Repaired extensor tendons have traditionally been immobilized for a period of 3 to 4 weeks prior to the commencement of active movement. Because of the propensity toward tendon adhesion, treat-ment results were frequently disappointing. The introduction of controlled mobilization techniques in the management of extensor tendon injuries has led to improved results, particularly in the more challenging Zone III over the PIP joint.
Evans and Burkhalter (1986) reported their 6-year experience using controlled motion in the treatment of untidy extensor injuries. Their treat-ment protocol was developed using knowledge of extensor tendon excursion as reported by Bunnell (from Boyes, 1970), Elliot and McGrouther (1986) and Brand and Hollister (1993). The effectiveness of early dynamic splinting has been verified by Browne and Ribik (1989), Hung et al. (1990) and Saldana et al. (1991).
It has been suggested that 3–5 mm of tendon excursion (Duran and Houser, 1975 and Gelber-man et al., 1986) is sufficient to promote glide and stimulate cellular activity without causing gapping or rupture of the repair. Evans and Burkhalter
(1986) determined that 30 to 40 degrees of MCP joint motion effected 5 mm of extensor glide in Zones III, IV, V, VI and VII. In the case of extensor pollicis (EPL) repair, 60 degrees of IP joint flexion effected 5 mm of tendon excursion at Lister’s tubercle with the wrist in neutral and the thumb MCP joint in extension.
The controlled passive and/or active mobiliza-tion protocol is only used with patients who are able to comply with the regimen. While the first few treatments are labour-intensive and time-consuming in terms of splint fabrication and patient education, the rate of progress and overall result far outweigh these initial commitments.
Where patients being treated with immobilization are just commencing their active therapy pro-gramme at week 4, most patients being managed with the controlled mobilization protocol are nearing the end of formal therapy. It is our experience that patients involved in this protocol also benefit psychologically from early active participation.
The treatment programmes described below will include conservative management of closed inju-ries together with static and controlled mobiliza-tion protocols following surgical repair of extensor tendons. Discussion between surgeon and therapist is essential in determining the protocol most suitable for each patient.
Zones I and II
Interruption of the extensor mechanism over the DIP joint and the distal portion of the middle phalanx results in a flexion deformity of the joint, i.e. a mallet finger. The injury can be either closed or open. These injuries are frequently associated with a small avulsion fracture at the base of the distal phalanx where the tendon inserts (Fig. 4.5).
Conservative management of closed injury
Closed injuries are treated with a dorsal or volar splint which maintains the DIP joint in extension for a period of 6 to 8 weeks. The position of the DIP joint in the splint needs to be critically evaluated as even slight flexion at the joint will cause attenuation of the tendon callus and a resultant extensor lag. Correct positioning within the splint is best maintained with taping rather than strapping (Fig. 4.6).
Figure 4.4. Technique for extensor tendon repair. The horizontal mattress suture is suitable for broad, flat tendons with longitudinal fibres.
(a)
(b)
(c)
Extensor tendons 47
A layer of paper tape (e.g. Micropore or Hypafix) applied to the skin prior to splint application will help prevent maceration. If the distal joint is swollen, as is often the case with an associated avulsion fracture, the splint may need to be adjusted until swelling has stabilized. Coban used beneath the splint will hasten resolution of oedema. Full PIP joint mobility should be main-tained throughout this period.
If the patient demonstrates joint hypermobility, the splint can hold the DIP joint in slight hyperextension where this position can be gained with ease. Hypermobile joints often require pro-longed splinting, i.e. an additional 3 to 4 weeks.
Whether the joint is splinted in neutral extension or slight hyperextension, care is taken to avoid restricting the circulation. The patient is instruc-ted in skin and splint care. The splint should be removed at least once each day to ‘air’ the finger and to check for adverse effects from the splint.
The patient must ensure that the DIP joint is supported in full extension whenever the splint is removed. While the splint is off, the skin is gently tapped and massaged to stimulate the circulation.
Following the immobilization period, gentle active DIP joint flexion exercises are com-menced. Night and intermittent day splinting is maintained for a further 2 weeks. The patient attempts gentle unforced composite IP joint flex-ion. The finger is then straightened from the flexed position and extension range of the distal joint is carefully assessed for any sign of lag.
Exercise sessions are performed every 2 h with 5 to 10 repetitions. A desirable DIP joint flexion range during the first week is 20 to 30 degrees.
The goal is then to achieve a further 10 degrees during each ensuing week. Patients who demon-strate significant flexion range when the splint is removed tend to be more prone to a recurrence of the deformity. If the DIP joint flexion deformity appears to be recurring, extension splinting is reinstituted for a further 2 weeks when the situation is reassessed. Resisted activities are avoided until the 10th week.
If the mallet deformity has resulted in a secondary swan-neck deformity (i.e. the PIP joint has assumed a posture of hyperextension in association with the flexion deformity at the DIP joint), then both IP joints will need to be included in the splint. The PIP joint is placed in 35 to 45 degrees of flexion to advance the lateral bands, while the DIP joint is held in neutral extension.
Figure 4.5. Types of mallet finger injury: (a) rupture of distal extensor tendon; (b) avulsion fracture of the base of the distal phalanx; (c) fracture separation of epiphysis of distal phalanx.
Figure 4.6. A closed mallet finger injury is treated with 6 weeks of immobilization. The DIP joint is maintained in full extension with a thermoplastic splint that can be worn volarly or dorsally. The splint should allow full PIP joint flexion range.
Central slip disruption
Oblique retinacular ligament
Joint axis Lateral band
Open injury
Open wounds are best treated by repair and internal fixation of the distal joint with a K-wire which is removed 2 to 3 weeks later. An extension splint is then applied for a further 3 to 4 weeks.
Oedema in the distal segment of the finger is managed with Coban wrap (25 mm). Management is then as for closed mallet injury.
Zones III and IV
Conservative management for closed injury
Injury to the extensor tendon mechanism over the PIP joint can produce a buttonhole deformity which, if untreated, becomes a fixed deformity with PIP joint flexion contracture and DIP joint hyperextension contracture (Fig. 4.7).
This deformity results when the lateral bands fall below the axis of the PIP joint. When this occurs, the lateral bands become flexors of the joint while at the same time concentrating their extension force at the DIP joint. Shortening of the oblique retinacular ligaments quickly ensues. This further compounds loss of DIP flexion range which is often the most disabling aspect of this deformity.
Suspected closed injuries of the central slip are treated by splinting which maintains the PIP joint in full extension for a period of 6 weeks. The DIP joint is left free to move. A variety of splints can be used to achieve this goal, e.g. thermoplastic finger splint, Capener or a circumferential plaster cast.
Because the finger is frequently swollen, a plaster cast is the splint of choice (Fig. 4.8). This will provide gentle even compression and will alleviate joint discomfort. The cast may need to be changed every few days until swelling has fully settled. The cast should not impede DIP joint flexion which should be carried out passively and actively on an hourly basis with 10 to 20 repetitions. In most cases, it can be left in place for about 10 days before it softens and needs replacing.
If the deformity presents late, serial casting is used to overcome the flexion deformity prior to the 6-week splinting period which will begin when neutral extension range has been achieved. Gentle dynamic flexion splinting of the DIP joint can be incorporated into the plaster to overcome tightness of the oblique retinacular ligament.
Gentle unresisted active PIP joint flexion/
extension exercises are commenced after 6 weeks of extension splinting. Night splinting in a ther-moplastic finger splint is maintained for a further 2 weeks. Flexion of the PIP joint should be regained gradually over a number of weeks.
Forced flexion of the joint will result in attenua-tion of the tendon and a recurrence of the deformity.
Figure 4.7. Buttonhole deformity following injury to the central slip of the extensor tendon. The lateral bands fall below the axis of the PIP joint and become flexors of this joint. Their extension force at the DIP joint becomes more concentrated, resulting in DIP joint hyperextension.
Figure 4.8. The PIP joint is plaster-casted to maintain full extension. In the presence of a flexion contracture, serial casting is undertaken until full extension range has been regained. The 6-week splinting period is then commenced from that time. Passive and active DIP joint exercises are performed hourly.
Extensor tendons 49
Open injury
The traditional postoperative treatment following repair in Zones III and IV has involved immobili-zation of the PIP joint for a 6-week period. Due to the significant tendon-bone interface and prox-imity to joint structures, this area is particularly prone to adhesion formation resulting in restricted tendon excursion, extensor lag and joint stiffness (Newport et al., 1990). Implementation of the active short arc motion protocol as proposed by Evans (1994) has shown statistically superior results when compared with traditional manage-ment of these zones.
The author has now used this protocol for several years with good results. Minor modifica-tions to the original protocol have been made.
These include:
1. A dorsal finger splint rather than a volar one.
2. The use of only one template (instead of two) during active exercise; the author does not use the second template used for active DIP joint flexion exercises.
Active short arc motion protocol
Within a day or two of surgery, the inter-phalangeal joints are fitted with a thermoplastic finger splint that maintains both joints in full extension (i.e. 0 degrees). Maintenance of the fully extended position between exercise sessions is most important in avoiding elongation of the tendon (Fig. 4.9).
To help eliminate digital oedema, the finger is wrapped in a single layer of Coban (25 mm)
applied over a non-bulky dressing in a distal to proximal direction. The initial splint may need to be replaced if postoperative swelling has been significant.
A volar template splint is then made which will accommodate 30 degrees of active PIP joint flexion and 25 degrees of active DIP joint flexion (Fig. 4.10). This splint is used every waking hour.
The prescribed exercises are performed with the wrist in 30 degrees of flexion and the MCP joint in neutral extension or slight flexion. With the volar template splint held in place, the patient flexes both IP joints to the limit of the splint and then actively extends the digit to neutral extension at both IP joints. The position of extension is held for
Figure 4.9. One or two days following open repair of the extensor tendon in Zone III or IV, the digit is fitted with a thermoplastic finger splint that maintains both IP joints in full extension. Coban wrap is used over the dressing to treat postoperative oedema.
Figure 4.10. The volar template splint allows 30 and 25 degrees of active flexion at the PIP and DIP joints, respectively. The wrist should be maintained in 30 degrees of flexion and the MCP joints maintained in neutral extension during the manoeuvre.
Figure 4.11. Following active flexion to the limit of the volar splint, both IP joints are then actively extended to neutral extension. This extended position is held for several seconds before the manoeuvre is repeated.
several seconds prior to again flexing to the limit of the splint (Fig. 4.11). This manoeuvre is repeated 20 times every hour.
The other component of the hourly exercise routine involves active flexion of the DIP joint with the PIP joint held in full extension. This can be performed by undoing the distal strap of the splint and stabilizing the PIP joint during active flexion of the distal joint (Fig. 4.12). Movement of this joint is important in maintaining excursion of the lateral bands and the oblique retinacular ligaments. If the lateral bands have not been repaired, the distal joint is fully flexed and extended. Where they have undergone repair, active DIP joint flexion is limited to 30 degrees and is followed by active DIP joint extension. This exercise is repeated 10 to 15 times.
If no extensor lag has developed, the volar template splint is modified or replaced after 2 weeks to allow 40 degrees of PIP joint flexion during the described manoeuvre. This is increased to 50 degrees by week 3, and to 70 or 80 degrees by the end of the 4th week.
Static extension splinting between hourly exer-cise sessions is maintained for 6 weeks. Composite active finger flexion can begin at the end of the 5th week. Return of flexion range should be gradual so as not to jeopardize PIP joint extension range.
Fully resisted activity is avoided until the 10th week.
Zones V and VI
These two zones lie between the MCP joints and the extensor retinaculum. Closed injuries to the sagittal hood system over the MCP joints can occur with blunt trauma and result in an extensor lag or ulnar drift of the tendon. These injuries are treated by splinting the involved MCP joint in neutral extension for a period of 4 to 6 weeks.
Tendon glide is more readily restored in these proximal zones because this area has greater soft tissue mobility. Nonetheless, adhesion of the repaired tendon to skin and bone does still occur, particularly if the injury has involved other struc-tures, e.g. bone and intrinsic musculature, follow-ing a crush injury.
Because the dorsum of the hand can accom-modate significant swelling, the propensity toward adhesion formation is great. Prompt management of postoperative oedema is important in minimiz-ing the risk of these adhesions.
Postoperative management
As for Zones III and IV, tendon injuries in these zones can be managed by:
1. Static splinting and immobilization.
2. Dynamic splinting and early controlled motion.
The controlled motion protocol in these zones was originally devised by Evans to overcome problems associated with complex injuries. Because of the undisputed biochemical and biomechanical advan-tages associated with early controlled motion, Evans now also uses the dynamic approach with the simple tendon injury. Since starting on the dynamic protocol four years ago, this author has not used the static splinting method other than for patients considered unable to cope with the regimen. Both methods of management will be described.
1. Static splint and immobilization
On the 2nd or 3rd postoperative day the plaster is replaced with a volar thermoplastic splint which maintains the wrist in 45 degrees of extension and the MCP joints in 0 to 20 degrees of flexion. The interphalangeal joints are maintained in full exten-sion with a distal splint component that is removed for IP joint exercises. The maintenance of IP joint extension is important in preventing palmar plate Figure 4.12. The exercise session is completed with
active stabilized DIP joint flexion/extension exercises which maintain DIP joint mobility and excursion of the lateral bands and oblique retinacular ligament. If the lateral bands have been repaired, active DIP joint flexion is limited to 30 degrees for the first two weeks. The PIP joint must be kept in full extension during DIP joint exercises.
Extensor tendons 51
contracture and subsequent flexion deformity. The splint extends from two-thirds along the forearm to just proximal to the PIP joints so IP joint flexion can be performed (Fig. 4.13).
Days 3 to 24
Because IP joint motion produces only minimal extensor tendon excursion in Zones V and VI (Brand and Hollister, 1993), active IP joint flexion exercises are performed every 2 h with 10 repeti-tions. These are followed by IP joint passive extension. The distal component of the splint is worn between exercise sessions to maintain full digital extension.
When the sutures are removed after about 10 days, the hand is bathed in warm, soapy water (with care taken to maintain the correct position of wrist and finger extension) and gentle oil massage is begun. Scar is managed with silicone gel which is worn beneath Tubigrip elastic stocking. All traces of oil are removed prior to application of the gel.
Day 24 onwards
At 312 weeks, gentle active motion of the MCP joints is commenced. The following exercises are performed:
1. Because wrist flexion is synergistic with finger extension, active MCP joint extension exercises are performed with the wrist in 20 to 30 degrees
of flexion. This position reduces the passive tension of the opposing extrinsic digital flexors.
‘Place and hold’ exercises are performed with the wrist supported in 20 to 30 degrees of flexion and the fingers supported in full exten-sion (Fig. 4.14). The supporting hand is then removed from the fingers and the patient is asked to maintain active digital extension with minimal exertion for several seconds before relaxing. The patient is then asked to actively flex the MCP joints to 30 degrees, hold this position for several seconds, and then actively extend the MCP joints to neutral extension.
This exercise is repeated 10 to 20 times every 1 to 2 hours.
2. The wrist is then extended to 45 degrees and the patient attempts 40 to 60 degrees of MCP joint flexion with the IP joints maintained in exten-sion, i.e. the ‘intrinsic-plus’ position.
3. The third exercise involves active flexion and extension of the IP joints with the wrist in 20 to 30 degrees of extension and MCP joints held in neutral extension range.
At week 4, composite flexion (i.e. all three finger joints flexing simultaneously), is begun with the wrist held in 45 degrees of extension. Protective splinting is maintained between exercise sessions until the end of the 6th week.
At week 6, extrinsic extension exercises are added to the programme. This involves extending the MCP joints while maintaining maximum IP Figure 4.13. Postoperative splint following extensor
tendon repair for Zones V and VI using the static immobilization protocol. A removable distal
component (not shown) is worn at night and between exercise sessions to prevent flexion deformity at the interphalangeal joints. Full active IP joint flexion should be possible within the splint.
Figure 4.14. ‘Place and hold’ extension exercises are performed with the wrist in 20 to 30 degrees of flexion while the fingers are supported in full extension. The supporting hand is then removed and the patient is asked to maintain active digital extension for several seconds.
joint flexion and is performed with the wrist in neutral extension. The patient can engage in light unresisted daily activity at this stage.
If MCP joint flexion range is still restricted by
If MCP joint flexion range is still restricted by