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FLEXOR TENDON INJURIES OF THE HAND
Michael Zlowodzki MDPGY-3 Resident
University of MinnesotaDepartment of Orthopaedic
Surgery
OUTLINE
AnatomyClinical assessmentTreatment depending on Zone of injuryTendon healing biologyRepair techniques Post-op motion protocolsDelayed grafting
ANATOMY
FDS
Origin (2 muscle bellies)– Medial epicondyle – Radial shaft
Tendons arise from separate muscle bundles
ACT INDEPENDANTLY
FDP
Origin: ulna & interosseous membrane FDP: Common muscle origin for several
tendons
SIMULTANEOUS FLEXION OF MULTIPLE DIGITS
FDP
FDSFDPFPLLumbricals
origin from radial side of FDP
CAMPER’s CHIASMA
FDS divides and passes around the FDP tendon, the two portions of the FDS reunite at “Camper’s Chiasma”
TENDON SHEETS
Preserve A2 and A4 pulley to prevent bowstringing. NOTE: There is a Preserve A2 and A4 pulley to prevent bowstringing. NOTE: There is a mistake in this diagram: The C1 pulley is DISTAL to the A2 pulley!mistake in this diagram: The C1 pulley is DISTAL to the A2 pulley!
PULLEYS
TENDON EXCURSION
- 9 cm of flexor tendon excursion with wrist and digital flexion- only 2.5 cm of excursion is required for full digital flexion with the wrist stabilized in neutral position
TENDON EXCURSION
MP motion = no flexor tendon excursion1.5 mm of excursion per 10 degrees of
joint motion for DIP (FDP) and PIP (FDS, FDP)
BLOOD SUPPLY
Segmental branches of digital arteries which enter the tendon through: – vincula– osseous insertions
Synovial fluid diffusion
VINCULAE
CLINICAL EXAM
FDS: Clinical Exam
TENODESIS EFFECT Passive extension of the wrist does not produce the
normal “tenodesis” flexion of the fingers if flexors are injured
FDS: Clinical Exam
FDP: Clinical Exam
FDP RUPTURE
No active DIP motion (present passive DIP motion)
ZONES
REPAIR ALL COMPLETE TEARS AT ALL LEVELS!
ZONE 1 INJURIES:
Jersey Finger
JERSEY FINGER
JERSEY FINGER
LEDDY CLASSIFICATION
Type 1: Retraction into palmType 2: Retraction to PIP levelType 3: Bony avulsion (tendon attached)Type 4: Bony avulsion (tendon attached
not attached to bony fragment)
REPAIR WITHIN 7-10 DAYS
TYPES OF REPAIR
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 ADVANCEMENT
BUTTON STRONGER THAN SUTURE ANCHORS
Tendon Advancement
– Previously advocated for zone 1 repairs, as moving the repair site out of the sheath was felt to decrease adhesion formation
– Disadvantages• Shortening of flexor system• Contracture• Quadriga effect
QUADRIGA EFFECT
If FDP tendon advanced too distally Entire muscle bells gets pulled distally Tendon excursion of FDP of other digits is limited Loss of grip strength
ZONE 2 INJURIES
ZONE 2 INJURIES Zone 2: Deep and superficial flexor gliding inside
tendon sheets Traditionally “No man’s land”: Stiffness after repair
INJURY: Tendons retract
ZONE 2: PARTIAL LACERATIONS
Partial laceration
No repair if 40% of the tendon intact
Potential complications:–Triggering–Tendon entrapment
Eval for the risk of triggering; debride if necessary
dorsal block splinting for 6 to 8 weeks
– N=15 patients with zone II partial flexor tendon lacerations of the width of the tendon (Avg. 71%)
– Conservative treatment:• Dorsal blocking splint with wrist in 10° of flexion• Immediate guarded active ROM• Splint removed @ 4w• No restriction @ 6w
– excellent results in 93% and good in 7%
Why not fix a partial laceration when you staring at it in the OR anyway?
Because the dissection necessary to fix it might cause too much scarring, which might outweigh the benefit
ZONE 2:COMPLETE LACERATIONS
MORE STRANDS: STRONGER & STIFFER REPAIR
Ultimate Strength and Repair Technique
Proportional to number of strands– 6 and 8 strand repairs strongest
• Steep learning curve• Increased bulk and resistance to glide• Increased tendon handling and adhesion formation • May not be necessary for forces of early active
motion
4-STRAND REPAIR ADEQUATE STRENGTH WITHOUT
COMPLEXITY OF 6-8 STRANDS
Proximal Tendon Retrieval
Fix FDP and FDS or just FDP?
Why?Because the blood supply to the FDP
tendon is jeopardized if the FDS is not also fixed (due to the vinculae anatomy)(Personal communication: Dr. James House)
FIX FDP AND FDS!
COMPLICATIONS
StiffnessRe-ruptureTenolysis may be required in an estimated
18% to 25% of patients – No earlier than 3 months after repair– If no ROM improvement for 1-2 months
ZONE 3 INJURIES
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 4 INJURIES
ZONE 4: Carpal Tunnel
TENDON HEALING
Flexor tendon healing
Intrinsic healing: occurs without direct blood flow to the tendon
Extrinsic healing: occurs by proliferation of fibroblasts from the peripheral epitenon– adhesions occur and limit tendon gliding
PHASES OF TENDON HEALING
1.Inflammatory (0-5 days) : strength of the repair is reliant on the strength of the suture itself
2.Fibroblastic (5-28 days) : or so-called collagen-producing phase
3.Remodelling (28 days - 4months)
TENDON WEAKEST @ 10-14 DAYS
BRUNNER INCISION
SUTURE TECHNIQUES
Kessler
Modified Kessler(1 suture)
Advantage: Only one node inside the repair site. Easier to use a monofilament suture like a 4.0 Proline to re-approximate tendon edges.
Kessler-Tajima(2 sutures)
SUTURE MATERIAL
Non-absorbableMost authors prefer a synthetic braided
3.0 or 4.0 suture, usually of polyester material (Mersilene, Tycron, Tevdek)
However, monofilament sutures like nylon and wire are also used (e.g. Proline)
Additional running, circumferential 5-0 or 6-0 nylon is used often
IN: Interference with healing
OUT: Interference with tendon gliding
SUTURE KNOT LOCATION
SUTURE KNOT LOCATION
Knots outside superior in one in vitro study (Aoki)
Statistically significant increase in tensile strength at 6 wks with knots inside technique in canine model (Pruitt)
FEW STUDIES – NO CONSENSUS
SHEAT REPAIR
Advantages– Barrier to extrinsic adhesion formation– More rapid return of synovial nutrition
Disadvantages– Technically difficult– Increased foreign material at repair site– May narrow sheath and restrict glide
NO CLEAR ADVANTAGE ESTABLISHED
POST-OP REHAB
HISTORICAL
Bunnel (1918)– Postoperative immobilization– Active motion beginning at 3 wks postop.– Suboptimal results by today’s standards
• Improved suture material/technique as well as postoperative rehabilitation protocols
STIFFNESS
RUPTURE
Too much motion
To little motion
RUPTURE
STIFFNES
POST-OP PROTOCOLS
1. Kleinert: Active extension, passive flexion by rubber bands
2. Duran: Controlled Passive Motion Methods
3. Strickland: Early active ROM
GOAL: FULL ACTIVE ROM @ 10-12 weeks
Kleinert Protocol
Duran protocol
DURAN PROTOCOL
Dorsal Splint in 20 deg wrist flexionNo rubber bandsPassive flexionDesigned in response to notion 3-5mm of
tendon gliding sufficient to prevent restrictive adhesions
Rehabilitation
Strickland (1980s-1990s)– Uses a 4 strand repair with epitendinous suture– Dorsal blocking splint with wrist at 20 deg of flexion– Supervised active ROM starts POD #3 – Unsupervised AROM at 4 weeks
Rarely used, because it requires a pretty extensive “bulky” repair to allow for early active ROM. A lot of surgeons thinks that too much suture material may be problematic for tendon healing
CHILDREN
Usually not able to reliably participate in rehabilitation programs
No benefit to early mobilization in patients under 16 years
Immobilization >4 wks may lead to poorer outcomes
Role for Botox?
DELAYED RECONSTRUCTION
Single Stage Tendon Grafting: Indications
Segmental tendon loss
Delay in definitive repair (>3-6 weeks)
Need – Full PROM– Competent pulleys
Single Stage Tendon Grafting Zone 2 Injuries
Graft donors– Palmaris longus– Plantaris– Long toe extensors– (FDS)– (EIP)– (EDM)
Two Stage ReconstructionIndications
Extensive soft tissue scarring– Crush injuries– Associated fractures, nerve injuries
Loss of significant portion of pulley system
Two Stage Reconstruction: Stage 1
Excision of tendon remnants Hunter rod then placed through pulley
system and fixed distally Reconstruct pulleys as needed if implant
bowstrings
Two Stage Reconstruction: Stage 2
Implant removal and tendon graft insertion– FDS transfer from adjacent digit described
Postop– Early controlled motion x 3 wks, then slow
progression to active motion
Two Stage Reconstruction
Patient selection– Motivated– Absence of neurovascular injury– Good passive joint motion
Balance benefits of two additional procedures in an already traumatized digit with amputation/arthrodesis
COMPLICATIONS
COMPLICATIONS
Joint contracture Adhesions Rupture Bowstringing Infection
MY PREFERENCE(Based on this review and the subsequent feedback)
MY PREFERENCE
Fix FDS and FDP asap - ideally within 7 days of injury
3.0 Proline modified Kessler stitch (one node inside)
If tendon is big enough use another 4.0 Proline modified Kessler stitch
Additional 5.0 Proline running epitendinous suture
Kleinert or Duran post-op protocol
OITE Question
Answer
OITE Question
OITE Imaging
Answer
THANK YOU
Special thanks to Daniel Marek MD for borrowing some of the slides