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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
THANK YOU