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Ortho > Tendon Injuries > Flashcards

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
Q

Ventral hand zone 5

A

Forearm
Proximal to transverse carpal ligament , wrist flexors, FDS, FDP, Median and ulnar N

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26
Q

What flexor zone is most complicated

A

ZOne 2

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27
Q

Flexor Protocol 1 indications

A

immobilization
cast or splint
doctors choice, children
if unreliable or impaired cognition
poor healing characteristics

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28
Q

Flexor immobilization protocol

A

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

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29
Q

What type of splint is used for all flexor protocols

A

Dorsal blocking splint

30
Q

Dorsal blocking splint

A

Wrist: neutral to slight extension
MCPs: 40-50 degrees flexion
IPs: full extension
Want repaired tendon to be put on slack

31
Q

Flexors Protocol 2 indications

A

early passive mobilization
less than 4 strand repair
comorbidities/ poor healing
cognition
unable to attend regular therapy
significant edema

32
Q

Early passive protocol

A

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
Q

Flexors protocol 3 indications

A

Early active mobilization
time from repair
string suture
absence of conflicting injury
reliable patent
knowledgable therapist

34
Q

Flexor EAM duration

A

Initiate day 3-5 continue for 3.5-5 weeks, completing 4-6 times a day

35
Q

Flexor EAM Passive warm up

A

Passive flexion, active extension to hood
PROM of each joint
All digits even unaffected

36
Q

Flexor EAM protected active extension

A

Reverse curl
minimize PIP flexion contractures
Block MCPs 90 degrees, active IP extension relax back into flexion

37
Q

Flexor EAM short arc active motion

A

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
Q

3 exercise components for flexor EAM

A

Passive warm-up
protected active extension
Short arc active motion

39
Q

What fist allows for greater FDS excursion

A

Straight fist

40
Q

What fist allows for greatest FDP excursion

A

full fist

41
Q

What fist allows for maximum gliding between FDP and FDS

A

hook fist

42
Q

Complications of flexor tendon repairs

A

PIP flexion contracture
lack of tendon glide at DIP joint
Pulley repair and bowstringing
Ruptures

43
Q

Extensor tendon movements

A

passive extension, active flexion

44
Q

What type of splint is used for extensor tendon injuries

A

volar blocking spint

45
Q

What I the toughest zone to repair for extensors

A

Zone 7 under dorsal retinaculum
Scarring like to gob and get stuck

46
Q

What extensor zones have the best outcome

A

5-8

47
Q

Contributing factors to poor results for extensor tendon repairs

A

shape of tendon
tight spaces
nature of injury
Lympahatics are on dorsal side
often leads to extensor lag

48
Q

What number zones are on joints on the dorsal hand

A

odd numbers

49
Q

Rehabilitation goals for all extensor zones

A

Prevent extensor lag- much easier to prevent than fix
make gradual gains in flexion while maintaining extension

50
Q

Are flexors or extensors stronger

A

flexors

51
Q

Injury at Extensor Zone 1-2

A

mallet finger
Lag at DIP

52
Q

Rehab for extensor zone 1-2

A

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
Q

Injury at Extensor Zone 3-4

A

Boutonniere deformity : PIP flexion, DIP hyper extension, lateral bands volar
Swan neck: PIP hyper extension, DIP flexion, lateral bands dorsal

54
Q

Rehab for Boutonniere Deformity

A

PIP neutral splint for 6-8 weeks
DIP flexion exercises to encourage dorsal migration of lateral bands

55
Q

Rehab for Swan neck

A

PIP slight flexion splint

56
Q

3 protocols for extensor injury zones 4-7

A

immobilization
conservative management
immediate controlled active mobilization (ICAM)

57
Q

Splinting protocols for repair proximal vs distal to juncture tendinum

A

Proximal to JT: splint all the digits
Distal to JT: splint the adjacent finger

58
Q

What zone is the juncture tendinum in

A

zone 6

59
Q

What movement does EI, EDC and EDM make

A

only claw extension

60
Q

What muscle is responsible for extension of PIP and DIP joints

A

lumbricals

61
Q

Extensor Conservative management indications

A

all digits involved
Decreased repair strength
delayed repair
noncompliant pt

62
Q

Extensor Conservative management orthosis

A

Volar blocking
Wrist extion 30 degrees
MCPs 0-25 degrees hyper extended
IPs free
want extensors on slack

63
Q

Extensor Conservative management protocol

A

Initate AROM week 3: hook fist with digit extension AAROM
Week 4: Digit extension/ flexion AROM
Week 5: composite fist/ digit flexion

64
Q

Inclusion criteria for Extensor ICAM

A

nondnelayed tendon repair
At least one but not all extensors repaired
compliant patient

65
Q

Phase 1 of ICAM

A

Week 0-3
weist extension splint and RMO
Goal: full digit flexion/ extension within confines of splint

66
Q

Phase 2 of ICAM

A

Week 3-5
wrist extension only for heavier activities, continue RMO 24/7
Exercise: Wrist tenodesis AROM

67
Q

Phase 3 of ICAM

A

Week 5-7
RMO for heavy activity

68
Q

Orthosis for ICAM

A

wrist 20-30 degrees of extension
MCP 15-30 degrees of extension

69
Q

Relative Motion Orthosis (RMO)

A

MCP of affected digits in 20-30 degrees of extension relative to unaffected digits

70
Q

Tenolysis

A

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
Q

Complications of Tenolysis

A

gapped tendon
release of joint contractures
reconstruct pulleys

72
Q

Post tenolysis op therapeutic management

A

get object eval data
begin AROM immediately
gentle PROM immediately
begin resistance 3-4 weeks

Ortho (7 decks)

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