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What is the earliest time frame within which the Place-Hold Active Mobilization Protocol should begin postoperatively?
Which of the following protocols is associated with Strickland's methodology?
What is the limitation for wrist extension as stated in the Place-Hold Active Mobilization Protocol?
At what stage postoperatively should active tendon gliding exercises begin?
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Which statement accurately describes 'Place-Hold Active Mobilization'?
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What type of splint is indicated in the Place-Hold Active Mobilization Protocol?
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What is one of the key focuses of early active mobilization protocols?
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What is a distinguishing factor of the Belfast & Sheffield Protocol?
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Which method is specifically aimed at improving tendon gliding?
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Which of the following assessments indicates a decrease in inflammation?
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What is a primary goal of using gentle active or passive mobilization exercises?
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Which intervention technique is suggested for reducing residual swelling?
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What sign indicates a healthier wound condition after treatment?
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Which phase of recovery involves assessing soft tissue adhesions and scars?
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What treatment strategy is often used to combat joint stiffness post-injury?
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What type of therapy was previously used for wound care but has since been abandoned?
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Which assessment would you expect to find in a patient with post-infection tissue changes?
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What is the primary aim of tendon gliding exercises in the post-infection phase?
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Which intervention method is used to address soft tissue adhesions or scars after infection?
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What is the most common infecting organism responsible for paronychia?
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What type of infection is a felon characterized by?
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In the context of tenosynovitis, what is a common treatment approach?
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What is often assessed in the work conditioning/simulation programme during the post-infection phase?
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Which common strategy is utilized to improve finger joint range of motion post-infection?
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What is a key characteristic of infections in immunocompromised patients?
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Which method is specifically used to improve muscle strength during recovery?
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In addition to treating infections, what is a crucial goal of rehabilitation in the post-infection phase?
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What position maximizes flexor digitorum profundus (FDP) gliding in relation to flexor digitorum superficialis (FDS)?
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Which statement about early controlled passive mobilization is true?
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What is the recommended initial action for patients after flexor tendon repair?
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What was the finding regarding patient compliance with splinting after tendon repairs?
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How does the surgical technique influence the outcomes of flexor tendon rehabilitation?
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What does the 4% rupture rate pooled estimate refer to?
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What was a key finding regarding compliance between dominant and non-dominant hands during rehabilitation?
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What factor did not significantly influence the rehabilitation outcomes according to the findings?
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In the context of flexor tendon rehabilitation, what is the implication of a heterogeneous treatment in trial results?
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What exercise position includes maximum gliding of FDS?
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What is traditionally regarded as a challenging topic in hand surgery and rehabilitation?
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What complicates flexor tendon injuries in hand surgery?
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Which phase of tendon healing starts from 0 to 7 days?
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What is the primary goal of rehabilitation after flexor tendon repair?
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Tendon strength increases immediately after the injury.
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The __________ phase is characterized by the early deposition of disorganized type III collagen.
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What are the three major approaches to rehabilitation after flexor tendon repair?
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What mechanism is used to prevent the bowstring effect in tendons?
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The flexor tendon rehabilitation aims to maintain a full range of motion and prevent __________.
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What is the starting timeframe for the Place-Hold Active Mobilization Protocol?
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Which of the following exercises emphasizes more FDP gliding than FDS?
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Active motion should be delayed until 3-5 days after surgical repair.
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The Pooled estimate of rupture rate is ___%.
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What percentage of patients with flexor or extensor tendon repair removed their splint during a 4-week period?
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What was the compliance rate for non-dominant hands in week 1?
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What is the limit for wrist extension in the Place-Hold Active Mobilization Protocol?
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When can passive motion commence after surgery?
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What are the three major approaches to rehabilitation after extensor tendon repair?
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What is the primary function of the sagittal band?
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Extensor tendon repair techniques have greater tensile strength compared to flexor tendon repair.
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What is a potential complication of extensor tendon repair?
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The chronic rupture of the central slip can lead to __________ deformity.
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What is the recommended duration for using a short mallet splint for Zone I closed injuries?
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What is the purpose of tendon gliding exercises?
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In the early post-operative phase, exercises should be avoided completely.
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During the acute phase of hand infection, which of the following symptoms is NOT typically present?
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What is Paronychia?
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What is the most common infecting organism in Paronychia?
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What is a Felon?
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What condition involves inflammation of the synovial sheath in the hand?
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Tenosynovitis can spread to other areas.
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What is the recommended bandaging position for hand fingers?
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What is essential for assessing the integrity of the central slip?
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What is a recommended procedure for an infected open wound in immunocompromised patients?
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Study Notes
Atraumatic Handling of Tendons
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Tendon gliding resistance is influenced by the gliding surface and edema.
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Sutures, location of suture knots, and exposure of suture materials affect tendon gliding resistance.
Postoperative Resistance to Tendon Gliding
- Core sutures are used to repair tendons
- Two-strand modified Kessler repair is a common core suture technique.
- Peripheral sutures provide additional tensile strength and smooth the surface.
- Four-strand core sutures are standard for tendon repair.
- Six-strand core sutures can help avoid interrupting blood circulation from bone to tendon.
Whirlpools and Saline Irrigation
- Whirlpool therapy is no longer the preferred method for wound care.
Post-Acute Phase
- Assessment includes:
- Reduction of inflammation (swelling, redness, temperature increase, pain).
- Healthy wound condition (reduce pus and abscesses).
- Joint range of motion and soft tissue adhesions.
- Intervention aims to:
- Prevent or improve finger joint stiffness and soft tissue contracture.
- Prevent tendon adhesions and improve tendon gliding.
- Reduce residual swelling.
Post-Infection Phase
-
Assessment includes:
- Decreased range of motion and joint stiffness.
- Soft tissue adhesions and scars.
- Residual swelling.
- Decreased muscle strength.
- Pain.
- Decreased function.
-
Intervention aims to:
- Improve finger joint range of motion, stiffness and soft tissue contracture.
- Improve soft tissue adhesions and scars.
- Improve tendon gliding.
- Increase muscle strength.
- Improve function.
Specific Infection Cases
- Paronychia (infection around the nail) is often caused by Staphylococcus aureus.
- Felons (infection in the finger pad) are painful.
- Tenosynovitis (infection of the tendon sheath) can spread to the wrist.
- Wounds in immunocompromised patients require drainage and open wound management.
- Boxing Glove Bandaging immobilizes the hand in a specific position.
Central Slip Assessment
- Assessing the integrity of the central slip involves examining extension of the involved finger.
- Passive extension is reduced in the case of a central slip rupture.
References
- References are included to give context and support the claims made in the document.
Early Controlled Active Mobilization (ECAM)
- ECAM is a rehabilitation protocol for flexor tendon repair.
- Variations exist in protocols for ECAM, such as Strickland’s “Place‐Hold Active Mobilization” Protocol.
- ECAM emphasizes active motion after 3-5 days post-surgery.
- Active motion should be delayed to minimize work of flexion.
- The wrist should be in neutral or slight extension to decrease force required for active motion.
Place‐Hold Active Mobilization Protocol
- Place‐Hold Active Mobilization Protocol must commence within 24-48 hours of surgery.
- Wrist extension is limited to 30 degrees.
- Passive finger and interphalangeal joint (IPJ) flexion is encouraged.
Active Tendon Gliding Exercises
- Active tendon gliding exercises are initiated 5-6 weeks postoperatively.
- Exercises target specific tendon movements and gliding:
- Straight fingers: Flexor digitorum profundus (FDP) and flexor digitorum superficialis (FDS) in anatomical neutral position
- Table-top: Metacarpophalangeal joint (MPJ) flexed, IPJ extended
- Straight fist: MPJ and PIPJ flexed to 90 degrees, DIPJ extended
- Hook fist: Maximizes FDP gliding over FDS
- Full fist: Maximizes FDP excursion
Blocking Exercises
- Blocking exercises are implemented at 6 weeks postoperatively.
- These exercises focus on isolating FDS and FDP movements to promote controlled tendon gliding.
Current Trend in ECAM
- Recent trends favor early controlled active mobilization.
- Early passive and active motion is encouraged.
- Wide-awake Local Anesthesia No Tourniquet (WALANT) is emerging as a technique for flexor tendon repair.
Current Evidence on ECAM
- Contradictions regarding the benefit of 3-5 day immobilization persist.
- Active motion should be delayed until 3-5 days after surgery to minimize workload.
- Wrist should be in neutral or slight extension to reduce force required for active motion.
Outcome Evaluation of ECAM
- Difficult to compare rehabilitation protocols for flexor tendon repair.
- Outcome influenced by surgical technique, expertise, and patient compliance.
Patient Compliance
- Studies show a significant number of patients remove splints preemptively during rehabilitation.
- Qualitative studies indicate fluctuations in compliance across treatment phases.
Outcome Evaluation – Research
- Comprehensive research is lacking for most rehabilitation interventions.
- Cochrane reviews highlight a lack of evidence from randomized controlled trials (RCTs) for most rehabilitation interventions.
- The pooled estimate of rupture rate is 4%.
Post-Acute Phase
- Assessment*
- Reduction in inflammation, redness, swelling, temperature increase, and pain.
- Healthy wound condition with minimal pus.
- Evaluation of joint range of motion (ROM) and soft tissue adhesions.
- Intervention*
- Gentle active and passive mobilization exercises to prevent or improve finger joint stiffness and soft tissue contracture.
- Tendon gliding exercises to prevent tendon adhesions and improve tendon gliding.
- Reduce residual swelling through pneumatic compression therapy, massage, bandaging, and proper elevation.
Post-Infection Phase
- Assessment*
- Evaluate joint ROM, stiffness, and soft tissue adhesions.
- Assess residual swelling, muscle strength, pain, and functional limitations.
- Intervention*
- Improve finger joint ROM, stiffness, and soft tissue contracture with active and passive exercises and stretching.
- Address soft tissue adhesions through massage and ultrasound therapy.
- Improve tendon gliding with dedicated exercises.
- Increase muscle strength through targeted exercises.
- Enhance function with dexterity training and work conditioning programs.
Specific Infection Cases
- Paronychia: Infection around the fingernail, commonly attributed to Staphylococcus aureus.
- Felon: Infection in the fingertip area, typically characterized by intense pain.
- Tenosynovitis: Infection affecting the synovium and fibrous sheath surrounding tendons, requiring urgent care.
- Infections in Immunocompromised Patients: May require more extensive drainage procedures due to decreased immune response.
Flexor Tendon Repair
- Traditionally regarded as a complex topic in hand surgery and rehabilitation due to complex anatomy and a high risk of complications, often resulting in poor hand function.
Anatomy of Flexor Tendons
- Flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) tendons are responsible for finger flexion.
- The A1 pulley is located at the level of the metacarpophalangeal joint (MPJ), A2 pulley is located at the proximal phalanx, A3 pulley is located at the middle phalanx, A4 pulley is located at the distal phalanx, A5 pulley is located at the fingertip.
- Zone II is the most challenging area to treat because it is located in the "no man's land" between the A1 pulley and the distal palmar crease.
- Zone II is where both tendons are within the digital flexor synovial and fibrous sheath, making it more susceptible to adhesions, rupture, and dysfunction.
- Vincular system provides blood supply to the tendon, supplemented by synovial diffusion and the process of 'purchase' from the bone.
Rehabilitation Goals After Flexor Tendon Repair
- Allow the repaired tendon to heal with minimal peritendinous adhesions to prevent tendon gapping, rupture, or insufficient tensile strength.
- Ensure adequate range of motion, muscle strength, and proper function of the hand.
Phases of Tendon Healing
- Inflammatory phase (0-7 days): healing involves a combination of intrinsic and extrinsic healing. Intrinsic healing involves the tenocytes, while extrinsic healing is from surrounding tissue.
- Proliferative phase (3-5 days to 4 weeks): deposition of disorganized type III collagen resulting in weak tendons, collagen remodeling begins at the late proliferative phase (after 21 days).
- Remodeling phase (4 weeks onwards): takes months or even years to complete; repaired tendons have thinner collagen fibrils with inferior strength compared to uninjured tendons; repaired tendons have 40%‐70% strength of a normal tendon after complete healing.
Postoperative Resistance to Tendon Gliding
- Immediately after repair, strength of repair is related to strength of suture (suture type & method) and surgical technique.
- Tendon gliding resistance is affected by gliding surface (type of sutures, location of suture knots, exposure of suture materials) and oedema.
Postoperative Rehabilitation Options
- Static immobilization: immobilized in dorsal splint or plaster with wrist in flexion and MPJs and IPJs in extension.
- Early Controlled Passive Mobilization: limited efficacy in achieving significant tendon gliding and excursion.
- Early Controlled Active Mobilization: Active mobilization contraindicated in certain flexor tendon repair methods due to inability to withstand tensile force.
Early Controlled Active Mobilization Variations
- Strickland’s “Place‐Hold Active Mobilization” Protocol: passive finger flexion, active wrist flexion, and MPJ extension.
- Belfast & Sheffield Protocol: involves a graded increase in active flexion, active wrist extension, and active grip strength.
Differential Gliding
- Hook fist: More FDP gliding than FDS, maximum differential gliding
- Full fist: More FDP gliding than FDS, less differential gliding than hook fist, maximum FDP excursion
Blocking Exercises
- Blocking exercises are for post-operative (6 weeks)
- FDS exercises are performed after 6 weeks
- FDP exercises are performed after 6 weeks
Current Trend
- Early passive/active motion with Wide-awake Local Anesthesia No Tourniquet (WALANT)
- Check for gapping tendency to loosen
- Tendons have a tendency to loosen, with early passive and active motion
Current Evidence
- Early controlled passive mobilisation: Can be started on post-operative day 1, contradictory evidence if immobilization for 3-5 days is beneficial
- Early controlled active mobilisation: Should be delayed for 3-5 days, minimum work of flexion, neutral or slight extension to reduce force required, wrist neutral or slight extension
Outcome Evaluation
- Difficult to evaluate rehabilitation protocols as outcome depends upon:
- Surgical technique such as number of suturing strands and surgical expertise
- Patient compliance
Patient Compliance
- 67% of 76 patients removed splint during a 4-week period
- Qualitative study : Observation of precautions for 19 patients
- Non-dominant hand: Compliance decreases with time
- Dominant hand: Compliance decreases with time
Cochrane Review
- Pooled estimate of rupture rate is 4% (95% confidence interval 3% - 5%)
Extensor Tendon Repair
- Extensor tendon repair is complex due to its anatomy
- Different programs for repair at different zones of the extensor tendons
Anatomy
- Extensor tendon has different zones from carpal bones to the tip of the finger
- 6 dorsal wrist compartments
Anatomy - Sagittal Band
- Sagittal band forms a sling around extensor tendon, attaching to volar plate
- It centralizes the EDC tendon and aids in extension
- Tightness of ORL can cause DIPJ flexion limitation
- Conjoined tendon of the central slip inserts into the distal phalanx
- TRL aids in MPJ flexion
Extensor Tendon Anatomy
- Extensor tendon is smaller and flatter compared to flexor tendon
- Repair techniques have less tensile strength compared to flexor tendon repair
Rehabilitation Goals for Extensor Tendon Repair
- Allow the repaired extensor tendon to heal
- Prevent tendon gapping or rupture
- Allow free gliding and excursion of tendons
- Minimize peritendinous adhesions
- Adequate range of motion (full fist), muscle strength and function of hand
Rehabilitation Programs for Extensor Tendon Repair
- Static immobilization
- Early controlled passive mobilization
- Early controlled active mobilization
Static Immobilization
- Zone I and II injuries: Short mallet splint for 6 weeks, active PIPJ and MPJ mobilization
- Zone III injuries: Rupture of central slip, long mallet splint for 3-6 weeks, active MPJ mobilization, can change to Capener splint if progress is good, Capener splint from week 4 to 6
- Zone III injuries (chronic rupture): Long mallet splint allowing active and passive DIPJ flexion
- Zone IV to VIII injuries: Wrist in 30-45 degrees extension, MPJs in 0-15 degrees flexion, IPJs in full extension, immobilization for 3-6 weeks then active mobilization begins
Early Controlled Passive Mobilization
- Zone IV to VIII injuries: Extension dynamic splint, wrist in 30-40 degrees extension, MPJs rest in 15 degrees flexion (dorsal block hood) allowing active 30 degrees (flexion block)
Early Controlled Active Mobilization
- Zone III injuries: Early active short arc motion, long mallet splint at rest, 2 template splints for active exercises, splint 1, splint 2, can start as early as 24 hours post-surgery
- Zone IV to VIII injuries: Early active mobilization, post-operative immobilization with volar POP slab, active IPJ and MPJ extension exercises
Hand Infections
- Assessment
- Acute inflammation: Redness, swelling, temperature increase, pain, loss of function
- Wound condition: Red, yellow and black wounds; pus or abscess collection, necrosis
- Intervention:
- Minimize inflammation and infection: Rest, immobilization, compression, elevation
- Prevent joint contracture: Rest, immobilization in intrinsic plus position, drain pus, clean wound
Post-Acute Phase
- Assess inflammation markers: redness, swelling, temperature increase, pain.
- Evaluate wound condition: healthy appearance with antibiotics and debridement, decrease in pus or abscess formation.
- Evaluate joint range of motion (ROM) and soft tissue adhesions.
Post-Acute Phase: Intervention
- Improve finger joint stiffness and soft tissue contracture: Gentle active and passive finger mobilization exercises.
- Prevent tendon adhesions and improve tendon gliding: Tendon gliding exercises.
- Reduce residual swelling: pneumatic compression therapy, massage, bandaging (eg. Coban wrap), advise on continuing elevation.
Post-Infection Phase
- Assess decreased joint ROM and stiffness, soft tissue adhesions/scars, residual swelling, decreased muscle strength, pain, and decreased function.
Post-Infection Phase: Intervention
- Improve finger joint ROM, stiffness, and soft tissue contracture: active and passive finger mobilization exercises, stretching.
- Improve soft tissue adhesions/scars: massage, ultrasound therapy.
- Improve tendon gliding: tendon gliding exercises.
- Increase muscle strength: muscle strengthening exercises.
- Improve function: dexterity training, work conditioning/simulation program.
Specific Infection Cases
- Paronychia: infection affecting the side of the nail, Staphylococcus aureus is the most common infecting organism.
- Felon: infection in the pad area, characterized by severe pain.
- Tenosynovitis: infection affecting the fibrous sheath of the hand, inject saline and drain pus, use boxing glove bandaging.
- Infection in Immunocompromised Patients: require frequent open wound drainage.
Boxing Glove Bandaging
- Immobilizes hand in "intrinsic plus" position: MPJs in 80-90 degrees flexion, IPJs in full extension, thumb in abduction.
Assessing Integrity of Central Slip
- Assess passive extension, compare to unaffected hand.
- A positive result could indicate central slip rupture.
- A positive result may also indicate area with skin tethering.
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Description
This quiz explores the methods and principles of atraumatic handling of tendons, including suture techniques and their impact on tendon gliding resistance. It also covers postoperative assessments and the importance of wound care practices in recovery.
