Flexor Tendon Injuries Flashcards
1
Q
blood supply of the hand
A
-the hand is supplied with blood from both the ulnar and radial arteries
Ulnar and radial arteries join in 2 arches
- Superficial palmar arch: superficial to flexor tendon
- Deep palmar arch (deep to flexor tendons)
-Allen’s test confirms the blood supply integrity
Usually the artery and the nerve are also cut when you get hand cut injuries. Doc has to repair both the tendon and the arteries and nerves.
People often have anatomical variations- there are always anomalies. Sometimes the deep arch can be a little more proximal.
2
Q
Fingers Blood Supply
A
Neurovascular bundles
- contain digital artery, vein, and nerve
- two bundles: one radial and the other ulnar
Everything goes together in little tubes up the side of our fingers.
3
Q
Tendon Nutrition
A
nutrition to tendons comes from 2 sources
- Intrinsic- vascular perfusion
- Extrinsic- Diffusion from synovial fluid. diffusion from synovial fluid that our tendons are bathed in. helps tendons glide freely in the body so we can use our hand.
4
Q
Intrinsic Tendon Nutrition: Vinculi
A
- Branch off the common digital artery
- There is a short vinculum (vinculum brevis) and long vinculum (vinculum longus) for each FDS and FDP tendon.
- The vascular supply is mainly on the dorsal side of the tendons
- how the fingers and hand get blood.
- There are 4 vanculi on the dorsal side of the tendon. (VBP, VLP, VBS, VLS)
5
Q
Extrinsic Tendon Nutrition
A
- Extrinsic nutrition is provided by synovial fluid diffusion.
- The flexor tendon sheath is a double-walled fibro osseous tunnel that is sealed at both ends- Can be bad with infection cause it spreads through all of the area.
- Diffusion is accomplished by movement
6
Q
Extrinsic Tendon Nutrition Cont’d
A
- Synovial fluid bathes the tendon, which provides nutrition and lubrication for low friction glide.
- Diffusion occurs as the synovial fluid gets pumped into the tendon fibers during flexion and extension of the fingers (hence, movement is important for tendon healing)
- When you move it pushed fluid from one end to the other. Movement is important for tendon healing.-
7
Q
Annular Pulley System
A
5 annular pulleys (A1-A5) that hold the tendons close to the bone.
- Pulleys improve the biomechanical efficiency of the flexor tendon system
- Key pulleys are A2 and A4
- Impairment to the pulley system can cause bowstringing (this can contribute to reduction in AROM due to changes in the lever arm of the tendon.. (when A2 and A4 are cut)
8
Q
Thumb pulley system
A
- A1: located at the level of MP joint.
- Oblique: Located over the middle of the proximal phalanx
- A II: located at the level of IP joint.
- the Oblique pulley is the most important.
9
Q
Camper’s Chiasm
A
- Adhesions can occur here
- Important area for us because that is where a lot of gliding occurs and if there is a scar there it can effect the function of the profundus to make its way through and can affect gliding ability.
10
Q
Flexor Tendon Zones: Zone 1
A
- Extends from the fingertip to the midportion of the middle phalanx
- FDP is involved thus can’t bend the tip of the finger.
- An injury in this area is known as jersey finger.
- has the second worst prognosis
11
Q
Jersey Finger
A
- Ring finger commonly involved
- Painful, swollen finger, especially of the volar DIPJ
- Inability to bend/flex the tip (distal phalanx)
12
Q
Jersey finger Cont’d
A
- Xray to assess for tendinous rupture or bony avulsion fracture
- Surgical repain required
- Immobilization 3 to 4 weeks for younger children
Avulsion- pulls tendon away. May see a chip off of the bone still on the tendon that ripped off and helps the know the cause of the injury.
13
Q
Zone 2
A
- Extends from the midportion of the middle phalanx (FDS insertion) to the distal palmar crease
- Adhesions reduce excursion and results in a stiff finger.
- used to be called “no man’s land”
- the worst prognosis, the most common and the most difficult to treat.
- cut when chopping vegetable, broken glasses, pumpkin carving
- Can include both the FDS and the FDP
14
Q
Zone 2 tendon injuries
A
- the most common area for flexor tenon laceration
- Depending on how deep the cut is, it can affect both the flexor digitorum profundus and the FDS
- Gliding of this tendons distal, proximal and against each other is imperative to hand function.
15
Q
Zone III
A
- extends the distal palmar crease to the distal portion of the transverse carpal ligament.
- not as much scarring in this area. this area is a lot of traumatic injuries such as firecrackers
16
Q
Zone IV
A
Overlies the transverse carpal ligament. doesn’t scar too bad.
17
Q
Zone V
A
-extends from the wrist crease to the level of the musculotendinous junction of the flexor tendons. (also known as spaghetti wrist)
- Because all the tendons are in the wrist and if they cut across it effects all of those tendons.
- common in suicide attempts and busting through windows in vehicles and homes.
- nerve function is a big issue, muscular functionality is a big issue as well
18
Q
Incisions: Z plasty
A
Will always have a zig zag position to preserve the length of the tissue and prevent skin from contracting.
-Incisions should address the digital creases
19
Q
Primary repair
A
- within the first two weeks of tendon laceration
- The optimal time for repair of the flexor tendons is within 24 hours of the injury but definitely within 2 weeks.
- The longer the severed tendons have to develop adhesions and scar tissue, the less the possibility of restoring full function.
20
Q
Secondary repair
A
-for lacerations that were not repaired soon enough
Have worse prognoses
- the tendon ends and tendon sheaths become scarred
- the musculotendinous units retract
Require tendon graft or 2 stage repair using Huntington rods. (Use rods to make the bed in hand to make the tunnel for about 4 weeks and then come in and do a transfer or graft and replace the tunnel with the graft.
)
21
Q
repair strength
A
- the strength of the flexor tendon repair is proportional to the number of core suture strands crossing the repair site.
- More scarring may be evident with more core strands but new techniques are causing a change in this. 6 to 8 strand core suture doing well and allow for early active motion inside protective dorsal shell splint.
*Do a core suture in the middle. Repair the middle of the tendon first. It’s a fancy stitch
The suture technique and type of material used helps with tendon repair strength.
Can also be a problem with gliding because of the size and amount of nots from sutures.
22
Q
non-bulky vs bulky repairs
A
non-bulky: old school 2 strand repair
- pros: passes under pulleys secondary to less bulk
- cons: Gaps and is weak
Bulky
- 6 strand core
- Doesn’t pass easily under pulleys normally
- New technique to vent pulleys have solved this problem.
23
Q
epitendinous suture
A
- core suture followed by an epitendinous suture to complete the tendon repair
- Repairs sheath, helps prevent adhesion formation
- Helps prevent triggering.
24
Q
Repair strength
A
2 strand- 0 weeks (5.5 Lbs), 6 weeks (5.95 Lbs)
4 strand- 0 weeks (9.5 Lbs), 6 weeks (11.5 Lbs)
6 strand- 0 weeks (13 Lbs), 6 weeks (15.8 Lbs)
Repair site loses about 50% of its strength at end of week one (then starts working up to week 6 strength.
25
Tensile strength in a repaired tendon
- Tendon repair is at its weakest day 10-12
- Immobilized tendon is 50% weaker day 5-10 than at day one of repair
- Estimated core suture tensile strength decreases by 50% by the end of week one
- Ends of a repaired tendon take about 21 days to stick together.
26
Therapy goals (hand therapy)
- Prevent tendon rupture
- Patient Education
- Promote tendon healing
- Encourage tendon gliding
- Prevent flexion contractures
- Restore PROM and AROM
- Maintain ROM of uninvolved joints
- Return to previous level of function
27
Therapy approaches
3 main approaches:
1) controlled mobilization
2) early active mobilization
3) immobilization
28
Precautions before therapy
instruct patient to:
-NEVER bend fingers by themselves, only bend them using uninjured hand
- NEVER make a fist with injured hand
- Never puck up anything using injured hand
- NEVER straighten fingers using uninjured hand (no passive extension)
29
Duran protocol
Day 1: Dorsal blocking splint which positions the wrist in 20 degrees flexion, MP joints in about 60 degrees of flexion, and IP joints in neutral
- Velcro straps are positioned to hold the IP joints in neutral extension during sleep.
- Day 3: the patient is started on a protected passive ROM program
*Median nerve was affected (carpal tunnel) when placed in 60 degrees of flexion.
We don’t want them to get collateral ligament contractures.
30
Controlled mobilization: first week
- the splint must allow full IP extension (will get a PIP contracture quick)
- Bulky surgical dressing is removed carefully adhering to protective motion precautions.
31
Duran Protocol: first week
Wound is redressed with either xeroform or adaptic and 1 inch gauze wrap. SOme folks use coban or digisleeve but it is not usually necessary.
*Used to help with swelling at times but cannot be too tight. Always check capillary refill when putting something like that on.
32
Controlled mobilization: first 4 weeks
- Patient begins active extension within the confines of the dorsal blocking splint
- The patient performs passive PIP and DIP movement within the splint one joint at a time
- Must be gentle. Goal is for PROM to proximal palmar crease in 2 to 3 weeks. Swelling and dressings create drag on the tendon so you have to use clinical judgement
- After 2 weeks, suture are removed
- Scar massage can be initiated but finger must be kept in protective position.
33
Controlled mobilization after 4 weeks
- after 4 weeks, dorsal splint may be removed and gentle composite rand of motion can be performed
- wrist ROM and tendon gliding can be initiated
- Continue with PROM
- Continue to use a static dorsal blocking splint between exercises and at night for 1 more week.
34
Controlled mobilization: 6 weeks
Discontinue splint
-No gripping anything heavier than a toothbrush
- DO NOT push or pull anything with injured hand
- DO NOT lift any heavy objects
35
Controlled mobilization after 8 weeks
- After 8 weeks: light strengthening exercises such as squeezing a sponge or nerf ball can be initiated.
- PROM in extension can be performed if there is a deficit.
- After 10 weeks, moderate strengthening exercises are begun
- After 12 weeks, the patient resumes normal activities
36
Early active mobilization
- Dr. Strickland
- Used with 4 strand repairs and greater.
- tendon gliding is elicited by active contraction of the injured muscles using tenodesis.
37
Indiana flexor tendon protocol
Make a fin on the dorsal MCP joint surface that prevents extension of wrist.
38
Immobilization
-complete immobilization for 4 weeks following tendon repair
Used with:
- young patients (children younger than 10)
- Cognitive deficits (unable to follow the protocol)
- Incompliant patients (unwilling to follow the protocol)
- Greater incidence of tendon rupture because tendon gains tensile strength when repair site is submitted to gentle tension.
- has not resulted in consistently good results
39
Complications: adhesion formation
-the most common complication
-causes stiff joints
-Factors that promote adhesions are:
trauma to the tendon and sheath,
tendon ischemia,
digital immobilization,
prolonged edema
40
factors that suppress adhesion formation are:
- good surgical technique
- Tendon mobilization early
- Motion between the tendon and its sheath.
41
complications: rupture of the tendon repair
- Most common between the 7th and 10th post op day
| - must refer back to surgeon as soon as possible.
42
complications: flexor contractures of PIP joints
- dorsal strap in extension to shell at night
| - Might require a volar gutter component
43
causes of rupture
- non-compliance
- accidental injury
- place and hold exercises
- blocking exercises
- poor repair
- poor nutrition
- other diagnoses affecting healing (infection, DM, smoker)
44
complications
- injury to neurovascular structures
- Hypersensitivity
- Complex regional pain syndrome
- Bowstringing of the tendon
- infection
45
Tendon gapping
- Separation of the two ends that creates a space and causes the tendon to have a gap from end to end (surgical technique and over aggressive stretching)
- Makes the tendon longer therefore it can not pull as effectively.
46
Walant
- Dr. Don Lalonde
- Wide Awake Lidocaine Anesthesia, no Tourniquet
- Epinephrine
- Patient is awake, can check the repair and educate patient during procedure.
