Hand Therapy presentation

1. Flexor Tendons
Zone 2
Rose Gospel (OT) and Georgia McGuinness (OT)

2. 12wks post FDP, A2 pulley repair L MF

3. Current TQEH Tendon Guidelines
• Finger extensor tendons
» 6 official guidelines for different zones
• Finger flexors tendons
»2 guidelines covering all zones
1. Modified Kleinert
2. Early Active

4. Systematic Review – Zone II
• Evaluation of Outcomes
– AROM
– Grip strength
– Quality of motion
– Rupture rate (primary outcome)
• Early active motion protocols and combined
Kleinert and Duran protocols
– Low rates of ruptures
– “Acceptable range of motion”

5. Flexor Tendon Guidelines
• Kleinert (1973)
• Duran (1975)
• Modified Kleinert (1989)
• Silfverskiold Controlled Motion (1993)
• LEAF – Zone I (2005)
• Tang (2007)
• Early Active Motion Protocols
- Adelaide Flexor Tenorrhaphy Protocol (2008)
• Evans (2012)
• Manchester Short Splint (2013)

6. Manchester Short Splint
• Mr Jason Wong
– Clinical Lecturer in Plastic and Reconstructive Surgery,
Manchester
• Fiona Peck
– MCSP
• Professor Gus McGrouther
– 1989 Chair in Plastic and Reconstructive Surgery at UCL,
University of Manchester in 2001 with laboratory programmes
in tendon repair. Clinical practice principally concerned with
hand injuries, microsurgery and the care of wounds and scars.
• Professor Vivien Lees
– Consultant Plastic, Reconstructive and Aesthetic Surgeon
known for her expertise in hand, wrist and upper limb surgery.
ASSH Meeting and IFSSH &IFSHT Congress (2013)

7. Manchester Short Splint Results
• Historical cohort study (level 3 evidence)
• Group A
– In 2011, 62 patients (76 digits) with acute,
uncomplicated zone II flexor tendon injuries
rehabilitated using traditional forearm based
splint
• Group B
– In 2012, 40 patients (45 digits) with same injuries
rehabilitated using the Manchester short splint

8. What is Manchester Short Splint?
• Wrist
– Finishes at dorsal wrist crease
– Allows 45 degrees extension
• MCPj’s
– 30 degrees flexion
• Exercises
– Commence 4th or 5th day
– Motion initiated at DIPj’s
– Outer range or first 1/3 (early phase)
– No ‘place and hold’

9. 12wks post FDP, A2 pulley repair L MF

10. Proposed changes for Zone II
• Day 1 post op
– splint, oedema mx, education
– Splint geometry: wrist 30degrees extension, MCPJ 40degrees flex
• Day 3-5 start AROM
– PROM ex's always prior to AROM
– isolated DIPjt ROM to at least 35degrees, with lateral joint support
(suitable patients or in therapy only)
– Focus on initiating AROM with DIPjt rather than flat fist
– Focus on IPjt extension exercises
– Early synergistic wrist exercises (not with our patients?)
• Avoid full composite flexion until 4wks
– Active assisted exercises when start to meet resistance in individual
movement cycles

11. ReferencesAmadio PC (2005) Friction of the Gliding Surface: Implications for Tendon Surgery and Rehabiliation. Journal of Hand Therapy 18:2:112-119
Brinkley et al (2013) Flexor Tendon Repair, Rehabilitation, and Reconstruction. Plastic and Reconstructive Surgery. 132: 1493 – 1503.
Chan et al (2006) Functional outcome of the hand following flexor tendon repair at the “no man’s land”. Journal of Orthopaedic Surgery. 14: 178-183.
Chesney et al (2011) Systematic Review of Flexor Tendon Rehabiliation Protocols in Zone II of the Hand. Plastic and Reconstructive Journal. April 1583-1592
Dobbe et al (2002) Patient Compliance with a Rehabilitation Program after Flexor Tendon Repair in Zone II of the Hand. Journal of Hand Therapy. 15:16-21
Evans R (2012) Managing the injured tendon: current concepts. Journal of Hand Therapy. 25:173-90
Evans R (2005) Zone I Flexor Tendon Rehabilitation with Limited Extension and Active Flexion. Journal Hand Therapy. 18: 128-40
Gail NG (2005) Current Practice Patterns of Flexor Tendon Rehabilitation. Journal of Hand Therapy. 18: 169-174
Griffin et al (2012) An Overview of the Management of Flexor Tendon Injuries. Open Orthopaedic Journal. 6: 28-35
Howell et al (2013) Rehabilitation of flexor and extensor tendon injuries in the hand: Current updates. Injury. Int. J. Care Injured 44: 397-402
Kaskutas et al (2009) The impact of flexor tendon rehabilitation restrictions on individuals’ independence with daily activities: Implications for hand therapists. Journal of
Hand Therapy. 26: 22-29
Klein L (2003) Early Active Motion Flexor Tendon Protocol Using One Splint. Journal of Hand Therapy. 16: 199-206.
Pang et al (2005) Active mobilisation after flexor tendon repair: comparison of results following injuries in zone 2 and other zones. Journal of Orthopaedic Surgery. 13: 158-
163.
Pettengill KM (2005) The Evolution of Early Mobilization of the Repaired Flexor Tendon. Journal of Hand Therapy. 18: 157-168
Sandow & Kay (2008) Flexor Tenorrhaphy - Adelaide Protocol
Tanaka et al (2005) Flexor Digitorum Profundus Tendon Tension during Finger Manipulation. Journal Hand Therapy. 18: 330-338
Tang JB (2007) Indications, methods, postoperative motion and outcome evaluation of primary flexor tendon repairs in zone 2. Journal Hand Surgery 32:118-29.
Tang et al (2003) Repair Strength of Tendons of Varying Gliding Curvature: A Study in a Curvilinear Model. The Journal of Hand Surgery. 28: 243-249.
Stickland JW (2005) The Scientific Basis for Advances in flexor Tendon Surgery. Journal of Hand Therapy. Apr-Jun 18: 94-110
Zhang et al (2012) Value of High Frequency Ultrasonography in Diagnosis and Surgical Repair of Traumatic Finger Tendon Ruptures. Medical Principles and Practices. 21: 472-
475

12. Repair Strength
Sandow & Kay, 2008

13. Prevent Ruptures – Prevent Functional
Use
• Wally bars
• Include thumb in splint
• Include thumb in palmar bar
• One handed training
• Composite fist splint
• Adaptations to splint to assist function
• Leave IF free if LF to prevent removal of splint
completely for function?