January 30, 2021

Patient presented with Zone 2 FDS/FDP and digital nerve repair of the left index finger. 2 strand repair was performed

Patient presented to the clinic in a half cast with wrist and fingers in extension. Patient was performing normal ROM exercises and not taking precautions for flexor tendon

Patient was fitted with a dorsal blocking splint with wrist in neutral to 10 deg flexion, MCPs at 60 deg and IPs extended and instruction were provided to perform exercises in the splint and avoid composite extension or full active or resistive flexion of the finger.

When i saw her for the 2nd visit i determined that the tendon was ruptured, but on her visit to the surgeon, he didnt want to acknowledge that and wanted to continue with therapy.

The patient always complained of burning sensation in the finger. Patient had developed this habit of hooking the middle finger behind the index finger when performing partial active motion after passive ROM. Instructions were given to perform edema management, passive ROM followed by partial active ROM of the finger. Patient was educated in checking the cascade of the hand after passive ROM.

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But pretty soon it was evident that the tendon had ruptured with a palpable nodule present at A1 of the index finger.

After a second opinion and MRI it revealed that the tendons were ruptured along with the nerve and the patient needed a second surgery

2nd surgery included FDP repair, FDS one slip repaired along with digital nerve.

Every visits included checking the cascade of the hand after passive ROM. Which followed the partial active ROM. Checking the cascade ensured the tendon viability.

We also used pulley to help with shoulder, elbow motion and assist in reducing swelling. Precautions were taken to avoid any gripping or extension of the wrist and fingers by strapping the pulley to the wrist.

Patient was educated to initiate the partial active motion from the tip of the finger instead of using FDS or intrinsic plus motion.

Partial active motion was tabulated every visits to ensure improvement

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Patient was making steady progress as evident from these pictures.

Progress at 8 weeks s/p second surgery.

We slowly started to release the restrictions from 8 weeks onwards and finally released all restrictions at 12 weeks

She did have difficulty fully extending the finger at the MCP joint and slightly at the PIP joint

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At 10 weeks patient ruptured the one slip of FDS that was repaired partly since the tendon was repaired in tension

The first day when all the restrictions were released patient ruptured FDP as well, trying to blow dry her hair.

Then the question was whether it was worth doing another surgery to restore the tendon or if the patient can live without FDS/ P of the left index finger. Patient stated that she needed the finger to type as it was her means of living as an administrative assistant.

She was then referred to a 3rd surgeon who decided to do a 2 stage tendon repair

Goals after the 1st stage was to soften the scar tissue and improve passive ROM.

Once passive ROM was achieved then the 2nd stage was scheduled. Tendon graft was used to replace the hunter rod and secured with a button. A side to side repair was done at the level of the wrist.

The tendon rehab started again with edema / scar management, PROM followed by Partial AROM, checking cascade.

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Well despite our best efforts, patient developed scar tissue at the wrist level and restricted tendon gliding at around 6 weeks.

She underwent another tenolysis at 6 weeks and then within 2 weeks she was stuck again.

This time we decided that she needs to take it slow and it may be the swelling from too much exercising (patient was very diligent about her exercises)

We reduced her frequency of exercises along with frequency of her visits in therapy and buddy taped her fingers to keep the passive motion going.

Monthly upgrades were done to her exercise routine.

The surgeon finally sent her results after almost a year after the 5th surgery.

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So, moral of the story, persistence pays off. Keep working, change the plan as needed based on the symptoms presented. And despite your best efforts things will go wrong so be ready to accept the results as well.

The hardest part is after all that work when it ruptures, consoling the patient is the hardest thing to do.

Saba Kamal, OTR, CHT