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FESSH exam 2022 > Tendon > Flashcards

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
Q

8 important technical factors for tendon sutures

A
  • Core placement (dorsal better)
  • Core size
  • Tendon purchase 7-12mm
  • Assymmetry
  • Locking vs grasping sutures
  • Type of sutures
  • Knot placement
  • Epitendinous sutures
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26
Q

How to easily pull FDP through A4-pulley in zone 1 injury?

A

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.

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27
Q

FDP avulsion classification

A

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
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28
Q

FDP reinsertion zone 1a

A

No tendon remnants

  • Buttons, over nail, through bone (Sood and Elliot 1996)
  • 12 strand suture Tang “Suture what you find) including volar plate
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29
Q

What is Campers chiasm?

A

Crossing of FDS fibers on the dorsal side of FDP. Volarly is the bifurcation of FDS

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30
Q

Strength of epitendoinous suture?

A

30%

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31
Q

Most elastic suture material?

A

Prolene - not good for tendons

Ethilone gets more elastic in moist

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32
Q

Zone 1 finger pulley

A

Distal to insertions of FDS (inside A4)

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33
Q

Zone 2 finger pulley

A

FDS insertion to A1

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34
Q

Zone T1 (thumb pulley)

A

Distal to IPj (A2)

35
Q

Zone T2 (thumb pulley)

A

Between IPj (A2) and MPj (A1)

36
Q

Zone T3 (thumb pulley)

A

Distal to carpal tunnel to A1

37
Q

How many bands do EDM mostly have?

How often is it absent?

A

Two (1-4)

20-40%

38
Q

Difference between EIP and EDC2?

A 
EIP is:
Always ulnar to EDC at the wrist
More distal muscular belly
No junctura
Often radial to EDC at MPj
39
Q

How much extension strength is lost when you harvest EIP

A

35-50%

40
Q

What is joining the flexor and extensor system and on what side?

A

Interosseous is on both sides

It is the Lumbricals (on radial side)

41
Q

What joins the extensor system together?

A

Retinacular system

42
Q

Interossei origin and number

A

PAD DAB

Palmar ADduct - 3 unipennate
Dorsal ABduct - 4 bipennate

43
Q

Does dig 5 have a volar or dorsal interossei?

A

Volar

For adduction. Abduction is by ADM

44
Q

Does dig 3 have volar or dorsal interosseus muscles?

A

2 dorsal interosseus muscles, one on each side (bipennate)

45
Q

Lumbrical muscle function?

A

Proprioception

Very little function in flexion and extension. Bigger in primates walking on knuckles.

46
Q

What happens with EDC with claw finger

A

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
Q

Doyle classification of Mallet finger

A

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
Q

Sagittal band Injury classification

A

Rayan and Murray, type:

  1. simple contusion
  2. tendon subluxation
  3. tendon luxation
49
Q

Tenodermodesis technique for drop finger?

A

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
Q

Swan neck - intrinsic plus

A

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
Q

Acute boutonniere treatment

A
  1. Closed injury - Splint 6v then dynamic

2. Open injury over 50% suture

52
Q

Chronic boutonniere treatment

A
  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
Q

Zone 5 closed sagittal band tendon Injury treatment

A

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
Q

Splinting after extensor tendon rupture

A

Zone 1-4: 40d/6w spring (excursion only 1-2mm, adhesion less problem)

Zone 5-7: Controlled motion after 3w

55
Q

6 basic principles of tendon transfers

A

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
Q

Standard FCU transfer for radial nerve palsy

A

PT to ECRB
FCU to EDC
PL to EPL

57
Q

FCR transfer for radial nerve palsy

A

PT to ECRB
FCR to EDC
PL to EPL

58
Q

Boyes superficiales transfer for radial nerve palsy

A

PT to ECRB
FDS4 to EDC 2-5
FDS3 to EIP and EPL
(FCR to APL/EPB)

59
Q

Difference between EIP and EDC2

A

EIP has no junctura, is always ulnar AT WRIST and its muscular body more distal. (Often ulnar at MCP but not always)

60
Q

Claw hand correction

A

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
Q

Sean neck classification

A
62
Q

Treatment for swan neck

A
63
Q

Mild Boutonnière treatment in RA

A
64
Q

Moderate Boutonnière treatment in RA

A

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
Q

Traditional Postop regime ext tendon

A

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
Q

Evans and burkhalter method for ext tendon rehab

A

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
Q

Merritt

A

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
Q

Fowler central slip tenotomy

A

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
Q

ORL reconstruction

A

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
Q

Chronic mallet treatment

A

6m figure of 8 splint
Fowler central slip tenotomy
ORL if no distal tendon maybe with graft

71
Q

Zone 3 open inj surgery
Ext tendon

A

Suture >50%
PIP wire 5-6w (some say dynamic early rehab)
Then part time splint 4w

If defect use snow

72
Q

Classification of chronic Boutonniere and treatment

A

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
Q

Burton 7 principles of Boutonniere deforimity

A
  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
Q

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.

A

Dorsal capsule/lig tightness
Intact ORL
DIPj extension splint 8w but removed daily for active range of motion

75
Q

Curtis staged surgery for Boutonniere

If more than 30degree ext lag (otherwise not big benefit)

A

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
Q

Zone 4 dynamic splint after injury

A

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
Q

Sagittal band injury and layers

A

Ishizuki identified superficial and deep layer. Superficial inj in “Spontaneous” and both in traumatic.

78
Q

When treat sagittal band rupture conservatively

A

Subluxation + no subluxation in MPj extension seen <3w

  • Full time 8w 25-35degree hyperextension RMS
  • Or cast 4w IPj free
79
Q

Sagittal band reconstruction

A

Carrol prefered around RCL

80
Q

Secretan’s syndrome

A

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
Q

Zone 7 inj

A

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
Q

Early active mobilization

A

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
Q

Tendon healing

A

Intrinsic
Tenocytes

Extrinsic
Synovial fluid and inflammatory cells
Producera scarring

  1. Inflammatory phase 0-5d
  2. Fibroblastic 5-28
  3. Remodelling >28d linser collagen

FESSH exam 2022 (12 decks)

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