Relative motion orthoses for early active motion after finger extensor and flexor tendon repairs: A systematic review.

BACKGROUND: The relative motion (RM) orthosis was introduced over 40 years ago for extensor tendon rehabilitation and more recently applied to flexor tendon repairs. PURPOSE: We systematically reviewed the evidence for RM orthoses following surgical repair of finger extensor and flexor tendon injuries including indications for use, configuration and schedule of orthosis wear, and clinical outcomes. STUDY DESIGN: Systematic review. METHODS: A PRISMA-compliant systematic review searched eight databases and five trial registries, from database inception to January 7, 2022. The protocol was registered prospectively (CRD42020211579). We identified studies describing patients undergoing rehabilitation using RM orthoses after surgical repair of acute tendon injuries of the finger and hand. RESULTS: For extensor tendon repairs, ten studies, one trial registry and five conference abstracts met inclusion criteria, reporting outcomes of 521 patients with injuries in zones IV-VII. Miller's criteria were predominantly used to report range of motion; with 89.6% and 86.9% reporting good or excellent outcomes for extension lag and flexion deficit, respectively. For flexor tendon repairs, one retrospective case series was included reporting outcomes in eight patients following zones I-II repairs. Mean total active motion was 86%. No tendon ruptures were reported due to the orthosis not protecting the repair for either the RME or RMF approaches. DISCUSSION: Variation was seen in use of RME plus or only, use of night orthoses and orthotic wear schedules, which may be the result of evolution of the RM approach. Since Hirth et al's 2016 scoping review, there are five additional studies, including two RCTs reporting the use of the RM orthosis in extensor tendon rehabilitation. CONCLUSIONS: There is now good evidence that the RM approach is safe in zones V-VI extensor tendon repairs. Limited evidence currently exists for zones IV and VII extensor and for flexor tendon repairs. Further high-quality clinical studies are needed to demonstrate its safety and efficacy.

Effect of a Text Message-Based Support Program on Outcomes of Patients After Flexor Tendon Injury Repair.

PURPOSE: Although the effectiveness of using text messages in home-based rehabilitation programs has been investigated, its ability to engage patients in home rehabilitation exercises and, as a result, improve hand outcomes, specifically in patients with flexor tendon injuries, has not been evaluated. The aim of this study was to determine whether the addition of a text message-based intervention to usual care is effective in improving hand outcomes in patients with flexor tendon injuries after repair. METHODS: In this 2-arm parallel randomized controlled trial, 40 patients were randomly assigned to either the intervention group (usual care plus the support program) or the control group (usual care only). Intervention included an automated package of instructional text messages containing links to a secure website for instructional rehabilitation videos delivered over 12 weeks. The Quick Disabilities of the Arm, Shoulder, and Hand and visual analog scale for pain scores were assessed at 6 and 12 weeks. Physician-reported grip strength and total active motion were assessed after 12 weeks. RESULTS: The study was completed by 90% (36 of 40) of the patients who were enrolled. There were statistically significant differences between the 2 groups with respect to Quick Disabilities of the Arm, Shoulder, and Hand and visual analog scale scores at the 6-week and 12-week assessments. In addition, there were statistically significant differences between the 2 groups with respect to total active motion and grip strength at 12 weeks. Finally, a high level of satisfaction with the intervention was reported. CONCLUSIONS: The text message-based program was associated with improved outcomes over the first 12 weeks after flexor tendon repair. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Ultrasonographic assessment in vivo of the excursion and tension of flexor digitorum profundus tendon on different rehabilitation protocols after tendon repair.

STUDY DESIGN: Interpretive description study. PURPOSE: In management of patients with flexion tendon injuries, passive, control active and active motion protocols were proposed after repair to minimize tendon adhesion. The purpose of this study was to compare the excursion distance and the tension of Flexor Digitorum Profundus (FDP) during simulated active and passive motion using ultrasonography techniques using normal subjects. METHODS: Ultrasonographic assessment of FDP tendon of the middle finger was performed at the wrist level on 20 healthy college students using 3 types of treatment protocols: modified Kleinert protocol, modified Duran protocol, and active finger flexion protocol. The excursion distance was measured following the musculotendinous junction of FDP using the B mode ultrasound system. The elasticity of FDP tendon was measured using the shear wave elastography technique. The excursion distance and the elasticity value were compared among 3 protocols using one-way ANOVA analysis. RESULTS: Twelve male and 8 female students with mean age of 22.6 ± 1.8 years were invited to join the study. The excursion distance of FDP was 21.82 ± 3.77 mm using the active finger flexion protocol, 8.59 ± 2.59 mm using the modified Duran protocol, and 12.26 ± 2.71 mm using the modified Kleinert protocol. The elasticity was significantly higher in extension position when compared to passive flexion positions, but found lower than active flexion position. DISCUSSION: The active finger protocol was found to require strongest tension of the tendon and with longest excursion. There was similar tension generated using both passive motion protocols. The modified Duran protocol appeared to create less excursion upon movements than the modified Kleinert approach using the objective ultrasonic evaluation. It is suggested that if the surgical repair was strong and without any complications, the active flexion protocol might work best to regain tension excursion. However, if there are complex problems involved, then the Kleinert approach or Duran approach would be chosen.

A smartphone application to facilitate adherence to home-based exercise after flexor tendon repair: A randomised controlled trial.

OBJECTIVE: Evaluate the effect of a smartphone application on exercise adherence, range of motion and self-efficacy compared to standard rehabilitation after repair of the flexor digitorum profundus tendon. DESIGN: Prospective multi-centre randomised controlled trial. SETTING: Four hand surgery departments in Sweden. SUBJECTS: A total of 101 patients (35 women) (mean age 37.5 ± 12.8) were randomised to control (n = 49) or intervention group (n = 52). INTERVENTION: A smartphone application to facilitate rehabilitation. MAIN OUTCOME MEASURES: Adherence assessed with the Sport Injury Rehabilitation Adherence Scale at two and six weeks (primary outcome). Secondary outcomes were self-reported adherence in three domains assessed at two and six weeks, self-efficacy assessed with Athlete Injury Self-Efficacy Questionnaire at baseline, two and six weeks. Range of motion and perceived satisfaction with rehabilitation and information were assessed at 12 weeks. RESULTS: Twenty-five patients were lost to follow-up. There was no significant between group difference in Sport Injury Rehabilitation Adherence Scale at two or six weeks, mean scores (confidence interval, CI 95%) 12.5 (CI 11.8-13.3), 11.8 (CI 11.0-12.8) for the intervention group, and 13.3 (CI 12.6-14.0), 12.8 (CI 12.0-13.7) for the control group. Self-reported adherence for exercise frequency at six weeks was significantly better for the intervention group, 93.2 (CI 86.9-99.5) compared to the controls 82.9 (CI 76.9-88.8) (P = 0.02). There were no differences in range of motion, self-efficacy or satisfaction. CONCLUSION: The smartphone application used in this study did not improve adherence, self-efficacy or range of motion compared to standard rehabilitation for flexor tendon injuries. Further research regarding smartphone applications is needed. LEVEL OF EVIDENCE: I. Randomised controlled trial.

Use of a relative motion flexion orthosis for postoperative management of zone I/II flexor digitorum profundus repair: A retrospective consecutive case series.

STUDY DESIGN: A retrospective, single-center, consecutive case series. INTRODUCTION: In concept, a relative motion flexion (RMF) orthosis will induce a "quadriga effect" on a given flexor digitorum profundus (FDP) tendon, limiting its excursion and force of flexion while still permitting a wide range of finger motion. This effect can be exploited in the rehabilitation of zone I and II FDP repairs. PURPOSE OF THE STUDY: To describe the use of RMF orthoses to manage zone I and II FDP 4-strand repairs. METHODS: Medical record review of 10 consecutive zone I and II FDP tendon repairs managed with RMF orthosis for 8 to 10 weeks in combination with a static dorsal blocking or wrist orthosis for the initial 3 weeks. RESULTS: Indications included sharp lacerations (n = 6), ragged lacerations (n = 2), staged flexor tendon reconstruction (n = 1), and type IV avulsion (n = 1). In 8 of the 10 cases that completed follow-up, the mean arc of proximal interphalangeal/distal interphalangeal active motion were as follows: sharp, 0° to 106°/0° to 75°; ragged, 0° to 90°/0° to 25°; reconstruction, 0° to 90°/10° to 45°; and avulsion, 0° to 95°/0° to 20°. Grip performance available for 6 of 10 cases was 62% to 108% of the dominant hand. There were no tendon ruptures, secondary surgeries, or proximal interphalangeal joint contractures. CONCLUSION: Based on this small series, the RMF approach appears to be safe and effective. It can lead to similar mobility and functional recovery as other early active motion protocols, with certain practical advantages and without major complications. Further investigation with larger, multicenter, prospective, longitudinal cohorts and/or randomized clinical trials is necessary.

[Postoperative treatment and rehabilitation following flexor tendon injuries]. / Weiterbehandlung und Rehabilitation nach Beugesehnenverletzungen.

BACKGROUND: The ideal surgical and postoperative treatment for flexor tendon injuries, especially in zone 2, is still subject to continuous modifications and professional discussions. OBJECTIVE: Presentation of established rehabilitation concepts, specific problems and new treatment approaches with practical recommendations for application. MATERIAL AND METHODS: Comparison of commonly used treatment concepts by assessing surgical flexor tendon repair, splint choice and clinical application in patients. Discussion of new surgical approaches and standards and their influence on postoperative therapy after flexor tendon injuries. RESULTS: The Washington regimen has retained its status as the standard in the current follow-up treatment of flexor tendon injuries. New suture materials and techniques enable early active rehabilitation of sutured flexor tendons with good clinical results, such as increased range of motion for interphalangeal joint extension and improved distal interphalangeal joint flexion with overall acceptable frequencies of suture rupture. CONCLUSION: A stable tendon repair with smooth gliding is the foundation for treatment after flexor tendon injuries. After intraoperative active digital extension-flexion testing of the sutured tendon an early active rehabilitation approach should follow. New splint designs in combination with primary stable tendon suture techniques have the potential to improve the postoperative outcome, presupposing a reliable cooperation of the patient.

Postsurgical Rehabilitation of Flexor Tendon Injuries.

Rehabilitation after surgical repair of flexor injuries is a controversial topic. Motion at the repair site decreases risk for adhesions but increases risk for rupture. We review the current concepts behind various rehabilitation protocols based on zone of injury and the evidence behind each.

Evaluation of written and video education tools after mallet finger injury.

STUDY DESIGN: Prospective cohort. INTRODUCTION: Successful nonoperative treatment of mallet finger injuries requires compliance to prolonged immobilization and understandable educational materials. PURPOSE OF THE STUDY: This study evaluated the use of written and online video education tools after mallet finger injury. METHODS: After ethics board approval and informed consent, adults with an acute mallet finger injury referred to hand therapy were included. Standard nonoperative treatment was instituted with orthotic immobilization and verbal instructions, in addition to an education pamphlet and an online video link. A questionnaire regarding the educational materials was administered at the follow-up appointment. RESULTS: There were 61 patients (mean age, 42 ± 14 years). The middle (n = 21) and ring (n = 22) fingers were most commonly injured. All patients were fluent in English. Written instructions (n = 57) were used by more patients than the videos (n = 30). Comparing patients who viewed the video with those who did not, there were no differences (P > .05) in demographics (sex, age, education, work status, and second language). Both written and video instructions were reported as helpful; mean helpful score for the video was significantly (P = .03) higher than written instructions. Most patients preferred having written and video instructions, and both were easy to understand and convenient. DISCUSSION: In our study of patients with acute mallet finger injuries, written and video instructions were utilized and both were reported as helpful. CONCLUSIONS: This study provides evidence of the usefulness of online videos as an educational aid and the opportunity for future investigations to improve patient access to education materials.

Prognostic factors for digital range of motion after intrasynovial flexor tendon injury and repair: Long-term follow-up on 273 patients treated with active extension-passive flexion with rubber bands.

STUDY DESIGN: Observational cohort study. INTRODUCTION: Investigating prognostic factors using population-based data may be used to improve functional outcome after flexor tendon injury and repair. PURPOSE OF THE STUDY: The aim of this study is to investigate the effect of concomitant nerve transection, combined flexor digitorum profundus (FDP) and flexor digitorum superficialis (FDS) tendon transection and the age of the patient, on digital range of motion (ROM) more than 1 year after FDP tendon transection and repair in zone I and II. METHODS: Two hundred seventy-three patients with a total of 311 fingers admitted for FDP injury in zone I and II were treated with active extension-passive flexion with rubber bands and followed for at least 1 year. We compared outcome by evaluating digital mobility using Strickland's evaluation system. RESULTS: At 12 months 72% of patients aged > 50 had fair or poor ROM compared to 17% of patients aged 0-25 years. At 24 months the results for patients aged > 50 had improved to 33% with fair or poor ROM, whereas no improvement had occurred for patients aged 0-25 (17% with fair or poor ROM). Concomitant nerve transection and FDS tendon transection had no negative effects on digital mobility. DISCUSSION: Age above 50 was significantly associated with impaired digital ROM during the first year after flexor tendon injury and repair but not at 2 years follow-up. Concomitant nerve transection and combined transection of FDP and FDS do not affect digital mobility. CONCLUSIONS: Older patients are likely to have a slower healing process and impaired digital ROM during the first year after surgery.

[Treatment Options for Inveterate Injuries of Deep Finger Flexors - Primary Transplantation with Tendon Graft]. / Moznosti osetrení u zastaralých poranení hlubokých flexoru prstu ruky ­ primární transplantace slachovým stepem.

Injuries of the flexor finger apparatus are very common. Primarily, it is routinely treated by suture of the tendon. Isolated deep flexor injuries, when the flexion restriction only reaches the DIP joint, are sometimes overlooked by the surgeon or by the patients themselves, especially if the deep flexor is injured, after a closed rupture or cutaneous injury with a small skin wound. The patient is then sent to a department specializing in hand surgery after a few weeks. Subsequent shortening of the tendon apparatus makes flexor suture more difficult or sometimes even impossible. Many ways of suturing the tendons and subsequent treatment are described. The treatment results vary immensely. It depends on the mechanism of injury, injury zone, the suture suture technique used, time that has elapsed since primary treatment, surgeon experience and subsequent postoperative and rehabilitative care. One of them is reconstruction of the flexor apparatus by primary transplantation of an autologous tendon graft. Most commonly, the tendon graft is taken from the palmaris longusfrom the same hand. The tendon graft can subsitute the entire area of zones I and II. The tendon suture is made in the palm proximal to the A1 pulley outside the tendon sheath in the area where the muscular belly of thelumbricalis is located on the tendon of the deep flexor. The distal end is reinserted to the base of the distal phalanx. The primary use of the autologous tendon graft can be used in the reconstruction of obsolete deep-flexor injuries in Zone II, but also in primary treatments. This type of treatment has a number of advantages. Performing the reinforcement of the tendon at the base of the distal phalanxand the suture in the palm of the hand completely eliminates the complications caused by the tendon suture in zone II. There is no injury to the tendon sheath, or the need for intersection of the tendons. The transplanted tendon is smaller in diameter than the deep flexor, so it can also be used for older injuries when the tendon sheath is in partially missing. It removes painful palmar resistance by restoring the right position and a tension of tendon of lumbricalis and the tendon of the deep flexor. This type of reconstruction allows immediate active or semi-rehabilitation of the hand and fingers. Key words:tendon, injury, hand, transplantation, surgery, flexor, reconstruction, rupture, treatment.

Two case reports-Use of relative motion orthoses to manage extensor tendon zones III and IV and sagittal band injuries in adjacent fingers.

STUDY DESIGN: Case report. INTRODUCTION: Injuries to adjacent fingers with differing extensor tendon (ET) zones and/or sagittal band pose a challenge to therapists as no treatment guidelines exist. PURPOSE OF THE STUDY: This report highlights how the relative motion flexion/extension (RMF/RME) concepts were combined into one orthosis to manage a zone IV ET repair (RME) and a zone III central slip repair (RMF) in adjacent fingers (Case 1); and how a single RME orthosis was adapted to limit proximal interphalangeal joint motion to manage multi-level ET zone III-IV injuries and a sagittal band repair in adjacent fingers (case 2). METHODS: Adapted relative motion orthoses allowed early active motion and graded exercises based on clinical reasoning and evidence. Outcomes were standard TAM% and Miller's criteria. RESULTS: 'Excellent' and 'good' outcomes were achieved by twelve weeks post surgery. Both cases returned to unrestricted work at 6 and 7 weeks. Neither reported functional deficits at discharge. DISCUSSION: Outcomes in 2 cases involving multiple digit injuries exceeded those previously reported for ET zone III-IV repairs. CONCLUSIONS: Relative motion orthoses can be adapted and applied to multi-finger injuries, eliminating the need for multiple, bulky or functionally-limiting orthoses. LEVEL OF EVIDENCE: 4.

The challenge of the mallet orthosis: A simple solution.

This author provides instruction regarding an alternative, simple, and custom-made orthotic device to manage the mallet finger that may stay in place more securely while also allowing for proximal interphalangeal joint flexion during the healing of the terminal tendon. - KristinValdes, OTD, OT, CHT, Practice Forum Editor, Journal of Hand Therapy.

Mallet finger injuries-A new method to maintain distal interphalangeal joint extension.

Ensuring that distal interphalangeal joint extension is maintained is an important but challenging part of the treatment process. These authors describe a simple approach to ensuring distal interphalangeal joint extension for these patients. - VictoriaPriganc, PhD, OTR, CHT, CLT, Practice Forum Editor.

A randomized controlled trial of the effect of 2-step orthosis treatment for a mallet finger of tendinous origin.

STUDY DESIGN: A randomized clinical trial, with patients treated either by new 2-step orthosis or by the figure-eight-type orthosis with the distal interphalangeal (DIP) joint extended. PURPOSE OF THE STUDY: To report on our new orthosis and to evaluate the treatment efficacy of using a 2-step orthosis for the treatment of a mallet finger of tendinous origin compared with a conventional orthosis. METHODS: Forty-four patients were randomized into the 2-step or conventional orthosis groups. Primary outcomes were active DIP joint flexion and extensor lag, pain, and the Abouna-Brown criteria. RESULTS: The 2-step orthosis was associated with a smaller active DIP extensor lag, compared with the conventional orthosis (-7.5 ± 4.5° vs -16.4 ± 6.9°, P = .001), combined with a significantly higher Abouna-Brown criteria (χ2 = 14.57, P = .01). No other between-group differences were identified. CONCLUSION: The therapeutic effectiveness of the 2-step orthosis, over a conventional orthosis, was supported by a large effect size of the treatment in improving residual active extensor lag at the DIP and overall Abouna-Brown criteria. Our study thus suggested that the initial immobilization involved in new 2-step orthosis and is thus a good immobilization technique. LEVEL OF EVIDENCE: Ib.

Therapeutic taping for soft tissue-based digit malrotation.

Patients with soft-tissue based digit malrotation often report scissoring with digit flexion, limiting functional grasp capability. This author has successfully utilized a taping technique to improve function for these patients. - Victoria Priganc, PhD, OTR, CHT, CLT, Practice Forum Editor.

Custom-Made Finger Orthoses Have Fewer Skin Complications Than Prefabricated Finger Orthoses in the Management of Mallet Injury: A Systematic Review and Meta-Analysis.

OBJECTIVE: To investigate which orthosis results in (1) fewer complications; (2) the least extensor lag; and (3) the highest rates of treatment success according to the Abouna and Brown criteria for soft tissue mallet injury in adults. DATA SOURCES: Electronic databases AMED, CINAHL, Embase, MEDLINE, PubMed, OTseeker, and PEDro were searched from the earliest available date until September 16, 2014. STUDY SELECTION: Controlled trials evaluating orthosis type in the conservative management of mallet injury were included. Database searching yielded 1024 potential studies, of which 7 met inclusion criteria with a total of 491 participants. DATA EXTRACTION: Data were extracted using an author-designed extraction form by one reviewer, and accuracy was assessed by a second reviewer. The PEDro scale was used to assess methodological quality. DATA SYNTHESIS: Results were pooled using a random-effects model with inverse variance methods. Dichotomous outcomes are expressed as risk ratios (RRs) and 95% confidence intervals (CIs) and continuous outcomes as standardized mean differences and 95% CIs. There is moderate quality evidence that prefabricated orthoses had 3 times the risk of developing skin complications as compared with all other orthoses (RR, 3.17; 95% CI, 1.19-8.43; I(2)=47%) and nearly 7 times the risk of developing skin complications as compared with custom-made thermoplastic orthoses (RR, 6.72; 95% CI, 1.59-28.46; I(2)=0%). Treatment outcomes were found to be similar for treatment success when prefabricated orthoses were compared with custom-made orthoses (RR, .99; 95% CI, 0.80-1.22; I(2)=39%; very low quality evidence), as well as for extensor lag when custom-made thermoplastic orthoses were compared with other orthoses (standardized mean difference, .03; 95% CI, -.29 to .36; I(2)=0%; moderate quality evidence). CONCLUSIONS: Prefabricated orthoses were found to increase the risk of developing skin complications as compared with custom-made orthoses, but there were no differences in treatment success, failure, or extensor lag.

Flexor tendon injuries in children: Rehabilitative options and confounding factors.

Research pertaining to the rehabilitation of children with flexor tendon injuries is less prevalent than that in the adult population, and most authors agree that immobilization protocols comprise a safe and efficacious choice. This article presents suggested protocols and correlated literature regarding the outcomes of immobilization, early passive motion, and early active motion in the pediatric population. Confounding factors which influence rehabilitative choices, both personal and environmental, are also presented.

Zone III flexor tendon injuries - A proposed modification to rehabilitation.

In this manuscript, these authors have utilized years of clinical experience to suggest rehabilitation modifications for Zone III flexor tendon injuries. - VictoriaPriganc, PhD, OTR, CHT, CLT, Practice Forum Editor.