complete guide for surgical techniques used in repair of extensor tendon injury with post operative splinting and physiotherapy programs.

1. Hand rehabilitation after
Extensor tendon injury repair
By:
Dr.Mohammed Abd Alhussein
Plastic surgeon
Baghdad university -Alkindy
college of medicine

2. • Hand rehabilitation after extensor
tendon repair differ according to injury
zone .
• There are many protocols e.g.
immobilization
Passive or active mobilization .
Most currently used protocols are
combination of these protocols.

3. Injury zones

4. Zone I Injuries
• Injuries to the distal end of the extensor
tendon mechanism in zone I are also
known as mallet finger injuries
• Splinting remains the hallmark of
treatment for most mallet finger
injuries, especially closed injuries
without subluxation of the distal
phalanx.

5. •The mallet finger splint is best customized. To increase
patient compliance and avoid the complication of tissue
maceration and necrosis.
•The DIP joint should be placed into slight hyperextension.
•The PIP joint is left free, and immediate range-of-motion
exercising of this and all other joints is continued.
•All patients should be continuously splinted for 6 to 8
weeks.
•After 6 to 8 weeks, the splint is removed. If there is no
extensor lag, the patient is progressed to night splinting for
an additional 2 weeks, after which the splint is discontinued.
•If extensor lag remains, the patient is again splinted for
another 6 weeks or until the extensor lag has resolved.
•The patient may then need controlled active flexion
exercises to regain DIP flexion.

6. Stack splint.

7. Aluminum splint.

8. Zone 2 Extensor Tendon
Injuries
• Zone II injuries, which occur at the level
of the middle phalanx of the fingers or
proximal phalanx of the thumb.
• For complete tendon lacerations
requiring repair, splinting protocols are
similar to those for zone I mallet finger
injuries.

10. Zone III Injuries
• Zone III injuries, which occur over the
PIP joints, consist of disruption of the
central slip from the base of the middle
phalanx.

12. • In both closed injuries and postprocedure repaired
central slip injuries:
• the finger is placed into a splint with the PIP joint
extended and the DIP joint left free.
• At 3 weeks, the patient is placed into a spring-loaded
splint, which
• allows for active PIP flexion and passive extension. The
splint is worn at all times up to 8 weeks .
• Night splinting and active and passive range-of-motion
exercises are instituted between 8 and 11 weeks after the
operation.

15. Zone IV Injuries
• the hand Immobilized in wrist extension
,MCP joint flexion IP joint extended for 4
weeks .
• Early, controlled, active or passive range-
of-motion protocols indicated in a
properly selected patient only.
• Thumb zone 4 tendon large enough that
can be repaired by core suture so Early,
controlled, active or passive range-of-
motion protocols can be initiated.

17. Zone V Injuries
• Involve tendon laceration alone or with
sagital band laceration which could be
open laceration or closed rupture.

18. • If tendon laceration alone which repaired
by core suture then splinting the hand in
wrist extension MCP joint 30 degree
flexion the IPJ. Allowed for active motion
.
• early motion rehabilitation can be used in
selected patient with dynamic extension
splinting within the limits defined at
surgery.

19. Sagittal band injuries
• Open sagital band injury repaired by
mattress suture then buddy splinting to
adjacent finger for 3 weeks which allow
gentle mobilization.
• closed Sagittal band injuries that do not
cause EDC subluxation may be treated
with “buddy taping” to an adjacent
digit for 4 weeks.

20. • Closed Sagittal band injuries with EDC subluxation
that are seen within 3 weeks of injury may be
treated non operatively.
• An MP joint flexion block splint, or “sagittal band”
splint, may be used to limit MP joint flexion of the
involved finger.
• The splint is applied to hold the injured MP joint in
25 to 35 degrees of hyperextension compared with
the adjacent MP joints. It is recommended that the
splint be worn full-time for 8 weeks.
• Active motion of the MP and IP joints is permitted
with the splint in place.

21. sagittal band splint

23. buddy taping

24. Zone 6 and 7 Injuries
• Postoperatively, either static or dynamic
splinting may be employed.
• Static splinting involves wrist extension of 30 to
45 degrees, MP joints at neutral to 15 degrees of
flexion, and IP joints free for active range of
motion.
• Dynamic splinting involves wrist extension,
dynamic rubber band MP joint extension, and
Active MP joint flexion to the level of repair
tension determined at the time of surgery.

25. Zones VIII/IX
• Adequate repair of muscles and tendons can be
very difficult in this area. Sutures of muscle
fibers alone have virtually no tensile strength.
Therefore an effort should be made to suture
tendons or fascial layers instead of muscle
fibers alone.
• these sutures are usually not strong enough for
dynamic postoperative treatment protocols and
immobilization for 3–4 weeks should be
initiated postoperatively.

26. Standard rehabilitation in zones
VI through IX injury
• Following tendon repair inpatients are
placed in a static volar splint with the
wrist in 30 degrees of extension, the
MCP joints in 0 to 15 degrees of flexion,
and the interphalangeal (IP) joints in
full extension.

27. • The splint is worn at all times and no
active or passive motion is allowed at
the fingers.
• While wearing the splint, the patient
may start passive MCP hyperextension
exercises.

28. • Between 3 and 6 weeks, the patient is
placed into a dynamic splint with the wrist
in 30 degrees extension, the MCP is in
increasing flexion, and the IP joints are
held in full dynamic extension by the
splint.
• Guarded active flexion is begun at the IP
joints, using a volar guard to block the
amount of flexion allowed.
• The static splint should be worn at night.

29. • Between 6 and 8 weeks, the patient
may begin exercises, consisting of active
digital flexion with the wrist in
extension and active finger extension,
out of the splint.
• Wrist flexion and extension are also
begun with the fingers in a relaxed,
extended posture.

30. • At 8 to 12 weeks postrepair, the patient
is slowly weaned from the splints. Full
range of motion is allowed with the
avoidance of simultaneous finger and
wrist flexion.
• The patient should also start light grip-
strength activities.

31. • At 12 weeks postoperative, the patient
is allowed to flex both the fingers and
thewrist.
• These protocols may be advanced more
quickly in the compliant patient.

32. Dynamic splinting
• It can be used early from 2nd postoperative
day in zone 4,5,6,7 when early
mobilization protocol used.
• It should be started later after 3rd week
when static splint protocol used.
• It should be started later after 3rd week in
zone 8,9.
• It used to the end of 8 weeks.
• 10 movement in hour in a day time.

33. Dynamic splint for early motion
of extensor tendon injuries.

35. Suture technique in different
zones

36. Controlled active
mobilization
• involves active joint extension.
• limiting joint flexion with a palmar
splint to allow MP joint flexion to about
30 degrees.
• it is called (“short arc motion”) which
used in zone III–V only.

37. Controlled active
mobilization
• For the protocol, three finger splints are required.
• The affected digit is immobilized between training sessions in
an extension split in 0° extension of the DIP and PIP joints.
• At every waking hour, the splint is removed and a controlled
active motion protocol is followed.
• First a splint is put on to block flexion of the PIP joint at 30° and
flexion of the DIP at 20–25°. After 20 repetitions of active and
passive motion within the defined limits,
• a third splint is put on that stabilizes the PIP joint in 0°
extension while sparing the DIP joint. The patient then actively
extends and flexes the DIP joint 20 times.
• During the second and third week of the protocol, flexion of the
PIP joint is increased to 40° and 50°

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