IT 18 - Flexor Tendon PP

8/10/2019 IT 18 - Flexor Tendon PP

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Flexor Tendon Injuries


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Introduction

Muscles insert in bones via tendons

Tendons

white fibrous cords that are lined with aloose tissue (paratenon) & whichsometimes run through a fibrous tube(tendon sheath)

have the ability to glide over bone andthrough tissues


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Introduction

Muscle contraction transmitted via

tendons causing intervening joints to

move Muscles that bend the fingers and

wrist "flexor"

Muscles that straighten the fingersand wrist "extensors"


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Anatomy

Flexor systems : Fingers 2 tendons

thumb 1 tendon

Blood supply viaMesotenon VincularSystem

Retinacular pulleysystem

to keep the flexortendons approximatedto the underlying bonystructures

Mechanical leverage forfull fingers motion


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Vascularization

tendons are able to obtain theirnutrients from two different sources :

direct blood supply

the synovial fluid


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Zone of Fingers

Flexor TendonsVerdanclassification :

1. Zone I :extends fromdistal ins/ of FDS to theins/ of FDP

2. Zone II:extends from

the midportion of themiddle phalang to theneck of MC

3. Zone III:extends fromthe prox neck of MC to thedistal edge transverse

carpal ligament4. Zone IV:the region

under the transversecarpal ligament

5. Zone V:proximal to thecarpal canal


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Zone of Flexor

Tendons in Thumb

Verdanclassification : Zone I :distal at the

insertion of the flexortendon

Zone II:from the neck ofprox.phalang to the neck ofMC (within the flexorretinaculum of the thumb)

Zone III :the area of thethenar muscle

Zone IV :the region ofcarpal canal

Zone V :proximal totheproximal edge of the carpalligament


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Tendon Injuries

caused by : involving sharp things (open injury)

overstressed in sports (closed injury)

damage to single or multiple tendons

immediate loss of its function

need cerefully assessment


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Position

The normal cascade

Hand Posture when relaxedthe thumb-tip held slightly

flexed

fingers held in a cascade


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Active movement

use the tendon by moving or tensing the relevant joint

flexion of the fingers loss of active movement

at the tip of the ring finger (closed FDP rupture)


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Passive movement

assessed by gentlepressure over themuscles in theforearm somemovement of therelevant tendon

an alternative wayto move thewrist


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Tendon Healing

An early time :

Process in which paratendinous tissuesinvaded the healing area

Determining factors :

Age

Mechanism & extent of the injuryLevel of the tendon laceration

Individual healing respons


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Tendon Healing

Two mechanisms Intrinsic healingmediated by the epitenon

with cell migration into the depths of the repairsite

Extrinsic healingdependent upon ingrowthof cells from outside the tendon

The extrinsic is less desirable

adhesion formation (lacerated edge of thetendon)

leading to restricted tendon gliding


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Classification

BoyesPreoperative Classification : Grade I : Good

Minimal scar w/ mobile joints

No trophic changes Grade II : Cicatrix

Heavy skin scarring due to injury / surgery

Deep scarring due to failed primary repair /

infection Grade III : Joint Damage

Injury to the joint

Restricted ROM


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Classification

Grade IV : Nerve Damage

Injury to the digital nerves

Trophic changes in the finger

Grade V : Multiple Damage Involvement of multiple fingers

Combination of problems

(cicatrix-joint damage-nerve damage)


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Tendon Reconstruction

The soonerreconstructive the more

likely will return to full function

The latereconstructive :

missed injuries

severely contaminated wounds

severely damaged soft tissues

patients not tolerate by acute treatment

failure of primary reconstructive efforts

considered 3 weeksafter injury


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Flexor Tendon Reconstruction

Type of incision

Principle :

1. Timing

2. Staging

3. Technique

4. Suture & Matl

5. Post Op Prog


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Options for Late Reconstructive

direct repair

tenolysis

one- or two-stage grafting tendon transfer

tendon advancement with or without

tendon lengthening


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Direct Repair

contraction of the musculotendinous

scar tissue within the flexor sheath

in the thumb (even >3 months after

injury) some loss of excursion & IP jointmotion is well-tolerated

has no lumbricales

its flexor sheath has only three pulleys

only one flexor tendon within the sheath


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Direct Repair

In the fingers upto 4 weeks frominjury

If tendon retractionis significant, oneoption islengthening

With or without atendon graft ortransfer


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Tenolysis

Indication : surgical release of

non-gliding &

localized adhesion limitation of active

motion

risk of further

decreased thevascular supply &innervation


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Tenolysis

After repair treating a stiff digit(combination of joint contracture &adhesion)

Adhesions in the repair site orresult of edema & immobility of anuninjured digit

not performed prior to 3 monthsfrom repair


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Tendon Grafting

Indication : (i) the ends have retracted apart and

shortened

(ii) the tendons become stuck to the sheath

(iii) the sheath narrows Donor Site :

PL

Plantaris

Foot Flexor & Extensor EIP

FDS

Allograft


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Tendon Transfer

Principles : Mobile Joints, skin & soft tissue

contractures

Adequate power

Sufficient

Maximal work capacity of Power

An adequate length

A satisfactory line of pull should beachieved

An adequate glide

Functional integrity must be preserved


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Tendon Transfer

Surgical Consideration : Timing Planning Technique Joinning the tendons

Achieving proper tensile

Failed of Reconstruction : Infection Tendon exposed

Stiffness Rupture Scar Nerve damage


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Rehabilitation

Mobilization affects the mechanism oftendon healing :

motion interrupts the tendon and the periphery

motion stimulates the epitenon & promotesdifferentiation between the tendon and thesheath

Early mobilization resulting in tensilestrength improved tendon gliding

Tendon mobilization stimulates intrinsichealing & limits extrinsic healing


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Rehabilitation

Program For 4 :

4 passiveflexions

4 active flexions

4 activeextensions


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Thanks

Documents

IT 18 - Flexor Tendon PP