FLEXOR TENDON

INJURIES OF THE HAND

Michael Zlowodzki MD
PGY-3 Resident
University of Minnesota
Department of Orthopaedic
Surgery
OUTLNE
Anatomy
Clinical assessment
Treatment depending on Zone of injury
Tendon healing biology
Repair techniques
Post-op motion protocols
Delayed grafting
ANATOMY
DS
Origin (2 muscle bellies)
Medial epicondyle
Radial shaft
Tendons arise from separate
muscle bundles
ACT INDEPENDANTLY
DP
Origin: ulna & interosseous membrane
DP: Common muscle origin for several
tendons
SIMULTANEOUS FLEXION OF
MULTIPLE DIGITS
FDP
DS
DP
PL
Lumbricals
origin from
radial side of
DP
CAMPER's CHASMA
DS divides and passes around the DP tendon, the
two portions of the DS reunite at "Camper's
Chiasma
TENDON SHEETS
Preserve A2 and A4 puIIey to prevent bowstringing. NOTE: There is a Preserve A2 and A4 puIIey to prevent bowstringing. NOTE: There is a
mistake in this diagram: The C1 puIIey is DISTAL to the A2 puIIey! mistake in this diagram: The C1 puIIey is DISTAL to the A2 puIIey!
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 EXCURSON
MP motion = no flexor tendon excursion
1.5 mm of excursion per 10 degrees of
joint motion for DP (DP) and PP (DS,
DP)
LOOD SUPPLY
Segmental branches of digital arteries
which enter the tendon through:
vincula
osseous insertions
Synovial fluid diffusion
'INCULAE
CLINICAL
EXAM
FDS: CIinicaI Exam
TENODESS EECT
Passive extension of the wrist does not produce the
normal "tenodesis flexion of the fingers if flexors are
injured
FDS: CIinicaI Exam
FDP: CIinicaI Exam
DP RUPTURE
No active DP motion (present passive DP
motion)
ONES
REPAIR ALL COMPLETE TEARS AT
ALL LE'ELS!
ONE 1
INJURIES:
Jersey
Finger
ERSEY NGER
ERSEY NGER
LEDDY CLASSCATON
Type 1: Retraction into palm
Type 2: Retraction to PP level
Type 3: ony avulsion (tendon attached)
Type 4: ony avulsion (tendon attached
not attached to bony fragment)
REPAIR WITHIN 7-10 DAYS
TYPES O REPAR
Direct repair: if laceration is more than 1
cm from DP insertion
Tendon advancement: if the laceration is
less then 1 cm from insertion.
TENDON ADVANCEMENT
UTTON 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
QUADRGA EECT
f DP tendon advanced too distally
Entire muscle bells gets pulled distally
Tendon excursion of DP of other digits is limited
Loss of grip strength
ONE 2
INJURIES
ZONE 2 NURES
Zone 2: Deep and superficial flexor gliding inside
tendon sheets
Traditionally "No man's land: Stiffness after repair
NURY: Tendons retract
ONE 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 partial flexor
tendon lacerations of the width of the tendon
(Avg. 71%)
Conservative treatment:
Dorsal blocking splint with wrist in 10 of flexion
mmediate guarded active ROM
Splint removed @ 4w
No restriction @ 6w
excellent results in 93% and good in 7%
hy not fix a partial laceration when
you staring at it in the OR anyway?
ecause the dissection necessary to fix it
might cause too much scarring, which
might outweigh the benefit
ONE 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
ncreased bulk and resistance to glide
ncreased 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
ix DP and DS or just DP?
hy?
ecause the blood supply to the DP
tendon is jeopardized if the DS is not
also fixed (due to the vinculae anatomy)
Personal communication: Dr. James House)
FIX FDP AND FDS!
COMPLCATONS
Stiffness
Re-rupture
Tenolysis may be required in an estimated
18% to 25% of patients
No earlier than 3 months after repair
f no ROM improvement for 1-2 months
ONE 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).
ONE 4
INJURIES
ZONE 4: Carpal Tunnel
TENDON
HEALING
lexor tendon healing
Intrinsic heaIing: occurs without direct
blood flow to the tendon
Extrinsic heaIing: occurs by
proliferation of fibroblasts from the
peripheral epitenon
adhesions occur and limit tendon gliding
PHASES O TENDON HEALNG
1.nflammatory (0-5 days) : strength of the
repair is reliant on the strength of the
suture itself
2.ibroblastic (5-28 days) : or so-called
collagen-producing phase
3.Remodelling (28 days - 4months)
TENDON WEAKEST @ 10-14 DAYS
RUNNER
INCISION
SUTURE
TECHNIQUES
essler
Modified essler
(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.
essler-Tajima
(2 sutures)
SUTURE MATERAL
Non-absorbable
Most 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 heaIing
OUT: Interference
with tendon gIiding
SUTURE NOT LOCATON
SUTURE NOT LOCATON
nots 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 REPAR
Advantages
arrier to extrinsic adhesion formation
More rapid return of synovial nutrition
Disadvantages
Technically difficult
ncreased foreign material at repair site
May narrow sheath and restrict glide
NO CLEAR AD'ANTAGE
ESTALISHED
POST-OP
REHA
HSTORCAL
unnel (1918)
Postoperative immobilization
Active motion beginning at 3 wks postop.
Suboptimal results by today's standards
mproved suture material/technique as well as
postoperative rehabilitation protocols
STIFFNESS
RUPTURE
Too much motion
To little motion
RUPTURE
STIFFNES
POST-OP PROTOCOLS
1. leinert: Active extension, passive
flexion by rubber bands
2. Duran: Controlled Passive Motion
Methods
3. Strickland: Early active ROM
GOAL: FULL ACTI'E ROM @
10-12 weeks
leinert Protocol
Duran protocol
DURAN PROTOCOL
Dorsal Splint in 20 deg wrist flexion
No rubber bands
Passive flexion
Designed 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
CHLDREN
Usually not able to reliably participate in
rehabilitation programs
No benefit to early mobilization in patients
under 16 years
mmobilization >4 wks may lead to poorer
outcomes
Role for otox?
DELAYED
RECONSTRUCTION
Single Stage Tendon Grafting:
ndications
Segmental tendon
loss
Delay in definitive
repair (>3-6 weeks)
Need
ull PROM
Competent pulleys
Single Stage Tendon Grafting
Zone 2 njuries
Graft donors
Palmaris longus
Plantaris
Long toe extensors
(DS)
(EP)
(EDM)
Two Stage Reconstruction
ndications
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
mplant removal and tendon graft insertion
DS 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
alance benefits of two additional
procedures in an already traumatized digit
with amputation/arthrodesis
COMPLICATIONS
COMPLCATONS
oint contracture
Adhesions
Rupture
owstringing
nfection
MY PREFERENCE
(ased on this review and the subsequent feedback)
MY PREERENCE
ix DS and DP asap - ideally within 7
days of injury
3.0 Proline modified essler stitch (one
node inside)
f tendon is big enough use another 4.0
Proline modified essler stitch
Additional 5.0 Proline running
epitendinous suture
leinert or Duran post-op protocol
OTE Question
Answer
OTE Question
OTE maging
Answer
THANK YOU
SpeciaI thanks to DanieI Marek MD for
borrowing some of the sIides