Splinting at 6 Months Post-Injury for Extensor Tendon Injury at PIP
It is too late to splint this injury at 6 months post-trauma, and splinting at this stage may actually cause harm rather than benefit. 1
Why Splinting is Not Recommended at This Stage
Timing Considerations
- Splinting is most effective when applied as soon after musculoskeletal injury as possible and should be maintained only until the injury heals sufficiently for protected limb function without pain 2
- The 6-month timeframe far exceeds the typical healing window for extensor tendon injuries, which generally heal within 6-12 weeks with appropriate early immobilization 3
- Even in trigger finger (a stenosing tenosynovitis condition similar to what this patient has), splinting for an average of only 6 weeks showed 66% success rates, but this was initiated acutely, not months after injury 4
Potential Harms of Late Splinting
The occupational therapy consensus guidelines specifically warn against splinting in chronic tendon conditions due to multiple risks: 1
- Increased attention and focus to the area, potentially exacerbating symptoms 1
- Increased accessory muscle use and compensatory movement strategies 1
- Immobilization leading to muscle deconditioning 1
- Learnt non-use of the affected digit 1
- Increased pain 1
- Serial casting for fixed functional dystonia has been associated with worsening symptoms and onset of complex regional pain syndrome 1
What Should Be Done Instead
Current Clinical Picture
The ultrasound findings of mild tendinosis and tenosynovitis at 6 months indicate chronic changes rather than acute injury: 5, 6
- The "bump" likely represents thickening of the extensor retinaculum or tendon itself 6
- Chronic tenosynovitis with tendon sheath effusion is common in this presentation 6
Recommended Management Approach
Active rehabilitation rather than immobilization is the appropriate strategy: 1
- Encourage normal movement patterns and optimal postural alignment during functional activities 1
- Grade activities to increase the time the affected digit is used with normal movement techniques 1
- Engage in tasks that promote normal movement, good alignment, and even weight-bearing 1
- Begin active finger motion exercises of the PIP and MCP joints to prevent further stiffness 3
Conservative treatment options to consider: 6
- US-guided steroid injection has shown effectiveness for chronic extensor tenosynovitis 6
- Medical management for the inflammatory component 7
- Physical/occupational therapy focused on restoring function rather than immobilization 1
When to Consider Surgical Referral
Surgical evaluation should be considered if: 7
- The tenosynovitis does not resolve with conservative management 7
- There is concern for impending tendon rupture 7
- Progressive functional limitation despite appropriate therapy 7
- Dynamic ultrasound demonstrates significant impingement of the extensor tendon 6
Key Clinical Pitfall to Avoid
The most important pitfall is attempting to treat a 6-month-old injury as if it were acute. The window for primary splinting has closed, and the focus must shift from immobilization to restoration of function. Splinting now risks creating more problems (stiffness, pain, learned non-use) than it solves. 1