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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
Describe flexor zone 3
- 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
Describe flexor zone 4
- Area of carpal tunnel - Results in potential injury to FDP, FDS, & FPL
27
Describe flexor zone 5
- Proximal to carpal tunnel up to musculature junction in forearm - Results in potential injury to wrist flexors
28
Describe extensor zone 1
- Over DIP joint & distal portion of middle - Can result in mallet deformity - Results in injury to EDC (thumb- EPL)
29
Describe extensor zone 2
- Over middle phalanx - Results in the same as zone 1 (thumb- EPB)
30
Describe extensor zone 3
- Over PIP joint - Can result in Boutonniere deformity - Results in the same as zone 2
31
Describe extensor zone 4
- Over proximal phalanx - Results in the same as zone 3 (thumb possible APL)
32
Describe extensor zone 5
- Over MP joint - Results in same as zone 4
33
Describe extensor zone 6
- Over dorsum of hand - Results in the same as zone 5 (increased likelihood of multiple EDC tendon involvement)
34
Describe extensor zone 7
- At extensor retinaculum (wrist) - Results in likely multiple EDC tendon involvement
35
Describe extensor zone 8
- Proximal to extensor retinaculum - Results in likely multiple EDC tendon involvement
36
General principles of protocols
- 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
Why is the healing process so long
- 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
What are the phases of healing
- 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
List complicating factors of healing
- 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
What are the 3 general approaches for flexor tendon protocols
- Immobilization Protocol - Early Passive Mobilization Protocol: modified Duran & Dynamic flexion traction - Early Active Mobilization Protocol: Manchester
41
General approach and population the gets the immobilization protocol
- 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
General approach and population the gets the early passive mobilization protocol
- 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
General approach and population the gets the early active mobilization protocol
- 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
Basic protocols for extensor tendons
- Immobilization protocol - Early controlled motion protocols: early active short arc motion (SAM) and early mobilization - Big goal is to prevent extensor lag
45
Common splints for flexor tendon repair
- 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
Common splints for extensor tendon repair
- Static Extensor Tendon Splint - Dynamic Forearm Based Splint with - Outrigger
47
Order for evaluation and documentation
- Observations on arrival: guarding, posture, grimacing, edema, skin condition, condition of post-op dressings - Cognition, awareness, understanding - PROM - Wound/surgical site - Edema - Sensation
48
Goals for the initial treatment
- 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
Long term goals for ultimately return to overall function
- AROM - Strengthening - Sensation: restore as able
50
Interventions for edema management
- Elevation - Compression - ROM
51
Slide 47
52
Interventions for scar management
- Compression - Massage - ROM
53
Slide 50-53
54
General rules for modalities
- 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
Complications of tendon repairs
- Rupture - Tendon adhesions (Tenolysis) - Non-compliance: hard headed and/or financially challenged - Missed appointments
56
Assessment of Objective Attainment
- 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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