Professional Documents
Culture Documents
Rehabilitation
Moderator: Presenter:
Dr. Maninder shah
Dr. Amit goyal
singh
Jr. Resident DNB
Sr. consultant and Ortho
chief Foot and
Dept. of Orthopaedics
ankle services
What we need to know?
ZONE II:
critical area of pulleys (bunnell’s “no man’s land”)
Contains both FDP & FDS tendons
Between distal palmar crease & insertion of sublimis tendon.
IIc : it is area in which satisfactory functional recovery is most difficult to achieve after 10 repair of both FDP
& FDS tendons.
Includes fibroosseous sheath extending just proximal to metacarpal head & MCP joint.
ZONE III: comprises area of lumbrical origin
Between distal margin of transverse carpal ligament & beginning of critical area of pulleys or 1st
annulus.
Area of metacarpal beneath thenar muscles
ZONE IV:
Zone covered by transverse carpal ligament
Corresponds to carpal tunnel
ZONE V:
Zone proximal to transverse carpal ligament and include forearm
Distal forearm just proximal to wrist.
The initial evaluation of a patient with a flexor tendon injury is important for
•
PATIENT EVALUATION:
Formulating a diagnosis
• Establishing a treatment plan
• Counseling the patient regarding expected outcomes.
The mechanism of injury has implications for
• Quality of the tendon
• status of the surrounding soft tissues.
A sharp laceration is more likely to have a cleanly cut tendon end and less soft tissue
damage than a crushing or avulsion type mechanism.
The position of the finger at the time of injury can help predict the location and lengths
z In the absence of any concomitant bone or joint Injuries, a digit with lacerated FDP
and FDS tendons will assume an extended position (Fig. 1)
• In this scenario, the tenodesis effect, which would typically cause flexion of the digit, will not occur.
Each flexor tendon must be examined
independently
Stabilizing the middle phalanx of
the injured digit and asking the
patient to actively flex the Dip
joint isolates the FDP.
During tendon suturing, handling should be gentle & delicate, causing as little reaction & scaringas
possible.
Pinching & grasping of uninjured surfaces should be avoided, as it can contribute to adhesions formation.
Strickland stressed 6 characteristics of an ideal tendon repair:
1. Easy placement of sutures in tendon
2. Secure suture knots
3. Smooth juncture of tendon ends
4. Minimal gapping at repair site
5. Minimal interference with tendon vascularity
6. Sufficient strength throughout healing to permit application of early motion stress to tendon.
SUTURE MATERIAL:
Although monofilament stainless steel has highest tensile strength,
Difficult to handle
Tends to pull through the tendon limits use in fingers
Makes a large knot
Can be used satisfactorily in distal forearm
Catgut & polyglycolic acid group(dexon, vicryl) becomes weak too early after surgery
Synthetic sutures of caprolactum family & nylon maintain their resistance to disrupting forces longer
than polypropylene (prolene) & polyester suture.
Polydioxanone has been shown to be strong as polypropylene.
Flexor Tendon Injuries of the Hand
DAVID P. SCHNUR, MD • LAWRENCE L. KETCH, MD
Schnur DP, Ketch LL. Flexor Tendon Injuries of the Hand. InSurgical Decision Making (Fifth Edition)
Comparison of polyglycolide-trimethylene carbonate & polydioxanone found
Polydioxanone repairs maintained better strength over 28 days.
Monofilament nylon permitted earlier gap formation & failure of the repair compared with braided polyester.
In biomechanical study
Braided polyethylene & braided stainless steel wire are most suitable mechanically.
Braided polyester was intermediate.
Monofilament nylon & polypropylene were least satisfactory.
In cadaver biomechanical analysis
Intratendendious, crimped, single-strand, multifilament stainless steel device (teno fix) compared favorably
with 4-strand cruciate repairs.
Intratendendious device group had lower rupture rate & compared favorable in grip, pinch strength.
SUTURE CONFIGURATIONS:
Various tendon repair types can be divided into 3 groups:
1. Group 1: exemplified by simple sutures; suture pull is
parallel to tendon collagen bundle, transmitting stress of
repair directly to opposing tendon ends.
2. Group 2: exemplified by bunnell suture; stress is transmitted
directly across juncture by suture material & depends on
strength of suture.
Complete immobllizallon after flexor tendon repair is indicated only in limited situations such as
pediatric patients,
patients with concomitant bone or soft tissue Injuries requiring immobilization,
patients who are unable to comply with a protected motion protocol
In most cases, a protected motion protocol is used postoperatively
Early motion of flexor tendons improves recovery of tensile strength, decreases adhesions,
improves tendon excursion, and promotes Intrinsic healing
optimal time for initiating therapy has not been established, but can be as early as the first
postoperative day.
Experimentally, Gliding resistance has been shown to be lowest on the fifth postoperative day, but the extent
to which this is clinically relevant has not been documented
Rehabilitation protocols that emphasize higher degrees of excursion of the tendons with
low applied force have been shown to be beneficial.
Various postoperative protocols exist. The selection of a specific protocol is dependent on
the strength of repair and the compliance of the Patient
The Kleinert and Duran protocols are Passive motion protocols, which use dorsal
blocking splints to limit wrist and digital extension.
The Kleinert protocol uses a rubber band attached to the nail plate to effect passive
flexion of the digit. Active extension exercises are performed to the limit of the splint.
The Duran protocol uses controlled passive motion, alternating DIP flexion, PIPflexion
& full composite flexion
Recently, protocols that permit early active motion have been increasingly used.
This can be accomplished by the use of a hinged dorsal blocking splint, which at
baseline holds the wrist in 200 of Flexion, the MP joints in 50°, and the IP joints
extended, but has a removable block that allows the splint to extend 300 at thewrist.
Patients are instructed to passively flex the digits into the palm.
The wrist is then gently extended while the digits are actively maintained in flexion.
This "place and hold“ maximizes intrasynovial excursion while minimizing force at
the repair site
Given that active motion increases the force across the repair site and risk of rupture,
these protocols require strict patient compliance and a controlled environment.
In a systemic review of postoperative protocols after tendon repair, passive protocols
had a statistically significant lower risk of rupture but also had a higher risk of decreased
range of motion.
In a recent prospective randomized study comparing active place-and-hold therapy and
passive-motion therapy, Trumble and colleagues found greater active interphalangeal
joint motion at all time points with early active motion without an increased risk of
rupture.
Factors associated with poor outcomes include smoking, multiple digit Injury, and
concomitant nerve injury
It remains unknown whether an injury to a specific digit causes more disability than others,
but active therapy in the small finger has been associated with more ruptures.
Trumble and colleagues reported significantly better combined active flexion of the injured
digit with less PIP and DIP joint contracture when treated by certified hand therapists for
both active-therapy and passive-therapy groups.
Matarrese and Hammert recommend Initiating postoperative exercises supervised by hand
therapists within 5 days.
SUMMARY
Flexor tendon injury remains a challenging problem in hand surgery due to intimate
anatomy of the FDP, FDS & pulley system.
Repair need to be strong enough to begin early range of motion, while avoiding bulkiness
within confines of pulley system.
Currently, although many repair configurations are acceptable, it is recommended that at
minimum 4-strand core suture repair with epitendinous suture is used.
Although every attempts should be made to repair both FDP & FDS tendon, sacrificing one
limb of FDS is acceptable should a repair become too bulky with A2 pulley.
Venting of pulley system should be done prudently to allow smooth gliding of repaired tendon
while avoiding excessive release.
Compliance with postoperative motion protocols is vital in securing a successful results.
Future advances in the biology of tendon healing may aid in better outcomes, but ultimately, the
healing of the tendon repair is dependent on the surgeon, the patient & the therapist.
MANCHESTER SMALL SPLINT
THANK YOU
The Saint John Protocol
\ manchester short splint
• Rust RA, Eckersley R. Twenty questions on tendon
injuries in the hand. Curr Orthop. 2008;22:17–24