Single Handed Progress

Yep, that's my actual nerve there, all sutured up

It is now 5 weeks since I had surgery to mend my severed digital nerve and flexor tendons.  Whilst it was the obvious injury to the nerve in my finger that prompted my medivac, my prolonged UK stay is due to the tendon damage found in theatre.  As I approach the halfway point of my stay in the UK I thought I'd explain in more detail what I have injured, and the hows/whys of my long recovery.

The Injury

There are two tendons that flex the finger: FDP (flexor digitorum profundus) flexes the tip of the finger, and FDS (flexor digitorum superficialis) flexes the middle joint.  

Around about the palmar crease where the finger joins the palm, the FDS tendon splits into two slips, and the FDP tendon emerges from underneath through the gap.  As you bend your finger, the FDP thus glides back and forth through a tunnel created by the divided FDS.  As sod's law would have it I've injured my tendons right at the bifurcation - one of the more awkward places in terms of recovering good function.

Location of tendon lacerations (not my finger!)

Whilst the damage was relatively limited, the unknown is how well the tendons will glide past each other as they heal and scar.  Outcomes for injuries in this zone are the most variable, with fewer patients regaining 100% normal function than other zones.

The nerve injury is much more straightforward.  I partially severed one of the two nerves which give sensation to my finger, leaving my index finger numb on the side abutting my middle finger.  This 'ulnar digital nerve' is the preferable one to sever, as sensation on the opposite 'radial' side of the index finger is much more important for fine grip.  It is now a waiting game as the axons regenerate at a rate of 1mm a day.  The sensation will never be normal, but already at this early stage I can feel things a little better.

Rehabilitation

Rehabilitation for flexor tendon injuries is all about finding a balance between protecting the tendon from rupture by limiting finger movement, and moving the finger enough to minimise the formation of sticky adhesions which would stop the tendons gliding.  

Dorsal-blocking thermoplastic splint: Mark I

48hrs post-op I first met Flo - my hand therapist and thus most important person in my recovery for the next few months.  First job was to exchange the plaster cast applied in theatre for a custom-moulded thermoplastic splint.  This holds my fingers flexed almost 90 degrees at the knuckles and prevents the healing tendons from stretching too much.  I have to wear the splint 24hrs a day for 6 weeks.  

I was then shown two simple exercises which keep the tendons gliding without putting too much stress on the repair.  The temptation is to push hard with the exercises and try to achieve PB's in movement each day.  But in the flexor tendon game working harder doesn't produce quicker results - in fact it is likely to result in tendon rupture.  The emphasis is on slow, gentle and controlled movement within the limits set by Flo.

Passive Flexion:  Using my good hand I gently curl each finger of my left hand into the palm.  The first time I do this every morning my finger is very stiff and sore, but it slowly loosens out.  I like to think of it as my warm up exercise.  Now at 5 weeks post op I can usually bend my finger at least 90% of the way - only persistent swelling seems to be preventing full passive flexion.

Active Flexion:  From full extension in the splint I bend all the fingers down towards the palm at the same time, concentrating on moving the top joint first not the middle joint.  It is easier to lead with the middle joint, but this does not move the tendons in an optimal way.  For the first two weeks I was only allowed to bend the fingers about a third of the way and I found even this limited movement very difficult.  Flo had a horrified look on her face when I tried it for the first time two days post op - I struggled to move my finger at all.  Thankfully this was just due to significant swelling as a result of the inevitable delay to surgery.  She was positively delighted, and a little bit relieved, when I showed her my progress a week later.  At 4 weeks post op a modification was added where at the limit of active flexion I passively flex my fingers into the palm and then let go and try and hold them in position.  This 'place and hold' exercise increases the range of movement and strength in the finger, but does place more tension on the repair.

Steady Progress: Active Flexion at 3wks Post Op

The finger extension component of these exercises is just as important.  As my finger rests unused in a flexed position for 90% of the day, there is a risk of the middle joint seizing up and not being able to extend fully.  This fixed flexion deformity becomes permanent in some cases.  So after each passive and active flexion I must carefully extend again from the middle joint as fully as possible.  The first few extensions of a session are now getting rather painful with stiffness, which hammers home to me the importance of doing it properly.

These exercises have been subtly modified over the weeks, but remain essentially the same.  6 reps of each exercise, 6 times a day, for 6 weeks.  And that's it.  The rest of the time I am not allowed to use any part of my hand at all, for anything.  Not even a cheeky little finger.  Cheating = tendon rupture.

After two weeks the skin sutures were removed and I was mercifully allowed to bathe my hand.  In fact warm bathing, along with massage of the scar is another key part of the rehab program.  The bathing is soothing and softens the skin, and the massage helps keep the tissues over the repair mobile, reducing adhesions.  This is a little more difficult to achieve in my case as the palmar-finger crease scar, directly below which lies the repair, is flexed in the splint and so less accessible and prone to scar contracture.  I said it was an awkward place to injure!

Managing one-handed

More and more I find myself referring to my injury as a hand not just finger injury.  I am aware that my whole hand and wrist has become significantly weaker within the splint, but it is the inability to use any part my hand that I have found disabling.  Mark II TP splint is also rather unwieldy with a harsher 90 degree bend at the knuckles.  It does makes for fine head/chin rest at least!

Doing things one-handed has been a matter of just getting on with it through trial and error.  Getting dressed obviously takes a little longer but actually even things like putting on socks and bra has proven easy to adapt to.  After needing help to lace my shoes I now just keep them all laced up use a shoe-horn, or a desert spoon!   In the shower I have learnt that standing on one leg and squirting a measured amount of shampoo etc onto my thigh is preferable to emptying a whole bottle on my head.  I can even do the twirly towel on head thing pretty quickly - that one involves teeth.  In fact most things can be done with a matter of patience and creative use of elbows/knees/feet/teeth.  I have definitely become more dexterous with my right hand over the weeks though.

I have to keep my hand elevated still due to the swelling but discarded the sling almost immediately, preferring to use at least some muscles in my left arm.  In practice when out and about my arm is usually found tucked up inside my jacket.  This is mostly for the very practical reason that I cannot fit the splint through most sleeves.  It keeps my hand nice and warm too.  I'm looking forward to my wardrobe choices increasing in a few weeks. 

Can you tell I was happy to get a run out?! Fun in the mud one week post op

I was delighted to be told I was allowed to run with my injury.  I was warned that vibration could be uncomfortable but luckily this hasn't been the case for me.  So I have been able maintain my fitness, and my sanity.

Halfway

So this week marks the halfway point of my stay in the UK and the countdown towards returning to South Georgia.  I am much more optimistic than when I wrote my first injury blog but I still have my moments.  I remain immensely jealous of my colleagues across Antarctica whose adventures I continue to follow from afar.  And I continue to be angry with myself for allowing the injury to happen and messing up such a fantastic and one-off experience for myself.  I do get frustrated at the necessary limits placed on activities and the limited control I have over the outcome of my injury.  Mild anxiety always niggles that one wrong move, an incorrectly performed exercise or just a stretch during sleep could jeopardise my return. And even if all continues to go to plan the finger will never have normal sensation and movement.  All for an avocado.  So it has been hard.

But there is plenty to look forward to: I get to remove the splint at the end of the week, and perhaps even use my hand for the first time.  We're getting there, slowly but surely.

It ain't South Georgia but Ainsdale Dunes in the winter sun isn't bad