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Original article
Early return to work and improved
range of motion with modified relative
motion splinting: a retrospective
comparison with immobilization
splinting for zones V and VI extensor
tendon repairs
Melissa J Hirth,*§Kate Bennett,*§Eldon Mah,†Hamish C Farrow,†
Andrew V Cavallo,†Morris Ritz‡and Michael W Findlay†
*Occupational Therapy Department, Austin Health, PO Box 5444, Heidelberg West, Melbourne, Victoria 3081,
Australia;
†
Plastic and Reconstructive Surgery Unit, Austin Health, Melbourne, Victoria, Australia;
‡
Melbourne
Institute of Plastic Surgery, Malvern, Melbourne, Victoria, Australia;
§
Malvern Hand Therapy, Malvern, Melbourne,
Victoria, Australia
Correspondence: Melissa Hirth. Email: melissa.hirth@austin.org.au
Abstract
Introduction. There is a lack of evidence on the best method for rehabilitating extensor tendon injuries in
zones V and VI. The purpose of this study was to evaluate the outcomes of modified relative motion splinting
compared with immobilization following repair of extensor tendons in zones V and VI.
Methods. A retrospective analysis compared the outcomes of relative motion splinting with immobilization.
Sixteen patients (16 fingers) were treated by conventional immobilization splinting for four weeks (immo-
bilization group) followed by mobilization with avoidance of ‘at-risk/heavy’ activities for a further 4–6 weeks.
Twenty-three patients (23 fingers) were treated with the modified relative motion splint (mRMS group) during
the day and a resting splint worn overnight for the first four weeks. The relative motion splint was continued
for ‘at-risk/heavy’ activities for a further 4–6 weeks.
Results. The mRMS group demonstrated statistically significant improvement in range of motion compared
with the immobilization group. This effect was most marked at six weeks (P¼0.0194, two-way mixed
ANOVA) with the mRMS group achieving a 12% higher mean percentage total active motion (P¼0.0076,
Mann-Whitney Utest). Results were similar for both groups 12 weeks postoperatively. Differences in return to
work times between groups were statistically significant (P¼0.0062, Mann-Whitney Utest). Average return to
work was 9.4 weeks for the immobilization group and 3.3 weeks for the mRMS group, equating to a 42 days
earlier return to work for the mRMS group. There was no incidence of tendon rupture in either group.
Conclusion. This study demonstrates that modified relative motion splintage ( finger based without wrist
component) can be applied in the postoperative management of single zone V or VI extensor tendon repairs.
The main advantages of this protocol, compared with immobilization include the small simple splint design,
and straightforward patient instructions that enable earlier mobilization, functional hand use and return to
both daily living and work.
Keywords: Extensor tendon injuries, relative motion splinting, splinting, hand therapy
Introduction
Extensor tendon injuries are common in zones V and VI
due to their superficial location on the dorsum of the
hand and minimal soft tissue protection. Historically
postoperative management of these injuries has consisted
of immobilization of the repair for 3–4 weeks.
1
This
increases the risk of tendon adhesions, can delay return to
Hand Therapy 2011; 16: 86–94. DOI: 10.1258/ht.2011.011012
86 Hand Therapy Vol. 16 No. 4 December 2011
work and limits daily activities of living, thereby adding
to the burden of the injury. An ideal treatment regimen
provides protection for the tendon repair, is simple and
easy to apply and avoids these risks. No treatment
regimen currently within the literature meets this ideal.
Early mobilization protocols were developed in an
effort to minimize the complications of immobilization
by applying controlled stress to a repair and hence limit-
ing adhesions.
2,3
A systematic review by Talsma et al.
4
demonstrated that ‘early controlled mobilization’ is
superior to ‘immobilization’ in the short term for the
postoperative management of zone IV to zone VIII
extensor tendon injuries. However, their results were less
conclusive when comparing ‘early controlled mobiliz-
ation’ with ‘early active mobilization’ and there was no
evidence to suggest that any of the three rehabilitation
regimens is superior when assessing longer-term out-
comes.
4
Only five studies met the criteria for the sys-
tematic review with most studies in the literature being
excluded due to their single cohort design. Talsma et al.
4
emphasized the need for further research related to reha-
bilitation protocols. The three rehabilitation categories
used to treat zone V and VI extensor tendon repairs are
outlined below.
Immobilization
Over the last 70 years, numerous studies have demon-
strated acceptable long-term range of motion results from
immobilization following extensor tendon repairs.
1,5,6
Immobilization regimens aim to provide protection to
healing tendon/s by preventing tendon movement. They
are simple to apply, have a low profile design, require no
exercise programmes and are suitable for use in non-
compliant patients.
3
Immobilization, however, limits
functional use of the affected hand.
Early controlled mobilization
Early controlled mobilization regimens seek to achieve
passive motion of the repaired tendons. Techniques such
as dynamic outriggers or extension splinting are most
commonly used. Further, immobilizing the metacarpo-
phalangeal (MCP) joints, preventing active MCP joint
extension and leaving the interphalangeal (IP) joints free
to mobilize is another therapy technique.
Many authors advocate dynamic splinting.
2,7–10
Techniques typically involve the use of elastic traction
that limits active flexion and allows passive extension of
the MCP joints while also allowing active IP flexion and
extension. Disadvantages of a dynamic splint include
wrist immobilization, a high profile design, and disci-
plined compliance with an exercise regimen.
Recommended time for splint wear is between three and
five weeks, with functional use of the hand not possible
until splint removal.
2,8
Another splint design is the low-profile Levame splint
that allows early controlled mobilization.
11
This hand-
based splint with steel leaf springs passively returns the
repaired finger/s into extension. It is most suitable in
simple zone V repairs while a forearm-based splint is used
for zone VI and more complex zone V repairs.
11
Limited-active flexion of the MCP and IP joints of the
injured finger occurs and the uninjured fingers are free
from the splint, allowing some functional hand use.
Additionally, functional static splinting was introduced
by Slater and Bynum.
12
The simple static splint is worn
for an average of six weeks and is fabricated to immobilize
the wrist, hold the MCP joints in 20–308of flexion
while the IP joints are free to mobilize and patients are
allowed to use the hand cautiously for basic activities of
daily living.
12
Early active mobilization
Safe active motion of a repaired extensor tendon has been
achieved via regimens that permit limited motion across
the MCP and IP joints with support from static and
dynamic splints. Two early active regimens have modified
early passive protocols and have created an ‘early active
regimen’ by including either active MCP joint extension
13
or active wrist extension
14
while preserving the use of a
dynamic outrigger.
Another protocol, the Norwich regimen
15
uses a static
forearm-based palmar splint and includes an exercise
programme of combined active MCP and IP extension
and MCP extension with IP flexion. Functional hand use
is commenced after removal of the splint at four weeks.
The study advocates this regimen as the splint and the
protocol are not cumbersome and results are comparable
with those found with dynamic splints.
15
Khandwala
et al.
16
introduced active MCP extension and synchronous
flexion of all MCP and IP joints with their palmar block-
ing splint that left the IP joints free. In their study, no
statistically significant difference was found with regards
to the outcome measure of range of motion analysed
using both the Miller and total active motion (TAM)
assessments between a dynamic outrigger splint and the
palmar blocking splint.
16
They concluded the latter
technique was preferred due to its simplicity, low cost,
patient convenience and reduced therapy time.
16
The ‘relative motion splint’ was designed in the early
1980’s by Merritt et al;
17
however, its supporting data were
not published until 2000. The original version of this
splint consisted of a static wrist splint linked via a strap to
a static finger yoke-gutter splint. With time the splinting
technique has been enhanced to produce the Immediate
Controlled Active Motion (ICAM) splint programme,
currently in its third version. This splint consists of two
components worn full time for the first three postopera-
tive weeks: a wrist extension splint with 20–258of exten-
sion, and a finger yoke splint holding the repaired
tendon/s in 15–208more extension relative to the unin-
jured digit/s. Between weeks 3 and 5 the wrist component
is discarded unless performing medium to heavy-duty
tasks. Following this, to protect the repaired tendon while
completing medium to heavy-duty tasks, the yoke splint
is applied. Patients are given individual exercise pro-
grammes to achieve full active motion within the limits of
the splint.
18
Merritt highlights that the splint allows the
patient to continue normal activities.
18
Thomas et al.
11
describe in a personal communication
with Hoel in 1993, a yoke splint in the postoperative
M J Hirth et al. Relative motion splinting of extensor tendon repairs
Hand Therapy Vol. 16 No. 4 December 2011 87
management of incomplete lesions and isolated lesions of
extensors to the index and little fingers. However, no data
or trial outcomes of this splint have been reported in the
literature.
This article describes the implementation of an
alternative early active mobilization protocol. It is a
modified version of ‘the relative motion splint’ and ICAM
protocol described by Merritt et al.
17
and Howell et al.
18
We have labelled it the ‘Modified Relative Motion Splint’
(mRMS).
Modified relative motion splinting
Review of the literature suggests, with similar range of
motion outcomes, a simple splint design is preferable to a
dynamic outrigger.
15,16
By integrating the features of several splint designs and
rehabilitation protocols the mRMS was developed.
Central to the rehabilitation programme is a simple, small
splint that permits functional hand use.
The main design modification from the ICAM
18
splint
was to discard the wrist component, leaving only the
finger yoke. The clinical reasoning behind this decision
was four-fold. Firstly, Thomas et al.
11
had achieved suc-
cessful results with their hand-based Levame splint for
zone V injuries and reported successful results using a
yoke-only splint for incomplete tendon lacerations and
isolated injuries of the index and little fingers. Secondly,
Evans’
13
immediate short arc motion protocol supported
active finger extension when the wrist was positioned in
208of flexion. Thirdly, Eissens et al.
14
advocated early
active wrist mobilization. Finally, if synchronous wrist
and finger flexion were avoided, a wrist splint may be
unnecessary. Sharma et al.
19
in examining relative motion
splinting in a cadaveric model, set the wrist at 258exten-
sion and found it to be effective in reducing strain on
repaired zone VI tendons. The authors reported that with
the wrist splinted in extension, synchronous wrist and
finger flexion is prevented and they recommended future
studies to evaluate decreased wrist extension on repair site
strain.
19
Methods
Following ethical approval from the Human Research
Ethics Committee at Austin Health, a retrospective review
was undertaken of 46 consecutive single finger zone V and
VI extensor tendon repairs. The 46 patients received
either immobilization or modified relative motion
splinting between 2000 and 2009. Patients with isolated
extensor indicis, extensor digiti minimi or extensor digi-
torum communis injuries and/or an associated capsular
repair were included in the study. The exclusion criteria
included patients with tendon repairs to more than one
finger, associated fractures, incomplete data-sets and
failure to attend for follow-up, or those aged 17 years and
under. A total of 39 patients met these criteria. The Austin
Health Plastic and Reconstructive Surgery Unit performed
all tendon repairs and patients were referred to occu-
pational therapy for postoperative management following
an outpatient clinic appointment with the treating
surgeon. Mode of rehabilitation was selected on the basis
of delay of referral to therapy. This delay was due to
administrative issues, primarily clinic availability for
patients to attend and did not relate to any surgical vari-
able. All patients were immobilized after surgery by a
plaster of Paris back slab. Patients seen by the therapist
within seven days of surgical repair were selected for the
mRMS protocol and patients seen after seven days con-
tinued to be treated by immobilization. Sixteen patients
(16 fingers) were in the immobilization group and 23
patients (23 fingers) in the modified relative motion splint
(mRMS) group. Details of the protocols and splint designs
are outlined below.
Treatment protocols
Immobilization group
A resting splint was fabricated at the initial outpatient
clinic appointment following surgery. Patients were
instructed to wear their splint at all times until review
with the therapist. Mobilization was commenced four
weeks following tendon repair. At this time splinting was
ceased and a home exercise programme began that
addressed any joint stiffness, tendon lag or scar adhesion.
Patients attended therapy sessions weekly or fortnightly,
depending on need. They were advised to avoid ‘heavy’
tasks for a total of 8–10 weeks.
mRMS group
At the initial outpatient clinic appointment, between two
and seven days postoperatively, both the mRMS and the
resting splint were fabricated. Patients were instructed to
wear the mRMS during the day and to wear the resting
splint overnight. No specific home exercises were pre-
scribed. Patients were encouraged to use their hands
functionally when wearing the mRMS, but were asked to
avoid simultaneous wrist and finger flexion. Patients
attended therapy at least fortnightly. The resting splint
was ceased after four weeks when a home exercise pro-
gramme began addressing any joint stiffness, tendon lag
or scar adhesion. Patients were encouraged to wear the
mRMS when performing ‘heavy’ tasks for a total of 8–10
weeks.
Splint designs
Resting splint
Forearm-based splints were fabricated with 3.2 mm ther-
moplastic. The wrist was immobilized in 308extension,
and the MCP joints in 308flexion. IP joints were posi-
tioned in full extension. (Figure 1).
Modified relative motion splint
A 3.2 mm thermoplastic strip (1.5 cm 15 cm) was
moulded over the proximal phalanges holding the
injured finger in 15–208of relative extension to the
uninjured fingers. (Figures 1–10). All four fingers are
included in this splint design.
M J Hirth et al. Relative motion splinting of extensor tendon repairs
88 Hand Therapy Vol. 16 No. 4 December 2011
Outcome measures
Range of motion was measured using a 15 cm plastic
goniometer. Kleinert and Verdan’s total active motion
assessment of extensor tendons (TAM) system was then
employed to compare group results at 6 and 12 weeks
following surgery.
20
TAM is calculated by the following
formula: TAM ¼([MCP þPIP þDIP flexion] 2[MCP þ
PIP þDIP extension lag]).
20
Ratings are achieved via
comparison to the contralateral finger with ‘excellent’
corresponding to an equal TAM, ‘good’ for TAM .75%,
‘fair’ for a TAM .50% and poor with a TAM ,50%.
20
Information on return to work and return to activities of
daily living was also recorded. Return to work data were
collected in two categories: average return to work time-
frame and manual workers return to full duties.
Statistical analysis
Two-way mixed analysis of variance (ANOVA) was used to
examine the interaction between splinting regimen and
time. The significance of the effect of treatment protocol
on mean %TAM and return to work data were tested using
the Mann-Whitney Utest with statistical significance set
to P¼0.05 (GraphPad Prism 5 Software).
Results
Patient demographics are summarized in Table 1. The
immobilization group mean age was 39.4, with a range of
18–69 years, and consisted of 13 men and three women.
The mRMS group mean age was 37.2 with a range of 19–
72 years, and consisted of 22 men and one woman.
The majority of lacerations occurred in zone V, 13 in the
immobilization group and 21 in the mRMS group. The
joint capsule was breached in 6/13 zone V injuries in the
immobilization group and in 12/21 in the mRMS group.
Fewer lacerations occurred in zone VI, three in the
immobilization group and two in the mRMS group.
As illustrated in Table 2, the mRMS group demonstrated
significantly improved range of motion when compared
with the immobilization group. This effect was most
marked at six weeks with a 12% difference in mean %TAM
Figure 2 A 1.5 cm strip of thermoplastic is cut to fabricate
the modified relative motion splint
Figure 1 Resting splint beside modified relative motion splint Figure 3 The injured finger is held in relative extension
Figure 4 The modified relative motion splint is moulded over
the proximal phalanges
M J Hirth et al. Relative motion splinting of extensor tendon repairs
Hand Therapy Vol. 16 No. 4 December 2011 89
between the two groups (P¼0.0076, Mann-Whitney U
test). Figure 11 shows the corresponding mean category
ratings for the two groups over time. At the six-week
assessment the immobilization group achieved a mean
category rating of ‘fair’ compared with the ‘good’ category
rating of the mRMS group. In this way, the mRMS-treated
patients achieved ‘good’ and ‘excellent’ range of motion
scores earlier than the immobilization group. Of the
patients in the mRMS group, 18 of the 23 recorded ‘good’
or ‘excellent’ results six weeks postoperatively, while the
immobilization group recorded ‘good’ results in 10 out of
16 patients. Similarities were observed between groups 12
weeks postoperatively. All 23 fingers in the mRMS group
and 15/16 fingers in the immobilization group recorded
‘excellent’ or ‘good’ results at this time point. Two-way
ANOVA was used to test for a possible interaction between
time and splinting regimen. No statistically significant
interaction was found (P¼0.092); however, the use of
mRMS protocol and increased time postsurgical repair (12
versus 6 weeks) both demonstrated statistically significant
improvements in TAM scores (P¼0.014 and P,0.0001,
two-way ANOVA).
Differences in return to work times between groups
were statistically significant (P¼0.0062, Mann-Whitney
Utest) and details of return to work timeframes are pre-
sented in Table 3. The average return to work was
Figure 5 The therapist ensures the injured finger is held in
relative extension to the uninjured fingers
Figure 6 Lateral view of modified relative motion splint
Figure 8 Volar view of modified relative motion splint
Figure 9 Functional use of the hand including drinking from
a cup is encouraged with modified relative motion splint
Figure 7 Dorsal view of modified relative motion splint
M J Hirth et al. Relative motion splinting of extensor tendon repairs
90 Hand Therapy Vol. 16 No. 4 December 2011
significantly better in the mRMS group (mean return to
work 3.3 weeks) compared with the return to work data
for the immobilization group (mean return to work 9.4
weeks). Those in the mRMS group returned to work on
average 42 days earlier than those in the immobilization
group. Seventeen patients were manual workers, 6/16 in
the immobilization group and 11/23 in the mRMS group.
Injuries sustained at work comprised nine of the 39
patients studied. Again, there was a significantly earlier
return to work for manual workers in the mRMS group
compared with the immobilization group (P¼0.0071
Mann-Whitney Utest). None of the six manual workers in
the immobilization group returned to any form of work
duties by six weeks, with an average return to full
duties at 11.7 weeks. Five of the 11 manual workers in the
mRMS group returned to full work duties by six weeks
with an average return to full duties at 7.7 weeks.
There was no incidence of infection or tendon rupture in
either group.
Discussion
Multiple postoperative protocols for the management of
extensor tendon repairs have been described in the lit-
erature. When comparing the various regimens, range of
motion is the predominant outcome measure. Similar
range of motion outcomes are demonstrated 12 weeks
postoperatively for each of the ‘immobilization’, ‘early
controlled mobilization’ and ‘early active’ protocols.
4
Our
study replicated these results with both treatment groups
experiencing no significant difference in range of motion
12 weeks postoperatively. While direct comparison
between studies is difficult due to differing study par-
ameters, there is enough evidence to indicate a benefit
associated with ‘early controlled or ‘early active’ protocols
over ‘immobilization.’
5
The range of motion outcomes for
our ‘immobilization’ group are similar to other outcomes
reported in the literature.
1,5,6
As with other studies com-
paring immobilization and early mobilization protocols,
patients in our study achieved statistically significant
differences between groups.
8,21,22
At the six-week post-
operative time point, the early mobilization group
attained 12% more TAM when compared with the
immobilization group. The magnitude of this effect
resulted in the mean %TAM score being graded as ‘good’
for the mRMS group, but only a ‘fair’ grading for the
immobilization group. Clinically, this improved rating for
the mRMS group may translate into improved hand
function; however, this would require further investi-
gation to accurately quantify.
When comparing results of our study with other ‘early
mobilization’ protocols, (either ‘early controlled’ or ‘early
active’ protocols) the results are comparable. All patients
in the mRMS group scored ‘excellent’ and ‘good’ results
12 weeks postoperatively. While direct comparison is dif-
ficult with varying outcome measures, our results appear
similar to the 97% using the Levame splint,
23
the 86%
using a functional static splint via Millar’s classification
12
and 92% in the Norwich Regimen using the Dargan
criteria.
15
Important considerations when designing a splint
include splint size, aesthetics, costs, and ease of rehabili-
tation and protocol implementation. Most importantly
the splint must protect the tendon repair.
Despite the wrist being free to mobilize during the day
in the mRMS, no tendon rupture or tendon lag was noted
in our 23 patients. The intraoperative trial conducted by
Howell et al.
18
reported tension on an extensor tendon
repair was reduced when the wrist was placed in 208of
extension. It is assumed that the majority of functional
tasks occur within the tenodesis range. Hence, the simple
instruction to avoid simultaneous wrist and finger flexion
while wearing the mRMS may have prevented tendon
rupture or gapping. Further studies are warranted to
investigate the degree of tension placed on a tendon
repair with this approach. Additionally, the overnight
resting splint may have decreased the risk of tendon
rupture or gapping by avoiding unintentional composite
wrist and finger flexion during sleep. Furthermore, the
Figure 10 Early return to activities such as writing is possible
with modified relative motion splint
Table 1 Patient demographics
Immobilization mRMS
n516 Proportion of
patients (%)
n523 Proportion of
patients (%)
Average age 39.43 37.17
Age range 18–69 19–72
Gender 3 F:13 M 18.75 F:
81.25 M
1 F:22 M 4.35 F:
95.65 M
Zone V 13 81.25 21 91.30
Zone VI 3 18.75 2 8.70
Index 3 18.75 8 34.78
Middle 8 50.00 10 43.48
Ring 1 6.25 3 13.04
Little 4 25.00 2 8.70
EDC 11 68.75 18 78.26
EDM 3 18.75 0 0.00
EI and EDC 1 6.25 5 21.74
EDM and EDC 1 6.25 0 0.00
Capsular
repair
6 37.50 12 52.17
mRMs, modified relative motion splint; EDC, extensor digitorum
communis; EDM, extensor digiti minimi; EI, extensor indicis
M J Hirth et al. Relative motion splinting of extensor tendon repairs
Hand Therapy Vol. 16 No. 4 December 2011 91
night splint can assist in managing any oedema that
occurred while wearing the mRMS. Thomas et al.
11
describe using Hoel’s yoke splint for incomplete tendon
repairs or isolated tendon repairs of the index and little
finger only. Our study, however, has trialled and found
that a yoke-only splint can be applied safely to complete
tendon repairs of any finger.
It has been recommended that due to its simplicity an
immobilization protocol should be implemented for
non-compliant patients.
22
Hall et al.
21
have suggested
that an immobilization protocol decreases the risk of
tendon rupture, as a patient is not required to complete a
precise home exercise programme. Patient compliance in
regards to splint wear and therapy is essential for safe and
effective rehabilitation. According to Khandwala et al.
16
many patients were excluded from their study due to
failure to participate in therapy and suggested this is a
recurring problem in a young, largely male population.
The majority of patients within our study fit into this
demographic. Further to this, with similar postoperative
results of early mobilization protocols using either
dynamic or static splints, use of a simple, inexpensive
splint design is preferable to dynamic splints, which can
be more expensive, complex to fabricate and inconveni-
ent to wear.
12,15,16,21
Based on this hypothesis that sim-
plicity encourages compliance, we postulate that our
modified relative motion splint with simple design and
simple instructions may not only yield better measurable
results than an immobilization design, but also yield
improved compliance as it enables early functional hand
use.
Models of health, such as that described by
Townsend,
24
reflect the importance of participation in
meaningful daily living activities to promote wellbeing.
All patients were able to perform activities of daily living
while wearing the mRMS with the exception of activities
requiring simultaneous wrist and finger flexion.
Currently, there are three designs that enable early func-
tional hand use. These are: the Levame splint,
23
Slater and
Bynum’s
12
functional static splint and the relative motion
splint introduced by Merritt et al.
17
with the later devel-
opment of the ICAM protocol by Howell et al.
18
It is
understood that functional hand use is restricted while
wearing any splint. However, we believe that our modified
version of relative motion splinting is the smallest splint
design presented in the literature, with the least func-
tionally limiting protocol. An example of early return to
functional activities when wearing the mRMS is the
capacity to complete bilateral tasks such as eating, dres-
sing and showering. In the latter case once showered,
patients are instructed to remove the splint while their
hand is supported on a table, dry the hand and splint, and
then re-apply the splint. Additionally, functional hand
use translates into the ability to return to work.
Hall et al.
21
state, ‘ultimately, the patient’s goal is rapid
return to work’ ( p. 687). Little is published with regards to
return to work activity for those treated with an immo-
bilization regimen. Purcell et al.
6
noted in their study, all
patients had returned to their previous employment at a
four-month assessment; however, time from injury to
return to work was not detailed. In our case, the immo-
bilization group returned to work at an average of 9.4
weeks post-tendon repair, consistent with litera-
ture.
7,9,15,16,25
This was significantly later than the mRMS
group, who returned on average at 3.3 weeks. These
findings are consistent with the results obtained using the
Table 2 Mean %TAM and proportion of patients in each outcome category
Immobilization mRMS
6 Weeks 12 Weeks 6 Weeks 12 Weeks
n516 Proportion
of patients
(%)
Mean
%TAM
n516 Proportion
of patients
(%)
Mean
%TAM
n523 Proportion
of patients
(%)
Mean
%TAM
n523 Proportion
of patients
(%)
Mean
%TAM
Excellent – – – 7 43.75 99.77 1 4.35 99.63 18 78.26 100.61
Good 10 62.5 77.70 8 50 86.28 17 73.91 86.58 5 21.74 86.35
Fair 4 25 58.38 1 6.25 70.12 5 21.74 56.47 – – –
Poor 2 12.5 44.53 – – – – – – – – –
TAM, total active motion
Figure 11 Total active motion (TAM) ratings and mean
%TAM changes over time
Table 3 Mean return to work times and patient proportions
of return to work
Immobilization mRMS
Mean RTW (weeks) 9.38 3.33
Proportion of RTW prior to 6 weeks
postoperatively
1/16 14/23
Mean RTW manual workers full duties
(weeks)
11.67 7.72
Proportion of RTW manual workers prior
to 6 weeks postoperatively
0/65/11
mRMs, modified relative motion splint; RTW, return to work
M J Hirth et al. Relative motion splinting of extensor tendon repairs
92 Hand Therapy Vol. 16 No. 4 December 2011
two-part splint and ICAM protocol.
18
The Norwich
regimen, another early active mobilization protocol,
recorded a lengthier return to work timeframe with an
average return to work of 6.5 weeks for simple tendon
injuries and 8.5 weeks for complex injuries.
15
Similarly,
early controlled mobilization protocols detailed lengthier
return to work timeframes. Browne and Ribik
9
reported an
average return to work of 9.5 weeks, Bruner et al.
7
10
weeks, Hung et al.
25
8.5 weeks and Khandwala et al.
16
reported return to light work at 4 weeks, driving at
8 weeks and heavy manual work at 12 weeks. It is
therefore, believed that the mRMS is a valuable splint
option for return to work.
Return to manual work prior to 10–12 weeks post-
tendon repair has not been recommended in the litera-
ture.
14,16
Manual workers in our study allocated to the
mRMS group were able to return to full duties by 7.7
weeks. Discussion with the patient is essential to deter-
mine their work duties and suitability for return to work.
An electrician within our group chose to wait 10 weeks
before returning to work, as he believed he could not
avoid composite wrist and finger flexion in his role. In
contrast, a carpenter was able to return to work and use
his tools following mRMS application 10 days following
surgery. We believe that while the mRMS is being worn
and after adequate education, earlier return to work is
permitted as the tendon is sufficiently protected and the
wrist is free to move. For patients aiming to return to full
manual work prior to the previously anticipated 10–12
weeks, this splint may allow them to return immediately
following splint application. A suitable return to work
plan would be enhanced via collaboration between the
treating surgeon, therapist and patient.
Implications for hand therapy practice
Considering comparable range of motion results are
ascertained using either the mRMS protocol or other early
mobilization protocols, we advocate use of the mRMS as it
is small, inexpensive, simple to fabricate and associated
with a simple treatment regimen.
Successful outcomes using the mRMS protocol in this
study were achieved by patients wearing the mRMS
during the day and a resting splint overnight for the first
four weeks, then continuing to wear the mRMS for a total
of 8–10 weeks for ‘at risk’ activities. Further investigation
into the temporal components of this protocol are war-
ranted, such as reviewing the postoperative timing of
initial mRMS application, and the length of time the
splint should be worn to adequately protect the healing
tendon/s. Exploration of adjunctive therapy in treatment
sessions is also recommended. For instance, incorporating
active flexion and extension exercises in the first four
postoperative weeks, such as those outlined in the
Norwich regimen,
15
may enhance this protocol and
minimize any later therapy required to regain movement,
in particular MCP flexion. Optimal patient outcomes will
also be achieved when the treating therapist considers
both the art and science of hand therapy via clinical
reasoning. Individual variations to the mRMS protocol
need to be made based on patient progress and therapist
judgement. For example, the frequency of exercises may
need to be increased for a particularly stiff joint, or early
detection of a tendon lag can be addressed by decreasing
the amount of MCP joint flexion in the night resting
splint.
The mRMS protocol should be explored to assess its
suitability for use in more complex cases where associated
injuries exist other than underlying capsular repair. The
inclusion criteria for this study were single finger tendon
repairs. External to this study, the authors have success-
fully used the modified relative motion splint for patients
who have sustained tendon injuries to two fingers. This
splint design has enabled a patient who had bilateral ring
and little finger tendon repairs in zone V to be function-
ally independent following splint application five days
after surgery.
The small sample size and lack of random allocation to
the two treatment groups are limitations of this retro-
spective review. There is potential for selection bias and
systematic differences in the groups as a result.
Additionally, different therapists collected data and
various plastic and reconstructive surgeons conducted the
surgical tendon repairs adding to the number of variables
in this retrospective review. We recommend future ran-
domized controlled trials.
Conclusion
The modified relative motion splint used in conjunction
with a night resting splint can be safely applied in the
postoperative management of a single zone V or VI
extensor tendon repair. Advantages to this protocol
include the small simple splint design, and straightfor-
ward patient instructions that enable early mobilization,
early functional hand use and early return to both daily
living and work.
Acknowledgements: The authors wish to thank: Tanya
Cole, Pearse Fay and Georgia McGuinness, Occupational
Therapy colleagues at Austin Health for assisting in data
collection; Amanda Bladen, Austin Health Occupational
Therapy Manager for her support and encouragement, the
late Leanne Breen who was involved in the early
implementation of this splint design and Natalie Horman
for her assistance with manuscript preparation.
Competing interest: None declared.
Accepted: 18 May 2011
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