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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
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
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
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
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
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
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
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
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
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
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
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