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HAND AND MICROSURGERY > FLEXOR TENDON INJURIES > Flashcards

FLEXOR TENDON INJURIES Flashcards

1
Q

2 main reasons why Zone 2 flexor tendon injuries (no mans land) are difficult to manage

A
  1. Relative avascularity of tendons over proximal phalanx

2. Complexity of repair due to pulleys

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2
Q

Anatomy of FDS and FDP origin

A 
FDS:
- 4 tendons arising from separate muscle bellies = act independently
- innervation by ulnar nerve
- LF FDS absent in 20% of population
FDP
- 4 tendons arising from common muscle belly = subject to quadrigia effect
- IF FDP separates early
- dual inneration = AIN and ulnar nerve
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3
Q

Anatomy of Camper’s chiasm

A
  • FDS splits into 2 slips over proximal phalanx
  • FDP passes between slips to lie superficial to FDS
  • Slips of FDS spiral around and under FDP to attach to base of middle phalanx
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4
Q

Blood supply to flexor tendons

A
  1. Proximally = muscle belly
  2. Distally = periosteal vessels at insertion
  3. Palm = longitudinal vessels
  4. Within the flexor sheaths
    - long vincula
    - nutrition via diffusion from synovial fluid = imbibition
    Dorsal 1/2 of flexor tendon has better blood supply than volar 1/2
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5
Q

Vinculae of flexor tendons

A
  • FDS = long and short vincular over proximal phalanx
  • FDP = long and short vinculae over middle phalanx
  • long vincula = vascular
  • short vincula = attaches to joint capsule and pulls tendon out of joint during finger flexion
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6
Q

Tenodesis effect

A
  • Used to assess tendon continuity
  • Passive wrist flexion should cause fingers to extend
  • Passive wrist extension should cause fingers to flex
  • Negative tenodesis effect = tendon disruption
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7
Q

Composition of tendons

A

Predominantly Type I collagen = forms 80% of dry weight

High water content = forms 60% wet weight

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8
Q

2 mechanisms for 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

5 zones of flexor tendon injury

A
  1. Zone 1 = distal to FDS insertion
    - Jersey finger
  2. Zone 2 (no mans land) = proximal A1 pulley to FDS insertion
    - historically poor prognosis
  3. Zone 3 (palm) = distal carpal tunnel to proximal A1 pulley
    - may be associated with NV injury
    - outcomes worse with NV injury
  4. Zone 4 = carpal tunnel
    - risk of postoperative adhesions
    - transverse carpal ligament can be repaired in lengthened fashion to prevent bowstringing
  5. Zone 5 = proximal to carpal tunnel
    - may be associated with NV injury
    - outcomes worse with NV injury
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11
Q

Indications for nonoperative management of flexor tendon injuries

A

Closed partial ruptures involving < 60% tendon width

- direct repair of partial ruptures requires epitendinous sutures only (studies show no need for core sutures)

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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

Tendon repair failure

A
  • Most common in first 2 wks = inflammatory and proliferative phases
  • Most common at knot
  • Gapping is 1st step in repair failure
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14
Q

2 layers of flexor tendon repair

A
  1. 4-strand core suture with 3.0 or 4.0 nonabsorbable braided material like Ethibond or Ticron
  2. Continuous/ running epitendinous suture with 6.0 nonabsorbable monofilament material like Proline
    - continuous suture decreases tendon CSA and improves gliding
    - epitendinous suture increases repair strength by 20%
    - epitendinous suture minimises gap formation
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15
Q

Optimal core strands for flexor tendon repair

A
  • Direct correlation between repair strength and number of core sutures crossing repair site
  • Optimal is 4-strand core suture
  • 6 and 8-strand core sutures are stronger but they devascularise tendon due to too much suture material
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16
Q

4 main options to improve tendon gliding

A
  1. Debulk tendon
  2. Repair only 1 slip of FDS
  3. Repair only FDP and don’t repair FDS
  4. Pulley venting
    - studies show up to 25% of A2 pulley and 100% of A4 pulley can be released down 1 side without bowstringing
17
Q

Postoperative rehabilitation of flexor tendon repair

A
  • Early controlled motion with dynamic splinting

- Kleinert protocol = active extension and passive flexion

18
Q

2 indications for extended immobilisation post flexor tendon repair

A
  1. Children

2. Non-compliant patients

19
Q

4 indications for tendon reconstruction

A
  1. Failure of repair
  2. Acute segmental rupture
  3. Delayed diagnosis > 3 wks = tendon retraction and scarring
  4. Inadequate tendon post tenolysis
20
Q

5 prerequisites for tendon reconstruction

A
  1. Supple skin
  2. Sensate digit
  3. Adequate vascularity
  4. Healthy bed
  5. Supple joints
21
Q

2-stage tendon reconstruction technique

A 
Stage 1
- insertion of silicone tendon rod 
- anchored distally
- early ROM to allow formation of pseudosheath
Stage 2 
- performed 3-4 mo after Stage 1
- removal of tendon rod and insertion of tendon graft
- Pulvertaft weave proximally
22
Q

Indication for tendon transfer

A

Chronic ruptures where muscle is too contracted or nonfunctional

23
Q

Indication for tenolysis

A
  • Normal passive ROM but severely restricted active ROM due to adhesions
  • Trial aggressive therapy first
24
Q

Complications with flexor tendon repair

A
  1. Wound problems and infection
  2. Adhesions (most common) = decreased excursion and ROM
  3. Joint stiffness
  4. Re-rupture = re-rupture rate 20%
  5. Weakness
  6. Deformity
    - swan neck deformity
    - trigger digit
    - quadrigia effect

HAND AND MICROSURGERY (63 decks)

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