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Advanced Orthopedics > Hand Tendon Repairs > Flashcards

Hand Tendon Repairs Flashcards

1
Q

Joint motions of the 1st digit

A
  • Thumb
  • Flexion
  • Extension
  • Abduction
  • Adduction
  • Opposition
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2
Q

Joint motions of the 2nd, 3rd, & 4th digits

A
  • Flexion & extension
  • Can isolate MCP flexion & extension hook fist, full fist/composite
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3
Q

Joint motions of the 2nd, 4th, & 5th digits

A
  • Abduction & adduction (3rd digit is point of reference)
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4
Q

Origin and insertion of the flexor digitorum superficial (FDS)

A
  • Origin: common flexor tendon on the medial epicondyle, coronoid process, & radius
  • Insertion: sides oof middle phalanx of the four fingers
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5
Q

Extrinsic versus intrinsic muscles

A
  • E: muscle organ in proximal to the hand and the insertion is in the hand
  • I: both the organ and insertion is within the hand
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6
Q

Origin and insertion of the flexor digitorum profundus (FDP)

A
  • Origin: upper 3/4 of ulna
  • Insertion: distal phalanx of four fingers
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7
Q

Origin/insertion of extensor digitorum or extensor digitorum communes (ED/EDC)

A
  • Origin: lateral epicondyle of humerus
  • Insertion: base of distal phalanx of the 2nd through 5th
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8
Q

Origin/insertion of flexor pollicis longus

A
  • Origin: radius anterior surface
  • Insertion: distal phalanx of thumb
  • Action: flexes all 3 joints of the thumb (CMC, MCP, IP)
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9
Q

Origin/insertion of abductor pollicis longus

A
  • Origin: posterior radius, interosseous membrane & middle ulna
  • Insertion: base of 1st metacarpal
  • Action: abducts thumb
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10
Q

Origin/insertion of extensor pollicis brevis

A
  • Origin: posterior distal radius
  • Insertion: base of proximal phalanx of thumb
  • Action: extends CMC & MCP joints of thumb
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11
Q

Origin/insertion of extensor pollicis longus

A
  • Origin: middle posterior ulna & interosseous membrane
  • Insertion: base of distal phalanx of thumb
  • Action: extends all 3 joints of the thumb
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12
Q

Origin/insertion of extensor indicis

A
  • Origin: distal ulna
  • Insertion: base of distal phalanx of the 2nd finger
  • Action: extends all 3 joints of the 2nd finger (MCP, PIP, DIP)
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13
Q

Origin/insertion of extensor digiti minimi

A
  • Origin: lateral epicondyle of humerus
  • Insertion: base of distal phalanx of 5th
  • Action: extends all 3 of the joints of the 5th finger (MCP, PIP, DIP)
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14
Q

Damage to the ulnar or median nerve leads to what

A
  • Median nerve damage = blind hand
  • Ulnar nerve damage = loss of power grip
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15
Q

Describe a power grip

A
  • Grips that require the fingers and thumb to flex around an object. Generally in a forceful manner while moving about while keeping in contact with palm.
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16
Q

What are the 3 common types of grips

A
  • Cylindrical: holding a handle
  • Spherical: opening a jar
  • Hook: carrying a briefcase
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17
Q

Describe a lateral cylindrical grip

A
  • Finger are in the cylindrical grip and the thumb is in a lateral pinch grip
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18
Q

Describe precision grips/pinches

A
  • Holds the object between the thumb and fingertips. More fine movement and accuracy.
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19
Q

Types pf precision grips/pinches

A
  • Pad to pad
  • Tip to tip: pincer
  • Pad to side: lateral pinch
  • Side to side
  • Lumbrical grip: plate grip
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20
Q

Common causes of tendon injuries in the hand

A
  • Saw accidents
  • Knife slips
  • Glass breaking in hand
  • Factory line: caught in machines
  • Post wrist fracture: adhesion with rupture
  • Sports
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21
Q

Surgical techniques/approaches vary depend on

A
  • Surgeon skill level
  • Type of injury
  • MOI
  • Length of time b/w injury & repair
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22
Q

Difference between flexor tendons and extensor tendon structure

A
  • Flexor tendons are typically round
  • Extensor tendons are typically flat
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23
Q

Describe flexor zone 1

A
  • Proximal to insertion of the FDP tendon at distal phalanx
  • Results in injury to FDP & may involve pulleys (thumb-FPL)
24
Q

Describe flexor zone 2

A
  • No mans land due to difficulty of healing & higher rupture & adhesion formation
  • From zone 1 to MP level
  • Results in injury to FDP & FDS and may involve pulleys (thumb- FPL and intrinsic FPB)
25
Q

Describe flexor zone 3

A
  • Proximal to A1 pulley at MP joint extending into solar carpal ligament (palm of hand)
  • Results in FDP and FDS and may evolve more intrinsic musculature (thumb- intrinsic musculature)
26
Q

Describe flexor zone 4

A
  • Area of carpal tunnel
  • Results in potential injury to FDP, FDS, & FPL
27
Q

Describe flexor zone 5

A
  • Proximal to carpal tunnel up to musculature junction in forearm
  • Results in potential injury to wrist flexors
28
Q

Describe extensor zone 1

A
  • Over DIP joint & distal portion of middle
  • Can result in mallet deformity
  • Results in injury to EDC (thumb- EPL)
29
Q

Describe extensor zone 2

A
  • Over middle phalanx
  • Results in the same as zone 1 (thumb- EPB)
30
Q

Describe extensor zone 3

A
  • Over PIP joint
  • Can result in Boutonniere deformity
  • Results in the same as zone 2
31
Q

Describe extensor zone 4

A
  • Over proximal phalanx
  • Results in the same as zone 3 (thumb possible APL)
32
Q

Describe extensor zone 5

A
  • Over MP joint
  • Results in same as zone 4
33
Q

Describe extensor zone 6

A
  • Over dorsum of hand
  • Results in the same as zone 5 (increased likelihood of multiple EDC tendon involvement)
34
Q

Describe extensor zone 7

A
  • At extensor retinaculum (wrist)
  • Results in likely multiple EDC tendon involvement
35
Q

Describe extensor zone 8

A
  • Proximal to extensor retinaculum
  • Results in likely multiple EDC tendon involvement
36
Q

General principles of protocols

A
  • Post-op time frame: 12-16 wks
  • Splinting
  • Edema management
  • ROM exercises
  • Scar management/prevention/manipulation
  • Place & hold
  • AROM
  • Graded strengthening
  • Modalities
  • Desensitization or sensory re-education
  • Lots of EDUCATION
37
Q

Why is the healing process so long

A
  • Process varies due to individual biological responses to healing. Think of not as absolute, but rather a guide to the average. There is a balance that we want of adhesion and glide.
  • Glides to easily: may slow down.
  • Difficulty gliding: may advance more quickly.
38
Q

What are the phases of healing

A
  • Inflammatory phase: Day 1-21; proliferation of cells begins along outer edge with migration into tendon with collagen beginning to stabilize usually around 3-4 wks
  • Inflammatory/Proliferation phase: Day 1-42; Around 3-4 wks is where we are able to initiate some degrees of AROM, during this time tension to tendon allows for restructuring/reorientation of collagen fibers
  • Remodeling phase: Day 43-84; 6-10 wks splints warned to discontinued, 8 wks begin strengthening
39
Q

List complicating factors of healing

A
  • Nerve lacerations
  • Intrinsic involvement
  • Multiple tendon involvement
  • Concurrent involvement of both extensor & flexor tendons
  • Annular pulley involvement
  • Fractures
  • Additional wound care needs
  • Compromised skin
  • Poor health/compromised health
  • Smoking
40
Q

What are the 3 general approaches for flexor tendon protocols

A
  • Immobilization Protocol
  • Early Passive Mobilization Protocol: modified Duran & Dynamic flexion traction
  • Early Active Mobilization Protocol: Manchester
41
Q

General approach and population the gets the immobilization protocol

A
  • Population: risk of noncompliance outweighs benefits of early motion, living in severely poor environmental conditions, & concomitant injuries which contraindicate motion
  • Will not see therapist for 3 wks
  • No AROM/PROM of affected digit for 3 wks
  • Increased adhesions
  • After 3rd wk tend to use motion driven protocol within dorsal block splint
42
Q

General approach and population the gets the early passive mobilization protocol

A
  • Population: not candidates for early AROM protocols, significant post operative edema, & cannot attend therapy 2-3x per wk
  • Passive flexion & passive/active extension begins within 1st few days post-op
43
Q

General approach and population the gets the early active mobilization protocol

A
  • Population: specific surgical repair & strong patient compliance
  • Motion initiated within 1st 5 days post-op
  • Incorporates place & hold flexion and/or true active flexion of affected digits earlier
  • Manchester = monitor for compliance to determine if patient fit for full protocol
44
Q

Basic protocols for extensor tendons

A
  • Immobilization protocol
  • Early controlled motion protocols: early active short arc motion (SAM) and early mobilization
  • Big goal is to prevent extensor lag
45
Q

Common splints for flexor tendon repair

A
  • Static Dorsal Blocking Splint
  • Dorsal Blocking Splint with Dynamic Traction
  • Dorsal Blocking with Articulating Wrist/Wrist Hinge
  • Manchester (Distal portion of Forearm based blocking)
  • Between 2-4 weeks, the forearm portion is removed, and patient remains in distal hand-based portion
46
Q

Common splints for extensor tendon repair

A
  • Static Extensor Tendon Splint
  • Dynamic Forearm Based Splint with - Outrigger
47
Q

Order for evaluation and documentation

A
  • Observations on arrival: guarding, posture, grimacing, edema, skin condition, condition of post-op dressings
  • Cognition, awareness, understanding
  • PROM
  • Wound/surgical site
  • Edema
  • Sensation
48
Q

Goals for the initial treatment

A
  • Protect to preserve structures
  • Prevent excessive development of/decrease any presence of edema
  • Promote wound healing/prevent infection
  • Initiate early protected motion as able/maintain PROM
  • Prevent scar adhesions
  • Maintain AROM of any uninvolved joints: *Splint- depends on protocol for tendon and zone; Education: edema management, early motion, scar/wound/surgical site management, general protocol anticipated.
49
Q

Long term goals for ultimately return to overall function

A
  • AROM
  • Strengthening
  • Sensation: restore as able
50
Q

Interventions for edema management

A
  • Elevation
  • Compression
  • ROM
51
Q

Slide 47

A
52
Q

Interventions for scar management

A
  • Compression
  • Massage
  • ROM
53
Q

Slide 50-53

A
54
Q

General rules for modalities

A
  • Depending on tendons & zone the protocol may initiate NMES during AROM exercises as early as 4-5 wks
  • Ultrasound is typically not initiated until 8-10 wks unless there is dense scarring
55
Q

Complications of tendon repairs

A
  • Rupture
  • Tendon adhesions (Tenolysis)
  • Non-compliance: hard headed and/or financially challenged
  • Missed appointments
56
Q

Assessment of Objective Attainment

A
  • Identify the basic bone and joint anatomy of the hand.
  • Differentiate between Flexor and Extensor tendons and their respective role in hand movement and function.
  • Identify common causes of tendon laceration/rupture.
  • Recognize factors that contribute toward selection of protocol.
  • Describe generally the timeline of tendon repairs and why the timeline is such.
  • Describe initial goals and long term goals associated with tendon repair.
  • Identify and describe essential features of splints associated with various tendon repairs.
  • Describe factors which may contribute to poor therapeutic outcomes.
  • Describe potential complications associated with tendon repair.

Advanced Orthopedics (29 decks)

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