Flexion tendon injuries Flashcards
1
Q
How do tendons heal?
A
- INFLAMMATORY= 0-7days- cellular proliferation (no strength- strength due to suture !)
- FIBROBLASTIC=- 1-3 wks- fibroblastic proliferation with disorganised collagen( inital Type 3m replaced by Type 1)- strength increasing
- REMODELLING- >3 wks linear collagen organisation- will tolerate active motion
2
Q
Where does FDP insert?
A
- Base of distal phalanx 2-5 fingers
3
Q
What is FDP innervation?
A
- Medial part-little/ring fingers - ulna nerve C8/T1
- Ulna part- AIN - branch of median c8/T1= index/middle fingers
4
Q
What is FDP action?
A
- Flexor of DIPJ
- Assists with PIPJ and MCPJ flexion
- Shares a common muscle belly in forearm
5
Q
What is FDS insert and what is its innervation?
A
- Bodies of middle phalanges index- ring
- Median Nerve C7,C8,T1
6
Q
What is FDS action?
A
- Flexes PIPJ at digits 2-5
- Flexes proximal phalanges at MCPJ
7
Q
What is FPL insertion?
A
- Base of distal phalanx of thumb
8
Q
What is FPL innervation?
A
- AIN- median C8/T1
9
Q
what is FPL action?
A
- Flex phalanges of 1st digit thumb
10
Q
Where is FPL located in the wrist?
A
- IN the carpal tunnel
- as most radial structure
11
Q
What is FCR insertion?
A
- Base of 2nd MC
12
Q
what is FCR action?
A
- Flexes** and **abducts wrist
13
Q
What is FCR innervation?
A
- median nerve c6/7, closest tendon to median nerve
14
Q
What is FCU insertion?
A
- pisiform bone
- hook of hamate
- 5th MC
15
Q
What is FCU action?
A
- wrist flexion and adducts hand
16
Q
What is FCU innervation?
A
- Ulnar nerve c7/8
17
Q
What is the blood supply to the tendons ?
A
- 2 sources
- Diffusion thru synovial sheaths when tendon within the sheath-most important proximal to MCPJ
- Direct vascular supply those outside sheaths- via digital artery to long/short veniculum
18
Q
What is campers chasm?
A
Location of the level of the proximal phalanx where FDP splits FDS in two - goes thru the middle of it!
19
Q
Can you describe the zones for flexor tendon injures ?
A
Zones 1-5
- Zone 1- distal to FDS insertion
- Zone 2- Prox to FDS insertion to palm crease
- Zone 3- palm crease to carpal tunnel
- Zone 4- carpal tunnel zone
- Zone 5- Proximal to carpal tunnel
thumb
- Zone 1- tip to distal IPJ- FPL had no lumbricals or veneulae so can retract to palm!
- Zone 2- Over thenar eminence- can have injuried to thenar muscles and recurrent branch of median nerve
20
Q
What injuries pccur at zone 1?
A
- Distal to FDS insertion ( distal to prox phalanx iin fingers)-
- Jersey Finger
21
Q
Can you describe the classification?
A
NB remember worse first!!
Type 1- FDP tendon retracts to PALM!!!! disrupts vascular supply- tx with prompt surgery within 7-10 days
Type 2- FDP retracts to PIPJ- attempt repair within several wks
Type 3- Large AVULSION fracture- LIMITS retraction to level of DIPJ- attempt to repair
Type 4- osseous fragment and AVULSION of tendon from fragment- DOUBLE AVULSION- tendon goes to PALM- if tendon separated from fracture fix fracture first then tendon
22
Q
What is the tx for Zone 2 flexor tendon injuries?
A
- Prox to FDS insertion to palm
- Unusual as FDS and FDP share same tendon sheath
- Direct repair of BOTH TENDONS
- Then EARLY ROM
- PRESERVE A2 and A4 PULLEY
- historically poor outcome ‘noman’s land’ but improved due to modern repair techniques and advancment in post op motion protocols
23
Q
What is the tx for Zone 3 flexor tendon injuries?
A
- Palm area
- Often associated with NV injury so worse prognosis
- Direct tendon repair
24
Q
What is the tx for Zone 4 flexor tendon injuries?
A
- Carpal tunnel area
- often complicated by post op ADHESIONS due to close to synovial sheath of carpal tunnel
- Direct tendon repair
- Transverse Carpal ligament should be repaired in a lengthened fashion
25
what is the tx for zone 5 flexor tendon injuries?
* **Prox to carpal tunnel, wirst to forearm**
* often associated with NV injury
* **Direct tendon repair**
26
What is the tenodesis effect?
* Normally **wrist extension-\> passive flexion MCP, PIPJ and dipj**
* Need to test for each digit
* Maintaince of **dipj/pipj extension** with wrist extension suggests **flexor tendon rupture**
27
What are the signs and symptoms of flexor tendon rupture?
_Symptoms_
Loss of active flexion to DIPJ/PIPJ/MCPJ
_Signs_
* Malignment of finger cascade= fracture
* Assess skin integrity- tendon rupture
* Traumatic arthrotomy sites
* Test **tenodesis effect**= wrist extension-\> flexion at MCPJ/PIPJ/DIPJ
* If flexor tendon ruptured wrist extension-\> dipj/pipj held in extension
* Test Active DIPJ/PIPJ each finger
* Neurovascular exam- close proximity of flexor tendons to digital nerves
28
When would you not operate?
* In **Partial Lacerations \<60% width**
* may be associated with triggering/ gap formation
29
What surgical tx are there?
* When **laceration \>60%**
* **Flexor tendon repair and controlled mobilization**
* **Flexor tendon reconstruction and intensive post op rehab**= failed primary repair, surgical tenolysis required in \>50% of time
30
What incision would you make to repair a flexor tendon?
* **Bruner zigzag incision** ( _avoids vascular compromise)_
* cross **flexion creases transversely or obliquely** to _avoid contractures_ - NEVER LONGITUDINALLY
31
When is the ideal time for repair?
* **Within 3 weeks of injury** ( 2 wks ideal) longer -\> _tendon retracture_
32
What is the technique for repair?
* **4 strand core suture**- crucitate- using **non absorbable monofilament prolene gd compatibility,retains strength**
* **_No of suture strands that x repair more_** important than _no of grasping loops_
* linear relationship _strength of repair and no of sutures crossing repair_
* **4-6 strands** adequate strength for early active rom
* locking loops decrease gap formation
* core sutures placed dorsally are stronger
* atruamatic handlng Circumferential
* **Circumferential Epitendinous suture 6.0** **prolene**- improves tendon gliding , strength of repair ( adds 20%) and allows for less gap formation.Simple running suture best
* Sheath repair contraversial - thought to improve tendon nutrition through tendon sheath but clinical studies have found no diff from repair to non repair
33
When are flexor tendon repairs weakest? where does repair fail?
* Post op day 6 and 12
* At suture knots
34
What has been the best improvement of outcomes?
* Post op controlled mobilisation
* T**o reduce adhesions** and **leads to increase tendon excursion**
35
Can you describe the principles of rehab?
what are the different types?
* Motion of repaired tendin unit leads to **predominacne of intrinsic cf extrinisic tendon healing and reduce adhesions**
* **Passive motion protocols-** low force low excursion
* **Early active motion protocols-** high force/high ex
* **Synergistic motion regimen-** low force/high excur
36
What are is the difference between passive motion vs early atcive motion vs synergistic protocols of rehab?
_Passive motion_
**LOW force and low exercusion**
* **Klinert technique**-uses a dorsal block slpint with wrist at 45o of lfexion and elxastic bands secured to nails nails adn more proximal attachment.Once IPJ are actively fully extended , recoil is elastic flexes them down passively
* Duran Protocol- uses a splint with wrist in flexion 20o. relies on pt to alternatively passively extend the DIPJ/PIPJ with other joints of fingers flexed. aim to withdraw reapired fds/fdp away from repaired site.Pt compliance is requisite
_Early Motion protocols_
**Moderate force and potential high extercusion**
* involves the generation of light muscle forces to assist digital flexion or preform 'place and hold' exercises w digit
* Dorsal blocking splint used to limit wrist extension
* Although some evidence of increased tensile strength at repair site compared to passive protocols, high risk of rerupture, gap formation potential concerns
_Synergestic motion_
**Low force high exercusion**
* **Passive digit flexion combined with active wrist extension**, followed by **active digit extension coupled with active wrist flexion**
* Tendon exercusion by employing wrist motion is greater than that provided in an extension blocking splint
37
How about children post op?
* Initlally in cast with the wrist and mcl positioned in flexion and ipj in extension- edinburgh position
38
Can you describe the technique for reconstruction surgery?
* Normally 2 stage
* silcone impant inserted -\> favourable tendon bed
* **Wait 3-4 months** then pass a biological tendon thru the tendon sheath created after removeal of the silicone rod.
* single stage preformed if flexor sheath prestene and from of joints
* use Palmaris longus, plantaris ( extrasynovial grafts),2nd toe FDL ( intrasynovial grafts)
* Intrasynovial grafts less tissue necrosis, better preservation of gliding.
* Pulleys to be constructed proximal and distal to joint
39
What are the indications for 2 stage flexor tendon reconstruction?
* Require supply skin,adequate vascularity, passive from adjacent joints, sensate digit
* use in crush injuries of adj soft tissues, delayed or failed primary repair
40
what are the complications of flexor tendon injuries?
* **Tension adhesions**
* **Rerupture**-5-15%:around **7-10 days post op** if \<1cm scar, excise and direct repair but if scar\>1cm need tendon reconstruction
* **Joint contracture**-**17 %**
* **Swann neck deformity**
* **Trigger finger**
* **Lumbrical plus hand**
* **Quadrigia**
41
What would be the indications for tenolysis?
* Localised tendon adhesions with minimal to no joint contracture and full passive rom
* Preform at .3 months to wait for soft tissue stabilisation and full passive rom of joints
* Preserve A2/A4 pulley
* follow with intensive physio
