This document discusses trauma to the hand, specifically extensor tendon injuries and flexor tenosynovitis. It describes two cases - the first involving a laceration to the extensor tendon of the right thumb requiring surgical repair. The second case involves flexor tenosynovitis of the right ring finger from a fishhook injury, requiring IV antibiotics and possible surgery. It provides details on the anatomy, mechanisms of injury, clinical presentations, diagnostic criteria, non-operative and operative treatment options, post-operative care and potential complications for both extensor tendon injuries and flexor tenosynovitis. Surgical management focuses on debridement, irrigation and repair or reconstruction depending on the

1. TRAUMA FILMS
29 MARCH 2019
phakjiranut maneepradit

2. ✖ผู้หญิงไทย อายุ 19 ปี no U/D
✖CC : แผลฉีกขาดนิ้วโป้งมือขวา 1 hrPTA
✖PI : 1 hrPTA ขณะฟันหัวมันสาปะหลัง ถูกมีดฟันนิ้วโป้ง
มือขวา แผลฉีกขาดลึกถึงเส้นเอ็น กระดกนิ้วโป้งมือขวาไม่ได้ ไปรพช.
จึง refer มา
Case 1

3. Physical examination
ABCD passed, vital signs stable
Extremities:
Inspection : Laceration wound 1 cm.
deep to tendon
Palpation :
Motion : can’t extend Rt. thumb
Neurovascular : normal sensation ,
radial pulse 2+

4. diagnosis
Tear Extensor tendon zone III of Right thumb

5. management
• Set OR for debridement and repair extensor tendon
Rt thumb

6. Extensor Tendon Injuries
 Injury can be caused by laceration, trauma, or overuse
 zone VI is the most frequently injured zone.

7. • Mallet Finger
DIP extension splinting
• Disruption of tendon over middle phalanx or
proximal phalanx of thumb (EPL)
• Boutonniere deformity
PIP extension splinting
• Disruption over the proximal phalanx of
digit or metacarpal of thumb (EPL and EPB)
• "Fight bite" common
• Sagittal band rupture
MCP extension splinting
• Nerve and vessel injury likely
• Disruption at the wrist joint
• Must repair retinaculum to prevent
bowstringing
• Usually from penetrating trauma
• Often have associated neurologic injury

8. treatment
✖ Nonoperative
• immobilization with early protected motion
Indications : lacerations < 50% of tendon in all zones if patient
can extend digit against resistance
o DIP extension splinting
Indications : acute (<12 weeks) Zone 1 injury (mallet finger)
nondisplaced bony mallet
chronic mallet finger (>12 weeks) if joint congruent
o PIP extension splinting
Indications : closed central slip injury (zone III)
o MCP extension splinting
Indications : closed zone V sagittal band rupture

9. treatment
✖Operative
• immediate I&D
Indications : fight bite to MCP joint
• tendon repair
Indications :laceration > 50% of
tendon width in all zones
• fixation of bony avulsion
Indications : boney mallet finger
with P3 volar subluxation
• tendon reconstruction
Indications : chronic tendon injury or
when repair not possible
• central slip reconstruction
• EIP to EPL tendon transfer
Indications : chronic EPL rupture

10. Complications
✖Adhesion formation
- leads to loss of finger flexion
- common in zone IV and VII and older patients
- prevented with early protected ROM and dynamic splinting (zone IV)
✖Tendon rupture
- causes include poor suture material or surgical technique,
aggressive therapy, and noncompliance
- most frequently during first 7 to 10 days post-op
✖Swan neck deformity
caused by prolonged DIP flexion with dorsal subluxation
of lateral bands and PIP joint hyperextension
✖ Boutonniere deformity(DIP hyperextension)
caused by central slip disruption and lateral band volar
subluxation

11. ✖ผู้ป่วยชายไทย อายุ 75 ปี U/D HT
✖CC : ปวดบวมนิ้วนางมือขวา 3 dPTA
✖PI : 5 dPTA ถูกหนามปักมือขวา ปวดบวมมือขวาเล็กน้อย
ไม่ได้ไปรักษาที่ใด
3 dPTA นิ้วนางมือขวาบวมแดง ขยับได้ลดลง เริ่มมี
หนองไหล ไปรพช. จึง refer มา
Case 2

12. Physical examination
ABCD passed, vital signs stable
Extremities:
Inspection : Rt ring finger slightly
flexion, swelling
Palpation : tender along tendon
Motion : pain with passive stretching Rt.
Index finger
Neurovascular : normal sensation ,
radial pulse 2+

13. diagnosis
Flexor tenosynovitis Rt ring finger

14. management
• Surgery
• IV ATB

15. flexor tenosynovitis

16. Anatomy
Synovial sheath
• Extend from the mid-palmar crease at a1 pulley to the DIP
• Small finger continuous with the Ulnar Bursa
• Thumb( FPL) is continuous with the Radial Bursa

17. Flexor tendon sheath infection
• Flexor tendon sheath infection : penetrating trauma
• More likely at joint flexion creases
• Usual agent: S. Aureus
• Most commonly affected : Ring,Middle& index fingers
• Purulence > destroys gliding > adhesions > loss of function
• destroys the blood supply producing tendon necrosis

18. Diagnosis
✖Kanavel's cardinal signs
1) Tenderness over & limited to the flexor sheath
2) Symmetrical enlargement of the digit ("fusiform")
3) Severe pain on passive extension of the finger (> proximally)
4) Flexed posture of the involved digit

19. Treatment
• First 24 hr
• may initially with IV Antibiotics
• Ceftriaxone/ Ciprofloxacin / vancomycin
• Failed ATB in 24 hr -> Surgery

20. Surgery
Open drainage
• Decompression of the entire tendon sheath via mid-axial &
palmar incisions
• Wounds are left open to drain & heal secondarily
• resection of necrotic tendon is required
• Rehab is prolonged; permanent finger
• Most useful for advanced cases where

21. Surgery
Closed tendon-sheath irrigation
2 incisions made
• Proximal palm: proximal to the Al pulley
• Distal mid-axial: distal to the A4 pulley
• Long catheter (16- 18g) in the proximal sheath
witha drain left in the distal incision'
then close, and irrigate for 48- 72 hrs.

22. Postop care
• Intravenous antibiotics
• Pain management
• First dressing change between 8 and 12 hours
• Soaks in dilute povidone-iodine solution three times per day with
range-of-motion exercises
• Repeat debridement and irigation in 48 hours if Kanave's signs not
resolving.

23. Thankyou