Tendon Injuries and Conditions

Question 1

what is minimal active muscle-tendon tension (MAMTT)?

Answer 1

MAMTT is defined as the minal tension required to overcome the viscoelastic resistance of the antagonistic muscle-tendon unit. Tendon forces are the sum of the muscle contraction and the resistance of viscoelastic drag imposed on the repair site by the swollen tendon, periarticular soft tissues, edema, tension in the antragonistic muscle-tendon unit, and bandaging.

Question 2

how are the tendons managed in an MAMTT program?

Answer 2

digit flexors are worked with wrist in slight extension and digit extensors are worked with wrist in slight flexion

Question 3

what are juncturae tendinum (JT)?

Answer 3

interconnections of the EDC in zone 6. Thicker on the ulnar side of the hand.Assist with transmission of force during digital extension. ALso function to stabilize MCPJs. Limit independent function of EDC tendons, but preserve extension in the absence of EDC fucntion proximal to the JT

Question 4

how many pulleys are in the thumB?

Answer 4

3 – one oblique pulley at the proximal phalanx and 2 annular pulleys: A1 just proximal to MCP and A2 at the volar plate of the IP

Question 5

The surgeon has orders for you to follow Silfverskiold & May’s Early Active Mobilization protocol for flexor tendon lacerations. The correct splint for this protocol is:

Answer 5

Wrist at neutral, MPs flexed 50 to 70 degrees, dynamic flexion to all four digits, use a palmar pulley, fingers held in IP extension at night only

Question 6

what is Vaughan-Jackson syndrome

Answer 6

disruption of the digital extensor tendons, beginning on the ulnar side with the extensor digiti minimi and extensor digitorum communis tendon of the small finger. It is most commonly associated with rheumatoid arthritis.

Question 7

what is Mannerfelt syndrome?

Answer 7

Mannerfelt syndrome refers to rupture of the flexor pollicis longus (FPL) tendon from attrition caused by a bony spur in the carpal tunnel.

Question 8

how do the extensor tendons get nutrition under the extensor retinaculum?

Answer 8

vascular perfusion through the mesotendons provides 30% of the nutrition, and synovial diffusion provides 70%

Question 9

what pharmacological agent has been shown to reduce tendon adhesion?

Answer 9

ibuprofen
through inhibition of COX-1 and COX-2, which can also increase tendon excursion

Question 10

what are vincula?

Answer 10

folds of the mesotendon that provide blood supply to flexor tendons. supplied by transverse communicating branches of the common digital artery

Question 11

what is mesotendon?

Answer 11

connecive tissue sheath attaching the tendon to its fibrous sheath

Question 12

what is a late deformity of an unrepaired FDS?

Answer 12

a swan neck from an unbalanced pull of FDP

Question 13

median or ulnar nerve injuries are most commonly found in which flexor tendon zones?

Answer 13

IV and V

Question 14

what must be true in order to perform a primary flexor tendon graft after a delayed injury?

Answer 14

the fibre-osseous tunnel must be in adequate position

Question 15

how to chose between flexor tendon graft or a primary repair?

Answer 15

if appropriate muscle length-tension can be achieved or if the gap distance between the tendon ends is small, a primary repair should be performed?

Question 16

when does a tendon have the least amount of tensile strength?

Answer 16

3-5 days after surgical repair, secondary to softening of the tendon ends

from days 5-21, strength slowly increases as collagen matures and cross-linking continues

studies indicate that this decrease in strength may not occur with an early motion program

Question 17

small finger FDS is absent in what % of the population?

Answer 17

21%

Question 18

after EPL rupture, which tendon can still allow for some IP joint extension?

Answer 18

Abductor pollicis brevis (APB)
originates on scaphoid tubercle and flexor retinaculum and inserts on lateral side of P1 and the dorsal apparatus, which is also part of EPL

Question 19

what are the anatomical differences of FPL, compared to the other flexor tendons?

Answer 19

travels alone in its flexor sheath
has only on vincula
no associated lumbricals originate on it
spans onto two digital joints
inserts at base of distal phalanx

Question 20

in the Evan’s active short arc motion (SAM) protocol, what position should the wrist be in and why?

Answer 20

30 degress of wrist flexion, which reduces flexor tendon resistance, facilitates interossei function to extend the PIP, and thus reduces the force required of the EDC to extend the PIPJ

Question 21

when should you NOT perform DIP flexion exercises after central slip repair?

Answer 21

DIP flexion exercises can be performed with the PIPJ held in absolute 0, UNLESS the lateral bands were involved.
DIP flexion transmits force through the lateral bands, which is contraindicated if they were repaired
If lateral bands involved, DIP flexion is delayed until week 4-5 post-op and start from 30deg and progress slowly to avoid overstretching repair

Question 22

What is the Evans recommended “place and hold” fist position using the MAMTTor SAM?

Answer 22

wrist in 20deg extension
MCPs in 83deg flexion
PIPs in 75deg flexion
DIPs in 40deg flexion

Question 23

how many muscle bellies does EDC have?

Answer 23

usually only ONE; hoever, in some cases, EDC has 4 distinct muscle bellies with separate and distinct innervation from the PIN

Question 24

with isolated loss of EDM, how can small finger extension still be retained?

Answer 24

EDC anatomy is variable, and in some cases, juncturae tendinum from the RF can exclusively extend the SF in the absence of EDM

Question 25

how can you assess for a central slip weakness or rupture?

Answer 25

assess the ability to extend the DIP while the PIP is in mid-flexion and full flexion. In a normal finger, the lateral bands won’t transmit tension to the DIP when the PIP is in full flexion, and only a small amount of forece when PIP is in mid-flexion. If there is a strong DIP extension while holding the PIP in these positions, it means the central slip has ruptured and DIP is being extended by the lateral bands.

If the DIP doesn’t move when holding PIP in these positions, but the patient still can’t reach full PIP extension, it is likely a weakened central slip

Question 26

how many muscle bellies does FDP have?

Answer 26

there is a common muscle belly for the middle, ring, and small fingers, typically preventing us from bending the tip of one of these fingers without the others bending as well. There is a separate muscle belly for the index finger FDP, though, contributing to its independence.

Question 27

How many muscle bellies does FDS have?

Answer 27

FDS has four independent muscle bellies from which four tendons arise

Question 28

what is the quadrigia affect?

Answer 28

occurs when the FDP of the injured finger is advanced too distally which results in decreased tendon excursion of the other digits limiting flexion of the uninvolved digits due to the common muscle belly of the profundus

Question 29

what is extensor quadrigia?

Answer 29

the decreased excursion of some or all of the extensor tendons due to an injury to one of them. lack of excursion to one EDC tendon can affect all due to the common muscle belly. Can also occur due to flexion contractures at the MCP level, adhesion formation following a fracture, and attenuation/laceration of a saggital band or juncturae

Question 30

what is the “four finger method” protocol for flexor tendon repair?

Answer 30

developed by May and colleagues, uses rubber band traction on all 4 fingers with palmar pulleys. All 4 fingers are in traction, even if uninjured

Question 31

describe an early passive motion protocol for a zone V extensor tendon repair?

Answer 31

dorsal forearm-based dynamic extension orthosis with wrist in 40deg extension and MPs in dynamic traction at 0deg. Pt can actively flex digits and outrigger passively returns them to 0

Question 32

describe an immobilization protocol for a zone V extensor tendon repair

Answer 32

volar forearm-based static orthosis with wrist in 40deg extension, MPs in 0-20deg, and instruct pt to actively flex/extend PIPs in the orthosis

Question 33

describe an immediate active tension protocol for a zone V extensor tendon repair

Answer 33

dorsal forearm-based dynamic extension orthosis with wrist in 40deg extension and MCPs in dynamic traction at 0deg. Instruct pt in “active hold” of the digital extensors while therapist passively places wrist in 20deg flexion and all digit joints in 0deg extension

Question 34

describe a controlled active mobilization protocol for a zone V extensor tendon repair

Answer 34

volar forearm-based orthosis with wrist in 30deg extension and MCPs in 45 deg flexion; instruct pt to actively flex and extend MCPs and IPs together, but limit MCP flexion to 45deg (using orthosis) and MCP extension to 0deg

Question 35

what side of the EDC do the EIP and EDM tendons rest?

Answer 35

both have independent muscle bellies and run on the ULNAR side of the EDC tendon

Question 36

which early active protocol uses a tenodesis orthosis?

Answer 36

The Strickland/Cannon program from the Indiana Hand Center

Question 37

what is the order of the pyramid of progressive force from least to most resistance?

Answer 37

1. passive protective position/extension
2. place and hold
3. active composite fist
4. active hook and straight fist
5. isolated joint motion
6. discontinuation of protective splint
7. resistive composite fist
8. resistive hook and straight fist
9. resistive isolated joint movement

in the first 5 levels, the wrist is protected

Question 38

what is Elson’s test?

Answer 38

designed to assess for rupture of the central slip.
from a 90deg flexed position over the end of a table, pt attempts to extend PIP against resistance. absence of extension at the PIP and fixed extension/rigidity at the DIP are immediate signs of a complete rupture of central slip. WILL NOT demonstate a partial rupture