Thumb flexor tendon repair

Who is the leaflet for? What is its aim?

This leaflet is for people who have had surgery to repair a flexor tendon to their thumb. It will explain what a flexor tendon is, how to protect the repair and what treatments will be required as part of hand therapy.

What are flexor tendons?

Flexor tendons are cords of tissue that connect the large muscles on the front of your forearm to the bones of your hand. They allow you to bend your fingers / thumb / wrist.

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

If you damage a flexor tendon you will be unable to bend one or more fingers or your thumb. Surgical repair of the tendon 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, are the only things holding the repair together. You need to follow the advice in this leaflet to protect the repair.

The repaired tendon will be very fragile until the ends heal together. It can take up to three 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 to mend it.

What can you expect immediately following surgery?

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

You might experience some discomfort or pain following surgery and it is important to take regular pain relief as required.

What to expect at your first appointment?

Your first appointment will last an 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 six 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 experience more comfortable.

Splint care (once you have been fitted with a thermoplastic splint)

Do not place the splint in hot water or near a heater or it will 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 problem occurs.

If your splint becomes too loose or too tight please contact your hand therapist.

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

Exercise (including uninvolved joints) – why it is important

Exercise is important to help your recovery. It will reduce stiffness and swelling in the hand and thumb and help to prevent complications. Your therapist will teach you specific exercises which you must complete throughout the day – normally four repetitions, every two hours initially. Too much or too little exercise can cause problems including risk of rupture or adhesions to your repaired tendons, so please follow the exercise programme as advised by your therapist.

Why is it important to look after your wound and scar?

Wound care

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 and dry, which is approximately 10 to 14 days following surgery.

Scar care

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 they 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 the scar and make it softer as well as reducing the chance of scar tissue sticking (adhesions).

When can I start my scar care?

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

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

You will need a basic, un-perfumed moisturising cream, such as aqueous cream or ‘E45 cream’, which is ideal for massaging 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). Be careful not to damage your tendons.

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. 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.

Time frames for resuming activities

Depending upon your job we would advise:

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” or sick note, please contact your GP.

Potential signs of infection or possible rupture and what to do

If you notice that your hand feels hot to the touch, is red, has an unpleasant smell or you have increased pain, this may be a sign of an infection. You should contact the plastic surgery unit on: 01223 348507 (Monday to Friday 08:30 to 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 thumb’s ability to move, this may suggest the tendons have ruptured. You should contact the plastic surgery unit on: 01223 348507 (Monday to Friday 08:30 to 16:30), or the hand therapy department on 01223 216769 (Monday to Friday 08:30 to 16:30) or your local emergency department if out of hours.

Thumb flexor 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 to week 4

Passive thumb flexion

Keeping your injured hand relaxed, use your other hand to push the thumb towards the crease of the palm, ensuring the top joint is bending forwards as much as possible as comfort allows. In the first two or three weeks, aim to bend in line as far as the middle finger. Hold for 5 seconds then let the thumb relax back up to the splint (but do not use your other hand to force it straight). You should be aiming to reach a full passive bend by the end of the fourth week after the operation.

Complete . . . . . . repetitions every . . . . . . . hours.

Active thumb flexion

Starting with your thumb against the splint, bend the top joint of your injured thumb and then actively bend towards the palm, bending inline as far as the middle finger. Do not aim to bend as far as the base of the little finger in the first three to four weeks. Do not force the movement; go as far as you can comfortably. Hold this position actively for five seconds, then straighten your thumb to the back of the splint without using your other hand.

Complete . . . . . . repetitions every . . . . . hours.

Protected extension within the splint

Try to straighten the top joint of your affected thumb within the splint, so the nail touches the back of the splint. Hold for 5 seconds, then relax.

Complete . . . . . repetitions every . . . . . hours.

Contacts/further information

The occupational therapy department is located in clinic 30 in the Addenbrooke’s Treatment Centre (ATC). The occupational therapy reception telephone number is: 01223 216769.

References/sources of evidence

NICE clinical guideline No 74: Surgical site infection (October 2008); Department of Health: High Impact Intervention No 4: Care bundle to preventing surgical site infection (August 2007)

Standards of Hand Therapy Practice in the Rehabilitation of Flexor tendon Injures’ published by BAHT in 2015.

Privacy and dignity

Same sex bays and bathrooms are offered in all wards except critical care and theatre recovery areas where the use of high-tech equipment and/or specialist one to one care is required.