Dorsal Block Splint Research Articles

Variation in patient information and rehabilitation regimens after flexor tendon repair in the United Kingdom.

There is clinical uncertainty regarding the optimal method of rehabilitation following flexor tendon repair. Many splint designs and rehabilitation regimens are reported in the literature; however, there is insufficient evidence to support the use of any one regimen. The aim of this study was to describe rehabilitation guidelines used in the United Kingdom (UK) following zone I/II flexor tendon repair. Using a cross-sectional design, hand units in the UK were invited to complete a short survey and to upload their flexor tendon rehabilitation guidelines and patient information material. Approval was granted by the British Association of Hand Therapists. Data were extracted in duplicate, using a pre-piloted form, and analysed using descriptive statistics. Thirty-five hand units responded (21%), providing 52 treatment guidelines. Three splinting regimens were described, and all involved early active mobilisation: (i) long dorsal-blocking splint (DBS); (ii) short DBS; and (iii) relative motion flexion splint. Duration of full-time splint wear ranged from 4 to 6weeks. There were variations in splint design and composition of home exercise programmes, particularly for the long DBS. Where reported, recommended return to driving ranged from 8 to 12weeks, and return to light work activities ranged from 5 to 10weeks. Treatment guidelines varied across UK hand therapy departments, suggesting that patients receive differing advice about how to protect, move and use their hand after zone I/II flexor tendon repair. The disparity in splint wear duration, home exercise frequency and prescribed functional restrictions raises potential financial and social implications for patients. Future research should explore rehabilitation burden in addition to clinical outcomes.

Dorsal Block Splinting of Volar Plate Injuries at Neutral Position.

Volar plate injuries of the proximal interphalangeal joint (PIPJ) of a finger are common, often occurring in sporting or workplace incidents. Treatment of a stable dorsal dislocation entails a conservative approach, directed at preventing hyperextension and allowing the ligament to heal in position that does not negatively impact on healing. Current treatment regimens include dorsal block splinting (DBS) in 30° of flexion, which maintains the PIPJ in flexion in order to prevent any strain on the healing tissue while attempting to restore anatomical position. Recognized complications of DBS are flexion deformities of the joint and hyperextensibility. We propose that DBS in neutral position, rather than 30° flexion, reduces hyperextensibility as well as preventing flexion deformities of the PIPJ, allowing sooner return of function and participation in daily activities. A retrospective review of patients sustaining volar plate injuries was undertaken. Inclusion criteria involved patients splinted at either 30° or neutral position, both those having undergone surgical or conservative regimens and the joint assessed as stable. Data were collected focusing on the number of hand therapy sessions, the time from injury to discharge, active angles of flexion and extension of the PIPJ, and pain. Over 2 years, 125 patients were treated for volar plate injuries: 20 with DBS at neutral position and 105 DBS at 30°. There were no significant differences in patient demographics. There were fewer hand therapy appointments required for those splinted in neutral position and weeks of hand therapy predischarge. There were no flexion deformities for patients undergoing DBS at neutral position, but no difference in PIPJ extension. There were no differences in hyperextensibility or pain. Dorsal block splinting at neutral position results in fewer flexion deformities following volar plate injuries of the PIPJ, without resultant hyperextensibility. There are fewer demands on hand therapy. Dorsal block splinting at neutral position may result in better function for patients suffering this injury, with decreased complications and quicker return to daily activities.

Surgery and Rehabilitation Following Flexor Tendon Zone II Injury Of The Hand: A Literature Review

Background : Flexor tendon injury of the hand is common and it used to end up with poor outcomes. It gives negative effects to patient’s daily life. Successful treatment for these cases is a challenge for surgeons. Before 1967, Injury in Zone II was called as “No Man’s Land”. Flexor tendon repair and rehabilitation have been substantially improved through advances in repair and rehabilitation. Method : We reviewed literatures from PubMed, MEDLINE, Cochrane and Google Scholar. It was researched using the terms flexor tendon zone II injury, flexor tendon zone II repair and flexor tendon zone II rehabilitation. Topics covered included anatomy, suture repair and material, and rehabilitation. Result : There is no significant difference of rupture rates and functional outcomes in the number of core suture. Braided polyester suture is the choice for core suture and monofilament for peripheral suture. There is no significant difference in rehabilitation using early passive motion or early active motion. The preference for post operative treatment is by using short splint without immobilization of the wrist. Discussion : Repair sutures techniques and suture materials have been improved as well as active mobilization rehabilitation protocols including a change of wrist position by modification of splints. Improvement in putting splint from a traditional dorsal blocking splint into splint that not immobilize the wrist. Despite all of these modifications, tendon ruptures have not been eliminated. The definitive answer remains elusive.

Flexor tendon repairs in children: Outcomes from a specialist tertiary centre

We evaluate the functional outcomes of early active mobilization (EAM) after paediatric flexor tendon repair at one centre from 2006 to 2013. A generic rehabilitation protocol was used for the first four to six weeks: boxing glove immobilization (<5 years), dorsal blocking splint and cage (5-10 years) or dorsal blocking splint±cage (10-16 years). Outcomes were assessed using the Total Active Mobilization (TAM) method of the American Society for Surgery of the Hand and original Strickland criteria (OSC). Sixty-three fingers and 99 tendons were identified, in 57 children. Thirty-five per cent (n=20) were in zone 2, 23% in zone 1, 18% in zone 5, 14% in zone 3 and 2% in zone 4. Good/excellent results were obtained in 82% by the TAM method and 79% by the OSC of those suitable for analysis (56 tendons in 44 children). The surgical approaches used varied in technique and material; a modified Kessler stitch (n=42) using prolene (n=60) represented the majority of core sutures. Epitendinous repair was employed in 76% of repairs (n=75). The median length of hand therapy follow-up was 83.5 days (IQR 43.5-143.75 days). Complications included: one rupture, one post-operative infection requiring washout and three contractures, two requiring re-operation. EAM is a practical and safe way to rehabilitate children after flexor tendon repair, without increasing ruptures or adhesions. Most children under five are managed effectively in a bulky bandage.

Open metacarpophalangeal dislocations: literature review and case report.

Open dorsal metacarpophalangeal joint dislocations are rare. We report the case of a 62-year-old man who fell from a height of 10m onto his left outstretched hand and presented to us with four open dorsal metacarpophalangeal joint dislocations. We review the literature and present our case to elucidate the best treatment protocol for open dorsal metacarpophalangeal joint dislocations. A systematic review was conducted using MEDLINE, Embase, and PubMed from 1946 to present. Publications were found using key terms and cross-referencing. Detail on patient demographic, presentation, mechanism of injury, injury management, and outcome were collected. A total of 102 articles of metacarpophalangeal joint dislocation (excluding thumb dislocations) were identified. Of these, only four were of open dorsal metacarpophalangeal joint dislocation involving the four long fingers. Open dislocation of the metacarpophalangeal joint in these studies showed no hand predominance, nor association with hand dominance. Open dorsal metacarpophalangeal joint dislocations of the four long fingers are unusual. Based on the available case reports and our experience, we suggest addressing this injury intraoperatively with minimal delay. Most cases will be associated with volar plate injury, and we encourage its repair with figure-of-eight stitches. Postoperatively, we suggest a dorsal blocking splint for 2weeks followed by occupational therapy consisting of passive and active range of motion (ROM) exercises and adjunctive therapies to control edema and optimize scar tissue. Inadequate management of such injuries could be highly detrimental to hand function.

Zone 2 lacerations of both flexor tendons of all fingers in the same patient

Over an eight-year period, the author has treated five males (mean age of 31 years) with clean-cut zone 2 lacerations of both flexor tendons of all fingers using the same surgical technique (profundus only repair using three 'figure of eight' core sutures and proximal venting of the pulley system) and the same postoperative mobilization programme (a dorsal blocking splint with immediate active motion that allowed full extension at the interphalangeal joints). There were no ruptures of the repaired 20 fingers. At final follow-up (mean of 22 months after surgery), the outcome was considered excellent in 12 fingers, good in four fingers and fair in the remaining four fingers by the Strickland-Glogovac criteria. The outcome was similar in all four fingers for every patient supporting the hypothesis of previous studies that the outcome of repair of clean-cut flexor tendon lacerations in zone 2 is related to the psychological and biologic characteristics of the patient.

CLINICAL RESULTS OF EARLY ACTIVE MOBILISATION AFTER FLEXOR TENDON REPAIR

Between 2005 and 2006, ten patients with flexor digitorum profundus zone II injuries were included. The mean age was 41 (19-84) years. One thumb, two index, four middle, one ring and two little fingers were injured. Repair method comprised four-strand core suture and 6-0 circumferential sutures. Post-operative rehabilitation included immediate active extension, progressive passive full flexion and active hold in dorsal block splint. Follow-up was four (three to seven) months. Grip strength, pinch strength, ROM was 90% (70%-90%), 90% (60%-110%) and 90% (80%-100%) of normal digit, respectively. Mayo wrist scores were five excellent, two good and three fair. All patients were satisfied. Compared with another group of ten patients with the same suture method and Kleinert splintage, grip strength, pinch strength and ROM were 50%, 40% and 40% of normal side, respectively. All differences between these two groups were statistically significant (p < 0.01) by paired samples T-test. There was no re-rupture.

Dorsolaterale Dislokation des proximalen Interphalangealgelenkes: Geschlossene Reposition und frühe aktive Mobilisation oder Gipsruhigstellung

In this follow-up examination, the outcome of two conservative treatment regimens (immobilisation versus early active motion) were evaluated in 50 patients with dorsolateral dislocation of the proximal interphalangeal joint after a mean follow-up time of 7.9 years. The aim of this study was to prove whether early mobilisation results in better clinical outcome compared to prolonged immobilisation. In group A, 25 patients were treated by static splinting in a cast for four weeks. At follow-up, 21 patients were free of pain, three patients complained of pain following maximum loading and one patient experienced permanent pain. The mean range of motion was 89.4 degrees, the mean lack of extension was 12.7 degrees and the mean joint circumference was 3.4 mm thicker than the uninjured side. Pinch power was reduced to 78 % of the uninjured side. All joints were clinically stable. Degenerative arthritis was seen in five patients. In group B, 25 patients were treated by dorsal block splinting of the interphalangeal joint. The patients were allowed to extend their finger and to perform daily active exercises of the injured joint. At follow-up, eighteen patients were pain free, five experienced pain after maximum loading and two patients complained of permanent pain. The mean range of motion was 96.6 degrees, the mean limitation of extension was 5.3 degrees and the mean joint circumference was 4.1 mm thicker than on the uninjured side. Pinch power was reduced to 85 % of the uninjured side. All joints were clinically stable. Degenerative arthritis was seen in six patients. Early active motion following dorsolateral dislocation of the proximal interphalangeal joint leads to significantly superior results regarding the active range of motion and pinch power.

Early active motion flexor tendon protocol using One splint

This article describes an early active motion protocol for use after a four-strand flexor tendon repair. The protocol uses a simple dorsal blocking splint with the wrist in neutral and four fingers in rubber band traction for the first five weeks, then gradually advances the patient over the next seven weeks. The patient is able to perform the exercises without changing the splint at home during the first five weeks of the protocol. The results of the retrospective chart review are promising. Of 40 digits, 95% experienced excellent and good results in zone II, and 87.5% experienced excellent and good results in zones I, II, and III. One rupture (2.5%) occurred in a noncompliant patient. The DASH scale was used to determine functional outcome, with results of 7.82 on the physical function/symptoms category, 16.07 in sports/performing arts, and 10.23 in the work category.

Adding a Barrel to a Dorsal Block Splint to Improve Metacarpophalangeal Joint Flexion in the Pediatric Burned Hand

Adding a Barrel to a Dorsal Block Splint to Improve Metacarpophalangeal Joint Flexion in the Pediatric Burned Hand

Early passive mobilization after digital nerve repair and grafting in a fresh cadaver.

In the clinical management of combined tendon and nerve injuries, there are competing treatment strategies. Isolated tendon injuries should be rapidly mobilized after repair to prevent adhesion formation, whereas isolated nerve repairs are usually immobilized to prevent disruption and to allow axon regrowth. Recommendations in the published literature for the management of combined tendon and nerve injuries are vague and advise up to 3 weeks of immobilization. The goals of this study were to determine which length of nerve gap resulted in rupture of a repair following postoperative mobilization with the modified Duran protocol and with unrestricted motion and to determine whether nerve grafts are at risk of rupture after mobilization. A total of 100 digital nerves from 10 cadaver hands were tested with the modified Duran and the unsplinted protocols. Each digital nerve on each hand was sequentially resected and repaired at five progressively larger gap lengths after testing with both protocols. The mean nerve gaps at which disruption occurred were significantly different between the splinted (9.7 +/- 0.8 mm, n = 100) and unsplinted (7.3 +/- 1.9 mm, n = 100) protocols (t test, p < 0.001). One hundred percent of repairs remained intact, with up to 5 mm of resection with the modified Duran protocol (n = 100) and with up to 2.5 mm of resection with the unsplinted protocol (n = 100). All nerve grafts remained intact after mobilization within a dorsal-blocking splint (n = 100). Considering mechanical integrity of the nerve repair only, these data suggest that early mobilization with tendon protocols may be considered after a nerve injury to avoid the detrimental tendon sequelae that result from immobilization. The adequacy of functional recovery of mobilized nerves is yet to be determined.

An evaluation of early motion management following primary flexor tendon repair: Zones 1–3

This study examined consecutive clinic charts for 95 patients with primary or delayed primary repair of traumatically severed flexor superficialis or profundus tendons without concomitant fractures or joint trauma, in digits 2–5, zones 1–3. Patient traits, wound characteristics, surgical variables, therapeutic programs, and intervention outcomes including rupture, need for tenolysis, and total active motion (TAM) were examined. The study included 117 injured fingers and 174 lacerated tendons. The average number of therapy visits was 8.6. The dorsal blocking splint was almost universally used in conjunction with a modified Duran approach. Outcomes of intervention included the following: 7% of patients required follow-up tenolysis; 4% of repaired tendons ruptured; mean TAM at discharge was 217°. Mann-Whitney U and one-way analysis of variance tests indicated that discharge TAM for injuries involving both tendons in a finger and injuries occurring in zone 2 were significantly lower than TAM for injuries involving only the profundus or occurring in zone 1. Pearson correlation identified independent variables that correlated with TAM. Further investigation of the effects of wound and intervention variables on outcome is warranted.