Flexor tendon injuries.m

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Flexor tendon injuries.m

  1. 1. HMC Plastic & reconstruction mansoor khan Dec, 2011 Injuries & Repair ofFlexor Tendons of the Hand !!
  2. 2. Presentation: Questions to consider:A 30-year old female presents to the 1. What aspects of the physicalEmergency room after falling on a piece examination would you focus on?of glass. She complains of 2. What anatomic structures maypain, numbness and bleeding of her have been disrupted given this typeright hand. She is right hand dominant of injury?and works for a local telemarketing firm.
  3. 3. “glistening structure between muscle & bone which ” transmit force from muscle to the bone
  4. 4. Tendons tertiary bundles fasciles fibers fibrils endotenoncollagen
  5. 5. FLEXORDIGITSUBLIMIS
  6. 6. FLEXORDIGITpROFUNDUS
  7. 7. FLEXORPOLLICISLONGUS
  8. 8. LUMBERICALS
  9. 9. PULLEYS
  10. 10. Skin laceration with loss of normal cascade of the fingerd in resting position!!
  11. 11. Loss of active flexionat DIP in FDP laceration!!
  12. 12. Loss of normaltenodesis effect!!
  13. 13. Passive flexionwith forearm squeez!!
  14. 14. Complain of numbness preceeded by execissive bleedConcider neurovascular insult!!
  15. 15. Goals of reconstruction: Coaptation of tendons, anatomical repair with alimited accordion effect at the repair site, multiple strand drepair to permit active range of motion rehabilitation Pully reconstruction to minimize bow- stringing, atraumatic surgical technique to minimize adhesionns, strict adherence to rehabilitation protocole.
  16. 16. Timing of flexor tendon injuries: Primary: repair within 24 hours (contraindicated in case of high grade condtamination i.e. human bites, infection)Delayed Primary: 1-14 days when the wound can be still pulled open without incision Early Secondary: 2-5 weeks. Late Secondary : after 5 weeks i.e. tendon substitution techniques/salvage process.
  17. 17. Leddy classification of zone I flexor tendon injuries!! Type I: tendon retracted into palm (fullness in palm) Type II: tendon traped in the sheath at PIP (unable to flex PIP) Type III: tendon traped in A4 pully
  18. 18. Type II injury!!
  19. 19. Type I injury!!
  20. 20. Direct repair:if laceration is more than 1 cm from FDP insertion Tendon advancement:if the laceration is less then 1 cm from insertion.
  21. 21. Tendon-to-bone attachment!!
  22. 22. WilsonOne method of attaching tendon to bone. A, Small area of cortex is raised with osteotome.B, Hole is drilled through bone with Kirschner wire in drill. C, Bunnell crisscross stitch is placedin end of tendon, and wire suture is drawn through hole in bone. D, End of tendon is drawnagainst bone, and suture is tied over button.
  23. 23. Kleinert method oftendon advancement!!
  24. 24. Tendon advancement shortens the FDP & completes the grip before the normal fingerd and limit their flexion and thus week grip Quadrigia effect!!
  25. 25. Laceration during flexion leads to retraction of cut ends of the tendons!!
  26. 26. Complications: complete disruption, entrapment, triggering. Assess for entrapment, debride if risk of entrapment No drepair if less than <25% laceration, onlyepitenon repair in 25-50% lacerations, core suture plus epitenon repair when >50% laceration Dorsal blocking splintage for 6-8 weeks as consevative measure Partial lacerations of the tendons!!
  27. 27. Commonly used incidions for flexor tendon exploration!!
  28. 28. Brunner incision !!
  29. 29. Because the blood supply to the FDP tendon is jeopardized if the FDS is notalso fixed (due to the vinculae anatomy) Repair both tendons:
  30. 30. Complications: Adhesions & stiffness requiring tenolysis in 18-25% casesTenolysis is indicated after 3 months if no improvement is noted for 1-2 months extensive physiotherapy.
  31. 31. Lumbrical muscle bellies usually are not sutured because this can increase the tension of these muscles and result in a “lumbrical plus” finger(paradoxical proximal interphalangeal extension on attempted active finger flexion). Zone 3 injuries
  32. 32. Tendon repair strength: Core suture: Material, caliber, number ofstrands, knot location, dorsal vs ventral location Epitendinous suture: Depth, locking, cross hatching, simple
  33. 33. THREEBASICTYPES
  34. 34. Silfverskiöld
  35. 35. Fish-Mouth End-to-End Suture (Pulvertaft)
  36. 36. End-to-Side methodtendon repair!!
  37. 37. Active range of motion rehabilitation Kleinert !!
  38. 38. Place and holdpost-operative exercised!!
  39. 39. Differential passive exercises for FDP & FDS!!
  40. 40. Post-operative passive exercises Duran’s
  41. 41. Lumbrical plus!!
  42. 42. Risk factors for adhesions: Composite tendon/tissue damage Gap formation Ischaemia due to over mobalizations of tendon ends Immobalization Persistant inflammation Secondary trauma

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