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Extensor Tendon Injuries of the Hand

Original Editors - Sofie Christiaens as as part of the Vrije Universiteit Brussel's Evidence-based Practice project

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Introduction

Extensor tendon injuries are relatively common and, if not treated appropriately, can cause permanent impairment of hand function. An extensor lag is often present and this can predispose the affected area to further injury. It can also influence the performance of different hand activities. Extensor tendons of the hand are located superficially with thin soft tissue covering. This leads to these tendons being more prone to injury. Management of these injuries are aimed at restoring tendon continuity and function, as well as early motion of the affected digit.[1]

Definition/Description

Courtesy of Primal Pictures

An extensor tendon injury is a cut or tear to one of the extensor tendons. Due to this injury, there is an inability to fully and forcefully extend the wrist and/or fingers.

Clinically Relevant Anatomy

Extensor tendons of the hand lie very superficially[2] and the soft tissue covering the tendons is very thin.[3] This makes these tendons susceptible to injuries[2] such as lacerations or open injuries.[3] Another reason is the lack of subcutaneous tissue between the tendons and the overlying skin.[4]

Extensor Digitorum Communis (EDC)

The extensor digitorum communis (EDC) is the main extensor tendon of the hand[5] and is centrally placed in the posterior compartment of the forearm. It originates from the lateral epicondyle of the humerus via the common extensor tendon, the covering fascia, and the intermuscular septa at its sides. In the lower part of the forearm, the muscle forms four tendons. These tendons pass deep to the extensor retinaculum and diverge towards the medial four digits on the dorsum of the hand.[6]

Each tendon helps to form an aponeurosis over the dorsum of the hand - the dorsal digital expansion or extensor hood. It has been suggested to think about the extensor hood as a "moveable triangular hood"[6] with its base lying proximally over the metacarpophalangeal joint, while the sides of the hood wrap around the phalanx. At the proximal interphalangeal joint, the hood is reinforced by the interosseous and lumbrical muscles. At the distal end of the proximal phalanx, the extensor hood divides into three parts: the central part inserts onto the base of the middle phalanx on the dorsal aspect, while the two collateral parts reunite to insert onto the dorsal aspect of the base of the distal phalanx.[6]

The EDC is innervated by the posterior interosseous branch of the radial nerve. Its primary action is extension of the metacarpophalangeal joints, and it also helps to extend both interphalangeal joints.[6]

Extensor Pollicis Longus (EPL)

The extensor pollicis longus (EPL) lies deep to the extensor digitorum in the posterior compartment of the forearm. It originates from the lateral part of the middle third of the posterior surface of the ulna and the adjacent interosseous membrane, then inserts at the dorsal surface of the base of the distal phalanx of the thumb. Innervation is supplied by the posterior interosseous branch of the radial nerve. The primary action of this muscle is to extend all of the joints of the thumb. It also assists with extension and abduction of the wrist.[6]


Tendon Zones

Extensor tendons are located in the dorsal region of the hand and fingers. The function of these tendons is to extend the wrist and the fingers. According to Kleinert and Verdan (1983), there are eight anatomic zones in which the extensor mechanism of the fingers and wrist is divided.[7][8][9] Odd-numbered zones refer to injuries over the joints, and the even-numbered zones refer to the segments between two joints.[3]

  • Zone I: DIP joint
  • Zone II: middle phalanx
  • Zone III: PIP joint
  • Zone IV: proximal phalanx
  • Zone V: MCP joint
  • Zone VI: metacarpals
  • Zone VII: wrist (carpus and extensor retinaculum)
  • Zone VIII: distal third of the forearm[9][10]

Epidemiology /Aetiology

Extensor tendon injuries represent a significant portion of acute tendon trauma, accounting for more than 50% of all cases, with a reported incidence of 14 cases per 100 000 person-years.[11] These injuries represent 16.9% of orthopaedic soft tissue injuries[12] and are particularly common in young manual workers[13], predominantly affecting men in their 30s who represent the working-age demographic.[14] The dominant hand is more likely to be injured. The clinical burden of hand injuries is substantial, representing up to 30% of all emergency department visits in the UK[15] and more than 25% of all soft tissue injuries in the USA.[16] Beyond the clinical impact, extensor tendon injuries carry a considerable economic burden, with the total cost of extensor tendon lacerations estimated at $307 million per year.[17]

Mechanism of injury

Extensor tendon injuries of the hand occur through open wounds and closed ruptures.[12] Open wounds often require urgent medical attention, and patients with these injuries tend to present at a hospital. These include direct lacerations by sharp objects, knives or scissors, saw injuries, burns, blunt trauma, bites, crush injuries, avulsions, and deep abrasions.

Closed ruptures occur as a result of conditions that weaken the tendon structure, such as rheumatoid arthritis, attrition by internal hardware often used for internal fixation, and under situations of extreme load.[8]

Characteristics/Clinical Presentation

Dependent on the zone of injury, different characteristics are shown.

Table 1. Different characteristics of extensor tendon injuries based on the tendon zone
Tendon Zone Characteristics of Injury
Zone I Mallet finger
Zone II No complete rupture of the tendon, but partially injured[8]
Zone III Disruption of the central slip, also called a Boutonnière deformity or jammed finger. This is characterised by a flexed position of the PIP joint and an extension or hyperextension of the DIP joint.[18]
Zone IV Injuries are frequently partial, with or without loss of extension at the PIP joint[10]
Zone V Fight bite injuries (open injuries) or non-fight bite injuries (for example: blunt trauma): a possible effect of such an injury is a rupture of the sagittal bands, attended with following extensor tendon subluxation.[10] This is presented as a difficulty in actively straightening the flexed MCP joint[8]
Zone VI The MCP joint can still be extended via the juncturae tendinum
Zone VII Physical injury to the extensor retinaculum[10]

Differential Diagnosis

Several conditions should be considered when evaluating extensor tendon injuries. Mallet finger refers to a drooping end-joint of a finger (i.e. at the distal interphalangeal joint), occurring when an extensor tendon has been cut or torn from the bone - commonly seen when a ball or other object strikes the tip of the finger or thumb and forcibly bends it.[13][19] Boutonnière deformity[13] describes the bent-down (flexed) position of the middle joint of the finger, which can result from a cut or tear of the extensor tendon.[13] Cuts on the back of the hand can injure the extensor tendons, making it difficult to straighten the fingers. Trigger finger[13] [20] presents with no passive movement possible. Posterior interosseous nerve (PIN) syndrome should be considered when a patient is unable to extend actively, though tenodesis remains normal.[13]

Diagnostic Procedures

Radiographs are recommended because associated injuries of surrounding structures are common. For example, a piece of bone may be pulled off with the tendon.[10] X-rays can rule out or confirm associated bone injuries.[12] High-resolution ultrasound is considered a reliable and useful diagnostic tool in the detection of tendon injuries.[21] MRI has high diagnostic value to assess tendon injuries of the hand and may be helpful in the diagnosis of extensor tendon injuries.[22]

Clinical tests can also aid in diagnosis and include the following tests:[23]

Extensor Digitorum Communis (EDC)

Position the hand in hook position with PIP and DIP joints flexed then ask the patient to actively extend the MCP joints.

Extensor Pollicis Longus (EPL)

Have the patient rest their hand on the table and lift the thumb off the table. If EPL laceration is present, there will be significantly less movement, and the patient will be unable to extend the IP joint of their thumb.

Outcome Measures

Medical Management

Patients with an extensor tendon injury can be treated in two ways, surgically or conservatively (namely splinting). The choice of treatment depends on the degree of the injury. In general, open injuries and entire ruptures demand surgical treatment. Closed injuries and partial lacerated tendons require splinting.[25]

General Principles

Factors that should be considered when deciding the appropriate treatment include the characteristics of the extensor tendon injury, mechanism of injury or trauma, the injury site, involvement of soft tissue and/or nerve and vascular bundles, and patient characteristics such as age, work, comorbidities and functional requests.[13]

Surgery

Surgery should preferably be performed the same day as the injury. The greater the number of tissues involved, the more challenging it becomes to restore hand function.[26] Primary repair is the standard approach, though tendon transfer (for example, extensor indices transfer to EPL) is an option in cases where there is a delay between the time of injury and time of surgery, the tendon is too frayed, or the tendon is too short.[23] Preserving and restoring appropriate tendon length is important to the outcome of the repair, since even minor changes in tendon tension can have negative effects on finger movement.[16] Miller's criteria are used to evaluate extensor tendon injury, with factors that are all important to the outcome of the repair, including severity of laceration, injury zone, surgical technique used for repair, other trauma to surrounding tissues, hand therapy, and patient compliance.[27]

Rehabilitation Management

The rehabilitation therapist's (OT, hand therapist, physiotherapist) task is to improve the functionality of the hand, with the intention of achieving the pre-injury condition. This will be done by gradually enlarging the range of motion. For the best possible outcome, it is necessary to adapt the rehabilitation programme to the individual.[8]

Examination

Examination of extensor tendon injuries contains different points of interest.

Pre-operatively, the function of the fingers and wrist can be tested in three ways: passively, actively, and then with resistance. It is important that each finger is tested separately because the juncturae tendinum between the communis tendons can mask a dysfunction.

The wound characteristics should be evaluated, such as size and location, to give the physical therapist an idea of which structures may have been damaged. A complete neurovascular examination should also be performed.

Post-Surgical Rehabilitation

It is important to see patients as soon as one to five days postoperatively for the best possible outcome.[23]

Wound Care and Scar Management

Provide wound care by keeping the wound dry and clean and monitor the wound for signs of infection.[23] A common clinical complication is the formation of tendon adhesions after surgery[28], therefor it is important to commence scar management early to prevent adhesions.[23] Extensor tendons lie superficially and a scar on the dorsum of the hand may adhere quite quickly and this can restrict flexion range of motion in the fingers. Massage the scar and aim to keep the skin on the dorsum of the hand as mobile as possible.[23]

Oedema Control

Control swelling of the hand by having the patient keep their hand elevated to reduce and prevent swelling. Performing the active range of motion exercises prescribed within the provided protocol will also help control swelling.[29] Compression can be applied where needed to control swelling.[23]

Orthosis

Examples of extensor tendon repair splints[30]

The therapist provides the patient with the specified splint or orthosis as well as the exercises relative to the rehabilitation protocol provided by the surgeon or therapist.[23] Considerations in designing an appropriate orthosis include the position of the joint, external load and resistance to tendon glide, as determined by friction and adhesions.[31]

Patient Education

Patient education is an important part of the postoperative management of extensor tendon injuries. It is important for patients to know the following[23]:

  • To keep the wound dry and clean
  • To keep the splint in place 24/7
  • To perform their exercises with their splint on, unless the therapist advised them differently
  • If the splint is taken of the patient must keep their hand and forearm in the safe position to keep the tendons on no stretch. This position is the forearm in supination and the fingers relaxed. It is very important for patients to be aware of this and follow this recommendation as this will reduce the risk of tendon rupture or the extensor tendons EPL and EDC from overstretching, if they are ever out of the splint.

Rehabilitation Protocols

Extensor Digitorum Communis (EDC)

Merritt Protocol
Image of RME plus orthosis/ EAM approach[32]

The Merritt Protocol is the most popular protocol to treat zone V extensor tendon injuries.[9] Good outcomes are achieved with this protocol, and patients feel that they have some freedom as fingers are not immobilised.[24] This protocol allows patients to use their hand for very light functional activities throughout the course of rehabilitation. It is only appropriate for use in extensor tendon injuries to the EDC in zones V to VII (from MCP joints to wrist) and only if the patient has lacerated one to three tendons and had tendon repair.[33] Due to the nature of the splint, this protocol cannot be used for more than three lacerated tendons.[23]

The splint consists of two pieces: the volar wrist splint positions the wrist in 20°-30° of extension[33], while the second component is a relative motion splint for the fingers that positions the affected finger in slight MCP extension relative to the unaffected fingers. This allows the patient to flex the MCP joints and assists with tendon glide to prevent adhesions.[33]

Merritt Protocol Exercises
Hook fist

All Merritt protocol exercises are performed with the splint on and include active MCP flexion, hook fist, composite flexion, and active finger extension. Exercises are done 5 times a day with 10 repetitions of each exercise. The patient continues with these exercises for the duration of splinting, usually about 6 weeks, while wearing both the wrist splint and the relative motion splint. It is important to ensure that the PIP joint maintains full extension within the splint.[23]

Composite flexion

If a patient has an extension lag, a finger trough or finger extension splint can be used at night on the affected finger. If more than one finger is involved, a volar extension splint at night or for resting is recommended. The resting splint should keep the wrist in slight extension, MCPs in 20-30 degrees of flexion, and the PIP and DIP joints in neutral. At four weeks post-operatively, the wrist splint is taken of and ceased, while the relative motion finger component is continued until 6 weeks postoperatively. At 6 weeks postoperatively, all splints are stopped, and the patient is encouraged to use their hand for light functional use and full range of motion. Passive stretching commences at 7 weeks postoperatively, and strengthening commences at around 8 weeks postoperatively.[23] The videos below demonstrate examples of active MCP flexion and active finger extension. Keep in mind that these exercises are done in the splints for the first six weeks (4 weeks with volar wrist splint and thereafter with relative motion finger splint).

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Norwich Protocol

The Norwich protocol has high reported usage[9] and is often used in patients who are less reliable, when the patient has had two or more tendons repaired, when surgical repair is not as strong as it could be, or in patients with tendon lacerations of zones V to VII. The patient is initially seen on days one to four postoperatively.[36]

Resting Hand Orthosis

For the resting hand orthosis[9], the therapist fabricates a volar splint with the wrist in 45 degrees extension, MCPs flexed to 50 degrees, and IP joints extended. This is a tricky position to splint, but the IP joint extension is important to prevent any extension lags. The splint should be fabricated with the patient’s forearm in supination, as this will allow the therapist to drape and mould the thermoplastic well over the hand to ensure a good wrist-extended position.

Exercises in Norwich Protocol
Hook fist in splint

The resting splint is worn 24/7, and exercises are performed with the splint on at a frequency of 10 repetitions of each exercise, 5 times a day. The exercises include combined IP and MCP joint extension off the splint and hook fist with splint in place.[37]

The patient continues with these exercises for 6 weeks until weaned from the splint. If there is no evident extension lag after 6 weeks, the patient can stop wearing the splint at 6 weeks and is encouraged to use the hand for unlimited use. Grip strengthening is commenced at 7 weeks, and at 8 weeks postoperatively, full passive flexion stretches can be commenced if full finger flexion has not yet been regained. A dynamic flexion splint may be considered at 12 weeks if it is required to regain flexion. Should there be an extension lag greater than 30 degrees, the patient needs to continue wearing the splint until 8 weeks postoperatively.[23]

Extensor Pollicis Longus

Volar thermoplastic splint for EPL tendon repair[38]

A volar thermoplastic splint is used for extensor pollicis longus tendon repair.[38] The splint positions the wrist in slight extension and the thumb is held in extension as well. The splint comes to below the MCP joints, just through the distal palmar crease of the hand and up to two thirds of the forearm. The splint also extends to the tip of the thumb because the EPL tendon inserts at the base of the distal phalanx and the distal phalanx, should not be flexing freely.[23]

Exercises

Early active range of motion exercise should be started from the first appointment.[23] With the splint on, the patient performs active extension. With the splint on, but the thumb strap released and the wrist in extension, isolated IP joint flexion can be performed as well as isolated MCP joint flexion.

Thumb extension with splint on[39]

The only exercise that the patient may perform with the splint off is gradual opposition of the thumb, but these exercises must be performed with the forearm in supination. Gradual opposition of the thumb to each fingertip is performed, with progression to a different finger tip each week. Week 1 involves opposing the thumb to the index finger. Week 2 involves opposing the thumb to the middle finger. Week 3 involves opposing the thumb to the ring finger, and so on until the patient is able to flex the thumb down to the proximal crease over the MCP joint of the little finger by week 6.

Isolated IP and MCP joint flexion in splint[40]

Exercises remain the same until 6 weeks postoperatively. After this point, the patient can be weaned out of the splint. The patient is encouraged to use their hand for full range of motion and light functional activities. Strengthening exercises are commenced at 8 weeks postoperatively, if the surgeon gives clearance. Theraputty can be used for strengthening exercises. For example, for finger extension exercises, the patient can make a little doughnut shape out of Theraputty, place it around their fingers, and then actively extend their fingers. For finger flexion, they can make a fist around the Theraputty. This is important as patients will often have lost grip strength during their period of immobilisation.[23]

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Red Flags in Extensor Tendon Injuries

Red flags that therapists need to be aware of and look out for in patients with extensor tendon repairs in EDC zones V - VII and EPL zones II - VIII include ruptures, extensor lags, and infection.[23]

Ruptures are always a concern with tendon repairs. If a patient has ruptured the EPL, they will be unable to extend the IP joint, while an EDC rupture results in inability to extend MCP joints when isolated. Therapists should look out for ruptures during the first 6 weeks postoperatively, but especially within the first 3 weeks postoperatively.

Extensor lags are often difficult to correct once they have developed, so it is key to identify a lag as soon as possible. A volar extension splint at night or for resting is recommended for patients with a lacerated EDC tendon who are using the Merritt Protocol and are unable to actively extend their affected finger at the PIP joint. If there is an extension lag at the PIP joint in multiple fingers, a night resting splint should be considered.

Infection should be monitored by looking out for any redness, pain, oozing, or odorous smells around the wound site. Any signs of infection should be flagged with the surgeon. Other complications found include persistent oedema, ongoing stiffness, and tendon tethering.[43]

Key Messages to Remember

  1. Know your Anatomy. This will inform treatment approach and inform your clinical reasoning. Know which tendon was lacerated and in what zone as the treatment protocols for the various zones differ.
  2. Know the patient’s history. This will influence your treatment of the patient. Was the tendon cleanly cut? Was the surgery performed immediately or was there a delay? Is the patient reliable and can the therapist trust the patient to perform their exercises according to the protocol provided to them. Is the patient educated about the injury and will the patient be compliant. It is important to come up with an appropriate treatment protocol in conjunction with the surgeon to best treat the individual patient.
  3. Be confident in your splinting skills. Practice before you fabricate a splint for the first time, especially with the relative motion splint in the Merritt Protocol. Be familiar with the degrees of the angles of the different joints that you need to place them in.
  4. Monitor patient progress. Monitor patient progress closely and check the tendon status and look out for extension lags
  5. Know your rehabilitation protocol. Be familiar with the selected protocol. Educate your patient and be a good teacher. Give them the confidence to manage their injury and a good outcome will be achieved.

References

  1. ↑ Beutel BG, Gutowski KS, Marappa-Ganeshan R. Hand Extensor Tendon Lacerations. InStatPearls [Internet] 2024 Oct 5. StatPearls Publishing.
  2. ↑ 2.0 2.1 Dalton SS, Maharjan LM, Yousuf H, Pientka WF. Extensor tendon repair outcomes based on zone of injury. Hand. 2024 Jul;19(5):831-6.
  3. ↑ 3.0 3.1 3.2 Yoon AP, Chung KC. Management of acute extensor tendon injuries. Clinics in plastic surgery. 2019 Jul 1;46(3):383-91.
  4. ↑ Saini N, Sharma M, Sharma VD, Patni P. Outcome of early active mobilization after extensor tendon repair. Indian journal of orthopaedics. 2008 Jul;42(3):336.
  5. ↑ Palastanga NP, Field D, Soames R. Anatomy and Human Movement: Structure and Function. 5th Edition. Edinburgh: Butterworth Heinemann, Elsevier. 2006.
  6. ↑ 6.0 6.1 6.2 6.3 6.4 Soames RW. Anatomy and human movement. Structure and function. Elsevier Health Sciences; 2024.
  7. ↑ Brotzman SB, Manske RC. Clinical orthopaedic rehabilitation e-book: An evidence-based approach-expert consult. Elsevier Health Sciences; 2011 May 6.
  8. ↑ 8.0 8.1 8.2 8.3 8.4 Milner C, Russell P. Focus on extensor tendon injury. British Editorial Society of Bone and Joint Surgery 2011.
  9. ↑ 9.0 9.1 9.2 9.3 9.4 Hirth MJ, Howell JW, Feehan LM, Brown T, O'Brien L. Postoperative hand therapy management of zones V and VI extensor tendon repairs of the fingers: An international inquiry of current practice. Journal of Hand Therapy. 2020 Mar 9.
  10. ↑ 10.0 10.1 10.2 10.3 10.4 Matzon JL, Bozentka DJ. Extensor tendon injuries. The Journal of hand surgery. 2010 May 1;35(5):854-61.
  11. ↑ de Jong JP, Nguyen JT, Sonnema AJ, Nguyen EC, Amadio PC, Moran SL. The incidence of acute traumatic tendon injuries in the hand and wrist: a 10-year population-based study. Clinics in orthopedic surgery. 2014 Jun 1;6(2):196-202.
  12. ↑ 12.0 12.1 12.2 Colzani G, Tos P, Battiston B, Merolla G, Porcellini G, Artiaco S. Traumatic extensor tendon injuries to the hand: clinical anatomy, biomechanics, and surgical procedure review. Journal of hand and microsurgery. 2016 Apr;8(1):2.
  13. ↑ 13.0 13.1 13.2 13.3 13.4 13.5 13.6 Moore A, Marappa-Ganeshan R. Hand Extensor Tendon Lacerations. InStatPearls [Internet] 2020 Feb 4. StatPearls Publishing.
  14. ↑ Amirtharajah M, Lattanza L. Open extensor tendon injuries. The Journal of Hand Surgery. 2015 Feb 1;40(2):391-7.
  15. ↑ Miranda BH, Spilsbury ZP, Rosala-Hallas A, Cerovac S. Hand trauma: a prospective observational study reporting diagnostic concordance in emergency hand trauma which supports centralised service improvements. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2016 Oct 1;69(10):1397-402.
  16. ↑ 16.0 16.1 Dy CJ, Rosenblatt L, Lee SK. Current methods and biomechanics of extensor tendon repairs. Hand clinics. 2013 May 1;29(2):261-8.
  17. ↑ Mehrzad R, Mookerjee V, Schmidt S, Jehle C, Rao V, Mehrzad M, Liu PY. The economic impact of extensor tendon lacerations of the hand in the United States. Ann Plast Surg. 2022 Feb 1;88(2):168-72.
  18. ↑ Geoghegan L, Wormald JC, Adami RZ, Rodrigues JN. Central slip extensor tendon injuries: a systematic review of treatments. Journal of Hand Surgery (European Volume). 2019 Oct;44(8):825-32.
  19. ↑ Khera B, Chang C, Bhat W. An overview of mallet finger injuries. Acta Biomed. 2021 Nov 3;92(5):e2021246.
  20. ↑ Donati D, Ricci V, Boccolari P, Tedeschi R, Origlio F, Vita F, Naňka O, Catani F, Tarallo L. Trigger Finger: A Narrative Review of Dynamic Ultrasound and Personalized Therapies. Journal of Clinical Ultrasound. 2025 Mar 21.
  21. ↑ Weinreb JH, Sheth C, Apostolakos J, McCarthy MB, Barden B, Cote MP, Mazzocca AD. Tendon structure, disease, and imaging. Muscles, ligaments and tendons journal. 2014 Jan;4(1):66.
  22. ↑ Soni P, Stern CA, Foreman KB, Rockwell WB. Advances in extensor tendon diagnosis and therapy. Plastic and reconstructive surgery. 2009 Feb 1;123(2):52e-7e.
  23. ↑ 23.00 23.01 23.02 23.03 23.04 23.05 23.06 23.07 23.08 23.09 23.10 23.11 23.12 23.13 23.14 23.15 23.16 Thorn, K. Extensor Tendon Injury Management. Course, Plus. 2020.
  24. ↑ 24.0 24.1 24.2 Collocott SJ, Kelly E, Foster M, Myhr H, Wang A, Ellis RF. A randomized clinical trial comparing early active motion programs: earlier hand function, TAM, and orthotic satisfaction with a relative motion extension program for zones V and VI extensor tendon repairs. Journal of Hand Therapy. 2020 Jan 1;33(1):13-24.
  25. ↑ Dickson K, Mantelakis A, Reed AJ, Izadi D, Wade RG, Wormald J, Furniss D. The management of partial extensor tendon lacerations of the hand and forearm: A systematic review. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2023 Oct 1;85:34-43.
  26. ↑ Carty MJ, Blazar PE. Complex flexor and extensor tendon injuries. Hand Clinics. 2013 May 1;29(2):283-93.
  27. ↑ Mehdinasab SA, Pipelzadeh MR, Sarrafan N. Results of primary extensor tendon repair of the hand with respect to the zone of injury. Archives of trauma research. 2012;1(3):131.
  28. ↑ Xiao G, Wang J, Zhang N, Hao J. Factors predicting the adhesion and prolonged lost days of work in patients with extensor tendon adhesion of the hand. Frontiers in Surgery. 2024 May 1;11:1304202.
  29. ↑ Miller LK, Jerosch-Herold C, Shepstone L. Effectiveness of edema management techniques for subacute hand edema: A systematic review. Journal of Hand Therapy. 2017 Oct 1;30(4):432-46.
  30. ↑ Hirth MJ, Howell JW, Feehan LM, Brown T, O'Brien L. Postoperative hand therapy management of zones V and VI extensor tendon repairs of the fingers: An international inquiry of current practice. Journal of Hand Therapy. 2020 Mar 9.
  31. ↑ Wong AL, Wilson M, Girnary S, Nojoomi M, Acharya S, Paul SM. The optimal orthosis and motion protocol for extensor tendon injury in zones IV-VIII: a systematic review. Journal of Hand Therapy. 2017 Oct 1;30(4):447-56.
  32. ↑ Hirth MJ, Howell JW, Brown T, O'Brien L. Relative motion extension management of zones V and VI extensor tendon repairs: Does international practice align with the current evidence?. Journal of Hand Therapy. 2020 Mar 9.
  33. ↑ 33.0 33.1 33.2 Merritt WH. Relative motion splint: active motion after extensor tendon injury and repair. The Journal of Hand Surgery. 2014 Jun 1;39(6):1187-94.
  34. ↑ Rehab my patient. Painful finger exercise. Available from https://www.youtube.com/watch?v=jR2_3qdTd8k&feature=emb_logo [last accessed 25 September 2020]
  35. ↑ Rehab my patient. Active finger extension. Available from https://www.youtube.com/watch?v=GrA_541Ks_8&feature=emb_logo [last accessed 25 September 2020]
  36. ↑ Kitis A, Ozcan RH, Bagdatli D, Buker N, Kara IG. Comparison of static and dynamic splinting regimens for extensor tendon repairs in zones V to VII. Journal of Plastic Surgery and Hand Surgery. 2012 Sep 1;46(3-4):267-71.
  37. ↑ Sussex Hand Surgery. Extensor Tendon Repair Zone V - VIII (Norwich regime, following surgical repair.) Available from http://sussexhandsurgery.co.uk/downloads/rehabilitation/hand/ETR%20-%20Norwich%20-%20V%20to%20VIII%20Weeks%200%20to%204.pdf [last accessed 25 September 2020]
  38. ↑ 38.0 38.1 Sussex Hand Surgery. Available fromhttp://sussexhandsurgery.co.uk/downloads/rehabilitation/hand/EPL%20Zone%20II%20to%20VIII%20Weeks%200%20to%204.pdf
  39. ↑ Sussex Hand Surgery. Available fromhttp://sussexhandsurgery.co.uk/downloads/rehabilitation/hand/EPL%20Zone%20II%20to%20VIII%20Weeks%200%20to%204.pdf
  40. ↑ Sussex Hand Surgery. Available fromhttp://sussexhandsurgery.co.uk/downloads/rehabilitation/hand/EPL%20Zone%20II%20to%20VIII%20Weeks%200%20to%204.pdf
  41. ↑ Rehab my patient. How to improve finger strength using putty. Available from https://www.youtube.com/watch?v=wtSn4B8lKm4&feature=emb_logo [last accessed 25 September 2020]
  42. ↑ Rehab my patient. Thumb strengthening with band part 1. Available from https://www.youtube.com/watch?v=0me9b2Kjkbc&feature=emb_logo [last accessed 25 September 2020]
  43. ↑ Collocott S, Wang A, Hirth MJ. Systematic review: Zone IV extensor tendon early active mobilization programs. Journal of Hand Therapy. 2023 Apr 1;36(2):316-31.
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