Tendon Injuries of the Hand and Forearm
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1 Tendon Injuries of the Hand and Forearm Robert Goitz, M.D. Chief, Hand & Upper Extremity Surgery Department of Orthopaedic Surgery University of Pittsburgh Medical Center
2 Extensor Tendon Injuries
3 Extensor Tendon Anatomy
4 Extensor Tendon Anatomy
5 Extensor Tendon Injuries Prognosis Ø 60% assoc w/other injuries Fracture Dislocation Joint Flexor tendon Ø Outcome Dependent on assoc injuries
6 Mallet Finger Ø Extensor mechanism disruption from the distal phalanx Ø Soft tissue vs. avulsion Ø Obtain radiograph to evaluate for: Fracture Subluxation Physeal Injury
7 Bony Mallet Finger
8 Swan Neck
9 Mallet Finger
10 Mallet Finger Treatment Ø First 6 weeks Stack splint - Continuous Ø At 6 weeks AROM with removable splint Ø At 8 weeks PROM & night splint
11 Mallet Finger Treatment Ø Surgery if: Physeal injury Subluxation Displaced bony mallet Chronic swan neck
12 Zone II/IV Injury Middle/Proximal Phalanx Tendons very flat < 50% lac and strong extension Splint for 10 d AROM afterwards >50% Repair with core suture Continuous splinting x 6 wks
13 Zone III Injury Central Slip Disruption at PIP Mechanism Forceful PIP hyperflexion Volar PIP Dislocation Laceration Boutonniere later develops
14 Zone III Injury Closed Boutonniere Lesion Treatment: Splint PIP in extension Continuously - 6 weeks Leave DIP free
15 Zone III Injury Open Boutonniere Lesion Treatment I&D joint Suture repair K wire PIP in ext for 6 wks
16 Zone V Injury MP Joint Ø Human Bites I&D, leave open, ABX Return in 7-10 d for tendon repair Retraction in this zone uncommon
17 Ø Longitudinal tear of extensor hood Ø Traumatic or spontaneous Flicking finger Ø Ulnar dislocation (radial tear) Ø Results in incomplete extension and ulnar deviation Ø Treat by repair and 4 wks of MP ext splinting Zone V Injury MP Joint Tendon Dislocation
18 Zone VI/VII Injury Ø Tendons thicker Ø Treatment Core suture repair
19 Extensor Tendon Injury Summary Ø Anatomy Complicated Ø Treatment Simple: Repair tendon Immobilize 4 weeks Ø Outcome Dependent on associated injuries
20 Flexor Tendon Zones
21 Volar Digital Anatomy
22 Volar Digital Anatomy
23 Diagnosis?
24 Volar Laceration Extent of Injury Ø Cascade
25 Volar Laceration Extent of Injury Tenodesis
26 Flexor Tendon Exam FDS- Superficialis FDP-Profundus
27 Volar Laceration Extent of Injury Forearm Compression
28 Diagnosis?
29 Jersey Finger Ø Definition FDP avulsion Ø Mechanism Eccentric contraction
30 Jersey Finger Ø Staging (Retraction) Type I: Palm Type II: A2 pulley Type III: A4 pulley
31 Jersey Finger Treatment Ø Surgical repair Ø Timing and feasibility based on level of retraction
32 Jersey Finger Treatment Return to sport/work in 3 month
33 Palmar Anatomy
34 Forearm Flexor Tendon Injuries Zone VI Zone V
35 Forearm Flexor Tendon Injuries Ø Mechanism of Injury Accidental Trauma Glass window Suicide attempt Volar radius plates
36 Volar Forearm Anatomy Superficial Layer
37 Volar Forearm Anatomy Middle Layer Deep Layer
38 Volar Forearm Anatomy
39 Volar Forearm Anatomy
40 Volar Forearm Laceration Extent of Injury Ø Confounding Variables Intoxication Pain Anxiety Psychiatric Issues
41 Volar Forearm Injuries Repair Ø Extensile Exposure Ø Identify all structures first Ø Tendon repair Core suture Ø Nerve repair Epineural Ø Arterial repair
42 Volar Forearm Injuries Muscle Repair Nishimura et al, Acta Anat 1994
43 Volar Forearm Injuries Muscle Repair Ø Include epimysium and muscle (Kragh et al, J Am Coll Sur 2005) Ø Directly repair any tendinous tissue in center of muscle Ø Core stitch with transverse limb Increase strength of repair 20% Kragh et al, J Am Coll Sur 2005
44 Volar Forearm Injuries Muscle Repair Ø Include epimysium and muscle Ø Directly repair any tendinous tissue in center of muscle Ø Core stitch with transverse limb
45 Volar Forearm Injuries Muscle Repair Ø Include epimysium and muscle Ø Directly repair any tendinous tissue in center of muscle Ø Core stitch with transverse limb
46 Flexor Tendon Rupture Volar Plate Prominence
47 Flexor Tendon Rupture Volar Plate Prominence
48 Flexor Tendon Rupture Volar Plate Prominence
49 Flexor Tendon Injury Outcome Ø Knowledge of anatomy Ø Optimize strength of repair to allow early mobilization Ø Full digital motion uncommon Ø Worst outcomes in Zone II Tight flexor sheath Ø Confounding issues of host Noncompliance Psychiatric issues Ø Tenolysis (10%)
50 Thank you!
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If you or a loved one have suffered because of a negligent error during spinal surgery, you will be going through a difficult time.
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