short guideline for hand rehabilitation after flexor tendon injury repair.

1. REVIEW OF HAND REHABILITATION
PROTOCOLS AFTER FLEXOR
TENDON INJURY REPAIR
BY:
Dr. Mohammed A.Alhussein
Baghdad university
Alkindy college of medicine

2. Terms should be explained
• standard protocols employ a dorsal shell with the wrist, MCPs, and IPs flexed.
• Active extension (to prevent PIP contracture) and passive flexion are
encouraged after the first postoperative day, when bleeding should not be
provoked.
• After 2 to 3 weeks, “place and hold no power” can be initiated along with
protected passive motion to maintain joint mobility and avoid contractures
especially the PIP joint.
• Differential gliding of the uninjured tendons can also start at that time with
wrist tenodesis and “suitcase” power fist.
• isolated active tendon differential gliding of the injured tendon begins by at
least 4 to 6 weeks and active, assisted, complete fist and passive range of
motion.
• Protective splinting may continue with progressive resistance exercises for up
to 8 weeks total
• With gradually increased active resistance-strengthening exercises up to 12
weeks

3. In this lecture I will try to give short review on
the common rehabilitation protocols.
Rehabilitation involve mainly 3 objects:
1. Immobilization method and positions
2. Type and timing of mobilization
3. Time of splint removal and return to full
unprotected functioning.

4. • In order to facilitate dealing with this hard
subject I will divide type of physiotherapy
according to zone of injury then I will
summarize these common protocols.
• By the end of this lecture we should be
familiar with the common terms used above.

5. Repair of Zone 1 Lacerations or
Avulsions:
• Definition: Laceration of the FDP tendon distal to the
insertion of the FDS tendon or avulsion from its
insertion at the base of the proximal aspect of the
distal phalanx .
• If the tendon is lacerated, and the distal tendon stump
is less than 1 cm long, FDP tendon advancement and
primary repair to bone is usually indicated.
• If more than 1 cm of FDP stump is available for suture,
primary tenorrhaphy is usually done because
shortening of the FDP tendon by greater than 1 cm
may result in a “quadrigia” effect.

6. Zone 1 Rehabilitation
Immobilization:
• Apply dorsal splint with wrist and MP joints
flexed and PIP and DIP joints at 0 to 10
degrees flexion.

7. Zone 1 Rehabilitation
• Mobilization:
The rehabilitation protocol generally follows the
same progression as for zone 2 injuries.
• Return to Activities:
The patient may return to full activity at 4 to 6
months after surgery.

8. Zone II injury
• definition : any injury at the proximal portion
of the flexor tendon sheath A1 pulley and
extends to the FDS insertion.

9. Zone II injury Rehabilitation
• Immobilization: the wrist flexed (20 to 30
degrees) and MP joints flexed (50 to 70
degrees), and PIP and DIP joints at zero or
slight flexion.

10. Zone II injury Rehabilitation
• Rehabilitation divided into 3 groups according to
protocol used in 1st 3-4 wks :
1. Immobilization:
2. Early Controlled Motion
– Duran & Houser
– Kleinert & Chow
3. Active Mobilization
– Silfversksold & May
– Strickland

11. • Return to Activities
• The patient may return to unrestricted
activity at 4 to 6 months after surgery

12. Tendon injury in Zones 3, 4, and 5
• Zone III is between the distal palmer crease
distally and the distal margin of the carpal
tunnel proximally.
• Zone IV is within the carpal tunnel.
• Zone V is proximal to the carpal tunnel in the
distal forearm.

13. • Both immobilization and mobilization protocol
are similar to zone 2 except modification
which should be done when there is
association with Arterial and nerve injuries in
these areas are which are common.

14. Total Immobilization
• Indication:
1. Children
2. Non-compliant adults
3. Patients unable to understand the protocol
4. Any contraindication for early mobilization:
.Nerve injury repair
.Replantation and vascular repair
. Fractures with unstable repair.

15. Immobilization position
• Cast or splint hold the wrist in neutral or slight
flexion.
• MCP significantly flexed.
• IPJ only slightly flexed or extended.
• Splint removed after 3-4 weeks to start active
and passive movement.

16. Contraindication for mobilization
.Nerve injury
.Replantation and vascular repair
. fractures

17. Early Controlled Motion
All Early Controlled Motion should minimize edema
and allow IPJ extension to prevent joint contracture.
Kleinert & Chow protocol:
• a controlled active extension–passive flexion
motion protocol.
• The wrist is palmary flexed with a dorsal
protective splint with 30–40° wrist flexion, 50–
70° MCP joint flexion, and the IP joints are
allowed full extension.

18. Original Kleinert

19. Modified Kleinert regime (Chow)

20. • Original Kleinert regime had been changed to Modified
Kleinert regime (Chow) due to rubber band traction
was found to lead to flexion contractures of the finger.
• Modified Kleinert regime (Chow) differ by:
1. a palmer bar at the level of the MCP joint as a pulley
for the rubber bands to create greater flexion of both
the PIP and DIP joints.
2. the elastic band is detached at night and the fingers
are strapped into extension within the splint to
minimize the risk of flexion contractures of the
fingers.

21. • All fingers should be included in the rubber band
traction to ensure added FDP protection and to
promote better tendon excursion also decrease
risk of PIP contracture through more efficient
action of EDC.
• mobilization program is begun 1 to 3 days
postoperatively.
• The finger to be actively extended within the
limitations of the splint. The patient is instructed
to perform this exercise 10 times every waking
hour.

22. • At 3 weeks, the splint is altered to further
extend the metacarpophalangeal joints with
the wrist neutral.
• At 4 weeks, the dorsal splint can be removed,
leaving the line/rubber band attached to a
wristlet. Wrist exercises are encouraged.
• at 5th week, the rubber band is discontinued;
the patient actively flexes without resistance.

23. Duran–Houser method
• This is a controlled passive finger flexion protocol
without traction of rubber bands.
• dorsal splint is applied with the wrist in 20°
flexion, the MCP joint in 50° flexion, and the IP
joints are allowed full extension .
Within the first 4-5 weeks, the patients perform:
• 10 passive DIP joint extensions with PIP and
MCP joint flexions.
• 10 passive PIP joint extensions with MCP and
DIP joint flexions hourly within the splint.

24. In other word it include:
• Full isolated passive flexion of DIP joint.
• Full isolated passive flexion of PIP joint.
• Full passive flexion of MP, PIP, and DIP joints.

26. Advantages:
• decreased the frequency of PIP joint contracture
seen with Kleinert’s rubber band traction.
• Better differential gliding.
• Improved protection between exercise time.
Disadvantages:
• Greater tension on repair site.
• Patient may not be able to resist temptation to
flex against volar strap.

30. Early controlled Active Mobilization
All early active mobilization technique require strong
tendon repair at least 4 strand core stitches with
strong epitendinous repair.

33. Early controlled Active Mobilization
• Strickland indiana protocol(Controlled “place-and-hold”):
• After removal of the surgical bandage, a traditional dorsal
blocking splint that positions the wrist in 20 degrees of
palmer flexion, MP joints in 50 degrees of flexion, and IP
joints in extension is applied.
• A another tenodesis splint with a wrist hinge is fabricated
to allow for full wrist flexion, wrist extension of 30 degrees,
and maintenance of MP joint flexion of at least 60 degrees.
• After composite passive digital flexion, the wrist is
extended, and passive flexion is maintained. The patient
actively maintains digital flexion and holds that position for
about 5 seconds. Patients are instructed to use the lightest
muscle power necessary to maintain digital flexion.

34. • This exercise should be repeated fo 25 time
per awake hour for 4 weeks.
• After 5 weeks light active flexion with wrist
extension commenced.

36. Early controlled Active Mobilization
• Silfversksold & May:
• All fingers are placed in dynamic traction with
palmer bar and the patient use their uninjured hand
to ensure complete flexion.
• by post operative day 1 to 3 supervised unassisted
active flexion is commenced patient are kept in the
hospital for 3 to 4 days .
• PIP joint is actively flexed through about 30° and the
DIP joint through 5–10°. In subsequent weeks, the
range of active motion is gradually increased.

37. • there after un assisted active flexion is done only
weekly with medical supervision
• active flexion is continued at home in conjunction
with passive flexion.
• Active extension is encouraged and interphalangeal
joints are held in full extension by volar strap at
night.
• After 4 weeks all splints are removed and active
flexion and extension are allowed.

38. Differential gliding exercises

39. Extrinsic stretching for maximum FDS
and FDP glide.

40. Isolated PIP joint blocking for isolation
of FDS contraction.

41. FDP and FDS blocking exercises.

42. Resistive exercise

43. summery