A1 pulley to FDS insertion - no man’s land - chiasm of campers - within tendon sheath - neurovascular injury

End of carpal tunnel to A1 pulley - no Flexor sheath except 5th - intrinsic injury (lumbrical)

Flexor Tendon Repair Flashcards by Keren Poulose

Origin of FDS

Medial epicondyle
Coronado process
Proximal radius

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Insertion of FDS

Bifurcates around FDS
Meets up at Casper’s chiasm
Middle phalanx

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Action fo FDS

PIP flex

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Action of FDP

DIP flex

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Origin of FDP

Volar and medial ulna surface
Interosseous membrane
Maybe proximal radius

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Insertion of FDP

Palmar base of distal phalanx

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Innervation of FDS

Median nerve

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Lumrbical action

Flex MCP

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Origin of lumbricals

FDP

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Insertion of lumbricals

Extensor expansion

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Strong, broad

Provides mechanical stability

Annual pulley

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Provides flex

Cruciate pulley

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Need to keep intact during surgery

A2 and A4

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Bowstringing, which pulley

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Most common way of injuring flexor tendon

Sharp transection through glass or knife

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Zone 1

FDS to distal

- FDP avulsion or laceration

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Zone 2

A1 pulley to FDS insertion

no man’s land
chiasm of campers
within tendon sheath
neurovascular injury

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Zone 3

End of carpal tunnel to A1 pulley

no Flexor sheath except 5th
intrinsic injury (lumbrical)

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Zone 4

Within carpal tunnel

Zone 5

Proximal to carpal tunnel

FDS injured

No PIP flex

FDP injured

No DIP flex

How do you know index finger is intact for FDS?

It can do PIP flex and DIP extension

If fingers were extended during injury

Skin and tendons cut at Same level

If fingers were flexed during injury

Tendon injury is distal to cut

Which suture are needed for 25-50% laceration

Epitenon suture

Which 2 core sutures most common

Modified Kessler | 4 strand cruciate

Which technique most common for epitenon

Cross-stitch

Optimal surgical technique

4-6 core and epitendon sutures

Tendon gliding force | Passive mvmt

2-4 N

Tendon gliding force AAROM

Up to 10 N

Tendon gliding force AROM (strong grasp)

More than 70 N

4 strand suture force allows for

40-45 N

Goal of surgical mgmt

Strong repair site that wont allow more than 3 mm length with gentle AROM therapy designed to prevent adhesions

Weakest time for post surgical healing

First 10 days | Minimal strength at day 5

Early controlled ROM and why

Promote 3-5 mm of tendon gliding to prevent adhesions and contractures

Contraindications for 0-5 days | Inflammatory phase

Active tendons contraction | Passive tendon length into extension

Contraindications for fibroplastic phase | 5-21 days

Active grasping | Full passive tendon length into extension

Normal glide, responsive tendon

Less than 5 deg between AROM and PROM No adhesions Continue with protocol

Decreased glide, but tendon is responsive

More than 10 deg between AROM and PROM: lag present More than 10% resolution of active lag between sessions Plan: dont increase force until next visit

Decreased glide, NON-responsive tension

More than 10 deg between AROM and PROM: lag present Less than 10% resolved b/w sessions Plan: increase force

Zone 1 rehab concerns | How much DIP flex needed?

Stiffness and less FDP glide | 40 DIP flex needed for function

Zone 2 rehab concerns

Hardest to repair - no mans land Camper chiasm where FDP and FDS meet FDP and FDS strong adhesion impairs gliding Early active protocol is more effective

Zone 3 rehab concerns

Intrinsic contracture and tight | Better results b/c no tendon sheath

Zone 4 rehab concerns

Adhesions b/w tendon and median nerve b/c of carpal tunnel

Zone 5 rehab concerns

Risk for neurovascular injury | Quicker healing, less adhesions, more mobile tissue