Immediate Post-Operative Period:

• Immobilization for the first 3-5 days post-operatively in a surgical splint with the wrist in 10-30 degrees of extension, MPJ at 30 degrees flexion and IPJ in full extension.
• Patients are instructed to not move the fingers at all and to keep the hand elevated at all times in these early postoperative days to avoid bleeding into the wound. Bleeding causes clotting, and clotting becomes scar. Waiting 3 to 5 days before moving lets the swelling, work of flexion, and friction decrease to minimize the risk of rupture. Collagen formation does not start until day 3, so detrimental immediate movement is not necessary.

3-5 Days Post-Op – 2 weeks Post-op:

• Placement into a forearm-based dorsal block splint with wrist in 10-30 degrees extension, MPJ in 30 degrees flexion and IPJ into full extension.
• Edema control through elevation of the hand and gentle wrapping with Coban between exercises and at night
• TAM measurement
• Within the dorsal blocking splint, patients are taught the following 3 exercises at 25 repetitions every waking hour: (no tension, painful or forceful movement) “You can move it but you can’t use it” should be emphasized several times at each visit.

1. Passive flexion of all digits as a “warm-up” before active flexion
2. Active IPJ extension with MP joint blocked in flexion to prevent interphalangeal joint flexion contractures
3. True active flexion up to 1/3 to 1/2 of a fist, initiating movement at the DIPJ (active hook fist)

2-4 Weeks Post-Op:

• Dorsal block splint is shortened to a hand-based Manchester orthosis
• Continue use of Coban between exercises and at night
• Scar massage as needed
• TAM measurement
• Patients are instructed to complete the exercises below at 25 repetitions every waking hour:

1. Continue passive flexion of all digits,
2. Continue active IPJ extension with MP blocked in flexion,
3. Continue true active flexion ½ to full active fisting and up to 45 degrees of wrist extension, working toward full active fisting by 6 weeks post-op
4. Add active synergistic exercises in the Manchester orthosis

4-6 Weeks Post-op:

• Continue use of hand-based Manchester orthosis
• Continue use of Coban between exercises and at night
• Scar massage as needed
• TAM measurement
• Continue the following at 25 repetitions every waking hour:

1. Passive flexion of all digits,
2. Active IPJ extension with MP blocked in flexion
3. Active flexion ½ to full active fisting and up to 45 degree of wrist extension, working toward full fisting by 6 weeks post-op
4. Active synergistic exercises in the Manchester orthosis

6 Weeks Post-Op:

• Manchester short orthosis is discontinued
• Scar management as needed
• TAM measurement
• Patients can start to use the hand for light activity
• Start palm-based or digit extension splinting at night if needed to correct IPJ flexion contracture
• Relative motion flexion orthosis during daytime activity may be used to regain active flexion
• Relative motion extension orthosis may be used to address PIP flexion contracture

8 Weeks Post-op:

• TAM measurement
• May begin strengthening