Tendon Injuries of the Hand and Forearm

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Transcription:

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

Extensor Tendon Injuries

Extensor Tendon Anatomy

Extensor Tendon Anatomy

Extensor Tendon Injuries Prognosis Ø 60% assoc w/other injuries Fracture Dislocation Joint Flexor tendon Ø Outcome Dependent on assoc injuries

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

Bony Mallet Finger

Swan Neck

Mallet Finger

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

Mallet Finger Treatment Ø Surgery if: Physeal injury Subluxation Displaced bony mallet Chronic swan neck

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

Zone III Injury Central Slip Disruption at PIP Mechanism Forceful PIP hyperflexion Volar PIP Dislocation Laceration Boutonniere later develops

Zone III Injury Closed Boutonniere Lesion Treatment: Splint PIP in extension Continuously - 6 weeks Leave DIP free

Zone III Injury Open Boutonniere Lesion Treatment I&D joint Suture repair K wire PIP in ext for 6 wks

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

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

Zone VI/VII Injury Ø Tendons thicker Ø Treatment Core suture repair

Extensor Tendon Injury Summary Ø Anatomy Complicated Ø Treatment Simple: Repair tendon Immobilize 4 weeks Ø Outcome Dependent on associated injuries

Flexor Tendon Zones

Volar Digital Anatomy

Volar Digital Anatomy

Diagnosis?

Volar Laceration Extent of Injury Ø Cascade

Volar Laceration Extent of Injury Tenodesis

Flexor Tendon Exam FDS- Superficialis FDP-Profundus

Volar Laceration Extent of Injury Forearm Compression

Diagnosis?

Jersey Finger Ø Definition FDP avulsion Ø Mechanism Eccentric contraction

Jersey Finger Ø Staging (Retraction) Type I: Palm Type II: A2 pulley Type III: A4 pulley

Jersey Finger Treatment Ø Surgical repair Ø Timing and feasibility based on level of retraction

Jersey Finger Treatment Return to sport/work in 3 month

Palmar Anatomy

Forearm Flexor Tendon Injuries Zone VI Zone V

Forearm Flexor Tendon Injuries Ø Mechanism of Injury Accidental Trauma Glass window Suicide attempt Volar radius plates

Volar Forearm Anatomy Superficial Layer

Volar Forearm Anatomy Middle Layer Deep Layer

Volar Forearm Anatomy

Volar Forearm Anatomy

Volar Forearm Laceration Extent of Injury Ø Confounding Variables Intoxication Pain Anxiety Psychiatric Issues

Volar Forearm Injuries Repair Ø Extensile Exposure Ø Identify all structures first Ø Tendon repair Core suture Ø Nerve repair Epineural Ø Arterial repair

Volar Forearm Injuries Muscle Repair Nishimura et al, Acta Anat 1994

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

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

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

Flexor Tendon Rupture Volar Plate Prominence

Flexor Tendon Rupture Volar Plate Prominence

Flexor Tendon Rupture Volar Plate Prominence

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%)

Thank you!

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