Tendon Repair of the Hand 2

8/6/2019 Tendon Repair of the Hand 2

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Tendon repair of thehand is a surgical

procedure to repairtendons that havebeen damaged andsplit. Most cases oftendon damage occur

as a result of cuts tothe hands.


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Tendons

Tendons are tough cords of tissue that connect muscles tobones. When you contract (tighten) a group of muscles, theattached tendons will pull on certain bones, allowing you tomake a wide range of physical movements.

Tendons in the hand

There are two groups of tendons in the hand:

1. Extensor tendonsExtensor tendons run from the muscles in your forearmacross the back of your hand to each of your fingers andthumbs. Your extensor tendons allow you to straighten yourfingers and thumbs.

2. Flexor tendonsFlexor tendons also run from the muscles in your forearm,passing through a number of channels in your wrist andacross the palm of your hand to each of your fingers andthumbs. Your flexor tendons allow you to bend your fingers,

make a fist and grip objects.


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Tendon repair

Tendon repair involves locating the split tendons, making anincision in your hand, then stitching the tendons together.

Extensor tendons are easily accessible, so repairing them isrelatively straightforward. Depending on the type of injury, it

may be possible to repair extensor tendons in an accidentand emergency (A&E) department using a local anesthetic tonumb the affected area.

Repairing flexor tendons is more complex because they can

be difficult to access and are often located near importantnerves. Flexor tendon repair usually needs to be carried outby an experienced orthopedic surgeon (a surgeon whospecializes in joint and bone surgery) in an operatingtheatre.


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The flexor tendons are smooth, flexible, thick strings whichbend your fingers - they look a bit like clothesline rope. Theywork like a bicycle brake cable to bend your fingers, sliding inand out of the finger as it straightens and bends. If a flexortendon is cut in half, the end connected to the muscle is oftenpulled back into the palm - no way to heal on its own. This isa very precision mechanism, and it doesn't take much to gumup the works. Even a cut only part way into the tendon can bea big problem.

The most common and difficult problem that people haveafter a tendon injury is stiffness - losing the ability to eitherfully bend or straighten the finger - which can be permanent.This is a possible problem for anyone who has had a flexortendon injury. Surgery and other special treatment are usually

needed to make this as little a problem as possible.


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What caused it?

Most often, flexor tendons are damaged froma cut. Fingers have special creases which letthe skin fold when you make a fist - at these

points, the tendons are justbeneath theskin, and are easily injured by even a smallcut in the skin.

Less often, flexor tendons may tear or betorn off the bone by a sudden pull against astrong grip, without tearing the skin.

What can you do to help?

Ice, elevation, and have it checked out by adoctor. If the injury involved a cut, medicalevaluation is particularly important - to checkwhether or not tetanus shot, antibiotics or

other treatment is required, even if stitchesaren't needed.

After injury, if surgery is needed, there is alimited amount of time to operate and getthe best possible result. Surgery delayed formore than two weeks has less of a chance of

having a satisfactory outcome.


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What can a therapist do to help?

Surgery is only half the battle for this problem. Therapy is a

necessary and essential treatment for most peoplerecovering from a flexor tendon injury.

Special hand therapy usually involves making one or morecustom splints, performing and supervising specialexercises, and making the hand feel better in general.

What can a doctor do to help?

Confirm that this is the problem, and check for nerve injuryor other problems which can occur at the same time.

Treatment really depends on the type of injury. Your doctormay recommend:

Moving the fingers and doing exercises right away. Hand therapy.

A splint or a cast, along with special exercises.

Performing surgery to repair the damage.


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Sewing a cut flexor tendon together is something like sewingtwo small ropes together, end to end. Special stitches areused on both the inside and the outside - but even with thebest stitches, the repair can still be pulled apart if it is notprotected by a special splint. It can take as long as twomonths before healing has made the repair strong.

Sometimes the end of the tendon is cut or pulled off thebone. This may require stitches through the bone or aspecial implant to anchor the tendon back to the bone.


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How successful is treatment?

It depends on many things - getting full motion back is lesslikely if

there is a nerve injury or a broken bone next to the tendoninjury

there is a long healing period before surgery

the person is prone to thick scars

the damage was caused by a crush injury

there are problems participating in hand therapy aftersurgery


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The location of the injury also has a biginfluence on how well people recoverafter surgery - cuts in the fingers don'tdo as well as those in the forearm. These

locations are referred to as "zones, asshown in this diagram. The areas shownin red are referred to as "no man'sland" - because stiffness is such acommon problem after injuries in this

area.In addition, there are many other factorswhich can also affect the odds of havinga good result versus a stiff hand.

After a flexor tendon injury, most people

lose some movement in the finger,despite all efforts. It really takeseverything going in your favor, includingluck, to have a full recovery. However, ifall goes well, the hand will work betterafter surgery than if surgery were not

done, and that's the reason for doing it.


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How are Extensor Tendons Injured?Extensor tendons are just under the skin, directly on the bone,on the back of the hands and fingers. Because of theirlocation, even a minor cut can easily injure them. Jamming afinger may cause these thin tendons to rip apart from theirattachment to the bone. After this type of injury, you mayhave a hard time straightening one or more joints. Treatmentis necessary to return use to the tendon and finger.How are Extensor Tendon Injuries Treated?Cuts that split the tendon may need stitches, but tears caused

by jamming injuries are usually treated with splints. Splintsstop the healing ends of the tendons from pulling apart andshould be worn at all times until the tendon is fullyhealed. Your doctor will apply the splint in the correct placeand give you directions on how long to wear it. Sometimes apin is placed through the bone across the joint as an internalsplint in addition to the external splint.


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What are the Common Extensor Tendon Injuries?

Mallet finger refers to the droop of the end joint where anextensor tendon has been cut or separated from the bone.Sometimes a piece of bone is pulled off with the tendon, butthe result is the same: a fingertip that cannot activelystraighten. Whether the tendon injury is caused by a cut or

jammed finger, splinting is necessary. Often the cut tendon

requires stitches. A splint is used to keep the fingertipstraight until the tendon is healed. The size of the splintand length of time you will have to wear it is determined bythe type and location of your injury. The splint shouldremain in place constantly during this time. The tendonmay take four to eight weeks or longer in some patients, toheal completely. Removing the splint early may result indrooping of the fingertip, which may then require additionalsplinting. Your physician will instruct you to remove thesplint at the proper time. Sometimes there is a mildpermanent droop, despite proper splint wear.


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Boutonniere deformity describes the bent-down (flexed)position of the middle joint of the finger from a cut or tear ofthe extensor tendon at the middle joint. Treatment involvessplinting the middle joint in a straight position until the injured

tendon is fully healed. Sometimes, stitches are necessarywhen the tendon has been cut and even if the tendon istorn. If the injury is not treated, or if the splint is not wornproperly, the finger can quickly become even more bent andfinally stiffen in this position. Be sure to follow your doctorsinstructions and wear your splint for a minimum of four to eightweeks. Your doctor will tell you when you may stop wearingthe splint.Lacerations or cuts on the back of the hand that gothrough the extensor tendons cause difficulty in straighteningthe finger at the large joint where the fingers join the

hand. Stitching the tendon ends together is the usual way oftreating these injuries, followed by splinting to protect therepair. The splint for a tendon injury in this area may includethe wrist and part of the finger. Dynamic splinting, which is asplint with slings that allows some finger motion, may be usedfor injuries of this kind. The dynamic splint allows earlymovement and protects the healing tendon.


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Figure 1: Extensor tendons, locatedon the back of the hand and fingers,allow you to straighten your fingersand thumb.

Figure 2: The mallet finger deformity

causes a droop of the fingertip. Thisis caused by injury to the extensortendon at the last finger joint.

Figure 3: The boutonnire deformitywith progressive flexion, or bending,of the middle joint may result in astiff finger in this position if nottreated. The end joint alsohyperextend (bends backward) from

the altered force across the finger.


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What Can I Expect as a Result of my ExtensorTendon Injury?

Extensor tendon injuries may form scar that causes thetendon to adhere to nearby bone and scar tissue, limitingthe movement of the tendon. The scar tissue that formsmay prevent full finger bending and straightening evenwith the best of treatment. Many factors can affect the

seriousness of the injury, including fracture, infection,medical illnesses, and individual differences. To improvemotion, hand therapy may be necessary. Surgery to freescar tissue may sometimes by helpful in serious cases ofmotion loss. Your physician will explain the risks and

benefits of the various treatments of extensor tendoninjuries.


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Tendon Repair of the Hand 2