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Tendon Injuries Flashcards

1
Q

Causes of Tendon Injuries

A

Traumatic
Spontaneous rupture
Chronic arthritis
Iatrogenic

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2
Q

what type of tendon injury is more common, flexor or extensor?

A

Extensors

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3
Q

Tendon nutrition

A

synovial fluid- surrounds tendons, mainly around flexors
Vascular perfusion- veins and arteries around tendons

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4
Q

Intrinsic vs extrinsic healing

A

intrinsic- tenocytes bridge the gap to bring the tendon back together
Extrinsic- fibroblast, similar to bony callus

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5
Q

What modality and when should we use to minimize scar adhesions?

A

Ultrasound
around 3 weeks

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6
Q

When is the tendon weakest

A

at days 7-14

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7
Q

Inflammation stage of healing

A

day 0-5
Strength of repair= strength of suture
No ultrasound yet

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8
Q

Fibroplasia phase of healing

A

day 5-28
Collagen producing phase

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9
Q

Scar maturation/ remodeling phase

A

Day 28-4 months

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10
Q

What is tensile strength

A

how much tension the tendon can withstand without rupturing

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11
Q

Tensile strength during healing

A

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

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12
Q

What can change the tensile strength

A

whether or not it is immobilized

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13
Q

Benefits of early motion

A

increase rate of revascularization
enhances nutrition
increases healing and strength
helps break down scar tissue to make sure that it does not adhere

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14
Q

Risks of early motion

A

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

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15
Q

How much excursion is necessary and why

A

3-5 mm
helps stimulate intrinsic repair site without creating a gap between tendon ends

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16
Q

Tendon gapping and what it looks like for flexors vs extensors

A

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

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17
Q

How many strands do you need for early active motion

A

at least 4 strands
doctors might do less so its important to know

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18
Q

3 protocols for flexor tendon injury

A

Immobilization
Early passive mobilization
Early active mobilization

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19
Q

When should protocol begin and why

A

Day 3-5
don’t want it sooner to allow for some healing and b/c tendons are weak

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20
Q

Ventral Hand Zone 1

A

DIP to proximal end of A4 tendon FDP

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21
Q

What do Pulley 2 and 4 do

A

Holds flexor tendons against the bone

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22
Q

ventral hand Zone 2

A

A3 to proximal end of A 1
two tendon moving independently
No mans land
so much content in this zone

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23
Q

ventral hand zone 3

A

3 structures- 2 tendons
lumbricals

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24
Q

ventral hand zone 4

A

carpal tunnel
4 structures (FDP, FDS, FPL, median N)
moving independently in tightly packed tunnel

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25
Ventral hand zone 5
Forearm Proximal to transverse carpal ligament , wrist flexors, FDS, FDP, Median and ulnar N
26
What flexor zone is most complicated
ZOne 2
27
Flexor Protocol 1 indications
immobilization cast or splint doctors choice, children if unreliable or impaired cognition poor healing characteristics
28
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
29
What type of splint is used for all flexor protocols
Dorsal blocking splint
30
Dorsal blocking splint
Wrist: neutral to slight extension MCPs: 40-50 degrees flexion IPs: full extension Want repaired tendon to be put on slack
31
Flexors Protocol 2 indications
early passive mobilization less than 4 strand repair comorbidities/ poor healing cognition unable to attend regular therapy significant edema
32
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
33
Flexors protocol 3 indications
Early active mobilization time from repair string suture absence of conflicting injury reliable patent knowledgable therapist
34
Flexor EAM duration
Initiate day 3-5 continue for 3.5-5 weeks, completing 4-6 times a day
35
Flexor EAM Passive warm up
Passive flexion, active extension to hood PROM of each joint All digits even unaffected
36
Flexor EAM protected active extension
Reverse curl minimize PIP flexion contractures Block MCPs 90 degrees, active IP extension relax back into flexion
37
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
38
3 exercise components for flexor EAM
Passive warm-up protected active extension Short arc active motion
39
What fist allows for greater FDS excursion
Straight fist
40
What fist allows for greatest FDP excursion
full fist
41
What fist allows for maximum gliding between FDP and FDS
hook fist
42
Complications of flexor tendon repairs
PIP flexion contracture lack of tendon glide at DIP joint Pulley repair and bowstringing Ruptures
43
Extensor tendon movements
passive extension, active flexion
44
What type of splint is used for extensor tendon injuries
volar blocking spint
45
What I the toughest zone to repair for extensors
Zone 7 under dorsal retinaculum Scarring like to gob and get stuck
46
What extensor zones have the best outcome
5-8
47
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
48
What number zones are on joints on the dorsal hand
odd numbers
49
Rehabilitation goals for all extensor zones
Prevent extensor lag- much easier to prevent than fix make gradual gains in flexion while maintaining extension
50
Are flexors or extensors stronger
flexors
51
Injury at Extensor Zone 1-2
mallet finger Lag at DIP
52
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
53
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
54
Rehab for Boutonniere Deformity
PIP neutral splint for 6-8 weeks DIP flexion exercises to encourage dorsal migration of lateral bands
55
Rehab for Swan neck
PIP slight flexion splint
56
3 protocols for extensor injury zones 4-7
immobilization conservative management immediate controlled active mobilization (ICAM)
57
Splinting protocols for repair proximal vs distal to juncture tendinum
Proximal to JT: splint all the digits Distal to JT: splint the adjacent finger
58
What zone is the juncture tendinum in
zone 6
59
What movement does EI, EDC and EDM make
only claw extension
60
What muscle is responsible for extension of PIP and DIP joints
lumbricals
61
Extensor Conservative management indications
all digits involved Decreased repair strength delayed repair noncompliant pt
62
Extensor Conservative management orthosis
Volar blocking Wrist extion 30 degrees MCPs 0-25 degrees hyper extended IPs free want extensors on slack
63
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
64
Inclusion criteria for Extensor ICAM
nondnelayed tendon repair At least one but not all extensors repaired compliant patient
65
Phase 1 of ICAM
Week 0-3 weist extension splint and RMO Goal: full digit flexion/ extension within confines of splint
66
Phase 2 of ICAM
Week 3-5 wrist extension only for heavier activities, continue RMO 24/7 Exercise: Wrist tenodesis AROM
67
Phase 3 of ICAM
Week 5-7 RMO for heavy activity
68
Orthosis for ICAM
wrist 20-30 degrees of extension MCP 15-30 degrees of extension
69
Relative Motion Orthosis (RMO)
MCP of affected digits in 20-30 degrees of extension relative to unaffected digits
70
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
71
Complications of Tenolysis
gapped tendon release of joint contractures reconstruct pulleys
72
Post tenolysis op therapeutic management
get object eval data begin AROM immediately gentle PROM immediately begin resistance 3-4 weeks

Ortho (7 decks)

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