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Orthobullets/ FRCSC Canadian Board > Flexor Tendon Injuries > Flashcards

Flexor Tendon Injuries Flashcards

1
Q

Blood supply

A

2 sources exist

  • diffusion through synovial sheaths
    • occurs when flexor tendons are located within a sheath
    • it is the more important source distal to the MCP joint
  • direct vascular perfusion
    • nourishes flexor tendons located outside of synovial sheaths
    • supplied by the vincular system, osseous bony insertions, reflected vessels from the tendon sheath, and longitudinal vessels from the palm
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2
Q

Classification

A
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3
Q

Presentation

A
  • observe resting posture of the hand and assess the digital cascade
    • evidence of malalignment or malrotation may indicate an underlying fracture
  • assess skin integrity to help localize potential sites of tendon injury
  • look for evidence of traumatic arthrotomy
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4
Q

Nonoperative

A

wound care and early range of motion

  • indications
    • partial lacerations < 60% of tendon width
  • outcomes
    • may be associated with gap formation or triggering
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5
Q

Operative

A
  1. Flexor tendon repair controlled mobilization
    • Wide-awake flexor tendon repair
  2. Flexor tendon reconstruction and intensive postoperative rehabilitation
  3. FDS4 transfer to thumb
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6
Q

Flexor tendon repair controlled mobilization

indications

A

indications

  • > 75% laceration
  • ≥ 50-60% laceration with triggering
    • epitendinous suture at the laceration site is sufficient
    • no benefit of adding core suture
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7
Q

Flexor tendon repair controlled mobilization

fundamentals of repair

A

fundamentals of repair

  • easy placement of sutures in the tendon
  • secure suture knots
  • smooth juncture of the tendon ends
  • minimal gapping at the repair site
  • minimal interference with tendon vascularity
  • sufficient strength throughout healing to permit application of early motion stress to the tendon
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8
Q

timing of repair

A

perform repair within three weeks of injury (2 weeks is ideal)

  • delayed treatment leads to difficulty due to tendon retraction
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9
Q

approach

A
  • incisions should always cross flexion creases transversely or obliquely to avoid contractures (never longitudinal)
  • meticulous atraumatic tendon handling minimizes adhesions
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10
Q

Technique depends on

A
  1. core sutures
  2. circumferential epitendinous suture
  3. sheath repair
  4. pulley management
  5. FDS repair
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11
Q

core sutures

A
  • # of suture strands that cross the repair site is more important than the number of grasping loops
    • linear relationship between strength of repair and # of sutures crossing repair
    • 4-6 strands provide adequate strength for early active motion
  • high-caliber suture material increases strength and stiffness and decreases gap formation
  • locking-loops decrease gap formation
  • ideal suture purchase is 10mm from cut edge
  • core sutures placed dorsally are stronger
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12
Q

circumferential epitendinous suture

A
  • improves tendon gliding by reducing the cross-sectional area
  • improves strength of repair (adds 20% to tensile strength)
  • allows for less gap formation (first step in repair failure)
  • simple running suture is recommended
    • produces less gliding resistance than other techniques
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13
Q

sheath repair

A
  • theoretically improves tendon nutrition through synovial pathway
  • controversia
    • clinical studies show no difference with or without sheath repair
    • most surgeons will repair if it is easy to do
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14
Q

pulley management

A
  • historically believef to be critical to preserve A2 and A4 pulleys in digits and oblique pulley in thumb
  • recent biomechanical studies have shown that 25% of A2 and 100% of A4 can be incised with little resulting functional deficit
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15
Q

FDS repair

A
  • in zone 2 injuries, repair of one slip alone improves gliding
  • compared to repair of both slips
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16
Q

outcomes

A
  • repair failure
    • tendon repairs are weakest between postoperative day 6 and 12
    • repair usually fails at suture knots
    • repair site gaps > 3mm are associated with an increased risk of repair failure
  • adhesion formation
    • increased risk with zone 2 injuries
17
Q

Wide-awake flexor tendon repair

A
  • hand surgery performed under local anesthesia only without a tourniquet, alsocalled “Wide Awake Local Anesthesia No Tourniquet” (WALANT
  • performed under tumescent local anesthesia using lidocaine with epinephrine
18
Q

local anesthesia in Wide-awake flexor tendon repair

A
  • usually epinephrine 1:100,000 and 7mg/kg lidocaine
  • from 1:400,000 to 1:1000 is safe
  • if < 50cc is needed
    • 1% lidocaine with 1:100,000 epi for a 70kg person
  • if 50-100cc is needed
    • dilute with saline (50:50) to get 0.5% lidocaine, 1:200,000 epi
  • if 100-200cc is needed for large fields (tendon transfer, spaghetti wrist)
    • dilute with 150cc saline to get 0.25% lidocaine and 1:400,000 epi
  • for longer surgery > 2 hours
    • add 10cc of 0.5% bupivacaine with 1:200,000 epi
19
Q

location where we can use the Wide-awake flexor tendon repair

A
  • proximal and middle phalanges, use 2ml
  • distal phalanx, use 1ml
  • palm, use 10-15ml
20
Q

Advantages of Wide-awake flexor tendon repair

A
  1. allows intraoperative assessment for repair gaps by getting awake patient to actively flex digit
  2. reduces need for postop tenolysis by allowing intraoperative assessment of whether repair will fit through pulleys
    1. allows on-the-spot debulking of bunched repairs
    2. allows division of A4 pulley and venting (partial division) of A2 pulleys
  3. allows repair of tendons inside tendon sheaths as patients can demonstrate that the inside of the sheath has not been inadvertently caught
  4. facilitates postop early active motion
    1. immobilize for 3 days
    2. begin active midrange motion after day 3 (form a partial fist with 45 degree flexion at MP, PIP and DIP joints, or “half a fist 45/45/45 regime”)
21
Q

Flexor tendon reconstruction

requirements

A
  • supple skin
  • sensate digit
  • adequate vascularity
  • full passive range of motion of adjacent joints
22
Q

Flexor tendon reconstruction

techniques

A
  1. single-stage procedures
  2. two-stage procedures
23
Q

single-stage procedures RECON

A

single-stage procedures

  • only perform if the flexor sheath is pristine and the digit has full ROM
24
Q

two-stage procedures RECON

A
  1. Hunter-Salisbury
  2. Paneva-Holevich
25
Q

Hunter-Salisbury

A
  • Stage I - SR is placed to create a favorable tendon bed
  • Stage II (3-4 months) - SR is retrieved and a tendon graft is placed through the mesothelium-lined pseudosheath
    • pulvertaft weave proximally and end-to-end tenorrhaphy distally
26
Q

Paneva-Holevich

A
  • Stage I - SR is placed in the flexor sheath, pulleys are reconstructed (as needed), and a loop between the proximal stumps of FDS and FDP is created in the palm
  • Stage II - SR is retrieved, FDS is cut proximally and reflected distally through the pseudosheath and either attached directly to FDP stump or secured with a button
27
Q

Advantages AND Disadvantes of Paneva-Holevichages

A
  • advantages
    • graft (FDS) size is known at the time of silicone rod selection
      • less graft diameter-rod diameter mismatch
    • FDS graft is intrasynovial
      • fewer adhesions than extrasynovial grafts
    • relies on only 1 tenorrhaphy site (distal or proximal) to heal at any one time (vs. Hunter technique where 2 tennoprhaphy sites are healing simultaneously)
  • disadvantages
    • graft tensioning is at the distal end during stage II
      • the proximal end has already healed after stage I
28
Q

graft selection in recon

A
  • palmaris longus (absent in 15% of population)
    • most common
  • plantaris (absent in 19%)
    • indicated if longer graft is needed
  • extensor digitorum longus to 2nd-4th toes
  • extensor indicis proprius
  • flexor digitorum longus to 2nd toe
  • FDS
29
Q

pulley reconstruction

A
  • one pulley should be reconstructed proximal and distal to each joint
  • pulley reconstruction should occur first if a tendon graft is being used
  • methods
    • belt loop method
    • FDS tail method
30
Q

outcomes in Recon

A

outcomes

  • subsequent tenolysis is required more than 50% of the time
31
Q

Postoperative Rehabilitation Protocols

A
  • Immobilization
    • indicated for children and non-compliant patients
    • casts/splints are applied with the wrist and MCP joints positioned in flexion and the IP joints in extension
  • Early passive motion
    • Duran protocol
      • low force and low excursion
      • active finger extension with patient-assisted passive finger flexion and static splint
    • Kleinert protocol
      • low force and low excursion
      • active finger extension with dynamic splint-assisted passive finger flexion
    • Mayo synergistic splint
      • low force and high tendon excursion
      • adds active wrist motion which increases flexor tendon excursion the most
  • Early active motion
    • moderate force and potentially high excursion
    • dorsal blocking splint limiting wrist extension
    • perform “place and hold” exercises with digits
32
Q

Postoperative controlled mobilization has improved results with tendon repair why?

A
  • especially in zone II
  • improved tendon healing biology
  • limits restrictive adhesions and leads to increased tendon excursion
33
Q

Basic types of suturing

A

Simple

  • Shearing parallel to bundles
  • Weak

End-to-end locking

  • Pull converted to compressive force around bundles
  • Strength near that of suture

Interweave

  • Strongest
  • Bulky
34
Q

Common End-to-end types

A

A, Bunnell
B, Crisscross
C, Mason-Allen
D, Kessler grasping
E, Mod Kessler
F, Tajima-Kessler

Orthobullets/ FRCSC Canadian Board (121 decks)

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