Extensor System Anatomy--Tendon System
Extensor System Anatomy--Zones of Injury
Tendon Healing Phase
~Exudative phase
- 0~4 days Inflammatory response
~Fibroblastic phase
- 5~21 days Collagen synthesis
~Remodeling phase
- 3wk~6mo/1yr Scar remodeling
History Review
~A study of the dynamic anatomy of extensor tendons and implication for
treatment :
- Dynamic extensor tendon splint with elstic traction slings
- Palmar blocking limited MP flexion in the arc of motion Evans RB ,
Burkhalter J Hand Surgery
1986 ; 11A:774
~Early dynamic splinting of extensor tendons :
- Dynamic splint for MP flexion 70° , PIP flexion 70° , DIP flexion 50°
- Full extension in 77 / 82 , no rupture Browne EI , J Hand Surgery 1989
; 14A:72
~A comparison of results of extensor tendon repair followed by early
controlled mobilization versus
static immobilization :
- Faster recovery and return to work , better functional
results and avoidance of secondary
procedure in dynamic extension splint protocol
Chow JA , J Hand Surgery 1989 ; 14A:72
~Early controlled mobilization with dynamic splinting for treatment of
extensor tendons injuries :
- Injury distal to the MP joint had Poor results than those
proximal Hung LK , J Hand Surgery 1990;
15A:251
~Long - term results of extensor tendons repair : Newport ML , J Hand
Surgery 1990; 15A:961
~Wrist position and extensor tendons amplitude following repair :
- NO tension after extensor tendon repairs with full flexion
of the digits when the wrist in 45° of
extension Minamikawa , J Hand Surgery 1992;
17A:268
~Postoperative management of extensor tendon repairs in Zone V, VI, and
VII :
- Levame type , dorsal steel leaf blade spring protective splint for Zone
V, VI
- Tom splint for Zone VII Thomas D , Moutet F J Hand Therapy 1996 ;
9(4):309-14
~Immediate active short arc motion following extensor tendon repair :
- Active SAM with minimal tension and wrist tenodesis programs
- Safe and effective for Zones III, IV, V, VI, VII, T IV, TV Evans RB ,
Hand Clinics 1995 ;
11(3):483-512
Three components for Successful Extensor tendon rehabilitation
o Skilled surgeon
o Skilled hand therapist
o Cooperative patients
Extensor Tendon Repair
Zone I and Zone II (DIP and Mid-Phalanx)
o Possible Deformity ：Mallet Finger
o Major Types ：
o 1.Closed terminal tendon complete or incomplete rupture
o 2. Terminal tendon rupture combined articular avulsion fracture
Extensor Tendon Repair
Zone I and Zone II (DIP and Mid-Phalanx)
0 ~ 6 weeks
o Splint 1. custom made ( dorsal or volar )
2. stax splint ( commercial avalible )
o Keep DIP extension 0 or hyperextension
o PIP joint free
Extensor Tendon Repair
Zone I and Zone II (DIP and Mid-Phalanx)
0 ~ 6 weeks
o Exercise Program
- DIP joint ：Full immobilization
Not allow DIP flexion
When the splint is removed
- PIP joint and other unaffected joints：Active / Passive ROM
Extensor Tendon Repair
Zone I and Zone II (DIP and Mid-Phalanx)
6 ~ 8 weeks
o Splint 1. Protective splint ( dorsal or volar )
2. Blocking splint ( block PIP flexion when DIP
flexion exercise )
Extensor Tendon Repair
Zone I and Zone II (DIP and Mid-Phalanx)
6 ~ 8 weeks
o Exercise Program
- Allow DIP 20 ~ 25 flexion 1st week.Increased to 35 flexion 2nd week
- If extension lag occurred , 2 more weeks immobilization
Extensor Tendon Repair
Zone I and Zone II (DIP and Mid-Phalanx)
8 ~ 12 weeks
o Splint 1. Night splint ( keep DIP extension )
2.Template splint ( gradual progression flexion of DIP
starting at 20 ~ 25 )
Extensor Tendon Repair
Zone I and Zone II (DIP and Mid-Phalanx)
8 ~ 12 weeks
o Exercise Program - Gradually progress to composite. active/passive
flexion/extension
- If extension lag occurred , 2 more weeks immobilization
Extensor Tendon Repair
Zone I and Zone II (DIP and Mid-Phalanx)
12 weeks
o Splint ： Night splint discontinued - as long as no extensor lag
Extensor Tendon Repair
Zone I and Zone II (DIP and Mid-Phalanx)
12 weeks
o Exercise Program - Beginning resistive exercise. active/passive
flexion/extension
- ADL progressed to normal
Extensor Tendon Repair
Zone III and Zone IV (PIP and Proximal-Phalanx)
o Possible Deformity ：Traumatic Boutonnier Finger
- 1. Acute ：within 6 weeks of injury Central slip rupture, ORL
tight﹝-﹞
- 2. Chronic ：longer than 6 weeks Central slip rupture, ORL
tight﹝+﹞
Extensor Tendon Repair
Zone III and Zone IV (PIP and Proximal-Phalanx)
o Major Types ：1. Closed ：Forced flexion on active extended PIP
joint
2. Open ：laceration wound deep to central slip rupture
Extensor Tendon Repair
Zone III and Zone IV (PIP and Proximal-Phalanx)
0 ~ 6 weeks
o Splint ： Volar static gutter splint
1. Lateral band involved-PIP,DIP
immobilize
2. Lateral band uninvolved -PIP
immobilize only
o Keep PIP extension 0 or hyperextension
o MP joint free
Extensor Tendon Repair
Zone III and Zone IV (PIP and Proximal-Phalanx)
0 ~ 6 weeks
o Exercise Program ( 1 )
- PIP joint ：Full immobilization Not allow
PIP flexion When the splint is removed
- MP joint and other unaffected joints：
Active / Passive ROM
Extensor Tendon Repair
Zone III and Zone IV (PIP and Proximal-Phalanx)
0 ~ 6 weeks
o Exercise Program ( 2 )
- If lateral band uninvolved encourage DIP
flexion , but make sure PIP joint in extension position
Extensor Tendon Repair
Zone III and Zone IV (PIP and Proximal-Phalanx)
6 ~ 8 weeks
o Splint 1. Protective splint ( volar static gutter )
2.Dynamic extension splint ( as feedback during PIP flexion exercise )
Extensor Tendon Repair
Zone III and Zone IV (PIP and Proximal-Phalanx)
6 ~ 8 weeks
o Exercise Program
- Gradually increase PIP 30 flexion 1st week
Increased to 5 flexion per treatment session
- Monitor whether extension lag presence
- Monitor whether ORL tightness presence
Extensor Tendon Repair
Zone III and Zone IV (PIP and Proximal-Phalanx)
8 ~ 12 weeks
o Splint 1. Night splint ( keep PIP extension )
2.Template splint ( gradual progression flexion of PIP starting at 30
)
Extensor Tendon Repair
Zone III and Zone IV (PIP and Proximal-Phalanx)
8 ~ 12 weeks
o Exercise Program - Gradually progress to composite active/passive
flexion/extension
- If extension lag occurred , 2 more weeks immobilization
Extensor Tendon Repair
Zone III and Zone IV (PIP and Proximal-Phalanx)
12 weeks
o Splint ： Night splint discontinued - as long as no extensor lag
Extensor Tendon Repair
Zone III and Zone IV (PIP and Proximal-Phalanx)
12 weeks
o Exercise Program - Beginning resistive exercise active/passive
flexion/extension
- ADL progressed to normal
Extensor Tendon Repair
Zone V ~ Zone VII (Proximal to MP joint)
0 ~ 4 weeks
o Splint 1. Static volar splint
2. dynamic splint
o Keep wrist extension 40 ~ 45 , MP extension
o If wrist extensor repair only, immobilize wrist only
Extensor Tendon Repair
Zone V ~ Zone VII (Proximal to MP joint)
0 ~ 4 weeks
o Exercise Program
- Wrist joint ：Full immobilization
Not allow wrist drop
When the splint is removed
- PIP joints and MP joints： ROM exercise under therapist supervise
Extensor Tendon Repair
Zone V ~ Zone VII (Proximal to MP joint)
4 ~ 6 weeks
o Splint 1. Static volar splint
2. dynamic splint ( flexion/extension)
o Keep wrist extension 40 ~ 45 , MP extension when rest and night time
o Dynamic splint to resolve joint stiffness
Extensor Tendon Repair
Zone V ~ Zone VII (Proximal to MP joint)
4 ~ 6 weeks
o Exercise Program
- Wrist joint ：60 ~ 0 extension , gravity eliminated
Radial / Ulnar deviation : 50% ROM
- PIP joints and MP joints： Full fist when wrist extension
Extensor Tendon Repair
Zone V ~ Zone VII (Proximal to MP joint)
6 ~ 12 weeks
o Splint 1. Protective splint discontinued
2. staticic splint as night splint , if extension lag presence
3.dynamic splint if necessary
Extensor Tendon Repair
Zone V ~ Zone VII (Proximal to MP joint)
6 ~ 12 weeks
o Exercise Program
- Wrist joint ：Full ROM exercise
Radial / Ulnar deviation : 100% ROM
- PIP joints and MP joints：
composite wrist,MP,IP joints extension
composite wrist,MP,IP joints flexion
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