flexor tendon

flexor tendon zones

• “Five Flexors” (as opposed to 7 extensors)

2 sets of flexors

flexor digitorum profundus

• passes through and goes to the distal phalanges (DIP)

flexor digitorum superficialis

• splits, stops, and attaches to the middle phalanges (PIP)

cause of flexor tendon injuries

deep cuts, assault, or injury to the flexor tendons on the PALMAR side of the hand (e.g., deep cuts, sports, RA)

• e.g., Jersey Finger = pull on shirt and finger gets caught, resulting in tendon being pulled from bone

• e.g., Rheumatoid Arthritis = weakens the flexor tendons, making them more likely to tear

==> must be put back together with either stiches or sutures

flexor tendon repair approaches

“‘full flexion, no tension; the decision hinges on 2, 4, or more”

• surgical repair approaches are differentiated by strand count

  • usually 2 or 4 are standard, but can be 6+

    • more threads = more stable

      • more stable = earlier PROM or AROM

• follow physician’s protocol

mend vs move

respect a damaged, healing structure

• too much movement or force can lead to damage— immobilize!

• too little movement can lead to adhesions and contractures— mobilize!

• we strike a balance (within the physician’s precautions)

mend vs move— flexor tendon

• in other topics, especially with fractures, we were concerned mainly about the force exerted on a joint

• for tendon injuries, we need to pay special attention to the tension on the tendons

tension-limiting mobility progression

tension-limiting: immobilization, PROM, AROM

• as opposed to standard: immobilization, gentle AROM, gentle PROM

• this is because we are most concerned with tension in the tendons; strictly controlled PROM will have less tension than AROM

  • AROM requires tension for movement

• treatment will follow the protocol the physician/surgeon has chosen, which will start with immobilization, immediate PROM, or immediate AROM

3 protocol

patient will have 1 of 3 possible protocols from physician/surgeon; all protocols will involve some kind of dorsal block splint to relieve tension

• immobilization

• early PROM

• early AROM

early immobilization

dorsal blocking splint (follows antideformity position) within 2-3 days post-surgery to block fingers from extending and creating another rupture/injury

• wrist: flexion; MCP: flexion; IPs: extension

• early phase: 0-4 weeks

• discharge splint at week 6

• rarely used, typically for noncompliance (i.e., children or adults with dementia)

early mobilization method 2-3 days after operation

the duran protocol

• move digits passively in flexion and extension using your other finger while your hand is in the splint

• exercises are done using a dorsal blocking splint— no rubber bands or active muscle contractions (i.e., no AROM)

early mobilization method: place and hold

PASSIVELY bring your hand to a fist and HOLD it

early PROM

passive flexion + active extension within dorsal block splint

early mobilization method: the kleinert protcool

passive digit flexion + active digit extension via rubber band traction

• think of actively extending the rubber band waistband in calvin “KLEIN”ert underwear

early AROM

use dorsal block splint most of the time, and then a separate orthosis with a hinge for wrist extension for gentle active flexion (place and hold, etc.)

• slight wrist extension will allow for easy, low-tension AROM of finger flexion

early mobilization method: 4-6 weeks post-op

differential flexor tendon gliding exercises

early mobilization method: 6-8 weeks post-op

light occupation-based activities +

• discharge splint ~6 weeks

• continue tendon gliding exercise

8 weeks post-op

strengthening and work

12 weeks post-op

resume normal activities

no man’s land = zone __

2

• “no man attempted”— hard to diagnose and treat 2/2 high risk of complications

• but due to advanced technology + therapy, we can now treat!