5. Physical eXam
Left HAND
Cut wound size 2 cm at base of left index finger with active bleeding
Resting position: Left index finger in mild flexion position
Left fingers can flex and extend in full ROM
Normal tenodesis effect
Normal capillary refill time (< 2 sec)
Normal pinprick sensation
Vital Signs : BP 110/70 HR 92 RR18 BT 37
11. Extensor tendon injury
Injury can be caused by laceration, trauma, or overuse
zone VI is the most frequently injured zone
Mechanism
Zone I : forced flexion of extended DIP joint
Zone II : dorsal laceration or crush injury
Zone V
commonly from "fight bite"
sagittal band rupture ("flea flicker injury")
forced extension of flexed digit
most common in long finger
16. Physical eXam
•Zone I
•Inability to extend at the DIP joint
•Zone III
•Elson test
•flex the patient's PIP joint over a table 90 degrees and ask them to extend against
resistance
•if central slip is intact, DIP will remain supple
•if central slip disrupted, DIP will be rigid
•Zone V
•extensor lag and flexion loss common
•junctura tendinae may allow partial/temporary extension by connecting with intact adjacent
extensor tendons
17. Non operative
•immobilization with early protected motion
•indications : lacerations < 50% of tendon in all zones
if patient can extend digit against resistance
•DIP extension splinting for 6 weeks
•Indication : mallet finger type 1, 2 ,3 (no fracture)
•avoid hyperextension, which may cause skin necrosis
•maintain PIP motion
•outcomes
•noncompliance is a common problem
ZONE I
มี Tendon gap เย็บtendon skinพร้อมกัน
ไม่มีtendon gap เย็บแค่skin tendonติดเ อง
18. Non operative
•PIP extension splinting
•indications : closed central slip injury (zone III)
•techniques
•full-time splinting for six weeks
•part-time splinting for four to six weeks
•maintain DIP flexion
•MCP extension splinting
•indications : closed zone V sagittal band rupture
•techniques
•full-time splinting for four to six weeks
ZONE III
ZONE V
19. Operative •tendon repair
•indications : laceration > 50% of tendon width in all zones
•tendon reconstruction
•indications : chronic tendon injury or when repair not possible
•central slip reconstruction
•techniques
•tendon graft
•extensor turndown
•lateral band mobilization
•transverse retinacular ligament
•FDS slip
•EIP(extensor indices proprius) to EPL tendon transfer
•indications : chronic EPL rupture
ZONE III
20. Tendon Repair
incision technique
longitudinal incision may be utilized across joints, unlike the palmar side
suture technique
4-6 strands(core suture) >> adequate strength for early active motion
+/- circumferential epitendinous suture
repair failure (weakest POD 6 -12)
usually fails at knots
22. Complication
Adhesion formation >> loss of finger flexion
common in zone IV and VII and older patients
prevented with early protected ROM and dynamic splinting (zone IV)
treatment
extensor tenolysis with early motion indicated after failure of nonoperative management,
usually 3-6 months
Tendon rupture
incidence 5% most frequently during first 7 to 10 days post-op
treatment
revision repair (early recognition)
tendon reconstruction for late rupture or rupture with excessive scarring
23. Complication
Swan neck deformity
caused by prolonged DIP flexion with dorsal subluxation of lateral bands and PIP joint hyperextension
treatment
Fowler central slip tenotomy
spiral oblique ligament reconstruction
Boutonniere deformity (DIP hyperextension)
caused by central slip disruption and lateral band volar subluxation
(central slip disruped ไม่repairใน10วัน)
treatment
dynamic splinting or serial casting for maximal passive motion
terminal extensor tenotomy, PIP volar plate release
