8.7 Rehabilitation after extensor tendon repair The dorsal tendon of the hand is superficial, has a high injury rate, and is prone to adhesions to bone. The extensor tendon is weaker than the flexor tendon and is easily overstretched at the start of activity; therefore, care must be taken to protect it during the first week of activity. The extensor tendon is flat, thin, broad, and more prone to rupture. The extension tendon has less sliding range than the flexor tendon and, therefore, has less compensatory capacity in terms of length. Changes in length or adhesions of the extensor tendon can influence the transmission and thus alter the range of motion of the joint. A laceration (2 mm) at the site of extension tendon repair may produce a 40° extension restriction distal to the tendon injury. In addition, each joint extensor tendon has a bony connection, so the extensor tendon has little to no ability to regulate itself. Once the bony ligaments of the extensor tendon are altered, serious problems can arise. It has been clinically observed that the percentage loss of finger flexion is greater than the percentage loss of finger extension, and that the average loss of finger flexion is greater than the average loss of extension angle. Traditionally, extension tendons are treated with immobilization after surgery. Recent studies have demonstrated that early flexion activity within a controlled range after extension tendon repair (zones IV-VII) helps to reshape the scar tissue, allowing greater mobility of the tendon and also prevents adhesions after extension tendon repair using a palmar splint to immobilize the wrist joint in 30° to 40° extension position while stretching all interphalangeal joints with a rubber band. A palmar splint is also used to prevent flexion of the MP joint. The patient was instructed to actively flex the fingers within the splint and to rely on elastic traction to passively extend the fingers. 8.7.1 1 to 3 weeks postoperatively Practice active finger flexion and passive finger extension within the control of the splint. Passive finger flexion and active finger extension are prohibited. 8.7.2 After 3 weeks postoperatively, remove the palmar splint and instruct the patient to continue active finger flexion exercises; continue passive finger extension exercises with elastic traction. 8.7.3 After 6 weeks postoperatively, the splint was removed and active finger extension exercises, including tendon sliding exercises, were started. 8.7.4 At 7 weeks postoperatively, resistance exercises are started. 8.7.5 Postoperative complications of extensor tendon repair Severe dorsal swelling, limited extension, and tightness of the extrinsic muscles. Management of edema: refer to the section on edema control techniques; management of extension restriction: scar release techniques, individual tendon extension exercises, splinting at night; management of extrinsic muscle contracture: loosening and softening of scar tissue, massage, ultrasound and audio therapy, flexion-type power splint traction, etc. 8.8 Hammer finger deformity (Zone I and II injury) 8.8.1 Conservative treatment Splint fixation of DIP joint in 0° to 15° hyperextension position for 6 weeks. If there is no extension restriction at 6 weeks, the splint can be removed and active fist clenching exercises can be started. If DIP joint extension is restricted, splinting continues for 2 weeks. 8.8.2 Exercise method Active fist clenching and extension of the MP joint and flexion of the IP joint (controlled flexion within 25°) are started at week 6; the PIP joint is fixed and active DIP extension is practiced; active DIP flexion is practiced at week 7-8 (after fixation of the PIP joint). If there is no limitation of extension, DIP flexion can be increased to 35°. at 8 to 9 weeks, passive flexion of the DIP joint is started. 8.9 Button-shaped deformity (Zone III) 8.9.1 Conservative treatment Splinting is performed for 4 weeks to maintain the PIP joint in a straight position. the DIP joint is not fixed. The patient is instructed to actively flex and extend the DIP joint to prevent DIP contracture, and the splint is removed after 4 weeks. If there is limited extension, the splint is extended for 4 weeks. 8.9.2 Exercise method Active and passive movement of the MP and DIP joints for 1 to 8 weeks. Gradually increase passive flexion of the DIP with the aim of stretching the oblique fasciculus support ligament; in week 8, gentle active and passive flexion of the PIP joint (with the use of a parallel finger sleeve, using flexion of the adjacent finger to assist in the flexion and extension of the injured finger); in weeks 10-12, focus on restoring flexion. flexion and extension exercises of the PIP joint. 8.10 Rehabilitation of gooseneck deformity PIP joint hyperextension, DIP joint flexion deformity. Maintain a posture opposite to the deformity with mild flexion of the PIP joint to prevent hyperextension. Also allow full flexion of the interphalangeal joint.8 Rehabilitation after tendon repair 8.1 Rehabilitation program after flexor tendon repair Hand function is based on the biomechanical balance of the extensor, flexor, and intrinsic muscles, and injury to any one tendon can affect this balance. The flexor tendons of the hand are divided into five zones. Traditionally zone II flexor tendon injuries are the most difficult to manage, and are particularly prone to adhesions because the superficial and deep finger flexor tendons are in the same tendon sheath. The theory behind flexor tendon repair is early activity, with particular emphasis on the importance of early activity after zone II repair. This recommendation was first made by Kleinert and Duran/Houser. After surgery, the injured hand is immobilized with a dorsal plaster brace or a splint made of low-temperature thermoplastic material, maintaining the wrist in 20° to 30° flexion, the MP joint in 45° to 60° flexion, and the interphalangeal joint allowed in the straight position. One end of the rubber band was fixed to the nail with adhesive, and its other end was fixed to the dressing on the flexor side of the forearm with a pin after passing through the slide of the palm. Early activity was started 1 to 2 d after surgery, using rubber band traction to passively flex the interphalangeal joint. Active extension of the interphalangeal joint was performed within the splinting range, and active flexion of the interphalangeal joint and passive extension of the interphalangeal joint were prohibited during this period. To prevent PIP joint flexion contracture, the PIP joint should be maintained in full extension. The PIP is immobilized with rubber bands between exercises and at night, and is kept in a straight position in a splint. From the beginning of the procedure until 4 weeks, passive flexion/extension exercises of individual fingers are performed in the splint. At week 4, active flexion of the injured finger was allowed. For example, good flexor tendon glide (joint flexion ROM > 75% of normal) indicates a mild post-repair scar and requires continued splinting for 1.5 weeks. If there is little tendon glide, which indicates heavy post-operative scar adhesions, the splint is removed and active motion exercises are performed. This includes exercises for individual fingers, superficial and deep finger flexion tendons, hooking fingers, and making fists. (Figure 35) Figure 35 Sliding exercises for superficial and deep finger flexor tendons 8.1.1 Exercises for superficial finger flexor tendons alone Maintain the MP joint in extension, fix the proximal end of the PIP joint, and ask the patient to actively flex the PIP joint while keeping the DIP joint in extension. 8.1.2 Exercises for deep finger flexor tendons alone Maintain the MP and PIP joints in extension, fix the proximal end of the DIP joint, and ask the patient to actively flex the DIP joint. 8.1.3 Hook fist exercise method The PIP and DIP joints are flexed while the MP is straightened, thus ensuring maximum range of motion of the superficial and deep finger flexor tendons. 8.1.4 Right angle grip exercise The MP and PIP joints are flexed while the DIP is kept straight. This exercise allows for maximum range of motion of the superficial finger flexor tendons. 8.1.5 Compound grip exercise Flexion of the MP, PIP, and DIP joints with maximum glide of the superficial and deep finger flexor tendons. Mild functional activity at week 6 postoperatively. If PIP joint flexion contracture is present, finger traction splints may be used. At postoperative week 7, resistance exercises, e.g., sponge ball and plastic therapy clay exercises of varying strength to maintain hand grip. In the 8th postoperative week, intensive resistance exercises to enhance muscle strength and endurance. Active activities at postoperative week 12. 8.2 Postoperative rehabilitation after first-stage flexor tendon grafting (Zone II) Postoperative immobilization in the flexor wrist position with a dorsal plaster brace or Kleinert traction splint for 4 weeks. Active finger extension and passive finger flexion exercises were performed within the control of the splint. To prevent interphalangeal joint stiffness, train DIP and PIP joint flexion, respectively. 4 to 6 weeks: active practice exercises. 7 weeks: resistance exercises. 8 to 9 weeks: passive distraction exercises or distraction splinting to improve the range of motion of IP joint extension. For specific exercises, refer to rehabilitation after flexor tendon repair.8.3 Second-stage flexor tendon reconstruction rehabilitation.7.3.1 Phase 1 A silicone strip is implanted with its distal end fixed to the bone or distal tendon, allowing the silicone strip to slide over the palm or forearm. Purpose: to form a pseudo-sheath around the silicone strip.7.3.2 Phase 2 After approximately 3 months, the silicone strip is removed and the graft tendon is implanted. Rehabilitation: use a dorsal plaster brace (or plastic splint) to maintain the wrist, MCP, PIP, and DIP joints. After the 3rd week, remove the splint and continue passive movement exercises, possibly using a juxtaposition finger sleeve, using the healthy finger to assist with movement. Functional activities were started. Purpose: To reduce edema, improve passive joint mobility and prevent infection. The rehabilitation program is similar to that of a phase I tendon repair. Objective: To reduce edema, reduce adhesions, promote tendon gliding, and prevent interphalangeal joint contracture. 8.4 Rehabilitation after flexor tendon and median nerve repair Postoperative fixation with a dorsal plaster brace or Kleinert traction splint for flexion of the wrist, maintaining 45° flexion of the wrist, 40° flexion of the MP joint, extension of the IP joint, and 90° flexion of the elbow. 8.4.1 1 1-3 weeks Exercise principles Active Extension of fingers, passive flexion of fingers, no active movement of the wrist joint. (exercise within the control of the splint), several times per d, gradually increasing the number of exercises; start to extend the IP joint on the 2nd postoperative day; in the MP and PIP flexion position, gently and passively move the DIP joint; in the MP flexion position, passively and completely straighten the PIP joint; in the MP flexion 90° position, passively flex and extend the IP joint. 8.4.2 4-6 weeks Adjust the dorsal plaster rest, maintain the wrist joint in 0° extension position 8.4.3 Week 5 Slow wrist movement, wrist extension in flexion and wrist extension in flexion, but not wrist extension and finger extension at the same time, and not excessive stretching of the nerve suture; 8.4.4 Week 6 Plaster brace or splint may be applied. 8.4.5 Week 7 to 8 Active flexion/extension exercises. Resistance exercises for flexion and extension graded from small to large. 8.4.6 Week 9 Running and sensory retraining. 8.5 Rehabilitation program before and after tendon transposition surgery 8.5.1 Preoperative preparation for tendon transposition No inflammation of the soft tissue of the skin, no obvious scar tissue in the tendon repair area, good skin re-covering; passive ROM of the joint can meet the functional needs and exercises for range of motion of the joint; muscle strength training of the selected power muscle 8.5 .2 Postoperative rehabilitation 8.5.2.1 Postoperative fixation period (three weeks for flexor tendons and six weeks for extensor tendons) Elevate the affected limb and control edema. 8.5.2.2 After removal of external fixation, retrain the displaced muscles. 8.6 Post-tendon release rehabilitation In order to achieve the desired goal of tendon release, firstly, the joint should be moved as much as possible before surgery, and secondly, the tendon should be completely released during surgery. 8.6.1 Starting 24 hours after release, remove the dressing and the patient should practice active flexion and extension. The exercises include The exercises include: finger flexion superficial and deep tendon sliding alone, hooked fingers, fist clenching, right angle fist clenching, etc. Active + assisted movement of the MP, PIP and DIP joints to maximize flexion and extension. 8.6.2 Symptomatic management Pain and edema are the most important impediments to exercise and must be treated symptomatically, refer to the section on rehabilitation techniques. 8.6.3 Removal of stitches 2 weeks after surgery. Softening release scar management. If there is no tendon slippage after the release, functional stimulation can be given 48 h after surgery. 8.6.4 Functional mobility exercises 2 to 3 weeks after surgery. 8.6.5 Resistance exercises are started 6 weeks after surgery. If the contracture of the PIP joint has been corrected after tendon release, an extension splint can be used postoperatively to maintain the straightness obtained during surgery. For a few days after the release, exercises are performed several times a day with about 10 strokes each time, and then the number and intensity of activities are gradually increased.