Flexor Tendons

Question 1

Describe the splint used in the rehabilitation of flexor tendons

Answer 1

Ezeform flexor hood, wrist 0-30 degrees extension, MCPJs 45 degrees flexion, IPJs neutral. Use elastic with alpha for top strap. Wear full time - can remove for exercises if patient compliant

Question 2

What are the aims of the exercises in the flexor tendon protocol?

Answer 2

• Differential glide of repaired tendons without attenuation at repair site
  -Regaining passive flexion, decreasing oedema
  -Regaining extension - blocked or to splint
  -Active flexion to comfortable mid range without resistance
  -Aim to increase flexion gradually over first four weeks

Question 3

What are the primary exercises in flexor tendon rehab?

Answer 3

-Passive flexion of individual digits - fist and hook for 30 seconds
-Tenodesis
-Blocked active IPJ extension (10x hourly for zones 1/2) OR active extension of fingers to splint for zones 3,4,5 or those without PIPJ contractures
-Fully mobilise everything else

Question 4

What are the secondary exercises in flexor tendon rehab?

Answer 4

• Active flexion, all digits together, fist, hook, flat fist
  -Flat fist for FDS rehab - can be done individually due to separate muscle bellies
  -Abduction / adduction for zone 3-4 repairs / significant oedema
  -Consider place and hold exercises for those struggling with active flexion

Question 5

Why should you see flexors after 3-5 days?

Answer 5

To allow inflammation to settle before starting an exercise regime.

Question 6

How frequently should a flexor be seen initially?

Answer 6

Weekly for the first 4 weeks, unless progressing exceptionally well.

Question 7

Name some techniques to try if the patient is anxious to move

Answer 7

-Reassurance and encouragement
-massage of upper forearm
-bilateral movements
-imagined movement
-simplify exercise regime

Question 8

How should your regime change at week 4?

Answer 8

-Wean splint to NT and protection
-Continuation of previous HEP - aiming for full AROM of all fingers / joints + normal tenodesis
- resistance into extension if extension poor
-VERY light function

Question 9

How should your regime change at week 6?

Answer 9

-Discontinue NT splint
-Light resistance into flexion

Question 10

What approaches can help if the patient develops a marked FFD?

Answer 10

-?volar splint during the day
-?continue with dorsal block splint with top strap at night
-?protected passive extension - pt must understand this well
-If poor flexion: ?lateral blocked flexion if patient has good understanding

Question 11

How should your regime change at week 8?

Answer 11

-Introduce passive extension
-Gentle blocked active flexion acceptable
-increase resistance
-increase function (driving)

Question 12

How should your regime change at week 10?

Answer 12

-Increase blocked active flexion
-Increase resistance

Question 13

Describe the extension-flexion test that the surgeon should perform

Answer 13

1: Full extension to see if gapping occurs
2: Mild to moderate flexion of the digit to observe whether the tendon can passively glide
3: Marked / full flexion of the digit to ensure the repair site doesn’t impinge on the pulley / sheath - this is done actively or passively dependant on whether or not WALANT was used

Question 14

Why do we begin exercise after 3 days?

Answer 14

Collagen will not form at this point so adhesions will not have formed.

Question 15

When should passive and active exercises be started?

Answer 15

Passive: 3 days ideally
Active: 2-3 days after active

Question 16

What complications can severe oedema cause in the initial stages post-repair? What can be done about this?

Answer 16

increased risk of rupture / gapping.
Consider coflex and a few days rest. If this continues consider a passive gliding program

Question 17

How should passive and active exercises relate to one another?

Answer 17

Passive exercises should be seen as a “warm up” - do these until the finger feels supple and then start active exercises.

Question 18

Why should tenodesis be encouraged?

Answer 18

To support active tendon glide

Question 19

Why do we limit the arc of flexion initially?

Answer 19

This limits force on the flexor tendons allowing for active excursion through the pulleys.
Furthermore, increased force and strain may cause gapping of the tendon or tendon rupture

Question 20

Why might you encourage exercises with wrist extension / slight MCPJ flexion?

Answer 20

To overcome the force of the extrinsic extensors

Question 21

What must be promoted to prevent adherence of the FDS to the FDP?

Answer 21

Differential glide

Question 22

Which exercises promote differential glide?

Answer 22

Flat fist, Active hook, Full fist

Question 23

In zone 2 flexor tendon repairs, what impact does flexion of the MCPJ have?

Answer 23

None - it does not produce glide in zone 2.

Question 24

Describe the different flexor zones.

Answer 24

Zone 4: Over the carpals and carpal tunnel

Zone 3+: The distal crease of the palm, where the tendons exit the carpal tunnel and enter the fingers.

Zone 2: (No Man’s Land): The proximal phalanx, where the tendons pass through a fibro-osseous digital canal and interweave with each other. This zone is notorious for its complexity and difficulty in repair due to the risk of adhesion formation and limited mobility.

Zone 1: The distal phalanx, where the tendons insert onto the distal phalanges.

Question 25

which position of the fingers indicates maximal differential glide of the FDS and FDP?

Answer 25

Full active hook
Tidbit: active hook provides:
-max interosseous elongation
-max lumbrical elongation
-max lymphatic pumping
-max joint movement distal to laceration

Question 26

What decreases as the curvature of the gliding arc of the FDS and FDP increases?

Answer 26

Repair strength and gap resistance of the tendon.

Question 27

Which joints need to move in order for differential glide to take place?

Answer 27

PIPJ and DIPJ

Question 28

What are the two sources of flexor tendon nutrition?

Answer 28

Vascular, Synovial