Flexor and Extensor Tendon Laceration vs. Occupational Therapy

24,467 views
24,097 views

Published on

This is a presentation I did for the OTAT program at Cuyahoga Community College on flexor and extensor tendon lacerations. I also discuss, briefly, the application of certain aspects of occupational therapy's domain as outlined in the OTPF. I collected data from scholarly as well as non-scholarly resources. I hope you find this to be helpful.

0 Comments
23 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
24,467
On SlideShare
0
From Embeds
0
Number of Embeds
8
Actions
Shares
0
Downloads
572
Comments
0
Likes
23
Embeds 0
No embeds

No notes for slide
  • A tendon is part of the muscle that attaches the muscle to bone. It is a strong, fibrous connective tissue that is responsible for transferring the forces generated by the muscle to the bone, thus producing movement at the joint (Benjamin C Wood, 2012). Tendon lacerations occur when the tendons (such as in the forearm that pass through the wrist joint and into the hand) experience a traumatic cut—severing the connection between the muscle and bone, thus losing its function (Department of Rehabilitation Services , 2007).
  • Tendons in the wrist include the flexor tendons that bend the fingers and wrist are the: flexor digitorumprofundus and superficialis, flexor pollicislongus, flexor carpi radialis and ulnaris, Palmaris longus. The extensor tendons that extend the fingers and wrist are the: extensor digitorum, extensor indicis, extensor digit minimi, abductor pollicislongus, extensor pollicisbrevis, extensor carpi ulnaris, extensor carpi radialisbrevis and longus (Wood, 2012; Henry, 2012).
  • Extensor chart
  • Flexor chart
  • Flexor tendons are divided into 5 zones. Zone 1 is distal and Zone 5 is proximal. The five zones are: Zone 1—containing flexor digitorumprofundus only distal to the insertion of flexor digitorumsuperficialis; Zone 2—also known as “No Man’s Land”—from insertion of flexor digitorumsuperficialis to the proximal edge of the A1 pulley; Zone 3—from the proximal edge if the A1 pulley to the distal edge of the carpal tunnel; Zone 4—within the carpal tunnel; and Zone 5—proximal to the carpal tunnel (Wood, 2012; Henry, 2012). A flexor tendon that has been injured between the distal palmar crease and the insertion of the flexor digitorumsuperficialis (Zone 2) is considered the most difficult to treat due to the fact that the tendons lie in their sheaths in this area beneath the fibrous pulley system, and any scarring will cause adhesions (Poole, 2013, p. 605).
  • Extensor tendons are divided into 8 zones. Zones 1, 3 and 5 lie over the DIP, PIP and MCP joints (Al-Qattan, 2007).
  • Tendon lacerations are caused by a severe traumatic injury that cuts open the wrist (Al-Qattan, 2007). The most common mechanisms of injury include, but are not limited to: accidental laceration with broken glass, kitchen knives or table saws, motor vehicle accidents, and suicide attempts, crush injury, avulsions, burns, animal or human bites, and deep abrasions (Henry, 2012).
  • Patients who have tendon lacerations may experience an inability to bend the wrist or one or more of the joints in the finger. Other signs and symptoms of tendon lacerations include pain when bending the finger; an open injury like a cut on the palm side of the hand—particularly in the area where the skin folds as the fingers bend; mild swelling over the joint closest to the fingertip; tenderness along the effected fingers on the palm side of the hand (Wood, 2012; Henry, 2012; R. G. Xie, 2008).
  • FlexorMost common complications of tendon grafting include rupture, adhesion, flexion contracture, recurvatum deformity (swan neck), bowstringing, lumbrical plus, and quadriga syndrome. The rupture rate after tenolysis is high (21% in Lister's series). This is most commonly at the proximal repair site (Wood, 2012). A recent meta-analysis of 29 studies examining the incidence of complications following tendon repair demonstrated a 6% reoperation rate, and a 4% rate of tendon rupture and adhesion formation. The study found that use of a modified Kessler technique reduces the development of adhesions by 57%, and the presence of an epitendinous suture decreases the rate of reoperation by 84%. The swan neck deformity results from excision of the flexor digitorumsuperficialis. It can be prevented by retaining the part of the flexor digitorumsuperficialis to which the V2 vinculum attaches. It is corrected by either capsulodesis or by the construction of a spiral oblique retinacular ligament. Lumbrical plus occurs when the graft is too long and the tension then is taken up by the lumbrical insertion, resulting in paradoxical extension of the IP joints with forced flexion. The division of the lumbrical corrects this complication. Because the grafted finger reaches the palm prior to the other fingers, this places a block on further flexion of the other fingers (the quadriga syndrome) (Wood, 2012).ExtensorComplications that impair finger and hand movement by hindering the ability of the tendon to glide smoothly include adhesions between repaired tendons and surrounding tissue, stretching (attenuation) or rupture of the repair (most common between 7 and 10 days following surgery), and joint or soft tissue contractures. Other potential complications following surgery include infection, nerve and blood vessel damage, and delayed healing due to underlying medical conditions (Al-Qattan, 2007). In some cases, the severity of tendon damage is underestimated at the time of the original evaluation, especially if a hand surgeon was not involved at this stage. This may result in long-term disability from what initially was thought to be a rather insignificant injury. Joint stiffness and tendon adhesions are common complications of even excellent repairs of extensor tendon lacerations. The longer the immobilization period lasts, the higher the chance of joint capsule fibrosis and of forming volar plate adhesions (check-rein ligaments). These issues are mainly treated with hand therapy for stretching out the scarring. Tendon adhesions are always a risk of tendon repair, especially at the site of the repair (Xie, 2008). Extensor tendons have fewer challenges with this complication than flexor tendons because only one major extensor tendon group is present (vs 2 flexor groups) and because the fibrous-osseous tunnel created by the pulley system does not exist in the extensor system. Most postoperative tendon adhesions can be addressed with therapy; occasionally, tenolysis (surgical clearing of surrounding tendon scar) has to be performed to regain function (Henry, 2012). Misdiagnosis or failure to repair significant partial lacerations (>30% of tendon) can result in extension triggering. The partially torn surface can get transitionally caught on nearby structures such as other tendon slips, extensor aponeurosis or the extensor retinaculum. With forced flexion or extension most patients can clear temporary impediment to extensor tendon gliding. However, symptoms worsen over time, and surgical revision of the partial laceration surface is required (Al-Qattan, 2007). Delayed rupture or failure of tendon repair is a relatively uncommon occurrence. Usually, the cause is a technical error or an underestimation of the repair effectiveness or related injuries that leads to an inappropriate level of early postoperative activity. When tendon repair rupture is diagnosed, early return for revision repair is essential. Tendon grafts maybe required for revision. The patient must informed of the decreased overall function expected in a revision repair and the increased likelihood of further necessary surgery (eg, tenolysis) (Department of Rehabilitation Services , 2007). Untreated extensor tendon lacerations in certain regions lead to imbalance of forces at the proximal interphalangeal (PIP) joint and cause significant deformities that impact the function of the affected finger and entire hand (Henry, 2012). A complete laceration at the terminal tendon overlying the distal interphalangeal (DIP) joint causes a lack of extension of the distal phalanx. This chronically flexed position of the DIP joint is called a mallet finger deformity. A chronic mallet finger that persists over time can lead to further deformity at the PIP joint. The PIP volar plate becomes lax as the individual repeatedly hyperextends the PIP joint in order to compensate for the DIP chronic flexion when attempting to grasp large objects. Over time, a malpositioning of the lateral bands and fixed imbalance of the dynamic and static forces around the PIP joint result in a new deformity, called the swan-neck deformity, that presents with flexion of the DIP joint and hyperextension of the PIP joint. Treatment for this deformity is mostly surgical and should be avoided by proper treatment of the mallet finger before it progresses (Al-Qattan, 2007). Complete central slip lacerations can also result in imbalance at the PIP joint if left untreated. Without extension forces over the PIP joint, it becomes chronically flexed, and the lateral bands slip volar to the central axis of the PIP. This causes a chronic flexion of the PIP joint and extension of the DIP joint as the lateral bands tighten in the malposition. This condition is called a boutonniere deformity and can be effectively treated with therapy if caught in the early stages. As with all surgical procedures, infection and wound dehiscence are possible complications (Henry, 2012). The risk of infection is increased in a contaminated wound (eg, fight bite) that is not properly cleaned before tendon repair (Xie, 2008).Other complicationsOther potential complications following surgery include infection, nerve and blood vessel damage, and delayed healing due to underlying medical conditions. In some cases, the severity of tendon damage is underestimated at the time of the original evaluation, especially if a hand surgeon was not involved at this stage (Department of Rehabilitation Services , 2007). This may result in long-term disability from what initially was thought to be a rather insignificant injury.Complications that impair finger and hand movement by hindering the ability of the tendon to glide smoothly include adhesions between repaired tendons and surrounding tissue, stretching (attenuation) or rupture of the repair (most common between 7 and 10 days following surgery), and joint or soft tissue contractures (Department of Rehabilitation Services , 2007; Xie, 2008).
  • This is an illustrations of injuries and deformities.
  • A history and physical will be completed initially to determine if the patient has a laceration. Examination of the wound will reveal the damage to the tendon. The healthcare provider can also detect the injury by demonstrating weakness or failure to move the involved extremity. However, utilization of bedside ultrasonography in the emergency room is more sensitive and precise than physical examination for identifying tendon lacerations. In one study, sensitivity, specificity, and accuracy of US were 100%, 95%, and 97%, respectively (Henry, 2012). Bedside ultrasonography in the emergency department takes significantly less time to implement than the traditional method of utilizing wound exploration techniques or MRIs. A 3-view x-ray of the hand, wrist, or forearm must be performed on all but the most benign tendon laceration injuries to exclude foreign bodies or bony injury (R. G. Xie, 2008). Also, in all blunt trauma cases, radiographs are used to assess for possible fractures or dislocations(Department of Rehabilitation Services , 2007).
  • The history of tendon reconstruction dates back to the times of Hippocrates and Galen. “Interestingly, Galen (131-201 AD), in his ArsParva, stated that tendons were composed of both ligaments and nerves. He warned, therefore, that placing sutures in tendons would lead to pain, twitching, and eventual convulsions. This erroneous concept was not refuted until 1682, when Meekren observed that tendons are insensitive and described the successful repair of incompletely severed tendons.” (Ginard I Henry, 2012).
  • Immediate surgical repair of the tendon is indicated in lacerations. Delaying surgery can lead to shortening of the tendon, formation of scar tissue and decreased blood flow, which can lead to a poor outcome. Following surgery the patient’s wrist will be put in an immobilizing device. Over the next 2-4 weeks hand therapy will be initiated. The surgeon will determine the hand therapy timeline and program (Department of Rehabilitation Services , 2007). Once the decision for surgical intervention has been made, the general principles of definitive wound debridement, early tendon repair, and early range of motion hand therapy guide the treatment plan for all extensor tendon injuries. As in all hand surgery, meticulous handling of the tissues and thorough knowledge of the relevant anatomy is vital. In an extensor injury of any area, all the pertinent structures must be carefully dissected and examined. However, because scar formation occurs at every along the entire plane of dissection, judicious restraint must be used in determining the extent of dissection (Department of Rehabilitation Services , 2007).The objectives are to maintain the blood supply as completely as possible, obtain adequate exposure, and obtain optimal scar contracture. Bunnell developed the midlateral incision as the stationary line, either volar or dorsal to the neurovascular bundle. Littler demonstrated the diamonds of skin-to-skin contact during digital flexion. The Bruner zigzag incision avoids these areas. Preservation of the vincula is difficult if the dorsal midlateral incision is used, and hence either the Bruner or the volar midlateral incision is recommended. Midlateral incisions should not be made on surfaces exposed to much contact (eg, ulnar border of little finger, radial border of index finger). The distal extent of either incision is over the pulp of the phalanx (Al-Qattan, 2007).
  • Information from the AOTA’s website.
  • This treatment strategy completely immobilizes the tendon for 3 ½ weeks after tendon repair. Immobilization may not yield consistently desirable results due to the fact that it often leads to scar adherence and can lead to a higher incidence of tendon rupture (Wood, 2012). Nevertheless, if there are other injuries (e.g., a fractured phalanx that cannot be moved), this technique may be required. Furthermore, if a patient seems unable to participate fully in the treatment (e.g., a person with cognitive impairments), the immobilization method may be chosen (Poole, 2013, p. 605).
  • “Durand and Houser suggest the use of controlled passive motion, which allows 3 to 5 mm of tendon excursion, to achieve optimal results after tendon repair”. They found this technique adequate to prevent adherence of the repaired tendons (Wood, 2012; Poole, 2013, p. 605). On the third postoperative day, the patient starts a twice-daily exercise routine of passive flexion and extension of 6 to 8 repetitions per tendon (Xie, 2008). It’s important to have the wrist flexed and the MCPs in 70 degrees of flexion during passive exercise. “After 4 ½ weeks the protective dorsal splint is removed and the rubber band traction is attached to a wristband. Active extension and passive flexion are done for 1 additional week and gradually increased over the next several weeks” (Poole, 2013, p. 605).
  • “Dr. Harold Kleinert, a pioneer of flexion tendon surgery, was an early advocate of rubber band traction after repair of flexor tendons. This technique is often called the Kleinert techniques” (Poole, 2013, p. 605). Once the tendon is surgically repaired, rubber bands are attached to the nails of the involved digits with a suture through the nail or with a hook held in place with cyanoacrylate glue. A dorsal blocking splint is constructed with the MCP joints held in about 60 degrees of flexion and the PIPs in gentile flexion (Poole, 2013, p. 605). The patient must have the ability to fully extend the interphalangeal (IP) joints actively within the splint; if not, joint contractures will develop (Wood, 2012). Kleinert’s original protocol has been modified over the years yet it still remains the foundation for most of the early active motion protocols detailed in the literature. Both his protocols and the Washington approach utilize early active extension and passive flexion. The Indian and MAMTT (minimal-active muscle-tendon tension) protocols permit early gentile supervised active flexion of the involved tendon. “There is some evidence that early active motion such as “place-and-hold” exercises do result in greater finger motion after a Zone II tendon injury” (Poole, 2013, p. 605).In the Kleinhert and Washington protocols the patient wears the splint 24 hours a day for 3 weeks and is taught to actively extend the digits several times a day in the splint, permitting the elastic bands to pull the digits into flexion (Wood, 2012). The movement of the tendon through the tendon sheath and pulley system minimizes scar adhesions while enhancing tendon nutrition and blood flow. The dorsal blocking splint is discontinued at 3 weeks, depending on the surgeon’s decision (Poole, 2013, pp. 605, 607).To be effective, all of the early mobilization methods necessitate a motivated patient who thoroughly comprehends the program. Some early active mobilization techniques presently allow early active extension and flexion of the repaired tendons, as well as other changes. “Only the most experienced surgeon should attempt these treatments” (Poole, 2013, p. 607).
  • Though each protocol has a specific and sometimes slightly different time line, when active flexion is begun out of the splint after any of the postoperative management techniques described previously, patients should be instructed in exercises to facilitate differential tendon gliding (Poole, 2013, p. 607).“Wehbe recommends three positions—hook fist, straight fist, and composite fist—to maximize isolated gliding of the flexor digitorumsuperficialis and the flexor digitorumprofundus tendons, as well as stretching the of the intrinsic musculature and gliding of the extensor mechanism” (Poole, 2013, p. 607). These tendon glide exercises should be repeated for 10 repetitions in per position, two to three times daily. Isolated exercises to assist tendon gliding may be performed with a blocking splint or by using the other hand (Xie, 2008). The MCP joint is held in extension during blocking, so the intrinsic muscles that act on it cannot overcome the repaired flexor tendons. It is important not to hyperextend the PIP joint because this would overstretch the repaired tendons (Poole, 2013, p. 607).“After 6 to 8 weeks, passive extension may be started and a volar finger splint may be necessary to correct a flexion contracture at a PIP joint. Alternately, the therapist may fabricate a cylindrical plaster splint to apply constant static pressure on the contracture” (Poole, 2013, p. 607).After roughly 8 weeks, the patient can initiate light resistive exercises, light ADL, and other activities (Wood, 2012). The patient must avoid lifting with or applying excessive resistance to the involved hand. Participating in sports activities should be discouraged. However, activities such as working with soft clay, woodworking, and macramé are excellent. Full resistance and normal work activities may begin again at 3 months after the surgery (Poole, 2013, pp. 607, 608).Though performance of ADL is generally not an issue, therapy practitioners should ask patients about any complications they may have or anticipate. “Disuse and neglect of a finger, especially the index finger, are common and should be prevented” (Poole, 2013, p. 608).Gains in finger flexion and extension may continue to be recorded for 6 months or more after the surgical repair has taken place (Xie, 2008). A digit with flexible joints and slight scarring preoperatively will function better after surgery than one that is stiff and scarred or that has trophic skin changes. “A ‘functional’ to ‘excellent’ result is obtained when there is minimal extension lag at the PIP and DIP joints and the finger can flex to the palm” (Poole, 2013, p. 608).
  • This is an illustration of tendon gliding exercises.
  • This is an illustration of tendon gliding exercises.
  • The immobilization method maintains the tendon in a shortened position by way of splinting or casting. “Tendons are immobilized for three weeks; in week 4, gentle active motion of the repaired tendon is introduced” (Poole, 2013, p. 609).
  • Extensor tendons damaged proximal to the MCP joints frequently become adherent to the structures above and below them. This will require the occupational therapist to initiate a splinting program. A removable volar splint is utilized between exercise periods to protect the tendon for two additional weeks. Dynamic flexion splinting may be started 6 weeks after surgery to recover flexion if required (Poole, 2013, p. 609).Extensor tendons injured proximal to the MCP joint may be immobilized for 3 weeks. After this, the digit might be placed in a removable volar splint that is worn between exercise periods for an additional two weeks (Hall, 2010). Progressive ROM is initiated after 3 weeks, and if full flexion is not recovered promptly, dynamic flexion may be initiated after 6 weeks (Poole, 2013, p. 609). Extensor tendon injuries that occur distal to the MCP joint necessitate a longer period of immobilization—usually for 6 weeks. A progressive exercise program is then initiated with dynamic splinting during the day and static splinting at night to preserve extension (Poole, 2013, p. 609).
  • The early passive motion method reverses what was done for the flexor tendons (Hall, 2010). The extensor tendons are held in extension by dynamic, gentle rubber band traction, and the patient is permitted to actively flex the fingers, thus passively moving the surgically repaired extensor tendons. “These splints must have a dorsal component to provide a block to flexion so as not to move the tendons too much, which could lead to overstretching or rupture of the extensor tendon. This method facilitates tendon strength and can prevent the scarring that ultimately limits motion and function” (Poole, 2013, p. 609).
  • The early active short arc program, developed by Evans, permits the tendon to actively move 3 days after surgery. The therapist must take care to make sure that the stress applied by early active motion does not override the strength of the surgical repair. “The splinting program is quite complex and specific and requires a skilled occupational therapist” (Poole, 2013, p. 609).
  • Information from the AOTA’s website.
  • Consider whether vincula (flexor tendons) or mesotendons (extensor tendons) were damaged. Vincula provide 70% of nutritional support to flexor tendons in zones 1 and 2. Mesotendons provide 30% of nutritional support to the extensor tendons via vascular perfusion in all zones. Synovial diffusion provides the remaining 70%. (p449 rehab of the hand). Any fractures, pulley, nerve and/or artery repairs may indicate a longer immobilization phase or other modifications to the program. Therapist must assess the patient’s cognitive status to determine ability to understand and comply with a complex home program. Monitor for any signs of infection. Any positive findings should be reported to the referring MD immediately. Send the patient to emergency room if referring MD is not available. Consider specific details of the tendon repair (e.g. number of strands, type of suture, whether epitenon/tendon sheaths were repaired.) Repair of epitenon adds 10-50% strength to the repair and reduces gap formation. Also, consider that immediately after surgery, postoperative edema and inflammation will increase the stress placed on the tendon repair site with active motion. Therefore, it is advised to wait at least 72 hours before initiating any active motion of the repaired tendon. Biomechanically, the immobilized tendon loses strength after repair: 50% at the end of week one, 33% at the end of week three, and 20% at the end of week six. 4 Tendons that move as they heal have better motion and strength than those that do not move. The difference is not improved by adding a load over and above the amount needed to initiate tendon gliding (Department of Rehabilitation Services , 2007).
  • The patient must not remove the splint under any circumstance. Failure to follow this advice could result in rupture of the repaired tendon requiring further surgery and a delay in your recovery. If patents have any problems with the splint such as discomfort or poor fitting, they should be encouraged to contact one of the hand therapists. Patients should not attempt to adjust the splint yourself. Patients must keep their hand elevated at all times; this is particularly important during the early recovery period; the therapist should advise the patient when this is no longer necessary (Department of Rehabilitation Services , 2007). Patients must carefully follow the exercise regime. Before the patients discharge from hospital the hand therapists will see the patient and the exercise regime will be explained to them. To optimize your recovery it is advised to follow the regime exactly as instructed. Failure to do so may result in stiffness of the fingers and/or rupture of the repaired tendons and require further surgery. Either of these complications may increase the likelihood of the patient developing permanently stiff fingers (American Occupational Therapy Association, Inc., 2007).
  • The patient should be encouraged not to: use the injured hand for anything other than performing your exercise regime; use the hand for driving for at least 10 weeks following surgery; operate machinery of any sort whilst wearing a protective splint; participate in any sporting activities. The patient should be instructed to contact the hospital in the event of the following: sudden increase in pain, swelling and redness of the injured fingers; a sudden inability to move the injured fingers (this may suggest that the tendons have ruptured, this is sometimes associated with a ‘snap’); keep all hospital appointments; your injury should be well healed and the hand back to nearly full strength after three months, providing the instructions from the surgical and hand therapy team are followed carefully (American Occupational Therapy Association, Inc., 2007; Department of Rehabilitation Services , 2007).
  • The outcomes of treatment depend on the cause, type, site, and extent of the tendon laceration, length of time between injury and repair, and the type of repair. If the damaged tendon can be restored to its normal length with adequate strength, good function should return. Fractures, infection, involvement of more than one tendon, or concomitant injuries to the hand make it more difficult to achieve complete restoration of finger and hand function (Wood, 2012). Staged reconstruction of a flexor tendon repair following initial surgery is often necessary for complex cases and results in prolonged incapacitation. Proper postoperative splinting, hand therapy, and excellent compliance with treatment plans are essential to the success of any tendon laceration repair (Xie, 2008). If normal tendon function cannot be completely restored or if there are concomitant injuries to the joints, manual dexterity may be compromised (Wood, 2012; Henry, 2012).
  • Tendons do not heal as well as other body tissues, so recovery is guarded in extensive or more complicated cases. Smoking may affect tendon strength. Late tendon repair is not very successful and sometimes not even possible. If repair and treatment are initiated immediately, individuals with a laceration the tendons in the wrist generally do well. Delay can result in the formation of scar tissue and retraction of the tendons (Al-Qattan, 2007). Other factors that can affect recovery are: age—older individuals are generally weaker and take longer to heal affecting the functional outcome; strength and health—individuals who are strong and in good health prior to the injury generally do better following surgical repair; and tissue quality prior to the surgical repair—will effect healing and recovery following surgery. Poor circulation and presence of scar tissue will also interfere with the healing process (Wood, 2012; Henry, 2012).The healing time for a tendon repair will take up to 8-12 weeks but restoration of function and ability to accept full activity, load and stress can take up to one year (Department of Rehabilitation Services , 2007).
  • Now I willdiscuss ways the OTPF may apply to individuals with flexor and extensor tendon lacerations.
  • Tendon injuries will compromise the ability to perform IADL’s (drive, manage finances, self-administer medications, make a meal, etc.). Due to limitations of the involved extremity, the patient would have difficulty with all areas of occupation, including grooming, oral hygiene, bathing, toilet hygiene, dressing, meal preparation, feeding and eating, driving, administering medications, and using the telephone. The patient may have trouble resting and sleeping due to pain and discomfort from the splint. Patient may be unable to work. Patient should be educated in one-handed techniques to dampen occupational disruption. Family may be available to provide the patient with some assistance. Patient may experience anxiety about the recovery timeframe and uncertainty of the prognosis. If the patients recovery is less than complete, his or her job should be analyzed to see if it can be adapted to allow him or her perform it (American Occupational Therapy Association, 2008).Full resistance and normal work activities may resume at 3 months after surgery. Although performance of ADL is generally not a problem, therapy providers should ask patients about any problems they may have or anticipate (Xie, 2008)
  • The motor skills of manipulating, stabilization and coordination are disrupted. The abilities to move, transport, lift, calibrate, and grip are lost in the affected hand due to medical precautions. The patient may experience reduced activity tolerance due to increased demands of performing activities one-handed. Skills related to handling and holding are challenging because the involved hand cannot be used to stabilize. Disturbances in timing of tasks will result from one-handed performance. The patient may need to rely on others more. His/her relationship with others may change due to his/her temporary dependent occupational status. (American Occupational Therapy Association, 2008).
  • Habits, routines, roles and rituals may be altered. It will take longer to perform tasks. Some previous habits and routines may not be possible while the tendon is healing (e.g., adhering to daily housework schedule). Loss of the worker role and changes in the performance of parent and household maintainer roles may be psychologically devastating (American Occupational Therapy Association, 2008)
  • Having the use of only one have is restrictive and will affect the patient’s ability to carry things for long distances or up and down stairs. The patient may experience difficulty negotiating and navigating his or her physical environment. Decisions regarding workforce involvement can be emotional and may negatively affect occupational identity and self-worth. Relationships with spouse, friends, and caregivers may become strained. Relationships with systems (e.g., economic or institutional) that are influential in establishing norms, role expectations, and social routines may be negatively impacted. Because the patient is not going to work every day, he or she may be at risk for isolation and occupational alienation (American Occupational Therapy Association, 2008).
  • Since this is an orthopedic disorder, the biomechanical frame of reference is appropriate. “The goals of [this] approach are to evaluate specific physical limitations in ROM, strength, and endurance; restore these functions; and prevent or reduce deformity…Biomechanical principles are also applied in ergonomics and work hardening, with an emphasis on proper positioning and the optimum fit between the biomechanics of the individual and the work environment.” (Early, 2013, p.10)
  • Flexor and Extensor Tendon Laceration vs. Occupational Therapy

    1. 1. Flexor and Extensor Tendon Lacerations By Chevahlyan Dozier
    2. 2. DESCRIPTION O Tendon = part of the muscle that attaches the muscle to bone. O Transfers forces generated by muscle to bone; produces movement at joint. O Lacerations occur when the tendons experience a traumatic cut.
    3. 3. ANATOMY & PHYSIOLOGY Flexor tendons that bend fingers and wrist Extensor tendons that extend fingers and wrist O flexor digitorum profundus and superficialis O flexor pollicis longus O flexor carpi radialis and ulnaris O Palmaris longus O extensor digitorum communis O extensor indicis proprius O extensor digitorum minimi O abductor pollicis longus O extensor pollicis brevis and longus O extensor carpi ulnaris O extensor carpi radialis brevis and longus
    4. 4. Abbreviation Full Name Function APL Abductor pollicis longus Abduction of thumb EPB Extensor pollicis brevis Extension of thumb proximal phalanx ECRL ECRB Extensor carpi radialis longus/brevis Extends and abducts hand EPL Extensor pollicis longus Extends thumb IP joint EDC (4 tendons: II - V) Extensor digitorum communis Extends digits II - V EIP Extensor indicis proprius Extends digit II EDM (EDC) Extensor digitorum minimi (quinti) Extends digit V ECU Extensor carpi ulnaris Extends and abducts hand
    5. 5. Abbreviation Full Name Function FDL Flexor pollicis longus Thumb flexion PL Palmaris longus Flexion of wrist FCU Flexor carpi ulnaris Flexion and adduction of hand FDP Flexor digitorum profundus flexion of distal interphalangeal joints and helps wrist flexion FDS Flexor digitorum superficialis Flexion of proximal interphalangeal joints and flexion of proximal phalanges at metacarpophalangeal joints FCR Flexor carpi radialis Flexion and abduction of hand at wrist
    6. 6. Flexor Tendon Injury Zones 1: flexor digitorum profundus distal to insertion of flexor digitorum superficialis 2: insertion of flexor digitorum superficialis to proximal edge of A1 pulley (“No Man’s Land”) 3: proximal edge if the A1 pulley to distal edge of carpal tunnel 4: within the carpal tunnel 5: proximal to the carpal tunnel
    7. 7. Extensor Tendon Injury Zones O Extensor tendons are divided into 8 zones O Zones 1,3 and 5 lie over the DIP, PIP and MCP joints
    8. 8. ETIOLOGY Common mechanisms of injury include, but are not limited to: “Fight Bite” injury O sharp object direct laceration (broken glass, kitchen knives or table saws) O crush injury O avulsions O burns O animal or human bites O suicide attempts O motor vehicle accidents
    9. 9. SIGNS & SYMPTOMS O Unable to bend one or more finger joints O Pain when bending finger/s O Open injury to hand (e.g., cut on palm side of hand, particularly in area where skin folds as fingers bend) O Mild swelling over joint closest to fingertip O Tenderness along effected finger/s on palm side of hand
    10. 10. OTHER COMPLICATIONS O adhesions O ruptures O Infections O postoperative edema and inflammation O wound dehiscence O attenuation O joint or soft tissue contractures O nerve and blood vessel damage O pain O delayed rupture/failure of tendon repair O delayed healing due to underlying medical conditions O Mallet finger deformity O Boutonniere deformity O Lumbrical plus O Bowstringing O Swan neck deformity O Quadriga syndrome O Finger cascade O Extensor lag O Trigger finger
    11. 11. DETECTION O History and physical O Examination of wound O Use of bedside ultrasonography in ER (more sensitive and specific than physical examination) O Wound exploration techniques or MRI. O 3-view x-ray must be done (except most benign) to rule out foreign bodies or bony injury. O Radiographs to evaluate for possible fractures or dislocations (blunt trauma cases)
    12. 12. HISTORY O History of tendon reconstruction can be traced back to the times of Hippocrates and Galen. O Galen (131-201 AD) stated that tendons were composed of both ligaments and nerves. He warned that suturing tendons would lead to pain, twitching, and eventual convulsions. O Was not refuted until 1682, when Meekren observed that tendons are insensitive and described the successful repair of incompletely severed tendons.
    13. 13. MEDICAL MANAGEMENT O Immediate surgical repair and wound debridement O Immobilizing immediately following surgery O Analgesics (Vicodin and Percocet) O Nonsteroidal anti-inflammatories (NSAIDs) are generally not prescribed as they can delay healing. O Antibiotics may be prescribed as a post-operative precaution. O Hand therapy (2-4 week post-op; hand therapy timeline and program determined by surgeon)
    14. 14. What can a therapist do? O Evaluate the client’s injury following care by an orthopedist to coordinate treatment plans and determine the course of intervention. O Analyze the client’s environment at home and work to identify potential barriers to the client’s performance O Fabricate a protective splint for the injured part of the hand and teach the client how to manage daily activities while wearing the splint O Recommend a home exercise program that will facilitate healing and optimum use of the hand O Apply techniques to reduce swelling, prevent further injury, care for wounds, and improve movement O Show the client how to complete activities safely and independently while the hand is being rehabilitated O Incorporate the client’s goals and desires into the treatment plan The American Occupational Therapy Association, Inc.
    15. 15. FLEXOR TENDON MANAGEMENT 3 methods of post-op flexor tendon management are Immobilization, controlled passive motion, and early active motion
    16. 16. IMMOBILIZATION O Complete immobilization of tendon for 3 ½ weeks after surgery O May not yield consistently good results due to production of scar adherence O May lead to a greater incidence of tendon rupture O May be necessary if other injuries are present (e.g., a fractured phalanx that cannot be moved) O May be selected if patient appears unable to participate fully in treatment (e.g., child or a person with cognitive impairments)
    17. 17. CONTROLLED PASSIVE MOTION O Durand and Houser protocol allows 3 to 5 mm of tendon excursion after repair O On 3rd postoperative day, patient begins twice-daily exercise regimen of passive flexion and extension (6 to 8 motions per tendon) O Keep wrist flexed and MCPs in 70 degrees of flexion O After 4 ½ weeks, protective dorsal splint is removed and rubber band traction is attached to a wristband. O Active extension and passive flexion are done 1 additional week and gradually increased over next several weeks. O Found sufficient to prevent adherence of the repaired tendons
    18. 18. EARLY ACTIVE MOTION O Kleinhert and Washington protocols use early active extension but passive flexion O Indian and MAMTT (minimal-active muscle-tendon tension) protocols allow early gentile supervised active flexion of tendon O Rubber bands are attached to fingernails of the involved digits O Dorsal blocking splint with MCP joints held in ~ 60 degrees of flexion and PIPs in gentile flexion O Patient wears splint 24 hours a day for 3 weeks and is instructed to actively extend fingers several times a day in splint, allowing rubber bands to pull fingers into flexion O Patient must be able to fully extend IP joints actively within splint to prevent joint contractures O Splint is removed at 3 weeks, depending on the surgeon’s judgment O Method minimizes scar adhesions while enhancing tendon nutrition and blood flow
    19. 19. POSTACUTE FLEXOR TENDON REHAB O Once active flexion is begun out of splint (after postoperative management), patient should be instructed in exercises to facilitate differential tendon gliding O Wehbe recommends 3 positions—hook fist, straight fist, and composite fist O Tendon glide exercises should be repeated 10x’s in each position, 2-3x’s daily O Isolated exercises to assist tendon gliding may be performed with a blocking splint or by using opposite hand O MCP joint is held in extension during blocking, so intrinsic muscles that act on it cannot overcome power of repaired flexor tendons O After 6 to 8 weeks, passive extension may be started (cylindrical plaster splint or volar finger splint may be necessary to correct flexion contracture at PIP joint) O After ~ 8 weeks, patient may begin light resistive exercises, light ADL, and other activities; patient must avoid lifting with or applying excessive resistance to affected hand O Activities such as working with soft clay, woodworking, and macramé are excellent
    20. 20. EXTENSOR TENDON MANAGEMENT 3 current treatment approaches to extensor tendon rehabilitation are immobilization, early controlled passive mobilization, and early active motion
    21. 21. IMMOBILIZATION O Keeps the tendon in a shortened position through splinting or casting O Tendons immobilized for 3 weeks O In week 4, gentle active motion of the repaired tendon is introduced O Rehabilitation depends on zone of injury
    22. 22. IMMOBILIZATION INJURIES IN ZONES PROXIMAL TO MCPs INJURIES IN ZONES DISTAL TO MCPs O May be immobilized for 3 weeks. O Afterwards, finger may be placed in removable volar splint between exercise periods for additional 2 weeks O Progressive ROM after 3 weeks O If full flexion is not regained rapidly, dynamic flexion may be started after 6 weeks. O Require a longer period of immobilization (usually 6 weeks) O A progressive exercise program is then initiated O Dynamic splinting during day and static splinting at night to maintain extension.
    23. 23. EARLY PASSIVE MOTION O Reverses protocol for the flexor tendons O Extensors are held in extension by dynamic, gentle rubber band traction, and the patient is allowed to actively flex the fingers—passively moving the repaired extensor tendons O Splints must have dorsal component governing flexion to inhibit overstretching or rupture of the extensor tendon O Facilitates tendon strength and can prevent the scarring that ultimately limits motion and function
    24. 24. EARLY ACTIVE MOTION O Early active short arc program (developed by Evans) allows tendon to actively move 3 days after surgery O Therapist must take care to ensure stress applied by early active motion does not overpower strength of surgical repair O Splinting program is complex and specific and requires a skilled occupational therapist
    25. 25. What can the patient do? O Implement a home exercise program recommended by the occupational therapist O Learn how to improve coordination to increase the use of his or her hand under the supervision of an occupational therapist O Strengthen the hand and progress toward full use of the hand O Set short- and long-term rehabilitation terms upon consulting an occupational therapist and other health professionals O Learn how to perform daily activities, such as dressing, grooming, and driving, in a safe manner while the hand is being rehabilitated The American Occupational Therapy Association, Inc.
    26. 26. PRECAUTIONS & CONTRAINDICATIONS O Consider any fracture, pulley, nerve and/or artery repairs that may require longer immobilization phase or other modifications to program O Assess patient’s cognitive status to determine ability to understand and comply with complex home program O Monitor for signs of infection; report positive immediately O It is advised to wait at least 72 hours before initiating any active motion of the repaired tendon O Do not add load over and above amount needed to initiate tendon gliding.
    27. 27. more PRECAUTIONS & CONTRAINDICATIONS PATIENT INFORMATION O Keep your hand elevated at all times (particularly important during the early recovery period) O Therapist will advise when this is no longer necessary. O Carefully follow the exercise regime. O Do not remove the splint under any circumstance. O For any problems with the splint such as discomfort or poor fitting, please contact a hand therapists. O Do not attempt to adjust the splint yourself.
    28. 28. even more PRECAUTIONS & CONTRAINDICATIONS PATIENT INFORMATION O Do not use the injured hand for anything other than performing your exercise regime. O Do not use the hand for driving for at least 10 weeks following surgery. O Do not hyperextend the PIP joint (this would overstretch the repaired tendons) O Do not operate machinery of any sort whilst wearing a protective splint. O Do not participate in any sporting activities.
    29. 29. PROGNOSIS O Depends on cause, type, site, and extent of tendon laceration; length of time between injury and repair; and type of repair. O If damaged tendon can be restored to normal length with adequate strength, good function should return. O Fractures, infection, involvement of more than one tendon, or concomitant injuries to hand make it more difficult to achieve complete restoration of finger and hand function. O Staged reconstruction of tendon repair following initial surgery is often necessary for complex cases and results in prolonged incapacitation. O Proper postoperative splinting, hand therapy, and excellent compliance with treatment plans are essential O If normal tendon function cannot be completely restored or if there are concomitant injuries to joints, manual dexterity may be compromised.
    30. 30. PROGNOSIS cont...O Tendons do not heal as well as other body tissues O Smoking may affect tendon strength. O Late tendon repair is not very successful and sometimes not even possible. O Delay can result in the formation of scar tissue and retraction of tendons O Other factors that can affect recovery include age, tissue quality, strength and health O Healing time for tendon repair will take 8-12 weeks but restoration of function and ability to accept full activity, load and stress can take up to one year. O Full resistance and normal work activities may resume at 3 months after surgery O “Functional” to “excellent” result = minimal extension lag at PIP and DIP joints and finger can flex to palm.
    31. 31. OCCUPATIONAL THERAPY FRAMEWORK APPLICATION Aspects of Occupational Therapy’s Domain
    32. 32. AREAS OF OCCUPATION O Patient would experience difficulty in various areas of occupation, including bathing, toilet hygiene, dressing, driving, administering medications, meal preparation, feeding and eating, resting and sleeping O Work hardening may be indicated pending work demands and level of injury O Patient should be educated in one-handed techniques to lessen occupational disruption. O Family may be available for support O May experience anxiety about recovery timeframe and uncertainty of the prognosis. O If recovery is less than complete, patient’s job should be analyzed for adaptation potential
    33. 33. PERFORMANCE SKILLS O Motor skills (manipulating, stabilization, coordination, etc.) are disrupted. O Abilities to move, transport, lift, calibrate, and grip are lost in affected extremity due to medical precautions. O May experience reduced activity tolerance due to increased demands of performing activities one-handed. O Skills related to handling and holding are challenging because the involved hand cannot be used to stabilize. O Disturbances in timing of tasks resulting from one-handed performance. O May need to rely on others more. O Relationship with others may change due to temporary dependent occupational status.
    34. 34. PERFORMANCE PATTERNS O Habits, routines, roles and rituals may be altered O It will take longer to perform tasks O Previous habits and routines may not be possible while tendon healing (e.g., adhering to daily housework schedule) O Loss of worker role and changes in performance of parent and household maintainer roles may be psychologically devastating
    35. 35. CLIENT FACTORS O Neuromusculoskeletal and movement-related functions most obviously affected O Disuse and neglect of finger (especially index finger) are common and should be prevented. O Limited strength and range or motion in affected hand while the tendon is healing O No reason to expect any cognitive deficits O May be depressed over injury and anxious about future O May affect experience of self and ability to cope with situation.
    36. 36. CONTEXT & ENVIRONMENT O Decreased ability to carry things for long distances or up and down stairs O May experience difficulty negotiating and navigating physical environment O Decisions regarding workforce involvement may negatively affect occupational identity and self-worth O Relationships with spouse may become strained O Relationships with systems (e.g., economic or institutional) may be negatively impacted. O Inability to work everyday can increase risk for isolation and occupational alienation.
    37. 37. GUIDE for INTERVENTION O Biomechanical practice approach is most appropriate. O Goals of this approach: O evaluate specific physical limitations in ROM, strength, and endurance O restore these functions O prevent or reduce deformity O Biomechanical principles are also applied in ergonomics and work hardening O Limitations: approach is reductionistic rather than holistic
    38. 38. PROFESSIONAL ORGANIZATIONS O International Federation of Societies for Surgery of the Hand (IFSSH) O American Association for Hand Surgery (AAHS) O American Society for Surgery of the Hand (ASSH)
    39. 39. CONCLUSION O Persons experiencing tendon injury in hand may experience difficulties with performance in all areas of occupation O Every person’s injury is different and rate of recovery depends on the severity of the injury as well as other client factors O Occupational therapy practitioners can provide rehabilitation intervention that enables the hand to function well and prevent further injury O Must have understanding of tendon anatomy of the hand and of the type of surgical repair O Must have good communication with the surgeon.
    40. 40. Thank you :)
    41. 41. Glossary O Paradoxical extension (“Lumbrical Plus Finger”): when the patient attempts to flex the fingers, the relatively tight lumbrical will cause PIP extension O No man’s land injury: injury to the area between the distal palmar crease and the insertion of the flexor digitorum superficialis (zone II); this is considered the most difficult to treat because the tendons lie in their sheaths in this area beneath the fibrous pulley system, and any scaring will cause adhesions. O Quadriga effect: uneven tension applied to the common muscle belly of the flexor profundus tendons due to advancement of tendon leading to limited flexion of the remaining profundus tendons O Extensor lag: incomplete extension O Tenolysis: surgical clearing of surrounding tendon scar O Adhesions: fibrous bands that form between tissues and organs, often as a result of injury during surgery; may be thought of as internal scar tissue that connect tissues not normally connected.
    42. 42. Glossary O Rupture: the tearing apart of a tissue O Wound dehiscence: the parting of the sutured lips of a surgical wound O Attenuation: a reduction in thickness and density due to stretching O Delayed rupture: a tendon rupture which does not immediately occur after injury; may also refer to tendon rupture which occurs after surgical repair of the tendon (not at site of repair). O Mallet finger deformity: an involuntary flexion of the distal phalanx of a finger caused by avulsion of the extensor tendon O Swan neck: DIP hyperflexion with PIP hyperextension
    43. 43. Glossary O Avulsion: an injury in which a body structure is forcibly detached O Boutonniere deformity: a chronic flexion of the PIP joint and extension of the DIP joint O Bowstringing: a loosening of the tendon from the finger allowing tendon taking shortest distance between remaining pulleys O Trigger finger: difficulty flexing or extending the finger caused by catching, snapping or locking of the involved finger flexor tendon, associated with dysfunction and pain O Finger cascade: Excessive trimming and advancement of the profundus tendon leading to flexed position of finger compared with other fingers.
    44. 44. RESOURCES O www.twinboro.com O emedicine.medscape.com O www.mdguidelines.com O www.aota.org O www.brighamandwomens.org O www.cuh.org.uk O www.brighamandwomens.org O ajot.aotapress.net
    45. 45. References Al-Qattan, M. (2007). Surgical treatment and results in 17 cases of open lacerations of the extensor hallucis longus tendon. Journal of Plastic, Reconstructive & Aesthetic Surgery, 360-367. doi:10.1016/j.bjps.2006.05.003 American Occupational Therapy Association. (2008). Occupational Therapy Practice Framework: Domain & Process 2nd Edition. American Journal of Occupational Therapy, 62, 625-683. American Occupational Therapy Association, Inc. (2007, May 16). Intervention for Tendon Injuries. Retrieved from American Occupational Therapy Association: http://www.aota.org/Consumers/consumers/Work/Tendon/35184.aspx
    46. 46. References Barbara Hall, H. L. (2010). Research Scholars Initiative—Comparing Three Postoperative Treatment Protocols for Extensor Tendon Repair in Zones V and VI of the Hand. The American Journal of Occupational Therapy, 64, 682–688. doi:10.5014/ajot.2010.09091 Benjamin C Wood, M. (2012, March 9). Flexor Tendon Lacerations . Retrieved from Medscape Reference: Drugs, Diseases & Procedures: http://emedicine.medscape.com/article/1286303-overview#a04 Department of Rehabilitation Services . (2007). Standard of Care: Flexor /Extensor Tendon Laceration of the Forearm, Wrist, Digits. Retrieved from Brigham and Women's Hospital: A Teaching Affiliate of Harvard Medical School: http://www.brighamandwomens.org/About_BWH/default.aspx
    47. 47. References Ginard I Henry, M. (2012, January 31). Extensor Tendon Lacerations . Retrieved from Medscape Reference: Drugs, Diseases & Procedures: http://emedicine.medscape.com/article/1286225-overview#a04 Poole, S. E. (2013). Acute Hand Injuries: Introduction to Tendon Injuries. In M. B. Early, Physical Dysfunction Practice Skills for the Occupational Therapy Assistant (pp. 604-609). St. Louis: Mosby. R. G. Xie, Y. C. (2008). The Gliding Force and Work of Flexion in The Early Days After Primary Repair of Lacerated Flexor Tendons: An Experimental Study. The Journal of Hand Surgery, 192–196. doi:10.1177/1753193408087035

    ×