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 conside...
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...
Introduction• History  – no repair possible in the digit  – “no man’s land”• Current evidence  – 1970s: 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 re...
Introduction• General goals of repair  – primary tendon repair – avoid grafting  – sufficient strength for passive motion re...
Introduction• General goals of repair  – primary tendon repair – avoid grafting  – sufficient strength for passive motion re...
Introduction• General goals of repair  – primary tendon repair – avoid grafting  – sufficient strength for passive motion re...
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...
Anatomy • FDS   – O: volar humerus, radius, ulna   – divided muscle belly in mid forearm (FA)      • super cial – long and...
Anatomy • FDS   – O: volar humerus, radius, ulna   – divided muscle belly in mid forearm (FA)      • super cial – long and...
Anatomy • FDS   – O: volar humerus, radius, ulna   – divided muscle belly in mid forearm (FA)      • super cial – long and...
Anatomy • FDS   – O: volar humerus, radius, ulna   – divided muscle belly in mid forearm (FA)      • super cial – long and...
Anatomy • FDS   – O: volar humerus, radius, ulna   – divided muscle belly in mid forearm (FA)      • super cial – long and...
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: bene...
Anatomy• In the hand  – ve zones     • V: musculo-tendinous junction to       proximal edge of carpal canal     • IV: bene...
Anatomy
Anatomy• Zones (cont.)
Anatomy• Zones (cont.)  – III: distal edge of transverse    carpal ligament to origin of     bro-osseous sheath at the    ...
Anatomy• Zones (cont.)  – III: distal edge of transverse    carpal ligament to origin of     bro-osseous sheath at the    ...
Anatomy• Zones (cont.)  – III: distal edge of transverse    carpal ligament to origin of      bro-osseous sheath at the   ...
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 ...
Anatomy
Anatomy • Profundus
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 dig...
Anatomy • Profundus   – passes through chiasma to insert at proximal base     of distal phalanx (P3)   – FDP = primary dig...
Anatomy
Anatomy
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...
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   – p...
Nutrition • Two sources of tendon nutrition   – vascular   – synovial • Vascularity sources   – longitudinal vessels   – p...
Nutrition • Two sources of tendon nutrition   – vascular   – synovial • Vascularity sources   – longitudinal vessels   – p...
Nutrition
Nutrition
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 u...
Nutrition • Avascular segments   – FDP and FDS: over proximal phalanx   – FDP: short zone over middle phalanx • Synovial u...
Nutrition
Nutrition
Nutrition
Nutrition • Vascularity
Nutrition • Vascularity   – damage to vascular and uid nutritional systems     may further hamper healing of repaired exor...
Nutrition • Vascularity   – damage to vascular and uid nutritional systems     may further hamper healing of repaired exor...
Nutrition
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 d...
Biomechanics
Biomechanics • Moment arm
Biomechanics • Moment arm   – increased distance of tendon from joint center of     rotation = higher moment arm = less mo...
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 alt...
Biomechanics• Moment arm  – pulley system constraint governs these parameters  – loss of portions of pulley system may alt...
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-produ...
Tendon Healing • Phases   – in ammatory – 48-72 hours      • repair strength reliant upon suture itself   – collagen-produ...
Tendon Healing • Phases   – in ammatory – 48-72 hours      • repair strength reliant upon suture itself   – collagen-produ...
Tendon Healing • Phases   – in ammatory – 48-72 hours      • repair strength reliant upon suture itself   – collagen-produ...
Tendon Healing        inflammatory
Tendon Healing        inflammatory
Tendon Healing      collagen-producing
Tendon Healing      collagen-producing
Tendon Healing        remodeling
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)        – ten...
Tendon Healing• Adhesion formation and control  – Contributing factors     • trauma (from injury and surgery)        – ten...
Tendon Healing• Adhesion formation and control  – Contributing factors     • trauma (from injury and surgery)        – ten...
Tendon Healing• Adhesion formation and control  – Contributing factors     • trauma (from injury and surgery)        – ten...
Tendon Healing• Adhesion formation and control  – Contributing factors     • trauma (from injury and surgery)        – ten...
Tendon Healing• Adhesion formation and control  – Contributing factors     • trauma (from injury and surgery)          – t...
Tendon Healing
Tendon Healing • How is healing related to motion?
Tendon Healing             • How is healing related to motion?                      – passive mobilization enhances healin...
Tendon Healing             • How is healing related to motion?                      – passive mobilization enhances healin...
Tendon Healing             • How is healing related to motion?                      – passive mobilization enhances healin...
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 c...
Tendon Repair• Contraindications  – severe multiple tissue injuries to ngers, palm  – gross wound contamination  – signi c...
Tendon Repair• Contraindications  – severe multiple tissue injuries to ngers, palm  – gross wound contamination  – signi c...
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...
Examination• High index of suspicion for multiple structures  injured through a small laceration or crush injury• Complete...
Examination• High index of suspicion for multiple structures  injured through a small laceration or crush injury• Complete...
Examination
Examination• Alterations in posture
Examination
Examination• Alterations in posture
Examination
Examination• Tenodesis effect
Examination
Examination• Functional testing (FDS, FDP)
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     • k...
Surgery• Planning  – inform the patient of the injury severity and potential    need for more surgery  – incisions     • k...
Surgery• Planning  – inform the patient of the injury severity and potential    need for more surgery  – incisions     • k...
Surgery• Planning  – inform the patient of the injury severity and potential    need for more surgery  – incisions     •  ...
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...
Surgery - principles• Ideal repair   – easy placement of sutures in the tendon   – secure suture knots   – smooth junction...
Surgery - principles• Ideal repair   – easy placement of sutures in the tendon   – secure suture knots   – smooth junction...
Surgery - principles• Ideal repair   – easy placement of sutures in the tendon   – secure suture knots   – smooth junction...
Surgery
Surgery• Core suture considerations
Surgery• Core suture considerations  – strength of a repair is proportional to the number of    suture strands crossing th...
Surgery• Core suture considerations  – strength of a repair is proportional to the number of    suture strands crossing th...
Surgery• Core suture considerations  – strength of a repair is proportional to the number of    suture strands crossing th...
Surgery• Core suture considerations  – strength of a repair is proportional to the number of    suture strands crossing th...
Surgery• Core suture considerations  – strength of a repair is proportional to the number of    suture strands crossing th...
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 str...
Surgery• Suture material  – absorbable materials seem attractive     • less foreign body reaction long-term     • less str...
Surgery• Suture material  – absorbable materials seem attractive     • less foreign body reaction long-term     • less str...
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  – reduce...
Surgery• Circumferential (peripheral) sutures  – may provide a 10-15% increase in exor tendon repair    strength  – reduce...
Surgery• Circumferential (peripheral) sutures  – may provide a 10-15% increase in exor tendon repair    strength  – reduce...
Surgery• Circumferential (peripheral) sutures  – may provide a 10-15% increase in exor tendon repair    strength  – reduce...
Surgery• Circumferential (peripheral) sutures  – may provide a 10-15% increase in exor tendon repair    strength  – reduce...
Surgery• Circumferential (peripheral) sutures  – may provide a 10-15% increase in exor tendon repair    strength  – reduce...
Surgery
Surgery
Surgery
Surgery
Surgery
Surgery
Surgery• Strickland conclusion: Any 4-strand core suture +  running lock or horizontal mattress circumferential  suture sh...
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     • pr...
Surgery• Sheath repair  – cumulative work of several investigators fails to give clear    direction  – advantages     • pr...
Surgery• Sheath repair  – cumulative work of several investigators fails to give clear    direction  – advantages     • pr...
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     •   ...
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     •   ...
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 lace...
Surgery• Partial lacerations   – lacerations of 50% or less do not need to be sutured   – Grewal: nonrepaired partial lace...
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 a...
Surgery• Zone I injury – FDP avulsion  – occurs w/ forcible extension during strong DIP      exion  – three types (Leddy a...
Surgery• Zone I injury – FDP avulsion  – occurs w/ forcible extension during strong DIP      exion  – three types (Leddy a...
Surgery• Zone I injury – FDP avulsion  – occurs w/ forcible extension during strong DIP      exion  – three types (Leddy a...
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 = perfo...
Surgery• FDP laceration – Zone I  – laceration distal to FDS insertion = Zone I injury  – distal stump < 1 cm long = perfo...
Surgery• FDP laceration – Zone I  – laceration distal to FDS insertion = Zone I injury  – distal stump < 1 cm long = perfo...
Surgery• FDP laceration – Zone I  – laceration distal to FDS insertion = Zone I injury  – distal stump < 1 cm long = perfo...
Rehabilitation (zone ii)
Rehabilitation (zone ii)
Rehabilitation (zone ii)
Rehabilitation (zone ii)
Talk Summary
Talk Summary• Basic science  – anatomy  – nutrition  – biomechanics  – healing• Surgical considerations  – lacerations  – ...
OITE
OITE2004 #10A partial laceration of the exor tendon should be repaired when the   percentage of tendon lacerated is more t...
OITE2004 #10A partial laceration of the exor tendon should be repaired when the   percentage of tendon lacerated is more t...
OITE
OITE2005 #246
OITE2005 #246
OITE2005 #246A 21 year-old left-handed college student was playing rugby 3 days ago and     felt the sudden onset of pain ...
OITE2005 #246A 21 year-old left-handed college student was playing rugby 3 days ago and     felt the sudden onset of pain ...
OITE2005 #246A 21 year-old left-handed college student was playing rugby 3 days ago and     felt the sudden onset of pain ...
OITE2005 #246A 21 year-old left-handed college student was playing rugby 3 days ago and     felt the sudden onset of pain ...
OITE2005 #246A 21 year-old left-handed college student was playing rugby 3 days ago and     felt the sudden onset of pain ...
OITE2005 #246A 21 year-old left-handed college student was playing rugby 3 days ago and     felt the sudden onset of pain ...
OITE2005 #246A 21 year-old left-handed college student was playing rugby 3 days ago and     felt the sudden onset of pain ...
OITE2005 #246A 21 year-old left-handed college student was playing rugby 3 days ago and     felt the sudden onset of pain ...
OITE
OITE2005 #246
OITE2005 #246
OITE2005 #246A 21 year-old left-handed college student was playing rugby 3 days ago and     felt the sudden onset of pain ...
OITE2005 #246A 21 year-old left-handed college student was playing rugby 3 days ago and     felt the sudden onset of pain ...
OITE2005 #246A 21 year-old left-handed college student was playing rugby 3 days ago and     felt the sudden onset of pain ...
OITE2005 #246A 21 year-old left-handed college student was playing rugby 3 days ago and     felt the sudden onset of pain ...
OITE2005 #246A 21 year-old left-handed college student was playing rugby 3 days ago and     felt the sudden onset of pain ...
OITE2005 #246A 21 year-old left-handed college student was playing rugby 3 days ago and     felt the sudden onset of pain ...
OITE2005 #246A 21 year-old left-handed college student was playing rugby 3 days ago and     felt the sudden onset of pain ...
OITE2005 #246A 21 year-old left-handed college student was playing rugby 3 days ago and     felt the sudden onset of pain ...
OITE
OITE2003 #10Active mobilization following exor tendon repair is best accomplished   with the wrist in1. exion and the meta...
OITE
OITE2003 #10Active mobilization following exor tendon repair is best accomplished   with the wrist in1. exion and the meta...
OITE
OITE2003 #126What is the major advantage of allowing early active motion of a repaired zone II exor tendon injury?•   1- I...
OITE
OITE2003 #126What is the major advantage of allowing early active motion of a repaired zone II exor tendon injury?• 1- Inc...
OITE
OITE2005 #21e ideal exor tendon rehab protocol that minimizes peritendinous    adhesions includes1.   Casting for 6 weeks...
OITE
OITE2005 #21e ideal exor tendon rehab protocol that minimizes peritendinous    adhesions includes1.   Casting for 6 weeks...
OITE
OITE2005 #103A 3 year-old child undergoes repair of lacerated exor tendons of the     ring and little ngers in zone II. Po...
OITE
OITE2005 #103A 3 year-old child undergoes repair of lacerated exor tendons of the     ring and little ngers in zone II. Po...
OITE
OITE2002 #70A 4 year old girl undergoes repair of both exor tendons in zone II.  Initial postoperative physical therapy sh...
OITE
OITE2002 #70A 4 year old girl undergoes repair of both exor tendons in zone II.  Initial postoperative physical therapy sh...
Bibliography Trumble, ed. Hand Surgery Update 3., 2003. Green, ed. Green’s Operative Hand Surgery, 5th ed., 2003. Canale, ...
Bibliography Trumble, ed. Hand Surgery Update 3., 2003. Green, ed. Green’s Operative Hand Surgery, 5th ed., 2003. Canale, ...
Bibliography
Bibliography        Schmidt. Surgical Anatomy of the Hand. 2004
Flexor Tendons - Anatomy, Injury, Treatment
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Flexor Tendons - Anatomy, Injury, Treatment

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I gave this talk on flexor tendon injury to a group of orthopaedic surgeons. Find out more about hand and arm problems at http://www.noelhenley.com.

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  • achievement\nof a primary tendon repair of sufficient\ntensile strength to allow application of\na postoperative passive-motion rehabilitation\nprotocol that inhibits formation\nof intrasynovial adhesions,\nstimulates restoration of the gliding\nsurface, and facilitates healing of the\nrepair site48.\n
  • achievement\nof a primary tendon repair of sufficient\ntensile strength to allow application of\na postoperative passive-motion rehabilitation\nprotocol that inhibits formation\nof intrasynovial adhesions,\nstimulates restoration of the gliding\nsurface, and facilitates healing of the\nrepair site48.\n
  • achievement\nof a primary tendon repair of sufficient\ntensile strength to allow application of\na postoperative passive-motion rehabilitation\nprotocol that inhibits formation\nof intrasynovial adhesions,\nstimulates restoration of the gliding\nsurface, and facilitates healing of the\nrepair site48.\n
  • achievement\nof a primary tendon repair of sufficient\ntensile strength to allow application of\na postoperative passive-motion rehabilitation\nprotocol that inhibits formation\nof intrasynovial adhesions,\nstimulates restoration of the gliding\nsurface, and facilitates healing of the\nrepair site48.\n
  • achievement\nof a primary tendon repair of sufficient\ntensile strength to allow application of\na postoperative passive-motion rehabilitation\nprotocol that inhibits formation\nof intrasynovial adhesions,\nstimulates restoration of the gliding\nsurface, and facilitates healing of the\nrepair site48.\n
  • achievement\nof a primary tendon repair of sufficient\ntensile strength to allow application of\na postoperative passive-motion rehabilitation\nprotocol that inhibits formation\nof intrasynovial adhesions,\nstimulates restoration of the gliding\nsurface, and facilitates healing of the\nrepair site48.\n
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  • chiasm&amp;#xA0;(chi&amp;#xB7;asm) (ki&amp;#xB4;az-&amp;#x259;m) [L., Gr. chiasma] &amp;#xA0;a decussation or X-shaped crossing; see chiasma.\nc. of digits of hand &amp;#xA0;chiasma tendinum digitorum manus. \noptic c. &amp;#xA0;chiasma opticum. \ntendinous c. of fingers &amp;#xA0;chiasma tendinum digitorum manus. \nchiasma&amp;#xA0;(chi&amp;#xB7;as&amp;#xB7;ma) (ki-az&amp;#xB4;m&amp;#x259;) &amp;#xA0;pl. chias&amp;#xB4;mata [L., from Gr. &amp;#x201C;a cross, crosspiece&amp;#x201D;, from the shape of the letter chi, (X)] &amp;#xA0;1.&amp;#xA0; [TA]&amp;#xA0;a general term in anatomical nomenclature for a decussation or X-shaped crossing, such as of nerves. &amp;#xA0;2.&amp;#xA0;in genetics, the places where pairs of homologous chromatids remain in contact during late prophase to anaphase of the first meiotic division, indicating where an exchange of homologous segments has taken place between non-sister chromatids by crossing over. \noptic c. ,&amp;#xA0;&amp;#xA0;c. op&amp;#xB4;ticum &amp;#xA0;[TA] &amp;#xA0;optic chiasm: the part of the hypothalamus formed by the decussation, or crossing, of the fibers of the optic nerve from the medial half of each retina; called also optic decussation.Click here to view imagec. ten&amp;#xB4;dinum digito&amp;#xB4;rum ma&amp;#xB4;nus &amp;#xA0;[TA] &amp;#xA0;tendinous chiasm of fingers: the crossing of the tendons of the flexor digitorum profundus through the tendons of the flexor digitorum superficialis; called also chiasm of digits of hand.\n
  • chiasm&amp;#xA0;(chi&amp;#xB7;asm) (ki&amp;#xB4;az-&amp;#x259;m) [L., Gr. chiasma] &amp;#xA0;a decussation or X-shaped crossing; see chiasma.\nc. of digits of hand &amp;#xA0;chiasma tendinum digitorum manus. \noptic c. &amp;#xA0;chiasma opticum. \ntendinous c. of fingers &amp;#xA0;chiasma tendinum digitorum manus. \nchiasma&amp;#xA0;(chi&amp;#xB7;as&amp;#xB7;ma) (ki-az&amp;#xB4;m&amp;#x259;) &amp;#xA0;pl. chias&amp;#xB4;mata [L., from Gr. &amp;#x201C;a cross, crosspiece&amp;#x201D;, from the shape of the letter chi, (X)] &amp;#xA0;1.&amp;#xA0; [TA]&amp;#xA0;a general term in anatomical nomenclature for a decussation or X-shaped crossing, such as of nerves. &amp;#xA0;2.&amp;#xA0;in genetics, the places where pairs of homologous chromatids remain in contact during late prophase to anaphase of the first meiotic division, indicating where an exchange of homologous segments has taken place between non-sister chromatids by crossing over. \noptic c. ,&amp;#xA0;&amp;#xA0;c. op&amp;#xB4;ticum &amp;#xA0;[TA] &amp;#xA0;optic chiasm: the part of the hypothalamus formed by the decussation, or crossing, of the fibers of the optic nerve from the medial half of each retina; called also optic decussation.Click here to view imagec. ten&amp;#xB4;dinum digito&amp;#xB4;rum ma&amp;#xB4;nus &amp;#xA0;[TA] &amp;#xA0;tendinous chiasm of fingers: the crossing of the tendons of the flexor digitorum profundus through the tendons of the flexor digitorum superficialis; called also chiasm of digits of hand.\n
  • chiasm&amp;#xA0;(chi&amp;#xB7;asm) (ki&amp;#xB4;az-&amp;#x259;m) [L., Gr. chiasma] &amp;#xA0;a decussation or X-shaped crossing; see chiasma.\nc. of digits of hand &amp;#xA0;chiasma tendinum digitorum manus. \noptic c. &amp;#xA0;chiasma opticum. \ntendinous c. of fingers &amp;#xA0;chiasma tendinum digitorum manus. \nchiasma&amp;#xA0;(chi&amp;#xB7;as&amp;#xB7;ma) (ki-az&amp;#xB4;m&amp;#x259;) &amp;#xA0;pl. chias&amp;#xB4;mata [L., from Gr. &amp;#x201C;a cross, crosspiece&amp;#x201D;, from the shape of the letter chi, (X)] &amp;#xA0;1.&amp;#xA0; [TA]&amp;#xA0;a general term in anatomical nomenclature for a decussation or X-shaped crossing, such as of nerves. &amp;#xA0;2.&amp;#xA0;in genetics, the places where pairs of homologous chromatids remain in contact during late prophase to anaphase of the first meiotic division, indicating where an exchange of homologous segments has taken place between non-sister chromatids by crossing over. \noptic c. ,&amp;#xA0;&amp;#xA0;c. op&amp;#xB4;ticum &amp;#xA0;[TA] &amp;#xA0;optic chiasm: the part of the hypothalamus formed by the decussation, or crossing, of the fibers of the optic nerve from the medial half of each retina; called also optic decussation.Click here to view imagec. ten&amp;#xB4;dinum digito&amp;#xB4;rum ma&amp;#xB4;nus &amp;#xA0;[TA] &amp;#xA0;tendinous chiasm of fingers: the crossing of the tendons of the flexor digitorum profundus through the tendons of the flexor digitorum superficialis; called also chiasm of digits of hand.\n
  • chiasm&amp;#xA0;(chi&amp;#xB7;asm) (ki&amp;#xB4;az-&amp;#x259;m) [L., Gr. chiasma] &amp;#xA0;a decussation or X-shaped crossing; see chiasma.\nc. of digits of hand &amp;#xA0;chiasma tendinum digitorum manus. \noptic c. &amp;#xA0;chiasma opticum. \ntendinous c. of fingers &amp;#xA0;chiasma tendinum digitorum manus. \nchiasma&amp;#xA0;(chi&amp;#xB7;as&amp;#xB7;ma) (ki-az&amp;#xB4;m&amp;#x259;) &amp;#xA0;pl. chias&amp;#xB4;mata [L., from Gr. &amp;#x201C;a cross, crosspiece&amp;#x201D;, from the shape of the letter chi, (X)] &amp;#xA0;1.&amp;#xA0; [TA]&amp;#xA0;a general term in anatomical nomenclature for a decussation or X-shaped crossing, such as of nerves. &amp;#xA0;2.&amp;#xA0;in genetics, the places where pairs of homologous chromatids remain in contact during late prophase to anaphase of the first meiotic division, indicating where an exchange of homologous segments has taken place between non-sister chromatids by crossing over. \noptic c. ,&amp;#xA0;&amp;#xA0;c. op&amp;#xB4;ticum &amp;#xA0;[TA] &amp;#xA0;optic chiasm: the part of the hypothalamus formed by the decussation, or crossing, of the fibers of the optic nerve from the medial half of each retina; called also optic decussation.Click here to view imagec. ten&amp;#xB4;dinum digito&amp;#xB4;rum ma&amp;#xB4;nus &amp;#xA0;[TA] &amp;#xA0;tendinous chiasm of fingers: the crossing of the tendons of the flexor digitorum profundus through the tendons of the flexor digitorum superficialis; called also chiasm of digits of hand.\n
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  • The thin, condensable cruciate\nsections of the sheath&amp;#x2014;C1\n(between A2 and A3 ), C2 (between A3\nand A4), and C3 (between A4 and\nA5)&amp;#x2014;collapse to permit the annular\npulleys to approximate each other\nduring digital flexion. The flexor tendons\nare weakly attached to the sheath\nby filmy mesenteries composed of\nvincula\n
  • The thin, condensable cruciate\nsections of the sheath&amp;#x2014;C1\n(between A2 and A3 ), C2 (between A3\nand A4), and C3 (between A4 and\nA5)&amp;#x2014;collapse to permit the annular\npulleys to approximate each other\nduring digital flexion. The flexor tendons\nare weakly attached to the sheath\nby filmy mesenteries composed of\nvincula\n
  • The thin, condensable cruciate\nsections of the sheath&amp;#x2014;C1\n(between A2 and A3 ), C2 (between A3\nand A4), and C3 (between A4 and\nA5)&amp;#x2014;collapse to permit the annular\npulleys to approximate each other\nduring digital flexion. The flexor tendons\nare weakly attached to the sheath\nby filmy mesenteries composed of\nvincula\n
  • The thin, condensable cruciate\nsections of the sheath&amp;#x2014;C1\n(between A2 and A3 ), C2 (between A3\nand A4), and C3 (between A4 and\nA5)&amp;#x2014;collapse to permit the annular\npulleys to approximate each other\nduring digital flexion. The flexor tendons\nare weakly attached to the sheath\nby filmy mesenteries composed of\nvincula\n
  • The thin, condensable cruciate\nsections of the sheath&amp;#x2014;C1\n(between A2 and A3 ), C2 (between A3\nand A4), and C3 (between A4 and\nA5)&amp;#x2014;collapse to permit the annular\npulleys to approximate each other\nduring digital flexion. The flexor tendons\nare weakly attached to the sheath\nby filmy mesenteries composed of\nvincula\n
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  • from L. imbibere &quot;absorb, drink in, inhale,&quot; from in- &quot;in&quot; + bibere &quot;to drink,&quot; \n\nSynovial fluid diffusion provides an effective alternative\nnutritional and lubricating pathway for\nflexor tendons. The rapid delivery of nutrients is\napparently accomplished by a pumping mechanism\nknown as imbibition in which fluid is forced into the\ninterstices of the tendon through small conduits in\nthe tendon surface as the digit is flexed and extended.\n
  • from L. imbibere &quot;absorb, drink in, inhale,&quot; from in- &quot;in&quot; + bibere &quot;to drink,&quot; \n\nSynovial fluid diffusion provides an effective alternative\nnutritional and lubricating pathway for\nflexor tendons. The rapid delivery of nutrients is\napparently accomplished by a pumping mechanism\nknown as imbibition in which fluid is forced into the\ninterstices of the tendon through small conduits in\nthe tendon surface as the digit is flexed and extended.\n
  • from L. imbibere &quot;absorb, drink in, inhale,&quot; from in- &quot;in&quot; + bibere &quot;to drink,&quot; \n\nSynovial fluid diffusion provides an effective alternative\nnutritional and lubricating pathway for\nflexor tendons. The rapid delivery of nutrients is\napparently accomplished by a pumping mechanism\nknown as imbibition in which fluid is forced into the\ninterstices of the tendon through small conduits in\nthe tendon surface as the digit is flexed and extended.\n
  • from L. imbibere &quot;absorb, drink in, inhale,&quot; from in- &quot;in&quot; + bibere &quot;to drink,&quot; \n\nSynovial fluid diffusion provides an effective alternative\nnutritional and lubricating pathway for\nflexor tendons. The rapid delivery of nutrients is\napparently accomplished by a pumping mechanism\nknown as imbibition in which fluid is forced into the\ninterstices of the tendon through small conduits in\nthe tendon surface as the digit is flexed and extended.\n
  • from L. imbibere &quot;absorb, drink in, inhale,&quot; from in- &quot;in&quot; + bibere &quot;to drink,&quot; \n\nSynovial fluid diffusion provides an effective alternative\nnutritional and lubricating pathway for\nflexor tendons. The rapid delivery of nutrients is\napparently accomplished by a pumping mechanism\nknown as imbibition in which fluid is forced into the\ninterstices of the tendon through small conduits in\nthe tendon surface as the digit is flexed and extended.\n
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  • Gelberman R, Goldberg V, An KN, et al: Tendon, in Woo SLY, Buckwalter JA\n(eds): Injury and Repair of the Musculoskeletal Soft Tissues. Park Ridge, Ill:\nAmerican Academy of Orthopaedic Surgeons, 1988, pp 5-40.\n
  • Gelberman R, Goldberg V, An KN, et al: Tendon, in Woo SLY, Buckwalter JA\n(eds): Injury and Repair of the Musculoskeletal Soft Tissues. Park Ridge, Ill:\nAmerican Academy of Orthopaedic Surgeons, 1988, pp 5-40.\n
  • Gelberman R, Goldberg V, An KN, et al: Tendon, in Woo SLY, Buckwalter JA\n(eds): Injury and Repair of the Musculoskeletal Soft Tissues. Park Ridge, Ill:\nAmerican Academy of Orthopaedic Surgeons, 1988, pp 5-40.\n
  • Gelberman R, Goldberg V, An KN, et al: Tendon, in Woo SLY, Buckwalter JA\n(eds): Injury and Repair of the Musculoskeletal Soft Tissues. Park Ridge, Ill:\nAmerican Academy of Orthopaedic Surgeons, 1988, pp 5-40.\n
  • Gelberman R, Goldberg V, An KN, et al: Tendon, in Woo SLY, Buckwalter JA\n(eds): Injury and Repair of the Musculoskeletal Soft Tissues. Park Ridge, Ill:\nAmerican Academy of Orthopaedic Surgeons, 1988, pp 5-40.\n
  • Gelberman R, Goldberg V, An KN, et al: Tendon, in Woo SLY, Buckwalter JA\n(eds): Injury and Repair of the Musculoskeletal Soft Tissues. Park Ridge, Ill:\nAmerican Academy of Orthopaedic Surgeons, 1988, pp 5-40.\n
  • Gelberman R, Goldberg V, An KN, et al: Tendon, in Woo SLY, Buckwalter JA\n(eds): Injury and Repair of the Musculoskeletal Soft Tissues. Park Ridge, Ill:\nAmerican Academy of Orthopaedic Surgeons, 1988, pp 5-40.\n
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  • factors:\n\nposition, length, and direction of original laceration,\n\nneed to gain access to other injured structures\n\npersonal experience and preferences\n
  • factors:\n\nposition, length, and direction of original laceration,\n\nneed to gain access to other injured structures\n\npersonal experience and preferences\n
  • factors:\n\nposition, length, and direction of original laceration,\n\nneed to gain access to other injured structures\n\npersonal experience and preferences\n
  • factors:\n\nposition, length, and direction of original laceration,\n\nneed to gain access to other injured structures\n\npersonal experience and preferences\n
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  • Repair of Zone I Lacerations or Avulsions \n\nRecent in-vivo experiments on the canine FDP-bone repair site have led to several new concepts of flexor tendon repair to bone.43,45,47,397 First, the tendon-bone repair site does not appear to accrue strength during the 3 to 6 week period postoperatively. 397 Second, even at 6 weeks postoperatively (the time at which the grasping suture and dorsal button are usually removed) there is substantial inflammatory tissue still present at the repair site, signifying a potential biologic &quot;immaturity&quot; of the repair site. 45 In addition, there is a substantial tendency for the repair site to elongate during the immediate postoperative period, which may not be apparent clinically. These findings suggest that tendon-bone healing does not follow the same time course as the healing of intrasynovial flexor tendon repairs.\n\n Laceration of the FDP tendon distal to the insertion of the FDS tendon or avulsion from its insertion at the base of the proximal aspect of the distal phalanx is by definition an injury in zone I of the flexor sheath. If the tendon is lacerated and the distal tendon stump is less than 1 cm long, FDP tendon advancement and primary repair to bone are indicated. If more than 1 cm of FDP stump is available for suture, then primary tenorrhaphy is indicated because shortening of the FDP tendon by greater than 1 cm may result in a quadrigia effect on attempted composite flexion of the digits. 458 In this clinical situation, the laceration may lie near or beneath the A4 pulley, making the repair technically difficult. \n\nTendon to Bone Repair\n\n Many techniques of core suture placement have been advocated for affixing the FDP tendon stump to bone. Theoretically, most of the techniques employed for tendon-tendon repair can be utilized for tendon-bone repair; however, several of these have been accepted more widely since removal of the dorsal button and transfixing suture at 6 weeks postoperatively has been advocated generally. The utilization of suture material of high tensile strength that is absorbed after months rather than weeks has led to increased advocacy of core suture techniques that need not be placed in the proximal stump with an intention toward their eventual removal.43,47,397 In addition, the increased utilization of intraosseous anchors in hand surgery has led some investigators to advocate their utilization in this clinical setting.61,62,151,365,403 If bone quality is good and experimental data are supported with clinical efficacy, their use could become more widespread.\n
  • Repair of Zone I Lacerations or Avulsions \n\nRecent in-vivo experiments on the canine FDP-bone repair site have led to several new concepts of flexor tendon repair to bone.43,45,47,397 First, the tendon-bone repair site does not appear to accrue strength during the 3 to 6 week period postoperatively. 397 Second, even at 6 weeks postoperatively (the time at which the grasping suture and dorsal button are usually removed) there is substantial inflammatory tissue still present at the repair site, signifying a potential biologic &quot;immaturity&quot; of the repair site. 45 In addition, there is a substantial tendency for the repair site to elongate during the immediate postoperative period, which may not be apparent clinically. These findings suggest that tendon-bone healing does not follow the same time course as the healing of intrasynovial flexor tendon repairs.\n\n Laceration of the FDP tendon distal to the insertion of the FDS tendon or avulsion from its insertion at the base of the proximal aspect of the distal phalanx is by definition an injury in zone I of the flexor sheath. If the tendon is lacerated and the distal tendon stump is less than 1 cm long, FDP tendon advancement and primary repair to bone are indicated. If more than 1 cm of FDP stump is available for suture, then primary tenorrhaphy is indicated because shortening of the FDP tendon by greater than 1 cm may result in a quadrigia effect on attempted composite flexion of the digits. 458 In this clinical situation, the laceration may lie near or beneath the A4 pulley, making the repair technically difficult. \n\nTendon to Bone Repair\n\n Many techniques of core suture placement have been advocated for affixing the FDP tendon stump to bone. Theoretically, most of the techniques employed for tendon-tendon repair can be utilized for tendon-bone repair; however, several of these have been accepted more widely since removal of the dorsal button and transfixing suture at 6 weeks postoperatively has been advocated generally. The utilization of suture material of high tensile strength that is absorbed after months rather than weeks has led to increased advocacy of core suture techniques that need not be placed in the proximal stump with an intention toward their eventual removal.43,47,397 In addition, the increased utilization of intraosseous anchors in hand surgery has led some investigators to advocate their utilization in this clinical setting.61,62,151,365,403 If bone quality is good and experimental data are supported with clinical efficacy, their use could become more widespread.\n
  • Repair of Zone I Lacerations or Avulsions \n\nRecent in-vivo experiments on the canine FDP-bone repair site have led to several new concepts of flexor tendon repair to bone.43,45,47,397 First, the tendon-bone repair site does not appear to accrue strength during the 3 to 6 week period postoperatively. 397 Second, even at 6 weeks postoperatively (the time at which the grasping suture and dorsal button are usually removed) there is substantial inflammatory tissue still present at the repair site, signifying a potential biologic &quot;immaturity&quot; of the repair site. 45 In addition, there is a substantial tendency for the repair site to elongate during the immediate postoperative period, which may not be apparent clinically. These findings suggest that tendon-bone healing does not follow the same time course as the healing of intrasynovial flexor tendon repairs.\n\n Laceration of the FDP tendon distal to the insertion of the FDS tendon or avulsion from its insertion at the base of the proximal aspect of the distal phalanx is by definition an injury in zone I of the flexor sheath. If the tendon is lacerated and the distal tendon stump is less than 1 cm long, FDP tendon advancement and primary repair to bone are indicated. If more than 1 cm of FDP stump is available for suture, then primary tenorrhaphy is indicated because shortening of the FDP tendon by greater than 1 cm may result in a quadrigia effect on attempted composite flexion of the digits. 458 In this clinical situation, the laceration may lie near or beneath the A4 pulley, making the repair technically difficult. \n\nTendon to Bone Repair\n\n Many techniques of core suture placement have been advocated for affixing the FDP tendon stump to bone. Theoretically, most of the techniques employed for tendon-tendon repair can be utilized for tendon-bone repair; however, several of these have been accepted more widely since removal of the dorsal button and transfixing suture at 6 weeks postoperatively has been advocated generally. The utilization of suture material of high tensile strength that is absorbed after months rather than weeks has led to increased advocacy of core suture techniques that need not be placed in the proximal stump with an intention toward their eventual removal.43,47,397 In addition, the increased utilization of intraosseous anchors in hand surgery has led some investigators to advocate their utilization in this clinical setting.61,62,151,365,403 If bone quality is good and experimental data are supported with clinical efficacy, their use could become more widespread.\n
  • Repair of Zone I Lacerations or Avulsions \n\nRecent in-vivo experiments on the canine FDP-bone repair site have led to several new concepts of flexor tendon repair to bone.43,45,47,397 First, the tendon-bone repair site does not appear to accrue strength during the 3 to 6 week period postoperatively. 397 Second, even at 6 weeks postoperatively (the time at which the grasping suture and dorsal button are usually removed) there is substantial inflammatory tissue still present at the repair site, signifying a potential biologic &quot;immaturity&quot; of the repair site. 45 In addition, there is a substantial tendency for the repair site to elongate during the immediate postoperative period, which may not be apparent clinically. These findings suggest that tendon-bone healing does not follow the same time course as the healing of intrasynovial flexor tendon repairs.\n\n Laceration of the FDP tendon distal to the insertion of the FDS tendon or avulsion from its insertion at the base of the proximal aspect of the distal phalanx is by definition an injury in zone I of the flexor sheath. If the tendon is lacerated and the distal tendon stump is less than 1 cm long, FDP tendon advancement and primary repair to bone are indicated. If more than 1 cm of FDP stump is available for suture, then primary tenorrhaphy is indicated because shortening of the FDP tendon by greater than 1 cm may result in a quadrigia effect on attempted composite flexion of the digits. 458 In this clinical situation, the laceration may lie near or beneath the A4 pulley, making the repair technically difficult. \n\nTendon to Bone Repair\n\n Many techniques of core suture placement have been advocated for affixing the FDP tendon stump to bone. Theoretically, most of the techniques employed for tendon-tendon repair can be utilized for tendon-bone repair; however, several of these have been accepted more widely since removal of the dorsal button and transfixing suture at 6 weeks postoperatively has been advocated generally. The utilization of suture material of high tensile strength that is absorbed after months rather than weeks has led to increased advocacy of core suture techniques that need not be placed in the proximal stump with an intention toward their eventual removal.43,47,397 In addition, the increased utilization of intraosseous anchors in hand surgery has led some investigators to advocate their utilization in this clinical setting.61,62,151,365,403 If bone quality is good and experimental data are supported with clinical efficacy, their use could become more widespread.\n
  • Repair of Zone I Lacerations or Avulsions \n\nRecent in-vivo experiments on the canine FDP-bone repair site have led to several new concepts of flexor tendon repair to bone.43,45,47,397 First, the tendon-bone repair site does not appear to accrue strength during the 3 to 6 week period postoperatively. 397 Second, even at 6 weeks postoperatively (the time at which the grasping suture and dorsal button are usually removed) there is substantial inflammatory tissue still present at the repair site, signifying a potential biologic &quot;immaturity&quot; of the repair site. 45 In addition, there is a substantial tendency for the repair site to elongate during the immediate postoperative period, which may not be apparent clinically. These findings suggest that tendon-bone healing does not follow the same time course as the healing of intrasynovial flexor tendon repairs.\n\n Laceration of the FDP tendon distal to the insertion of the FDS tendon or avulsion from its insertion at the base of the proximal aspect of the distal phalanx is by definition an injury in zone I of the flexor sheath. If the tendon is lacerated and the distal tendon stump is less than 1 cm long, FDP tendon advancement and primary repair to bone are indicated. If more than 1 cm of FDP stump is available for suture, then primary tenorrhaphy is indicated because shortening of the FDP tendon by greater than 1 cm may result in a quadrigia effect on attempted composite flexion of the digits. 458 In this clinical situation, the laceration may lie near or beneath the A4 pulley, making the repair technically difficult. \n\nTendon to Bone Repair\n\n Many techniques of core suture placement have been advocated for affixing the FDP tendon stump to bone. Theoretically, most of the techniques employed for tendon-tendon repair can be utilized for tendon-bone repair; however, several of these have been accepted more widely since removal of the dorsal button and transfixing suture at 6 weeks postoperatively has been advocated generally. The utilization of suture material of high tensile strength that is absorbed after months rather than weeks has led to increased advocacy of core suture techniques that need not be placed in the proximal stump with an intention toward their eventual removal.43,47,397 In addition, the increased utilization of intraosseous anchors in hand surgery has led some investigators to advocate their utilization in this clinical setting.61,62,151,365,403 If bone quality is good and experimental data are supported with clinical efficacy, their use could become more widespread.\n
  • Repair of Zone I Lacerations or Avulsions \n\nRecent in-vivo experiments on the canine FDP-bone repair site have led to several new concepts of flexor tendon repair to bone.43,45,47,397 First, the tendon-bone repair site does not appear to accrue strength during the 3 to 6 week period postoperatively. 397 Second, even at 6 weeks postoperatively (the time at which the grasping suture and dorsal button are usually removed) there is substantial inflammatory tissue still present at the repair site, signifying a potential biologic &quot;immaturity&quot; of the repair site. 45 In addition, there is a substantial tendency for the repair site to elongate during the immediate postoperative period, which may not be apparent clinically. These findings suggest that tendon-bone healing does not follow the same time course as the healing of intrasynovial flexor tendon repairs.\n\n Laceration of the FDP tendon distal to the insertion of the FDS tendon or avulsion from its insertion at the base of the proximal aspect of the distal phalanx is by definition an injury in zone I of the flexor sheath. If the tendon is lacerated and the distal tendon stump is less than 1 cm long, FDP tendon advancement and primary repair to bone are indicated. If more than 1 cm of FDP stump is available for suture, then primary tenorrhaphy is indicated because shortening of the FDP tendon by greater than 1 cm may result in a quadrigia effect on attempted composite flexion of the digits. 458 In this clinical situation, the laceration may lie near or beneath the A4 pulley, making the repair technically difficult. \n\nTendon to Bone Repair\n\n Many techniques of core suture placement have been advocated for affixing the FDP tendon stump to bone. Theoretically, most of the techniques employed for tendon-tendon repair can be utilized for tendon-bone repair; however, several of these have been accepted more widely since removal of the dorsal button and transfixing suture at 6 weeks postoperatively has been advocated generally. The utilization of suture material of high tensile strength that is absorbed after months rather than weeks has led to increased advocacy of core suture techniques that need not be placed in the proximal stump with an intention toward their eventual removal.43,47,397 In addition, the increased utilization of intraosseous anchors in hand surgery has led some investigators to advocate their utilization in this clinical setting.61,62,151,365,403 If bone quality is good and experimental data are supported with clinical efficacy, their use could become more widespread.\n
  • Figure 7-7 Profundus avulsion classification of Leddy and Packer. \n\nType I: FDP is avulsed from its insertion and retracts into the palm. \n\nType II: the profundus tendon is avulsed from it insertion but the stump remains within the digital sheath, implying that the vinculum longum profundus is still intact. \n\nType III: a bony fragment is attached to the tendon stump, which remains within the flexor sheath. Further proximal retraction is prevented at the distal end of the A4 pulley. \n\nLeddy and Packer classified FDP avulsions into three types (Fig. 7-7).221,222 In type I avulsions, the FDP tendon retracts into the palm. By definition, the vincular blood supply of the tendon has been disrupted. The sheath may, after a few days, be noncompliant and not permit passage of the FDP tendon through it in an attempt to repair the stump to bone. Additionally, proximal muscle contracture may prevent tendon stump advancement. In type II avulsions, the tendon stump retracts to the level of the PIP joint. The sheath is not compromised, and proximal muscle-tendon contracture does not develop substantially. Attempts to advance the tendon stump through the sheath, especially the A4 pulley, may require gentle pulley dilation as well. Repair may be attempted for 6 weeks, or longer, after injury. A large bone fragment is attached to the stump of the FDP tendon in type III injuries. This fragment usually prevents tendon retraction proximal to the distal edge of the A4 pulley. Bony repair using Kirschner wire or screw fixation is often all that is required. A type III injury may be deceptive preoperatively after clinical and radiographic examination because, on occasion, the FDP stump itself is avulsed from the bony fragment (a so-called type IV injury, not initially classified by Leddy and Packer). 222 The stump may be located either within the tendon sheath or within the palm. Repair of the fracture is done first, after which the tendon is advanced and affixed to the distal phalanx. Immobilization of the DIP joint is required, and the range of motion that may be expected after repair is substantially less. Repair of Zone II Lacerations\n
  • Figure 7-7 Profundus avulsion classification of Leddy and Packer. \n\nType I: FDP is avulsed from its insertion and retracts into the palm. \n\nType II: the profundus tendon is avulsed from it insertion but the stump remains within the digital sheath, implying that the vinculum longum profundus is still intact. \n\nType III: a bony fragment is attached to the tendon stump, which remains within the flexor sheath. Further proximal retraction is prevented at the distal end of the A4 pulley. \n\nLeddy and Packer classified FDP avulsions into three types (Fig. 7-7).221,222 In type I avulsions, the FDP tendon retracts into the palm. By definition, the vincular blood supply of the tendon has been disrupted. The sheath may, after a few days, be noncompliant and not permit passage of the FDP tendon through it in an attempt to repair the stump to bone. Additionally, proximal muscle contracture may prevent tendon stump advancement. In type II avulsions, the tendon stump retracts to the level of the PIP joint. The sheath is not compromised, and proximal muscle-tendon contracture does not develop substantially. Attempts to advance the tendon stump through the sheath, especially the A4 pulley, may require gentle pulley dilation as well. Repair may be attempted for 6 weeks, or longer, after injury. A large bone fragment is attached to the stump of the FDP tendon in type III injuries. This fragment usually prevents tendon retraction proximal to the distal edge of the A4 pulley. Bony repair using Kirschner wire or screw fixation is often all that is required. A type III injury may be deceptive preoperatively after clinical and radiographic examination because, on occasion, the FDP stump itself is avulsed from the bony fragment (a so-called type IV injury, not initially classified by Leddy and Packer). 222 The stump may be located either within the tendon sheath or within the palm. Repair of the fracture is done first, after which the tendon is advanced and affixed to the distal phalanx. Immobilization of the DIP joint is required, and the range of motion that may be expected after repair is substantially less. Repair of Zone II Lacerations\n
  • Quadrigia\n\nQuadrigia syndrome manifests as a decrease in flexion of an adjacent normal finger after the proximal excursion of the FDP tendon of the involved digit has been limited. 392 It was first described by Bunnell 60 and later by Verdan471,473 after the Roman four-horse chariots driven by one charioteer who controlled four horses through individual reins. If injury or a surgical procedure prevents normal proximal excursion of a single FDP, a tethering effect will be experienced by the other FDP tendons that share a common musculotendinous origin. The adjacent FDP tendons then cannot fully flex their respective digits. The adjacent fingers will lose some distal flexion besides creating a flexion deformity in the operated finger.\n\nThe quadrigia syndrome may occur in a number of settings such as when one FDP is advanced too far distally in a reattachment procedure in zone I. 271 Other causes include a tendon graft that is too short, a distal finger amputation in which the flexor is sutured over the tip to the extensor tendon, or an amputation in which the FDP adheres to the proximal phalanx. The patient will complain not only of the flexion deformity in the injured finger but also of weakness of grasp in the adjacent fingers. The adjacent fingers would, on clinical examination, show weakness and deficiency in their FDP function. The treatment is to lengthen, tenolyse, or even sever the offending tendon to allow the other normal adjacent fingers to flex fully.\n
  • Quadrigia\n\nQuadrigia syndrome manifests as a decrease in flexion of an adjacent normal finger after the proximal excursion of the FDP tendon of the involved digit has been limited. 392 It was first described by Bunnell 60 and later by Verdan471,473 after the Roman four-horse chariots driven by one charioteer who controlled four horses through individual reins. If injury or a surgical procedure prevents normal proximal excursion of a single FDP, a tethering effect will be experienced by the other FDP tendons that share a common musculotendinous origin. The adjacent FDP tendons then cannot fully flex their respective digits. The adjacent fingers will lose some distal flexion besides creating a flexion deformity in the operated finger.\n\nThe quadrigia syndrome may occur in a number of settings such as when one FDP is advanced too far distally in a reattachment procedure in zone I. 271 Other causes include a tendon graft that is too short, a distal finger amputation in which the flexor is sutured over the tip to the extensor tendon, or an amputation in which the FDP adheres to the proximal phalanx. The patient will complain not only of the flexion deformity in the injured finger but also of weakness of grasp in the adjacent fingers. The adjacent fingers would, on clinical examination, show weakness and deficiency in their FDP function. The treatment is to lengthen, tenolyse, or even sever the offending tendon to allow the other normal adjacent fingers to flex fully.\n
  • Quadrigia\n\nQuadrigia syndrome manifests as a decrease in flexion of an adjacent normal finger after the proximal excursion of the FDP tendon of the involved digit has been limited. 392 It was first described by Bunnell 60 and later by Verdan471,473 after the Roman four-horse chariots driven by one charioteer who controlled four horses through individual reins. If injury or a surgical procedure prevents normal proximal excursion of a single FDP, a tethering effect will be experienced by the other FDP tendons that share a common musculotendinous origin. The adjacent FDP tendons then cannot fully flex their respective digits. The adjacent fingers will lose some distal flexion besides creating a flexion deformity in the operated finger.\n\nThe quadrigia syndrome may occur in a number of settings such as when one FDP is advanced too far distally in a reattachment procedure in zone I. 271 Other causes include a tendon graft that is too short, a distal finger amputation in which the flexor is sutured over the tip to the extensor tendon, or an amputation in which the FDP adheres to the proximal phalanx. The patient will complain not only of the flexion deformity in the injured finger but also of weakness of grasp in the adjacent fingers. The adjacent fingers would, on clinical examination, show weakness and deficiency in their FDP function. The treatment is to lengthen, tenolyse, or even sever the offending tendon to allow the other normal adjacent fingers to flex fully.\n
  • Quadrigia\n\nQuadrigia syndrome manifests as a decrease in flexion of an adjacent normal finger after the proximal excursion of the FDP tendon of the involved digit has been limited. 392 It was first described by Bunnell 60 and later by Verdan471,473 after the Roman four-horse chariots driven by one charioteer who controlled four horses through individual reins. If injury or a surgical procedure prevents normal proximal excursion of a single FDP, a tethering effect will be experienced by the other FDP tendons that share a common musculotendinous origin. The adjacent FDP tendons then cannot fully flex their respective digits. The adjacent fingers will lose some distal flexion besides creating a flexion deformity in the operated finger.\n\nThe quadrigia syndrome may occur in a number of settings such as when one FDP is advanced too far distally in a reattachment procedure in zone I. 271 Other causes include a tendon graft that is too short, a distal finger amputation in which the flexor is sutured over the tip to the extensor tendon, or an amputation in which the FDP adheres to the proximal phalanx. The patient will complain not only of the flexion deformity in the injured finger but also of weakness of grasp in the adjacent fingers. The adjacent fingers would, on clinical examination, show weakness and deficiency in their FDP function. The treatment is to lengthen, tenolyse, or even sever the offending tendon to allow the other normal adjacent fingers to flex fully.\n
  • Quadrigia\n\nQuadrigia syndrome manifests as a decrease in flexion of an adjacent normal finger after the proximal excursion of the FDP tendon of the involved digit has been limited. 392 It was first described by Bunnell 60 and later by Verdan471,473 after the Roman four-horse chariots driven by one charioteer who controlled four horses through individual reins. If injury or a surgical procedure prevents normal proximal excursion of a single FDP, a tethering effect will be experienced by the other FDP tendons that share a common musculotendinous origin. The adjacent FDP tendons then cannot fully flex their respective digits. The adjacent fingers will lose some distal flexion besides creating a flexion deformity in the operated finger.\n\nThe quadrigia syndrome may occur in a number of settings such as when one FDP is advanced too far distally in a reattachment procedure in zone I. 271 Other causes include a tendon graft that is too short, a distal finger amputation in which the flexor is sutured over the tip to the extensor tendon, or an amputation in which the FDP adheres to the proximal phalanx. The patient will complain not only of the flexion deformity in the injured finger but also of weakness of grasp in the adjacent fingers. The adjacent fingers would, on clinical examination, show weakness and deficiency in their FDP function. The treatment is to lengthen, tenolyse, or even sever the offending tendon to allow the other normal adjacent fingers to flex fully.\n
  • Quadrigia\n\nQuadrigia syndrome manifests as a decrease in flexion of an adjacent normal finger after the proximal excursion of the FDP tendon of the involved digit has been limited. 392 It was first described by Bunnell 60 and later by Verdan471,473 after the Roman four-horse chariots driven by one charioteer who controlled four horses through individual reins. If injury or a surgical procedure prevents normal proximal excursion of a single FDP, a tethering effect will be experienced by the other FDP tendons that share a common musculotendinous origin. The adjacent FDP tendons then cannot fully flex their respective digits. The adjacent fingers will lose some distal flexion besides creating a flexion deformity in the operated finger.\n\nThe quadrigia syndrome may occur in a number of settings such as when one FDP is advanced too far distally in a reattachment procedure in zone I. 271 Other causes include a tendon graft that is too short, a distal finger amputation in which the flexor is sutured over the tip to the extensor tendon, or an amputation in which the FDP adheres to the proximal phalanx. The patient will complain not only of the flexion deformity in the injured finger but also of weakness of grasp in the adjacent fingers. The adjacent fingers would, on clinical examination, show weakness and deficiency in their FDP function. The treatment is to lengthen, tenolyse, or even sever the offending tendon to allow the other normal adjacent fingers to flex fully.\n
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  • Transcript of "Flexor Tendons - Anatomy, Injury, Treatment"

    1. 1. Flexor TendonInjuriesC. Noel Henley, MD
    2. 2. Flexor TendonInjuriesIU Orthopaedic SurgeryC. Noel Henley, MD
    3. 3. Flexor TendonInjuriesIU Orthopaedic SurgeryApril 5, 2006C. Noel Henley, MD
    4. 4. Talk Summary
    5. 5. Talk Summary• Introduction
    6. 6. Talk Summary• Introduction• Basic science – anatomy – nutrition – biomechanics – healing• Surgical considerations – lacerations – avulsions• Rehabilitation
    7. 7. Introduction
    8. 8. Introduction• History
    9. 9. Introduction• History – no repair possible in the digit
    10. 10. Introduction• History – no repair possible in the digit – “no man’s land”
    11. 11. Introduction• History – no repair possible in the digit – “no man’s land”• Current evidence
    12. 12. Introduction• History – no repair possible in the digit – “no man’s land”• Current evidence – 1970s: repair is possible without delayed grafting, reconstruction
    13. 13. 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
    14. 14. Introduction
    15. 15. Introduction• General goals of repair
    16. 16. Introduction• General goals of repair – primary tendon repair – avoid grafting
    17. 17. Introduction• General goals of repair – primary tendon repair – avoid grafting – sufficient strength for passive motion rehab which will allow for
    18. 18. Introduction• General goals of repair – primary tendon repair – avoid grafting – sufficient strength for passive motion rehab which will allow for • minimum adhesion formation
    19. 19. 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
    20. 20. 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
    21. 21. Anatomy
    22. 22. Anatomy • FDS
    23. 23. Anatomy • FDS – O: volar humerus, radius, ulna
    24. 24. Anatomy • FDS – O: volar humerus, radius, ulna – divided muscle belly in mid forearm (FA)
    25. 25. Anatomy • FDS – O: volar humerus, radius, ulna – divided muscle belly in mid forearm (FA) • super cial – long and ring ngers (LF, RF)
    26. 26. 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)
    27. 27. 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
    28. 28. 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
    29. 29. 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
    30. 30. 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
    31. 31. Anatomy
    32. 32. Anatomy• In the hand
    33. 33. Anatomy• In the hand – ve zones
    34. 34. Anatomy• In the hand – ve zones • V: musculo-tendinous junction to proximal edge of carpal canal
    35. 35. Anatomy• In the hand – ve zones • V: musculo-tendinous junction to proximal edge of carpal canal • IV: beneath (dorsal to) the transverse carpal ligament
    36. 36. 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
    37. 37. Anatomy
    38. 38. Anatomy• Zones (cont.)
    39. 39. Anatomy• Zones (cont.) – III: distal edge of transverse carpal ligament to origin of bro-osseous sheath at the distal palmar crease
    40. 40. 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
    41. 41. 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
    42. 42. Anatomy
    43. 43. Anatomy • Super cialis
    44. 44. Anatomy • Super cialis – FDS divides into two slips, wrapping around FDP; reunite at Camper’s chiasma
    45. 45. 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)
    46. 46. Anatomy
    47. 47. Anatomy • Profundus
    48. 48. Anatomy • Profundus
    49. 49. Anatomy • Profundus – passes through chiasma to insert at proximal base of distal phalanx (P3)
    50. 50. Anatomy • Profundus – passes through chiasma to insert at proximal base of distal phalanx (P3) – FDP = primary digital exor
    51. 51. Anatomy • Profundus – passes through chiasma to insert at proximal base of distal phalanx (P3) – FDP = primary digital exor – FDS + intrinsics combine for forceful exion
    52. 52. Anatomy
    53. 53. Anatomy
    54. 54. Anatomy
    55. 55. Anatomy • Sheath
    56. 56. Anatomy • Sheath – visceral and parietal synovial layers enclose the tendons
    57. 57. Anatomy • Sheath – visceral and parietal synovial layers enclose the tendons – Pulleys
    58. 58. 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)
    59. 59. Anatomy
    60. 60. Anatomy • Sheath
    61. 61. Anatomy • Sheath – Pulleys
    62. 62. Anatomy • Sheath – Pulleys • A1, A3, and A5 arise from volar plates of MCP, PIP, and DIP joints respectively
    63. 63. Anatomy
    64. 64. Anatomy • Sheath
    65. 65. Anatomy • Sheath – Pulleys
    66. 66. Anatomy • Sheath – Pulleys • cruciate pulleys collapse to allow annular pulley apposition during exion
    67. 67. Nutrition
    68. 68. Nutrition • Two sources of tendon nutrition
    69. 69. Nutrition • Two sources of tendon nutrition – vascular
    70. 70. Nutrition • Two sources of tendon nutrition – vascular – synovial
    71. 71. Nutrition • Two sources of tendon nutrition – vascular – synovial • Vascularity sources
    72. 72. Nutrition • Two sources of tendon nutrition – vascular – synovial • Vascularity sources – longitudinal vessels
    73. 73. Nutrition • Two sources of tendon nutrition – vascular – synovial • Vascularity sources – longitudinal vessels – proximal synovial fold vessels
    74. 74. Nutrition • Two sources of tendon nutrition – vascular – synovial • Vascularity sources – longitudinal vessels – proximal synovial fold vessels – segmental branches from paired digital vessels (vincular system)
    75. 75. 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
    76. 76. Nutrition
    77. 77. Nutrition
    78. 78. Nutrition
    79. 79. Nutrition • Avascular segments
    80. 80. Nutrition • Avascular segments – FDP and FDS: over proximal phalanx
    81. 81. Nutrition • Avascular segments – FDP and FDS: over proximal phalanx – FDP: short zone over middle phalanx
    82. 82. Nutrition • Avascular segments – FDP and FDS: over proximal phalanx – FDP: short zone over middle phalanx • Synovial uid diffusion
    83. 83. Nutrition • Avascular segments – FDP and FDS: over proximal phalanx – FDP: short zone over middle phalanx • Synovial uid diffusion – imbibition
    84. 84. Nutrition
    85. 85. Nutrition
    86. 86. Nutrition
    87. 87. Nutrition • Vascularity
    88. 88. Nutrition • Vascularity – damage to vascular and uid nutritional systems may further hamper healing of repaired exor tendons
    89. 89. 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
    90. 90. Nutrition
    91. 91. Nutrition
    92. 92. Biomechanics
    93. 93. Biomechanics • Excursion
    94. 94. Biomechanics • Excursion – 9 cm of excursion for composite wrist, full digital exion
    95. 95. Biomechanics • Excursion – 9 cm of excursion for composite wrist, full digital exion – 2.5 cm required for full digital exion with wrist at neutral
    96. 96. Biomechanics
    97. 97. Biomechanics • Moment arm
    98. 98. Biomechanics • Moment arm – increased distance of tendon from joint center of rotation = higher moment arm = less motion per muscle contraction force
    99. 99. Biomechanics
    100. 100. Biomechanics• Moment arm
    101. 101. Biomechanics• Moment arm – pulley system constraint governs these parameters
    102. 102. Biomechanics• Moment arm – pulley system constraint governs these parameters – loss of portions of pulley system may alter balance between exor, intrinsic, and extensor tendons
    103. 103. 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
    104. 104. Tendon Healing
    105. 105. Tendon Healing • Phases
    106. 106. Tendon Healing • Phases – in ammatory – 48-72 hours
    107. 107. Tendon Healing • Phases – in ammatory – 48-72 hours • repair strength reliant upon suture itself
    108. 108. Tendon Healing • Phases – in ammatory – 48-72 hours • repair strength reliant upon suture itself – collagen-producing phase – 5 days to 4 weeks
    109. 109. 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
    110. 110. 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
    111. 111. 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
    112. 112. Tendon Healing inflammatory
    113. 113. Tendon Healing inflammatory
    114. 114. Tendon Healing collagen-producing
    115. 115. Tendon Healing collagen-producing
    116. 116. Tendon Healing remodeling
    117. 117. Tendon Healing remodeling
    118. 118. Tendon Healing
    119. 119. Tendon Healing• Adhesion formation and control
    120. 120. Tendon Healing• Adhesion formation and control – Contributing factors
    121. 121. Tendon Healing• Adhesion formation and control – Contributing factors • trauma (from injury and surgery)
    122. 122. Tendon Healing• Adhesion formation and control – Contributing factors • trauma (from injury and surgery) – tendon surface crushing
    123. 123. Tendon Healing• Adhesion formation and control – Contributing factors • trauma (from injury and surgery) – tendon surface crushing – vincula disruption
    124. 124. Tendon Healing• Adhesion formation and control – Contributing factors • trauma (from injury and surgery) – tendon surface crushing – vincula disruption • tendon ischemia
    125. 125. Tendon Healing• Adhesion formation and control – Contributing factors • trauma (from injury and surgery) – tendon surface crushing – vincula disruption • tendon ischemia • tendon immobilization
    126. 126. Tendon Healing• Adhesion formation and control – Contributing factors • trauma (from injury and surgery) – tendon surface crushing – vincula disruption • tendon ischemia • tendon immobilization • repair gapping
    127. 127. 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
    128. 128. Tendon Healing
    129. 129. Tendon Healing • How is healing related to motion?
    130. 130. 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.
    131. 131. 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.
    132. 132. 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.
    133. 133. Tendon Repair
    134. 134. Tendon Repair• Contraindications
    135. 135. Tendon Repair• Contraindications – severe multiple tissue injuries to ngers, palm
    136. 136. Tendon Repair• Contraindications – severe multiple tissue injuries to ngers, palm – gross wound contamination
    137. 137. Tendon Repair• Contraindications – severe multiple tissue injuries to ngers, palm – gross wound contamination – signi cant skin loss over the exor system
    138. 138. 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
    139. 139. 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
    140. 140. Examination
    141. 141. Examination• High index of suspicion for multiple structures injured through a small laceration or crush injury
    142. 142. Examination• High index of suspicion for multiple structures injured through a small laceration or crush injury• Complete neurovascular exam
    143. 143. 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
    144. 144. 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
    145. 145. Examination
    146. 146. Examination• Alterations in posture
    147. 147. Examination
    148. 148. Examination• Alterations in posture
    149. 149. Examination
    150. 150. Examination• Tenodesis effect
    151. 151. Examination
    152. 152. Examination• Functional testing (FDS, FDP)
    153. 153. Examination• Functional testing (FDS, FDP)
    154. 154. Examination
    155. 155. Examination• Functional testing (FDS)
    156. 156. Examination
    157. 157. Examination• Functional testing (FDP)
    158. 158. Surgery
    159. 159. Surgery• Planning
    160. 160. Surgery• Planning – inform the patient of the injury severity and potential need for more surgery
    161. 161. Surgery• Planning – inform the patient of the injury severity and potential need for more surgery – incisions
    162. 162. Surgery• Planning – inform the patient of the injury severity and potential need for more surgery – incisions • keep tendon retraction in mind
    163. 163. 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
    164. 164. 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
    165. 165. 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
    166. 166. Surgery - planning
    167. 167. Surgery - planning• Volar incisions
    168. 168. Surgery - planning• Volar incisions • Mid-axial incision
    169. 169. Surgery - principles
    170. 170. Surgery - principles• Ideal repair
    171. 171. Surgery - principles• Ideal repair – easy placement of sutures in the tendon
    172. 172. Surgery - principles• Ideal repair – easy placement of sutures in the tendon – secure suture knots
    173. 173. Surgery - principles• Ideal repair – easy placement of sutures in the tendon – secure suture knots – smooth junction of tendon ends
    174. 174. 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
    175. 175. 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
    176. 176. 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
    177. 177. Surgery
    178. 178. Surgery• Core suture considerations
    179. 179. Surgery• Core suture considerations – strength of a repair is proportional to the number of suture strands crossing the repair site
    180. 180. 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
    181. 181. 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
    182. 182. 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
    183. 183. 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
    184. 184. Surgery
    185. 185. Surgery• Core suture methods
    186. 186. Surgery
    187. 187. Surgery• Suture material
    188. 188. Surgery• Suture material – absorbable materials seem attractive
    189. 189. Surgery• Suture material – absorbable materials seem attractive • less foreign body reaction long-term
    190. 190. Surgery• Suture material – absorbable materials seem attractive • less foreign body reaction long-term • less stress-shielding of the host tissue
    191. 191. 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
    192. 192. 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
    193. 193. Surgery
    194. 194. Surgery• Circumferential (peripheral) sutures
    195. 195. Surgery• Circumferential (peripheral) sutures – may provide a 10-15% increase in exor tendon repair strength
    196. 196. Surgery• Circumferential (peripheral) sutures – may provide a 10-15% increase in exor tendon repair strength – reduces gapping between ends
    197. 197. Surgery• Circumferential (peripheral) sutures – may provide a 10-15% increase in exor tendon repair strength – reduces gapping between ends – methods
    198. 198. Surgery• Circumferential (peripheral) sutures – may provide a 10-15% increase in exor tendon repair strength – reduces gapping between ends – methods • running lock loop (Lin)
    199. 199. 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)
    200. 200. 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)
    201. 201. 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)
    202. 202. Surgery
    203. 203. Surgery
    204. 204. Surgery
    205. 205. Surgery
    206. 206. Surgery
    207. 207. Surgery
    208. 208. 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
    209. 209. Surgery
    210. 210. Surgery• Sheath repair
    211. 211. Surgery• Sheath repair – cumulative work of several investigators fails to give clear direction
    212. 212. Surgery• Sheath repair – cumulative work of several investigators fails to give clear direction – advantages
    213. 213. Surgery• Sheath repair – cumulative work of several investigators fails to give clear direction – advantages • provides a barrier to extrinsic adhesions
    214. 214. 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
    215. 215. 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
    216. 216. 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
    217. 217. 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
    218. 218. 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
    219. 219. 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
    220. 220. Surgery
    221. 221. Surgery• Partial lacerations
    222. 222. Surgery• Partial lacerations – lacerations of 50% or less do not need to be sutured
    223. 223. 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
    224. 224. 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)
    225. 225. Surgery
    226. 226. Surgery• Zone I injury – FDP avulsion
    227. 227. Surgery• Zone I injury – FDP avulsion – occurs w/ forcible extension during strong DIP exion
    228. 228. 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
    229. 229. 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
    230. 230. 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
    231. 231. 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
    232. 232. Surgery – FDP avulsion
    233. 233. Surgery – FDP avulsion• Leddy and Packer classi cation
    234. 234. Surgery
    235. 235. Surgery• FDP laceration – Zone I
    236. 236. Surgery• FDP laceration – Zone I – laceration distal to FDS insertion = Zone I injury
    237. 237. 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
    238. 238. 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
    239. 239. 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
    240. 240. 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
    241. 241. Rehabilitation (zone ii)
    242. 242. Rehabilitation (zone ii)
    243. 243. Rehabilitation (zone ii)
    244. 244. Rehabilitation (zone ii)
    245. 245. Talk Summary
    246. 246. Talk Summary• Basic science – anatomy – nutrition – biomechanics – healing• Surgical considerations – lacerations – avulsions• Rehabilitation
    247. 247. OITE
    248. 248. 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%
    249. 249. 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%
    250. 250. OITE
    251. 251. OITE2005 #246
    252. 252. OITE2005 #246
    253. 253. 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?
    254. 254. 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?
    255. 255. 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
    256. 256. 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
    257. 257. 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
    258. 258. 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
    259. 259. 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
    260. 260. 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
    261. 261. OITE
    262. 262. OITE2005 #246
    263. 263. OITE2005 #246
    264. 264. 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?
    265. 265. 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?
    266. 266. 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
    267. 267. 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
    268. 268. 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
    269. 269. 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
    270. 270. 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
    271. 271. 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
    272. 272. OITE
    273. 273. 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.
    274. 274. OITE
    275. 275. 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.
    276. 276. OITE
    277. 277. 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
    278. 278. OITE
    279. 279. 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
    280. 280. OITE
    281. 281. 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
    282. 282. OITE
    283. 283. 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
    284. 284. OITE
    285. 285. 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
    286. 286. OITE
    287. 287. 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
    288. 288. OITE
    289. 289. 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.
    290. 290. OITE
    291. 291. 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.
    292. 292. 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.
    293. 293. 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.
    294. 294. Bibliography
    295. 295. Bibliography Schmidt. Surgical Anatomy of the Hand. 2004

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