Authors:

Alp C etin, MD Fitnat Dinc er, MD Abdullah Kec ik, MD Meral C etin

Exercise

Afliations:
From the Departments of Physical Medicine and Rehabilitation (AC, FD) and Plastic and Reconstructive Surgery (AK), Hacettepe University Medical School, Ankara, Turkey; and Department of Statistics, Hacettepe University, Ankara, Turkey (MC).

Research Article

Correspondence:
All correspondence and requests for reprints should be addressed to Alp C etin, MD, Celikkent Sitesi A1 Blok Daire: 3,06530 Cayyolu, Ankara, Turkey. 0894-9115/01/8010-0721/0 American Journal of Physical Medicine & Rehabilitation Copyright 2001 by Lippincott Williams & Wilkins

Rehabiliation of Flexor Tendon Injuries by Use of a Combined Regimen of Modied Kleinert and Modied Duran Techniques
ABSTRACT
C etin A, Dinc er F, Kec ik A, C etin M: Rehabilitation of exor tendon injuries by use of a combined regimen of modied Kleinert and modied Duran techniques. Am J Phys Med Rehabil 2001;80:721728. Objective: Kleinert (active extension, rubber-band passive exion) and Duran (passive extension, passive exion) protocols are two basic types of early motion programs for rehabilitation of exor tendon injuries. Researchers have been working on various modications or combinations of these two protocols to improve rehabilitation results. The purpose of this study was to analyze the quality of the functional results of exor tendon repair after a postoperative regimen of early mobilization by use of a combined regimen of modied Kleinert and modied Duran techniques. Design: Thirty-seven patients (74 digits) with repaired exor tendon injuries were treated. Functional results of the ngers were evaluated by the Buck-Gramcko system and total active motion measurements. Results: The results were excellent in 73% of the ngers, good in 24%, fair in 1.5%, and none was rated poor. Conclusion: Our results are comparable with the previous studies that used various postoperative rehabilitation techniques. This postoperative management provides an effective way of achieving satisfactory results. Patient-assisted passive exercises are very safe and more cost effective than therapist-assisted passive exercises. Key Words: Hand Injuries, Rehabilitation, Tendon Injuries, Exercise

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and injuries form an important part of a hospitals accident and emergency services, and exor tendons are commonly affected.13 Despite numerous advances in our understanding of the anatomy, biomechanics, nutrition, and healing of exor tendons and technical and postoperative care improvements, the results following exor tendon repair show relatively high rates of failure.4,5 Adhesion formation that prevents the tendon from gliding is the most frequent cause of failure after exor tendon repair.5 Because surgical management of acute exor tendon injuries is well understood, the real problem is how to decrease or eliminate the formation of the peritendinous scarring that prevents a freely gliding tendon capable of restoring good function.6,7 Attempts have therefore been made to decrease or eliminate the peritendinous scarring that limits tendon gliding.5 Researchers have shown that early mobilization can prevent the formation of scar tissue without jeopardizing tendon healing, and they have developed many different forms of early mobilization programs.8 Kleinert et al. introduced a program of early controlled motion after exor tendon repair by use of a dorsal splint with a rubber-band traction device and early active extension of the digit against the tension of the passive rubberband exion.9 In the original Kleinert protocol, the dorsal protective splint blocked the wrist at 45 degrees of exion and the metacarpophalangeal (MP) joints at 10 20 degrees. Dynamic traction, provided by rubber bands between ngertips and volar aspects of the wrist, maintains the involved digits in exion to further relax the tendon and prevent inadvertent active exion. The patients actively extend the ngers to the limits of the splint and then relax so that the tension in the rubber bands returns the ngers to their previous exed position. This technique is well

accepted and has been subjected to several modications.8,10 12 The most important change was the introduction of a palmar pulley by Slattery and McGrouther.11 This application redirects the line of the pull into the palm and increases distal interphalangeal joint motion. This allows an increased excursion of the exor tendons, minimizing adhesions and allowing differential gliding of exor digitorum supercialis and exor digitorum profundus tendons. Early passive-controlled motion was popularized by Duran and associates.13 They stated that 35 mm of passive motion of the tendon anastomosis was sufcient to prevent adhesions. This limited motion (controlled motion) protects the newly repaired tendon and controls tension at the tenorrhaphy site. In this technique, controlled passive motion to both involved and uninvolved ngers is continued for 4 5 wk after surgery, and the hand is placed in a dorsal protective splint between exercise periods. Chow and associates have developed a combined regimen of controlled motion after repair of exor tendons of the hand called the Washington regimen.6 In this program, a modied Kleinert splint with a palmar pulley is used, and the essential feature of the program is that the active extension exercises are completed by frequent protected passive motion by the therapist to prevent or minimize exion contractures. Some clinicians reported the use of early active mobilization programs after exor tendon repair with encouraging results.14 19 The ideal method of rehabilitation after exor tendon repair has yet to be fully claried.20 On the basis of the results of clinical investigations, the Washington regimen seems to be an effective method for the management of exor tendon repairs.12 However, patients in this regimen should be hospitalized or visit the hospital every day for therapist-assisted pas-

sive exercises. In this study, we adapted the Washington regimen by the use of patient-assisted passive exercises instead of therapist-assisted passive exercises. The aim of this study was to analyze the quality of the functional results of exor tendon repair after a postoperative regimen of early mobilization by the use of a combination of modied Kleinert splint with palmar pulley and early passive motion performed by the patients themselves.

MATERIALS AND METHODS

This study was conducted at the Department of Physical Medicine and Rehabilitation, Hacettepe University Medical School. From November 1994 to December 1996, 37 patients (74 digits) with repaired exor tendon injuries participated in this study. Ages, gender, and dominant hands of the patients were recorded. Time of splint application after repair and associated injuries were also recorded. According to the level of injury, tendon injuries were classied into ve zones (Fig. 1). Zone 1 extends from the insertion of the exor digitorum profundus in the middle phalanx to that of the exor digitorum supercialis in the base of the distal phalanx. Injuries at this level involve isolated lacerations of the exor digitorum supercialis. Zone 2 is the region in which both exor tendons travel within the bro-osseous tunnel from the A1 pulley to the exor digitorum profundus insertion. Usually, both exor tendons are injured at this level. The area in the palm between the distal border of the carpal tunnel and the proximal border of the A1 pulley comprises zone 3. Common digital nerves and vessels, lumbrical muscles, and one or both exor tendons may be injured in this region. Zone 4 consists of that segment of the exor tendons covered by the transverse carpal ligament. Injuries at this level involve median or ulnar

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Figure 1: Zone 1, distal to the insertion of the exor digitorum profundus tendon into the base of distal phalanx. Zone 2, between the insertion of the exor digitorum profundus tendon and A1 pulley (at the level of MP joints). Zone 3, between the A1 pulley and the distal edge of the exor retinaculum. Zone 4, in the carpal tunnel. Zone 5, proximal to the carpal tunnel. Postoperative Management. Controlled mobilization was begun on the rst to the seventh postoperative day. An aluminum, modied Kleinert splint with a palmar pulley was tted on all patients. This splint was placed on the forearm, extending to just beyond the ngertips, with the wrist positioned at 30 35 degrees of exion, MP joint positioned at 50 60 degrees of exion, and interphalangeal (IP) joints were allowed to assume complete active extension. After application of the dorsal splint, a nylon shing line was attached to the ngernail hook of the injured nger or ngers. The shing line was then run through the eye of the palmar pulley to a rubber band anchored at the proximal forearm (Fig. 2A). The length of the shing line was long enough to allow for full extension of the involved digit or digits without making contact with the palmar pulley, the junction of the nylon line, and the rubber band. The tension of

nerves and tendons. The forearm from the musculotendinous junction of the extrinsic exors to the proximal border of the transverse carpal ligament comprises zone 5. Interference with tendon gliding is less of a problem in this region. Patients 6 yr old, patients with associated injuries that required immobilization, and patients with the time of splint application more than 7 days after the repair were not included in this study. Surgical Technique. All patients were operated on in the plastic and reconstructive surgery department at Hacettepe University Hospital. Tendons were repaired by use of the modied Kessler technique with 4-0 Prolene sutures. The epitenon was approximated by use of a continuous 6-0 nylon suture. Both profundus and supercialis tendons were repaired in all cases. October 2001

the rubber band was adjusted to be light enough to allow full active extension of the IP joints and strong enough to pull the ngers back into exion. Early controlled active extension exercises were initiated after the fabrication and application of the dorsal splint and the palmar pulley dynamic traction system. The patients were instructed to actively extend the involved digit or digits against the tension of the rubber band 10 times per hour (Fig. 2B). Patients who could not actively extend the involved digit or digits against the rubber-band tension were allowed to manually release some rubber-band tension during the exercise to reach full active extension of the IP joints. In addition, a passive exercise program was engaged four times per day for all digits, including uninvolved digits. All passive exercises were performed by the patients themselves. Passive exion exercises were performed for isolated MP, proximal interphalangeal (PIP), and distal interphalangeal exion followed by full passive exion of these three joints (Fig. 2C). Passive PIP extension was performed to prevent PIP exion contractures. During passive extension of the IP joints, the MP joint was held at 90 degrees of exion to avoid excessive tension on the repair site (Fig. 2D). All passive exercises were repeated 10 times, and each position was held for 5 sec. Patients were instructed to keep the hand and limb elevated for edema control, not to replace the splint, and not to actively ex the involved digit or digits. Patients were seen every other day to check splint position, tension of the rubber band, and whether patients performed the exercises correctly. Patients were instructed to gently ex the involved digit at every control visit to determine possible tendon rupture. After 4 wk, the dorsal splint was removed and active nger exion exercises were begun. Patients were instructed to avoid simultaneous

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Figure 2: A, modied Kleinert splint with palmar pulley. B, active nger extension against the tension of the rubber band. C, passive exion exercises of the MP and IP joints. D, passive extension exercise of IP joints. wrist and nger extension. Passive exercises were continued after removal of the splint as in the rst 4 wk. The place hold exercises were started during this time. In place hold exercises, the patient presses the nger or ngers passively into full exion with the uninvolved hand. Then, on releasing the pressure of the uninvolved hand, the patient attempts to hold the exed position of the ngers. Differential exor tendon gliding exercises including three different hand positions (hook-st, straight-st, and full-st positions) to produce maximum differential glide between exor digitorum supercialis, exor digitorum profundus, and surrounding tissues were also started. In patients with median or ulnar nerve injuries, or both, splint application was continued for 6 wk, but the rubber band traction was discontinued and active nger exion exercises were begun on the fourth week. After 6 wk, patients were permitted to use the involved hand in light daily activities. Passive stretching exercises and corrective splints were recommended during this period if necessary. Resistive exercises were not initiated until the eighth week. Functional Evaluation. The range of motion measurements of MP and IP joints were made with a standard nger goniometer, and the results were adjusted to the nearest 5-degree level. MP exion past 90 degrees and extension past 0 degrees were not included in the measurements of range of motion. Two systems were used to evaluate the functional results of exor tendon repair. In the rst, the BuckGramcko system was used.21 This system consists of two measurements. First is the sum of angles formed by the MP, PIP, and distal interphalangeal joints in maximal active exion minus active extension decit at each joint. Second is the distance between the ngertip and distal palmar crease. The BuckGramcko classication is presented in Table 1. In the second system, total active motion (TAM) of the involved ngers was measured.22 TAM resulted from the summation of exion of the MP, PIP, and distal interphalangeal joints minus the extension decit of the same joints. Statistical Analyses. Correlation and multiple regression analysis were performed to determine the inuence

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TABLE 1 Buck-Gramcko classication

Scores Distance between ngertip and distal palmar crease (cm)/composite exion (degrees) 02.5/200 2.54/180 46/150 6/150 030 3150 5170 70 160 140 120 120 Excellent Good Fair Poor 6

TABLE 3 Distribution of multiple digit injury by zone

No. of Injured Digits Zone 1 2 12 1 1 5 21 2 1 1 2 3 1 2 1 3 7 4 1 6 7 1 2 3 4 5 Thumb Total

Extension decit (degrees)

Composite exion minus composite extension (degrees)

4 2 0 3 2 1 0 6 4 2 0 1415 1113 710 06

Evaluation

of variables on the functional outcome of the involved nger. The age and gender of the patients, time of splint application after repair, associated injuries, number of injured digits, zone of the injury, and mechanism of injury were included as independent variables. According to backward elimination method, independent variables and P values greater than 0.05 were eliminated one by one. The procedure was stopped when P values of all variables were less than 0.05 in the regression model.

RESULTS
Thirty-seven patients with 74 injured ngers were followed up for 12.9 5.4 wk. Thirty-one of the patients were male and 6 were female. Their ages ranged from 6 to 65 yr, with a mean age of 26.4 13.7 yr. Thirty-four patients were right handed and 3 were left handed; 20 patients injured their dominant hand and 17 injured their non-dominant hand. The most frequent areas of injury were in zone 2 and zone 5 (Table 2). There were 21 patients (56.8%)

TABLE 2 Distribution of tendon injury by zone

Zone 1 2 3 4 5 Thumb Total
a

No. of Patients 2 15 3 2 10 5a 37

% 5.4 40.6 8.1 5.4 27.0 13.5 100

No. of Fingers 2 21 7 5 33 6 74

with one nger injury. Two patients injured two ngers, seven patients injured three ngers, and seven patients injured four ngers (Fig. 3). There was an average of two injured ngers per patient. Single nger injuries were frequently seen in zone 1 and zone 2, whereas multiple nger injuries were more common in zones 3, 4, and 5 (Table 3). Knife wounds and glass injuries were responsible for 94.6% of the injured tendons (Table 4). There were 17 patients who had associated injuries (Table 5). The mean time of modied Kleinert splint application was 4.5 2.1 days after repair. In patients without nerve injury, this splintage was maintained for 4 wk. In patients with nerve injuries, the hand was splinted for 6 wk. The mean time of splintage was 4.5 0.9 wk. When evaluated by the BuckGramcko system, 54 ngers (73%) were rated excellent, 18 ngers (24%) were rated good, 1 nger (1.5%) was rated fair, and none was rated poor.

% 2.7 28.4 9.4 6.8 44.6 8.1 100

TABLE 4 Causative agents

No. of Patients Glass Knife Crash Total 24 11 2 37 % 64.9 29.7 5.4 100

Number of patients whose thumb only was injured. There was a patient with both thumb and zone 5 injury together.

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Figure 3: Number of patients with multiple nger injuries. One nger was not rated because of a tendon rupture that occurred during the third week after primary repair. The results of all ngers were excellent in zone 1 and zone 5 (Table 6). According to the backward elimination procedure of multiple regression analysis, age, zone of the injury, and time of splint application after repair were proved to have a signicant inuence on the nal TAM results (P 0.05). The gender of the patients, number of injured digits, mechanism of injury, and associated injuries had no signicant inuence on the nal TAM results (P 0.05). There was a statistically signicant negative correlation between the age of the patient and the TAM values (r 0.357, P 0.05). Statistically signicant correlation was found between the number of ngers injured and the nal TAM values (r 0.442, P 0.05). We found a negative correlation between the TAM results and time of splint application after repair, but this was not statistically signicant (r 0.253, P 0.05). In 40 ngers, there was no residual extension decit of IP joints. The degree of extension decit was between 0 and 15 degrees in 20 ngers. There was a residual extension decit greater than 15 degrees in 13 ngers. In the little-nger injuries, 46.5% of the ngers had a residual extension decit greater than 15 degrees; however, this ratio was 11.3% for the other four ngers (Table 7).

DISCUSSION
There is still controversy with regard to postoperative management of

exor tendon injuries. However, there is some evidence suggesting that early mobilization procedures yield better results.5 In this study, we used a modied Kleinert splint with a palmar pulley and combined active extension, passive exion, and passive exion and passive extension exercises. Although we did not compare our results with the Washington regimen, we wanted to point out the difference between two protocols. The main difference between our protocol and the Washington regimen was that passive exercises were not assisted by a therapist in our program but performed by the patients themselves. According to Buck-Gramcko classication, we obtained 97% excellent and good results, and our results compare well with the previous studies that used various postoperative rehabilitation techniques (Table 8). Among these ve studies, Savage and Risitano17 and Edinburg et al.5 had lower ratios (81% and 61%, respectively). Edinburg et al. used active extension and rubber-band passive traction with no combination of passive exion and extension exercises.5 Savage and Risitano also used controlled active motion exercises only.17 Their relatively low percentages might be caused by the lack of these passive exercises in their treatment protocols. Singer and Maloon pointed out that poor patient compliance, associ-

TABLE 5 Associated injuries

No. of Patients Nerves Median Ulnar Digital Median ulnar Arteries Radial Ulnar Fracture Phalanx Carpal Total 5 3 3 2 1 1 1 1 17

TABLE 6 Buck-Gramcko evaluation of functional results in 74 ngers after exor tendon repair
Zone 1 2 3 4 5 Thumb Total
a

No. of Digits 2 21a 7 5 33 6 74

Excellent 2 (100%) 10 (47%) 4 (57%) 2 (40%) 33 (100%) 3 (50%) 54 (73%)

Good 9 (43%) 3 (43%) 3 (60%) 3 (50%) 18 (24%)

Fair 1 (5%) 1 (1.5%)

Poor

One patient with zone 2 injury was not rated because of tendon rupture.

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TABLE 7 Extension decit of the ngers after exor tendon repair

Extension Decit (degrees) Finger Thumb Index Middle Ring Little Total 0 (%) 3 (50) 9 (50) 9 (56) 12 (67) 7 (47) 40 (55) 015 (%) 3 (50) 7 (39) 5 (31) 4 (22) 1 (6.5) 20 (27.5) 1630 (%) 2 (11) 2 (13) 2 (11) 6 (40) 12 (16.5) 31 (%) 1 (6.5) 1 (1)

ated injuries, and number of injured digits per patient were causes of poor prognosis.1 However, in our study we found that associated injuries had no inuence on nal TAM values. It is known that associated injuries do not preclude good functional results if they do not require more protection and limit initiation of movement.23 In our study group, none of the associated injuries required more protection, and this explains why associated injuries did not affect the functional results. Contrary to the results of Singer and Maloon, we found a signicant positive correlation between the number of injured digits and the TAM values, indicating that results improved with the greater number of ngers injured. In our study, this may be caused by excellent functional results after the zone 5 injuries in which multiple digit injuries were more common.

Permanent exion contracture of the IP joints is a common complication after exor tendon repair.23 This would be particularly likely after elastic-band traction because the resting position of the PIP joint is at 60 90 degrees of exion. In studies using Kleinert protocol, it was reported that 29 40% of the ngers had an extension decit more than 15 degrees.16,24 This ratio was found to be 28% with early passive motion protocol24 and 10 24% with early active motion protocols.14,18,19 In this study, there was a 17.5% incidence of extension decit of more than 15 degrees. Despite the elastic-band traction used in this study, our results were comparable with the studies using early active motion regimen. In our study, the addition of controlled passive extension of the IP joints to the Kleinert regimen might prevent the development of exion contracture of these two joints.

Another major complication is dehiscence of the repair.23 Rupture rate after exor tendon repair was reported to be between 2.4% and 46% in previous studies using various a early mobilization regimen.1,14,16 19,24 26 This study has demonstrated a rupture rate of 1.5%. We suggest that elastic-band traction may offer increased protection to the repaired tendon in the healing process, thereby offering some explanation for the lower rate of ruptures experienced in this study. To determine tendon ruptures, at every visit we instructed patients to gently ex the involved digit. This gentle, active exion of the involved digit can be added to every early motion program, except early active motion, without increasing the possibility of tendon rupture. Many authors think that good functional recovery after exor pollicis longus tendon repair is easier to achieve than after repair in other digits.7 In this study, 100% of six thumbs were rated excellent or good after exor pollicis longus repair. A possible explanation is that the anatomic architecture of this tendon within its sheath is less complex. Also, being a single tendon within its sheath, there are fewer chances of adhesion formation during healing. In the literature, the results with little ngers were poor.11,27 This may reect comparative weakness of the

TABLE 8 Comparison of results from recently published series using Buck-Gramcko criteria
Method Gault Soa Savage Edinburg This studya
a

No. of Digits 100 95 41 71 74

Excellent (%) 86 73.7 64 31 73

Good (%) 6 16.8 17 30 24

Fair (%) 3 1 14 20 1.5

Poor (%) 5 3.2 5 19

1987 1990 1989 1987 1997

Kleinert Modied Kleinert Early active motion Modied Kleinert Modied Kleinert early passive motion

Tendon ruptures were not rated.

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extensor and exor mechanisms of the little nger or the smaller size of its tendon sheath, which may be less able to accommodate the small bulge where the tendon ends are joined. In agreement with the literature, we found that an extension decit greater than 15 degrees was more frequent in the little-nger injuries than the other ngers (46.5% and 11.3%, respectively). Our results showed that, age, zone of the injury, and time of splint application after repair have a significant inuence on the nal TAM results. However, some other factors that we did not study such as surgical procedure, patients cooperation, dexterity, strength, and pain syndromes may also have an impact on hand function.

problems. Eur J Phys Med Rehabil 1996; 6:38 4. Steinberg DR: Acute exor tendon injuries. Orthop Clin North Am 1992;23: 125 40 5. Edinburg M, Widgerow AD, Biddulph SL: Early postoperative mobilization of exor tendon injuries using a modication of the Kleinert technique. J Hand Surg (Am) 1987;12:34 8 6. Chow JA, Thomes LJ, Dovelle S, et al: A combined regimen of controlled motion following exor tendon repair in No Mans Land Plast Reconstr Surg 1987; 79:44753 7. Saldana MJ, Chow JA, Gerbino P, et al: Further experience in rehabilitation of zone II exor tendon repair with dynamic traction splinting. Plast Reconstr Surg 1991;87:543 6 8. Stewart KM: Review and comparison of current trends in the postoperative management of tendon repair. Hand Clin 1991;7:447 60 9. Kleinert HE, Kutz JE, Atasoy E, et al: Primary repair of exor tendons. Orthop Clin North Am 1973;4:86576 10. Strien G: Postoperative management of exor tendon injuries, in Hunter JM, Schneider LH, Mackin EJ, et al. (eds): Rehabilitation of the Hand: Surgery and Therapy. St. Louis, C. V. Mosby Company, 1990, pp 390 409 11. Slattery PG, McGrouther DA: A modied Kleinert controlled mobilization splint following exor tendon repair. J Hand Surg (Br) 1984;9:217 8 12. Dovelle S, Heeter PK: The Washington regimen: rehabilitation of the hand following exor tendon injuries. Phys Ther 1989;69:1034 40 13. Duran RJ, Coleman CR, Nappi JF, et al: Management of exor tendon lacerations in zone 2 using controlled motion postoperatively, in Hunter JM, Schneider LH, Mackin EJ, et al. (eds): Rehabilitation of the Hand: Surgery and Therapy. St. Louis, C. V. Mosby Company, 1990, pp 410 3 14. Small JO, Brennen MD, Colville J: Early active mobilisation following exor tendon repair in zone 2. J Hand Surg (Br) 1989;14:38391 15. Elliot D, Moiemen NS, Flemming AFS, et al: The rupture rate of acute exor

CONCLUSION
In conclusion, this postoperative management provides an effective way of achieving satisfactory results. The addition of patient-assisted passive extension of IP joints to the Kleinert regimen successfully reduced development of exion contracture without the need of daily medical supervision. These results might be improved by the earlier application of a modied splint and careful follow-up of the patients, especially with little-nger injuries.

REFERENCES
1. Singer M, Maloon S: Flexor tendon injuries: the results of primary repair. J Hand Surg (Br) 1988;13:269 72 2. Haese JB: Psychological aspects of hand injuries: their treatment and rehabilitation. J Hand Surg (Br) 1985;10: 2837 nanc F, Dinc 3. C eliker R, I er F: Classication and etiological evaluation of hand

tendon repairs mobilized by the controlled active motion regimen. J Hand Surg (Br) 1994;19:60712 16. Cullen KW, Tolhurst P, Lang D, et al: Flexor tendon repair in zone 2 followed by controlled active mobilisation. J Hand Surg (Br) 1989;14:3925 17. Savage R, Risitano G: Flexor tendon repair using a six strand method of repair and early active mobilisation. J Hand Surg (Br) 1989;14:396 9 18. Bainbridge LC, Robertson C, Gillies D, et al: A comparison of postoperative mobilization of exor tendon repairs with passive exion-active extension and controlled active motion techniques. J Hand Surg (Br) 1994;19:51721 19. Baktr A, Tu rk CY, Kabak S , et al: Flexor tendon repair in zone 2 followed by early active mobilization. J Hand Surg (Br) 1996;21:624 8 20. Silfverskio ld KL, May EJ, To rnvall AH: Tendon excursions after exor tendon repair in zone II: results with a new controlled-motion program. J Hand Surg (Am) 1993;18:40310 21. Buck-Gramcko D: A new method for evaluation of results in exor tendon repair. Handchirurgie 1976;8:659 22. Cambridge CA: Range of motion measurements of the hand, in Hunter JM, Schneider LH, Mackin EJ, et al. (eds): Rehabilitation of the Hand: Surgery and Therapy. St. Louis, C. V. Mosby Company, 1990, pp 8292 23. Taras JS, Gray RM, Culp RW: Complications of exor tendon injuries. Hand Clin 1994;10:93109 24. May EJ, Silfverskio ld KL, Sollerman CJ: Controlled mobilization after exor tendon repair in zone II: a prospective comparison of three methods. J Hand Surg (Am) 1992;17:94252 25. So YC, Chow SP, Pun WK, et al: Evaluation of results in exor tendon repair: a critical analysis of ve methods in ninetyve digits. J Hand Surg (Am) 1990;15: 258 64 26. Peck FH, Bu cher CA, Watson JS, et al: A comparative study of two methods of controlled mobilization of exor tendon repairs in zone 2. J Hand Surg (Br) 1998; 23:415 27. Y NW, Urban M, Elliot D: A prospective study of exor tendon repair in zone 5. J Hand Surg (Br) 1998;23:642 8

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