RS3580 Hand Dysfunction and Physiotherapy Management II PDF

For personal use only RS3580 Hand Dysfunction and Physiotherapy Management II Raymond TSANG Professor of Practice (Physiotherapy) All rights reserved Outline For personal use only...

For personal use only RS3580 Hand Dysfunction and Physiotherapy Management II Raymond TSANG Professor of Practice (Physiotherapy) All rights reserved Outline For personal use only 1. Flexor tendon repair 2. Extensor tendon repair 3. Hand infections 4. Video – Boxing glove bandaging 5. Videos – Cases All rights reserved 2  1. Flexor Tendon Repair For personal use only Traditionally regarded as a challenging topic in hand surgery and rehabilitation Complex anatomy - Prone to develop complications and to result - in poor hand function All rights reserved 3 Anatomy For personal use only (Tubiana et al, 1998) All rights reserved 4  · DPJ Flexor Tendon For personal use only Zones (Zone II as “No Man’s Land” – two flexor tendons within digital ↑ to distal flexor synovial and palmar crease fibrous sheath) adhesion y proce for -carpal area (van Kampen & Amadio, 2012, p.6) All rights reserved 5 (Wilson‐Jones & Laing, 2006) S For personal use only All rights reserved 6 Pulleys to prevent Anatomy For personal use only bowstring effect Thumb : (van Kampen & Amadio, 2012, p.7 & 13) All rights reserved 7 Anatomy from color side of bone Vincular side of tendon - system dorsal For personal use only ⑳ 00 = Tendon nutrition in Zone II: Blood circulation via vincular system and supplemented by t synovial diffusion (van Kampen & Amadio, 2012, p.7) All rights reserved 8  Rehabilitation Goals after Flexor Tendon Repair For personal use only To allow repaired flexor tendon to heal while: To prevent tendon gapping or rupture - sufficient tensile strength To allow free gliding and excursion of tendon - minimal peritendinous adhesions - - To - have adequate range of motion (prevent flexion contracture), muscle strength and - function of hand - All rights reserved 9 Physiological Response after Tendon Repair For personal use only Tendon healing starts with a series of overlapping phases: O (24h to 7 days) & (3‐5 days to 4 wk) (4 wk onward) - (McBeath & Chung, 2023) All rights reserved 10  Inflammatory Phase (0–7 days) For personal use only Healing by a combination of c lack just appropriate Extrinsic Healing aumont] dhesion of ↓ insufficient(migration of -> Tendon & tensile extrinsic cells) & surrounding +issue strength Intrinsic Healing (intrinsic across of the tendon tenocytes) - gap (Rosenblum & Robinson, 1986) All rights reserved 11 Flexor Tendon Healing in a Mouse Model For personal use only (Wong & Peck, 2014) All rights reserved 12  Partial Laceration – In Vitro For personal use only (Wong & Peck, 2014) All rights reserved 13 Inflammatory Phase – Clinical Significance For personal use only Immediately after repair,- strength of repair is related to strength of suture (suture type & method) and surgical technique (e.g. # atraumatic handling – handling of tendon without making further trauma during repair) -Tendon gliding resistance is affected by gliding surface (e.g. type of sutures, location of suture knots, exposure of suture materials) and*oedema* - All rights reserved 14 Postop Resistance to Tendon Gliding i For personal use only ↳ ① ↳ ③ ↳ (Tang, 2019) All rights reserved 15 Core Sutures – 2‐strand For personal use only ① 2‐strand Modified Kessler repair + Peripheral sutures to smooth the surface & provide additional tensile strength (Tang & Xie, 2012, p.40‐1) All rights reserved 16 Core Sutures – 4‐strand ⑳ For personal use only Common now (Standard suturing method) (Cao et al, 2006) All rights reserved 17 ③ Core Sutures – 6‐strand - For personal use only avoid interrupt of the blood circulation from bone to tendon (Xie et al, 2002) All rights reserved 18  purchase For personal use only (Lee et al, 2015) 22kg A B C D > - prohibited E strong hand F All rights reserved grip 19. Surgical Repair of Flexor Tendon For personal use only I z Of Distance between suture - inside the 3 tendon O - e Y - - O O 20 (Tang & Xie, 2012, p.37, 42) All rights reserved 20  Oedema For personal use only (Wu & Tang, 2013) E merinpresent Days 0‐3: increasing resistance with development of oedema Days 4‐7/9: consistent resistance with continuing oedema Days 7/9‐14: hardening of oedematous tissues; adhesions start All rights reserved 21 peak at Proliferative Phase – Clinical Significance For personal use only Tendons are e weakest during early proliferative period (7‐10 days) after surgery - - when initial deposition of disorganized type - III- collagen occurs Tendon strength does not increase until the late proliferative period (after 21 days) when collagen remodeling begins at late proliferative peroid - Tendon strength (Sasor & Chung, 2023) cafter 21 days) All rights reserved 22 : 'collagen remodelling Remodeling Phase – Clinical Significance For personal use only Remodeling of repaired tendon takes months or even year to complete => Repaired tendons have thinner collagen fibrils with inferior strength and mechanical =properties compared with uninjured tendons Repaired tendons have 40%‐70% strength of a normal tendon after complete healing - (Sasor & Chung, 2023) All rights reserved 23 Rehabilitation Programmes after Flexor Tendon Repair For personal use only 3 Major Approaches (Pettengill & van Strien, 2011; Skirven, 2002) Static Immobilization Early Controlled Passive Mobilization Early Controlled Active Mobilization All rights reserved 24  Static Immobilization For personal use only > - m The hand is immobilized in dorsal splint or plaster slab with wrist and MPJs in flexion and IPJs in extension for 3‐4 weeks before - active and passive mobilizations start = - /patients of Suitable for children ( juy do the Now usethis tenodesis , - splint ex For personal use only Additional use of synergistic dynamic tenodesis splint with active wrist extension (passive finger flexion) and active wrist flexion (passive finger extension) maximizing tendon excursions and -- differential gliding of FDP and FDS Suggested to start after postop day 10 as by Horii et al in 1992; now it is considered to be safe to - start in early postop days - All rights reserved 41 Cooney et al (1989) For personal use only All rights reserved 42  Early Controlled Passive Mobilization - ver For personal use only It was queried that passive mobilization techniques may not be able to achieve - significant tendon gliding and excursion (Manske, 1988) - Horri et al (1992) showed in an in vitro study that measured tendon excursion under low tendon tension was only half of - theoretically predicted values - All rights reserved 43 Early Controlled Passive Mobilization For personal use only They also found that flexor tendons bunched up or - buckled at level of middle phalanx when the finger & was passively flexed diminished possible gliding - II - inside fibroosseous tunnel during active finger - extension (Mesplie & Grelet, 2015, p.297) All rights reserved 44  Early Controlled Passive Mobilization X For personal use only Theoretically, early active # mobilization involves active - flexor muscle contraction, better gliding of tendon should result However, active mobilization is prohibited by the use of flexor (Mesplie & Grelet, 2015, tendon repair methods that p.297) - cannot withstand the tensile force generated by active - - mobilization All rights reserved 45 Early Controlled Active Mobilization Schuind et al (1992) measured in vivo flexor For personal use only tendon forces in patients with CTS: &> - rupture of tendom 1 2 All rights reserved 8kg 29 46  Early Controlled Active Mobilization Strickland (2000) stated that “4‐ and 6‐strand flexor tendon For personal use only repair methods combined with - strong circumferential - - sutures should be sufficiently strong to withstand light active forces throughout the healing period” gm Six strand Four strand. Sg. ↑ P (Formby, 2016, p.164) In a not even resist light active crorogue47 All rights reserved the patient to only do gentle active Early renab staty educate : mob. Early Controlled Active Mobilization For personal use only Variations in early active mobilization protocols Strickland’s “Place‐Hold Active Mobilization” Protocol (Strickland, 1993) Belfast & Sheffield Protocol (Gratton, 1993) (detailed protocols referred to separate file) All rights reserved 48  Place‐Hold Active Mobilization Protocol pinti ringed dynamic splinth do Resti n g For personal use only. 40 Wrist extension limited to 300 - Ad (Strickland, 2000) for see > - passive finger # All rights reserved 49 IP full # Dace : passive Place‐Hold Active Mobilization Protocol gm Must start within postop 24‐48 hours For personal use only ↑ low gu (Formby, 2016, p.164) 50 All rights reserved N Active Tendon Gliding Exercises starting For personal use only (Postop 5‐6 weeks) A. Straight fingers – FDP and FDS in anatomical neutral position B. Table-top – MPJ flexed with IPJ extended – lumbrical action C. Straight fist – MPJ & PIPJ flexed to 900 with DIPJ extended; more FDS gliding than FDP * D. Hook fist – more FDP gliding than FDS; maximum differential gliding between FDP and FDS E. Full fist – more FDP gliding than FDS; less differential gliding than in hook; fist maximum FDP excursion All rights reserved 51 Blocking Exercises For personal use only (Postop 6 weeks) FDS Exercises FDP Exercises All rights reserved 52  For personal use only (Pettengill & van Strien, 2011, p.475) All rights reserved 53 Current Trend For personal use only (Tang, 2019) - Eary - passive/ - & active 3 - - - finger F > active Wide‐awake Local Anesthesia No Tourniquet (WALANT) - > - check gapping tendency to loosen - - All rights reserved 54  Current Evidence For personal use only Early Controlled Passive Mobilization Passive motion can commence as early as - postoperative day 1 - Evidence is contradictory on whether a short period of immobilization of 3‐5 days is beneficial - Early Controlled Active Mobilization Active motion should be delayed until 3‐5 days - after surgical repair to have minimum work of - - flexion Wrist should be in neutral or slight extension to - reduce force required for active motion (McRae et al, 2021) All rights reserved 55 Outcome Evaluation For personal use only Difficult to evaluate different rehabilitation protocols for flexor tendon repair as outcome also depends on Surgical technique such as number of suturing strands, and surgical expertise Patient compliance All rights reserved 56  Patient Compliance For personal use only 67% of 76 patients with flexor or extensor tendon repair removed their splint during a 4‐ week period (Sandford et al, 2008) All rights reserved 57 Patient Compliance For personal use only Qualitative study of 19 patients with flexor tendon repair – observance of precautions (Kaskutas & Powell, 2013) Hand Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Injured Non‐ 97% 96% 90% 89% 87% 84% dominant > - ↓ Dominant 90% 89% 86% 78% 73% 77% - > - compliance < non-dominant hand ↓ All rights reserved 58  Outcome Evaluation For personal use only Cochrane review of flexor tendon rehabilitation protocols in mostly Zone II (Peters et al, 2021) 16 RCTs and 1 quasi‐RCT with 1108 participants Heterogeneous in terms of types of rehabilitation treatments, intensity, duration of treatment and treatment setting Trials were generally at high risk of bias for one or more domains lack of evidence from RCTs on most rehabilitation interventions (Dy et al, 2012) - Pooled estimate of rupture rate is 4% (95% CI 3%‐5%) All rights reserved 59 2. Extensor Tendon Repair For personal use only Complex anatomy at digits -Different programmes for repair at different - zones - of extensor tendons All rights reserved 60  Anatomy DIPJ For personal use only PIPJ Extensor Tendon MCPJ ‐ zones g Mc bone carpal bone wrist & trogant Fram All rights reserved 61 Anatomy For personal use only Zone VII 6 dorsal wrist compartments: 2, 2, 1, 2, 1, 1 All rights reserved 62  Anatomy Prevents conjoined For personal use only lateral bands from Sagittal band forms a sling around extensor tendon attaching to volar subluxation volar plate – centralizes EDC tendon & aids in extension ORL – oblique retinacular lgt tightness can cause DIPJ flexion limitation > extend PIDJ - > insert - into base of middle phalanx - conjoint tendom of central slip insert into distal I TRL – transverse retinacular lgt aids phalany in MPJ flexion (Matzon & Bozentka, 2010) All rights reserved 63 Anatomy For personal use only Compared with flexor tendon, extensor tendon is much smaller with relatively flat - cross section Extensor tendon repair techniques have less - - tensile strength compared with flexor tendon repair (Newport & Tucker, 2005) All rights reserved 64  Rehabilitation Goals after Extensor Tendon Repair For personal use only To allow repaired extensor tendon to heal while: To prevent tendon gapping or rupture sufficient tensile strength To allow free gliding and excursion of tendon minimal peritendinous adhesions= To have adequate range of motion (full fist), muscle strength and function of hand All rights reserved 65 Rehabilitation Programmes after Extensor Tendon Repair For personal use only 3 Major Approaches (Newport, 1997; Saunders, 2016; Watts & Hooper, 2004) Static Immobilization Early Controlled Passive Mobilization Early Controlled Active Mobilization ↑ HK no centres adopt All rights reserved 66  Static Immobilization market S finger For personal use only Zone I & II Injuries Short mallet splint for 6 weeks (for Zone I closed injuries, surgery is usually (Boscheinen‐Morrin & Conolly, 2001) not required) Active PIPJ & MPJ mobilization All rights reserved 67 Static Immobilization For personal use only Zone III Injuries Rupture of central slip Long mallet splint for 3‐6 week + active MPJ mobilization; / change from long mallet splint Capener to splint if patient's progress good is Capener splint from week 4 to - 6 (dynamic splintage – - allowing active PIPJ flexion but passive PIPJ extension) All rights reserved 68  Static Immobilization Hyperextension of DIPJ For personal use only Flexion of PIPJ Zone III Injuries Chronic rupture of central E slip leading to boutonniere deformity (volar subluxation of lateral - bands and tightness of ORL) (Boscheinen‐Morrin & Conolly, 2001) Long mallet splint allowing active - and passive DIPJ flexion - All rights reserved stretch the ORL 69 Static Immobilization Zone IV to VIII Injuries cusuamy not petre For personal use only I Wrist in 300‐450 extension MPJs in 00‐150 flexion & IPJs in full extension Immobilization for 3‐6 weeks, then active mobilization begins Potential complications – tendon rupture, - adhesion formation requiring tenolysis, - extension lag, loss of flexion, grip strength (Newport & Tucker, 2005) All rights reserved 70 - Early Controlled Passive Mobilization A For personal use only Zone IV to VIII Injuries Extension dynamic splint Wrist in 300‐400 extension MPJs rest in 150 flexion (dorsal block hood) allowing active 300 flexion (flexion block) initially Cp activity ofextensor musue EMG testing with MPJ testing in 00, extensor muscles are active during MPJ flexion and at rest in 84% of test subjects (Newport & Shukla, 1992) All rights reserved 71 Early Controlled Passive Mobilization Zone IV to VIII Injuries For personal use only Extension dynamic splint Dorsal block hood would reduce the EMG activity of - extensor muscles to 5% of test subjects (Newport & Shukla, 1992) All rights reserved 72  Early Controlled Passive Mobilization Zone IV to VIII Injuries For personal use only O ~30 MPJ flexion for⑳no 0 I/F & M/F and ~40 MPJ 0 flexion for20 R/F & L/F would produce 5mm EDC excursion (Evans & Burkhalter, 1986) (detailed protocol referred to separate file) All rights reserved 73 - Early Controlled Active Mobilization Zone III Injuries For personal use only Early Active Short Arc Motion (Evans, 1994) Long mallet splint at rest 2 template splints for active exercises Splint 1 allows PIPJ 300 flexion & DIPJ 200‐250 flexion and - active extension (Saunders, 2016, p.191) 74 All rights reserved  Early Controlled Active Mobilization Zone III Injuries For personal use only Early Active Short Arc Motion (Evans, 1994) 2 template splints for active exercises Splint 2 supports PIPJ in neutral & allows DIPJ flexiona (full - flexion for unrepaired lateral bands; 300‐350 flexion with lateral bands repaired) (Saunders, 2016, p.192) 75 All rights reserved Early Controlled Active Mobilization Zone III Injuries For personal use only Early Active Short Arc Motion (Evans, 1994) 2 template splints for active exercises Exercise can start as early as 24 hours after surgery; 20X/hour Wrist at 300 flexion & MPJ in neutral with digit supported at proximal phalanx by contralateral hand Progression: No PIPJ extension lag after 2 weeks splint 1 adjusted to allow 400 flexion and then 500 flexion at postop 4/52 PIPJ extension lag continue PIPJ 300 flexion Splint removal at 6/52 76 All rights reserved  Early Controlled Active Mobilization Zone IV to VIII Injuries For personal use only Early Active Mobilization (Chester et al, 2002) Postop immobilization – volar POP slab with wrist 300 extension, MPJ 300 flexion & IPJ in extension Day 1 – active exercises within POP Active IPJ extension and MPJ extension 5X/hour Active MPJ extension & then active IPJ flexion 5x/hour Day 5‐7 – changed to static splint 77 All rights reserved For personal use only All rights reserved 78  3. Hand Infection For personal use only In general, 3 phases for Assessment & Intervention for Physiotherapist: e Acute Phase – acute inflammation & infection e Post‐Acute Phase – resolving inflammation & infection Post‐Infection Phase – infectionC under J control All rights reserved 79 Acute Phase For personal use only Assessment 1. Acute Inflammation Redness Swelling Temperature increase Pain 3 Loss of function - All rights reserved 80  Acute Phase For personal use only Assessment 2. Wound Condition - 3‐colour concept – red, yellow & black wound Any pus or abscess collection necrosis (von der Heyde & Evans, All rights reserved 2011, p.225‐6) 81 > - infection cpry Acute Phase For personal use only Intervention – Aims & Methods 1. To minimize exacerbation of inflammation & infection Rest/immobilization (boxing glove bandaging) Compression (boxing glove bandaging) Elevation > control oedema - All rights reserved 82  Acute Phase For personal use only Intervention – Aims & Methods 2. 2. To prevent joint contracture - Rest/immobilization in intrinsic plus position (position of immobilization) 3. To drain pus and clean wound H-AntepS Hibitane bath All rights reserved 83 Acute Phase For personal use only Intervention – Aims & Methods 3. To drain pus and clean wound Whirlpool therapy (abandoned now) Saline irrigation All rights reserved 84  Post‐Acute Phase For personal use only Assessment 1.  Inflammation  Redness  Swelling  Temperature increase  Pain & symptoms All rights reserved 85 Post‐Acute Phase For personal use only Assessment 2. Wound Condition More healthy wound condition (with the use of antibiotics  debridement)  Pus or abscess collection 3. Joint ROM & Soft Tissue Adhesions All rights reserved 86  Post‐Acute Phase For personal use only Intervention – Aims & Methods 1. To prevent/improve finger joint stiffness & soft tissue contracture Gentle active  passive finger mobilization exercises All rights reserved 87 Post‐Acute Phase For personal use only Intervention – Aims & Methods 2. To prevent tendon adhesions & improve tendon gliding Tendon gliding exercises All rights reserved 88  Post‐Acute Phase Intervention – Aims & Methods For personal use only 3. To reduce residual swelling , Pneumatic compression therapy Massage Bandaging; Coban wrap Advice on continuing & appropriate elevation All rights reserved 89 Elastic For personal use only banadaging (Villeco, 2011, p.855) All rights reserved  Post‐Infection Phase For personal use only Assessment 1.  Joint ROM & Joint Stiffness in 2. Soft Tissue Adhesions/Scars 3 3. Residual Swelling 5 4.  Muscle Strength 4 5. Pain 6 6.  Function All rights reserved 91 Post‐Infection Phase For personal use only Intervention – Aims & Methods 1. To improve finger joint ROM, stiffness & soft tissue contracture Active  passive finger mobilization exercises Stretching All rights reserved 92  Post‐Infection Phase For personal use only Intervention – Aims & Methods 2. To improve soft tissue adhesions/Scars Massage Ultrasound therapy 3. To improve tendon gliding Tendon gliding exercises 4. To increase muscle strength Muscle strengthening exercises All rights reserved 93 Post‐Infection Phase For personal use only Intervention – Aims & Methods 5. To improve functions Dexterity training Work conditioning/simulation programme All rights reserved 94  Specific Infection Cases For personal use only -H + +- Paronychia (side of the nail) - Staphylococcus aureus as most common infecting organism All rights reserved 95 Specific Infection Cases For personal use only ↓ Felon (pad area) > - painful All rights reserved 96  Specific Infection Cases For personal use only 11) Tenosynovitis synovial of + fibrous the hand sheath of zone # invision inject saline - and drain out All rights reserved 97 the purs - in boxing glove bandaging Specific Infection Cases For personal use only Tenosynovitis > - can spread to the mist All rights reserved 98  Specific Infection Cases For personal use only Infection in immunocompromised patient * open would drainage for infected All rights reserved round 99 Specific Infection Cases For personal use only Infection in immunocompromised patient balive game All rights reserved 100  Specific Infection Cases For personal use only Infection in immunocompromised patient /extensor 6 weeks later All rights reserved 101 vac For personal use only All rights reserved 102  4. Boxing Glove Bandaging For personal use only Hand fingers in- “intrinsic plus” position or position of immobilization MPJs in 800‐900 flexion IPJs in full extension Thumb in abduction All rights reserved 103 For personal use only All rights reserved 104  of central slip Assessing integrity. the WinFintact it extensio · - Passive rupture - > passive extension 5. Cases > + X For personal use only All rights reserved 105 For personal use only All rights reserved 106 Admension > - area with skin tethering  References Boscheinen‐Morrin J, Conolly WB. The Hand: Fundamentals of Therapy, 3rd ed, Oxford: Butterworth‐Heinemann, 2001, p.43‐56. Cao Y, Zhu B, Xie RG, Tang JB. Influence of core suture purchase length on strength For personal use only of four‐strand tendon repairs. J Hand Surg 2006; 31A(1): 107‐112. doi: 10.1016/j.jhsa.2005.09.006. Cooney WP, Lin GT, An KN. Improved tendon excursion following flexor tendon repair. J Hand Ther 1989; 2(2): 102‐106. doi: 10.1016/S0894‐1130(89)80047‐X. Duran R, Houser R. Controlled passive motion following flexor repair in zones 2 and 3. In AAOS Symposium on Tendon Surgery in the Hand, St Louis: Mosby, 1975, p.105‐114. Dy CJ, Hernandez‐Soria A, Ma Y, Roberts TR, Daluiski A. Complications after flexor tendon repair: a systematic review and meta‐analysis. J Hand Surg 2012; 37A(3): 543‐551.e1. doi: 10.1016/j.jhsa.2011.11.006. Evans RB, Burkhalter WE. A study of the dynamic anatomy of extensor tendons and implications for treatment. J Hand Surg 1986; 11A(5): 74‐79. doi: 10.1016/s0363‐5023(86)80039‐9. Formby M. Flexor tendon repair. In: Saunders RJ, Astifidis RP, Burke SL, Higgins JP, McClinton MA (Eds) Hand and Upper Extremity Rehabilitation: A Practical Guide, 4th ed, St. Louis: Elsevier, 2016, p.159‐172. Gelberman RH, Manske PR, Akeson WH, Woo SL‐Y, Lundberg G, Amiel D. Flexor tendon repair. J Orthop Res 1986; 4(1): 119‐128. doi: 10.1002/jor.1100040116. All rights reserved 107 References Gratton P. Early active mobilization after flexor tendon repairs. J Hand Ther 1993; 6(4): 285‐289. doi: 10.1016/s0894‐1130(12)80329‐2. Groth GN. Pyramid of progressive force exercises to the injured flexor tendon. J For personal use only Hand Ther 2004; 17(1): 31‐42. doi: 10.1197/j.jht.2003.10.005. Horii E, Lin GT, Cooney WP, Linscheid RL, An KN. Comparative flexor tendon excursion after passive mobilization: an in vitro study. J Hand Surg 1992; 17A(3): 559‐566. doi: 10.1016/0363‐5023(92)90371‐u. Kaskutas V, Powell R. The impact of flexor tendon rehabilitation restrictions on individuals’ independence with daily activities: implications for hand therapists. J Hand Ther 2013; 26(1): 22‐28. doi: 10.1016/j.jht.2012.08.004. Kleinert HE, Kutz JE, Ashbell TS, Martinez E. Primary repair of lacerated flexor tendon in no man’s land. J Bone Joint Surg 1967; 49A: 577. Kleinert HE, Kutz JE, Cohen MJ. Primary repair of zone 2 flexor tendon lacerations. In: AAOS Symposium on Tendon Surgery in the Hand, St. Louis: Mosby, 1975, p.91‐ 104. Lee HI, Lee JS, Kim TH, Chang S‐H, Park MJ, Lee GJ. Comparison of flexor tendon suture techniques including 1 using 10 strands. J Hand Surg 2015; 40A: 1369‐1376. doi: 10.1016/j.jhsa.2015.03.021. Lister GD, Kleinert HE, Kutz JE, Atasoy E. Primary flexor tendon repair followed by immediate controlled mobilization. J Hand Surg 1977; 2A(6): 441‐451. doi: 10.1016/s0363‐5023(77)80025‐7. All rights reserved 108  References McBeath R, Chung KC. Principles of tendon structure, healing, and the microenvironment. Hand Clin 2023; 39(2): 119‐129. doi: For personal use only 10.1016/j.hcl.2023.01.002. McRae M, McRae M, Waltho D, Santos J. Flexor tendon injuries: rehabilitation. In: Bhandari M (Ed). Evidence‐Based Orthopedics, 2nd edition, UK: John Wiley & Sons Ltd, 2021, p.931‐4. Mesplie G, Grelet V. Injuries of the flexor tendons. In: Mesplie G, Grelet V (Eds) Hand and Wrist Rehabilitation: Theoretical Aspects and Practical Consequences, Switzerland: Springer, 2015, p.275‐306. Newport ML. Extensor tendon injuries in the hand. J Am Acad Orthop Surg 1997; 5(2): 59‐66. doi: 10.5435/00124635‐199703000‐00001. Newport ML, Shukla A. Electrophysiologic basis of dynamic extensor splinting. J Hand Surg 1992; 17A(2): 272‐277. doi: 10.1016/0363‐5023(92)90404‐d. Newport ML, Tucker RL. New perspectives on extensor tendon repair and implications for rehabilitation. J Hand Ther 2005; 18(2): 175‐181. doi: 10.1197/j.jht.2005.01.006. Manske PR. Flexor tendon healing. J Hand Surg 1988; 13B(3): 237‐245. doi: 10.1016/0266‐7681_88_90077‐0. Matzon JL, Bozentka DJ. Extensor tendon injuries. J Hand Surg 2010; 35A(5): 854‐ 861. doi: 10.1016/j.jhsa.2010.03.002. All rights reserved 109 References Pettengill KMS, van Strien G. Postoperative management of flexor tendon injuries. In: Skirven TM, Osterman AL, Fedorczyk JM, Amadio PC (Eds) Rehabilitation of the Hand and Upper Extremity, 6th ed, Philadelphia: Elsevier Mosby, 2011, p.457‐478. For personal use only Rosenblum NI, Robinson SJ. Advances in flexor and extensor tendon management. In: Moran CA (Ed) Hand Rehabilitation, New York: Churchill Livingstone, 1986. Sandford F, Barlow N, Lewis J. A study to examine patient adherence to wearing 24‐hour forearm thermoplastic splints after tendon repairs. J Hand Ther 2008; 21(1): 44‐52. doi: 10.1197/j.jht.2007.07.004. Sasor SE, Chung KC. Surgical considerations for flexor tendon repair: timing and choice of repair technique and rehabilitation. Hand Clin 2023; 39(2): 151‐163. doi: 10.1016/j.hcl.2022.08.016. Saunders RJ. Management of extensor tendon repairs. In Saunders RJ, Astifidis RP, Burke SL, Higgins JP, McClinton MA (Eds) Hand and Upper Extremity Rehabilitation: A Practical Guide, 4rd ed, St Louis: Elsevier, 2016, p.187‐204. Schuind F, Garcia‐Elias M, Cooney III WP, An KN. Flexor tendon forces: in vivo measurements. J Hand Surg 1992; 17A(2): 291‐298. doi: 10.1016/0363‐ 5023(92)90408‐h. Peters SE, Jha B, Ross M. Rehabilitation following surgery for flexor tendon injuries of the hand. Cochrane Database of Systematic Reviews, 2021, Issue 1. Art. No.: CD012479. All rights reserved 110  References Skirven TM. Rehabilitation after tendon injuries in the hand. Hand Surg 2002; 7(1): 47‐59. doi: 10.1142/s0218810402000807. For personal use only Skirven TM, DeTullio LM. Therapy after flexor tendon repair. Hand Clin 2023; 39(2): 181‐192. doi: 10.1016/j.hcl.2022.08.019. Slattery P, McGrouther D. A modified Kleinert controlled mobilization splint following flexor tendon repair. J Hand Surg 1984; 9B(2): 217‐218. Strickland JW. Biologic rationale, clinical application, and results of early motion following flexor tendon repair. J Hand Ther 1989; 2(2): 71‐83. doi: 10.1016/S0894‐ 1130(89)80045‐6. Strickland JW. Flexor tendon repair: Indiana method. Indiana Hand Centre Newsletter 1993; 1: 1‐12. Strickland JW. Development of flexor tendon surgery: twenty‐five years of progress. J Hand Surg 2000; 25A(2): 214‐235. doi: 10.1053/jhsu.2000.jhsu25a0214. Tang JB. Flexor tendon injuries. Clin Plast Surg 2019; 46(3): 295‐306. doi: 10.1016/j.cps.2019.02.003. Tang JB, Xie RG. Biomechanics of core and peripheral tendon repairs. In: Tang JB, Amadio PC, Guimberteau JC, Chang J (Eds) Tendon Surgery of the Hand, Philadelphia: Elsevier Saunders, 2012, p.35‐48. Tubiana R, Thomine J‐M, Mackin E. Examination of the Hand and Wrist. Boca Raton, FL: CRC Press, 1998. All rights reserved 111 References van Kampen RJ, Amadio PC. Anatomy of the tendon systems in the hand. In: Tang JB, Amadio PC, Guimberteau JC, Chang J (Eds) Tendon Surgery of the Hand, Philadelphia: Elsevier Saunders, 2012, p.3‐15. Villeco JP. Edema: therapist’s management. In: Skirven TM, Osterman AL, For personal use only Fedorczyk JM, Amadio PC (Eds) Rehabilitation of the Hand and Upper Extremity, 6th ed, Philadelphia: Elsevier Mosby, 2011, p.845‐857. von der Heyde RL, Evans RB. Wound classification and management. In: Skirven TM, Osterman AL, Fedorczyk JM, Amadio PC (Eds) Rehabilitation of the Hand and Upper Extremity, 6th ed, Philadelphia: Elsevier Mosby, 2011, p.219‐232. Watts AC, Hooper G. Extensor tendon injuries in the hand. Curr Orthop 2004; 18(6): 477‐483. doi: 10.1016/j.cuor.2004.12.003. Wilson‐Jones N, Laing H. Acute injuries to the flexor and extensor tendons of the hand. Surg 2006; 24(12): 441‐445. doi: 10.1053/j.mpsur.2006.10.009. Wong JKF, Peck F. Improving results of flexor tendon repair and rehabilitation. Plast Reconstr Surg 2014; 134(6): 913e‐925e. doi: 10.1097/PRS.0000000000000749. Wu YF, Tang JB. Tendon healing, oedema, and resistance to flexor tendon gliding: clinical implications. Hand Clin 2013; 29(2): 167‐178. doi: 10.1016/j.hcl.2013.02.002. Xie RG, Zhang S, Tang JB, Chen F. Biomechanical studies of 3 different 6‐strand flexor tendon repair techniques. J Hand Surg 2002; 27A(4): 621‐627. doi: 10.1053/jhsu.2002.34311. All rights reserved 112