Flexor Tendon Repair: Splinting and Early Motion Protocol Documentation
- Flexor tendon repairs are classified by the anatomic zone of injury, with Zone II injuries (the region from the A1 pulley to the mid-portion of the middle phalanx) historically presenting the greatest rehabilitation challenge because the tendons share a sheath with adjacent structures that can adhere to the repaired tendon during healing. The American Society for Surgery of the Hand (ASSH) clinical guidelines support early controlled mobilization protocols after primary flexor tendon repair to reduce adhesion formation and improve range of motion outcomes. Discharge instructions must document the specific early motion protocol prescribed, because early motion protocols vary by surgeon preference and repair technique, and a patient who receives instructions to keep the hand immobile when the surgeon intended early mobilization will develop adhesions that require tenolysis.
- Early controlled mobilization protocols after flexor tendon repair include the Kleinert protocol (passive flexion with active extension within a dorsal blocking splint), the Duran protocol (passive range of motion exercises within a protective splint), and place-and-hold protocols (therapist-guided active motion within a protective splint starting in the first week). Each protocol requires a specific splint configuration: the dorsal blocking splint typically positions the wrist in 20 to 30 degrees of flexion and the metacarpophalangeal joints in 70 to 90 degrees of flexion. Discharge instructions must specify the splint type and position, the exercises to be performed, the frequency and number of repetitions, and the physical or occupational therapy appointment date for supervised protocol initiation. Without this specificity, the patient cannot perform the protocol correctly at home.
- The dorsal blocking splint applied after flexor tendon repair must be worn at all times except during prescribed exercises, including during sleep, for the first 4 to 6 weeks after repair. Discharge instructions must explicitly state that the splint may not be removed unless directed by the surgeon or therapist, that the repaired finger must not be actively extended against resistance during the protective phase, and that passive extension of the finger within the splint limits is permitted for some protocols but must be clarified by the supervising therapist. Instructions that tell the patient to wear the splint but do not describe the motion restrictions that apply within that splint create ambiguity that leads to inadvertent stress on the repair.
- Rupture of a primarily repaired flexor tendon during the protective mobilization phase is the most serious early complication. Discharge instructions must specify the warning signs of repair rupture: a sudden pop or give felt during exercises, sudden loss of the ability to flex the repaired finger that was present before, or sudden severe pain during exercises. Instructions must provide a specific same-day contact pathway for reporting these signs. The American Society for Surgery of the Hand (ASSH) patient education resources, available through the ASSH website, describe tendon repair aftercare expectations in patient-accessible language that practices may use as a supplement to physician-specific instructions.
Nerve Repair and Peripheral Nerve Injury Aftercare Requirements
- Digital nerve repairs in the hand restore sensation to the affected finger and, when the motor nerve to an intrinsic muscle is included, motor function as well. Recovery after peripheral nerve repair is determined by the rate of axon regeneration, which averages approximately 1 millimeter per day based on established peripheral nerve physiology. For a digital nerve repair at the level of the proximal phalanx with a distal nerve gap of 20 millimeters, the patient should expect sensory recovery to begin at approximately 20 to 40 days after repair, progressing distally over the following weeks. Discharge instructions must communicate realistic recovery timelines based on the nerve repaired, the level of the injury, and the age of the patient, since younger patients have faster nerve regeneration rates.
- Splinting after digital nerve repair protects the repair from tension during the early healing phase. The repair must be positioned to avoid longitudinal tension on the nerve, which typically means positioning the adjacent joint in slight flexion. The specific splint position depends on the location and direction of the nerve repair. For median nerve repairs at the wrist, the wrist is typically splinted in slight flexion for 3 to 4 weeks to protect the repair from longitudinal tension. Discharge instructions must specify the splint position and duration of immobilization, and whether any motion is permitted in the early post-operative period.
- Sensory re-education is an important component of recovery after peripheral nerve repair and is initiated when protective sensation returns, typically beginning 3 to 6 months after repair for digital nerve injuries at the finger level. Discharge instructions should note that sensory re-education will be introduced at a future therapy visit and should explain that initial sensation upon recovery may be abnormal: patients often experience hypersensitivity, tingling, or paresthesias as axons re-innervate sensory end organs. Discharge instructions that do not prepare patients for abnormal sensory experiences during recovery lead to anxiety and unnecessary follow-up calls, because patients interpret hypersensitivity as a complication rather than a sign of recovery.
- Cold intolerance is a predictable and prolonged symptom after peripheral nerve injuries of the hand, documented extensively in hand surgery literature, and sometimes persisting for 1 to 2 years post-injury. Discharge instructions should specify that cold intolerance is expected, that it does not indicate the nerve repair failed, and that it typically improves with time and desensitization exercises. Instructions should also address protective measures: patients should wear gloves in cold environments, avoid prolonged cold exposure, and report to the surgeon if cold intolerance is severe enough to limit daily activities, because pharmacologic management options exist for refractory cases.
Distal Radius Fracture and Metacarpal Fracture Discharge Documentation
- Distal radius fractures treated with volar locking plate fixation are among the most common fractures managed operatively in hand surgery. Discharge instructions after volar locking plate fixation must specify: whether a cast or splint was applied and its duration, when to begin formal hand therapy, any weight-bearing restrictions on the wrist, wound care instructions for the incision site, and the follow-up appointment date with timing for radiographic assessment. Patients who leave the facility without knowing when to start therapy or when their first post-operative X-ray is scheduled are at risk for delayed mobilization, which can compromise the ultimate range of motion outcome after a technically successful fixation.
- Finger and metacarpal fractures stabilized with percutaneous pinning require discharge instructions addressing pin care and the risk of pin tract infection. Instructions must specify: wound care for each pin site (typically daily cleaning with a saline-soaked cotton swab), the signs of pin tract infection (redness extending beyond the pin site, warmth, purulent drainage, fever, increasing pain at the pin site), the date for pin removal, and activities that risk pin migration or breakage. Pin tract infections, though typically superficial, can develop rapidly and require prompt antibiotic treatment to prevent spread to the periosteum. Instructions should specify same-day contact with the practice for any signs of pin tract infection.
- Distal radius fractures treated non-operatively with closed reduction and casting require discharge instructions that address cast care, cast complications, and the cast change or removal timeline. Instructions must specify that the cast should not get wet, the signs of compartment syndrome requiring emergency evaluation (pain disproportionate to the injury and worsening with passive finger extension, pallor, pulselessness, paresthesias, paralysis), and finger exercises permitted and required during cast immobilization to prevent finger stiffness. Instructions must specify to go to the emergency department immediately for any signs of compartment syndrome. Compartment syndrome after distal radius fracture is a time-sensitive surgical emergency that cannot wait for a scheduled appointment.
- Return to activities of daily living and work after hand fracture fixation must be documented with restrictions specific to the injury and fixation type. A patient who works at a keyboard may return to light use within 2 to 4 weeks after volar locking plate fixation, provided the incision has healed. A patient who works with tools requiring power grip or vibration will not return to full-duty work for 3 to 4 months. Discharge instructions should document the current functional restrictions and the criteria for advancing activities, and should specify that return-to-work clearance for manual labor will require formal assessment at a follow-up appointment, not at the time of discharge.
Carpal Tunnel Release, Trigger Finger, and Dupuytren Aftercare
- Open carpal tunnel release and endoscopic carpal tunnel release produce different post-operative wound care and activity restriction requirements. After open carpal tunnel release, the incision extends approximately 3 to 4 centimeters in the palm and requires wound care for 10 to 14 days until suture removal. Discharge instructions must address: wound care frequency and technique, the date of suture removal, restrictions on heavy lifting and gripping during wound healing (typically 2 to 4 weeks), and scar management instructions after suture removal, since scar massage and silicone sheeting reduce the risk of a hypertrophic or tender palmar scar. After endoscopic carpal tunnel release, incision sites are smaller, activity restrictions are shorter, and return to light work is typically possible within 1 to 2 weeks.
- Trigger finger release (A1 pulley release) requires discharge instructions specifying that active finger range of motion exercises must begin the day after surgery to prevent adhesion formation. Unlike flexor tendon repair, trigger finger release does not involve a repair and permits immediate active motion. Discharge instructions must specify the exercises (active finger flexion and extension, multiple repetitions several times daily) and the timeframe for starting them. Instructions that recommend keeping the finger still after trigger finger release are incorrect and lead to stiffness that requires occupational therapy to resolve.
- Dupuytren contracture treated with open fasciectomy requires discharge documentation addressing wound closure type, since the wound may be closed primarily or left open to heal by secondary intention depending on the degree of contracture and the technique used. For open-wound fasciectomy with secondary intention healing, a bulky dressing is typically applied and changed every 2 to 3 days until the wound is closed, a process that takes 3 to 6 weeks. Instructions for open-wound Dupuytren surgery must describe the expected appearance of granulation tissue so patients do not interpret normal secondary healing as a wound complication. Occupational therapy for range of motion maintenance and night splinting to prevent contracture recurrence must also be addressed.
- Collagenase injection for Dupuytren contracture (Xiaflex) involves injection on day one followed by cord manipulation under local anesthesia on day two or three. Discharge instructions after the manipulation procedure must specify: wound care for the skin tears that typically occur at the cord disruption site, the finger splint to be worn at night for up to 3 months to maintain extension, the active extension exercises to be performed during the day, and the signs of complications specific to collagenase injection. Flexor tendon rupture after Xiaflex presents as inability to flex the finger and requires emergent evaluation. The FDA-approved prescribing information for collagenase clostridium histolyticum (Xiaflex) requires providers to inform patients of the tendon rupture risk and to advise them to seek immediate care if they are unable to bend their finger after the manipulation procedure.