Rehabilitation protocol

1. FLEXOR TENDON INJURIES
REHABILITATION PROTOCOLS
Dr. Akshai George Paul
DNB Resident
Department of Plastic surgery

3. • Tendons connect muscle to the bone
• Flexor tendon injuries can be caused by RTA,
Machine cut injuries, knife or glass, Self inflicted
wounds etc.

12. GOALS OF REHABILITATION
• To promote intrinsic healing and reduce extrinsic
scarring
• Decrease adhesions and to have smooth pop
function
• Biologically alter the process of scar formation

13. PROTOCOLS
IMMOBILIZATION
EARLY PASSIVE MOBILIZATION
EARLY ACTIVE MOBILIZATION

14. IMMOBILIZATION PROTOCOL
• Patients who are younger than 10 yrs
• Cognitive deficit
• Unable or unwilling to participate in complex
rehabilitation program
• To protect other injuries like fractures.

15. a) Early Stage (0 to 3 or 4 weeks)
1) Splint
-Dorsal forearm based splint holds the wrist in 10-30
degree flexion, MP joints in 40-60 degree flexion,IP in
full extension
- Splint is worn 24 hrs a day except for therapy visits
one to two times a week, when splint may be
removed by the therapist.

17. 2) Exercises
- Provided by the therapist one or 2 times a week for
gentle protected PROM. The therapist hold adjacent
joints in flexion while extending and flexing each
joint
- Protected intrinsic stretch excercises are
performed(Wrist flexed maximally and while MP
joint in neutral and IP joints flexed passively)

18. b) Intermediate Stage ( 3 to 4
weeks)
1) Splint
- Modified to bring wrist in neutral

19. 2) Excercise
-Remove splint, with the wrist at 10 degree of
extension, the patient perform 10 repeats of passive
digit flexon and extension
-Followed by 10 repeats of active differential tendon
gliding excercises.

21. • After 3 or 4 days of therapy,tendon function is
evaluated
• Total active and passive flexion at PIP and DIP is
measured

22. c) Late Stage (4 to 6 wkswks)
1)Splint
-Dorsal blocking splint is discontinued
2)Excercise
-Gentle tendon blocking excercises for isolated FDP
and FDS glide 4-6 times a day with 10 rpts
-Tendon gliding excercises continues

24. • After 1 week if active flexion has not improved, the
program is upgraded
• Towel gripping or putty squeezing excercises

26. Disadvantages:-
• Outcome may not be optimal
• Heavy adhesion formation and difficult to mobilise
after wards

27. EARLY PASSIVE MOBILIZATION
PROTOCOL
• Inhibit restrictive adhesion formation
• Improves synovial diffusion- promote intrinsic
healing

28. A. DURAN and HOUSER
a) Early stage (0 to 4.5 wks)
1) Splint
Wrist is held in 20 degree flexion and MP joint in
relaxed position of flexion
2) Excercise
-With MP and PIP joint flexed the DIP joint is
passively extended, them moving the FDP repair
distally, away from FDS repair

29. -Then with DIP and MP joint flexed, the PIP is
extended, Both repair glide distally away from the
site of repair and surrounding tissues.

30. b) Intermediate Stage(4.5 to 7.5
wks)
1)Splint
- After 4.5 wks, splint is replaced with a wrist band to
which rubber band traction is attached

32. 2) Excercise
- Active extension excercise begin with in the
limitation imposed by wrist band
-Active flexion (Blocking, FDS gliding and fisting) is
initiated on the removal of wrist band at 5.5 wks

33. C) Late Stage
Resisted Flexion

34. B. KLEINERT and Colleagues
a) Early Stage ( 0 to 3 wks)
1)Splint
-Dorsal blocking splint blocked the wrist in 45 degree
flexion and MP joint in 10 to 20 degree flexion
- Rubber band traction was directed to the finger nail
from wrist or just proximal to the wrist

35. 2) Excercise
Every hour the patient actively extends the fingers to
the limits of the splint 10 times allowing the rubber
band to flex the fingers

36. b) Intermediate stage(3 to 5 wks)
1)Splint
- Rubber band from injured digit is attached to a
wrist band from 3 wks to 5 wks

38. 2) Excercise
All active movements to the wrist and hand are
encouraged although the injured digit is still
teathered through 5 wks
At 5 wks gentle active flexion may begin

39. c) Late Stage (Starting at 6 wks)
Resisted Excercises
In nutshell
Elastic pull acts as the repaired flexor tendon without
flexor muscle contraction
Passive flexion and active extension of digit

40. Drawbacks of Kleinert
-Flexion contracture at PIPJ
-Loss of active DIP motion

42. EARLY ACTIVE MOBILIZATION
PROTOCOL

43. A. BELFAST and SHEFFIELD
a) Early Stage (Upto 4 to 6 wks)
1)Splint
Wrist at 20 degree flexion,MPJ at 80 to 90 flexion
allowing full IPJ extension
2)Excercise
Zone 3-After 24 hrs
Zone 2 -After 48 hrs

44. Excercise performed every 4 hrs within splint, include
all digits and consists of 2 repetition each of full
passive flexion, active flexion and active extension

45. b) Intermediate stage (Beginning
at 4-6 wks)
1)Splint
Discontinue at
4 wks - If tendon glide is poor
5wks - In most
6wks - in good gliding

46. 2) Excercises
-Protected passive IP extension
-Blocking excercises and tendon glide excercises at 6
wks
- Heavier hand use atv8 wks
- Full function by 12 wks

47. B. STRICKLAND (Indiana Hand Center)
a) Early Stage(upto 4 wks)
1)Splint
Dorsal Blocking splint- For Most times
Excercise Splint- Hinged wrist allowing full wrist
flexion, but wrist extension is limited to 30 degree.
Full digit flexion and extension are allowed, but MP
extension is limited to 60 degree

48. 2) Excercise
- Every hour patient perfom 15 rpts of PROM to the
PIP and DIP in the Dorsal blocking splint
- Followed by 25 repetition of digit flexion in
excercise splint
-Patient actively extend the wrist with simultaneous
passive digit flexion

49. b) Intermediate Stage (4 to 7 or 8
wks)
1)Splint
Excercise splint discontinued
Dorsal blocking splint continue except during
excercise
2) Excercise
Excercise continue every 2 hrs with 15 min repetition
of active flexion and extension excercise for wrist and
digits

50. c) Late Stage (7 to 8 wks)
Splint is discontinued and resistance excercise
initiated

51. C. EVAN and THOMPSON
- Minimal tension is required to overcome the
viscoelastic resistance of the antagonistic muscle
tendon unit.
-Active motion component is performed only by
therapist upto 3 wks

52. D. SILVERSKIOLD and MAY
1.Spint
- Dorsal blocking splint hold the wrist in neutral
position,MCP 50 to 70 degree flexion,IP in full
extension and finger tips have a elastic traction
through a palmar pulley

53. 2) Excercise
-Active extension/ passive flexion with elastic
traction to the distal palmar crease are performed 10
times hrly
- Active motion is only under supervision
-Splint is removed at 8 wks

54. LATEST ADVANCES
• Robotic Therapy
• Ultrasound therapy
• Matrix Rhythm therapy
• LASER therapy
• Cryo ultrasound therapy

55. CONCLUSION
• Application of the “right” force to move the digits is
important to moving the repaired tendon while
avoiding repair rupture. “Proper” positioning of the
joints is important to reducing tension in the
tendon.
• An ideal protocol improves gliding of a repaired
tendon, avoids repair rupture or gapping
potential,and leads to a better functional return.

56. A variety of protocols are available, which should be
selected and modified according to the extent of
trauma to the tendon, strength of the tendon repair,
and compliance of the patient.

57. • Deviation from a regimen is a common practice
because each individual patient presents with
specific factors that can affect the decision of use of
specific components of regimens.
• It is possible to use multiple aspects of different
protocols to fit the patient’s needs or physiologic
profile change.

58. 47 yrs old female patient
with knife cut injury to Left
index finger
O/e
Cut injury on palmar aspect
of index finger below the
level of PIPJ crease (Flexor
Zone 2)
Active spurt bleeding+
Spo2 100
CASE

59. Sensory deficit distal to the wound
Movements are painfully restricted
Intraoperatively:
Radial digital NVB Cut
Ulnar Digital NVB intact
FDS, FDP Cut

60. Tendon repaired with 4-0 prolene
Digital nerve coapted with 9-0 nylon
Digital artery anastomosed with 9-0 nylon
Skin suturing done with 4-0 ethylon
Dorsal blocking splint applied-

61. Post operative Rehabilitation
Started on Graded Early Mobilization from 1 week
with in the splint
Follow up in Regular OPD visit and continuing
physiotherapy achieving full range of motion in 3
months
Sensory deficits improving - It will take another 6-12
months to improve