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Flexor and Extensor
Tendon Lacerations
By Chevahlyan Dozier
DESCRIPTION
O Tendon = part of the muscle that attaches
the muscle to bone.
O Transfers forces generated by muscle to
bone...
ANATOMY & PHYSIOLOGY
Flexor tendons that
bend fingers and wrist
Extensor tendons that
extend fingers and
wrist
O flexor di...
Abbreviation Full Name Function
APL Abductor pollicis longus Abduction of thumb
EPB Extensor pollicis brevis Extension of ...
Abbreviation Full Name Function
FDL Flexor pollicis longus Thumb flexion
PL Palmaris longus Flexion of wrist
FCU Flexor ca...
Flexor Tendon Injury
Zones
1: flexor digitorum profundus
distal to insertion of flexor
digitorum superficialis
2: insertio...
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
j...
ETIOLOGY
Common mechanisms of
injury include, but are not
limited to:
“Fight Bite” injury
O sharp object direct
laceration...
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 ...
OTHER COMPLICATIONS
O adhesions
O ruptures
O Infections
O postoperative edema and
inflammation
O wound dehiscence
O attenu...
DETECTION
O History and physical
O Examination of wound
O Use of bedside ultrasonography in ER (more sensitive and
specifi...
HISTORY
O History of tendon reconstruction can be traced
back to the times of Hippocrates and Galen.
O Galen (131-201 AD) ...
MEDICAL MANAGEMENT
O Immediate surgical repair and wound debridement
O Immobilizing immediately following surgery
O Analge...
What can a therapist do?
O Evaluate the client’s injury following care by an orthopedist to coordinate
treatment plans and...
FLEXOR TENDON
MANAGEMENT
3 methods of post-op flexor tendon management are
Immobilization, controlled passive motion, and
...
IMMOBILIZATION
O Complete immobilization of tendon for 3 ½ weeks after
surgery
O May not yield consistently good results d...
CONTROLLED PASSIVE
MOTION
O Durand and Houser protocol allows 3 to 5 mm of tendon
excursion after repair
O On 3rd postoper...
EARLY ACTIVE MOTION
O Kleinhert and Washington protocols use early active extension but passive
flexion
O Indian and MAMTT...
POSTACUTE FLEXOR
TENDON REHAB
O Once active flexion is begun out of splint (after postoperative management), patient
shoul...
EXTENSOR TENDON
MANAGEMENT
3 current treatment approaches to extensor tendon
rehabilitation are immobilization, early cont...
IMMOBILIZATION
O Keeps the tendon in a shortened position
through splinting or casting
O Tendons immobilized for 3 weeks
O...
IMMOBILIZATION
INJURIES IN ZONES
PROXIMAL TO MCPs
INJURIES IN ZONES
DISTAL TO MCPs
O May be immobilized for 3
weeks.
O Aft...
EARLY PASSIVE MOTION
O Reverses protocol for the flexor tendons
O Extensors are held in extension by dynamic, gentle
rubbe...
EARLY ACTIVE MOTION
O Early active short arc program (developed by
Evans) allows tendon to actively move 3 days
after surg...
What can the patient do?
O Implement a home exercise program recommended by the
occupational therapist
O Learn how to impr...
PRECAUTIONS &
CONTRAINDICATIONS
O Consider any fracture, pulley, nerve and/or artery repairs that
may require longer immob...
more PRECAUTIONS &
CONTRAINDICATIONS
PATIENT INFORMATION
O Keep your hand elevated at all times (particularly
important du...
even more PRECAUTIONS &
CONTRAINDICATIONS
PATIENT INFORMATION
O Do not use the injured hand for anything other than
perfor...
PROGNOSIS
O Depends on cause, type, site, and extent of tendon laceration; length of
time between injury and repair; and t...
PROGNOSIS cont...O Tendons do not heal as well as other body tissues
O Smoking may affect tendon strength.
O Late tendon r...
OCCUPATIONAL THERAPY
FRAMEWORK APPLICATION
Aspects of Occupational Therapy’s Domain
AREAS OF OCCUPATION
O Patient would experience difficulty in various areas of occupation,
including bathing, toilet hygien...
PERFORMANCE SKILLS
O Motor skills (manipulating, stabilization, coordination, etc.) are
disrupted.
O Abilities to move, tr...
PERFORMANCE PATTERNS
O Habits, routines, roles and rituals may be
altered
O It will take longer to perform tasks
O Previou...
CLIENT FACTORS
O Neuromusculoskeletal and movement-related functions
most obviously affected
O Disuse and neglect of finge...
CONTEXT & ENVIRONMENT
O Decreased ability to carry things for long distances or up and down
stairs
O May experience diffic...
GUIDE for INTERVENTION
O Biomechanical practice approach is most appropriate.
O Goals of this approach:
O evaluate specifi...
PROFESSIONAL
ORGANIZATIONS
O International Federation of Societies for
Surgery of the Hand (IFSSH)
O American Association ...
CONCLUSION
O Persons experiencing tendon injury in hand may experience
difficulties with performance in all areas of occup...
Thank you
:)
Glossary
O Paradoxical extension (“Lumbrical Plus Finger”): when the patient
attempts to flex the fingers, the relatively ...
Glossary
O Rupture: the tearing apart of a tissue
O Wound dehiscence: the parting of the sutured lips of a surgical
wound
...
Glossary
O Avulsion: an injury in which a body structure is forcibly detached
O Boutonniere deformity: a chronic flexion o...
RESOURCES
O www.twinboro.com
O emedicine.medscape.com
O www.mdguidelines.com
O www.aota.org
O www.brighamandwomens.org
O w...
References
Al-Qattan, M. (2007). Surgical treatment and results in 17 cases of open lacerations of the
extensor hallucis l...
References
Barbara Hall, H. L. (2010). Research Scholars Initiative—Comparing Three Postoperative Treatment
Protocols for ...
References
Ginard I Henry, M. (2012, January 31). Extensor Tendon Lacerations . Retrieved from
Medscape Reference: Drugs, ...
Flexor and Extensor Tendon Laceration vs. Occupational Therapy
Flexor and Extensor Tendon Laceration vs. Occupational Therapy
Flexor and Extensor Tendon Laceration vs. Occupational Therapy
Flexor and Extensor Tendon Laceration vs. Occupational Therapy
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Flexor and Extensor Tendon Laceration vs. Occupational Therapy

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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.

  • I would like to offer my appriciation for your hard work and assessment. I am a current COTA student, within the OTA program for Keiser University located in Tallahassee Florida. I found your SlideShare to be most informative as well as functionally informational within the occupational performance boundries pertaining the OTPF guidelines I was researching. Thank you for your contrabution to this occupational therapy field as well as my needs for my educational path.
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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

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