Attempt to leave one pulley intact to prevent bowstringing. occurs when flexor tendons are located within a sheath ; it is the more important source distal to the MCP joint; direct vascular perfusion. You explore a 2 centimeter wound in zone 2 and find his flexor tendons to the index are 40% lacerated. Resection of scar and adjacent 1cm of tendon, placement of Hunter rod for staged reconstruction. When cut, the tendon acts like a rubber band, and the end pulls away from one another. Oblique pulley is more important than the A1 pulley; however both may be incised if necessary. Rest, anti-inflammatory medications and hand physiotherapy may be all that is necessary. A 34-year-old man sustains a finger flexor tendon laceration and undergoes operative repair. If a tendon becomes torn, any tension on it will create a rubber band effect and cause it to weaken. The median nerve lies immediately ulnar to which of the following structures at the level of the distal radioulnar joint? When surgery is required, a splint and hand therapy may be used after the procedure to protect you and to aid in recovery. You are seeing a 26-year-old man after he was involved in a knife fight. No epitendinous suture. If a tendon is completely ruptured or lacerated, you will not be able to bend part of your arm or hand . The DDFT is found in the horse's front and hind limbs. When a muscle contracts, or tightens, the muscles power the tendons to move our bones. Oblique pulley is more important than the A1 pulley; however both may be incised if necessary. Copyright © 2020 Lineage Medical, Inc. All rights reserved. The ability to bend our fingers to make a fist is controlled by the flexor tendon. Which of the following techniques uses the least amount of suture necessary to prevent gap formation >2mm? Flexor Tendons that have been strained may benefit from conservative treatment. 2 sources exist. Direct tendon repair. The Flexor Tendons are located on the palm side of the hand. The flexor tendons in the arm, wrist and hand are in very close proximity to nerves and arteries. Physical exam reveals a zone 2 flexor tendon laceration. Two months later, he feels a "pop" while using his hand and is no longer able to flex the distal phalanx of the involved digit. diffusion through synovial sheaths. A range of activities may cause the condition with the chief symptom being sharp pain. Even small lacerations can result in significant problems with movement if they occur in an important location. Tested Concept, 2 strand core suture technique and gentle active flexion and extension exercises with wrist in extension, 2 strand core suture technique and cast immobilization for 8 weeks, 4 strand core suture technique and gentle active flexion and extension exercises with wrist in extension, 4 strand core suture technique and cast immobilization for 4 weeks, 4 strand core suture technique and cast immobilization for 8 weeks, (OBQ05.21) Grade 3 tears — the muscle fibers are completely torn. A laceration to the forearm, hand or wrist can result in injury to the flexor tendons. Important considerations include fractures of the metacarpals or phalanges that may entrap the flexor tendon, limiting its motion. When this happens it becomes impossible to bend your finger(s). Causes of a hip flexor tear or strain. Debulking of scar, partial excision of 25% of the A2 and A4 pulleys. Resection of scar and primary repair of tendon ends. Which method of tendon repair will give him the best results in terms of load to failure and gliding resistance? He is taken to the operating room for surgical exploration where 1.8 cm of scar tissue between the tendon ends is identified. He is taken to the operating room and the lesion is repaired primarily. This strain can cause unwanted pain and stress. Which of the following variables has the greatest effect on increasing the strength of the tendon repair? Flexor tendon injuries do not heal by themselves and frequently require surgery to put the injured tendon back to its normal position. It is often easier to treat these injuries early after injury. Tested Concept. Early motion protocols do not improve long-term results and there is a higher re-rupture rate than flexor tendon repair in fingers. Direct repair of both tendons followed by early ROM (Duran, Kleinert). Repair with core suture purchase 10mm from the cut edge. Circumferential simple running epitendinous suture. Which of the following statements best describes the tendon motion rehabilitation protocol as depicted in Figures A where the splint holds the wrist at 45 degrees of flexion? Tested Concept, Trim the frayed tendon edges and begin early range of motion, Trim the frayed tendon edges and cast in an intrinsic positive position for 2 weeks, Peritendinous 6/0 and Core 4/0 suture repair, (OBQ08.227) The ability to bend our fingers to make a fist is controlled by the flexor tendon. (OBQ13.225) Grade 2 tears — a moderate amount of muscle fiber is damaged, and there is a potential for loss of function in the hip flexor. An MRI can show a strain or tear of the tendon as well as rule out an injury to the ulnar collateral ligament, also known as the Tommy John injury. However, if you lose motion in a part of your arm, then tendon injury, even without a laceration, should be considered a possible cause. Not all tendon injuries are due to lacerations. Flexor tendonitis can occur when there is a strain on the tendons. They are thick cord-like connective tissues that attach the finger bones to muscles in the forearm and allow the fingers to bend. A 24-year-old male cuts his left middle finger with a knife while chopping vegetables. Typically, any additional injured structures are repaired at the same time as the tendon. The horse's DDFT provides support to the fetlock joint, acts as a spring that stores energy upon movement, and stabilizes the leg under full weight-bearing load. It is not unusual to have numbness, tingling and a lot of bleeding after a tendon is lacerated. Tested Concept, (OBQ08.165) This lack of movement can involve just a small area in your hand, or it can be the inability to move multiple joints in the arm. If you are worried about a flexor tendon injury, please see a hand surgeon right away. Flexor tendons are quite prone to injury due to their location below the skin and lack of flesh in the hand. A clinical photograph is shown in Figure A. Deep digital flexor tendon (DDFT) injuries are a common type of tendon injury that occurs in performance horses. Transverse carpal ligament should be repaired in a lengthened fashion if tendon bowstringing is present. Often complicated by postoperative adhesions due to close quarters and synovial sheath of the carpal tunnel. (OBQ12.182) What is the next step in management? What are Flexor Tendon Injuries? However, depending on the mechanism and extent of injury, other injuries may also be present. There is no triggering present as the patient's finger is passively extended and flexed fully. The most appropriate treatment is: Attempt to leave one pulley intact to prevent bowstr, loss of active flexion strength or motion of the involved digit(s), evidence of malalignment or malrotation may indicate an underlying fracture, assess skin integrity to help localize potential sites of tendon injury, look for evidence of traumatic arthrotomy, passive wrist flexion and extension allows for assessment of the, normally wrist extension causes passive flexion of the digits at the MCP, PIP, and DIP joints, maintenance of extension at the PIP or DIP joints with wrist extension indicates flexor tendon discontinuity, active PIP and DIP flexion is tested in isolation for each digit, important given the close proximity of flexor tendons to the digital neurovascular bundles, partial lacerations < 60% of tendon width, may be associated with gap formation or triggering, incisions should always cross flexion creases transversely or obliquely to avoid contractures (never longitudinal), meticulous atraumatic tendon handling minimizes adhesions, linear relationship between strength of repair and # of sutures crossing repair, 4-6 strands provide adequate strength for early active motion, high-caliber suture material increases strength and stiffness and decreases gap formation, ideal suture purchase is 10mm from cut edge, core sutures placed dorsally are stronger, improves tendon gliding by reducing the cross-sectional area, improves strength of repair (adds 20% to tensile strength), allows for less gap formation (first step in repair failure), produces less gliding resistance than other techniques, theoretically improves tendon nutrition through synovial pathway, clinical studies show no difference with or without sheath repair, recent biomechanical studies have shown that 25% of A2 and 100% of A4 can be incised with little resulting functional deficit, weakest between postoperative day 6 and 12, usually epinephrine 1:100,000 and 7mg/kg lidocaine, 1% lidocaine with 1:100,000 epi for a 70kg person, dilute with saline (50:50) to get 0.5% lidocaine, 1:200,000 epi, if 100-200cc is needed for large fields (tendon transfer, spaghetti wrist), dilute with 150cc saline to get 0.25% lidocaine and 1:400,000 epi, add 10cc of 0.5% bupivacaine with 1:200,000 epi, allows intraoperative assessment for repair gaps by getting awake patient to actively flex digit, reduces need for postop tenolysis by allowing intraopera, allows division of A4 pulley and venting (partial division) of A2 pulleys, allows repair of tendons inside tendon sheaths as patients can demonstrate that the inside of the sheath has not been inadvertently caught, begin active midrange motion after day 3 (form a partial fist with 45 degree flexion at MP, PIP and DIP joints, or "half a fist 45/45/45 regime"), only perform if the flexor sheath is pristine and the digit has full ROM, is placed to create a favorable tendon bed, Stage II (3-4 months) - SR is retrieved an, through the mesothelium-lined pseudosheath, pulvertaft weave proximally and end-to-end tenorrhaphy distally, Stage I - SR is placed in the flexor sheath, pulleys are reconstructed (as needed), and a loop between the proximal stumps of FDS and FDP is created in the palm, Stage II - SR is retrieved, FDS is cut proximally and reflected distally through the pseudosheath and either attached directly to FDP stump or secured with a button, graft (FDS) size is known at the time of silicone rod selection, less graft diameter-rod diameter mismatch, fewer adhesions than extrasynovial grafts, relies on only 1 tenorrhaphy site (distal or proximal) to heal at any one time (vs. Hunter technique where 2 tennoprhaphy sites are healing simultaneously), graft tensioning is at the distal end during stage II, the proximal end has already healed after stage I, extensor digitorum longus to 2nd-4th toes, subsequent tenolysis is required more than 50% of the time, Postoperative controlled mobilization has been the major reason for improved results with tendon repair, limits restrictive adhesions and leads to increased tendon excursion, casts/splints are applied with the wrist and MCP joints positioned in flexion and the IP joints in extension, active finger extension with patient-assisted passive finger flexion and static splint, adds active wrist motion which increases flexor tendon excursion the most, moderate force and potentially high excursion, dorsal blocking splint limiting wrist extension, perform “place and hold” exercises with digits, most common complication following flexor tendon repair, perform if 4-6 months after tendon repair and significant loss of excursion, if < 1cm of scar is present, resect the scar and perform primary repair, if > 1cm of scar is present, perform tendon graft, if the sheath is intact and allows passage of a pediatric urethral catheter or vascular dilator, perform primary tendon grafting, if the sheath is collapsed, place Hunter rod and perform staged grafting, Lunate Dislocation (Perilunate dissociation), Gymnast's Wrist (Distal Radial Physeal Stress Syndrome), Scaphoid Nonunion Advanced Collapse (SNAC), Carpal Instability Nondissociative (CIND), Constrictive Ring Syndrome (Streeter's Dysplasia), Thromboangiitis Obliterans (Buerger's disease), flexor tendon injuries are a traumatic condition, stimulated by surrounding synovial fluid and inflammatory cells, implicated in the formation of scarring and adhesions, allows the annular pulleys to approximate each other during digital flexion, most important pulley to prevent flexor tendon bowstringing (along with A1 pulley), minimal interference with tendon vascularity, sufficient strength throughout healing to permit application of early motion stress to the tendon, delayed treatment leads to difficulty due to tendon retraction, historically believef to be critical to preserve, in zone 2 injuries, repair of one slip alone improves gliding, repair site gaps > 3mm are associated with an increased risk of repair failure, allows on-the-spot debulking of bunched repairs, full passive range of motion of adjacent joints, pulley reconstruction should occur first if a tendon graft is being used, localized tendon adhesions with minimal to no joint contracture and full passive digital motion, may be required if a discrepancy between active and passive motion exists after therapy, wait for soft tissue stabilization (> 3 months) and full passive motion of all joints, careful technique to preserve A2 and A4 pulleys, active finger extension with dynamic splint-assisted passive finger flexion.
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