Extensor Tendon Injuries Flashcards
How do you test for
- ORL tightness
- Intrinsic tightness
- Extrinsic tightness
- ORL tightness
- extension of PIP leads to less DIP flexion
- Intrinsic tightness
- hyperextension of MCP leads to less PIP flexion
- Extrinsic tightness
- flexion of MCP leads to less PIP flexion
How do you test for central slip injury?
Elson’s test
- with PIP in max flexion, you normally cannot extend DIP jt because central slip holds extensor apparatus out to length and lateral bands to DIP are lax
- IF central slip injury, can actively extend DIP jt with PIP in maximum flexion
What are the extensor zones of the hand/forearm
- 1- DIPJ
- 2- MP
- 3- PIPj
- 4- PP
- 5- MCPj
- 6- MC
- 7- CT
- 8- tendinous extrinsics
- 9- muscle forearm
- T1- IPj
- T2 - PP
- T3- MCPj
- T4- MC
- T5 - CMCj
What is the excursion of wrist extensors and digit extensors?
- Wirst - 3cm
- Digit - 5.5cm
Describe your extensor repair for each zone
- Zone 1
- dermatotenodesis, running monofilament
- splint 6wks, then 2wks nighttime
- Zone 2 <50% lacerated
- splint only 1wk then AROM
- Zone 2 - >50% lacerated
- running braided 4-0 + epitendinous 5-0
- splint 6wks, then 2wks nighttime
- THUMB - CORE + epitendinous (EPL)
- Zone 3 - central slip
- splint PIP full extension 6ks w DIP and MCP free, then 2wks nighttime
- IF failed split, volar dislocation, >50% avulsion f# of MP base
- Acute with large bone segment; OR ->dorsal approach, ORIF w kwire/tension band/miniscrew. If Acute and CS inadequate length, Snow of Aiche repair then splint 6wks. May add Kwire
- THUMB: CORE + epitendinous EPL EPB, splint extended 3wks
- Zone 4
- centrally can do core/epitendinous. Splint W 30ext, MCP 45-70 flexion, IP straight. Passive extension 1wk, active extension 4wks
- Zone 5
- Ext apparatus - as above
- Sagittal band
- acute<2wks - flexion block splint to keep MCP at ) for 6wks
- delayed >2wks - repair , MP extension 1wk then gentle flex/ext exercise
- Zone 6- 7 - as above
- Zone 8 - core repair/epitendinous, splint W ext 40, MCP 20, fingers FREE 5wks
- Zoen 9 - muscle repair figure 8, splint above elbow at 90, W ext 40, MCP 20, fingers free 4wks
What is the sequence of extensor imbalance
- swan neck
- boutonniere
- extrinsic tightness
- intrinsic tightness
- extensor subluxation adn ulnar drift
What is the origin insertion and function of Sagittal bands
O: EDC tendon
I: Volar plae, intermetacarpal ligament
Fx: maintain EDC central over MCPj, assists in extension of MCP
What is the origin insertion and function of TRL
O: flexor sheath
I: Lateral band of lateral conjoined band
Fx: prevent dorsal subluxation of lateral bands
What is the origin insertion and function of trasnverse and oblique fibers
O: IO and lumbricals
I: extensor tendon over PP
Fx: assist in MCP flexion
What is the origin insertion and function of ORL
O: flexor sheath
I: TT
F: coordinate fx b/w DIP and PIP
How do you classify mallet finger injury
Leddy Packer
- 1- Closed, with loss of tendon continuity +/- avulsion F# (most common)
- 2- Open laceration with loss of tnedon continuity
- 3- deep abrasion with loss of tendon substance
- 4A- transepiphyseal plate F#
- 4B - Hyperextension injury involving 20-50% of articular surfcae
- 4C - Hyperextension injury involving >50% of articular surfcae & early/late volar subluxation of PP
How do you treat mallet finger according to classification
Type 1 - closed
- splint 6wks then 6wks at night
- if failed, K-wire
Type 2- open
- Dermatotenodesis
- splint 6wks then 6wks at night
Type 3- substance loss
- ST covreage +/- Kwire (FTSG, 2’ intent, local flap)
- splint 6wks then 6wks at night
- may delay recon w graft
Type 4A- transepiphyseal
- CR
- splint 6wks then nighttime 6wks
Type 4B - articular F# 20-50%
- CR. Kwire extension block pinning if unstable
- splint 6wks then 6wks at night
Type 4C - articular >50%/volar sublux DP
- Kwire extension block pinning
- flex DIP, insert pin into MP to wedge fragment
- extend DP and place longitudinal pin across DP
- Kwire in place 6wks
CHRONIC MALLET
- Attempt splint
- Kwire w dermatotenodesis OR
- Arthrodesis if OA
- Fowler tenotomy - release central slip=>improved DP extension
How do you manage a fight bite
- Xray - FB
- I&D, 2’ intention healing
- Joint invovlement - washout, packing, IV abx
Describe rehabilitation protocols for extensor repairs
- Immobilization
- Controlled Early Passive (Dynamic Extension Splinting)
- static splint 2wks then DES 4wks
- Early Active
What are two methods of central slip injury repair when there is insufficent length/tissue for repair
Snow - distally based flap from extensor aponeurosis
Aiche - bilateral advancement flaps
List 3 methods of secondary reconstruction of ruptured unrepaired sagittal bands (with ED slipping into ulnar gutter
- Dorsal Tenodesis
- release ulnar sagittal band
- on adjacent radial EDC, create longitudinal distally absed flap and wrap around EDC of interest to keep centralized
- Sling procedure
- distally absed flap on injured EDC is used slung around intrinsics or dTMClig
- Dynamic Lumbrical muscle transfer
- transfer lumbrical to serve as a direct antagonist
What is a swan neck deformity and the acute and chronic changes which occur
Def: PIP Hyperextension, DIP hyperflexion
ACUTE
- dorsal subluxation of lateral bands
- attenuation of TRL
- laxity of PIP Volar Plate
CHRONIC
- lateral bands contract
- PIP DIPjoint contractures
- extensor tendon adhesions
- joint surface changes
What are causes of Swan neck Deformity
@ PIP
- VP injury (dorsal dislocation, synovitis, RA)
- Intrinsic tightness (intrinsic contracture post stroke/CP, RA)
- FDS injury
@ DIP
- chronic Mallet
- shortened MP
How do you classify Swan neck deformity
Stage 1 - supple, no tightness/ full AROM/PROM
Stage 2 - Intrinsic tightness - less PIP flexion w MCP extension
Stage 3- LImited PIP PROM - capsule contraction, tendon adhesions
Stage 4 - fixed PIP hyperextension
What are treatment options for swan neck deformity
NON-OP
- splint and exercise for contractures and intrinsic tightness
OPERATIVE
- Correct MP length
- Repair Mallet
- Limit PIP hyperextension
- VP capsulodesis/repair
- FDS tensodeis to PP bone (one slip only)
- Intrinsic rerouting (ulnar lateral band distally based flap rerouted palmar and into flexor sheath at PP
- SORL reconstruction - spiral ORL - tendon graft inserted into drill hole dorsal DP, routed palmar to PIP and insert palmar into drill hole of PP
For ALL, Kwire at 30’ flexion PIP and dorsal block splint for DIP
What is boutonniere deformity and features of the deformity
Def: PIP flexion with DIp hyperextension
ALWAYS starts with PIPJ
ACUTE
- central slip discontinuity
- lateral bands sublux volarly and become PIP flexors
- DIP HYPEREXTENSION
CHRONIC
- ORL tightness
How is the boutonniere deformity staged?
- 1- central slip disrupted, lat bands dorsal to PIP axis
- PIP extensor lag <30
- 2- volar subluxation of lat bands
- PIP extensor lag >30
- 3- ORL contracture
- limited flexion DIP w PIP flex.+ORL tightness
- 4- Fixed flexion contracture PIP
- contracture of VP, ORL, TRL, collaterals
- 5- PIP arthritis
How is boutonniere deformity treated non-operatively?
NON-OPERATIVE
MOST (acute AND chronic) treated non-op successfully
Step 1- restore passive PIP extension
- spliting, capsulotomy
Step 2- Rebalance extensor apparatus
- with PIP fully extended, AROM/PROM of DIP to relocate the lateral bands and ORL
Step 3 - maintain PIP extension
- static splint 8wks PIP only
How is boutonniere deformity treated operatively?
OPERATIVE
* requires tenolysis of contracted segemtns (ORL, TRL), repositioning of lat bands and reconstitution of CS
1- Fowler terminal tenotomy (or dolphin - just distal to CS to ensure ORL preserved)
- release TT to allow DIP flexion. Ext apparatus migrates proximally, allows strong flexors to work on DIP and ORL maintains concerted fx of PIP/DIP
2- Extensor apparatus recon (of CS) with tendon graft
- PL graft used- 2drill holes in MP, graft passd through, secured to contralateral lateral band
3- Littler lateral band transfer
- lateral bands (minus the lumbricals) are excised off conjoint bands and centralized to reconstruct CS (extension force transfered form DIP to PIP). ORL and lumbricals left intact and extend IPs
What is the cause of extrinsic tightness
- Post-traumatic adhesions, muscle contractures
- RA- flexion deformity of MCP/wrist
- CP- muscle spasticity
What is the treatment for extrinsic tightness
NON-OP
- splinting, exercise program
OPERATIVE
- tenolysis, extrinsic extesor tendon release
