Lancashire Teaching Hospitals NHS

NHS Foundation Trust

Hand Therapy Guidelines

Extensor Tendon Repair – Fingers Zones IV-VII

Norwich Regime

Adults and children with repairs of >50% division to EI, EDC, EDM. Less than 50%
division at surgeon’s request

Post-op
Bulky dressing and POP applied in theatre: wrist 45˚ extension, MCP’s 50˚ flexion,
IP’s full extension
Advise to elevate affected limb given by day-case nursing staff.
Appointment made by nursing staff for therapy-led dressing clinic (TLDC) 5-7 days
post surgery.

1 Week
Appointment in TLDC
Wound review and light dressing application
Volar hand/wrist thermoplastic splint manufactured. ( Wrist 45°, MCP 50° flexion, IP’s 0°
extension).
Splint to remain in place continuously
Encourage active movement of thumb and elbow

Norwich exercise regime commenced:

Undo the top strap of splint, wrist to remain resting on the splint whilst exercising.
 Combined active MCP & IP extension from the splint. Gently lower back to
splint.
 If no extension lag present at the MCP joint, then actively flex the IP joints
whilst maintaining MCP extension.
 If lag present then restrict movement to first exercise only (MCPJ &IPJ
extension)
 Repeat 4 reps 4 x per day (i.e. breakfast, lunchtime, dinner, supper)

2 Weeks
Wound review in TLDC and removal of sutures if required
Once wound is healed commence scar massage and provide written information
Consider ultrasound if scar adhesion evident
Check splint fit and remould if necessary to achieve desired position
Advise patient re safe removal of strapping/splint for hygiene / scar massage
Check exercise regime and progress IP flexion if no lag present
Check plastics ESP appointment booked at week 4-6

Updated Jan 2018 Review Jan 2020

 Lancashire Teaching Hospitals NHS
NHS Foundation Trust

End of Week 4
Plastics ESP clinic or hand therapy dept. if ESP unavailable
Check MCP/IP active extension exercise. If able to achieve full ext (<30˚ lag) then
advise patient to remove splint in the day but continue with splint at night and for
protection for further 2 weeks
If a lag of > 30° is present at this stage then remould splint to increase MCP
extension to 30°. Continue above exercises with unlimited frequency.

If splint is able to be removed during the daytime then progress active wrist and
finger ROM exercises and provide with written exercise sheet.
Commence light functional activities
Continue scar management

Week 6
ESP clinic if not seen at week 4
Discard splint
Continue AROM exercises
Commence passive isolated IP joint flexion if required
Carpal mobilisation in cases of stiffness

Week 8
Commence gentle passive wrist flexion if necessary
Start to increase strength exercises
Commence moderate functional demand activities including driving if safe to do so

Week 10
No further restrictions
Return to contact sports and heavy manual work

Outcomes Measure
AROM 4/52, 6/52, 12/52
Grip Strength 10/52
Quick DASH on discharge
Friends & Family Test on discharge

Complications
Tendon rupture
Wound infection
Wrist /digit stiffness
Tendon adhesion
Problematic scarring

Reference:
Sylaidis P, Youatt M, Logan A (1997) Early Active Mobilisation for Extensor Tendon Injuries. The
Norwich Regime. J.Hand Surgery (British and European Vol 22B:5:594-596

Updated Jan 2018 Review Jan 2020