flexor tendon injuries of the hand
TRANSCRIPT
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Evaluation• Perform prior to digital block!
• Skin
• Posture – extended finger
• Is finger perfused?– Cap refill– Doppler signal– Digital Allen’s test
• Digital nerves – radial & ulnar
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Wound inspection
• May see lacerated tendon
• May be misleading– Flexed fingers at injury
– Extended fingers at examination
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FDS examination
• Adjacent finger DIPs, PIPs, and MCPs are held in full extension to eliminate FDP action
• Ask patient to actively flex at PIP
• Perform each finger seperately
• Can not rule out partial tendon injury
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FDP examination
• Isolate DIP joint by grasping middle phalanx
• Ask patient to flex DIP
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Imaging
• Xray– Avulsion fractures (Jersey fingers)– Foreign bodies
• MRI/Ultrasound– More commonly used in delayed presentation
of closed injuries
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• FDS decussation at A1 pulley
• 2 FDS slips rotate 180° around FDP
• Slips rejoin at PIP – Camper’s Chiasm
• Insert on P2
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Pulleys
• A2 & A4 – Originate off P1 & P2– Most important to
prevent bowstringing
• A1, A3, A5 originate off palmar plates
• A2– Approximately 2 cm
long– Can resect up to 50%
if needed
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Tendon nutrition• Parietal paratenon
– Passive nutrition by diffusion
• Vincula and bony attachments– Direct nutrition– Segmental nutrition
• Vincula may prevent retraction
• Vascularity dominance is deep surface of tendon– Consider with suture
placement– Biomechanically superior
to place suture deep
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Timing of repair
• 3 weeks– Commonly referenced– The earlier the better (easier)
• Emergent repair if impaired vascularity
• >3 weeks – possible reconstruction
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Leddy classificationType I: retraction into the palm
– Repair in 7-10 days due to disrupted vascularity
• Type II: retraction to PIP joint– Vincula intact, prohibit further retraction
– Repair up to 6 weeks
• Type III: avulsed with volar lip of P3– Can not retract past A4 pulley (DIP joint)– Repair up to 6 weeks
• Type IV: tendon avulsed off bony fragment
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Zone I Fixation
• Leddy I: repair within 3 weeks
• Leddy II or III: repair up to 6 weeks
• Bone anchors into P3– 1 or 2 microanchors
• Pull through sutures over nail plate or button
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• Historically poor results
• Adhesions, limited motion
• Fraught with complications
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Core suture
• Repair strength directly related to number of core sutures
• At least 4 core sutures for early AROM
• Types: Kessler, Strickland, cruciate, etc.
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Epitendinous Suture
• Enhances repair strength by up to 50%
• Smooths tendon, decreases bulk
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Post-op care
• Splint 3-5 days to allow swelling to subside
• Then early AROM– May increase repair site strength– Commitment to hand therapy is critical
• PROM also used
• Advance activity over 2-3 months
• Unrestricted use at 3 months
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Partial tendon lacerations
• Repair if >60% lacerated
• <60% → debride if entrapped – Hard to distinguish without direct visualization
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On the horizon
• Fiberwire– 4-0 looped
• Lubricants – 5-Fluorouracil (mitotic
inhibitor)– Hyaluronic acid
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Quadriga • Uninjured fingers unable to fully flex
• Usually due to shortening of injured flexor
• Common FDP muscle belly to SF, RF, MF
• Flexion excursion of other fingers is limited by the shortest tendon (usually injured finger)
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Swan Neck
• DIP flexion, PIP hyperextension
• Mallet + lax/injured PIP volar plate
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Boutonniere
• DIP hyperextension + PIP flexion
• Central slip avulsion
• Triangular ligament injury → volar migration of lateral bands
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Lumbrical plus
• Paradoxical extension of IPs with attempted forceful flexion– IP extension – intrinsics– MCP flexion – intrinsics– IP flexion – FDP/FDS– MCP extension – EDC/EIP/EDQ
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• Causes:– FDP laceration distal to lumbrical origin
• Lumbricals originate on FDP just distal to TCL
• Insert into extensor hood – act to extend IPs
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• Causes:– FDP graft too long– Amputation distal to central slip insertion
– All due to altered tension of FDP – load applied to lumbrical first
– Imbalance
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Anatomy
• Nerve compressions– Ulnar nerve (AMECF)
• Arcade of struthers• Medial intermuscular
septum• Epicondyle• Cubital tunnel• FCU
– Radial nerve (FLEAS)• Fibers off lat IM septum• Leash of henry• ECRB• Arcade of frohse• Supinator
• Median nerve (SLAPS)– Supracondylar process– Ligament of struthers
• SC process – med epicondyle
– Aponeurosis (lacertus fibrosis)
– Pronator– FDS
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• EIP – last muscle innervated by PIN
• Parona’s space– potential space volar to PQ– Thenar space infection can communicate to
hypothenar
• Space of Poirier – weak space in volar carpal ligaments b/w RSC and RLT ligs
• Contents of carpal tunnel
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• APL – multiple tendon slips to release in Dequervain’s dz
• TCL – floor of Guyon’s canal
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Dual innervated muscles
• FPB – median and ulnar
• Lumbricals– IF & MF – Median– RF & SF – Ulnar
• Brachialis – Musculocutaneous & Radial