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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
Q

components of intrinsic tendon healing?

A
  • Intratendinous blood supply
  • end to end tendon fibroplastic activity
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26
Q

what is healing dependent on in the first 1-20 days?

A

Dependent of suture material and type of repair

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27
Q

what happens with healing in the first 1-10 days?

A

Strength decreases, minimum at 5 days

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28
Q

what happens in the next 3-6 weeks of tendon repair?

A

Strength increases

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29
Q

what happens at 12 weeks post tendon repair?

A

full strength

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30
Q

what does motion in tendon healing lead to?

A
  • more rapid recovery of strength
  • less adhesions
  • improved tendon excursion
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31
Q

what is postoperative therapy often dependent on?

A
  • 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
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32
Q

what are the post operative treatment aims?

A
  • 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
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33
Q

3 main approaches to post-operative management are:

A
  1. Immobilisation - rare
  2. Early passive mobilization - rare
  3. Early active mobilization – combination of immobilization,
    passive and active mobilisation
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34
Q

what do early active mobilisation programs involve?

A

Active contraction of the involved flexor with caution and within carefully prescribed limits

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35
Q

what are early active mobilisation programs dependent on?

A
  • good repair – require minimum of 4 strands
  • early referral to therapy
  • high patient compliance
36
Q

what do you use a splint to protect with early active mobilisation programs?

A

Dorsal thermoplastic
Wrist: Neutral position
MCPs: 60° flexion
IPs: full extension
+/- protective bar

37
Q

early active regime week 1 example

A
  • 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
Q

week 2 early active mobilisation example

A

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
Q

week 3 example early active regime

A
  • splint review
  • scar management
  • Exercise: increase to full
    flexion range x 10
  • consider blocking
    exercises - FDS or FDP to
    promote differential gliding
40
Q

week 5-6 early active regime example

A
  • avoid composite wrist/hand extension
  • scar management
41
Q

week 7 early active regime example

A
  • commence light theraputty exercises
  • gradual increase in hand function
  • ultrasound if tendon adhesions
42
Q

week 8 early active regime example

A

progress strengthening, splinting for FFD if required.

43
Q

week 12 early active regime example

A

full strength

44
Q

tendon gliding exercises
fist FDP movement?

A

maximum FDP excursion

45
Q

tendon gliding exercises
straight fist FDS movement?

A

maximum FDS excursion

46
Q

tendon gliding exercises
hook FDP & FDS movement?

A

Maximum differential glide, Much more FDP than FDS

47
Q

summary flexor tendons

A
  • Involved anatomy
  • Need to liaise closely with surgeon
  • Education of patient vital
  • Early Active Motion preferred
  • Consider timeframes
48
Q

how many zones are there in extensor tendon injuries?

A

7

49
Q

zone 1& 2 damage

A

mallet finger

50
Q

zone 3 & 4 damage

A

central slip - boutonneire deformity

51
Q

zone 5 damage

A

level of MCPs

52
Q

what is a mallet finger injury an injury of?

A

passive DIP flexion with resisted extension

53
Q

what does mallet finger disrupt?

A

terminal extensor expansion, Can involve bony fragment - +/- need for surgery

54
Q

when does mallet finger mostly occur?

A

ball and contact sports

55
Q

goal of Mallet Finger Rx

A

facilitate full healing of the tendon

56
Q

what is the preferred Rx for Mallet finger?

A

conservative- unless large bony fragment

57
Q

how long does healing take post injury?

A

at least 3 months - as long as inflam response is still occurring

58
Q

splint position

A

DIP/ PIP extension

59
Q

how long do you wear the splint for in Mallet Finger

A

continuously for 6-8 weeks

60
Q

what must you educate patient for splint?

A

don & doff technique

61
Q

Mallet finger Therapy considerations:

A
  • 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
Q

things to look out for with Mallet Finger:

A
  • Skin breakdown
  • Compliance – poor results
  • PIP hyperextension – swan neck
  • Persistent lag
  • Fracture >1/3 joint surface seek surgical opinion
63
Q

aims of nerve laceration repair surgery

A

join as accurately as possible the connective tissue tubes of the peripheral nerve, requires microsurgery

64
Q

NERVE LACERATION REPAIR
direct repair can occur when:

A

no tension on repair

65
Q

what suture is requred for small nerves?

A

small, epineural suture

66
Q

what happens with larger nerve repairs?

A

groups of fascicules are identified and repaired

67
Q

how long does the nerve sheath take to heal?

A

3-4 weeks to gain sufficient strength to withstand stress

68
Q

what are other viable nerve repair options when direct nerve repair isnt an option?

A

nerve graft / transfer

69
Q

nerve graft

A

when significant nerve loss, requires donor nerve, two repair sites

70
Q

nerve transfer

A

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
Q

DIRECT NERVE REPAIRS
0- 3/4 weeks

A
  • Wound/Oedema
  • Splinted in protected position - usually flexion
  • if no other tissues involved commence active ROM
    exercise within splint
  • Sensory considerations
72
Q

DIRECT NERVE REPAIRS
3-4+ weeks

A
  • gradual active regaining of FROM
  • Sensory considerations
  • prevention of joint contracture–>exercise, splintage
  • Await development of muscle twitch
73
Q

what is splintage used for in therapy of nerve repairs

A
  • Prevent deformity associated with muscle loss eg median
    nerve and ulnar
  • Prevent overstretching of muscles and joint eg radial nerve
  • Improve function
74
Q

Median Nerve - low Lesion
Muscles affected

A

FPB, OP, ABP, Lumbricals I & II

75
Q

Median Nerve - low Lesion
what does the hand look like

A

ape hand

76
Q

Median Nerve - low Lesion
Deviations/ deformities

A
  • 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
Q

Ulnar Nerve - low Lesion
Muscles affected

A

ADM, FDM, ODM,
Interossei, Lumbricals ring and
little, AP, FPB deep head

78
Q

Ulnar Nerve - low Lesion
appearance

A

claw hand

79
Q

Ulnar Nerve - low Lesion
Deviations/ deformities

A
  • Loss of Lateral pinch –
    Froment’s sign
  • Decreased power grip
  • Flattened metacarpal arch
80
Q

‘Skier’s Thumb’ defintion

A

Injury to ulnar collateral lig of the Th MCP joint involving instability

81
Q

skier’s thumb where?

A

Usually from base of Proximal
phalanx

82
Q

what can the skier’s thumb involve?

A

volar plate, adductor
aponeurosis, stener lesion,
dorsal capsule and P1#

83
Q

CR management questions to ask yourself

A
  • 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
Q

skier’s thumb Mx

A

splint

85
Q
A

PHTY207 (7 decks)

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