Flexor tendon injuries

1. FLEXOR TENDON INJURIES

2. INVOLVE LACERATIONS ,RUPTURES MALES COMMONLY B/W 15 -30 YEARS ZONES OF INJURY INFLUENCE THE TYPE OF REPAIR AND POST OPERATIVE REGIMEN INTRODUCTION

3. CARPAL TUNNEL : HERE MIDDLE AND RING FINGER TENDONS LIE SUPERFICIAL TO SMALL AND INDEX FINGER TENDONS 34 GREATER THAN 25 FLEXOR TENDON ANATOMY

4. EACH FINGER HAS FDP AND FDS TENDON SHEATH BEGINS AT THE LEVEL OF METACARPAL NECK DIGITAL ARTERY BRANCHES OR VINCULA ASSIST TENDON NUTRITION DIGITAL SHEATH

5. ONCE INSIDE DIGITAL SHEATH,THE FDS FORMS CAMPERS CHIASM BY SPLITTING INTO TWO SLIPS THAT ATTACH ON THE PALMAR SIDE OF MIDDLE PHALANX. FDS PASSES THRU THIS TO ATTACH ON THE VOLAR ASPECT OF DISTAL PHALANX CAMPERS CHIASM

6. FLEXOR TENDON SHEATH HAS 5 ANNULAR AND 3 CRUCIATE PULLIES A2 AND A4 ARE MOST IMP TO PREVENT BOW STRINGING OF THE TENDONS WITHOUT PULLEYS TENDONS CAN NO LONGER GLIDE JUXTAPOSED TO PHALANGES AND GREATER AMOUNT OF FORCE WILL BE NEEDED TO OBTAIN THE SAME AMOUNT OF FLEXION

7. ONLY FPL CONTAINS 2 ANNULAR PULLIES AND ONE OBLIQUE PULLIES THUMB SHEATH

8. TENDON ZONES

9. REGION B/W MIDDLE ASPECTS OF MIDDLE PHALANX TO FINGER TIPS CONTAINS ONLY ONE TENDON-FDP TENDON LACERATION OCCURS CLOSE TO ITS INSERTION TENDON TO BONE REPAIR IS REQUIRED THAN TENDON REPAIR ZONE 1:ZONE OF FDP AVULSION INJURIES

10. TYPE 1:RETRACT INTO THE PALM TYPEII:RETRACT TO THE LEVEL OF PIP JOINT TYPE III:TO LEVEL OF DIP JOINT FDP AVULSION INJURIES-LEDDY CLASSIFICATION

11. FROM METACARPAL HEAD TO MIDDLE PHALANX CALLED SO COZ INITIAL ATTEMPTS FOR TENDON REPAIR HERE PRODUCED POOR RESULTS FDS N FDP WITHIN ONE SHEATH ADHESION FORMATION RISK IS AMPLIFIED AT CAMPERS CHIASM ZONE II-NO MANS LAND

12. B/W TRANSVERSE CARPAL LIGAMENT AND PROXIMAL MARGIN OF TENDON SHEATH FORMATION LUMBRICALS ORIGIN HERE PREVENTS PROFUNDUS TENDONS FROM OVER ACTING DELAYED TENDON REPAIRS ARE SUCCESFULL EVEN AFTER SEVERAL WEEKS OF INJURY ZONE III-DISTAL PALMAR CREASE

13. LIES DEEP TO DEEP TRANSVERSE LIGAMENT TENDON INJURIES ARE RARE ZONE IV-TRANSVERSE CARPAL LIGAMENT

14. LIES PROXIMAL TO TRANSVERSE CARPAL LIGAMENT ZONE V-PROXIMAL

15. INSPECTION THERE IS A NORMAL ARCADE TO HAND WITH INDEX FINGER SHOWING LEAST AND LITTLE FINGER SHOWING MAX FLEXION IF AFFECTED FINGER SHOWS MORE EXTENSION THAN OTHER DIGITS,CHANCE OF TENDON INJURIES ARE HIGH, EXAMINATION

16. FDP Hold the metacarpophalangeal and proximal interphalangeal joints of the finger being tested ,in extension. Ask the patient to flex the finger at the distal interphalangeal joint. If the patient cannot flex the finger, the flexor digitorum profundus tendon is cut or non-functional. PALPATION-PROVOCATIVE TESTING

17. Hold the fingers in extension except the finger being tested. Ask the patient to flex the finger at the proximal interphalangeal joint. If the patient cannot flex the finger, the flexor digitorum superficialis tendon is cut or non-functional. FDS

18. STABILISE THE MCP JOINT ASK THE PT TO FLEX IP JOINT FPL

19. TO EXCLUDE UNDERLYING INJURIES LIKE FRACTURES. IMAGING STUDIES

20. REPAIR WITHIN 1 ST TWO WEEKS,LATE REPAIR DECREASE THE ULTIMATE MOBILITY OF THE FINGERS STRENGTH AND ABILITY TO PREVENT GAPPING DEPENDS ON THE NO OF SUTURES THAT CROSS THE REPAIR SITE TENDON GAPPING IS THE HALLMARKOF TENDON FAILURE DORSALLY PLACED SUTURES HELPS TO MINIMISE GAPPING TENDON REPAIR CHARACTERISTICS

21. EPITENON SUTURES HELPS TO IMPROVE THE STRENGTH AND QUALITY OF TENDON REPAIRS NO NEED FOR TENDON SHEATH REPAIR PARTIAL TENDON LACERATIONS OF LESS THAN 60% OF CROSS SECTIONAL AREA OF TENDON SHOULD BE TREATED WITHOUT TENORRHAPHY AND EARLY MOBILISATION

22. IN TRANSVERSE LACERATIONS, LONGITUDINAL INCISIONS ARE PUT ON OPPOSITE SIDES EXTENDING PROXIMALLY AND DISTALLY OBLIQUE SKIN LACERATIONS CAN BE EXTENDED IN A ZIG ZAG FASHION EXPOSURE OF SITE OF INJURY DURING REPAIR

23. WOUND EXTENDED PROXIMALLY AND DISTALLY PROXIMAL TENDON RETRIEVED,CORE SUTURES ARE PLACED KEITH NEEDLES USED TO PASS THE SUTURES AROUND THE DISTAL PHALANX EXITING THROUGH NAIL PLATE DISTALLY REMAINING DISTAL END OF TENDON SUTURED TO THE RE-ATTACHED PROXIMAL PORTION ZONE 1 REPAIR

24. REPAIR BOTH TENDON LACERATIONS TENDON SHEATH MAY BE OPENED FOR EXPOSURE BUT A2 AND A4 ARE PRESERVED AS MUCH AS POSSIBLE FDS IS REPAIRED FIRST FOLLOWED BY FDP ZONEII REPAIRS

25. If both tendons are lacerated, both are repaired, end to end with circumferential re-enforcing sutures May affect lumbricals inaddition to flexor tendons Damaged lumbrical is either repaired or excised depending on severity of injury and the location of the laceration ZONE III REPAIRS

26. Lacerations of flexor tendons within the carpal canal are typically associated with partial or complete laceration of median nerve Here median nerves should be repaired first and the tendons last ZONE IV REPAIR

27. In this area there may be concomitant ulnar nerve & artery damage as well as radial artery & median nerve damage. Primary repair of the arteries is usually indicated If wound is contaminated, arteries are repaired and delayed repair of tendons and nerves is planned ZONE V REPAIR

28. TWO PROTOCOLS ARE FOLLOWED PASSIVE FLEXOR TENDON PROTOCOL EARLY ACTIVE TENSION PROTOCOL REHABILITATION

29. 0-3 WEEKS:NO ACTIVE FINGER FLEXION,DORSAL BLOCK SPLINT IS APPLIED 3-6 WEEKS:SPLINTING CHANGES WITH WRIST IN NEUTRAL POSITION ,PASSIVE FLEXION AND ACTIVE EXTENSION EXERCIZES STARTTED 6-9 WEEKS:WEANING FROM SPLINT,LIGHT FUNCTIONAL ACTIVITIES STARTTED. PASSIVE FLEXOR TENDON PROTOCOL

30. 9-12 WEEKS:JOINT CONTRACTURES IF PRESENT ARECORRECTED.RESISTIVE EXERCIZES ARE BEGUN. 12-16 WEEKS:PROGRESS TO FULL RESISTIVE EXERCIZES BEYOND 16 WEEKS:RESIDUAL DEFICITS IF ANY CORRECTED PASSIVE FLEXOR TENDON PROTOCOL ….CONTD….

31. 24-48 HRS POST OP:DORSAL BLOCK SPLINTING,PASSIVE AND ACTIVE EXTENSIONS STARTTED WITHIN THE SPLINT 24-72 HRS POST OP TO 4 WEEKS:ACTIVE EXERCIZES IN A HINGED TENODESIS SPLINT AND DORSAL BLOCK SPLINT RE-APPLIED AFTER EACH EXERCIZE SESSION EARLY ACTIVE MOTION PROTOCOL

32. 4-6 WK POST OP:ACTIVE EXERCIZES DONE OUTSIDE THE SPLINT 6-8 WKS POST OP:SPLINT DISCONTINUED 8-9 WKS POST OP:LIGHT STRENGTHENING EXERCIZES BEGUN 10-14 WKS POST OP:PROGRESSIVE RESISTIVE STRENGTHENING EXERCIZES BEGUN. BEYOND 14 WKS:RETURN TO FULL UNRESTRICTED ACTIVITY AT 14 WKS EARLY ACTIVE MOTION PROTOCOL …CONTD…

33. SUCCESSFUL RESULTS REQUIRE PRECISE SURGICAL TECHNIQUE AND STRICT ADHERENCE TO REHABILITATION PROGRAM. CONCLUSION

34. THANK YOU