Important points for rehabilitation after flexor tendon laceration and repair

Figure 1-1 Author’s technique of flexor tendon repair in zone II. A, Knife laceration through zone II with the digit in full flexion. The distal stumps retract distal to the skin incision with digital extension. B, Radial and ulnar extending incisions are used to allow wide exposure of the flexor tendon system. Note appearance of the flexor tendon system of the involved fingers after the reflection of skin flaps. The laceration occurred through the C1 cruciate area. Note the proximal and distal position of the flexor tendon stumps. Reflection of small flaps (“windows”) in the cruciate-synovial sheath allows the distal flexor tendon stumps to be delivered into the wound by passive flexion of the distal interphalangeal (DIP) joint. The profundus and the superficialis stumps are retrieved proximal to the wound by passive flexion of the DIP joint. The profundus and superficialis stumps are retrieved proximal to the sheath by the use of a small catheter or infant feeding gastrostomy tube. C, The proximal flexor tendon stumps are maintained at the repair site by means of a transversely placed small-gauge hypodermic needle, allowing repair of the FDS slips without extension. D, Completed repair of both FDS and FDP tendons is shown with the DIP joint in full flexion. Extension of the DIP joint delivers the repair under the intact distal flexor tendon sheath. Wound repair is done at the conclusion of the procedure.

Figure 1-2 Blood supply to the flexor tendons within the digital sheath. The segmental vascular supply to the flexor tendons is by means of the long and short vincular connections. The vinculum brevis superficialis (VBS) and the vinculum brevis profundus (VBP) consist of small triangular mesenteries near the insertion of the FDS and FDP tendons, respectively. The vinculum longum to the superficialis tendon (VLS) arises from the floor of the digital sheath of the proximal phalanx. The vinculum longum to the profundus tendon (VLP) arises from the superficialis at the level of the proximal interphalangeal (PIP) joint. The cut-away view depicts the relative avascularity of the palmar side of the flexor tendons in zones I and II as compared with the richer blood supply on the dorsal side, which connects with the vincula.

Rehabilitation rationale and basic principles of treatment after flexor tendon repair

Anatomy

The anatomic zone of injury of the flexor tendons influences the outcome and rehabilitation of these injuries. The hand is divided into five distinct flexor zones (Fig. 1-3):

• Zone 1—from the insertion of the profundus tendon at the distal phalanx to just distal to the insertion of the sublimus

• Zone 2—Bunnell’s “no-man’s land”: the critical area of pulleys between the insertion of the sublimus and the distal palmar crease

• Zone 3—“area of lumbrical origin”: from the beginning of the pulleys (A1) to the distal margin of the transverse carpal ligament

• Zone 4—area covered by the transverse carpal ligament

• Zone 5—area proximal to the transverse carpal ligament

Figure 1-3 The flexor system has been divided into five zones or levels for the purpose of discussion and treatment. Zone II, which lies within the fibro-osseous sheath, has been called “no man’s land” because it was once believed that primary repair should not be done in this zone.

As a rule, repairs to tendons injured outside the flexor sheath have much better results than repairs to tendons injured inside the sheath (zone 2).

It is essential that the A2 and A4 pulleys (Fig. 1-4) be preserved to prevent bowstringing. In the thumb, the A1 and oblique pulleys are the most important. The thumb lacks vincula for blood supply.

Figure 1-4 The fibrous retinacular sheath starts at the neck of the metacarpal and ends at the distal phalanx. Condensations of the sheath form the flexor pulleys, which can be identified as five heavier annular bands and three filmy cruciform ligaments (see text).

Rehabilitation after flexor tendon repair

The rehabilitation protocol chosen (Rehabilitation Protocols 1-1 and 1-2) depends on the timing of the repair (delayed primary or secondary), the location of the injury (zones 1 through 5), and the compliance of the patient (early mobilization for patients who are compliant and delayed mobilization for patients who are noncompliant and children younger than 7 years of age). A survey of 80 patients with flexor and extensor tendon repairs determined that two thirds were nonadherent to their splinting regimen, removing their splints for bathing and dressing (Sandford et al. 2008).

REHABILITATION PROTOCOL 1-1 Rehabilitation Protocol after Immediate or Delayed Primary Repair of Flexor Tendon Injury: Modified Duran Protocol

Marissa Pontillo, PT, DPT, SCS

Postoperative Day 1 to Week 4.5

• Keep dressing on until Day 5 postoperative.

• At Day 5: replace with light dressing and edema control prn.

• Patient is fitted with dorsal blocking splint (DBS) fashioned in:

• 20 degrees wrist flexion.

• 45 degrees MCP flexion.

• Full PIP, DIP in neutral

• Hood of splint extends to fingertips.

• Controlled passive motion twice daily within constraints of splint:

• 8 repetitions of passive flexion and active extension of the PIP joint

Passive flexion and extension exercises of the proximal interphalangeal (PIP) joint in a dorsal blocking splint (DBS).

Passive flexion and extension exercises of the distal interphalangeal (DIP) joint in a dorsal blocking splint (DBS).

• 8 repetitions of passive flexion and active extension of the DIP joint

• 8 repetitions of active composite flexion and extension of the DIP and PIP joints with the wrist and MCP joints supported in flexion

4.5 Weeks

• Continue passive exercises as needed.

• Removal of DBS every 2 hours to perform 10 repetitions of each active flexion and extension of the wrist and of the digits

• May start intrinsic minus (hook fist) position and/or tendon gliding exercises

• Active wrist extension to neutral only

• Functional electrical stimulation (FES) with the splint on

5.5 Weeks

• Continue passive exercises.

• Discontinue use of DBS.

• Exercises are performed hourly:

• 12 repetitions of PIP blocking

• 12 repetitions of DIP blocking

• 12 repetitions of composite active flexion and extension

• May start PROM into flexion with overpressure

6 weeks

• Initiate passive extension for the wrist and digits.

8 weeks

• Initiate gentle strengthening.

• Putty, ball squeezes

• Towel walking with fingers

• No lifting or heavy use of the hand

10–12 weeks

• Return to previous level of activity, including work and sport activities.

In a comparison of early active mobilization and standard Kleinert splintage,Yen et al. (2008)found at an average 4-month follow-up (3 to 7 months) that those in the early active mobilization group had 90% of normal grip strength, pinch, and range of motion compared to 50%, 40%, and 40%, respectively, in those with Kleinert splinting.

Sueoka and LaStayo (2008) devised an algorithm for zone 2 flexor tendon rehabilitation that uses a single clinical sign—the lag sign—to determine the progression of therapy and the need to modify existing protocols for individual patients. They defined “lag” as PROM—AROM (active ROM) ≥15 degrees and consider it a sign of tendon adherence and impairment of gliding. Rehabilitation begins with an established passive ROM Protocol (Duran), which is followed for 3.5 weeks before the presence or absence of a lag is evaluated. The presence or absence of lag is then evaluated at the patient’s weekly or twice-weekly visits, and progression of therapy is modified if a lag sign is present (Rehabilitation Protocol 1-3).

REHABILITATION PROTOCOL 1-3 Zone 2 Lag Sign Algorithm

Background

Trigger finger is a painful snapping phenomenon that occurs as the finger flexor tendons suddenly pull through a tight A1 pulley portion of the flexor sheath. The underlying pathophysiology of trigger finger is an inability of the two flexor tendons of the finger (FDS and FDP) to slide smoothly under the A1 pulley, resulting in a need for increased tension to force the tendon to slide and a sudden jerk as the flexor tendon nodule suddenly pulls through the constricted pulley (triggering). The triggering can occur with flexion or extension of the finger or both. Whether this pathologic state arises primarily from the A1 pulley becoming stenotic or from a thickening of the tendon remains controversial, but both elements are usually found at surgery.

Clinical history and examination

Trigger finger most commonly occurs in the thumb, middle, or ring fingers. Patients typically present with clicking, locking, or popping in the affected finger that is often painful, but not necessarily so.

Patients often have a palpable flexor tendon nodule in the area of the thickened A1 pulley (which is at the level of the distal palmar crease). This nodule can be felt to move with the tendon and is usually painful to deep palpation.

To induce the triggering during examination, it is necessary to have the patient make a full fist and then completely extend the fingers because the patient may otherwise avoid triggering by only partially flexing the fingers.

Treatment

Spontaneous long-term resolution of trigger finger is rare. If left untreated, the trigger finger will remain a painful nuisance; however, if the finger should become locked, the patient may develop permanent joint stiffness. Historically, conservative treatment included splinting of the finger in extension to prevent triggering, but this has been abandoned because of stiffening and poor result.

Currently, nonoperative treatment involves injection of corticosteroids with local anesthetic into the flexor sheath. A meta-analysis of the literature found convincing evidence that combining lidocaine with the corticosteroid obtains results superior to those with corticosteroid alone(Chambers 2009). In a cost-minimization analysis, the use of two steroid injections before resorting to surgery was found to be the least costly treatment strategy compared to one or three injections before surgery and open or percutaneous release(Kerrigan and Stanwix 2009).

Our preference is 0.5 ml lidocaine, 0.5 ml bupivicaine, and 0.5 ml methylprednisolone acetate (Depo-Medrol) (Fig. 1-5). A single injection can be expected to relieve triggering in about 66% of patients. Multiple injections have been reported to relieve triggering in 75% to 85% of patients. Current reports indicate a success rate of 47% to 87% with this type of treatment. Systematic review of levels I and II studies in the Journal of the American Academy of Orthopedic Surgeons (Fleisch et al. 2007) indicates a success rate of 57%. Prognostic indicators of recurrence of trigger digits after corticosteroid injection include younger age, insulin-dependent diabetes mellitus, involvement of multiple digits, and a history of other tendinopathies of the upper extremity (Rozental et al. 2008).

Figure 1-5 A, Needle entrance points (dots) are located approximately one third distance from the distal palmar crease and two thirds the distance from the proximal distal crease. This corresponds to the center of the A1 pulley. B, Diagram depicts the location of the A1 pulleys in the fingers and the A2 pulley in the ring finger. Half of the A2 pulleys are located in the distal palm. C, A1 pulley of the thumb. D, Diagram depicts the optimal insertion point for the needle.

The risk of cortisone injection here is of inadvertent injection into the flexor tendon with possible tendon weakening or rupture. Ultrasound guidance has been reported to help avoid this complication and improve results (Bodor and Flossman 2009).

Physical therapy usually is not necessary to regain motion after cortisone injection because most patients are able to regain motion once the triggering resolves.

Surgery to “release” a trigger finger is a relatively simple outpatient procedure done with the patient under local anesthesia. The surgery involves a 1- to 2-cm incision in the palm overlying the A1 pulley to identify and completely divide the A1 pulley. Gentle active motion is initiated early, and return to unrestricted activities usually is possible at about 3 weeks (Rehabilitation Protocol 1-4).

Pediatric trigger thumb

Pediatric trigger thumb is a congenital condition in which stenosis of the A1 pulley of the thumb in infants causes locking in flexion (inability to extend) of the IP joint. It often is bilateral. Usually no pain or clicking occurs because the thumb remains locked. A recent report by Baek et al. (2008) indicates spontaneous resolution in 63% of cases. The rest require surgical intervention when the patient is around 2 to 3 years old to release the tight A1 pulley and prevent permanent joint flexion contracture.

Background

Avulsion of the flexor digitorum profundus (“jersey finger”) can occur in any digit, but it is most common in the ring finger. This injury usually occurs when an athlete grabs an opponent’s jersey and feels sudden pain as the distal phalanx of the finger is forcibly extended as it is concommitantly actively flexed (hyperextension stress applied to a flexed finger).

The resultant lack of active flexion of the DIP joint (FDP function loss) must be specifically checked to make the diagnosis (Fig. 1-6). Often the swollen finger assumes a position of extension relative to the other, more flexed fingers. The level of retraction of the FDP tendon back into the palm generally denotes the force of the avulsion.

Figure 1-6 With avulsion of the flexor digitorum profundus, the patient would be unable to flex the distal interphalangeal (DIP) joint, shown here.

(From Regional Review Course in Hand Surgery. Rosemont, Illinois, American Society of Surgery of the Hand, 1991, Fig. 7).

Leddy and Packer (1977) described three types of FDP avulsions based on where the avulsed tendon retracts: type I, retraction of the FDP to the palm; type II, retraction to the proximal interphalangeal (PIP) joint; and type III, bony fragment distal to the A4 pulley. Subsequently, a type IV injury was described in which a type III lesion is associated with a simultaneous avulsion of the FDP from the fracture fragment. Treatment is based on the anatomy of the injury.

Treatment

The treatment of FDP avulsion is primarily surgical. The success of the treatment depends on the acuteness of diagnosis, rapidity of surgical intervention, and level of tendon retraction. Tendons with minimal retraction usually have significant attached avulsion bone fragments, which may be reattached bone-to-bone as late as 6 weeks. Tendons with a large amount of retraction often have no bone fragment and have disruption of the vascular supply (vinculum), making surgical repair more than 10 days after injury difficult because of retraction and the longer healing time of the weaker nonbone-to-bone fixation and limited blood supply to the repair. Based on a review of the literature and their clinical experience, Henry et al. (2009) listed four essentials for successful treatment of type IV extensor tendon injuries: (1) a high index of suspicion for this injury, with the use of magnetic resonance imaging (MRI) or ultrasound for confirmation if needed, (2) rigid bony fixation that prevents dorsal subluxation of the distal phalanx, (3) tendon repair that is independent of the bony fixation, and (4) early range of motion therapy (Rehabilitation Protocol 1-5).

Surgical salvage procedures for late presentation include DIP joint arthrodesis, tenodesis, and staged tendon reconstructions.

Anatomy

Extensor mechanism injuries are grouped into eight anatomic zones, according to Kleinert and Verdan (1983). Odd-number zones overlie the joint levels so that zones 1, 3, 5, and 7 correspond to the DIP, PIP, metacarpal phalangeal (MCP), and wrist joint regions, respectively (Figs. 1-7 and 1-8; Table 1-2).

Figure 1-7 A, The extensor tendons gain entrance to the hand from the forearm through the series of six canals, five fibro-osseous and one fibrous (the fifth dorsal compartment, which contains the extensor digit minimi [EDM]). The first compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB); the second, the radial wrist extensors; the third, the extensor pollicis longus (EPL), which angles around Lister’s tubercle; the fourth, the extensor digitorum communis (EDC) to the fingers and the extensor indicis proprius (EIP); the fifth, the EDM; and the sixth, the extensor carpi ulnaris (ECU). The communis tendons are joined distally near the MR (metacarpophalangeal) joints by fibrous interconnections called juncturae tendinum. These juncturae are found only between the communis tendons and may aid in surgical recognition of the proprius tendon of the index finger. The proprius tendons are usually positioned to the ulnar side of the adjacent communis tendons, but variations may be present that alter this arrangement (see text). Beneath the retinaculum, the extensor tendons are covered with a synovial sheath. B, The proprius tendons to the index and little fingers are capable of independent extension, and their function may be evaluated as depicted. With the middle and ring fingers flexed into the palm, the proprius tendons can extend the little and ring fingers. Independent extension of the index finger, however, is not always lost after transfer of the indicis proprius and is less likely to be lost if the extensor hood is not injured and is probably never lost if the hood is preserved and the juncturae tendinum between the index and middle fingers is excised (see text). This figure represents the usual anatomic arrangement found over the wrist and hand, but variations are common, and the reader is referred to the section on Anatomic Variations. ECRB, extensor carpi radialis brevis; ECRL, extensor carpi radialis longus.

Figure 1-8 Extensor tendon zones of injury as described by Kleinart and Verdan and by Doyle.

Table 1-2 Zones of Extensor Mechanism Injury

DIP, distal interphalangeal; IP, interphalangeal; PIP, proximal interphalangeal; MCP, metacarpophalangeal.

From Kleinert HE, Verdan C. Report of the committee on tendon injuries. J Hand Surg 1983;8:794.

Normal extensor mechanism activity relies on concerted function between the intrinsic muscles of the hand and the extrinsic extensor tendons. Although PIP and DIP joint extension is normally controlled by the intrinsic muscles of the hand (interossei and lumbricals), the extrinsic tendons may provide satisfactory digital extension when MCP joint hyperextension is prevented.

An injury at one zone typically produces compensatory imbalance in neighboring zones; for example, a mallet finger deformity at the DIP joint may be accompanied by a more striking secondary swan-neck deformity at the PIP joint.

Disruption of the terminal slip of the extensor tendon allows the extensor mechanism to migrate proximally and exert a hyperextension force to the PIP joint by the central slip attachment. Thus, extensor tendon injuries cannot be considered simply static disorders.

Extensor tendon injuries in zones 1 and 2

Extensor tendon injuries in zones 1 and 2 in children should be considered Salter-Harris type II or III physeal injuries. Splinting of extremely small digits is difficult, and fixing the joint in full extension for 4 weeks produces satisfactory results. Open injuries are especially difficult to splint, and the DIP joint may be transfixed with a 22-gauge needle (see Mallet Finger section). A study of 53 extensor tendon injuries in children, all of which were treated with primary repair within 24 hours of injury, reported that 98% had good or excellent results, although 22% had extension lag or loss of flexion at latest follow-up (Fitoussi et al. 2007). Factors predictive of a less successful outcome were injuries in zones 1, 2, and 3; age younger than 5 years; and complete tendon laceration.

A recent literature review (Soni et al. 2009) found that traditional postoperative static splinting was equivalent to early motion protocols for all uncomplicated thumb injuries and zone 1 to 3 injuries of the second through fifth digits. The only benefit of early motion therapy compared with static splinting was a quicker return to final function for proximal zones of injury in the second through fifth digits. At 6 months after surgery, results of static splinting were comparable to those with early active and passive motion. Static splinting also was associated with a lower rupture rate than early active motion and a lower cost than early active and passive motion. An earlier meta-analysis (Talsma et al. 2008) found that short-term outcomes (4 weeks postoperative) after immobilization were significantly inferior to outcomes after early controlled mobilization, but at 3 months postoperatively no significant differences were found (Rehabilitation Protocol 1-6).

4–5 Weeks

Zone 5 Extensor Tendon Subluxations

Zone 5 extensor tendon subluxations rarely respond to a splinting program. The affected MCP joint can be splinted in full extension and radial deviation for 4 weeks, with the understanding that surgical intervention will probably be required. Painful popping and swelling, in addition to a problematic extensor lag with radial deviation of the involved digit, usually require prompt reconstruction.

Acute injuries can be repaired directly, and chronic injuries can be reconstructed with local tissue. Most reconstructive procedures use portions of the juncturae tendinum or extensor tendon slips anchored to the deep transverse metacarpal ligament or looped around the lumbrical tendon(Rehabilitation Protocol 1-8).

Indications

Figure 1-9 Passive supple digit with an extensor lag is an indication for possible extensor tenolysis.

(From Strickland JW: The Hand: Master Techniques in Orthopaedic Surgery. Philadelphia, Lippincott-Raven, 1998.)

Surgical intervention for extension contractures frequently follows an extensive period of presurgical therapy. Patients who have been active in their rehabilitation are more apt to appreciate that an early postsurgical program is vital to their final outcome. Presurgical patient counseling should always be attempted to delineate and establish the immediate postsurgical tenolysis program.

The quality of the extensor tendon, bone, and joint encountered at surgery may alter the intended program, and the surgeon relays this information to the therapist and the patient. Ideally, the surgical procedures are done with the patient under local anesthesia or awakened from the general anesthesia near the end of the procedure to allow active digit movement by the patient at the surgeon’s request. The patient can then see the gains achieved, and the surgeon can evaluate active motion, tendon glide, and the need for additional releases. Unusual circumstances may be well served by having the therapist observe the operative procedure.

Frequently, MCP and PIP joint capsular and ligament releases are necessary to obtain the desired joint motion. Complete collateral ligament resection may be required, and special attention may be necessary in the early postoperative period for resultant instability. Extensive tenolyses may require analgesic dosing before and during therapy sessions. Indwelling catheters also may be needed for instillation of local anesthetics for this purpose (Rehabilitation Protocol 1-10).

Background

Avulsion of the extensor tendon from its distal insertion at the dorsum of the DIP joint produces an extensor lag at the DIP joint. The avulsion may occur with or without a bony fragment avulsion from the dorsum of the distal phalanx. This is termed a mallet finger of bony origin or mallet finger of tendinous origin (Fig. 1-10). The hallmark finding of a mallet finger is a flexed or dropped posture of the DIP joint and an inability to actively extend or straighten the DIP joint. The mechanism is typically forced flexion of the fingertip, often from the impact of a thrown ball.

Figure 1-10 A, Stretching of the common extensor mechanism. B, Mallet finger of tendinous origin (complete disruption of the extensor tendon). C, Mallet finger of bony origin.

(From Delee J, Drez D [eds]: Orthopaedic Sports Medicine. Philadelphia, WB Saunders, 1994, p. 1011.)

Classification of Mallet Finger

Doyle (1993) described four types of mallet injury:

Treatment

Abound and Brown (1968) found that several factors are likely to lead to a poor prognosis after mallet finger injury:

The results of mallet finger treatment are not universally good by any method of treatment.

Continuous extension splinting of the DIP joint, leaving the PIP free for 6 to 10 weeks is the typical treatment for mallet fingers of tendinous origin (Fig. 1-11). A variety of splints has been developed for treatment of mallet finger. Most commonly used are the Stack splint, the perforated thermoplastic splint, and the aluminium-foam splint. If no extensor lag exists at 6 weeks, night splinting for 3 weeks and splinting during sports activities for an additional 6 weeks are used.

Figure 1-11 A, Use of a stack splint at the distal interphalangeal (DIP) joint for closed treatment of mallet finger (note extension lag). The splint is held in place with paper or adhesive tape. B, Active range of motion exercises of the proximal interphalangeal (PIP) joint used to keep the joint from stiffening during DIP joint immobilization.

(A and B, From Regional Review Course in Hand Surgery. Memphis, American Society of Surgery of the Hand, 1991, Fig. 13.)

The patient must work on active ROM of the MCP and PIP joints to avoid stiffening of these uninvolved joints. At no point during the healing process is the DIP joint allowed to drop into flexion or the treatment must be repeated from the beginning. During skin care or washing, the finger must be held continuously in extension with the other hand while the splint is off.

Although splinting is the treatment of choice for most acute and chronic mallet finger injuries, surgery may be indicated for individuals who are unable to comply with a splinting regimen or for patients who would have difficulty performing their jobs with an external splint. Surgical options for acute mallet fractures include transarticular pinning of the DIP joint, compression pinning, and extension block pinning. For chronic injuries (more than 4 weeks after injury) surgical options include terminal extensor tendon shortening, tenodermodesis, reconstruction of the oblique retinacular ligament, and central slip tenotomy (see Rehabilitation Protocol 1-6 on page 43). Arthrodesis may be required as a salvage procedure for mallet fingers caused by arthritis, infection, or failed surgery.

Metacarpal and phalangeal fractures

General Principles

• General rehabilitation principles for hand fractures include early active ROM and tendon gliding using synergistic wrist positions and blocking techniques, including blocking splints.

• Radiographic evidence of healing in hand fractures almost always lags behind clinical healing. At 6 weeks, with a nontender clinically healed fracture the radiograph typically still shows the original fracture line. The clinician must go by clinical examination (presence or absence of point tenderness) when making treatment decisions.

• Most metacarpal and phalangeal fractures can be treated nonoperatively using closed methods that emphasize alignment and early protected motion.

• All splinting programs for metacarpal or phalangeal fractures recognize the need to position the metacarpophalangeal joints in flexion to avoid extension contractures.

• The thumb metacarpophalangeal is not exempt from this rule, and many stiff thumbs result from hyperextended thumb spica immobilization.

• The interphalangeal joints typically are rested in full extension.

• Greer’s principles of splinting (REDUCE) should be incorporated in casting or splinting of these fractures.

R:Reduction of the fracture is maintained.

E:Eliminate contractures through proper positioning.

D:Don’t immobilize any of these fractures for more than 3 weeks.

U:Uninvolved joint should not be splinted in stable fractures.

C:Creases of the skin should not be obstructed by the splint.

E:Early active tendon gliding is encouraged.

• Edema is poorly tolerated by the hand. RICE (rest, ice, compression, elevation) is emphasized for edema control. Distended, edematous joints predictably move into positions that permit the greatest expansion of the joint capsule and collateral ligaments. Edema postures the hand into wrist flexion, metacarpophalangeal joint extension, interphalangeal joint flexion, and thumb adduction: a “dropped claw hand.” Functional splinting seeks to place the hand in a position that avoids this deformed posturing.

• The most important tendon-gliding exercises (Fig. 1-12) to initiate early rehab are for the flexor digitorum superficialis (FDS), FDP, extensor digitorum communis (EDC), and central slip to prevent tendon adherence to fracture callus.

Figure 1-12 Tendon glide exercises. A, Intrinsic plus posture to achieve central slip/lateral bands glide over proximal phalanx (P1). B, Sublimis fist posture to promote selective FDS tendon glide. C, Claw posture to achieve extensor digitorum communis (EDC) tendon glide over metacarpal bone. D, Flexor digitorum profundus (FDP) blocking exercises to glide FDP tendon over P1. E, Hook fist posture to promote selective FDP tendon glide. F, Flexor digitorum sublimis (FDS) blocking exercise to glide FDS tendon over middle phalanx.

Metacarpal fractures

Table 1-3 Potential Problems with Metacarpal Fractures and Strategies for Therapeutic Intervention Maureen A. Hardy PT, MS CHT

MP, metacarpophalangeal; EDC, extensor digitorum communis; IP, interphalangeal; NMES, neuromuscular electrical stimulation; AROM, active range of motion.

Nondisplaced metacarpal fractures are stable injuries and are treated with application of an anteroposterior splint in the position of function: the wrist in 30 to 60 degrees of extension, the MCP joints in 70 degrees of flexion, and the IP joints in 0 to 10 degrees of flexion. In this position the important ligaments of the wrist and hand are maintained in maximal tension to prevent contractures (Fig. 1-13). Exceptions to splinting for metacarpal fractures may include treatment of boxer’s fractures (see page 13).

Figure 1-13 Position of immobilization of the hand involves splinting the wrist in approximately 30 degrees of extension, the metacarpophalangeal (MCP) joints in 60 to 80 degrees of flexion, and the interphalangeal (IP) joints in full extension.

(From Delee J, Drez D [eds]: Orthopaedic Sports Medicine. Philadelphia, WB Saunders, 1994.)

Allowing early PIP and DIP joint motion is essential. Motion prevents adhesions between the tendons and the underlying fracture and controls edema.

Background

Metacarpal neck fractures are among the most common fractures in the hand. Fracture of the fifth metacarpal is by far the most frequent and has been termed a boxer’s fracture because the usual mechanism is a glancing punch that does not land on the stronger second and third metacarpals.

Clinical history and examination

Patients usually have pain, swelling, and loss of motion about the MCP joint. Occasionally a rotational deformity is present. Careful examination should be performed to ensure that there is no malrotation of the fifth finger when the patient makes a fist (Fig. 1-14), no significant prominence of the distal fragment (palmarly displaced) in the palm, and no extensor lag of the involved finger.

Figure 1-14 A, To determine rotational and angular alignment of the hand skeleton, the nails should be parallel with the digits in extension. B, In flexion, the digits should all point to the scaphoid tuberosity.

On the lateral radiograph, the angle of the metacarpal fracture is determined by drawing lines down the shafts of the metacarpal and measuring the resultant angle with a goniometer.

Treatment

Treatment is based on the degree of angulation or displacement, as measured on a true lateral radiograph of the hand. Metacarpal neck fractures are usually impacted and angulated, with the distal fragment displacing palmarly because of the intrinsic muscle pull. Excessive angulation causes loss of the MCP joint knuckle and may cause the palmar metacarpal head to be prominent during activities. Only about 10 degrees of angulation can be accepted in second and third metacarpal neck fractures, whereas up to 30 degrees in the fourth metacarpal and 40 degrees in the fifth metacarpal can be accepted because of greater mobility in the fourth and fifth CMC joints.

If displacement is unacceptable, closed reduction can be attempted with wrist block anesthesia using the maneuver credited to Jahss (1938), in which the proximal phalanx is flexed to 90 degrees and used to apply a dorsally directed force to the metacarpal head (Fig. 1-15). The hand is then splinted in an ulnar gutter splint for about 3 weeks with the MCP joint at 80 degrees of flexion, the PIP joint straight, and the DIP joint free.

Figure 1-15 Maneuver of Jahss. A, The proximal interphalangeal (PIP) joint is flexed 90 degrees, and the examiner stabilizes the metacarpal proximal to the neck fracture, then pushes the finger to dorsally displace the volar angulated boxer’s fracture to “straight.” B, Splint is molded in reduced position with the ulnar gutter in the position of function.

(From Regional Review Course in Hand Surgery. Rosemont, Illinois, American Society for Surgery of the Hand, 1991.)

Rapid mobilization of the fingers is required to avoid scarring, adhesions, and stiffness unrelated to the fracture itself but rather to the propensity of an immobilized hand to quickly stiffen.

Statius Muller et al. (2003) prospectively treated 35 patients with boxer’s fractures with a mean fracture angulation of 39 degrees (range 15 to 70 degrees). Patients were randomly allocated to treatment with either an ulnar gutter plaster cast for a period of 3 weeks followed by mobilization or a pressure bandage for only 1 week and immediate mobilization within limits imposed by pain. Between the two groups, no statistical differences were found with respect to ROM, satisfaction, pain perception, return to work and hobby, or need for physical therapy. In our clinic we employ the pressure bandage technique for our boxer’s fractures with good result.

Bansal and Craigen (2007) treated 40 boxer’s fractures with reduction and casting and 40 with buddy taping and range of motion only with instructions to return only if problems were experienced. The Disabilities of the Arm, Shoulder, and Hand (DASH) scores for the two groups were identical at 12 weeks, and the untreated group returned to work 2 weeks earlier and had a significantly higher satisfaction rate on their “care.”

Operative treatment of boxer’s fractures is indicated if the following occur:

Operative fixation usually involves percutaneous pinning of the fracture, but ORIF may be required. Fractures treated operatively still require about 3 weeks of protective splinting and ROM exercises.

Phalangeal Fractures of the Hand

• Phalangeal fractures lack intrinsic muscle support, are more unstable than metacarpal fractures, and are adversely affected by the tension in the long tendons of the fingers.

• Because of the pull of the FDS insertion into the middle phalanx, a proximal fracture of the middle phalanx will angulate with the fracture apex dorsal and a distal fracture will involve angulation with the apex volar (Fig. 1-16). Because of the deforming tendon forces fractures in these areas that present initially as displaced are unlikely to remain reduced after reduction and typically require operative fixation.

• Phalangeal fractures respond less favorably to immobilization than metacarpal fractures, with a predicted 84% return of motion compared with 96% return of motion in the metacarpals (Shehadi 1991).

• If phalangeal immobilization is continued for longer than 4 weeks, the motion drops to 66%.

• Reasons cited for poor results in the literature typically are comminuted fractures, open fractures, and multiple fractures.

• Weiss and Hastings (1993) investigated initiation of motion in patients with proximal phalangeal fractures treated with Kirschner-wire fixation and found no long-term differences in finger range of motion when motion was initiated between 1 and 21 days; however, if motion was delayed more than 21 days, there was a significant loss of motion.

• Table 1-4 lists potential problems and interventions for phalangeal fractures.

Figure 1-16 Deforming forces on phalangeal fractures.

(Adapted with permission from Breen TF: Sports-related injuries of the hand, in Pappas AM, Walzer J [eds]: Upper Extremity Injuries in the Athlete. New York, Churchill Livingston, 1995, p 475.)

Table 1-4 Potential Problems with Phalangeal Fractures and Strategies for Therapeutic Intervention Maureen A. Hardy PT, MS CHT

Potential Problems	Prevention and Treatment
Loss of MP flexion	Circumferential PIP and DIP extension splint to concentrate flexor power at MP joint; NMES to interossei
Loss of PIP extension	Central slip blocking exercises; during the day MP extension block splint to concentrate extensor power at PIP joint; at night PIP extension gutter splint; NMES to EDC and interossei with dual-channel setup
Loss of PIP flexion	Isolated FDP tendon glide exercises; during the day MP flexion blocking splint to concentrate flexor power at PIP joint; at night flexion glove; NMES to FDS
Loss of DIP extension	Resume night extension splinting; NMES to interossei
Loss of DIP flexion	Isolated FDP tendon glide exercises; PIP flexion blocking splint to concentrate flexor power at DIP joint; stretch ORL tightness; NMES to FDP
Lateral instability, any joint	Buddy strap or finger-hinged splint that prevents lateral stress
Impending boutonnière deformity	Early DIP active flexion to maintain length of lateral bands
Impending swan neck deformity	FDS tendon glide at PIP joint and terminal extensor tendon glide at the DIP joint
Pseudo claw deformity	Splint to hold MP joint in flexion with PIP joint full extensor glide
Pain	Resume protective splinting until healing is ascertained; address edema, desensitization program

MP, metacarpophalangeal; PIP, proximal interphalangeal; DIP, distal interphalangeal; NMES, neuromuscular electrical stimulation; EDC, extensor digitorum communis; FDP, flexor digitorum profundus; FDS, flexor digitorum superficialis; ORL, oblique retinacular ligament.

Comminuted phalangeal fractures, especially those that involve diaphyseal segments with thick cortices, may be slow to heal and may require fixation for up to 6 weeks.

Proximal Interphalangeal Joint Injuries

Three types of proximal interphalangeal joint dislocations (Fig. 1-17; Table 1-5) or fracture-dislocations have been described: lateral, volar (rotatory), and dorsal (Fig. 1-18). Each results from a different mechanism of injury and has specific associated complications. The treatment of PIP injuries is dictated by the stability of the injury.

Figure 1-17 Anatomy of the volar plate and collateral ligaments of the proximal interphalangeal (PIP) joint.

(Adapted with permission from Breen TF: Sports-related injuries of the hand, in Pappas AM, Walzer J [eds]: Upper Extremity Injuries in the Athlete. New York, Churchill Livingston, 1995, p 459.)

Table 1-5 Managing Proximal Interphalangeal Joint Injuries of the Hand

Injury	Clinical Manifestations or Special Considerations	Treatment
Sprain	Stable joint with active and passive motion; negative radiographs; pain and swelling only	Buddy tape for comfort; begin early ROM exercises, ice, NSAIDs
Open dislocation	Dislocated exposed joint	Irrigation, débridement, and antibiotics; treat as any open fracture or dislocation
Dorsal PIP Dislocation
Type 1	Hyperextension, volar plate avulsion, minor collateral ligament tear	Reduction; very brief immobilization (3–5 days) followed by ROM exercises with buddy taping and close x-ray follow-up
Type 2	Dorsal dislocation, volar plate avulsion, major collateral ligament tear	Same as type 1
Type 3	Stable fracture-dislocation: <40% of articular arc on fracture fragment	Extension block splint; refer to hand surgeon
	Unstable fracture-dislocation: >40% of articular arc on fracture fragment	Extension block splint; open reduction with internal fixation if closed treatment impossible; refer to hand surgeon
Lateral dislocation	Secondary to collateral ligament injury and avulsion and/or rupture of volar plate; angulation >20 degrees indicates complete rupture	Same as dorsal dislocation types 1 and 2 if joint is stable and congruous through active ROM
Volar PIP Dislocation
Straight volar dislocation	Proximal condyle causes significant injury to central extensor slip (may reduce easily, but extensor tendon may be seriously injured; requires careful examination)	Refer to a hand surgeon experienced in these rare injuries; closed reduction with traction with metatarsophalangeal and PIP flexed and extended wrist; full-extension immobilization of PIP joint if post-reduction x-rays show no subluxation; if closed reduction is not achieved or subluxation persists, surgery recommended
Ulnar or radial volar displacement	Condyle often buttonholes through central slip and lateral band; reduction often extremely difficult	Same as straight volar PIP dislocation

ROM, range of motion; NSAIDs, nonsteroidal anti-inflammatory drugs; PIP, proximal interphalangeal.

From Laimore JR, Engber WD. Serious, but often subtle finger injuries. Phys Sports Med 1998;l26(6):226.

Figure 1-18 Dislocations in the hand are classified by the position of distal skeletal unit in relation to its proximal counterpart. A, Dorsal proximal interphalangeal (PIP) joint dislocation. B, Lateral PIP joint dislocation. C, Palmar PIP joint dislocation.

(From Browner B, Skeletal Trauma, 4^th Ed. Philadelphia, Saunders, 2009. Fig 38-132.)

Stable lesions are treated with buddy taping of the injured digit to the noninjured digit adjacent to the torn or compromised collateral ligament. Unstable injuries are often associated with an intra-articular fracture of the middle phalanx (usually affecting more than 20% of the joint surface). However, even very tiny volar avulsion fractures may be associated with dorsal subluxation of the middle phalanx and be unstable. This is best assessed with fluoroscopy where the point of reduction can be accurately ascertained by sequential flexion of the PIP joint (Morgan and Slowman 2001).

Unstable injuries often are treated by dorsal extension block splinting (Fig. 1-19) with the initial digit flexion at the point where the stable reduction was obtained fluoroscopically. Incremental increase of extension of the splint and digit is done on a weekly basis for 4 weeks or until full extension at the joint has been obtained. Buddy taping is continued for 3 months during sports participation.

Figure 1-19 Dorsal extension block splint.

(Adapted with permission from Breen TF: Sports-related injuries of the hand, in Pappas AM, Walzer J [eds]: Upper Extremity Injuries in the Athlete. New York, Churchill Livingston, 1995, p 461.)

If reduction cannot be obtained or easily held by closed methods, then operative intervention is a must.

Early edema management and early active and passive ROM (within the confines of the extension block splint) are paramount to minimize scar adhesion formation and subsequent contractures.

Volar PIP joint dislocations are less common than dorsal dislocations and are often difficult to reduce by closed techniques because of entrapment of the lateral bands around the flare of the proximal phalangeal head. If not treated properly, these injuries may result in a boutonnière deformity (combined PIP joint flexion and DIP joint extension contracture). Usually, the joint is stable after closed or open reduction; however, static PIP joint extension splinting is recommended for 6 weeks to allow healing of the central slip (Rehabilitation Protocol 1-11).

REHABILITATION PROTOCOL 1-11 Rehabilitation Protocol After Volar Proximal Interphalangeal Joint Dislocation or Avulsion Fracture

After Closed Reduction

• An extension gutter splint is fitted for continuous wear with the PIP joint in neutral position.

• The patient should perform active and passive ROM exercises of the MCP and DIP joints approximately six times a day.

• PIP joint motion is not allowed for 6 weeks.

• Begin active ROM exercises at 6 weeks in combination with intermittent daytime splinting and continuous night splinting for an additional 2 weeks.

After ORIF

• The transarticular pin is removed 2 to 4 weeks after the wound has healed.

• Continuous splinting in an extension gutter splint is continued for a total of 6 weeks.

• The remainder of the protocol is similar to that after closed reduction.

Extension splinting is continued as long as an extensor lag is present, and passive flexion exercises are avoided as long as an extension lag of 30 degrees or more is present.

Avulsion fractures involving the dorsal margin of the middle phalanx occur at the insertion of the central slip. These fractures may be treated by closed technique; however, if the fragment is displaced more than 2 mm proximally with the finger splinted in extension, ORIF of the fragment is indicated.

Dorsal fracture-dislocations of the PIP joint are much more common than volar dislocations. If less than 50% of the articular surface is involved, these injuries usually are stable after closed reduction and protective splinting (Rehabilitation Protocol 1-12).

REHABILITATION PROTOCOL 1-12 Rehabilitation Protocol After Dorsal Fracture-Dislocation of the Proximal Interphalangeal Joint

• If the injury is believed to be stable after closed reduction, a dorsal blocking splint (DBS) is applied with the PIP joint in 30 degrees of flexion. This allows full flexion but prevents the terminal 30 degrees of PIP joint extension.

• After 3 weeks, the DBS is adjusted at weekly intervals to increase PIP joint extension by about 10 degrees each week.

• The splint should be in neutral position by the sixth week, then discontinued.

• An active ROM program is begun, and dynamic extension splinting is used as needed.

• Progressive strengthening exercises are begun at 6 weeks.

Dorsal fracture-dislocations involving more than 40% of the articular surface may be unstable, even with the digit in flexion, and may require surgical intervention. The Eaton volar plate advancement is probably the most common procedure used (Fig. 1-20). The fracture fragments are excised, and the volar plate is advanced into the remaining portion of the middle phalanx. The PIP joint usually is pinned in 30 degrees of flexion (Rehabilitation Protocol 1-13).

Figure 1-20 A, Pathology of injury demonstrating loss of collateral ligament support to the joint, producing marked instability. Eaton volar plate arthroplasty is commonly used when more than 40% comminution or impaction of the inferior aspect of the middle phalanx of the proximal interphalangeal (PIP) joint is present. B, Sutures are passed through the lateral margins of the defect, exiting dorsally. The comminuted fragment has been excised, and the volar plate is being advanced. C, Sutures are tied over a padded button, drawing the volar plate into the defect and simultaneously reducing the PIP joint.

(From Strickland JW: The Hand: Master Techniques in Orthopaedic Surgery. Philadelphia, Lippincott-Raven, 1999.)

REHABILITATION PROTOCOL 1-13 Rehabilitation Protocol After Dorsal Fracture-Dislocation of the Proximal Interphalangeal Joint Involving More Than 40% of the Articular Surface

• At 3 weeks after surgery, the pin is removed from the PIP joint and a DBS is fitted with the PIP joint in 30 degrees of flexion for continuous wear.

• Active and active-assisted ROM exercises are begun within the restraints of the DBS.

• At 5 weeks, the DBS is discontinued and active and passive extension exercises are continued.

• At 6 weeks, dynamic extension splinting may be necessary if full passive extension has not been regained.

Dorsal dislocations of the PIP joint without associated fractures are usually stable after closed reduction. Stability is tested after reduction under digital block, and, if the joint is believed to be stable, buddy taping for 3 to 6 weeks, early active ROM exercises, and edema control are necessary. If instability is present with passive extension of the joint, a dorsal blocking splint (DBS) similar to that used in fracture-dislocations should be used.

Background

The classic “gamekeeper’s thumb” was first described in Scottish gamekeepers. “Skier’s thumb” was coined by Schultz, Brown, and Fox in 1973, with skiing being the most common cause of acute ulnar collateral ligament (UCL) rupture (e.g., after a fall causing the ski pole to stress and tear the ulnar collateral ligament of the thumb MCP joint).

Stability of the thumb on the ulnar side is maintained by four structures: the adductor aponeurosis, the adductor pollicis muscle, the proper and accessory UCL, and the volar plate. The UCL provides resistance to radially applied forces (e.g., pinching or holding large objects). A torn UCL weakens the key pinch grip strength and allows volar subluxation of the proximal phalanx. With prolonged instability, the MCP joint frequently degenerates.

The amount of valgus laxity of normal thumbs varies widely. In full MCP joint extension, valgus laxity averages 6 degrees, and in 15 degrees of MCP joint flexion it increases to an average of 12 degrees. The adductor aponeurosis (when torn and pulled distally) occasionally entraps the UCL, preventing anatomic reduction or healing of the UCL (Stener lesion) (Fig. 1-21). The typical mechanism of injury is an extreme valgus stress to the thumb (e.g., falling on an abducted thumb).

Figure 1-21 Complete rupture of the ulnar collateral ligament resulting in a Stener lesion. The distal attachment has been avulsed from the bone.

Evaluation

Patients typically have a history of a valgus injury to the thumb followed by pain, swelling, and frequently ecchymosis at the ulnar aspect of the thumb MCP joint. Palpation of the ulnar aspect of the MCP joint may reveal a small lump, which may be indicative of a Stener lesion or avulsion fracture.

In addition to plain films (three views of the thumb and carpus), valgus stress testing radiographs should be obtained. Because patients who are acutely injured will guard from pain, 1% lidocaine should be injected into the joint before stress testing. The integrity of the proper (ulnar collateral) ligament is assessed by valgus stress testing with the MCP joint of the thumb in 30 degrees of joint flexion. This test can be done clinically or with radiographic documentation. The literature varies as to the degree of angulation on valgus stressing that is compatible with complete rupture of the UCL. Thirty to 35 degrees of radial deviation of the thumb on valgus stressing indicates a complete UCL rupture and is an indication for surgical correction. With complete ruptures (>30 degrees of opening) the likelihood of an UCL ligament displacement (a Stener lesion) is greater than 80%.

Treatment