Evaluation of modified Kleinert's Traction Early Mobilisation Regimen for Flexor Tendon Injuries in Zone V

INTRODUCTION: “One of the most baffling problems in hand surgery is to restore normal function to a finger in which the tendons have been injured” – wrote Sterling Bunnell in his classic book on Surgery of the Hand. Sixty years hence, there has been much improvement in the management of tendon injuries and is an evolving field of hand surgery. There is now an emphasis on primary tendon repair and early mobilization for optimal results whenever possible. The early mobilisation protocols for rehabilitation after flexor tendon repair have been evolved by better understanding of biomechanics and healing potential of tendons. Flexor tendon injuries occur mostly in young individuals in the prime of their lives, resulting in significant socioeconomic impact. Hence restoration of a functional hand after flexor tendon repair by the plastic surgeon is of paramount importance to the patients. AIM OF STUDY: This study is done to evaluate the functional outcome of Modified Kleinert’s Rubber band traction as early mobilisation regime following flexor tendon repairs in Zone V in our setup in terms of : Digital range of motion. Differential digital tendon excursion. MATERIALS AND METHODS: The study was conducted in Dept. of Plastic and Reconstructive Surgery, Madras Medical College and Govt. General Hospital from July 2003 to August 2005 . A total of 20 patients (18 male, 2 female) were included in the study. Inclusion Criteria Adult patients with flexor tendon injuries in Zone V. Exclusion Criteria Children with flexor tendon injuries in Zone V. Patients with flexor tendon injuries in multiple zones. Patients with flexor tendon injuries with concomitant bony injuries and skin loss. Patients with both flexor and extensor tendon injuries. METHODS: All patients were operated under suitable anaesthesia - axillary (or) supraclavicular blocks (or) general anaesthesia. 2 cases of secondary repair were referred to us after skin suturing elsewhere and 1 case had primary management for head injury and hence primary tendon repair was deferred. A total of 120 tendons were repaired which included, 1) 58 flexor digitorum superficialis, 2) 52 flexor digitorum profundus, 3) 10 flexor pollicis longus. RESULTS: 17 patients who had primary tendon repair were followed up for a mean period of 5 months and 3 patients of early secondary tenorrhaphy were followed up for a mean period of 10 months. All the results were graded at 12 weeks after injury and thereafter. Of the 17 patients with primary tenorrhaphy, digital flexion was graded excellent in 7 patients, good in 7 patient, fair in 3 patients. Thumb flexion was graded excellent in 8 patients and good in 2 patients. Of 3 patients with early secondary tenorrhaphy, digital function was graded excellent in 2 patients and fair in 1 patient. Totally digital flexion function was excellent in 45% / Good in 35% / Fair in 20%. There were no tendon ruptures in our study during the period of follow-up. Flexion contracture of DIP joint was encountered in 1 patient which was picked up early and treated with passive stretching exercises and night splints. Tenolysis was required in 2 patients out of 20. There was independent FDP and FDS actions in 9 out of 20 patients. In one patient (Group I injury) who showed good range of motion even after 8th week, restrictive exercises were delayed by 2 weeks for fear of late tendon rupture as suggested by Schneider. The patient faired well without any complications on further follow-up. In a patient who had only fair range of movement after early secondary tendon repair, in which there was extension deficit due to flexor tendon shortening, he was advised dynamic extension out trigger splint but he lost follow up afterwards. CONCLUSION: Improved understanding of the physiologic benefits of early active tension at a tendon repair site over passive motion and immobilisation, the development of stronger suture repair techniques and improvements in post operative management techniques have led to an increased acceptance of early mobilisation in management of repaired flexor tendons. With a simple and cost effective modified Kleinert’s rubber band traction early mobilisation protocol we have achieved satisfactory results for repaired digital flexor tendon in Zone V in the selected group of patients in our setup. Nevertheless the overall hand function after such volar wrist lacerations after primary repair of injured structures depends on success of nerve repairs even though the range of motion of repaired tendons is satisfactory