Tendon injuriesRobert Spawski MD, PhDPawe Surdziel MD, PhDDepartment of Traumatology and Hand SurgeryUniversity of Medical Sciences in PoznanHead of Department:Prof. Wadysaw Manikowski

Historical notesTendon surgery is as old as surgery itself

2698 BC Yu-FuBC Hippocrates280 BC Herophilos from Chalkedon129-199 Galen980-1037 Avicenna1641- Ambrosius Pare1880 - Nikoladoni1881 Gluck1882 HenckHistorical notes

Historical notesHippocrates if injury of Achilles tendon occurs it would cause acute fever, convulsins etc.Avicenna - tenth century strongly advocated tendon sutureWorld War I and II stimulated the development of modern hand surgery

Tendon consists of :Cells fobroblastsExtracellular matrix mainly collagen fibers, elastin fibers ground substance (proteoglicans, glycosaminoglycans, structural proteins, plasma proteins and other small molecules)

Collagen

typI composed of three chains 70% glicine, 15% proline and 15% hydroxyprolineCollagen molecules are combined in a right-handed triplehelix. The stabilisation between helixs is maintain by hydrogens bonds.

Collagen moleculemicro fibrilsFibril of collagentendonepitendonendotendon

Blood supply

1 artery, 1 veins, a lot of nervs2 fascicls 1 artery , 1vein, 2-3 nervs2 arteris, 2 veins , a lot of small arteries5 fascicles 1 artery i 2 veinsBlood supply

Blood supply

Flexor tendon nutrition

Tendon healing

Tendon healing

Zones of flexor tendon injury

Primary flexor tendon sutureDelayed flexor tendon suture

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

TreatmentZone IReinsertion after avilsion injuryEnd to end sutureZone IIEnd to end sutureZone IIIEnd to end suture

TreatmentActive extension-passive flexion Kleinert method of rehabilitationControlled passive motion -Duran-Houser method /active motion after 5 weeks/3.Controlled active motion method.

Active extension-passive flexion

PM

CAM

Tendon reconstructionPrimary end to end tendon suture. To 3-4 weeks.Secondary - staged techniques

single stage good conditions

two stage after complicated injuris1-st stage endoprothesis2-nd stage tendon graft.

Secondary tendon repair1.One stage reconstruction FTG /free tendon graft/1.1. Bunnel graft zone I-IIII wg Boys`a1.2. Matev graft zone I-V1.3. Interposition graft III-V2. TFTI (temporary flexor tendon implant)2.1. Short graft I-III2.2. Long tendon graft I-V

Tendon reconstructionTendon grafts

Short zone 1-3Long zone 1-5

Prostowniki

Mallet fingerType I- closed trauma , with or without small avulsion fractureType II- laceration, loss of tendon continuityType III- II+deep abrasionType IV- A-transepiphiseal plate fracture; B- fracture of artic. surf. 20-50%; C- fracture of artic. surf. >50% , or subluxation aDIPZone I

Zone I

Zone II1.Open injury tendon suture; immobilization in hyperextension for 6 weeks.

2.Closed injury- split in hyperextension in aPIP

Zones III, IV,VOpen injury:tendon suture, immobilization aPIP 0 to 5-6 weeks - exerciseZone V wrist immobilization in flexion 40. MP joints in flexion 10-20.Closed injury:- splint for 6 weeks

Zones VI-IXEnd to end tendon suture.Immobilization wrist in hyperextension 40-45 for 4-5 weeks

Controlled active flexion passive extension

createI distal to insertion FDSII so colled no man`s land because of difficulty of returning flaexor tendon function afert injury in this area.III zone of lumbrical origin distal to the distal edge of transverse carpal ligamentIV carpal tunnel zoneV- forearm zoneDigital canalHow to recognize the tendon injury? We can see difference between digit position result of the tendon tension.Tendon graft . It`s plantar muscle tendon graft.