flexor tendon injuries tricks of the trade mr andrew mahon consultant orthopaedic and hand surgeon...
Post on 22-Dec-2015
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Flexor Tendon InjuriesTricks of the Trade
Mr Andrew MahonConsultant Orthopaedic and Hand
SurgeonUniversity Hospital North Durham
History
• Demographics– Age, Hand Dominance, Occupation, Hobbies
• Mechanism– Blade, Glass, Power Tools, Closed Avulsion
• Time of Injury
• Tetanus
• Fitness for theatre
Examination
• Look at the Hand!!– Posture, Colour
• Wounds– Tidy, Untidy, Contaminated
• Test Sensation
• Know how to examine tendons
Question 1
• Linburg – Comstock anomaly
Question 2
• How do you assess the injured hand in a young child?
Examination - Children
• Look
• Sweating – pen test
• Wrinkling test
• Tenodesis
• Direct pressure over tendons / muscles
Don’t Under-estimate the Injury!
Question 3
• What is the injury?
Leddy and Packer
Take an X-Ray
Surgery
• Skin
• Associated structures
• Flexor sheaths
• FDS
• FDP
Skin - Incisions
• Need adequate exposure
• Avoid scar contracture
Associated Structures
• Inspect Nerves and Vessels
Question 4
• Which are the most important pulleys in the flexor sheath?
Question 4
• Which are the most important pulleys in the flexor sheath?
• A2
• A4
Flexor Sheath
• Lister’s Windows
• A4 Pulley
Deliver the Tendon
Zone 1 Repair
• < 1cm reattach to bone– Button– Suture anchor
• > 1cm tenorraphy
Tendon Repair Techniques
• Core suture– 2, 4, 6, 8 strands
• Circumferential (epitendinous) suture– Running– Halsted– Silfverskiold
Core Sutures
Core Sutures
• Kessler
Core Sutures
4 strand cruciate
Strickland
Question 5
• What is the most important factor affecting core suture strength?
Question 5
• What is the most important factor affecting core suture strength?
• The number of suture strands crossing the repair site
Question 6
• What is the optimum suture bite length for a core suture?
Question 6
• What is the optimum suture bite length for a core suture?
• 7mm to 1 cm
• Aim for 1cm
Circumferential Sutures
• Adds to repair strength
• Reduces bulk at repair site
Sequence of Repair
• In finger repair FDS first
Goals of Repair (Zone 2)
• Strong enough for active motion
• No gapping• Free glide through
pulleys• Minimal handling to
reduce adhesions Untidy Repair
Rehabilitation
• Controlled active movement (Belfast)
Rehabilitation
• Kleinert– Active extension– Passive flexion
Rehabilitation
Question 6
• What is the optimum wrist position for immobilisation following flexor tendon repair?
Question 6
• What is the optimum wrist position for immobilisation following flexor tendon repair?
• Slight extension– (Savage)
Rehabilitation
• Dorsal splint– MCPs 70 - 90°– Full extension allowed at PIPs
• Full time 6 weeks
• At night / in crowds until 12 weeks
• No resisted exercises until 8 weeks
• Driving 10 weeks