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HAND AND MICROSURGERY > EXTENSOR TENDON INJURIES > Flashcards

EXTENSOR TENDON INJURIES Flashcards

1
Q

2 main types of tendons

A
  1. Sheathed = synovial cover
    - flexor tendons
  2. Non-sheathed = paratenon cover
    - extensor tendons
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2
Q

Blood supply to the extensor tendons

A
  1. Proximally = muscle belly
  2. Distally = periosteal vessels at insertion
  3. Palm = longitudinal vessels
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3
Q

Anatomy of the extensor mechanism

A
  • Extensor expansion/ hood over proximal phalanx
  • Sagittal bands stabilise extensor tendon at MCPJ
  • Extensor tendon trifurcates over proximal phalanx
  • Central slip attaches to base of middle phalanx
  • Lateral bands pass volar to axis of PIPJ and dorsal to axis of DIPJ
  • Lateral bands come together and form the terminal extensor tendon which attaches to base of distal phalanx
  • Triangular ligament prevents volar subluxation of lateral bands
  • Transverse retinacular ligament prevents dorsal subluxation of lateral bands
  • Interossei attach to extensor expansion (before trifurcation)
  • Lumbricals attach to radial lateral band (after trifurcation)
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4
Q

Juncturae tendinum

A
  • Tendinous slips between extensor tendons of MF, RF and LF over the metacarpals
  • May allow some finger extension with extensor tendon rupture
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5
Q

Anatomy of thumb extensor tendons

A
  • EPB attaches to base of proximal phalanx
  • EPL attaches to base of distal phalanx
  • No extensor expansion/ hood
  • EPL stabilised at MCPJ by fascial bands from adductor pollicis ulnarly and APB radially
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6
Q

Deformities associated with Zone 1 and Zone 3 extensor tendon injuries

A

Zone 1 injury = mallet finger

Zone 3 injury = boutonniere deformity

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7
Q

Elson’s test

A
  • To assess integrity of central slip
  • PIPJ flexed to 90deg over edge of table
  • Resist PIPJ extension
  • If central slip intact = DIPJ remains supple
  • If central slip not intact = DIPJ rigid in hyperextension as lateral bands recruited for extension
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8
Q

2 mechanisms of tendon healing

A 
Intrinsic vs. extrinsic:
1. Intrinsic healing = desirable
- via tenocytes within tendon
- occurs with early controlled motion
2. Extrinsic healing = not desirable
- involves scar formation
- occurs with prolonged immobilisation
Intrinsic healing associated with:
1. Fewer adhesions = better excursion and ROM
2. Better strength of repair = load to failure double
3. Better functional outcomes
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9
Q

3 phases of tendon healing

A
  1. Inflammatory = 1 wk
    - tendon weak
  2. Fibroblastic/ proliferative = 1-4 wks
    - disorganised collagen
  3. Remodelling > 4 wks
    - organised collagen along long axis of tendon due to tensile stress at repair site
    Tendon unlikely to return to original mechanical properties/ strength
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10
Q

Classification of extensor tendon injuries

A 
Odd zones = over joints
Even zones = over bones
Zone I = over DIPJ (mallet finger)
Zone II = over middle phalanx
Zone III = over PIPJ (boutonniere deformity)
Zone IV = over proximal phalanx
Zone V = over MCPJ (fight bites)
Zone VI = over metacarpals (most common location, association with NV injury)
Zone VII = over carpus/ wrist
Zone VIII = proximal to wrist
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11
Q

Nonoperative management of extensor tendon injuries

A 
Extensor tendon injuries involving < 50% of tendon width can be managed nonoperatively
Splint in position of safety for 4-6wks
- wrist in 30deg extension
- MCPs in 30deg flexion
- IPs in extension
Start ROM at 4-6wks
Resisted exercises at 12wks
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12
Q

6 main principles of tendon repair

A
  1. Smooth tendon ends
  2. Placement of sutures on tension side of tendon
    - dorsal side for flexor and extensor tendons
  3. Secure knots
  4. Minimal gapping
    - locking loops and epitendinous sutures minimise gap formation
    - gap > 3mm = increased risk of repair failure
  5. Preservation of blood supply
  6. Sufficient repair strength to allow early controlled motion
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13
Q

3 main surgical options for extensor tendon injuries

A
  1. Direct repair
    - 4-stand core repair only
    - 3.0 or 4.0 nonabsorbable braided suture like Ethobond or Ticron
  2. Tendon reconstruction = 1-stage vs. 2-stage
  3. Tendon transfer
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14
Q

Postoperative rehabilitation of extensor tendon repair

A
  • Passive splinting and immobilisation (compared to dynamic splinting and early controlled motion for flexor tendons)
  • Short Arc Motion Protocol popular for Zone III repairs
  • Optimal excursion for flexion and extensor tendons is 4mm
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15
Q

Complications with extensor tendon repair

A
  1. Wound problems and infection
  2. Adhesions = decreased excursion and ROM
  3. Joint stiffness
  4. Re-rupture = re-rupture rate 5%
  5. Weakness
  6. Deformity
    - swan neck deformity
    - boutonniere deformity
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16
Q

4 main reasons for re-rupture post tendon repair

A
  1. Poor suture material
  2. Poor repair technique
  3. Aggressive therapy
  4. Non-compliance

HAND AND MICROSURGERY (63 decks)

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