Flexor Tendons - Anatomy, Injury, Treatment

Flexor TendonInjuriesC. Noel Henley, MD

Flexor TendonInjuriesIU Orthopaedic SurgeryC. Noel Henley, MD

Flexor TendonInjuriesIU Orthopaedic SurgeryApril 5, 2006C. Noel Henley, MD

Talk Summary

Talk Summary• Introduction

Talk Summary• Introduction• Basic science – anatomy – nutrition – biomechanics – healing• Surgical considerations – lacerations – avulsions• Rehabilitation

Introduction

Introduction• History

Introduction• History – no repair possible in the digit

Introduction• History – no repair possible in the digit – “no man’s land”

Introduction• History – no repair possible in the digit – “no man’s land”• Current evidence

Introduction• History – no repair possible in the digit – “no man’s land”• Current evidence – 1970s: repair is possible without delayed grafting, reconstruction

Introduction• History – no repair possible in the digit – “no man’s land”• Current evidence – 1970s: repair is possible without delayed grafting, reconstruction – Now: adhesion-free, primarily healed tendon repair is possible

Introduction

Introduction• General goals of repair

Introduction• General goals of repair – primary tendon repair – avoid grafting

Introduction• General goals of repair – primary tendon repair – avoid grafting – suﬃcient strength for passive motion rehab which will allow for

Introduction• General goals of repair – primary tendon repair – avoid grafting – suﬃcient strength for passive motion rehab which will allow for • minimum adhesion formation

Introduction• General goals of repair – primary tendon repair – avoid grafting – suﬃcient strength for passive motion rehab which will allow for • minimum adhesion formation • restoration of gliding surface

Introduction• General goals of repair – primary tendon repair – avoid grafting – suﬃcient strength for passive motion rehab which will allow for • minimum adhesion formation • restoration of gliding surface • facilitation of repair site healing

Anatomy

Anatomy • FDS

Anatomy • FDS – O: volar humerus, radius, ulna

Anatomy • FDS – O: volar humerus, radius, ulna – divided muscle belly in mid forearm (FA)

Anatomy • FDS – O: volar humerus, radius, ulna – divided muscle belly in mid forearm (FA) • super cial – long and ring ngers (LF, RF)

Anatomy • FDS – O: volar humerus, radius, ulna – divided muscle belly in mid forearm (FA) • super cial – long and ring ngers (LF, RF) • deep – index and small ngers (IF, SF)

Anatomy • FDS – O: volar humerus, radius, ulna – divided muscle belly in mid forearm (FA) • super cial – long and ring ngers (LF, RF) • deep – index and small ngers (IF, SF) • FDP

Anatomy • FDS – O: volar humerus, radius, ulna – divided muscle belly in mid forearm (FA) • super cial – long and ring ngers (LF, RF) • deep – index and small ngers (IF, SF) • FDP – O: anteromedial ulna, IO membrane

Anatomy • FDS – O: volar humerus, radius, ulna – divided muscle belly in mid forearm (FA) • super cial – long and ring ngers (LF, RF) • deep – index and small ngers (IF, SF) • FDP – O: anteromedial ulna, IO membrane – dorsal to FDS in volar FA

Anatomy • FDS – O: volar humerus, radius, ulna – divided muscle belly in mid forearm (FA) • super cial – long and ring ngers (LF, RF) • deep – index and small ngers (IF, SF) • FDP – O: anteromedial ulna, IO membrane – dorsal to FDS in volar FA – four tendons usually arise from common belly

Anatomy

Anatomy• In the hand

Anatomy• In the hand – ve zones

Anatomy• In the hand – ve zones • V: musculo-tendinous junction to proximal edge of carpal canal

Anatomy• In the hand – ve zones • V: musculo-tendinous junction to proximal edge of carpal canal • IV: beneath (dorsal to) the transverse carpal ligament

Anatomy• In the hand – ve zones • V: musculo-tendinous junction to proximal edge of carpal canal • IV: beneath (dorsal to) the transverse carpal ligament – IF, SF FDS are dorsal to LF, RF FDS here

Anatomy

Anatomy• Zones (cont.)

Anatomy• Zones (cont.) – III: distal edge of transverse carpal ligament to origin of bro-osseous sheath at the distal palmar crease

Anatomy• Zones (cont.) – III: distal edge of transverse carpal ligament to origin of bro-osseous sheath at the distal palmar crease – II: origin of bro-osseous sheath to FDS insertion

Anatomy• Zones (cont.) – III: distal edge of transverse carpal ligament to origin of bro-osseous sheath at the distal palmar crease – II: origin of bro-osseous sheath to FDS insertion – I: distal to FDS insertion

Anatomy

Anatomy • Super cialis

Anatomy • Super cialis – FDS divides into two slips, wrapping around FDP; reunite at Camper’s chiasma

Anatomy • Super cialis – FDS divides into two slips, wrapping around FDP; reunite at Camper’s chiasma – continues to insert along the proximal half of the middle phalanx (P2)

Anatomy

Anatomy • Profundus

Anatomy • Profundus – passes through chiasma to insert at proximal base of distal phalanx (P3)

Anatomy • Profundus – passes through chiasma to insert at proximal base of distal phalanx (P3) – FDP = primary digital exor

Anatomy • Profundus – passes through chiasma to insert at proximal base of distal phalanx (P3) – FDP = primary digital exor – FDS + intrinsics combine for forceful exion

Anatomy

Anatomy • Sheath

Anatomy • Sheath – visceral and parietal synovial layers enclose the tendons

Anatomy • Sheath – visceral and parietal synovial layers enclose the tendons – Pulleys

Anatomy • Sheath – visceral and parietal synovial layers enclose the tendons – Pulleys • A2 and A4 arise from periosteum of proximal P1 and midportion of P2 (prox- prox and mid-middle)

Anatomy

Anatomy • Sheath

Anatomy • Sheath – Pulleys

Anatomy • Sheath – Pulleys • A1, A3, and A5 arise from volar plates of MCP, PIP, and DIP joints respectively

Anatomy

Anatomy • Sheath

Anatomy • Sheath – Pulleys

Anatomy • Sheath – Pulleys • cruciate pulleys collapse to allow annular pulley apposition during exion

Nutrition

Nutrition • Two sources of tendon nutrition

Nutrition • Two sources of tendon nutrition – vascular

Nutrition • Two sources of tendon nutrition – vascular – synovial

Nutrition • Two sources of tendon nutrition – vascular – synovial • Vascularity sources

Nutrition • Two sources of tendon nutrition – vascular – synovial • Vascularity sources – longitudinal vessels

Nutrition • Two sources of tendon nutrition – vascular – synovial • Vascularity sources – longitudinal vessels – proximal synovial fold vessels

Nutrition • Two sources of tendon nutrition – vascular – synovial • Vascularity sources – longitudinal vessels – proximal synovial fold vessels – segmental branches from paired digital vessels (vincular system)

Nutrition • Two sources of tendon nutrition – vascular – synovial • Vascularity sources – longitudinal vessels – proximal synovial fold vessels – segmental branches from paired digital vessels (vincular system) – insertional vessels at FDP, FDS insertions

Nutrition

Nutrition • Avascular segments

Nutrition • Avascular segments – FDP and FDS: over proximal phalanx

Nutrition • Avascular segments – FDP and FDS: over proximal phalanx – FDP: short zone over middle phalanx

Nutrition • Avascular segments – FDP and FDS: over proximal phalanx – FDP: short zone over middle phalanx • Synovial uid diﬀusion

Nutrition • Avascular segments – FDP and FDS: over proximal phalanx – FDP: short zone over middle phalanx • Synovial uid diﬀusion – imbibition

Nutrition

Nutrition • Vascularity

Nutrition • Vascularity – damage to vascular and uid nutritional systems may further hamper healing of repaired exor tendons

Nutrition • Vascularity – damage to vascular and uid nutritional systems may further hamper healing of repaired exor tendons – their integrity must be respected during all reparative eﬀorts

Nutrition

Biomechanics

Biomechanics • Excursion

Biomechanics • Excursion – 9 cm of excursion for composite wrist, full digital exion

Biomechanics • Excursion – 9 cm of excursion for composite wrist, full digital exion – 2.5 cm required for full digital exion with wrist at neutral

Biomechanics

Biomechanics • Moment arm

Biomechanics • Moment arm – increased distance of tendon from joint center of rotation = higher moment arm = less motion per muscle contraction force

Biomechanics

Biomechanics• Moment arm

Biomechanics• Moment arm – pulley system constraint governs these parameters

Biomechanics• Moment arm – pulley system constraint governs these parameters – loss of portions of pulley system may alter balance between exor, intrinsic, and extensor tendons

Biomechanics• Moment arm – pulley system constraint governs these parameters – loss of portions of pulley system may alter balance between exor, intrinsic, and extensor tendons – loss of A2 or A4 pulleys may diminish motion/power or lead to contractures of IP joints

Tendon Healing

Tendon Healing • Phases

Tendon Healing • Phases – in ammatory – 48-72 hours

Tendon Healing • Phases – in ammatory – 48-72 hours • repair strength reliant upon suture itself

Tendon Healing • Phases – in ammatory – 48-72 hours • repair strength reliant upon suture itself – collagen-producing phase – 5 days to 4 weeks

Tendon Healing • Phases – in ammatory – 48-72 hours • repair strength reliant upon suture itself – collagen-producing phase – 5 days to 4 weeks • strength accelerates rapidly here

Tendon Healing • Phases – in ammatory – 48-72 hours • repair strength reliant upon suture itself – collagen-producing phase – 5 days to 4 weeks • strength accelerates rapidly here – remodeling phase – until 112 days

Tendon Healing • Phases – in ammatory – 48-72 hours • repair strength reliant upon suture itself – collagen-producing phase – 5 days to 4 weeks • strength accelerates rapidly here – remodeling phase – until 112 days • Predominance of extrinsic over intrinsic healing leads to more adhesions

Tendon Healing inflammatory

Tendon Healing collagen-producing

Tendon Healing remodeling

Tendon Healing

Tendon Healing• Adhesion formation and control

Tendon Healing• Adhesion formation and control – Contributing factors

Tendon Healing• Adhesion formation and control – Contributing factors • trauma (from injury and surgery)

Tendon Healing• Adhesion formation and control – Contributing factors • trauma (from injury and surgery) – tendon surface crushing

Tendon Healing• Adhesion formation and control – Contributing factors • trauma (from injury and surgery) – tendon surface crushing – vincula disruption

Tendon Healing• Adhesion formation and control – Contributing factors • trauma (from injury and surgery) – tendon surface crushing – vincula disruption • tendon ischemia

Tendon Healing• Adhesion formation and control – Contributing factors • trauma (from injury and surgery) – tendon surface crushing – vincula disruption • tendon ischemia • tendon immobilization

Tendon Healing• Adhesion formation and control – Contributing factors • trauma (from injury and surgery) – tendon surface crushing – vincula disruption • tendon ischemia • tendon immobilization • repair gapping

Tendon Healing• Adhesion formation and control – Contributing factors • trauma (from injury and surgery) – tendon surface crushing – vincula disruption • tendon ischemia • tendon immobilization • repair gapping • excision of tendon sheath components

Tendon Healing

Tendon Healing • How is healing related to motion?

Tendon Healing • How is healing related to motion? – passive mobilization enhances healing by stimulating tendon wound maturation and scar remodeling* , 110*Gelberman R, Goldberg V, An KN, et al: Tendon, in Woo SLY, Buckwalter JA(eds): Injury and Repair of the Musculoskeletal Soft Tissues. Park Ridge, Ill:American Academy of Orthopaedic Surgeons, 1988, pp 5-40.

Tendon Healing • How is healing related to motion? – passive mobilization enhances healing by stimulating tendon wound maturation and scar remodeling* , 110 – use a strong, gap-resistant suture technique + controlled-motion stress postoperatively*Gelberman R, Goldberg V, An KN, et al: Tendon, in Woo SLY, Buckwalter JA(eds): Injury and Repair of the Musculoskeletal Soft Tissues. Park Ridge, Ill:American Academy of Orthopaedic Surgeons, 1988, pp 5-40.

Tendon Healing • How is healing related to motion? – passive mobilization enhances healing by stimulating tendon wound maturation and scar remodeling* , 110 – use a strong, gap-resistant suture technique + controlled-motion stress postoperatively – 3-5 mm of excursion needed at repair site to prevent adhesions 144*Gelberman R, Goldberg V, An KN, et al: Tendon, in Woo SLY, Buckwalter JA(eds): Injury and Repair of the Musculoskeletal Soft Tissues. Park Ridge, Ill:American Academy of Orthopaedic Surgeons, 1988, pp 5-40.

Tendon Repair

Tendon Repair• Contraindications

Tendon Repair• Contraindications – severe multiple tissue injuries to ngers, palm

Tendon Repair• Contraindications – severe multiple tissue injuries to ngers, palm – gross wound contamination

Tendon Repair• Contraindications – severe multiple tissue injuries to ngers, palm – gross wound contamination – signi cant skin loss over the exor system

Tendon Repair• Contraindications – severe multiple tissue injuries to ngers, palm – gross wound contamination – signi cant skin loss over the exor system• Reduce fractures, repair neurovascular injuries concomitantly

Tendon Repair• Contraindications – severe multiple tissue injuries to ngers, palm – gross wound contamination – signi cant skin loss over the exor system• Reduce fractures, repair neurovascular injuries concomitantly• Repair tendons acutely/subacutely to avoid deterioration of tendon ends and extrinsic muscle shortening

Examination

Examination• High index of suspicion for multiple structures injured through a small laceration or crush injury

Examination• High index of suspicion for multiple structures injured through a small laceration or crush injury• Complete neurovascular exam

Examination• High index of suspicion for multiple structures injured through a small laceration or crush injury• Complete neurovascular exam – division of two digital nerves indicates arterial division as well

Examination• High index of suspicion for multiple structures injured through a small laceration or crush injury• Complete neurovascular exam – division of two digital nerves indicates arterial division as well – dysvascularity could compromise repair or skin ap healing +/- cold intolerance

Examination

Examination• Alterations in posture

Examination

Examination• Alterations in posture

Examination

Examination• Tenodesis eﬀect

Examination

Examination• Functional testing (FDS, FDP)

Examination

Examination• Functional testing (FDS)

Examination

Examination• Functional testing (FDP)

Surgery

Surgery• Planning

Surgery• Planning – inform the patient of the injury severity and potential need for more surgery

Surgery• Planning – inform the patient of the injury severity and potential need for more surgery – incisions

Surgery• Planning – inform the patient of the injury severity and potential need for more surgery – incisions • keep tendon retraction in mind

Surgery• Planning – inform the patient of the injury severity and potential need for more surgery – incisions • keep tendon retraction in mind • no bonus points for small incisions

Surgery• Planning – inform the patient of the injury severity and potential need for more surgery – incisions • keep tendon retraction in mind • no bonus points for small incisions • maintain ap viability

Surgery• Planning – inform the patient of the injury severity and potential need for more surgery – incisions • keep tendon retraction in mind • no bonus points for small incisions • maintain ap viability • avoid skin/scar contracture

Surgery - planning

Surgery - planning• Volar incisions

Surgery - planning• Volar incisions • Mid-axial incision

Surgery - principles

Surgery - principles• Ideal repair

Surgery - principles• Ideal repair – easy placement of sutures in the tendon

Surgery - principles• Ideal repair – easy placement of sutures in the tendon – secure suture knots

Surgery - principles• Ideal repair – easy placement of sutures in the tendon – secure suture knots – smooth junction of tendon ends

Surgery - principles• Ideal repair – easy placement of sutures in the tendon – secure suture knots – smooth junction of tendon ends – minimal gapping at the repair site

Surgery - principles• Ideal repair – easy placement of sutures in the tendon – secure suture knots – smooth junction of tendon ends – minimal gapping at the repair site – minimal interference with tendon vascularity

Surgery - principles• Ideal repair – easy placement of sutures in the tendon – secure suture knots – smooth junction of tendon ends – minimal gapping at the repair site – minimal interference with tendon vascularity – suﬃcient strength for early motion stress to the tendon

Surgery

Surgery• Core suture considerations

Surgery• Core suture considerations – strength of a repair is proportional to the number of suture strands crossing the repair site

Surgery• Core suture considerations – strength of a repair is proportional to the number of suture strands crossing the repair site – increasing crossing strands increases diﬃculty and risk of tendon damage, vascularity compromise

Surgery• Core suture considerations – strength of a repair is proportional to the number of suture strands crossing the repair site – increasing crossing strands increases diﬃculty and risk of tendon damage, vascularity compromise – repairs usually rupture at the suture knots

Surgery• Core suture considerations – strength of a repair is proportional to the number of suture strands crossing the repair site – increasing crossing strands increases diﬃculty and risk of tendon damage, vascularity compromise – repairs usually rupture at the suture knots – locking loop con gurations usually allow less gapping than grasping types

Surgery• Core suture considerations – strength of a repair is proportional to the number of suture strands crossing the repair site – increasing crossing strands increases diﬃculty and risk of tendon damage, vascularity compromise – repairs usually rupture at the suture knots – locking loop con gurations usually allow less gapping than grasping types – larger caliber sutures increase repair strength

Surgery

Surgery• Core suture methods

Surgery

Surgery• Suture material

Surgery• Suture material – absorbable materials seem attractive

Surgery• Suture material – absorbable materials seem attractive • less foreign body reaction long-term

Surgery• Suture material – absorbable materials seem attractive • less foreign body reaction long-term • less stress-shielding of the host tissue

Surgery• Suture material – absorbable materials seem attractive • less foreign body reaction long-term • less stress-shielding of the host tissue – optimal rates of material absorption, strength reduction are unknown

Surgery• Suture material – absorbable materials seem attractive • less foreign body reaction long-term • less stress-shielding of the host tissue – optimal rates of material absorption, strength reduction are unknown – 3-0, 4-0 braided polyester is most commonly used

Surgery

Surgery• Circumferential (peripheral) sutures

Surgery• Circumferential (peripheral) sutures – may provide a 10-15% increase in exor tendon repair strength

Surgery• Circumferential (peripheral) sutures – may provide a 10-15% increase in exor tendon repair strength – reduces gapping between ends

Surgery• Circumferential (peripheral) sutures – may provide a 10-15% increase in exor tendon repair strength – reduces gapping between ends – methods

Surgery• Circumferential (peripheral) sutures – may provide a 10-15% increase in exor tendon repair strength – reduces gapping between ends – methods • running lock loop (Lin)

Surgery• Circumferential (peripheral) sutures – may provide a 10-15% increase in exor tendon repair strength – reduces gapping between ends – methods • running lock loop (Lin) • horizontal mattress method (Mashadi)

Surgery• Circumferential (peripheral) sutures – may provide a 10-15% increase in exor tendon repair strength – reduces gapping between ends – methods • running lock loop (Lin) • horizontal mattress method (Mashadi) • Halsted continuous horizontal mattress method (Wade)

Surgery• Circumferential (peripheral) sutures – may provide a 10-15% increase in exor tendon repair strength – reduces gapping between ends – methods • running lock loop (Lin) • horizontal mattress method (Mashadi) • Halsted continuous horizontal mattress method (Wade) • cross-stich technique (Silfverskiold)

Surgery

Surgery• Strickland conclusion: Any 4-strand core suture + running lock or horizontal mattress circumferential suture should permit light composite grip during the entire healing period

Surgery

Surgery• Sheath repair

Surgery• Sheath repair – cumulative work of several investigators fails to give clear direction

Surgery• Sheath repair – cumulative work of several investigators fails to give clear direction – advantages

Surgery• Sheath repair – cumulative work of several investigators fails to give clear direction – advantages • provides a barrier to extrinsic adhesions

Surgery• Sheath repair – cumulative work of several investigators fails to give clear direction – advantages • provides a barrier to extrinsic adhesions • quicker return of synovial nutrition

Surgery• Sheath repair – cumulative work of several investigators fails to give clear direction – advantages • provides a barrier to extrinsic adhesions • quicker return of synovial nutrition • serves as a mold for the remodeling tendon

Surgery• Sheath repair – cumulative work of several investigators fails to give clear direction – advantages • provides a barrier to extrinsic adhesions • quicker return of synovial nutrition • serves as a mold for the remodeling tendon • results in better sheath-tendon biomechanics

Surgery• Sheath repair – cumulative work of several investigators fails to give clear direction – advantages • provides a barrier to extrinsic adhesions • quicker return of synovial nutrition • serves as a mold for the remodeling tendon • results in better sheath-tendon biomechanics – disadvantages

Surgery• Sheath repair – cumulative work of several investigators fails to give clear direction – advantages • provides a barrier to extrinsic adhesions • quicker return of synovial nutrition • serves as a mold for the remodeling tendon • results in better sheath-tendon biomechanics – disadvantages • diﬃcult

Surgery• Sheath repair – cumulative work of several investigators fails to give clear direction – advantages • provides a barrier to extrinsic adhesions • quicker return of synovial nutrition • serves as a mold for the remodeling tendon • results in better sheath-tendon biomechanics – disadvantages • diﬃcult • may restrict tendon gliding

Surgery

Surgery• Partial lacerations

Surgery• Partial lacerations – lacerations of 50% or less do not need to be sutured

Surgery• Partial lacerations – lacerations of 50% or less do not need to be sutured – Grewal: nonrepaired partial lacerations had higher ultimate load and stiﬀness than repaired tendons

Surgery• Partial lacerations – lacerations of 50% or less do not need to be sutured – Grewal: nonrepaired partial lacerations had higher ultimate load and stiﬀness than repaired tendons – entrapment, rupture, triggering of unrepaired partial severed tendons has been reported (Schlenker)

Surgery

Surgery• Zone I injury – FDP avulsion

Surgery• Zone I injury – FDP avulsion – occurs w/ forcible extension during strong DIP exion

Surgery• Zone I injury – FDP avulsion – occurs w/ forcible extension during strong DIP exion – three types (Leddy and Packer) – relevant to nding the fragment/tendon end and to repair timing

Surgery• Zone I injury – FDP avulsion – occurs w/ forcible extension during strong DIP exion – three types (Leddy and Packer) – relevant to nding the fragment/tendon end and to repair timing – tendon repair to cancellous bone provides the best result

Surgery• Zone I injury – FDP avulsion – occurs w/ forcible extension during strong DIP exion – three types (Leddy and Packer) – relevant to nding the fragment/tendon end and to repair timing – tendon repair to cancellous bone provides the best result • done with sutures exiting dorsally tied over a button

Surgery• Zone I injury – FDP avulsion – occurs w/ forcible extension during strong DIP exion – three types (Leddy and Packer) – relevant to nding the fragment/tendon end and to repair timing – tendon repair to cancellous bone provides the best result • done with sutures exiting dorsally tied over a button • OR with suture anchors

Surgery – FDP avulsion

Surgery – FDP avulsion• Leddy and Packer classi cation

Surgery

Surgery• FDP laceration – Zone I

Surgery• FDP laceration – Zone I – laceration distal to FDS insertion = Zone I injury

Surgery• FDP laceration – Zone I – laceration distal to FDS insertion = Zone I injury – distal stump < 1 cm long = perform FDP advancement and tendon to bone repair

Surgery• FDP laceration – Zone I – laceration distal to FDS insertion = Zone I injury – distal stump < 1 cm long = perform FDP advancement and tendon to bone repair – > 1 cm distally = repair primarily

Surgery• FDP laceration – Zone I – laceration distal to FDS insertion = Zone I injury – distal stump < 1 cm long = perform FDP advancement and tendon to bone repair – > 1 cm distally = repair primarily • laceration may be near A4  diﬃcult repair

Surgery• FDP laceration – Zone I – laceration distal to FDS insertion = Zone I injury – distal stump < 1 cm long = perform FDP advancement and tendon to bone repair – > 1 cm distally = repair primarily • laceration may be near A4  diﬃcult repair • advancement of FDP > 1 cm may result in the quadrigia eﬀect

Rehabilitation (zone ii)

Talk Summary

Talk Summary• Basic science – anatomy – nutrition – biomechanics – healing• Surgical considerations – lacerations – avulsions• Rehabilitation

OITE2004 #10A partial laceration of the exor tendon should be repaired when the percentage of tendon lacerated is more than1. 10%2. 20%3. 40%4. 60%5. 80%

OITE2005 #246

OITE2005 #246A 21 year-old left-handed college student was playing rugby 3 days ago and felt the sudden onset of pain in his right ring nger when another played pulled away from him. A clinical photo is shown in Figure 86. What is the most likely diagnosis?

OITE2005 #246A 21 year-old left-handed college student was playing rugby 3 days ago and felt the sudden onset of pain in his right ring nger when another played pulled away from him. A clinical photo is shown in Figure 86. What is the most likely diagnosis?1. Volar plate avulsion of the proximal interphalangeal joint

OITE2005 #246A 21 year-old left-handed college student was playing rugby 3 days ago and felt the sudden onset of pain in his right ring nger when another played pulled away from him. A clinical photo is shown in Figure 86. What is the most likely diagnosis?1. Volar plate avulsion of the proximal interphalangeal joint2. Avulsion of the distal exor digitorum profundus tendon

OITE2005 #246A 21 year-old left-handed college student was playing rugby 3 days ago and felt the sudden onset of pain in his right ring nger when another played pulled away from him. A clinical photo is shown in Figure 86. What is the most likely diagnosis?1. Volar plate avulsion of the proximal interphalangeal joint2. Avulsion of the distal exor digitorum profundus tendon3. Musculotendinous rupture in the forearm

OITE2005 #246A 21 year-old left-handed college student was playing rugby 3 days ago and felt the sudden onset of pain in his right ring nger when another played pulled away from him. A clinical photo is shown in Figure 86. What is the most likely diagnosis?1. Volar plate avulsion of the proximal interphalangeal joint2. Avulsion of the distal exor digitorum profundus tendon3. Musculotendinous rupture in the forearm4. Stretch injury to the ulnar nerve at the wrist

OITE2005 #246A 21 year-old left-handed college student was playing rugby 3 days ago and felt the sudden onset of pain in his right ring nger when another played pulled away from him. A clinical photo is shown in Figure 86. What is the most likely diagnosis?1. Volar plate avulsion of the proximal interphalangeal joint2. Avulsion of the distal exor digitorum profundus tendon3. Musculotendinous rupture in the forearm4. Stretch injury to the ulnar nerve at the wrist5. Ulnar artery thrombosis

OITE2005 #246

OITE2005 #246A 21 year-old left-handed college student was playing rugby 3 days ago and felt the sudden onset of pain in his right ring nger when another played pulled away from him. A clinical photo is shown in Figure 86. What is the most likely diagnosis?

OITE2005 #246A 21 year-old left-handed college student was playing rugby 3 days ago and felt the sudden onset of pain in his right ring nger when another played pulled away from him. A clinical photo is shown in Figure 86. What is the most likely diagnosis?1. Volar plate avulsion of the proximal interphalangeal joint

OITE2005 #246A 21 year-old left-handed college student was playing rugby 3 days ago and felt the sudden onset of pain in his right ring nger when another played pulled away from him. A clinical photo is shown in Figure 86. What is the most likely diagnosis?1. Volar plate avulsion of the proximal interphalangeal joint2. Avulsion of the distal exor digitorum profundus tendon

OITE2005 #246A 21 year-old left-handed college student was playing rugby 3 days ago and felt the sudden onset of pain in his right ring nger when another played pulled away from him. A clinical photo is shown in Figure 86. What is the most likely diagnosis?1. Volar plate avulsion of the proximal interphalangeal joint2. Avulsion of the distal exor digitorum profundus tendon3. Musculotendinous rupture in the forearm

OITE2005 #246A 21 year-old left-handed college student was playing rugby 3 days ago and felt the sudden onset of pain in his right ring nger when another played pulled away from him. A clinical photo is shown in Figure 86. What is the most likely diagnosis?1. Volar plate avulsion of the proximal interphalangeal joint2. Avulsion of the distal exor digitorum profundus tendon3. Musculotendinous rupture in the forearm4. Stretch injury to the ulnar nerve at the wrist

OITE2005 #246A 21 year-old left-handed college student was playing rugby 3 days ago and felt the sudden onset of pain in his right ring nger when another played pulled away from him. A clinical photo is shown in Figure 86. What is the most likely diagnosis?1. Volar plate avulsion of the proximal interphalangeal joint2. Avulsion of the distal exor digitorum profundus tendon3. Musculotendinous rupture in the forearm4. Stretch injury to the ulnar nerve at the wrist5. Ulnar artery thrombosis

OITE2003 #10Active mobilization following exor tendon repair is best accomplished with the wrist in1. exion and the metacarpophalangeal joints in exion.2. exion and the metacarpophalangeal joints in extension.3. neutral and the metacarpophalangeal joints in extension.4. neutral and the metacarpophalangeal joints in exion.5. extension and the metacarpophalangeal joints in exion.

OITE2003 #126What is the major advantage of allowing early active motion of a repaired zone II exor tendon injury?• 1- Increased tendon excursion• 2- Greater repair strength• 3- Less postoperative pain• 4- Better patient compliance• 5- Faster tendon healing

OITE2005 #21e ideal exor tendon rehab protocol that minimizes peritendinous adhesions includes1. Casting for 6 weeks2. A synergistic wrist and digit motion rehabilitation protocol3. Dorsal blocking splint with unrestricted active nger exion4. Dynamic extension outrigger splinting5. Early aggressive active motion and a strengthening program

OITE2005 #103A 3 year-old child undergoes repair of lacerated exor tendons of the ring and little ngers in zone II. Postoperative rehabilitation should consist of1. Passive exion and extension exercises2. Passive exion and active extension exercises3. Active exion and extension exercises4. Cast immobilization for 4 weeks5. Cast immobilization for 8 weeks

OITE2002 #70A 4 year old girl undergoes repair of both exor tendons in zone II. Initial postoperative physical therapy should consist of1. passive mobilization only.2. active extension and passive exion mobilization.3. active place and hold mobilization.4. immobilization.5. unrestricted active mobilization.

OITE2002 #70A 4 year old girl undergoes repair of both exor tendons in zone II. Initial postoperative physical therapy should consist of1. passive mobilization only.2. active extension and passive exion mobilization.3. active place and hold mobilization.4.immobilization.5. unrestricted active mobilization.

Bibliography Trumble, ed. Hand Surgery Update 3., 2003. Green, ed. Green’s Operative Hand Surgery, 5th ed., 2003. Canale, ed. Campbell’s Operative Orthopaedic Surgery, 10th ed., 2003.

Bibliography

Bibliography Schmidt. Surgical Anatomy of the Hand. 2004

Flexor Tendons - Anatomy, Injury, Treatment

by C Noel Henley MD on Feb 26, 2011

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Flexor Tendons - Anatomy, Injury, Treatment — Presentation Transcript