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Flashcards in Tendon injuries Deck (53):
1

What is De Quervain's Tenosynovitis?

  • A stenosing inflammatory Tenosynovitis of the 1st extensor compartment of the forearm

2

What tendon are involved in De Quervain's Tenosynovitis?

  • Extensor pollicis brevis- EPB
  • Abductor pollicis Longus -ABL

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3

What is the epidemiology of De Quervain's Tenosynovitis?

  • Females > males
  • 30-50
  • racket sports

 

4

What is the aetiology of De Quervain's Tenosynovitis?

  • Post trauma
  • Idopathic
  • Overuse- golfers/racket sports
  • Post-partum- lifting baby

 

5

Name the extensor compartments at the wrist and what is in them?

  • 1- Extensor pollicis brevis
    • Abductor pollicis longus
  • 2- Extensor capri radialis longus/ Extensor carpi radialis brevis
  • 3- Extensor pollicis longus
  • 4- Extensor indicis propris/ Extensor digitorium communis
  • 5-Extensor digiti minimi
  • 6- Extensor carpi ulnaris

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6

Describe the signs and symptoms of de Quervains tenosynovitis

Symptoms

radial sided wrist pain

Signs

  • FInklestein provocative manoever- thumb clenched in hand and ulnar deviate wrist. Tenderness in 1st dorsal compartmetnt at radial styloid
  • Different from Intersection syndrome( 2nd compartment) as pain 5cm from wrist joint

 

7

What is the tx of  de Quervains tenosynovitis?

Non operative

  • Rest, nsaids, thumb spica splint, steriod injection ( 1st dorsal compartment)

Operative

  • Surgical release of 1st dorsal compartment

8

Can you describe the technique for decompressing the 1st dorsal compartment?

  • transverse incision with release on dorsal side of 1st compartment to prevent volar subluxation of the tendon
     
  • has variable anatomy with APL usually having at least 2 tendon slips and its own fibro-osseous compartment
  •  distinct EPB sheath is often encountered dorsally
  • http://www.orthobullets.com/video/view?id=209

 

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9

What are the complications of DE quervains Tenosynovitis?

  • Sensory branch of radial nerve injury
  • Neuroma formation
  • Recurrence with Failure to decompress tendons- failure to realise APL/EPB in separate subsheaths!!
  • Complex regional pain syndrome

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10

What is Intersectional syndrome?

Due to inflammation at crossing point of 1st dorsal compartment and 2nd dorsal compartment

 

11

Name the tendons that are in dorsal compartments 1 and 2?

  • 1= Abductor Pollicis longus, Extensor pollicis brevis
  • 2= Ext carpi radialis brevis and longus

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12

what is the epidemiology of  Intersectional syndrome?

  • Typical in rowers and weight lifters

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13

What is the pathoanatomy of Intersectional syndrome?

  • Repetitive Wrist extenson

14

What are the signs and symptoms of Intersectional syndrome?

Symptoms

  • Pain over dorsum of wrist
  • Swelling 1/2 dorsal compartment

Signs

15

What are the tx options for intersectional syndrome?

Non operative

  • Rest , wrist Splint, Steriod injection into 2nd comparment ( DDx : De quervains)

Operative

  • Surgical debridment and release
  • release of 2nd dorsal compartment 6cm from wrist joint

16

Defne Flexor carpi radialis tendonitis?

  • Inflammation of the FCR tendon sheath

17

What is the epidemiology of flexor carpi radialis tendonitis?

  • Rare
  • Racket sports- tennis
  • Risk factors- repetitive wrist flexion

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18

Describe the anatomy of the FCR tendon course?

Origin - medial epicondyle

Inserts-  small slip to trapexial crest, 80% to Base of 2nd MC, 20% base 3rd MC

Flexes and abducts hand at wrist

Innervation: Median

 

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19

Describe the anatomy of the FCR tendon?

  • Enveloped in sheath by musculotendinous origin to trapezium
  • No fibrous sheath distal to trapezium
  • Enters fibrous tunnel at proximal border of the trapezium
  • Within the tunnel occupies 90% space- in direct contact with trapezium-> prone to constriction/tendonitis/attritution/rupture
  • proximal to tunnel- FCR occupies 50-60% space so less prone to constriction but more prone to mechnical irritation form ostephytes

20

Describe the borders of fibroosseous tunnel of FCR tendon?

  • Radial- body of trapezium
  • palmar- trapezial crest, transvese carpal ligament
  • ulnar- retinacular septum form transverse carpal ligament ( separates FCR from carpal tunnel)
  • Dorsal- reflexion of retinaculuar septum on trapezium body

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21

What are the signs and symptoms of FCR tendonitis?

Symptoms

Tenderness of volar radial aspect of wrist

Signs

  • Tenderness over volar radial foreearm along FCR tendon at distal wrist flexion crease
  • Provaction test= resisted wrist flexion->pain,resisted radial wrist deviation->pain

 

22

What investigations are helpful in FCR tendonitis?

  • Xray- primary tendonitis normal
  • secondary may see healed distal radius fracture/healed scaphoid fracture
  • MRI- increased signal around FCR sheath on T2 image 
  • Diagnostic injection along FCR sheath relieves symptoms

23

What are the DDX of volar radial wrist pain?

  • FCR tendonitis
  • Thumb CMC arthritis
  • Scaphoid cyst
  • Ganglion
  • De Quervains tenosynovitis

24

What is the TX of FCR tendonitis?

non operative

  • Immobilisation, NSaids, steriod injection (proximity not in tendon)

operative

Surgical release of FCR tendon

25

Describe the technique for surgical release of FCR?

  • Approach- volar longitudinal incision proximal to wrist crease, extending over proximal thenar eminence
  • avoid
    • Palmar cutaneous branch of median n
    • Lateral antebrachial cutaneous n
    • superficial sensory radial n
  • Elevate and reflect thenar muscles radially
  • expose FCR sheath
  • Open FCR sheath proximal in distal forearm, extend to trapezial crest
  • Where it enters trapezial crest incise sheath along ulnar margin, take care not to injur the tendon
  • mobilise tendon from trapezidal groove, release trapezial insertion

26

Name the complications of FCR tendonitis?

  • FCR attrition and rupture

Surgery

  • Palmar cutaneous banch median n
  • lateral antebrachial cutaneous branch n
  • superificial sensory radial n
  • injury to deep plamar arch
  • injury to FPL tendon- lies superficial to FCR
  • injury to FCR tendon within tunnel

27

What is the snapping ECU?

  • Overuse of wrist can lead to spectrum of ECU tendonitis and instability

28

Describe the pathoanatomy of snapping ECU?

  • ECU subluxation is secondary to attenuation and rupture of ECU subsheath in 6th dorsal compartment
  • ECU subluxates in volar and ulnar direction
  • subluxation and snapping-> tendonitis

29

Decribe the anatomy of the ECU tendon?

Origin- lateral condyle of humerus and post border of ulna

insertion- base of 5th Metacarpal

action- wrist extension and adduction

innervation- PIN

ECU SUBsheath is part of TFCC- criticial to ECU stability

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30

Describe the signs and symptoms of snapping ECU?

Symptoms

Pain and snapping over dorsal ulnar wrist

Signs

  • Extension and supination of wrist-> pain
  • ECU tendon reduces with pronation

31

what investigations are helpful in snapping ECU?

  • USS- assess ECU stability
  • MRI- show tendonitis, TFCC pathology 

32

Decribe tx of snapping ECU?

Non operative

  • wrist spint or long arm cast- in pronation & slight radial deviation

Operative

  • ECU subsheath reconstruction + wrist arthroscopy
  • direct repair 
  • chronic cases- extensor retinculum flap for ECU subsheath reconstruction
  • wrist arthroscopy= recurrent TFCC tears in 50% of cases

33

What does sagittal band rupture lead to?

  • Dislocation of extensor tendons
  • aka Boxer's knuckle

34

Epidemiology of Sagittal band rupture?

  • Most common in fist fighters- pugilists
  • index and middle in professionals
  • ring and little in amateurs
  • Middle finger most commonly affected 48%
  • radial sagittal band more commonly involved 9:1 ulna

 

35

Describe the aetiology of sagittal band rupture?

  • Trauma
    • Forceful resisted Flexion or Extension
    • laceration to extensor hood
    • direct blow to MCPJ
  • Atraumatic
    • ​Inflammatory- RA
    • spontaneouS

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36

Describe what the extensor mechanism is made up of?

  • Interossei
  • Lumbricals
  • EDC
  • EIP
  • EDM
  • Retinaculum system
    • sagittal bands ( part of cylindrial tube which surround MC head and volar plate
    • retinacular ligament
    • triangular ligament

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37

What is the function of the sagittal band?

  • Primary stabiliser of the extensor tendon at the MCPJ
  • Juncturae tendinum are the secondary stabilisers
  • resists ulnar deviation of the tendon
  • prevents tendon bowstringing during MCPJ hyperextension

38

Describe the biomechanics of the sagittal band?

  • Ulnar sagittal band- partial or complete sectioning doesn't lead to extensor tendon dislocation
  • radial sagittal band
    • distal sectioning doesn't produce ext tendon instability
    • complete sectioning ->dislocation
    • sectioning 50% of proximal SB->ext tendon subluxation
  • Extensor tendon instability > wrist flexion, > central digits with middle finger least stable tendon
  • most stable ext tendon is little finger as junctura tendinum stabilises it.

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39

Name the classification system of the sagittal band rupture?

Rayan and Murray

  • Type 1- SB injury wout Extensor Instability
  • Type 2- SB injury w Tendon subluxation
  • Type 3- SB injury w tendon dislocation

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40

What are the signs and symptoms of sagittal band rupture?

Symptoms

  • MCP soreness

​Signs

  • Tendon snapping
  • ulnar deviation of digits at MCPJ= RA
  • Inability to initiate extension
  • Pseudo-triggering
  • Ext tendon dislocation into Intermetacarpal gully
    • most unstable during MCP flexion+wrist flexion
    • least unstable during MCP flexion+wrist extensn
  • Provocation test- reisisted extension at MCP= Pain

41

What investigations are useful for sagittal band rupture?

  • Xray- hand PA , lateral and oblique
    • may showed dropped fingers/ulnar deviation in RA
  • Dynamnic USS- when swelling obscures physical exam- subluxation of EDC tendon relative to MCP flexion ( see pic)
  • MRI - can show dislocation of ext tendon into ulnar intermetacarpal gully radial SB defect or subluxation radial for ulnar SB defect

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42

DDX for inability to extend fingers?

Congential

  • Congential sagittal band deficiency

Acquired 

  • MCPJ collateral ligament injury
  • EDC tendon rupture
  • Trigger finger
  • Juctura tendium disruption
  • MCPJ arthritis

 

43

Describe the tx for sagittal band rupture?

Non operative

  • Extension splint 4-6wks- acute injuries <1week

operative

  • Direct repair= Kettlekamp- chronic injury >1wk where DIRECT repair is POSSIBLE
  • Extensor centralization procedure- chronic injury where direct repair is IMPOSSIBLE

 

44

Describe the techniqures for extensor centralistion procedure?

Various described....

  • Trapdoor flap
    • ulnar based partial thickness capsular flap created
    • tendon placed deep to flap
    • flap resutured to capsule

others include

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45

Describe the aetiology of extensor tendon injuries?

  • laceration
  • Trauma
  • overuse

46

Describe the epidemiology of extensor tendon injuries?

  • Most commonly injured digit is the long finger
  • Zone IV most frequently injured zone

47

Describe the mechanims of injury of extensor tendons?


  • Zone 1Forced flexion of extended DIPJ 



  • Zone 2- dorsal Laceration/ Crush injury 





  • Zone V-
     

  • fight bite
     



  • Sagittal band rupture- flea flicker injury​
     

  • ​forced extension of flexed digit
     



  • most common in long finger
     







 

 

 

 

48

Describe the zones for extensor tendon ruptures?

  • Zone 1- disruption of terminal ext tendon distal to/at DIPJ and ipj of thumb-> Mallet finger
  • Zone 2- disruption tendon over middle phalanx/prox phalanx of thumb ( EPL)
  • Zone 3- Disruption over PIPJ of digit(central slip) of MCP thumb-> Boutonniere deformity
  • Zone 4- Disruption over prox phalanx of digit/MC thumb (EPL/EPB)
  • Zone 5- Disruption over MCPJ digit or CMC thumb-sagittal band rupture- fight bite
  • Zone 6- disruption over MC
  • Zone 7- disruption at wrist joint- must repair retinaculum to prevent bowstringing. repair then immobilise in wrist 40oextension/mcp flex 20o 3-4wks
  • Zone 8-disruption at distal forearm
    • ext muscle belly, usually penetrating injuries, assoc neurological injury, tendon repair then immobilisation elbow flexion, wrist extension

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49

Describe the signs and symptoms of extensor tendon ruptures?

Symptoms

  • Inability to extend at DIPJ= Zone 1
  • extensor lag and flexion loss = zone V

Signs

  •  Zone 3 injury = ELSON TEST
    •  flex patient's pipj over table at 600
    • ask them to extens against resistance
    • if central slip intact dip remain supple
    • if central slip disrupted dip will be rigid as use lateral bands
    • http://www.youtube.com/watch?v=G9HY0qXWUvE
  • Zone 5- sagittal band rupture- radial rupture-> extensor subluxation
    • with finger held in flexed position at MCPJ with no active extension

50

what investigations are helpful in suspected cases of extensor tendon rupture?

Xrays- to exlcude a bony avulsion and mallet deformity

51

When is consx tx appropriate?

  • When Laceration <50% of tendon in all Zones
  • Immobilisation with early protective motion

DIPJ extension splinting

  • Acute <12 wks
  • zone 1
  • non displaced bony mallet
  • Full time splinting 6wks then partime 4-6wks
  • avoid hyperextension-> skin necrosis
  • Maintain IPJ motion
  • non compliance a problem

​PIPJ extension splinting

  • closed Central slip zone 3
  • full time splinting 6 wks, part time 4-6
  • maintain dipj motion

MCPJ extension splinting

  • ​Closed zone v sagittal band
  • full time splinting 4-6 weeks

52

Describe the indications and operative tx available for ext tendon ruptures?

  • Immediate Incision and Drainage-= fight bite
  • Tendon repair- if lac >50%
  • fixation of bony avulsion- bony mallet w P3 volar subluxation
    • closed reduction and pinning thru dipj
    •  extension block pinning
    • ORIF if involves >50% articular surface
  • Tendon reconstruction- chronic tendon injury/direct not possible
  • `Central slip reconstruction- tendon graft, extensor turndown, lateral band mobilization
  • EIP to EPL tendon transfer- chronic EPL rupture

53

Complications of extensor tendon surgery?

  • Adhesions- limit flexion common older pt and zones 4 & 7
  • Tendon rupture- poor suture material/ surgical technique/ aggressive therapy/ non complicance
    • 5% incidence
    • most frequent 7-10 days post op
    • early recognition -> revision repair otherwise reconstruction
  • Swan neck deformity- by prolonged dipj flexion with dorsal subluxation of lateral bands and pipj hyperextension
    • Fowler central slip tenotomy
    • Spiral oblique ligament reconstruction
  • ​Boutonniere deformity- dip hyperextension caused by central slip disruption and lateral band volar subluxation
    • Dynamic splinting/ serial casting for maximal passive motion
    • Terminal extensor tenotomy , PIPJ volar plate release