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Tendon injuries Flashcards

1
Q

What is De Quervain’s Tenosynovitis?

A
  • A stenosing inflammatory Tenosynovitis of the 1st extensor compartment of the forearm
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2
Q

What tendon are involved in De Quervain’s Tenosynovitis?

A
  • Extensor pollicis brevis- EPB
  • Abductor pollicis Longus -ABL
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3
Q

What is the epidemiology of De Quervain’s Tenosynovitis?

A
  • Females > males
  • 30-50
  • racket sports
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4
Q

What is the aetiology of De Quervain’s Tenosynovitis?

A
  • Post trauma
  • Idopathic
  • Overuse- golfers/racket sports
  • Post-partum- lifting baby
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5
Q

Name the extensor compartments at the wrist and what is in them?

A
  • 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
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6
Q

Describe the signs and symptoms of de Quervains tenosynovitis

A

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
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7
Q

What is the tx of de Quervains tenosynovitis?

A

Non operative

  • Rest, nsaids, thumb spica splint, steriod injection ( 1st dorsal compartment)

Operative

  • Surgical release of 1st dorsal compartment
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8
Q

Can you describe the technique for decompressing the 1st dorsal compartment?

A
  • 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
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9
Q

What are the complications of DE quervains Tenosynovitis?

A
  • 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
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10
Q

What is Intersectional syndrome?

A

Due to inflammation at crossing point of 1st dorsal compartment and 2nd dorsal compartment

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11
Q

Name the tendons that are in dorsal compartments 1 and 2?

A
  • 1= Abductor Pollicis longus, Extensor pollicis brevis
  • 2= Ext carpi radialis brevis and longus
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12
Q

what is the epidemiology of Intersectional syndrome?

A
  • Typical in rowers and weight lifters
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13
Q

What is the pathoanatomy of Intersectional syndrome?

A
  • Repetitive Wrist extenson
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14
Q

What are the signs and symptoms of Intersectional syndrome?

A

Symptoms

  • Pain over dorsum of wrist
  • Swelling 1/2 dorsal compartment

Signs

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15
Q

What are the tx options for intersectional syndrome?

A

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
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16
Q

Defne Flexor carpi radialis tendonitis?

A
  • Inflammation of the FCR tendon sheath
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17
Q

What is the epidemiology of flexor carpi radialis tendonitis?

A
  • Rare
  • Racket sports- tennis
  • Risk factors- repetitive wrist flexion
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18
Q

Describe the anatomy of the FCR tendon course?

A

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

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19
Q

Describe the anatomy of the FCR tendon?

A
  • 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
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20
Q

Describe the borders of fibroosseous tunnel of FCR tendon?

A
  • 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
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21
Q

What are the signs and symptoms of FCR tendonitis?

A

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
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22
Q

What investigations are helpful in FCR tendonitis?

A
  • 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
23
Q

What are the DDX of volar radial wrist pain?

A
  • FCR tendonitis
  • Thumb CMC arthritis
  • Scaphoid cyst
  • Ganglion
  • De Quervains tenosynovitis
24
Q

What is the TX of FCR tendonitis?

A

non operative

  • Immobilisation, NSaids, steriod injection (proximity not in tendon)

operative

Surgical release of FCR tendon

25
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
26
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
27
What is the snapping ECU?
* Overuse of wrist can lead to spectrum of ECU tendonitis and instability
28
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
29
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
30
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
31
what investigations are helpful in snapping ECU?
* USS- assess ECU stability * MRI- show tendonitis, TFCC pathology
32
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
33
What does sagittal band rupture lead to?
* Dislocation of extensor tendons * aka Boxer's knuckle
34
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
35
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**
36
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
37
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_
38
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.
39
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**
40
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
41
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
42
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
43
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_
44
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
45
Describe the aetiology of extensor tendon injuries?
* **laceration** * **Trauma** * **overuse**
46
Describe the epidemiology of extensor tendon injuries?
* Most commonly injured digit is the **long finger** * **Zone IV** most frequently injured zone
47
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
48
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**
49
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](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**
50
what investigations are helpful in suspected cases of extensor tendon rupture?
Xrays- to exlcude a bony avulsion and mallet deformity
51
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
52
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
53
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**

Hands FRCS (28 decks)

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