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Surgery and Flexor Tendons

March 18, 2016

 

 

For those faint of heart, quit reading now...

 

This post is designed around the rehab of one special climber who underwent a traumatic injury in which her flexor tendon was sliced through with a piece of baking glass. (This is a very important time to note that glass dishes such as Pyrex can be dangerous… I have been educated by patients undergoing such injuries that it could very well glass will explode if heated in the oven and then quickly placed in water or onto a cold counter top.  Regardless of mechanism, if the tendon is completely severed, the surgeon must go find it, creating a zig zag incision and then finding the loose ends and trying to re-attach them. Several techniques exist however the photo below is the most common.

 

 

 

Does one need surgery, splinting and rehab afterwards?! 

 

In the case of a full rupture- Absolutely. If you have just sliced a part of the tendon, you might be able to leave it.

 

Industry Standard:

 

 

  • 100%  laceration requires surgery, splinting and rehabilitation.

  • 25-50%: Conservative repair of a covering over the tendon (Epitendon)

  • For less than 25% of the tendon being cut, surgery is not needed.

 

 

If you choose to undergo surgery, which I HIGHLY recommend,  splinting of the wrist and finger in flexion is worn for 6-8 weeks on average.

 

 

 

 

 

An Example Rehab Protocol after Surgery:

 

 

WEEK 1-3:

 

SPLINTING:

 

 Designed in a  good healing position, it is to be worn at all times, even during rehabilitation and sleep. IMPORTANT NOTE: Do not resist the strap that crosses your fingers in your splint as this may cause a tendon rupture.

 

SUTURES:  Removed on week 2.

 

MASSAGE:  Lightly begins week 2.

 

MOTION:  Every 2 hours, exercise wearing the split. Use the other hand to flex the fingers (which stay relaxed). Actively extend the fingers gently by themselves. This helps to keep scar tissue from forming and ensures motion stays in the region as it heals. 8-10 reps each. IMPORTANT NOTE: Please AVOID making a tight fist

 

 

 

  • Repetitions of independently bending and straightening the last two joints of the finger.

 

  • Repetitions of opening the hand and making a fist.

 

 

 

 

WEEK 3-6:

 

Begin active motion (without the assistance of the other hand) in flexion and extension. Change splint to neutral. Continue as per doctor recommendations until week 6.

 

 

 

WEEK 6:

 

Congrats, you can now remove your splint! Be cautious to protect your hand during daily activities. The focus of this week is more aggressive scar tissue removal by your therapist.

 

 

 

SPLINTING:  None unless required by provider.

 

MOTION: Continue the above exercises. “Non-resistive” functional activities such as picking up foam, rice, etc. are added. Now we take off the splint to add wrist glides. After you are done, put the splint back on! 

 

Exercises consist of 12-15 reps of:

 

  • Bending and straightening the fingers.

  • Opening and closing the hand.

  • Focal 'blocked' 1-joint motion of the end joint only.

  • Focal 'blocked' 1-joint motion of the middle joint only.

  • Gliding the wrist up and down in a fist

 

 

Important Note: Ensure you are being gentle, do not squeeze fist) and straight fingers. During 'blocking' ensure your fingers are holding the sides of the digit, and not top and bottom.

 

 

 

WEEK 7:

 

MOTION:

 

Continue same exercises and progress when ready.  Continue to protect your hand during daily activities. 

 

STRETCHING:

 

Begin to add gentle stretches to fingers and palm.

Let pain and fatigue be your guide.

 

 

WEEK 8-12:

 

Congrats, you may now begin to use your hand but be careful of not causing pain and/or fatigue.

 

Start with small things and no weight.  If your finger is contracted, your provider will put you in an extension splint to continue to stretch your finger back toward a normal alignment. 18-25% of cases will need an additional surgery, called a ‘tendinolysis’ to break up additional scar tissue from surgeries if no progress in mobility has been made at the 3 month mark.

 

 

MOTION:

 

Continue to progress weight and increase variety of motions to mimic your lifestyle keeping load to a minimum but slowly begin adding on more weight IF there is no pain or fatigue. 

 

STRETCHING:

 

Continue to move joints and work on palm, forearm and finger flexibility. Mimic hobbies and lifestyle uses to ensure flexibility in needed ranges.

 

STRENGTH:

 

Continue to work on palm, forearm and finger strength as well as shoulder elbow and core stability while we wait for this to heal. We now begin to mimic hobbies and lifestyle uses to ensure strength in needed ranges and to test loads before we return to climbing.

 

 

 

References: 

 

Flexor Tendon Repair Rehab Protocols. A Systematic Review. H. M. Starr et all. Journal of Hand Surgery. September 2013 Volume 38, Issue 9, Pages 1712–1717.e14

 

Dr. Kahn. Flexor Tendon Injuries. Teaching slideshow. Slideshare.net. Accessed on March 15, 2016. 

 

 Flexor tendon repair or graft early passive mobilization therapy.

The Electronic Textbook of Hand Surgery. Eatonhand.com. Accessed on March 15, 2016.

 

Flexor Tendon Repair Protocol.  Twin Cities Orthopedics.  Accessed online 3/17/16. https://www.tcomn.com

 

 

 

 

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