Week 12 - Extensor Tendon Injuries Flashcards
1
Q
why are extensor tendons vulnerable to injury?
A
little subcutaneous tissue on dorsal hand
2
Q
name 3 common post injury complications of extensor tendon injuries.
A
- tendon adhesions
- extensor lag
- significant stiffness
3
Q
what do extensor tendons have instead of a synovial sheath?
A
paratenon
4
Q
name 4 characteristics of extensor tendon anatomy.
A
- numerous soft tissue attachments and interconnections
- no synovial sheath but a paratenon
- extra-synovial course facilitates repair
- thinner and tend to become adherent to underlying bone
5
Q
the anatomical characteristics of extensor tendon prevent what?
A
retraction of divided tendon
6
Q
what do the characteristics of extensor tendons allow for?
A
conservative management
7
Q
describe extensor lag.
A
- good PIP passive extension but extensor tendon can’t fully extend actively
- don’t have full active extension ROM
8
Q
affects AROM but could still have good PROM
A
tendon adhesions
9
Q
- circulates around tendon and provides synovial fluid
- thinner than a sheath
A
paratenon
10
Q
name the extensor tendons of the first dorsal compartment.
A
- abductor pollicis longus
- extensor pollicis brevis
11
Q
name the extensor tendons of the second dorsal compartment.
A
- extensor carpi radialis longus
- extensor carpi radialis brevis
12
Q
name the extensor tendon of the 3rd dorsal compartment.
A
extensor pollicis longus
13
Q
name the extensor tendons of the 4th dorsal compartment.
A
- extensor digitorum communis
- extensor indicis proprius
14
Q
name the extensor tendon of the 5th dorsal compartment.
A
extensor digiti minimi
15
Q
name the extensor tendon of the 6th dorsal compartment.
A
extensor carpi ulnaris
16
Q
where is juncturae tendini located?*
A
proximal to MCP joint
17
Q
what does juncturae tendini bind to?*
A
extensor digitorum communis
18
Q
- proximal to MCP joint
- binds EDC
A
juncturae tendini
19
Q
broad fibrous band with fibers from sagittal bands
A
dorsal hood - MCP joint
20
Q
what is the purpose of the dorsal hood?
A
to center EDC
21
Q
innervation of EDC?
A
radial nerve
22
Q
name the three parts of EDC (each digit)
A
- central slip
- 2 lateral slips
23
Q
- proximal to lateral bands
- unite distally to form terminal tendon
A
lateral slips
24
Q
name the functions of the volar and dorsal interossei.
A
- flexion of MCP
- contribute to PIP extension when MCP is flexed
25
which tendon do the lumbricals rise from?
FDP
26
where do the lumbricals insert?
into extensor tendon - radial lateral band of each finger
27
where are the central and lateral slips located (in general)?
on outside of joint to keep everything in
28
critical for positioning and holding in the right place and observing for deformities
retinacular ligaments
29
stabilizes extensor tendon over PIP joint
transverse retinacular ligament
30
name the 3 retinacular ligaments.
- transverse
- oblique
- triangular
31
helps to center tendon on dorsal surface
oblique retinacular ligament
32
where is the oblique retinacular ligament located?
volar to axis of PIP joint and dorsal to DIP joint
33
prevents volar subluxation of lateral bands
triangular ligament
34
what are odd # zones of injury for extensor tendons?
over joints
35
what are even # zones of injury in extensor tendons?
-phalanxes, metacarpals, forearm
36
injury is distal to the DIP joint
zone I
37
injury is overlying the middle phalanx
zone II
38
injury is over the PIP joint
zone III
39
injury is overlying the proximal phalanx
zone IV
40
injury is over the MCP joint
zone V
41
injury is over the metacarpal
zone VI
42
what is the most common zone of extensor tendon injury?
zone VI
43
injury to the tendon and retinaculum over the wrist joint
zone VII
44
injury to the muscle belly in the distal forearm
zone VIII
45
injury is distal to the IP joint of the thumb
zone TI
46
injury is overlying the proximal phalanx of the thumb
zone TII
47
injury is over the MCP joint of the thumb
zone TIII
48
injury is over the CMC joint of the thumb
zone TIV
49
zone I - ET
DIP joint
50
zone II - ET
middle phalanx
51
zone III - ET
PIP joint
52
zone IV - ET
proximal phalanx
53
zone V - ET
MCP joint
54
zone VI - ET
metacarpals
55
zone VII - ET
carpals
56
zone VIII - ET
proximal wrist
57
which zone is mallet finger in?
zone I
58
describe an orthosis for a mallet finger.
- must be able to flex and extend PIPs
- maintains 10-15 degrees of DIP hyperextension
- allows PIP movement
59
name the 3 rehab approaches for extensor tendon injuries.
- immobilization (no movement)
- early but controlled mobilization (some movement) - short arc of motion
- early and active mobilization (full movement)
60
disruption of the terminal extensor tendon secondary to laceration, rupture, avulsion
mallet finger
61
what is the mechanism of mallet finger injury?
hyper flexion of DIP joint
62
what is the resulting deformity of mallet finger?
inability to extend DIP joint
63
how many weeks of immobilization does mallet finger require?
6-8 weeks
64
what can a mallet finger orthosis not allow?
cannot allow even slight flexion at DIP
65
for a mallet finger (closed injury) pt. must support finger tip at all times during splint ___ & ___.
removal and replacement
66
what type of exercise should begin during weeks 1-6 or 8 for a mallet finger (closed) injury?
active PIP flexion/extension in orthosis
67
n/a
n/a
68
what zone(s) is involved in a boutonniere injury?
zones III and IV
69
what is the resultant deformity of boutonniere injury?
PIP flexion with DIP extension
70
- results from either an open or closed zone III extensor tendon injury.
- resultant deformity is PIP flexion with DIP extension
boutonniere injury
71
name 4 causes of boutonniere injury.
- lacerating, rupture of central extensor tendon
- proximal phalanx head button holes through tendon
- volar migration of the lateral bands
- hyper-extension of DIP joint
72
describe the mechanism of injury of boutonniere deformity.
disruption of central slip and triangular ligament
73
name 6 causes of injury of boutonniere deformity.
- rupture
- avulsion
- burns
- laceration
- RA
- PIP joint dislocations
74
in order to be classified as boutonniere deformity - which 2 deformities must be present?
PIP flexion AND DIP extension
75
name the 3 components of boutonniere deformity injury.
1. central slip rupture
2. triangular ligament attenuation
3. lateral band volar migration
76
- very complex injuries involving soft tissue, PIP joint and/or DIP joints
- adhesion of either central slip and/or lateral bands causes limitation in BOTH flexion and extension
- if untreated, deformity becomes fixed
boutonniere injury
77
describe orthotic treatment for boutonniere deformity.
- static orthotic treatment
| - PIP in full extension, DIP is free
78
how long is a splint for boutonniere deformity worn for?
6 weeks
79
describe splinting for boutonniere deformity during weeks 6-9.
- may need dynamic extension but allow active flexion
| - continue night time static splinting
80
describe exercise during weeks 1-3 for boutonniere deformity.
DIP blocking - 10 reps, 5 times/day
81
describe exercise during weeks 3-6 for boutonniere deformity.
- flexion - GENTLE flexion to 30 degrees
- extension - active PIP extension with MCP in neutral
- continue night time static splinting
82
describe exercise during week 7 for boutonniere deformity.
begin PROM, watch for extensor lag
83
describe exercise during weeks 10-12 for boutonniere deformity.
start gentle strengthening
84
develops from either loss of extension mechanism at the distal phalanx or tightening or overpull of the extensor mechanism on the proximal phalanx.
swan neck deformity
85
name 3 causes of injury to the terminal tendon that leads to swan neck deformity.
- laceration
- closed avulsion from direct blow on the distal phalanx of an extended digit
- attrition by weakening from chronic inflammation of the DIP joint along with tendon subluxation due to RA or other inflammatory process.
86
hyperextension of the PIP joint can be due to the tightness of the intrinsic muscles and increased pull at the central slip. could be secondary to RA, spasticity from TBI, or stroke and intrinsic tightness alone
swan neck deformity
87
laxity of what is also a cause of swan neck deformity and the hyperextension seen at the PIP joint?
volar plate
88
which zone of injury is swan neck deformity?
zone III but cause usually elsewhere (DIP, PIP or MCP joints)
89
describe the deformities of swan neck deformity.
- PIP hyperextension with DIP flexion
| - MCP flexion can occur too
90
name 2 causes of swan neck deformity.
- usually at MCP joint (RA)
| - untreated mallet finger
91
name the 2 features (deformities) of swan neck deformity.
PIP hyperextension and DIP flexion
92
extensor tendon rises above PIP joint
swan neck deformity
93
describe the role of the ring splint.
prevents full extension of PIP, holds it in slight flexion
94
describe an orthosis for zone IV injury.
- hand based splint, involved finger in extension
| - MCP 0-30 flexion, PIP full extension
95
describe the orthotic timeline for zone IV injury.
- splint 4-6 weeks, 24 hours/day
| - continue splint for 10 weeks after injury (night time)
96
what does an orthosis for zone IV look like?
safe position
97
- applied for extensor tendons repair management
| - pt. can actively flex his digits while the metallic springs retrieve the extension position passively
Levame system
98
what does short arc of motion promote?
passive extension
99
- usually uncomplicated rehab if started early
- responds well due to mobility of dorsal skin
- not the complicated inter-dependence as seen in fingers
zone V & VI (dorsum of hand)
100
describe an immobilization orthosis for zone V and VI injuries.
- use resting hand splint pattern omit thumb
| - MCP in 10-20 degrees flexion, IPs full extension
101
describe a dynamic orthosis for zone V & VI injury.
dorsal outrigger and flexion block
- wrist 40-50 degrees extension
- allow 30 degree of active flexion at MCP joint to volar block splint
- keep IPs in extension
102
describe a dynamic orthosis at 3-4 weeks for zone V & VI injury.
- flexion block is discontinued
| - dynamic extension continues
103
describe a dynamic orthosis at weeks 4-6 for zone V & VI injury.
MCP block splint is worn until weeks 7-8
104
describe key aspects of rehab for zones V, VI, VII, and VIII injury.
- wrist extension is key to balanced hand function
| - importance of MCP joint extension
105
describe an early orthosis for zones V, VI, VII, and VIII injury.
wrist - 30 degrees extension
MCPs - slight flexion
PIPs, DIPs - extension at night, out of splint during day
106
what should you do if you suspect a wound is infected?
smell it and call doctor
107
vacuum to lift skin up
snake biting kit
108
early controlled mobilization results in what?
better range of motion at the end of 6 weeks
109
grip strength comes back faster and stronger with ___ ___ compared with ____.
controlled mobilization, immobilization
110
goes over middle and ring fingers and under index and small fingers
relative motion orthosis
111
what is a relative motion orthosis used for?
used for tendon balance - balances out the finger
112
static progressive splints can't have what?
elastic strings - fishing wire is used instead
113
which zones are involved in mallet finger?
I and II
114
which zones are involved in boutonniere deformity?
III and IV
115
describe general treatment methods for injury to zone I or II.
likely won't require surgical intervention and will be referred to therapy or the surgeon will simply immobilize the DIP in extension for 6 to 8 weeks.
116
describe general treatment methods for injury to zone III or IV.
can be treated conservatively or through surgery depending on the extent of the tendon damage
117
describe general treatment methods for injury to zones V, VI, or VII.
will require surgical repair followed by immobilization or controlled early motion protocols.
118
in mallet finger injuries, flexion activities must be balanced with active extension to ensure that there is no recurrence of what?
DIP extensor lag
119
describe splinting for boutonniere deformity.
-splint PIP in full extension for 6 weeks, and promote DIP active and passive flexion to prevent stiffness of the oblique retinacular ligament.
120
watch closely for __ ___ ___ in boutonniere injury when pt. is medically cleared to begin active exercises.
PIP extensor lag
121
injury in zones V and VI are typically treated with which 2 protocols?
- immobilization
| - controlled early motion
