True Active Motion after Flexor Tendon Repair

Saint John Regional Hospital

Amanda Higgins BSc OT OT Reg(NB)

Pyramid of Progressive Force Application

(Journal of Hand Therapy Groth 2004)

bull This was not working with our patients

bull Patients who were not compliant were doing really well

bull Patients who were following protocol were getting scarred down

Dorsal Blocking Splint

With passive range of motion

Duran amp Houser 1975)

Time For A Change

bull Wide Awake Approach to Hand Surgeries

bull Patients who were not following passive motion protocol were doing really well

bull The Wrist Position (Rebecca Von der Heyde)

bull Jin Bo Tang early active motion protocol

bull Manchester Short Splint ndash Fiona Peck

Wrist extension with MP flexion relaxes the extensors and reduces the minimum force necessary for active movement of IP joints

Savage 1988

Synergistic Splint (Cooney et al 1989 Cannon 1993 2002)

bull Rebecca Van der Hyde bull Savage 1988

ndash Wrist extension with MP flexion produced least passive tension and decreased minimal active tension

bull Cooney Lin amp An 1989 ndash Synergistic motion

produced highest amount of FDS FDP and differential excursion

Indiana Hand Protocol

Synergistic Motion

bull Lieber et al 1996-1999 ndash Synergistic motion resulted

in low passive forces on the flexor tendon with high excursion

bull Zhao et al 2002 ndash Passive digital flexion

during passive wrist extension as effective ldquopulling forcerdquo to facilitate proximal glide

bull Tanaka et al J Hand Ther 2005 18(3) 330ndash338

Pyramid of Progressive Force Application

(Journal of Hand Therapy Groth 2004)

bull This was not working with our patients

bull Patients who were not compliant were doing really well

bull Patients who were following protocol were getting scarred down

Dorsal Blocking Splint

With passive range of motion

Duran amp Houser 1975)

Time For A Change

bull Wide Awake Approach to Hand Surgeries

bull Patients who were not following passive motion protocol were doing really well

bull The Wrist Position (Rebecca Von der Heyde)

bull Jin Bo Tang early active motion protocol

bull Manchester Short Splint ndash Fiona Peck

Wrist extension with MP flexion relaxes the extensors and reduces the minimum force necessary for active movement of IP joints

Savage 1988

Synergistic Splint (Cooney et al 1989 Cannon 1993 2002)

bull Rebecca Van der Hyde bull Savage 1988

ndash Wrist extension with MP flexion produced least passive tension and decreased minimal active tension

bull Cooney Lin amp An 1989 ndash Synergistic motion

produced highest amount of FDS FDP and differential excursion

Indiana Hand Protocol

Synergistic Motion

bull Lieber et al 1996-1999 ndash Synergistic motion resulted

in low passive forces on the flexor tendon with high excursion

bull Zhao et al 2002 ndash Passive digital flexion

during passive wrist extension as effective ldquopulling forcerdquo to facilitate proximal glide

bull Tanaka et al J Hand Ther 2005 18(3) 330ndash338

Time For A Change

bull Wide Awake Approach to Hand Surgeries

bull Patients who were not following passive motion protocol were doing really well

bull The Wrist Position (Rebecca Von der Heyde)

bull Jin Bo Tang early active motion protocol

bull Manchester Short Splint ndash Fiona Peck

Wrist extension with MP flexion relaxes the extensors and reduces the minimum force necessary for active movement of IP joints

Savage 1988

Synergistic Splint (Cooney et al 1989 Cannon 1993 2002)

bull Rebecca Van der Hyde bull Savage 1988

ndash Wrist extension with MP flexion produced least passive tension and decreased minimal active tension

bull Cooney Lin amp An 1989 ndash Synergistic motion

produced highest amount of FDS FDP and differential excursion

Indiana Hand Protocol

Synergistic Motion

bull Lieber et al 1996-1999 ndash Synergistic motion resulted

in low passive forces on the flexor tendon with high excursion

bull Zhao et al 2002 ndash Passive digital flexion

during passive wrist extension as effective ldquopulling forcerdquo to facilitate proximal glide

bull Tanaka et al J Hand Ther 2005 18(3) 330ndash338

Wrist extension with MP flexion relaxes the extensors and reduces the minimum force necessary for active movement of IP joints

Savage 1988

Synergistic Splint (Cooney et al 1989 Cannon 1993 2002)

bull Rebecca Van der Hyde bull Savage 1988

ndash Wrist extension with MP flexion produced least passive tension and decreased minimal active tension

bull Cooney Lin amp An 1989 ndash Synergistic motion

produced highest amount of FDS FDP and differential excursion

Indiana Hand Protocol

Synergistic Motion

bull Lieber et al 1996-1999 ndash Synergistic motion resulted

in low passive forces on the flexor tendon with high excursion

bull Zhao et al 2002 ndash Passive digital flexion

during passive wrist extension as effective ldquopulling forcerdquo to facilitate proximal glide

bull Tanaka et al J Hand Ther 2005 18(3) 330ndash338

Synergistic Splint (Cooney et al 1989 Cannon 1993 2002)

bull Rebecca Van der Hyde bull Savage 1988

ndash Wrist extension with MP flexion produced least passive tension and decreased minimal active tension

bull Cooney Lin amp An 1989 ndash Synergistic motion

produced highest amount of FDS FDP and differential excursion

Indiana Hand Protocol

Synergistic Motion

bull Lieber et al 1996-1999 ndash Synergistic motion resulted

in low passive forces on the flexor tendon with high excursion

bull Zhao et al 2002 ndash Passive digital flexion

during passive wrist extension as effective ldquopulling forcerdquo to facilitate proximal glide

bull Tanaka et al J Hand Ther 2005 18(3) 330ndash338

Synergistic Motion

bull Lieber et al 1996-1999 ndash Synergistic motion resulted

in low passive forces on the flexor tendon with high excursion

bull Zhao et al 2002 ndash Passive digital flexion

during passive wrist extension as effective ldquopulling forcerdquo to facilitate proximal glide

bull Tanaka et al J Hand Ther 2005 18(3) 330ndash338

Jin Bo Tang

bull Indications methods postoperative motion and outcome evaluations of primary flexor tendon repairs in zone 2 (Journal of Hand Surgery European Volume 2007 32 E 2 118-129

bull Shifted from passive flexion to early controlled active flexion over the last 2 decades

bull Warm Up Exercise of passive flexion within a dorsal block splint before active digital flexion

bull Active exercises from full extension to one third or half of the full flexion range 30 times 5-6 sessions a day (First 25 weeks)

bull Active exercises from half fist to full active fist 30 times 5-6 sessions a day (25 weeks to 6 weeks) Saint John wrist is in 10-30 degrees

of extension at 3-5 days post op

Active Motion Programs

Tang et al (2003) ndash Resistance to digital flexion increases over the range ndash Least resistance in the first two-thirds of flexion ndash Resistance increases 5 ndash 10 x in final third of flexion

ndash Increased stress of tendon around pulleys and joints

Full fist bull Place and hold in this position may not be safe in digital repairs bull Early full range active flexion is not necessary or safe

bull passive exercises before active motion

bull reduction edema prior to active motion

MCP Joint Position

bull Fiona Peck and Gwen Van Strien

bull At 30deg MCP flexion bull motion is initiated at

the DIPj bull encouraging

differential glide bull HowellPeck(2013) bull Wong et al(2014)

Manchester Short Splint

bull Peck et al 2014

ndash The Manchester short splint A change to splinting practice in the rehabilitation of zone 2 flexor tendon repairs

bull Permits wrist motion which facilitates IP joint extension and flexion

Fiona Peck

bull Full passive flexion stretching of the IP joints to maximize digital motion before active motion

bull Active flexion exercises were initiated from the DIP joint to maximise differential glide ndash Tang (2003)

bull Active digital flexion exercises with wrist extended to 45 degrees and active digital extension with the wrist in maximal flexion

Saint John Regional Hospital Rehabilitation of Flexor Tendon Repairs

Zone 1 and 2

bull thermoplastic dorsal block splint wrist in extension (up to 45 degrees MCP joints in flexion (30 degrees) and IP joints in extension (For 2 weeks)

bull No active movement for the first 3-5 days

Saint John Regional Hospital Rehabilitation of Flexor Tendon Repairs bull Start with passive flexion

exercise within splint before active flexion ndash ldquowarm up exerciserdquo 5-10 reps

bull Controlled active movement starts at post-op day 4 or 5

bull Initiate movement at the DIPJ Try to make modified hook fist

bull Gentle active flexion to 13 or 12 of full fist is encouraged

bull Full IP joint extension within dorsal block splint

Saint John Regional Hospital Rehabilitation of Flexor Tendon Repairs

Zones 1 and 2 bull Two weeks post surgery bull dorsal block splint is

shortened so that wrist ROM is free (up to 45 degrees of wrist extension)

bull Gentle active flexion of frac12 a fist or frac34 fist is encouraged

bull Full IP joint extension within dorsal block splint (from week 2 to week 4)

bull Start active synergistic movement with Manchester splint on

Saint John Regional Hospital Rehabilitation of Flexor Tendon Repairs

bull Week 4-6 full active fist encouraged within Manchester splint

bull Synergistic movement continued

bull Week 5 exercises out of splint

bull Manchester short splint discontinued by 6 weeks

Saint John Regional Hospital Rehabilitation of Flexor Tendon Repairs

Zone 1 and 2 bull At 6 weeks patients can use

hand for light activity bull Start passive stretching or

night extension splinting to address any IPJ flexion contractures

bull Start resistive activity with theraputty

bull Start planning return to work (if not already doing light duties)

bull Still no torque activity allowed

Case 1 Zone 1 injury 13 year old female carving a pumpkin lacerated right small finger Presented in clinic one month post injury FDP repaired

Post op day 5 3 weeks post op

8 weeks post op

For PIP joint flexion Contractures try Relative Motion Flexion Splint

Relative Motion Flexion Orthosis to correct PIP joint flexion contracture

Case 1 Continued

Passive extension stretches Night extension splint Went from 39 degree flexion contracture to 12 degree flexion contracture

Four Months post surgery

Case 2 Zone 2 injury 39 year old male grabbed dirty knife in dish water lacerated right small finger FDP repair FDS was not repaired

4 days postop

10 days postop Passive exercise within short splint

10 days post synergistic movement

Case 2 Zone 2 injury 39 year old male grabbed dirty knife in dish water lacerated right small finger FDP repair

FDS was not repaired

25 weeks post op 35 weeks post op

75 weeks post op 10 weeks post op

Case 3 17 year old female with zone 1 flexor tendon laceration knife injury

Two weeks post repair

Active flexion

Two weeks post repair

Active synergistic movement

Five weeks post repair

Active Flexion

Conclusion

bullStart movement 3-4 days post bullYou can move your hand But you canrsquot use your hand bullActive motion no forceful Movement bullManchester short splint bullRelative motion flexion splint to Treat PIP joint flexion contractures bullClinical reasoningindividual program

Active Motion Programs

Tang et al (2003) ndash Resistance to digital flexion increases over the range ndash Least resistance in the first two-thirds of flexion ndash Resistance increases 5 ndash 10 x in final third of flexion

ndash Increased stress of tendon around pulleys and joints

Full fist bull Place and hold in this position may not be safe in digital repairs bull Early full range active flexion is not necessary or safe

bull passive exercises before active motion

bull reduction edema prior to active motion

MCP Joint Position

bull Fiona Peck and Gwen Van Strien

bull At 30deg MCP flexion bull motion is initiated at

the DIPj bull encouraging

differential glide bull HowellPeck(2013) bull Wong et al(2014)

Manchester Short Splint

bull Peck et al 2014

ndash The Manchester short splint A change to splinting practice in the rehabilitation of zone 2 flexor tendon repairs

bull Permits wrist motion which facilitates IP joint extension and flexion

Fiona Peck

bull Full passive flexion stretching of the IP joints to maximize digital motion before active motion

bull Active flexion exercises were initiated from the DIP joint to maximise differential glide ndash Tang (2003)

bull Active digital flexion exercises with wrist extended to 45 degrees and active digital extension with the wrist in maximal flexion

Saint John Regional Hospital Rehabilitation of Flexor Tendon Repairs

Zone 1 and 2

bull thermoplastic dorsal block splint wrist in extension (up to 45 degrees MCP joints in flexion (30 degrees) and IP joints in extension (For 2 weeks)

bull No active movement for the first 3-5 days

Saint John Regional Hospital Rehabilitation of Flexor Tendon Repairs bull Start with passive flexion

exercise within splint before active flexion ndash ldquowarm up exerciserdquo 5-10 reps

bull Controlled active movement starts at post-op day 4 or 5

bull Initiate movement at the DIPJ Try to make modified hook fist

bull Gentle active flexion to 13 or 12 of full fist is encouraged

bull Full IP joint extension within dorsal block splint

Saint John Regional Hospital Rehabilitation of Flexor Tendon Repairs

Zones 1 and 2 bull Two weeks post surgery bull dorsal block splint is

shortened so that wrist ROM is free (up to 45 degrees of wrist extension)

bull Gentle active flexion of frac12 a fist or frac34 fist is encouraged

bull Full IP joint extension within dorsal block splint (from week 2 to week 4)

bull Start active synergistic movement with Manchester splint on

Saint John Regional Hospital Rehabilitation of Flexor Tendon Repairs

bull Week 4-6 full active fist encouraged within Manchester splint

bull Synergistic movement continued

bull Week 5 exercises out of splint

bull Manchester short splint discontinued by 6 weeks

Saint John Regional Hospital Rehabilitation of Flexor Tendon Repairs

Zone 1 and 2 bull At 6 weeks patients can use

hand for light activity bull Start passive stretching or

night extension splinting to address any IPJ flexion contractures

bull Start resistive activity with theraputty

bull Start planning return to work (if not already doing light duties)

bull Still no torque activity allowed

Case 1 Zone 1 injury 13 year old female carving a pumpkin lacerated right small finger Presented in clinic one month post injury FDP repaired

Post op day 5 3 weeks post op

8 weeks post op

For PIP joint flexion Contractures try Relative Motion Flexion Splint

Relative Motion Flexion Orthosis to correct PIP joint flexion contracture

Case 1 Continued

Passive extension stretches Night extension splint Went from 39 degree flexion contracture to 12 degree flexion contracture

Four Months post surgery

Case 2 Zone 2 injury 39 year old male grabbed dirty knife in dish water lacerated right small finger FDP repair FDS was not repaired

4 days postop

10 days postop Passive exercise within short splint

10 days post synergistic movement

Case 2 Zone 2 injury 39 year old male grabbed dirty knife in dish water lacerated right small finger FDP repair

FDS was not repaired

25 weeks post op 35 weeks post op

75 weeks post op 10 weeks post op

Case 3 17 year old female with zone 1 flexor tendon laceration knife injury

Two weeks post repair

Active flexion

Two weeks post repair

Active synergistic movement

Five weeks post repair

Active Flexion

Conclusion

bullStart movement 3-4 days post bullYou can move your hand But you canrsquot use your hand bullActive motion no forceful Movement bullManchester short splint bullRelative motion flexion splint to Treat PIP joint flexion contractures bullClinical reasoningindividual program

MCP Joint Position

bull Fiona Peck and Gwen Van Strien

bull At 30deg MCP flexion bull motion is initiated at

the DIPj bull encouraging

differential glide bull HowellPeck(2013) bull Wong et al(2014)

Manchester Short Splint

bull Peck et al 2014

ndash The Manchester short splint A change to splinting practice in the rehabilitation of zone 2 flexor tendon repairs

bull Permits wrist motion which facilitates IP joint extension and flexion

Fiona Peck

bull Full passive flexion stretching of the IP joints to maximize digital motion before active motion

bull Active flexion exercises were initiated from the DIP joint to maximise differential glide ndash Tang (2003)

bull Active digital flexion exercises with wrist extended to 45 degrees and active digital extension with the wrist in maximal flexion

Saint John Regional Hospital Rehabilitation of Flexor Tendon Repairs

Zone 1 and 2

bull thermoplastic dorsal block splint wrist in extension (up to 45 degrees MCP joints in flexion (30 degrees) and IP joints in extension (For 2 weeks)

bull No active movement for the first 3-5 days

Saint John Regional Hospital Rehabilitation of Flexor Tendon Repairs bull Start with passive flexion

exercise within splint before active flexion ndash ldquowarm up exerciserdquo 5-10 reps

bull Controlled active movement starts at post-op day 4 or 5

bull Initiate movement at the DIPJ Try to make modified hook fist

bull Gentle active flexion to 13 or 12 of full fist is encouraged

bull Full IP joint extension within dorsal block splint

Saint John Regional Hospital Rehabilitation of Flexor Tendon Repairs

Zones 1 and 2 bull Two weeks post surgery bull dorsal block splint is

shortened so that wrist ROM is free (up to 45 degrees of wrist extension)

bull Gentle active flexion of frac12 a fist or frac34 fist is encouraged

bull Full IP joint extension within dorsal block splint (from week 2 to week 4)

bull Start active synergistic movement with Manchester splint on

Saint John Regional Hospital Rehabilitation of Flexor Tendon Repairs

bull Week 4-6 full active fist encouraged within Manchester splint

bull Synergistic movement continued

bull Week 5 exercises out of splint

bull Manchester short splint discontinued by 6 weeks

Saint John Regional Hospital Rehabilitation of Flexor Tendon Repairs

Zone 1 and 2 bull At 6 weeks patients can use

hand for light activity bull Start passive stretching or

night extension splinting to address any IPJ flexion contractures

bull Start resistive activity with theraputty

bull Start planning return to work (if not already doing light duties)

bull Still no torque activity allowed

Case 1 Zone 1 injury 13 year old female carving a pumpkin lacerated right small finger Presented in clinic one month post injury FDP repaired

Post op day 5 3 weeks post op

8 weeks post op

For PIP joint flexion Contractures try Relative Motion Flexion Splint

Relative Motion Flexion Orthosis to correct PIP joint flexion contracture

Case 1 Continued

Passive extension stretches Night extension splint Went from 39 degree flexion contracture to 12 degree flexion contracture

Four Months post surgery

Case 2 Zone 2 injury 39 year old male grabbed dirty knife in dish water lacerated right small finger FDP repair FDS was not repaired

4 days postop

10 days postop Passive exercise within short splint

10 days post synergistic movement

Case 2 Zone 2 injury 39 year old male grabbed dirty knife in dish water lacerated right small finger FDP repair

FDS was not repaired

25 weeks post op 35 weeks post op

75 weeks post op 10 weeks post op

Case 3 17 year old female with zone 1 flexor tendon laceration knife injury

Two weeks post repair

Active flexion

Two weeks post repair

Active synergistic movement

Five weeks post repair

Active Flexion

Conclusion

bullStart movement 3-4 days post bullYou can move your hand But you canrsquot use your hand bullActive motion no forceful Movement bullManchester short splint bullRelative motion flexion splint to Treat PIP joint flexion contractures bullClinical reasoningindividual program

Manchester Short Splint

bull Peck et al 2014

ndash The Manchester short splint A change to splinting practice in the rehabilitation of zone 2 flexor tendon repairs

bull Permits wrist motion which facilitates IP joint extension and flexion

Fiona Peck

bull Full passive flexion stretching of the IP joints to maximize digital motion before active motion

bull Active flexion exercises were initiated from the DIP joint to maximise differential glide ndash Tang (2003)

bull Active digital flexion exercises with wrist extended to 45 degrees and active digital extension with the wrist in maximal flexion

Saint John Regional Hospital Rehabilitation of Flexor Tendon Repairs

Zone 1 and 2

bull thermoplastic dorsal block splint wrist in extension (up to 45 degrees MCP joints in flexion (30 degrees) and IP joints in extension (For 2 weeks)

bull No active movement for the first 3-5 days

Saint John Regional Hospital Rehabilitation of Flexor Tendon Repairs bull Start with passive flexion

exercise within splint before active flexion ndash ldquowarm up exerciserdquo 5-10 reps

bull Controlled active movement starts at post-op day 4 or 5

bull Initiate movement at the DIPJ Try to make modified hook fist

bull Gentle active flexion to 13 or 12 of full fist is encouraged

bull Full IP joint extension within dorsal block splint

Saint John Regional Hospital Rehabilitation of Flexor Tendon Repairs

Zones 1 and 2 bull Two weeks post surgery bull dorsal block splint is

shortened so that wrist ROM is free (up to 45 degrees of wrist extension)

bull Gentle active flexion of frac12 a fist or frac34 fist is encouraged

bull Full IP joint extension within dorsal block splint (from week 2 to week 4)

bull Start active synergistic movement with Manchester splint on

Saint John Regional Hospital Rehabilitation of Flexor Tendon Repairs

bull Week 4-6 full active fist encouraged within Manchester splint

bull Synergistic movement continued

bull Week 5 exercises out of splint

bull Manchester short splint discontinued by 6 weeks

Saint John Regional Hospital Rehabilitation of Flexor Tendon Repairs

Zone 1 and 2 bull At 6 weeks patients can use

hand for light activity bull Start passive stretching or

night extension splinting to address any IPJ flexion contractures

bull Start resistive activity with theraputty

bull Start planning return to work (if not already doing light duties)

bull Still no torque activity allowed

Case 1 Zone 1 injury 13 year old female carving a pumpkin lacerated right small finger Presented in clinic one month post injury FDP repaired

Post op day 5 3 weeks post op

8 weeks post op

For PIP joint flexion Contractures try Relative Motion Flexion Splint

Relative Motion Flexion Orthosis to correct PIP joint flexion contracture

Case 1 Continued

Passive extension stretches Night extension splint Went from 39 degree flexion contracture to 12 degree flexion contracture

Four Months post surgery

Case 2 Zone 2 injury 39 year old male grabbed dirty knife in dish water lacerated right small finger FDP repair FDS was not repaired

4 days postop

10 days postop Passive exercise within short splint

10 days post synergistic movement

Case 2 Zone 2 injury 39 year old male grabbed dirty knife in dish water lacerated right small finger FDP repair

FDS was not repaired

25 weeks post op 35 weeks post op

75 weeks post op 10 weeks post op

Case 3 17 year old female with zone 1 flexor tendon laceration knife injury

Two weeks post repair

Active flexion

Two weeks post repair

Active synergistic movement

Five weeks post repair

Active Flexion

Conclusion

bullStart movement 3-4 days post bullYou can move your hand But you canrsquot use your hand bullActive motion no forceful Movement bullManchester short splint bullRelative motion flexion splint to Treat PIP joint flexion contractures bullClinical reasoningindividual program

Fiona Peck

bull Full passive flexion stretching of the IP joints to maximize digital motion before active motion

bull Active flexion exercises were initiated from the DIP joint to maximise differential glide ndash Tang (2003)

bull Active digital flexion exercises with wrist extended to 45 degrees and active digital extension with the wrist in maximal flexion

Saint John Regional Hospital Rehabilitation of Flexor Tendon Repairs

Zone 1 and 2

bull thermoplastic dorsal block splint wrist in extension (up to 45 degrees MCP joints in flexion (30 degrees) and IP joints in extension (For 2 weeks)

bull No active movement for the first 3-5 days

Saint John Regional Hospital Rehabilitation of Flexor Tendon Repairs bull Start with passive flexion

exercise within splint before active flexion ndash ldquowarm up exerciserdquo 5-10 reps

bull Controlled active movement starts at post-op day 4 or 5

bull Initiate movement at the DIPJ Try to make modified hook fist

bull Gentle active flexion to 13 or 12 of full fist is encouraged

bull Full IP joint extension within dorsal block splint

Saint John Regional Hospital Rehabilitation of Flexor Tendon Repairs

Zones 1 and 2 bull Two weeks post surgery bull dorsal block splint is

shortened so that wrist ROM is free (up to 45 degrees of wrist extension)

bull Gentle active flexion of frac12 a fist or frac34 fist is encouraged

bull Full IP joint extension within dorsal block splint (from week 2 to week 4)

bull Start active synergistic movement with Manchester splint on

Saint John Regional Hospital Rehabilitation of Flexor Tendon Repairs

bull Week 4-6 full active fist encouraged within Manchester splint

bull Synergistic movement continued

bull Week 5 exercises out of splint

bull Manchester short splint discontinued by 6 weeks

Saint John Regional Hospital Rehabilitation of Flexor Tendon Repairs

Zone 1 and 2 bull At 6 weeks patients can use

hand for light activity bull Start passive stretching or

night extension splinting to address any IPJ flexion contractures

bull Start resistive activity with theraputty

bull Start planning return to work (if not already doing light duties)

bull Still no torque activity allowed

Case 1 Zone 1 injury 13 year old female carving a pumpkin lacerated right small finger Presented in clinic one month post injury FDP repaired

Post op day 5 3 weeks post op

8 weeks post op

For PIP joint flexion Contractures try Relative Motion Flexion Splint

Relative Motion Flexion Orthosis to correct PIP joint flexion contracture

Case 1 Continued

Passive extension stretches Night extension splint Went from 39 degree flexion contracture to 12 degree flexion contracture

Four Months post surgery

Case 2 Zone 2 injury 39 year old male grabbed dirty knife in dish water lacerated right small finger FDP repair FDS was not repaired

4 days postop

10 days postop Passive exercise within short splint

10 days post synergistic movement

Case 2 Zone 2 injury 39 year old male grabbed dirty knife in dish water lacerated right small finger FDP repair

FDS was not repaired

25 weeks post op 35 weeks post op

75 weeks post op 10 weeks post op

Case 3 17 year old female with zone 1 flexor tendon laceration knife injury

Two weeks post repair

Active flexion

Two weeks post repair

Active synergistic movement

Five weeks post repair

Active Flexion

Conclusion

bullStart movement 3-4 days post bullYou can move your hand But you canrsquot use your hand bullActive motion no forceful Movement bullManchester short splint bullRelative motion flexion splint to Treat PIP joint flexion contractures bullClinical reasoningindividual program

Saint John Regional Hospital Rehabilitation of Flexor Tendon Repairs

Zone 1 and 2

bull thermoplastic dorsal block splint wrist in extension (up to 45 degrees MCP joints in flexion (30 degrees) and IP joints in extension (For 2 weeks)

bull No active movement for the first 3-5 days

Saint John Regional Hospital Rehabilitation of Flexor Tendon Repairs bull Start with passive flexion

exercise within splint before active flexion ndash ldquowarm up exerciserdquo 5-10 reps

bull Controlled active movement starts at post-op day 4 or 5

bull Initiate movement at the DIPJ Try to make modified hook fist

bull Gentle active flexion to 13 or 12 of full fist is encouraged

bull Full IP joint extension within dorsal block splint

Saint John Regional Hospital Rehabilitation of Flexor Tendon Repairs

Zones 1 and 2 bull Two weeks post surgery bull dorsal block splint is

shortened so that wrist ROM is free (up to 45 degrees of wrist extension)

bull Gentle active flexion of frac12 a fist or frac34 fist is encouraged

bull Full IP joint extension within dorsal block splint (from week 2 to week 4)

bull Start active synergistic movement with Manchester splint on

Saint John Regional Hospital Rehabilitation of Flexor Tendon Repairs

bull Week 4-6 full active fist encouraged within Manchester splint

bull Synergistic movement continued

bull Week 5 exercises out of splint

bull Manchester short splint discontinued by 6 weeks

Saint John Regional Hospital Rehabilitation of Flexor Tendon Repairs

Zone 1 and 2 bull At 6 weeks patients can use

hand for light activity bull Start passive stretching or

night extension splinting to address any IPJ flexion contractures

bull Start resistive activity with theraputty

bull Start planning return to work (if not already doing light duties)

bull Still no torque activity allowed

Case 1 Zone 1 injury 13 year old female carving a pumpkin lacerated right small finger Presented in clinic one month post injury FDP repaired

Post op day 5 3 weeks post op

8 weeks post op

For PIP joint flexion Contractures try Relative Motion Flexion Splint

Relative Motion Flexion Orthosis to correct PIP joint flexion contracture

Case 1 Continued

Passive extension stretches Night extension splint Went from 39 degree flexion contracture to 12 degree flexion contracture

Four Months post surgery

Case 2 Zone 2 injury 39 year old male grabbed dirty knife in dish water lacerated right small finger FDP repair FDS was not repaired

4 days postop

10 days postop Passive exercise within short splint

10 days post synergistic movement

Case 2 Zone 2 injury 39 year old male grabbed dirty knife in dish water lacerated right small finger FDP repair

FDS was not repaired

25 weeks post op 35 weeks post op

75 weeks post op 10 weeks post op

Case 3 17 year old female with zone 1 flexor tendon laceration knife injury

Two weeks post repair

Active flexion

Two weeks post repair

Active synergistic movement

Five weeks post repair

Active Flexion

Conclusion

bullStart movement 3-4 days post bullYou can move your hand But you canrsquot use your hand bullActive motion no forceful Movement bullManchester short splint bullRelative motion flexion splint to Treat PIP joint flexion contractures bullClinical reasoningindividual program

Saint John Regional Hospital Rehabilitation of Flexor Tendon Repairs bull Start with passive flexion

exercise within splint before active flexion ndash ldquowarm up exerciserdquo 5-10 reps

bull Controlled active movement starts at post-op day 4 or 5

bull Initiate movement at the DIPJ Try to make modified hook fist

bull Gentle active flexion to 13 or 12 of full fist is encouraged

bull Full IP joint extension within dorsal block splint

Saint John Regional Hospital Rehabilitation of Flexor Tendon Repairs

Zones 1 and 2 bull Two weeks post surgery bull dorsal block splint is

shortened so that wrist ROM is free (up to 45 degrees of wrist extension)

bull Gentle active flexion of frac12 a fist or frac34 fist is encouraged

bull Full IP joint extension within dorsal block splint (from week 2 to week 4)

bull Start active synergistic movement with Manchester splint on

Saint John Regional Hospital Rehabilitation of Flexor Tendon Repairs

bull Week 4-6 full active fist encouraged within Manchester splint

bull Synergistic movement continued

bull Week 5 exercises out of splint

bull Manchester short splint discontinued by 6 weeks

Saint John Regional Hospital Rehabilitation of Flexor Tendon Repairs

Zone 1 and 2 bull At 6 weeks patients can use

hand for light activity bull Start passive stretching or

night extension splinting to address any IPJ flexion contractures

bull Start resistive activity with theraputty

bull Start planning return to work (if not already doing light duties)

bull Still no torque activity allowed

Case 1 Zone 1 injury 13 year old female carving a pumpkin lacerated right small finger Presented in clinic one month post injury FDP repaired

Post op day 5 3 weeks post op

8 weeks post op

For PIP joint flexion Contractures try Relative Motion Flexion Splint

Relative Motion Flexion Orthosis to correct PIP joint flexion contracture

Case 1 Continued

Passive extension stretches Night extension splint Went from 39 degree flexion contracture to 12 degree flexion contracture

Four Months post surgery

Case 2 Zone 2 injury 39 year old male grabbed dirty knife in dish water lacerated right small finger FDP repair FDS was not repaired

4 days postop

10 days postop Passive exercise within short splint

10 days post synergistic movement

Case 2 Zone 2 injury 39 year old male grabbed dirty knife in dish water lacerated right small finger FDP repair

FDS was not repaired

25 weeks post op 35 weeks post op

75 weeks post op 10 weeks post op

Case 3 17 year old female with zone 1 flexor tendon laceration knife injury

Two weeks post repair

Active flexion

Two weeks post repair

Active synergistic movement

Five weeks post repair

Active Flexion

Conclusion

bullStart movement 3-4 days post bullYou can move your hand But you canrsquot use your hand bullActive motion no forceful Movement bullManchester short splint bullRelative motion flexion splint to Treat PIP joint flexion contractures bullClinical reasoningindividual program

Saint John Regional Hospital Rehabilitation of Flexor Tendon Repairs

Zones 1 and 2 bull Two weeks post surgery bull dorsal block splint is

shortened so that wrist ROM is free (up to 45 degrees of wrist extension)

bull Gentle active flexion of frac12 a fist or frac34 fist is encouraged

bull Full IP joint extension within dorsal block splint (from week 2 to week 4)

bull Start active synergistic movement with Manchester splint on

Saint John Regional Hospital Rehabilitation of Flexor Tendon Repairs

bull Week 4-6 full active fist encouraged within Manchester splint

bull Synergistic movement continued

bull Week 5 exercises out of splint

bull Manchester short splint discontinued by 6 weeks

Saint John Regional Hospital Rehabilitation of Flexor Tendon Repairs

Zone 1 and 2 bull At 6 weeks patients can use

hand for light activity bull Start passive stretching or

night extension splinting to address any IPJ flexion contractures

bull Start resistive activity with theraputty

bull Start planning return to work (if not already doing light duties)

bull Still no torque activity allowed

Case 1 Zone 1 injury 13 year old female carving a pumpkin lacerated right small finger Presented in clinic one month post injury FDP repaired

Post op day 5 3 weeks post op

8 weeks post op

For PIP joint flexion Contractures try Relative Motion Flexion Splint

Relative Motion Flexion Orthosis to correct PIP joint flexion contracture

Case 1 Continued

Passive extension stretches Night extension splint Went from 39 degree flexion contracture to 12 degree flexion contracture

Four Months post surgery

Case 2 Zone 2 injury 39 year old male grabbed dirty knife in dish water lacerated right small finger FDP repair FDS was not repaired

4 days postop

10 days postop Passive exercise within short splint

10 days post synergistic movement

Case 2 Zone 2 injury 39 year old male grabbed dirty knife in dish water lacerated right small finger FDP repair

FDS was not repaired

25 weeks post op 35 weeks post op

75 weeks post op 10 weeks post op

Case 3 17 year old female with zone 1 flexor tendon laceration knife injury

Two weeks post repair

Active flexion

Two weeks post repair

Active synergistic movement

Five weeks post repair

Active Flexion

Conclusion

bullStart movement 3-4 days post bullYou can move your hand But you canrsquot use your hand bullActive motion no forceful Movement bullManchester short splint bullRelative motion flexion splint to Treat PIP joint flexion contractures bullClinical reasoningindividual program

Saint John Regional Hospital Rehabilitation of Flexor Tendon Repairs

bull Week 4-6 full active fist encouraged within Manchester splint

bull Synergistic movement continued

bull Week 5 exercises out of splint

bull Manchester short splint discontinued by 6 weeks

Saint John Regional Hospital Rehabilitation of Flexor Tendon Repairs

Zone 1 and 2 bull At 6 weeks patients can use

hand for light activity bull Start passive stretching or

night extension splinting to address any IPJ flexion contractures

bull Start resistive activity with theraputty

bull Start planning return to work (if not already doing light duties)

bull Still no torque activity allowed

Case 1 Zone 1 injury 13 year old female carving a pumpkin lacerated right small finger Presented in clinic one month post injury FDP repaired

Post op day 5 3 weeks post op

8 weeks post op

For PIP joint flexion Contractures try Relative Motion Flexion Splint

Relative Motion Flexion Orthosis to correct PIP joint flexion contracture

Case 1 Continued

Passive extension stretches Night extension splint Went from 39 degree flexion contracture to 12 degree flexion contracture

Four Months post surgery

Case 2 Zone 2 injury 39 year old male grabbed dirty knife in dish water lacerated right small finger FDP repair FDS was not repaired

4 days postop

10 days postop Passive exercise within short splint

10 days post synergistic movement

Case 2 Zone 2 injury 39 year old male grabbed dirty knife in dish water lacerated right small finger FDP repair

FDS was not repaired

25 weeks post op 35 weeks post op

75 weeks post op 10 weeks post op

Case 3 17 year old female with zone 1 flexor tendon laceration knife injury

Two weeks post repair

Active flexion

Two weeks post repair

Active synergistic movement

Five weeks post repair

Active Flexion

Conclusion

bullStart movement 3-4 days post bullYou can move your hand But you canrsquot use your hand bullActive motion no forceful Movement bullManchester short splint bullRelative motion flexion splint to Treat PIP joint flexion contractures bullClinical reasoningindividual program

Saint John Regional Hospital Rehabilitation of Flexor Tendon Repairs

Zone 1 and 2 bull At 6 weeks patients can use

hand for light activity bull Start passive stretching or

night extension splinting to address any IPJ flexion contractures

bull Start resistive activity with theraputty

bull Start planning return to work (if not already doing light duties)

bull Still no torque activity allowed

Case 1 Zone 1 injury 13 year old female carving a pumpkin lacerated right small finger Presented in clinic one month post injury FDP repaired

Post op day 5 3 weeks post op

8 weeks post op

For PIP joint flexion Contractures try Relative Motion Flexion Splint

Relative Motion Flexion Orthosis to correct PIP joint flexion contracture

Case 1 Continued

Passive extension stretches Night extension splint Went from 39 degree flexion contracture to 12 degree flexion contracture

Four Months post surgery

Case 2 Zone 2 injury 39 year old male grabbed dirty knife in dish water lacerated right small finger FDP repair FDS was not repaired

4 days postop

10 days postop Passive exercise within short splint

10 days post synergistic movement

Case 2 Zone 2 injury 39 year old male grabbed dirty knife in dish water lacerated right small finger FDP repair

FDS was not repaired

25 weeks post op 35 weeks post op

75 weeks post op 10 weeks post op

Case 3 17 year old female with zone 1 flexor tendon laceration knife injury

Two weeks post repair

Active flexion

Two weeks post repair

Active synergistic movement

Five weeks post repair

Active Flexion

Conclusion

bullStart movement 3-4 days post bullYou can move your hand But you canrsquot use your hand bullActive motion no forceful Movement bullManchester short splint bullRelative motion flexion splint to Treat PIP joint flexion contractures bullClinical reasoningindividual program

Case 1 Zone 1 injury 13 year old female carving a pumpkin lacerated right small finger Presented in clinic one month post injury FDP repaired

Post op day 5 3 weeks post op

8 weeks post op

For PIP joint flexion Contractures try Relative Motion Flexion Splint

Relative Motion Flexion Orthosis to correct PIP joint flexion contracture

Case 1 Continued

Passive extension stretches Night extension splint Went from 39 degree flexion contracture to 12 degree flexion contracture

Four Months post surgery

Case 2 Zone 2 injury 39 year old male grabbed dirty knife in dish water lacerated right small finger FDP repair FDS was not repaired

4 days postop

10 days postop Passive exercise within short splint

10 days post synergistic movement

Case 2 Zone 2 injury 39 year old male grabbed dirty knife in dish water lacerated right small finger FDP repair

FDS was not repaired

25 weeks post op 35 weeks post op

75 weeks post op 10 weeks post op

Case 3 17 year old female with zone 1 flexor tendon laceration knife injury

Two weeks post repair

Active flexion

Two weeks post repair

Active synergistic movement

Five weeks post repair

Active Flexion

Conclusion

bullStart movement 3-4 days post bullYou can move your hand But you canrsquot use your hand bullActive motion no forceful Movement bullManchester short splint bullRelative motion flexion splint to Treat PIP joint flexion contractures bullClinical reasoningindividual program

Relative Motion Flexion Orthosis to correct PIP joint flexion contracture

Case 1 Continued

Passive extension stretches Night extension splint Went from 39 degree flexion contracture to 12 degree flexion contracture

Four Months post surgery

Case 2 Zone 2 injury 39 year old male grabbed dirty knife in dish water lacerated right small finger FDP repair FDS was not repaired

4 days postop

10 days postop Passive exercise within short splint

10 days post synergistic movement

Case 2 Zone 2 injury 39 year old male grabbed dirty knife in dish water lacerated right small finger FDP repair

FDS was not repaired

25 weeks post op 35 weeks post op

75 weeks post op 10 weeks post op

Case 3 17 year old female with zone 1 flexor tendon laceration knife injury

Two weeks post repair

Active flexion

Two weeks post repair

Active synergistic movement

Five weeks post repair

Active Flexion

Conclusion

bullStart movement 3-4 days post bullYou can move your hand But you canrsquot use your hand bullActive motion no forceful Movement bullManchester short splint bullRelative motion flexion splint to Treat PIP joint flexion contractures bullClinical reasoningindividual program

Case 1 Continued

Passive extension stretches Night extension splint Went from 39 degree flexion contracture to 12 degree flexion contracture

Four Months post surgery

Case 2 Zone 2 injury 39 year old male grabbed dirty knife in dish water lacerated right small finger FDP repair FDS was not repaired

4 days postop

10 days postop Passive exercise within short splint

10 days post synergistic movement

Case 2 Zone 2 injury 39 year old male grabbed dirty knife in dish water lacerated right small finger FDP repair

FDS was not repaired

25 weeks post op 35 weeks post op

75 weeks post op 10 weeks post op

Case 3 17 year old female with zone 1 flexor tendon laceration knife injury

Two weeks post repair

Active flexion

Two weeks post repair

Active synergistic movement

Five weeks post repair

Active Flexion

Conclusion

bullStart movement 3-4 days post bullYou can move your hand But you canrsquot use your hand bullActive motion no forceful Movement bullManchester short splint bullRelative motion flexion splint to Treat PIP joint flexion contractures bullClinical reasoningindividual program

Case 2 Zone 2 injury 39 year old male grabbed dirty knife in dish water lacerated right small finger FDP repair FDS was not repaired

4 days postop

10 days postop Passive exercise within short splint

10 days post synergistic movement

Case 2 Zone 2 injury 39 year old male grabbed dirty knife in dish water lacerated right small finger FDP repair

FDS was not repaired

25 weeks post op 35 weeks post op

75 weeks post op 10 weeks post op

Case 3 17 year old female with zone 1 flexor tendon laceration knife injury

Two weeks post repair

Active flexion

Two weeks post repair

Active synergistic movement

Five weeks post repair

Active Flexion

Conclusion

bullStart movement 3-4 days post bullYou can move your hand But you canrsquot use your hand bullActive motion no forceful Movement bullManchester short splint bullRelative motion flexion splint to Treat PIP joint flexion contractures bullClinical reasoningindividual program

Case 2 Zone 2 injury 39 year old male grabbed dirty knife in dish water lacerated right small finger FDP repair

FDS was not repaired

25 weeks post op 35 weeks post op

75 weeks post op 10 weeks post op

Case 3 17 year old female with zone 1 flexor tendon laceration knife injury

Two weeks post repair

Active flexion

Two weeks post repair

Active synergistic movement

Five weeks post repair

Active Flexion

Conclusion

bullStart movement 3-4 days post bullYou can move your hand But you canrsquot use your hand bullActive motion no forceful Movement bullManchester short splint bullRelative motion flexion splint to Treat PIP joint flexion contractures bullClinical reasoningindividual program

Case 3 17 year old female with zone 1 flexor tendon laceration knife injury

Two weeks post repair

Active flexion

Two weeks post repair

Active synergistic movement

Five weeks post repair

Active Flexion

Conclusion

bullStart movement 3-4 days post bullYou can move your hand But you canrsquot use your hand bullActive motion no forceful Movement bullManchester short splint bullRelative motion flexion splint to Treat PIP joint flexion contractures bullClinical reasoningindividual program

Conclusion

bullStart movement 3-4 days post bullYou can move your hand But you canrsquot use your hand bullActive motion no forceful Movement bullManchester short splint bullRelative motion flexion splint to Treat PIP joint flexion contractures bullClinical reasoningindividual program