The document summarizes flexor tendon injuries and their treatment. It discusses the anatomy and biology of flexor tendons, mechanisms of tendon healing, assessment of tendon injuries including history and examination, and surgical techniques for repair. Surgical techniques discussed include primary repair, tendon grafting, and rehabilitation protocols. Positive outcomes are associated with techniques that minimize adhesion and allow early active motion, such as using biological amnion grafts and modified repair methods with pulley release.
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
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
Deformity: It’s the position of a limb/Joint, from which it cannot be brought back to its normal anatomical position.
Described as abnormalities of :
Length
Angulation
Rotation
Translation
Combination
At the end of this lecture, you should be able to:-
Understand and describe the anatomy of the flexor tendon system in the hand and its relevance in surgery
Describe and relate the normal physiology of the tendon and its implications in injury
Understand the reaction of tendon to injury and its healing process and its implications in surgery and rehabilitation
Hand rehabilitation following flexor tendon injuriesAbey P Rajan
hand rehabilitation following flexor tendon injuries include introduction, clinical anatomy, tendon nutrition, tendon healing, post op. management, special cases, summary
Deformity: It’s the position of a limb/Joint, from which it cannot be brought back to its normal anatomical position.
Described as abnormalities of :
Length
Angulation
Rotation
Translation
Combination
At the end of this lecture, you should be able to:-
Understand and describe the anatomy of the flexor tendon system in the hand and its relevance in surgery
Describe and relate the normal physiology of the tendon and its implications in injury
Understand the reaction of tendon to injury and its healing process and its implications in surgery and rehabilitation
Hand rehabilitation following flexor tendon injuriesAbey P Rajan
hand rehabilitation following flexor tendon injuries include introduction, clinical anatomy, tendon nutrition, tendon healing, post op. management, special cases, summary
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This research investigates the potential of two advanced AI language models, ChatGPT-4 and Co-Pilot, to transform medical education through clinical scenario generation. Focusing on scenarios for Diabetic Neuropathy, Acute Myocardial Infarction, and Pediatric Asthma, the study compares the accuracy, depth, and practical teaching utility of content generated by each platform. A panel of medical experts assessed the AI-generated scenarios, and healthcare professionals provided feedback on their perceived usefulness in educational settings. Results suggest that ChatGPT-4 excels in providing structured foundational knowledge, while Co-Pilot offers greater depth through realistic patient narratives and a focus on holistic care. This indicates that both platforms have value, with their suitability depending on specific educational objectives – ChatGPT-4 aligns better with introductory learning, and Co-Pilot better serves advanced applications emphasizing practical clinical reasoning.
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The objectives of this specialised workshop are to:
• Explore the core principles of AI, emphasising its applications and significance in modern healthcare.
• Examine the role of AI in enhancing clinical judgment and patient management, with live demonstrations of relevant tools.
• Uncover the potential of AI in revolutionising teaching and learning experiences for healthcare professionals and students.
• Illustrate the integration of AI in healthcare research, focusing on tasks such as literature review, data analytics, and manuscript development.
• Provide a hands-on experience with various AI platforms tailored to healthcare professionals' unique needs and demands
A one day workshop on the use of AI in Healthcare for practice, teaching and research.
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The slide deck for the "AI for Learning Design" workshop, hosted at Asia Pacific University, serves as a comprehensive guide to integrating Artificial Intelligence into educational settings. Designed to empower educators and instructional designers, the presentation offers actionable strategies for curriculum integration, insights into personalized learning through AI, and a deep dive into the ethical considerations that accompany AI adoption in education. The deck is structured to facilitate an interactive and engaging workshop experience, featuring real-world examples, hands-on activities, and spaces for thought-provoking discussions. Don't miss this invaluable resource for transforming your teaching practices and enhancing educational impact through AI.
empowereing practice in healthcare with generative AI. How to use vairous AI tools to enhance and empowere healthc are practice inlcuidng teaching and research
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Flexor tendon surgery Review
1. Flexor Tendon Injuries
Mr Vaikunthan Rajaratnam
Hand Review Course 19 Aug 2022
http://tinyurl.com/HandTendon
2. Learning
Objectives
• Understand and describe the
anatomy of the flexor tendon
system in the hand and its
relevance in surgery
• Describe and relate the normal
physiology of the tendon and its
implications in injury
• Understand the reaction of
tendon to injury and its healing
process and its implications in
surgery and rehabilitation
5. Our results demonstrate that A2 and A4 absence did
not produce major bowing if adjacent annular pulley
are intact. This has significant impact during flexor
tendon surgery in zone 1 and 2 and the practice of
venting of A2 and A 4 pulleys.
6.
7. Biology
• Tendon nutrition
1. Blood supply provided
through the vincular
circulation
2. Synovial fluid
• FPL does not have a
vinculum >>> can
tolerate more tendon
advancement without
disturbing its blood supply
8.
9. Tendon Healing
Three mechanisms
1. Extrinsic: From
surrounding tissue
(epitenon fibroblast),
for gap healing
2. Intrinsic: Within the
tendon (tenoblast,
stimulated by
movement
3. Combination
14. Assessment
Feel ….
• Empty synovial sheath
• Loss of tendon tension
Move ….
• No tenodesis effect in
passive wrist movement
• Gentle compression on
forearm (ulnar half at
the junction middle and
distal thirds)
15. Assessment
Beware
• Independent FDP index >>>(Pulp to pulp test)
• Tendon anatomical variation: - Deficient FDS
little finger (35%)
- No FDP little finger
• Cut FDP at the wrist >>> normal action
• Partial cut; - Common in FPL
- Painful
• Neuro-vascular injuries
• Others
18. Zone 1
• Leddy type I – treat within 3 weeks
• type II and III treatable even after 6 weeks.
• Ultrasound helpful in locating the proximal
stump.
• Microsuture anchors or ORIF if bone fragment
• Ensure tendon-bone contact before final knot-
tying.
• Too tight repair - quadrigia.
• > Two-strand repair techniques
22. Primary Repair of Flexor Tendons
Verdan, Claude E, JBJS. 42(4):647-657, June 1960
• Clean & Fresh
• Excising FDS
• Precise FDP repair core and epitendinous stitches
• Repair the sheath
• Detension repair site with transverse 2 pins
• Consider secondary tenolysis
23. Principles of repair
Muscle relaxation
Adequate but minimal
exposure
4-6 core sutures sufficient
grasping
Coaptation without
gapping and bunching
Epitendinous suture
No impingement on
pulley
25. Zone 2
< 3 weeks Primary repair
>6 weeks old - recon
Tendon retrieval
Strong repair site vs gentle
passive range-of-motion
therapy
< 1 cm of FDP stump
advancement and repair to
bone
slips of the FDS special
techniques, and needles
Post Op AROM ?
Frayed tendon end
debridement
A2 and A4 myth??
26. Tang, J.B., 2018. New Developments
Are Improving Flexor Tendon Repair:
Plastic and Reconstructive Surgery
141, 1427–1437.
27. The proposed algorithm for pulleys and FDS management
according to the subzone of tendon lesion
Giesen, T et al 2018. Flexor tendon repair in the hand with the M-Tang technique (without
peripheral sutures), pulley division, and early active motion. J Hand Surg Eur Vol 43, 474–479.
28. Primary Flexor Tendon Repair with Early Active
Motion: Experience in Europe
• A 6-strand core suture is performed using the M modification of
Tang’s original technique.
• No circumferential suture is added after a 6-strand core suture.
• The pulleys are divided as much as needed to allow free excursion
of the repaired tendon within the tendon sheath, including, when
necessary, full division of the A4 or A2 pulley.
• To avoid the repaired structures within the sheath being too bulky,
the authors generally repair only half of the flexor digitorum
superficialis, resecting the other half. In zone 2C, and in specific
cases, the flexor digitorum superficialis is excised completely.
• Rehabilitation is controlled active motion, but with modifications.
Giesen, T., Calcagni, M., Elliot, D., 2017. Primary Flexor Tendon Repair with Early
Active Motion: Experience in Europe. Hand Clinics, Hand Surgery in Asia and
Europe 33, 465–472
29. A 2, 4 and 6 core tendon suture of 4/0 nylon and standard 6/0 epitendinous sutures
were placed by a consultant hand surgeon on the intact FDP tendon in Zone 2
• The increase in volume of the
tendon by placement of the suture
• Space between tendon and pulley in
the flexor sheath
• Complete obstruction of the tendon
passage through the pulley system
after sutures
Index finger/ A0:
Volume of pulley 386.3 mm3
volume of tendon + suture 287.1mm3
Little finger/ A1:
Volume of pulley: 124.9 mm3
Volume of tendon + suture: 148.3 mm3
FDP
FDS
PHALANX
30. WALANT and tendon surgery
• there are no evidence about effective positive
outcome on the results of surgical repair of
flexor tendon injuries between Walant
anaesthesia and traditional anaesthesiologic
technique.
Orthopedic Reviews 2020; volume 12(s1):8668
31. Biological Amnion Prevents Flexor
Tendon Adhesion
• freeze-dried amniotic membrane
transplantation was applied to promote
healing of the flexor tendon in zone II and
prevent adhesion.
• 89 patients 160 injured fingers
Liu C, Bai J, Yu K, Liu G, Tian S, Tian D. Biological Amnion Prevents Flexor
Tendon Adhesion in Zone II: A Controlled, Multicentre Clinical Trial. BioMed
Research International. April 2019:1-9. doi:10.1155/2019/2354325
32. Biomechanical Analysis Using
Barbed Suture
• The use of the barbed sutures in the
Asymmetric repair technique flexor
tendon, whilst more time consuming, has
shown promising improvement to its
biomechanical performance
Lee JS, Wong Y-R, Tay S-C. Asymmetric 6-Strand Flexor Tendon Repair –
Biomechanical Analysis Using Barbed Suture. Journal of Hand Surgery
(Asian-Pacific Volume). 2019;24(3):297-302.
doi:10.1142/S2424835519500371
Xing Fu Hap D, Rung Wong Y, Rajaratnam V. The use of barbed sutures in the
Pulvertaft weave: a biomechanical study. Journal of Hand Surgery (European
Volume). 2020;45(10):1055-1060. doi:10.1177/1753193420909452
33. Neiduski, et al 2019. Flexor tendon rehabilitation in the 21st century: A systematic review.
Journal of Hand Therapy, SI: Evidence Updates 32, 165–174.
• Place and hold exercises
provide better outcomes
than passive flexion
protocols
• Active, functional
performance should be
consistently used to
evaluate outcomes.