Flexor and Extensor Tendon Injuries

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Flexor and Extensor Tendon Injuries

• Angie Dickerson-Schnatz MPT,OCS,CHT
• UD ORTHO LECTURE 2007

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Flexor tendon zones

• What are the contents of each zone?
• Zone I
• Zone II
• Zone III
• Zone IV
• Zone V

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Flexor tendon anatomy

• FDP
• FDS

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Flexor tendon sheath

• Its all about gliding
• House FDS and FDP
• Synovial lining
• Reinforced by pulleys
• A2, A4 loss reduces efficiency
• Lose lots of ROM

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Incisions for flexor tendon repair

• Zigzag
• Increases exposure
• Decreases contracture

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Flexor tendon repair

• Variety of suture techniques
• Strength of suture technique guides post-op rehab
  progression

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Goals following tendon repair

• Prevent rupture/gapping
• Promote wound healing
• Edema control
• Tendon gliding
• Prevent hypertrophic scar
• 80-90 TAM
• Return to functional grip
• 
  tenodesis rom

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Prevent gap/rupture

• Protective splint
• 40yo CPA tuft fx c FDP LF

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Prevent gap/rupture

• 40yo manual laborer, non-English speaking

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Prevent gap/rupture

• 40yo manual laborer, non-English speaking
• IF FDP/?FDS repair, ?fracture

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Progression of therapy based on tensile strength

• Protective phase (0-4.5 w)
• passive flexion/active extension
• 200-500 grams tensile strength across repair
• poor splint position

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Progression of therapy based on tensile strength

• Protective phase/ Early stage (0-4.5 w)
• passive flexion/active extension
• 200-500 grams tensile strength across repair
• Motion phase/ Intermediate stage (4.5-8 w)
• Light composite grip
• 1500 grams
• Strengthening/ Late stage(8-12 w)
• maximum composite grip
• 5000 grams

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Goals Protective phase 0-4.5 w

• Prevent tendon rupture
• Restore full passive digit flexion
• Prevent PIP flexion contracture
• Control edema
• Promote tendon excursion

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Modified Duran protocol

• Splint
• MP flexion 40-50
• Wrist flexion 20-20
• IPS_at_ 0
• Passive flexion
• Passive extension
• Tenodesis
• poor splint
  position

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Post op Kleinert

• Splint
• MP flexion 40
• Wrist flexion 30-45
• Passive flexion
• Active PIP, IP extension within confines of
  splint

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Post op Kleinert

• Splint
• MP flexion 40
• Wrist flexion 30-45
• Passive flexion
• Active PIP, IP extension within confines of
  splint

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Early active motion

• With some repair techniques
• Check with physician
• Operational definition of early active motion
• place/hold

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Kleinert Protective phase

• Passive flexion
• Assist to flex with elastic bands
• Wrist to neutral at 3 weeks

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Active finger extension

• Block MPs dorsally to promote PIP extension

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Motion phase at 4.5 weeks
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Complications

• Fractures
• retraction
• time til repair

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Complications

• Fractures
• retraction
• time til repair

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Complications

• Fractures
• retraction
• time til repair

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Tendon Gliding

• If tendon gliding is occurring freely, protect
  longer
• If tendon is adhered, motion attempts can be more
  vigorous

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Goals for motion phase

• Restore active flexion
• Reduce flexion contractures if present
• Protect against tendon rupture

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Week 4.5 p.o.

• Place/hold
• Tenodesis
• Active finger flexion
• No blocking exercises yet.

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Intermediate stage 3-6w

• Begin gentle active flexion
• Begin specific tendon gliding exercise
• Begin gentle blocking exercise

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DIP blocking exercises

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PIP blocking exercises

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Goals for strengthening phase/ Late stage

• Promote tendon gliding if active digital flexion
  lacking
• Use of hand for ADL and work activities

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Promote tendon glide

• Progressive resistance

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Extensor Tendon Injury

• Zone I DIP
• Zone II middle phal
• Zone III PIP
• Zone IV prox phal
• Zone V MCP

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Zone I Mallet fingerIntervention

• Non-operative
• closed injury
• Operative
• open injury
• More distal injury? longer protection

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Zone I Mallet fingerIntervention

• Based on mechanism of injury
• Closed
• Splint in full extension
• Potential extension lag
• Splint 4-6 weeks, check

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Zone I Mallet fingerIntervention

• Open
• ? Repair
• ? Infection
• Xray

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Zone I after continuous immobilization

• Splint except for exercise
• 1 to 2 weeks
• Flexion of DIP
• Immobilize if extensor lag gt 15-20o
• Can use volar splint template to limit flexion

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Extensor Tendon Injuries

• Splinted in Ext for other zones including joints
• 30yo installer, Zone V, Table
  Saw

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Extensor Tendon Injuries

• Splinted in Ext for other zones including joints
  
• outrigger style dynamic extension splint, used

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Extensor Tendon Injuries

• Splinted in Ext for other zones including joints
• Progressive active flexion/passive ext to
  protocol joint limitation/use template
• progress flexion without ext lag

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Extensor Tendon Injuries

• Example
• wrist 30 ext, MPs 0, PIP to 30 DIP to 25
• 2 weeks po, PIP to 40 etc.