Tendon injuries of hand by Dr Saumya Agarwal
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flexor and extensor tendon injuries of hand and their management
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Tendon injuries of hand by Dr Saumya Agarwal
- 1. Tendon Injuries of Hand Dr Saumya Agarwal Junior resident MS Ortho Dept of Orthopaedics J.N.Medical College and Dr. Prabhakar Kore Hospital and MRC, Belgaum
- 2. muscle to the bone glistening structure between muscle & bone which transmit force from “
- 6. Tendon Morphology • 70% collagen (Type I) • Extracellular components • Elastin • Mucopolysaccharides (enhance water- binding capability) • Endotenon – around collagen bundles • Epitenon – covers surface of tendon • Paratenon – visceral/parietal adventitia surrounding tendons in hand.
- 7. Tendon Nutrition • Longitudinal vessels Enter in palm Enter at proximal synovial fold • Segmental branches from digital arteries • Long and short vinculae • Vessels at osseous insertions • Synovial fluid diffusion • Imbibition (pumping mechanism)
- 8. Tendon Nutrition • Avascular zones • FDS(over proximal phalanx) • FDP (over middle phalanx) • Nutrition vital for rapid healing, minimization of adhesion and restoration of gliding
- 10. ANATOMY
- 11. Abbreviation Full Name Function FPL Flexor pollicis longus Thumb flexion PL Palmaris longus Flexion of wrist FCU Flexor carpi ulnaris Flexion and adduction of hand FDP Flexor digitorum profundus flexion of distal interphalangeal joints and helps wrist flexion FDS Flexor digitorum superficialis Flexion of proximal interphalangeal joints and flexion of proximal phalanges at metacarpophalangeal joints FCR Flexor carpi radialis Flexion and abduction of hand at wrist
- 12. Abbreviation Full Name Function APL Abductor pollicis longus Abduction of thumb EPB Extensor pollicis brevis Extension of thumb proximal phalanx ECRL ECRB Extensor carpi radialis longus/brevis Extends and abducts hand EPL Extensor pollicis longus Extends thumb IP joint ED (4 tendons: II - V) Extensor digitorum Extends digits II - V EI Extensor indicis Extends digit II EDM (EDC) Extensor digitorum minimi (quinti) Extends digit V ECU Extensor carpi ulnaris Extends and abducts hand
- 13. Flexor Tendon Injury Zones 1: flexor digitorum profundus distal to insertion of flexor digitorum superficialis 2: insertion of flexor digitorum superficialis to proximal edge of A1 pulley (“No Man’s Land”) 3: proximal edge of the A1 pulley to distal edge of carpal tunnel 4: within the carpal tunnel 5: proximal to the carpal tunnel
- 14. Extensor Tendon Injury Zones O Extensor tendons are divided into 8 zones O Zones 1,3 and 5 lie over the DIP, PIP and MCP joints
- 15. PULLEYS
- 16. • ONLY FPL • CONTAINS 2 ANNULAR PULLIES AND ONE OBLIQUE PULLIES THUMB SHEATH
- 18. Camper’s Chiasma
- 20. ETIOLOGY Common mechanisms of injury include Osharp object direct laceration (broken glass, kitchen knives or table saws) Ocrush injury Oavulsions Oburns Oanimal or human bites Osuicide attempts Omotor vehicle accidents
- 21. Flexor tendon healing • 2 forms: – Intrinsic healing: occurs without direct blood flow to the tendon – Extrinsic healing: occurs by proliferation of fibroblasts from the peripheral epitendon; adhesions occur because of extrinsic healing of the tendon and limit tendon gliding within fibrous synovial sheaths
- 22. Phases of Intrinsic healing 1.Inflammatory (0-5 days) : strength of the repair is reliant on the strength of the suture itself 2.Fibroblastic (5-28 days) : or so-called collagen-producing phase 3.Remodelling (>28 days)
- 24. • Region b/w middle aspects of middle phalanx to finger tips • Contains only one tendon-fdp • Tendon laceration occurs close to its insertion • Tendon to bone repair is required than tendon repair ZONE 1: ZONE OF FDP AVULSION INJURIES
- 25. Leddy classification of zone I flexor tendon injuries!! Type I: tendon retracted into palm (fullness in palm) Type II: tendon trapped in the sheath at PIP (unable to flex PIP) Type III: tendon trapped in A4 pully
- 26. Type I injury!!
- 27. Type II injury!!
- 28. • From metacarpal head to middle phalanx • Called so because initial attempts for tendon repair here produced poor results • FDS and FDP within one sheath • Adhesion formation risk is amplified at campers chiasma ZONE II-NO MANS LAND
- 29. • B/w transverse carpal ligament and proximal margin of tendon sheath formation • Lumbricals origin here prevents profundus tendons from over acting • Delayed tendon repairs are succesfull even after several weeks of injury ZONE III-DISTAL PALMAR CREASE
- 30. • Lies deep to deep transverse ligament • Tendon injuries are rare ZONE IV-TRANSVERSE CARPAL LIGAMENT
- 31. • LIES PROXIMAL TO TRANSVERSE CARPAL LIGAMENT ZONE V-PROXIMAL
- 32. SIGNS & SYMPTOMS • Unable to bend one or more finger joints • Pain when bending finger/s • Open injury to hand (e.g., cut on palm side of hand, particularly in area where skin folds as fingers bend) • Mild swelling over joint closest to fingertip • Tenderness along effected finger/s on palm side of hand
- 33. Complain of numbness preceeded by execissive bleed Consider neurovascular insult!!
- 34. INSPECTION • There is a normal arcade to hand with index finger showing least and little finger showing max flexion • If affected finger shows more extension than other digits, chance of tendon injuries are high EXAMINATION
- 37. • Stabilise the MCP joint • Ask the pt to flex IP joint FPL
- 38. DETECTION • History and physical • Examination of wound • Use of bedside ultrasonography in ER (more sensitive and specific than physical examination) • Wound exploration techniques or MRI. • 3-view x-ray must be done (except most benign) to rule out foreign bodies or bony injury. • Radiographs to evaluate for possible fractures or dislocations (blunt trauma cases)
- 39. DICTUM • Flexor tendon repair is not a surgical emergency. It is proved that equal or better results can be achieved by delayed primary repair. • Better to repair both FDP & FDS tendons rather than FDP alone
- 40. Goals of reconstruction: •Coaptation of tendons • anatomical repair • multiple strand repair to permit active range of motion rehabilitation •Pully reconstruction to minimize bow-stringing • atraumatic surgical technique to minimize adhesions • strict adherence to rehabilitation protocol.
- 41. What can we provide? • Minimal dissection and handling • Tendon apposition without gapping • Early protected mobilization
- 42. Timing of flexor tendon repair: Primary: repair within 24 hours (contraindicated in case of high grade condtamination i.e. human bites, infection) Delayed Primary: 1-10 days when the wound can be still pulled open without incision Early Secondary: 2-4 weeks. Late Secondary : after 4 weeks
- 43. No repair if less than <25% laceration, only epitenon repair in 25-50% lacerations, . core suture plus epitenon repair when >50% laceration Dorsal blocking splint for 6-8 weeks as conservative measure
- 44. Bunnell stitch Crisscross stitch Mason-Allen stitch Robertson and Al-Qattan Interlock stitch Core Suture Techniques
- 45. Kessler stitch Modified Kessler Tajima modification Of kessler stitch with double loop at repair site
- 46. Sheath repair • Advantages: – barrier to the formation of extrinsic adhesions – quicker return of synovial nutrition – better tendon-sheath biomechanics
- 47. Sheath repair • Disadvantages: – technically difficult – may narrow and restrict tendon gliding
- 48. Suture Materials • Core Non-absorbable 4/0 suture • Different configurations • 6/0 monofilament running epitenon suture. • As noted by Singer MD et al. 1998, 3-0 prolene or mersilene suture may be suture of choice
- 49. • WOUND EXTENDED PROXIMALLY AND DISTALLY • PROXIMAL TENDON RETRIEVED,CORE SUTURES ARE PLACED • KEITH NEEDLES USED TO PASS THE SUTURES AROUND THE DISTAL PHALANX EXITING THROUGH NAIL PLATE DISTALLY • REMAINING DISTAL END OF TENDON SUTURED TO THE RE-ATTACHED PROXIMAL PORTION ZONE 1 REPAIR
- 50. Direct repair: if laceration is more than 1 cm from FDP insertion Tendon advancement: if the laceration is less then 1 cm from insertion
- 51. • REPAIR BOTH TENDON LACERATIONS • TENDON SHEATH MAY BE OPENED FOR EXPOSURE BUT A2 AND A4 ARE PRESERVED AS MUCH AS POSSIBLE • FDS IS REPAIRED FIRST FOLLOWED BY FDP ZONE II REPAIRS
- 52. • If both tendons are lacerated, both are repaired, end to end with circumferential re-enforcing sutures • May affect lumbricals in addition to flexor tendons • Damaged lumbrical is either repaired or excised depending on severity of injury and the location of the laceration ZONE III REPAIRS
- 53. • Lacerations of flexor tendons within the carpal canal are typically associated with partial or complete laceration of median nerve • Here median nerves should be repaired first and the tendons last ZONE IV REPAIR
- 54. • In this area there may be concomitant ulnar nerve & artery damage as well as radial artery & median nerve damage. • Primary repair of the arteries is usually indicated • If wound is contaminated, arteries are repaired and delayed repair of tendons and nerves is planned ZONE V REPAIR
- 58. One method of attaching tendon to bone. A, Small area of cortex is raised with osteotome. B, Hole is drilled through bone with Kirschner wire in drill. C, Bunnell crisscross stitch is placed in end of tendon, and wire suture is drawn through hole in bone. D, End of tendon is drawn against bone, and suture is tied over button. Wilson
- 59. Kleinert method of Tendon advancement!!
- 61. Repair both tendons: Because the blood supply to the FDP tendon is jeopardized if the FDS is not fixed (due to the vinculae anatomy)
- 62. Lumbrical muscle bellies usually are not sutured because this can increase the tension of these muscles and result in a “lumbrical plus” finger (paradoxical proximal interphalangeal extension on attempted active finger flexion). Zone 3 injuries
- 63. Lumbrical plus!!
- 64. Quadriga effect!! Tendon advancement shortens the FDP & completes the grip before the normal fingers, if the tension on tendon graft is set too high, and limit their flexion and thus week grip
- 67. Silfverskiöld
- 68. Fish-Mouth End-to-End Suture (Pulvertaft)
- 71. Newer Protocols Most of them involve active motion exercises. Then the suture strength has to increase
- 72. Different Methods 1. Active Extention-Rubber Band Flexion Method: e.g. Kleinert , and Brooke-Army 2. Immobilization 3. Controlled Passive Motion Methods: e.g. Duran’s protocol 4. Strickland: Early active ROM
- 73. Kleinert Protocol • Combines dorsal extension block with rubber- band traction proximal to wrist • Originally, included a nylon loop placed through the nail, and around the nail is placed a rubber band • This passively flexes fingers, & the patient actively extends within the limits of the splint
- 74. Active range of motion rehabilitation Kleinert !!
- 75. Duran protocol • At surgery, a dorsal extension-block splint is applied with the wrist at 20-30° of flexion, the MCP joints at 50-60° of flexion, and the IP joints straight
- 77. Differential passive exercises for FDP & FDS!!
- 78. Position of Immobilization for Flexor Tendon Injury •Wrist – 30 degree flexon •MP joint 60-70 degree flexon •Slight flexon of PIP & DIP
- 79. Complications • Joint contracture • Adhesions • Rupture • Bowstringing • Infection
- 80. Complications: Adhesions & stiffness requires tenolysis in 18-25% cases Tenolysis is indicated after 3 months if no improvement is noted For 1-2 months extensive physiotherapy.
- 81. DONOR TENDONS FOR GRAFTING: Palmaris Longus: Tendon of choice (fulfils requirement of length, diam & availability) Plantaris Tendon: Equally satisfactory & advantage of being almost twice as long, but is not accessible. Others: FDS, EDC
- 82. Summary • Meticulous technique – Minimal handling – Appropriate suture configuration – Minimal resection of tendon sheath • Postoperative mobilization • Supervision!
- 83. Extensor Tendon Injury • Extensor apparatus – Extrinsic muscles (ED, EI, EDM) – Intrinsic Muscles ( Lumbricals and Interossei) – Fixed fibrous structures.
- 84. Injury : Zone- I – Mallet finger – persistent flexon of distal phalanx • Closed: splinting 6-8 weeks • Open: suture repair, Soft tissue reconstruction
- 85. Zone II injury- Middle Phalanx Level: – Repair by interrupted suture. – Immobilization for 5-6 weeks – DIP joint in extension – PIP joint left free
- 86. Zone III injury- PIP joint level – Most complex anatomically and physiologically – Causes two deformities • Boutonniere • disruption of central tendon Closed: splinting MCP and PIP in hyperextension for 6 weeks Open: suture repair (figure of 8 suture) • Swan Neck –excessive traction of central tendon –Closed : splinting DIP –Open : suture repair
- 87. Zone IV injury- shaft of proximal phalanx level – Repair relatively easy – Adhesion is the problem
- 88. Zone V injury – MP joint level • Closed: splinting, 45 extension at wrist and 20 flexion at MCP • Open: suture repair by 5.0 prolene
- 89. Zone VI injury- Metacarpal level Better prognosis than in fingers All structures, even intertendinous band should be repaired. Core type suture possible. Delayed suture is possible
- 90. Zone VII- wrist level –Extensor tendons are under dorsal retinaculum –Retinaculum should be repaired or partially preserved. –Adhesion is the problem –Grasping core suture should be used. –Immobilization for 5-6 weeks.
- 91. EXTENSOR TENDON MANAGEMENT 3 current treatment approaches to extensor tendon rehabilitation are Immobilization Early controlled passive mobilization Early active motion
- 92. Position of Immobilization for Extensor Tendon Injury •The finger should remain parallel to forearm with wrist in full extension •PIP & DIP – Neutral
- 93. IMMOBILIZATION • Keep the tendon in a shortened position through splinting or casting • Tendons immobilized for 3 weeks • In week 4, gentle active motion of the repaired tendon is introduced • Rehabilitation depends on zone of injury
- 94. IMMOBILIZATION INJURIES IN ZONES PROXIMAL TO MCPs INJURIES IN ZONES DISTAL TO MCPs • May be immobilized for 3 weeks. • Afterwards, finger may be placed in removable volar splint between exercise periods for 2 weeks • Progressive ROM after 3 weeks • If full flexion is not regained rapidly, dynamic flexion may be started after 6 weeks • Require a longer period of immobilization (usually 6 weeks) • A progressive exercise program is initiated • Dynamic splinting during day and static splinting at night to maintain extension
- 95. EARLY PASSIVE MOTION • Extensors are held in extension by dynamic, gentle rubber band traction, and the patient is allowed to actively flex the fingers—passively moving repaired extensor tendons
- 96. EARLY ACTIVE MOTION • Early active short arc program (developed by Evans) allows tendon to actively move 3 days after surgery • Therapist must take care to ensure stress applied by early active motion does not overpower strength of surgical repair • Splinting program is complex and specific and requires a skilled occupational therapist
- 97. What is Manchester Short Splint? • Wrist – Finishes at dorsal wrist crease – Allows 45 degrees extension • MCPJ – 30 degrees flexion • Exercises – Commence 4th or 5th day – Motion initiated at DIPJ
- 99. Proposed changes for Zone II Day 1 post op –splint, oedema management –Splint : wrist 30degrees extension, MCPJ 40degrees flexion Day 3-5 start AROM –PROM exercise always prior to AROM –Isolated DIPJ ROM to at least 35degrees, with lateral joint support
- 100. –Focus on initiating AROM with DIPJ rather than flat fist –Focus on IPJ extension exercises • Avoid full composite flexion until 4wks
Notes de l'éditeur
- Extensor chart
- Flexor tendons are divided into 5 zones. Zone 1 is distal and Zone 5 is proximal. The five zones are: Zone 1—containing flexor digitorum profundus only distal to the insertion of flexor digitorum superficialis; Zone 2—also known as “No Man’s Land”—from insertion of flexor digitorum superficialis to the proximal edge of the A1 pulley; Zone 3—from the proximal edge if the A1 pulley to the distal edge of the carpal tunnel; Zone 4—within the carpal tunnel; and Zone 5—proximal to the carpal tunnel (Wood, 2012; Henry, 2012). A flexor tendon that has been injured between the distal palmar crease and the insertion of the flexor digitorum superficialis (Zone 2) is considered the most difficult to treat due to the fact that the tendons lie in their sheaths in this area beneath the fibrous pulley system, and any scarring will cause adhesions (Poole, 2013, p. 605).
- Extensor tendons are divided into 8 zones. Zones 1, 3 and 5 lie over the DIP, PIP and MCP joints (Al-Qattan, 2007).
- Patients who have tendon lacerations may experience an inability to bend the wrist or one or more of the joints in the finger. Other signs and symptoms of tendon lacerations include pain when bending the finger; an open injury like a cut on the palm side of the hand—particularly in the area where the skin folds as the fingers bend; mild swelling over the joint closest to the fingertip; tenderness along the effected fingers on the palm side of the hand (Wood, 2012; Henry, 2012; R. G. Xie, 2008).
- A history and physical will be completed initially to determine if the patient has a laceration. Examination of the wound will reveal the damage to the tendon. The healthcare provider can also detect the injury by demonstrating weakness or failure to move the involved extremity. However, utilization of bedside ultrasonography in the emergency room is more sensitive and precise than physical examination for identifying tendon lacerations. In one study, sensitivity, specificity, and accuracy of US were 100%, 95%, and 97%, respectively (Henry, 2012). Bedside ultrasonography in the emergency department takes significantly less time to implement than the traditional method of utilizing wound exploration techniques or MRIs. A 3-view x-ray of the hand, wrist, or forearm must be performed on all but the most benign tendon laceration injuries to exclude foreign bodies or bony injury (R. G. Xie, 2008). Also, in all blunt trauma cases, radiographs are used to assess for possible fractures or dislocations (Department of Rehabilitation Services , 2007).
- The immobilization method maintains the tendon in a shortened position by way of splinting or casting. “Tendons are immobilized for three weeks; in week 4, gentle active motion of the repaired tendon is introduced” (Poole, 2013, p. 609).
- Extensor tendons damaged proximal to the MCP joints frequently become adherent to the structures above and below them. This will require the occupational therapist to initiate a splinting program. A removable volar splint is utilized between exercise periods to protect the tendon for two additional weeks. Dynamic flexion splinting may be started 6 weeks after surgery to recover flexion if required (Poole, 2013, p. 609). Extensor tendons injured proximal to the MCP joint may be immobilized for 3 weeks. After this, the digit might be placed in a removable volar splint that is worn between exercise periods for an additional two weeks (Hall, 2010). Progressive ROM is initiated after 3 weeks, and if full flexion is not recovered promptly, dynamic flexion may be initiated after 6 weeks (Poole, 2013, p. 609). Extensor tendon injuries that occur distal to the MCP joint necessitate a longer period of immobilization—usually for 6 weeks. A progressive exercise program is then initiated with dynamic splinting during the day and static splinting at night to preserve extension (Poole, 2013, p. 609).
- The early passive motion method reverses what was done for the flexor tendons (Hall, 2010). The extensor tendons are held in extension by dynamic, gentle rubber band traction, and the patient is permitted to actively flex the fingers, thus passively moving the surgically repaired extensor tendons. “These splints must have a dorsal component to provide a block to flexion so as not to move the tendons too much, which could lead to overstretching or rupture of the extensor tendon. This method facilitates tendon strength and can prevent the scarring that ultimately limits motion and function” (Poole, 2013, p. 609).
- The early active short arc program, developed by Evans, permits the tendon to actively move 3 days after surgery. The therapist must take care to make sure that the stress applied by early active motion does not override the strength of the surgical repair. “The splinting program is quite complex and specific and requires a skilled occupational therapist” (Poole, 2013, p. 609).
- 30 secs The Manchester guideline is for for robust uncomplicated repairs with compliant patients It has a dorsal blocking splint which finishes on the dorsal wrist crease which allows 45 degrees extension and full flexion. MCP joints are splinted at 30 degrees flexion Exercises commence on the 4th or 5th day Motion is initiated at the DIP joints, rather than the PIP or MCP joints In the early phase they do not encourage a full active fist They do not do place and hold READ FROM SLIDE ONLY (Info below only if questioned) Wrist 45 degrees extension – In 1988 Suave suggested that a wrist position of 45 degrees extension was optimal for minimising the force required to move the Ipj’s against passive resistance. Other authors have confirmed the superiority of synergistic wrist motion on tendon glide. In Manchester they have removed the forearm part of the splint for compliant patients with uncomplicated repairs. The splint is fabricated to finish at the proximal wrist crease, allowing the wrist to extend to 45 degrees during active digital flexion and to flex during active digital extension (demo with model) Care must be taken in the position of the MCP joints Fiona writes in her article that In an oedematous finger, where there is resistance to tendon glide, placing MP joints in excessive flexion, will bias motion to the PIPj and force the patient to attempt DIPjoint flexion at the end of range, thereby increasing the work of flexion Therefore too much MCP joint flexion rather than being protective, actually increases the risk of rupture. A common complication of injuries in zone 2 is cross union of the flexor tendons. During active motion it is paramount that motion is initiated from the DIP joint to optimise differential glide. Fiona writes that therefore, a position of 30 degrees MCP join flexion is both effective and comfortable Oedema peaks around 3rd or 4th day increasing WOF. Fiona writes that it is judicious to commence the exercise regimen when the gliding resistance is likely to be lower at around the 4th or 5th day post op. Motion should be initiated at the DIPj to maximise differential glide During the early phase of rehabilitation motion should be confined to the outer range or first third of flexion. She writes that early range of flexion is not necessary or safe Care should be taken if using a ‘place and hold’ regimen that patients are not required to put a greater effort into holding a full fist position.
- Day 1 post op. Immediate referrals post op are still ideal, so that we can see the patient before discharge. We propose that we make the splint, change the dressing to mepilex lite, commence oedema management, and do lots of patient education such as the extreme importance of compliance with the splint and no functional use of the hand Splint Geometry Queen Liz current guidelines recommend Splint with wrist in 0-20 degrees extension We are proposing wrist 30 degrees extension Tanaka and Amadio both state that wrist extension is not harmful during motion of Ipj’s infact, finger WOF is reduced with an extended wrist ** There is no consensus in the recent guidelines for wrist position. Georgia and I both feel that the Manchester guideline with wrist in extension from the beginning would be best in our busy setting because other guidelines require splint remolding at different points which is time consuming and may be difficult to coordinate with some patients. Our current guidelines recommend MCP’s 70-90 degrees flexion We are proposing MCP’s 40 degrees flexion As Georgia has mentioned, too much MCPjt flexion restricts FDP glide due to the difficulty in completing a hook fist **Evans says that excessive MP flexion has the possibility of overstressing a repair during active flexion. This is because ultimate strength and gap resisistance decreases as the curvature of the glide arc increases. ** Tangs research demonstrated that tendon strength reduces by approximately a half in full fist due to the extreme curvature of the glide arc around pulleys. ** Pettengill says excessive MCPj flexion might also overstress a repair during active flexion **The possiility of developping intrinsic tightness ** Tang recommends MCP’s in slight degrees flexion. ** Manchester guideline has MCP’s 30 degrees flexion ** The designers of the Manchester guideline clearly don’t see it as an issue as they have wrist in 45 degrees extension, MCPj in 30 degrees flexion and IPJ’s in extension with no increase in gapping or rupturing. **At Queen Liz our guideline states IP’s neutral or maximum active extension with double layer tubigrip. Other hospitals strap into extension which may be necessary for some patients at risk of FFD’s, but otherwise I think the practice of double tubigrip is a good one that we should continue. Commence Exercises day 3-5 (ideal is day 5) Georgia and I would like to propose changing this to Splinting and oedema management and active IPJ extension day 1, but delaying exercises to day 3-5. An article by Amadio states that early motion can be too early There are several studies with animal models that demonstrate this Very early motion can be associated with increased risk of adhesion formation from fresh bleeding During the Inflammatory phase, the strength of the repair is almost entirely suture with a modest contribution from fibrin and clot between tendon ends – there is high risk of rupture at this time with nothing to be gained as no adhesions will have formed yet In the collagen phase from day 5 – granulation tissue is formed in the defect so there is less risk of rupture Day 5 is probably preferable to day 3 because there is still significant oedema from day 3-5 which is increasing WOF Zhao – Day 5 most favourable Evans – Day 3 – 5 Tang – Day 3-5 (preferably day 4 or 5) **After 7 days of no movement, it is my understanding that adhesion formations to the tendon puts it at risk of rupture if you attempt active movement, so this is too late. Exercises Passive exercises always prior to active – all the new guidelines are stressing the importance of this. This is already in our guideline Isolated DIP joint active ROM to at least 35 degrees, with lateral joint support (suitable patients or in therapy only) Volar joint blocking is not done until week 8 currently and we think this should remain. However supporting the lateral sides of the DIPJ decreases resistance that occurs with volar joint blocking and is therefore safe to start early with some patients All patients need to be focusing more on hook fist rather than a normal fist and this could also be updated on a special zone II handout Focus on IPJ extension exercises – this is not currently on our patient handouts, but is in the therapists guideline to instruct patient to do this exercise. Perhaps we could have this on our patient handout as well due to the importance of preventing FFD’s Georgia mentioned a study by Pettengill that states synergistic wrist motion increases excursion of both FDS and FDP and also produces better differential gliding between the 2. The Manchester group certainly think that synergistic wrist exercises (eg. Tenodesis type hand movement) is safe and important to start from the beginning. Our current guidelines mention the option of therapist supervised synergistic wrist motion at week 4 with surgeon approval. This is not something that I have tried, but perhaps this is something that could be considered for our patient group? Avoid full composite flexion until 4 weeks I was taught a few years ago to tell patients that if they didn’t achieve a full fist within the first 1-2 weeks there would be too many adhesions and they would never get full ROM later. This was just folklore I believe as I have found no evidence for this. May be there is more of a case for this in zone 4 and 5, but I now know it’s not the case for zone II. I have seen that it is possible to achieve full ROM by working smarter not harder, plus we greatly increase the safety margin of preventing gapping and ruptures by going more gently. ** Evans comments that finger flexion is safer with modified rather than full fist and her guideline recommends 50-70% composite flexion depending on joint stiffness and oedema Tang recommendeds a “range that patient feels comfortable”, “gentle force” for first 2.5 weeks and then 1/3, ½ or even 2/3 if achieved with ease. “Full active flexion only if achieved “very easily”. Tang guideline also states - No maximal active flexion of the finger when meets remarkable resistance – instead active finger flexion up to mid-range and passive motion from mid to maximal flexion into individual motion cycles (eg. Active assisted) Our current guidelines recommend 30% muscle effort Some therapists are telling patients ¼ fist first week, ½ fist second week, ¾ fist third week, and towards full week 4. I have been using this over the last 6 months and it seems to be about right for what is possible when working with zone II, but perhaps doesn’t account for individual differences enough? Personally I think Tang has the right idea as it accounts for the differences in progress for individual patients. I think the model of ¼ and ½ fist etc might be useful as a round guide for patients to show them how on track they are. Evans suggests a load of less than 5 Neutons (500 grams) Our current guideline and hadout recommends 30% muscle effort for the full 6 weeks