Tendon injuries Flashcards
What is De Quervain’s Tenosynovitis?
- A stenosing inflammatory Tenosynovitis of the 1st extensor compartment of the forearm
What tendon are involved in De Quervain’s Tenosynovitis?
- Extensor pollicis brevis- EPB
- Abductor pollicis Longus -ABL
What is the epidemiology of De Quervain’s Tenosynovitis?
- Females > males
- 30-50
- racket sports
What is the aetiology of De Quervain’s Tenosynovitis?
- Post trauma
- Idopathic
- Overuse- golfers/racket sports
- Post-partum- lifting baby
Name the extensor compartments at the wrist and what is in them?
- 1- Extensor pollicis brevis
- Abductor pollicis longus
- 2- Extensor capri radialis longus/ Extensor carpi radialis brevis
- 3- Extensor pollicis longus
- 4- Extensor indicis propris/ Extensor digitorium communis
- 5-Extensor digiti minimi
- 6- Extensor carpi ulnaris
Describe the signs and symptoms of de Quervains tenosynovitis
Symptoms
radial sided wrist pain
Signs
- FInklestein provocative manoever- thumb clenched in hand and ulnar deviate wrist. Tenderness in 1st dorsal compartmetnt at radial styloid
- Different from Intersection syndrome( 2nd compartment) as pain 5cm from wrist joint
What is the tx of de Quervains tenosynovitis?
Non operative
- Rest, nsaids, thumb spica splint, steriod injection ( 1st dorsal compartment)
Operative
- Surgical release of 1st dorsal compartment
Can you describe the technique for decompressing the 1st dorsal compartment?
- transverse incision with release on dorsal side of 1st compartment to prevent volar subluxation of the tendon
- has variable anatomy with APL usually having at least 2 tendon slips and its own fibro-osseous compartment
- distinct EPB sheath is often encountered dorsally
- http://www.orthobullets.com/video/view?id=209
What are the complications of DE quervains Tenosynovitis?
- Sensory branch of radial nerve injury
- Neuroma formation
- Recurrence with Failure to decompress tendons- failure to realise APL/EPB in separate subsheaths!!
- Complex regional pain syndrome
What is Intersectional syndrome?
Due to inflammation at crossing point of 1st dorsal compartment and 2nd dorsal compartment
Name the tendons that are in dorsal compartments 1 and 2?
- 1= Abductor Pollicis longus, Extensor pollicis brevis
- 2= Ext carpi radialis brevis and longus
what is the epidemiology of Intersectional syndrome?
- Typical in rowers and weight lifters
What is the pathoanatomy of Intersectional syndrome?
- Repetitive Wrist extenson
What are the signs and symptoms of Intersectional syndrome?
Symptoms
- Pain over dorsum of wrist
- Swelling 1/2 dorsal compartment
Signs
- Tenderness dorsal forearm 5cm proximal from wrist joint
- Crepitus on resisted wrist/thumb extension
- http://www.orthobullets.com/video/view?id=658
What are the tx options for intersectional syndrome?
Non operative
- Rest , wrist Splint, Steriod injection into 2nd comparment ( DDx : De quervains)
Operative
- Surgical debridment and release
- release of 2nd dorsal compartment 6cm from wrist joint
Defne Flexor carpi radialis tendonitis?
- Inflammation of the FCR tendon sheath
What is the epidemiology of flexor carpi radialis tendonitis?
- Rare
- Racket sports- tennis
- Risk factors- repetitive wrist flexion
Describe the anatomy of the FCR tendon course?
Origin - medial epicondyle
Inserts- small slip to trapexial crest, 80% to Base of 2nd MC, 20% base 3rd MC
Flexes and abducts hand at wrist
Innervation: Median
Describe the anatomy of the FCR tendon?
- Enveloped in sheath by musculotendinous origin to trapezium
- No fibrous sheath distal to trapezium
- Enters fibrous tunnel at proximal border of the trapezium
- Within the tunnel occupies 90% space- in direct contact with trapezium-> prone to constriction/tendonitis/attritution/rupture
- proximal to tunnel- FCR occupies 50-60% space so less prone to constriction but more prone to mechnical irritation form ostephytes
Describe the borders of fibroosseous tunnel of FCR tendon?
- Radial- body of trapezium
- palmar- trapezial crest, transvese carpal ligament
- ulnar- retinacular septum form transverse carpal ligament ( separates FCR from carpal tunnel)
- Dorsal- reflexion of retinaculuar septum on trapezium body
What are the signs and symptoms of FCR tendonitis?
Symptoms
Tenderness of volar radial aspect of wrist
Signs
- Tenderness over volar radial foreearm along FCR tendon at distal wrist flexion crease
- Provaction test= resisted wrist flexion->pain,resisted radial wrist deviation->pain
What investigations are helpful in FCR tendonitis?
- Xray- primary tendonitis normal
- secondary may see healed distal radius fracture/healed scaphoid fracture
- MRI- increased signal around FCR sheath on T2 image
- Diagnostic injection along FCR sheath relieves symptoms
What are the DDX of volar radial wrist pain?
- FCR tendonitis
- Thumb CMC arthritis
- Scaphoid cyst
- Ganglion
- De Quervains tenosynovitis
What is the TX of FCR tendonitis?
non operative
- Immobilisation, NSaids, steriod injection (proximity not in tendon)
operative
Surgical release of FCR tendon
Describe the technique for surgical release of FCR?
- Approach- volar longitudinal incision proximal to wrist crease, extending over proximal thenar eminence
- avoid
- Palmar cutaneous branch of median n
- Lateral antebrachial cutaneous n
- superficial sensory radial n
- Elevate and reflect thenar muscles radially
- expose FCR sheath
- Open FCR sheath proximal in distal forearm, extend to trapezial crest
- Where it enters trapezial crest incise sheath along ulnar margin, take care not to injur the tendon
- mobilise tendon from trapezidal groove, release trapezial insertion
Name the complications of FCR tendonitis?
- FCR attrition and rupture
Surgery
- Palmar cutaneous banch median n
- lateral antebrachial cutaneous branch n
- superificial sensory radial n
- injury to deep plamar arch
- injury to FPL tendon- lies superficial to FCR
- injury to FCR tendon within tunnel
What is the snapping ECU?
- Overuse of wrist can lead to spectrum of ECU tendonitis and instability
Describe the pathoanatomy of snapping ECU?
- ECU subluxation is secondary to attenuation and rupture of ECU subsheath in 6th dorsal compartment
- ECU subluxates in volar and ulnar direction
- subluxation and snapping-> tendonitis
Decribe the anatomy of the ECU tendon?
Origin- lateral condyle of humerus and post border of ulna
insertion- base of 5th Metacarpal
action- wrist extension and adduction
innervation- PIN
ECU SUBsheath is part of TFCC- criticial to ECU stability
Describe the signs and symptoms of snapping ECU?
Symptoms
Pain and snapping over dorsal ulnar wrist
Signs
- Extension and supination of wrist-> pain
- ECU tendon reduces with pronation
what investigations are helpful in snapping ECU?
- USS- assess ECU stability
- MRI- show tendonitis, TFCC pathology
Decribe tx of snapping ECU?
Non operative
- wrist spint or long arm cast- in pronation & slight radial deviation
Operative
- ECU subsheath reconstruction + wrist arthroscopy
- direct repair
- chronic cases- extensor retinculum flap for ECU subsheath reconstruction
- wrist arthroscopy= recurrent TFCC tears in 50% of cases
What does sagittal band rupture lead to?
- Dislocation of extensor tendons
- aka Boxer’s knuckle
Epidemiology of Sagittal band rupture?
- Most common in fist fighters- pugilists
- index and middle in professionals
- ring and little in amateurs
- Middle finger most commonly affected 48%
- radial sagittal band more commonly involved 9:1 ulna
Describe the aetiology of sagittal band rupture?
-
Trauma
- Forceful resisted Flexion or Extension
- laceration to extensor hood
- direct blow to MCPJ
-
Atraumatic
- Inflammatory- RA
- spontaneouS
Describe what the extensor mechanism is made up of?
- Interossei
- Lumbricals
- EDC
- EIP
- EDM
- Retinaculum system
- sagittal bands ( part of cylindrial tube which surround MC head and volar plate
- retinacular ligament
- triangular ligament
What is the function of the sagittal band?
- Primary stabiliser of the extensor tendon at the MCPJ
- Juncturae tendinum are the secondary stabilisers
- resists ulnar deviation of the tendon
- prevents tendon bowstringing during MCPJ hyperextension
Describe the biomechanics of the sagittal band?
- Ulnar sagittal band- partial or complete sectioning doesn’t lead to extensor tendon dislocation
- radial sagittal band
- distal sectioning doesn’t produce ext tendon instability
- complete sectioning ->dislocation
- sectioning 50% of proximal SB->ext tendon subluxation
- Extensor tendon instability > wrist flexion, > central digits with middle finger least stable tendon
- most stable ext tendon is little finger as junctura tendinum stabilises it.
Name the classification system of the sagittal band rupture?
Rayan and Murray
- Type 1- SB injury wout Extensor Instability
- Type 2- SB injury w Tendon subluxation
- Type 3- SB injury w tendon dislocation
What are the signs and symptoms of sagittal band rupture?
Symptoms
- MCP soreness
Signs
- Tendon snapping
- ulnar deviation of digits at MCPJ= RA
- Inability to initiate extension
- Pseudo-triggering
- Ext tendon dislocation into Intermetacarpal gully
- most unstable during MCP flexion+wrist flexion
- least unstable during MCP flexion+wrist extensn
- Provocation test- reisisted extension at MCP= Pain
What investigations are useful for sagittal band rupture?
-
Xray- hand PA , lateral and oblique
- may showed dropped fingers/ulnar deviation in RA
- Dynamnic USS- when swelling obscures physical exam- subluxation of EDC tendon relative to MCP flexion ( see pic)
- MRI - can show dislocation of ext tendon into ulnar intermetacarpal gully radial SB defect or subluxation radial for ulnar SB defect
DDX for inability to extend fingers?
Congential
- Congential sagittal band deficiency
_Acquired _
- MCPJ collateral ligament injury
- EDC tendon rupture
- Trigger finger
- Juctura tendium disruption
- MCPJ arthritis
Describe the tx for sagittal band rupture?
Non operative
- Extension splint 4-6wks- acute injuries <1week
operative
- Direct repair= Kettlekamp- chronic injury >1wk where DIRECT repair is POSSIBLE
- Extensor centralization procedure- chronic injury where direct repair is IMPOSSIBLE
Describe the techniqures for extensor centralistion procedure?
Various described….
- Trapdoor flap
- ulnar based partial thickness capsular flap created
- tendon placed deep to flap
- flap resutured to capsule
others include
Describe the aetiology of extensor tendon injuries?
- laceration
- Trauma
- overuse
Describe the epidemiology of extensor tendon injuries?
- Most commonly injured digit is the long finger
- Zone IV most frequently injured zone
Describe the mechanims of injury of extensor tendons?
- Zone 1- Forced flexion of extended DIPJ
- Zone 2- dorsal Laceration/ Crush injury
- Zone V-
- fight bite
- Sagittal band rupture- flea flicker injury
- forced extension of flexed digit
- most common in long finger
Describe the zones for extensor tendon ruptures?
- Zone 1- disruption of terminal ext tendon distal to/at DIPJ and ipj of thumb-> Mallet finger
- Zone 2- disruption tendon over middle phalanx/prox phalanx of thumb ( EPL)
- Zone 3- Disruption over PIPJ of digit(central slip) of MCP thumb-> Boutonniere deformity
- Zone 4- Disruption over prox phalanx of digit/MC thumb (EPL/EPB)
- Zone 5- Disruption over MCPJ digit or CMC thumb-sagittal band rupture- fight bite
- Zone 6- disruption over MC
- Zone 7- disruption at wrist joint- must repair retinaculum to prevent bowstringing. repair then immobilise in wrist 40oextension/mcp flex 20o 3-4wks
-
Zone 8-disruption at distal forearm
- ext muscle belly, usually penetrating injuries, assoc neurological injury, tendon repair then immobilisation elbow flexion, wrist extension
Describe the signs and symptoms of extensor tendon ruptures?
Symptoms
- Inability to extend at DIPJ= Zone 1
- extensor lag and flexion loss = zone V
Signs
- ** Zone 3 injury = ELSON TEST**
- flex patient’s pipj over table at 600
- ask them to extens against resistance
- if central slip intact dip remain supple
- if central slip disrupted dip will be rigid as use lateral bands
- http://www.youtube.com/watch?v=G9HY0qXWUvE
-
Zone 5- sagittal band rupture- radial rupture-> extensor subluxation
- with finger held in flexed position at MCPJ with no active extension
what investigations are helpful in suspected cases of extensor tendon rupture?
Xrays- to exlcude a bony avulsion and mallet deformity
When is consx tx appropriate?
- When Laceration <50% of tendon in all Zones
- Immobilisation with early protective motion
DIPJ extension splinting
- Acute <12 wks
- zone 1
- non displaced bony mallet
- Full time splinting 6wks then partime 4-6wks
- avoid hyperextension-> skin necrosis
- Maintain IPJ motion
- non compliance a problem
PIPJ extension splinting
- closed Central slip zone 3
- full time splinting 6 wks, part time 4-6
- maintain dipj motion
MCPJ extension splinting
- Closed zone v sagittal band
- full time splinting 4-6 weeks
Describe the indications and operative tx available for ext tendon ruptures?
- Immediate Incision and Drainage-= fight bite
- Tendon repair- if lac >50%
- fixation of bony avulsion- bony mallet w P3 volar subluxation
- closed reduction and pinning thru dipj
- extension block pinning
- ORIF if involves >50% articular surface
- Tendon reconstruction- chronic tendon injury/direct not possible
- `Central slip reconstruction- tendon graft, extensor turndown, lateral band mobilization
- EIP to EPL tendon transfer- chronic EPL rupture
Complications of extensor tendon surgery?
- Adhesions- limit flexion common older pt and zones 4 & 7
-
Tendon rupture- poor suture material/ surgical technique/ aggressive therapy/ non complicance
- 5% incidence
- most frequent 7-10 days post op
- early recognition -> revision repair otherwise reconstruction
-
Swan neck deformity- by prolonged dipj flexion with dorsal subluxation of lateral bands and pipj hyperextension
- Fowler central slip tenotomy
- Spiral oblique ligament reconstruction
-
Boutonniere deformity- dip hyperextension caused by central slip disruption and lateral band volar subluxation
- Dynamic splinting/ serial casting for maximal passive motion
- Terminal extensor tenotomy , PIPJ volar plate release
