Flexor Tendon Repairs - Old Protocol, Poor Results. Why small changes can make a big difference.
Elizabeth Hands is a chef on a yacht in the Caribbean Islands. She did the classic thing - flicked a knife into an avocado pip that was in the palm of her hand and lacerated her digital neves, FDS and FDP tendons of her left index finger. She received her initial treatment in Miami in March 2019 and then returned to Plettenburg Bay, South Africa for Hand Therapy. She was provided with a splint that positioned her wrist in flexion and her MCP joints in almost 90 degrees of flexion. She was treated using an Early Active Movement Regime but never achieved differential glide. Her tendons became adherent and she was unable to make a fist. Both FDS and FDP function was poor. She was referred for a Tenolysis and although she began to move her fingers immediately after the operation, she still did not gain much differential tendon glide. She persevered with hand therapy but became increasingly fearful that she would not regain functional use of her hand. She has not been able to work since March this year and can not return until she has regained full AROM and strength. Her Hand Therapist refereed her to Hand Therapy Consulting for the CMMS technique as a last resort 6 months after her injury. These images show her hand soon after surgery (Image I), the splint she was provided with (Image 2), digital flexion lateral view (Image 3) and digital flexion palmar view (Image 4). Follow her journey this week as I reveal the results of the CMMS technique after only 2 days in a cast.
What could have been done differently?
The splint and the splint position could have been changed.
A Manchester Hand-Based splint that does not include the wrist and positioned the MCP joints in 20-40 degrees of flexion would have been preferable. Wrist tenodesis motion facilitates differential glide in Zone II. The position of the MCP joints in more than 40 degrees of flexion makes it very difficult to achieve differential glide of the tendons. Furthermore, digital flexion is difficult to achieve with the wrist positioned in flexion.
As soon as it became apparent that the tendons were adherent, the CMMS technique should have been applied. A cast that supports the wrist and blocks the MCP joints into flexion is necessary to facilitate tendon glide and active motion into a hook fist position.
A relative motion flexion splint could have been used to drive profundus function.
I decided to apply the CMMS technique as the cast cannot be removed and therefore compliance with exercises is encouraged.