day ten: flexor tendon injuries Flashcards
what two arteries supply the hand?
ulnar and radial
what two arches do you have?
superficial and deep palmer arch
what confirms the blood supply integrity
allens test
what would you use the allens test on?
to confirm the blood supply integrity
what do neurovascular bundles contain?
digital arteries vein and nerves
how many neurovascular bundles are there
two
- one radial and
- one ulnar
where does tendon nutrition come from?
- intrinsic : vascular perfusion
2. extrinsic: diffusion from synovial fluid
where does intrinsic nutrition come from?
vascular perfusion
where does extrinsic nutrition come from
diffusion from synovial fluid
vinculi branch
off the common digital artery
two types of vinculi
short and long
what does the vinculi supply?
FDS and FDP
vascular supply mainly comes form where?
the dorsal side of the hand
why is movement important for tendon healing?
synovial fluid bathes tendon = lubrication for glide
diffusion occurs as the synovial fluid gets umped into the tendon fibers during flexion and extension of the fingers
how many pulleys do you have?
five
what do pulleys do?
hold tendons close to the bone
pulleys improve
the biomechanical efficiency of the flexor tendon system
key pulley are
A-2 and A-4
pulley damage causes:
bowstringing
how does bowstringing present?
flexion of all dip pip mcps
how many pulleys does the thumb have?
three pulleys
what is the camper’s chiasm?
the space between the FDS and FDP tendons
injury at zone 1 is
jersey finger
jersy finger means
the FDP is involved so you can’t bend the tip of the finger
zone 1 does
extends from the fingertip to the midportion of the middle phalanx
zone 2 :
extends from the midportion of the middle phalanx FDS insertion to the distal palmar crease
injury at zone 2 is
no man’s land
where is the most common area for flexor tenodn laceration ?
zone 2
zone three does
extends from the distal palmar crease to the distal portion of the transverse carpal ligament
- not as much scarring in this area
zone four does:
overlies the transverse carpal ligament
zone five
extends from the wrist crease to the level of the muscultendinous junction of the flexor tendon
injury to zone five is
a spaghetti wrist
surgical tendon repairs are called
incisions: z plasty
a primary repair is when
within the first two weeks of tendon laceration you fix tendon
a secondary repair is when
they were repaired after two weeks
you would prefer a _______ repair
primary
in a secondary repair what happens to the tendons?
the teonds and tendon sheaths become scarred
the musculotendinous units retract
non bulky
old school 2 strand repair
bulky
6 strand core: Strickland method
pro cons of non bulky
pro passes under pulleys secondary less bulk
con; gaps and is weak
bulky pros cons
con: doesn’t pass through pulleys
pro: you can just vent the pulley
epitendinous suture
core suture followed by an epiteninous suture to complete the tendon reapire
when you repair the sheath it
helps prevent adhesion formation
helps prevent triggering
tendon repair is at its weakest day
10-12
estimated core suture tensile strength decreases by _________
by end of the week one
50%
list four therapy goals
prevent tendon rupture
patient education
promote tendon healing
encourage tendon gliding
three main therapy approaches to tendon management
controlled mobilization
early active mobilization
immolbization
duran protocol entails
dorsal blocking splint which positions the wrist 20* flex
MCP 60* flex
ip neutrals
in controlled mobilization the splint must allow
full IP extension
controlled mobilization 4 weeks:
passive PIP and DIP movement
controlled mobilization after 4 weeks
dorsal splint may be removed and gentle composite ROM
controlled mobilization 6 weeks
completely remove splint
controlled mobilization after 8 weeks
light strengthening
controlled mobilization after 10 weeks
moderate strengthening exercises are begun
controlled mobilization 12 weeks
pt resumes normal activities
when is early active mobilization used?
4 strand repairs and greater
what do you do with early active mobilization?
tendon gliding is elicted by active contraction of the injured muscle using tenodesis
when you would use immobilization method?
young patient
cognitive deficits
non compliant patients
what would you do with the immobilization method?
completely immobilize the patient for 4 weeks following tendon repair
what is the most common complication
adhesion formation
what does adhesion formation cause
stiff joints - limits ROM
factors that promote adhesions are:
trauma to the tendon and sheath
tendon ischemia
digital immobilization
prolonged edema
factors that suppress adhesion formation are:
good surgical technique
tendon mobilization early
motion between the tendon and its sheath
list four reasons for a tendon rupture:
non compliance
accidental injury or fall
place and hold exercises
blocking exercises
list five complications:
injury to neurovascular structures hypersensitivity complex regional pain syndrome bowstringing of the tendon infection
tendon gapping:
separation of the two ends that creates a space and causes the tendon to have gap form end to end
why is tendon gapping bad?
makes the tendon longer therefore it can not pull as effectively
what is a WALANT method?
Wide Awake Lidocaine Anesthesia No Tourniquet
