Flexor tendon injuries.m

Injuries & Repair of Flexor Tendons of the

Hand !!

mansoor khanDec, 2011

HMC Plastic& reconstruction

Presentation:A 30-year old female presents to the Emergency room after falling on a piece of glass. She complains of pain, numbness and bleeding of her right hand. She is right hand dominant and works for a local telemarketing firm.

Questions to consider:1. What aspects of the physical examination would you focus on?2. What anatomic structures may have been disrupted given this type of injury?

muscle to the bone

glistening structurebetween muscle

& bone whichtransmit force from

“”

collagen

fibrils

fibers

fasciles

tertiary bundles

Tendons

endotenon

Loose areolar tissue

encasing tendon in low mechanical stress area

Paratenon..?

Tendon Sheath..?

a dense fibrous

tissue tunnel

enclosing tendon in

high mechanical

stress area

FLEXOR

DIGIT

SUBLI

MIS

FLEXOR

DIGIT

pROFUNDUS

FLEXOR

POLLICIS

LONGUS

LUMBERICALS

PULLEYS

Skin laceration with loss of normal cascade of the fingerd in resting position!!

Loss of active flexion at DIP in FDP laceration!!

Loss of normaltenodesis effect!!

Passive flexion with forearm squeez!!

Complain of numbness preceeded by execissive bleed

Concider neurovascular insult!!

Goals of reconstruction:

Coaptation of tendons, anatomical repair with a limited accordion effect at the repair site, multiple

strand drepair to permit active range of motion rehabilitation

Pully reconstruction to minimize bow-stringing, atraumatic surgical technique to minimize

adhesionns, strict adherence to rehabilitation protocole.

Timing of flexor tendon injuries:

Primary: repair within 24 hours (contraindicated in case of high grade

condtamination i.e. human bites, infection)Delayed Primary: 1-14 days when the wound

can be still pulled open without incisionEarly Secondary: 2-5 weeks.

Late Secondary : after 5 weeks i.e. tendon substitution techniques/salvage process.

Leddy classification of zone I flexor tendon injuries!!

Type I: tendon retracted into palm (fullness in palm)

Type II: tendon traped in the sheath at PIP (unable to flex PIP)

Type III: tendon traped in A4 pully

Type II injury!!

Type I injury!!

Direct repair: if laceration is more than 1 cm

from FDP insertion

Tendon advancement: if the laceration is less then 1

cm from insertion.

Tendon-to-bone attachment!!

One method of attaching tendon to bone. A, Small area of cortex is raised with osteotome. B, Hole is drilled through bone with Kirschner wire in drill. C, Bunnell crisscross stitch is placed in end of tendon, and wire suture is drawn through hole in bone. D, End of tendon is drawn against bone, and suture is tied over button.

Wilson

Kleinert method of tendon advancement!!

Tendon advancement shortens the FDP & completes the grip before the normal fingerd and limit their

flexion and thus week grip

Quadrigia effect!!

Laceration during flexion leads to retraction of cut ends of the

tendons!!

Partial lacerations of the tendons!!

Complications: complete disruption, entrapment, triggering.

Assess for entrapment, debride if risk of entrapment

No drepair if less than <25% laceration, only epitenon repair in 25-50% lacerations, core suture

plus epitenon repair when >50% lacerationDorsal blocking splintage for 6-8 weeks as

consevative measure

Commonly used incidions for flexor tendon exploration!!

Brunner incision !!

Because the blood supply to the FDP tendon is jeopardized if the FDS is not

also fixed (due to the vinculae anatomy)

Repair both tendons:

Complications:Adhesions & stiffness requiring

tenolysis in 18-25% casesTenolysis is indicated after 3 months if

no improvement is noted for 1-2 months extensive physiotherapy.

Lumbrical muscle bellies usually are not sutured because this can increase the tension of these muscles and result in a “lumbrical plus” finger

(paradoxical proximal interphalangeal extension on attempted active finger flexion).

Zone 3 injuries

Tendon repair strength:

Core suture:Material, caliber, number of strands,

knot location, dorsal vs ventral locationEpitendinous suture:

Depth, locking, cross hatching, simple

THREE BASIC

TYPES

Silfverskiöld

Fish-Mouth End-to-End Suture (Pulvertaft)

End-to-Side method tendon repair!!

Active range of motion rehabilitationKleinert !!

Place and hold post-operative exercised!!

Differential passive exercises for FDP & FDS!!

Post-operative passive exercisesDuran’s

Lumbrical plus!!

Risk factors for adhesions:

Composite tendon/tissue damageGap formation

Ischaemia due to over mobalizations of tendon ends

ImmobalizationPersistant inflammation

Secondary trauma