Tendon injuriesTendon injuries

Robert Spławski MD, PhDPaweł Surdziel MD, PhDRobert Spławski MD, PhDPaweł Surdziel MD, PhD

Department of Traumatology and Hand SurgeryDepartment of Traumatology and Hand Surgery

University of Medical SciencesUniversity of Medical Sciences in Poznan in PoznanUniversity of Medical SciencesUniversity of Medical Sciences in Poznan in Poznan

Head of Department:Head of Department:Prof. Władysław ManikowskiProf. Władysław ManikowskiHead of Department:Head of Department:Prof. Władysław ManikowskiProf. Władysław Manikowski

Historical notesHistorical notes

Tendon surgery is as old as surgery Tendon surgery is as old as surgery itselfitself

2698 BC – Yu-Fu2698 BC – Yu-Fu460460BC – HippocratesBC – Hippocrates280 BC – Herophilos 280 BC – Herophilos fromfrom Chalkedon Chalkedon129-199 – Galen129-199 – Galen980-1037 – Avicenna980-1037 – Avicenna1641- Ambrosius Pare1641- Ambrosius Pare1880 - Nikoladoni1880 - Nikoladoni1881 – Gluck1881 – Gluck1882 – Henck1882 – Henck

Historical notesHistorical notes

Historical notesHistorical notes

Hippocrates – if injury of Achilles tendon occurHippocrates – if injury of Achilles tendon occurs it would s it would cause acute fever, convulsins etc.cause acute fever, convulsins etc.Avicenna - tenth century strongly advocated tendon sutureAvicenna - tenth century strongly advocated tendon sutureWorld War I and II stimulated the development of modern World War I and II stimulated the development of modern hand hand surgerysurgery

Tendon Tendon cconsistonsistss of : of :• Cells – fobroblastsCells – fobroblasts• Extracellular matrixExtracellular matrix mainly collagen fibers, mainly collagen fibers, elastinelastin fibers fibers ground substance ground substance (proteoglicans, glycosaminoglycans, (proteoglicans, glycosaminoglycans,

structural proteins, plasma proteins and other small molecules)structural proteins, plasma proteins and other small molecules)

CollagenCollagen

typI – composed of three chains typI – composed of three chains 70% glicine, 15% proline and 15% hydroxyproline70% glicine, 15% proline and 15% hydroxyproline

Collagen molecules are combined in a right-handed tripleCollagen molecules are combined in a right-handed triplehelix. helix. The sThe stabilisation between helixs tabilisation between helixs is maintain is maintain by by hydrogens bonds.hydrogens bonds.

Collagen molecule

micro fibrils

Fibril of collagen

tendon

epitendon

endotendon

Blood supplyBlood supply

1 artery, 1 veins, a lot of nervs

2 fascicls – 1 artery , 1vein, 2-3 nervs

2 arteris, 2 veins , a lot of small arteries

5 fascicles – 1 artery i 2 veins

Blood supplyBlood supply

Blood supplyBlood supply

Flexor tendon nutrition

Tendon healingTendon healing

Tendon healingTendon healing

Zones of flexor tendon injury

Primary flexor tendon suturePrimary flexor tendon sutureDelayed flexor tendon sutureDelayed flexor tendon suture

Secondary repair /late reconstruction/Secondary repair /late reconstruction/- - one stage tendon reconstructionone stage tendon reconstruction- - two stage tendon reconstructiontwo stage tendon reconstruction

TreatmentTreatment

Zone I Reinsertion after avilsion injuryReinsertion after avilsion injuryEnd to end sutureEnd to end suture

Zone II End to end sutureEnd to end suture

Zone III End to end sutureEnd to end suture

TreatmentTreatment

1.1. Active extension-Active extension-ppassive flexion assive flexion Kleinert Kleinert method method ooff rehabilitation rehabilitation

2.2. Controlled passive motion -Controlled passive motion -Duran-HouserDuran-Houser method method /active motion after 5 weeks//active motion after 5 weeks/

3.3. Controlled active motion methodControlled active motion method..

Active extension-passive flexion

PM

CAM

Tendon reconstructionTendon reconstruction

Primary end to end tendon suture. To 3-4 weeks.Primary end to end tendon suture. To 3-4 weeks.Secondary - staged techniquesSecondary - staged techniques

single stage – good conditionssingle stage – good conditions

two stage – after complicated injuristwo stage – after complicated injuris1-st stage – endoprothesis1-st stage – endoprothesis2-nd stage – tendon graft.2-nd stage – tendon graft.

Secondary Secondary tendon tendon repairrepair

1.1.One stage reconstruction One stage reconstruction FTG /free tendon graft/ FTG /free tendon graft/

1.1. Bunnel1.1. Bunnel graft zone graft zone I-III I-III I° wg Boys`aI° wg Boys`a

1.2. Matev 1.2. Matev graft zone graft zone I-VI-V

1.3. 1.3. Interposition graftInterposition graft III-V III-V

2. TFTI (temporary flexor tendon implant)2. TFTI (temporary flexor tendon implant)

2.1. 2.1. ShortShort graft graft I-IIII-III

2.2. 2.2. LongLong tendon graft tendon graft I-VI-V

Tendon reconstructionTendon reconstruction

Tendon graftsTendon grafts

Short – zone 1-3Short – zone 1-3Long – zone 1-5Long – zone 1-5

Prostowniki

Mallet fingerMallet finger

Type I- closed trauma , with or without small avulsion fracture

Type II- laceration, loss of tendon continuity

Type III- II+deep abrasion

Type IV- A-transepiphiseal plate fracture; B- fracture of artic. surf. 20-50%; C- fracture of artic. surf. >50% , or subluxation aDIP

Zone I

Zone I

Zone II

1.1.Open injuryOpen injury – – tendon suturetendon suture; ; immobilization in immobilization in hyperextension for 6 weekshyperextension for 6 weeks..

2.2.Closed injury- Closed injury- split in hyperextension insplit in hyperextension in aPIP aPIP

Zones III, IV,V

Open injury:- tendon suture, immobilization aPIP 0° to 5-6 weeks -

exercise- Zone V – wrist immobilization in flexion 40°. MP joints in

flexion 10-20°.

Closed injury:- splint for 6 weeks

Zones VI-IX

End to end tendon suture.Immobilization – wrist in hyperextension 40-45° for 4-5 weeks

Controlled active flexion –passive extension