Tendon Flashcards

1
Q

Extensor compartments of the wrist

A
  1. EPB, APL (2-3 senor)
  2. ECRL, ECRB
  3. EPL
  4. EDC, EIP
  5. EDM
  6. ECU
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2
Q

Intersection syndrome?

A

Due to inflammation at crossing point of 1st dorsal compartment and 2nd. (rowers, weight lifters), Approx 5cm pros of wrist.
Rest, wrist splint, steroid injection to 2nd compartment. Rarely release of 2nd dorsal compartment approx 6cm proximal to radial styloid.

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3
Q

Eichhoffs maneuver

A

De Quarvain test added to Finkelstein maneuver. Ulnar deviated wrist while patient clenches thumb in fist, followed by relief of pain once the thumb is extended even if the wrist remains ulnar deviated

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4
Q

Causes of snapping ECU?

A
  1. Attenuation
  2. Rupture
    Can lead to ECU-tendinitis.

Wrist splint or long arm cast with wrist pronation and slight radial dev.
Surg: Acute repair, ext retinaculum flap, TFCC 50% concurrent
(tennis golf)

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5
Q

Intrinsic minus

  • causes
  • pathoanatomy
A
  1. MCP hyperextension
  2. PIP and DIP flexion

Causes: 1. Ulnar nerve palsy

  1. Median nerve palsy (Volkmanns ischemic contracture, leprosy aka Hansen’s disease, failure to splint in intrinsic plus)
  2. Charcot-Marie -Tooth
  3. Compartment syndrom of the hand

Pathoanatomy:

  • loss of intrinsics
  • strong EDC
  • strong FDP and FDS
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6
Q

Intrinsic plus

A
  1. MCP flex
  2. PIP & DIP ext

Causes:

  • Spastic intrinsics (interosseoi and lumbricals). Central: traumatic brain injury, CP, stroke, parkinson
  • Weak extrinsic
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7
Q

Bunnell test

A

Intrinsic tightness test

Pos test when PIP flex is less with MCP extension than with MCP flexion = intrinsic tightness

Differentiates intrinsic and extrinsic tightness. Extrinsic tightness ex EDC gives opposite result

Surg:
prox muscel slide
distal intrinsic release (distal to the transverse fibers responsible for MCP-joint flex)

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8
Q

Nonoperative Treatment Boutonniere

A

Nonoperative splint PIP 6w. DIP movement for ORL avoid contraction. Additional part-time splint 4-6w

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9
Q

Surgical treatment Boutonniere

A

Terminal tendon tenotomy (Fowler och Dolphin)

Secondary tendon reconstruction (tendon graft, Littler, Matev)

Triangular lig reconstruction

PIP-arthrodesis

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10
Q

Swan neck causes

A
  • MCP volar sublux (RA)
  • Mallet finger
  • FDS laceration
  • Intrinsic contracture
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11
Q

Swan neck treatment - no intrinsic plus

A

Double ring splint

Volar plate advancement (adresses laxity)
with balancing with:
- Spiral oblique reticular leg reconstruction
- Central slip tenotomy (Fowler)
- FDS-slip tenodesis

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12
Q

Quadriga effect

A

FDP common muscle belly and excursion of the combined tendon I equal to the shortest. Leads to inability to fully flex adjacent fingers

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13
Q

Lumbrical anatomy

A

1+2nd
- unipennate, median, radial side FDP 2+3

3-4
- bipennate, ulnar, from 3+4 and 4+5

All insert radial side of extensor expansion (lateral band mostly)

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14
Q

Jersey finger classification

A

Leedy and Packer:
Type 1: Retracted to the palm (surg 7-10d)

  1. FDP retracts to PIP-joint (<3w)
  2. Large avulsion fracture limit retraction to DIP-joint
  3. Double avulsion; avulsion fx + tendon avulsion into palm
  4. Bone avulsion + comminution
    a) extraatricular
    b) intra-articular
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15
Q

Transverse band att PIPj - function and pathology

A
  • flexor sheath to lateral band

Attenuation leads to dorsal translation - swan neck

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16
Q

ORL

A

Oblique reticular ligament of Landsmeer. Volar/lat prox phalanx to terminal tendon

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17
Q

Clelands lig

A

Remember C for ceiling. Dorsal to digital nervers (not involved in Dup)

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18
Q

Graysons lig

A

“G for ground”. Volar to digital nerves

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19
Q

Insertion and relation to transverse metacarpal ligament of

lumbricals and interossei

A

Lumbrical goes volar to transverse metacarpal lig and -> terminal tendon through lateral band

Interossei goes dorsal to transverse metacarpal lig and -> lateral band and base of metacarpal.

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20
Q

RCL/UCL Coll lig.

A

Proper (taut in 30 flexion)

Accessory (taut in ext) to volar plate

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21
Q

Flexor pulley system - finger

A
A1 - MCPj
A2 Prox phalanx ( prox 2/3)
C1
A3 - PIPj
C2
A4 - Middle phalanx, FDS insertion
C3
A5 -DPIj

Cruciate facilitate approximation of annular pulleys during flexion and precent cheat collapse/expansion

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22
Q

Thumb Flexor pulley system

A

A1
Av pulley - (3 types, 1: gap to A1, 2: no gap to A1, A3: oblique)
Oblique pulley - most important
A2

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23
Q

6 types pulley reconstruction

A

“Around the bone” deep to ext tendon in pros phalanx!)

  1. Single loop (Bunnell)
  2. Triple loop (okutsu) (best for A2)
Nonencircling
3. Ever present rim (Kleinert)
4. Belt loop (Karev)
5 Extensor retinaculum (Lister)
6. PL through volar plate (Doyle & Blythe)

For A4; use double loop, superficial to tendons!

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24
Q

How much can you vent pulleys?

A

<2/3 of A2 or complete A4. A2 fully vented only if A1 intact.

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25
8 important technical factors for tendon sutures
- Core placement (dorsal better) - Core size - Tendon purchase 7-12mm - Assymmetry - Locking vs grasping sutures - Type of sutures - Knot placement - Epitendinous sutures
26
How to easily pull FDP through A4-pulley in zone 1 injury?
Elliot 2001 JHS - "Demi tendon" use only one of the two halfs. Cut the other half proximal to A4 when tendon is stretched over A4.
27
FDP avulsion classification
Leddy-Packer 1. FDP fully retracted, both vincula injuries 2. Long vinculum intact - better cirkulation, maybe small bone avulsion 3. Large bone avulsion (A4), both vincula intact
28
FDP reinsertion zone 1a
No tendon remnants - Buttons, over nail, through bone (Sood and Elliot 1996) - 12 strand suture Tang "Suture what you find) including volar plate
29
What is Campers chiasm?
Crossing of FDS fibers on the dorsal side of FDP. Volarly is the bifurcation of FDS
30
Strength of epitendoinous suture?
30%
31
Most elastic suture material?
Prolene - not good for tendons | Ethilone gets more elastic in moist
32
Zone 1 finger pulley
Distal to insertions of FDS (inside A4)
33
Zone 2 finger pulley
FDS insertion to A1
34
Zone T1 (thumb pulley)
Distal to IPj (A2)
35
Zone T2 (thumb pulley)
Between IPj (A2) and MPj (A1)
36
Zone T3 (thumb pulley)
Distal to carpal tunnel to A1
37
How many bands do EDM mostly have? | How often is it absent?
Two (1-4) | 20-40%
38
Difference between EIP and EDC2?
``` EIP is: Always ulnar to EDC at the wrist More distal muscular belly No junctura Often radial to EDC at MPj ```
39
How much extension strength is lost when you harvest EIP
35-50%
40
What is joining the flexor and extensor system and on what side?
Interosseous is on both sides | It is the Lumbricals (on radial side)
41
What joins the extensor system together?
Retinacular system
42
Interossei origin and number
PAD DAB Palmar ADduct - 3 unipennate Dorsal ABduct - 4 bipennate
43
Does dig 5 have a volar or dorsal interossei?
Volar For adduction. Abduction is by ADM
44
Does dig 3 have volar or dorsal interosseus muscles?
2 dorsal interosseus muscles, one on each side (bipennate)
45
Lumbrical muscle function?
Proprioception Very little function in flexion and extension. Bigger in primates walking on knuckles.
46
What happens with EDC with claw finger
EDC hyperextends MPj and can only secondarily extend PIPj/DIPj if interosseous is functional Cruveilhier´s experiment - Stabilize MPj and PIPj and DIPj can extend
47
Doyle classification of Mallet finger
Type 1 - closed +/- bone avulsion 2 - open with tendon lesion 3 - open with cutaneous and tendon loss of substance 4 - closed with phalanx fracture a<20 B20-50% of articular surface C>50
48
Sagittal band Injury classification
Rayan and Murray, type: 1. simple contusion 2. tendon subluxation 3. tendon luxation
49
Tenodermodesis technique for drop finger?
3-4mm skin elliptical removal down to tendon Big mattress sutures including skin and tendon size 3-0 - 4 weeks K-wire DIPj for 6 weeks
50
Swan neck - intrinsic plus
Fractioned lengthening in mild cases, neurectomy in severe cases. Test with ulnar nerve motorblock before. If capsular contracture MPj fusion may give better function.
51
Acute boutonniere treatment
1. Closed injury - Splint 6v then dynamic | 2. Open injury over 50% suture
52
Chronic boutonniere treatment
1. Passively correctable - surgery 2. Not passively correctable - rehab Surgery WALANT: 1. Cut transverse reticular lig (holding lateral bands down) 2. Tighten triangular lig. (pulling lateral bands up) 3. Shorten central slip 4. Fowler tenotomy (DIPj for hyperextension of DIPj)
53
Zone 5 closed sagittal band tendon Injury treatment
Conservatively 4-6w with hyperextension MPj. Dig 3,4 use sagittal band bridge. ``` Surgery if unsuccessful: Junctura tendon flap Ulnar EDC strip - "Feldon Harris" attach in capsule - "Nicolle" around collateral lig. ```
54
Splinting after extensor tendon rupture
Zone 1-4: 40d/6w spring (excursion only 1-2mm, adhesion less problem) Zone 5-7: Controlled motion after 3w
55
6 basic principles of tendon transfers
Soft tissue equilibrium Full passive range of motion of involved joints Adequate amplitude of donor muscle Single function for each tendon transfer Synergy of transfer
56
Standard FCU transfer for radial nerve palsy
PT to ECRB FCU to EDC PL to EPL
57
FCR transfer for radial nerve palsy
PT to ECRB FCR to EDC PL to EPL
58
Boyes superficiales transfer for radial nerve palsy
PT to ECRB FDS4 to EDC 2-5 FDS3 to EIP and EPL (FCR to APL/EPB)
59
Difference between EIP and EDC2
EIP has no junctura, is always ulnar AT WRIST and its muscular body more distal. (Often ulnar at MCP but not always)
60
Claw hand correction
Littler modified Stiles Bunell (A) risk for PIP hyperextension B - Burkhalter C - Omer (more MCP flexion Tham zancolli lasso A1) D- Anderson and Oberlin Using FDS3 if strong nog 4 (week in ulnar palsy)
61
Sean neck classification
62
Treatment for swan neck
63
Mild Boutonnière treatment in RA
64
Moderate Boutonnière treatment in RA
All at the same procedure: Lateral band regálese and rosal suture Shortening of central slip Tenotomy of extensor to DIP 2-3w k wire PIP in extension then dynamic splint, move DIP
65
Traditional Postop regime ext tendon
Zone 1-2: 6w splint or K wire Zone 3-5: wrist 40, MCP flight flex, PIP straight 4W Zone6-7: same with full PIP active motion 4w
66
Evans and burkhalter method for ext tendon rehab
Zone 5-7 in motivated patient 3d start dynamik splint Dynamic outrigger Splint prevents MP flexion more than 30 degrees 5w maintained, 10x/h Dynamik splint may not be better in long term
67
Merritt
Zone 4-7 Relative motion splint RMS Dig 3-4 MP 20 extension, PIP-free 3w Jfr aktive motion Active extension, splint stop Max flexion
68
Fowler central slip tenotomy
From midlateral, open transverse retiñacular and slide scalpel on insertion - Postop 2w ext block 20 degree PIP and straight DIP - DIP protection but full movement, not hyperextension PIP - 4-8w DIP night splint Expect 37->9 degree ext lag
69
ORL reconstruction
Próx lateral band (littler) release and secure to volar sheet volar to rotation axis of PIP Or Thomson 78 with PL graft and buttons, deep to neurovasc bundle Klein am Petersen 84 modification Wire in DIP neutral 4,5w PIP 15 degree flexion 3w
70
Chronic mallet treatment
6m figure of 8 splint Fowler central slip tenotomy ORL if no distal tendon maybe with graft
71
Zone 3 open inj surgery Ext tendon
Suture >50% PIP wire 5-6w (some say dynamic early rehab) Then part time splint 4w If defect use snow
72
Classification of chronic Boutonniere and treatment
Stage I: Supple, passively correctable deformity Stage II: Fixed contracture, contracted lateral bands I and II -> therapy to full ext then 6-12w splint Stage III: Fixed contracture, joint fibrosis, collateral ligament, and palmar plate contractures -> release Stage IV: Stage III plus PIP joint arthritis, added to this classification -> release + fusion or arthroplasty
73
Burton 7 principles of Boutonniere deforimity
1. Surgery by hand surgeons 2. Rarely necessary in Supple joints (responds to therapy) 3. Surgery in context of rehab/splints long time 4. Surgery best after full passive movement. If stiff surgery in 2 stages. Often enough with release only with PIP ext splint + DIP flex exercise 5. Arthritis-> fusion or release + arthroplasty 6. Risk jeopardize flexor function - discuss 7. All procedures involve a rebalancing of the extensor system, decreasing the tone at the distal joint and diverting it to the proximal joint.
74
Why is mallet finger not developed after distal Fowler a.k.a. Dolphin tenotomy It is done just dstal to triangular lig between middle and prox 1/3.
Dorsal capsule/lig tightness Intact ORL DIPj extension splint 8w but removed daily for active range of motion
75
Curtis staged surgery for Boutonniere If more than 30degree ext lag (otherwise not big benefit)
WALANT, full passive range of motion 1. tenolysis lat band 2. transverse retinacular lig free or divided so lat band can slide dorsally 3. not full correction but <20 degree PIP ext lag do a distal Fowlar tenotomy/Dolphin 4. if >20 degree PIP ext lag; excise 4-6mm scar in central tendon and advance its insertion
76
Zone 4 dynamic splint after injury
Often partial because convex, if >50% suture. Kessler + cross stitch Compliant patientes: Observe in theatere how much you can flex -> determin how flexed splint can be for splint + outriggers 4w. Less compliant: 4w splint in extension, DIP free motion
77
Sagittal band injury and layers
Ishizuki identified superficial and deep layer. Superficial inj in "Spontaneous" and both in traumatic.
78
When treat sagittal band rupture conservatively
Subluxation + no subluxation in MPj extension seen <3w - Full time 8w 25-35degree hyperextension RMS - Or cast 4w IPj free
79
Sagittal band reconstruction
Carrol prefered around RCL
80
Secretan's syndrome
Chronic blunt trauma to the dorsal hand: Secretan’s syndrome A factitious illness characterized by dorsal hand edema and fibrosis, Secretan’s syndrome is a self-inflicted condition in which the patient is intentionally causing the signs and symptoms.
81
Zone 7 inj
2-0 for wrist extensors 3-0 digit extensors Kessle + four strand cruciate + circumfelx 5-0 cross stitsh IP free if digit extensor inj dynamic splint in motivated patientes
82
Early active mobilization
Wrist splinted 15 degree ext, MP 45 flex, PIP/DIP 0 1. Passive flex, active ext (passive if needed), active flex 1/2 (10-20x every second h) 2. 2 weeks: Active flex 2/3 3. 3 week: Full active flex "no resistance feeling" 4. 4 week: remove cast, not more than 25 degree wrist extension with max finger flex 5. No restrict, no load, very easy activity 6. Easy home activiy, resistance beginned 7. 12w full load
83
Tendon healing
Intrinsic Tenocytes Extrinsic Synovial fluid and inflammatory cells Producera scarring 1. Inflammatory phase 0-5d 2. Fibroblastic 5-28 3. Remodelling >28d linser collagen