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Ebopras > Tendon Injuries > Flashcards

Tendon Injuries Flashcards

1
Q

From where do tendons receive their nourishment?

A

In the forearm, from vessels in the paratenon.
In the hand, from the vincular vessels (intrinsic system) and from the synovial fluid (extrinsic system) within the tendon sheath.

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2
Q

Which source is more important to the tendons in the hand?

A

Synovial fluid.

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3
Q

What are the vincula?

A

Folds of mesotendon containing blood vessels. Each tendon (Flexor digitorum superficialis [FDS] and Flexor digitorum profundus [FDP]) has two vincula, a short vinculum distally and a long vinculum proximally, that enter the dorsal surface of the tendons.

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4
Q

What are the source vessels of the vincula?

A

The transverse digital arteries, which enter the fibro-osseous tunnel at the levels of the cruciate pulleys.

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5
Q

How is the short vinculum of the superficialis tendon related to the long vinculum of the profundus tendon?

A

They cross each other at the distal P1 level.

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6
Q

How many pulleys are there in the fingers?

A

Eight (five annular and three cruciate).

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7
Q

What effect do the pulleys have?

A

They prevent bowstringing of the flexor tendons in flexion increasing the effective excursion of the tendons and thus the degree of finger flexion.

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8
Q

Which pulleys are the most important in the fingers, and where are they located?

A

r A2, at the proximal part of the proximal phalanx r A4, at the middle part of the middle phalanx

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9
Q

The interval between which annular ligaments has no cruciate ligament?

A

Between A1 and A2. The first cruciate ligament lies between A2 and A3.

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10
Q

How many pulleys are there in the thumb?

A

Three:
r A1 at the MP level
r Oblique at the P1 level r A2 at the IP level
The oblique and A2 pulleys are the most important in the thumb.

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11
Q

What comprises the floor of the fibro-osseous tunnel?

A

The periosteum of the phalanges and the volar plates of the MP and PIP joints.

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12
Q

What lies immediately volar to the volar plate of the PIP joint?

A

FDS tendon.

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13
Q

Describe the orientation of the FDS tendons within the carpal tunnel.

A

The tendons of the index and small fingers are dorsal to the tendons of the long and ring fingers.

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14
Q

What are the two main deficits resulting from zone I tendon laceration?

A

Loss of DIP flexion and diminution of grip strength.

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14
Q

Describe the boundaries of the five flexor zones of the fingers.

A

Zone I: Distal to the insertion of FDS on P2.
Zone II: Within the fibro-osseous tunnel (from the A1 pulley to the FDS insertion). Zone III: The area of the palm between the carpal tunnel and the fibro-osseous tunnel. Zone IV: Within the carpal tunnel.
Zone V Proximal to the carpal tunnel.

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15
Q

What provides the stronger repair in zone I injuries—suturing of tendon ends together or anchoring of tendon end directly to bone?

A

Anchoring directly to bone.

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16
Q

What is the farthest the FDP tendon should be advanced to achieve direct anchoring to bone?

A

1 cm.

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17
Q

What is a jersey finger?

A

Avulsion of the FDP tendon from its insertion on P3 (an injury that might occur when a football player reaches outto grab an opponent’s jersey).

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18
Q

What finger is most commonly affected, and why?

A

The ring finger, because:
1. It has the weakest FDP insertion.
2. It is the most protruding finger when the hand is in the grasping position.
3. The juncturae tendinae prevent independent extension of the ring finger (much more so than the other fingers). 4. The common muscle belly of FDP prevents independent relaxation of the FDP tendon.

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19
Q

Describe the four types of FDP avulsion injuries.

A

Type I: Type II: Type III: Type IV:
Tendon retracts into palm.
Tendon retracts to level of PIP.
Tendon avulsed with large bony fragment, which catches at A4.
Large bony fragment, with avulsion and retraction of tendon from fragment

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20
Q

Which type of FDP avulsion is most common? Which has the best prognosis? The worst?

A

Most common: type II.
Best prognosis: type III.
Worst prognosis: type I and type IV.

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21
Q

What is the lumbrical plus deformity?

A

If an injured FDP tendon retracts into the palm (type I avulsion), the lumbrical (which originates on the FDP tendon) will be under tension, creating an extension force on the IP joints. When one attempts to make a fist, the FDP tendon will place even greater tension on the lumbrical, paradoxically extending the finger. This can also happen if an FDP tendon in the finger is reconstructed with a tendon graft that is too long.

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22
Q

Why must type I FDP avulsion be repaired without significant delay?

A

Because both the vincular and synovial nutritional supplies have been disrupted.

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23
Q

What holds the FDP tendon at the level of the PIP in a type II FDP avulsion?

A

The vincula.

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24
Q

A heavy laborer sustained a type I FDP avulsion 1 month ago. What treatment should be considered?

A

DIP fusion, if the joint is symptomatically unstable.

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25
Q

Where is a zone II flexor tendon laceration usually located with respect to the skin laceration?

A

Distal (the finger is usually flexed at the time of injury).

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26
Q

If the vinculum is ruptured in a zone II injury, to where will the tendon usually retract?

A

To the palm, held in place by the lumbrical.

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27
Q

How can the tendon be retrieved from the palm?

A

A rubber catheter or infant feeding tube is guided down the tendon sheath from the site of injury in retrograde manner. An incision is made at the distal palmar crease, and the catheter is retrieved from the proximal end of the fibro-osseous tunnel. The tendon is attached to the catheter and pulled back into the tunnel.

28
Q

What can happen if the FDP tendon is repaired but the FDS is not?

A

High risk of rupture of the FDP repair, loss of dexterity and grip strength, and hyperextension deformity at the PIP.

29
Q

When should flexor tendon lacerations be repaired?

A

As soon as possible, but successful tendon healing may be possible after a delay of several weeks if the vincular or
synovial nutritional supplies are intact.

30
Q

What percentage of the total strength of a tendon repair is attributable to the epitendinous suture?

A

Approximately 20%.

31
Q

Following repair, when does tendon rupture most commonly occur?

A

Around the 10th postoperative day.

32
Q

How should the patient be splinted following flexor tendon repair?

A

The wrist should be held in approximately 30◦ of flexion, the MPs in 50◦ to 70◦ of flexion, and the IPs in full
extension.

33
Q

When should passive range-of-motion exercises be initiated following flexor tendon repair? Active range of motion?

A

Passive: as soon as possible.
Active: depends on the strength of the repair. If a strong repair is achieved (ie, at least four core suture strands), active motion can be started immediately. If not, about 4 weeks.

34
Q

How is a splint commonly constructed to permit active extension and passive flexion?

A

A rubber band is attached to the nail of the involved finger and to the splint in the region of the distal volar forearm. The rubber band provides resistance against active IP extension (the MP is blocked at 60◦ to 70◦ of flexion) and passively pulls the finger into flexion.

35
Q

What are the most important prerequisites to flexor tendon grafting?

A

Full passive range of motion and intact flexor sheath.

36
Q

What are the most common donor sites for flexor tendon grafts?

A

Palmaris longus, plantaris, and the long toe extensors.

37
Q

Where is plantaris with respect to the Achilles tendon?

A

Anterior and medial.

38
Q

In reconstructing a zone II FDP injury with a graft, how can the appropriate length of the graft be
determined?

A

By matching the cascade of the injured digit with its uninjured neighbors.

39
Q

What can happen if the graft is too long?

A

Lumbrical plus deformity, in which attempts to flex the finger cause paradoxical extension of the interphalangeal
joints.

40
Q

What is quadriga syndrome?

A

If one FDP is tethered or shortened following a repair, the others cannot shorten enough to achieve full flexion. Try flexing your ring finger DIP while holding your long finger in extension with the other hand. Named by Verdan for the Roman charioteers who controlled teams of four horses with four sets of reins slung over their backs.

41
Q

What is the most common complication of tendon grafting?

A

Adhesions.

42
Q

Following a zone II flexor tendon repair, a patient has limited active range of motion and has made little progress in therapy. When is the earliest that flexor tenolysis should be considered?

A

At least 3 months of therapy should be attempted prior to performing tenolysis.

43
Q

What is a Hunter rod?

A

A Hunter rod is a flexible silicone implant that is placed within a scarred flexor tendon bed. Formation of a capsule
around this implant will create a pseudosheath within which a tendon graft can later be placed.

44
Q

At what level do the extensor tendons lie within a synovial sheath?

A

At the level of the extensor retinaculum. The extensor tendons are surrounded only by paratenon at all other levels.

45
Q

What tendons are present within each of the six extensor compartments?

A

r First
r Second r Third r Fourth r Fifth
r Sixth
APL, EPB ECRL, ECRB EPL
EDC, EIP EDQ
ECU

46
Q

Which tendon inserts on the second MC? On the third? On the fifth?

A

r ECRL on the second r ECRB on the third
r ECU on the fifth

47
Q

What is the relationship of the proprius tendons (EIP and EDQ) to the communis tendons at the level of the
MPs?

A

The proprius tendons lie ulnar to the communis tendons.

48
Q

The EDC tendon is often missing from which finger?

A

The small finger. In these instances, there are often two slips of EDC to the ring finger. There may also be two slips
of EDQ to the small finger.

49
Q

What muscles extend the MP joints?

A

The extrinsic extensors (EDC, EIP, and EDQ) are the only muscles that extend the MP joints.

50
Q

What muscles flex the MP joints?

A

Primarily the intrinsic (lumbricals and interossei). The extrinsic flexors (FDP and FDS) have a relatively weak effect
at the MP joints.

51
Q

What muscles extend the IP joints?

A

When the MPs are flexed, the extrinsics extend the IPs. When the MPs are extended, the intrinsics extend the IPs. Remember that muscles can create little force if they are not under stretch. When the MPs are extended, the intrinsics are under stretch and can thus extend the IPs. When the MPs are flexed, it is the extrinsics that are under stretch.

52
Q

What is the intrinsic minus deformity?

A

Extension of the MPs and flexion of the IPs, as in the claw deformity seen with low ulnar nerve palsies. This is a
good way to remember the function of the intrinsics (ie, to flex the MPs and extend the IPs).

53
Q

A patient sustains a dorsal hand laceration at the mid-metacarpal level, completely transecting the EDC tendon to the long finger. Yet he is still able to extend the MP joint of the long finger. How is this possible?

A

The juncturae tendinae are interconnections between the extensor tendons at the level of the distal metacarpals. The juncturae extend in a distal-oblique direction from the EDC tendon of the ring finger to those of the small finger and long finger, and from the EDC tendon of the long finger to that of the index finger. In this case, the tendon was lacerated proximal to the junctura, which transmits extensile force from the ring finger tendon to the long finger tendon.

54
Q

Which extensor tendons do not have juncturae?

A

The proprius tendons (EIP and EDQ).

55
Q

What are the sagittal bands?

A

The sagittal bands are transverse ligamentous structures that pass from the extensor tendon to the volar plate of the MP. Their function is to hold the extensor tendon in place over the MP. They also transmit force from the extensor tendon to the proximal phalanx, thus extending the MP joint. They are somewhat analogous to the A1 pulley of the flexor system, except that the sagittal bands undergo proximal and distal excursion with extension and flexion of the MP, much like a bucket handle.

56
Q

What is a common option for reconstructing a sagittal band that is not primarily repairable?

A

Use of a strip of junctura tendinae.

57
Q

What holds the extensor mechanism in place over the PIP?

A

Transverse retinacular ligament.

58
Q

Where is the extensor trifurcation?

A

Proximal to the PIP, the extensor tendon trifurcates into a central slip and two lateral bands. The central slip inserts
on the dorsal base of P2, while the lateral bands bypass the PIP and insert on P3.

59
Q

Where is the triangular ligament? What does it do?

A

The triangular ligament spans the dorsal surface of the middle phalanx, connecting the lateral bands to each other.
It helps to prevent the lateral bands from migrating volarly

60
Q

What deformity results from laceration of the central slip with preservation and volar migration of the lateral bands?

A

Boutonnie`re deformity.

61
Q

What is the oblique retinacular ligament of Landsmeer?

A

A ligament extending from the volar aspect of the PIP to the dorsal aspect of the DIP. It functions to coordinate flexion and extension of the IP joints—if the PIP flexes, the ligament relaxes, permitting the DIP to flex; if the PIP extends, the ligament tightens, helping the DIP to extend. In a long-standing Boutonniere deformity, this ligament gradually contracts, potentially making the deformity permanent. Thus, resistance to passive flexion of the DIP is a hallmark of a boutonniere.

62
Q

How do you splint a patient with a Boutonniere deformity?

A

Splint the PIP in extension (usually with a static progressive [spring-loaded] splint), keeping the DIP free. This
encourages dorsal migration of the lateral bands and stretching of the ligament of Landsmeer

63
Q

A patient has sustained a complete laceration of the EPL tendon, yet can still extend the IP joint of the thumb. How is this possible?

A

The intrinsics of the thenar eminence insert on the extensor hood and can provide weak extension of the IP. In addition, the EPB can have a superficial division that inserts on the extensor hood. However, only the EPL can extend the entire first ray. Thus, if the patient places the palm flat on a table, he or she will be unable to lift the thumb off the table in the presence of a complete EPL laceration.

64
Q

Describe the zones of injury of the extensor tendons of the fingers.

A

Odd zones are over joints.
Zones I, III, V, and VII overlie the DIP, PIP, MP, and carpal joints, respectively. Zones II, IV, VI, and VIII overlie the P2, P1, MC, and distal forearm, respectively.

65
Q

What can be done to prevent adhesions in the repair of a zone VII extensor tendon laceration?

A

Excision of the portion of the extensor retinaculum that overlies the repair site.

66
Q

What is a mallet finger?

A

Flexion

67
Q

Describe the classification of mallet finger injuries.

A

TypeISplinting of the DIP in slight hyperextension (no more than 5◦) for 6 to 8 weeks, followed by night splinting for 2 weeks.Type II:Repair of skin and tendon with a single figure-of-eight suture, followed by splinting as above.Type IIISkin coverage and tendon graftType IV-AClosed reduction of the fracture, followed by extension splinting for 3 to 4 weeks.Type IV-BExtension splinting, with ORIF reserved for cases in which the fragment is significantly displaced or the distal phalanx has subluxated volarly.Type IV-C:As above.

68
Q

What can happen if a mallet injury is left unrepaired?

A

Hyperextension at the PIP (ie, swan neck deformity). This is because the force of the extensor tendon is
concentrated only at the PIP, creating PIP hyperextension.

Ebopras (32 decks)

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