Rehabilitation protocols for post-operative flexor tendon repair have changed over the past few decades. As surgical techniques have improved with better visualisation instruments and advanced suturing techniques, new approaches to post-operative rehabilitation have emerged.
The dorsal blocking orthosis, which is used to limit the amount of active and passive finger extension and thereby prevent possible tendon rupture following surgical repair, has remained a constant in all rehabilitation protocols, even though exact wrist and finger joint placement may differ among the various regimens.
This article will review some of the basic therapeutic protocols for the post-operative management of lacerated and repaired flexor tendons and also discuss new advances. In addition, we will give suggestions for the most appropriate thermoplastic materials and tips for the fabrication of a dorsal blocking orthosis.
Therapeutic protocols following flexor tendon repair
The table below includes all details regarding the specific wrist and finger positioning in the dorsal blocking orthosis outlined for each protocol:
A basic regimen of complete immobilisation following surgical repair of flexor tendons may be implemented for children that are unable to follow directions, elderly patients with cognitive deficits and/or patients deemed to be non-compliant with exercises.
- Orthosis: patients can be immobilised in either a long arm or short arm orthosis with no passive or active motion exercises initiated for 3 weeks. At 3 weeks post-surgery, the wrist position might be modified to neutral.
- Exercises: Check with your referring physician for complete directions on when to start an exercise regimen. Exercises must proceed with caution as immobilised tendons are generally weaker due to the lack of stress that is applied as they heal.
The Kleinert protocol was established to incorporate a dynamic pull on the involved finger(s) so that no tension would be placed on the sutured tendon.
- Orthosis: The involved wrist and fingers are placed in a dorsal blocking orthosis. Elastic thread or a rubber band is typically attached to the involved finger via a suture through the nail, via a hook glued to the nail, or using an elastic thread attached to a finger cap. This rubber band pulls the involved finger(s) into complete PIP and DIP flexion and is attached to the volar forearm or a volar placed strap. A pulley or bar, placed on a palmar component, ensures that both full DIP and PIP flexion are achieved.
- Exercises: Patients are instructed to perform passive flexion and active extension exercises to each individual finger joint and to the entire finger on an hourly basis.
Complications from this protocol, primarily PIP flexion contractures due to holding the injured finger in flexion all of the time, contributed to the creation of another passive motion protocol called the Modified Duran Protocol.
Modified Duran Protocol
The original Duran orthosis stopped at the PIP joints in order to visualise full PIP extension during the exercises and included rubber band traction, which was eliminated in the modified Duran orthosis. The modified version incorporated the full length of the fingers in the orthosis and added strapping of the fingers in full extension overnight, thereby reducing the problems with PIP joint contractures.
The Indiana Protocol is classified as an Early Active Mobilisation protocol. It is designed for clients who demonstrate minimal oedema and minimal complications. It relies on a strong surgical repair of 4 strands across the tendon plus an epitendinous suture.
- Orthosis: Every hour, patients switch from a dorsal blocking orthosis to a hinged Tenodesis orthosis which allows limited active wrist extension.
- Exercises: Patients are instructed to place their fingers in full passive flexion and hold this (Place and Hold) while actively extending the wrist.
The Manchester Protocol is intended for patients following surgical repair of flexor tendon lacerations in Zone 2, treated with a 4 strand surgical repair.
- Orthosis: a short dorsal based orthosis that allows maximal wrist flexion and up to 45 degrees of wrist extension with a block to MP joint extension at 30 degrees.
- Exercises: Patients perform active finger flexion with the wrist extended and active finger extension with the wrist flexed. Patients are fitted with volar thermoplastic finger extension orthoses at night to prevent flexion contractures.
A recent study compared patients treated with this short orthosis protocol to patients treated with the traditional forearm based orthosis and found that the short orthosis favoured an improved PIP flexion arc early on, with a greater gain in DIP flexion at the final comparison.
St. John Protocol
The St. John Protocol is implemented following a wide-awake surgical repair of the lacerated tendon. This surgical technique allows the surgeon to address gapping of the tendon during active movement and make sure that there is sufficient gliding of the repaired tendon underneath the finger pulleys while the wound remains open. More information on this protocol is available on: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5142498/pdf/gox-4-e1134.pdf
- Orthosis: Following wound closure, a dorsal blocking orthosis is applied. Active motion is only initiated after 3-5 days.
- Exercises: Exercises commence with passive range of motion to warm up the finger joints, followed by gentle active flexion into ½ of a full fist and active extension in the orthosis.
- A relative motion orthosis might be added to the program to address PIP joint contractures at 6 weeks post surgery.
New evidence gained from the wide-awake surgical procedure indicates that “place and hold” exercises cause a “buckle and jerk” motion, placing stress on the repaired tendon, whereas active motion into ½ of a full fist allows gentle gliding of the tendon without added stress.
Disclaimer: It is important to discuss each individual patient with the referring surgeon to determine which rehabilitation protocol to follow. Use these protocol descriptions as guidelines that can be modified based on a patient’s exact requirements and needs.
Choosing the right materials
Dorsal blocking orthoses are placed over the dorsum of the forearm, wrist and digits and therefore place stress over the ulnar head, the flexed MP joints and the dorsal PIP and DIP joints. A conforming material will drape and capture the shape of these bony landmarks and prevent stress and shearing forces.
You can use a heat gun to further bump out these spots on the orthosis. Another tip is to place a piece of theraputty over the ulnar head and form the dorsal orthosis over this putty, creating a larger bumped out spot. The putty can be removed from the inside when the orthosis has hardened. Be sure to use a non-coated material, and rub a little lotion over the putty to prevent adherence.
Consider using a material with adequate memory, as the orthosis may require further modifications to alter the wrist position and to help reduce oedema.
Suggested thermoplastic materials:
- Orfilight, Orfilight Atomic Blue NS and Orfilight Black NS: extremely lightweight and highly conforming, which makes them perfect for the fabrication of these types of orthoses. Thanks to the stretch, these materials contour well to the anatomy and make the fabrication process considerably easier.
Note: These products are offered in three thicknesses and different perforation patterns. Orthoses made from Orfilight products are comfortable and supportive without adding additional weight to the injured body part. Orfilight products feel light and foamy during the orthotic fabrication, but are strong and maintain the specific desired posture when hardened.
- Orfit Flex NS: a material with high drape and low resistance to stretch, which makes it a good option for a strong and well conforming orthosis for the flexor tendon protocols outlined here.
- Orficast: ideal for the fabrication of the relative motion orthosis which can be helpful at addressing PIP flexion contractures. Position the MP joint of the involved finger in flexion to elicit the transmission of force towards active PIP extension.
Tips for the fabrication of a dorsal blocking orthosis
- Have the patient sit with both elbows on the table. Let him/her make a fist with the uninvolved hand and support the involved hand so that the wrist is in the desired position and the MP joints are supported in flexion, with the fingers in extension.
- Use a rectangular piece of thermoplastic material wide enough to capture the widest part of the patient’s hand and forearm.
- Stretch the material distally over the fingertips and pull proximally towards the elbow. The material will stretch and conform to the flexion of the MP joints and the wrist position.
- Only minimal handling is needed to secure the position of the material around the wrist and forearm. Avoid excessive handling as this will cause fingerprints and marks which can irritate the patient’s arm.
Watch this video for more tips on fabricating a dorsal blocking orthosis:
Evans, R. B. (2012). Managing the injured tendon: current concepts. Journal of Hand Therapy, 25(2), 173-190.
Higgins, A., & Lalonde, D. H. (2016). Flexor tendon repair postoperative rehabilitation: the Saint John Protocol. Plastic and Reconstructive Surgery Global Open, 4(11).
Peck, F. H., Roe, A. E., Ng, C. Y., Duff, C., McGrouther, D. A., & Lees, V. C. (2014). The Manchester short splint: A change to splinting practice in the rehabilitation of zone II flexor tendon repairs. Hand Therapy, 19(2), 47-53.
Tang, J. B. (2015). Wide-awake primary flexor tendon repair, tenolysis, and tendon transfer. Clinics in orthopedic surgery, 7(3), 275-281.
Vögelin, E. (2015). IFSSH Scientific Committee on Flexor Tendon Repair. ezine ifssh, 5(4), 21-34.
Written by Debby Schwartz, OTD, OTR/L, CHT
Physical Rehabilitation Product and Educational Specialist at Orfit Industries America.
Debby is a certified hand therapist with over 36 years of clinical experience. She completed her Doctorate of Occupational Therapy at Rocky Mountain University of Health Professions in 2010. She has worked at Orfit Industries America as Product and Educational Specialist since 2007.
Debby is also an adjunct professor at the Occupational Therapy Department of Touro College in NYC and has written many book chapters in the field of hand therapy and multiple articles for hand therapy journals, including the ASHT Times and the Journal of Hand Therapy. She has published a new textbook on orthotic fabrication together with Dr. Katherine Schofield, entitled “Orthotic Design and Fabrication for the Upper Extremity: A Practical Guide”.
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