This document discusses extensor tendon injuries and deformities of the hand. It begins with the anatomy of the extensor tendons of the forearm and their arrangement at the wrist. It then describes the mechanics of the extensor mechanism in the fingers and different zones of injury. Specific injuries like mallet finger and boutonniere deformity are explained in detail. Surgical techniques for repairing zone I and II injuries are also summarized.
The document discusses extensor tendon injuries, including their anatomy, zones of injury, clinical evaluation, treatment techniques such as suturing and splinting, and specific injuries like mallet finger and boutonniere deformity. Extensor tendons are vulnerable to injury due to their superficial location and precise suturing and rehabilitation is needed for optimal functional recovery.
The knee joint is superficial on three sides, making it ideal for arthroscopic approaches. Two main arthroscopic approaches and seven open approaches are described for accessing the knee joint. The medial para patellar approach, also known as the von Langenbeck approach, is the most commonly used open approach and involves a longitudinal incision along the medial border of the patella. Care must be taken to avoid damaging nerves like the infrapatellar branch of the saphenous nerve during surgical approaches to the knee.
1. Flexor tendon injuries can occur in any of the 5 zones defined by Kleinert and Verdan and require different surgical approaches depending on the location and severity of the injury.
2. Primary repair within 12-24 hours of injury provides the best functional outcomes while delayed or secondary repairs have higher risks of adhesion formation.
3. Flexor tendon repair techniques aim to accurately approximate the tendon ends with core sutures while minimizing handling and restoring the normal gliding relationship between tendons. Postoperative rehabilitation is crucial.
4. Flexor tendon grafting is indicated for injuries with segment
1) Radial nerve palsy can be classified as high or low lesions, with high lesions demonstrating total loss of wrist extension in addition to finger and thumb losses.
2) Tendon transfers are commonly used to restore wrist, finger, and thumb extension when radial nerve function cannot be recovered. Jones pioneered many tendon transfer techniques still used today.
3) Common tendon transfers include the palmaris longus to the extensor pollicis longus to provide thumb extension and abduction, the flexor carpi ulnaris to the extensors digitorum communis to provide finger extension, and the pronator teres to the extensor carpi radialis brevis to provide wrist
This document summarizes flexor tendon injuries and repairs. It describes tendon nutrition, zones of ischemia, tendon healing phases, factors that cause adhesions, examination techniques, and types of tendon repairs. Flexor tendon injuries are evaluated based on the location of the injury (Verdan zones I-V) and repaired accordingly. Primary repair is preferred if possible, while complications like adhesions or gap formation require techniques like tenolysis. Postoperative rehabilitation aims to restore tendon gliding and function while avoiding issues like bowstringing.
1. The extensor mechanism of the fingers consists of the central slip and lateral bands which insert at various joints to extend the fingers.
2. Injuries can occur in different zones from the DIP to the forearm. Zone I injuries occur at the DIP joint while zone II injuries involve the lateral bands.
3. Boutonniere deformities result from zone III injuries where the central slip is disrupted. Management depends on the chronicity and flexibility of the deformity.
This document discusses flexor tendon injuries, including anatomy, healing, diagnosis, repair techniques, and postoperative rehabilitation. It describes the five zones of the hand where flexor tendon injuries can occur and techniques for primary repair or tendon advancement depending on the zone and extent of the injury. Various suture methods and postoperative protocols like Kleinert and Duran are presented. Complications of repairs like adhesion formation and joint contracture are also reviewed.
The document discusses extensor tendon injuries, including their anatomy, zones of injury, clinical evaluation, treatment techniques such as suturing and splinting, and specific injuries like mallet finger and boutonniere deformity. Extensor tendons are vulnerable to injury due to their superficial location and precise suturing and rehabilitation is needed for optimal functional recovery.
The knee joint is superficial on three sides, making it ideal for arthroscopic approaches. Two main arthroscopic approaches and seven open approaches are described for accessing the knee joint. The medial para patellar approach, also known as the von Langenbeck approach, is the most commonly used open approach and involves a longitudinal incision along the medial border of the patella. Care must be taken to avoid damaging nerves like the infrapatellar branch of the saphenous nerve during surgical approaches to the knee.
1. Flexor tendon injuries can occur in any of the 5 zones defined by Kleinert and Verdan and require different surgical approaches depending on the location and severity of the injury.
2. Primary repair within 12-24 hours of injury provides the best functional outcomes while delayed or secondary repairs have higher risks of adhesion formation.
3. Flexor tendon repair techniques aim to accurately approximate the tendon ends with core sutures while minimizing handling and restoring the normal gliding relationship between tendons. Postoperative rehabilitation is crucial.
4. Flexor tendon grafting is indicated for injuries with segment
1) Radial nerve palsy can be classified as high or low lesions, with high lesions demonstrating total loss of wrist extension in addition to finger and thumb losses.
2) Tendon transfers are commonly used to restore wrist, finger, and thumb extension when radial nerve function cannot be recovered. Jones pioneered many tendon transfer techniques still used today.
3) Common tendon transfers include the palmaris longus to the extensor pollicis longus to provide thumb extension and abduction, the flexor carpi ulnaris to the extensors digitorum communis to provide finger extension, and the pronator teres to the extensor carpi radialis brevis to provide wrist
This document summarizes flexor tendon injuries and repairs. It describes tendon nutrition, zones of ischemia, tendon healing phases, factors that cause adhesions, examination techniques, and types of tendon repairs. Flexor tendon injuries are evaluated based on the location of the injury (Verdan zones I-V) and repaired accordingly. Primary repair is preferred if possible, while complications like adhesions or gap formation require techniques like tenolysis. Postoperative rehabilitation aims to restore tendon gliding and function while avoiding issues like bowstringing.
1. The extensor mechanism of the fingers consists of the central slip and lateral bands which insert at various joints to extend the fingers.
2. Injuries can occur in different zones from the DIP to the forearm. Zone I injuries occur at the DIP joint while zone II injuries involve the lateral bands.
3. Boutonniere deformities result from zone III injuries where the central slip is disrupted. Management depends on the chronicity and flexibility of the deformity.
This document discusses flexor tendon injuries, including anatomy, healing, diagnosis, repair techniques, and postoperative rehabilitation. It describes the five zones of the hand where flexor tendon injuries can occur and techniques for primary repair or tendon advancement depending on the zone and extent of the injury. Various suture methods and postoperative protocols like Kleinert and Duran are presented. Complications of repairs like adhesion formation and joint contracture are also reviewed.
The document discusses anatomy and injuries of the extensor tendons in the hand, including mallet finger injuries at the DIP joint, boutonniere deformities involving the central slip of the extensor tendon near the PIP joint, and evaluation and treatment of various zones of extensor tendon injuries including splinting, tendon repair techniques, and reconstruction procedures.
This document discusses implant selection considerations for revision total knee replacement (TKR) surgery. It begins by outlining common causes for revision TKR such as aseptic loosening and polyethylene wear. Key challenges in revision TKR are managing bone defects from osteolysis, compromised soft tissues, and restoring proper limb alignment. Implant options discussed include metaphyseal sleeves and stems to provide fixation in bone defect zones, as well as augmentations. Constraint levels from unconstrained to fully constrained implants are reviewed. Clinical cases demonstrate approaches for addressing instability, significant bone loss, and peri-prosthetic fractures in revision TKR.
The Masquelet technique is a two-stage process for treating bone defects using an induced membrane. In the first stage, radical debridement is performed followed by insertion of an antibiotic-loaded cement spacer and soft tissue coverage. This induces the formation of a membrane rich in growth factors. In the second stage 6-8 weeks later, the spacer is removed and cancellous bone graft is placed within the membrane chamber, which acts as a bioreactor promoting graft healing. The technique provides an alternative to bone transport or vascularized grafts for reconstructing large defects.
This document summarizes a presentation on distal tibiofibular syndesmosis injuries. It discusses the anatomy of the syndesmosis, mechanisms of injury, diagnosis using imaging and stress tests, treatment options including conservative care and surgical fixation methods like screws or suture buttons, and outcomes such as malreduction risks and hardware complications. Key points include disagreement among surgeons on treatment, high malreduction rates even with fixation, and implant-related issues like breakage requiring potential removal.
This document describes a tendon transfer procedure called the ECRL four tail tendon transfer to correct clawing of the ring and little fingers caused by ulnar nerve palsy. The procedure involves harvesting the extensor carpi radialis longus tendon and splitting it into four tails that are passed through the fingers and attached to the lateral bands to restore extension. Care must be taken to ensure equal tensioning of the tails. Post-operatively, the hand is splinted for six weeks followed by physiotherapy to restore function. Complications can include bleeding, median nerve injury, stiffness, and deformities.
This document provides an overview of distal radioulnar joint (DRUJ) issues and management. It discusses the anatomy and biomechanics of the DRUJ and its primary stabilizer, the triangular fibrocartilage complex (TFCC). It describes common injuries to the TFCC, including Palmer classification types 1A and 1B tears. Imaging options for evaluating the DRUJ are outlined. Initial conservative treatment is typically recommended for type 1A tears while type 1B tears often require arthroscopic or open repair depending on chronicity of the injury.
The document describes a study evaluating the "Remplissage" arthroscopic technique for treating traumatic shoulder instability accompanied by glenoid bone loss and Hill-Sachs defects. The study involved 28 patients who underwent the Remplissage procedure. Post-operatively, patients showed excellent functional outcomes with no reoccurrences of dislocation, nearly full return to work and sports, and significant improvements in shoulder scoring systems. The conclusion is that Remplissage offers excellent short-term results for addressing shoulder instability with humeral bone loss, despite some loss of external rotation.
Knee arthrodesis is a surgical fusion of the knee joint that is used as a salvage procedure for a damaged or diseased knee that cannot be reconstructed or replaced. The document discusses indications for knee arthrodesis including failed total knee arthroplasty, post-traumatic arthritis, and loss of the knee extensor mechanism. It also covers surgical techniques for knee arthrodesis such as external fixation, internal fixation with plates, and intramedullary nailing. Complications associated with knee arthrodesis include nonunion, infection, and degenerative changes in adjacent joints from altered gait biomechanics.
Overview Lecture for Occupational Therapists Aug 2022 . At the end of the lecture you should be able to:
Describe the common injuries of the extensor mechanism
Describe the various chronic pathological processes of extensor tendons
List and describe the patho-anatomical basis for their clinical presentation and their complications
Assess, diagnose and describe the principles of management of them
Plan and prescribe a rehabilitation program for the conditions
This document provides an overview of the anatomy of the extensor apparatus of the hand and deformities that can result from injuries at various levels. It describes the intrinsic and extrinsic muscles, variations in anatomy, and deformities that can occur from injuries in different zones. Zone 1 injuries over the DIP joint can cause mallet finger. Zone 3 injuries can disrupt the central slip leading to boutonniere deformity. Chronic conditions like swan neck deformity can develop from synovitis at various joints causing attenuation of structures.
This document summarizes the evolution of intramedullary nails for long bone fracture fixation from the 16th century to modern times. It describes the early use of wooden sticks and ivory implants, the introduction of metallic rods during WWI, and the development of modern locked intramedullary nails in the mid-20th century. Key figures who advanced nail design include Kuntscher, who introduced reamed nailing in 1940, and Russell and Taylor, who developed the first closed section interlocking nail in the 1980s. The document outlines the progression from first to fourth generation nails, incorporating improvements in materials, locking mechanisms, and designs to optimize stability and healing.
This document discusses radial nerve palsy and tendon transfers to restore function after radial nerve injury. It begins by describing the anatomy and functions of the radial nerve. Radial nerve palsy results in loss of wrist, finger, and thumb extension. Tendon transfers can restore this function, such as using the palmaris longus tendon to restore thumb extension via transfer to the extensor pollicis longus. Post-operative rehabilitation focuses on protecting the tendon transfers during early mobilization and strengthening exercises.
This document discusses treatment options for radial head fractures, including conservative treatment, fixation, excision, partial excision, and replacement. It provides guidelines for treating different Mason types of fractures, noting that Mason type 1 fractures can be treated conservatively, Mason type 2 fractures should be fixed, and Mason types 3 and 4 may require fixation with ligament repair or replacement depending on associated injuries. Reasons for replacing versus fixing the radial head are discussed. While there is a lack of level 1 evidence, studies at lower levels generally show better outcomes with replacement compared to fixation for complex injuries or fractures with three or more fragments. Precise sizing and avoiding overstuffing are important with replacement.
Poller or blocking screws are used to stabilize fractures treated with small diameter intramedullary nails. They guide the nail like "poller" traffic devices guide vehicles. Blocking screws increase stability of distal and proximal metaphyseal fractures after nailing and can help manage malunited fractures. They work by narrowing the canal to guide the nail anteriorly and prevent sagittal plane deformity. Blocking screws are typically placed medially and laterally as close to the fracture as possible for optimal stabilization. Their placement on the concave side of deformities helps improve reduction by deflecting the nail.
High tibial osteotomy (HTO) is a surgical procedure that involves correcting angular deformities of the tibia. It has been used to treat conditions like osteoarthritis, osteochondritis dissecans, and malalignment. There are several techniques for HTO including lateral closing wedge osteotomy, medial opening wedge osteotomy, and dome osteotomy. HTO can help relieve pain from unicompartmental osteoarthritis and delay the need for knee replacement in young, active patients. Potential complications include fracture, nonunion, nerve palsy, and issues that can make later knee replacement more difficult. Precise surgical planning and fixation are important for achieving good outcomes from HTO.
This document discusses various techniques for pollicization, which is a hand surgery to create a functioning thumb from another finger. It begins by defining pollicization and describing the anatomy and function of the thumb. It then discusses different conditions that may require pollicization, including thumb hypoplasia, absence due to trauma, macrodactyly, multifinger hands, and mirror hands. For each condition, it provides details on the surgical procedure for pollicization, including steps like isolating nerves/vessels, shortening bones, transferring muscles/tendons, and positioning the new thumb. Post-operative casting is also addressed. The document contains many diagrams illustrating thumb anatomy and different pollicization procedures.
Cartilage is derived (embryologically) from mesenchyme. . Chondroblasts produce the intercellular matrix as well as the collagen fibres. Chondroblasts that become imprisoned within this matrix become chondrocytes. The articular surface of most synovial joints are lined by hyaline cartilage
This document discusses flexor tendon injuries and repairs in the hand. It covers tendon anatomy, zones of injury, types of repairs, and postoperative rehabilitation protocols. Flexor tendon injuries most commonly occur in males aged 15-30 years old. There are two main postoperative protocols - passive flexion protocol with splinting for 6-9 weeks or early active tension protocol with splinting for 4 weeks and early active exercises. Precise surgical technique and strict adherence to rehabilitation are needed for successful results.
This document discusses the anatomy, examination, investigations, timing of surgery, surgical techniques, and complications related to flexor tendon injuries of the hand. It notes that clinical examination, radiography and MRI are used for investigations. Primary repair within 24 hours is preferred if the wound is clean, with care also given to any neurovascular injuries or fractures. Surgical techniques discussed include various suture configurations, epitenon and core sutures, tendon-to-bone attachment, and the use of tendon grafts if needed. Post-operative immobilization and potential complications are also mentioned.
This document summarizes a seminar presentation on flexor and extensor tendon injuries of the hand. It begins with an introduction to tendon anatomy and zones of injury. It then describes the specific anatomy and function of flexor and extensor tendons. Flexor tendon injuries are discussed based on their zone of injury, with details on clinical examination, repair techniques, and postoperative rehabilitation protocols. Complications and the use of tendon grafts are also summarized. The document concludes with sections on extensor tendon anatomy, testing, and associated structures like the sagittal bands.
The document discusses anatomy and injuries of the extensor tendons in the hand, including mallet finger injuries at the DIP joint, boutonniere deformities involving the central slip of the extensor tendon near the PIP joint, and evaluation and treatment of various zones of extensor tendon injuries including splinting, tendon repair techniques, and reconstruction procedures.
This document discusses implant selection considerations for revision total knee replacement (TKR) surgery. It begins by outlining common causes for revision TKR such as aseptic loosening and polyethylene wear. Key challenges in revision TKR are managing bone defects from osteolysis, compromised soft tissues, and restoring proper limb alignment. Implant options discussed include metaphyseal sleeves and stems to provide fixation in bone defect zones, as well as augmentations. Constraint levels from unconstrained to fully constrained implants are reviewed. Clinical cases demonstrate approaches for addressing instability, significant bone loss, and peri-prosthetic fractures in revision TKR.
The Masquelet technique is a two-stage process for treating bone defects using an induced membrane. In the first stage, radical debridement is performed followed by insertion of an antibiotic-loaded cement spacer and soft tissue coverage. This induces the formation of a membrane rich in growth factors. In the second stage 6-8 weeks later, the spacer is removed and cancellous bone graft is placed within the membrane chamber, which acts as a bioreactor promoting graft healing. The technique provides an alternative to bone transport or vascularized grafts for reconstructing large defects.
This document summarizes a presentation on distal tibiofibular syndesmosis injuries. It discusses the anatomy of the syndesmosis, mechanisms of injury, diagnosis using imaging and stress tests, treatment options including conservative care and surgical fixation methods like screws or suture buttons, and outcomes such as malreduction risks and hardware complications. Key points include disagreement among surgeons on treatment, high malreduction rates even with fixation, and implant-related issues like breakage requiring potential removal.
This document describes a tendon transfer procedure called the ECRL four tail tendon transfer to correct clawing of the ring and little fingers caused by ulnar nerve palsy. The procedure involves harvesting the extensor carpi radialis longus tendon and splitting it into four tails that are passed through the fingers and attached to the lateral bands to restore extension. Care must be taken to ensure equal tensioning of the tails. Post-operatively, the hand is splinted for six weeks followed by physiotherapy to restore function. Complications can include bleeding, median nerve injury, stiffness, and deformities.
This document provides an overview of distal radioulnar joint (DRUJ) issues and management. It discusses the anatomy and biomechanics of the DRUJ and its primary stabilizer, the triangular fibrocartilage complex (TFCC). It describes common injuries to the TFCC, including Palmer classification types 1A and 1B tears. Imaging options for evaluating the DRUJ are outlined. Initial conservative treatment is typically recommended for type 1A tears while type 1B tears often require arthroscopic or open repair depending on chronicity of the injury.
The document describes a study evaluating the "Remplissage" arthroscopic technique for treating traumatic shoulder instability accompanied by glenoid bone loss and Hill-Sachs defects. The study involved 28 patients who underwent the Remplissage procedure. Post-operatively, patients showed excellent functional outcomes with no reoccurrences of dislocation, nearly full return to work and sports, and significant improvements in shoulder scoring systems. The conclusion is that Remplissage offers excellent short-term results for addressing shoulder instability with humeral bone loss, despite some loss of external rotation.
Knee arthrodesis is a surgical fusion of the knee joint that is used as a salvage procedure for a damaged or diseased knee that cannot be reconstructed or replaced. The document discusses indications for knee arthrodesis including failed total knee arthroplasty, post-traumatic arthritis, and loss of the knee extensor mechanism. It also covers surgical techniques for knee arthrodesis such as external fixation, internal fixation with plates, and intramedullary nailing. Complications associated with knee arthrodesis include nonunion, infection, and degenerative changes in adjacent joints from altered gait biomechanics.
Overview Lecture for Occupational Therapists Aug 2022 . At the end of the lecture you should be able to:
Describe the common injuries of the extensor mechanism
Describe the various chronic pathological processes of extensor tendons
List and describe the patho-anatomical basis for their clinical presentation and their complications
Assess, diagnose and describe the principles of management of them
Plan and prescribe a rehabilitation program for the conditions
This document provides an overview of the anatomy of the extensor apparatus of the hand and deformities that can result from injuries at various levels. It describes the intrinsic and extrinsic muscles, variations in anatomy, and deformities that can occur from injuries in different zones. Zone 1 injuries over the DIP joint can cause mallet finger. Zone 3 injuries can disrupt the central slip leading to boutonniere deformity. Chronic conditions like swan neck deformity can develop from synovitis at various joints causing attenuation of structures.
This document summarizes the evolution of intramedullary nails for long bone fracture fixation from the 16th century to modern times. It describes the early use of wooden sticks and ivory implants, the introduction of metallic rods during WWI, and the development of modern locked intramedullary nails in the mid-20th century. Key figures who advanced nail design include Kuntscher, who introduced reamed nailing in 1940, and Russell and Taylor, who developed the first closed section interlocking nail in the 1980s. The document outlines the progression from first to fourth generation nails, incorporating improvements in materials, locking mechanisms, and designs to optimize stability and healing.
This document discusses radial nerve palsy and tendon transfers to restore function after radial nerve injury. It begins by describing the anatomy and functions of the radial nerve. Radial nerve palsy results in loss of wrist, finger, and thumb extension. Tendon transfers can restore this function, such as using the palmaris longus tendon to restore thumb extension via transfer to the extensor pollicis longus. Post-operative rehabilitation focuses on protecting the tendon transfers during early mobilization and strengthening exercises.
This document discusses treatment options for radial head fractures, including conservative treatment, fixation, excision, partial excision, and replacement. It provides guidelines for treating different Mason types of fractures, noting that Mason type 1 fractures can be treated conservatively, Mason type 2 fractures should be fixed, and Mason types 3 and 4 may require fixation with ligament repair or replacement depending on associated injuries. Reasons for replacing versus fixing the radial head are discussed. While there is a lack of level 1 evidence, studies at lower levels generally show better outcomes with replacement compared to fixation for complex injuries or fractures with three or more fragments. Precise sizing and avoiding overstuffing are important with replacement.
Poller or blocking screws are used to stabilize fractures treated with small diameter intramedullary nails. They guide the nail like "poller" traffic devices guide vehicles. Blocking screws increase stability of distal and proximal metaphyseal fractures after nailing and can help manage malunited fractures. They work by narrowing the canal to guide the nail anteriorly and prevent sagittal plane deformity. Blocking screws are typically placed medially and laterally as close to the fracture as possible for optimal stabilization. Their placement on the concave side of deformities helps improve reduction by deflecting the nail.
High tibial osteotomy (HTO) is a surgical procedure that involves correcting angular deformities of the tibia. It has been used to treat conditions like osteoarthritis, osteochondritis dissecans, and malalignment. There are several techniques for HTO including lateral closing wedge osteotomy, medial opening wedge osteotomy, and dome osteotomy. HTO can help relieve pain from unicompartmental osteoarthritis and delay the need for knee replacement in young, active patients. Potential complications include fracture, nonunion, nerve palsy, and issues that can make later knee replacement more difficult. Precise surgical planning and fixation are important for achieving good outcomes from HTO.
This document discusses various techniques for pollicization, which is a hand surgery to create a functioning thumb from another finger. It begins by defining pollicization and describing the anatomy and function of the thumb. It then discusses different conditions that may require pollicization, including thumb hypoplasia, absence due to trauma, macrodactyly, multifinger hands, and mirror hands. For each condition, it provides details on the surgical procedure for pollicization, including steps like isolating nerves/vessels, shortening bones, transferring muscles/tendons, and positioning the new thumb. Post-operative casting is also addressed. The document contains many diagrams illustrating thumb anatomy and different pollicization procedures.
Cartilage is derived (embryologically) from mesenchyme. . Chondroblasts produce the intercellular matrix as well as the collagen fibres. Chondroblasts that become imprisoned within this matrix become chondrocytes. The articular surface of most synovial joints are lined by hyaline cartilage
This document discusses flexor tendon injuries and repairs in the hand. It covers tendon anatomy, zones of injury, types of repairs, and postoperative rehabilitation protocols. Flexor tendon injuries most commonly occur in males aged 15-30 years old. There are two main postoperative protocols - passive flexion protocol with splinting for 6-9 weeks or early active tension protocol with splinting for 4 weeks and early active exercises. Precise surgical technique and strict adherence to rehabilitation are needed for successful results.
This document discusses the anatomy, examination, investigations, timing of surgery, surgical techniques, and complications related to flexor tendon injuries of the hand. It notes that clinical examination, radiography and MRI are used for investigations. Primary repair within 24 hours is preferred if the wound is clean, with care also given to any neurovascular injuries or fractures. Surgical techniques discussed include various suture configurations, epitenon and core sutures, tendon-to-bone attachment, and the use of tendon grafts if needed. Post-operative immobilization and potential complications are also mentioned.
This document summarizes a seminar presentation on flexor and extensor tendon injuries of the hand. It begins with an introduction to tendon anatomy and zones of injury. It then describes the specific anatomy and function of flexor and extensor tendons. Flexor tendon injuries are discussed based on their zone of injury, with details on clinical examination, repair techniques, and postoperative rehabilitation protocols. Complications and the use of tendon grafts are also summarized. The document concludes with sections on extensor tendon anatomy, testing, and associated structures like the sagittal bands.
This document summarizes several common sports-related hand injuries. It discusses mallet finger, which involves an extensor tendon injury at the DIP joint. It can be caused by forced flexion or hyperextension. Treatment options include splinting or K-wire fixation. Jersey finger is an avulsion of the FDP tendon from the distal phalanx. Gamekeeper's thumb refers to an injury of the ulnar collateral ligament of the MCP joint of the thumb. Trigger finger causes a catching or locking of the involved finger flexed.
This document summarizes a seminar on flexor and extensor tendon injuries of the hand. The seminar was chaired by Prof. Dr. Kiran Kalaiah and presented by Dr. Yashavardhan.T.M. It provided an overview of tendon anatomy, classification of tendon injuries by zone, surgical techniques for repair, and postoperative rehabilitation protocols. Key points included the pulley system that guides tendon movement, zones of injury from I to V, and techniques like the six strand repair that aim to minimize complications like adhesion formation.
A 30-year old female presented to the emergency room with a laceration and bleeding in her right hand after falling on glass. She was right hand dominant and worked in telemarketing. Physical examination would focus on the extent of the laceration and potential injury to flexor tendons and nerves. Flexor tendon injuries can lead to loss of finger flexion and grip strength if not repaired properly. The goals of reconstruction are to anatomically repair the tendons with limited motion restrictions and adhere to post-operative rehabilitation to regain function and prevent complications like adhesions.
The document describes the anatomy and pathologies of the finger extensor mechanism. It details the anatomy of the extrinsic and intrinsic tendons that provide extension to the finger joints. It then discusses several common deformities that can result from injuries or imbalances in the extensor mechanism, including Boutonniere deformity, Swan neck deformity, Mallet finger, and Jersey finger. For each, it provides descriptions of the mechanism of injury, clinical presentation, classification systems, and general treatment approaches.
The Lisfranc joint was named after a field surgeon who described an amputation through the joint due to gangrene from an injury sustained after a soldier fell from a horse. Lisfranc injuries account for less than 1% of fractures and can result from high-energy trauma or less stressful twisting injuries. Diagnosis can be difficult as swelling and pain in the midfoot region are often the only findings. Treatment involves immobilization for mild sprains but surgery within 1-2 days for fractures or dislocations to ensure proper healing and prevent long-term disability. Surgical techniques include open reduction and internal fixation to anatomically realign the bones which allows for better functional outcomes compared to fusion or casting.
This document discusses the assessment and management of extensor tendon injuries. It begins by describing the anatomy of the extensor tendon system. It then discusses the classification of extensor tendon injuries by zone. Zone I injuries, known as mallet fingers, involve disruption of the extensor tendon over the distal interphalangeal joint, often from forced flexion. Zone I injuries are generally treated conservatively with immobilization. Surgical repair is recommended for open injuries or injuries to higher zones. The document provides guidance on examination, repair techniques, and post-operative mobilization for different types of extensor tendon injuries.
This document discusses the management of extensor tendon injuries. It begins by describing the anatomy of the extensor tendon system. It then discusses that extensor tendon injuries are common and need to be properly treated to avoid impairment. The document outlines how to examine and assess extensor tendon injuries, including taking history and testing range of motion and strength. It describes the different zones where injuries can occur and provides guidelines for managing injuries in each zone, including splinting or surgical repair depending on the severity of the injury. The goal is to provide guidance to properly treat extensor tendon injuries.
The document describes the anatomy of the extensor apparatus of the hand and fingers and deformities that can result from injuries at various levels. It discusses the extrinsic and intrinsic muscles, tendons, and their anatomy at the wrist, hand, and digit levels. Acute and chronic injuries are described for each zone, along with classification systems and treatment options depending on the extent of injury and chronicity. Surgical exploration and repair is often needed for open or complete tendon lacerations to properly identify the injury and restore extension.
Supra condylar humerus fracture in childrenSubodh Pathak
Upper-extremity fractures account for 65-75% of all fractures in children, with 7-9% involving the elbow. Supracondylar fractures of the distal humerus are the most common elbow injuries in children, typically occurring between ages 5-10 years old. These fractures are classified into Types 1-3 based on displacement. Type 1 fractures are non-displaced, Type 2 have angulation/displacement with an intact posterior cortex, and Type 3 have complete displacement of fragments. Closed reduction and percutaneous pinning is the most common treatment, with pins placed medially and laterally for stability. Open reduction is rarely needed but may be indicated for inadequate closed reduction or vascular injury.
The document provides an overview of hand trauma, including mechanisms of injury, approaches to patients, and management of various structural injuries like cutaneous injuries, tendon injuries, nerve injuries, bone injuries, and amputation and replantation. It outlines the anatomy, typical presentations, and treatment approaches for each type of injury. For example, it describes that extensor tendon injuries are divided into zones and discusses the presentations and management depending on the zone. The document emphasizes the importance of thorough history, physical exam, and imaging to properly diagnose hand injuries and optimize outcomes through appropriate treatment.
Medial epicondyle apophyseal injuries most commonly occur in baseball pitchers aged 9-14 years old during periods of rapid growth. Over 50% are associated with elbow dislocation. Signs include sudden elbow pain following forceful pitching. Treatment is usually 4-6 weeks of casting, though surgery may be needed for incarcerated fragments or those with ulnar nerve dysfunction. Proper evaluation with imaging can help detect fracture displacement and incarceration.
The document discusses hand injuries and their management. It covers relevant hand anatomy, types of common hand injuries including tendon injuries, fractures, and dislocations. The key principles of management are early debridement and stabilization of injuries, restoration of anatomy, and rapid mobilization. Specific techniques are described for repairing tendons, fixing fractures like Bennett's fracture, and achieving proper skeletal stabilization while preserving hand function.
Orthopedic surgery 5th injuries to the upper limb ( 2 )RamiAboali
The document discusses various orthopedic injuries and conditions around the elbow and upper limb, including proximal humerus fractures, humeral shaft fractures, distal humerus fractures, biceps tendon ruptures, lateral and medial epicondylitis, fractures around the elbow in children including supracondylar humerus fractures and lateral/medial epicondyle fractures, pulled elbow, and elbow dislocations. Treatment options including nonsurgical and surgical management are provided for many of the conditions.
This document discusses mallet finger injuries, which involve disruption of the extensor tendon mechanism at the distal interphalangeal joint. It covers the anatomy of the finger extensor mechanism, classification of mallet finger injuries, clinical evaluation, treatment options including nonsurgical management with splinting and surgical repair or fixation, and management approaches for different types of acute mallet finger injuries.
PT Management of Fractures of Condyles of FemurNavKalsi1
This document discusses the management of fractures of the femoral condyles. It begins by classifying distal femur fractures, which include fractures of the femoral condyles. It then describes the conservative and surgical treatment options for supracondylar fractures and intercondylar fractures of the femur. Conservative treatment involves traction and casting, while surgical options include external or internal fixation devices. Post-treatment physiotherapy aims to restore range of motion, strength, and function. Exercises and weight bearing status progress over 16 weeks as healing allows. Potential complications are also outlined.
This document outlines principles of fracture management including reduction, retention, and rehabilitation. It discusses various methods of reduction including closed and open reduction. Immobilization techniques like skin traction, skeletal traction, casting, and internal/external fixation are explained. Complications and indications for different techniques are also provided. The goal of fracture management is to reduce fractures, immobilize the bone during healing, and rehabilitate the injury through regaining function and range of motion.
Zone 1 injuries refer to injuries distal to the insertion of the flexor digitorum superficialis tendon. The document discusses the anatomy of the flexor tendons, examination of zone 1 injuries, considerations for repair, techniques for tendon-to-bone repair or primary repair, postoperative rehabilitation, and complications. Key points are that zone 1 injuries are best treated early with direct tendon repair if there is over 1cm of tendon, tendon repair must be securely seated in the bone footprint, and rehabilitation follows a graded protocol to prevent tendon complications.
Travel Clinic Cardiff: Health Advice for International TravelersNX Healthcare
Travel Clinic Cardiff offers comprehensive travel health services, including vaccinations, travel advice, and preventive care for international travelers. Our expert team ensures you are well-prepared and protected for your journey, providing personalized consultations tailored to your destination. Conveniently located in Cardiff, we help you travel with confidence and peace of mind. Visit us: www.nxhealthcare.co.uk
5-hydroxytryptamine or 5-HT or Serotonin is a neurotransmitter that serves a range of roles in the human body. It is sometimes referred to as the happy chemical since it promotes overall well-being and happiness.
It is mostly found in the brain, intestines, and blood platelets.
5-HT is utilised to transport messages between nerve cells, is known to be involved in smooth muscle contraction, and adds to overall well-being and pleasure, among other benefits. 5-HT regulates the body's sleep-wake cycles and internal clock by acting as a precursor to melatonin.
It is hypothesised to regulate hunger, emotions, motor, cognitive, and autonomic processes.
Breast cancer: Post menopausal endocrine therapyDr. Sumit KUMAR
Breast cancer in postmenopausal women with hormone receptor-positive (HR+) status is a common and complex condition that necessitates a multifaceted approach to management. HR+ breast cancer means that the cancer cells grow in response to hormones such as estrogen and progesterone. This subtype is prevalent among postmenopausal women and typically exhibits a more indolent course compared to other forms of breast cancer, which allows for a variety of treatment options.
Diagnosis and Staging
The diagnosis of HR+ breast cancer begins with clinical evaluation, imaging, and biopsy. Imaging modalities such as mammography, ultrasound, and MRI help in assessing the extent of the disease. Histopathological examination and immunohistochemical staining of the biopsy sample confirm the diagnosis and hormone receptor status by identifying the presence of estrogen receptors (ER) and progesterone receptors (PR) on the tumor cells.
Staging involves determining the size of the tumor (T), the involvement of regional lymph nodes (N), and the presence of distant metastasis (M). The American Joint Committee on Cancer (AJCC) staging system is commonly used. Accurate staging is critical as it guides treatment decisions.
Treatment Options
Endocrine Therapy
Endocrine therapy is the cornerstone of treatment for HR+ breast cancer in postmenopausal women. The primary goal is to reduce the levels of estrogen or block its effects on cancer cells. Commonly used agents include:
Selective Estrogen Receptor Modulators (SERMs): Tamoxifen is a SERM that binds to estrogen receptors, blocking estrogen from stimulating breast cancer cells. It is effective but may have side effects such as increased risk of endometrial cancer and thromboembolic events.
Aromatase Inhibitors (AIs): These drugs, including anastrozole, letrozole, and exemestane, lower estrogen levels by inhibiting the aromatase enzyme, which converts androgens to estrogen in peripheral tissues. AIs are generally preferred in postmenopausal women due to their efficacy and safety profile compared to tamoxifen.
Selective Estrogen Receptor Downregulators (SERDs): Fulvestrant is a SERD that degrades estrogen receptors and is used in cases where resistance to other endocrine therapies develops.
Combination Therapies
Combining endocrine therapy with other treatments enhances efficacy. Examples include:
Endocrine Therapy with CDK4/6 Inhibitors: Palbociclib, ribociclib, and abemaciclib are CDK4/6 inhibitors that, when combined with endocrine therapy, significantly improve progression-free survival in advanced HR+ breast cancer.
Endocrine Therapy with mTOR Inhibitors: Everolimus, an mTOR inhibitor, can be added to endocrine therapy for patients who have developed resistance to aromatase inhibitors.
Chemotherapy
Chemotherapy is generally reserved for patients with high-risk features, such as large tumor size, high-grade histology, or extensive lymph node involvement. Regimens often include anthracyclines and taxanes.
Nano-gold for Cancer Therapy chemistry investigatory projectSIVAVINAYAKPK
chemistry investigatory project
The development of nanogold-based cancer therapy could revolutionize oncology by providing a more targeted, less invasive treatment option. This project contributes to the growing body of research aimed at harnessing nanotechnology for medical applications, paving the way for future clinical trials and potential commercial applications.
Cancer remains one of the leading causes of death worldwide, prompting the need for innovative treatment methods. Nanotechnology offers promising new approaches, including the use of gold nanoparticles (nanogold) for targeted cancer therapy. Nanogold particles possess unique physical and chemical properties that make them suitable for drug delivery, imaging, and photothermal therapy.
- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
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Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
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DECLARATION OF HELSINKI - History and principlesanaghabharat01
This SlideShare presentation provides a comprehensive overview of the Declaration of Helsinki, a foundational document outlining ethical guidelines for conducting medical research involving human subjects.
NAVIGATING THE HORIZONS OF TIME LAPSE EMBRYO MONITORING.pdfRahul Sen
Time-lapse embryo monitoring is an advanced imaging technique used in IVF to continuously observe embryo development. It captures high-resolution images at regular intervals, allowing embryologists to select the most viable embryos for transfer based on detailed growth patterns. This technology enhances embryo selection, potentially increasing pregnancy success rates.
1. Extensor tendon injury
& associated deformities
Dr Sumer Yadav
Mch – Plastic and Reconstructive surgery
sumeryadav2004@gmail.com
2. ANATOMY OF EXTENSOR
FORE ARM
Proximal group: The
ECU,EDM,EDC,ECRL,ECRB tendons
originate adjacent to the lateral epicondyle of
the humerus and are innervated proximally
Distal group: The EPL,EIP,AbPL & EPB
originate in the distal half of the forearm.
There fore, a proximal laceration with loss of
function in distal group probably represents a
motor nerve injury.
sumeryadav2004@gmail.com
6. Muscles of the Forearm lateral
(Extensor Surface)
Outcropping Group
Extensor Pollicis Brevis/
Abductor Pollicis Longus
Extensor pollicis longus
Medial Group
Extensor Carpi radialis
L/B
Bracioradialis
sumeryadav2004@gmail.com
7. ARRANGEMENT OF
EXTENSOR TENDONS AT
WRIST
The Extensor tendons gain entrance to hand
from the fore arm through a series of six
canals, 5 fibro-osseus & 1 fibrous( the 5th
dorsal compartment containing EDM)
The Communis tendons are joint distally near
the MP joint by fibrous inter connections
called Junturae Tendinum
The Proprius tendons( EIP&EDM) are
independent finger extensors and they lie on
the ulnar side of the their respective EDC
tendons
sumeryadav2004@gmail.com
11. EXTENSOR MECHANISM IN
FINGER
At the MP joint, the Extensor mechanism flattens into a broad
hood and envelops the dorsal third of proximal & middle
phalanges
Fibers of the common extensor tendon blend with the fibers of
lateral bands to form the central slip which inserts in the base of
the middle phalanx & effects PIP joint extension
The central slip is kept in its dorsal position by the Transverse
Retinacular ligament
The lateral bands are held dorsal to the axis of the PIP joint by
fibers of the Triangular ligament
SORL originates on the palmer plate & flexion sheath beneath
the PIP joint .These fibers move dorsally to insert in the terminal
tendon. With PIP extension , fibers of the SORL tighten to assist
DIP extension
sumeryadav2004@gmail.com
15. MECHANICS OF HAND
Two set of muscles, INTRINSIC (originating in the hand itself &
innervated by the Ulnar and Medial nerves) and EXTRINSIC
(originating in the forearm & innervated by the Radial nerve) act
synergistically
The extensor system prepares the hand for grasp & pinch by
positioning the hand in various degrees of extension.
The most frequent activities of daily living occur in positions
close to the position of function like holding a cup or writing with
a pen. More specialized activities like grasping a large or a very
small object occur at the extremes of extension & flexion
An Extensor tendon laceration results in the decrease in the
extensor force distal to the injury. This force is then transferred
to the joint proximal to the injury, resulting in a net increase of
extensor force at that joint, which causes a change in that joint
position leading to characteristic deformities
sumeryadav2004@gmail.com
18. TENODESIS EFFECT
Dynamic Tenodesis is defined as the concept
of movement at one joint transmitting power to
an adjacent joint( usually distal)
As the wrist flexes , the extensor tendons
tighten and the flexor tendons relax, both
actions serving to produce extension of the MP
joints. The intrinsic tendons tighten with MP
extension, augmenting PIP extension
The lateral bands & the ORL are lax with PIP
flexion and tighten with PIP extension. The
Tenodesis effect of the ORL can be
demonstrated by checking passive flexion of
the DIP joint with the PIP joint in flexion and
extension
sumeryadav2004@gmail.com
19. ZONES OF INJURY
ZONE FINGER
THUMB
I DIP joint IP joint
II Middle Phalanx Proximal Phalanx
III PIP joint MCP joint
IV Proximal Phalanx Metacarpal
V MCP joint Carpometacarpal joint/
Radial Styloid
VI Metacarpal
VII Dorsal Retinaculam
VIII Distal forearm
IX Mid & Proximal forearm
sumeryadav2004@gmail.com
20. Each zone in the fingers refers to an identical
location. The thumb lacks a middle phalanx.
Consequently the thumb zones I to V refer to
different anatomic location relative to the
fingers
60% of Tendon injuries occur in zone V to
VIII ( MP joint to distal fore arm)
Outcome is more favorable in zone V to VIII
injury as compared to zone I to IV injury
More than 50% of injuries have an associated
injury such as fracture, dislocation or flexor
tendon injury
sumeryadav2004@gmail.com
22. CLINICAL EVALUATION
Testing for EDC, EIP & EDM
musculotendinous function
The proprius tendon to the index &
little finger are capable of
independent extension.
Their function together can be
evaluated with the middle & ring
finger flexed into the palm , the
proprius tendons can extend the ring
& little finger
sumeryadav2004@gmail.com
23. TESTING PROPRIUS
TENDONS
With the middle & ring fingers flexed into
the palm, the Proprius tendon can
extend the index and little fingers
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24. EPB tendon can be checked by
placing a finger in the anatomical
snuff box and asking the patient to
extend the thumb in a flat position
APL tendon can be checked by
asking the patient to abduct the
thumb against resistance
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27. ZONE I INJURY
Occurs at the DIP joint of the finger or
the IP joint of the thumb
Mechanism of injury is usually forced
flexion of an actively extended distal
joint
aka Mallet finger, Base ball finger,
Dropped finger, or Extension lag
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28. MALLET FINGER
Mechanism : a blow from a thrown ball
strikes the tip of the finger--- ‘forced flexion’.
It tears the extensor tendon from its insertion
+/- dorsal tip of distal phalanx
Clinically , there is extensor lag with localized
DIP joint tenderness . The athlete is unable to
extend the DIP
Investigation : radiographs to rule out
fracture with volar subluxation
sumeryadav2004@gmail.com
31. MALLET FINGER
Management : continuous splint immobilization for 4 to 6
weeks in full extension
Indications for surgery: open injuries, closed injuries in a
person who will be unable to work with a splint on e.g. health
care worker and a large dorsal fragment with palmar
subluxation of the distal fragment
Complications : skin ulceration is most common.
Compensatory Swan neck deformity is known to occur.
Chronic Mallet injuries with compensatory swan neck
deformity are reconstructed with SORL reconstruction
techniques . Those chronic deformities which are painful,
arthritic, and interfere with hand function are treated with DIP
fusion
sumeryadav2004@gmail.com
32. Zone I injury: Surgical
Intervention
Placement of a permanent buried suture
can be avoided by :
A. The tendon ends are incorporated
with the interrupted skin sutures
B. The proximal end of the divided
tendon is advanced into the insertion
site with the use of a pull out suture
tied over a bolster on the finger pad
sumeryadav2004@gmail.com
33. Zone I injury: Surgical
Intervention
Technique of extensor tendon repair at
the DIP joint , in which the skin and the
tendon are simultaneously
approximated
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34. SORL Reconstruction
A. A Mallet deformity with
compensatory swan neck deformity
B&C. The Tendon graft is fixed to the
distal phalanx with a pull out suture.
The graft is passed between the flexor
tendon sheath & the neurovascular
bundles palmar to the PIP joint. The
graft is tensioned & anchored into the
shaft of the proximal phalanx
SORL reconstruction is advocated for
correction of a swan neck deformity
which is secondary to a mallet finger
sumeryadav2004@gmail.com
35. ZONE II INJURY
Extensor tendon width is greater in zone II than zone
I & the extensor mechanism has two lateral bands
which extend the distal phalanx
Lacerations of less than 50% of the tendon cut can
be treated by skin closure alone, rest are repaired by
a pull out suture technique
Typically seen in conjunction with sharp lacerations,
saw injuries, and crushing injuries
The DIP is splinted in extension for 4 to 6 weeks
Turrent Exostosis is a mass of bone formed
secondary to a periosteum injury in a zone II
laceration. This mass limits DIP flexion and resection
is the treatment of choice
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36. Doyle’s repair : Sharp laceration of zone II repaired with a running suture
and over sewn by a Silverskiold cross stitch
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37. Immobilization Of Zone I & II
injuries
Aluminum splint
Stack splint
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38. ZONE III INJURY
Disruption of the extensor apparatus at or just
proximal to the PIP joint results in a loss of extensor
power at the PIP joint
Forced flexion of the PIP joint damages the central
slip of the extensor tendon
After central slip disruption the triangular ligament
stretches over time shifting the lateral bands in a
volar direction
The head of the proximal phalanx ‘buttonholes’
through the extensor mechanism, creating the
Boutonniere deformity
Lateral bands falling volar become PIP joint flexors
instead of extensors while continuing to exert an
extensor force on the DIP joint
Boutonniere deformity can be acute –(closed or
open) and chronic
sumeryadav2004@gmail.com
40. Patho mechanics of Boutonniere deformity: A. Attenuation of the central
slip results in unopposed flexion at the PIP joint; B. With PIP flexion the
lateral bands drift palmar( due to decreased support from the stretched
triangular ligament) to the axis of rotation at the PIP jointsumeryadav2004@gmail.com
43. Treatment plan in Boutonniere
deformity
Acute closed Boutonniere injuries: extension
splinting of PIP joint
Acute open Boutonniere injuries: primary
repair ( Doyle’s, Snow’s, Aiche’s methods)
Chronic Boutonniere deformity: Stage 1 & 2-
therapy regimen of active assisted extension
of the PIP joint combined with passive flexion
of the DIP joint . Stage 3 – options include
Tenotomy, Tendon grafting, Tendon
relocation
sumeryadav2004@gmail.com
44. Burton & Melchior’s guidelines
for Boutonniere surgery
Boutonniere reconstruction are most successful on
supple joints. If necessary, a joint release can be
performed as a first stage.
An Arthritic joint usually precludes soft tissue
reconstruction. The surgeon should consider either a
PIP joint fusion or Arthroplasty with extensor tendon
reconstruction
Boutonniere deformity rarely compromise PIP flexion
& grip strength. Do not trade extension at the PIP
joint for a stiff finger & a weak hand
Goal of Boutonniere reconstruction is to rebalance
the extensor system by reducing extensor tone at the
DIP joint and increasing tone at the PIP joint
Splinting is an important component of the post
operative care; it may be necessary for several
months
sumeryadav2004@gmail.com
45. A Bunnell splint is applied to maintain extension at the PIP joint. The strap over
the PIP joint is progressively tightened until the PIP joint is fully extended. The
patient is encouraged to flex the DIP joint.sumeryadav2004@gmail.com
46. Reconstruction of Boutonnière
A. The boutonniere deformity with the lateral
bands & ORL volar to the PIP joint
B. Dorsal zigzag incision
C. The ORL is separated from the lateral bands
& a tenotomy of the lateral bands is done
distal to the central slip insertion
D. If active PIP extension is still not possible,
the lateral bands are suture together, dorsal
to the PIP joint
E. Sequence of events
F. The PIP joint is fixed with a transarticular K
wire
G. The mechanics of the reconstruction
sumeryadav2004@gmail.com
47. Central slip laceration with sufficient tendon to repair with core
suture & over sew with silverskiold epitendinous suture
sumeryadav2004@gmail.com
48. When the tendon laceration is distal, leaving a small stump of central slip;
the core suture can be passed through a trough in the base of the middle
phalanx
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49. Snow’s technique of central slip
reconstruction ( distally based flap)
Aiche’s technique of central slip
reconstruction (central halves of lateral
bands)sumeryadav2004@gmail.com
50. Littler’s tendon graft
technique: a thin graft is
woven through the base of
the middle phalanx and
through the extensor
tendon to restore extensor
tone to the PIP joint
sumeryadav2004@gmail.com
51. Extensor Tenotomy for Supple
Boutonniere deformity
Dolphin or Fowler procedure: The
lateral bands are released distal to
the insertion of the central slips . The
lateral resulting proximal migration of
the extensor mechanism reduces
tension at the DIP joint & increases
extensor tension at the PIP joint
sumeryadav2004@gmail.com
52. Post burn Boutonniere
Defomity
Primary damage is that of the central slip, leading to
the sliding of the lateral bands below the axis of
rotation of the PIP joint
The lateral bands thus become PIP joints Flexors
rather than extensors, and the PIP joint is flexed up
to 90 degrees
The absence of Central slip allows the system to
move proximally resulting in excessive pull on DIP
joint causing its hyper extension
Before surgery its necessary to its necessary to
eliminate the related contractures of other hand joints
There is a constant battle between the options of
Tendoplasty vs Arthrodesis
sumeryadav2004@gmail.com
53. Pseudo Boutonniere
Deformity
Flexion deformity of PIP joint, often
following an axial load injury
Hyper extension injury to PIP joint
Volar plate avulsion on X-ray with volar
PIP joint tenderness
More common than Boutonniere
deformity
Protected immobilization required
sumeryadav2004@gmail.com
54. ZONE IV INJURY
Partial zone IV injury is more common than a
complete laceration because the extensor
mechanism is flat & it curves around the
proximal phalanx
Often associated with a proximal phalanx
fracture
Treatment is repair with modified Kessler’s
suture using 4-0 braided polyester
Within 1 week of repair the patient is started
on passive extension & active flexion
sumeryadav2004@gmail.com
56. ZONE V INJURY
A complete division of the extensor mechanism in
this zone is uncommon owing to the width of the
tendon
A partial laceration with division of the central tendon
is common because of the tendon’s prominence over
the metacarpal head
The central tendon is repaired with a grasping suture
& the hand is splinted in wrist extension & 30 degrees
of MP flexion. The IP joint is allowed active motion
Sagittal band injury can also occur in zone V, can be
either open or closed . Treatment of open injuries is
straight forward exploration & repair
sumeryadav2004@gmail.com
57. HUMAN BITE INJURIES
Partial extensor tendon injuries over the MP joint
(zone V) are often caused by a punch to an
opponent’s mouth, so called clench fist injury or fight
bites
The tendon injury is proximal to the skin laceration
because the MP joint is flexed at the time of injury
Bacterial growth consists of Streptococcus,
Staphylococcus, Bacteroides & E.Corrodens
Treatment consists of prompt surgical exploration of
the wound. The extensor tendon should be split
longitudinally and the MP joint opened, cultured,&
irrigated with antibiotic solution. Repair of lacerations
is deferred ( usually 7 to 10 days) until the infection is
cleared
sumeryadav2004@gmail.com
58. Closed Sagittal band injuries
(Extensor tendon subluxation)
Result from direct blow, from forced MP joint flexion
or from daily activities such as flicking the finger or
crumpling the paper
Symptoms range from pain & loss of MP joint motion
to extensor tendon snapping or catching during
finger flexion
Acute injuries that are 2 -3 week old can be treated
with extension splinting of the MP joint
Patients who fail splint treatment or who have an
injury more than 3 weeks old should be treated with
direct repair of the Sagittal band
sumeryadav2004@gmail.com
60. ZONE VI INJURY
Have a better prognosis than distal injuries
because decreased surface area & increased
subcutaneous tissue lessens adhesion
formation and also there is greater tendon
excursion with no complex tendon
imbalances
Modified Bunnel or Kessler’s core suture
supplanted with epitendinous sutures is the
standard treatment
Complications after zone VI repair are loss of
flexion, loss of extension, & tendon rupture in
the order of frequency
sumeryadav2004@gmail.com
61. ZONE VII INJURY
There is almost always an associated injury
to the extensor Retinaculum
Point in favor of excision of Retinaculum are
that it improves exposure & prevents friction
between bulky repairs and the retinaculum
while its preservation prevents bow stringing
or subluxation of the extensor tendons
Treatment is same as zone VI in acute cases
sumeryadav2004@gmail.com
62. Chronic injuries of zone VII
Most common cause is attritional rupture e.g.
EPL rupture after distal radius fracture or with
Rheumatoid Arthritis
Management is difficult as there is no Para
Tenon in this region leading to retraction of
the proximal tendon. Also, since the ends are
frayed, end to end repair is not possible
without unacceptable shortening of the
musculotendinous unit & a loss of flexion
Tendon transfer or a graft is the standard
treatment
sumeryadav2004@gmail.com
63. Reconstruction after EPL
rupture
Reconstructive options:
1. The Palmaris longus tendon is used
as a intercalated graft
2. EIP is transferred to the distal end of
EPL
3. The Palmaris longus is transferred
around the radial side of the wrist to
the EPL
sumeryadav2004@gmail.com
64. ZONE VIII INJURY
Includes ruptures of musculotendinous
junction and muscle belly lacerations
Repair of these injuries is complicated
by the difficulty of placing sutures in the
thin fascia overlying the muscle
When repair is not feasible, a side to
side tendon transfer provides the best
means to restore tendon function
sumeryadav2004@gmail.com
65. ZONE IX INJURY
Penetrating trauma in this region can be
accompanied by nerve injuries making
assessment difficult
A proximal forearm laceration with a loss of
distal muscle group function is probably a
motor nerve injury rather than a tendon
division
Multiple interrupted absorbable sutures are
used to repair the Epimysium & fibrous
intramuscular septum.
Suture repair of muscle lacerations have
virtually no tensile strength. Post op treatment
is 4 weeks of cast immobilizationsumeryadav2004@gmail.com
68. Swan Neck Deformity
Cause : Volar plate rupture at the PIP with often
accompanying triangular ligament rupture.
Pathology :Lateral bands drift dorsally and
exacerbate the hyperextension at the PIP joint.
They become ineffective in extension at the DIP
joint and the unopposed action of the profundus
causes flexion at the DIP joint.
Clinically : Causes “jamming” dislocations
Immediately noticeable, if not immobilized will
become surgical finger.
Treatment: involves SORL reconstruction
sumeryadav2004@gmail.com
69. SURGICAL ASPECTS
ZONE SUTURE TECHNIQUE SUTURE MATERIAL
I & II Splint only none
Skin with tendon (simple) 5-0 monofilament
Tendon suture (Cross stitch) 6-0 monofilament
Pull out tendon 4-0 monofilament
III,IV & V Grasping tendon suture 4-0 braided synthetic
+/- simple or cross stitch 6-0 monofilament
VI,VII & VIII Grasping core suture 4-0 braided synthetic
+ epitenon 6-0 monofilament
Multiple slips to same digit 4-0 braided synthetic
sutured together
sumeryadav2004@gmail.com
70. Regional anaesthesia
Brachial plexus block ( above the
clavicle):
Inter scalene – anterior or posterior
Supra clavicular – Classic,
Plump bob, Para scalene,
Inter strernocleidomastoid,
Subclavian perivascular
sumeryadav2004@gmail.com
72. LOCAL BLOCKS
Wrist blocks
Median nerve block
Superficial branch of Radial block
Ulnar nerve block
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73. LOCAL BLOCKS
Technique of giving a dorsal digital
block
DIGITAL NERVE BLOCKS
Ring block
Volar block
Dorsal block
Flexor tendon sheath
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74. TOURNIQUET
A penrose drain can be used as a
finger tourniquet
For the upper limb as a whole a
tourniquet is kept at a pressure of 150
-250 mm of Hg for a period ranging
from 45 mins to 2 hours
sumeryadav2004@gmail.com
76. Thin flat tendons repaired in
pairs
When the core diameter of two tendon slips makes a core grasping
suture technically difficult , the two sips can be incorporated into one
repair, A. FIGURE OF EIGHT, B. MODIFIED GRASPING SUTURE
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77. Suture technique for flat broad
tendons
Flat , broad tendons of zone III, IV & V are repaired by A. core suture, B. cross
stitch suture techniques sumeryadav2004@gmail.com
78. IMPORTANT POINTS IN
EXTENSOR TENDON
REPAIR
Extensor tendon suture technique vary according to
the location of the injury & the size of the tendon.
Distal to the MP joint, in zone I to V, the extensor
tendon is wide and flat. In zone VI to VIII, the tendon
is narrow and thick.
A grasping technique is used when the tendon is
large enough to allow placement of sutures.
Suture technique should be chosen to maximize
strength & minimize shortening of the tendon.
Extensor retinaculum when involved should be
preserved
The highest priority of extensor tendon injury is not
regaining full extension. The goal is to increase
motion in the functional range of the patient’s normal
activities. sumeryadav2004@gmail.com
79. COMPLICATIONS
Most common complication after tendon repair is the
formation of adhesions between the repair site,
adjacent skin and the bone. The adhesions can
restrict joint flexion as well as extension.
Treatment includes Tenolysis, Capsulotomy or
Collateral ligament release
Gapping
Disruption
Non healing skin site
Scarring
Decreased Joint mobility
sumeryadav2004@gmail.com
80. PHYSIOTHERAPY
Zone I & II injuries are treated with a static
Splint. Only 1 to 2 mm of tendon excursion is
necessary for DIP flexion, a fact that makes
adhesions at the injury site less of a problem.
Early motion rehabilitation protocols are
recommended for injuries in zone III to VIII
The patient actively flexes the finger followed
by passive extension with rubber band
traction
Children & non cooperative patients are best
treated with immobilization
sumeryadav2004@gmail.com