Flexor Tendon Repair Flashcards
Origin of FDS
Medial epicondyle
Coronado process
Proximal radius
Insertion of FDS
Bifurcates around FDS
Meets up at Casper’s chiasm
Middle phalanx
Action fo FDS
PIP flex
Action of FDP
DIP flex
Origin of FDP
Volar and medial ulna surface
Interosseous membrane
Maybe proximal radius
Insertion of FDP
Palmar base of distal phalanx
Innervation of FDS
Median nerve
Lumrbical action
Flex MCP
Origin of lumbricals
FDP
Insertion of lumbricals
Extensor expansion
Strong, broad
Provides mechanical stability
Annual pulley
Provides flex
Cruciate pulley
Need to keep intact during surgery
A2 and A4
Bowstringing, which pulley
A2
Most common way of injuring flexor tendon
Sharp transection through glass or knife
Zone 1
FDS to distal
- FDP avulsion or laceration
Zone 2
A1 pulley to FDS insertion
- no man’s land
- chiasm of campers
- within tendon sheath
- neurovascular injury
Zone 3
End of carpal tunnel to A1 pulley
- no Flexor sheath except 5th
- intrinsic injury (lumbrical)
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
