Post-Operative Management of Extensor Tendon Repairs in Zone III and Distal Zone IV: An Evaluation of Therapy Outcomes at The Norfolk and Norwich University Hospital Sarah Hazelden and Bhavana Jha Introduction Methods Conclusion Objectives References Demographics  To identify which regimes were being used in our unit.  To evaluate our therapy outcomes.  To compare our outcomes with the relevant published outcomes. 1.Kleinert HE, Verdan C. Report of the committee on tendon injuries. Journal of Hand Surgery 1983: 8: Crosby CA, Wehbé MA. Early protected motion after extensor tendon repair. Journal of Hand Surgery 1999; 24: Newport ML, Blair WF, Stayers CM. Long term results of extensor tendon repair. Journal of Hand Surgery 1990; 15a: Thomes LJ, Thomes BJ. Early mobilization method for surgically repaired zone III extensor tendons. Journal of Hand Therapy (American) 1995: 8: Pratt Al, Burr N, Grobbelaar AO. A Prospective Review of Open Central Slip Laceration Repair and Rehabilitation. Journal of Hand Surgery (Br) 2002: 27B(6): Evans RB, Beach V. Early Active Short Arc Motion for the Repaired Central Slip. Journal of Hand Surgery 1994; 19 (A): Retrospective review of therapy records between Inclusion criteria:  Acute zone III or distal zone IV extensor tendon injury greater than 50%  Surgical tendon repair  Hand therapy assessment at 6 weeks and 3 months post op Exclusion Criteria:  Closed Injuries  Patients who did not attend or comply to therapy Outcome Measurements:  Range of Motion measured by goniometry Used to calculate Total Active Motion (TAM) at PIPJ & DIPJ, extension lag and Strickland-Glogovac score  Grip strength measured with a calibrated dynamometer expressed as a percentage of the unaffected side  Disability of the Arm, Shoulder and Hand (QuickDASH) Questionnaire The management of extensor mechanism injuries in the hand is determined by the zone of injury 1. A range of complications are reported following surgical repairs including elongation of Extensor Digitorum Communis resulting in extension lag; decreased Proximal Interphalangeal Joint (PIPJ) and Distal Interphalangeal Joint (DIPJ) flexion and tightening of the Oblique Retinacular Ligament 2.It is argued that loss of flexion may be more significant and more functionally limiting than loss of extension after this injury 3. The regimes used in the UK can be categorised into 4 main groups:  Immobilisation 4-6 weeks with static splint +/- k-wire 3  Immediate passive/controlled movement regimes using dynamic splints 4  Early Immobilisation followed by controlled mobilisation with a Capener Splint 5  Early Active Short Arc Motion (SAM) regime 6 Currently there is no gold standard and regimes differ between units in the UK. Following a change of practice in our unit, we present a review of our outcomes. Results NNUH Outcomes At 3 months SAM regime n=17 Other regimes n=7 Mean extension / flexion at PIPJ 5.82° / 96.17° 10.14° / 63.28° Mean extension / flexion at DIPJ 1.41° / 57.94°2.57° / 38.85° Mean grip strength73% 75% Function Mean QuickDASH Score Average treatment sessions SAM Outcomes NNUH 6/52 (n=14) Evans 6 6/52 (n=26) NNUH 3/12 (n=17) Mean PIPJ flexion 69.78° 88° ° Mean PIPJ Extension Lag 7.21° 3° 5.82 ° TAM ( PIPJ & DIPJ) 93.64° 132° °  Unless severity of injury dictates immobilisation, we are selecting the SAM regime for zone III and distal zone IV extensor tendon repair rehabilitation. This supports our unit philosophy of early mobilisation.  Our outcomes with the immobilisation regime were not as good as our SAM regime. However these patients had more complex injuries and our sample size was small.  Our results at 6 weeks for the SAM regime are good and compare favourably with those published by Evans.  Our patients demonstrated significant improvement between 6 weeks and 3 months. Without further study, we cannot confirm whether this is a direct result of therapy.  N= 23 patients with 24 digits injured.  Simple : complex : complex fracture SAM 9 : 5 : 3 Delayed SAM 2 : 0 : 0 Immobilisation 0 : 2 : 3 Dynamic 0 : 0 : 0