Tendons Flashcards
How many annular and cruciform pulleys does the finger flexor pulley system contain?
There are 5 annular pulleys and 3 cruciform pulleys. The annular pulleys (A1–A5) guide tendons closely, while cruciform pulleys (C1–C3) provide flexible spacing.
What is the significance of dividing A1 and A2 pulleys regarding finger movement range?
Dividing A1 and A2 reduces total finger range of movement by approximately 5.7%, indicating their crucial role in effective tendon excursion.
Which annular pulleys of the flexor tendon pulley system are considered the largest, thickest, and most consistent?
The second (A2) and fourth (A4) annular pulleys are the largest, thickest, and most consistent, playing key roles in tendon excursion efficiency.
What is the initial imaging modality to confirm a suspected Zone 1 FDP avulsion (‘Jersey finger’) injury?
X-ray of the finger is necessary initially to identify any avulsed bone fragments or fractures at the distal phalanx, assisting in surgical planning.
Why is a mallet splint not suitable for Zone 1 FDP avulsion injuries?
A mallet splint addresses extensor injuries at the DIP joint; Zone 1 FDP avulsion is a flexor injury requiring surgical repair to restore flexion.
What is the classification system typically used for describing Zone 1 FDP avulsion injuries?
Zone 1 FDP avulsion injuries (‘Jersey finger’) are classified according to the Leddy and Packer system, modified into five types based on tendon retraction and bony fragment presence.
What is the appropriate management step for persistent finger stiffness 6 months after flexor tendon repair, confirmed as intact by ultrasound?
Exploration and flexor tenolysis are indicated, as passive movement is present, indicating adhesions rather than tendon rupture or injury.
Why is steroid injection into the A1 pulley ineffective in established tendon adhesions post-flexor tendon repair?
Steroid injections target inflammatory conditions like trigger finger; established adhesions require surgical intervention (tenolysis) for functional recovery.
In cases of persistent stiffness post-flexor tendon repair, why is arthrodesis of the DIP and PIP joints generally not the first-line treatment?
Arthrodesis significantly reduces function; adhesions can be addressed by tenolysis, preserving joint movement and functional tendon glide.
Which tendon core suture repair technique involves a 4-strand cruciate configuration described by McLarney?
The Cruciate (McLarney) suture technique is a 4-strand cruciate pattern designed for balance between strength, bulkiness, and ease of performance.
Compared to the Cruciate (McLarney) suture, how many strands does the Savage technique typically utilize?
The Savage technique employs a 6-strand repair, providing greater strength but increased bulk compared to McLarney’s 4-strand cruciate technique.
Why might excessive bulk from tendon suture techniques like the Savage method lead to increased complications post-repair?
Increased bulk raises friction and gliding resistance, potentially impairing tendon excursion and increasing the risk of adhesion formation and rupture.
Anatomically, where is the plantaris tendon located relative to the tendoachilles for graft harvesting?
The plantaris tendon is located medial and anterior to the tendoachilles at the ankle, facilitating easy identification and harvest.
What percentage of patients typically have a plantaris tendon suitable for harvesting?
Approximately 80% of individuals possess a plantaris tendon, making it commonly available as a graft source for flexor tendon reconstruction.
Describe the recommended incision site for harvesting a plantaris tendon graft.
A vertical incision approximately 5 cm in length just anterior to the medial aspect of the Achilles tendon insertion is recommended, progressing proximally.
What clinical term describes paradoxical extension at the IP joints upon attempting flexion, commonly seen with un-repaired FDP injuries?
Lumbrical plus finger, where attempted FDP flexion paradoxically extends IP joints due to proximal lumbrical origin pull.
Why does the lumbrical plus finger phenomenon occur after an FDP injury?
It occurs because the FDP tendon retraction proximally drags lumbrical origins proximally, paradoxically extending the IP joints upon attempted flexion.
What tendon graft-related complication can lead to lumbrical plus finger after staged FDP reconstruction?
Excessive graft length or inadequate graft tensioning during staged reconstruction places abnormal proximal pull on lumbricals, causing paradoxical IP joint extension.
What anatomical feature helps identify the FPL tendon during exploration at the wrist level after proximal retraction?
Unipennate tendon with muscle fibers extending until the wrist helps differentiate the FPL tendon from other flexor tendons at this level.
Why does the FPL tendon typically retract proximally after transection?
Due to significant resting muscle tension and its unique anatomical path, the FPL tendon commonly retracts proximally into the forearm post-injury.
At wrist level exploration, why would a lack of muscle fibers not be indicative of the FPL tendon?
Lack of muscle fibers at wrist level usually characterizes the other digital flexors (FDS, FDP), whereas FPL typically has muscle fibers present at this level.
After delayed presentation (>3 weeks) of FDP injury with a 2 cm tendon gap, what is the preferred initial management?
Insert a silicone rod as preparation for a two-stage tendon reconstruction due to inadequate tendon approximation and gap tension.
Why is primary grafting with the FDS tendon contraindicated in delayed FDP repairs with considerable gap and tension?
Using FDS for grafting leads to significant scarring, adhesion formation, and potentially quadriga effect, compromising finger function.
Why is leaving a gap in the FDP tendon repair without further intervention likely detrimental to hand function?
Untreated gaps predispose to lumbrical plus deformities and poor flexion, making later two-stage reconstructions complicated and functionally suboptimal.
What is the most appropriate management of suspected early (11 days post-repair) flexor tendon rupture?
List for emergency exploration and tendon repair; early re-exploration improves functional outcomes by promptly addressing rupture.
Why is delaying flexor tendon re-exploration to await imaging disadvantageous at 11 days post-surgery?
Delay allows tendon retraction and shortening, increasing difficulty in achieving successful primary repair, thus negatively affecting outcomes.
Why is early active mobilization after flexor tendon repair associated with higher early rupture risk?
Early active mobilization places increased tension on healing tendon repairs, especially at their weakest (typically weeks 1–2), raising rupture risk.
Following combined nerve and tendon injury with clawed posture and absent FDS, which tendon transfer is preferred for dynamic anti-claw correction?
ECRB dynamic anti-claw tendon transfer (Brand transfer) is preferred due to uninjured ECRB and scarring limiting FDS availability.
Why are static anti-claw procedures ineffective after extensive nerve injuries with inability to actively extend fingers?
Static procedures rely on active extension; significant central slip weakness or absence makes dynamic tendon transfer necessary.
What does a successful Bouvier maneuver indicate about claw hand deformity treatment?
Successful Bouvier maneuver indicates joints are passively correctable, supporting dynamic anti-claw tendon transfer as optimal management.
What lesion is associated with attrition rupture of the flexor pollicis longus (FPL) tendon in rheumatoid arthritis patients?
Mannerfelt lesion; rupture occurs due to osteophytes/spurs penetrating the volar wrist capsule causing attrition of FPL.
How is a Mannerfelt lesion usually treated?
Surgical exploration, osteophyte debridement, tenosynovectomy, followed typically by tendon transfer due to tissue damage.
Differentiate Vaughn-Jackson lesion from Mannerfelt lesion.
Vaughn-Jackson lesion refers to sequential extensor tendon ruptures (rheumatoid arthritis), while Mannerfelt involves FPL tendon attrition rupture volarly.
How should fingers be positioned when examining isolated FDS function in the middle finger?
Other digits hyperextended to eliminate indirect FDP action, isolating FDS at the middle finger’s PIP joint.
What is a Linburg-Comstock anomaly?
An anomalous tendinous connection between flexor pollicis longus (FPL) and FDP of the index finger.
Why is a flexed-finger injury more likely to injure digital nerves than an extended-finger injury?
Flexed fingers elevate flexor tendons superficially, placing digital nerves at greater risk compared to fingers in extension.
Main complication associated with Kleinert’s original rehabilitation protocol (elastic band technique)?
Development of PIP joint contractures due to flexed resting position and DIP hyperextension from elastic bands.
Why did Kleinert’s original protocol result in contractures at the PIP joints?
Rubber bands attached distally caused DIP hyperextension, leading to persistent PIP flexion contractures.
Why has Kleinert’s regimen largely been replaced by early active mobilization protocols?
Early active mobilization provides fewer joint contractures and reduces intensive hand therapy requirements.
Recommended action for a bulky FDP repair causing catching in Zone II, with associated partial FDS injury?
Continue FDP repair with epitendinous suture; debride the FDS tendon slip to prevent increased bulk and impaired gliding.
Why should pulley venting be considered cautiously in Zone II flexor tendon repair?
Venting increases risk of bowstringing; selective minimal venting (A2 partial) preferred to maintain tendon glide without compromising function.
Role of epitendinous suture in Zone II flexor tendon repair?
Epitendinous suture increases repair strength by 30-50%, reducing rupture risk and smoothing tendon surface for gliding.
Optimal management for spontaneous EPL rupture after distal radius fracture?
Extensor indicis proprius (EIP) to extensor pollicis longus (EPL) tendon transfer.
Why not choose arthrodesis of IP joint as primary management for EPL rupture?
Arthrodesis severely restricts thumb function; reserved as salvage procedure after failed tendon transfers.
Why is spontaneous EPL rupture common after distal radius fracture?
EPL lies within a hypovascular ‘watershed’ zone and crosses Lister’s tubercle, making it prone to ischemic rupture post-injury.
Classic clinical test to differentiate De Quervain’s syndrome from other radial wrist pathologies?
Eichhoff test—patient clenches thumb, examiner ulnarly deviates wrist, eliciting radial-sided wrist pain.
How does Intersection syndrome differ clinically from De Quervain’s syndrome?
Intersection syndrome pain is more proximal/dorsal with palpable crepitus, not isolated at first dorsal compartment.
Clinical hallmark distinguishing radial sensory nerve entrapment from De Quervain’s syndrome?
Positive Tinel’s sign, sensory paresthesia, and burning pain suggest radial sensory nerve entrapment rather than isolated tendon inflammation.
Management of persistent (>30°) extensor lag after 6 weeks conservative treatment of mallet finger without subluxation?
Reapply splint for an additional 6 weeks to ensure complete DIP extension recovery.
When is surgical fixation indicated for mallet finger injuries?
For chronic mallet injuries (>4 weeks untreated), joint subluxation, or significant functional impairment.
Role of DIP arthrodesis in mallet finger?
DIP joint arthrodesis is a salvage procedure only, reserved for chronic mallet deformity failing conservative or primary surgical management.
Which ligament attenuation leads to the boutonnière deformity after central slip rupture?
Triangular ligament attenuation leads to volar migration of lateral bands causing boutonnière deformity.
Initial injury in boutonnière deformity pathology sequence?
Rupture of the central slip of extensor mechanism, resulting in inability to extend at the PIP joint.
Anatomical effect of lateral band migration in boutonnière deformity?
Lateral bands move volarly, producing PIP flexion and DIP hyperextension characteristic of boutonnière deformity.
Advantage of modified Paneva-Holevich over Hunter-Salisbury technique for two-stage flexor tendon reconstruction?
No additional donor site is required; uses the FDS as an intrasynovial graft.
Why is the intrasynovial FDS graft advantageous in Paneva-Holevich reconstruction?
Intrasynovial grafts have fewer adhesions compared to extrasynovial grafts like palmaris longus.
Why does Hunter-Salisbury technique require dual healing of tenorrhaphy sites simultaneously?
Palmaris graft connects proximally and distally simultaneously, unlike Paneva-Holevich’s staged reconstruction.
When are tendon repairs weakest postoperatively, with the highest rupture risk?
Between postoperative days 6 and 12 due to transitioning fibroblastic healing phase.
Which tendon healing pathway involves tenocytes?
Intrinsic pathway mediated by tenocytes within the tendon substance itself.
Which collagen type is dominant in the remodeling phase of tendon healing?
Mature type 1 collagen, replacing disorganized type 3 collagen, provides greater tensile strength for mobilization.
A patient 14 weeks post volar plating of distal radius fracture presents unable to actively flex thumb or index finger, with plate prominence and swelling at the wrist. What is the appropriate management?
Removal of the plate and tendon grafts to FPL and FDP index.
Plate prominence at the watershed line can cause attritional rupture of flexor tendons; tendon grafting is necessary due to delayed presentation, rendering direct repair impossible.
Why is direct tendon repair usually not possible following delayed presentation of flexor tendon ruptures caused by prominent distal radius plates?
Delayed presentation leads to tendon attrition, scarring, and attenuation, making direct end-to-end tendon repair infeasible, thus necessitating tendon graft reconstruction.
What critical factor contributes to spontaneous flexor tendon rupture following volar plating of distal radius fractures?
Tendon rupture results primarily from plate prominence at the watershed line, causing repeated friction and attritional damage to flexor tendons, especially during wrist extension and finger flexion.
Which bedside examination technique helps diagnose central slip injuries prior to boutonniere deformity becoming clinically apparent?
Elson’s test.
Weakness or inability to extend the PIP joint actively against resistance and rigid DIP extension indicates central slip injury.
A rugby player presents with a suspected central slip injury diagnosed by Elson’s test, without radiographic abnormalities. What is the initial recommended management?
Capener splint for 6 weeks, with DIP joint free.
This maintains PIP extension to facilitate central slip healing, while free DIP movement prevents ORL contracture.
When is surgical central slip reconstruction indicated in cases of central slip injury?
Surgical reconstruction with tendon graft (modified Fowler’s procedure) is indicated for chronic cases or failed conservative treatment, typically after prolonged untreated injury.
What is the typical clinical progression in Vaughan-Jackson syndrome?
Sequential attritional rupture of extensor tendons starting ulnarly (typically EDM first) progressing radially, associated with rheumatoid arthritis-induced DRUJ instability and dorsal ulnar head subluxation.
In Vaughan-Jackson syndrome with rupture of both EDM and EDC, what surgical procedure is most appropriate?
Darrach’s procedure combined with EIP to EDC5 tendon transfer.
Removal of the unstable distal ulna (Darrach’s procedure) addresses the cause, while tendon transfers restore function.
Why is primary tendon repair not effective in chronic rheumatoid-related attritional extensor tendon ruptures?
Due to chronic tendon fraying, attenuation, and poor quality, primary tendon repairs often fail, requiring tendon transfers or grafts for functional restoration.
What is the first-line conservative management for a Grade 1 trigger finger according to Green’s classification?
Splinting of either the MCP or DIP joint (leaving the PIP joint free), along with activity modification and NSAIDs, is effective as initial conservative management.
What percentage of trigger finger patients typically respond favorably to corticosteroid injections?
60% to 90% of patients experience relief with corticosteroid injections, making it an effective non-surgical intervention.
When is surgical release of the A1 pulley indicated for trigger finger?
Surgery (A1 pulley release ± FDS slip excision) is indicated in higher-grade trigger fingers or after conservative treatment, including splinting and corticosteroid injections, has failed.
After a dorsal forearm laceration, a patient cannot extend fingers beyond neutral at MCP joints but has full IP joint extension. What tendon injury has likely occurred?
Complete extrinsic extensor tendon laceration with intact intrinsic muscles.
Intrinsics can still extend IP joints, but MCP extension beyond neutral requires intact extrinsic extensors.
Why can intrinsic hand muscles maintain IP joint extension despite extrinsic extensor tendon lacerations at the forearm level?
The lumbricals and interossei muscles insert into the extensor expansion distal to the MCP joints, enabling IP joint extension independent of extrinsic tendon function.
Do accessory extensor tendons significantly influence clinical extension ability after forearm extensor tendon injuries?
No. Meaningful accessory extensor tendons typically do not exist; IP joint extension following injury is due solely to intrinsic muscle action (lumbricals/interossei), not accessory tendons.
In surgical treatment of De Quervain’s tenosynovitis, which tendons are surgically released?
1st compartment: Abductor pollicis longus & Extensor pollicis brevis.
After volar plating of a distal radius fracture, which tendon may rupture due to hardware placement?
Extensor pollicis longus (3rd compartment).
Intersection syndrome involves friction between tendons from which two extensor compartments?
Between 1st (APL/EPB) and 2nd (ECRL/ECRB) compartments.
When harvesting posterior interosseous nerve graft, tendons from which compartment must be retracted?
4th compartment: Extensor digitorum communis & Extensor indicis.
In Vaughn-Jackson syndrome (rheumatoid arthritis), rupture progresses radially from which tendon initially?
Extensor digiti minimi (5th compartment).
Which tendon repair technique is described as a 2-strand, looping anchor method?
Becker technique.
Which tendon repair technique uses 4-strand, looping anchors?
Grasping Cruciate (MacLarney) technique.
Name the 6-strand tendon repair technique known for an X-stitch anchor design.
Savage technique.
What is the 4-strand tendon repair technique involving four locking anchors called?
Adelaide technique.
Identify the 4-strand repair technique that uses two double-ended sutures secured with two knots.
Strickland technique.
For a tenuous flexor tendon repair in unhealthy tissue, which protected rehab protocol is best?
Duran protocol (passive motion without active flexion).
What early passive-motion rehabilitation protocol is ideal after a moderate (2-strand) tendon repair?
Kleinert protocol (passive flexion with active extension).
Which flexor tendon rehab protocol is safest in a non-compliant child, such as a child with autism?
Immobilization in a cast.
Which wrist-immobilized active-mobilization protocol is recommended following a strong (4-strand) tendon repair with concurrent nerve repair at the wrist?
Belfast regimen.
For patients requiring early return to activity, who prefer no wrist immobilization, which rehab splint should be selected after an excellent tendon repair?
Manchester Short Splint.
Which tendon repair zone corresponds precisely to the insertion site of the Flexor Digitorum Superficialis (FDS) tendon on the middle phalanx?
Zone IIa.
When performing an FDP tendon repair at the distal insertion needing a bone anchor, which zone are you operating in?
Zone I.
During carpal tunnel release, you visualize the FDS tendons. Which tendon zone are you in?
Zone IV.
After an FDP tendon repair, the repaired tendon is snagging at the A2 pulley. In which tendon zone is this occurring?
Zone IIc.
When managing a flexor sheath infection tracking proximally into the space of Parona, in which flexor tendon zone is your exploration?
Zone V.
For reconstruction after spontaneous rupture of the Extensor Pollicis Longus (EPL), typically due to distal radius fracture fixation, which tendon is the preferred donor?
Extensor indicis proprius (EIP).
In chronic ulnar nerve injury with persistent clawing requiring dynamic anti-claw reconstruction, which tendon is commonly transferred?
Flexor digitorum superficialis (FDS).
Following trapeziectomy, surgeons may reconstruct thumb base ligaments using which tendon as the preferred donor?
Flexor carpi radialis (FCR).
When planning second-stage FDP reconstruction and the patient lacks bilateral palmaris longus tendons, which alternate tendon can be used?
Plantaris tendon.
Which tendon transfer is optimal for performing opponensplasty in a patient with combined high median and ulnar nerve palsy?
Extensor indicis proprius (EIP) using Burkhalter opponensplasty.
