lecture 21(Extensor Tendon Injuries) .pdf

Tendon injuries

1. TENDON INJURIES II
DR. MONA M IBRAHIM
MSC, PHD IN ORTHOPEDIC PHYSICAL THERAPY
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2. •Tendon are cord like structures that
connect muscles to bone
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3. EXTENSOR
TENDON
INJURIES
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4. EXTENSOR MECHANISM
INJURIES ARE GROUPED INTO
EIGHT ANATOMIC ZONES
Odd number zones overlie
the joint levels so that zones
1, 3, 5, and 7 correspond to
the DIP, PIP, MCP, and wrist
joint respectively
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5. EXTENSOR TENDON INJURIES
•The normal extensor mechanism depends on the
cooperation between the intrinsic muscles of the hand
and the extrinsic extensor tendon. Any injury at one
zone typically produces compensatory imbalance in
the neighboring zones.
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6. EXTENSOR TENDON INJURIES
•Disruption of the terminal slip of the extensor tendon
allow the extensor mechanism to migrate proximally
and exert a hyperextension force to the PIP joint by the
central slip attachment. Thus, extensor tendon injuries
cannot be considered simply static disorders
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7. CAUSES OF EXTENSOR TENDON
INJURIES
•Cut to hand or fingers
•Over stretching to fingers such as when catching a
baseball
•Direct blow to the fingers
•Weak tendons due to general health problem e.g. RA
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8. TREATMENT GOALS
•Preventtendon rupture
•Promote tendon healing
•Encourage tendon gliding while minimizing tendon
gapping and extensor lag
•Restore AROM and PROM
•Edema control
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9. TREATMENT GOALS
•Pain control
•Scar management
•Maintain full range of motion (ROM) of all
uninvolved joints of the affected upper extremity
•Return to previous level of function
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10. TREATMENT OF EXTENSOR
TENDON INJURIES
Non operative
•Cut < 50% of tendon
Operative surgical intervention
•Cut > 50% of tendon
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11. NON-OPERATIVE TREATMENT OF
EXTENSOR TENDON INJURY
•Immobilization with early protected
motion just as flexor tendon injuries
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12. NON-OPERATIVE TREATMENT OF
EXTENSOR TENDON INJURY
•DIP extension splinting
•PIP extension splinting
•MCP extension splinting
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13. DIPEXTENSION SPLINTING
Indications:
•Acute (<12 weeks) Zone 1 injury (mallet finger)
•Nondisplaced bony mallet
•Chronic mallet finger (>12 weeks) if joint supple, congruent
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14. DIPEXTENSION SPLINTING
Techniques
•Full-time splinting for six weeks
•Part-time splinting for four to six weeks
•Avoid hyperextension, which may cause skin necrosis
•Maintain PIP motion
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15. PIPEXTENSION SPLINTING
Indications:
•Closed central slip injury (zone III)
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16. PIPEXTENSION SPLINTING
Techniques
•Full-time splinting for six weeks
•Part-time splinting for four to six
weeks
•Maintain DIP flexion
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17. MCPEXTENSION SPLINTING
Indications:
Closed zone V sagittal band rupture
Techniques
•Full-time splinting for four to six
weeks
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18. POSTOPERATIVE PRECAUTIONS FOR
THERAPY
1)Infection
2)Combined flexor tendon repair
3)Associated injuries: fractures, nerve repairs, vessel
repairs
4)Type and strength of repair; degree of tendon
shortening
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19. POSTOPERATIVE PRECAUTIONS FOR
THERAPY
5) Extreme pain
6) Severe edema
7) The patient’s level of understanding of his or
her injury and ability to comply with the
protocol
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20. POSTOPERATIVE PRECAUTIONS FOR
THERAPY
•Extension lag: the patient's ability to extend needs to be
monitored closely as activities in finger flexion progress
•The flexors are threeto four times as strong as the extensors
•The goal is to maintainor improve extension as flexion
progresses.
•It is much easier to preventan extension lag than it is to fix one.
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21. POSTOPERATIVE THERAPY
GENERAL CONSIDERATIONS
•Wound care: universal precautions should be used when performing
dressing changes and exercises. Dressingsshould not be constrictive
and interfere with ROM exercises.
•Edema control: as in the case of acute hand injuries, the effective
management of edema is critical for a successful outcome.
Postoperative edema needs to be monitored closely as prolonged or
severe edema can cause increased adhesions and decrease the ability to
mobilize the joints.
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22. POSTOPERATIVE THERAPY
GENERAL CONSIDERATIONS
•Edema control: Postoperative edema should gradually subside over
2-3 weeks, Edema control includes:
1.Elevation of the injury to above the level of the heart to reduce limb
dependency
2.The use of light compressive dressings
3.Kinesio tape
4.Active exercise.
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23. POSTOPERATIVE THERAPY
GENERAL CONSIDERATIONS
•Pain management:
Pain, if present, needs to be managed effectively so that patients
can participate in therapy and in their home exercise programs.
Transcutaneous electrical nerve stimulation (TENS), high-
voltage galvanic stimulation (HVGS), and other types of
electrical stimulation can be helpful in reducing postoperative
discomfort.
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24. EXTENSOR TENDON INJURIES IN
ZONES I AND II
•Flexion deformity of the DIP
joint, commonly referred to as
the mallet
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25. TREATMENT
•A custom-molded thermoplastic
splint, or aluminum foam splint.
The patient wears the splint
continuously for 6-7 weeks
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26. TREATMENT
1.Gentle AROM in flexion after
6-7 weeks, no more than 20-
25 of active flexion in the first
week
2.Prehension and coordination
exercises
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27. EXTENSOR TENDON INJURIES IN
ZONES III AND IV
•Early Active Short Arc Motion (SAM)
protocol:
Motionbegins as early as 24 hours after surgery
`
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28. EARLY ACTIVE SHORT ARC MOTION
(SAM) PROTOCOL
1. A volar thermoplastic orthosis
involved digit with the PIP and DIP at 0 degrees and is
always worn excluding during exercise.
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29. EARLY ACTIVE SHORT ARC MOTION
(SAM) PROTOCOL
2. Two template orthoses
usedduring active exercises to control the excursion of
the repaired tendon and the application of stress
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30. EARLY ACTIVE SHORT ARC
MOTION (SAM) PROTOCOL
a. Template orthosis 1
Allows 30 degrees of PIP flexion and 20 to 25 degrees
of DIP flexion
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31. EARLY ACTIVE SHORT ARC MOTION
(SAM) PROTOCOL
b. Template orthosis 2
•Supports the PIP at neutral and allows DIP flexion.
A B
C
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32. EARLY ACTIVE SHORT ARC MOTION
(SAM) PROTOCOL
3. Exercises
•Performed every waking hour for 20 repetitions per template each
session.
•The exercise slowly with hold at extended position.
•The position of wrist for 30°flexion and MCP joint is at neutral or slight
flexion
•This position reduces the resistance of the flexors and facilitates
assistance of the interossei in PIP extension.
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33. EARLY ACTIVE SHORT ARC MOTION
(SAM) PROTOCOL
4. Progression of PIP ROM
•If no PIP extension lag develops after 2 weeks of controlled
motion at 30 degrees of flexion, template orthosis 1 adjusted to
allow 40 degrees flexion; 50 degrees flexion is allowed at 4
weeks postoperatively
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34. EARLY ACTIVE SHORT ARC MOTION
(SAM) PROTOCOL
4. Progression of PIP ROM
If a PIP extension lag develops, continue limiting excursion at
30 degrees flexion and contactthe referring physician to discuss
further progression. Depending on the severity of the lag, it may
be necessary to resume fulltime orthosis use for 1 to 2 weeks.
Exercise should always emphasis active extension only with
continued extension orthosis use in between exercise sessions.
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35. EARLY ACTIVE SHORT ARC MOTION
(SAM) PROTOCOL
5. Remove orthosis at 6 weeks
•Patients can be discharged with a home program of
exercise and strengthening.
•Patients who still have limitations in ROM may
benefit from further supervised therapy at this point.
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36. EARLY ACTIVE SHORT ARC MOTION
(SAM) PROTOCOL
6. Begin light use of the hand and progress to
strengthening at 8 weeks. The degree of extension lag needs
to be monitored closely as activities and use of the hand are
progressed
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37. FINGER AND
WRIST
EXTENSORS
TENDON
INJURIES IN
ZONES V AND
VI, AND VII
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38. EARLY PASSIVE MOTION PROTOCOL
1.24h-3 days post operative
a. Two-part dynamic orthosis
(1) Dorsal component: dynamic MCP
extension orthosis with MCPs supported at neutral; the
wrist is positioned at 30 degrees extension.
(2) Interlocking volar component: MCPs permitting active
flexion of 30 degrees for finger flexion
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39. EARLY PASSIVE MOTION PROTOCOL
1.24h-3 days post operative
b. Exercises
•Orthosis adjustment to monitor tension on the outrigger to
maintain extension to neutral
•Controlled IP PROM
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40. EARLY PASSIVE MOTION PROTOCOL
3 weeks post operative
a. Orthosis
•Continue use of the dorsal dynamic
orthosis.
•Night: wear the volar static orthosis
(adjusted to 30 degrees wrist extension and
0 degrees MCP/IP extension).
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41. EARLY PASSIVE MOTION PROTOCOL
3 weeks post operative
a. Exercises
•Begin protected gradual active motion of MCP and IP
joints within the dynamic extension orthosis.
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42. EARLY PASSIVE MOTION PROTOCOL
4-5 weeks post operative
•Initiate composite finger flexion with the wrist in
extension.
•Orthosis use continues between exercise sessions
and at night until 6 to 8 weeks postoperatively,
depending on the tendons involved and the
patient's ability to maintain extension.
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43. EARLY PASSIVE MOTION PROTOCOL
6-12 weeks post operative
•Continue use of the protective orthosis up to 8
weeks due to the load requirements of the wrist
extensor tendons.
•Progressive strengthening exercises for wrist and
fingers
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44. 11/18/2020Mona M Ibrahim

45. REFERENCES
•BrotzmanS Brent and ManskeRobert C: Clinical
orthopedic rehabilitation, evidence based
approach 3
rd
edition 2011,
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