The effect of mirror therapy in the rehabilitation of flexor tendon injuries after primary surgical repair.

OBJECTIVE: The aim of this study was to evaluate the effectiveness of mirror therapy and to provide a clinical basis for better functional recovery in the rehabilitation of patients with flexor tendon injury. MATERIALS AND METHODS: Thirty patients were included and randomly divided between two groups: mirror therapy and conventional treatment. A physical therapy program consisting of whirlpool, ultrasound and transcutaneous electrical nerve stimulation was applied to both groups. In the mirror therapy group, flexor tendon gliding, blocking exercises, joint range of motion and resistance exercises were performed with the healthy hand via a mirror. In the conventional treatment group, the same exercises were performed with the affected hand without mirror. This treatment was continued for 12 sessions over 4 weeks. Joint range of motion, handgrip strength, pain, functionality, dexterity and kinesiophobia were evaluated before and after treatment. RESULTS: More improvement was observed in the mirror therapy group in terms of pain on visual analog scale, Patient-Rated Wrist Evaluation, Hand Function Index and Disabilities of the Arm, Shoulder and Hand scores (p = 0.025, p = 0.004, p < 0.001 and p < 0.001, respectively). There was no significant difference between groups for the other parameters (Tampa Kinesiophobia Scale, Purdue Pegboard test, total active range movement, or handgrip strength: p > 0.05). CONCLUSION: This study shows that mirror therapy in postoperative rehabilitation of flexor tendon injuries is more effective than conventional in terms of reducing the severity of pain and restoring hand function.

Distal forearm squeeze test for the diagnosis of digital flexor tendon injuries.

BACKGROUND: The forearm/wrist squeeze/compression test has been used to examine digital flexor tendon injuries with varied names. Furthermore, the test has not been minutely described and its mechanism remains unclear. We renamed the test the "distal forearm squeeze test". The purpose of this study was to elaborate on the test and elucidate the mechanism. METHODS: Two patients with digital flexor tendons ruptured in zone 3 and zone 1 respectively and 50 outpatients with intact digital tendons underwent the test. Then the test was performed on 3 chickens under 4 conditions. First, when the digital flexor and extensor tendons were all intact. Second, after the flexor tendons of the third toe were transected. Third, after the flexor tendons of all toes of the foot were transected. Finally, after the flexor and extensor tendons of all toes of the foot were transected. RESULTS: In the patient with digital flexor tendons ruptured in zone 3, the test showed that the injured digit was flexed slightly while the uninjured digits were flexed obviously. In the patient with digital flexor tendon ruptured in zone 1, after separate stabilization of the proximal interphalangeal (PIP) joints of the injured and uninjured fingers in extension, the test showed that the distal interphalangeal joint of the patient's injured finger had no response, while those of the uninjured fingers were flexed. All 50 subjects showed clenched or half-clenched hands in response to the test. The test showed that all toes were flexed when the digital tendons of the chicken were intact. All toes were flexed except the third toe after the flexor tendons of the third toe were transected. All toes were extended after all the digital flexor tendons were transected. All toes had no response after all the digital flexor and extensor tendons were transected. CONCLUSIONS: The distal forearm squeeze test is valuable in examining digital flexor tendon injuries. If only the flexor digitorum profundus tendon is examined, the PIP joint of the finger should be stabilized in extension during the test.

Management of flexor tendon injuries in the digits: an update.

Currently used techniques of flexor tendon repair and methods of postoperative rehabilitation differ significantly from those used still 10-15 years ago. Techniques of the repair evolved from 2-strand sutures (the Kessler suture) in the direction of much stronger 4-strand and 6-strand sutures (the Adelaide and Savage sutures), what reduced the risk of failure of the repair and made possible more intensive rehabilitation. Also rehabilitation regimes changed on more comfortable for patients than older protocols and allowed to achieve better functional outcomes of the treatment. This study presents updated trends in management of flexor tendon injuries in the digits, with regard to operative technique and postoperative rehabilitation protocols.

Role of Ultrasound in Flexor Tendon Injuries of the Hand: A New Insight.

This study was aimed at validating the diagnostic accuracy of ultrasound (US) scans in pre-operative evaluation of flexor tendon injuries in the hand and to determine its value in the management of such injuries and in the prediction of patient outcome. This descriptive cross-sectional prospective study included 35 patients with penetrating trauma to the volar aspect of the hand or wrist with questionable clinical findings. They had 50 injured tendons and were candidates for exploratory surgery versus physiotherapy. They underwent pre-operative US to guide their management. Ultrasound results were compared with the operative findings as the gold standard test. Patients were followed up postoperatively, and functional outcome was assessed and correlated with pre-operative sonographic findings. Our results indicate that sonographic examination of hand tendon injury has high accuracy in diagnosing complete or partial flexor injuries, with 100% accuracy, sensitivity and specificity in diagnosing full-thickness tears as well as tenosynovitis of hand flexor tendons. Zonal II injury was the most frequent among our study population and correlated with poorest functional outcome after rehabilitation at 3 mo follow-up. US of the hand is a fast, inexpensive and potentially indispensable dynamic tool for accurate assessment of flexor tendon injuries. It provides data on the extent of injury that effectively helps both set up an appropriate operative plan and predict the patient's functional outcome post-operatively, which in turn will have a direct impact on the patient's rehabilitation plan and lifestyle. Thus, it should be a fundamental part of the management of patients with tendon injuries.

Protocolo de Durán modificado en rehabilitación precoz de lesiones tendinosas flexoras de la mano / Modified Duran protocol in early rehabilitation of flexor tendon injuries of the hand

OBJETIVOS: conocer la efectividad del Protocolo de Durán Modificado en las Lesiones Tendinosas Flexoras de la Mano determinando el grado de discapacidad funcional en pacientes atendidos por el Servicio de Medicina Física y Rehabilitación del Hospital de Clínicas en el periodo agosto ­ diciembre de 2016. MATERIAL Y MÉTODOS: se incluyeron dos grupos paralelos: al primer grupo (9 pacientes) se aplicó el protocolo de Durán Modificado y al segundo (9 pacientes) el tratamiento rehabilitador convencional. La valoración de la funcionalidad fue a través de la fórmula de Strickland, el sistema de Bruck Gramcko y la Distancia Pulpejo-Palma. Se realizó en 36 sesiones de 30 minutos aproximadamente para cada modalidad terapéutica con la correspondiente evaluación al finalizar los 3 meses de terapia. RESULTADOS: los que realizaron el protocolo de Durán Modificado finalizaron el tratamiento con una funcionalidad excelente en 4 casos, bueno en 3 y regular en 2 según la fórmula de Strickland. Según el sistema de Buck Gramcko la funcionalidad fue excelente para 5 pacientes y regular para 4. Y finalmente con la evaluación de la distancia pulpejo - palma se determinó que 4 pacientes obtuvieron un rango excelente, 4 bueno y 1 regular. CONCLUSIONES: la aplicación del protocolo de Durán modificado como rehabilitación precoz en pacientes con lesiones tendinosas flexoras de la mano es de mayor efectividad que el tratamiento rehabilitador convencional siendo una herramienta que puede ser aplicada de manera temprana en pacientes postoperados por esta afección

OBJECTIVES: to determine the effectiveness of the Modified Duran Protocol on flexor tendon injuries of the hand determining the degree of functional disability in patients treated by the Department of Physical Medicine and Rehabilitation at the Hospital de Clinicas during term August - December 2016.MATERIAL AND METHODS: we included two parallel groups: The Duran Modified protocol was applied on the first group (9 patients) and the Conventional Rehabilitation (9 patients) Treatment on the second. The assessment of the functionality was carried out with the formula Stricklan, Bruck Gramcko System and Pulpejo-Palma Distance. It was conducted in 36 sessions of approximately 30 minutes for each treatment modality with the corresponding evaluation at the end of 3 months of therapy. RESULTS: those who carried out the Modified Duran protocol completed treatment with excellent functionality in 4 cases, good in 3 and fair in 2 according to the formula Strickland. According Gramcko Buck system functionality was excellent for 5 patients and Fair for 4. Finally the evaluation of the pulpejo - palm distance showed that four patients had an excellent range, 4 good and 1 fair. CONCLUSIONS: the application the Modified Duran protocol as immediate rehabilitation in patients with flexor tendon injuries of the hand is more effective than conventional rehabilitation treatment being a tool that can be applied early in patients after surgery for this injury

Comparison Of Outcome Of 1- And 2-Knot, 4-Strand, Doublemodified Kessler Flexor Tendon Repair With Early Active Mobilization Protocol In Patients With Flexor Tendon Lacerations Of Hand.

BACKGROUND: Hand is unique for the dexterity of its function and flexor tendons have most important function in hand. Its injury is a challenging treatment. Purpose of this study is to compare the success of 1- and 2-knot, flexor tendon repair (good to excellent results) with early active mobilization in terms of total active motion (TAM) of affected hand postoperatively. METHODS: Hundred patients with age range of 5-70 years of age presenting with flexor tendon lacerations of hand were included in the study. Subjects were randomly divided into Group A, who underwent flexor tendon repair using 4 strands of double modified Kessler repair with 1 knot and Group B, in which 4 strand double modified Kessler repair with 2 knot technique was used. All patients followed early active motion protocol started in first 48 hours. They were followed at 3, 6 and 8 weeks after surgery for TAM. Data was entered and analysed in SPSS-21.0. Frequency and percentages were calculated for outcome of procedure. RESULTS: In group A 89.8% (44) of patients had good to excellent results in terms of total active motion (TAM) as compared with 90.9% (40) in group B using early active mobilization protocol. CONCLUSIONS: The study concluded that that four strand double modified flexor tendon repair using either 1 or 2 knot technique are excellent choices of repair with early active mobilization protocols.

Flexor tendon repairs: techniques, eponyms, and evidence.

The evolution in surgical technique and suture technology has provided an abundance of options for flexor tendon repairs. Multiple biomechanical studies have attempted to identify the best surgical technique based on suture properties, technical modifications, and repair configurations. However, the burgeoning amount of research on flexor tendon repairs has made it difficult to follow, and no gold standard has been determined for the optimal repair algorithm. Therefore, it seems that repairs are usually chosen based on a combination of familiarity from training, popularity, and technical difficulty. We will discuss the advantages, disadvantages, and technical aspects of some of the most common core flexor tendon repairs in the literature. We will also highlight the nomenclature carried through the years, drawings of the repairs referred to by that nomenclature, and the data that support those repairs.

Mobilidade articular dos dedos não lesados pós-reparo em lesão dos tendões flexores da mão / Joint range of motion of uninjured fingers after repairs to flexor tendon injuries of the hand

OBJETIVO: Verificar a amplitude de movimento (ADM) em mãos que sofreram reparo tendinoso dos músculos flexores superficial e profundo dos dedos, comparando os dados de cada dedo na mão lesada e entre mãos lesadas e não lesadas. MÉTODOS: Foi realizada a goniometria ativa em 15 pacientes e 120 dedos, 60 dedos de mãos lesadas e 60 de mãos controle não lesadas. Os sujeitos foram avaliados no momento da retirada da tala gessada, tendo sido realizada a movimentação precoce pelo método de Duran modificado. A partir dos dados goniométricos, foram registrados os valores do índice TAM (Total Active Motion) dos dedos nas mãos lesadas e controle. Para análise dos dados, foi acessada a fórmula de índices funcionais proposta pela American Society for Surgery of the Hand (ASSH) e para cálculo estatístico, foi escolhido o Modelo de Efeitos Mistos. RESULTADOS: A fórmula da ASSH para os dedos lesados mostrou que 18,33 por cento tiveram a classificação do movimento "bom", 18,33 por cento, "regular" e 63,34 por cento, "pobre". Foram comparadas as médias das medidas em graus de todos os dedos entre si dentro de cada grupo, controle ou lesado, e as médias das medidas entre os grupos, encontrando-se um p-valor significante apenas entre os grupos controle e lesado. Não houve diferença estatística entre o TAM de cada dedo na mão lesada. CONCLUSÃO: Independente de quantos dedos tenham sofrido lesão tendinosa em uma mão, os dedos não lesados também terão suas ADMs ativas diminuídas no período logo após a retirada da imobilização.

OBJECTIVE: To assess the range of motion (ROM) in hands that underwent tendon repair in the flexor digitorum superficialis and flexor digitorum profundus muscles of the fingers, comparing the data between the fingers on the injured hand, and between the injured and uninjured hands. METHOD: Active goniometry was performed on 15 patients, making a total of 120 fingers (60 on injured hands and 60 on noninjured control hands). The patients were examined at the time of removing the plaster splint. Early mobilization was performed using the modified Duran method. Goniometric data were used for recording the TAM (total active motion) values of the fingers on the injured and uninjured (control) hands. To analyze the data, the functional index formula proposed by the American Society for Surgery of the Hand (ASSH) was utilized, and for statistical calculations the mixed-effect model was selected. RESULTS: The ASSH formula for the injured fingers classified the movement as "good" in 18.33 percent, "fair" in 18.33 percent and "poor" in 63.34 percent. The means, in degrees, of the measurements for all the fingers were compared with each other within each group (control and injured) and between the groups. A significant difference was found between control and injured groups. There was no statistical difference between the TAM of each finger on the injured hand. CONCLUSION: Independent of how many fingers on one hand had suffered tendon injuries, the uninjured fingers also presented diminished active ROM during the period immediately after removal of the immobilization.