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Flashcards in Flexion tendon injuries Deck (41):
1

How do tendons heal?

  • INFLAMMATORY= 0-7days- cellular proliferation (no strength- strength due to suture !)
  • FIBROBLASTIC=- 1-3 wks- fibroblastic proliferation with disorganised collagen( inital Type 3m replaced by Type 1)- strength increasing
  • REMODELLING- >3 wks linear collagen organisation- will tolerate active motion

2

Where does FDP insert?

  • Base of distal phalanx 2-5 fingers

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3

What is FDP innervation?

  • Medial part-little/ring fingers - ulna nerve C8/T1
  • Ulna part- AIN - branch of median c8/T1= index/middle fingers

4

What is FDP action?

  • Flexor of DIPJ
  • Assists with PIPJ and MCPJ flexion
  • Shares a common muscle belly in forearm

5

What is FDS insert and what is its  innervation?

  • Bodies of middle phalanges index- ring
  • Median Nerve C7,C8,T1

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6

What is FDS action?

  • Flexes PIPJ at digits 2-5
  • Flexes proximal phalanges at MCPJ

7

What is FPL insertion?

  • Base of distal phalanx of thumb

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8

What is FPL innervation?

  • AIN- median C8/T1

9

what is FPL action?

  • Flex phalanges of 1st digit thumb

10

Where is FPL located in the wrist?

  • IN the carpal tunnel
  • as most radial structure

11

What is FCR insertion?

  • Base of 2nd MC

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12

what is FCR action?

  • Flexes and abducts wrist

13

What is FCR innervation?

  • median nerve c6/7, closest tendon to median nerve

14

What is FCU insertion?

  • pisiform bone
  • hook of hamate
  •  5th MC

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15

What is FCU action?

  • wrist flexion and adducts hand

16

What is FCU innervation?

  • Ulnar nerve c7/8

17

What is the blood supply to the tendons ?

  • 2 sources
  • Diffusion thru synovial sheaths when tendon within the sheath-most important proximal to MCPJ
  • Direct vascular supply those outside sheaths- via digital artery to long/short veniculum 

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18

What is campers chasm?

Location of the level of the proximal phalanx where FDP splits FDS in two - goes thru the middle of it!

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19

Can you describe the zones for flexor tendon injures ?

Zones 1-5

  • Zone 1- distal to FDS insertion
  • Zone 2- Prox to FDS insertion to palm crease
  • Zone 3- palm crease to carpal tunnel
  • Zone 4- carpal tunnel zone
  • Zone 5- Proximal to carpal tunnel

thumb

  • Zone 1- tip to distal IPJ- FPL had no lumbricals or veneulae so can retract to palm!
  • Zone 2- Over thenar eminence- can have injuried to thenar muscles and recurrent branch of median nerve

 

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20

What injuries pccur at zone 1?

  • Distal to FDS insertion ( distal to prox phalanx iin fingers)-
  • Jersey Finger

21

Can you describe the classification?

NB remember worse first!!

Type 1- FDP tendon retracts to PALM!!!! disrupts vascular supply- tx with prompt surgery within 7-10 days

Type 2- FDP retracts to PIPJ- attempt repair within several wks

Type 3- Large AVULSION fracture- LIMITS retraction to level of DIPJ- attempt to repair

Type 4- osseous fragment and AVULSION of tendon from fragment- DOUBLE AVULSION- tendon goes to PALM- if tendon separated from fracture fix fracture first then tendon

22

What is the tx for Zone 2 flexor tendon injuries?

  • Prox to FDS insertion to palm
  • Unusual as FDS and FDP share same tendon sheath
  • Direct repair of BOTH TENDONS
  • Then EARLY ROM
  • PRESERVE A2 and A4 PULLEY
  • historically poor outcome 'noman's land' but improved due to  modern repair techniques and advancment in post op motion protocols

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23

What is the tx for Zone 3 flexor tendon injuries?

  • Palm area
  • Often associated with NV injury so worse prognosis
  • Direct tendon repair

24

What is the tx for Zone 4 flexor tendon injuries?

  • Carpal tunnel area
  • often complicated by post op ADHESIONS due to close to synovial sheath of carpal tunnel
  • Direct tendon repair
  • Transverse Carpal ligament should be repaired in a lengthened fashion

25

what is the tx for zone 5 flexor tendon injuries?

  • Prox to carpal tunnel, wirst to forearm
  • often associated with NV injury
  • Direct tendon repair

26

What is the tenodesis effect?

  • Normally wrist extension-> passive flexion MCP, PIPJ and dipj
  • Need to test for each digit
  • Maintaince of dipj/pipj extension with wrist extension suggests flexor tendon rupture

27

What are the signs and symptoms of flexor tendon rupture?

Symptoms

Loss of active flexion to DIPJ/PIPJ/MCPJ

Signs

  • Malignment of finger cascade= fracture
  • Assess skin integrity- tendon rupture
  • Traumatic arthrotomy sites
  • Test tenodesis effect= wrist extension-> flexion at MCPJ/PIPJ/DIPJ
  • If flexor tendon ruptured wrist extension-> dipj/pipj held in extension
  • Test Active DIPJ/PIPJ each finger
  • Neurovascular exam- close proximity of flexor tendons to digital nerves

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28

When would you not operate?

  • In Partial Lacerations <60% width
  • may be associated with triggering/ gap formation

29

What surgical tx are there?

  • When laceration >60%
  • Flexor tendon repair and controlled mobilization
  • Flexor tendon reconstruction and intensive post op rehab= failed primary repair, surgical tenolysis required in >50% of time

30

What incision would you make to repair a flexor tendon?

  • Bruner zigzag incision ( avoids vascular compromise)
  • cross flexion creases transversely or obliquely to avoid contractures - NEVER LONGITUDINALLY

31

When is the ideal time for repair?

  • Within 3 weeks of injury ( 2 wks ideal) longer -> tendon retracture

32

What is the technique for repair?

  • 4 strand core suture- crucitate- using non absorbable monofilament prolene gd compatibility,retains strength
  • No of suture strands that x repair more important than no of grasping loops
  • linear relationship strength of repair and no of sutures crossing repair
  • 4-6 strands adequate strength for early active rom
  • locking loops decrease gap formation
  • core sutures placed dorsally are stronger
  • atruamatic handlng Circumferential
  • Circumferential Epitendinous suture 6.0 prolene- improves tendon gliding , strength of repair ( adds 20%) and allows for less gap formation.Simple running suture best
  • Sheath repair contraversial - thought to improve tendon nutrition through tendon sheath but clinical studies have found no diff from repair to non repair

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33

When are flexor tendon repairs weakest? where does repair fail?

  • Post op day 6 and 12
  • At suture knots

34

What has been the best improvement of outcomes?

  • Post op controlled mobilisation
  • To reduce adhesions and leads to increase tendon excursion

35

Can you describe the principles of rehab?

what are the different types?

  • Motion of repaired tendin unit leads to predominacne of intrinsic cf extrinisic tendon healing and reduce adhesions
  • Passive motion protocols- low force low excursion
  • Early active motion protocols- high force/high ex
  • Synergistic motion regimen- low force/high excur

36

What are is the difference between passive motion vs early atcive motion vs synergistic protocols of rehab?

Passive motion

LOW force and low exercusion

  • Klinert technique-uses a dorsal block slpint with wrist at 45o of lfexion and elxastic bands secured to nails nails adn more proximal attachment.Once IPJ are actively fully extended , recoil is elastic flexes them down passively
  • Duran Protocol- uses a splint with wrist in flexion 20o. relies on pt to alternatively passively extend the DIPJ/PIPJ with other joints of fingers flexed. aim to withdraw reapired fds/fdp away from repaired site.Pt compliance is requisite

Early Motion protocols

Moderate force and potential high extercusion

  • involves the generation of light muscle forces to assist digital flexion or preform 'place and hold' exercises w digit
  • Dorsal blocking splint used to limit wrist extension
  • Although some evidence of increased tensile strength at repair site compared to passive protocols, high risk of rerupture, gap formation potential concerns

Synergestic motion

Low force high exercusion

  • Passive digit flexion combined with active wrist extension, followed by active digit extension coupled with active wrist flexion
  • Tendon exercusion by employing wrist motion is greater than that provided in an extension blocking splint

 

 

 

 

37

How about children post op?

  • Initlally in cast with the wrist and mcl positioned in flexion and ipj in extension- edinburgh position

38

Can you describe the technique for reconstruction surgery?

 

  • Normally 2 stage
  • silcone impant inserted -> favourable tendon bed
  • Wait 3-4 months then pass a biological tendon thru the tendon sheath created after removeal of the silicone rod.
  • single stage preformed if flexor sheath prestene and from of joints
  • use Palmaris longus, plantaris ( extrasynovial grafts),2nd toe FDL ( intrasynovial grafts)
  • Intrasynovial grafts less tissue necrosis, better preservation of gliding.
  • Pulleys to be constructed proximal and distal to joint

39

What are the indications for 2 stage flexor tendon reconstruction?


  • Require supply skin,adequate vascularity, passive from adjacent joints, sensate digit 



  • use in crush injuries of adj soft tissues, delayed or failed primary repair
     

40

what are the complications of flexor tendon injuries?

  • Tension adhesions
  • Rerupture-5-15%:around 7-10 days post op if <1cm scar, excise and direct repair but if scar>1cm need tendon reconstruction
  •  Joint contracture-17 %
  • Swann neck deformity
  • Trigger finger
  • Lumbrical plus hand
  • Quadrigia

41

What would be the indications for tenolysis?

  • Localised tendon adhesions with minimal to no joint contracture and full passive rom
  • Preform at .3 months to wait for soft tissue stabilisation and full passive rom of joints
  • Preserve A2/A4 pulley
  • follow with intensive physio