O Intervention Group (Cases Sheet and Management) : Case 1

o Intervention group (cases sheet and management)
Case 1
 Personal history
 Name :- Asmaa Abdelrahman
 Age :-28 years
 Sex :- female
 Adress:- Khorshid , Alex
 Occupation :- House wife
 Handedness:- right handed
 Present history of current problem :- the trauma occurred by sharp

knife thrown on the patient’s right hand that caused a tear in EDC
tendon .
 Past history :- cervical spondylosis
 Medical diagnosis :- tear of extensor digitorum communis tendon

(lateral aspect of zone 6)
 Surgical intervention
 date of surgery:- 29/6/2020
 type of suture:- running suture
 Chief complain :-
1) Burning sensation in the dorsal aspect of the hand (specially at the

little finger)
2) Cannot hold objects in hand
3) Weak hand grip and finger pressors
4) Inability to do normal hand ADL’s

 Pain assessment :- by VAS (visual analogue scale)
0 1 2 3 4 5 6 7 8 9
10
 Nature :- dull aching pain with burning sensation radiated to shoulder

with wrist flextion
 Provocation:- with wrist and fingers’s flexion
 ROM assessment:
 limited flexion and extension of the wrist
 limited fingers flexion
 wrist extension:- 30 degrees
 wrist flexion:- 25 degrees
 Muscle testing: group muscle test
 Hand extensors (grade 2)
 Hand flexors (grade3)
 Muscle power:
 weak grip strength
 weak finger pressors
 Scar assessment: by modified Vancouver scale(MVS)
1) Vascularity:- red
2) Pigmentation :- hyperpigmented
3) Pliability:- supple
4) Height:- flat
Case 2
 Name :- Ramadan Abdelsalam Elsayed
 Age :-30 years
 Sex :-male
 Adress:- Elmandara, Alexandria
 Occupation :- Deputy Assistant
 Present history of current problem :- hand hit a hard glass and the
glass had shuttered into pieces and caused tear of (EDC) tendon in
zone 5.
 Past history
Ankle surgery with plates and screws
 Medical diagnosis :- tear of extensor digitorum communis tendon

(middle aspect of zone 5)
 date of surgery:-23/7/2020
 type of suture:- horizontal mattress

 Pain in the dorsal aspect of the hand
 Cannot practice his normal activities in work
 Inability to drive his motorbike
 Cannot grasp the pen and similar objects
0 1 2 3 4 5 6 7 8 9
10
 Nature :- sharp and stabbing pain
 Provocation:- with finger and wrist flexion
 ROM assessment:
 highly limited extension , pronation and flexion of hand
 inability to do supination
 wrist extension:- 30 degrees
 wrist flexion:- 20 degrees
 Hand extensors :- grade 2
 Hand flexors:- grade 2
 Muscle power:
 Weak hand grip
 Weak finger pressors
 Scar assessment:
1) Vascularity:- pink
2) Pigmentation:- hypopigmented
3) Pliability:-firm
4) Height:-flat
Case 3
 Name :- Eslam Mohamed Ibrahim
 Age :- 32
 Sex :- male
 Adress:- Muharam Bek_ Alexandria
 Occupation :- police officer
 Handedness:- left handed
 Present history of current problem the trauma occurred because of

car accident that caused a cut of Extensor pollicis longus (lateral
aspect of zone8)
 Past history fracture of tibia since 3 years
 Medical diagnosis :- tear of extensor hallucis longus (lateral aspect

of zone8)
 Severe pain when he do and hand function
 Inability to hold the drexion while driving the car
 Poor hand function

 Pain that awake him from sleep
0 1 2 3 4 5 6 7 8 9
10
 Nature :- sharp aching pain
 Provocation:- during wrist extension and supination
 ROM assessment:
 Limited flexion, extension and supination
 Limited pronation an finger flexion
 Wrist extension:- 25 degrees
 Wrist flexion:- 30 degrees
 Hand extensors :- grade 2
 Hand flexors :- grade 3
 Muscle power:
 Weak hand grip
2) Pigmentation:- hyperpigmented
3) Pliability:- normal
4) Height:- flat
Case 4
 Name :- Mohamed Gaber Kamel
 Age :- 23 years
 Sex :-male
 Adress:- Antoniadis , Kafr Eldawar
 Occupation :- Bucher
 Present history of current problem:- the patient cut his hand with
very sharp knife while he was cutting the meet which cause a serious
tear in (EDC) tendon of the left hand (all dorsal aspect of zone 6)
 Past history ______
 Medical diagnosis :- tear in (EDC) tendon (all dorsal aspect of zone

6)
 type of suture:- Modified Kessler
 Severe pain in hand even at rest
 Cannot practice his job
 Cannot do his normal ADL’s
He feel that his hand is very weak
 Pain assessment :- by VAS (visual analogue scale)

0 1 2 3 4 5 6 7 8 9
10
 Nature :- dull aching pain
 Provocation:- while moving hand in all directions
 ROM assessment:
 Highly limited wrist motion in all directions
 Wrist extension :- 15 degrees
 Wrist flexion:- 15 degrees
 Wrist extensors:- grade 1
 Wrist flexors:- grade 2
 Muscle power:
 Weak hand grasp
 Weak finger pressors
 Vascularity:- pink
 Pigmentation:- hypopigmentation
 Pliability:- contracture
 Height :- flat
Case 5
 Name :- Ahmed Awad Mohamed
 Age :- 24 years
 Sex :- male
 Address:- Sedi Shehata, Kafr Eldawar
 Occupation :- Baker
 Handedness:-right handed
 Present history motorbike accident cause severe tear in extensor

hallucis longus of left hand ( medial aspect of zone 7)
 Past history shoulder dislocation , carpal tunnel syndrome
 Medical diagnosis :- tear in extensor hallucis longus of left hand

( medial aspect of zone 7)
 date of surgery:-11/8/2020
 type of suture:- Modified Kissler
 Inability to bake bread because of pain
 Pain while moving his hand
 Cannot rotate his hand to either sides
 Inability to fully close his hand and fingers
0 1 2 3 4 5 6 7 8 9
10
 Nature :- sharp ,stabbing and burning pain
 Provocation:- thumb and wrist extension and forearm supination and

pronation
 ROM assessment:
 Wrist flexion :- 15degrees
 Limited and painful thumb extension and flexion
 Muscle power:
 Weak grip strength
 Weak opposition
 Vascularity:- red
 Pigmentation:- normal
 Pliability:- contracture
 Height :- <2
Management of group 1 (intervention group)

 This treatment was done with frequency (3 sessions/week)
 Therapeutic modalities
1) Faradic ( 15 minutes )
2) Ultrasound (10min)
3) Low level laser theray (400mw for 5 min. ,with 4J/cm2)
 Manual therapy
1) Scar management
 Positioning
 Massage(friction and skin rolling)
 Once the stitches are removed and the wound is closed (with
no signs of infection). Scar massage is introduced using a non-
perfumed moisturizer (E45 or aqueous cream)
 Patients are taught to use circular motions along the scar

working distal to proximal to help the reduction of edema.
 Wounds dressed.
2) Stretching exercise for wrist extensors
3) Strengthening of all hand muscles
4) Strength hand grip
5) Mobilization with movement
6) Oedema control-
 Patients are taught to elevate the arm at every opportunity, keeping

the hand above heart level. At night they are advised to prop the
arm up on pillows.
7) Hand Hygiene
 Patients are taught to place the hand/forearm on a flat surface
(maintaining the position of hand held in a splint). The
hand/forearm should be wiped with hypo allergic wipes (alcohol
based).
Week Exercise Precautions Other

Phase 1 (week 0-3)  AROM flexion:  Full fisting  May consider
isolated joint and may place too option of total
tendon gliding much stress on immobilization if
(hook and straight the repair. necessary.
fist). Assess on a
 Eoedema control
 Passive extension case-by-case
within limits basis.  Scar management
 10-20 reps /session  Goal: Full AROM
 Begin active MP resistive
activity. digits prior to
flexion to 30-40 progressing to
degrees Phase II.
 Progress MP
flexion as tolerated.
 Perform wrist and
digit PROM in
extension
 AROM of digits
Phase 2 (week4-5)  Progress MP  No maximal  Goal: Full wrist
flexion to 40-60 resistance until 6- AROM prior to
(week 4), 70-80 8 weeks removing wrist
(week 5). splint for light
 Initiate full fisting activities.
if not already done.
 Composite wrist
and finger flexion.
 Active digital
extension exercises
out of splint.
 Mobilization with
movement
Phase3 (week 6-7)  AAROM, heat and
stretch.  Ongoing scar
 Wrist flex/ management
extension exercise
 Active tendon glide
 Composite flexion
 Strengthening ex.
For hand grip
 Strengthening
exercises include
using Thera putty
for finger extension
exercises – make a
little doughnut
shape out of Thera
putty, place around
the fingers and then
actively extend the
fingers.
 Another example is
using the Thera
putty for finger
flexion exercises
into a full fist – as
patients often lost
grip strength as a
result of the period
of immobilization
Home advice
1. Introduce light use of the hand in ADL’s.
2. Do not lift anything heavier than a mug of fluid.
3. No passive flexion of wrist and fingers.
4. Maintain ROM in shoulder and elbow.
5. Do not extend fingers against strap.
6. Do not force finger into flexion.
7. Oedema control. (elevate hand all the day to control swelling)
8. Ice application for 10min. 2 times /day
9. Cover splint with plastic bag while showering

Standard of care group
Case 1
 Name :- Asmaa Mahdy Atiya
 Age :-20 years
 Sex :-female
 Adress:- Al_tamleek , KafrEldawar
 Occupation :- student
 Handedness:-left handed
 Present historyof current problem:- the trauma occurred as the

patient fall on the stairs and on her dorsal aspect of the hand on a piece
of sharp glass and the tendon of EDC of left hand affected and was
torn.
 Past history ____

 Medical diagnosis :- tear of the tendon of EDC muscle ( middle part
of zone 6)
 Inability to study her lessons because she cannot hold the pen
 Pain at the back of hand with movement
 Inability to cut vegetables to cook
 Cannot do her normal ADL’s
0 1 2 3 4 5 6 7 8 9 10
 Nature :- sharp and burning pain
 Provocation:- wrist extension with elbow extended .
 ROM assessment:
 Limited wrist flexion more than extension and pronation more than
supination
 Limited elbow extension
 Wrist flexion :- 20 degrees
 Muscle testing: (group muscle test)
 Muscle power
 poor hand grip
 poor function of hand
1. Vascularity:- pink
2. Pigmentation:- normal
3. Pliability:- supple
4. Height:- flat
Case 2
 Name :- Ibrahim Shaaban Mohamed
 Age :-21 years
 Sex :-male
 Adress:- Al_Akreesha , KafrEldawar
 Occupation :- student
 Present historyof current problem:- the trauma occurred because of

car accident that cause significant tear of EDC tendon of left hand .
 Past history ____
 Medical diagnosis :- tear of the tendon of EDC muscle ( middle part

of zone 7)
 Cannot carry his books while going to college
 Pain at the back of hand with movement and during hand closure
 Disturbance of sleep because of pain

0 1 2 3 4 5 6 7 8 9 10
 Nature :- dull and aching pain
 Provocation:- wrist flexion with elbow extended and with gasping

any object.
 ROM assessment:
 Limited wrist flexion more than extension and pronation more than
supination
 Limited finger flexion :- 10 degrees
 Muscle power
 poor hand grip and hook grip
 poor function of hand
 porr finger pressors strength
1) Vascularity:- brown
2) Pigmentation:- hypopigmentation
3) Pliability:- firm
4) Height:- flat
Case3
 Name :- Ahmed Abdo Elsayed
 Age :-26 years
 Sex :-male
 Adress:- Al_Tamleek , KafrEldawar
 Occupation :- driver
 Present historyof current problem:- the trauma occurred during car

accident that cause tear in EPL tendon of the right hand( medial aspect
of zone 6).
 Past history surgery in kidney since 5 years, elbow fracture since 2

years
 Medical diagnosis :- tear in EPL tendon of the right hand( medial

aspect of zone 6).
 Inability to drive the car because of pain and weakness
 Pain during flexion of wrist and other movements

 Inability to carry his 3years old baby
 Difficulty holding the spoon to eat
0 1 2 3 4 5 6 7 8 9 10
 Nature :- sharp and stabbing pain
 Provocation:- wrist flexion, any thumb movement .
 ROM assessment:
 Limited wrist flexion and extension
 Limitation of allthumb movement
 Wrist extension :- 35degrees
 Thumb extensors :- grade 1
 Muscle power
 Poor thumb opposition
 poor grip and pressing strength
2) Pigmentation:- hyperpigmentation
4) Height:- flat
Case4
 Name :- Nadia Mohamed Elsayed
 Age :- 30 years
 Sex :- female
 Adress:- Khorshid ,Alexandria
 Occupation :- house wife
 Present historyof current problem:- the trauma occurred as a result

of glass crush on her hand that caused tear in the tendon of EDC
muscle of the right hand (lateral aspect of zone 7)
 Past history severe anaemia the made her have treated by blood for
1 week
 Medical diagnosis :- tear in the tendon of EDC muscle of the right

hand (lateral aspect of zone 7)
 type of suture:- Modified Kessler
 Pain during flexion of wrist and closure of fingers
 Inability to care of her children
 Cannot hold knife and any other object to cook
 Severe pain that awake her from sleep
 Cannot do her normal ADL’s and carry any heavy thing

0 1 2 3 4 5 6 7 8 9 10
 Nature :- pinprick and pressure pain
 Provocation:- any wrist movement provocate pain .
 ROM assessment:
 Limitation of wrist pronation and supination
 Muscle power
 Poor thumb opposition
 poor grip and pressing strength
 poor hook strength
5) Vascularity:- red
7) Pliability:- firm
8) Height:- flat
Case 5
 Name :- Farida Ameen Ahmed
 Age :-22 years
 Sex :- female
 Adress:- KafrEldawar
 Occupation :- teacher
 Present historyof current problem:- the trauma occurred as a sharp

knife fall on her dorsal aspect of hand that caused tear in EDC tendon
of the right hand( medial aspect of zone8).
 Past history _______
 Medical diagnosis :- tear in EDC tendon of the right hand( medial

aspect of zone8).
 Severe pain with any wrist movement
 Pain may appear during elbow extension and flexion
 Inability to go to work because she cannot hold the pen and cannot
write anything
 Cannot practice her normal activities in house
0 1 2 3 4 5 6 7 8 9 10
 Nature :- sharp and pressure pain
 Provocation:- wrist flexion, and elbow movement .
 ROM assessment:
 Limitation of pronation and supination
 Muscle power
 Poor hook strength
 poor grip strength
 weak hand function
9) Vascularity:- brown
12) Height:- flat
 Management of group 2 (standard of care ):

 Medications
 Mobic tablets 7.5 mg
 Scaro gel
 Scarotex cream
 Voltaren cream
 Felden injection
 Ambeziem
 Physical advices
Phase I : Weeks 0-3

 Goals
1. Prevent tendon rupture and promote tendon healing
2. Edema and pain control
3. Scar management
 Intervention:
1. Splinting – volar – wrist 40-45 degrees extension, 0 to 20 degrees

of MP flexion, and 0 degrees or IP flexion
2. Wound care (frequently moisturize the wound with medical

creams and change dressing of wound if present )
3. Edema control, use of modalities(ice application for 15 min ,2

times/day)
Phase II : Weeks 3-6

 Goals:
1. Continue edema and pain control
2. Initiate AROM
3. Control extrinsic extensor tightness
 Intervention:
Week 3
 Splinting – volar – wrist 20 degrees extension, MPs 0 degrees

extension. With PIP extension lag or flexion contracture, use
removable volar component. With MP joint flexion less than 30 to 40
degrees with a “hard” end feel
 MP joint protective AROM (with the splint the patient try to flex and
extend wrist within pain limits)
 PIP and DIP joint protective AROM(the splint supports wrist and
MPs in full extension)
 A removable volar component may be applied sleeping and/or

intermittently during day to prevent PIP joint flexion contracture
and/or extensor lag
Week 4 - 5
 Continue splinting , but patient do AROM while splint is off may be

initiated to decrease extrinsic extensor tightness
 Composite MCP/IP flexion with wrist extension
 Individual finger extension
 Isolated EDC extension (the patient is asked to fix the wrist at the end
of table and extend only the metacarpophalangeal joints
Phase III : Weeks 6-7

 Goals:
1. Initiation of self-stretching strengthening
2. Full PROM
 Intervention:
 Splinting – only if needed
 Composite finger and wrist flexion (ask patient to do it carefully)
 Mild progressive strengthening including wrist flexion/extension and

forearm pronation/supination(the patient is asked to hold a 1kg subject
and try to extent ,flex and rotate hand to either sides carefully)
 Self-stretching exercise (teach patient to put the hand on a table and

try to stretch wrist as far as possible).
 Sampling and study
 A cross section study has been done to 10 patients who had had an
extensor tendon repair of the wrist.
 The study was done at police hospital in Alexandria.
 The 10 patients were divided into 2 groups ; intervention group in

which they were treated with a total physical therapy program and ;
standard of care group in which patients were treated with
medications and some physical advices to follow at home.
 This study was done for 6 weeks. In this study I compare the 2
groups according to the change of pain intensity every week and
number of patients who respond quickly to treatment and who
respond slowly every week.
 While comparing 2 groups ; it was clear that the progression and

response to treatment was faster in intervention group than the
standard of care group.

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o Intervention group (cases sheet and management)

 Name :- Asmaa Abdelrahman

 Age :-28 years

 Adress:- Khorshid , Alex

 Occupation :- House wife

 Handedness:- right handed

 Present history of current problem :- the trauma occurred by sharp

 Past history :- cervical spondylosis

 Medical diagnosis :- tear of extensor digitorum communis tendon

 date of surgery:- 29/6/2020

 type of suture:- running suture

1) Burning sensation in the dorsal aspect of the hand (specially at the

2) Cannot hold objects in hand

3) Weak hand grip and finger pressors

4) Inability to do normal hand ADL’s

 Nature :- dull aching pain with burning sensation radiated to shoulder

 Provocation:- with wrist and fingers’s flexion

 limited flexion and extension of the wrist

 limited fingers flexion

 wrist extension:- 30 degrees

 wrist flexion:- 25 degrees

 Muscle testing: group muscle test

 Hand extensors (grade 2)

 Hand flexors (grade3)

 weak grip strength

 weak finger pressors

 Scar assessment: by modified Vancouver scale(MVS)

 Name :- Ramadan Abdelsalam Elsayed

 Age :-30 years

 Adress:- Elmandara, Alexandria

 Occupation :- Deputy Assistant

 Handedness:- right handed

Ankle surgery with plates and screws

 Medical diagnosis :- tear of extensor digitorum communis tendon

 type of suture:- horizontal mattress

 Pain in the dorsal aspect of the hand

 Cannot practice his normal activities in work

 Inability to drive his motorbike

 Cannot grasp the pen and similar objects

 Pain assessment :- by VAS (visual analogue scale)

 Nature :- sharp and stabbing pain

 Provocation:- with finger and wrist flexion

 highly limited extension , pronation and flexion of hand

 wrist extension:- 30 degrees

 wrist flexion:- 20 degrees

 Muscle testing: group muscle test

 Hand extensors :- grade 2

 Hand flexors:- grade 2

 Weak hand grip

 Weak finger pressors

 Name :- Eslam Mohamed Ibrahim

 Adress:- Muharam Bek_ Alexandria

 Occupation :- police officer

 Handedness:- left handed

 Present history of current problem the trauma occurred because of

 Past history fracture of tibia since 3 years

 Medical diagnosis :- tear of extensor hallucis longus (lateral aspect