Medbridge Tendon rehabilitation Flashcards
Supplementary info
Camper’s Chiasm
area where FDS splints just proximal to the PIP, where the FDS tendons rotate 180* and insert deep to FDP tendon
Annular pulleys
A1-A5 over joints, perform heavy lifting
Vincula
Blood supply to dorsal 2/3 of flexor tendon within digital sheath (volar aspect of tendon is avascular zone)
Linburg-Comstock tenodesis
Connection between FPL and fDP of index finger. Flexion of thumb IP>obligatory flexion of index DIP. (full index extension limits thumb IP flexion)
Junctura tendinae
side to side connection between middle ring small fingers.
Lumbrical
only muscle with no bony origin or insertion. proprioceptive function, PIP and DIP extension
Paradoxical extension
occurs when unrestricted finger flexion results in PIP and DIP extension. Increased tension in lumbrical due to injury or scarring or excessive length in FDP tendon (too long tendon graft) can result in paradoxical extension. Also known as lumbrical plus finger.
Quadriga
finger stiffness or adhesions of one finger FDP tendon prevents full FDP excursion of remaining fingers. Only affects middle ring small bc of common muscle belly. Flexion of one limits flexion of all. Can occur with digit amputation or excessive scarring of one FDP tendon. Causes limitations on composite finger flexion and weakness with grip
Timing of Flexor tendon repair
Primary repair <2 weeks
Delayed primary repair 2-5 weeks
Secondary: tendon graft >5 weeks
Extrinsic vs. Intrinsic healing of tendons
Extrinsic - relies on granulation tissue/scar from surrounding areas to heal tendon.
Intrinsic - relies on tenocytes within tendon to heal injury
Tendons heal by combination of intrinsic and extrinsic means. Differential gliding is the only way to modulate adhesion formation.
Phases of wound healing
0-10 days inflammatory stage
3-10 days proliferative stage
30-270 days remodeling stage
Epitendinous stitch
running stitch around tendon and tidies repair improving gliding. increases the strength of the repair by 21%
Tensile strength of tendon after repair
weakest at 4-9 days, considered healed at 3 months
Flexor tendon repair protocol: Immobilization
children, cognitively impaired, noncompliant
orthosis: wrist slight flexion, MP flexion, IP extension
Immobilize 3-4 weeks
Then modify splint to neutral, passive finger flexion and extension with wrist 10* extension
active tendon glides
6 weeks discontinue orthosis, begin gentle blocking, light resistance 1 week later
Flexor tendon protocol: early passive mobilization
rationale: beneficial in promoting synovial diffusion for healing, inhibiting dense adhesion formation
Indiana modified duran vs. Kleinert
Indiana Modified Duran flexor tendon protocol
Indiana Modified Duran
orthosis: dorsal block ip to 25* extension, MPs 45-60 flexion, IP full extension (used to be wrist flexion)
protocol: 1-3 weeks passive flexion with active IP extension within orthosis
Week 3: add active finger flexion and extension within orthosis
week 4: remove orthosis for tenodesis, place and hold active flexion, composite flexion, extension
week 6 d/c orthosis begin passive PIP extension, gentle blocking
week 7 dynamic extension orthosis for PIP flex contracture
week 8: light resistance with putty>hand exerciser
weeks 10-12: 5 lb max
heavy lifting by 4 months
Flexor tendon repair protocol modified Kleinert
orthosis: originally rubber band traction to maintain flexion but resulted in contractures. now protected extension at night. dorsal block orthosis with wrist 45 flexion, MP 45 flexion IP full extension
summary:
weeks 0-4/6: active IP extension with rubber bands for flexion
weeks 4-6: remove orthosis for wrist motion, gentle active flexion of fingers
week 6: d/c dorsal block, initiate tendon gliding
week 6-8: gentle resistance depending on gliding (delay if good)
week 12: normal activity
