Busy. Please wait.
or

show password
Forgot Password?

Don't have an account?  Sign up 
or

Username is available taken
show password

why


Make sure to remember your password. If you forget it there is no way for StudyStack to send you a reset link. You would need to create a new account.
We do not share your email address with others. It is only used to allow you to reset your password. For details read our Privacy Policy and Terms of Service.


Already a StudyStack user? Log In

Reset Password
Enter the associated with your account, and we'll email you a link to reset your password.

Remove Ads
Don't know
Know
remaining cards
Save
0:01
To flip the current card, click it or press the Spacebar key.  To move the current card to one of the three colored boxes, click on the box.  You may also press the UP ARROW key to move the card to the "Know" box, the DOWN ARROW key to move the card to the "Don't know" box, or the RIGHT ARROW key to move the card to the Remaining box.  You may also click on the card displayed in any of the three boxes to bring that card back to the center.

Pass complete!

"Know" box contains:
Time elapsed:
Retries:
restart all cards




share
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.

  Normal Size     Small Size show me how

H/W Tendon Injuries

Hand & Wrist Tendon Injuries Presentation

QuestionAnswer
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