Week 13 - Flexor Tendon Injuries Flashcards
name 2 examples of closed flexor tendon injuries
- punctures
- forced extension during finger flexion
name an example of a closed flexor tendon injury.
“jersey injury” FDP rupture from distal insertion while grabbing players jersey
usually associated with other neurovascular deficits
open flexor tendon injuries
name the 4 superficial flexor tendons of forearm.
- pronator teres
- flexor carpi radialis
- palmaris longus
- flexor carpi ulnaris
name the intermediate flexor tendon of the forearm.
flexor digitorum superficialis
name the 2 deep flexor tendons of the forearm.
- flexor digitorum profundus
- flexor pollicis longus
travels through carpal tunnel to base of proximal phalanx
FDS
travels through carpal tunnel and through camper’s chiasm becoming more superficial to DIP
FDP
name the 2 flexor tendons that travel to the fingers.
FDS and FDP
between joints
annular pulleys
over joints
cruciform pulleys
what is the role of the pulley system?
keep tendons close to bone for mechanical advantage (prevent bowstringing)
what is a jersey injury?
hyperextension of PIP causing FDP to rupture/pull out
- pulling up of tendon without pulleys
- can’t make a full fist
bowstringing
name the 2 sources of nutrition for tendons.
- perfusion
- diffusion
blood enters tendon
perfusion
extrinsic via synovial fluid; degree of difference in concentration (surrounding area)
diffusion
what are critical for bringing blood to tendon?
vincula
the passages of fluid through the circulatory system (blood stream) or lymphatic system to an organ or tissue, usually referring to the delivery of blood to an area
perfusion
the tendency of the molecules of a substance (gas, liquid, or solid) to move from a region of high concentration to one of lower concentration. ex: oxygen and co2
diffusion
zone 1 - flexor tendon
FDP only
- “no man’s land”
- insertion of FDS to A1
zone II
lumbrical origin in palm
zone III
carpal tunnel
zone IV
proximal to CT in forearm
zone V
zone I
FDP only
zone II
- no man’s land
- insertion of FDS to A1
zone III
lumbrical origin in palm
zone IV
carpal tunnel
zone V
proximal to CT in forearm
what is the optimal time of flexor tendon repair?
within 24 hours of injury
unrepaired tendons develop which 2 things?
- adhesions
- scar which impedes restoring full function
unlike extensor tendons, flexors can what?
retract into forearm if not repaired
name 3 key outcomes of “wide awake” flexor tendon surgeries.
- decreases rupture rates
- decreases tenolysis rates
- facilitates active protected movement after surgery
surgery needed to clean tendon scarring
tenolysis
name 2 aspects of flexor tendon injury post operative care and rehab (OT).
- precautions to safely participate in their ADLs
- educate the pt. on one handed techniques.
describe rehab during the first 2 to 4 days post surgery.
keep the hand elevated and immobile in an orthosis with the wrist in comfortable extension.
describe a flexor tendon orthosis 2 to 4 days post surgery.
- wrist in comfortable extension
- MCP joint flexed to 80-90 and PIP and DIP joints extended
describe OT rehab on days 4 to 21 post surgery.
- full active extension of IP joints with MP joints flexed.
- passively warm up MP, PIP, and DIP joints to decrease friction and work of the tendons before starting active movement.
- midrange active movement: pts. make half a fist, 45 degrees flexion of each of MP, PIP, and DIP joints active flexion
name the general goals of OT rehab in flexor tendon injuries.
- assist development of strong tendon
- assist freely gliding tendon
- be careful to maintain joint mobility
- STRIKE BALANCE - between protection and application of controlled stress
name the 5 methods of flexor tendon rehab.
- immobilization
- immediate passive flexion
- delayed mobilization
- early active flexion
- immediate active flexion
*what is the splint called that is used for flexor tendon injuries?
dorsal blocking splint
describe the positioning of a dorsal blocking splint.
- wrist: 20-30 degrees flexion
- MCP: 50-70 degrees flexion
- PIPs/DIPs: extension
which populations should be immobilized during flexor tendon injuries?
- children under 12 years old
- adults with cog./psych issues
- other injuries (fractures, burns, skin grafts)
how long should a flexor tendon splint/cast be in place (immobilized)?
3-5 weeks
how should an OT exercise the pt. when immobilized in splint post flexor tendon injury?
- passive if possible in splint to maintain joint mobility
- edema control
name 2 purposes of the dorsal blocking splint.
- shortens flexors a little
- prevents pts. from over pulling tendons
no matter which protocol you follow you will likely make which type of splint?
dorsal blocking splint
what is the immediate passive protocol also known as?
modified duran
name a protocol that does “immediate active”?
indiana protocol
describe the indiana protocol.
- 1st - passively flex fingers into palm
- actively hold fingers down
- PLACE/HOLD
- 2nd - active fist and straighten fingers within splint
how many splints are required in the indiana protocol?
2
describe the indiana protocol (2nd - hinged splint).
- passively extend wrist while simultaneously holding fingers in flexion
- after 5 seconds, relax the muscle contraction and allow wrist to drop into flexion - automatically allows fingers to gently straighten.
name 3 main exercises of the indiana protocol.
- place/hold, then flex wrist
- actively make a fist (composite and hook) followed by active extension
- blocking exercises
describe general time frame of PROM and AROM.
passive flexion active extension right away
what is place/hold also known as?
tenodesis
- begins in all protocols eventually
- requires 1 tendon to do all the work
blocking
eventually needs to be done in all flexor tendon injuries.
tendon gliding
used to hold the space of a tendon
hunter rod
what type of motion is used when hunter rod is in?
must be PROM
name 4 OT goals used for hunter rod patients.
- control edema
- manage scar
- improve/maintain joint mobility especially PIP joint
- begin tendon rehab after tendon graft
name 4 treatments used for adhesions restricting tendon glide.
- blocking
- NMES
- scar massage/release techniques
- ultrasound (8th week)
name 2 treatment methods for decreased tendon length restricting extension at 2 or more joints.
- ultrasound (8th week)
- dynamic or static progressive extension splinting
name 3 treatment methods for flexion contractures of PIP or DIP joints.
- heat with stretch in direction of limitation
- dynamic or static progressive splint
- joint mobilization techniques
name 5 treatment methods for skin to tendon adherence.
- ultrasound for scar softening
- stretch scar adhesion
- myofascial release
- friction massage
- NMES to involved finger (move skin in opposite direction)
describe the duran protocol.
- passive digital flexion and extension within a protective orthosis
- gentle active motion begins with medical clearance about 4 weeks after surgery.
when does AROM (flexion) of digits usually begin for flexor tendon injuries?
4 to 6 weeks from initial repair and increases in frequency and intensity until full function (12 weeks after repair)
name 2 typical early techniques following the discontinuation of the dorsal protective orthosis.
- tendon gliding exercises
- place and hold exercises
in general, describe the duran protocol.
passive flexion and extension of fingers
when does strengthening begin?
week 8
when is the splint not used anymore?
6 weeks
