Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

We mold it in this position and we want patients to maintain their shoulder and elbow exercises and then the main exercise is thumb. And then we're also going to do a three finger wall. Um, so they, they need to bring their fingers down. So they're creating a three finger wall to the distal palmar crease level. So we're also gonna at work on active extension to the hood of the splint as well. Then, uh, on the second week, we continue the shoulder and elbow and thumb exercises. But now, all we do is we increase the flexion to a two f finger wall from the distal palm crease. So we're just increasing that each, each week and then continuing on with the pump exercises as well. At this point, we're gonna clean, we're gonna take the splint off and clean it as well. So again, encouraging them not to take it off themselves and then we move on to weeks 3 to 5. So now they can do a full fist so they can actively fully flex the fingers to the palm. And, oh, sorry. At week two, we also want to encourage them to do a passive, roll up of all joints as well. So we're really trying to get that range and at week three, they can do that actively along with passively. Uh, then we see them again at week five. And at week five, the splint now goes into a night and protection phase. So at this point, uh, with their wrist and neutral, they can continue to do their exercises. But without the splint on and they're also gonna start doing their active wrist flexion and extension 10 times every hour. At this point, they can also start to use their hand for light use only for personal hygiene and feeding. And then at eight weeks, POSTOP, we now can discard all the, all the splints and um, continuous exercises. We might also want to at this point, start passive exercises and, um, do serial splinting splinting if it's required to regain that extension. Uh, they can also now return to light work and driving. And then the next stage after that is 12 weeks, uh, where they can return to heavy work and contact sports again. So, very similar again, all quite similar. But the next one on it is the thumb cm. So same kind of splint. But as you can see in the picture, you've also got a part for the thumb. You want to block out the fingers as well just to stop them using that hand. This again is made 3 to 7 days POSTOP the wrists, um, the fingers are foot extension. But then you'd obviously, you, you'd make it for the fingers as well if they were also involved. And, uh, and the same again, it's, it's five weeks, um, for the Splint and then three weeks for NA protection. So the first week we go through the same things again, we're going through the shoulder and other exercises, maintaining the finger flexion and extension. But now with the exercises. So at the first week, we're going thumb to the tip of the middle finger 10 times every hour. And again, week two, we're now progressing that onto thumb to uh the, so the base of the ring finger. So we're just coming down a bit further. But at this point, again, we get to start doing our passive flexion and maintain full movement of the fingers. And then weeks, 3 to 5, we can now progress on to full thumb movement as well as the passive range of movement for the thumb as well as maintaining full movement of the fingers as well. And then again, we just 5 to 8, we're now going on to the night protection phase. Um And again, we're looking at creating full active and passive flexion of the thumb and active extension. Um active thumb abduction and opposition can be started if needed. And then we start off the wrist flexion extension. Uh Again, at post 88 weeks, POSTOP, we then um can continue we can start our passive extension exercises and we can splint them as well if needed and they can return to light work and driving. And then at 12 weeks again, it's, it's that heavy work and contact sports. So it's the same time frames. Um, very similar again for the wrist. So you can see it's a dorsal blocking splint for the wrist. Um, 3 to 5 to 7 day, 3 to 7 days POSTOP, the wrists are neutral, the fingers stays three and the thumb stays three. This is, but this is the only different one. This is, uh, worn consistently for four weeks and then at four weeks, we then go to night on protection. So it's a week less than the thumb and the fingers. Uh, so very similar to the other ones. They tend weekly for hand hygiene. So they're not taking it off regularly. Maintain your shoulder and elbow exercises and maintain full movements of the finger and the thumb. You can start your passive exercises with them at, at the start as well. Uh, and then at week four, you then go into the splint night time of protection, er, with full active and passive flexion extension of the fingers and the thumb and wrist, active wrist flexion extension. And then from eight weeks, like all the others, it goes on to discarding the splints, continue exercises and you can splint if required and you return to light work and drive me So it's really important that we know the, um, the zones and the percentage that helps our treatment. Uh, and that you let, and that the, the patients are told not to remove their splints as well and that they, and they follow the exercises that we give and they don't start doing other exercises. So now I'm gonna go on to the extensors. So, with the extensors, um, again, the aim of the extensor is to protect the tendon repairs, maintain tendon gliding, prevent adhesions and contractors and maintain movement. Both of the extensor. It's, it's very, very important that we get the right zones. Um, because this will change our treatment plan, um, quite drastically. This is different types of splints. So the first one, we've got the zone one and two, the mallet Splint. So these are done as a to the terminal tendon frequently through sport injuries, like grabbing rugby shirts and the splint that we want to make of them. Um, so we make ad IP flexion blocking Splint, which looks a bit like this. And the idea is that you can still keep the, um P IP moving once the D IP is into extension. Uh, these are made as soon as possible and, and they're worn consistently for eight weeks and then we will tend to wear them again for night and protection for another four weeks and then, um, keep wearing it if there's a lag present. So the exercises that we go through with the man injury. So we want to maintain that MCP and, and P IP, um range of movements. So we're just doing down to the palm, we can isolate them as well if they're particularly stiff and we can do our passive exercises as well if they're particularly stiff. And again, similar to the flexors at eight weeks, they can return to light work and driving and um, it continues for night and protection and then 12 weeks for heavy work and contact sports, we begin passive D IP flexion at 10 weeks or if it's um, a tendon repair, then I'll do 12 weeks. But we kind of judge it by how, how we're finding it. So then your zones three and four. So these are central slip injuries and um, these are normally a closed injury or laceration. They may involve the central slip and the lateral bands. Um, and they, they happen as due to Ebola displacement of lateral bands that places the, the B to the flexor axes. And then, uh, what can happen is that the P IP flex er, along with, they then become API P flexor with attempted P IP extensions, then this can cause the er, plutonia deformity. So, with our regime that we use to splint, central slip injuries, so we use a sound regime to the short arc of motion. We have three splints, no small one that is. So we have um, our splint number one, which just maintains full extension of the P IP and D IP. So just hold it in that. So, Splint number two, which, uh, allows the MCP to be free. But then it's a, it's a one thing, the P IP to flex to 30 degrees and the D IP to 20 to 25 degrees and then Splint three which keeps the MCP free, the P IP in extension and we're just allowing that D IP to flex over the tip of it. Um, and this is, if the lateral bands aren't injured, if they are injured, we just want to maintain only a 30 to 45 degrees there. So, the Splint one is worn all the time, but you should remove it for exercises. Uh, Splint two, you apply every hour to complete your 10 repetitions to the Splint and you hold it down there for five seconds and then you go back up. So you're just coming down, holding it there every hour and extending it back up 10 times and then Splint threes replied hourly and again, five seconds and five ups again, a gradual increase. So the regime part of it. So every week they come in for the first four weeks. So, er, the first week we, we did 30 degrees and then we remold this the second week to then bring it a bit further to 40 degrees and then we remold it then a week after that to bring it down to 50 degrees. At four weeks, they can then change to night and protection. So the flexor is always five weeks of, of the extent of it's four weeks and Splint one then just goes to night time and protection and they can begin full active, um, range of movement exercises. Uh, then at six weeks, we can discard splint one if there's no lag present and return to driving and puncture activity and then eight weeks, return to light work in 12 weeks. No restrictions. Again, zones, four and uh, five and six repairs. So these are typically are stone splints or if there's an extensor lab, we might do a dynamic extension splint, but they are normally the stone splints are much bigger. So this is why it's really important to get the zones, right. So it makes quite a difference to their quality of life. And this will just restrict their whole hands. Like, say so again, this is done, uh, 5 to 7 days POSTOP. The wrist wants to be in 30 degrees extension with the M CPS blocked at 40 degrees. This top bit here, they're blocked to 40 degrees. This is worn consistently for 24 hours a day until four weeks. POSTOP. Um, and then it's at night time for another four weeks for night of protection. Uh, you maintain range of movement of the shoulder, the elbow and the thumb. So the exercises for this one, we're doing actively over the Splint 10 times an hour at two weeks, POSTOP and then re mold this part up here and then bring that down further. So they can go to 70 degrees at M CPS. And then at four weeks, we, then the Splint goes to night time and protection and they can begin active wrist flexion extension and light activity. And then eight weeks return to light work and driving the dynamic extension. Splint again, we don't make many of these at all, but it's just got slightly different time frames, um, and slightly different exercises and then the zone seven, Splint. So if it's an isolated wrist extension injury, a cock up splint is fabricated allowing full movement of the fingers. So this one's just coming down a bit lower and it just doesn't block at the MCP and just allows you to move it fully over the splint and again, very similar time frames again. So it's made 24 hours POSTOP walk consistently for four weeks and then four weeks for night protection, maintain the range of movement of the finger and the thumb. At four weeks, you can begin light activity again. Eight weeks driving and 12 weeks back to heavy work and contact sports, then going on to the thumb. So it's quite a big chunky one for the thumb. This is our splint for the thumb. So it's got a nice big dynamic extension splint and this is where the difference comes in with the zones as well. Cos it's quite different if this, one zone, two, zones, one and two. So this is worn consistently for four weeks and then four more weeks for nine protection. Again, maintain movement of all the other joints. The first week we, um, want to do isolated IP and MCP flexion every hour. Then at week two, we're then going to base of, uh, uh, weeks, basically d four and then weeks, three and five and then going uh four and five weeks, five and then going to basically five. Um, at four weeks, we, we are aiming for full thumb movement five times an hour. And then again, we can start light, uh, begin wrist flexion extension at four weeks and eight weeks back to light work and driving. So the difference being is that if it's below a zone two, zone 34 or five, then we've got this big chunky splint and if it's a zone one or two, then we're just gonna treat it in a man splint. This is worn consistently for four weeks and then four more weeks, um, when you can remove it each hour for your exercises. So a bit of a slower recovery. But yeah, four weeks worn consistently and then four weeks taking it off for your exercises and you want MCP flexion of the thumb five times an hour and the, and the digits five times an hour at eight weeks, you can then begin your passive ip flexion if it's needed and again, return flight work and driving. Uh, so especially with the extensors really important to get the zone, right, because that's gonna change quite large, uh, parts of their treatment. Um, and especially if they're working as well, it's gonna make a big impact to how much work they can do. Uh, we get a lot of patients that are quite surprised with how long they're gonna be out of action for. So, um, when we tell them 12 weeks, they normally aren't too happy. So if they, if they already know that before they go in, then at least they'll be a bit more prepared. Um, and sometimes the place of Paris isn't strong enough to last the seven days it might take to see us. So making sure us doing its job for those full seven days is helpful. Um, and then just also making sure that they don't take it off for their own hygiene as we really want to make sure they protect that tendon for the whole time and they don't start doing their own exercises. And that is just a brief update into the, um, flexors that the, the splints or flex and the extensors that we use here. Thank you very much. Can I ask you a question? Yeah. So with Ac A Splint, which is for, uh, flex at tendon injuries, it's a right for the thumb. No, no, the thumb, the the finger one. Yeah. Yeah. Yeah. Yeah. So, so you said that initially you keep them, you, you avoid full flexion, uh, 33 thumbs or three inch, three centimeters from the full palm and then you, and then you, you then achieve full flexion like, you know, down the line. Uh But why, why, because it's, it's the flexor which, you know, when you flex it's looser. So why, why you do you prevent full flexion in a flexor tendon repair? So, so it's the first week. Oh, yeah. Um So I think, you know, because you, even though it's looser, you're still, uh you're still uh putting pressure on it and they can be. So this is for Flexor tendon repairs you're talking about, right? Penelope. Yes. Yeah. So you've repaired the flexor tendon. So, you know, even though it's loose, if it's shorter, you're still putting pressure on it, right? You're still, you're still pulling, you don't want that to be gapping at the tendon side. And it's, and initially they are very, very, um they're still very friable. So it, there is a high chance of uh tendon failure and they've shown a lot of tendon failures that happen within 6 to 12 days, which is why early on you do a sort of controlled movement just to get it gliding, but without putting too much pressure, is that right? So, why are we preventing flexion? I understand why we prevent a full extension. But why we prevent full flexion. So you, because you're still pulling, when you're flexing, the muscles are still contracting and pulling. Oh, I see. So, yeah. So it's, you're, you're thinking about you, you're preventing full extension because you don't want that movement to pull in extension. But then with contraction, you're still a activating the muscle. So there's still force going through at the, at the, at the, at the repair site. I see. Ok. Thank you. Yeah. No, don't worry that it was a concept that takes a while to understand. You just got to think about that, you know, and that, that's why, you know, the over time the tendon repair protocols have changed quite significantly. So, which is the key thing is the controlled active movement. Is that right, Michael? Have I got that right. Yeah. That's, yeah. Perfect. Yeah. Right. Lots of people here. Any questions, like I said, today's session is slightly shorter because unfortunately, we've had one per one of the consultants not be able to come last minute. Um So we've talked about flexor extensor, we've talked about rehab.