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JOURNAL CLUB ON FLEXOR TENDON INJURIES.pptx
- 1. JOURNAL CLUB ON FLEXOR TENDON INJURIES Presenter: Dr. Shubhanshu Guide : Dr John
- 2. Introduction • 4.8 per lakh persons • Digits function after flexor tendon laceration and repair is challenging • Mason and Allen – recommended post op restricted or protected for better functional outcomes
- 4. FDP
- 5. Pulley flexor tendons • Fibrous flexor sheath surrounding tendon from neck of metacarpal till base of distal phalanx • Certain places its get thicken; Pulley • Annular : A1 to A5 • Cruciate : C1 to C3
- 6. Nutrition • Vascular – Longitudinal vessels – Intraosseous vessels – Vincular circulation • Synovial
- 7. Zone of Ischemia • FDS beneath A2 pulley proximal phalanx • FDP: A2 and A4 pulley
- 8. Tendon healing • Extrinsic – cause adhesion • Intrinsic – early mobilization possible • Three phases : – Inflammatory (48-72hr) – Fibroblastic (5days-4wks) – Remodelling (4wks-3.5months)
- 10. Repair goal • Sufficient strength • Minimum adhesion • Restoration of gliding surface • Fascilitation of repair site healing • Early passive and active ROM
- 11. Suture technique Epitendinous suture A.Bunnell stitch. B, Kessler grasping stitch. C, Kessler-Tajima stitch. D, Tsuge stitch. E, Double-grasping, single suture. F, Double-grasping, two sutures. G, Bevel technique. H, Double loop. I, Interlock stitch. J, Indiana four-strand repair with running lock suture. K, Single-cross grasp, six-strand. L, Six-strand, using three suture pairs. M, Four-strand cruciate repair. N, Eight-strand repair
- 12. Core suture • The core suture exit at about 1 cm from the cut end • loop of suture - tendon substance bite of about 2 mm to have a good hold on the tendon.
- 13. Timing for surgery • Primary repair – within 24hrs • Delay primary repair – 24hr- 10 days • Secondary repair – after 10 days • Late secondary - > 4 weeks
- 14. Partial injury • <50% no need to repair • Immediate active ROM start
- 15. Approach
- 16. Management of pulleys • A2 and A4 should be preserved • Venting of pulley can be done • A2 25%; A4 75%; A2 A4 25% can be excised without any angular deformity Tomaino et al. hand surgery 1998
- 17. Post op splinting • Dorsal slab or splint • 10-20 degree flexion • MCP flexed 40-60 • IP in neutral • Extended beyond finger tips
- 18. Rehabilitation • 3-4 wks – protective period(tensile strength weak) • Remodeling start – start mobilization or remove splint • 6-8 wks - Muscle strengthening and daily activities started
- 19. Modified Duran Passive ROM
- 20. Active ROM
- 21. Complication • Rupture- mostly within 2wks(sudden popping/loss of flexion power) • Adhesions • Joint contracture • Quadriga effect
- 22. Case Discussion on Jersey Finger
- 23. • 55yr male History RTA(bike) on 20/2/23 • C/o pain over right DIP joint of ring finger and unable to flex DIP joint • K/c/o T2DM
- 24. • Clinical…. • MOI- Jersey finger results from forceful hyperextension of DIP joint with FDP in maximal contraction. • FDP avulsion distal to FDS insertion.
- 26. Diagnosis • Type 1 zone 1 flexor tendon injury (jersey finger) which is confirm by MRI. • Treatment- Tendon repair with suture anchor
- 27. Rehablitation • Active and passive ROM begin at 4wks • Discontinue DBS 6wk post operatively and allow full extension actively and passively • At 8 wk add gentle resistance exercises with squeeze ball and progress over the next 4wks to full use
- 28. Take home message • Early fixation/repair for good outcome. • Intact FDS function should never be scarified to permit reconstruction of an injured FDP tendon. • FDP advancement of >1cm carries risk of DIP joint contracture or Quadrigia • Good Post op rehabilitation protocol achieve better outcome
Editor's Notes
- thumb pulley anatomy (A) and the flexor system zones (B). A, The A1 pulley is at the level of the metacarpophalangeal joint. The oblique pulley originates at the proximal half of the proximal phalanx. The A2 pulley is over the interphalangeal joint. B, The flexor system zones: I, distal to the flexor digitorum superficialis insertion; II, proximal aspect of the A1 pulley to the insertion of the flexor digitorum superficialis; III, defined by the distal transverse aspect of the carpal ligament to the A1 pulley; IV, the carpal tunnel; and V, proximal to the carpal tunnel.
- James position