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

1. Vaikunthan Rajaratnam
Extensor tendon injuries

2. At the end of this 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
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3. Introduction
• Account for 60% of tendon injuries
• most commonly injured is middle finger
• zone VI is the most frequently injured zone ("fight bite“)
• sagittal band rupture ("flea flicker injury")
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4. Vaikunthan Rajaratnam

5. • Mallet finger – recon
• Swan Neck recon
• Boutonniere deformity
• MP deviation
• EDC dislocation/rupture
• Chronic extensor contractures
• EPL
• Vaughn Jackson

6. Post trauma

7. Examination
• Extend DIP for Zone I
• Elson test Zone III central slip rupture
• flex PIP joint over support to 90 degrees
• Active extension against resistance
• Central slip is intact - DIP will remain supple
• Central slip disrupted - DIP will be rigid
• Sagittal band rupture – ulnar subluxation
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8. Treatment
• Laceration < 50% of tendon in all
zones – splint to healing
• Operative for others
• Exposure and grasping technique
• 4-6 strands provide adequate
strength for early active motion
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http://www.boneandjoint.org.uk/content/focus/extensor-tendon-injury
Woo SH, Tsai TM, Kleinert HE, Chew WY, Voor MJ. A biomechanical comparison of four extensor tendon
repair techniques in zone IV. Plast Reconstr Surg. 2005;115:1674-81.

9. Tendon Reconstruction
• two stage procedure
• silicon tendon implant min 6 weeks then tendon graft (PL,APL,Fascia Lata)
• single stage reconstruction
• Tendon sharing
• Tendon transfer
• Special considerations
• Rheumatoid , Burns, Snake bites and composite tissue loss
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10. Rehabilitation
• Splint
• extension for 4-6 weeks followed by controlled active-motion exercises and
night-time extension splintage for a further four to six weeks
• Controlled active mobilisation - 90% good or excellent results
• NEEDS SUPERVISON
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11. Complications
• Rupture – early – redo, late – recon
• Adhesions – wait 3 months then tenolysis
• Secondary deformities
• San neck
• Buttornaire
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12. Mallet Finger
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13. Repair with Mitek
Ann Plast Surg. 2005 Apr;54(4):393-6.
Repair of chronic mallet finger deformity using Mitek micro arc bone anchor.
Ulkür E, Açikel C, Ergun O, Celiköz B.
Abstract
Surgical correction of chronic mallet finger caused by terminal tendon disruption was
carried out in 22 patients. The distal stump of the tendon was fixed to the base of
the distal phalanx with a Mitek micro arc bone anchor. In all patients the mallet
finger deformity was corrected. There were 15 patients with excellent results, 5 with
good results, and 2 with fair results. None of the patients had a poor result. No
further treatment was needed. The Mitek micro arc bone anchor system is a reliable
alternative for the treatment of chronic mallet finger deformity without proximal
interphalangeal hyperextension.

14. Reviews
Ann Plast Surg. 2011 Jun;66(6):670-2.
Surgical treatment of chronic mallet finger.
Makhlouf VM, Deek NA.
Abstract
• No PIPJ deformity – confine surgery to the distal interphalangeal joint
• conversion of the chronic injury into an acute one
• Scar / joint capsule excision and reattached to bone
• 80% to 100% success rate
• Fowler release is easy for symptomatic secondary swan neck,
• Spiral retinacular reconstruction (SORL) for associated swan neck deformity

15. Tenodermodesis for Mallet finger

16. Mallet Finger Reconstruction
• Spiral oblique retinacular ligament
reconstruction. A, Lateral view. The tendon graft is
secured to the dorsum of the distal phalanx with a
pullout suture or wire. The graft is passed along
the radial border of the middle phalanx, deep to
the neurovascular bundle and volar to the flexor
tendon sheath. B, Volar view. The graft is then
sutured to the ulnar edge of the flexor tendon
sheath at the level of the proximal phalanx.
(Adapted with permission from Kleinman WB,
Petersen DP: Oblique retinacular ligament
reconstruction for chronic mallet finger
deformity. J Hand Surg [Am]1984;9:399-404.)

17. Swan Neck

18. Swan Neck recon
J Hand Surg Am. 1993 Nov;18(6):984-9.
Soft tissue reconstruction for rheumatoid swan-neck and boutonniere deformities: long-
term results.
Kiefhaber TR, Strickland JW.
Abstract
Ninety-two fingers with rheumatoid swan-neck deformity were treated with dorsal
capsulotomy and lateral band mobilization. An initial increase of 55 degrees of motion
into flexion was noted, but this proximal interphalangeal motion deteriorated over time. Of
15 fingers followed at 3 and 12 months, there was a mean loss of 17 degrees of the early
postoperative flexion. Nineteen fingers with rheumatoid boutonniere deformity were
treated with central slip reconstruction. The results were unpredictable, with only modest
improvement in the proximal interphalangeal extension, which deteriorated over time. The
authors now recommend arthrodesis for most severe rheumatoid boutonniere
deformities.

20. Intrinsic Release

22. Boutonniere deformity
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23. Boutonniere deformity
Matev Procedure

24. EDC dislocation

25. RA synovectomy
Abernethy, P.J., Dennyson, W.G., 1979.
Decompression of the extensor tendons at the
wrist in rheumatoid arthritis. J. Bone Joint Surg. Br.
61, 64–68

26. Vaughn Jackson
disruption of the digital extensor tendons,
beginning on the ulnar side of the hand and wrist
with the EDM and EDC secondary to OA/RA