begun. • After 14 weeks, activity is unrestricted.
(From Neumeister M, Wilhelmi BJ, Bueno Jr, RA: Flexor tendon lacerations: Treatment. http://emedicine.medscape.com/orthopedic_surgery)
1 Flexor Tendon Injuries
Passive ROM
REHABILITATION PROTOCOL 1.3 Zone 2 Lag Sign Algorithm 3–7 days
Kleinert
Duran
Full passive flexion?
Yes
3 weeks Place and hold
No
Greater emphasis on passive ROM LAG?
1 3.5 weeks
Yes
No 2
4 weeks
LAG? Yes
Active ROM
4.5 weeks
No
No
Yes
Blocking
LAG?
5 weeks Composite wrist and digit motion
No
5.5 weeks
Yes
Putty, ultrasound, and NMES
Yes
Incorporate composite extension splint and blocking splint
LAG? Composite wrist and digit motion
No
LAG?
6 weeks DC DBS, consider wrist control splint
Resistance
Fisting series
LAG? Composite wrist and digit motion
7.5 weeks
Continue with active ROM
8 weeks
Putty
10 weeks
RTW
12 weeks
Continue with PROM, start active flexion
No
Yes
Continue same approach as above for 6 months before tenolysis
Unrestricted use and sports
Passive flexion and extension exercises of the distal interphalangeal (DIP) joint in a dorsal blocking splint (DBS).
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SECTION 1 Hand and Wrist Injuries
REFERENCES A complete reference list is available at https://expertconsult .inkling.com/. FURTHER READING Amadio PC. Friction of the gliding surface. Implications for tendon surgery and rehabilitation. J Hand Ther. 2005;18:112–119. Boyer MI, Goldfarb CA, Gelberman RH. Recent progress in flexor tendon healing. The modulation of tendon healing with rehabilitation variables. J Hand Ther. 2005;18:80–85. Boyer MI, Strickland JW, Engles D, et al. Flexor tendon repair and rehabilitation: state of the art in 2002. Instr Course Lect. 2003;52:137–161. Elliott D, Southgate CM. New concepts in managing the long tendons of the thumb after primary repair. J Hand Ther. 2005;18:141–156. Evans RB. Zone I flexor tendon rehabilitation with limited extension and active flexion. J Hand Ther. 2005;18:128–140. Groth GN. Clinical decision making and therapists’ anatomy in the context of flexor tendon rehabilitation. J Hand Ther. 2008;21:254–259. Groth GN. Current practice patterns of flexor tendon rehabilitation. J Hand Ther. 2005;18:169–174.
Lilly SI, Messer TM. Complications after treatment of flexor tendon injuries. J Am Acad Orthop Surg. 2006;14:387–396. Pettengill KM. The evolution of early mobilization of the repaired flexor tendon. J Hand Ther. 2005;18:157–168. Powell ES, Trail I. Forces transmitted along human flexor tendons—the effect of extending the fingers against the resistance provided by rubber bands. J Hand Surg Eur. 2009;34:186–189. Savage R, Pritchard MG, Thomas M, et al. Differential splintage for flexor tendon rehabilitation: an experimental study of its effect on finger flexion strength. J Hand Surg Br. 2005;30:168–174. Strickland JW. Development of flexor tendon surgery: twenty-five years of progress. J Hand Surg Am. 2000;25:214–235. Tang JB. Clinical outcomes associated with flexor tendon repair. Hand Clin. 2005;21:199–210. Tang JB. Indications, methods, postoperative motion and outcome evaluation of primary flexor tendon repairs in zone 2. J Hand Surg Eur. 2007;32:118–129. Thien TB, Becker JH, Theis JC. Rehabilitation after surgery for flexor tendon injuries in the hand. Cochrane Database Syst Rev. 2004;(4):CD003979. Vucekovich K, Gallardo G, Fiala K. Rehabilitation after flexor tendon repair, reconstruction, and tenolysis. Hand Clin. 2005;21:257–265. Waitayawinyu T, Martineau PA, Luria S, et al. Comparative biomechanical study of flexor tendon repair using FiberWire. J Hand Surg Am. 2008;33:701–708.
REFERENCES Aoki M, Manske P, Pruitt D, et al. Work of flexion after tendon repair according to the placement of sutures. Clin Orthop Related Res. 1996;320:205–210. Baskies MA, Tuckman DV, Paksima N. Management of flexor tendon injuries following surgical repair. Bull NYU Hosp Jt Dis. 2008;66:35–40. Bezuhly M, Sparkes GL, Higgins A, et al. Immediate thumb extension following extensor indicis proprius-to-extensor pollicis longus tendon transfer using the wide-awake approach. Plast Reconstr Surg. 2007;119:1507–1512. Cao Y, Zhu B, Xie R, et al. Influence of core suture purchase length on strength of four-strand tendon repair. J Hand Surg Am. 2006;31:107–112. Diao E, Hariharan J, Soejima O, et al. Effect of peripheral suture depth on strength of tendon repairs. J Hand Surg Am. 1996;21:234–239. Duran RJ, Houser RG. Controlled passive motion following flexor tendon repair in zones 2 and 3. St. Louis: American Academy of Orthopaedic Surgeons Symposium on Tendon Surgery of the Hand Mosby; 1975. Green DP, Hotchkiss RN, Pederson WC, et al. Operative Hand Surgery. 3rd ed. New York: Churchill Livingstone; 1993. Kang N, Marsh D, Dewar D. The morbidity of the button-over-nail technique for zone 1 flexor tendon repairs. Should we still be using this technique? J Hand Surg Eur. 2008;33:566–570. Kubat W, Hsu J, Azharian A, et al. The use of Teno Fix tendon repair device in a patient with multiple flexor tendon ruptures. J Hand Microsurg. 2010;2:28–30. Lalonde D, Martin A. Epinepherine in local anesthesia in finger and hand surgery: the case for wide-awake anesthesia. J Am Acad Orthop Surg. 2013; 21:443–447. Matsuzaki H, Zaegel MA, Gelberman RH, et al. Effect of suture material and bone quality on the mechanical properties of zone 1 flexor tendon-bone reattachment with bone anchors. J Hand Surg Am. 2008;33:709–717. McCallister WV, Ambrose HC, Katolik LI, et al. Comparison of pullout button versus suture anchor for zone I flexor tendon repair. J Hand Surg Am. 2006;31:246–251.
Paillard P, Amadio P, Zhou C, et al. Pulley plasty versus resection of one slip of the flexor digitorum superficialis after repair of both flexor tendons in zone II. J Bone Joint Surg Am. 2002;84:2039–2045. Pike J, Boyer M, Gelberman R. Zone II combined FDS and FDP repair distal to the A2 pulley. J Hand Surg Am. 2010;35:1523–1527. Sandford F, Barlow N, Lewis J. A study to examine patient adherence to wearing 24-hour forearm thermoplastic splints after tendon repairs. J Hand Ther. 2008;21:44–52. Su BW, Solomons M, Barrow A, et al. A device for zone-II flexor tendon repair. A multicenter, randomized, blinded clinical trial. J Bone Joint Surg Am. 2005;87:932–935. Su BW, Solomons M, Barrow A, et al. A device for zone-II flexor tendon repair. Surgical technique. J Bone Joint Surg Am. 2006;88(suppl 1 Pt 1):37–49. Sueoka SS, LaStayo PC. Zone II flexor tendon rehabilitation: a proposed algorithm. J Hand Ther. 2008;21:410–413. Tang J, Xie R. Effect of the A3 pulley and adjacent sheath integrity on tendon excursion and bowstringing. J Hand Surg Am. 2001;26:855–861. Wolfe S, Willis A, Campbell D, et al. Biomechanic comparison of the Teno Fix tendon repair device with the cruciate and modified Kessler techniques. J Hand Surg Am. 2007;32:356–366. Xu Y, Tang J. Effects of superficialis tendon repairs on lacerated profundus tendons within or proximal to the A2 pulley: an in vivo study in chickens. J Hand Surg Am. 2003;28:994–1001. Yen CH, Chan WL, Wong JW, et al. Clinical results of early active mobilization after flexor tendon repair. Hand Surg. 2008;13:45–140. Zhou C, Amadio P, Zobitz M, et al. Resection of the flexor digitorum superficialis reduced gliding resistance after zone II flexor digitorum profundus repair in vitro. J Hand Surg Am. 2002;27:316–321.
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Flexor Tendon Injuries S. Brent Brotzman, MD | Steven R. Novotny, MD
IMPORTANT POINTS FOR REHABILITATION AFTER FLEXOR TENDON LACERATION AND REPAIR • The goal of the tendon repair is to coapt the severed ends without bunching or leaving a gap (Fig. 1.1). • Repaired tendons subjected to appropriate early motion stress will increase in strength more rapidly and develop fewer adhesions than immobilized repairs. • Flexor rehabilitation protocols must take into account the typical tensile stresses on normally repaired flexor tendon tendons (Bezuhly et al. 2007). Passive motion: 500–750 g (4.9–13 N) Light grip: 1500–2250 g (14.7–22 N) Strong grip: 5000–7500 g (49–73.5 N) Tip pinch, index flexor digitorum profundus (FDP): 9000– 13,500 g (88.2–132.3 N) • Initially rather strong, the flexor tendon repair strength decreases significantly between days 5 and 21 (Bezuhly et al. 2007). • The tendon is weakest during this time period because of minimal tensile strength. Strength increases quickly when controlled stress is applied in proportion to increasing tensile strength. Stressed tendons heal faster, gain strength faster, and have fewer adhesions. Tensile strength generally begins gradually increasing at 3 weeks. Generally, blocking exercises are initiated 1 week after active range of motion (ROM) excursion (5 weeks postoperative) (Baskies 2008). • The A2 and A4 pulleys are the most important to the mechanical function of the finger. Loss of a substantial portion of either may diminish digital motion and power or lead to flexion contractures of the interphalangeal (IP) joints. • The flexor digitorum superficialis (FDS) tendons lie on the palmar side of the FDP until they enter the A1 entrance of the digital sheath. The FDS then splits (at Champer’s chiasma) and terminates into the proximal half of the middle phalanx. • Flexor tendon excursion of as much as 9 cm is required to produce composite wrist and digital flexion. Excursion of only 2.5 cm is required for full digital flexion when the wrist is stabilized in the neutral position. • Tendons in the hand have both intrinsic and extrinsic capabilities for healing. • Factors that influence the formation of excursion-restricting adhesions around repaired flexor tendons include the following: Amount of initial trauma to the tendon and its sheath Tendon ischemia Tendon immobilization Gapping at the repair site Disruption of the vincula (blood supply), which decreases the recovery of the tendon (Fig. 1.2) • Delayed primary repair results (within the first 10 days) are equal to or better than immediate repair of the flexor tendon. 2
• Immediate (primary) repair is contraindicated in patients with any of the following: Severe multiple tissue injuries to the fingers or palm Wound contamination Significant skin loss over the flexor tendons
REHABILITATION RATIONALE AND BASIC PRINCIPLES OF TREATMENT AFTER FLEXOR TENDON REPAIR Timing The timing of flexor tendon repair influences the rehabilitation and outcome of flexor tendon injuries. • Primary repair is done within the first 12 to 24 hours after injury. • Delayed primary repair is done within the first 10 days after injury. • If primary repair is not done, delayed primary repair should be done as soon as there is evidence of wound healing without infection. • Secondary repair is done 10 and 14 days after injury. • Late secondary repair is done more than 4 weeks after injury. After 4 weeks it is extremely difficult to deliver the flexor tendon through the digital sheath, which usually becomes extensively scarred. However, clinical situations in which the tendon repair is of secondary importance often make late repair necessary, especially for patients with massive crush injuries, inadequate soft tissue coverage, grossly contaminated or infected wounds, multiple fractures, or untreated injuries. If the sheath is not scarred or destroyed, single-stage tendon grafting, direct repair, or tendon transfer can be done. If extensive disturbance and scarring have occurred, two-stage tendon grafting with a silicone (Hunter) rod should be performed. Before tendons can be secondarily repaired, these requirements must be met: • Joints must be supple and have useful passive range of motion (PROM) (Boyes grade 1 or 2, Table 1.1). Restoration of PROM is aggressively obtained with rehabilitation before secondary repair is done. • Skin coverage must be adequate. • The surrounding tissue in which the tendon is expected to glide must be relatively free of scar tissue. • Wound erythema and swelling must be minimal or absent. • Fractures must have been securely fixed or healed with adequate alignment. • Sensation in the involved digit must be undamaged or restored, or it should be possible to repair damaged nerves at the time of tendon repair directly or with nerve grafts. • The critical A2 and A4 pulleys must be present or have been reconstructed. Secondary repair is delayed until these are reconstructed. During reconstruction, Hunter (silicone) rods are useful to maintain the lumen of the tendon sheath while the grafted pulleys are healing.
1 Flexor Tendon Injuries Extending skin incision line
3
Passive DIP joint flexion
Distal FDS/FDP stumps Cruciate-synovial sheath flap
Approximation of distal and proximal stumps
Proximal FDS/FDP stumps
Tendon repair
Laceration of zone ll Skin flaps
Wound repair
Tube attachment
A
B
C
D
Fig. 1.1 Author’s technique of flexor tendon repair in zone 2. A, Knife laceration through zone 2 with the digit in full flexion. The distal stumps retract distal to the skin incision with digital extension. B, Radial and ulnar extending incisions are used to allow wide exposure of the flexor tendon system. Note appearance of the flexor tendon system of the involved fingers after the reflection of skin flaps. The laceration occurred through the C1 cruciate area. Note the proximal and distal position of the flexor tendon stumps. Reflection of small flaps (“windows”) in the cruciate-synovial sheath allows the distal flexor tendon stumps to be delivered into the wound by passive flexion of the distal interphalangeal (DIP) joint. The profundus and the superficialis stumps are retrieved proximal to the wound by passive flexion of the DIP joint. The profundus and superficialis stumps are retrieved proximal to the sheath by the use of a small catheter or infant feeding gastrostomy tube. C, The proximal flexor tendon stumps are maintained at the repair site by means of a transversely placed small-gauge hypodermic needle, allowing repair of the FDS slips without extension. D, Completed repair of both FDS and FDP tendons is shown with the DIP joint in full flexion. Extension of the DIP joint delivers the repair under the intact distal flexor tendon sheath. Wound repair is done at the conclusion of the procedure. Proper palmar digital artery
TABLE
1.1
VBP VLP VBS VLS Superficialis tendon Profundus tendon Fig. 1.2 Blood supply to the flexor tendons within the digital sheath. The segmental vascular supply to the flexor tendons is by means of the long and short vincular connections. The vinculum brevis superficialis (VBS) and the vinculum brevis profundus (VBP) consist of small triangular mesenteries near the insertion of the FDS and FDP tendons, respectively. The vinculum longum to the superficialis tendon (VLS) arises from the floor of the digital sheath of the proximal phalanx. The vinculum longum to the profundus tendon (VLP) arises from the superficialis at the level of the proximal interphalangeal (PIP) joint. The cut-away view depicts the relative avascularity of the palmar side of the flexor tendons in zones 1 and 2 as compared with the richer blood supply on the dorsal side, which connects with the vincula.
Anatomy The anatomic zone of injury of the flexor tendons influences the outcome and rehabilitation of these injuries. The hand is divided into five distinct flexor zones (Fig. 1.3): • Zone 1—from the insertion of the profundus tendon at the distal phalanx to just distal to the insertion of the sublimus • Zone 2—Bunnell’s “no-man’s land”: the critical area of pulleys between the insertion of the sublimus and the distal palmar crease
Boyes’ Preoperative Classification
Grade
Preoperative Condition
1
Good: minimal scar with mobile joints and no trophic changes Cicatrix: heavy skin scarring from injury or previous surgery; deep scarring from failed primary repair or infection Joint damage: injury to the joint with restricted range of motion Nerve damage: injury to the digital nerves resulting in trophic changes in the finger Multiple damage: involvement of multiple fingers with a combination of the above problems
2 3 4 5
• Zone 3—“area of lumbrical origin”: from the beginning of the pulleys (A1) to the distal margin of the transverse carpal ligament • Zone 4—area covered by the transverse carpal ligament • Zone 5—area proximal to the transverse carpal ligament As a rule, repairs to tendons injured outside the flexor sheath have much better results than repairs to tendons injured inside the sheath (zone 2). It is essential that the A2 and A4 pulleys (Fig. 1.4) be preserved to prevent bowstringing. In the thumb, the A1 and oblique pulleys are the most important. The thumb lacks vincula for blood supply.
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SECTION 1 Hand and Wrist Injuries
Distal to FDS tendon l l
l l
ll No man’s land
l
ll ll Lumbrical origin
lll lV
lll lV
Carpal tunnel V Muscle-tendon V junction
Fig. 1.3 The flexor system has been divided into five zones or levels for the purpose of discussion and treatment. Zone 2, which lies within the fibro-osseous sheath, has been called “no man’s land” because it was once believed that primary repair should not be done in this zone.
A5 C3 A4
Distal transverse digital artery Intermediate transverse digital artery
C2 A3
Proximal transverse digital artery
C1 A2
A1
Branch to viniculum longus Proper palmar digital artery Common digital artery Flexor tendon
Fig. 1.4 The fibrous retinacular sheath starts at the neck of the metacarpal and ends at the distal phalanx. Condensations of the sheath form the flexor pulleys, which can be identified as five heavier annular bands and three filmy cruciform ligaments (see text).
Tendon Healing The exact mechanism of tendon healing is still unknown. Healing probably occurs through a combination of extrinsic and intrinsic processes. Extrinsic healing depends on the formation of adhesions between the tendon and the surrounding tissue, providing a blood supply and fibroblasts, but unfortunately it
also prevents the tendon from gliding. Intrinsic healing relies on synovial fluid for nutrition and occurs only between the tendon ends. Flexor tendons in the distal sheath have a dual source of nutrition via the vincular system and synovial diffusion. Diffusion appears to be more important than perfusion in the digital sheath (Green 1993). Several factors have been reported to affect tendon healing: • Age—The number of vincula (blood supply) decreases with age. • General health—Cigarettes, caffeine, and poor general health delay healing. The patient should refrain from ingesting caffeine and smoking cigarettes during the first 4 to 6 weeks after repair. • Scar formation—The remodeling phase is not as effective in patients who produce heavy keloid or scar. • Motivation and compliance—Motivation and the ability to follow the postoperative rehabilitation regimen are critical factors in outcome. • Level of injury—Zone 2 injuries are more apt to form limiting adhesions from the tendon to the surrounding tissue. In zone 4, where the flexor tendons lie in close proximity to each other, injuries tend to form tendon-to-tendon adhesions, limiting differential glide. • Trauma and extent of injury—Crushing or blunt injuries promote more scar formation and cause more vascular trauma, impairing function and healing. Infection also impedes the healing process. • Pulley integrity—Pulley repair is important in restoring mechanical advantage (especially A2 and A4) and maintaining tendon nutrition through synovial diffusion. • Surgical technique—Improper handling of tissues (such as forceps marks on the tendon) and excessive postoperative hematoma formation trigger adhesion formation. The two most frequent causes for failure of primary tendon repairs are formation of adhesions and rupture of the repaired tendon. Through experimental and clinical observation, Duran and Houser (1975) determined that tendon glide of 3 to 5 mm is sufficient to prevent motion-limiting tendon adhesions. Exercises are thus designed to achieve this motion.
Treatment of Flexor Tendon Lacerations Partial laceration involving less than 25% of the tendon substance can be treated by beveling the cut edges. Lacerations between 25% and 50% can be repaired with 6-0 running nylon suture in the epitenon. Lacerations involving more than 50% should be considered complete and should be repaired with a core suture and an epitenon suture. No level 1 studies have determined superiority of one suture method or material, although a number of studies have compared different suture configurations and materials. Most studies indicate that the number of strands crossing the repair site and the number of locking loops directly affect the strength of the repair, with six- and eight-strand repairs generally shown to be stronger than four-strand or two-strand repairs; however, the increased number of strands also increases bulk and resistance to glide. Several four-strand repair techniques appear to provide adequate strength for early motion. The following discussion is mainly for zone 2 flexor tendon lacrations. The other zones are repaired similarly, but the peculiarities of zone 2 tendon repairs will be emphasized. I still
1 Flexor Tendon Injuries
5
prefer a standard Brunner type incision instead of a midaxial. My exposure and opening of the tendon sheath depends on the location of its laceration and the quality of the traumatized sheath. If the laceration is through the A2 pulley, I will make controlled sheath incisions distal or proximal to the pulley. If the pulley is cut asymmetrically, I have vented the pulley for a better exposure. I prefer to work through distally based triangular openings if possible, believing the repaired sheath apex will allow enhanced gliding for the tendon anastomosis, as opposed to the transversely sutured sheath flap. Rectangular flaps for larger exposure are sometimes needed. When retrieving a tendon from the palm, I have no qualms about excising the A1 pulley for enhanced visualization. I place my core sutures approximately 1 cm from the laceration (Cao et al. 2006). The proximal core sutures are captured with a 26-gauge looped steel wire as a passer, causing minimal trauma to the native sheath. I try not to use hypodermic needles, Keith needles, or a manufactured tendon approximator unless needed, to minimize epitendon trauma. A skilled assistant can often tension the proximal stump with traction on one set of core sutures. The core sutures should be placed dorsal as opposed to volar (Aoki et al. 1996), the running epitendon suture must have reasonable depth (Daio et al. 1996), and I repair the sheath whenever possible (Tang and Xie 2001). Tendons lacerated sharply without need of débridement are repaired as described in Pike, Boyer and Gelberman’s 2010 publication. Not surprisingly, many patients have significantly traumatized tendon edges in need of débridement. I use the ASSI Peripheral Nerve and Tendon Cutting Set (ASSI, Westbury, NY) to restore quality tendon edges. In this scenario I am more likely to use basic science principles (Zhao et al. 2002; Paillard et al. 2002; Xu and Tang 2003) and débride one slip of the superficialis tendon.
should not be advanced more than 1 cm to avoid the quadregia effect (a complication of a single digit with limited motion causing limitation of excursion and, thus, the motion of the uninvolved digits). Citing complications in 15 of 23 patients with pull-out wire (button-over-nail) repairs, 10 of which were directly related to the technique, Kang et al. (2008) questioned its continued use. Complications of the pull-out wire technique included nail deformities, fixed flexion deformities of the distal interphalangeal (DIP) joint, infection, and prolonged hypersensitivity. A more recent technique for FDP lacerations is the use of braided polyester/monofilament polyethylene composite (FiberWire, Arthrex, Naples, FL) and suture anchors rather than pullout wires (Matsuzaki et al. 2008; McCallister et al. 2006). Reports of outcomes currently are too few to determine if this technique will allow earlier active motion than standard techniques.
Teno Fix Repair
Rehabilitation After Flexor Tendon Repair
A stainless-steel tendon repair device (Teno Fix, Ortheon Medical, Columbus, OH) was reported to result in lower flexor tendon rupture rates after repair and similar functional outcomes when compared with conventional repair in a randomized, multicenter study, particularly in patients who were noncompliant with the rehabilitation protocol (Su et al. 2005, 2006). Active flexion was allowed at 4 weeks postoperatively. Solomon et al. (unpublished research) developed an “accelerated active” rehabilitation program to be used after Teno Fix repairs: Active digital flexion and extension maximum-attainable to the palm are started on the first day with the goal of full flexion at 2 weeks postoperatively. The anticipated risks with this protocol are forced passive extension, especially of the wrist and finger (e.g., fall on outstretched hand), and resisted flexion, potentially causing gapping or rupture of the repair. The possibility of a more rapid return of function, or at least being more forgiving of rehabilitation mistakes, adds some potential attractiveness to the use of Teno Fix for flexor tendon repairs. At least one research group (Wolfe 2007) noted no benefit of using the Teno Fix system compared to the sutures techniques they used. What one doesn’t know is the cost to the consumer of the product. Is the product cost worth the benefit? Kubat (2010) describes a case report with multiple tendon involvement and proposes that, at least with his patient, the savings of operative time and its associated expense may make using this product more palatable. FDP lacerations can be repaired directly or advanced and reinserted into the distal phalanx with a pull-out wire, but they
The rehabilitation protocol chosen (Rehabilitation Protocols 1.1 and 1.2) depends on the timing of the repair (delayed primary or secondary), the location of the injury (zones 1 through 5), and the compliance of the patient (early mobilization for patients who are compliant and delayed mobilization for patients who are noncompliant and children younger than 7 years of age). A survey of 80 patients with flexor and extensor tendon repairs determined that two thirds were nonadherent to their splinting regimen, removing their splints for bathing and dressing (Sandford et al. 2008). In a comparison of early active mobilization and standard Kleinert splintage, Yen et al. 2008 found at an average 4-month follow-up (3 to 7 months) that those in the early active mobilization group had 90% of normal grip strength, pinch, and range of motion compared to 50%, 40%, and 40%, respectively, in those with Kleinert splinting. Sueoka and LaStayo (2008) devised an algorithm for zone 2 flexor tendon rehabilitation that uses a single clinical sign— the lag sign—to determine the progression of therapy and the need to modify existing protocols for individual patients. They defined “lag” as PROM—AROM (active ROM) ≥15 degrees and consider it a sign of tendon adherence and impairment of gliding. Rehabilitation begins with an established passive ROM Protocol (Duran), which is followed for 3.5 weeks before the presence or absence of a lag is evaluated. The presence or absence of lag is then evaluated at the patient’s weekly or twiceweekly visits, and progression of therapy is modified if a lag sign is present (Rehabilitation Protocol 1.3).
Bloodless Surgery A current topic of interest is bloodless awake surgery for more complex hand problems. I refer the reader to a recent publication by Lalonde and Martin (2013). I firmly believe in the science and employ it when appropriate. However, some patients refuse to proceed under local anesthesia. Vasculopaths, such as those with Buerger’s disease, may not be appropriate candidates. Lastly, repairing extensor tendons, an easier proposition, can still be challenging when the patient involuntarily contracts muscles as the proximal tendon stump is pulled distally for repair. A posterior interosseous nerve block is easy to perform to prevent inadvertent muscle pull; a proximal median nerve block in the antecubital fossa is a little different. Gaining the skill to use an ultrasound or having an anesthesiologist perform the block if needed could be difficult.
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SECTION 1 Hand and Wrist Injuries
REHABILITATION PROTOCOL 1.1 Rehabilitation Protocol After Immediate or Delayed Primary Repair of Flexor Tendon Injury: Modified Duran Protocol Marissa Pontillo, PT, DPT, SCS • Active wrist extension to neutral only • Functional electrical stimulation (FES) with the splint on
Postoperative Day 1 to Week 4.5 • Keep dressing on until Day 5 postoperative. • At Day 5: replace with light dressing and edema control prn. • Patient is fitted with dorsal blocking splint (DBS) fashioned in: • 20 degrees wrist flexion. • 45 degrees MCP flexion. • Full PIP, DIP in neutral • Hood of splint extends to fingertips • Controlled passive motion twice daily within constraints of splint: • 8 repetitions of passive flexion and active extension of the PIP joint
A
5.5 Weeks • Continue passive exercises. • Discontinue use of DBS. • Exercises are performed hourly: 12 repetitions of PIP blocking • 12 repetitions of DIP blocking • 12 repetitions of composite active flexion and extension • May start PROM into flexion with overpressure
B
Passive flexion and extension exercises of the proximal interphalangeal (PIP) joint in a dorsal blocking splint (DBS). A, Passive flexion of PIP joint. B, The finger being extended from flexed position.
• 8 repetitions of passive flexion and active extension of the DIP joint • 8 repetitions of active composite flexion and extension of the DIP and PIP joints with the wrist and MCP joints supported in flexion
4.5 Weeks • Continue passive exercises as needed. • Removal of DBS every 2 hours to perform 10 repetitions of each active flexion and extension of the wrist and of the digits • May start intrinsic minus (hook fist) position and/or tendon gliding exercises
6 Weeks • Initiate passive extension for the wrist and digits. 8 Weeks • Initiate gentle strengthening. • Putty, ball squeezes • Towel walking with fingers • No lifting or heavy use of the hand 10–12 Weeks • Return to previous level of activity, including work and sport activities.
REHABILITATION PROTOCOL 1.2 Indianapolis Protocol (“Active Hold Program”) • Indicated for patients with four-strand Tajima and horizontal mattress repair with peripheral epitendinous suture • Patient who is motivated and compliant • Two splints are used: the traditional dorsal blocking splint (with the wrist at 20 to 30 degrees of flexion, MCP joints in 50 degrees of flexion, and IP joints in neutral) and the Strickland tenodesis splint. The latter splint allows full wrist flexion and 30 degrees of dorsiflexion, while digits have full ROM, and MCP joints are restricted to a 60-degree extension. • For the first 1 to 3 weeks, the modified Duran protocol is used. The patient performs repetitions of flexion and extension to the PIP and DIP joints and to the whole finger 15 times per hour. Exercise is restrained by the dorsal splint. Then, the Strickland hinged wrist splint is applied. The patient passively flexes the digits while extending the wrist. The patient then gently contracts the digits in the palm and holds for 5 seconds.
• At 4 weeks, the patient exercises 25 times every 2 hours without any splint. A dorsal blocking splint is worn between exercises until the sixth week. The digits are passively flexed while the wrist extends. Light muscle contraction is held for 5 seconds, and the wrist drops into flexion, causing digit extension through tenodesis. The patient begins active flexion and extension of the digits and wrist. Simultaneous digit and wrist extension is not allowed. • After 5 to 14 weeks, the IP joints are flexed while the MCP joints are extended, and then the IP is extended. • After 6 weeks, blocking exercises commence if digital flexion is more than 3 cm from the distal palmar flexion crease. No blocking is applied to the small finger FDP tendon. • At 7 weeks, passive extension exercises are begun. • After 8 weeks, progressive gradual strengthening is begun. • After 14 weeks, activity is unrestricted.
(From Neumeister M, Wilhelmi BJ, Bueno Jr, RA: Flexor tendon lacerations: Treatment. http://emedicine.medscape.com/orthopedic_surgery)
1 Flexor Tendon Injuries
Passive ROM
REHABILITATION PROTOCOL 1.3 Zone 2 Lag Sign Algorithm 3–7 days
Kleinert
Duran
Full passive flexion?
Yes
3 weeks Place and hold
No
Greater emphasis on passive ROM LAG?
1 3.5 weeks
Yes
No 2
4 weeks
LAG? Yes
Active ROM
4.5 weeks
No
No
Yes
Blocking
LAG?
5 weeks Composite wrist and digit motion
No
5.5 weeks
Yes
Putty, ultrasound, and NMES
Yes
Incorporate composite extension splint and blocking splint
LAG? Composite wrist and digit motion
No
LAG?
6 weeks DC DBS, consider wrist control splint
Resistance
Fisting series
LAG? Composite wrist and digit motion
7.5 weeks
Continue with active ROM
8 weeks
Putty
10 weeks
RTW
12 weeks
Continue with PROM, start active flexion
No
Yes
Continue same approach as above for 6 months before tenolysis
Unrestricted use and sports
Passive flexion and extension exercises of the distal interphalangeal (DIP) joint in a dorsal blocking splint (DBS).
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SECTION 1 Hand and Wrist Injuries
REFERENCES A complete reference list is available at https://expertconsult .inkling.com/. FURTHER READING Amadio PC. Friction of the gliding surface. Implications for tendon surgery and rehabilitation. J Hand Ther. 2005;18:112–119. Boyer MI, Goldfarb CA, Gelberman RH. Recent progress in flexor tendon healing. The modulation of tendon healing with rehabilitation variables. J Hand Ther. 2005;18:80–85. Boyer MI, Strickland JW, Engles D, et al. Flexor tendon repair and rehabilitation: state of the art in 2002. Instr Course Lect. 2003;52:137–161. Elliott D, Southgate CM. New concepts in managing the long tendons of the thumb after primary repair. J Hand Ther. 2005;18:141–156. Evans RB. Zone I flexor tendon rehabilitation with limited extension and active flexion. J Hand Ther. 2005;18:128–140. Groth GN. Clinical decision making and therapists’ anatomy in the context of flexor tendon rehabilitation. J Hand Ther. 2008;21:254–259. Groth GN. Current practice patterns of flexor tendon rehabilitation. J Hand Ther. 2005;18:169–174.
Lilly SI, Messer TM. Complications after treatment of flexor tendon injuries. J Am Acad Orthop Surg. 2006;14:387–396. Pettengill KM. The evolution of early mobilization of the repaired flexor tendon. J Hand Ther. 2005;18:157–168. Powell ES, Trail I. Forces transmitted along human flexor tendons—the effect of extending the fingers against the resistance provided by rubber bands. J Hand Surg Eur. 2009;34:186–189. Savage R, Pritchard MG, Thomas M, et al. Differential splintage for flexor tendon rehabilitation: an experimental study of its effect on finger flexion strength. J Hand Surg Br. 2005;30:168–174. Strickland JW. Development of flexor tendon surgery: twenty-five years of progress. J Hand Surg Am. 2000;25:214–235. Tang JB. Clinical outcomes associated with flexor tendon repair. Hand Clin. 2005;21:199–210. Tang JB. Indications, methods, postoperative motion and outcome evaluation of primary flexor tendon repairs in zone 2. J Hand Surg Eur. 2007;32:118–129. Thien TB, Becker JH, Theis JC. Rehabilitation after surgery for flexor tendon injuries in the hand. Cochrane Database Syst Rev. 2004;(4):CD003979. Vucekovich K, Gallardo G, Fiala K. Rehabilitation after flexor tendon repair, reconstruction, and tenolysis. Hand Clin. 2005;21:257–265. Waitayawinyu T, Martineau PA, Luria S, et al. Comparative biomechanical study of flexor tendon repair using FiberWire. J Hand Surg Am. 2008;33:701–708.
REFERENCES Aoki M, Manske P, Pruitt D, et al. Work of flexion after tendon repair according to the placement of sutures. Clin Orthop Related Res. 1996;320:205–210. Baskies MA, Tuckman DV, Paksima N. Management of flexor tendon injuries following surgical repair. Bull NYU Hosp Jt Dis. 2008;66:35–40. Bezuhly M, Sparkes GL, Higgins A, et al. Immediate thumb extension following extensor indicis proprius-to-extensor pollicis longus tendon transfer using the wide-awake approach. Plast Reconstr Surg. 2007;119:1507–1512. Cao Y, Zhu B, Xie R, et al. Influence of core suture purchase length on strength of four-strand tendon repair. J Hand Surg Am. 2006;31:107–112. Diao E, Hariharan J, Soejima O, et al. Effect of peripheral suture depth on strength of tendon repairs. J Hand Surg Am. 1996;21:234–239. Duran RJ, Houser RG. Controlled passive motion following flexor tendon repair in zones 2 and 3. St. Louis: American Academy of Orthopaedic Surgeons Symposium on Tendon Surgery of the Hand Mosby; 1975. Green DP, Hotchkiss RN, Pederson WC, et al. Operative Hand Surgery. 3rd ed. New York: Churchill Livingstone; 1993. Kang N, Marsh D, Dewar D. The morbidity of the button-over-nail technique for zone 1 flexor tendon repairs. Should we still be using this technique? J Hand Surg Eur. 2008;33:566–570. Kubat W, Hsu J, Azharian A, et al. The use of Teno Fix tendon repair device in a patient with multiple flexor tendon ruptures. J Hand Microsurg. 2010;2:28–30. Lalonde D, Martin A. Epinepherine in local anesthesia in finger and hand surgery: the case for wide-awake anesthesia. J Am Acad Orthop Surg. 2013; 21:443–447. Matsuzaki H, Zaegel MA, Gelberman RH, et al. Effect of suture material and bone quality on the mechanical properties of zone 1 flexor tendon-bone reattachment with bone anchors. J Hand Surg Am. 2008;33:709–717. McCallister WV, Ambrose HC, Katolik LI, et al. Comparison of pullout button versus suture anchor for zone I flexor tendon repair. J Hand Surg Am. 2006;31:246–251.
Paillard P, Amadio P, Zhou C, et al. Pulley plasty versus resection of one slip of the flexor digitorum superficialis after repair of both flexor tendons in zone II. J Bone Joint Surg Am. 2002;84:2039–2045. Pike J, Boyer M, Gelberman R. Zone II combined FDS and FDP repair distal to the A2 pulley. J Hand Surg Am. 2010;35:1523–1527. Sandford F, Barlow N, Lewis J. A study to examine patient adherence to wearing 24-hour forearm thermoplastic splints after tendon repairs. J Hand Ther. 2008;21:44–52. Su BW, Solomons M, Barrow A, et al. A device for zone-II flexor tendon repair. A multicenter, randomized, blinded clinical trial. J Bone Joint Surg Am. 2005;87:932–935. Su BW, Solomons M, Barrow A, et al. A device for zone-II flexor tendon repair. Surgical technique. J Bone Joint Surg Am. 2006;88(suppl 1 Pt 1):37–49. Sueoka SS, LaStayo PC. Zone II flexor tendon rehabilitation: a proposed algorithm. J Hand Ther. 2008;21:410–413. Tang J, Xie R. Effect of the A3 pulley and adjacent sheath integrity on tendon excursion and bowstringing. J Hand Surg Am. 2001;26:855–861. Wolfe S, Willis A, Campbell D, et al. Biomechanic comparison of the Teno Fix tendon repair device with the cruciate and modified Kessler techniques. J Hand Surg Am. 2007;32:356–366. Xu Y, Tang J. Effects of superficialis tendon repairs on lacerated profundus tendons within or proximal to the A2 pulley: an in vivo study in chickens. J Hand Surg Am. 2003;28:994–1001. Yen CH, Chan WL, Wong JW, et al. Clinical results of early active mobilization after flexor tendon repair. Hand Surg. 2008;13:45–140. Zhou C, Amadio P, Zobitz M, et al. Resection of the flexor digitorum superficialis reduced gliding resistance after zone II flexor digitorum profundus repair in vitro. J Hand Surg Am. 2002;27:316–321.
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