Flexor tendon injuries

FLEXOR TENDON INJURIES

INVOLVE LACERATIONS ,RUPTURES MALES COMMONLY B/W 15 -30 YEARSZONES OF INJURY INFLUENCE THE TYPE OF

REPAIR AND POST OPERATIVE REGIMEN

INTRODUCTION

CARPAL TUNNEL : HERE MIDDLE AND RING FINGER TENDONS

LIE SUPERFICIAL TO SMALL AND INDEX FINGER TENDONS

34 GREATER THAN 25

FLEXOR TENDON ANATOMY

EACH FINGER HAS FDP AND FDS TENDON SHEATH BEGINS AT THE LEVEL OF

METACARPAL NECK DIGITAL ARTERY BRANCHES OR VINCULA

ASSIST TENDON NUTRITION

DIGITAL SHEATH

ONCE INSIDE DIGITAL SHEATH,THE FDS FORMS CAMPERS CHIASM BY SPLITTING INTO TWO SLIPS THAT ATTACH ON

THE PALMAR SIDE OF MIDDLE PHALANX.FDS PASSES THRU THIS TO ATTACH ON THE VOLAR

ASPECT OF DISTAL PHALANX

CAMPERS CHIASM

FLEXOR TENDON SHEATH HAS 5 ANNULAR AND 3 CRUCIATE PULLIES

A2 AND A4 ARE MOST IMP TO PREVENT BOW STRINGING OF THE TENDONS

WITHOUT PULLEYS TENDONS CAN NO LONGER GLIDE JUXTAPOSED TO PHALANGES AND GREATER AMOUNT OF FORCE WILL BE NEEDED TO OBTAIN THE SAME AMOUNT OF FLEXION

ONLY FPL CONTAINS 2 ANNULAR PULLIES AND ONE OBLIQUE PULLIES

THUMB SHEATH

TENDON ZONES

REGION B/W MIDDLE ASPECTS OF MIDDLE PHALANX TO FINGER TIPS

CONTAINS ONLY ONE TENDON-FDP TENDON LACERATION OCCURS CLOSE TO

ITS INSERTION TENDON TO BONE REPAIR IS REQUIRED

THAN TENDON REPAIR

ZONE 1:ZONE OF FDP AVULSION INJURIES

TYPE 1:RETRACT INTO THE PALM TYPEII:RETRACT TO THE LEVEL OF PIP JOINT TYPE III:TO LEVEL OF DIP JOINT

FDP AVULSION INJURIES-LEDDY CLASSIFICATION

FROM METACARPAL HEAD TO MIDDLE PHALANX

CALLED SO COZ INITIAL ATTEMPTS FOR TENDON REPAIR HERE PRODUCED POOR RESULTS

FDS N FDP WITHIN ONE SHEATH ADHESION FORMATION RISK IS AMPLIFIED

AT CAMPERS CHIASM

ZONE II-NO MANS LAND

B/W TRANSVERSE CARPAL LIGAMENT AND PROXIMAL MARGIN OF TENDON SHEATH FORMATION

LUMBRICALS ORIGIN HERE PREVENTS PROFUNDUS TENDONS FROM OVER ACTING

DELAYED TENDON REPAIRS ARE SUCCESFULL EVEN AFTER SEVERAL WEEKS OF INJURY

ZONE III-DISTAL PALMAR CREASE

LIES DEEP TO DEEP TRANSVERSE LIGAMENT TENDON INJURIES ARE RARE

ZONE IV-TRANSVERSE CARPAL LIGAMENT

LIES PROXIMAL TO TRANSVERSE CARPAL LIGAMENT

ZONE V-PROXIMAL

INSPECTION THERE IS A NORMAL ARCADE TO HAND

WITH INDEX FINGER SHOWING LEAST AND LITTLE FINGER SHOWING MAX FLEXION

IF AFFECTED FINGER SHOWS MORE EXTENSION THAN OTHER DIGITS,CHANCE OF TENDON INJURIES ARE HIGH,

EXAMINATION

FDP Hold the

metacarpophalangeal and proximal interphalangeal joints of the finger being tested ,in extension.

Ask the patient to flex the finger at the distal interphalangeal joint.

If the patient cannot flex the finger, the flexor digitorum profundus tendon is cut or non-functional.

PALPATION-PROVOCATIVE TESTING

Hold the fingers in extension except the finger being tested.

Ask the patient to flex the finger at the proximal interphalangeal joint.

If the patient cannot flex the finger, the flexor digitorum superficialis tendon is cut or non-functional.

FDS

STABILISE THE MCP JOINT

ASK THE PT TO FLEX IP JOINT

FPL

TO EXCLUDE UNDERLYING INJURIES LIKE FRACTURES.

IMAGING STUDIES

REPAIR WITHIN 1ST TWO WEEKS,LATE REPAIR DECREASE THE ULTIMATE MOBILITY OF THE FINGERS

STRENGTH AND ABILITY TO PREVENT GAPPING DEPENDS ON THE NO OF SUTURES THAT CROSS THE REPAIR SITE

TENDON GAPPING IS THE HALLMARKOF TENDON FAILURE

DORSALLY PLACED SUTURES HELPS TO MINIMISE GAPPING

TENDON REPAIR CHARACTERISTICS

EPITENON SUTURES HELPS TO IMPROVE THE STRENGTH AND QUALITY OF TENDON REPAIRS

NO NEED FOR TENDON SHEATH REPAIR PARTIAL TENDON LACERATIONS OF LESS

THAN 60% OF CROSS SECTIONAL AREA OF TENDON SHOULD BE TREATED WITHOUT TENORRHAPHY AND EARLY MOBILISATION

IN TRANSVERSE LACERATIONS, LONGITUDINAL INCISIONS ARE PUT ON OPPOSITE SIDES EXTENDING PROXIMALLY AND DISTALLY

OBLIQUE SKIN LACERATIONS CAN BE EXTENDED IN A ZIG ZAG FASHION

EXPOSURE OF SITE OF INJURY DURING REPAIR

WOUND EXTENDED PROXIMALLY AND DISTALLY

PROXIMAL TENDON RETRIEVED,CORE SUTURES ARE PLACED

KEITH NEEDLES USED TO PASS THE SUTURES AROUND THE DISTAL PHALANX EXITING THROUGH NAIL PLATE DISTALLY

REMAINING DISTAL END OF TENDON SUTURED TO THE RE-ATTACHED PROXIMAL PORTION

ZONE 1 REPAIR

REPAIR BOTH TENDON LACERATIONS TENDON SHEATH MAY BE OPENED FOR

EXPOSURE BUT A2 AND A4 ARE PRESERVED AS MUCH AS POSSIBLE

FDS IS REPAIRED FIRST FOLLOWED BY FDP

ZONEII REPAIRS

If both tendons are lacerated, both are repaired, end to end withcircumferential re-enforcing sutures

May affect lumbricals inaddition to flexor tendons

Damaged lumbrical is either repaired or excised depending on severity of injury and the location of the laceration

ZONE III REPAIRS

Lacerations of flexor tendons within the carpal canal are typically associated with partial or complete laceration of median nerve

Here median nerves should be repaired first and the tendons last

ZONE IV REPAIR

In this area there may be concomitant ulnar nerve & artery damage as well as radial artery & median nerve damage.

Primary repair of the arteries is usually indicated

If wound is contaminated, arteries are repaired and delayed repair of tendons and nerves is planned

ZONE V REPAIR

TWO PROTOCOLS ARE FOLLOWED1. PASSIVE FLEXOR TENDON PROTOCOL2. EARLY ACTIVE TENSION PROTOCOL

REHABILITATION

0-3 WEEKS:NO ACTIVE FINGER FLEXION,DORSAL BLOCK SPLINT IS APPLIED

3-6 WEEKS:SPLINTING CHANGES WITH WRIST IN NEUTRAL POSITION ,PASSIVE FLEXION AND ACTIVE EXTENSION EXERCIZES STARTTED

6-9 WEEKS:WEANING FROM SPLINT,LIGHT FUNCTIONAL ACTIVITIES STARTTED.

PASSIVE FLEXOR TENDON PROTOCOL

9-12 WEEKS:JOINT CONTRACTURES IF PRESENT ARECORRECTED.RESISTIVE EXERCIZES ARE BEGUN.

12-16 WEEKS:PROGRESS TO FULL RESISTIVE EXERCIZES

BEYOND 16 WEEKS:RESIDUAL DEFICITS IF ANY CORRECTED

PASSIVE FLEXOR TENDON PROTOCOL….CONTD….

24-48 HRS POST OP:DORSAL BLOCK SPLINTING,PASSIVE AND ACTIVE EXTENSIONS STARTTED WITHIN THE SPLINT

24-72 HRS POST OP TO 4 WEEKS:ACTIVE EXERCIZES IN A HINGED TENODESIS SPLINT AND DORSAL BLOCK SPLINT RE-APPLIED AFTER EACH EXERCIZE SESSION

EARLY ACTIVE MOTION PROTOCOL

4-6 WK POST OP:ACTIVE EXERCIZES DONE OUTSIDE THE SPLINT

6-8 WKS POST OP:SPLINT DISCONTINUED 8-9 WKS POST OP:LIGHT STRENGTHENING

EXERCIZES BEGUN 10-14 WKS POST OP:PROGRESSIVE

RESISTIVE STRENGTHENING EXERCIZES BEGUN.

BEYOND 14 WKS:RETURN TO FULL UNRESTRICTED ACTIVITY AT 14 WKS

EARLY ACTIVE MOTION PROTOCOL…CONTD…

SUCCESSFUL RESULTS REQUIRE PRECISE SURGICAL TECHNIQUE AND STRICT ADHERENCE TO REHABILITATION PROGRAM.

CONCLUSION

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