Flexor and Extensor Tendon

Lacerations By Chevahlyan Dozier

DESCRIPTIONO 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.

ANATOMY & PHYSIOLOGYFlexor 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 propriusO extensor digitorum

minimiO abductor pollicis longusO extensor pollicis brevis

and longusO extensor carpi ulnarisO extensor carpi radialis

brevis and longus

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

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

Flexor Tendon Injury Zones

1: flexor digitorum profundus distal to insertion of flexor digitorum superficialis2: 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

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

ETIOLOGYCommon 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 injuryO avulsionsO burnsO animal or human bitesO suicide attemptsO motor vehicle accidents

SIGNS & SYMPTOMSO 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

OTHER COMPLICATIONS

O adhesionsO rupturesO InfectionsO postoperative edema and

inflammationO wound dehiscenceO attenuationO joint or soft tissue

contracturesO nerve and blood vessel

damageO painO delayed rupture/failure of

tendon repairO 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

DETECTIONO 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)

HISTORYO 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.

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)

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 planThe American Occupational Therapy Association, Inc.

FLEXOR TENDON MANAGEMENT

3 methods of post-op flexor tendon management are Immobilization, controlled

passive motion, and early active motion

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)

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

EARLY ACTIVE MOTIONO Kleinhert and Washington protocols use early active extension but passive

flexionO 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

Dorsal Blocking Splint (Kleinert)

After surgical repair, rubber bands are attached to the

nails of the involved fingers with a suture through the nail or with a hook held in place with cyanoacrylate

glue.

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

EXTENSOR TENDON MANAGEMENT

3 current treatment approaches to extensor tendon rehabilitation are immobilization,

early controlled passive mobilization, and early active motion

IMMOBILIZATIONO 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

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.

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

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

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.

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.

more PRECAUTIONS & CONTRAINDICATIONS

PATIENT INFORMATIONO 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.

even more PRECAUTIONS & CONTRAINDICATIONS

PATIENT INFORMATIONO 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.

PROGNOSISO 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.

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.

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 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

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.

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

CLIENT FACTORSO Neuromusculoskeletal and movement-related functions

most obviously affectedO 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.

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.

GUIDE for INTERVENTION

O Biomechanical practice approach is most appropriate.

O Goals of this approach:O evaluate specific physical limitations in ROM, strength,

and enduranceO restore these functionsO prevent or reduce deformity

O Biomechanical principles are also applied in ergonomics and work hardening

O Limitations: approach is reductionistic rather than holistic

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)

CONCLUSIONO 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.

Thank you :)

GlossaryO 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.

GlossaryO 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

GlossaryO 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.

RESOURCESO www.twinboro.comO emedicine.medscape.comO www.mdguidelines.comO www.aota.orgO www.brighamandwomens.orgO www.cuh.org.ukO www.brighamandwomens.orgO ajot.aotapress.net

ReferencesAl-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

ReferencesBarbara 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

ReferencesGinard 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