Background & Etiology
A tendon is part of the muscle that attaches the muscle to bone. It is a strong, fibrous tissue that is responsible for transferring the forces generated by the muscle to the bone, thus producing movement at the joint. Tendons can be cut, or lacerated. The flexor tendons in the hand are the most often damaged by a cute. Other structures in the hand, like nerves, are also located very close to the tendons, so if a tendon is cut it is likely that other structures are damaged as well.
Tendon lacerations in the wrist occur when the tendons in the forearm that pass through the wrist joint and into the hand experience a traumatic cut. Tendons in the wrist include the flexor tendons that bend the fingers and wrist (flexor digitorum profundus and superficialis, flexor pollicis longus, flexor carpi radialis and ulnaris, Palmaris longus) and the extensor tendons that extend the fingers and wrist (extensor digitorum, extensor indicis, extensor digit minimi, abductor pollicis longus, extensor pollicis brevis, extensor carpi ulnaris, extensor carpi radialis brevis and longus)
Tendon laceration is caused by a severe traumatic injury that cuts open the wrist. This can happen when any sharp object, broken glass, a knife, etc. pierces the wrist.
- An inability to bend one or more of the joints in the finger
- Pain when bending the finger
- An open injury like a cut on the palm side of the hand, particularly in the area where the skin folds as the fingers bend
- Mild swelling over the joint closest to the fingertip
- Tenderness along the effected fingers on the palm side of the hand
Early diagnosis and treatment is the key to a successful outcome for a wrist tendon laceration. If diagnosis or treatment is delayed the integrity of the healing tissue can be compromised as a result of scarring and decreased blood flow. Surgical repair followed by structured hand therapy is the treatment of choice for lacerations.
- Immediate surgical repair of the tendon is indicated in lacerations. Delaying surgery can lead to shortening of the tendon, formation of scar tissue and decreased blood flow, which can lead to a poor outcome.
- Following surgery your wrist will be put in an immobilizing device
- Over the next 2-4 weeks hand therapy will be initiated.
- The surgeon will determine the hand therapy timeline and program.
- Hand Therapy: treatment will emphasize gradual weaning off the immobilizing device, restoration of wrist and finger range of motion and strengthening of the forearm muscles. It is important that the physician and therapist communicate during the early stages and progress your program based on the principles of healing so as not to compromise the injured tendon.
- Patient will be progressed to more functional activities as normal wrist and finger range of motion and strength is restored.
Hand therapy for a tendon laceration must remain conservative at the onset in order to protect the repair. Emphasis will be on rest, tendon protection, reducing the inflammation and increasing the blood circulation for healing. Following the surgeon’s timeline and protocol, a program of progressive range of motion, stretching and strengthening will be initiated.
Hand Therapy Interventions
Hand Therapists are occupational therapists or physical therapists who through advanced study and experience specialize in treating individuals with conditions affecting the hands and upper extremity. A hand specialist may also have advanced certification as a Certified Hand Therapist (CHT). A qualified hand therapist is educated and trained to administer interventions. As stated in The Guide to Physical Therapist Practice, interventions are the skilled and purposeful use of therapy methods and techniques to produce changes consistent with the diagnosis, prognosis and goal of the patient or client. Common interventions in the treatment of Wrist Tendon Laceration include:
- Manual Therapeutic Technique (MTT): hands on care including soft tissue massage, deep friction massage, manual stretching and joint mobilization by a hand therapist to regain mobility and range of motion of the wrist and tendon.
- Wound care and physical therapy education in wound healing or care.
- Splinting: Fabrication of a custom-made splint or the fitting of a pre-fabricated splint to rest, position and stabilize the affected area to allow for healing as well as provide support during functional use of hand.
- Therapeutic Exercises (TE) including stretching and strengthening exercises to regain range of motion and strengthen the wrist and effected muscle.
- Neuromuscular Reeducation (NMR) to restore stability, retrain the upper extremity, and improve or modify movement technique and mechanics (for example, throwing, gripping, grasping, fine motor, and lifting activities) in daily use of the involved upper extremity.
- Modalities that can include the use of ultrasound, paraffin, electrical stimulation, ice, cold laser and others to decrease pain and inflammation at the wrist and tendon.
- Home program that includes strengthening, stretching and stabilization exercises and instructions/modifications to help the person perform daily tasks and advance to the next functional level.
If repair and treatment are initiated immediately, individuals with a laceration the tendons in the wrist generally do well. Delay can result in the formation of scar tissue and retraction of the tendons. Other factors that can affect recovery are:
- Age: Older individuals are generally weaker and take longer to heal affecting the functional outcome.
- Strength/Health: Individuals who are strong and in good health prior to the injury generally do better following surgical repair.
- Tissue: Tissue quality prior to the surgical repair will effect healing and recovery following surgery. Poor circulation and presence of scar tissue will interfere with the healing process.
The healing time for a tendon repair will take up to 8-12 weeks but restoration of function and ability to accept full activity, load and stress can take up to one year.