FLEXOR TENDON INJURIES OF THE HAND

Michael Zlowodzki MD
PGY-3 Resident University of Minnesota Department of Orthopaedic Surgery

OUTLINE
Anatomy Clinical assessment Treatment depending on Zone of injury Tendon healing biology Repair techniques Post-op motion protocols Delayed 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 .

FDS FDP FPL Lumbricals origin from radial side of FDP .

the two portions of the FDS reunite at “Camper’s Chiasma” .CAMPER’s CHIASMA  FDS divides and passes around the FDP tendon.

.

TENDON SHEETS .

NOTE: There is a mistake in this diagram: The C1 pulley is DISTAL to the A2 pulley! .PULLEYS Preserve A2 and A4 pulley to prevent bowstringing.

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 .

5 mm of excursion per 10 degrees of joint motion for DIP (FDP) and PIP (FDS. FDP) .TENDON EXCURSION MP motion = no flexor tendon excursion 1.

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 palm Type 2: Retraction to PIP level Type 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 .

.

as moving the repair site out of the sheath was felt to decrease adhesion formation – Disadvantages • Shortening of flexor system • Contracture • Quadriga effect .Tendon Advancement – Previously advocated for zone 1 repairs.

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 .

debride if necessary dorsal block splinting for 6 to 8 weeks .Partial laceration No repair if 40% of the tendon intact Potential complications: –Triggering –Tendon entrapment Eval for the risk of triggering.

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% .– N=15 patients with zone II partial flexor tendon lacerations of the width of the tendon (Avg.

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? FIX FDP AND FDS! 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) .

.

COMPLICATIONS Stiffness Re-rupture Tenolysis 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.Fibroblastic (5-28 days) : or so-called collagen-producing phase 3.Inflammatory (0-5 days) : strength of the repair is reliant on the strength of the suture itself 2.4months) TENDON WEAKEST @ 10-14 DAYS .Remodelling (28 days .

BRUNNER INCISION .

.

.

SUTURE TECHNIQUES .

.

Kessler .

.Modified Kessler (1 suture)  Advantage: Only one node inside the repair site.0 Proline to reapproximate tendon edges. Easier to use a monofilament suture like a 4.

Kessler-Tajima
(2 sutures)

SUTURE MATERIAL
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

SUTURE KNOT LOCATION
IN: Interference with healing

OUT: Interference with tendon gliding

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 RUPTURE To little motion STIFFNES .

passive flexion by rubber bands 2. Duran: Controlled Passive Motion Methods 3.POST-OP PROTOCOLS 1. Kleinert: Active extension. Strickland: Early active ROM GOAL: FULL ACTIVE ROM @ 10-12 weeks .

Kleinert 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. A lot of surgeons thinks that too much suture material may be problematic for tendon healing . because it requires a pretty extensive “bulky” repair to allow for early active ROM.

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) .

nerve injuries Loss of significant portion of pulley system .Two Stage Reconstruction Indications Extensive soft tissue scarring – Crush injuries – Associated fractures.

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 .