2. INVOLVE
LACERATIONS ,RUPTURES
MALES COMMONLY
B/W 15 -30 YEARS
ZONES OF INJURY INFLUENCE THE TYPE OF
REPAIR AND POST OPERATIVE REGIMEN
3. CARPAL TUNNEL :
HERE MIDDLE AND RING FINGER TENDONS LIE
SUPERFICIAL TO SMALL AND INDEX FINGER
TENDONS
34 GREATER THAN 25
4. EACH FINGER HAS FDP AND FDS TENDON
SHEATH BEGINS AT THE LEVEL OF
METACARPAL NECK
DIGITAL ARTERY BRANCHES OR VINCULA
ASSIST TENDON NUTRITION
5. ONCE INSIDE DIGITAL SHEATH,THE FDS FORMS CAMPERS
CHIASM BY SPLITTING INTO TWO SLIPS THAT ATTACH ON
THE PALMAR SIDE OF MIDDLE PHALANX.
FDS PASSES THRU THIS TO ATTACH ON THE VOLAR ASPECT
OF DISTAL PHALANX
CAMPERS CHIASM
6. A2 AND A4 ARE MOST IMP
TO PREVENT BOW
STRINGING OF THE
TENDONS
WITHOUT PULLEYS
TENDONS CAN NO LONGER
GLIDE JUXTAPOSED TO
PHALANGES AND GREATER
AMOUNT OF FORCE WILL BE
NEEDED TO OBTAIN THE
SAME AMOUNT OF FLEXION
7. ONLY FPL
CONTAINS 2
ANNULAR
PULLIES AND ONE
OBLIQUE PULLIES
9. REGION B/W MIDDLE ASPECTS OF MIDDLE
PHALANX TO FINGER TIPS
CONTAINS ONLY ONE TENDON-FDP
TENDON LACERATION OCCURS CLOSE TO ITS
INSERTION
TENDON TO BONE REPAIR IS REQUIRED THAN
TENDON REPAIR
10. TYPE 1:RETRACT INTO THE PALM
TYPEII:RETRACT TO THE LEVEL OF PIP JOINT
TYPE III:TO LEVEL OF DIP JOINT
11. FROM METACARPAL HEAD TO MIDDLE
PHALANX
CALLED SO COZ INITIAL ATTEMPTS FOR
TENDON REPAIR HERE PRODUCED POOR
RESULTS
FDS N FDP WITHIN ONE SHEATH
ADHESION FORMATION RISK IS AMPLIFIED AT
CAMPERS CHIASM
12. B/W TRANSVERSE CARPAL LIGAMENT AND
PROXIMAL MARGIN OF TENDON SHEATH
FORMATION
LUMBRICALS ORIGIN HERE PREVENTS
PROFUNDUS TENDONS FROM OVER ACTING
DELAYED TENDON REPAIRS ARE SUCCESFULL
EVEN AFTER SEVERAL WEEKS OF INJURY
13. LIES DEEP TO DEEP TRANSVERSE LIGAMENT
TENDON INJURIES ARE RARE
15. INSPECTION
THERE IS A NORMAL ARCADE TO HAND WITH
INDEX FINGER SHOWING LEAST AND LITTLE
FINGER SHOWING MAX FLEXION
IF AFFECTED FINGER SHOWS MORE
EXTENSION THAN OTHER DIGITS,CHANCE OF
TENDON INJURIES ARE HIGH,
16. FDP
Hold the
metacarpophalangeal
and proximal
interphalangeal joints of
the finger being tested
,in extension.
Ask the patient to flex
the finger at the distal
interphalangeal joint.
If the patient cannot
flex the finger, the
flexor digitorum
profundus tendon is cut
or non-functional.
17. Hold the fingers in
extension except the
finger being tested.
Ask the patient to flex
the finger at the
proximal
interphalangeal joint.
If the patient cannot
flex the finger, the
flexor digitorum
superficialis tendon is
cut or non-functional.
19. TO EXCLUDE UNDERLYING INJURIES LIKE
FRACTURES.
20. REPAIR WITHIN 1ST TWO WEEKS,LATE REPAIR
DECREASE THE ULTIMATE MOBILITY OF THE
FINGERS
STRENGTH AND ABILITY TO PREVENT GAPPING
DEPENDS ON THE NO OF SUTURES THAT CROSS
THE REPAIR SITE
TENDON GAPPING IS THE HALLMARKOF TENDON
FAILURE
DORSALLY PLACED SUTURES HELPS TO MINIMISE
GAPPING
21. EPITENON SUTURES HELPS TO IMPROVE THE
STRENGTH AND QUALITY OF TENDON
REPAIRS
NO NEED FOR TENDON SHEATH REPAIR
PARTIAL TENDON LACERATIONS OF LESS
THAN 60% OF CROSS SECTIONAL AREA OF
TENDON SHOULD BE TREATED WITHOUT
TENORRHAPHY AND EARLY MOBILISATION
22. IN TRANSVERSE
LACERATIONS,
LONGITUDINAL INCISIONS
ARE PUT ON OPPOSITE
SIDES EXTENDING
PROXIMALLY AND
DISTALLY
OBLIQUE SKIN
LACERATIONS CAN BE
EXTENDED IN A ZIG ZAG
FASHION
23. WOUND EXTENDED PROXIMALLY AND DISTALLY
PROXIMAL TENDON RETRIEVED,CORE SUTURES
ARE PLACED
KEITH NEEDLES USED TO PASS THE SUTURES
AROUND THE DISTAL PHALANX EXITING
THROUGH NAIL PLATE DISTALLY
REMAINING DISTAL END OF TENDON SUTURED
TO THE RE-ATTACHED PROXIMAL PORTION
24. REPAIR BOTH TENDON LACERATIONS
TENDON SHEATH MAY BE OPENED FOR
EXPOSURE BUT A2 AND A4 ARE PRESERVED
AS MUCH AS POSSIBLE
FDS IS REPAIRED FIRST FOLLOWED BY FDP
25. If both tendons are lacerated,
both are repaired, end to end
with
circumferential re-enforcing
sutures
May affect lumbricals inaddition
to flexor tendons
Damaged lumbrical is either
repaired or excised depending
on severity of injury and the
26. Lacerations of flexor tendons within the
carpal canal are typically associated with
partial or complete laceration of median
nerve
Here median nerves should be repaired first
and the tendons last
27. In this area there may be concomitant ulnar
nerve & artery damage as well as radial artery
& median nerve damage.
Primary repair of the arteries is usually
indicated
If wound is contaminated, arteries are
repaired and delayed repair of tendons and
nerves is planned
28. TWO PROTOCOLS ARE FOLLOWED
1. PASSIVE FLEXOR TENDON PROTOCOL
2. EARLY ACTIVE TENSION PROTOCOL
29. 0-3 WEEKS:NO ACTIVE FINGER
FLEXION,DORSAL BLOCK SPLINT IS APPLIED
3-6 WEEKS:SPLINTING CHANGES WITH WRIST
IN NEUTRAL POSITION ,PASSIVE FLEXION AND
ACTIVE EXTENSION EXERCIZES STARTTED
6-9 WEEKS:WEANING FROM SPLINT,LIGHT
FUNCTIONAL ACTIVITIES STARTTED.
30. 9-12 WEEKS:JOINT CONTRACTURES IF
PRESENT ARECORRECTED.RESISTIVE
EXERCIZES ARE BEGUN.
12-16 WEEKS:PROGRESS TO FULL RESISTIVE
EXERCIZES
BEYOND 16 WEEKS:RESIDUAL DEFICITS IF ANY
CORRECTED
31. 24-48 HRS POST OP:DORSAL BLOCK
SPLINTING,PASSIVE AND ACTIVE EXTENSIONS
STARTTED WITHIN THE SPLINT
24-72 HRS POST OP TO 4 WEEKS:ACTIVE
EXERCIZES IN A HINGED TENODESIS SPLINT
AND DORSAL BLOCK SPLINT RE-APPLIED
AFTER EACH EXERCIZE SESSION
32. 4-6 WK POST OP:ACTIVE EXERCIZES DONE
OUTSIDE THE SPLINT
6-8 WKS POST OP:SPLINT DISCONTINUED
8-9 WKS POST OP:LIGHT STRENGTHENING
EXERCIZES BEGUN
10-14 WKS POST OP:PROGRESSIVE RESISTIVE
STRENGTHENING EXERCIZES BEGUN.
BEYOND 14 WKS:RETURN TO FULL
UNRESTRICTED ACTIVITY AT 14 WKS
33. SUCCESSFUL RESULTS REQUIRE PRECISE
SURGICAL TECHNIQUE AND STRICT
ADHERENCE TO REHABILITATION PROGRAM.