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PHTY207 > Wk 10: Mx of tendon repairs > Flashcards

Wk 10: Mx of tendon repairs Flashcards

1
Q

Treatment principles

A
  1. Knowledge of Healing Timeframes
  2. Wound Management and Oedema Control
  3. How to keep still or promote appropriate movement -
    Splintage
  4. How to move – Therapeutic exercise, Manual therapy
  5. Scar Management
  6. Sensory re-education
  7. Functional integration
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2
Q

what are traumatic injuries to the FDS/ FDP caused by?

A

laceration / trauma - workplace/ home/rugby

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3
Q

what is the diagnosis of a flexor tendon injury?

A

clinical loss of motion and tenodesis effect of hand

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4
Q

how common are flexor tendon injuries?

A

relatively rare - 30-42 per 100 000

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5
Q

What is “jersey finger”?

A

rupture of FDP at level of distal phalanx

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6
Q

when does jersey finger occur?

A

in contact sports where finger caught on jersey/ pocket

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7
Q

what may you feel with jersey finger?

A

pop/ pain

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8
Q

does jersey finger involve a bony fragment?

A

may or may noy

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9
Q

what is the most common finger to injure with jersey finger?

A

ring finger (75%)

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10
Q

flexor tendon anatomy

A
  1. FDS
  2. FDP
  3. Retinacular Sheath
  4. Vincula brevis & longus
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11
Q

what is the FDP tendon excursion?

A

32 mm

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12
Q

what is the FDS tendon excursion?

A

24 mm

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13
Q

how much movement is @ the DIP jt 1mm?

A

10* ROM

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14
Q

how much movement is @ the PIP jt 1.3mm?

A

10* ROM

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15
Q

how many zones of flexor injury are there?

A

5

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16
Q

where is zone 1?

A

Distal to FDS insertion, adhesions A4&A5 pulley

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17
Q

where is zone 2?

A

FDS & FDP in fibro-osseous sheath, increases ruptures/adhesions

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18
Q

zone 3?

A

Distal to Transverse carpal ligament, better results

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19
Q

zone 4?

A

Beneath TCL, accompanying nerve injury

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20
Q

zone 5?

A
  • Wrist and forearm
  • Less frequent adhesions
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21
Q

what are the 3 types of surgical tendon repair?

A
  1. primary repair (end to end)
  2. delayed repair
  3. secondary repair (tendon graft)
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22
Q

4 types of techniques to repair tendon?

A
  1. bunnell stitch
  2. kessler grasping stitch
  3. tsuge stitch
  4. double grasping 1 suture
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23
Q

types of tendon healing?

A
  1. extrinsic
  2. intrinsic
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24
Q

what are the components of extrinsic tendon healing?

A
  • ingrowth of fibroblasts
  • scars with tendon sheath & surrounding structures
  • increased adhesions, decreased mobility
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25
components of intrinsic tendon healing?
- Intratendinous blood supply - end to end tendon fibroplastic activity
26
what is healing dependent on in the first 1-20 days?
Dependent of suture material and type of repair
27
what happens with healing in the first 1-10 days?
Strength decreases, minimum at 5 days
28
what happens in the next 3-6 weeks of tendon repair?
Strength increases
29
what happens at 12 weeks post tendon repair?
full strength
30
what does motion in tendon healing lead to?
- more rapid recovery of strength - less adhesions - improved tendon excursion
31
what is postoperative therapy often dependent on?
- mechanism of injury - clean, jagged - surgeon’s preference - type and position of repair - which zone? - condition of tendon - amount of tension on repair - other tissues involved - digital nerve, artery? - rate and quality of scar formation - patient age, general health, social influences
32
what are the post operative treatment aims?
- Restore maximal active Flexor tendon gliding by preventing: --> rupture of the tendon --> scarring with adhesions - Prevent flexion contractures - Maintain FlexROM of all uninvolved joints - Return to previous level of function
33
3 main approaches to post-operative management are:
1. Immobilisation - rare 2. Early passive mobilization - rare 3. Early active mobilization – combination of immobilization, passive and active mobilisation
34
what do early active mobilisation programs involve?
Active contraction of the involved flexor with caution and within carefully prescribed limits
35
what are early active mobilisation programs dependent on?
- good repair – require minimum of 4 strands - early referral to therapy - high patient compliance
36
what do you use a splint to protect with early active mobilisation programs?
Dorsal thermoplastic Wrist: Neutral position MCPs: 60° flexion IPs: full extension +/- protective bar
37
early active regime week 1 example
- ROM of all uninvolved joints - Oedema Mx, Wound care - Education and precautions - Example Exercises: Hourly: Active IP extension with MPs Flexed x 10 Second Hourly: Passive fist x 10 Place and hold flexion to 1/3 fist x 3 Active flexion to 1/3 fist x 3
38
week 2 early active mobilisation example
Wound care & debridement, Removal of sutures Exercises: Hourly - continue active IP extension 3x/day - passive fist x 10 - place and hold flexion to 2/3 fist x 5 - active flexion to 2/3 fist x 5
39
week 3 example early active regime
- splint review - scar management - Exercise: increase to full flexion range x 10 - consider blocking exercises - FDS or FDP to promote differential gliding
40
week 5-6 early active regime example
- avoid composite wrist/hand extension - scar management
41
week 7 early active regime example
- commence light theraputty exercises - gradual increase in hand function - ultrasound if tendon adhesions
42
week 8 early active regime example
progress strengthening, splinting for FFD if required.
43
week 12 early active regime example
full strength
44
tendon gliding exercises fist FDP movement?
maximum FDP excursion
45
tendon gliding exercises straight fist FDS movement?
maximum FDS excursion
46
tendon gliding exercises hook FDP & FDS movement?
Maximum differential glide, Much more FDP than FDS
47
summary flexor tendons
- Involved anatomy - Need to liaise closely with surgeon - Education of patient vital - Early Active Motion preferred - Consider timeframes
48
how many zones are there in extensor tendon injuries?
7
49
zone 1& 2 damage
mallet finger
50
zone 3 & 4 damage
central slip - boutonneire deformity
51
zone 5 damage
level of MCPs
52
what is a mallet finger injury an injury of?
passive DIP flexion with resisted extension
53
what does mallet finger disrupt?
terminal extensor expansion, Can involve bony fragment - +/- need for surgery
54
when does mallet finger mostly occur?
ball and contact sports
55
goal of Mallet Finger Rx
facilitate full healing of the tendon
56
what is the preferred Rx for Mallet finger?
conservative- unless large bony fragment
57
how long does healing take post injury?
at least 3 months - as long as inflam response is still occurring
58
splint position
DIP/ PIP extension
59
how long do you wear the splint for in Mallet Finger
continuously for 6-8 weeks
60
what must you educate patient for splint?
don & doff technique
61
Mallet finger Therapy considerations:
- ROM of other joints - If tendency for swan neck deformity may need to incorporate PIP joint - At 6-8 weeks – gentle active flexion, wean from splint -If lag develops, resplint and delay exercises for a few weeks
62
things to look out for with Mallet Finger:
- Skin breakdown - Compliance – poor results - PIP hyperextension – swan neck - Persistent lag - Fracture >1/3 joint surface seek surgical opinion
63
aims of nerve laceration repair surgery
join as accurately as possible the connective tissue tubes of the peripheral nerve, requires microsurgery
64
NERVE LACERATION REPAIR direct repair can occur when:
no tension on repair
65
what suture is requred for small nerves?
small, epineural suture
66
what happens with larger nerve repairs?
groups of fascicules are identified and repaired
67
how long does the nerve sheath take to heal?
3-4 weeks to gain sufficient strength to withstand stress
68
what are other viable nerve repair options when direct nerve repair isnt an option?
nerve graft / transfer
69
nerve graft
when significant nerve loss, requires donor nerve, two repair sites
70
nerve transfer
involves re-directing an intact motor nerve from one muscle to the undamaged section of a nerve eg FCU branch of ulnar nerve to Musculocutaneous nerve to restore elbow flexion
71
DIRECT NERVE REPAIRS 0- 3/4 weeks
- Wound/Oedema - Splinted in protected position - usually flexion - if no other tissues involved commence active ROM exercise within splint - Sensory considerations
72
DIRECT NERVE REPAIRS 3-4+ weeks
- gradual active regaining of FROM - Sensory considerations - prevention of joint contracture-->exercise, splintage - Await development of muscle twitch
73
what is splintage used for in therapy of nerve repairs
- Prevent deformity associated with muscle loss eg median nerve and ulnar - Prevent overstretching of muscles and joint eg radial nerve - Improve function
74
Median Nerve - low Lesion Muscles affected
FPB, OP, ABP, Lumbricals I & II
75
Median Nerve - low Lesion what does the hand look like
ape hand
76
Median Nerve - low Lesion Deviations/ deformities
- Inability to oppose thumb - Loss of web space which can lead to contracture - Inability to perform chuck pinch, functional loss - Decreased power grip - Sensation loss+++
77
Ulnar Nerve - low Lesion Muscles affected
ADM, FDM, ODM, Interossei, Lumbricals ring and little, AP, FPB deep head
78
Ulnar Nerve - low Lesion appearance
claw hand
79
Ulnar Nerve - low Lesion Deviations/ deformities
- Loss of Lateral pinch – Froment’s sign - Decreased power grip - Flattened metacarpal arch
80
'Skier's Thumb' defintion
Injury to ulnar collateral lig of the Th MCP joint involving instability
81
skier's thumb where?
Usually from base of Proximal phalanx
82
what can the skier's thumb involve?
volar plate, adductor aponeurosis, stener lesion, dorsal capsule and P1#
83
CR management questions to ask yourself
- Structure involved - Healing potential - Clinical reasoning – sprain? Bony Healing? Ligament to bone healing? - How long to heal? - Wound/Oedema to manage? - How to immobilise? - When to get moving? - When to restore function? - Sensory considerations?
84
skier's thumb Mx
splint
85

PHTY207 (7 decks)

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