cut wrist & flexor tendon injury ramy el nakeeb, md. orthopaedic department damanhour medical...

Cut Wrist & Flexor tendon

injuryRamy El Nakeeb, MD.Orthopaedic Department

Damanhour Medical institute

• FDS• FDP• FPL• Lumbricals

origin from radial side of FDP

ANATOMY

CAMPER’s CHIASMA

• FDS divides and passes around the FDP tendon, the two portions of the FDS reunite at “Camper’s Chiasma”

Preserve A2 and A4 pulley to prevent bowstringing. NOTE: There is a mistake Preserve A2 and A4 pulley to prevent bowstringing. NOTE: There is a mistake in this diagram: The C1 pulley is DISTAL to the A2 pulley!in this diagram: The C1 pulley is DISTAL to the A2 pulley!

PULLEYS

TENDON EXCURSION- 9 cm of flexor tendon excursion with wrist and digital flexion- only 2.5 cm of excursion is required for full digital flexion with the wrist stabilized in neutral position

BLOOD SUPPLY

• Segmental branches of digital arteries which enter the tendon through: –vincula–osseous insertions

• Synovial fluid diffusion

VINCULAE

ZONES

The goals of the surgical treatment is to achieve a primary tendon repair of sufficient tensile strength to allow application of a postoperative mobilization and rehabilitation protocol.

It is well-known by hand surgeons that the catastrophic

potential of a volar wrist laceration can result in a

functionless extremity. Tendon repair can be expected to heal and maintain individual gliding function when primary repair is

coupled with early and aggressive occupational

therapy.

Tendon Injury in Cut Wrist• Zone of injury

• Complications • Management

1. In the Emergency Room • First aid • Calm the patient• Examination

2. Surgical repair3. Rehabilitation 4. Cut wrist in a child

Tendon Injury in Cut Wrist• Zone of injury

• Complications • Management

1. In the Emergency Room • First aid • Calm the patient• Examination

2. Surgical repair3. Rehabilitation 4. Cut wrist in a child

Cut wrist injuries were defined as

lacerations occurring between

the distal wrist crease and the

flexor musculotendinous junctions. It may

involve as many as 16 different structures,

including 12 tendons, 2 nerves,

and 2 arteries.

Tendon Injury in Cut Wrist• Zone of injury

• Complications • Management

1. In the Emergency Room • First aid • Calm the patient• Examination

2. Surgical repair3. Rehabilitation 4. Cut wrist in a child

Adhesion formation• In many instances, it is unrealistic to

expect a tendon to heal without any adhesions, some loose adhesions may develop after surgery even with exercise.

• Adhesions influence tendon movement depending on their density. 1. loose adhesions arise from the

subcutaneous tissue2. adhesions of moderate density3. dense adhesions arise from the

bony floor or volar plates 4. A fourth type are adhesions

between the repaired tendons.

Repair rupture• Among all the consequences of flexor

tendon surgery, repair ruptures are of prime concern to hand surgeons, because

they require secondary operations.

The following factors may trigger the ruptures:

1.Overload of the repaired tendons

2.Tendon edema or bulky tendons3.Triggering in pulleys or edges of

opened sheath

Joint stiffness

• Clean-cut flexor tendon injuries themselves, however, usually do no trauma to finger joint structures. It is the postoperative protective finger position that causes joint contracture.

Nerve injury

• May lead to insenate hand• Loss of intrensic function

Vascular injury

• Cold intolerance• ischemia

A Case of Cut Wrist

Tendon Injury in Cut Wrist• Zone of injury

• Complications • Management

1. In the Emergency Room • First aid • Calm the patient• Examination

2. Surgical repair3. Rehabilitation 4. Cut wrist in a child

1. Tendon injury2. Nerve injury3. Vascular injury

First aid: Cut wristFirst aid: Cut wrist

Emergency????Emergency????

Vascular injuryVascular injury

bleedingbleeding ischemiaischemia

•Removal of tourniquettourniquet•elevation of the hand as high above the heart as possible.•packing of the wound and direct pressureBleeding from a partially severed vessel

Did not stop

Pleeeease

Do not clamp

&

No stitches

Now you can calm the Now you can calm the patientpatient

• Why not directly into the OR ?1. you can miss something2. you can avoid operating and

transfer the case if no proper facilities or expertise are available.

3. A superficial wound ????

Cut wristCut wrist

ExaminationWhat to search for in your

examination ? • Diagnosis of tendon injury

TENODESIS EFFECT• Passive extension of the wrist does not produce the

normal “tenodesis” flexion of the fingers if flexors are injured

FDS: Clinical Exam

FDP: Clinical Exam

FDP RUPTURE

• No active DIP motion (present passive DIP motion)

Nerve injury : Motor ulnar and radial, median sensory.

Tendon Injury in Cut Wrist• Zone of injury

• Complications • Management

1. In the Emergency Room • First aid • Calm the patient• Examination

2. Surgical repair3. Rehabilitation 4. Cut wrist in a child

I must have with I must have with me:me:• Basic instruments.Basic instruments.

• Magnification and microsurgery Magnification and microsurgery instrumentsinstruments

BRUNNER INCISION

Extension of the woundExtension of the wound

Extension of the wound Extension of the wound 22

Extension of the wound Extension of the wound 33

233 4

5

1.Distal structures2. Proximal structures should be

identified from deep to superficial and tagged……..N.B. Follow the Hematoma

3. FDS

Identification and Identification and taggingtagging

numerous studies have demonstrated the superiority of the four-strand core suture overthe two-strand core suture and the greater strengths achieved with six- and eight-strandcore suture techniques.

• The limiting factor

to more widespread use of modern multistrand suture techniques remains the surgeon’s ability toperform the repair using atraumatic techniquesuch that trauma to the tendon stumps and the circumferential visceral epitenon is minimized.

How to choose which kind of repair ??How to choose which kind of repair ??

the the epitendinous epitendinous suturesuture

2

• Suture material: non absorbable• Suture caliber :4-0 3-0, (the mode

of failure was affected by the configuration and the caliber of suture used)

• The needle

Nerve RepairNerve Repair The purpose of performing a nerve

suture is to align, as accurately as possible, the corresponding fascicular components of the proximal and distal nerve segments.

The evolution of surgical techniques has passed through many stages. One important step was the introduction of the operating microscope, which made it possible to identify and manipulate nerve structures with improved accuracy.

Nerve injuryNerve injury

crushingcrushingClean cutClean cut

ApparentNot apparent

Direct sutures

Trim+ direct repair, if under tension primary grafting

Direct sutures will give bad

resultsDo not clamp

Vascular repairVascular repair

Tendon Injury in Cut Wrist• Zone of injury

• Complications • Management

1. In the Emergency Room • First aid • Calm the patient• Examination

2. Surgical repair3. Rehabilitation 4. Cut wrist in a child

Complete your workComplete your work

Rehabilitation of cut Rehabilitation of cut wrist injurywrist injury

• Immobilization program: uncooperative, associated injury.

• Controlled motion program (passive)

1. Kleinert program2. Duran program

• Early active motion

STIFFNESS

RUPTURE

Too much motion

To little motion

RUPTURE

STIFFNES

Kleinert Kleinert program program

In the 1960s, Kleinert and others introduced an early

controlled passive motion protocol

using a dorsal protective splint (wrist, 30 flexion

and MCP, 30–40( flexion) with

elastic traction from the fingernail to the

volar forearm

two modifications became standard: a

palmar pulley was added to improve

DIP flexion, and at night the elastic

traction is detached and the fingers

strapped into extension within the splint to prevent PIP

joint flexion contractures.

Duran programDuran program

dorsal protective splint without elastic traction.

• The program was designed in response to their measurement that 3–5 mm of tendon glide would prevent restrictive adhesion in zone II.

• Passive DIP extension with PIP and MCP joint flexion was found to glide the FDP away from the FDS suture sites. Passive PIP joint extension with MCP and DIP flexed glides both tendons away from the injury site.

Early active motionEarly active motion

• Active motion from day one in a protective dorsal splint, better supervised in the first 3 weeks.

• The amount of force applied must be less than the tensile strength of the repair to prevent gapping or rupture.

• 4 strand technique, or a stronger configuration is required,

1. The patient in undependable

2. Hand Therapist

3. Financial reasons

4- The recurrent sessions of physiotherapy require a good movable splint

Why don’t we follow the international programs for rehabilitation??

Tendon Injury in Cut Wrist

• Zone of injury• Complications • Presentation and Examination• Management

1. First aid 2. Surgical anatomy3. Technique of repair4. Rehabilitation 5. Cut wrist in a child

Flexor tendon injuries in children differ from adults in their

diagnosis and postoperative rehabilitation principles. The child may be uncooperative, so indirect methods of tendon integrity must

be used for diagnosis. A high index of suspicion necessitates surgical exploration. Although

surgical approach and repair techniques are identical to those

in adults, postoperative immobilization for 3–4 weeks is used instead of an early motion

protocol.