Postoperative Management of Extensor TendonRepairs in Zones ~ VI, and VII

Dominique Thomas, RPTCentre Grenoblois de Reeducation de la Main etdu Membre SuperieurGrenoble, France

Fran~ois Moutet, MDProfessor Hand Surgery, Grenoble UniversityHospitalGrenoble, France

Didier Guinard, MDHand Surgeon, Grenoble University HospitalGrenoble, France

E arly mobilization of extensor tendon repairsunder protection of a splint is becoming, for

more hand surgery and therapy teams, the pre­ferred treatment over immobilization.15,16,21 Frereand Hoel in 1975 selected a modified Levamesteel leaf spring for protection.19,7,8 Allieu and Rou­zeau1,15,16 and Evans and Burkhalter3,5,6 further re-fined mobilization protocol. The concepts are stillevolving.

Depending on team philosophy, mobilizationstarts on the first postoperative dai or else is de­layed for up to two weeks.19 In 1986, Evans re­served early mobilization of extensor repairs forcomplex extensor injuries; however, she indicatedthat in a compliant patient it could be used for sim­ple injuries in zones V, VI, VII, TIV, and TV.4 In 1993Evans added that early mobilization, includingsome active motion, "should be applied only byknowledgeable hand therapists."5 In the same year,Guinard wrote, "For simple lesions of extensor ten­dons, the Levame splint may be considered as areal dynamic, protective splint. This simple tech­nique may be used for non-disciplined patients andby non-specialized therapists" providing that thepatient leaves the hand unit with the Levame splintin place.8

This paper presents the Grenoble team's ap­proach to protected mobilization of reI'aired ex­tensor laceration in zones V, VI, and VII. 7,8,19,18

• Tendons are repaired using a modified Kesslercent-ral suture for strength and peripheral epiten­dinous stitches for discretion.

• A protective splint is made either immediatelyafter or the day following surgery.

• The patient should flex his or her digit ten times,actively, every hour within the limits of thesplint.

Correspondence and reprint requests to Dominique Thomas,RPT, MCMK, Director, Centre Grenoblois de Reeducation de laMain, 1 Bd. Clemenceau 38100, Grenoble, France.

ABSTRACT: This paper describes the postoperative manage­ment plan for extensor tendon repair in zones V, VI, and VII asconceived by the Grenoble team. This plan includes immediate,postoperative systematic mobilization for all patients with sur­gical repairs in zones II through VIII. Postoperative mobiliza­tion in zones V and VI is performed under the protection of aLevame-type, dorsal steel leaf-blade spring. Depending on le­sion location, proximal or distal to juncturae tendinum, Frere'sthree-finger rule applies. In zone VII, differential tendon glidingbetween the wrist and finger extensors and surrounding tissueis accomplished with a Tom splint, which gives individual ex­tension assistance to each digit and the wrist while limitingflexion.JHAND THER 9:309-314, 1996.

• The splint is worn continuously for one month,then only at night for two additional weeks; thisprotocol is systematic even for a noncompliantpatient, for whom the splint is made so it cannotbe removed.

• Results of immediate postoperative extensor mo­bilization, as performed by the Grenoble, team,were published in 1981/7 1984/ and 1993.8 Re­sults progressed from 71% "good and excellent"in 1980 to 97% in the most recent study.

At the zone V, VI, and VII levels, as defined byVerdan and the International Federation of Societiesfor Surgery of the Hand (IFSSH) Tendon InjuryCommittee,lO protected extensor mobilization pre­sents several concerns, depending on the specificanatomy of each zone (Fig. 1).

FIGURE 1. Extensor tendon zones. Zone V: dorsal aspectof the metacarpophalangeal joint (MCP). Zone VI: dorsum ofthe hand. This is the zone of the juncturae tendinum. ZoneVII: dorsal aspect of the wrist joint.

October-December 1996 309

FIGURE 2. A low-profile type splint permits a more accu­rate limitation of MCP joint active flexion with a b~ad blockfixed to the traction line than does a Levame-type splmt. How­ever it requires more time to make.

• The extensor tendons are clearly individualizedonly in these zones.

• The only real reflexion pulleys of the ~xtensor

apparatus consist of the dorsal carpal hgamentin zone VII and, to a lesser degree, the dorsalhood of the metacarpophalangeal (MCP) joint.

• In zone V, the tendons of extensor proprius ofthe index and little finger connect with the ten­dons of extensor digitorum communis (EDC).The extensor tendon is maintained over the dor­sum of the MCP joint by the sagittal bands.

• In zone VI, the juncturae tendinurn assist exten­sion of adjacent interconnected digits by trans­ferring extension forces. Laceration of an exten­sor tendon proximally to a junctura can be partlyoccluded by adjacent finger extensi~m'.J~ncturae

tendinum vary greatly from one mdlVidual toanother. They play an important role in .fingermobilization and therefore must be consIderedwhen designing a postoperative mobilizationsplint. ..

• The index and little fingers have an addItionalextensor proprius. Lacerati.on of one ext~n~or,ei­ther proprius or commUnIS, to these dIgItS canalso be occluded by the extension force of theremaining sound tendon.

FIGURE 3. Levame splint modifiedfor extensor repair mo­bilization. The dorsal leaf spring returns the digit(s) to exten­sion and limits MCP joint flexion.

310 JOURNAL OF HAND THERAPY

• Only in zone VII are the extensors covered witha synovial sheath. .

• Only in zone VII, under the dorsal carpal reti­naculum, do the extensor tendons glide throughsix fibro-osseous compartments. Any adhesionsat this level will cause functional consequencesquite different from adhesions in zones V and VI.

Considerations such as the level and type ofinjury and the specific anatomy of each patient(presence or absence of juncturae tendinum) influ­ence the choice of splint design and the subsequentprotocol.

PROTECTED MOBILIZATION INZONES V AND VI

How Much Active Flexion?

The principle of extensor repair-site mobiliza­tion is simple: full passive extension and limitedactive flexion. However, the amount of active flex­ion to allow is still a controversial issue and willrequire additional studies.

Evans and Burkhalter, basing their studies onDuran's suggestion that 3 mm to 5 mm of pass~ve

glide will safely influence flexor tendon adheSIOnformation, Eropose a formula using Brand's workon radians. ,5,6

joint motion (in degrees)tendon excursion (in mm)

= degrees of motion required

Thus, joint motion divided by tendon excursion forthat particular joint is equal to the number of de­grees of motion required to a~fect 1 mn: of tendonglide. For zones V and VI WIth the WrIst blockedin extension at 45°, MCP flexion should be as fol­lows: index finger: 28.3°; middle: 27S; ring: 40.9°;little: 38.3°.

Allieu and Rouzaud write that 14 mm of ten­don glide with thewrist blocked at 30° extensiondoes not jeopardize the suture.1

,16 They s~ggest aprotocol authorizing 50° to 60° of MCP fl~xIOn.dur­ing the first postoperative week, then 70 until thefifteenth day and 90° from the fifteenth to the thir­tieth day postoperatively. They experienced onerupture in a series of 120 cases.

Frere authorized 50% of maximum range ofMCP flexion from the first postoperative day untilthe splint is removed at one mc:>nth. The .±~5%

range of motion (ROM) is au.tho~Ized and hmI.tedby the dorsal leaf spring, whIch IS 0.40 mm thI~k.

For zones II to V, the splint does not block the WrIst.For zone VI, the wrist is immobilized at 30° by thesplint. Frere's study and others by the Grenoblegroup report no rupture.

Choice of Splint Technology

Various types of springs can return a joint to

extension. Choosing the proper type of spring de­termines the splint.

A rubber band, a coiled spring, or a clockspring calls for a low-profile or a high-profile splintdesign. A palmar block or a bead block placed onthe traction line is necessary for limiting flexion(Fig. 2).1,19,11 A piano wire "fishinp pole" type ofsplint will require a palmar block.

Levame and Durafourg12,21 describe a dorsal

steel leaf-blade spring, 0.4 mm thick and 1 em wide,that is fixed to the splint and allows up to 700 ofactive MCP flexion if the interphalangeal (IP) jointsare kept in extension. However, in our experience,patients never perform an isolated MCP flexion andnever try to flex as far as the resistance providedby the blade (Fig. 3).21 For clinical applications, after20 years' experience, we most frequently choose theLevame-type splint for zones V and VI because itis the fastest and safest splint to make, even thoughit permits less accurate mobilization than the low­profile models do.

Choice of the Basic Splint Model: Hand orForearm Based

For passive mobilization of extensor tendons inzones V and VI, Allieu1 and Minamikawa13 rec­ommend that the splint immobilize the wrist be­tween 200 and 450 of extension in order to reducetension on the repair site.

In our approach, the wrist is not immobilizedfor protected mobilization of zone V extensor re­pairs except when the extent of the wound or thenumber of tendons repaired requires spreading thepressure over a wider area. Also, a hand-anchoredsplint will easily limit wrist flexion if it has beendesigned to impinge on the wrist palmar flexioncrease.

For zone VI, we make a hand-forearm-basedsplint that blocks the wrist in 300 to 400 of exten­sion. Depending on the side of the hand affected,the splint opens from either the ulnar or the radialaspect of the hand.

The Importance of the Juncturae Tendinum

In zone V, injury and repair are distal to thejuncturae tendinum. Flexing the digits adjacent tothe repaired extensor tendon does not pull on thesuture but approximates it, reducing the tension(Fig. 4).7,15 Only the digit with the extensor repairneeds to be maintained in extension.

In zone VI, injury can be either proximal ordistal to the juncturae tendinum. Laceration distalto the jUncturae tendinurn presents the same situ­ation as in zone V. When laceration is proximal tothe juncturae tendinum, flexion of an adjacent digitor digits pulls on the repair site (Fig, 5). Thus, it isnecessary to splint the affected and adjacent digit(s)in extension. We follow Frere's three-finger rule(Fig. 6).7

When the location of the juncturae tendinumis in doubt and the operating surgeon is not avail­able, use Frere's rule systematically and splint theadjacent digit(s) in extension.

FIGURE 4. A zone V lesion is distal to the juncturae ten­dinum. Adjacent digit Mep joint flexion does not pull onsutures; it approximates the repair site.

FIGURE 5. With a zone VI lesion proximal to the juncturaetendinum, adjacent digit flexion pulls on the sutures.

Placement of Suspension Sling at DigitLevel

The extrinsic extensor primarily extends theMCP joint and has little action on IP joint extension.Therefore, it is tempting, in order to minimize thesize of the splint, to shorten the outriggers and toplace the suspension sling under the proximal pha­lanx.16 However, if adhesions develop between theextrinsic extensor and the interosseous muscles (asoften happens with contusion, crush injury, orwhen prolonged edema is present), it is better toplace the sling under the distal phalanx and tape itin place so that it will not slip off. Leaving the IPjoints in flexion will lead to proximal interphalan­geal (PIP) joint extension lag, which is difficult tocorrect. It is always easier to regain active and pas­sive flexion ROM than active extension ROM. Thisis why we prefer placing the suspension sling un­der the distal phalanx.

INCOMPLETE AND ISOLATEDLESIONS OF INDEX AND LITTLEFINGER EXTENSOR TENDONS

Incomplete lesions and isolated lesions of ex­tensors to the index and little fingers do not requireas much protection as complete lesions (Fig. 7). Inthese cases we use the Yoke splint designed byHoe1.23 This is a "buddy taping" splint made of thin

October-December 1996 311

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thermoplastic material placed on the proximal pha­langes of the injured and adjacent digits, followingFrere's three-finger rule. It maintains the affecteddigit in extension in relation to the adjacent digits.The adjacent digits assist the extension of the af­fected MCP joint and limit its flexion. The yoke isworn postoperatively for 30 to 45 days (Fig. 8).

PROTECTED MOBILIZATION INZONE VII

Complete laceration of wrist and finger exten­sor tendons in zone VII is rare. Most teams use thesame protected mobilization protocol as for zonesV and VI: wrist immobilization and protected mo­bilization of MCP joints.4

,13,14,9 Minamikawa admitsthf-t the results are deceiving.13 In our experience,when the wrist is immobilized, even if the patienthas followed a protected mobilization program forthe fingers, adhesions will limit tendon differentialglide and result in a tenodesis effect when thesplint is removed one month after surgery. Fullwrist extension is not possible with full finger ex­tension. Finger extensors, which need longer ex­cursion and are bound to the dorsal retinaculumand surrounding tissues, act as wrist extensors. Inorder to extend the MCP joint fully, the patientneeds to flex the wrist, placing tension on the ex-

312 JOURNAL OF HAND THERAPY

FIGURE 7. Incomplete extensor lesions and isolated lesionsto extensor digitorum communis or extensor proprius of theindex and little fingers do not require as extensive protectionas complete lacerations.

tensor tendon portion distal to zone VII. Combinedwrist and finger flexion is limited, if not altogetherabsent. Fingers can be flexed with the wrist in ex­tension; fingers can be extended with the wrist inflexion. This is commonly known as the "tenodesiseffect."

Having seen this tenodesis phenomenon sev­eral times since 1987, we have developed a teamprotocol that consists of immediate, protected, anddifferential mobilization in order to influence for­mation of adhesions.24

Protected differential mobilization is governedby the Tom splint/8 a modification of the Radial Bisdesign,zo Each digit, as well as the wrist, has itsindividual extension assist. Flexion of each digitand of the wrist is limited by a bead block placedon the traction line (Fig. 9). The wrist is maintainedin 40° extension. From this wrist position, with theMCP joint in full extension, it is possible to flex thePIP and distal interphalangeal (DIP) joints fully.When the wrist is in extension, with the PIP andDIP joints in extension, the MCP joint can flex ac­tively to 45° (Fig. 10). With the MCP, PIP, and DIPjoints in extension, it is possible to flex the wrist tothe neutral position (Fig. 11). Simultaneous wristand full finger flexion are prohibited by bead blocksplaced on the traction lines, and the wrist is unable

FIGURE 8. Hoel's yoke splints the affected digit in exten­sion in relation to the adjacent digits. It assists extension ofthe affected digit's Me? joint and limits flexion.

FIGURE 9. The Tom splint includes an individual exten­sion assist for each digit and for the wrist. Flexion ROM islimited by bead blocks fixed to traction lines.

to reach the neutral position. The movements ren­dered possible by the splint are in fact four exer­cises and they are to be performed ten times hourlyfor one month. The splint is then removed andworn only while the patient sleeps for two addi­tional weeks.

Study

Even though immediate protected mobilizationhas been systematically used by the Grenoblegroup since 1975, few studies have been published.The most recent one was published by Guinard.8 Itassessed a homogeneous group of 88 extensor ten­don lacerations. Patients were reviewed one yearafter surgery.

Protocol

Patients were asked to rate their functional out­come according to four levels: very satisfied, satis­fied, average, and poor. The subjective data in­cluded dysesthesia, pain, and sensitivity to cold.

Patients were again given four grades: excel­lent, good, average, and poor. The objective resultsrated total active motion (TAM), Boyes' pulp-to-dis­tal palmar crease distance, and muscle strengthcompared with the uninjured side.

FIGURE 11. The wrist may be flexed only with the MCPjoint in extension.

FIGURE 10. When the wrist is in 40° extension, activeMCP joint flexion is possible to 45°.

Results

Among the results reported by the patients,92% were excellent, 5.7% were good, and 2.3% wereaverage; there were no poor results reported. Theaverage time lost from work was 71 days. Handtherapy time averaged 10 weeks, ranging from 2 to41 weeks, and 61% of the patients regained fullROM sixty days after surgery.

CONCLUSION

Promoting tendon healing and adhesion for­mation is the most critical part of the postoperativemanagement of tendon repair. This is accomplishedby protected exercises within a specific splint. Ifthat phase is performed correctly, further rehabili­tation after splint removal is minimized, the needfor additional surgery is reduced, recovery is morecomplete, and the return to work is faster. 8

•22 As

Allieu has observed, "Controlled passive mobili­zation enhances tendon healing, decreases adhe­sions, hastens tendon callus remodeling, and alle­viates the risk of stiffness."l

Splints designed for each particular patient arethe essential tools of protected mobilization. Theyensure ambulatory, portable, 24-hour-a-day reha­bilitation.

REFERENCES

1. Allieu Y, Asencio G, et al: Suture des tendons extenseurs dela main avec mobilisation assistee, a propos de 100 cas,SCFCOT, reunion annuelle nov. 1983, supp!. II. Rev ChirOrthop Reparatrice Appar Mot 1984.

2. Borelli PP: La Riabilitazione della mano traumatizzata conortesi statico-dinamiche, pp. 165-170, Marrapese, Roma1992.

3. Evans R, Burkhalter W: A study of the dynamic anatomyof extensor tendons and implications for treatment. Am JHand Surg llA:774-779, 1986.

4. Evans R: Therapeutic management of extensor tendon in­juries. Hand Clinics 2:157-169,1986.

5. Evans R, Thompson D: An analysis of factors that supportearly active short arc motion of the repaired central slip. JHand Ther 1992.

October-December 1996 313

6. Evans R: An update on extensor tendon management. InHunter J, Mackin E, Callahan A (eds): Rehabilitation of theHand: Surgery and Therapy, 4th ed. St. Louis, Mosby, 1995.

7. Frere G, Moutet F, et al: Controlled postoperative mobili­zation of sutured extensor tendons of the long fingers. AnnChir Main Memb Super 3:139-144, 1984.

8. Guinard D, Lantuejoul JP: Early protected mobilization witha Levame splint after primary repair of hand extensor ten­dons: report on a series of 88 cases. Ann Chir Main MembSuper 12:342-351, 1993.

9. Jouan N: Lesions recentes des tendons extenseurs. KineScientifique 327:83-84, 1993.

10. Kleinert HE, Verdan C: Report of the committee on tendoninjuries. J Hand Surg 8:795, 1983.

11. Lepley, Zander C: The use of early mobilization followingcomplex injury to the extensor tendons. J Hand Ther 1:38­41,1987.

12. Levame JH, Durafourg MP: Reeducation des Traumatisesde la Main, Maloine, Paris 1987, pp 109-114.

13. Minamikawa Y, Peimerc A, Ymamguchi T: Wrist positionand extensor tendon amplitude following repair. J HandSurg 17A:268-271, 1992.

14. Rosenthal E: The extensor tendons. In Hunter J, Mackin E,Callahan A (eds): Rehabilitation of the Hand, 3rd ed. St.Louis, Mosby, 1990.

314 JOURNAL OF HAND THERAPY

15. Rouzaud JC: Critiques des techniques de mobilisations,Kine Scientifique 327:87, 1993.

16. Rouzaud JC: Les lesions des tendons extenseurs de la main.Ann Kinesitherapie 17:255-265, 1990.

17. Schuller C: Utilisation d'un appareil de Levame apres su­ture des tendons extenseurs des doigts autre que Ie pouce,These de diplome d'etat de Docteur en Medecine, Univer­site Scientifique et Medicale de Grenoble, 1981.

18. Thomas D: Les attelles dans Ie traitement des lesions desextenseurs. Kine Scientifique 327:89-94, 1993.

19. Thomas D, Lance X, Moutet F: Etude comparative des at­telles de "Levame" et "Low Profile," incidence sur les in­dications therapeutiques. Ann Chir Main Memb Super 13:308-316, 1994.

20. Thomas D: L'attelle "Radial Bis": Attelle de fonction et desuppleance apres atteinte des extenseurs. Ann Kinesither­apie 7:271-274,1990.

21. Vion M: La confection des ortheses de la main et leur ap­plication dans les lesions traumatiques des tendons exten­seurs des doigts. Ann Kinesitherapie 6:361-370,1979.

22. Walsh M, Rinehimer W, et al: Early controlled motion withdynamic splinting versus static splinting for zones III andIV extensor tendon laceration. J Hand Ther 7:232-236, 1994.

23. Personal communication, Dr. Gerard Hoel, 1993.24. Thomas D: Controlled passive mobilization. Paris, 2nd

IFSHT Conference, 1992.