7. Conclusion

• The new splint allows for passive flexion of the digits and active extension of the digits against dynamic traction using rubber bands to facilitate the traction mechanism. These bands are placed on the volar aspect of the splint and directed towards the distal nail plate from just proximal to the wrist.

• At 1 month, the splint is removed, and active flexion and extension exercises begin. However, the dorsal splint must be worn when these exercises are not

• Two months following the repair, resistive exercises are incorporated into the

• Resumption of normal activities occurs approximately 3 months following the

A major issue with the Kleinert protocol is the development of flexion contrac-

Continuous passive motion (CPM) uses devices that allow for joints to move through a predetermined arc of motion [73]. The goal is to increase the duration and repetition of exercises. A randomised control comparing traditional early passive motion to CPM exercises [88] showed that, at 6 months, the CPM group had significantly greater range of motion. However, further research in evaluating the

An early active mobilisation (EAM) protocol refers to active contraction of the repaired muscles [89, 90]. EAM has been shown to promote the formation of large diameter fibrils, and it demonstrates the greatest cellular response to injury [83]. There are many different EAM regimens in the literature [91, 92]. Gratton [93] combined the Belfast and Sheffield practices [89] to form a widely used regimen:

• A thermoplastic dorsal blocking splint is applied at postoperative day 2–5 with the wrist positioned in 20° of flexion, the MCP joints in 80° of flexion and the IP joints in full extension. Active ROM exercises are delayed until day 5 if there is significant oedema which should be treated with compression and elevation.

• In the absence of significant oedema, exercises begin with passive flexion of the digits and active extension to the constraints of the dorsal splint.

• At the completion of the above exercises, active flexion exercises begin. Here, a finger of the opposite hand is placed in the palm of the affected hand, and the patient flexes the affected fingers against the contralateral fingers aiming to

tures of the PIP joint [85]. These can be treated with continued intermittent splinting of the IP joints in neutral [86]. In recent years, rubber band traction has been almost completely abandoned, largely because of the problems arising from

• Early passive ROM exercises are started within the dorsal splint.

• At 6 weeks, the dorsal splint is discontinued, and blocking exercises

being performed.

commence.

Tendons

regimen.

surgical repair.

the flexed resting position of the PIP joint [87].

CPM following flexor tendon repair is lacking.

progress one finger width per week.

114

6.3 Early active mobilisation

The fine, tailored movements of the flexor tendon are essential to hand function. It is clear that the consequences of extrinsic healing of flexor tendons must be overcome to achieve optimal outcomes in patients who have injured their flexor tendons. Until the intrinsic healing process can be biologically augmented, surgical repair and rehabilitation of the injured flexor tendon will remain the mainstays of treatment. It is therefore essential that the surgeon bear in mind the basic tenets of tendon healing and the foundational principles of surgical repair.

### Acknowledgements

The author wishes to acknowledge the immense contribution to flexor tendon pathology by the researchers, scientists and clinicians cited in this chapter.

### Conflict of interest

None to declare.
