Rehabilitation following thumb extensor tendon repair to abductor pollicis longus (APL) and/or extensor pollicis brevis (EPB)

Introduction

This leaflet is for people who have had surgery to repair one or both of two tendons that help to straighten the thumb: the abductor pollicis longus (APL) and extensor pollicis brevis (EPB). It will explain what a tendon is, how to protect the repair and what treatments will be required as part of the hand therapy rehabilitation process.

This is the first phase of your rehabilitation following repair of the tendon(s). Once you have completed this phase your therapist will advise you on new exercises to ensure the best possible results.

What are extensor tendons?

Extensor tendons are cords of tissue that connect the large muscles on the back of your forearm to the bones of your hand. They are responsible for straightening your fingers, thumb and wrist. There are three tendons that contribute to straightening your thumb: extensor pollicis longus (EPL), extensor pollicis brevis (EPB) and abductor pollicis longus (APL).

Why have they been repaired and why is it important to protect these repairs?

If you damage an extensor tendon, you will be unable to straighten your thumb. Surgery repairs the tendon which aims to restore this function in the hand. The ends of the divided tendon are located and stitched together. The stitches used are thinner than a strand of hair and for the first few weeks are the only things holding the repair together.

The repaired tendon will be very fragile until the ends heal together. It can take up to 3 months for the repaired tendon to regain its previous strength and during this time you will need to follow a strict hand therapy programme to maximise your recovery. There is a possibility of rupturing the repair if the correct precautions are not followed. If you do rupture the repair, further surgery would be required.

What can you expect immediately following surgery?

You will be contacted by the hand therapy team to arrange an appointment within 2 weeks of your surgery. It may be possible to transfer your hand therapy care closer to home after the first few appointments, depending what specialist services are available in your local area.

It is not uncommon to experience some discomfort/pain following surgery and it is important to take regular pain relief as required.

What can you expect at your first Hand Therapy appointment?

Following the surgery, it is normal for the hand to be swollen. To reduce this swelling try to keep the hand elevated above your heart (for example resting on your opposite shoulder or propped up on pillows).

Until you are seen, do not remove your post-surgery cast or attempt to use your hand at all. Don’t attempt any of the exercises until seen or spoken to by your Hand Therapist.

Splint care (once a thermoplastic splint has been made for you)

Do not place the splint in hot water or near a heater as it will change shape.

Check your skin regularly for red/pressure areas and when you remove the splint to do this, ensure you keep the hand in the position it would be in if you still had the splint on. Contact your therapist if any problems occur.

If your splint becomes too loose or tight, please contact your hand therapist.

Use a plastic bag over the whole arm when in the bath or shower (DO NOT take the splint off).

How should your splint be worn?

Please see the image below for a visual image of how the splint should be worn. Your fingers should be free to move, but the wrist and thumb (up to the end joint) secured to the splint. Your splint is to be worn full time, day and night, for 4-5 weeks post-surgery. Your therapist will advise you when your repair is strong enough to begin removing your splint.

Wound care

Why is it important to look after your wound?

To prevent infection, it is important to look after the wound whilst it is healing. It should be kept clean and dry until it is healed which is approximately 10-14 days following surgery.

Potential signs of infection or possible tendon rupture

You may have an infection if your hand feels hot to the touch, is hot, you have increased pain or there is an unpleasant smell. You should contact the plastic surgery unit on: 01223 348507 (Mon-Fri 08.30-16.30), your local GP practice or your local emergency department if out of hours.

If you feel a popping or snapping sensation and notice any sudden pain, swelling, or a change in your thumbs ability to move, this may suggest the tendons have ruptured. You should contact the plastic surgery unit on: 01223 348507 (Mon-Fri 08.30-16.30), the hand therapy department on 01223 216769 (Mon-Fri 08.30 – 16.30) or your local emergency department if out of hours.

Scar massage

Scars are collagen fibres produced because of the body’s normal healing process. The amount of scar tissue produced by the body varies depending on the individual and type of surgery/injury. As the wound heals there will be little scar tissue produced but over time the body may develop more.

Why is it important to massage your scar?

Initially scars can be firm, thick and red in colour (active phase) but over time soften and become pale in colour (matured). This whole process may take 12 to 18 months or more.

During the “active phase” you can use treatments to influence your scar. Initially as scar tissue forms it is thick and lumpy and can stick to structures around it; scar massage helps to flatten, make it softer and reduces the chance of scar tissue sticking (adhesions).

When can I start scar massage?

24-48 hours after your stitches have been removed, if the wound is healed and dry.

If you have dissolvable stitches, you can start massaging your scar at approximately 12-14 days after surgery, providing the wound is healed and dry.

You will need a basic, un-perfumed moisturising cream. For example, aqueous cream or ‘E45 cream’, are ideal for massaging the scars.

Please keep your splint on when doing scar massage.

The scar massage needs to be in circular movements, on and around the scar line, to keep the skin moving freely. In the first few days you may only tolerate gentle massage, but you should then aim to increase it to a deep and firm massage to reduce the risk of adhesions (see picture below).

How can you help your recovery?

To help your recovery you should cut down or stop smoking and drinking alcohol.

Keep your hand elevated as much as practically possible to prevent swelling in your hand.

Do not use your hand for anything other than your exercises until advised by your hand therapist.

Time frames for resuming activities

It may be possible for you to return to work on light duties earlier than above as long as you are not using your injured hand, but please discuss this first with your hand therapist.

If you need a “fit note”, please speak with your treating therapist or contact your GP.

Exercise – why is it important?

Exercise is important to facilitate your recovery. It will reduce stiffness and swelling in the hand thumb and fingers and help your tendon-repair to glide in a controlled way. This helps to prevent adhesions but protects the repair from being damaged or rupturing. Your therapist will teach you specific exercises which you must complete throughout the day

Thumb extensor repair exercises

It is recommended that the exercises are done in the order outlined below. DO NOT begin or progress exercises unless you have been advised by your hand therapist.

Week 0-4

Do try to keep your unaffected joints (elbow, shoulder, neck) moving freely to avoid unnecessary stiffness.

Further information

Your therapist will check your progress regularly and will adjust your therapy programme if necessary.

It is vital that you attend all therapy appointments. If you do not carry out your exercise programme or attend all your therapy appointments you will not get the best results and may make the repair of your tendon more difficult.

If you require further information please contact your occupational therapist on 01223 216769.

References

• Burr and Pratt (2006) Early active motion rehabilitation versus immobilisation for thumb extensor tendon repairs: a review of two case studies, Hand Therapy, 11(4), p114-119.
• Cannon, M, Indiana Hand to Shoulder Centre, Diagnosis and treatment manual for physicians and therapist, Upper extremity rehabilitation, 4th edition.
• Fujimoto et al (2009) Spontaneous rupture of the extensor pollicis brevis tendon in a baseball pitcher: a case report, Upsala Journal of Medical Sciences, 114, p189-192.
• Soni et al (2009) Advances in extensor tendon diagnosis and therapy, Plastics Reconstructive Surgery, 123(2), p52-57e.
• Talsma et al (2008) The effect of mobilisation on repaired extensor tendon injuries of the hand: a systematic review, Archives of Physical medicine and rehabilitation, 89, p236-72.