EXTENSOR POLLICIS LONGUS

Wound care and Scar Management

 Provide wound care – keep the wound dry and clean and monitor the wound for
signs of infection [17]
 Commence scar management early to prevent adhesions [17]
 Extensor tendons lie superficially and a scar on the dorsum of the hand may
adhere quite quickly and this can restrict flexion range of motion in the fingers.
 Massage the scar and aim to keep the skin on the dorsum of the hand as mobile
as possible

Oedema control

 Control swelling of the hand [22]

 Patient should keep hand elevated to reduce and prevent swelling [22]
 Performing the active range of motion exercises prescribed within the provided
protocol will also control swelling [22]
 Compression can be applied where needed to control swelling [17]

Orthosis

Examples of extensor tendon repair splints [23]

The therapist also provides the patient with the specified splint or orthosis as well as
the exercises relative to the rehabilitation protocol provided by the surgeon or
therapist[17]

Considerations in designing an appropriate orthosis include [24]:

 joint position
 external load
 resistance to tendon glide, as determined by friction and adhesions

Patient Education

Patient education is an important part of the postoperative management of extensor

tendon injuries. It is important for patients to know the following [17]:

 To keep the wound dry and clean

 To keep the splint in place 24/7
 To perform their exercises with their splint on, unless the therapist advised them
differently
 If the splint is taken of the patient must keep their hand and forearm in the safe
position to keep the tendons on no stretch. This position is the forearm in
supination and the fingers relaxed. It is very important for patients to be aware of
this and follow this recommendation as this will reduce the risk of tendon rupture
or the extensor tendons EPL and EDC from overstretching, if they are ever out of the
splint.

Volar thermoplastic splint for EPL tendon repair [33]

Splint used[17]:

 Volar Thermoplastic splint with the wrist in slight extension and thumb held in
extension as well
 Splint comes to below the MCP joints, just through the distal palmar crease of
the hand and up to two thirds of the forearm
 Splint also comes up to the tip of the thumb – because the EPL tendon inserts at
the base of the distal phalanx and the distal phalanx should not be flexing freely
Exercises

Thumb extension with splint on [34]

Early active range of motion exercises should be started from the first
appointment [17]

Isolated IP and MCP joint flexion in splint [35]

With the splint on – the patient performs active extension

 With the splint on, but the thumb strap released, with the wrist in extension,
isolated IP joint flexion can be performed, as well as isolated MCP joint flexion.
 Only exercise that patient may perform with splint of is gradual opposition of the
thumb, BUT these exercises must be performed with the forearm in supination
 Gradual opposition of the thumb to each fingertip is performed, with progression to
a different finger tip each week. Week 1 – oppose the thumb to index finger. Week
2 – oppose the thumb to the middle finger, Week 3 – oppose the thumb to the ring
finger, etc. Until patient is able to flex the the thumb down to the proximal crease
over the MCP joint of the little finger by week 6
 Exercises remain the same until 6 weeks postoperatively
 After 6 weeks the patient can be weaned out of the splint
 Encourage patient to use hand for full range of motion and light functional activities
 Strengthening exercises are commenced at 8 weeks postoperatively if surgeon gives
clearance
 Strengthening exercises include using Theraputty for finger extension exercises –
make a little doughnut shape out of Theraputty, place around the fingers and then
actively extend the fingers.
 Another example is using the Theraputty for finger flexion exercises into a full fist –
as patients often lost grip strength as a result of the period of immobilisation [17]
Red flags that therapists need to be aware of and look out for in patients with extensor
tendon repairs in EDC zones V - VII and EPL zones II - VIII include [17]:

1. Ruptures
 This is always a concern with tendon repairs
 If a patient has ruptured the EPL – unable to extend the IP joint
 EDC rupture – unable to extend MCP joints when isolate
 Look out for ruptures during the first 6 weeks postoperatively, but especially
within the first 3 weeks postoperatively
2. Extensor Lags
 Extensor lags are often difficult to correct once it has developed, so it is key
to identify a lag as soon as possible. In a patient with a lacerated ECD tendon
and using the Merrit Protocol, who is unable to actively extend the affected
finger at the PIP joint - a volar extension splint at night or for resting is
recommended.
 If more than one finger is involved with an extensive lag at the PIP joint – a
night resting splint should be considered.
3. Infection
 Look out for any redness, pain, oozing, odorous smells around the wound
site.
 Flag any signs of infection with the surgeon.

Key Messages to Remember

1. Know your Anatomy

 This will inform treatment approach and inform your clinical reasoning.
Know which tendon was lacerated and in what zone as the treatment
protocols for the various zones differ.
2. Know the patient’s history
 This will influence your treatment of the patient. Was the tendon cleanly
cut? Was the surgery performed immediately or was there a delay? Is the
patient reliable and can the therapist trust the patient to perform their
exercises according to the protocol provided to them. Is the patient
educated about the injury and will the patient be compliant.
 It is important to come up with an appropriate treatment protocol in
conjunction with the surgeon to best treat the individual patient.
3. Be confident in your splinting skills
 Practice before you fabricate a splint for the first time, especially with the
relative motion splint in the Merrit Protocol.
  Be familiar with the degrees of the angles of the different joints that you
need to place them in.
4. Monitor patient progress
 Monitor patient progress closely and check the tendon status and look out
for extension lags
5. Know your rehabilitation protocol
 Be familiar with the selected protocol.
 Educate your patient and be a good teacher.
 Give them the confidence to manage their injury and a good outcome will be
achieved.