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Questions Hand Therapists Ask about Treatment of Tendon Injuries
Questions Hand Therapists Ask about Treatment of Tendon Injuries Erik A. Rosenthal, MD Baystate Medical Center Shriners Hospital for Children Springfield, Massachusetts Department of Orthopaedic Surgery Tufts University School of Medicine Boston, Massachusetts
Carol W. Stoddard, OTR/L, CHT Adjunct Faculty Springfield College American International College Springfield, Massachusetts Private Consultant in Hand Therapy
Management of tendon injuries is a challenging responsibility for the surgeon and the hand therapist. Outcomes are improved by a clear understanding of concepts and indications that are pertinent to the clinical situation. We have given a comprehensive course, Surgical and Therapeutic Management of Flexor and Extensor Tendon Injuries, several times a year at various centers since 1998. The participants’ questions indicate their understanding but also confirm that some concepts are difficult to assimilate and implement. In this article, we address the most frequent questions put forth by therapists, residents, and surgeons. Our intention is to provide practical information that can be applied clinically.
1. HOW SHOULD A THERAPIST DECIDE WHICH TENDON PROTOCOL WILL PROVIDE THE OPTIMUM RESULT AFTER REPAIR? Selection of the appropriate protocol needs to be made with the referring surgeon. The surgeon may dictate his or her preferred protocol, but the decision may be influenced strongly by the opinions and observations of the therapist. The surgeon and
Correspondence and reprint requests to Erik A. Rosenthal, MD, 111 Woodsley Road, Longmeadow, MA 01106; e-mail:. doi:10.1197/j.jht.2005.02.006
therapist both need to be communicative, flexible, and open minded. There is specific information regarding the patient, injury and operative treatment that the therapist needs to make this determination. The therapist must know the mechanism of injury, date of injury and repair, details of injured structures, and technical specifics of the repair(s). This includes number and caliber of suture strands and the method of core and peripheral suture technique, where the suture knots were placed, and condition of retinacular structures such as the flexor fibroosseous sheath and dorsal carpal ligament. A copy of the operative report is invaluable in this regard. Are there any pertinent medical conditions that may influence healing or clinical progression? The currently available protocol options are immobilization, early controlled mobilization, and early active mobilization. Numerous refinements within these broad categories have been advocated. In a perfect world, implementation of a protocol follows open communication between the surgeon and the therapist. The therapist should explore and clarify any concerns or reservations with the surgeon before embarking on treatment. Treatment progression is monitored by appropriate communication with the surgeon to convey developments and discuss problems. An unfortunate quandary occurs when the referral notes are sparse and not informative, or verbal authorization comes from an intermediary other than the surgeon. The therapist should April–June 2005 313
endeavor to acquire sufficient information and maintain rapport that supports appropriate treatment. There is still a role for postoperative immobilization, without controlled motion, until the tendon is sufficiently healed to permit active motion. This approach is appropriate with young children or patients who are not compliant. There is no currently available tendon repair that can withstand unrestricted normal activity immediately after repair without likelihood of rupture. A compromised repair or a weak two-strand repair is also an indication for immobilization in lieu of early controlled motion. Early controlled mobilization is appropriate for the compliant patient in the hands of an experienced therapist after a technically competent repair by an experienced surgeon. Early active protocol is the most sophisticated and potentially risky of all protocols. It should be reserved for the ideal patient in an ideally proficient therapy setting after a strong, atraumatic, and technically strong tendon repair.
2. HOW DOES THE SUTURE TECHNIQUE AFFECT SELECTION OF THE POSTOPERATIVE TREATMENT PROTOCOL? The treatment protocol should never impart stresses to a repaired tendon that exceed the tensile strength of the repair itself. The reported in vivo stress levels in a digital flexor digitorum profundus (FDP) tendon during unrestricted active motion is 19 N and 80 N with an effective tip pinch of 34 N. The in vitro failure load for fully lacerated human flexor tendons is reportedly 20–40 N for two-strand or fourstrand core repairs. The mean breaking strength of a lacerated flexor tendon repaired with a 6-0 suture criss-cross peripheral suture is 63 N.1 The failure load of the interlocking horizontal mattress suture is 52 N.2 The addition of a peripheral circumferential suture that grasps tendon fibers in addition to the delicate epitenon adds approximately 50% suture strength to a repair. The configuration and caliber of sutures determine the strength of the repair and, therefore, whether the repair can withstand the stresses of motion with a specific protocol. Strength of the repair is basically proportional to the number of suture strands that cross the repair. A six-strand core suture is stronger than a four-strand, which is stronger than a twostrand. A six-strand core suture is strongest, but is technically difficult, is bulky, and insertion causes added trauma to the tendon. A 3-0-caliber suture is two to three times stronger than a 4-0-caliber suture. A locking loop stitch is stronger than a grasping loop and a criss-cross stitch is stronger than a loop stitch. A grasping loop stitch usually fails by suture pullout, whereas a locking loop stitch fails by suture 314
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breakage. The four-strand cruciate cross-stitch3 is stronger that a four-strand cruciate loop stitch.4 Both use a core suture method that is sufficiently strong by testing to support stresses of early motion protocols, but the Sandow and McMahon3 modification is technically easier to insert. Core sutures can be inserted so that the suture knot is between the cut tendon ends rather than on the tendon periphery. This lessens drag and surface friction but does not diminish the strength of the stitch. The combination of these core and peripheral sutures is sufficiently strong to support anticipated loads with early controlled or active motion protocols. Any repair that has a greater risk of rupture by virtue of the condition of the tendon or the caliber of the sutures or the number of core strands used or the absence of a peripheral suture—one that poses a significant risk of rupture—should be protected by immobilization until the tendon heals. The decision regarding protocols depends on the experience and skill level of the surgeon and therapist. This decision considers the wound and the patient, and recognizes that active motion introduces greater stresses with increased risk than does a more protected protocol.
3. WHEN SHOULD ONE BEGIN MOTION AFTER TENDON REPAIR OR TENOLYSIS? Motion should be initiated when the tissues are ready. This implies that the wound is stable and comfortable, without significant edema. Delay of early motion until postoperative day 3 has been shown experimentally to decrease the work of flexion after flexor tendon repair.5 Comfortable immobilization with elevation, in our opinion, should continue until the third postoperative day when the wound is first inspected unless pain or excessive swelling or bleeding necessitates an earlier dressing change. If the wound is healthy and stable, gentle motion is initiated on the third day. If there is swelling, wound instability or undue discomfort with motion, progress is tempered to permit the tissues to adjust. There is no single protocol or schedule that is applicable to all patients. This delay in imparting motion after tenolysis runs counter to traditional teaching, but has been validated by the experimental work cited earlier and by our clinical experience. There are no adhesions that have formed by the third postoperative day that cannot be modified or interrupted by gentle, judicious therapy. It is counterintuitive to recommend a peripheral nerve block or wound injection and to proceed with motion without the protective benefit of normal pain response. Pain is a warning, and should be respected as the natural response of tissues to excessive stress. Progress should be comfortable.
4. HOW CAN ONE DETERMINE WHETHER A REPAIRED FLEXOR TENDON IN ZONE 2 IS RESTRICTED BY ADHESIONS, GAPPED OR RUPTURED? The ultimate decision regarding the repair is made only after careful clinical assessment by palpation and comparison of the clinical performance with previously recorded assessments. Accurate records that document range of motion (ROM), swelling and pain are essential when determining whether there has been any disruption at the repair site. ROM records are the baseline for comparison. A disparity between active and passive ROM is normally observed during early treatment with any controlled or early motion protocol. There should be a progressive lessening in this disparity; the active range should improve and eventually equal the passive range of motion. Persistent, significant difference between active and passive motion after competent therapy of sufficient duration is one of the diagnostic hallmarks of intractable tendon adhesions that may indicate the need for a surgical tenolysis. The patient’s comments and subjective assessment are invaluable diagnostic aids. A ‘‘pop’’ or ‘‘zing’’ may indicate an adhesion rupture or may signify rupture of the repair. A ‘‘squeak’’ or ‘‘my finger needs oil’’ suggests reactive inflammation about the repair. A dramatic falloff in distal pull-through or loss of active range of motion compared with previous records suggests new adhesions or repair gapping. Active pull-through distal to the repair site confirms that there is continuity through the repair. Strong distal response through the expected range of motion is consistent with a healthy, gliding repair. A ‘‘tweak’’ of distal movement only at the inception of the motion arc is suggestive of some repair continuity but does not rule out adhesions or gapping. The determination whether this is due to adhesions or gapping or rupture is the important challenge that confronts the therapist and surgeon. Ultrasonography of the repair site offers an economical, reliable confirmation of tendon continuity, gapping or rupture. Ultrasound can differentiate partial from complete lacerations and verify integrity of tendon repair.6 The beam must be perpendicular to the tendon for an accurate reading. An oblique beam can produce a hypoechoic image that may be misinterpreted as a false positive sign of repair gap.
5. HOW DO I TREAT IMPAIRED TENDON GLIDE DUE TO ADHESIONS, GAPPED TENDON REPAIR AND TENDON RUPTURE? The diagnostic hallmark of restrictive adhesions is a disparity between active and passive motion. These
restraints are treated with active ROM, tendon gliding and blocking exercises, resistive exercises, custom splints, ultrasound, heat modalities, and electrical stimulation. Resistive exercises require both resistance throughout the range and sustained end range muscle contraction. Active and resistive flexion is the most effective means of altering adhesions and improving excursion. These cannot be implemented until the tendon is sufficiently healed. Active flexion usually begins at three to four weeks; resistance begins later at five to eight weeks. A small gap in a zone 2 flexor tendon repair is of greater significance than a comparable gap in a zone 6 extensor tendon. A repair with an acceptable gap—one that is recognized but not considered sufficient to warrant operative intervention—should be put to rest in a position of reduced tension across the repair. Any flexor tendon gap of more than 2 mm is considered detrimental to the clinical outcome, but there are instances where a recognized gap is acknowledged and accepted in lieu of another operation. The extensor tendons to the digits proximal to zone V have a significantly greater capacity for adaptation by bridging of the gap with scar that remodels, with satisfactory function, a functional pseudotendon. A gapped flexor tendon is treated by reducing the demands on the repair. This depends on what protocol has been adopted and the phase of treatment. An active motion protocol would be converted to an early controlled mobilization program. In an early controlled mobilization program, active and resistive motion should be delayed. The length of time delay is based on clinical assessment. A gapped extensor tendon in zone V, VI, or VII is treated by putting the tendon to rest to encourage formation of a functional pseudotendon. The digit of the injured tendon is positioned in more extension—less metacarpophalangeal (MCP) flexion—than the digits without injured tendons. The MCP joints of uninjured fingers can be positioned in slight flexion, about 30 degrees. The wrist is positioned in 30-degree extension with zone VI injuries. The wrist is usually positioned in neutral for zone VII or VIII injuries, especially when there has been injury to the dorsal carpal ligament. Fine adjustments of position can be designed according to the level and character of the injury. The juncturae tendinum provide another anatomic safeguard in positioning the digits after repair. These tendinous interconnections diverge distally from the ring finger extensor digitorum communis (EDC) tendon. Passive MCP joint flexion creates distal traction of the EDC through the juncturae tendinum that can relax a repair further. Definitive treatment follows after an accurate determination of repair status is made. A ruptured repair diagnosis should be communicated to the surgeon for consideration of secondary repair. A repair gap has significant dimensions with varying implications. April–June 2005 315
6. WHAT IS THE DIFFERENCE BETWEEN SYNDROME OF THE QUADRIGA AND A TENODESIS? Tenodesis is tethering that prevents tendon glide. The etiologies of a tenodesis are myriad, and include a fracture, surgical fixation device, or inelastic scar (adhesions). Whatever the cause, the result is the same: the tendon is anchored. It is deprived of its normal excursion and all distal structures are linked to the tether by a fixed tendon link. Verdan7 described syndrome of the quadriga to illustrate the undesirable consequences of suturing distal flexor and extensor tendons together over the end of a digital amputation, a common surgical practice until the mid-20th century. This was performed to provide a cushion to the amputation. The result was tethering, a tenodesis, of the FDP tendon that impaired grasp. The tenodesis limits contraction of the FDP muscle, which is manifest clinically as incomplete terminal flexion of the uninjured digits during grip. A FDP tendon may scar proximally within its fibroosseous sheath, retract and adhere after laceration, resulting in a quadriga syndrome. Skilled hand therapy with early active motion after tendon injury or digital amputation is the most effective preventative measures. Treatment of the established syndrome, or if hand therapy has been unsuccessful, is tenolysis with surgical release of the tethered flexor profundus tendon. Some specific deformity patterns associated with flexor or extensor tenodesis have been given descriptive names. Syndrome of the quadriga is a specific tenodesis, but all tenodeses are not quadriga syndromes. Extensor plus phenomenon, similarly, is another specific tenodesis with recognizable deformity patterns, but is not syndrome of the quadriga.
7. DO EARLY MOTION PROTOCOLS HAVE A ROLE IN POSTOPERATIVE TREATMENT OF WRIST FLEXOR OR EXTENSOR TENDON INJURIES? Early motion protocols at this time do not have a role in treatment of wrist flexor and extensor tendon injuries. These tendons are motored by powerful muscles, the tendons have relatively short excursion and loss of normal tendon glide poses a risk of a significant functional imbalance. Some isolated wrist tendon injuries are less prone to introduce an imbalance due to their anatomic station and resulting biomechanics. Isolated loss of the flexor carpi radialis or extensor carpi radialis brevis—as with attritional rupture from osteoarthritis, a tendon laceration, or harvesting for tendon transfer—is less likely to introduce an imbalance. It is nonetheless good practice to endeavor to repair and rehabilitate all injured wrist 316
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tendons if feasible. Repaired wrist tendons should be immobilized in a relaxed position for at least three weeks before controlled motion is begun. Wrist extensors are immobilized in approximately 30 degrees extension if the dorsal carpal ligament is intact. If the dorsal carpal ligament is deficient the wrist should be immobilized in neutral to avoid dorsal tendon bowing with formation of a dorsal dead space. Wrist flexors are immobilized in slight flexion, 30 degrees or less, only if the transverse carpal ligament is intact. Excessive wrist flexion is prone to promote carpal tunnel syndrome. The wrist is positioned in neutral if the transverse carpal ligament has been injured to avoid palmar bowing with displacement of the median nerve into the cleft in the lacerated ligament. Resistive wrist motion is not begun until six to eight weeks after repair.
8. WHAT IS THE OPTIMAL POSTOPERATIVE POSITION AFTER REPAIR OF THE EXTENSOR POLLICIS LONGUS (EPL)? Closed injury in zone I, a thumb mallet injury, is treated with immobilization of the interphalangeal (IP) joint in normal hyperextension with a QuickCastÒ or a pin for a minimum of six weeks. Immobilization of the MCP joint is not necessary. The thumb IP joint normally hyperextends and there is not the risk of dorsal ischemia that is associated with passive extension of the distal IP joints in the fingers when treating a mallet finger. Early motion protocols do not have a place in treating open or closed zone 1 thumb extensor tendon injuries because of the high incidence of loss of normal hyperextension after treatment. Immobilization of the wrist after EPL lacerations in thumb zone II is controversial. Proximal migration of the EPL is restrained by retinacular hood fibers about the MCP joint that are functionally analogous to the sagittal bands. Immobilization of the IP joint in hyperextension suffices to relax the repair, but does not address the risk of repair deformity from stress due to tenodesis associated with wrist flexion or stresses that occur involuntarily in the overactive, poorly compliant patient, or during sleep. For these reasons, we have preferred to protect EPL repairs proximal to zone I by immobilizing the wrist and the thumb in a thumb spica cast or custom splint. The wrist is immobilized in slight extension, and the thumb in comfortable palmar and radial abduction. It is most important to position the thumb MCP joint in slight flexion to avoid stiffness from dorsal capsule and ligament tightness that occurs quickly and limits flexion if this joint is immobilized in neutral or any extension. This stiffness is difficult to reverse. Thumb supination (retropulsion) should be scrupulously avoided during immobilization. Extensor
tendon lacerations proximal to thumb zone II are amenable to selective early-protected motion protocols.
9. WHAT IS THE OPTIMAL TIME FOR REFERRAL FOR THERAPY AFTER TENDON REPAIR? HOW DO YOU MODIFY TREATMENT WHEN A TENDON REPAIR ARRIVES LATER THAN DESIRED BECAUSE OF INTERVENTION OF MANAGED CARE, POOR PATIENT COMPLIANCE, OR CIRCUMSTANCES BEYOND YOUR CONTROL? Optimal referral time is on the third postoperative day. This is an opportune time for wound inspection, and is our customary postoperative day for initiation of an early motion protocol after tendon repair or tenolysis. Motion is not initiated earlier than day 3, which usually coincides with the end of the inflammatory stage of wound healing. The work of flexion lessens when early motion after flexor tendon repair is delayed until the third postoperative day. If the tissues are not comfortable and stable, motion at that time is inappropriate and should be delayed further. Reassessment is scheduled in 24–48 hours when tissues are again assessed, which determines if initiation of motion is appropriate. If motion is precluded by wound edema, inflammatory reaction, or other adverse conditions, treatment is modified and early motion should be delayed. Initial treatment during this delay includes custom splint fabrication, wound care, edema control, and patient education. When referral has been delayed further because of uncontrolled circumstances, careful assessment of injury, operative note, patient compliance, and wound status determine the appropriate treatment. An early motion protocol can be implemented, but with an awareness that the biologic environment of the repair is different. Adhesions have developed more substantially and the tendon repair is potentially weaker by virtue of softening that has accompanied immobilization. Therapy is less aggressive and progresses with greater caution.
10. HOW DO YOU ADJUST TREATMENT FOR COMBINED FLEXOR AND EXTENSOR TENDON REPAIRS? The position of immediate postoperative immobilization is modified to minimize stress on both flexor and extensor tendon repairs. In digital injuries the proximal interphalangeal joint is positioned in neutral. Relaxation of the flexor tendon is obtained by MCP joint flexion. This also passively positions the
sagittal bands more distally, limiting transmission of tension to the extensor tendon repair distally. In combined injuries proximal to the flexor fibroosseous sheath and sagittal bands about the MCP joints, the wrist is positioned in neutral. The MCP joints are slightly flexed and the IP joints are neutral. A bivalved cast is the most secure, and is therefore considered the safest immobilization. Today custom splints are the most common form of immobilization used. Motion is generally passive, and is applied with the wrist maintained in neutral. Excursion is partial and protected, which avoids excessive stretch of the antagonist muscle tendon unit(s).
11. WHEN IS THE BEST TIME TO INITIATE ACTIVE RANGE OF MOTION IN AN EARLY CONTROLLED MOBILIZATION FLEXOR TENDON PROTOCOL? The most appropriate time to initiate active ROM in an early controlled mobilization flexor tendon protocol is three to four weeks after flexor tendon repair. Full passive range of motion should be achieved before active range of motion is initiated. Restricted passive flexion may indicate extensor tendon adhesions or joint stiffness that introduce additional resistance to active flexion. Active flexion is begun with active place/hold that progresses gradually and gently to active range of motion, which then progresses to include active isolated tendon gliding and blocking exercises.
12. WHEN IS THE OPTIMAL TIME TO INITIATE RESISTED MOTION IN AN EARLY CONTROLLED MOBILIZATION PROTOCOL? This time depends on the status of the tendon repair as assessed clinically by physical examination (see Question 2). It has been demonstrated that physiologic loading increases individual and differential tendon excursions. A tendon that exhibits a significant discrepancy between active and passive range of motion is presumed to be adherent. The Indiana Hand Center has used 50-degree discrepancy as an indicator of a poorly gliding tendon. A poorly gliding tendon may benefit from resistance that is initiated between five and six weeks after repair. A tendon with less than 50-degree discrepancy is presumably gliding well and may not need additional resistance until a later time, six to eight weeks after repair. A clinical history of smoking, alcohol consumption, or systemic disease should be regarded as detrimental to tendon healing. When there is complete active motion by six weeks, resistive motion should be delayed until eight to April–June 2005 317
12 weeks. A tendon repair that glides well early is a weaker repair.
13. WHAT ARE THE SIGNS OF INFLAMMATION ABOUT A TENDON REPAIR OR TENOLYSIS? HOW DOES ONE MANAGE THIS CONDITION? Swelling and tenderness are abnormal findings when the tendon repair or tenolysis wound is healthy. Palpation of a squeaky (like a creaking hinge) or crepitant (like compressed cellophane) repair site associated with gentle active or passive tendon excursion indicates unacceptable inflammation about the repair. Inflammation requires modification of treatment protocol with decreased activity and increased immobilization. Crepitation or squeaks that disappear after a few excursions may not be a cause for concern. Persistent palpatory findings require program modification. Persistent painless swelling that continues after recovery of motion has plateaued can be responsible for incomplete active and passive motion and therefore may be an indication for a tenolysis. A tenolysis is usually not considered
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earlier than three months after a tendon repair, four months after a tendon graft and, in any case, only after there has been no measured improvement for at least four weeks.
REFERENCES 1. Silfverskio¨ld KL, Andersson CH. Two new methods of tendon repair: an in vitro evaluation of tensile strength and gap formation. J Hand Surg [Am]. 1993;18:58–65. 2. Dona E, Turner AWL, Gianoutsos MP, Walsh WR. Biomechanical properties of four circumferential flexor tendon suture techniques. J Hand Surg [Am]. 2003;28:824–31. 3. Sandow MJ, McMahon MM. Single-cross grasp six-strand repair for acute flexor tenorrhaphy. Atlas Hand Clin. 1996;1:41–64. 4. McLarney E, Hoffman H, Wolfe SW. Biomechanical analysis of the cruciate four-strand flexor tendon repair. J Hand Surg [Am]. 1999;24:295–301. 5. Halikis MN, Manske PR, Kubota H, Aoki M. Effect of immobilization, immediate mobilization, and delayed mobilization on the resistance to digital flexion using a tendon injury model. J Hand Surg [Am]. 1997;22:464–72. 6. Lee DH, Robbin ML, Galliot R, Graveman VA. Ultrasound evaluation of flexor tendon lacerations. J Hand Surg [Am]. 2000; 25:236–41. 7. Verdan C. Syndrome of the quadriga. Surg Clin North Am. 1960; 40:425–6.
Carol W. Stoddard, OTR/L, CHT Adjunct Faculty Springfield College American International College Springfield, Massachusetts Private Consultant in Hand Therapy
Management of tendon injuries is a challenging responsibility for the surgeon and the hand therapist. Outcomes are improved by a clear understanding of concepts and indications that are pertinent to the clinical situation. We have given a comprehensive course, Surgical and Therapeutic Management of Flexor and Extensor Tendon Injuries, several times a year at various centers since 1998. The participants’ questions indicate their understanding but also confirm that some concepts are difficult to assimilate and implement. In this article, we address the most frequent questions put forth by therapists, residents, and surgeons. Our intention is to provide practical information that can be applied clinically.
1. HOW SHOULD A THERAPIST DECIDE WHICH TENDON PROTOCOL WILL PROVIDE THE OPTIMUM RESULT AFTER REPAIR? Selection of the appropriate protocol needs to be made with the referring surgeon. The surgeon may dictate his or her preferred protocol, but the decision may be influenced strongly by the opinions and observations of the therapist. The surgeon and
Correspondence and reprint requests to Erik A. Rosenthal, MD, 111 Woodsley Road, Longmeadow, MA 01106; e-mail:
therapist both need to be communicative, flexible, and open minded. There is specific information regarding the patient, injury and operative treatment that the therapist needs to make this determination. The therapist must know the mechanism of injury, date of injury and repair, details of injured structures, and technical specifics of the repair(s). This includes number and caliber of suture strands and the method of core and peripheral suture technique, where the suture knots were placed, and condition of retinacular structures such as the flexor fibroosseous sheath and dorsal carpal ligament. A copy of the operative report is invaluable in this regard. Are there any pertinent medical conditions that may influence healing or clinical progression? The currently available protocol options are immobilization, early controlled mobilization, and early active mobilization. Numerous refinements within these broad categories have been advocated. In a perfect world, implementation of a protocol follows open communication between the surgeon and the therapist. The therapist should explore and clarify any concerns or reservations with the surgeon before embarking on treatment. Treatment progression is monitored by appropriate communication with the surgeon to convey developments and discuss problems. An unfortunate quandary occurs when the referral notes are sparse and not informative, or verbal authorization comes from an intermediary other than the surgeon. The therapist should April–June 2005 313
endeavor to acquire sufficient information and maintain rapport that supports appropriate treatment. There is still a role for postoperative immobilization, without controlled motion, until the tendon is sufficiently healed to permit active motion. This approach is appropriate with young children or patients who are not compliant. There is no currently available tendon repair that can withstand unrestricted normal activity immediately after repair without likelihood of rupture. A compromised repair or a weak two-strand repair is also an indication for immobilization in lieu of early controlled motion. Early controlled mobilization is appropriate for the compliant patient in the hands of an experienced therapist after a technically competent repair by an experienced surgeon. Early active protocol is the most sophisticated and potentially risky of all protocols. It should be reserved for the ideal patient in an ideally proficient therapy setting after a strong, atraumatic, and technically strong tendon repair.
2. HOW DOES THE SUTURE TECHNIQUE AFFECT SELECTION OF THE POSTOPERATIVE TREATMENT PROTOCOL? The treatment protocol should never impart stresses to a repaired tendon that exceed the tensile strength of the repair itself. The reported in vivo stress levels in a digital flexor digitorum profundus (FDP) tendon during unrestricted active motion is 19 N and 80 N with an effective tip pinch of 34 N. The in vitro failure load for fully lacerated human flexor tendons is reportedly 20–40 N for two-strand or fourstrand core repairs. The mean breaking strength of a lacerated flexor tendon repaired with a 6-0 suture criss-cross peripheral suture is 63 N.1 The failure load of the interlocking horizontal mattress suture is 52 N.2 The addition of a peripheral circumferential suture that grasps tendon fibers in addition to the delicate epitenon adds approximately 50% suture strength to a repair. The configuration and caliber of sutures determine the strength of the repair and, therefore, whether the repair can withstand the stresses of motion with a specific protocol. Strength of the repair is basically proportional to the number of suture strands that cross the repair. A six-strand core suture is stronger than a four-strand, which is stronger than a twostrand. A six-strand core suture is strongest, but is technically difficult, is bulky, and insertion causes added trauma to the tendon. A 3-0-caliber suture is two to three times stronger than a 4-0-caliber suture. A locking loop stitch is stronger than a grasping loop and a criss-cross stitch is stronger than a loop stitch. A grasping loop stitch usually fails by suture pullout, whereas a locking loop stitch fails by suture 314
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breakage. The four-strand cruciate cross-stitch3 is stronger that a four-strand cruciate loop stitch.4 Both use a core suture method that is sufficiently strong by testing to support stresses of early motion protocols, but the Sandow and McMahon3 modification is technically easier to insert. Core sutures can be inserted so that the suture knot is between the cut tendon ends rather than on the tendon periphery. This lessens drag and surface friction but does not diminish the strength of the stitch. The combination of these core and peripheral sutures is sufficiently strong to support anticipated loads with early controlled or active motion protocols. Any repair that has a greater risk of rupture by virtue of the condition of the tendon or the caliber of the sutures or the number of core strands used or the absence of a peripheral suture—one that poses a significant risk of rupture—should be protected by immobilization until the tendon heals. The decision regarding protocols depends on the experience and skill level of the surgeon and therapist. This decision considers the wound and the patient, and recognizes that active motion introduces greater stresses with increased risk than does a more protected protocol.
3. WHEN SHOULD ONE BEGIN MOTION AFTER TENDON REPAIR OR TENOLYSIS? Motion should be initiated when the tissues are ready. This implies that the wound is stable and comfortable, without significant edema. Delay of early motion until postoperative day 3 has been shown experimentally to decrease the work of flexion after flexor tendon repair.5 Comfortable immobilization with elevation, in our opinion, should continue until the third postoperative day when the wound is first inspected unless pain or excessive swelling or bleeding necessitates an earlier dressing change. If the wound is healthy and stable, gentle motion is initiated on the third day. If there is swelling, wound instability or undue discomfort with motion, progress is tempered to permit the tissues to adjust. There is no single protocol or schedule that is applicable to all patients. This delay in imparting motion after tenolysis runs counter to traditional teaching, but has been validated by the experimental work cited earlier and by our clinical experience. There are no adhesions that have formed by the third postoperative day that cannot be modified or interrupted by gentle, judicious therapy. It is counterintuitive to recommend a peripheral nerve block or wound injection and to proceed with motion without the protective benefit of normal pain response. Pain is a warning, and should be respected as the natural response of tissues to excessive stress. Progress should be comfortable.
4. HOW CAN ONE DETERMINE WHETHER A REPAIRED FLEXOR TENDON IN ZONE 2 IS RESTRICTED BY ADHESIONS, GAPPED OR RUPTURED? The ultimate decision regarding the repair is made only after careful clinical assessment by palpation and comparison of the clinical performance with previously recorded assessments. Accurate records that document range of motion (ROM), swelling and pain are essential when determining whether there has been any disruption at the repair site. ROM records are the baseline for comparison. A disparity between active and passive ROM is normally observed during early treatment with any controlled or early motion protocol. There should be a progressive lessening in this disparity; the active range should improve and eventually equal the passive range of motion. Persistent, significant difference between active and passive motion after competent therapy of sufficient duration is one of the diagnostic hallmarks of intractable tendon adhesions that may indicate the need for a surgical tenolysis. The patient’s comments and subjective assessment are invaluable diagnostic aids. A ‘‘pop’’ or ‘‘zing’’ may indicate an adhesion rupture or may signify rupture of the repair. A ‘‘squeak’’ or ‘‘my finger needs oil’’ suggests reactive inflammation about the repair. A dramatic falloff in distal pull-through or loss of active range of motion compared with previous records suggests new adhesions or repair gapping. Active pull-through distal to the repair site confirms that there is continuity through the repair. Strong distal response through the expected range of motion is consistent with a healthy, gliding repair. A ‘‘tweak’’ of distal movement only at the inception of the motion arc is suggestive of some repair continuity but does not rule out adhesions or gapping. The determination whether this is due to adhesions or gapping or rupture is the important challenge that confronts the therapist and surgeon. Ultrasonography of the repair site offers an economical, reliable confirmation of tendon continuity, gapping or rupture. Ultrasound can differentiate partial from complete lacerations and verify integrity of tendon repair.6 The beam must be perpendicular to the tendon for an accurate reading. An oblique beam can produce a hypoechoic image that may be misinterpreted as a false positive sign of repair gap.
5. HOW DO I TREAT IMPAIRED TENDON GLIDE DUE TO ADHESIONS, GAPPED TENDON REPAIR AND TENDON RUPTURE? The diagnostic hallmark of restrictive adhesions is a disparity between active and passive motion. These
restraints are treated with active ROM, tendon gliding and blocking exercises, resistive exercises, custom splints, ultrasound, heat modalities, and electrical stimulation. Resistive exercises require both resistance throughout the range and sustained end range muscle contraction. Active and resistive flexion is the most effective means of altering adhesions and improving excursion. These cannot be implemented until the tendon is sufficiently healed. Active flexion usually begins at three to four weeks; resistance begins later at five to eight weeks. A small gap in a zone 2 flexor tendon repair is of greater significance than a comparable gap in a zone 6 extensor tendon. A repair with an acceptable gap—one that is recognized but not considered sufficient to warrant operative intervention—should be put to rest in a position of reduced tension across the repair. Any flexor tendon gap of more than 2 mm is considered detrimental to the clinical outcome, but there are instances where a recognized gap is acknowledged and accepted in lieu of another operation. The extensor tendons to the digits proximal to zone V have a significantly greater capacity for adaptation by bridging of the gap with scar that remodels, with satisfactory function, a functional pseudotendon. A gapped flexor tendon is treated by reducing the demands on the repair. This depends on what protocol has been adopted and the phase of treatment. An active motion protocol would be converted to an early controlled mobilization program. In an early controlled mobilization program, active and resistive motion should be delayed. The length of time delay is based on clinical assessment. A gapped extensor tendon in zone V, VI, or VII is treated by putting the tendon to rest to encourage formation of a functional pseudotendon. The digit of the injured tendon is positioned in more extension—less metacarpophalangeal (MCP) flexion—than the digits without injured tendons. The MCP joints of uninjured fingers can be positioned in slight flexion, about 30 degrees. The wrist is positioned in 30-degree extension with zone VI injuries. The wrist is usually positioned in neutral for zone VII or VIII injuries, especially when there has been injury to the dorsal carpal ligament. Fine adjustments of position can be designed according to the level and character of the injury. The juncturae tendinum provide another anatomic safeguard in positioning the digits after repair. These tendinous interconnections diverge distally from the ring finger extensor digitorum communis (EDC) tendon. Passive MCP joint flexion creates distal traction of the EDC through the juncturae tendinum that can relax a repair further. Definitive treatment follows after an accurate determination of repair status is made. A ruptured repair diagnosis should be communicated to the surgeon for consideration of secondary repair. A repair gap has significant dimensions with varying implications. April–June 2005 315
6. WHAT IS THE DIFFERENCE BETWEEN SYNDROME OF THE QUADRIGA AND A TENODESIS? Tenodesis is tethering that prevents tendon glide. The etiologies of a tenodesis are myriad, and include a fracture, surgical fixation device, or inelastic scar (adhesions). Whatever the cause, the result is the same: the tendon is anchored. It is deprived of its normal excursion and all distal structures are linked to the tether by a fixed tendon link. Verdan7 described syndrome of the quadriga to illustrate the undesirable consequences of suturing distal flexor and extensor tendons together over the end of a digital amputation, a common surgical practice until the mid-20th century. This was performed to provide a cushion to the amputation. The result was tethering, a tenodesis, of the FDP tendon that impaired grasp. The tenodesis limits contraction of the FDP muscle, which is manifest clinically as incomplete terminal flexion of the uninjured digits during grip. A FDP tendon may scar proximally within its fibroosseous sheath, retract and adhere after laceration, resulting in a quadriga syndrome. Skilled hand therapy with early active motion after tendon injury or digital amputation is the most effective preventative measures. Treatment of the established syndrome, or if hand therapy has been unsuccessful, is tenolysis with surgical release of the tethered flexor profundus tendon. Some specific deformity patterns associated with flexor or extensor tenodesis have been given descriptive names. Syndrome of the quadriga is a specific tenodesis, but all tenodeses are not quadriga syndromes. Extensor plus phenomenon, similarly, is another specific tenodesis with recognizable deformity patterns, but is not syndrome of the quadriga.
7. DO EARLY MOTION PROTOCOLS HAVE A ROLE IN POSTOPERATIVE TREATMENT OF WRIST FLEXOR OR EXTENSOR TENDON INJURIES? Early motion protocols at this time do not have a role in treatment of wrist flexor and extensor tendon injuries. These tendons are motored by powerful muscles, the tendons have relatively short excursion and loss of normal tendon glide poses a risk of a significant functional imbalance. Some isolated wrist tendon injuries are less prone to introduce an imbalance due to their anatomic station and resulting biomechanics. Isolated loss of the flexor carpi radialis or extensor carpi radialis brevis—as with attritional rupture from osteoarthritis, a tendon laceration, or harvesting for tendon transfer—is less likely to introduce an imbalance. It is nonetheless good practice to endeavor to repair and rehabilitate all injured wrist 316
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tendons if feasible. Repaired wrist tendons should be immobilized in a relaxed position for at least three weeks before controlled motion is begun. Wrist extensors are immobilized in approximately 30 degrees extension if the dorsal carpal ligament is intact. If the dorsal carpal ligament is deficient the wrist should be immobilized in neutral to avoid dorsal tendon bowing with formation of a dorsal dead space. Wrist flexors are immobilized in slight flexion, 30 degrees or less, only if the transverse carpal ligament is intact. Excessive wrist flexion is prone to promote carpal tunnel syndrome. The wrist is positioned in neutral if the transverse carpal ligament has been injured to avoid palmar bowing with displacement of the median nerve into the cleft in the lacerated ligament. Resistive wrist motion is not begun until six to eight weeks after repair.
8. WHAT IS THE OPTIMAL POSTOPERATIVE POSITION AFTER REPAIR OF THE EXTENSOR POLLICIS LONGUS (EPL)? Closed injury in zone I, a thumb mallet injury, is treated with immobilization of the interphalangeal (IP) joint in normal hyperextension with a QuickCastÒ or a pin for a minimum of six weeks. Immobilization of the MCP joint is not necessary. The thumb IP joint normally hyperextends and there is not the risk of dorsal ischemia that is associated with passive extension of the distal IP joints in the fingers when treating a mallet finger. Early motion protocols do not have a place in treating open or closed zone 1 thumb extensor tendon injuries because of the high incidence of loss of normal hyperextension after treatment. Immobilization of the wrist after EPL lacerations in thumb zone II is controversial. Proximal migration of the EPL is restrained by retinacular hood fibers about the MCP joint that are functionally analogous to the sagittal bands. Immobilization of the IP joint in hyperextension suffices to relax the repair, but does not address the risk of repair deformity from stress due to tenodesis associated with wrist flexion or stresses that occur involuntarily in the overactive, poorly compliant patient, or during sleep. For these reasons, we have preferred to protect EPL repairs proximal to zone I by immobilizing the wrist and the thumb in a thumb spica cast or custom splint. The wrist is immobilized in slight extension, and the thumb in comfortable palmar and radial abduction. It is most important to position the thumb MCP joint in slight flexion to avoid stiffness from dorsal capsule and ligament tightness that occurs quickly and limits flexion if this joint is immobilized in neutral or any extension. This stiffness is difficult to reverse. Thumb supination (retropulsion) should be scrupulously avoided during immobilization. Extensor
tendon lacerations proximal to thumb zone II are amenable to selective early-protected motion protocols.
9. WHAT IS THE OPTIMAL TIME FOR REFERRAL FOR THERAPY AFTER TENDON REPAIR? HOW DO YOU MODIFY TREATMENT WHEN A TENDON REPAIR ARRIVES LATER THAN DESIRED BECAUSE OF INTERVENTION OF MANAGED CARE, POOR PATIENT COMPLIANCE, OR CIRCUMSTANCES BEYOND YOUR CONTROL? Optimal referral time is on the third postoperative day. This is an opportune time for wound inspection, and is our customary postoperative day for initiation of an early motion protocol after tendon repair or tenolysis. Motion is not initiated earlier than day 3, which usually coincides with the end of the inflammatory stage of wound healing. The work of flexion lessens when early motion after flexor tendon repair is delayed until the third postoperative day. If the tissues are not comfortable and stable, motion at that time is inappropriate and should be delayed further. Reassessment is scheduled in 24–48 hours when tissues are again assessed, which determines if initiation of motion is appropriate. If motion is precluded by wound edema, inflammatory reaction, or other adverse conditions, treatment is modified and early motion should be delayed. Initial treatment during this delay includes custom splint fabrication, wound care, edema control, and patient education. When referral has been delayed further because of uncontrolled circumstances, careful assessment of injury, operative note, patient compliance, and wound status determine the appropriate treatment. An early motion protocol can be implemented, but with an awareness that the biologic environment of the repair is different. Adhesions have developed more substantially and the tendon repair is potentially weaker by virtue of softening that has accompanied immobilization. Therapy is less aggressive and progresses with greater caution.
10. HOW DO YOU ADJUST TREATMENT FOR COMBINED FLEXOR AND EXTENSOR TENDON REPAIRS? The position of immediate postoperative immobilization is modified to minimize stress on both flexor and extensor tendon repairs. In digital injuries the proximal interphalangeal joint is positioned in neutral. Relaxation of the flexor tendon is obtained by MCP joint flexion. This also passively positions the
sagittal bands more distally, limiting transmission of tension to the extensor tendon repair distally. In combined injuries proximal to the flexor fibroosseous sheath and sagittal bands about the MCP joints, the wrist is positioned in neutral. The MCP joints are slightly flexed and the IP joints are neutral. A bivalved cast is the most secure, and is therefore considered the safest immobilization. Today custom splints are the most common form of immobilization used. Motion is generally passive, and is applied with the wrist maintained in neutral. Excursion is partial and protected, which avoids excessive stretch of the antagonist muscle tendon unit(s).
11. WHEN IS THE BEST TIME TO INITIATE ACTIVE RANGE OF MOTION IN AN EARLY CONTROLLED MOBILIZATION FLEXOR TENDON PROTOCOL? The most appropriate time to initiate active ROM in an early controlled mobilization flexor tendon protocol is three to four weeks after flexor tendon repair. Full passive range of motion should be achieved before active range of motion is initiated. Restricted passive flexion may indicate extensor tendon adhesions or joint stiffness that introduce additional resistance to active flexion. Active flexion is begun with active place/hold that progresses gradually and gently to active range of motion, which then progresses to include active isolated tendon gliding and blocking exercises.
12. WHEN IS THE OPTIMAL TIME TO INITIATE RESISTED MOTION IN AN EARLY CONTROLLED MOBILIZATION PROTOCOL? This time depends on the status of the tendon repair as assessed clinically by physical examination (see Question 2). It has been demonstrated that physiologic loading increases individual and differential tendon excursions. A tendon that exhibits a significant discrepancy between active and passive range of motion is presumed to be adherent. The Indiana Hand Center has used 50-degree discrepancy as an indicator of a poorly gliding tendon. A poorly gliding tendon may benefit from resistance that is initiated between five and six weeks after repair. A tendon with less than 50-degree discrepancy is presumably gliding well and may not need additional resistance until a later time, six to eight weeks after repair. A clinical history of smoking, alcohol consumption, or systemic disease should be regarded as detrimental to tendon healing. When there is complete active motion by six weeks, resistive motion should be delayed until eight to April–June 2005 317
12 weeks. A tendon repair that glides well early is a weaker repair.
13. WHAT ARE THE SIGNS OF INFLAMMATION ABOUT A TENDON REPAIR OR TENOLYSIS? HOW DOES ONE MANAGE THIS CONDITION? Swelling and tenderness are abnormal findings when the tendon repair or tenolysis wound is healthy. Palpation of a squeaky (like a creaking hinge) or crepitant (like compressed cellophane) repair site associated with gentle active or passive tendon excursion indicates unacceptable inflammation about the repair. Inflammation requires modification of treatment protocol with decreased activity and increased immobilization. Crepitation or squeaks that disappear after a few excursions may not be a cause for concern. Persistent palpatory findings require program modification. Persistent painless swelling that continues after recovery of motion has plateaued can be responsible for incomplete active and passive motion and therefore may be an indication for a tenolysis. A tenolysis is usually not considered
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earlier than three months after a tendon repair, four months after a tendon graft and, in any case, only after there has been no measured improvement for at least four weeks.
REFERENCES 1. Silfverskio¨ld KL, Andersson CH. Two new methods of tendon repair: an in vitro evaluation of tensile strength and gap formation. J Hand Surg [Am]. 1993;18:58–65. 2. Dona E, Turner AWL, Gianoutsos MP, Walsh WR. Biomechanical properties of four circumferential flexor tendon suture techniques. J Hand Surg [Am]. 2003;28:824–31. 3. Sandow MJ, McMahon MM. Single-cross grasp six-strand repair for acute flexor tenorrhaphy. Atlas Hand Clin. 1996;1:41–64. 4. McLarney E, Hoffman H, Wolfe SW. Biomechanical analysis of the cruciate four-strand flexor tendon repair. J Hand Surg [Am]. 1999;24:295–301. 5. Halikis MN, Manske PR, Kubota H, Aoki M. Effect of immobilization, immediate mobilization, and delayed mobilization on the resistance to digital flexion using a tendon injury model. J Hand Surg [Am]. 1997;22:464–72. 6. Lee DH, Robbin ML, Galliot R, Graveman VA. Ultrasound evaluation of flexor tendon lacerations. J Hand Surg [Am]. 2000; 25:236–41. 7. Verdan C. Syndrome of the quadriga. Surg Clin North Am. 1960; 40:425–6.