Anatomy

FLEXOR TENDON INJURYPRESENTER: DR. SOUVIK /DR.NAVEENMODERATOR:DR VIVEK SINGH

ANATOMYExtrinsic flexorsSuperficial groupPT, FCR, FCU, PLIntermediate groupFDS Deep groupFPL FDP

AnatomyCondensations of the fibrous retinacular sheath form the flexor pulleys

Cruciform pully:allow digital flexion to occur without significant deformation of annular pulley system

Annular pulley : stiffer and thicker A1A2A3A4A5

ZONE 1Contains only one tendon-FDPTendon laceration occurs close to its insertionTendon to bone repair is required

Green DP, JBJS 2002Kleinert and verdan classified into 5 anatomic zones

ZONE II-NO MANS LANDFrom metacarpal head to middle phalanxFDS n FDP within one sheathAdhesion formation risk is amplified at campers chiasm ZONE IIIB/W transverse carpal ligament and proximal margin of tendon sheath formationLumbricals origin here prevents profundus tendons from over acting

ZONE IVLies deep to deep transverse ligamentTendon injuries are rareLies proximal to transverse carpal ligament in the forearm ZONE V

DIAGNOSISHistoryClinical examinationSpecial tests

DiagnosisH/o trauma by sharp objects

completely transected :no active flexion and loss of tenodesis effect

Loss of inherent flexor tone and extended posture at PIP and DIP

Functional tests of FDS and FDP

light touch and static two-point discrimination

Capillary refill of the volar digital pulp and the nail bed

Flexor tendon repairTypes : Primary: first 12-24 hours of injury

Delayed primary repair : 24 hours to 10 days

Secondary repair: 10 to 14 days,

Late secondary repair: after 4 weeks

Ref campbell 12 th ed

Primary repairEmergency repair needed if altered digital perfusion present

Clean wound caused by sharp object.

Secondary repairIndicated if a/w extensive crushing with bony comminution severe neurovascular injurysevere joint injury and skin loss requiring a coverage procedure

Primary repair gives better functional outcomes than secondary repairs

Ref: Tang JB :Injury. 2006 Nov

Surgical IncisionsIncisions should not compromise viability of skin flaps shd not create contractures or cosmetically unsightly scars

Zigzag (Brunner) or midaxial incisions and midlateral incisions

Suture Materials

Core Non-absorbable 4/0 suture 4-0 or 3-0 prolene or mersilene suture may be used5-0 or 6-0 monofilament running epitenon suture.

Ref: J Bone Joint Surg Am.1998. Singer G,

Zone I InjuriesDirect repair (primary tenorraphy): laceration >1 cm from FDP insertion

Entire A4 annular pulley preserved

proximal tendon Retrieved by feeding tube and passed underneath A4 pulley

Tendon advancement(3 to 6 weeks with tendon degeneration and scar within the tendon sheath.

3. Large section of tendon has been damaged in zone 2 injury

4.Delayed presentation of FDP avulsion injuries associated with significant tendon retraction.

Boyes' Preoperative Classification

Grade 1 Good: Minimal scar with mobile joints and no trophic changes

Grade 2 Cicatrix: because of injury , failed primary repair or infection

Grade 3 Joint damage: with restricted range of motion

Grade 4 Nerve damage: resulting in trophic changes

Grade 5 Multiple damage: Involvement of multiple fingers with combination of above problems

From Boyes JH: J Bone Joint Surg Am 32:489-499, 1950.

Surgical principles One graft in each finger.Never sacrifice intact flexor digitorum superficialis (FDS).Graft of small caliber.Perform the junctions outside of the tendon sheath.Ensure adequate graft tension.

Graft choicesPalmaris longus[1] tendon present in approximately 85% of all individuals of sufficient length and size . Plantaris [2] when graft length is important. present in about 93% of population EDL[3]EI [3]EDM[3]FDS of unaffected finger[4]

Ref: 1. MARTIN I. BOYER.JBJS 20022.MorrisonWA J Hand Surg [Br]19923. HarveyFJ,J Hand Surg [Am]19834.SnowJW: Plast Reconstr Surg1968

Proximal anchoringTendon weave in any area outside the flexor sheath Stronger than the end-to-end suture techniques Allow to modulate graft tension

Ref:PulvertaftRG:JBJS Am1980;42:1363-1371. RankBK: 2nd ed.Edinburgh,E & S Livingstone,1988.

Distal anchoringProfundus stump not available:

Profundus stump available:

Technical Points 1cm FDP stump ,1 to 2cm FDS tendon near insertion Obtaining flexor graft Graft threaded under pulleys with suture passer(pediatric feeding tube/red rubber catheter Distal juncture created

Proximal juncture into the FDP tendon just distal to the lumbrical origin. (3 interweaves)

SourmelisSG:J Hand Surg Br1987;

.

In patients with DIP joint hyperextension, tenodesis or arthrodesis can be offered.

Postoperative Care Static dorsal blocking splint (4 to 6 weeks) with the wrist neutral, MP joints at 45 degrees, and IP joints neutral. Treat flexion contractures with passive stretching and splinting (6 to 8 weeks).

TWO-STAGE FLEXOR TENDON RECONSTRUCTION: STAGE I

Passive tendon implants at first surgery, placement of tendon graft at second surgery

Indications Crushing injuries a/w # or skin damage Damaged pulley system Excessive scarring of the tendon bed Failure of previous operations Contracted joints

Technical Points 1-cm FDP stump kept & proximal FDP tendon transected at the level of the lumbrical origin.

Through distal forearm incision identify the involved FDS tendon, draw it into the wound, and transect it near the musculotendinous junctionAppropriate size of the silicone implant.Assess pulley system

Pass implant from proximal palm to distal forearm between the FDP and FDS Distal juncture suture appliedROM checked

If implant assumes bowstring posture, pulley reconstruction done by Bunnell encircling method/ Kleinert technique

.

Postoperative Care :Splint with wrist in 35 degrees of flexion, MP joints at 60 to 70 degrees of flexion, and IP joints extended. Start passive motion on first postoperative visitContracture releases may benefit from dynamic splinting (6 to 8 weeks).

TWO-STAGE FLEXOR TENDON RECONSTRUCTION: STAGE II

Indication: Patient who underwent stage I of flexor reconstruction process

Interval between stages I and II :2-3 months.Hand must be soft, and joints well mobilized.

Surgical principles: Implant distal and proximal ends located Tendon graft obtained Graft sutured to proximal end of implant, and pull it distally through sheath.

Fix distal juncture and proximal juncture.(in palm or distal forearm)

.Proper tension of graft maintaining necessary

Postoperative Care

Apply a short arm dorsal blocking splint Protected passive range of motion early Dynamic splinting for contractures.

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