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Flexor Tendon Injury - Zone 2 - A Journey into 'No Mans Land'

History and treatment procedures for these types of injuries

Cathy Cassidy

on 26 December 2013

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Transcript of Flexor Tendon Injury - Zone 2 - A Journey into 'No Mans Land'

Flexor Tendon

A Journey into
'No Mans Land'
No Mans Land
Zone 2
Tendons attached to muscles in the forearm allow full flexion and extension of the fingers. These can become damaged in numerous ways through injury.
Early Mobilisation Management
of Zone 2
Tendon Injuries

Kleinert Protocol
Post operative Rehabilitation

A dorsal back slab splint is used with wrist in 30 degrees flexion and MCP joints in 60 - 70 degrees flexion, allowing full extension of IP joints.
Elastic bands are attached to the ends of the fingers and are used to replace the active flexion process of the tendon to reduce stress
Surgery is currently used to connect the ruptured ends of tendons together. A series of pulleys prevent the tendons bowstringing and adhesions can occur under these.

Splinting – in the 1960's Kleinert developed a protocol to help minimise these adhesions.

Hand Therapy – Exercise to reintroduce motion, build strength and reduce scarring.
History of

Hand Therapy

after Surgery

Early passive movement procedures were popularised by Kleinert and Duran during the 1970's.

As surgical procedures have advanced over the years, published studies have highlighted the importance of early controlled motion in zone 2.

Early active movement regimes were most commonly used before Kleinerts protocol.
Early Pioneers
Kleinerts Protocol
Zones of the hand

Bunnell (1944) described
zone II
of the hand as 'no mans land' as historically surgical repairs in this area were unsuccessful, resulting in poor range of motion.

The confined space, complex array of anatomical structures and grade of suture used were factors affecting poor results. Adhesions within the tendon sheath often occurred post surgery.
Duran Technique
Controlled passive motion using dorsal blocking splint but varies from Kleinhert protocol in following ways,

Wrist in 20 degrees of palmar flexion.

MP joints in 50 degrees of flexion and IP joints in neutral.

Splint is secured with velcro straps.

Twice daily exercise program performed for first 4 and half
weeks involving passive flexion and extension of PIP and DIP joints.
Early stage (0-3 weeks) after surgery

Splint: blocking splint to hold wrist in 45 degrees of flexion and MP joints in 10 to 20 degrees.

Rubber band traction from fingernail to wrist.

Exercise: hourly the patient extends fingers to splint limit, 10 times against rubber band tension

Intermediate stage (3 - 5 weeks) after surgery

Wrist band replaces back slab splint and is used with rubber band traction to affected fingers

Exercise: Active range of movements in hand and wrist encouraged. Injured digit still tethered at week 5, flexion thereafter.
After 5 weeks, elastic bands removed and exercises continue as in the early active movement regime.

BERGER Richard A, WEISS Arnold-Peter C, (2004) Hand Surgery, Philadelphia, Lippincott Williams & Wilkins

CANNON Nancy M, MALICK, MH , KASCH, MC (eds.). (1984) Manual on Management of Specific Hand Problems, Pittsburgh, Aren Publications.

HUNTER JM, MACKIN, EJ, CALLAHAN, AD. (2002) 5th edition. Rehabilitation of the Hand and Upper Extremity, St Louis, Mosby Publishing

NEWMEYER III, William L. (2003). Sterling Bunnell, MD: The Founding Father [online] The Journal of Hand Surgery 28, 1 161-164 last accessed on 2nd June 2013 at Science Direct, http//dx.doi.org/10.1053/jhsu

SALTER Maureen, CHESHIRE, Lynn (2000). Hand Therapy Principles and Practice. Oxford, Reed Educational and Professional Publishing Ltd.

With both the Kleinhert and modified Duran programs of rehabilitation, overall performance of flexor tendon repairs in zone 2 have greatly improved over the early active movement regimes.

Patients gained better range of movement with these techniques than those who were immobilized post surgery. (Malick and Kasch 1984)

Continuing research into this complex area is needed in the future due to the advancement in materials, surgical and therapeutic procedures and individual patient injury presentations.

Occupational Therapists working in hand therapy have an important role to play in the successful rehabilitation of such injuries. Current splinting and rehabilitation movement guidelines and incorporating patient health belief factors when planning intervention are crucial to success.
http://orthoinfo.aaos.org/topic.cfm?topic=a00015 American Academy of Orthopaedic Surgeons
Repairs to the flexor tendons in zone 2 which lies between the distal interphalangeal joint and the palmar crease of the hand have proved historically problematic.

Improvements in surgical suture techniques and the advancement of early controlled motion protocols mean the prognosis of patient hand recovery has greatly improved.
Bsc Occupational Therapy

Orthotics and Hand Therapy
Level 4

Chris Harlowe

Catherine Cassidy 22015351
Common Injuries

Lacerations from knives or glass to the hand

Crushing injuries

Accidents at home or work

Sports injuries where tendon is stretched

Rheumatoid arthritis can lead to ruptured tendons

Ends of the tendons can pull away from each other and the finger is unable to bend.

Pain when flexing fingers and numbness in a digit are common signs of tendon injury.
Course of Management
Early active movement regime

Most commonly used in flexor tendon rehabilitation.

A dorsal back slab splint is used with wrist in 30 degrees flexion and MCP joints in 60 - 70 degrees flexion, allowing full extension of IP joints.

Splint worn continuously for 4-8 weeks, no resistance or passive extension is allowed during this period.

0-4 weeks, exercises of active and passive flexion of fingers to palm and to the splint. Active extension of PIP joints with MCP joints flexed at 90 degrees.

4-8 weeks, back slab is removed during exercise for wrist and hand flexion.

8 weeks, back slab removed completely. Light hand use is encouraged.
Thank you

Any questions?

image obtained from, http://boneandspine.com/trauma/upper-limb-injuries/hand-injuries/zones-of-flexor-tendons-in-hand/
Occupational Therapists Role and Initial Assessment
The individual person is seen as a 'unique being' performing self directed tasks and activities within a variety of roles (Hagedorn 2001).

Any initial assessment needs to consider the persons psychosocial situation and any factors which may affect the full intervention process such as cultural, socio-economic, institutional. physical and social.

The following video clip shows an injury to a lady's little finger around 3 weeks ago.

At this time she was unable to flex her PIP and DIP joints of the little finger.

A transverse scar was seen on the palmar surface of her proximal phalanx.

She also had numbness on the ulnar half of her little finger.

Occupational Therapy Assessments and Intervention Planning
Post surgery, the OT assessed the patient by observing the movements of the hand and affected digit and recorded the observational results. These results (goniometer readings) could be used in future to act as a baseline for any improvements.

During the discussion, the patient outlined the areas of difficulty she would experience with ADL's and how the injury affected her family and other responsibilities.

The Occupational Therapist must have a clear understanding of loss of function with any musculoskeletal injury in order to fully engage with the patient. (Salter 2000)

As this injury occurred on the non dominant hand, the affects on ADL's were not as considerable.

Advice was given on adaptive equipment that may be useful and energy conservation techniques, as stability and bilateral activities would be affected.

A dorsal blocking splint was used and early active motion program was administered to reduce the occurrence of adhesion and improve the strength of the repair site and finger function.

The OT was able to successfully engage the patient in early active motion techniques (as outlined previously) and after a number of weeks the function of the affected finger was greatly improved.

This was shown through observed increase in movement and the recorded goniometer results after 6, 8 and 12 weeks.
Occupational Therapy Intervention
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