A systematic review of rehabilitation protocols following surgical repair of the extensor pollicis longus

Abstract

Introduction

The goal of this systematic review was to determine which rehabilitation protocol (static, dynamic or early active) yields the best outcomes following repair of the extensor pollicis longus (EPL) tendon in the following domains: total active motion (TAM), grip strength and range of motion.

Methods

A comprehensive and systematic literature search was run. The retrieved abstracts and titles were screened by two independent reviewers. Rehabilitation protocols were classified as static, dynamic or early active. Methodological quality of included randomized controlled trials and cohort studies were assessed using the SIGN50 scale.

Results

Fifteen articles were included in the final analysis (κ = 0.8). From this total, five studies employed static splinting, 12 dynamic splinting and two early active splinting. Static splinting yielded ‘excellent’/‘good’ results ranging from 50% (minimum) to 60% (maximum) on the TAM classification system and a weighted mean TAM of 73.0 ± 24.0° (range 58.75–85°). Dynamic splinting studies demonstrated ‘excellent’/‘good’ results ranging from 64.4% (minimum) to 98% (maximum) and a weighted mean TAM of 111.2 ± 11.7° (range 89–134°) (P < 0.001 and mean difference of 38.2 (95% confidence interval: 32.2–44.2). In one study, early active motion resulted in 83% of patients having ‘excellent’/‘good’ ratings.

Discussion

The available level II–IV evidence suggests better outcomes when using dynamic splinting over static splinting for rehabilitation of the EPL tendon repair. Further evidence is required to clinically confirm the differences between early active and dynamic rehabilitation protocols.

Keywords

Hand injuries thumb pollicus longus splints extensor tendon

Introduction

The division of the extensor pollicis longus (EPL) tendon is a frequent problem; however, the literature on this subject is scant and the management of these injuries is rarely discussed in isolation from the finger extensors.¹ The EPL is the main extensor of the thumb and is responsible for producing extension of the interphalangeal (IP) and metacarpophalangeal (MCP) and trapeziometacarpal joints.^2–5 However, many authors have largely ignored the obvious anatomical, biomechanical and functional differences between the thumb and the other digits with only a few authors considering EPL injuries in isolation.^1,6,7

Among studies examining postoperative rehabilitation regimens for EPL injuries, there does not appear to be a consensus with regard to which approach is best. Some common interventions include: immobilization of the thumb in extension^2,3,8 and dynamic extension splinting^1,6 which provides traction against the thumb by attachment of a rubber band over it to permit passive movement and facilitate early controlled motion. Finally, early active splinting allows the thumb to move freely at the MCPs and encourages active flexion and extension.⁹ Historically, the preferred method for EPL rehabilitation has been immobilization or static splinting. Although current studies demonstrate superiority of regimens employing motion, static splinting may be the best choice in patients who are non-compliant with the higher demands of a dynamic rehabilitation regimen. However, in dynamic splinting, these higher compliance demands are met with the healing benefit of early motion, which are known to minimize the formation of tendon adhesions. In the past, this approach has been applied to flexor tendons with good results^10,11 and is now increasingly being employed in extensor tendon rehabilitation.^12–16 Many of these studies indicate the benefits of early motion following surgical repair of extensor tendons in such parameters as total active motion (TAM), return to work, extensor or flexion deficit and grip strength.^16–21 Another approach, early active mobilization, capitalizes on the physiological gains afforded by early motion by giving the patient even more range of motion (ROM) by allowing the MCP joints to move freely as well as encouraging active flexion and extension immediately after the tendon repair.

The purpose of this review is to systematically evaluate the effectiveness and methodological rigour of static, dynamic and early active rehabilitation protocols following surgical repair of the EPL tendon. Specifically, this review attempts to answer the following: Does dynamic splinting provide superior functional outcomes in terms of TAM, ROM and grip strength post-EPL tendon repair in the short, intermediate or long-term periods compared with static splinting?

Methods

Search strategy

A literature search with the assistance of a professional librarian was conducted of the following electronic databases: Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, MEDLINE (January 1950 to November 2012), CINAHL and EMBASE (January 1980 to November 2012). The keywords used were a combination of ‘hand injuries’, ‘thumb’, ‘pollicus longus’, ‘extensor tendon’, ‘splints’ with limits, ‘English’ and ‘human’. Three additional studies following the screening were included into the final analysis after reviewing reference lists.

The search strategy is outlined in Figure 1 as well as described in greater detail in Appendix 1. Authors adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.²²

Figure 1

Search process.

Article eligibility

Two reviewers independently scanned the retrieved articles’ abstracts for potential relevance. In order to be included, the article had to meet the following inclusion criteria: the study must follow patients who have undergone EPL tendon repair with postoperative management with either a static, dynamic or early active rehabilitation protocol. The study had to assess postoperative EPL management including utilization of clinical outcome markers. Our exclusion criteria were as follows: articles exclusively examining non-living populations or animal studies or flexor tendon repair. We also excluded case reports, letters to editors, abstracts or meeting proceedings as well as articles that studied other variables outside of management of EPL repair.

Management classification and outcomes measures

Extensor tendon repair rehabilitation regimens were classified into three broad categories (1) static or immobilization (2) early controlled or dynamic (3) early active motion based on previous definitions and protocols used.^23,24 The results of each study were examined with regard to ROM using TAM, Miller, Geldmacher, Strickland–Glogovac scales and grip strength.^25–29 The most common assessment scale among all studies over the past 15 years is TAM, which is defined by (MCP + PIP + distal interphalangeal (DIP) flexion) – (MCP + PIP + DIP extension lag).^24,25 The TAM classification of the American Society for Surgery of the Hand consists of four qualitative distinctions (‘Excellent’, ‘Good’, ‘Fair’ and ‘Poor’), which correspond to the percentage of motion of the unaffected hand. Specifically, ‘Excellent’ was deemed to be a percent motion in the injured side that is similar to the uninjured side. ‘Good’, ‘Fair’ and ‘Poor’ were >75%, 50% and <50% of the motion of the uninjured hand.²⁵

Assessment of methodological quality

The methodological quality of randomized controlled trials (RCTs) and cohort studies were independently assessed by two reviewers (TJW and MS) using the checklist developed by the Scottish Intercollegiate Guidelines Network (SIGN50).³⁰ In a comparison by Wells et al.³¹ in a Canadian Cochrane Symposium, SIGN50 was shown to be a superior quality assessment tool based on its ability to cover factors including study population, statistical analysis, interventions, outcomes and funding compared with more popular quality assessment tools such as Jadad and many others. The SIGN50 scale assesses the quality based on a multipart questionnaire assessing facets such as concealment, reliability of outcome measures, attrition and randomization.

The mean score of the included prospective/retrospective studies was calculated separately from the RCTs. Since SIGN50 does not contain a protocol for descriptively evaluating the studies, we therefore decided to describe them according to the following divisions: out of a maximum score of 4.00, a score of >3.00 was considered ‘strong’, 2.00–2.99 was considered ‘intermediate quality’ and studies scoring 1.00–1.99 were considered ‘weak quality’ (see Appendix 2) (Table 1).

Table 1.

Characteristics and results of included studies.

Authors	Level of evidence	Quality of evidence	Study design	No. of tendon injuries	Zones	Interventions	Outcomes
Giessler et al. (2008)⁷	II	Intermediate	RCT	10 dynamic, 11 EAM	TIV and TV	Group 1: DES Group 2: Early active motion	At 3 weeks DES higher total and active ROM in IP joint (P = 0.027 and P = 0.005, respectively
Germann et al. (2001)⁶	II	Intermediate	RCT	10 static, 10 dynamic	TIV and TV	Group 1: DES Group 2: Static	GS higher in DES group at weeks 3, 4 and 6 (P < 0.05). At 4 weeks, dynamic group had higher active ROM (P < 0.05)
Brown et al. (1989)¹⁷	IV	Weak	RS	12	TI to TV	DES	100% GS compared with non-injured thumb, 100% full flexion
Marin-Braun et al. (1989)³³	IV	Weak	RS	14	TI to TV	DES	Mean TAM 64.4% excellent, GS 87.7% compared with non-injured
Newport et al. (1990)³⁴	IV	Intermediate	RS	10	TI to TV	Static	Average GS 95% of the unaffected hand. Overall TAM 85°
Purcell et al. (2000)³⁵	IV	Intermediate	PS	10	TI to TV	Static	Thumb: 50% excellent results, 30% good on AROM using SGS
Slater et al. (1997)⁹	IV	Weak	RS	6	TIII, TV	Custom moulded P/D blocking splint	83% excellent or good ratings on Miller scale
Ip et al. (1997)²⁰	IV	Intermediate	RS	25	TI to TVI	DES	Mean TAM 107°
Hung et al. (1990)³⁶	IV	Strong	PS	10	TI to TV	DES	Mean TAM 118°
Crosby et al. (1999)¹²	IV	Intermediate	RS	8	TI to TIII	Early passive motion and DES	Mean TAM 134°
Khandwala et al. (2004)¹	IV	Weak	RS	100	TI to TIV	DES	Mean TAM 81% excellent
Evans (1989)19	IV	Weak	RS	3 static, 8 dynamic	TIV and TV	Group 1:Static, Group 2: DES	1. TAM 82° 2. TAM 116°
Kerr et al. (1989)³⁷	IV	Weak	RS	26	TVI to TVIII	Dynamic extension brace	Mean TAM 118°
Justan et al. (2009)³⁸	IV	Intermediate	RS	10 DES, 10 Static	TI to TV	1. DES 2. Static	1. Mean TAM 87.5° 2. 58.75°
Figl et al. (2011)³⁹	IV	Weak	RS	25	TI to TV	DES	96% Very good/good on Geldmacher assessment

RS,retrospective study; PS, prospective study; RCT, randomized controlled trial; CS, case series; DES, dynamic extension splint; ROM, range of motion; TAM, total active motion; EAM, early active motion; P/D, palmar/dorsal; GS, grip strength, Miller Scale,²⁶ Geldmacher Assessment;²⁹ SGS, Strickland–Glogovac scale.²⁷

Data extraction

The following data were extracted from each primary article and used for descriptive comparisons: author, year, sample size, number of injuries, study design, zone of repair as described by Verdan et al.⁴⁰ (see Figure 2), duration of follow-up, study results and recommendations. Mean TAM with standard deviation, minimum and maximum were recorded.

Figure 2

Verdan’s zones of the thumb.

Data analysis

All data are summarized descriptively. A κ statistic, a measure of chance-corrected agreement was calculated to provide an estimate of agreement between reviewers with regard to the articles that were retrieved for evaluation. We chose an a priori criterion of κ≥0.60 to indicate adequate agreement.³² We decided a priori in case of less than three comparative studies (RCTs and cohort) to retrieve the data for each intervention from all studies and calculate the weighted mean with weighted standard deviations of TAM values for static or dynamic splinting. If the standard deviation was not reported, we used range to estimate assuming normal distribution. The weighted means were compared using independent t-test and a P value of 0.05 was considered statistically significant. Mean differences with 95% confidence intervals (CIs) are reported.

Results

Characteristics of included studies

The literature search identified 167 potential articles. After application of inclusion and exclusion criteria, 12 articles were deemed relevant and included into the final analysis (κ = 0.80). An additional three articles were included on the basis of relevance after reading through screened article reference lists, yielding a total of 15 articles to be included. From this total, five studies employed static splinting, 12 dynamic splinting and two early active splinting. Two of the 15 studies were RCTs, three were retrospective cohort and 10 were retrospective (8) or prospective (2) single-group cohort studies. The most commonly studied outcome measure was TAM, which was evaluated in nine out of 15 studies. This was closely followed by grip strength and ROM, which was evaluated in five out of 15 studies each.

The methodological quality of the RCTs and observational studies using the SIGN50 scale is seen in Appendix 2. The mean quality was 2.2 ± 0.23 (standard deviation) categorized as ‘intermediate’ quality and 2.0 ± 0.38 (standard deviation) also categorized as ‘intermediate’ quality, respectively.

Static rehabilitation

The vast majority (80%) of included studies examining static splinting were either prospective or retrospective in nature and level IV evidence. The quality of studies examining static splinting was found to be ‘intermediate’ with a mean score of 2.03 ± 0.30. Overall, studies evaluating static rehabilitation protocols yielded a weighted mean TAM of 73.0 ± 24.0 degrees (range 58.75–85),^6,19,34,38 with the percentage of ‘excellent’/‘good’ results ranging from 50% to 60%.^6,19,35 In one level II intermediate quality RCT, Germann et al.⁶ directly compared a dynamic motion protocol with an immobilization protocol in zones TIV and TV. At four weeks they demonstrated that the dynamic group had significantly higher active ROM (P < 0.05). Furthermore, grip strength was significantly higher in the dynamic group at weeks 3, 4 and 6 (P < 0.05), and pinch grip was significantly better in the dynamic group at week 3 (P < 0.05).

Dynamic rehabilitation

Of the 12 studies that evaluated dynamic extension splinting, two were level II intermediate quality randomized controlled studies. The quality of studies assessing dynamic splinting was deemed to be ‘intermediate’ with a mean score of 2.08 ± 0.41. Overall, studies that evaluated dynamic splinting rehabilitation protocols yielded a weighted mean TAM of 111.2 ± 11.7° (range 89–134°)^{12,19,36–38} and the percentage of ‘excellent’/‘good’ results ranged between 64.4% and 98%.^1,20,33 The weighted mean of 111.2 (11.7) degrees was significantly higher than the weighted mean of 73.0 (24.0) degrees for static splinting with a P value of <0.001 and mean difference of 38.2° (95% CI: 32.2–44.2). Giessler et al.,⁷ in a prospective randomized study comparing dynamic extension splinting (DES) and an early active protocol in zones TIV and TV showed at three weeks that DES had a significantly higher total and active ROM in the IP joint (P = 0.027 and 0.005, respectively). Power grip and tip pinch strength were also higher in the dynamic group at weeks 4, 6, 8 weeks; however, this failed to reach statistical significance.

Early active rehabilitation

Due to the recent emergence of this technique, our systematic review only yielded two studies that evaluated the rehabilitation of EPL tendon repair using early active rehabilitation protocols. One was a level II intermediate quality RCT and the other by Slater and Bynum⁹ was a level IV retrospective study. The latter study resulted in 83% of patients having ‘excellent’/’good’ ratings with no ruptures occurring. Overall, the quality of studies assessing early active splinting was deemed to be ‘weak’ with a mean score of 1.62 ± 0.07.

Discussion

The aim of this systematic review was to evaluate the efficacy and methodological rigour of static, dynamic and early active rehabilitation protocols following surgical repair of the EPL. Overall, the evidence presented in this review supports the use of dynamic extension splinting in the rehabilitation of EPL tendon repairs.

When evaluating static and dynamic splinting, we found consistent evidence suggesting that motion is beneficial during rehabilitation as compared with immobilization. Overall, this review yielded a combination of both weak and intermediate evidence, as per our classification outlined in Appendix 1, demonstrating that dynamic extension splinting is superior to static splinting. Specifically, there is intermediate level II evidence demonstrating the superiority of dynamic splinting over static splinting in ROM, TAM, grip strength and pinch grip.⁶ Comparing studies that evaluated TAM, dynamic splinting protocols yielded a weighted mean of 38.2° greater than static splinting protocols which was statistically significant P < 0.01. Furthermore, intermediate level II evidence would suggest that dynamic extension splinting produces superior grip strength as compared with static splinting (P < 0.05).⁶ Overall, the results of total active ROM and grip strength are concordant with the direct comparisons of dynamic versus static splinting, and both concluded that the early dynamic motion protocol is a superior approach that is safe, reliable, yields improved motion, reduces complications and shortens rehabilitation time.^6,19,38 In one study, the dynamic motion protocol saved an average of 10 days of treatment and time off work, with the average number of hand therapy sessions also markedly lower.⁶ Despite the subjectivity in such an outcome measure, it remains a patient important outcome.

The comparison between dynamic extension and early active rehabilitation protocols is a harder one to make. Very little data exist regarding the use of early active protocols; however, it compares well against dynamic splinting when considering the percentage of ‘excellent’/‘good’ results.⁹ One direct comparison between these protocols was made by Giessler et al. (2008), who provided intermediate quality level II evidence demonstrating that dynamic splinting was superior to early active motion protocols in TAM and ROM. Although power grip and tip pinch strength were higher for dynamic splinting this failed to reach significance.⁷ Further confirmatory studies are required before a recommendation to change practices is made.

Although not a primary outcome of this study, in a clinical environment many decisions are based on cost and compliance, unfortunately such parameters were rarely studied. Although immobilization of the thumb has been shown to have many poorer clinical performance markers postrehabilitation, the cost of making such a splint and number of appointments required to use this protocol are usually low. However, given the effectiveness of dynamic extension protocols and evidence of reduction in rehabilitation time, earlier return to work and potentially overall cost, many authors recommend that immobilization be appropriate only in non-complaint patients. Cost analysis of such protocols is potentially an area of future research.

There are certain limitations to this systematic review due to the inherent biases of observational studies. Most of the studies were single group retrospective studies. There were only two RCTs and two retrospective cohort studies. Furthermore, there was large variability between studies regarding zone of injury, duration of rehabilitation, frequency of rehabilitation, initiation of resistance exercises and follow-up. Specific recommendations are difficult to make due to this fact and in conjunction to the scarcity of high-quality data that are available. In our quality assessment only six of the 13 included prospective/retrospective studies received a score of ‘strong’ or ‘intermediate’, with the remaining seven studies being rated as ‘weak’ in quality. However, our scoring system identified both of the included RCTs as ‘intermediate’ quality. Despite this, almost half of the included studies are of ‘weak’ methodological quality according to a quantitative tally of the SIGN50 scale. Furthermore, studies examining early active splinting were found to be of ‘weak’ quality based on their average scores. Moreover, studies often did not report variation and some reported only range. We decided to consider larger variation for comparison purposes to avoid overestimating the mean difference between the treatment groups. Despite these limitations, the findings of this systematic review are also supported by the two RCTs.

In summary, our systematic review supports the use of dynamic splinting over static splinting following repair of the EPL tendon from the available level II–IV evidence. Currently, insufficient data exist to support dynamic splinting over early active splinting. This systematic review highlights the need for more high-quality, methodologically sound RCTs to assess differences between early active and early controlled rehabilitation regimens with cost-effective analysis as a potential secondary focus. Particular attention should be paid to the selection of outcome measurement scales validated specifically for the assessment of extensor tendon injuries.

Footnotes

Competing interests

None declared.

Appendix 1

Appendix 2

References

Khandwala

Blair

Harris

Foster

Elliot

. Immediate repair and early mobilization of the extensor pollicis longus tendon in zones 1 to 4. J Hand Surg 2004; 29B: 250–8.

Lemmen

Schreuders

Stam

Hovius

. Evaluation of restoration of extensor pollicis function by transfer of the extensor indicis. J Hand Surg 1999; 24B: 46–9.

Noorda

Hage

. Extensor indicis proprius transfer for loss of extensor pollicis longus function. Arch Orthop Trauma Surg 1994; 113: 327–9.

Magnussen

Harvey

Tonkin

. Extensor indicis proprius transfer for rupture of the extensor pollicis longus tendon. J Bone Joint Surg 1990; 72B: 881–3.

Schneider

Rosenstein

. Restoration of extensor pollicis longus function by tendon transfer. Plast Reconstr Surg 1983; 71: 533–7.

Germann

Wagner

Blome-Eberwein

Karle

Wittemann

. Early dynamic motion versus postoperative immobilization in patients with extensor indicis proprius transfer to restore thumb extension: a prospective randomized study. J Hand Surg 2001; 26 A: 1111–5.

Giessler

Przybilski

Germann

Sauerbier

Megerle

. Early free active versus dynamic extension splinting after extensor indicis proprius tendon transfer to restore thumb extension: a prospective randomized study. J Hand Surg 2008; 33 A: 864–8.

De Smet

Van Loon

Fabry

. Extensor indicis proprius to extensor pollicis longus transfer: results and complications. Acta Orthop Belg 1997; 63: 178–81.

Slater

Jr Bynum

. Simplified functional splinting after extensor tenorrhaphy. J Hand Surg 1997; 22 A: 445–51.

10.

Chow

Thomes

Dovelle

Milnor

Seyfer

Smith

. A combined regimen of controlled motion following flexor tendon repair in “no man's land”. Plast Reconstr Surg 1987; 79: 447–5.

11.

Chow

Stephens

Ngai

. A splint for controlled active motion after flexor tendon repair. design, mechanical testing, and preliminary clinical results. J Hand Surg 1990; 15 A: 645–51.

12.

Crosby

Wehbe

. Early protected motion after extensor tendon repair. J Hand Surg 1999; 24 A: 1061–70.

13.

Sylaidis

Youatt

Logan

. Early active mobilization for extensor tendon injuries. the norwich regime. J Hand Surg 1997; 22B: 594–6.

14.

Howell

Merritt

Robinson

. Immediate controlled active motion following zone 4–7 extensor tendon repair. J Hand Ther 2005; 18: 182–90.

15.

Russell

Jones

Grobbelaar

. Extensor tendon repair: mobilise or splint? Chir Main 2003; 22: 19–23.

16.

Bruner

Wittemann

Jester

Blumenthal

Germann

. Dynamic splinting after extensor tendon repair in zones V to VII. J Hand Surg 2003; 28B: 224–7.

17.

Browne

Jr Ribik

. Early dynamic splinting for extensor tendon injuries. J Hand Surg 1989; 14 A: 72–6.

18.

Chow

Dovelle

Thomes

Saldana

. A comparison of results of extensor tendon repair followed by early controlled mobilisation versus static immobilisation. J Hand Surg 1989; 14B: 18–20.

19.

Evans

. Clinical application of controlled stress to the healing extensor tendon: a review of 112 cases. Phys Ther 1989; 69: 1041–9.

20.

Chow

. Results of dynamic splintage following extensor tendon repair. J Hand Surg 1997; 22B: 283–7.

21.

O'Dwyer

Quinton

. Early mobilisation of acute middle slip injuries. J Hand Surg (Edinburgh, Scotland) 1990; 15: 404–6.

22.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses Checklist (2009). See http://www.prisma-statement.org/statement.htm (accessed March 2010).

23.

Talsma

de Haart

Beelen

Nollet

. The effect of mobilization on repaired extensor tendon injuries of the hand: a systematic review. Arch Phys Med Rehabil 2008; 89: 2366–72.

24.

Soni

Stern

Foreman

Rockwell

. Advances in extensor tendon diagnosis and therapy. Plast Reconstr Surg 2009; 123: 727–8.

25.

Kleinert

Verdan

. Report of the committee on tendon injuries (International Federation of Societies for Surgery of the Hand). J Hand Surg 1983; 8 A(5 Pt 2): 794–8.

26.

Miller

. Repair of severed tendons of the hand and wrist. Surg Gynecol Obstet 1942; 75: 693–8.

27.

Strickland

Glogovac

. Digital function following flexor tendon repair in Zone II: a comparison of immobilization and controlled passive motion techniques. J Hand Surg 1980; 5 A: 537–43.

28.

Dargan

. Management of extensor tendon injuries of the hand. Surg Gynecol Obstet 1969; 128: 1267–73.

29.

Geldmacher

Plank

Treuheit

. Significance of the preoperative status in the evaluation of results of the reconstruction of extensor tendons. Handchir Mikrochir Plast Chir 1986; 18(1): 23–29.

30.

Scottish Intercollegiate Guidelines Network (2004) Methodology checklist 3: cohort studies. In: SIGN 50: a guideline developers’ handbook. Edinburgh: The network. See http://www.sign.ac.uk/guidelines/fulltext/50/checklist3.html (accessed 22 January 2006).

31.

Wells

Shukla

Bai

Milne

. Systematic review of quality assessment instruments for randomized controlled trials. Can Cochrane Symp 2008.

32.

McGinn

Wyer

Newman

Keitz

Leipzig

. Tips for learners of evidence-based medicine: 3. measures of observer variability (kappa statistic). CMAJ 2004; 171: 1369–73.

33.

Marin-Braun

Merle

Sanz

Foucher

Voiry

Petry

. Primary repair of extensor tendons with assisted post-operative mobilisation. A series of 48 cases. Ann Chir Main 1989; 8: 7–21.

34.

Newport

Blair

Steyers

Jr . Long-term results of extensor tendon repair. J Hand Surg 1990; 15 A: 961–6.

35.

Purcell

Eadie

Murugan

O'Donnell

Lawless

. Static splinting of extensor tendon repairs. J Hand Surg 2000; 25B: 180–2.

36.

Hung

Chan

Chang

Tsang

Leung

. Early controlled active mobilization with dynamic splintage for treatment of extensor tendon injuries. J Hand Surg 1990; 15 A: 251–7.

37.

Kerr

Burczak

. Dynamic traction after extensor tendon repair in zones 6, 7, and 8: a retrospective study. J Hand Surg 1989; 14B: 21–2.

38.

Justan

Bistoni

Dvorak

Hyza

Stupka

Vesely

. Evaluation of early dynamic splinting versus static splinting for patients with transposition of the extensor carpi radialis longus to the extensor polliciis longus. In vivo 2009; 23: 853–8.

39.

Figl

Mayer

Lederer

Bogner

Leixnering

. Extensor pollicis longus rupture after distal radius fracture: results of reconstruction by transposition of the extensor indicis tendon and postoperative dynamic splinting. Wien Klin Wochenschr 2011; 123: 485–7.

40.

Verdan CE. Primary and secondary repair of flexor and extensor tendon injuries. In: JE Flynn (ed.), Hand surgery, 2nd Ed. Baltimore: Williams & Wilkins, 1975.