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H/W Tendon Injuries
Hand & Wrist Tendon Injuries Presentation
| Question | Answer |
|---|---|
| Extrinsic Muscles | FDS FDP FPL |
| Where do extrinsic muscles originate? | Medial epicondyle; Ulna; Interosseous membrane; Radius |
| Extrinsic Flexors | Become tendinous at distal 1/3 of forearm; All pass through carpal canal with median n. |
| FDS | Stacked 2 over 2; Long & ring more palmar; Small & index deeper |
| Flexor Tendon Sheath | FDS & FDP pair up for each finger; Enter sheath with FDS palmar to FDP; After entrance to sheath, FS splits into 2 slips that spiral around FDP to gain access to base of middle phalanx |
| Flexor Tendon Sheath | Tendon sheath occupied by 2 tendons from its beginning at the level of the distal palmar crease to the flexion crease of the PIP; FDP travels alone to its insertion on the distal phalanx |
| Pulleys | Condensations of flexor sheath; Maintains tendons closely applied to bones of fingers; Prevents bowstringing; Maintains constant moment arm for tendons |
| A1: First Annular Pulley | At neck of metacarpal; Location a tendon will "catch" most with trigger finger |
| A2 Pulley | Level of proximal phalanx; One of most important pulleys; Very large & dense; Must be preserved in tendon surgery |
| C1: First Cruciate Pulley | Level of PIP; Very thin, diagonal band; May be sacrificed to gain access to tendons for repair |
| A3 Pulley | In middle of PIP; Very narrow to allow PIP flexion; Attaches to PIP volar plate; May be sacrificed |
| C2 Pulley | Distal to A3 but still at level of PIP; Same as C1- very thin, may be sacrificed |
| A4 Pulley | Level of middle phalanx; 2nd most important- large & dense |
| A5 Pulley | Level of DIP; Narrow but dense; Attached to DIP volar plate |
| Tendon Nutrition | From synovial fluid & blood supply; Proximal palmar vessels at mm-tendon junction; Vincula longa & vincula brevia; Bony tendinous insertion |
| Zone 1 (tendon laceration zones) | Level of insertion of FDP to level of insertion of FDS; Only 1 tendon in the sheath; Prognosis better than zone 2 |
| Zone 2 (tendon laceration zones) | Distal palmar crease to insertion of FDS; 2 tendons in sheath; If both tendons cut & repaired, tenorraphy sites scar together restricting independent gliding; Special surgical technique required; Extra care taken during sx to avoid further tendon dama |
| Zone 2 (tendon laceration zones) | Core suture with buried knot to prevent impinging on pulleys; Tenorraphy completed with running epitendon suture to tighten tendon ends at tenorraphy juncture; Care taken to preserve pulleys (esp A2 & A4) & vincula to maintain as much circulation possib |
| Zone 2 (tendon laceration zones) | Rehab precautions must be used post-surgery; Early motion to minimize scarring; Immobilization of hand in position to minimize tension on repaired tendon |
| Zone 3 (tendon laceration zones) | Transverse carpal ligament to distal palmar crease; Good prognosis- no dense fibro-osseous sheath to tether healing tendon; good circulation |
| Zone 4 (tendon laceration zones) | Distal wrist crease to transverse carpal ligament; Carpal canal defines zone; Many tendons in very tight zone; Bony structures define canal on 3 sides & transverse carpal lig on other(Radial side: tuberosity of scaphoid & trapezium)(Ulnar: hook of hama |
| Zone 4 (tendon laceration zones) | Lacerations causing tendon injury here are uncommon b/c of protecting bony walls, all tendons could adhere to each other during healing |
| Zone 5 (tendon laceration zones) | Proximal to distal wrist crease; Frequently involves multiple tendons as well as arteries & nerves; Nerve injuries significantly affected rehab & expectations of fxnal recovery |
| Zone 5 (tendon laceration zones) | Multiple tendon lacerations frequently results in intertendinous adhesions (limits ROM); MOI: hand through glass window |
| Tendon Healing | When divided, ends retract & wound fills with hematoma; Fibroblasts from injured tissue/tendons invade hematoma; Tendon attempts to heal self & forms pseudo tendon; New fibrous tissue/edema causes injured/repair tendon to adhere with fibro-osseous tun |
| Tendon Repair | Repaired to one another with least disruption of blood supply; May use bridge graft to connect ends; All key pulleys preserved/resconstructed to maintain efficient tendon fxn |
| Primary Repair of flexor tendons | Done within 12-24 hours of injury; Clean sharp injuries |
| Delayed primary repair of flexor tendons | Done within 10 days of injury |
| Secondary repair of flexor tendons | Done 10-14 days after injury |
| Late secondary repair | Done >4 weeks post-injury |
| Timing of Flexor Tendon Repairs | Delayed primary/secondary- done in case of dirty/contaminated wound; Late secondary repairs- do poorly b/c of scarring, swelling of tendon ends & shortening of mm-tendon unit |
| Flexor tendons most commonly lacerated in which zones? | 1, 2, 3, 5 Zones 1 & 2 always difficult b/c lie in confines of annular ligaments & digital sheath |
| Pre-Reqs of Modified Duran Protocol | Compliant pt Clean/healed wound Repair within 14 days of injury |
| Goals of Modified Duran Protocol | Prevent joint stiffness (early passive flexion of IPs; early IP extension vs. rubber band to prevent PIP joint contracture); Regain max active flexion ROM & ensure return of fxn |
| 1-3 days to 4.5 weeks | Control edema with compression; Dorsal blocking splint: wrist 20-40 deg flexion, MCP 50 deg flexion, DIP/PIP full extension; Rubber band attached to nail for passive flexion, eccentric extension (pt can actively extend) |
| 1-3 days to 4.5 weeks | Initiate controlled PROM ex's to DIP/PIP; Passive flex/ext ex's: PIP, DIP, MCP while in DBS; Shoulder/elbow ROM several times/day |
| 1-3 days to 4.5 weeks | FDS intact: trap DIP of unaffected fingers in extension & gently flx PIP of affected digit; Any active mvmt should be preceded by full passive flexion warm-up & mvmts practiced are gentle gross flexion, never stabilized isolated flexion IP mvmts |
| Weeks 3-4 | Gentle active wrist flexion; Passive flexion continues; With MCP stabilized, gentle active IP flexion begins (unresisted) |
| 4.5 weeks | Begin active ROM for fingers/wrist flexion; With wrist flexed, gentle extension of all 3 finger joints begins; Pt should perform hourly ex's with splint off (wrist flex/ext to neutral, finger flex with wrist immobilized) |
| 4.5 weeks | Watch for PIP flexion contractures; if extension lag present, add protected passive extension of PIP with MCP in flexion; PIP should be blocked to 30 deg flex x3 weeks if nerve repair also done |
| 4.5 weeks | Pt may reach plateau in ROM 2 months post-surgery but max motion usually achieved by 3 months after surgery |
| 5 weeks | Fxnal e-stim can improve tendon excursion; Consider pt's quality of primary repair, nature of injury & medical hx before initiating fxnal e-stim |
| 5.5 weeks | Blocking ex's for PIP & DIP to previous HEP; D/c splint; Wrist ext begins, initially with fingers flexed, progressing gradually over next 2 wks to wrist & finger ext |
| 5.5 weeks | Focus on gaining PROM for flexion; Don't begin passive extension stretching yet; Restraining extension splint can be used & positioned in available range if tightness noted |
| 6 weeks | Begin passive extension ex's of wrist & digits; Fit extension resting pan splint in max extension if extrinsic flexor tendon tightness significant |
| 6-8 weeks | Protective splint for traveling & sleep until 8 weeks; Gentle resistance to IP flexion commenced |
| 8 weeks | Resistive ex's with sponge/nerf ball, progress to putty & hand helper; Allow use of hand in light work activities, but no lifting/heavy use of hand |
| 10-12 weeks | Full use of hand; Work stimulator/strengthening program to improve strength; Greatest ROM achievement seen b/t 12-14 wks post-surgery; Not uncommon for ROM plateaus b/t 6-8 wks |
| Jersey Finger | FDP Avulsion; Common in football; DIP actively flexed, then forced into extension; Rupture of FDP from insertion on distal phalanx; 75% at ring finger; Avulsed w/ or w/o bone |
| Jersey Finger Exam | TTP over volar DIP; May extend proximally along tendon sheath as FDP retract; Need to r/o avulsion fx |
| Testing isolated action of FDP | MCP & PIP in full extension, have pt attempt to flex DIP; If they can--tendon in tact; If they can't-- tendon torn |
| Types of Jersey Finger | Type 1: Retracted to palm; 7 days Type 2: Retracted to PIP; 10 days Type 3: Avulsion distal phalanx; 2 weeks |
| Treatment of Jersey Finger | Labor intensive surgery & rehab; Risk of scarring & re-rupture; Won't have full activity until ~12 wks |
| Non-Treatment of Jersey Finger | Pt. can't flex DIP; Decreased grip strength; TTP at site of attachment |
| Jersey Finger- if seen right after injury | Splint in 30 deg flexion at PIP & DIP joints; Surgery within 10 days esp if FDP has retracted significant distance Rehab follows Duran Protocol |
| Extensor Tendon Zones | Much more than on volar surface; Tendons become thinner & weaker more distally into hand; Immobilization progressively longer & active ex's started later than with proximal injuries |
| Extensor tendon repair | Horizontal mattres sutures; Extensor tendons flatter & thinner than flexors |
| Extensor Tendon repair complications | Adhesions; Rupture of repaired tendon; Loss of glide in extensor tendon at level of MCP &/or PIP will result in significant loss of mvmt of that digit |
| Mallet Finger | DIP; Baseball finger; Ball/object strikes DIP forcing into hyperflexion, while extensor mechanism active; Athlete can't extend DIP; Extensor lag with active contraction |
| Signs of Mallet Finger Injury | Full PROM, unable to actively extend DIP; Radiographs must be obtained to r/o fx; Crepitus, swelling, point tenderness in DIP are classic s/sx of fx; Sub-ungual hematoma; Flexion deformity of DIP |
| Mallet Finger Injury | Closed- splint in DIP extension x6-8 wks; Splint placed dorsal to allow normal sensory input to finger pad; Isolate DIP, leaving PIP free; Night splinting x3+ wks; If pt doesn't adhere to immobilization, add 6 more wks |
| Mallet Finger | Can continue to play sports with splint on; May need splint x6 months |
| 3 types of Mallet finger | 1. Rupture of distal extensor tendon; 2. Avulsion fx base of DIP; 3. Fx of epiphysis of DIP; Even with aggressive rehab, complete re-establishment of full DIP ROM rare when fx through joint |
| Boutonniere of Finger (PIP) | Splint pinned in extension x8 weeks; Active DIP ROM started immediately; If dislocated- PIP splinted acutely in extension, then eval'd; Active DIP ROM started immediately |
| Boutonniere between PIP & MP | Repair tendon; Splint- wrist max extension, MP 90 deg flexion x3 wks (wrist ext, MP flex is fxnal wrist position); Start active IP motion immediately; If no active PIP ROM before repair, splint PIP full ext x6 wks, start active DIP ROM immediately |
| Boutonniere between PIP & MP--rehab timeline | 3 wks post-op--wrist splint in neutral (IP/MP free) 6 weeks-- full AROM 8 weeks-- resistance & full motion allowed |
| Boutonniere at MP Joint | Repair tendon; Immobilize in volar splint with MPs 60 deg flexion; start active IP motion ASAP |
| Boutonniere at MP joint--rehab timeline | 3 weeks- wrist splint 20 deg extension; Start MP & IP extension ROM 6 weeks-- full AROM 8 weeks-- begin resistance & full ROM |
| Boutonniere- Dorsum of Hand | Post repair splinted in volar splint with wrist max extension, MP flexed 40-60 deg & IPs straight x 3 weeks |
| Boutonniere- Dorsum of Hand-- rehab timeline | 3 weeks- volar cockup wrist splint in 20 deg wrist ext x3 more wks; active MP/IP extension in splint; 6 wks-- full AROM out of splint 8 weeks-- begin resistance & full motion |
| Boutonniere at Retinaculum | Post-op- volar splint with wrist in max extension, MPs blocked at 40-60 deg flexion & IPs straight; Rubber band outrigger attached dorsally to passively pull MPs into extension; Every hour should actively flex & passively extend MPs; Splint x3 weeks |
| Boutonniere at Retinaculum-- rehab timeline | 6 weeks-- full AROM 8 weeks-- begin full motion & resistance |
| EPL Repair | Volar cockup splint with MP neutral, CMC extended, wrist extended x21 days; IP extended or hyperextended; Splint extends just beyond tip of thumb |
| EPL Repair: Day 1-Week 4 | Hand rested in splint; finger joint mobility by way of active flexion & extension ex's is maintained |
| EPL Repair: Week 4-6 | Hand removed from splint & thumb allowed to fall into line with index finger from where it is then actively extended; Gentle unresisted active flex/ext ex's of IP joint at beginning of 5th week |
| EPL Repair | Wrist cockup spint, start active thumb ROM in 3 weeks; 6 weeks-- full AROM |
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