4 F I S I O T E R A P I E DESEMBER 1 9 7 3 FLEXOR AND EXTENSOR TENDON INJURIES L. K. P R E T O R IU S , M B ., B.. T h is discussion o f flexor an d extensor ten d o n in ­ juries o f th e h an d has been a d ap te d to serve as a p ra c tic a l g u id e f o r physiotherapists. T Y P E C L A S S IF IC A T IO N In ju rie s are classified as 1. T id y w ounds, 2. U n tid y w ounds. 3. T im e facto r: 3.1 early; 3.2 late. 4. O ther structures dam aged. T yp e 1: A tidy w ound is a clean incised w ound w ith no lace ratio n o r contusion. T h e ob ject was e ith e r a sh arp k n ife o r th e equivalent of a glass shard. T yp e 2: A n untidy w ound is a m ore ragged type of in ju ry , w here th e skin an d deep structures a re cut in a ragged fash io n an d contusion is present. T yp e 3: T im e Factor: 3.1 Early presentation, i.e. within 6 - 1 2 h o u rs afte r in ju ry : th e re is a strong indication fo r th o ro u g h debridem ent an d p rim a ry suture, especially if this w o u n d is o f T ype 1 an d has been cleanly bandaged. 3.2 Late presentation: n o m atter w h at the type th e w ound should be debrided a n d then packed w ith an an tib io tic pack. T h e w ound should b e re-inspected after 48 hours. A decision m ay then be m ade ab o u t a fu rth e r p ro ced u re, e ith e r p rim a ry suture, delayed suture, o r no su tu re u n til healed. T yp e 4: O ther structures damaged: If possible all structures such as nerves and tendons should b e r e ­ p a ire d a t th e sam e sitting. BA SIC P R IN C IP L E S O F M A N A G E M E N T 1. D eco n tam in ate th e w ound an d su rro u n d in g skin, i.e. convert th e u n tid y w ound into a tid y w ound. 2. E xcise all contused tissue, including any non-viable o r d o u b tfu l tissue. 3. D elay re p a ir if necessary fo r a p erio d o f u p to 10 days. R epeated inspections in th eatre a n d d eb rid em en t sho u ld be d o n e if necessary a n d th e w ounds m u st b e packed w ith dam p an tib io tic, i.e. im ­ preg n ated swabs. 4. R e p a ir all stru ctu res a t o n e sitting. 5. D o n o t reg ard an tib io tics as a su b stitu te f o r a th o ro u g h debridem ent. T h is is axiom atic. C hoice o f a p p ro a c h depends on the expertise o f the surgeon an d on the facilities available. P rim ary repair is the m eth o d o f choice. A tidy type o f w ound o f less th an 12 ho u rs standing, m ay be d ealt w ith by an im m ediately p rim a ry re p a ir w ith th o ro u g h debridem ent. T h e w ound m ust be sufficiently enlarged to allow good access an d all structures should be rep aired a t one sitting. A care­ ful n o -touch technique is used. D ebridem ent and p a ck and delayed prim ary suture. If th e surgeon is n o t ab le o r w illing to re p a ir th e structures, h e m ay decide to pack th e clean w ound w ith im pregnated a n tib io tic swabs and tra n sfe r the p a tie n t to the n earest h o sp ital o r even a distant specialist hospital, p ro v id ed th a t th e delay is not too long. T h e w ound is then re-exam ined o n arriv al at th e definitive h o sp ital an d is eith er rep ack ed o r a delayed p rim a ry su tu re is perform ed. T h is delay m ay safely be u p to 10 days. S kin closure after debridem ent. N o attem pt is m ade to su tu re deep structures. W hen w ound healing has occurred, secondary su tu re is p erfo rm ed fro m three to six weeks afterw ards. T h is used to be the * S enior L ecturer, C h ief O rth o p aed ic Surgeon, D e p a rt­ m ent o f O rthopaedics, U niversity o f Stellenbosch, T ygerberg an d L ady M ichaelis H ospitals. .O., B.Ch., F.R .C .S. (Ireland)* stan d ard pro ced u re b u t is no longer accepted as ideal treatm en t unless d ictated by circumstances such as p o o r facilities, p o o r g eneral h ealth o f the patient, a non-expert surgeon. Skin closure and grafting several m o n th s later. Once again, th is used to b e th e sta n d a rd pro ced u re in th e days w hen p rim ary su tu re w as deem ed dangerous because o f th e possib ility of infection. U nfortunately m any cases are still seen in w hich p e rfo rc e this is all th a t can be done. V ario u s new er m ethods o f im p ro v in g th e gliding cap ab ility o f the g rafted tendon h av e been de­ veloped. A m ongst these is silicone ro d im plantation w hich creates a new tunnel fo r th e graft. T h e graft survives n o t only b y being placed in tissu e fluid in its new positio n , b u t also b y th e ingrow th of n e \f blood vessels and so-called adhesions w hich fo rm a r i ^ b in d th e g ra ft to its bed. O ften in these cases a tenolysis is necessary to o b tain m ovem ent, an d more often th an n o t the result is less th a n satisfactory. M eth o d s o f Suture in U se: 1. H olding-type suture (advocated by K essler). (Fig. 1.) T his su tu re is strong an d reliable. 2. H olding-type suture (advocated by B unnell) (Fig. 2.). T h is suture is strong and reliable. 3. H o ld in g -ty p e su tu re w ith buried k n o t (advocated by K lein ert) (Fig. 3). T h is suture is w eak an d needs to be well protected to achieve success. A circum ferential 6-zero p ro len e su tu re is used to tidy up the su tu re line. 4. In tra te n d in o u s rem ovable type su tu re (as used in T ygerberg H o sp ital) (Fig. 4). A circum ferential 6-zero p ro len e su tu re is used to tidy up th e suture. ; ! F ig . 3. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) pgCEMBER 1978 P H Y S I O T H E R A P Y F ig . 4. SPECIFIC A R EA S O F F L E X O R T E N D O N R E P A IR Zone I. T he area w here a deep cut involves the Vxor digitorum profundus (F.D .P.) tendon only and ihere is no damage to th e flexor digitorum sublim is ^ I f the distal stum p is less than 1,5 cm in length, it may be shortened o r excised, and th e proxim al stum p advanced and re-im planted into th e distal phalanx. This is done to avoid the presence o f a suture line in the pulley system. T h e re-im plantation m ust be firm and is usually m ade into bone. A pull-out type of suture over an external b u tto n is used. If the distal stum p is longer than 1,5 cm then ex­ cision is n o t done or advised, fo r this advancem ent would result in a severe flexion deform ity o f the finger. A decision m ust now be taken as to w hether to suture the tendon o r to do a tenodesis o f the distal inter- phalangeal joint. U n d er no circum stances should one interfere w ith th e action o f th e norm al F.D.S. If the F .D .P . tendon has retracted into the palm , an a p p ro p ria te incision will locate it and it m ay be rethreaded th ro u g h the pulley system to be re-im planted, provided th a t F.D .S. is n o t com prom ised. A F.D .P. that has retracted into th e palm and has lain there for longer th an fo u r weeks should n o t b e used b u t should be excised. In this case th e intratendinous vascu­ lature has been com prom ised an d the tendon is likely to ru p tu re on use ow ing to patchy necrosis; the excep­ tion m ay be in the young child in w hom such a tn d o n is often in an extrem ely good condition and ia y b e used. Z one II. “N o m an’s lan d ” o f Bunnell, o r some m an’s lan d ” o f K lein ert and others. O f th e various techniques available, K lein ert’s tech­ nique is th e m ost attractive. K lein ert does a prim ary suture an d then eith er excises a w indow in th e pulley system w here it lies over th e suture lin e or else carefully repairs the dam age to th e pulley sheath. T h e hand is then placed in slight flexion a t th e w rist and a back- cast is ap p lied to prevent m etacarpo-phalangeal exten­ sion o f m o re th a n 45° fro m full flexion. T raction elastics a re attach ed to th e fingernails of the affected fingers an d tied to an anchorage a t th e forearm E xercise m ay then begin im m ediately post-operatively, active extension only being used. T h is synergistically relaxes the flexors, allow ing them to b e m oved passively m ore distally. W h en th e extensors are relaxed the elastics w ill flex the fingers and thus no active flexion occurs w ith u n d u e strain on th e suture line. All this p rev en ts gross adhesion fo rm ation a t the suture line, i.e. betw een the suture line and the flexor sheath an d so facilitates eventual m ovem ent w ithout the need fo r a tenolysis, alth o u g h the la tte r m ay som e­ times be necessary. In Z one I I e ith e r the F.D.S. an d th e F .D .P . are re ­ paired o r th e F .D .S . is excised. T h e p o st-o p erativ e period is carefully checked an d controlled by th e surgeon and th e p hysiotherapist fo r fo u r to six weeks post-operatively, w hereupon the splint is rem oved an d active flexion perm itted. Z one III. T his is th e area of th e palm p roxim al to the pulley system and distal to th e deep flexor re tin a ­ culum o f the w rist. H ere both F.D .S. an d F .D .P . are rep aired by a K essler o r a Bunnell suture a n d if neces­ sary th e lu m b rical m uscle may be used to conceal th e suture lin e in th e F .D .P . This is a good pro ced u re r e ­ sulting in less adhesion form ation, b u t m ay result in the ‘lum brical p ositive” finger. T h is phenom enon occurs through fibrosis o r shortening o f th e lu m b rical m uscle; when finger flexion is attem pted, sim ultaneous finger extension occurs because the p u ll on th e flexor is transm itted via th e lum brical and the la te ra l b an d to the extensor apparatus. If th e lum brical is used as a “w rap a ro u n d ” , th en its tendon should be sectioned to prev en t the developm ent o f this “lum brical positive” finger. T h e K leinert-type o f post-operative regime is follow ed (elastics and cast). Z one IV . C arpal tunnel area. T here is a con­ centration o f n in e tendons and one nerve in to an a rea w here th e tip o f th e norm al m id d le finger w ill just fit tightly. I f the F.D .S. and the F .D .P . a re b o th severed, the procedure is to suture F.D .P. only an d excise th e F.D.S. A lternatively one m ay decide to suture th e p roxim al F.D .S. m o to r system to the distal F .D .P. tendon system in an attem pt to obtain m ore individualised finger action. T h e choice depends on th e surgeon and th e technical feasibility. If possible a p o rtio n o f th e flexor retinaculum should be left as a pulley. K essler o r B unnell-type of sutures are used f o r these cases. Z one V. T h e forearm. In this zone all structures should be repaired. Kessler o r B unnell-type sutures are indicated. E X T E N S O R T E N D O N SU TU R E T h e sam e general principles ap p ly as fo r flexor tendon injuries. Because o f the flat shape o f the ten d o n and its m o re delicate nature, a K essler o r B unnell-type o f suture is preferable. Post-operatively th e h a n d is placed in a full relaxed position in a p laster o f P aris cast fo r fo u r to six weeks. If a pulley o r retin acu lu m is involved, it should be excised over the excursion o f th e suture line. T he index and the little fingers each have an extra extensor tendon in addition to the extensor dig ito ru m com m unis (E.D.C.). These are very useful clinically to substitute for irreparable extensor tendons an d are otfen used as transfers. A lthough th ere is no digital pulley system on the extensor surface o f th e finger com parable with the flexor system , th e anatom ical arrangem ent is quite complicated. Injuries involving the im plantation o f th e extensor tendon into the distal phalanx create a lesion know n as “m allet finger”. This is a typical flexion d eform ity o f th e term inal joint due to the unopposed action o f the F.D .P. T he extensor tendon m ay be avulsed o r incised, o r it m ay be undamaged, in which case th e d eform ity is due to a fracture in the epiphyseal line o f th e distal phalanx. This last injury occurs in children and all m allet fingers must undergo X-ray exam ination in o rd er to differentiate this type of presentation. R ep air is effected by re-im planting th e tendon apparatus into the terminal phalanx b y direct su tu re o r by replacing the avulsed bone accurately. T h e p osition is then maintained by transfixing th e jo in t w ith a K irschner wire for six weeks. M obilization is effected after removal of the wire, b u t is very slow and R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 6 F I S I O T E R A P I E DESEMBER 1975 o ften incom plete. T h e trau m atic B outonniere lesion: In this case the in ju ry is to th e m iddle slip o f th e extensor tendon in ­ serted into the m iddle p h alan x o n its dorsal aspect. W hen this occurs the trian g u lar ligam ent u n itin g two lateral tendons p rio r to th e ir fusion is also disrupted and th e p ro x im al interphalangeal jo in t (P.I.P.), because o f the absence of a n extensor, progresses in to flexion. T his process is slow and due to gradual v olar displace­ m ent o f the lateral bands over th e area o f th e P.I.P. jo in t u n til they now act as flexors ra th e r than extensors o f this joint. As th e P .I.P. jo in t proceeds in to flexion, so the distal interphalangeal (D .I.P.) jo in t assum es a p o sitio n o f extension as a result of the increased pull of th e displaced lateral bands on th e ir eventual in sertio n into th e term in al phalanx. T h e lesion m ay be grouped into m o b ile and fixed versions. In th e m obile version, the P.I.P. jo in t is still m obile and m ay be passively placed into full extension. In the fixed version, th e P.I.P. jo in t is no longer able to be m oved passively into extension. I. T reatm ent o f the m obile version: This injury should b e treated aggressively w hilst still in th e m obile phase, a n d eith er efficiently splinted, o r surgically corrected and splinted. Splintage m ust be m ain tain ed fo r six weeks. A n efficient sp lin t is one w hich holds the P.I.P. jo in t in extension, w hilst allow ing flexion and extension a t th e D .I.P. joint. T h is action tends to close th e gap in the tria n g u la r ligam ent and to p rom ote healing and m ay be used as a conservative m ethod o f treatm ent. In the a u th o r’s o pinion, surgical correction is effective and a m ore satisfactory result is o b tain ed in th at the correction is anatom ical. T h e P .I.P. jo in t is transfixed w ith a K irsch n er w ire w hich ensures adequate healing A fter six weeks th e w ire is rem oved and active m obile zation is comm enced. It often takes up to two m onths f o r th e finger to be com pletely m obilized. 2. T reatm ent o f the fix e d version: T h e fixed type ;s very difficult to tre a t and attem pts m ust be m ade to m obilize th e finger before op eratio n . V arious form s of d ynam ic finger splints are used and all are effective if correctly designed and correctly applied. N o surgery should be attem pted u n til correction is obtained, if correction has to be obtained by surgical means, the end result is often extrem ely disap p o in tin g and the prognosis o f arthrodesis o f the P .I.P. jo in t is a distinct possibility. Bibliography: Weeks, P. M., C hristie W ray, R., (1973). M anagem ent y t A cu te H a n d Injuries, C. V. M osby C om pany, S-* Louis. R ank, B. K ., W akefield, A. R ., H ueston, J. T ., (1973). Surgery o f R epair as A p p lie d to H a n d Injuries, 4th Ed., C hurchill Livingstone, E dinburgh and London. Boyes, J. H ., personal com m unication. K leinert, H . E., personal com m unication. THE PHYSIOTHERAPY OF FLEXOR TENDON INJURIES TO THE HAND J. D U PLESSIS, B.Sc. in P h y sio th erap y (Stell.)* O f th e 92 n o n -E u ro p ean and 32 E u ro p ean hand patients referred to o u r D e p a rtm e n t fo r Physiotherapy during th e six m onth period Ja n u a ry to June 1978, 31% and 34% respectively had suffered flexor tendon in ­ juries, w ith o r w ith o u t nerve and blood vessel involve­ m ent. T hese form ed th e m ajo rity o f o u tp a t ie n t s , since any o th e r single type o f hand in ju ry am ounted to under 10% o f the total n u m b er o f patients treated. T h e causative factors w ill n o t be discussed, b u t this article w ill be confined to th e d escription o f phy sio ­ th erap y treatm en t o f flexor tendon injuries follow ing the types o f surgical re p a ir described in the preceding article by L. K . P retorius. G en eral considerations to be tak en in to account when treatin g ten d o n injuries are: (1) age; (2) infection; (3) associated injuries e.g. nerves, fractures; (4) m en tality of p atients; (5) occupation. Y oung patients n orm ally do very well, b u t w ith elderly patients o r p atien ts w hose in ju ry has been com plicated by sepsis, treatm en t m ust be carried o u t very carefully and m ay have to be m odified to su it the needs o f a p articu lar patient. P H Y SIO TH ER APY FOLLOW ING T H E BUN NE L L - TYPE R EPA IR W ITH BUT T O N (Zone I - II) T h e han d and fo rearm are placed in a plaster back- * P hysiotherapist, T ygerberg H o sp ital, P arow vallei. slab w ith the w rist in slight flexion and th e m etacarpo­ phalangeal (M P) joints in at least 90° flexion. A cling bandage fits into th e palm , keeping th e fingers in a p o sitio n o f semi-flexion. 0 - 2 weeks: N o m o b ilizatio n is carried o u t save fo r th e slig.vj active extension and flexion o f the fingers allowed by-' the p laster o f P aris (PO P) and cling bandages re­ spectively. 2 - 4 weeks: A t this stage, the cling bandage is rem oved and active extension o f the fingers to the lim it of th e plaster slab is perform ed. M ore flexion is now possible b u t no resistance is allowed. Specific passive physiological flexion and extension are given to th e in dividual inter­ phalangeal (IP) joints, w hilst keeping the relevant M P and o th er IP joints in as m uch flexion as possible w hen doing the extension. A t no tim e m ust any stretch be afforded th e tendon and each passive m ovem ent must be localized to th a t p a rtic u la r joint. I t is advisable to be conservative w ith passive m ovem ent a t th is stage. (See F ig 1.1 and 1.2.) 4 - 6 weeks: T he plaster slab is rem oved w hilst th e suture and b u tto n are retained. G entle m obilizing oil massage is applied to th e scar on the finger. N o passive stretch is as yet applied to th e lim ited joints. O ne now aim s fo r R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )