1. The patient is a 47-year-old Thai male who injured his left index finger while working as a sugarcane cutter. Physical examination revealed a 2 cm cut wound on the back of his left index finger with active bleeding and a tear of the extensor tendon in zone V. 2. The diagnosis was a cut wound with a tear of the extensor tendon in zone V of the left index finger. The management plan was to admit the patient, administer a tetanus booster and IV antibiotics, repair the extensor tendon with local anesthesia, and splint the finger. 3. Injuries to the extensor tendon zones, especially zone V, are commonly caused

1. Conference Extern
Ext. Matinee Werawatganon RAMA 5502123

2. Patient profile: ผู้ป่วยชายไทย อายุ 47 ปี อาชีพตัดอ้อย ภูมิลาเนา ห้วยแถลง
CC: โดนมีดตัดอ้อยบาดนิ้วชี้ซ้าย 2 ชม.ก่อนมารพ.

3.  Primary survey : ABCD Pass
 Adjunct to primary survey : None
Secondary survey :
Allergy:
Medication:
Past history:
Last meal: 12.00 น. (3 hr ago)
Event: 4 hr PTA โดนมีดตัดอ้อยบาดหลังนิ้วชี้ซ้ายขณะทางาน กาเหยียดนิ้วได้สุด
ขณะอยู่เฉยๆมีนิ้วตกเล็กน้อย ไม่ชา ไม่มีบาดเจ็บที่อื่น ไม่เคยบาดเจ็บที่นิ้วมือมาก่อน
NONE

4. Resting position

5. Physical eXam
Left HAND
 Cut wound size 2 cm at base of left index finger with active bleeding
 Resting position: Left index finger in mild flexion position
 Left fingers can flex and extend in full ROM
 Normal tenodesis effect
 Normal capillary refill time (< 2 sec)
 Normal pinprick sensation
Vital Signs : BP 110/70 HR 92 RR18 BT 37

7. Film
Left Hand
AP, Oblique

8. Zone of
extensor tendon

9. Diagnosis
Cut wound with tear extensor tendon Zone
V of left index finger
(Sagittal band rupture)

10. Management
 Admit
 Tetanus booster
 IV ATB
 Digital nerve block (Local anesthesia)
 Debridement
 Joint irrigation(NSS) >> suture
 Extensor tendon repair

11. Extensor tendon injury
Injury can be caused by laceration, trauma, or overuse
zone VI is the most frequently injured zone
Mechanism
Zone I : forced flexion of extended DIP joint
Zone II : dorsal laceration or crush injury
Zone V
commonly from "fight bite"
sagittal band rupture ("flea flicker injury")
forced extension of flexed digit
most common in long finger

14. Zone of
extensor tendon

15. IX

16. Physical eXam
•Zone I
•Inability to extend at the DIP joint
•Zone III
•Elson test
•flex the patient's PIP joint over a table 90 degrees and ask them to extend against
resistance
•if central slip is intact, DIP will remain supple
•if central slip disrupted, DIP will be rigid
•Zone V
•extensor lag and flexion loss common
•junctura tendinae may allow partial/temporary extension by connecting with intact adjacent
extensor tendons

17. Non operative
•immobilization with early protected motion
•indications : lacerations < 50% of tendon in all zones
if patient can extend digit against resistance
•DIP extension splinting for 6 weeks
•Indication : mallet finger type 1, 2 ,3 (no fracture)
•avoid hyperextension, which may cause skin necrosis
•maintain PIP motion
•outcomes
•noncompliance is a common problem
ZONE I
มี Tendon gap เย็บtendon skinพร้อมกัน
ไม่มีtendon gap เย็บแค่skin tendonติดเ อง

18. Non operative
•PIP extension splinting
•indications : closed central slip injury (zone III)
•techniques
•full-time splinting for six weeks
•part-time splinting for four to six weeks
•maintain DIP flexion
•MCP extension splinting
•indications : closed zone V sagittal band rupture
•techniques
•full-time splinting for four to six weeks
ZONE III
ZONE V

19. Operative •tendon repair
•indications : laceration > 50% of tendon width in all zones
•tendon reconstruction
•indications : chronic tendon injury or when repair not possible
•central slip reconstruction
•techniques
•tendon graft
•extensor turndown
•lateral band mobilization
•transverse retinacular ligament
•FDS slip
•EIP(extensor indices proprius) to EPL tendon transfer
•indications : chronic EPL rupture
ZONE III

20. Tendon Repair
 incision technique
longitudinal incision may be utilized across joints, unlike the palmar side
 suture technique
4-6 strands(core suture) >> adequate strength for early active motion
 +/- circumferential epitendinous suture
repair failure (weakest POD 6 -12)
usually fails at knots

21. Tendon Reconstruction
•usually done as two stage procedure

22. Complication
 Adhesion formation >> loss of finger flexion
 common in zone IV and VII and older patients
 prevented with early protected ROM and dynamic splinting (zone IV)
 treatment
extensor tenolysis with early motion indicated after failure of nonoperative management,
usually 3-6 months
 Tendon rupture
 incidence 5% most frequently during first 7 to 10 days post-op
 treatment
revision repair (early recognition)
tendon reconstruction for late rupture or rupture with excessive scarring

23. Complication
 Swan neck deformity
 caused by prolonged DIP flexion with dorsal subluxation of lateral bands and PIP joint hyperextension
 treatment
 Fowler central slip tenotomy
 spiral oblique ligament reconstruction
 Boutonniere deformity (DIP hyperextension)
 caused by central slip disruption and lateral band volar subluxation
(central slip disruped ไม่repairใน10วัน)
 treatment
 dynamic splinting or serial casting for maximal passive motion
 terminal extensor tenotomy, PIP volar plate release