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H/W Tendon Injuries

Hand & Wrist Tendon Injuries Presentation

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
Created by: 1190550002



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