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Post Op Care: for Flexor Tendon Repair

- Discussion:
    - initial postop plaster splint holds the wrist in 20 degree flexion, MP joints in at least 60 degree flexion, and digits should be held in extension inorder to avoid contractures;
    - motion is begun after a few days, once it is clear that the wounds are healing well;
    - early motion is started to decrease tendon adhesions & to improve digit motion;
    - active extension and passive flexion of the tendons are begun within 24 hrs;
    - a 4 strand core suture w/ a locked running epitendinous repair should allow light active tendon motion;
    - typically 10 times per hour;
    - between these sessions of hourly exercises and while the pt is asleep IP joints of fingers & thumb are maintained in extension by rubber band traction;
    - tendon excursion:
          - 9 cm of tendon excursion may occur w/ simultaneous wrist and finger flexion, where as only 2.5 cm of tendon excursion occurs w/ isolated digital motion;

- FDS Motion: flex PIP joint w/ the adjacent joints held in extension;

- FDP Motion: immobilize the PIP joint and flex the DIP joint;

- Kleinert Splint:
    - combines dorsal extension block w/ rubber-band traction proximal to wrist;
    - this passively flexes the fingers, and the patient actively extends within the limits of the splint;
    - originally, included a nylon loop placed thru the nail, and around the nail is placed a rubber band;
    - rubber band is inserted into the dressing (via paper clip), over distal radius;
    - this passively flexes fingers, & pt actively extends w/ in limits of the splint;
    - originally, rubber bands were applied for only 1-2 hrs / day, inorder to avoid finger flexion contractures;

- Brooke Army Hospital Splint:
    - uses rubber band traction to passively flex the fingers, but traction is thru pulley at distal palmar crease, which increases passive flexion at the IP joint;
    - during active extension exercises, pt is instructed to hold MP joint in flexed position and then to extend fully IP joints;
           - full excursion of IP joints is obtained while tendon is protected;
    - modified splint:
          - wrist and MP joints are held flexed (20 deg short of full flexion);
          - straps are placed at forearm, wrist, MP joints;
          - rubber band and nylon suture extend from nail to MP joint strap to the forearm strap;
          - when performing active extension exercises, the patient holds the MP joint in flexion;
                  - it is important the the patient concentrate on fully extending the PIP joint (inorder to avoid contracture);
          - patient should perform hourly active extension exercises;

- Passive Motion: (used in conjunction w/ Kleinert or Brooks splint)
    - patient needs to perform twice daily passive motion inorder to achieve full extension and flexion;
           - passive motion should also focus on individual ROM of the DIP and PIP joints, in order to maximize the excursion of the FDP and FDS, respectively;
           - some surgeons insist that the patient be seen everyday for 2 weeks to ensure compliance;
    - passive motion should continue beyond 2 weeks if the patient lacks full active extension;

- Medications:
    - three meds have been shown to decrease adhesions in animal studies;
          - ibuprofen, beta amino propionitrile, and steroids;
    - references:
          - Effects of Nonsteroidal Anti-Inflammatory Drugs on Flexor Tendon Adhesion

- Effects of Time on Tendon Healing:
    - strength duration curve show that healing is weak at 21 days, but of sufficient strength to tolerate active contraction of muscle;
    - at 6 weeks, external elastic traction can be applied if force is not excessive;
    - some surgeons allow gentle active ROM at 6 weeks;
    - at 3 months, moderate stress can be applied to the flexor tendon in both flexion and extension;
    - at 8 months, full tensile strength has been recovered

Influences of the protected passive mobilization interval on flexor tendon healing. A prospective randomized clinical study.

Effects of constant mechanical tension on the healing of rabbit flexor tendons.

Tendon excursions after flexor tendon repair in zone. II: Results with a new controlled-motion program.

The correlation between controlled range of motion with dynamic traction and results after flexor tendon repair in zone II.

Early postoperative mobilization of flexor tendon injuries using a modification of the Kleinert technique

The rupture rate of acute flexor tendon repairs mobilized by the controlled active motion regimen.

Flexor tendon repair in zone 2 followed by controlled active mobilisation.

Early active mobilisation following flexor tendon repair in zone 2

A combined regimen of controlled motion following flexor tendon repair in "No Man's Land."  

Ultrasonographic Assessment of Flexor Tendon Mobilization: Effect of Different Protocols on Tendon Excursion

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