Does dynamic extension splinting or early active motion provide better outcomes post extensor pollicis longus repair? A systematic review.

Background: Flexor tendon repair of the hand and the rehabilitation thereof are commonly discussed between hand surgeons and therapists. There are many patients in public hospitals in South Africa who require this surgery. They are regularly sent to the therapists for rehabilitation, using the early passive motion protocol. Although the early active motion protocol has yielded improved results globally, there is limited evidence on the comparison of the outcomes of these 2 protocols in the South African context. This study was implemented to compare the outcomes of these 2 protocols in a large public hospital post flexor tendon repair. Methods: Patients (n = 46) who sustained a zone II-IV flexor tendon injury were recruited for the study and equally distributed between the 2 groups (early active motion and early passive motion). Out of these participants, 11 did not return for the initial assessment at 4 weeks post surgery and were therefore excluded. There were 19 participants in the early active motion group and 16 participants in the early passive motion group. Results were collected and classified at 4, 8, and 12 weeks post surgery. The collection of data commenced in December 2014 and was completed in January 2016. Results: The results of the study included total active motion and tip to crease and tip to table measurements of the injured and uninjured fingers. At 12 weeks post surgery, the average total active motion of the injured fingers was similar between the early active and early passive motion protocols (57.46%, 61.00%, respectively). Tip to crease and tip to table measurements were also similar between the 2 groups. In terms of patient compliance, 52.17% of participants removed their splints in the initial 4-week period, and 56.52% carried out the prescribed exercises correctly. Tendon rupture occurred in 8.57% (n = 3, early active motion = 5.71%, early passive motion = 2.86%) of patients. Conclusion: There has been a global trend toward the use of an early active motion protocol post flexor tendon repair. This study found that there was no difference in outcomes between the 2 groups. Therefore, either protocol could be implemented in South African public hospitals. However, because the early active motion protocol takes less time to implement, this protocol is recommended. A larger study would be necessary to determine a significant comparison between the 2 groups; however, this is challenging due to poor patient compliance.

Spontaneous Rupture of the Extensor Pollicis Longus Tendon

This retrospective study compares the functional outcome after early active postoperative motion with the outcome after 6 weeks of immobilization by splinting in patients with proximal phalangeal fractures treated by percutaneous, antegrade pinning. 46 out of 90 patients treated by closed reduction and percutaneous antegrade pinning of isolated fractures of the proximal phalanges were re-evaluated on average after 18.5 months. There were 17 women and 29 men with a mean age of 42.8 years. 28 patients underwent early active postoperative motion and 18 patients were immobilized by splinting for 6 weeks postoperatively. The two groups were statistically comparable with respect to age, gender, fracture localisation and morphology, mechanism of injury and operative time. Follow-up examination included measurement of active and passive range of motion (TAM; TPM) of the injured finger and the uninjured finger of the opposite side as well as grip strength of both hands. In addition, postoperative complications, the DASH-score and time interval between surgery and return to work were registered. There were no significant differences between the two groups regarding rate of complication, number or required revisions, finger motion and grip strenght. Patients with early active motion returned earlier back to work than patients treated by postoperative splinting (2.5 vs. 9.0 weeks; p = 0.035). With 1.7 the DASH-score in the group with early active motion was better than in the splinting group with 2.5 (p = .269). Patients with early active postoperative motion returned earlier back to work. There was no significant difference between both groups respecting global finger function.Compliant patients with a fracture of the proximal phalanx treated by closed reduction and percutaneous pinning can be treated with early active motion postoperatively.

Introduction Forearm-based splints have been traditionally used for extensor pollicis longus (EPL) tendon repairs for zones T II–T V (T is used to represent thumb extensor tendon zones). Limited literature exists on hand-based splinting in the rehabilitation of zone T II EPL tendon repairs. This retrospective review of five case studies highlights the anatomical justification and the outcome of rehabilitation of zone T II EPL surgical repairs using a static hand-based thumb extension splint. Methods In this study, five patients were retrospectively reviewed. All patients attended hand therapy for initial treatment within three days postoperatively. The postoperative interphalangeal joint mobilization regimen utilized in this study was early active motion (EAM). Outcomes measured in the study were reliable and valid, including goniometry measurement at week 4, week 6 and week 8 postoperatively for range of motion, total active motion (TAM), Dargan's criteria assessing extensor lag and White's assessment of interphalangeal joint range of motion. Results The results demonstrated that a hand-based splint did not create undue stress on the EPL tendon repair, as there was no incidence of rupture. Hyperextension of EPL was within 8° compared with the non-injured thumb. ‘Excellent’ and ‘good’ categories were achieved when applying TAM criteria, White's assessment and Dargan's criteria. Conclusion A hand-based splint with an EAM regimen is a viable treatment option for zone T II EPL surgical repairs instead of a long forearm-based splint. Further research is warranted with a larger sample and using a control group.

To investigate the effects of early active motion versus early passive motion on functional recovery of repaired flexor digitorum tendon in Zone-II, and the feasibility of shear wave elastography in monitoring the tension of flexor tendons. Thirty-six patients were randomly divided into early active motion (n=18) and early passive motion (n=18) groups for accordingly treatments. Before treatment, Young’s modulus of flexor tendon was measured with shear wave elastography. The total active motion was evaluated at 4, 8, 12, and 16 w post-operation. At 16 w; grip strength, pinch strength, adjusted Strickland’s classification and the disabilities of the arm, shoulder and hand score were assessed. At a 16-w follow-up, the total active motion (215.48±22.75°) and grip strength (21.07±5.84 kg) of the early active motion group was significantly higher than those (191.00±33.15° and 15.75±7.91 kg) early passive motion group (p<0.05). The repeated measurement method of the general linear model of total active motion showed that treatment protocol, time, and the interaction between two elements had significant effects on the functional results. According to the adjusted Strickland’s system, the good and excellent recovery rate was 100 % in the early active motion group and 76.1 % in the early passive motion group. Early active mobilization had better tendon gliding and excursion even with the two-strand repair as active motion will decrease adhesion formation, with significant difference compared with the passive group. No significant differences between these two groups were found in the pinch force and disabilities of the arm, shoulder and hand score. Young’s Modulus in active finger flexion was significantly higher than that of immobilization position, and it was lowest in passive flexion status (p<0.05). Early active motion contributes to better joint mobility and grip strength after Zone-II flexor tendon repaired. Application of shear wave elastography in monitoring flexor tendon tension appears feasible.

Optimizing independent finger flexion with zone V flexor repairs using the Massachusetts General Hospital flexor tenorrhaphy and early protected active motion

Extensor pollicis longus (EPL) tendon ruptures have been treated succesfully with the transfer of the extensor indicis proprius (EIP) tendon. Situations exist in which, due to intraoperative observations, another tendon transfer may be considered preferable to the standard EIP transfer method. To determine whether transfer of the extensor digitorum communis II (EDC II) tendon from the index finger to the EPL tendon, leaving the EIP tendon to the index finger intact, would serve as an equally efficient transfer and not adversely affect the function of the hand. Two patients who had the EDC II tendon transferred to the ruptured EPL tendon, and two patients who had the EIP tendon transferred, were retrospectively reviewed. In each transfer type, one patient had suffered an EPL tendon rupture after a Colles' fracture, and the other had rheumatoid arthritis. The rupture occurred on the non-dominant side in one patient in each transfer type. Each patient was examined and subjected to range of motion and power testing at least one year following surgery. All four patients showed a minimal extension lag with the lift off test, but there was no noticeable difference in range of motion, pinch grip and hand grip strength between the transfer types. Both EDC II transfer patients demonstrated an 8° to 15° loss of thumb interphalangeal joint flexion compared with the unoperated side; EIP transfer patients demonstrated less than a 5° loss. Three patients demonstrated a minor extension lag in the index finger and middle finger. Extension power of the thumb and index finger in all patients varied with wrist flexion and extension and ranged from 50% to 150% of the unoperated side. These case reports suggest that either index finger tendon may be successfully transferred in EPL tendon ruptures.

Introduction The goal of this systematic review was to determine which rehabilitation protocol (static, dynamic or early active) yields the best outcomes following repair of the extensor pollicis longus (EPL) tendon in the following domains: total active motion (TAM), grip strength and range of motion. Methods A comprehensive and systematic literature search was run. The retrieved abstracts and titles were screened by two independent reviewers. Rehabilitation protocols were classified as static, dynamic or early active. Methodological quality of included randomized controlled trials and cohort studies were assessed using the SIGN50 scale. Results Fifteen articles were included in the final analysis ( κ = 0.8). From this total, five studies employed static splinting, 12 dynamic splinting and two early active splinting. Static splinting yielded ‘excellent’/‘good’ results ranging from 50% (minimum) to 60% (maximum) on the TAM classification system and a weighted mean TAM of 73.0 ± 24.0° (range 58.75–85°). Dynamic splinting studies demonstrated ‘excellent’/‘good’ results ranging from 64.4% (minimum) to 98% (maximum) and a weighted mean TAM of 111.2 ± 11.7° (range 89–134°) ( P &lt; 0.001 and mean difference of 38.2 (95% confidence interval: 32.2–44.2). In one study, early active motion resulted in 83% of patients having ‘excellent’/‘good’ ratings. Discussion The available level II–IV evidence suggests better outcomes when using dynamic splinting over static splinting for rehabilitation of the EPL tendon repair. Further evidence is required to clinically confirm the differences between early active and dynamic rehabilitation protocols.

Is Early Active Motion After 3-Ligament Tenodesis Noninferior to Late Active Motion? A Prospective, Multicenter Cohort Study

Background: Secondary rupture of the extensor pollicis longus (EPL) tendon is a known complication following distal radius fracture. While surgical options for EPL tendon tear have been extensively investigated, the surgical results of free tendon graft reconstruction for patients with EPL tendon rupture after distal radius fracture are relatively unexplored. Purpose: We aimed to investigate the outcomes of autogenous palmaris longus (PL) tendon grafting for treating EPL tendon rupture after distal radius fracture. Methods: The study included 9 adult patients (2 male, 7 female; age range, 30-78 years; mean age, 56.7 years) with delayed EPL tendon rupture after distal radius fracture treated at the Taoyuan Armed Forces General Hospital between September 2000 and September 2011. In our hospital, we adopted a protocol for EPL tendon reconstruction that uses the ipsilateral PL tendon. A dynamic splint was applied, and a rehabilitation program including wrist motion and occupational therapy was started within 3 days postoperatively. Extension lag at the interphalangeal joint of the injured thumbs, as well as Geldmacher scores were recorded. Results: At the final follow-up (15-34 months), the extension lag at the interphalangeal joint of the involved thumb had improved significantly (p ＜ 0.05), from a preoperative mean value of 41.7° (range, 35°-60°) to a postoperative mean value of 3.8° (range, 0°-6°). Regarding the Geldmacher scores, 5 patients (55%) achieved ＂excellent＂ results, and 4 (45%) achieved ＂good＂ results. No patients experienced tendon re-rupture, wound infections, nerve injury, or other complications. Conclusions: In this short-term follow-up study, using free PL grafts for treating EPL tendon rupture was found to provide good outcomes, suggesting that tendon grafting using the PL tendon is an effective method to treat delayed EPL tendon rupture after distal radius fracture.

The optimal orthosis and motion protocol for extensor tendon injury in zones IV-VIII: A systematic review

Objectives: The tendon transfer operation is the most preferred surgical method for chronic extensor pollicis longus (EPL) tendon rupture repair. The key factor in these operations is tension setting of the tendon transfer. In this article, we retrospectively reviewed our extensor indicis proprius (EIP) to EPL transfer cases for chronic EPL ruptures. Methods: Five patients were operated on for chronic rupture of the EPL tendon between December of 2011 and April of 2014. The EIP tendon was transferred to the EPL tendon using the wide-awake approach in order to optimally set the tension. Results: All five patients were able to extend their thumbs. No second operation was needed for tension adjusting. No complications were encountered postoperatively and during the follow-up period. Conclusion: Tendon transfers using the wide-awake approach provides the benefit of improved tendon tension setting with active movement and minimal risks of complication.

Objectives: When pitching a baseball, players must use the intrinsic muscles of the hand to effectively control and propel the ball. Grip and pinch strength are metrics that reflect the strength of these muscles and can be easily obtained both in clinic and in the training field. Grip strength has been found to be a marker of an individual’s overall muscular strength 1 and a strong predictor of pitched ball kinetic energy in young baseball players. 2 Additionally, there has been a reported weak, but not significant, association between elbow injury and grip strength in youth players. 3 Diminished grip and pinch strength could lead to a decrease in dynamic stability of the medial elbow resulting in increased load on the UCL. Further, research is limited comparing grip and pinch strength to the load at the elbow during throwing. Therefore, the purpose of this study was to evaluate bilateral grip and pinch strength and its relationship to both ball velocity and elbow varus torque in high school pitchers. Methods: Data from 25 high school pitchers were included in this study (182.8±5.4 cm, 78.7±10 kg). Pitchers were tested for bilateral grip strength using a digital dynamometer and a pinch gauge to measure three-point pinch strength. Pitchers were then evaluated while pitching full-effort fastballs at 480 Hz using a 3D motion capture system (Motion Analysis Corp., Santa Rosa, CA). Each pitcher’s maximum grip strength, pinch strength, and fastest pitch were used in the analysis. T-tests were used to compare measures bilaterally and linear regression was used to evaluate the relationship between grip and pinch strength to ball velocity and elbow varus torque. Results: Average ball velocity was 35.3±0.3 m/s (79.0±0.7 mph) and elbow varus torque was 70.9±3.3 Nm. Grip strength (477.9±57.5 vs 474.9±57.2 N, p&lt;0.001), and pinch strength (101.0±16.5 vs 95.2±16.0 N, p&lt;0.001) were greater in the throwing arm compared to non-throwing arm. Throwing arm grip strength was significantly related to both ball velocity (r 2 =0.020, p=0.020) and elbow varus torque (r 2 =0.167, p=0.034), but both correlations were considered weak. There were no significant associations between pinch strength to either ball velocity (r 2 =0.067, p=0.124) or elbow varus torque (r 2 =-0.023, p=0.486). When normalizing pinch and grip strength to player mass (N/kg), there was a statistically significant, but weak, relationship between pinch strength and elbow varus torque (r 2 =0.139, p=0.049). There were no significant associations between normalized grip and elbow varus torque (p=0.112) or normalized grip/pinch and ball velocity (p=0.509 and p=0.523, respectively). Conclusions: Grip strength revealed to be positively correlated, albeit weakly, with both ball velocity and elbow varus torque. Pinch strength normalized to mass was weakly correlated to elbow varus torque. These findings suggest that while grip strength may play a role in pitching performance and injury risk, its impact is limited. Other factors, such as height, weight, and pitch specialization, should also be considered. Adolescent growth may impact the relationship between a pitcher’s strength and his injury risk. Future research should investigate grip and pinch strength acutely (between innings and throwing days) and chronically (over the course of a season) to fully assess its benefits or detriments to the throwing arm.

Current literature suggests that tendonitis of the extensor pollicis longus (EPL) is a rare condition that has a high rate of progression to rupture. This study documents the prodrome of impending EPL rupture in patients with prior nondisplaced distal radial fracture. A retrospective study identified patients with EPL tendonitis or tendon rupture. Seven patients (6 females and 1 male) had sustained a nondisplaced distal radius fracture within the past year. Among these 7 patients, 4 eventually developed EPL tendon rupture and 3 had tendonitis without rupture. Of the 4 patients with EPL rupture, 2 presented to another provider before rupture with prodromal symptoms documented in the medical record, with pain and difficulty extending the affected thumb at the interphalangeal (IP) joint. The 3 patients with EPL tendonitis but no EPL tendon rupture all presented following a nondisplaced distal radius fracture with tenderness over the EPL tendon and pain with thumb motion. These 3 patients underwent EPL tendon decompression and subsequently did not go on to experience EPL rupture. Extensor pollicis longus tendonitis is a condition that is classically seen in the setting of nondisplaced distal radius fractures and often progresses to tendon rupture. In this study, the following prodrome of impending EPL rupture was identified: tenderness over the EPL tendon and Lister's tubercle and pain with thumb motion. This study suggests that patients with EPL tendonitis and possible impending rupture present with a prodrome of symptoms. If these patients can be identified, they may undergo EPL tendon decompression, which may prevent EPL tendon rupture. [Orthopedics. 2016; 39(5):318-322.].

Objective/Hypothesis: This audit purposed to compare the early active motion (EAM) and immediate controlled active motion (ICAM) regimes postextensor tendon repair in zones 4 to 8. No previous comparison of these regimes was found. In 2005, Wyndell Merritt et al. introduced the ICAM regime, which includes a wrist and yoke splint. The ICAM regime was presented at International Federation of Societies of Hand Therapy (IFSHT) 2013 and was trialed at our unit from 2015. Materials and Methods: A prospective audit was conducted between November 2015 and November 2016 of all extensor zones 4 to 8 patients. Patients were treated by either EAM or ICAM regime dependent on patient suitability, staff skills, and regime criteria. Demographics, outcome, and complication data were recorded. Results: Totally, 51 patients and 63 digits (70% index or middle) were audited. Twenty-six patients were in the EAM group (mean age, 34 years) and 25 in the ICAM group (mean age, 43 years). Of the EAM patients, 21 had a single digit (9 with multiple tendons affected either extensor indicis proprius [EIP]/ extensor digiti minimi [EDM]), 3 patients had 2 digits, 1 patient had 3 digits, and 1 patient had 4 digits affected. Of the ICAM patients, 23 had a single digit affected (4 multiple tendons), and the remainder had 2 digits affected. Injury zone was consistent with EAM:ICAM; zone 4, 5:5; zone 5, 17:18; and zone 6, 4:2. Days from injury to repair was 1 to 5 except for 3 delayed presentations, mean EAM was 2.5 and ICAM was 4.3. Mean days from repair to therapy was 2.9 for EAM and 2.5 for ICAM patients. In the EAM group, 5 patients were transferred to peripheral hospitals, 9 did not attend their appointments, and 1 patient with 4 digits involved was excluded from analysis to allow direct comparison between groups. For the remainder the mean therapy, attendances was 6.8 (range, 3-19) over 8.6 weeks. In the ICAM group, 1 patient transferred and 4 DNA’d. For the remainder the mean therapy, attendances were 5 (range, 2-9) over 7.6 weeks. Two range of motion (ROM) outcomes were used to allow comparison with other studies. Results for EAM:ICAM groups for total active motion were as follows: excellent, 5:9 and good, 6:11; and Millers: excellent, 4:9; good, 5:8; and fair, 2:3. No ruptures presented, but 6 EAM patients experienced scar tethering. At 6 weeks, 5 EAM patients returned to light work duties. At 5 days, 2 ICAM patients returned to light duties and a further 11 with yoke at 4 weeks. The remaining data were not captured. Despite audit limitations of opportunistic regime allocation and demographic variation, it adds valuable data to advancing extensor tendon rehabilitation. Conclusions: Our audit supports the growing evidence that the ICAM regime with low-profile, low-cost splints provides good/excellent outcomes with no complications, fewer therapy attendances, and supports early return to work. In response to the literature and an audit presented at British Association of Hand Therapists (BAHT) conference 2015 involving a yoke-only regime with good/excellent outcomes and no ruptures, we have progressed to a yoke-only ICAM regime and continue to audit the results. Despite the favorable outcomes, there is no level 1 evidence of the ICAM regime. A multicenter clinical trial is planned.