TpoA-2

Повреждение сухожилий сгибателей

imagesFlexor Tendon из книги" HAND AND UPPER EXTREMITY REHABILITATION"
Mary Formby
The healing of the repaired flexor tendon is at least a 6-month process. The “best” way to manage the first 12-week period remains controversial despite significant research and clinical advances over the last 50 years. Effective communication among surgeon, therapist, and patient throughout the rehabilitation process is essential for achievement of a successful outcome.


DEFINITION
Tendon healing occurs by both intrinsic and extrinsic processes.1 When intrinsic healing dominates, few adhesions form, and the result is more freely gliding tendons. Tendons with fewer adhesions must be carefully protected from resistive use, because they may be at greater risk for rupture. The rehabilitation timeline for such patients may need to be slowed. When extrinsic healing dominates, an increased inflammatory response occurs as the result of high-energy injury, postsurgical infection, or other factors. These patients have poorer tendon glide and may need their rehabilitation timeline advanced more quickly. Because each person’s biological response to healing is different, a “pyramid-of-force” model2 for flexor tendon rehabilitation was proposed by Groth in 2004. This model is based on a progression of force application that safely maximizes tendon excursion. Both time-based protocols and Groth’s new rehabilitation model are presented in this chapter.


SURGICAL AND TREATMENT PURPOSE
The purpose of surgery and rehabilitation is to restore maximum active flexor tendon gliding, to ensure effective finger joint motion. The most common impediments to restoration of good tendon gliding are gap formation at the repair site, rupture of the tendon repair, and scarring with adhesions. The surgical technique requires gentle tendon handling; strong, effective suture material with grasping stitches; and meticulous postoperative management. The zone of tendon injury may not coincide with the level of skin laceration because of finger position when the cut occurs (Fig. 17-1). For surgeons, a critical distinction is whether the tendon is injured in zone II (Bunnell’s “no-man’s land”) or another zone. The zone of injury dictates to some extent the therapeutic methods to be used (Fig. 17-2 and Table 17-1). The thumb flexor tendon lies alone in the digital sheath;
in contrast, two intimately related tendons—profundus and superficialiare in each digital sheath of the fingers. This fact alters some of the therapy
requirements for the fingers compared with the thumb. The causes of flexor tendon injury are most commonly traumatic; however, rheumatoid arthritis may also bring it about.

TREATMENT GOALS
I. Provide appropriate splint protection.
II. Prevent development of excessive edema.
III. Promote wound healing.
IV. Maintain active range of motion (AROM) of all uninvolved joints—including neck, shoulder, elbow, and wrist.
V. Maintain digital passive range of motion (PROM).
VI. Prevent flexion contractures.
VII. Restore digital tendon glide to achieve functional AROM.
VIII. Provide guidance for functional use of hand at the appropriate time.
IX. Gradually strengthen the hand when appropriate.
X. Return to previous level of function if possible. Guide patient toward vocational rehabilitation services if previous functional level cannot be achieved.

POSTOPERATIVE INDICATIONS/PRECAUTIONS FOR THERAPY
I. Indications
A. Surgical repair of flexor tendon laceration or rupture in fingers and/or thumb
II. Precautions
A. Infection: Notify surgeon if signs of infection appear.
B. Concomitant injuries (e.g., extensor tendons, fractures, nerve or vessel repair): discuss with surgeon how these injuries will change the treatment approach.
C. Sympathetically mediated pain (more common with associated nerve injuries):
1. Keep therapy gentle—use of transcutaneous electrical nerve stimulation (TENS) may help control pain.
2. Surgeon may prescribe medications or nerve blocks.
D. Severe edema or joint stiffness—both conditions add to the “work of flexion”4 and increase the force that is required to flex a digit through its range of motion. PROM should precede AROM to help decrease stiffness. AROM should be done only in the freely moving arc of motion, to avoid elongation at the repair site (gap formation). Gaps greater than 3 mm may be at increased risk for rupture throughout the rehabilitation process.5
E. Tendon rupture: If loss of normal postural “cascade” of digits and/or loss of AROM occurs, contact surgeon immediately.

POSTOPERATIVE THERAPY
In general, therapy protocols can be divided into three categories: immobilization, early passive mobilization, and early active mobilization. These protocols vary mainly in their management during the first 3 to 4 postoperative weeks. All protocols allow a gradual increase of active motion with splint protection from 3 to 6 weeks. A gradual increase of nonresistive functional use out of the splint is then allowed, with progression to resistance as needed for good tendon glide. Heavy resistive use is not recommended before 12 weeks postoperatively.
I. Immobilization protocol
A. With this method there is no active or passive motion of the affected digits for at least 3 weeks.
B. Immobilization is reserved for the following patients
1. Those in whom the risk of noncompliance outweighs the benefits of early motion (e.g., young children, cognitively or behaviorly impaired adults)
2. Those living under severely adverse environmental conditions
3. Those with concomitant injuries that preclude motion (e.g., some bone and joint injuries, complex skin injuries, revascularizations, replantations) Immobilization protocols have been shown in canine models to result in increased adhesion formation (extrinsic healing) and reduced ROM.6 These patients will not be seen by the therapist until the surgeon removes the cast or immobilizing dressing. They will probably achieve better tendon glide if treated with a motion-driven progression of therapy after
the first 3 weeks. They should be splinted in either a static or dynamic dorsal blocking splint when motion begins. Therapy management can proceed by either Collins’ early progressive-resistance program7 or Groth’s pyramid-of-force application2 (Boxes 17-1 and 17-2). Groth’s exercise pyramid is shown in Fig. 17-3.
II. Early passive mobilization protocols
A. This method uses passive flexion and passive/active extension of the affected digits. Motion is preferably initiated in the first few days postoperatively, but it can be started at any point during the first 3 weeks.
B. Early passive mobilization is recommended for the following patients
1. Those in whom surgical repair is inappropriate for AROM protocols—(e.g., less than four-strand core suture with epitendinous suture) or the type of surgical repair is unknown
2. Those with significant postoperative edema
3. Those who are unable to attend therapy sessions two to three times per week and are not capable of conducting an AROM protocol at home Boyer and colleagues8 and Strickland9 have provided reviews of the science that has led to a better understanding of flexor tendon healing. This healing is facilitated by passive motion protocols that inhibit formation of intrasynovial adhesions and help restore tendon glide. These protocols can be grossly grouped as those that use. 

1. Manual passive flexion and passive/active extension in a dorsal blocking splint10 (for splint positioning, see Figs. 17-4 through 17-7; for therapy protocols, see Boxes 17-3A, 17-3B, and 17-3C)
2. Dynamic flexion traction and active extension in a dorsal blocking splint11 (for splint positioning, see Figs. 17-8 and 17-9; for therapy protocols, see Boxes 17-4A and 17-4B)
III. Early active mobilization protocols
A. These protocols incorporate place-hold flexion and/or true active flexion of the affected digits. Motion must be initiated within the first 5 days postoperatively. Immediate mobilization (day 1 or 2) has been shown to be less effective than a delay of 3 to 5 days to allow inflammation to subside.4 Adhesions inhibit tendon glide as early as 1 week postoperatively; therefore, the work of flexion required to initiate active flexion after 7 days may be too great for the typical four-strand repair. Boyer and associates12 showed that an eight-strand repair results in approximately 35% greater strength and rigidity than a four-strand repair. Such repairs may not need the same time restrictions for AROM initiation, but more research is needed to resolve this issue. Active protocols may offer the best opportunity to limit adhesion formation with increased tendon glide.
B. These protocols should be used exclusively for the following patients
1. Those in whom a four-strand or greater core suture with epitendinous suture was performed by a surgeon who approves of an AROM protocol
2. Those without significant postoperative edema
3. Those who are compliant and able to attend therapy two to three times per week or able to conduct an AROM protocol safely with a home exercise program

C. For splint positioning see Figs. 17-5, 17-6, and 17-8. Early active therapy protocols can be found in Boxes 17-5A and 17-5B.


POSTOPERATIVE COMPLICATIONS
I. Tendon rupture
II. Minimal tendon gliding
III. Flexion contractures
IV. Excessive scar formation
V. Extreme pain
VI. Severe edema
VII. Infection
VIII. Triggering


EVALUATION TIMELINE
I. First postoperative therapy session
A. Wound—Determine appropriate dressing to be worn inside splint.
B. Edema—Compare girth of affected digit to unaffected hand.
C. Pain—scale from 0 to 10
D. Sensibility—especially important with concomitant nerve injuries

E. Flexion PROM—assessed grossly (deficits in flexion to distal palmar crease)
F. Extension deficit (inside dorsal blocking splint)
G. Flexion AROM if early AROM protocol is being initiated
II. 1 to 2 weeks postoperatively
A. Reassess flexion AROM if using early active or place/hold protocol.
B. Reassess pain, edema, and PROM.
III. 3 weeks postoperatively
A. Flexion AROM—Continue weekly reassessments to determine need for stress progression to facilitate tendon glide
B. Scar—Assess need for elastomer mold and/or desensitization.
C. Continue weekly reassessment of pain, edema, and PROM.
IV. 10 weeks postoperatively—grip and pinch strength assessment
V. 12 weeks postoperatively—provide data to surgeon for back-to-work assessment

OUTCOMES
ROM is the criterion set to determine successful outcomes after flexor tendon repair. Several methods of evaluating ROM results have been developed. Two of these methods are presented in Tables 17-2 and 17-3.  Strickland’s method includes only proximal interphalangeal (PIP) and distal interphalangeal (DIP) joint motion (although the measurements are made while the patient attempts to make a full fist). Kleinert’s method includes all three joints of the digit. Outcome information specific to the
zone of injury follows.
Zone I: Guinard and colleagues13 reported that patients’ subjective assessments of functional outcome after zone I repairs were less favorable than would be indicated by Strickland’s method of outcome assessment. Moiemen14 reported the results of 102 zone I injuries treated with an early active therapy protocol. The results were compared with earlier zone I reports by Evans15 and by Gerbino and associates.16 They suggested that a revision of Strickland’s method would be more appropriate for zone I
outcomes. The revised method would include only DIP joint motion (measured while attempting to make a full fist). Evans15 suggested that
a minimum of 40 degrees of DIP joint flexion is needed for good patient satisfaction.
Zone II: Elliot17 surveyed the literature and found a 5% rate of both rupture and tenolysis after zone II repairs, regardless of suture technique used. Strickland9 stated that good or excellent function may be expected more than 80% of the time if a strong repair is followed by an early postrepair motion protocol. Riaz and coworkers18 performed a 10-year review of patients who had been treated with an early active-motion protocol. The original results had been published by Small and associates.19 Riaz reported that 77% of the patients treated with early AROM continued to have good or excellent outcomes by Strickland’s criteria, and 75% by Kleinert’s criteria. Grip strength was 95.5% of that of the uninjured hand. Cold intolerance was a problem for 47% of these patients, although only
20% had associated nerve injuries. Flexor pollicis longus (FPL): Elliot and associates20 reported higher rupture rates for FPL repairs than for flexor digitorum superficialis (FDS) or flexor digitorum profundus (FDP) repairs among 233 patients treated with an early AROM protocol. More recently, Elliot and colleagues17 explained why the FPL rupture rate may be higher. Because the FPL glides alone within its sheath, fewer adhesions form during healing. The FPL also retracts proximally after laceration, making delayed repairs more difficult. 

Noonan and Blair21 did a long-term (mean 6.8 years) follow-up of FPL
repairs. The conclusion was that the method used to rehabilitate FPL
repairs (static splint, dynamic splint, or immobilization) did not statistically
affect the outcome.
Children: Outcomes in children seem to be better than in adults, possibly
because of a better blood supply to the flexor tendons and a greater
capacity for remodeling.22
REFERENCES
1. Wang ED: Tendon repair. J Hand Ther 11:105-110, 1998
2. Groth GN: Pyramid of progressive force exercises to the injured flexor tendon. J Hand
Ther 7:31-42, 2004
3. Kleinert HE, Schepel S, Gill T: Flexor tendon injuries. Surg Clin North Am 61:267-286,
1981
4. Halikis MN, Manske PR, Kubota H, et al.: Effect of immobilization, immediate
mobilization, and delayed mobilization on the resistance to digital flexion using
a tendon injury model. J Hand Surg Am 22:464-472, 1997
5. Gelberman RH, Boyer MI, Brodt MD, et al.: The effect of gap formation at the repair
site on the strength and excursion of intrasynovial flexor tendons. J Bone Joint Surg Am
81:975-982, 1999
6. Gelberman RH, Vande Berg JS, Lundborg GN, et al.: Flexor tendon healing and
restoration of the gliding surface. J Bone Joint Surg Am 65:70-80, 1993
7. Collins DC, Schwarze L: Early progressive resistance following immobilization of flexor
tendon repairs. J Hand Ther 4:111-116, 1991
8. Boyer MI, Strickland JW, Engles DR, et al.: Flexor tendon repair and rehabilitation.
J Bone Joint Surg Am 84:1684-1706, 2002
9. Strickland JW: Development of flexor tendon surgery: twenty five years of progress.
J Hand Surg Am 25:214-235, 2000
10. Duran RJ, Houser R: Controlled passive motion following flexor tendon repair in zones 2
and 3. In AAOS Symposium on Tendon Surgery in the Hand. Mosby, St. Louis, 1975
11. Kleinert HE, Kutz JE, Ashbell TS, et al.: Primary repair of lacerated flexor tendons in
“no man’s land.” Proceedings of the American Society for Surgery of the Hand.
J Bone Joint Surg Am 49:577, 1967
12. Boyer MI, Gelberman RH, Burns ME, et al.: Intrasynovial flexor tendon repair. J Bone
Joint Surg Am 83:891-899, 2001
13. Guinard D, Montanier D, Thomas D, et al.: The Mantero flexor tendon repair in zone I.
J Hand Surg Br 24:148-151, 1999
14. Moiemen NS, Elliot D: Primary flexor tendon repair in zone I. J Hand Surg Br 25:
78-84, 2000
15. Evans R: A study of the zone 1 flexor tendon injury and the implications for treatment.
J Hand Ther 3:133-146, 1990
16. Gerbino PG, Saldana MJ, Westerbeck P, et al.: Complications experienced in the
rehabilitation of zone I flexor tendon injuries with dynamic traction splinting. J Hand
Surg Am 16:680-686, 1991
17. Elliot D: Primary flexor tendon repair: operative repair, pulley management, and
rehabilitation. J Hand Surg Br 7:507-513, 2002
18. Riaz M, Hill C, Khan K, et al.: Long term outcome of early active mobilization following
flexor tendon repair in zone 2. J Hand Surg Br 24:157-160, 1999
19. Small JO, Brennen MD, Colville J: Early active mobilization following flexor tendon
repair in zone 2. J Hand Surg Br 14:383-391, 1989
20. Elliot D, Moimen N, Fleming A, et al.: The rupture rate of acute flexor tendon repairs
mobilized by controlled active mobilization. J Hand Surg Br 19:607-612, 1994
21. Noonan KJ, Blair WF: Long-term follow up of primary flexor pollicis longus
tenorrhaphies. J Hand Surg Am 16:653-662, 1991
22. Grobbelaar AO, Hudson DA: Flexor tendon injuries in children. J Hand Surg Br 19:
696-698, 1994
23. Hagberg L, Selvik G: Tendon excursions and dehiscence during early controlled
mobilization after flexor tendon repair in zone II: an x-ray stereophotogrammetric
analysis. J Hand Surg Am 16:669-680, 1991
24. Nunley JA, Levin LS, Devito D, et al.: Direct end-to-end repair of flexor pollicis longus
tendon lacerations. J Hand Surg Am 17:118-121, 1992
25. Strickland JW, Glogovac SV: Digital function following flexor tendon repair in zone II:
a comparison of immobilization and controlled passive motion techniques. J Hand Surg
Am 5:537-543, 1980
26. Lister GD, Kleinert HE, Kutz JE: Primary flexor tendon repair followed by immediate
controlled mobilization. J Hand Surg Am 2:441-451, Nov. 1977
27. Evans RB, Thompson DE: The application of force to the healing tendon. J Hand Ther
6:266-284, 1993
28. Wehbe MA, Hunter JM: Flexor tendon gliding in the hand: II. Differential gliding.
J Hand Surg Am 10:575-579, 1986
29. Cannon N: Post flexor tendon repair protocol. Indiana Hand Center Newsletter 1:13, 1993
30. Silfverskiold KL, May EJ, Tornvall AH: Flexor digitorum profundus tendon excursions
during controlled motion after flexor tendon repair in zone II: a prospective clinical
study. J Hand Surg Am 17:122-131, 1992
31. May EJ, Silfverskiold KL, Sollerman CJ: Controlled mobilization after flexor tendon
repair in zone II: a prospective comparison of three methods. J Hand Surg Am
17:942-952, 1992
32. Chow JA, Thomes LJ, Dovelle S, et al.: A combined regimen of controlled motion
following flexor tendon repair in “no man’s land.” Plast Reconstr Surg 79:447, 1987
33. Percival NJ, Sykes PJ: Flexor pollicis longus tendon repair: a comparison between
dynamic and static splintage. J Hand Surg Br 14:412-415, 1989
34. Evans RB, Thompson DE: Immediate active short arc motion following tendon
repair. In Hunter JM, Schneider LH, Mackin EJ (eds). Tendon and Nerve Surgery in
the Hand: A Third Decade. Mosby, St. Louis, Mosby, 1997, pp. 363-393
35. Klein L: Early active motion flexor tendon protocol using one splint. J Hand Ther
16:199-206, 2003
36. Strickland JW: The Indiana method of flexor tendon repair. In Taras JS, Schneider LH.
Atlas of the Hand Clinics. WB Saunders, Philadelphia, 1996, pp. 77-103
37. Silfverskiold KL, May EJ: Flexor tendon repair in zone II with a new suture technique
and an early mobilization program combining passive and active flexion. J Hand Surg
Am 19:53-60, 1994

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