Become a Creator today!Start creating today - Share your story with the world!
Start for free
00:00:00
00:00:01
Zone 3 Extensor Tendon Management
1k Plays2 years ago
Zone 3 Extensor Tendon Closed Injury. How do you manage these conservatively? Josh and Miranda cover treatment and splinting options for these patients.
Recommended
Transcript
Introduction and Case Study
00:00:07
Speaker
Hi, I'm Josh McDonald. And I'm random material and we are hand therapy Academy. We're going to do a little kind of case study here a little bit. We're going to talk about a zone three extensor tendon injury, but we're going to take it from kind of a closed presentation. So a patient who comes not necessarily from a hand surgeon, but someone who maybe came from, you know, a friend says, Hey, go to the clinic and see my buddy who's a hand therapist or maybe your primary care doctor or someone has a self referral.
Patient Presentation and Imaging
00:00:32
Speaker
They come in and they've got an injury and that PIP is kind of drooping.
00:00:37
Speaker
What do you do with that patient and where do you start? What are we going to do for treatment? So Miranda, what's kind of your first step when that patient presents?
00:00:44
Speaker
So my first thing to ask the patient is what imaging they've had done, right?
Elson's Test and Interpretation
00:00:48
Speaker
Because a lot of times if they do have a boot near deformity or a boot near injury, it's not showing up on an x-ray. So maybe even they've had x-rays and then they're coming to you and the diagnosis is PIP joint sprain or something like that, right? So you kind of have to be a detective and determine, well, are all their tendons intact? So the first thing I might go to is checking, doing an Elson's test.
00:01:11
Speaker
And then that's where you keep the PIPs at 90 degrees flexion and you point them against the other side. It's really hard to explain in a video, but then you have them try to extend their DIP joint, right? And if it looks the same as it does on the other side, then you know that that's probably a negative test. It's positive if that DIP really extends, then it's positive for having a Nelson's test. And that can be an indication that their central slip is not intact.
00:01:40
Speaker
So
Treatment Priorities for Central Slip Injuries
00:01:41
Speaker
now that we've determined their central slip isn't intact, what is the first thing that you're going to do, Josh? So I'm going to talk to them about prioritizing, protecting that central slip. It's very likely that it's not retracted all that much because it's got the lateral band still acting as a tether to that terminal tendon. And so let's back up for a second and talk about what a boutonniere is. If I have
00:02:05
Speaker
an attenuation or even a rupture of that central slip, the PIP joint will lose its ability to extend but those lateral bands will still be retracting and now unchecked they'll retract more with that muscle tension and pull that DIP into hyperextension. And so what I want to do is protect and keep that PIP joint in extension so that hopefully the distal and proximal ends on either side of that avulsion or rupture
00:02:31
Speaker
will tighten back up or even scar and adhere back together again, a lot like I would with a mallet injury. That extensor tendon is broad and has that ability to scar back in again. So I will try to protect that PIP in extension, but leave, as long as the lateral bands don't appear to be affected, leave those lateral bands at the DIP free to allow for ORL lengthening exercises. So I'll do a basically a burrito splint is what we call it, but a circumferential wrap that has PIP in extension,
00:02:59
Speaker
and D
Diagnosis and Referral Importance
00:03:00
Speaker
.I.P. free. My starting point is kind of like a mallet finger, prioritize protection. Don't let that P.I.P. joint bend because I may just be re attenuating or re evulsing that that site. Yeah, I'm with you on that. It's really making sure you have the right diagnosis to the right. So do you ever send them out to a hand surgeon then or you say I'm confident I know what this is?
00:03:23
Speaker
If I think that there's like specifically a trauma that happened or some kind of event, if I think that it is a ruptured central slip when they present in the clinic, I will immobilize them and then send them across the street.
00:03:37
Speaker
send them to a hand surgeon or whichever doctor happens to be in office that day. And I'll say like, listen, this is a big priority.
Conservative Management Plan
00:03:43
Speaker
This is something that is, that could be a lifelong problem if you don't get it addressed as soon as possible. So I may immobilize them, keep them protected and then send them off.
00:03:54
Speaker
If I'm not sure and I'm unclear, I might still default to the go get them taken care of and get an imaging and I'll tell them, I'd rather be wrong and you get imaging unnecessarily than me say, oh, I got this. We can figure this out, but it didn't repair. I might still do the same if it were a mallet injury too, kind of depends on the presentation of the patient, but certainly for a central slip because that can go bad with that boot near deformity creating and initiating hard to recover from that once it starts.
00:04:23
Speaker
Yeah, and then once you put them in the splint, how long are you leaving them in the splint for? And then are you initiating any early active PIP joint range of motion?
Casting vs. Splinting
00:04:34
Speaker
So let's assume maybe the doctor sent them back or for some reason they can't get to the doctor and I'm just gonna carry on with a conservative management of a central slip of ulcerative rupture. I might, I would probably then say we're on a six to eight week plan, a lot like I would for a mallet finger and say that's how long this tendon healing timeline is in scarring and we will start by protecting it. But I may do a blend with that
00:04:58
Speaker
that short arc active motion protocol where we're doing a blocked flexion where I'll give them a separate splint and say, put this on, it's a volar block that allows for like 20 to 25 degrees of active flexion just so that joint doesn't get stiff and just some short arc active motion into that flexion block that allows for some mobility in that joint, but then put that burrito splint right back on again. Do you ever cast these patients?
00:05:27
Speaker
I do. Yes, that's something I have done. I'm not typically a fan of it if the patient needs more management of soft tissue stuff, if you have wound stuff. So if it's a pretty clean presentation, yes, I'll put them in a cast if I'm worried that they'll not comply with the splint.
00:05:45
Speaker
but I'll have some patients that if there's some edema that's going to fluctuate or they've got a wound to manage, as soon as I wrap it in a cast, either if it's a edema, that edema goes down and it falls off. If it's a wound, I worry that the wound isn't going to get checked on or monitored like on a daily basis. So I have done that. It's not kind of my go-to. I prefer the splint
Real-Life Case Discussions
00:06:03
Speaker
option. It gives me more ability to check it, but kind of therapist preference. How about you, do you cast?
00:06:08
Speaker
I recently had a kid in my clinic and he was actually from a hand surgeon, but they didn't really know what was wrong. And I was like, well, I think it might be central slip. So I called his surgeon and I was like, hey, can we try immobilizing this kid, you know, for six weeks. So I wasn't really worried about him getting stiff, but he definitely presented like a true boot knee, right? He had the hyperextension of the DIP, but his MRI was negative.
00:06:34
Speaker
So we treated him like a boutonniere and we ended up casting him which worked really well because he was a young kid right and active and going to school so and we cast him for six weeks and his outcome was was nearly perfect knock on wood but I think we got lucky that he was a kid but I think the casting seemed to work really well just because I was really nervous about him not being compliant with our splinting.
00:06:58
Speaker
Yeah. Yeah. And that casting, I'm sure did a really good job of helping to re-centralize the lateral bands really well because there was zero opportunity for, you know, forgetting here, forgetting there. Those lateral bands were in the right place for an extended period of time. That's really helpful. Right. And then we left his DIP free so he could really stretch that ORL and then re-centralize the lateral bands to be more in the neutral position. Yeah.
00:07:24
Speaker
I've had some patients in this kind of situation present, unfortunately, really late in the process. I had one patient who was a musician and wanted to go back to school after working in the business world, wanted to go back to really focus on her music career and came back saying, I can't play violin and piano with this PIP boutonniere that I have from two years ago.
00:07:46
Speaker
What can we do to fix it? The doctor doesn't want to
Challenges in Late-Stage Injuries
00:07:48
Speaker
do surgery. Let's try conservative first. We threw a couple of things at it. We did serial casting with, you know, we'd come in for the serial cast revision, but before I put the new cast on, we would do some soft tissue stuff. We tried LMBs when the, uh, when the serial casting didn't seem to be effective that far out. It's real tough to make a difference. So it's huge. It's very helpful to get them as early as possible for sure.
00:08:10
Speaker
Yeah, in their age. I had a lady recently that was an elderly woman and she came in and it was her small finger. It was so tiny and getting that DIP blocked but keeping the PIP in full extension was almost impossible. Yeah, yeah. Small border digits but specifically small finger. So hard to do work on the PIP joint. Everything's so much smaller and packed in that little tiny container. It's just really hard to manage those effectively.
00:08:38
Speaker
Yeah. And unfortunately her outcome wasn't as good. So yeah. Yeah. It's good to get the diagnosis as early as possible in the plan of care. And hopefully someone who's got good healing potential and not a lot of the comorbidities and yeah, there are lots of factors that will affect the outcomes. And sometimes we have to kind of release ourselves and say like, if this doesn't have a great outcome, it's not necessarily because I didn't do everything possible. It's maybe just kind of the variables of the situation. Right. Yes. Yeah. Yeah.
00:09:04
Speaker
Lots of information there. Hopefully that gives you guys some ideas on what to do if you have a boutonniere presenting to your clinic, conservative management of it. So hopefully that helps you guys. If you have any questions, you can reach out to us on info at handtherapyacademy.com or messages at our Instagram at handtherapyacademy.