extensor tendon and tenosynovitis

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