Become a Creator today!Start creating today - Share your story with the world!
Start for free
00:00:00
00:00:01
Flexor Tendon Scar Management
328 Plays17 days ago
In this episode of Hand Therapy Academy, Miranda and Josh dive into the challenges of managing flexor tendon scarring. They discuss practical strategies, clinical insights, and evidence-based approaches to help therapists optimize outcomes in these complex cases.
Recommended
Transcript
Introduction and Importance of Scar Management
00:00:05
josh MacDonald
Hi, I'm Josh McDonald.
00:00:06
Miranda Materi
And I'm Miranda Materi, and we are Hand Therapy Academy.
00:00:10
josh MacDonald
We've been getting a couple of questions lately about scar management and flexor tendon injuries. And it's, we're all kind of a little scared sometimes, especially early on about how to deal with flexor tendon injuries. And we want to make sure we're not going to put the patient at risk, but we need to make sure we're not letting him scar in too much. So we had some people ask how and when should we start that? So Miranda, I'll put it to you first.
00:00:31
josh MacDonald
When do you start SCAR management stuff and how do you initiate that?
Early Scar Management Strategies
00:00:36
Miranda Materi
Yeah. So I'm thinking about scar management right away, right? That's one of the first things I'm thinking about. it's mainly in terms of that flexor tendon getting scarred down. So one way that we manage this early on is by doing an early active motion protocol. And what I mean by an early active is a volitional movement within a short arc.
00:00:55
Miranda Materi
And then another thing that we're thinking about is managing the wound. So that can be a part of your scar management as well. That doesn't mean you're going to go massage over the wound, but you can certainly start doing around the wound. You can start doing some gentle scar management.
Techniques for Preventing Tendon Scarring
00:01:10
Miranda Materi
And then if they have anything on there, like usually they'll have stitches in, but if they end up getting moved into, um, oh gosh, the suture tape or, you know, seri strips, those can serve as scar management as well. So sometimes people think those need to come off right away, but actually they can help manage the scar as well.
00:01:29
Miranda Materi
So those are a couple of things. And then I would say the third thing is, um if I have a really high suspicion that the flexor tendon is going get scarred in, starting protected reverse joint blocking early on.
00:01:42
Miranda Materi
And this is supported by Duran and his protocol, they start that they say in the protocol is zero to three weeks. so you can start it pretty early. The main thing is that you're not doing composite extension. You're doing isolated extension of each joint while the other joints are in our inflection.
Modified Duran Protocol Details
00:02:02
josh MacDonald
Yeah, so that gets a little hard to wrap your head around, especially if you're not like watching us on video to to know what we're talking about. So let's describe that a little bit. So this comes from the modified Duran protocol that's been around for for decades.
00:02:13
josh MacDonald
um So you can still get really good outcomes from some of these older protocols, but they will so they have you holding the MCP joint inflection and the PIP joint inflection to put slack on that flexor tendon.
00:02:25
josh MacDonald
and then getting distal excursion by doing light a light passive extension of the DIP joint. So everything is on slack with MCP and PIP inflection, but I'm passively extending the DIP joint to get distal excursion. All of our short R active stuff is proximal excursion, but then I don't pull it the opposite direction.
00:02:47
josh MacDonald
So there's a version where I do DIP extension and then It's hard to do on yourself, so I don't have patients do it, but if I keep the MCP inflection and the DIP inflection, I can extend the PIP joint.
00:03:00
josh MacDonald
Again, slack on everywhere else, and I'm only extending the PIP joint in that isolated joint extension, but that gives me proximal excuse it gives me distal excursion in um just to pair with the proximal of the short arc active.
00:03:14
Miranda Materi
yeah I think that's great. And then to clarify, you're talking about doing a passive movement.
00:03:19
josh MacDonald
Yes.
00:03:19
Miranda Materi
So you're doing passive protective extension.
00:03:20
josh MacDonald
Yeah.
00:03:22
Miranda Materi
You can also do active protective extension. But I think the modified Durand is just talking about passive.
00:03:26
josh MacDonald
Yes.
00:03:30
josh MacDonald
Yeah. So when Miranda mentioned the um active reverse joint blocking, that's holding that basically passively holding that fist down and having them actively extend that DIP joint.
00:03:42
josh MacDonald
And while they're actively extending that, that's also shifting that that tendon distally to pull it free from scar.
00:03:49
Miranda Materi
So I think
Advanced Scar Management Methods
00:03:50
Miranda Materi
that is great. What about, are you, for your Steri-Strips, are you thinking, and I know they don't always come get Steri-Strips after they have their stitches removed, but um if they don't have Steri-Strips, are you doing any type of silicone? Are you massaging over the incision line? Like what are some things you're doing to help manage the scar?
00:04:12
josh MacDonald
So before the wound is sealed and stable, I'm doing peri wound. So almost like with a centimeters border around the wound is my kind of no-go zone.
00:04:24
josh MacDonald
And I'll just work the area around that. But there is some secondary movement underneath that scar as well, um particularly if it's in ah proximal zone two or zone three. If it's in that palm and I can get a little bit more mobility in there,
00:04:38
josh MacDonald
um with a little bit more space than if it's just on the digit. So I'll do some of that. um The stereostrip thing is interesting. I like that as a way to almost tack down the skin and then whatever movement they have doesn't pull the skin as much. So it's getting that differential glide of the scar away from the the dural and dermal tissue just because it can't move. with The stereostrip is kind of locking it in place a little bit.
00:05:01
Miranda Materi
Right. And it also deoxygenates the scar. So there's no oxygen getting to that incision line, which we know helps with any type of thicker scarring or hypertrophic scarring.
00:05:12
josh MacDonald
Yeah, yeah. All of this to be said, we're only doing this on patients who are showing signs of good, healthy scar development and growth. We want to make sure we we don't have a patient who's moving great and they have full passive and active movement by week two.
00:05:27
josh MacDonald
Well, then I've got a little concern that they might not be scarring in enough. And so I want good scar adhesion. We want that middle ground. So I'm not doing this on those patients who don't have any scar forming at all. I'm doing this on those that are developing some scar and adhesions that we want to manage as best we can.
00:05:43
Miranda Materi
Right.
Desensitizing and Educating Patients
00:05:44
Miranda Materi
And then another secondary benefit is when we're going in and we're going around the wound or when you say that we're doing peri wound scar management is that you're also like letting the patient know that it's okay, you know, with clean hands or with gloves on to massage around that area. It helps, I think, desensitize them.
00:06:01
Miranda Materi
And it also gets them ah like thinking, okay, it's okay. I'm going to start. It's okay for me to move this and it's okay for me to touch it. And I think it helps kind of set them up for success versus we all have had those patients who are very afraid to touch it, to look at it, even to move it. So you're kind of starting to set that stage for when they are able to do more and we're wanting them to do a lot to start.
00:06:23
josh MacDonald
Yeah, we kind of sometimes forget that we're used to seeing these wounds all the time, but a lot of people cannot handle wounds, certainly on themselves, And it's just this intimidating thing. And everyone up to this stage has been scaring them about flexor tendon. Oh my gosh, could lose function. And it's really got to be careful, got be compliant, but it's, we have to kind of decondition them a little bit and say, it's okay to touch it.
00:06:46
josh MacDonald
Very sterile, obviously, but it's okay to touch it and to move it. I like the the phrase, move it, don't use it. And so it's okay to be interacting with that scar, that wound, the the movement around a ah dowel just for light, short arc active,
00:07:00
josh MacDonald
So all of that is a good thing for the patients to get used to.
Patient Education Post-Surgery
00:07:03
josh MacDonald
Okay.
00:07:04
Miranda Materi
And then another thing is oftentimes we're seeing these patients immediately post-op, or even three or four or five days after surgery. So a lot of times um they don't know like wound care, they don't know how to take the dressing down, how to change things.
00:07:19
Miranda Materi
And I think in that first appointment, we're telling them so much information. I think it's helpful to continue to repeat it and write it down for them. So you're repeating simple things like Josh said, move it, don't use it, move it, don't use it.
00:07:31
Miranda Materi
So you're giving them these cues that they can hold on to and remember because it's very overwhelming for a patients. It's the first time meeting you. It might be the first time coming into the clinic and you're telling them like 20 things to do.
00:07:42
Miranda Materi
And they're like, I have no idea. Right? So it's like, i I'm going to have you come back in a couple of days.
00:07:44
josh MacDonald
no
00:07:47
Miranda Materi
These are the things I want you to remember from today.
00:07:49
josh MacDonald
Yeah. And these patients, especially if we're only seeing them every couple of days or once a week, they're going to have to change their dressings. They're going to have to manage this wound. And so they need to not be afraid of it.
00:08:01
josh MacDonald
We've had patients who walk in and like they don't even want to see it and there they get like this anxious response to it. And so it's good to start to desensitize that and we touch it. And then they touch it a little bit and have them demo that in front of you in the clinic in a very safe environment. And it's kind of disarming for them to be like, oh, okay, this is okay. and We can all interact with this in a clean, sanitary way.
Integrating Traditional and New Protocols
00:08:21
Miranda Materi
Right.
00:08:22
josh MacDonald
Yeah. Yeah. Well, hopefully that answers some questions for you about managing scar and being maybe a little bit more proactive with your flexor tendon patients. And there's good information in some of these older protocols. Don't let the fact that we've come up with newer protocols mean we throw these out with the bathwater. There's still good value in some of those. So um still open yourself up to using some of the aspects and components of those protocols as well.
00:08:46
Miranda Materi
Awesome. So more information, or if you want to share some of your flexor tendon stories with us, please reach out. and Our email is info at hamtherapyacademy.com or reach out on Instagram at hamtherapyacademy.