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Kleinert Flexor Tendon Protocol
497 Plays6 months ago
Miranda and Josh discuss the Kleinert protocol for treating flexor tendon injuries.
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Transcript
Introduction to Kleinert Protocol
00:00:05
Speaker
Hi, I'm Josh McDonald. And I'm Brenda Vateri, and we are Ham Therapy Academy.
00:00:10
Speaker
So let's talk about everyone's favorite protocol to hate on, Kleinert.
Relevance of Kleinert Protocol
00:00:15
Speaker
Let's talk about the Kleinert flexor tendon protocol. It's been around for 50, 60 years. And it's what everyone kind of raises their nose at and says, this is old. It's out of date. It's bad medicine. Well, let's talk about it. And maybe when is a good time that you should use it? Or does it cause that many problems to begin with? Is it still an effective treatment approach? So let's talk about Kleinert.
00:00:38
Speaker
And first I would say, when was the last time you did a Kleiner?
Josh's Experience with Kleinert Protocol
00:00:42
Speaker
I would say I've done, honestly, I've done one Kleiner patient and it was probably, let's see, seven years ago. And the doctor was super worried about this patient's ability to be compliant, how tenuous the repair was, and just everything sketched him out. And he said, you know what? Go back to Kleiner and use that. Like, are you sure? He's like, yep, I know. We're going to get PIP stiffness.
00:01:08
Speaker
because it's always pulled into flexion. I know we're going to get that. Go use it anyway. I don't want him to rupture. Protect my repair. Okay, great. We'll do Kleiner. And so we glued a hook to his fingernail and we ran with it and the patient had okay outcomes. He wasn't super compliant. That's why the risk, but he turned out okay as flexor tendons go. Interesting.
Case Study and Protocol Comparison
00:01:29
Speaker
I got one probably like four months ago. Okay.
00:01:33
Speaker
And I remember I caught you as a doctor, you know, he was a little further away. But this was like someone I kind of knew was there her brother and she wanted me to see his brother. Okay, so no big deal. I called the doctor. I was like, Is this what you want? He's like, Yeah, I sewed the loop. So there was already like a loop sewn on the fingernail. Okay. The rubber band to it. So I was like, Well, that's nice. Because I feel like half the battle with Kleiner is
00:01:59
Speaker
keeping the hook on. So that's what we started with. And he wanted to do that. And I was fine with it. And I'm like, okay, well, I know these outcomes are, you know, going to probably be okay. But actually, the patient was so stuck. Interesting. Stuck in scarred? Stuck in scar. Okay. But also, you know, I don't know, you don't like was a pulley bent, you know, I don't know, I didn't know that they can do the surgeon that well. And, you know, but
00:02:26
Speaker
Yeah. So I didn't know what he, what his typical outcomes were either. And, and so there's an article by Rebecca Nodoski that's probably three, four years old now. I think we've referenced it a couple of times. Um, and she did a good job of comparing outcomes on patients with all the different major protocols Kleiner modified. He published that. Or was that just her talking about it? I thought she was just talking about it. That could be.
00:02:53
Speaker
I think so. I know we talk about which one. I think she presented at a conference. But I don't know. I don't think it's in print, but I could be wrong. But basically the patients were getting good outcomes on variety of different protocols that
00:03:10
Speaker
as long as you're doing no harm and you're protecting the repair, that there are good outcome potentials with all of these. We come up with new versions because we say, hey, here's a better way to do it. But when all we had was Kleiner 70 years ago or whatever, patients were still coming out okay. Now we know how to get them stuck in less or less stuck in scar, but this isn't going to cause them to rupture. You maybe have some complications, but if a doctor really wants you to do that, it's not like you're doing bad medicine.
Importance of Surgeon Collaboration
00:03:38
Speaker
Yeah. And I always tell my team, like one, we're not going to bad mouth our surgeon, right? That's our, you know, that's the leader of our team, right? We're going to support him. And you know, if this is what he wants, if we don't agree with it, then, you know, call him up and have that conversation. Why you want to do something different, but you're not going to tell the patient. We're not, you know, I don't know. I think there's a lot to be said about trusting the person that has, who's doing the procedure, right? So we need to trust what he sees intraoperatively and what
00:04:06
Speaker
he wants in his previous experiences. Yeah, yeah.
Kleinert Protocol Setup
00:04:11
Speaker
So let's talk a little bit about what Kleiner involves. You see them right off the bat. You splint them with the wrist in 40 degrees of flexion and MCPs in 40 degrees of flexion. And then I'm going to put a rubber band on a
00:04:27
Speaker
loop that's hooked is usually glued to their finger unless they've got it sewn on. There's some other options there. But that attaches to a rubber band that comes down and anchors to the proximal forearm strap. There are a couple of modifications that have come out since where they say if it's FDP, I should hook all of the fingers because of the common muscle belly. And they're now suggesting that you pulley that on the distal palmar crease strap.
00:04:55
Speaker
because pulling it on that adds D.I.P. flexion. So it loops through, and you can run the amount of filament through little slits in that strap. You can add like a sew-on, a metal pull. Lots of options to do that, but basically it needs to route through that distill polymer crease strap and then down to the form with the rubber band component.
00:05:16
Speaker
And so what you're going to do at like, I think it's two weeks, you're going to take that wrist back to neutral. So I will re-dip it and make the wrist in neutral, but for the first two to three weeks, it's going to be in that 40 degrees of flexion. But they're going to do active exercises against that rubber band. So it's active extension against resistance of the rubber band into the dorsal blocking splint.
00:05:38
Speaker
and then passive flexion down because the rubber band is pulling them. Now we know that it's not completely inactive flexion. We know that when you tell your brain shut off, your flexor muscles still do something, but the idea is 10 to 15 times every hour, I'm doing active extension to the block and the rubber band is passive flexion back down. Yeah, and that's pretty much it. Yeah, yeah. Right?
00:06:04
Speaker
There's more to how you progress them at different mile markers, but it starts to look very similar to when you wean them out of the splint, when you add strengthening. But that rubber band is your safety net to say they're not going to overextend and they're not going to do active flexion because the rubber band is the flexion component. But you're kind of hoping they might do a little active flexion, right?
00:06:24
Speaker
Yeah, and like I said, we know that when you try to eliminate that entirely, they're still going to do something, like with a radial palsy splint. They're still doing some of that activity, even though the rubber band's supposed to be doing all of it. Right. So we know there's a little bit of cheating going on, and that's OK. Yes, yeah, yeah, yeah.
Simplifying Kleinert Setup
00:06:43
Speaker
And so when it's time to make one of those, you do have to have some unique materials. You've got to have monofilament. You may have to have line connectors, unless you're a boy scout and good at knots.
00:06:52
Speaker
You have to make sure you've got a hook and some super glue to glue a hook onto the nail and you may have to redo that every once in a while. You tell them if it comes off of your finger and pops off in the middle of the day, come back in and we'll glue back on again and what to do to keep it down in the meantime.
00:07:11
Speaker
Yeah and you know honestly when the surgeon put that loop on it was so easy because we just connected to the rubber band to the loop and then made the palmer piece you know so we could get that composite flexion that you were talking about but it did make it a lot simpler like I was like oh this is great because we don't have to mess with the hook we don't have to have a connection whatever you're going to hook around the I guess you could hook a rubber band around the dressing hook too that you put on there but
00:07:37
Speaker
Yeah. Yeah. And I've seen that where it was like the finger was dressed in gauze and then you like embedded a hook in the gauze and wrapped it on that way. That's an option too. Just kind of depends on what wound care and dressings they need. Yeah. And then there's band-aids. You can talk along with band-aids.
00:07:54
Speaker
Honestly, it's a pain though. It's really a pain to get the hook to stay. So if, if you do have, I would say if you have a surgeon that's doing a lot of those and they want you to put the hook on, I would say, Hey, would you mind like sewing a loop on it? Cause they wouldn't, they go to get, it's time to take it out. You just cut it and pull it out through the nail. It's so simple. It functions a lot like a button from the FTP pulls or like if they're doing a button approach, it kind of pops through the nail like that. It's very easy to trim off. Yeah. It makes, it makes it so, I had never had a surgeon do that for me and I was like, that's,
00:08:24
Speaker
That's my guy. Yeah, right? Absolutely.
Nighttime Splinting and Complications
00:08:27
Speaker
I almost forgot there is a nighttime component piece in the first couple of weeks of that splint. So they can't wear the rubber band all night. It's going to break. It's going to get caught on things or come off entirely. So there's a volar piece to the fingers that you make that straps on and then sandwiches the fingers up against the dorsal block. So it's just an extra piece. You don't need the sticky back Velcro over the fingers because there's no strap holding them up.
00:08:53
Speaker
So now the sticky back Velcro that is there is just waiting for that nighttime pan, the kind of clam shell sandwiches, those fingers into that dorsal extensions position. Yeah. So still an okay option. Yeah. You get some complications with it. If you're not doing the rerouting through that Palmer strap, you're going to end up with a little bit of PIP flexion contracture. You might end up with some of that anyway, because it's PIP flexion.
00:09:17
Speaker
almost all the time, except for their exercises, so that you may get some flexion contracture there.
Defending the Kleinert Protocol
00:09:22
Speaker
It's protecting the repair, but SCAR may set in and get a little bit stuck down. Yeah.
00:09:29
Speaker
So there are other options besides just what we were comfortable with. And, you know, let's be nice to Kleiner. He came up with a good option for us and it's something maybe you'll use and you can still get good outcomes with it. But if you have any questions for us, don't hesitate to reach out to our emails, info at Hand Therapy Academy or on our social media platforms through the Handel Hand Therapy Academy.