REHABILITATION OF EXTENSOR TENDON INJURIES

JEFFREY S. BRAULT, DO, PT

Hand specialists commonly see extensor tendon injuries. These injuries pose a difficult rehabilitation challenge. In the past, postoperative repair was followed by prolonged immobilization before motion was initiated. In the last decade there has been a shift in rehabilitation strategies to begin motion early in the postoperative period. This article reviews rehabilitation strategies for commonly seen extensor tendon injuries. Copyright 9 2000 by W.B. Saunders Company
KEY WORDS: tendon injuries, hand injuries, rehabilitation

Injuries to the extensor tendons are more common than flexor tendon injuries: Because of their superficial position, they are prone to laceration, abrasion, crushing, burns, and bites3 These injuries can be difficult to manage, and many complications such as extensor tendon lag, joint stiffness, and poor tendon excursion can result if initial treatment and postoperative rehabilitation is suboptimal. 2,3 Extensor tendon injuries are categorized into anatomical regions. This system defines 7 zones overlying the dorsal hand and wrist# Roman numerals are used to identify the zones: Odd numbers overlie the respective joints, and even numbers represent areas of the intermediate tendon regions (Fig 1). Injuries of the differing zones require different surgical repair and appropriate rehabilitative measures. Traditionally, extensor tendon injuries were either treated nonoperatively or surgically repaired and placed in continuous immobilization for 4 to 6 weeks. Achieving full range of motion was difficult because of tendon adhesion and joint contractures after prolonged immobilization. Over the last decade there has been a shift in the rehabilitation of proximal extensor tendon injuries (zones III through VII). The concepts of passive short arch motion and immediate active tension have been described by many as beneficial to extensor tendon healing and recovery. 5-8 Early motion and active tension of the repaired tendons assist in maintaining the integrity of the surrounding soft tissue, controlling edema, reducing tendon adhesions, preventing contractures, and promoting tendon repair. 9,1~The intent of this early "rehabilitation of a healing tendon is simply reestablishing its ability to glide and transmit forces without creating gapping or rupture of the repair site. 'ql The purpose of this article is to review rehabilitative interventions for the most commonly encountered zone

injuries. This information will provide the hand surgeon with an understanding of the various types of splints and rehabilitation procedures used for treatment of extensor tendon injuries.

ZONE I
Injury to the most distal aspect of the extensor tendon overlaying the distal interphalangeal (DIP) joint usually results in a flexion deformity of the DIP joint. These injuries, commonly referred to as mallet, baseball, or dropped finger, are the result of forced flexion of an extended DIP joint. Bony avulsion of the distal tendon insertion may occur. If this deformity goes untreated, it may result in an imbalance collapse of the finger (hyperextension of the proximal interphalangeal [PIP] joint and flexion of the DIP joint), or swan neck deformity. 12 In closed zone I injury with mallet deformity, splint therapy is widely used over primary repair. 11,12Conservative treatment of acute injuries, lasting less than 3 weeks, consists of continuous immobilization of the DIP joint in slight hyperextension (0 ~ to 15~ Many types of DIP splints are available, but the most widely used is the Stack polyethylene splint 12 (Fig 2). Extension greater than 15 ~ of the DIP should be avoided to alleviate the potential for skin or tendon ischemia and potential necrosis. The extension splint should be worn continuously for 6 weeks and may be removed once a day to allow skin aeration and to prevent maceration. During splint removal the DIP joint must be held in extension. If flexion of the DIP joint is allowed, immobilization should be reimplimented for an additional 6 weeks, n During this immobilization period active and passive range of motion exercises should be initiated at the metacarpal phalangeal (MCP) and PIP joints (Fig 3). Re-evaluation should be performed weekly to ensure proper splint size and to monitor skin integrity. After 6 weeks, active DIP range of motion exercises should be performed hourly. At 7 weeks, if no extensor lag is identified, passive pain-free DIP range of motion can be initiated. Patients should continue to wear the splint

From the Mayo Clinic, Rochester, MN.

Address reprint requests to Jeffrey S. Brault, DO, PT, Mayo Clinic,

PM&R Department, E-10, 200 First St, SW, Rochester, MN 55905. Copyright 9 2000 by W.B. Saunders Company 1071-0949/00/0701-0006510.00/0

doi:10,1053/oa.2000.5801

Operative Techniques in Plastic and Reconstructive Surge04, Vol 7, No 1 (February), 2000: pp 25-30

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Fig 3. Motion exercises of the MCP and PIP joints.

exercise sessions and at night. The splint use is discontinued at 10 weeks if extensor lag is not present (Table 1).
Fig 1. Zones of extensor tendons.

ZONE II
Zone II injuries involve the terminal extensor tendon in the region of the middle phalanx. Distal to this region, the lateral bands fuse to form the terminal extensor tendon} 3 Zone II injuries are most often the results of laceration. In this region primary tendon repair is recommended; however, pinning and splint therapy have also been described. 12 Conservative and postoperative splint therapy protocols are the same as for zone I injuries (Table 1).

between exercise sessions and at night. At 8 weeks, if no extensor tendon lag is noted, the splint use m a y gradually be discontinued. In chronic DIP tendon injuries (ie, lasting longer than 3 weeks), immobilization in DIP extension should be maintained for 8 weeksJ 2 Active range of motion exercises of the MCP and PIP joints should be performed. After 8 weeks DIP active range of motion exercises should be done hourly. At 9 weeks, if extensor lag is less than 10 ~ hourly passive, pain-free DIP range of motion can be initiated. Patients should continue to wear the splint between

ZONE III
In zone III the central tendon is the primary extender of the PIP joint} 3 Injury in this region can be the result of direct forceful flexion of an extended PIP joint, laceration, abrasion, or bite. If untreated, the lateral bands slip volarly, resulting in a boutonni6re deformity. 12 Acute open injuries are usually repaired by primary central tendon repair. Acute closed injury treatment is controversial, but most surgeons recommend conservative immobilization for 6 weeks. 15,16In chronic nonfixed deformity, splinting is recommended, and for fixed deformity, reconstructive surgery is the treatment of choice. 12 Evans 14 has delineated a therapy program in which early motion and tension are introduced 24 to 48 hours after primary repair. Except for hourly exercise, the DIP and PIP joints should be splint immobilized in 0 ~ of flexion (Fig 4). Two exercise splints are fabricated for each patient. The first, a volar static splint, allows 30 ~ of PIP joint flexion and 20 ~ to 25 ~ of DIP joint flexion (Figs 5 and 6). During exercise the wrist is maintained in approximately 30 ~ of flexion and the MCP joints in a neutral position. The second volar splint maintains the PIP joint in 0 ~ of extension and allows for free DIP joint flexion unless the lateral bands are repaired;

Fig 2. Stack splint immobilizes the DIP joint in slight extension,

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JEFFREY S. BRAULT

TABLE 1. Zone I and Zone II Injuries Acute DIP injuries (Mallet Deformities Lasting < 3 Wk)
Weeks Splint 0-5 6 7 8 Exercises Wound and Skin Care Remove splint daily to check for skin integrity/ Continuous DIP extension (Stack splint) (Fig 2) Active flexion and extension of PIP and MCP hygiene (maintain DIP in extension) (hourly) Worn between exercises and at night Active flexion and extension of DIP (hourly) Worn between exercises and at night Passive flexion and extension of DIP (hourly) If no extensor lag, may gradually discontinue Continue with active and passive DIP exercises

splint Chronic DIP Injuries (Mallet Deformities Lasting >3 Wk)

Weeks Splint 0-7 8 9 10 Continuous DIP extension (Stack splint) (see Fig 2) Worn between exercises and at night Worn between exercises and at night If no extensor lag, may gradually discontinue splint Exercises Wound and Skin Care Remove splint daily to check for skin integrity/ Active flexion and extension of PIP and MCP hygiene (maintain DIP in extension) (hourly) Active flexion and extension of DIP (hourly) Passive flexion and extension of DIP (hourly) Continue with active and passive DIP exercises

Abbreviations: DIP, distal interphalangeal joint; MCP, metacarpophalangealjoint; PIP, proximal interphalangeal joint. Data from Evans 11and Minamikawa. t2

then flexion is limited between 0 ~ to 30 ~ (Figs 7 and 8). Patients are followed up weekly by a skilled therapist to ensure that no extensor lag develops. If extensor lag is not noted at 2 weeks, the first exercise splint can be modified to allow 40 ~ of flexion. This can be increased to 50 ~ at the fourth postoperative week, and full flexion is allowed at 6 weeks. The exercise splints should not be advanced if extensor lag is identified (Table 2).

ing have been described and are similar to those applied to zone III injuries 11,12(Table 2).

ZONE V
Zone V, located over the MCP joints, is the most c o m m o n area for extensor tendon injury. 12 In this region the tendon is susceptible to laceration, bite, or joint dislocation. If the tendon disruption is the result of a h u m a n bite (fist to the mouth), the injury should be copiously irrigated, the w o u n d left open, and the patient started on broadspectrum antibiotics. 12 Acute open injuries ( n o n h u m a n bites) and closed injuries are usually repaired} 4-15 M a n y authors have recommended that passive splinting be initiated within the first postoperative week, preferably before 48 hours. 6,8,12,14This is achieved by a forearm-based dorsal dynamic extension splint (Fig 9). This splint places the wrist at 40 ~ of extension and allows 30 ~ to 40 ~ of active MCP joint flexion, but only passive extension (Fig 10). The a m o u n t of active flexion can be limited by stop beads on the suspension line or by use of a volar block. This degree

ZONE IV
In zone IV, the extensor digitorum tendons run dorsal to the proximal phalanx. The tendons of the intrinsic h a n d muscles are located laterally. 13 In this region partial tendon injuries usually spare the lateral bands, x2 Because of the intricate relationship between the tendon and bone in this zone, injury can often result in considerable adhesions and loss of motion. If no extensor lag is noted at the PIP joint, repair of the tendon is rarely required. 2 If lag is present, primary repair is recommended. 12Rehabilitation and splint-

Fig 4. Immobilization splint of PIP and DIP joint,

Fig 5. Exercise splint #1; finger in neutral position.

REHABILITATION OF EXTENSOR TENDON INJURIES

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Fig 8. Active flexion and extension of the DIP joint. Fig 6. Active range of motion exercises allowing for 30 ~ of PIP and 20 ~ to 25 ~ of DIP flexion,

of motion results in 5 mm of tendon excursion in zone V.2 The amount of active flexion range can be increased to 50 ~ to 60 ~ by the fourth week. The patient is instructed to perform hourly exercises. A static night splint or MCP block splint holds the wrist in 30 ~ to 40 ~ of extension and the MCP joints at 0~ this is used throughout rehabilitation (Fig 11). In addition to early passive motion, immediate active exercises have been advocated. 8,14 These exercises are initiated by a skilled therapist who positions the wrist in 20 ~ of flexion and passively positions the MCP joint in 30 ~ of flexion. While maintaining the interphalangeal joints in the neutral position, the patient actively extends the MCP joints back to the neutral position. The weight of the patient's fingers provide a safe amount of stress through the repair site, stimulating tendon healing. 17At week 5 the dynamic splint is discontinued, and the MCP block splint is continued between exercise sessions and at night. At week 6 passive flexion exercises can be initiated and b u d d y taping used to enhance composite flexion of the digits. At week 7 progressive strengthening can be initiated. By week

9, if no extensor lag develops, all bracing can be discontinued, and progressive active exercises can be incorporated into a home program (Table 3).

ZONE VI
This zone of the hand lies over the metacarpals. Here, the 4 individual extensor digitorum tendons and extensor proprious tendons of the small and index fingers transverse. Injuries to this region present a similar clinical picture as in zone V. If there are partial or single tendon injuries, weakness may be difficult to detect because of the attachments of the juncturae tendinum between adjacent extensor tendons, s The only physical sign may be slight extensor lag of one finger relative to its neighbor. Treatment of this region has conventionally been primary repair followed by 4 to 6 weeks of immobilization with finger and wrist extension. Use of dynamic splints shortly after repair has been demonstrated to be of similar benefit as protocols used for zone V injuries 8,14(Table 3).

ZONE VII
Zone VII is at the level of the wrist. Tendons in this region run through a fibro-osseous tunnel covered by the extensor retinaculum. Complete laceration of the finger extensor tendons in this area is rare. 8 If injury does occur in this zone the tendons retract considerably. Primary repair requires greater exposure and increases the risk of adhesions. 12 Postoperative rehabilitation is similar to zone V rehabilitation protocols 8,14(Table 3).

CONCLUSION
The rehabilitation of extensor tendon injuries has been modified greatly in the last 10 years. The concept of prolonged immobilization has been replaced by early mobilization in postoperative repair of injuries in zones III through VII. Early referral to a qualified hand therapist for initiation of proper splinting, edema and pain control, patient education, and initiation of an early motion pro-

Fig 7. Exercise splint #2; PIP joint in neutral.

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JEFFREY S. BRAULT

TABLE 2. Zone III and IV Injuries (Immediate Motion)

Weeks Start 24-48 h 0-2 wk Splint PIP and DIP neutral splint (Fig 4) Exercises Exercise hourly with 2 splints: Splint I allows 30 ~ of PIP and 25 ~ of DIP ROM (see Figs 5 and 6) Splint 2 PIP in neutral position, DIP flexion (see Figs 7 and 8) Splint 1 increases PIP flexion to 40 ~ Splint 2 continues Splint 1 increases PIP flexion to 50 ~ Splint 2 continues Full active PIP and DIP flexion Wound and Skin Care --Daily removal of splint for wound cleaning - - E d e m a control with compressive wrap

2-3 wk 4-5 wk 6 wk

If no extensor lag noted, discontinue use of splints If no extensor lag noted, discontinue use of splints If no extensor lag noted, discontinue use of splints

Abbreviations: DIP, distal interphalangeal joint; PIP, proximal interphalangeal joint; ROM, range of motion. Data from Evans 11 and Minamikawa. 1-2

Fig 9. Forearm-based dorsal dynamic extension splint (low profile).

Fig 10. Splint allows for 30 ~ to 40 ~ of active MCP flexion with passive return to the neutral position. Flexion is limited by stop beads on outrigger strings.

Fig 11. MOP block splint.

TABLE 3. Zone V, VI, and VII Injuries

Weeks Splint Exercises Wound and Skin Care

Start 24-48 h Dorsal dynamic extension splint (Fig 10) 0-3 wk Night splint: MCP block splint (see Fig 11)

4 wk 5 wk 6 wk 7wk 9 wk

Exercise hourly in extension splint allowing Daily removal of splint for wound cleaning 300-40~ of MCP flexion Edema control with compressive wrap With skilled therapist--wrist at 20~, passive MCP flexion to 30~ performs active extension (daily to 3x wk) Continue with dynamic day splint, static night Increase active ROM to 50o--60~ splint Discontinue dynamic extension splint Increase active ROM exercises to full motion MCP block splint worn at night and between exercises MCP block splint Passive flexion exercises of MCP and IP joints (buddy tape) MCP block splint Progressive extension exercises, with mild resistance If no extensor lag, discontinue all splints Progress active and passive exercises

Abbreviations: IP, interphalangeal; MCP, metacarpophatangeal; ROM, range of motion. Data from Evans 11and Minamikawa. 12 g r a m is o p t i m a l . T h e s e e a r l y m o t i o n p r o g r a m s h a v e res u l t e d i n i m p r o v e m e n t o f r a n g e of m o t i o n , s h o r t e r t i m e to r e c o v e r y , l o w e r e x p e n s e , a n d b e t t e r f u n c t i o n a l o u t c o m e . 14 9. Amiel D, Woo SL, Harwood FL: The effect of immobilization on collagen turnover in connective tissue. A biochemical-biochemical correlation. Acta Orthop Scand 53, 325-332, 1982 10. Adriacchi T, Sabiston P, DeHaven K: Ligament: Injury and repair, in Woo SLY, Buchwalter JA (eds): Injury and Repair of the Musculoskeletal Soft Tissues. Park Ridge, IL, American Academy of Orthopaedic Surgeons, 1988, pp 103-128 11. Evans R: An update on extensor tendon management, in Hunter JM, Mackin EJ, Callahan AD (eds): Rehabilitation of the Hand: Surgery and Therapy, vol I (ed 4). St Louis, MO, Mosby, 1995, pp 565-606 12. Minamikawa Y: Extensor repair and rehabilitation, in Peimer C (ed): Surgery of the Hand and Upper Extremity, vol 1. New York, NY, McGraw-Hill, 1996, pp 1163-1188 13. Rosenthal EA: The extensor tendon: Anatomy and management, in Hunter JM, Mackin EJ, Callahan AD (eds): Rehabilitation of the Hand: Surgery and Therapy, vol 1 (ed 4). St Louis, MO, Mosby, 1995, pp 519-564 14. Evans RB: Rehabilitation techniques for applying immediate active tension to the repaired extensor system. Techniques Hand Upper Extremity Surg 3:139-150, 1999 15. Tubiana R: Injuries to the digital extensors. Hand Clin 2:149-156, 1986 16. Wilson RL: Management of acute extensor tendon injuries, in Hunter JM, Shneider LM, Mackin EJ (eds): Tendon Surgery in the Hand. St Louis, MO, Mosby, 1987, pp 284-294 17. Evans RB, Thompson DE: The application of stress to the healing tendon. J Hand Ther 6:262-298, 1993

REFERENCES
1. Hart RG, Uehara DT, Kutz JE: Extensor tendon injuries of the hand. Emerg Med Clin North Am 11:637-649, 1993 2. Evans RB, Burkhalter WE: A study of the dynamic anatomy of extensor tendons and implications for treatment. J Hand Surg [Am] 11A:774-779, 1986 3. Newport ML, Blair WF, Steyers CM: Long-term results of extensor tendon repair. J Hand Surg [Am] 15A:961-966, 1990 4. Kleinert HE, Verdan C: Report of the committee on tendon injuries. J Hand Surg [Am] 8:794-798, 1983 5. Evans RB: Early short arc motion for the repaired central slip. J Hand Surg [Am] 19A:991-997, 1994 6. Hung LK, Chan A, Chang J: Early controlled active mobilization with dynamic splintage for treatment of extensor tendon injuries. J Hand Surg [Am] 15A, 251-257, 1990 7. Saldana MJ, Choban S, Westerbeek P: Results of acute zone III extensor tendon injuries treated with dynamic extension splinting. J Hand Surg [Am] 16A,1145-1150, 1991 8. Thomas D: Postoperative management of extensor tendon repairs in zones V, VI, VII. J Hand Ther 9:309-314, 1996

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JEFFREY S. BRAULT