Tendon Injuries Flashcards
Causes of Tendon Injuries
Traumatic
Spontaneous rupture
Chronic arthritis
Iatrogenic
what type of tendon injury is more common, flexor or extensor?
Extensors
Tendon nutrition
synovial fluid- surrounds tendons, mainly around flexors
Vascular perfusion- veins and arteries around tendons
Intrinsic vs extrinsic healing
intrinsic- tenocytes bridge the gap to bring the tendon back together
Extrinsic- fibroblast, similar to bony callus
What modality and when should we use to minimize scar adhesions?
Ultrasound
around 3 weeks
When is the tendon weakest
at days 7-14
Inflammation stage of healing
day 0-5
Strength of repair= strength of suture
No ultrasound yet
Fibroplasia phase of healing
day 5-28
Collagen producing phase
Scar maturation/ remodeling phase
Day 28-4 months
What is tensile strength
how much tension the tendon can withstand without rupturing
Tensile strength during healing
Day 1 is only as string as the suture
Strength decreases 1-5 as inflammation softens the tendon
At day 9 strength returns to as strong as day one and then continually increases
What can change the tensile strength
whether or not it is immobilized
Benefits of early motion
increase rate of revascularization
enhances nutrition
increases healing and strength
helps break down scar tissue to make sure that it does not adhere
Risks of early motion
Moving too much or too aggressively
Keeping the tendons in inflammatory stage for too long
Adhesion formation
Gap formation between the tendon
Re-rupturing the tendon or sutures
How much excursion is necessary and why
3-5 mm
helps stimulate intrinsic repair site without creating a gap between tendon ends
Tendon gapping and what it looks like for flexors vs extensors
if past 3-5 mm, only the slack with be pulled and the not the whole tendon
Flexor- active insufficiency, loose mechanical advantage to make fist
Extensor- extensor lag
How many strands do you need for early active motion
at least 4 strands
doctors might do less so its important to know
3 protocols for flexor tendon injury
Immobilization
Early passive mobilization
Early active mobilization
When should protocol begin and why
Day 3-5
don’t want it sooner to allow for some healing and b/c tendons are weak
Ventral Hand Zone 1
DIP to proximal end of A4 tendon FDP
What do Pulley 2 and 4 do
Holds flexor tendons against the bone
ventral hand Zone 2
A3 to proximal end of A 1
two tendon moving independently
No mans land
so much content in this zone
ventral hand zone 3
3 structures- 2 tendons
lumbricals
ventral hand zone 4
carpal tunnel
4 structures (FDP, FDS, FPL, median N)
moving independently in tightly packed tunnel
Ventral hand zone 5
Forearm
Proximal to transverse carpal ligament , wrist flexors, FDS, FDP, Median and ulnar N
What flexor zone is most complicated
ZOne 2
Flexor Protocol 1 indications
immobilization
cast or splint
doctors choice, children
if unreliable or impaired cognition
poor healing characteristics
Flexor immobilization protocol
cast/splint 3-6 weeks
Initate therapy- exercise: passive, assisted, tendon glides
6-8 weeks: discharge dorsal blocking splint, progressive resistance as appropriate
8-12 weeks: job simulation or return to activities
What type of splint is used for all flexor protocols
Dorsal blocking splint
Dorsal blocking splint
Wrist: neutral to slight extension
MCPs: 40-50 degrees flexion
IPs: full extension
Want repaired tendon to be put on slack
Flexors Protocol 2 indications
early passive mobilization
less than 4 strand repair
comorbidities/ poor healing
cognition
unable to attend regular therapy
significant edema
Early passive protocol
Dorsal block splint- 0-6 weeks
Exercise occurs hourly
Exercise during 0-4 weeks: remove distal strap of splint, passive digit flexion active extension back to orthosis hood
week 4 +: begins to mirror EAM protocol
Flexors protocol 3 indications
Early active mobilization
time from repair
string suture
absence of conflicting injury
reliable patent
knowledgable therapist
Flexor EAM duration
Initiate day 3-5 continue for 3.5-5 weeks, completing 4-6 times a day
Flexor EAM Passive warm up
Passive flexion, active extension to hood
PROM of each joint
All digits even unaffected
Flexor EAM protected active extension
Reverse curl
minimize PIP flexion contractures
Block MCPs 90 degrees, active IP extension relax back into flexion
Flexor EAM short arc active motion
Hook fist
block P1 against orthosis hoot to prevent a full fist
slow gentle fingers curl around pencil motion
active extension back to hood
3 exercise components for flexor EAM
Passive warm-up
protected active extension
Short arc active motion
What fist allows for greater FDS excursion
Straight fist
What fist allows for greatest FDP excursion
full fist
What fist allows for maximum gliding between FDP and FDS
hook fist
Complications of flexor tendon repairs
PIP flexion contracture
lack of tendon glide at DIP joint
Pulley repair and bowstringing
Ruptures
Extensor tendon movements
passive extension, active flexion
What type of splint is used for extensor tendon injuries
volar blocking spint
What I the toughest zone to repair for extensors
Zone 7 under dorsal retinaculum
Scarring like to gob and get stuck
What extensor zones have the best outcome
5-8
Contributing factors to poor results for extensor tendon repairs
shape of tendon
tight spaces
nature of injury
Lympahatics are on dorsal side
often leads to extensor lag
What number zones are on joints on the dorsal hand
odd numbers
Rehabilitation goals for all extensor zones
Prevent extensor lag- much easier to prevent than fix
make gradual gains in flexion while maintaining extension
Are flexors or extensors stronger
flexors
Injury at Extensor Zone 1-2
mallet finger
Lag at DIP
Rehab for extensor zone 1-2
Splint dIP in 0 degrees extension to slight hyper extension for 6-8 weeks
PIP should be free to prevent contracture
Skin integrity is crucial
Injury at Extensor Zone 3-4
Boutonniere deformity : PIP flexion, DIP hyper extension, lateral bands volar
Swan neck: PIP hyper extension, DIP flexion, lateral bands dorsal
Rehab for Boutonniere Deformity
PIP neutral splint for 6-8 weeks
DIP flexion exercises to encourage dorsal migration of lateral bands
Rehab for Swan neck
PIP slight flexion splint
3 protocols for extensor injury zones 4-7
immobilization
conservative management
immediate controlled active mobilization (ICAM)
Splinting protocols for repair proximal vs distal to juncture tendinum
Proximal to JT: splint all the digits
Distal to JT: splint the adjacent finger
What zone is the juncture tendinum in
zone 6
What movement does EI, EDC and EDM make
only claw extension
What muscle is responsible for extension of PIP and DIP joints
lumbricals
Extensor Conservative management indications
all digits involved
Decreased repair strength
delayed repair
noncompliant pt
Extensor Conservative management orthosis
Volar blocking
Wrist extion 30 degrees
MCPs 0-25 degrees hyper extended
IPs free
want extensors on slack
Extensor Conservative management protocol
Initate AROM week 3: hook fist with digit extension AAROM
Week 4: Digit extension/ flexion AROM
Week 5: composite fist/ digit flexion
Inclusion criteria for Extensor ICAM
nondnelayed tendon repair
At least one but not all extensors repaired
compliant patient
Phase 1 of ICAM
Week 0-3
weist extension splint and RMO
Goal: full digit flexion/ extension within confines of splint
Phase 2 of ICAM
Week 3-5
wrist extension only for heavier activities, continue RMO 24/7
Exercise: Wrist tenodesis AROM
Phase 3 of ICAM
Week 5-7
RMO for heavy activity
Orthosis for ICAM
wrist 20-30 degrees of extension
MCP 15-30 degrees of extension
Relative Motion Orthosis (RMO)
MCP of affected digits in 20-30 degrees of extension relative to unaffected digits
Tenolysis
scraping of scar tissue
need at least 6 months of therapy before completing surgery
common after extensor repairs and zone 2 flexor tendon repairs without good result
Complications of Tenolysis
gapped tendon
release of joint contractures
reconstruct pulleys
Post tenolysis op therapeutic management
get object eval data
begin AROM immediately
gentle PROM immediately
begin resistance 3-4 weeks
