extensor tendons flexor tendons

1. Tendon Injuries of Hand
Dr P ROHIT RAJ
MS Ortho
Dept of Orthopaedics
Vishwabharathi medical college

2. muscle to the
bone
glistening structure
between muscle
& bone which
transmit force from
“ ”

6. Tendon Morphology
• 70% collagen (Type I)
• Extracellular components
•
•
Elastin
Mucopolysaccharides (enhance water-
binding capability)
.

8. ANATOMY

9. Abbreviation Full Name Function
FPL Flexor pollicis longus Thumb flexion
PL Palmaris longus Flexion of wrist
FCU Flexor carpi ulnaris Flexion and adduction of hand
FDP Flexor digitorum profundus flexion of distal interphalangeal joints
and helps wrist flexion
FDS Flexor digitorum superficialis Flexion of proximal interphalangeal
joints and flexion of proximal
phalanges at metacarpophalangeal
joints
FCR Flexor carpi radialis Flexion and abduction of hand at
wrist

10. Abbreviation Full Name Function
APL Abductor pollicis longus Abduction of thumb
EPB Extensor pollicis brevis Extension of thumb proximal phalanx
ECRL
ECRB
Extensor carpi radialis longus/brevis Extends and abducts hand
EPL Extensor pollicis longus Extends thumb IP joint
ED
(4 tendons: II - V)
Extensor digitorum Extends digits II - V
EI Extensor indicis Extends digit II
EDM (EDC) Extensor digitorum minimi (quinti) Extends digit V
ECU Extensor carpi ulnaris Extends and abducts hand

11. Flexor Tendon Injury Zones
1: flexor digitorum profundus distal to
insertion of flexor digitorum
superficialis
2: insertion of flexor digitorum
superficialis to proximal edge of A1
pulley (“No Man’s Land”)
3: proximal edge of the A1 pulley to
distal edge of carpal tunnel
4: within the carpal tunnel
5: proximal to the carpal tunnel

12. Extensor Tendon
Injury Zones
O Extensor tendons are
divided into 8 zones
O Zones 1,3 and 5 lie
over the DIP, PIP and
MCP joints

13. PULLEYS

14. • ONLY FPL
• CONTAINS 2
ANNULAR PULLIES
AND ONE OBLIQUE
PULLIES
THUMB SHEATH

16. Camper’s Chiasma

18. ETIOLOGY
Common mechanisms of injury include
Osharp object direct laceration
(broken glass, kitchen knives or
table saws)
Ocrush injury
Oavulsions
Oburns
Oanimal or human bites
Osuicide attempts

19. Flexor tendon healing
• 2 forms:
– Intrinsic healing: occurs without direct blood
flow to the tendon
– Extrinsic healing: occurs by proliferation of
fibroblasts from the peripheral epitendon;
adhesions occur because of extrinsic healing of
the tendon and limit tendon gliding within
fibrous synovial sheaths

20. Phases of Intrinsic healing
1.Inflammatory (0-5 days) : strength of the
repair is reliant on the strength of the
suture itself
2.Fibroblastic (5-28 days) : or so-called
collagen-producing phase
3.Remodelling (>28 days)

21. FLEXOR TENDON INJURIES

23. • 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
ZONE 1: ZONE OF FDP AVULSION
INJURIES

24. Leddy classification of zone I flexor tendon
injuries!!
Type I: tendon retracted into palm (fullness
in palm)
Type II: tendon trapped in the sheath at
PIP (unable to flex PIP)
Type III: tendon trapped in A4 pully

25. Type I injury!!

26. Type II injury!!

28. • From metacarpal head to middle phalanx
• Called so because initial attempts for tendon
repair here produced poor results
• FDS and FDP within one sheath
•
ZONE II-NO MANS LAND

30. • B/w transverse carpal ligament and proximal
margin of tendon sheath formation
• Delayed tendon repairs are succesfull even
after several weeks of injury
ZONE III-DISTAL PALMAR CREASE

32. • Lies deep to deep transverse ligament
• Tendon injuries are rare
ZONE IV-TRANSVERSE CARPAL
LIGAMENT

34. • LIES PROXIMAL TO TRANSVERSE CARPAL
LIGAMENT
ZONE V-PROXIMAL

35. SIGNS & SYMPTOMS
• Unable to bend one or more finger joints
• Pain when bending finger/s
• Mild swelling over joint closest to fingertip
• Tenderness along effected finger/s on palm side of
hand

36. Complain of numbness
preceeded by execissive bleed
Consider neurovascular insult!!

37. 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
EXAMINATION

40. • Stabilise the MCP joint
• Ask the pt to flex IP
joint
FPL

41. DETECTION
• History and physical Examination of wound
•
• Use of bedside ultrasonography in ER (more sensitive and specific than
physical examination)
• Wound exploration techniques or MRI.
• 3-view x-ray must be done (except most benign) to rule out foreign
bodies or bony injury.
• Radiographs to evaluate for possible fractures or dislocations (blunt
trauma cases)

42. DICTUM
• Flexor tendon repair is not a surgical
emergency. It is proved that equal or better
results can be achieved by delayed primary
repair.
• Better to repair both FDP & FDS tendons
rather than FDP alone

43. Goals of reconstruction:
•
• anatomical repair
• repair to permit active range of motion
•Pully reconstruction to minimize bow-stringing
• atraumatic surgical technique to minimize adhesions
• strict adherence to rehabilitation protocol.

44. Timing of flexor tendon repair:
Primary: repair within 24 hours (contraindicated
in case of high grade contamination i.e. human
bites, infection)
Delayed Primary: 1-10 days when the wound can
be still pulled open without incision
Early Secondary: 2-4 weeks.
Late Secondary : after 4 weeks

45. Bunnell stitch
Crisscross stitch
Mason-Allen stitch
Robertson and Al-Qattan
Interlock stitch
Core Suture Techniques

46. Kessler stitch Modified Kessler
Tajima modification
Of kessler stitch with
double loop at repair
site

47. Sheath repair
• Advantages:
– barrier to the formation of extrinsic adhesions
– quicker return of synovial nutrition
– better tendon-sheath biomechanics

48. Sheath repair
• Disadvantages:
– technically difficult
– may narrow and restrict tendon gliding

49. Suture Materials
• Core Non-absorbable 4/0 suture
• Different configurations
• 6/0 monofilament running epitenon suture.
• As noted by Singer MD et al. 1998, 3-0
prolene or mersilene suture may be suture
of choice

50. • 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
ZONE 1 REPAIR

51. Tendon-to-bone attachment!!

52. One method of attaching tendon to bone. A, Small area of cortex is raised with osteotome.
B, Hole is drilled through bone with Kirschner wire in drill. C, Bunnell crisscross stitch is
placed in end of tendon, and wire suture is drawn through hole in bone. D, End of tendon
is drawn against bone, and suture is tied over button.
Wilson

53. Kleinert method of
Tendon advancement!!

54. Direct repair:
if laceration is more than
1 cm from FDP insertion
Tendon advancement:
if the laceration is less
then 1 cm from insertion

55. • 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
ZONE II REPAIRS

56. • If both tendons are lacerated, both are
repaired, end to end with
circumferential re-enforcing sutures
• May affect lumbricalsin addition to
flexor tendons
• Damaged lumbrical is either repaired or
excised depending on severity of injury
and the location of the laceration
ZONE III REPAIRS

57. Lumbrical muscle bellies usually are
not sutured because this can
increase the tension of these
muscles and result in a “lumbrical
plus” finger (paradoxical proximal
interphalangeal extension on
attempted active finger flexion).
Zone 3 injuries

58. Lumbrical plus!!

59. Quadriga effect!!
Tendon advancement shortens the FDP
& completes the grip before the normal
fingers, if the tension on tendon graft is
set too high, and limit their flexion and
thus week grip

60. • 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
ZONE IV REPAIR

61. • 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
ZONE V REPAIR

63. Brunner incision !!

64. Postoperative Management

65. Different Methods
1. Active Extention-Rubber Band Flexion Method:
e.g. Kleinert, and Brooke-Army
2. Immobilization
3. Controlled Passive Motion Methods: e.g.
Duran’s protocol
4. Strickland: Early active ROM

66. Kleinert Protocol
• Combines dorsal extension block with rubber-
band traction proximal to wrist
•
•
This passively flexes fingers, & the patient
actively extends within the limits of the splint

67. Active range of motion rehabilitation
Kleinert !!

68. Duran protocol
• At surgery, a dorsal extension-block splint is
applied with the wrist at 20-30° of flexion, the
MCP joints at 50-60° of flexion, and the IP
joints straight

69. Post-operative passive
exercises
Duran’s

70. Differential passive
exercises for
FDP & FDS!!

71. Position of Immobilization for Flexor Tendon Injury
•Wrist – 30 degree
flexon
•MP joint 60-70 degree
flexon
•Slight flexon of PIP &
DIP

72. Complications
• Joint contracture
• Adhesions
• Rupture
• Bowstringing
• Infection

73. Complications:
Adhesions & stiffness
requires tenolysis in 18-25%
cases
Tenolysis is indicated after 3
months if no improvement is
noted
For 1-2 months extensive
physiotherapy.

74. DONOR TENDONS FOR GRAFTING:
Palmaris Longus: Tendon of choice (fulfils
requirement of length, diam & availability)
Plantaris Tendon: Equally satisfactory &
advantage of being almost twice as long, but is
not accessible.
Others: FDS, EDC

75. Summary
• Meticulous technique
– Minimal handling
– Appropriate suture configuration
– Minimal resection of tendon sheath
• Postoperative mobilization
• Supervision!

76. Extensor Tendon Injury
• Extensor
apparatus
– Extrinsic muscles
(ED, EI, EDM)
– Intrinsic Muscles
( Lumbricals and
Interossei)
– Fixed fibrous
structures.

79. Injury : Zone- I
– Mallet finger –
persistent flexon of
distal phalanx
• Closed: splinting 6-8
weeks
• Open: suture repair,
Soft tissue
reconstruction

81. Zone II injury- Middle Phalanx Level:
– Repair by interrupted suture.
– Immobilization for 5-6 weeks
– DIP joint in extension
– PIP joint left free

83. Zone III injury- PIP joint level
– Most complex anatomically and physiologically
– Causes two deformities
• Boutonniere
• disruption of central tendon
Closed: splinting MCP and PIP in hyperextension for
6 weeks
Open: suture repair (figure of 8 suture)
• Swan Neck
– excessive traction of central tendon
– Closed : splinting DIP
– Open : suture repair

85. Zone IV injury- shaft of proximal
phalanx level
– Repair relatively easy
– Adhesion is the
problem

87. Zone V injury – MCP joint level
• Closed: splinting, 45 extension at wrist and 20
flexion at MCP
• Open: suture repair by 5.0 prolene

89. Zone VI injury- Metacarpal level
Better prognosis
than in fingers
All structures, even
intertendinous
band should be
repaired.
Core type suture
possible.
Delayed suture is
possible

91. Zone VII- wrist level
– Extensor tendons are under dorsal
retinaculum
– Retinaculum should be repaired or partially
preserved.
– Adhesion is the problem
– Grasping core suture should be used.
– Immobilization for 5-6 weeks.

92. EXTENSOR TENDON MANAGEMENT
3 current treatment approaches to
extensor tendon rehabilitation are
Immobilization
Early controlled passive mobilization
Early active motion

93. Position of Immobilization for Extensor
Tendon Injury
•The finger should
remain parallel to
forearm with wrist
in full extension
•PIP & DIP –
Neutral

94. IMMOBILIZATION
• Keep the tendon in a shortened position through
splinting or casting
• Tendons immobilized for 3 weeks
• In week 4, gentle active motion of the repaired
tendon is introduced
• Rehabilitation depends on zone of injury

95. IMMOBILIZATION
INJURIES IN ZONES
PROXIMAL TO MCPs
INJURIES IN ZONES
DISTAL TO MCPs
• May be immobilized for 3
weeks.
• Afterwards, finger may be
placed in removable volar splint
between exercise periods for 2
weeks
• Progressive ROM after 3 weeks
• If full flexion is not regained
rapidly, dynamic flexion may be
started after 6 weeks
• Require a longer period
of immobilization
(usually 6 weeks)
• A progressive exercise
program is initiated
• Dynamic splinting during
day and static splinting
at night to maintain
extension

96. EARLY PASSIVE MOTION
• Extensors are held in extension by dynamic,
gentle rubber band traction, and the patient is
allowed to actively flex the fingers—passively
moving repaired extensor tendons

97. EARLY ACTIVE MOTION
• Early active short arc program (developed by
Evans) allows tendon to actively move 3 days
after surgery
•
• Splinting program is complex and specific and
requires a skilled occupational therapist