Rehabilitation following finger extensor tendon repair - Information for patients

This leaflet is for people have had surgery to repair an extensor tendon to one or more of their fingers. It will explain what an extensor tendon is, how to protect the repair and what treatments will be required as part of hand therapy.

This is the first phase of your rehabilitation following repair of your tendon(s). Once you have completed this phase your therapist will advise you on new exercises to ensure the best results.

What are extensor tendons?

Extensor tendons enable you to straighten your fingers. They attach the muscle belly, which is in the forearm, to the bones in the fingers. Your injury particularly affects the tendon that straightens the joint at the main knuckle, between your hand and fingers.

Why have they been repaired and why is it important to protect these repairs?

If you damage an extensor tendon, you will be unable to straighten one or more fingers. Surgery repairs the tendon, which aims to restore this function in the hand. The ends of the divided tendon are located and stitched together. The stitches used are thinner than a strand of hair and, for the first few weeks, they are the only things holding the repair together.

The repaired tendon will be very fragile until the ends heal together. It can take up to 3 months for the repaired tendon to regain its previous strength and during this time you will need to follow a strict hand therapy programme to maximise your recovery. There is a possibility of rupturing the repair if the correct precautions are not followed. If you do rupture the repair, further surgery would be required.

What can you expect immediately following surgery?

You will be contacted by the hand therapy team to arrange an appointment within 10 days of your surgery. It may be possible to transfer your hand therapy care closer to home after the first few appointments, depending what specialist services are available in your local area.

It is not uncommon for you to experience some discomfort/pain following surgery and it is important to take regular pain relief as required.

What to do in the few days before your first appointment?

Following the surgery it is normal for the hand to be swollen. To reduce this swelling keeping the hand elevated above your heart (for example resting on your opposite shoulder or propped up on pillows) can be beneficial.

Until you are seen in Hand Therapy, do not remove your post-surgery cast or attempt to use your hand at all. Do not attempt any of the exercises until you have seen or spoken to your Hand Therapist.

What to expect at your first appointment?

Your first appointment will last approximately one hour. Your dressings and cast will be removed and replaced with a lighter-weight thermoplastic splint. This splint needs to be worn 24 hours a day for up to 6 weeks as directed by your therapist. In most cases, you will start your exercises at your first appointment. We would recommend you eat something and take pain relief before attending your first appointment to make your appointment more comfortable.

Splint care (once the splint has been made for you)

Do not place the splint in hot water or near a heater as it can change shape.

Check your skin regularly for red/pressure areas and when you remove the splint to do this, ensure you keep the hand in the position it would be in if you still had the splint on. Contact your therapist if any problems occur.

If your splint become too loose or too tight then please contact the hand therapy department.

Use a plastic bag over the whole arm when in the bath or shower (do not take the splint off).

How should your splint be worn?

Straps should be applied firmly but not too tight. It needs to feel secure but not too tight.

Your splint is worn full-time for four weeks following surgery. After this point your hand therapist will advise you on how much you should wear it.

Why is it important to look after your wound?

To prevent infection it is important to look after the wound whilst it is healing. It should be kept clean and dry until it is healed, which is approximately 10-14 days following surgery.

Potential signs of infection or possible

If you notice that the hand feels hot to the touch, red, increased pain, or has an unpleasant smell, this may be a sign of an infection. You should contact the plastic surgery unit (PSU) on: 01223 348507 (Mon-Fri, 08.30-16.30), your local GP practice or your local emergency department if out of hours.

If you feel a popping or snapping sensation and notice any sudden pain, swelling, or a change in your fingers ability to move, this may suggest the tendons have ruptured. You should contact the plastic surgery unit (PSU) on: 01223 348507(Mon-Fri 08.30-16.30), the hand therapy department on 01223 216769 (Mon-Fri, 08.30 – 16.30) or your local accident and emergency department (A&E) if out of hours.

Why is it important to care for your scar?

Scars are collagen fibres produced as a result of the body’s normal healing process. The amount of scar tissue produced by the body varies depending on the individual and type of surgery/injury. As the wound heals there will be little scar tissue produced but over time the body may develop more.

Initially scars can be firm, thick and red in colour (active phase) but over time soften and become pale in colour (matured). This whole process may take 12 to 18 months or more.

During the “active phase” you can use treatments to influence your scar. Initially as scar tissue forms it is thick and lumpy and can stick to structures around it; scar care helps to flatten, make it softer and reduces the chance of scar tissue sticking (adhesions).

When can I start scar massage?

24-48 hours after your stitches have been removed, if the wound is healed and dry.

If you have dissolvable stitches you can start massaging your scar at approximately 12-14 days after surgery, providing the wound is healed and dry.

You will need a basic, un-perfumed moisturising cream. For example aqueous cream or ‘E45 cream’, are ideal for massaging the scars.

The scar massage needs to be in circular movements, on and around the scar line, to keep the skin moving freely. In the first few days you may only tolerate gentle massage but you should then aim to increase it to a deep and firm massage to reduce the risk of adhesions (see picture below).

Please keep your splint on when doing scar massage.

Start date: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Repeat . . . . . . . . . . times per day for approximately . . . . . . . . . . minutes, ideally before your exercises.

How can you help your recovery?

To help your recovery you should cut down or stop smoking and drinking as applicable.

Keep your hand elevated as much as practically possible to prevent swelling in your hand. Do not use your hand for anything other than your exercises until advised by your hand therapist. Do not progress to the next set of exercises unless advised by your hand therapist.

Time frames for resuming activities

It may be possible for you to return to work on light duties earlier than above as long as you are not using your injured hand, but please discuss this first with your hand therapist. If you need a “fit note”, please discuss this with your therapist or contact your GP to arrange one.

Examples of using the hand functionally

Exercises – Why are they important?

Exercise is important to benefit your recovery. It will reduce stiffness and swelling in the hand and fingers and help your tendon repair to glide in a controlled way to prevent adhesions but protect the repair from being damaged or rupturing. Your therapist will teach you the specific exercises that you must complete throughout the day.

Finger extensor tendon repair exercises

It is recommended that the exercises are done in the order outlined below. Do not begin or progress exercises unless you have been advised by your hand therapist.

Week 0 – Week 4

Undo the strap which rests across the fingers. Straighten all fingers together upwards away from the splint. Hold the position for a count of 5 seconds. Slowly relax your fingers back down into the splint.

Complete ____ repetitions every ___hours

Straighten all fingers upwards away from splint. Bend the top and middle joints of all fingers into a ‘hook’ position whilst keeping the big knuckles straight. Hold the position for a count of 5 seconds. Slowly straighten your fingers back up. After completing the exercise, you may rest your fingers back into the splint.

Complete ____ repetitions every ___hours

If you are struggling with either of these two exercises, your therapist may instruct you on the following methods in order to improve your technique;

If you cannot fully straighten your fingers then your therapist may instruct you to use your other hand to gently straighten the fingers before trying to hold them in that position with your own strength. After completing the exercise, you may rest your fingers back into the splint.

Complete ____ repetitions every ___hours

If you are struggling to bend the small joints in your fingers then try sliding your fingers up the splint to create clawed position; keeping the large knuckles (MCPJs) straight.

After completing the exercise, you may rest your fingers back into the splint.

Complete ____ repetitions every ___hours

If you are struggling to keep your large knuckles (MCPJs) straight whilst bending your IPJs your therapist may suggest using a pen as a visual guide.

Straighten your fingers up, place the pen gently at the base of your fingers and then try to bend the small joints of your fingers round the pen before straightening your fingers up again.

Complete ____ repetitions every ___hours

Week 4

Start with your fingers straight, bend at the large knuckles keeping the top joints of your fingers as straight as you can. Complete this slowly, holding the bend for a count of 5 seconds then straighten your fingers.

______ repetitions

______ times per day

Keeping the large knuckles and wrist straight, bend and straighten the top and middle joints of the fingers. Complete this slowly, holding the bend for a count of 5 seconds.

______repetitions

______times per day

Make a fist, being sure each joint bends as much as possible, Complete this slowly, holding the bend for a count of 5 seconds, then gently open your fingers to straighten them.

______repetitions

______times per day

Spread fingers wide apart and bring them together. Complete this exercise slowly holding your fingers apart for the count of 5 seconds then close together.

______repetitions

______times per day

With your hand and wrist flat on a surface, lift your fingers one at a time up as far as you can, keeping the middle and top knuckles straight (you may need to lift the little and ring fingers together)

______repetitions

______times per day

Further information

Your therapist will check your progress once a week and will adjust your therapy programme if necessary.

It is vital that you attend all therapy appointments as well as any video or phone reviews and complete you home programme as advised in order to improve your chances of a good outcome.

If you require further information please contact your occupational therapist on 01223 216769.

References

• Hirth et al (2020) Postoperative hand therapy management of zones V and VI extensor tendon repairs of the fingers: An international inquiry of current practice. Grad Dip Ergonomics, Grad Cert Clinical Research Methods Published:March 09, 2020
• Sylaidis et al (1997) Early active mobilisation for extensor tendon injuries. The Norwich regime. Journal of Hand Surgery; 22B:5: 594-596
• Sameem et al (2011) A Systematic Review of Rehabilitation Protocols after Surgical Repair of the Extensor Tendons in Zones V–VIII of the Hand. Journal of Hand Therapy. 24(4). 365-373.
• Minamikawa et al (1992) Wrist position and extensor tendon amplitude following repair. Journal of Hand Surgery; 17A: 268-271
• Ng et al. (2012) Rehabilitation Regimens Following Surgical Repair of Extensor Tendon Injuries of the Hand – A Systematic Review of Controlled Trials. Journal of Hand and Microsurgery. 4 (2): 65-73.
• Collocott SJ, Kelly E, Ellis RF(2018). Optimal early active mobilisation protocol after extensor tendon repairs in zones V and VI: A systematic review of literature. Hand Therapy;23(1):3-18
• Wong et al (2017) The optimal orthosis and motion protocol for extensor tendon injury in zones IV – VIII: A systematic review. Journal of Hand Therapy. 30 (4): 447-456.