This document discusses anatomy and injuries of the hand flexor tendons. It begins with the anatomy of the flexor tendon system including the fibrous pulley system. It then covers the different zones of flexor tendon injury and techniques for repair. The goals of repair are to control scar formation and allow for early motion rehabilitation. Post-operative therapy is critical and usually involves early passive motion or early active motion protocols. Complications can include adhesion, rupture, or flexion contractures.
The document discusses tendon injuries of the hand, including the anatomy, morphology, nutrition, and zones of injury of both flexor and extensor tendons. It covers the etiology, signs and symptoms, examination, detection, and treatment including surgical repair and postoperative rehabilitation of tendon injuries. The key aspects are meticulous surgical technique, appropriate postoperative mobilization, and supervision through rehabilitation to minimize complications of tendon injuries.
The document discusses ulnar nerve palsy and tendon transfers used to treat it. It begins by describing the anatomy of the ulnar nerve and its motor and sensory functions. It then discusses clinical findings associated with ulnar nerve injuries at different locations. Various tendon transfers are summarized that aim to restore small and ring finger flexion, key pinch, correct clawing, and improve grip strength for patients with ulnar nerve palsy. These include transferring forearm muscles like the ECRB to restore key pinch or correct clawing. The modified Stiles-Bunnell procedure is also summarized, which uses the middle finger superficialis tendon to dynamically correct clawing during finger flexion.
This document summarizes fractures and dislocations of the phalanges. It begins with anatomy of the hand and mechanisms of injury. It then discusses specific fracture patterns including tuft, shaft, mallet finger and jersey finger injuries. Treatment options are provided for each including splinting, pinning and open reduction techniques. Complications are also summarized. MCP dislocations of the thumb are reviewed including mechanisms, types and methods of closed and open reduction.
This document provides information on claw hand deformities, including definitions, anatomy, classifications, evaluation, and surgical reconstruction techniques. It begins with defining claw hand as a flattening of the transverse metacarpal arch with hyperextension of the MCP joints and flexion of the PIP and DIP joints. It then discusses the anatomy and biomechanics involved in normal versus paralytic claw hands. Various classification systems for claw hands are presented based on etiology, pattern of nerve injury, degree of involvement, and physical characteristics. Evaluation techniques such as specific tests and angle measurements are outlined. Both static and dynamic surgical reconstruction methods are then described in detail, including tendon transfers, capsulotomies, and tenode
Tendoachilles rupture and its managementRohan Vakta
Achilles tendon is the strongest tendon of body. There are many causes of its rupture. It can be acute or chronic rupture. Management of chronic rupture by semitendinosus tendon is mentioned here.
The document discusses the history and development of elastic stable intramedullary nailing (ESIN) for fractures in children. It describes early techniques using rigid pins and wires, and the development of the modern ESIN method in the 1980s using pre-bent titanium nails inserted from opposite sides of the bone for axial, lateral, and rotational stability. Key aspects of ESIN technique are outlined, including nail sizing, insertion points, pre-bending, and final positioning to stabilize fractures while minimizing soft tissue injury and allowing callus formation. Risks and special considerations for different bone fractures are also mentioned.
1) Median nerve injuries can result in loss of motor function to key muscles in the forearm and hand. Tendon transfers can help restore function by transferring muscles still innervated to replace lost functions.
2) Common tendon transfers include using the superficialis or EIP tendon to restore thumb opposition. The BR or ECRL can be used to restore thumb or index finger flexion.
3) Rehabilitation after tendon transfer focuses initially on splinting the transfers and mobilizing other joints, followed by gentle active and assisted range of motion exercises to strengthen and condition the transfers.
This document discusses proximal humerus fractures, including:
- They are common in older patients and often result from low-energy falls.
- Classification systems include the AO/OTA system and Neer system, which categorizes fractures as one, two, three, or four-part based on displacement of fragments.
- Nondisplaced or minimally displaced one-part fractures are most common and are typically treated non-operatively with rest and sling immobilization.
The document discusses tendon injuries of the hand, including the anatomy, morphology, nutrition, and zones of injury of both flexor and extensor tendons. It covers the etiology, signs and symptoms, examination, detection, and treatment including surgical repair and postoperative rehabilitation of tendon injuries. The key aspects are meticulous surgical technique, appropriate postoperative mobilization, and supervision through rehabilitation to minimize complications of tendon injuries.
The document discusses ulnar nerve palsy and tendon transfers used to treat it. It begins by describing the anatomy of the ulnar nerve and its motor and sensory functions. It then discusses clinical findings associated with ulnar nerve injuries at different locations. Various tendon transfers are summarized that aim to restore small and ring finger flexion, key pinch, correct clawing, and improve grip strength for patients with ulnar nerve palsy. These include transferring forearm muscles like the ECRB to restore key pinch or correct clawing. The modified Stiles-Bunnell procedure is also summarized, which uses the middle finger superficialis tendon to dynamically correct clawing during finger flexion.
This document summarizes fractures and dislocations of the phalanges. It begins with anatomy of the hand and mechanisms of injury. It then discusses specific fracture patterns including tuft, shaft, mallet finger and jersey finger injuries. Treatment options are provided for each including splinting, pinning and open reduction techniques. Complications are also summarized. MCP dislocations of the thumb are reviewed including mechanisms, types and methods of closed and open reduction.
This document provides information on claw hand deformities, including definitions, anatomy, classifications, evaluation, and surgical reconstruction techniques. It begins with defining claw hand as a flattening of the transverse metacarpal arch with hyperextension of the MCP joints and flexion of the PIP and DIP joints. It then discusses the anatomy and biomechanics involved in normal versus paralytic claw hands. Various classification systems for claw hands are presented based on etiology, pattern of nerve injury, degree of involvement, and physical characteristics. Evaluation techniques such as specific tests and angle measurements are outlined. Both static and dynamic surgical reconstruction methods are then described in detail, including tendon transfers, capsulotomies, and tenode
Tendoachilles rupture and its managementRohan Vakta
Achilles tendon is the strongest tendon of body. There are many causes of its rupture. It can be acute or chronic rupture. Management of chronic rupture by semitendinosus tendon is mentioned here.
The document discusses the history and development of elastic stable intramedullary nailing (ESIN) for fractures in children. It describes early techniques using rigid pins and wires, and the development of the modern ESIN method in the 1980s using pre-bent titanium nails inserted from opposite sides of the bone for axial, lateral, and rotational stability. Key aspects of ESIN technique are outlined, including nail sizing, insertion points, pre-bending, and final positioning to stabilize fractures while minimizing soft tissue injury and allowing callus formation. Risks and special considerations for different bone fractures are also mentioned.
1) Median nerve injuries can result in loss of motor function to key muscles in the forearm and hand. Tendon transfers can help restore function by transferring muscles still innervated to replace lost functions.
2) Common tendon transfers include using the superficialis or EIP tendon to restore thumb opposition. The BR or ECRL can be used to restore thumb or index finger flexion.
3) Rehabilitation after tendon transfer focuses initially on splinting the transfers and mobilizing other joints, followed by gentle active and assisted range of motion exercises to strengthen and condition the transfers.
This document discusses proximal humerus fractures, including:
- They are common in older patients and often result from low-energy falls.
- Classification systems include the AO/OTA system and Neer system, which categorizes fractures as one, two, three, or four-part based on displacement of fragments.
- Nondisplaced or minimally displaced one-part fractures are most common and are typically treated non-operatively with rest and sling immobilization.
The patella is the largest sesamoid bone in the body located within the quadriceps tendon. It articulates with the femur and is supplied by vessels from the geniculate arterial system. The patellar retinaculum connects the patella to the tibia and is formed by fascia and fibers from surrounding muscles. The patella can displace in various directions from its normal position. Lateral dislocation is most common due to anatomical and biomechanical factors that influence the patellofemoral joint. Evaluation and treatment depends on the nature and chronicity of the injury.
This document discusses mallet finger injuries, which involve disruption of the extensor tendon mechanism at the distal interphalangeal joint. It covers the anatomy of the finger extensor mechanism, classification of mallet finger injuries, clinical evaluation, treatment options including nonsurgical management with splinting and surgical repair or fixation, and management approaches for different types of acute mallet finger injuries.
The document discusses anatomy and injuries of the extensor tendons in the hand, including mallet finger injuries at the DIP joint, boutonniere deformities involving the central slip of the extensor tendon near the PIP joint, and evaluation and treatment of various zones of extensor tendon injuries including splinting, tendon repair techniques, and reconstruction procedures.
1. Flexor tendon injuries can occur in any of the 5 zones defined by Kleinert and Verdan and require different surgical approaches depending on the location and severity of the injury.
2. Primary repair within 12-24 hours of injury provides the best functional outcomes while delayed or secondary repairs have higher risks of adhesion formation.
3. Flexor tendon repair techniques aim to accurately approximate the tendon ends with core sutures while minimizing handling and restoring the normal gliding relationship between tendons. Postoperative rehabilitation is crucial.
4. Flexor tendon grafting is indicated for injuries with segment
This document discusses tendon anatomy, injury, and repair. It describes the composition and vascular supply of tendons. Common tendon injuries include open wounds requiring surgical repair and closed injuries causing deformities. The goals of repair are to reestablish tendon continuity and gliding function. Various suture techniques are discussed for end-to-end, end-to-side, and tendon-to-bone repairs. Post-operative rehabilitation aims to promote intrinsic healing while minimizing scarring through early controlled motion to optimize tendon gliding and range of motion recovery.
Modified sauve kapandji procedure for patients with old fracturesPonnilavan Ponz
The document discusses a study evaluating the clinical and radiographic outcomes of a modified Sauve-Kapandji procedure for patients with old fractures of the distal radius. The modified procedure involves resection and reinsertion of the distal ulna into the distal radius after a 90-degree rotation. The study reviewed 15 patients who underwent the procedure with at least 7 months of follow up. Results found 80% of patients had excellent outcomes with reduced pain, improved range of motion, and grip strength. The modified Sauve-Kapandji procedure provides an effective treatment for chronic distal radioulnar joint disorders in patients with old distal radius fractures.
This document discusses radial nerve palsy and tendon transfers to restore function after radial nerve injury. It begins by describing the anatomy and functions of the radial nerve. Radial nerve palsy results in loss of wrist, finger, and thumb extension. Tendon transfers can restore this function, such as using the palmaris longus tendon to restore thumb extension via transfer to the extensor pollicis longus. Post-operative rehabilitation focuses on protecting the tendon transfers during early mobilization and strengthening exercises.
The document describes claw hand, which is a deformity of the hand where the fingers are flexed into the palm at the middle knuckle. It discusses the anatomy, etiology, types, clinical signs, classification, and surgical techniques for correction. The main techniques discussed are static procedures like flexor pulley advancement and dynamic procedures using tendon transfers to restore muscle function. The goal of surgery is to maintain the middle knuckle in slight flexion to allow the extensors to straighten the fingers.
The document discusses hand injuries and their management. It covers relevant hand anatomy, types of common hand injuries including tendon injuries, fractures, and dislocations. The key principles of management are early debridement and stabilization of injuries, restoration of anatomy, and rapid mobilization. Specific techniques are described for repairing tendons, fixing fractures like Bennett's fracture, and achieving proper skeletal stabilization while preserving hand function.
This document discusses shoulder instability, including definitions, anatomy, evaluation, and treatment. It defines instability as the inability to maintain the humeral head in the glenoid fossa, ranging from dislocation to laxity. Static stabilizers include the labrum and ligaments, while dynamic stabilizers are the rotator cuff and scapulothoracic muscles. Evaluation involves history, exam, and imaging to classify instability by direction, degree, and etiology. Treatment depends on classification but may include immobilization, rehabilitation, or surgical repair of labral tears or bone defects.
This document provides information on meniscal tears of the knee. It begins with an introduction stating that meniscal tears are common injuries responsible for many arthroscopies annually. It then covers anatomy of the medial and lateral menisci, blood supply, classification of tears, mechanisms of injury, clinical features, investigations like MRI and arthroscopy, and treatment options including non-operative care, meniscectomy, and meniscal repair. The focus is on providing detailed information on meniscal anatomy, tears, and surgical and non-surgical management.
This document provides information on fractures of the distal end of the radius bone. It discusses the history, incidence, anatomy, classification, diagnosis, and treatment options for these fractures. Distal radius fractures most commonly result from falls on an outstretched hand and occur in three main age groups. Treatment depends on factors like fracture pattern and stability, and may involve closed reduction with casting or surgical options like percutaneous pinning, plating, or external fixation. The goals of treatment are to restore function, alignment, and stability while avoiding complications.
Apply gentle pressure proximally
Surgeon: Check distal pulses and capillary refill
If no improvement:
Consider temporary arteriotomy or venous shunt
Delay closure and observe
Flap or graft may be needed
Scaphoid fractures are the most common carpal bone fractures, often occurring in young adults from falls on an outstretched hand. The scaphoid has a tenuous blood supply and is prone to non-union, especially for proximal pole fractures. Treatment depends on fracture type and stability, ranging from casting to operative fixation with screws. Complications include malunion, delayed union, non-union and avascular necrosis, requiring further procedures like bone grafting or carpal fusion.
This document summarizes flexor tendon injuries and repairs. It describes tendon nutrition, zones of ischemia, tendon healing phases, factors that cause adhesions, examination techniques, and types of tendon repairs. Flexor tendon injuries are evaluated based on the location of the injury (Verdan zones I-V) and repaired accordingly. Primary repair is preferred if possible, while complications like adhesions or gap formation require techniques like tenolysis. Postoperative rehabilitation aims to restore tendon gliding and function while avoiding issues like bowstringing.
This document summarizes a seminar on flexor and extensor tendon injuries of the hand. The seminar was chaired by Prof. Dr. Kiran Kalaiah and presented by Dr. Yashavardhan.T.M. It provided an overview of tendon anatomy, classification of tendon injuries by zone, surgical techniques for repair, and postoperative rehabilitation protocols. Key points included the pulley system that guides tendon movement, zones of injury from I to V, and techniques like the six strand repair that aim to minimize complications like adhesion formation.
1. Elbow dislocations are most commonly caused by falls onto an outstretched hand and involve the disruption of the lateral and medial collateral ligaments and elbow capsule.
2. Simple elbow dislocations without fractures are typically treated non-operatively with closed manipulation and immobilization for less than 3 weeks to avoid stiffness.
3. Operative treatment is considered if closed reduction cannot be maintained or for recurrent dislocations and involves repair of the lateral collateral ligaments through bone tunnels or anchors.
This document discusses fractures of the olecranon bone. It begins with the epidemiology, noting these fractures have a bimodal distribution in younger individuals due to high-energy trauma and older individuals due to simple falls. The anatomy section outlines the subcutaneous position of the olecranon making it vulnerable to trauma, as well as its articulation with the elbow joint. Clinical presentation, evaluation, classification systems, treatment objectives, nonoperative and operative treatment options including various surgical techniques are then covered in detail.
Ligamentotaxis principle in the treatment of intra articular fractures of dis...Sitanshu Barik
This study assessed the correlation between radiological outcomes and functional outcomes in 45 patients treated with external fixation for intra-articular fractures of the distal radius. Good or acceptable restoration of radial length and palmar slope on radiographs post-operatively was found to produce good to excellent functional results regardless of fracture type. While poor radiological outcomes did not always lead to poor function, maintenance of radial length and correction of palmar tilt were important for functional outcomes. The study concluded that achieving good function is more important than surgical precision on radiographs alone.
The patella is the largest sesamoid bone in the body located within the quadriceps tendon. It articulates with the femur and is supplied by vessels from the geniculate arterial system. The patellar retinaculum connects the patella to the tibia and is formed by fascia and fibers from surrounding muscles. The patella can displace in various directions from its normal position. Lateral dislocation is most common due to anatomical and biomechanical factors that influence the patellofemoral joint. Evaluation and treatment depends on the nature and chronicity of the injury.
This document discusses mallet finger injuries, which involve disruption of the extensor tendon mechanism at the distal interphalangeal joint. It covers the anatomy of the finger extensor mechanism, classification of mallet finger injuries, clinical evaluation, treatment options including nonsurgical management with splinting and surgical repair or fixation, and management approaches for different types of acute mallet finger injuries.
The document discusses anatomy and injuries of the extensor tendons in the hand, including mallet finger injuries at the DIP joint, boutonniere deformities involving the central slip of the extensor tendon near the PIP joint, and evaluation and treatment of various zones of extensor tendon injuries including splinting, tendon repair techniques, and reconstruction procedures.
1. Flexor tendon injuries can occur in any of the 5 zones defined by Kleinert and Verdan and require different surgical approaches depending on the location and severity of the injury.
2. Primary repair within 12-24 hours of injury provides the best functional outcomes while delayed or secondary repairs have higher risks of adhesion formation.
3. Flexor tendon repair techniques aim to accurately approximate the tendon ends with core sutures while minimizing handling and restoring the normal gliding relationship between tendons. Postoperative rehabilitation is crucial.
4. Flexor tendon grafting is indicated for injuries with segment
This document discusses tendon anatomy, injury, and repair. It describes the composition and vascular supply of tendons. Common tendon injuries include open wounds requiring surgical repair and closed injuries causing deformities. The goals of repair are to reestablish tendon continuity and gliding function. Various suture techniques are discussed for end-to-end, end-to-side, and tendon-to-bone repairs. Post-operative rehabilitation aims to promote intrinsic healing while minimizing scarring through early controlled motion to optimize tendon gliding and range of motion recovery.
Modified sauve kapandji procedure for patients with old fracturesPonnilavan Ponz
The document discusses a study evaluating the clinical and radiographic outcomes of a modified Sauve-Kapandji procedure for patients with old fractures of the distal radius. The modified procedure involves resection and reinsertion of the distal ulna into the distal radius after a 90-degree rotation. The study reviewed 15 patients who underwent the procedure with at least 7 months of follow up. Results found 80% of patients had excellent outcomes with reduced pain, improved range of motion, and grip strength. The modified Sauve-Kapandji procedure provides an effective treatment for chronic distal radioulnar joint disorders in patients with old distal radius fractures.
This document discusses radial nerve palsy and tendon transfers to restore function after radial nerve injury. It begins by describing the anatomy and functions of the radial nerve. Radial nerve palsy results in loss of wrist, finger, and thumb extension. Tendon transfers can restore this function, such as using the palmaris longus tendon to restore thumb extension via transfer to the extensor pollicis longus. Post-operative rehabilitation focuses on protecting the tendon transfers during early mobilization and strengthening exercises.
The document describes claw hand, which is a deformity of the hand where the fingers are flexed into the palm at the middle knuckle. It discusses the anatomy, etiology, types, clinical signs, classification, and surgical techniques for correction. The main techniques discussed are static procedures like flexor pulley advancement and dynamic procedures using tendon transfers to restore muscle function. The goal of surgery is to maintain the middle knuckle in slight flexion to allow the extensors to straighten the fingers.
The document discusses hand injuries and their management. It covers relevant hand anatomy, types of common hand injuries including tendon injuries, fractures, and dislocations. The key principles of management are early debridement and stabilization of injuries, restoration of anatomy, and rapid mobilization. Specific techniques are described for repairing tendons, fixing fractures like Bennett's fracture, and achieving proper skeletal stabilization while preserving hand function.
This document discusses shoulder instability, including definitions, anatomy, evaluation, and treatment. It defines instability as the inability to maintain the humeral head in the glenoid fossa, ranging from dislocation to laxity. Static stabilizers include the labrum and ligaments, while dynamic stabilizers are the rotator cuff and scapulothoracic muscles. Evaluation involves history, exam, and imaging to classify instability by direction, degree, and etiology. Treatment depends on classification but may include immobilization, rehabilitation, or surgical repair of labral tears or bone defects.
This document provides information on meniscal tears of the knee. It begins with an introduction stating that meniscal tears are common injuries responsible for many arthroscopies annually. It then covers anatomy of the medial and lateral menisci, blood supply, classification of tears, mechanisms of injury, clinical features, investigations like MRI and arthroscopy, and treatment options including non-operative care, meniscectomy, and meniscal repair. The focus is on providing detailed information on meniscal anatomy, tears, and surgical and non-surgical management.
This document provides information on fractures of the distal end of the radius bone. It discusses the history, incidence, anatomy, classification, diagnosis, and treatment options for these fractures. Distal radius fractures most commonly result from falls on an outstretched hand and occur in three main age groups. Treatment depends on factors like fracture pattern and stability, and may involve closed reduction with casting or surgical options like percutaneous pinning, plating, or external fixation. The goals of treatment are to restore function, alignment, and stability while avoiding complications.
Apply gentle pressure proximally
Surgeon: Check distal pulses and capillary refill
If no improvement:
Consider temporary arteriotomy or venous shunt
Delay closure and observe
Flap or graft may be needed
Scaphoid fractures are the most common carpal bone fractures, often occurring in young adults from falls on an outstretched hand. The scaphoid has a tenuous blood supply and is prone to non-union, especially for proximal pole fractures. Treatment depends on fracture type and stability, ranging from casting to operative fixation with screws. Complications include malunion, delayed union, non-union and avascular necrosis, requiring further procedures like bone grafting or carpal fusion.
This document summarizes flexor tendon injuries and repairs. It describes tendon nutrition, zones of ischemia, tendon healing phases, factors that cause adhesions, examination techniques, and types of tendon repairs. Flexor tendon injuries are evaluated based on the location of the injury (Verdan zones I-V) and repaired accordingly. Primary repair is preferred if possible, while complications like adhesions or gap formation require techniques like tenolysis. Postoperative rehabilitation aims to restore tendon gliding and function while avoiding issues like bowstringing.
This document summarizes a seminar on flexor and extensor tendon injuries of the hand. The seminar was chaired by Prof. Dr. Kiran Kalaiah and presented by Dr. Yashavardhan.T.M. It provided an overview of tendon anatomy, classification of tendon injuries by zone, surgical techniques for repair, and postoperative rehabilitation protocols. Key points included the pulley system that guides tendon movement, zones of injury from I to V, and techniques like the six strand repair that aim to minimize complications like adhesion formation.
1. Elbow dislocations are most commonly caused by falls onto an outstretched hand and involve the disruption of the lateral and medial collateral ligaments and elbow capsule.
2. Simple elbow dislocations without fractures are typically treated non-operatively with closed manipulation and immobilization for less than 3 weeks to avoid stiffness.
3. Operative treatment is considered if closed reduction cannot be maintained or for recurrent dislocations and involves repair of the lateral collateral ligaments through bone tunnels or anchors.
This document discusses fractures of the olecranon bone. It begins with the epidemiology, noting these fractures have a bimodal distribution in younger individuals due to high-energy trauma and older individuals due to simple falls. The anatomy section outlines the subcutaneous position of the olecranon making it vulnerable to trauma, as well as its articulation with the elbow joint. Clinical presentation, evaluation, classification systems, treatment objectives, nonoperative and operative treatment options including various surgical techniques are then covered in detail.
Ligamentotaxis principle in the treatment of intra articular fractures of dis...Sitanshu Barik
This study assessed the correlation between radiological outcomes and functional outcomes in 45 patients treated with external fixation for intra-articular fractures of the distal radius. Good or acceptable restoration of radial length and palmar slope on radiographs post-operatively was found to produce good to excellent functional results regardless of fracture type. While poor radiological outcomes did not always lead to poor function, maintenance of radial length and correction of palmar tilt were important for functional outcomes. The study concluded that achieving good function is more important than surgical precision on radiographs alone.
This document discusses current trends in the management of spasticity in hemiplegic patients. It defines spasticity as a velocity-dependent increase in muscle tone caused by damage to the central nervous system. Spasticity can range from mild muscle stiffness to severe, painful muscle spasms. If left untreated, spasticity may lead to muscle contractures, deformities, and other complications. Common treatments discussed include oral medications, botulinum toxin injections, physical therapy, and the modified Ashworth scale for assessing spasticity severity.
This is a presentation I did for the OTAT program at Cuyahoga Community College on flexor and extensor tendon lacerations. I also discuss, briefly, the application of certain aspects of occupational therapy's domain as outlined in the OTPF. I collected data from scholarly as well as non-scholarly resources. I hope you find this to be helpful.
A 30-year old female presented to the emergency room with a laceration and bleeding in her right hand after falling on glass. She was right hand dominant and worked in telemarketing. Physical examination would focus on the extent of the laceration and potential injury to flexor tendons and nerves. Flexor tendon injuries can lead to loss of finger flexion and grip strength if not repaired properly. The goals of reconstruction are to anatomically repair the tendons with limited motion restrictions and adhere to post-operative rehabilitation to regain function and prevent complications like adhesions.
Hand Therapy Rehabilitation – Extensor TendonsLynne Pringle
This document discusses hand therapy rehabilitation for extensor tendons. It outlines key principles including patient education, wound healing, splinting techniques, and continuous evaluation. Static splinting is compared to dynamic/mobilizing splints. Different zones of the hand require specific splinting protocols to balance rest and range of motion. The goal of treatment is to achieve functional balance and allow full flexion while stabilizing the hand.
This document provides an overview of the anatomy of the extensor apparatus of the hand and deformities that can result from injuries at various levels. It describes the intrinsic and extrinsic muscles, variations in anatomy, and deformities that can occur from injuries in different zones. Zone 1 injuries over the DIP joint can cause mallet finger. Zone 3 injuries can disrupt the central slip leading to boutonniere deformity. Chronic conditions like swan neck deformity can develop from synovitis at various joints causing attenuation of structures.
The document discusses various types of skin grafts and flaps used in orthopedics. It describes split thickness skin grafts which contain part of the epidermis and dermis and are useful for covering defects when the area is too wide for a full thickness graft. It also discusses axial pattern flaps which contain a direct cutaneous artery and allow coverage of the hand while preserving movement. Local flaps are preferred over distant flaps when possible due to better color and texture matching and reduced risk of complications.
This document discusses different types of flaps used in plastic surgery for tissue reconstruction. It begins by explaining that flaps are vascularized tissue transferred from one part of the body to another to reconstruct areas of tissue loss. The document then categorizes flaps based on their components, configuration, congruity, circulation, and conditioning. It provides examples of various local, regional, pedicled, and free flaps. Key advantages and disadvantages of different flap types are highlighted. Monitoring techniques and potential complications of flap surgery are also summarized.
This document provides an overview of spasticity, including:
- Definitions and descriptions of spasticity and the underlying pathophysiology.
- Common causes of spasticity like cerebral palsy, stroke, multiple sclerosis, and spinal cord injury.
- Methods for assessing spasticity severity, including the Ashworth scale and pendulum tests.
- Goals and approaches for managing spasticity, which may involve eliminating triggers, non-pharmacological interventions, medications, and occasionally surgery.
This document discusses flexor tendon injuries and their treatment. It begins with an overview of flexor tendon anatomy, morphology, zones of injury, and the challenges of repair. It then describes techniques for clinical evaluation, including testing of the flexor digitorum profundus and superficialis tendons. Principles of flexor tendon repair are outlined, including approaches for zone 1 and zone 2 injuries. Core suture techniques like the Kessler and Tajima methods are explained. Post-repair management considers risks of adhesion formation and importance of early motion.
Jc flexor tendon injury, repair & rehabilitaionLove2jaipal
Flexor tendon injuries require careful surgical repair and rehabilitation to achieve a successful outcome. The anatomy of the flexor tendons and their blood supply is complex. A thorough patient evaluation including examination of each tendon is important for diagnosis and treatment planning. Various suture techniques exist for flexor tendon repair, with the goal of reapproximating the tendon ends while minimizing gaps and damage to the tendon vascularity. Proper suture material selection and postoperative rehabilitation are also crucial factors.
Flexor tendon injury final edit with picturesGautam Kalra
This document discusses flexor tendon injuries and their management. It covers the anatomy of flexor tendons and pulley system, zones of injury, tendon healing process, and approaches to repairing different types of injuries. For zone I injuries of the finger, which involve a single tendon in the osteofacial tunnel, the document recommends end-to-end repair if sufficient length is available, or transosseous techniques if the stump is too short. Avulsion injuries are classified and recommendations are given for repair timing based on the classification and presence of the vincular system.
This document summarizes a seminar presentation on flexor and extensor tendon injuries of the hand. It begins with an introduction to tendon anatomy and zones of injury. It then describes the specific anatomy and function of flexor and extensor tendons. Flexor tendon injuries are discussed based on their zone of injury, with details on clinical examination, repair techniques, and postoperative rehabilitation protocols. Complications and the use of tendon grafts are also summarized. The document concludes with sections on extensor tendon anatomy, testing, and associated structures like the sagittal bands.
The document provides an overview of hand anatomy including terminology, skin, fascia, muscles, tendons, bones, joints, nerves and vasculature. Key points include descriptions of various hand incisions and their purposes, fascial layers and spaces of the hand, flexor tendon anatomy and zones of injury, and anatomy of important muscles like the thenar and hypothenar muscles. The document covers the detailed functional anatomy of the hand.
Detailed Hand surgical anatomy by mohamed abdelhadyMohamed Abdelhady
Detailed Hand surgical anatomy including bones , blood and nerve supply and special structures eg flexor retiniculum , extensor compartments and anatomical snaff box
Tendon injuries of the hand can occur in different zones. Flexor tendon injuries are divided into 5 zones and extensor tendon injuries into 8 zones based on anatomical locations. Flexor tendon injuries require careful surgical repair and postoperative rehabilitation to prevent complications like adhesion and contracture. The timing of repair, surgical technique including suture type and post-operative mobilization protocol depends on the zone of injury. Proper management can restore tendon gliding and hand function.
Hand 2009 (2) Questions Included Not To PostPam Kasyan
The document summarizes the anatomy of the hand including bones, joints, muscles, nerves and common clinical tests. It describes 19 bones, 29 articulations and the intrinsic and extrinsic muscles. It outlines the median, ulnar and radial nerves, their points of entrapment and resulting clinical presentations such as carpal tunnel syndrome. Common hand disorders like tendon injuries and nerve palsies are also summarized.
The document describes the anatomy and pathologies of the finger extensor mechanism. It details the anatomy of the extrinsic and intrinsic tendons that provide extension to the finger joints. It then discusses several common deformities that can result from injuries or imbalances in the extensor mechanism, including Boutonniere deformity, Swan neck deformity, Mallet finger, and Jersey finger. For each, it provides descriptions of the mechanism of injury, clinical presentation, classification systems, and general treatment approaches.
The document describes the anatomy of the extensor apparatus of the hand and fingers and deformities that can result from injuries at various levels. It discusses the extrinsic and intrinsic muscles, tendons, and their anatomy at the wrist, hand, and digit levels. Acute and chronic injuries are described for each zone, along with classification systems and treatment options depending on the extent of injury and chronicity. Surgical exploration and repair is often needed for open or complete tendon lacerations to properly identify the injury and restore extension.
Dr. Gavinash Rao presented on the history and techniques of tendon reconstruction. The history of tendon repair before 1960 primarily involved single-stage free tendon grafting. In the 1960s, two-stage reconstruction using silicone implants was developed. Currently, the Hunter technique uses a silicone rod implant in the first stage followed by tendon grafting in the second stage. Primary tendon repair is preferred if possible, while reconstruction uses tendon grafts from the palmaris longus, plantaris, or toe extensors. Complications can include adhesions, implant failure, and joint contractures.
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
New microsoft office power point presentationPRIYAPRAJEESH
This document discusses reconstructive surgeries for leprosy, including procedures for foot drop, claw hand, lagophthalmos, and soft tissue reconstruction. Key surgeries mentioned are posterior tibial tendon transfer for foot drop, Zancolli lasso procedure for claw hand, temporalis muscle transfer for lagophthalmos, and various flap procedures for soft tissue defects. Post-operative care including physiotherapy is emphasized for successful outcomes. Hospitals performing reconstructive surgeries for leprosy in India are also listed.
The document describes the anatomy of the deep fascia and muscles of the wrist and hand. It discusses the flexor and extensor retinaculae which hold the long flexor and extensor tendons at the wrist. It describes the structures passing through the carpal tunnel including the median nerve. It discusses the palmar aponeurosis and small muscles of the hand including their origins, insertions, actions and nerve supplies.
This document provides an overview of the anatomy of the hand, including:
- Surface anatomy and bony landmarks of the hand and wrist
- Compartments and spaces of the hand, including the palmar aponeurosis and flexor retinaculum
- Intrinsic muscles of the hand grouped into thenar, hypothenar, lumbrical and interossei muscles
- Arterial arches including the superficial and deep palmar arches
- Nerve innervation including the median, ulnar and radial nerves
- Clinical concerns involving the hand like carpal tunnel syndrome and De Quervain's tenosynovitis are also discussed.
Zone 1 injuries refer to injuries distal to the insertion of the flexor digitorum superficialis tendon. The document discusses the anatomy of the flexor tendons, examination of zone 1 injuries, considerations for repair, techniques for tendon-to-bone repair or primary repair, postoperative rehabilitation, and complications. Key points are that zone 1 injuries are best treated early with direct tendon repair if there is over 1cm of tendon, tendon repair must be securely seated in the bone footprint, and rehabilitation follows a graded protocol to prevent tendon complications.
The document summarizes key anatomical features of the palmar aspect of the wrist and hand. It describes the skin, fascia, and muscles of the palm including the thenar and hypothenar muscles. It discusses the flexor retinaculum, palmar aponeurosis, and fibrous flexor sheaths. It also provides details on the intrinsic hand muscles and blood vessels including the superficial and deep palmar arches formed by the ulnar and radial arteries. Clinical anatomy of Dupuytren's contracture is also mentioned.
The use of Nauplii and metanauplii artemia in aquaculture (brine shrimp).pptxMAGOTI ERNEST
Although Artemia has been known to man for centuries, its use as a food for the culture of larval organisms apparently began only in the 1930s, when several investigators found that it made an excellent food for newly hatched fish larvae (Litvinenko et al., 2023). As aquaculture developed in the 1960s and ‘70s, the use of Artemia also became more widespread, due both to its convenience and to its nutritional value for larval organisms (Arenas-Pardo et al., 2024). The fact that Artemia dormant cysts can be stored for long periods in cans, and then used as an off-the-shelf food requiring only 24 h of incubation makes them the most convenient, least labor-intensive, live food available for aquaculture (Sorgeloos & Roubach, 2021). The nutritional value of Artemia, especially for marine organisms, is not constant, but varies both geographically and temporally. During the last decade, however, both the causes of Artemia nutritional variability and methods to improve poorquality Artemia have been identified (Loufi et al., 2024).
Brine shrimp (Artemia spp.) are used in marine aquaculture worldwide. Annually, more than 2,000 metric tons of dry cysts are used for cultivation of fish, crustacean, and shellfish larva. Brine shrimp are important to aquaculture because newly hatched brine shrimp nauplii (larvae) provide a food source for many fish fry (Mozanzadeh et al., 2021). Culture and harvesting of brine shrimp eggs represents another aspect of the aquaculture industry. Nauplii and metanauplii of Artemia, commonly known as brine shrimp, play a crucial role in aquaculture due to their nutritional value and suitability as live feed for many aquatic species, particularly in larval stages (Sorgeloos & Roubach, 2021).
The binding of cosmological structures by massless topological defectsSérgio Sacani
Assuming spherical symmetry and weak field, it is shown that if one solves the Poisson equation or the Einstein field
equations sourced by a topological defect, i.e. a singularity of a very specific form, the result is a localized gravitational
field capable of driving flat rotation (i.e. Keplerian circular orbits at a constant speed for all radii) of test masses on a thin
spherical shell without any underlying mass. Moreover, a large-scale structure which exploits this solution by assembling
concentrically a number of such topological defects can establish a flat stellar or galactic rotation curve, and can also deflect
light in the same manner as an equipotential (isothermal) sphere. Thus, the need for dark matter or modified gravity theory is
mitigated, at least in part.
BREEDING METHODS FOR DISEASE RESISTANCE.pptxRASHMI M G
Plant breeding for disease resistance is a strategy to reduce crop losses caused by disease. Plants have an innate immune system that allows them to recognize pathogens and provide resistance. However, breeding for long-lasting resistance often involves combining multiple resistance genes
Or: Beyond linear.
Abstract: Equivariant neural networks are neural networks that incorporate symmetries. The nonlinear activation functions in these networks result in interesting nonlinear equivariant maps between simple representations, and motivate the key player of this talk: piecewise linear representation theory.
Disclaimer: No one is perfect, so please mind that there might be mistakes and typos.
dtubbenhauer@gmail.com
Corrected slides: dtubbenhauer.com/talks.html
The ability to recreate computational results with minimal effort and actionable metrics provides a solid foundation for scientific research and software development. When people can replicate an analysis at the touch of a button using open-source software, open data, and methods to assess and compare proposals, it significantly eases verification of results, engagement with a diverse range of contributors, and progress. However, we have yet to fully achieve this; there are still many sociotechnical frictions.
Inspired by David Donoho's vision, this talk aims to revisit the three crucial pillars of frictionless reproducibility (data sharing, code sharing, and competitive challenges) with the perspective of deep software variability.
Our observation is that multiple layers — hardware, operating systems, third-party libraries, software versions, input data, compile-time options, and parameters — are subject to variability that exacerbates frictions but is also essential for achieving robust, generalizable results and fostering innovation. I will first review the literature, providing evidence of how the complex variability interactions across these layers affect qualitative and quantitative software properties, thereby complicating the reproduction and replication of scientific studies in various fields.
I will then present some software engineering and AI techniques that can support the strategic exploration of variability spaces. These include the use of abstractions and models (e.g., feature models), sampling strategies (e.g., uniform, random), cost-effective measurements (e.g., incremental build of software configurations), and dimensionality reduction methods (e.g., transfer learning, feature selection, software debloating).
I will finally argue that deep variability is both the problem and solution of frictionless reproducibility, calling the software science community to develop new methods and tools to manage variability and foster reproducibility in software systems.
Exposé invité Journées Nationales du GDR GPL 2024
ESPP presentation to EU Waste Water Network, 4th June 2024 “EU policies driving nutrient removal and recycling
and the revised UWWTD (Urban Waste Water Treatment Directive)”
Phenomics assisted breeding in crop improvementIshaGoswami9
As the population is increasing and will reach about 9 billion upto 2050. Also due to climate change, it is difficult to meet the food requirement of such a large population. Facing the challenges presented by resource shortages, climate
change, and increasing global population, crop yield and quality need to be improved in a sustainable way over the coming decades. Genetic improvement by breeding is the best way to increase crop productivity. With the rapid progression of functional
genomics, an increasing number of crop genomes have been sequenced and dozens of genes influencing key agronomic traits have been identified. However, current genome sequence information has not been adequately exploited for understanding
the complex characteristics of multiple gene, owing to a lack of crop phenotypic data. Efficient, automatic, and accurate technologies and platforms that can capture phenotypic data that can
be linked to genomics information for crop improvement at all growth stages have become as important as genotyping. Thus,
high-throughput phenotyping has become the major bottleneck restricting crop breeding. Plant phenomics has been defined as the high-throughput, accurate acquisition and analysis of multi-dimensional phenotypes
during crop growing stages at the organism level, including the cell, tissue, organ, individual plant, plot, and field levels. With the rapid development of novel sensors, imaging technology,
and analysis methods, numerous infrastructure platforms have been developed for phenotyping.
hematic appreciation test is a psychological assessment tool used to measure an individual's appreciation and understanding of specific themes or topics. This test helps to evaluate an individual's ability to connect different ideas and concepts within a given theme, as well as their overall comprehension and interpretation skills. The results of the test can provide valuable insights into an individual's cognitive abilities, creativity, and critical thinking skills
Current Ms word generated power point presentation covers major details about the micronuclei test. It's significance and assays to conduct it. It is used to detect the micronuclei formation inside the cells of nearly every multicellular organism. It's formation takes place during chromosomal sepration at metaphase.
6. FDP and FDS tendons have
fibrous sheaths on the palmar
aspect of the digits
Extent:ant to MCPJ to the distal
phalanges;
Fibrous arches and cruciate
(cross-shaped) ligaments, which
are attached posteriorly to the
margins of the phalanges and to
the palmar ligaments
hold the tendons to the bony
plane and prevent the tendons
from bowing when the digits are
flexed.
the tendons are surrounded by a
synovial sheath.
7. EXTENSOR HOODS
ED and EPL tendons expand
over the proximal phalanges to
form complex 'extensor hoods'
or 'dorsal digital expansions' .
EDM,EIP and EPB endons join
these hoods.
triangular in shape, with: the
apex attached to the distal
phalanx;
the central region attached to
the middle phalanx
base wrapped around the sides
of the MCPJ and corners attach
mainly to the deep transverse
metacarpal ligaments
8. EXTENSOR HOODS
The lumbrical, interossei,
and abductor digiti minimi
muscles attach to the
extensor hoods.
In the thumb, the
adductor pollicis and
abductor pollicis brevis
muscles insert into and
anchor the extensor hood.
14. BASIC PRINCIPLES (Sterling Bunnell)
Exact knowledge of pertinent anatomy and
physiology
Sound clinical judgment
Strict atraumatic surgical technique
“No Man’s Land” – Area within digital flexor sheath,
advised not to repair tendon injuries in this zone
15. DILEMMA
Despite modern advances, good results after flexor
tendon repair are not uniformly obtained.
Should both tendons be repaired or just the FDP?
Should the sheath be excised or repaired?
What type of sutures should be utilized?
What type of postoperative motion most beneficial?
16. ANATOMY
The tendons of the nine
digital flexors enter the
proximal aspect of the carpal
tunnel in a fairly constant
relationship.
The most superficial tendons
are the FDS tendons to the
long and ring fingers.
Immediately beneath them
are the FDS tendons to the
index and little fingers.
In the deepest layer are four
tendons of the FDP and the
FPL.
17. Anatomy
Flexor tendon system consists of intrinsic and
extrinsic components
Extrinsics:
FDP: flexing the DIP joint
FDS: Flexing the PIP Joint
FPL: Flexing the IP joint of the thumb
Intrinsics:
Lumbricals: Flex the MCP joints and Extend the IP
joints
18. FDP inserts on
base of distal
phalanx
FDS inserts on
sides of middle
phalanx
FPL inserts on
proximal portion
of the distal
phalanx
19. GOAL
Primary repair of injured flexor tendons within
the digital sheath is currently accepted.
Despite Modern advances, good results following
flexor tendon repair is not uniformly obtained.
Control the inevitable scar formation that interferes
with the beautiful gliding mechanism within the
flexor tendon system
20. FLEXOR TENDONS
FDP and FDS tendons fibrous
sheaths on the palmar aspect of
the digits
Extent:ant to MCPJ to the distal
phalanges;
Fibrous arches and cruciate
(cross-shaped) ligaments, which
are attached posteriorly to the
margins of the phalanges and to
the palmar ligaments
hold the tendons to the bony
plane and prevent the tendons
from bowing when the digits are
flexed.
the tendons are surrounded by a
synovial sheath.
21. Synovial sheath is reinforced by a
system of fibrous pulleys
5 annular pulleys (A) and
3 Cruciform pulleys (C)
A1: 8-10 mm over MCPJ
A2: 18-20mm over proximal phalanx
A3: 2-4 mm over PIPJ
A4: 10-12mm over middle phalanx
A5: 2-4 mm over DIPJ
C1, C2, C3 proximal to A3, A4, A5
Allow shortening of the pulley system in flexion
A2 and A4 are considered most important.
Their disruption leads to bowstringing,
reduced mechanical efficiency and decreased
flexion.
24. ZONES OF FLEXOR TENDON INJURY
Zone I: Between insertion of FDP
and FDS
Zone II: From insertion of FDS to
A1 Pulley
Zone III: Between A1 pulley and
distal limit of carpal tunnel
Zone IV: Within the carpal tunnel
Zone V: Between the entrance of
Carpal tunnel and musculo-
tendinous junction.
Thumb zones:
I: Distal to IPJ
II: from A1 to IPJ
III: Thenar eminence
25. Zone V
The Flexor tendons start
in the distal third of the
forearm at the
musculotendinous
junction
The superficialis group
lies palmar to the
conjoined profundus
tendon group covered
by loose subcutaneous
tissue and skin.
26. Zone IV
FPL and FDM enters its
continuous sheath
which becomes the
radial and ulnar bursae.
The FDS and the FDP
also enter a large sheath
and lie in the carpal
tunnell
28. Zone II
The flexor synovial
sheath begins at the
neck of the metacarpal.
The sheath is a double-
wall hallow sealed at
both ends
FDS is in a single layer
volar to FDP
Each Tendon splits that
diverges and wraps
around FDP
29. Synovium membrane
of the flexor tendon
consists of two layers:
Visceral layer: around
the structure within
the sheath
Parietal layer: covers
internal aspect of the
pulley system
30. FIBRO-OSSEOUS SHEATH
Allows smooth gliding of the tendon
Facilitates nutrition to the tendon by synovial
diffusion
Tendons are enclosed within this sheath and was
defined as “No Man’s Land”, because of the generally
worse outcome associated with this repair.
31. CAMPER’S CHIASMA
In each finger, the FDS
tendon enters the A1 pulley
and divides into two equal
halves that rotate laterally
and then dorsally.
The two slips rejoin deep to
the FDP tendon over the
distal aspect of the proximal
phalanx and the palmar plate
of the PIP joint at Camper's
chiasma
Insert as two separate slips
on the volar aspect of the
middle phalanx.
32. Nutrition in Z2
Dual Source:
Vascular
Synovial diffusion
Vascular: Segmental
vessels arising from the
paratenon enter the
tendons and travel
longitudinally between
the fasicles.
33. Vincular System
Flexor tendon receives
blood supply within the
tendon sheath
Each tendon is supplied by
a short Vinculum
(Vinculum Breve) and a
long Vinculum
(Vinculum Longus
VBP arises from distal transverse
digital artery at DIP
VBS & VLP from Central Transverse
digital artery at PIP
VLS arises just distal to MCP from
proximal transverse digital artery
34. NUTRITION
In summary
In distal forearm and palm: Perfusion
from longitudinally oriented vessels
over the paratenon
Within the digital sheath: Dual source
of nutrition:
Synovial fluid diffusion
Vincular system
Diffusion is more important than
perfusion
35. TENDON HEALING
Tendons are capable of actively participating in
the repair process through Intrinsic Healing
Intrinsic Tendon healing occurs in three
phases:
Inflammation
Active repair
Remodeling
36.
37. Early tendon motion has significant role in
modifying the repair response
Mobilized tendons showed progressively greater
ultimate load compared with immobilized tendons
Studies confirm “Wolff’s law” which states that the
strength of a healing tendon is proportional to the
controlled stress applied to it
38. BASIC PRINCIPLES OF REPAIR
All flexor tendon repairs should be done in the OR
Use of either general or axillary block
Use tourniquet unless contraindicated
Cleanse and debride the wound
39. POST OPERATIVE THERAPY
Critical part of treatment for flexor tendon repair
Early passive-motion protocols
Early Active motion
40. EARLY PASSIVE-MOTION PROTOCOLS
Dorsal blocking splint to maintain wrist and MCP in flexion
and block extension
Kleinert protocol uses rubber bands to maintain digital
flexion while allowing active extension
Extrinsic flexors are relaxed during active extension
Active extension moves the repaired tendon without
resistance
When the extensors are
relaxed,fingers are pulled back
in flexion by the rubber bands
4-5 weeks active flexion
8 weeks resisted flexion
41. Early Active Motion
Early Active motion
is used with
increasing frequency
This protocol
requires experience
Therapist
Surgeon
Reliable patient
Strong tendon repair
42. Ideal tendon repair:
Easy placement of sutures in the
tendon
Secure suture knots
Smooth junction of tendon ends
without gapping
Minimal interference with vascularity
strength
43. TECHNIQUES
Retrieve the tendon ends
through the sheath in an
atraumatic manner
Maintain the integrity of
the pulley system
(especially A2 and A4)
Create “retinacular
window” described by
Lister for preserving the
flexor sheath
44. TECHNIQUES
Extend the original
laceration for better
exposure
Zigzag
Midlateral
Avoid linear scars that
cross flexion crease
45. Milk the forearm with the wrist and MCP in flexion
Do not attempt blind retrieval more than twice
Make a separate incision if necessary
Use a pediatric feeding
tube to retrieve tendon
stump
46. Suture Technique
Suture material
Non reactive
Pliable
Small caliber
Strong
Easy to handle
Common material: Ethibond, Nylon, proline
47. The strength of the tendon repair is
proportional to the number of core
sutures that cross the tenorrhaphy site.
6-0 proline epitendinous suture is added
“tidy up” the repair
Contributes to the strength of the repair
59. Tendon Sheath Repair?
Role of diffusion of nutrients from synovial fluid
Tendon within the sheath have an intrinsic capacity
for healing
Gelberman and woo in 1990 study on dogs
Reconstruction of the sheath did not significantly
improve repaired tendons treated with early motion
rehabilitation.
60. Partial Tendon Laceration
Rupture, entrapment, triggering
Partial laceration involving 60% or less
are best treated by early mobilization
WITHOUT tenorrhaphy
61. Profundus Tendon Avulsion
Avulsion of FDP from
its insertion by forced
hyperextension
Most common in the
ring finger
Leddy and Parker
classification
Based on the level to
which the tendon
retracts
Status of the tendon
vascular anatomy
62. Type I
Profundus has
retracted proximally
into the palm
Surgery should be
done in 7-10 days
before a fixed
muscular
contracture develops
Least common
63. Distal digital exposure to
confirm diagnosis
In Type I, a second distal
palm incision will be
needed
Tendon is reinserted into
the base of distal phalanx
Distally based periosteal
flap is raised distal to volar
plate
Tendon is sutured through
drill holes in the distal
phalanx and button tied
over the nail plate
64. Maintain flexion of the wrist and MCPJ in a dorsal
blocking splint
Begin early passive motion
Active motion in 3-4 weeks
65. Type II
Profundus retracts to PIP
Disruption of Vinculum
Breve
Nutrition is maintained by
Vinculum longum
May be repaired up to 3
months
Delay may convert type II
into a type I if longum
subsequently ruptures
66. Type III
Attached bone
fragment that
fractures off the
volar base of distal
phalanx
A4 pulley prevents
proximal retraction
Both Vinculae are
preserved
69. COMPLICATIONS
Short term:
Infection
Injury to
neurovascular
structures or
pulley system
Abnormal scarring
Long term:
Adhesion
Rupture
Joint contracture
triggering
70. Complications
Adhesion
Most common complication despite early
motion protocols
Tenolysis when patients progressive gain
in digital motion has plateaued, usually 3-
6 months after repair
71. Tendon Rupture
Noted by the patient at “popping” in the
hand
7-10 days postop when tensile strength is
weakest
MRI may help in diagnosis
Flexion contracture
FDP advancement more than 1 cm may
lead to flexion contracture and weakened
hand grip because of quadrigia effect
72. Flexion contracture
FDP advancement
more than 1 cm
may lead to flexion
contracture and
weakened hand
grip because of
quadrigia effect
73. Quadriga effect
Over advancement of the
FDP
- weak grasp in
remaining fingers due to
FDP tethering;
- if one FDP is
tethered, the others can
not shorten;
- there is loss of
flexion in other digits and
patient may be unable to
make a full fist
76. Indications:
Primary repair is not possible
Segmental loss
Loss of the pulley system
Compromised wound
Delayed diagnosis
Scarring and rupture
77. Consideration for flexor
tendon reconstruction
Boyes’ grading scale of
flexor tendon injury
provides a guideline in
determining the
achievable outcome
after flexion tendon
reconstruction
78. The position of the digit to be reconstructed should
be considered
Ulnar ring and small digits need complete flexion to
provide strong grip
Full flexion of radial digits are less important because
they are used for precision pinch
Full flexion of the thumb is less important than providing
a stable and sensate thumb with adequate length
79. Prerequisite for flexor tendon reconstruction
Adequate soft tissue coverage
Digital vascularity
Healed fractures
Passively supple joints
Return of sensibility
80. Reconstruction
Modalities
Tenolysis
Tendon advancement
Tendon transfer
Tendon grafts with or
without creation of
artificial tendon sheath
by silicon rod
implantation
Alternatives
Amputation
Joint fusion
Tenodesis
Caspulodesis
81. Tendon grafting
Used when injury has resulted in a tendon gap
Can be carried out in one or two stages
One stage
Acute trauma: segment of flexor tendon lost in a clean,
vascularized wound with intact pulley
Tenolysis: when tendon is deemed inadequate to permit
immediate postoperative motion
82. TWO STAGE
Direct repair is not possible
Scarred tendon bed in which primary
tendon grafting has a low chance of
gliding
Reconstruction of profundus tendon
when sublimis is intact and there are
existing scars
83. Two stage technique
Create a supple pseudosynovial sheath
by implanting a silicone rod
Soft tissue coverage or pulley
reconstruction is performed at the first
stage
8 weeks later, when psuedosynovial
sheath is formed, the rod is replaced by
a tendon graft
84. Palmaris longus and
plantaris
Tendon grafts that
include synovial sheath
Toe extensors
Other donors
EDC to index,
EDL to 2nd, 3rd and 4th
toes,
EIP /EDQ
87. Tension adjustment
Proximal weave is adjusted
Wrist is extended to flex
the fingers into the cascade
of the hand
Overcorrect slightly
because some stretching
occurs after surgery
88. PULLEY RECONSTRUCTION
Must be done during the first stage
Well-healed pulley reconstruction facilitates early
mobilization and gliding of tendon graft
Reconstruction during the second stage increases the
likelihood of pulley rupture and adhesion formation
Material used
Autogenous grafts: PL, Plantaris, to extensors, EIP,
Extensor retinaculum, fascia lata
93. Finger Extensors
EDC has a common muscle belly with
multiple tendons
EIP & EDM lie on the ulnar side of the
respective EDC tendon
94. Thumb Extensors
APL inserts on the
metacarpal and
radially abducts it
EPB inserts on
proximal phalanx and
extends MCP Joint
EPL inserts on distal
phalanx and extends
IP Joint
95. Testing the Extrinsics
APL:Palpate with thumb abduction
EPB:MP extension with IP flexion,
palpate tendon
EPL:Palpate tendon with
retropulsed thumb
EDC:Test with wrist in
neutral-extension
100. EDC tendon trifurcates into
central slip & 2 lateral slips
Intrinsic extensor
tendons join the lateral
slips to form the lateral
bands
Extensor Apparatus
106. ANATOMICAL PATTERNS OF THE
EXTENSORS TO THE FINGERS
The most common
patterns
single extensor indicis
proprius inserting to the
ulnar side of the index
extensor digitorum
communis
a single extensor
digitorum communis to
the index finger
,
a single extensor
digitorum communis to
the long finger,
a double extensor
digitorum communis to
the ring finger,
an absent extensor
digitorum communis to
the small
finger, and a double
extensor digiti quinti with
double insertions.
,
107. JUNCTURAE TENDINIUM
Functional roles:
• spacing of ED tendons
• force redistribution
• coordinate extension
• MP stabilization
Ring finger has least independent extension due to
the orientation of the juncturae
109. Sagittal Bands
Stabilize the common
extensor during digital
flexion over MCPJ
Limit the excursion of
the common extensor
tendon during digital
extension
110. Sagittal bands
EDC allows extension of
MP joint via insertion
onto the sagittal bands
There is usually no
tendinous insertion of
EDC to the dorsal base of
the proximal phalanx.
111. No MP joint
hyperextension: EDC
extends MP, PIP, and DIP
joints even in the
absence of intrinsic
muscle function.
112. INTRINSIC PARALYSIS:
“slack” develops in EDC
system distal to the
sagittal bands all
producing a flexion
posture at PIP and DIP
joints, the “claw” finger.
116. 1
6
5
4
2
3
PIP Joint
• Limits the volar and
lateral shifting of the
lateral conjoined
extensor tendon during
digital flexion
• In boutonniere
deformity elongated
• In fixed swan neck
deformity retracted
117. Retinacular Ligament
Transverse bands:
Lateral continuation of
the triangular ligament
extending from the
lateral margin of the
lateral conjoined
extensor tendon to PIPJ
articular volar plate
127. Doyle[25] proposed the following techniques for extensor tendon repair:
Zone 1 (DIP joint): Running suture incorporating skin and tendon.
Zone 2 (middle phalanx): Running 5-0 stitch near cut edge of tendon,
completed with “basket-weave” or “Chinese fingertrap” type of cross-
stitch on the dorsal surface of the tendon .
Zones 3 through 5 in fingers, and zones 2 and 3 in thumb: Modified
Kessler suture of 4-0 synthetic material in the thickest portion of the
tendon. A 5-0 cross-stitch tied to itself at the beginning and end is run on
the dorsal surface of the tendon
Zones 6 and 7: Same as for zones 3 through 5 except the cross-stitch is run
around the entire circumference of the tendon, if feasible
129. Mallet Finger
Due to disruption of terminal tendon
Caused by forced flexion,
hyperextension or torsion
Can result in 20 Swan Neck Deformity
Early or late volar subluxation of DIP
131. Mallet Finger
Classification - Lange & Engber
I. Extensor tendon injury
a. rupture/attenuation
b. laceration
II. Extensor avulsion
III. Mallet #
a. transepiphyseal # of children
b. hyperextension mallet without
subluxation
c. hyperextension mallet with subluxation
140. Zone II (P2) Injury
Usually lacerations
Result in Mallet deformity
Approximate with horizontal
loop sutures
DIP pinning or splint
Post op as in Mallet
144. Zone IV Injury
Usually partial as P1 is rounded
Not much retraction of cut ends
Repair / Splinting for 3-4 weeks or
6 wks if total laceration
145. Zone V Injury
Extensor lag usually minimal due to
incomplete injury of sagittal band
Simple Lacerations – direct repair
Extensor dislocations – pathology in the proximal
radial sagittal band. Classically involves MF
147. Treatment of Sagittal Band Injuries
Conservative
volar splint, cast, buddy taping for 4-6 wks. Results
satisfactory when treated within 3 wks
Surgical
centralization of tendon by repair or reconstruction
of the radial band
148. Composite Tissue loss in Zone VI
Meticulous debridement and Flap cover with primary /
secondary extensor reconstruction
Staged reconstruction with free flaps, silicon tendon
implants followed by ext grafts
Single stage primary bone + tendon graft + free flaps
Dorsalis pedis tendocutaneous flap
149. Zone VII Injury
Area under the retinaculum with
6 compartments
Problem of retraction, tendon
adhesion, bowstringing due to
injury to the retinaculum
Closed tendon ruptures are also seen in this zone
150. Closed tendon ruptures of EPL, EDC mainly
reported with Colles’ #, Smith #, Galeazzi #, ulnar
subluxn, Madelung deformity, distal ulna excision,
Keinbocks
Proposed to be due to avascular necrosis of the
tendon, attrition
Treated by tendon transfers (preferably EIP) or
grafting
Zone VII Injury
151. Zone VIII Injuries
Usually multiple tendons are
affected
Repair at the musculotendinous
junctions are difficult
Associated nerve injuries must be identified
152. Thumb Tendons
Mallet thumb rare
EPB anomalies commonplace
Delayed rupture of EPL may follow fractures
eg. Colles, Galleazi, Smith’s, Madelung’s
deformity
EPL repair pitfalls
retraction - may require re-routing
153. Injury to Thumb Extensor
Zone I and II
Mallet injuries are rare
Operative treatment is a good option
esp in open lacerations
Zone V – VII
MCP area is designated zone V
Extensor lag usually minimal
Proximal to zone V, EPL retracts far
Repair >1mo requires rerouting EPL from Listers
tubercle
154. Long term results
60% has associated injuries
Excellent or good results in 62% (TAM –89% or
2300 ) when not associated with other injuries
45% (TAM 82% or 2120) when associated with
other injuries
Distal zones (I-IV) results less favorable
Loss of flexion is the most significant
complication
155. Summary
Extension of digits is an intricate and complex
mechanism
Extensor tendon injuries are common
Loss of flexion is significant
The deformity depends on the zone of injury
156. Summary
Zone III/IV injury has a poorer result
Associated injury to joint, bone etc results in
poorer results
EPM and EAM gives better results