Hand Tendon Repairs Flashcards
Joint motions of the 1st digit
- Thumb
- Flexion
- Extension
- Abduction
- Adduction
- Opposition
Joint motions of the 2nd, 3rd, & 4th digits
- Flexion & extension
- Can isolate MCP flexion & extension hook fist, full fist/composite
Joint motions of the 2nd, 4th, & 5th digits
- Abduction & adduction (3rd digit is point of reference)
Origin and insertion of the flexor digitorum superficial (FDS)
- Origin: common flexor tendon on the medial epicondyle, coronoid process, & radius
- Insertion: sides oof middle phalanx of the four fingers
Extrinsic versus intrinsic muscles
- 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
Origin and insertion of the flexor digitorum profundus (FDP)
- Origin: upper 3/4 of ulna
- Insertion: distal phalanx of four fingers
Origin/insertion of extensor digitorum or extensor digitorum communes (ED/EDC)
- Origin: lateral epicondyle of humerus
- Insertion: base of distal phalanx of the 2nd through 5th
Origin/insertion of flexor pollicis longus
- Origin: radius anterior surface
- Insertion: distal phalanx of thumb
- Action: flexes all 3 joints of the thumb (CMC, MCP, IP)
Origin/insertion of abductor pollicis longus
- Origin: posterior radius, interosseous membrane & middle ulna
- Insertion: base of 1st metacarpal
- Action: abducts thumb
Origin/insertion of extensor pollicis brevis
- Origin: posterior distal radius
- Insertion: base of proximal phalanx of thumb
- Action: extends CMC & MCP joints of thumb
Origin/insertion of extensor pollicis longus
- Origin: middle posterior ulna & interosseous membrane
- Insertion: base of distal phalanx of thumb
- Action: extends all 3 joints of the thumb
Origin/insertion of extensor indicis
- Origin: distal ulna
- Insertion: base of distal phalanx of the 2nd finger
- Action: extends all 3 joints of the 2nd finger (MCP, PIP, DIP)
Origin/insertion of extensor digiti minimi
- 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)
Damage to the ulnar or median nerve leads to what
- Median nerve damage = blind hand
- Ulnar nerve damage = loss of power grip
Describe a power grip
- 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.
What are the 3 common types of grips
- Cylindrical: holding a handle
- Spherical: opening a jar
- Hook: carrying a briefcase
Describe a lateral cylindrical grip
- Finger are in the cylindrical grip and the thumb is in a lateral pinch grip
Describe precision grips/pinches
- Holds the object between the thumb and fingertips. More fine movement and accuracy.
Types pf precision grips/pinches
- Pad to pad
- Tip to tip: pincer
- Pad to side: lateral pinch
- Side to side
- Lumbrical grip: plate grip
Common causes of tendon injuries in the hand
- Saw accidents
- Knife slips
- Glass breaking in hand
- Factory line: caught in machines
- Post wrist fracture: adhesion with rupture
- Sports
Surgical techniques/approaches vary depend on
- Surgeon skill level
- Type of injury
- MOI
- Length of time b/w injury & repair
Difference between flexor tendons and extensor tendon structure
- Flexor tendons are typically round
- Extensor tendons are typically flat
Describe flexor zone 1
- Proximal to insertion of the FDP tendon at distal phalanx
- Results in injury to FDP & may involve pulleys (thumb-FPL)
Describe flexor zone 2
- 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)
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)
Describe flexor zone 4
- Area of carpal tunnel
- Results in potential injury to FDP, FDS, & FPL
Describe flexor zone 5
- Proximal to carpal tunnel up to musculature junction in forearm
- Results in potential injury to wrist flexors
Describe extensor zone 1
- Over DIP joint & distal portion of middle
- Can result in mallet deformity
- Results in injury to EDC (thumb- EPL)
Describe extensor zone 2
- Over middle phalanx
- Results in the same as zone 1 (thumb- EPB)
Describe extensor zone 3
- Over PIP joint
- Can result in Boutonniere deformity
- Results in the same as zone 2
Describe extensor zone 4
- Over proximal phalanx
- Results in the same as zone 3 (thumb possible APL)
Describe extensor zone 5
- Over MP joint
- Results in same as zone 4
Describe extensor zone 6
- Over dorsum of hand
- Results in the same as zone 5 (increased likelihood of multiple EDC tendon involvement)
Describe extensor zone 7
- At extensor retinaculum (wrist)
- Results in likely multiple EDC tendon involvement
Describe extensor zone 8
- Proximal to extensor retinaculum
- Results in likely multiple EDC tendon involvement
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
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.
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
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
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
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
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
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
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
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
Common splints for extensor tendon repair
- Static Extensor Tendon Splint
- Dynamic Forearm Based Splint with - Outrigger
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
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.
Long term goals for ultimately return to overall function
- AROM
- Strengthening
- Sensation: restore as able
Interventions for edema management
- Elevation
- Compression
- ROM
Slide 47
Interventions for scar management
- Compression
- Massage
- ROM
Slide 50-53
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
Complications of tendon repairs
- Rupture
- Tendon adhesions (Tenolysis)
- Non-compliance: hard headed and/or financially challenged
- Missed appointments
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.
