EXTENSOR TENDON EXTENSOR TENDON INJURIESINJURIES

EXTENSOR TENDON INJURIESEXTENSOR TENDON INJURIES EXTENSOR TENDONS ARE PREDISPOSED TO EXTENSOR TENDONS ARE PREDISPOSED TO

LACERATIONLACERATION1. DUE TO SUPERFICIAL LOCATION ON 1. DUE TO SUPERFICIAL LOCATION ON DORSUM DORSUM

OF HANDOF HAND2. MINIMAL AMOUNT OF SUBCUT. TISSUE 2. MINIMAL AMOUNT OF SUBCUT. TISSUE

BETWEEN TENDONS AND OVERLYING SKINBETWEEN TENDONS AND OVERLYING SKIN RESULTS OF TREATMENT ARE NOT ALWAYS AS RESULTS OF TREATMENT ARE NOT ALWAYS AS FAVORABLE AS ONCE ASSUMEDFAVORABLE AS ONCE ASSUMED

EXTENSOR MECHANISMEXTENSOR MECHANISM

ANATOMYANATOMY EXTENSOR TENDON ON THE DORSUM OF THE EXTENSOR TENDON ON THE DORSUM OF THE

HAND TO THE LEVEL OF THE MCPJ ARE HAND TO THE LEVEL OF THE MCPJ ARE COMPOSED OF MUSCULOTENDINOUS UNITSCOMPOSED OF MUSCULOTENDINOUS UNITS

TENDONS RADIAL ===> ULNAR TENDONS RADIAL ===> ULNAR EPB,EPL,EIP,EDC,EDQMEPB,EPL,EIP,EDC,EDQM

GAIN ACCESS BY PASSING THROUGH FIBRO-GAIN ACCESS BY PASSING THROUGH FIBRO-OSSEOUS TUNNELS AT THE WRIST LEVEL, AND OSSEOUS TUNNELS AT THE WRIST LEVEL, AND AT THIS LEVEL ARE COVERED BY AT THIS LEVEL ARE COVERED BY TENOSYNOVIUMTENOSYNOVIUM

ANATOMYANATOMY NEAR THE MIDPORTION OF THE METACARPALS, NEAR THE MIDPORTION OF THE METACARPALS,

JUNCTURA TENDINUM PASS DISTALLY AND JUNCTURA TENDINUM PASS DISTALLY AND OBLIQUELY BETWEEN THE ULNAR THREE EDC OBLIQUELY BETWEEN THE ULNAR THREE EDC TENDONSTENDONS

COMPARTMENTS PREVENT EXT. TENDONS FROM COMPARTMENTS PREVENT EXT. TENDONS FROM BOWSTRINGING DORSALLY DURING ACTIVE BOWSTRINGING DORSALLY DURING ACTIVE FINGER EXTESION, PARTICULLARLY WHEN WRIST FINGER EXTESION, PARTICULLARLY WHEN WRIST IS EXTENDEDIS EXTENDED

JUNCTURA RESULT IN GROUPED EDC JUNCTURA RESULT IN GROUPED EDC EXTENSION, ESPECIALLY AT THE ULNAR ASPECT EXTENSION, ESPECIALLY AT THE ULNAR ASPECT OF THE HANDOF THE HAND

ANATOMYANATOMY AT THE MPJ LEVEL THE EIP AND EDC TO THE INDEX AT THE MPJ LEVEL THE EIP AND EDC TO THE INDEX

JOIN TOGETHER THE TENDONS AND ARE JOIN TOGETHER THE TENDONS AND ARE CENTRALIZED OVER THE DORSUM OF THE MPJ BY CENTRALIZED OVER THE DORSUM OF THE MPJ BY SAGITAL BANDSSAGITAL BANDS

TRANSVERSE FIBERS CONNECT THE LATERAL TRANSVERSE FIBERS CONNECT THE LATERAL MARGINS OF THE EXT TENDONS TO THE PALMAR MARGINS OF THE EXT TENDONS TO THE PALMAR PLATES OF THE MPJ AND TO THE PERIOSTEUM OF THE PLATES OF THE MPJ AND TO THE PERIOSTEUM OF THE PROXIMAL PHALLYNXPROXIMAL PHALLYNX

DISTAL TO THE SAGITTAL BANDS ARE TRANSVERSE DISTAL TO THE SAGITTAL BANDS ARE TRANSVERSE AND OBLIQUE FIBERS===>INITIAL CONTRIBUTIONS AND OBLIQUE FIBERS===>INITIAL CONTRIBUTIONS OF THE INTEROSSEOUS MM TO THE DORSAL OF THE INTEROSSEOUS MM TO THE DORSAL APPARATUSAPPARATUS

ANATOMYANATOMY DISTAL TO THE MPJ THE DIGITAL EXTENSOR DISTAL TO THE MPJ THE DIGITAL EXTENSOR

MECHANISM CONSISTS OF BOTH INTRINSIC AND MECHANISM CONSISTS OF BOTH INTRINSIC AND EXTRINSIC MUSCULOTENDINOUS UNITSEXTRINSIC MUSCULOTENDINOUS UNITS

AT THE MPJ LEVEL ALL COMPONENTS OF INTRINISIC AT THE MPJ LEVEL ALL COMPONENTS OF INTRINISIC MUSCLES ARE PALMAR TO THE AXIS OF ROTATION MUSCLES ARE PALMAR TO THE AXIS OF ROTATION AND SERVE AS MPJ FLEXORSAND SERVE AS MPJ FLEXORS

DISTAL TO THE MPJ EXTRINSIC AND INTRINSIC DISTAL TO THE MPJ EXTRINSIC AND INTRINSIC TENDONS JOIN TOGETHER FORMING THE DORSAL TENDONS JOIN TOGETHER FORMING THE DORSAL APPARATUSAPPARATUS

CONTINUATION OF THE EXTRINSIC EXTENSOR IS THE CONTINUATION OF THE EXTRINSIC EXTENSOR IS THE CENRAL SLIP WHICH INSERTS ON THE BASE OF THE CENRAL SLIP WHICH INSERTS ON THE BASE OF THE MIDDLE PHALLYNXMIDDLE PHALLYNX

ANATOMYANATOMY INTRINSIC TENDONS FORM THE LATERAL INTRINSIC TENDONS FORM THE LATERAL

BANDS WHICH SEND FIBERS MEDIALLY TO BANDS WHICH SEND FIBERS MEDIALLY TO FORM PART OF THE CENTRAL SLIPFORM PART OF THE CENTRAL SLIP

LATERAL BANDS JOIN ON THE DORSUM OF THE LATERAL BANDS JOIN ON THE DORSUM OF THE MIDDLE PHALLYNX FORMING THE CONJOIN MIDDLE PHALLYNX FORMING THE CONJOIN TENDON AND INSERTS ON THE BASE OF THE TENDON AND INSERTS ON THE BASE OF THE DISTAL PHALLYNXDISTAL PHALLYNX

VERDENS EXTENSOR VERDENS EXTENSOR ZONES ZONES

OPEN INJURIESOPEN INJURIESDISTAL FOREARM AND WRIST (ZONE 8 & DISTAL FOREARM AND WRIST (ZONE 8 &

7)7)

DEEP LACERATIONS USUAL CAUSE AT THIS LEVELDEEP LACERATIONS USUAL CAUSE AT THIS LEVEL TENDONS MAY RETRACT WELL PROXIMAL INTO TENDONS MAY RETRACT WELL PROXIMAL INTO

THE FOREARMTHE FOREARM LACERATIONS OF THE SUPERFICIAL RADIAL LACERATIONS OF THE SUPERFICIAL RADIAL

BRANCHES AND LATERAL ANTEBRACHIAL BRANCHES AND LATERAL ANTEBRACHIAL CUTANEOUS NERVES ARE COMMONLY ASSOC.CUTANEOUS NERVES ARE COMMONLY ASSOC.

SURGICAL APPROACH REQUIRES LONGITUDINAL SURGICAL APPROACH REQUIRES LONGITUDINAL EXPOSUREEXPOSURE

4-0 NONABSORBABLE SUTURE WITH KNOTS 4-0 NONABSORBABLE SUTURE WITH KNOTS BURIEDBURIED

DISTAL FOREARM AND WRISTDISTAL FOREARM AND WRISTZONE 8 & 7 CONT.ZONE 8 & 7 CONT.

SPECIFIC PROBLEMS OCCUR AT THE LEVEL OF SPECIFIC PROBLEMS OCCUR AT THE LEVEL OF THE EXTENSOR RETINACULUMTHE EXTENSOR RETINACULUM1. COMPARTMENTS ARE WELL DEFINED BY A 1. COMPARTMENTS ARE WELL DEFINED BY A

RETINACULUM AND SEPTA BOTH OF WHICH RETINACULUM AND SEPTA BOTH OF WHICH APPROXIMATE TENDONS CLOSELYAPPROXIMATE TENDONS CLOSELY 2. COMPARTMENTS MAY HAVE TO BE OPENED, 2. COMPARTMENTS MAY HAVE TO BE OPENED, OR A PORTION EXCISED TO RETRIEVE OR A PORTION EXCISED TO RETRIEVE RETRACTED ENDS AND ACCOMMODATE BULK RETRACTED ENDS AND ACCOMMODATE BULK OF TENDON REPAIROF TENDON REPAIR

OPEN INJURIESOPEN INJURIESZONE 8 & 7 POST-OP CAREZONE 8 & 7 POST-OP CARE

WRIST SPLINTED 20 DEGREES EXT. AND MP JOINTS WRIST SPLINTED 20 DEGREES EXT. AND MP JOINTS NEUTAL 10 DAYSNEUTAL 10 DAYS

SPLINT CHANGED TO ALLOW MPJ 30-40 DEGREES 4 SPLINT CHANGED TO ALLOW MPJ 30-40 DEGREES 4 WEEKSWEEKS

SPLINT REMOVED TO BEGIN PROTECTED AROM SPLINT REMOVED TO BEGIN PROTECTED AROM UNTIL 6 WEEKS POST-OPUNTIL 6 WEEKS POST-OP

MULTIPLE TENDON INJURIES:MULTIPLE TENDON INJURIES:1. DYNAMIC EXTENSION SPLINTING AS SOON AS 1. DYNAMIC EXTENSION SPLINTING AS SOON AS

LOCAL WOUND PERMITS.LOCAL WOUND PERMITS. 2. STATIC HAND AND WRIST SPLINT 4 WEEKS 2. STATIC HAND AND WRIST SPLINT 4 WEEKS AFTER SURGERYAFTER SURGERY 3. PERIODIC REMOVAL WITH AROM 6 WEEKS P/O3. PERIODIC REMOVAL WITH AROM 6 WEEKS P/O

OPEN INJURIESOPEN INJURIESZONE 6ZONE 6

TENDONS VERY SUPERFICIALTENDONS VERY SUPERFICIAL ASSOC INJURIES WITH PARATENON AND ASSOC INJURIES WITH PARATENON AND

PERIOSTEUM RESULT IN INC. ADHESIONSPERIOSTEUM RESULT IN INC. ADHESIONS ASSCO LACS OF BRANCHES OF SUP RADIAL ASSCO LACS OF BRANCHES OF SUP RADIAL

AND DORSAL ULNAR N.AND DORSAL ULNAR N. TENDONS ARE ROUND OR OVAL AND WILL TENDONS ARE ROUND OR OVAL AND WILL

ACCEPT KESSLER STITCH, 4-0 ACCEPT KESSLER STITCH, 4-0 NONABSORBABLENONABSORBABLE

OPEN INJURIESOPEN INJURIESZONE 6 POST OPZONE 6 POST OP

STATIC SPLINT WRIST 30 DEG EXT, MP STATIC SPLINT WRIST 30 DEG EXT, MP NEUTRAL 10 DAYSNEUTRAL 10 DAYS

SPLINT CHANGE AT 10 DAYS, FLEXING MPJ AT SPLINT CHANGE AT 10 DAYS, FLEXING MPJ AT 30 DEGREES30 DEGREES

4 WEEKS PERIODIC REMOVAL OF SPLINT, 4 WEEKS PERIODIC REMOVAL OF SPLINT, AROMAROM

D/C SPLINT AT 6 WEEKSD/C SPLINT AT 6 WEEKS SPLINT ALL THREE ULNAR DIGITS IF ONE OR SPLINT ALL THREE ULNAR DIGITS IF ONE OR

MORE INJURED, IF & THUMB TREATED INDEP.MORE INJURED, IF & THUMB TREATED INDEP.

OPEN INJURIESOPEN INJURIESMETACARPOPHALANGEAL JOINT METACARPOPHALANGEAL JOINT

LEVEL (ZONE 5)LEVEL (ZONE 5) LACERATIONS READILY ENTER THE JOINTLACERATIONS READILY ENTER THE JOINT MUST CONSIDER HUMAN BITE AT THIS LEVELMUST CONSIDER HUMAN BITE AT THIS LEVEL RADIOGRAPHS TO ASSESS METACARPAL HEAD RADIOGRAPHS TO ASSESS METACARPAL HEAD

ARE ESSENTIALARE ESSENTIAL OPEN JOINT INJURIES SECONDARY TO HUMAN OPEN JOINT INJURIES SECONDARY TO HUMAN

BITES REQUIRE THOROUGH DEBRIDEMENT AND BITES REQUIRE THOROUGH DEBRIDEMENT AND PARENTERAL ANTIBIOTICSPARENTERAL ANTIBIOTICS

TENDON ENDS DO NOT RETRACT AT THIS LEVELTENDON ENDS DO NOT RETRACT AT THIS LEVEL LACERATION MAY BE PROXIMAL TO SKIN LAC LACERATION MAY BE PROXIMAL TO SKIN LAC

DUE TO FLEXED MPJDUE TO FLEXED MPJ

OPEN INJURIESOPEN INJURIESMETACARPOPHALANGEAL JOINT METACARPOPHALANGEAL JOINT

LEVEL (ZONE 5)LEVEL (ZONE 5) LACERATIONS READILY ENTER THE JOINTLACERATIONS READILY ENTER THE JOINT MUST CONSIDER HUMAN BITE AT THIS LEVELMUST CONSIDER HUMAN BITE AT THIS LEVEL RADIOGRAPHS TO ASSESS METACARPAL HEAD RADIOGRAPHS TO ASSESS METACARPAL HEAD

ARE ESSENTIALARE ESSENTIAL OPEN JOINT INJURIES SECONDARY TO HUMAN OPEN JOINT INJURIES SECONDARY TO HUMAN

BITES REQUIRE THOROUGH DEBRIDEMENT AND BITES REQUIRE THOROUGH DEBRIDEMENT AND PARENTERAL ANTIBIOTICSPARENTERAL ANTIBIOTICS

TENDON ENDS DO NOT RETRACT AT THIS LEVELTENDON ENDS DO NOT RETRACT AT THIS LEVEL LACERATION MAY BE PROXIMAL TO SKIN LAC LACERATION MAY BE PROXIMAL TO SKIN LAC

DUE TO FLEXED MPJDUE TO FLEXED MPJ

OPEN INJURIESOPEN INJURIESMETACARPOPHALANGEAL JOINT METACARPOPHALANGEAL JOINT

LEVEL (ZONE 5)LEVEL (ZONE 5) LACERATIONS READILY ENTER THE JOINTLACERATIONS READILY ENTER THE JOINT MUST CONSIDER HUMAN BITE AT THIS LEVELMUST CONSIDER HUMAN BITE AT THIS LEVEL RADIOGRAPHS TO ASSESS METACARPAL HEAD RADIOGRAPHS TO ASSESS METACARPAL HEAD

ARE ESSENTIALARE ESSENTIAL OPEN JOINT INJURIES SECONDARY TO HUMAN OPEN JOINT INJURIES SECONDARY TO HUMAN

BITES REQUIRE THOROUGH DEBRIDEMENT AND BITES REQUIRE THOROUGH DEBRIDEMENT AND PARENTERAL ANTIBIOTICSPARENTERAL ANTIBIOTICS

TENDON ENDS DO NOT RETRACT AT THIS LEVELTENDON ENDS DO NOT RETRACT AT THIS LEVEL LACERATION MAY BE PROXIMAL TO SKIN LAC LACERATION MAY BE PROXIMAL TO SKIN LAC

DUE TO FLEXED MPJDUE TO FLEXED MPJ

OPEN LACERATIONSOPEN LACERATIONSMETACARPOPHALANGEAL JOINT METACARPOPHALANGEAL JOINT

ZONE 5ZONE 5 OBLIQUE LACERATIONS MAY INCLUDE SAGITTAL OBLIQUE LACERATIONS MAY INCLUDE SAGITTAL

BANDS, SHOULD BE CAREFULLY SUTURED TO BANDS, SHOULD BE CAREFULLY SUTURED TO PREVENT LATERAL MIGARATION OF THE EDCPREVENT LATERAL MIGARATION OF THE EDC

SIMPLE LACERATIONS WHICH EXTEND INTO JT.SIMPLE LACERATIONS WHICH EXTEND INTO JT.1. CAREFUL INSPECTION AND I&D OF JOINT 1. CAREFUL INSPECTION AND I&D OF JOINT

CLOSURE AS SEPARATE LAYTER 4-0 CLOSURE AS SEPARATE LAYTER 4-0 ABSORBABLE SUTUREABSORBABLE SUTURE

2. JOINT CONTAMINATED: PORTION OF CAPSULE 2. JOINT CONTAMINATED: PORTION OF CAPSULE EXCISED AND LEFT OPEN, WICK 48HRS, IV EXCISED AND LEFT OPEN, WICK 48HRS, IV

ABXABX

OPEN INJURIESOPEN INJURIESZONES 3 & 4 PIP JOINT LEVELZONES 3 & 4 PIP JOINT LEVEL

DORSAL APPARATUS THIS AND DORSAL APPARATUS THIS AND CIRCUMFERENTIALLY ORIENTEDCIRCUMFERENTIALLY ORIENTED

SIMPLE LACERATIONS SELDOM RESULT IN SIMPLE LACERATIONS SELDOM RESULT IN COMPLETE LACERATIONS OF DORSAL APP.COMPLETE LACERATIONS OF DORSAL APP.

ENDS DO NOT RETRACTENDS DO NOT RETRACT SIMPLE INJURIES RE-APPROX WITH 5-0 NONABSSIMPLE INJURIES RE-APPROX WITH 5-0 NONABS IF PARTIAL SUBSTANCE LOSS OF DORSAL APP.IF PARTIAL SUBSTANCE LOSS OF DORSAL APP.

1. BETTER TO ALLOW REMAINING TENDON 1. BETTER TO ALLOW REMAINING TENDON TO ASSUME NORMAL RESTING TENSION TO ASSUME NORMAL RESTING TENSION THAN TO APPROX. UNDER TENSION THAN TO APPROX. UNDER TENSION

OPEN LACERATIONSOPEN LACERATIONSPIPJ LEVEL ZONES 4 & 3PIPJ LEVEL ZONES 4 & 3

LACERATIONS DISTALLY INTO ZONE 3 MAY EXTEND LACERATIONS DISTALLY INTO ZONE 3 MAY EXTEND INTO PIPJINTO PIPJ

ZONE 3 LACERATIONS OCCUR WHERE THE ZONE 3 LACERATIONS OCCUR WHERE THE EXTENSORS AND LATERAL BANDS COMBINE TO EXTENSORS AND LATERAL BANDS COMBINE TO FORM THE CENTRAL SLIPFORM THE CENTRAL SLIP

OPEN INJURIES OF THE CENTRAL SLIP MAY CAUSE OPEN INJURIES OF THE CENTRAL SLIP MAY CAUSE ACUTE BOUTONIERE DEFORMITYACUTE BOUTONIERE DEFORMITY

PROGRESSION TO ADVANCED BOUTONNIERE PROGRESSION TO ADVANCED BOUTONNIERE DEFORMITY SHOULD NOT BE UNDERESTIMATEDDEFORMITY SHOULD NOT BE UNDERESTIMATED

EXPLORATION OF CENTRAL SLIP IS MANDATORYEXPLORATION OF CENTRAL SLIP IS MANDATORY PROTECTIVE SPLINTING ADVISEDPROTECTIVE SPLINTING ADVISED

OPEN LACERATIONSOPEN LACERATIONS ZONE 4 & 5ZONE 4 & 5

PARTIAL OR COMPLETE SIMPLE LACERATIONS, PARTIAL OR COMPLETE SIMPLE LACERATIONS, REPAIR WITH 5-0 NONABS. FIG-8 WITH NOT REPAIR WITH 5-0 NONABS. FIG-8 WITH NOT BURIEDBURIED

IF DISTAL STUMP TOO SMALL TO ACCEPT IF DISTAL STUMP TOO SMALL TO ACCEPT SUTURE==> ATTATCH PROXIMAL CENTRAL SUTURE==> ATTATCH PROXIMAL CENTRAL SLIP DIRECTLY TO DORSAL FLARE OF MIDDLE SLIP DIRECTLY TO DORSAL FLARE OF MIDDLE PHALANX WITH T-VERSE DRILL HOLESPHALANX WITH T-VERSE DRILL HOLES

IF EXT. TENDON LAC EXTENSIVE PRECLUDING IF EXT. TENDON LAC EXTENSIVE PRECLUDING DIRECT REPAIR, MAY RECONSTRUCT USING DIRECT REPAIR, MAY RECONSTRUCT USING PORTION OF THE LATERAL BANDSPORTION OF THE LATERAL BANDS

OPEN LACERATIONSOPEN LACERATIONSZONE 4 & 3 ZONE 4 & 3

PIVOTAL POINT IN REHAB FOR ZONE 4 & 3 PIVOTAL POINT IN REHAB FOR ZONE 4 & 3 INJURIES IS PREVENTION OF EARLY PIP INJURIES IS PREVENTION OF EARLY PIP FLEXION POSTUREFLEXION POSTURE

INCREASED TENSION IN THE REPAIRS AND INCREASED TENSION IN THE REPAIRS AND PALMAR MIGRATION OF THE LATERAL BANDS PALMAR MIGRATION OF THE LATERAL BANDS MUST BE AVOIDED ==> WILL OCCUR IF PIPJ IS MUST BE AVOIDED ==> WILL OCCUR IF PIPJ IS ALLOWED TO FLEXALLOWED TO FLEX

COMPLEX INJURIES/NONCOMPLIANT PATIENT COMPLEX INJURIES/NONCOMPLIANT PATIENT MAY REQUIRE K-WIRES TO TRANSFIX PIPJ IN MAY REQUIRE K-WIRES TO TRANSFIX PIPJ IN EXTENSIONEXTENSION

OPEN LACERATIONSOPEN LACERATIONSZONE 4 & 3ZONE 4 & 3

K-WIRES NEED TO BE REMOVED 3 WEEKSK-WIRES NEED TO BE REMOVED 3 WEEKS EXTERNAL SPLINTING ADDITIONAL 3-4 WEEKSEXTERNAL SPLINTING ADDITIONAL 3-4 WEEKS RUBBER-BAND OR SPRING LOADED REVERSE RUBBER-BAND OR SPRING LOADED REVERSE

KNUCKLE BENDERS ARE USED TO MAINTAIN KNUCKLE BENDERS ARE USED TO MAINTAIN EXTENSION WHILE ALLOWING ACTIVE FLEXION EXTENSION WHILE ALLOWING ACTIVE FLEXION EXERCISES AFTER TOTAL OF 6 WEEKS EXERCISES AFTER TOTAL OF 6 WEEKS INTERNAL/EXTERNAL STATIC SPLINTINGINTERNAL/EXTERNAL STATIC SPLINTING

ALL SPLINTING IS DISCONTINUED AT 8 WEEKSALL SPLINTING IS DISCONTINUED AT 8 WEEKS IF PLASTER SPLINTING: WRIST EXT 30 DEG. MP IF PLASTER SPLINTING: WRIST EXT 30 DEG. MP

FLEXED 30 DEG. AND PIPJ IS IN NEUTRALFLEXED 30 DEG. AND PIPJ IS IN NEUTRAL

OPEN INJURIESOPEN INJURIESMIDDLE PHALANGEAL AND DIPJMIDDLE PHALANGEAL AND DIPJ

ZONES 2 & 1 ZONES 2 & 1 LATERAL BANDS BLEND DORSALLY TO FORM THE LATERAL BANDS BLEND DORSALLY TO FORM THE

CONJOINT TENDON, THEY ARE THIN AND CONJOINT TENDON, THEY ARE THIN AND ORIENTED AROUND THE DORSAL HALF OF THE ORIENTED AROUND THE DORSAL HALF OF THE MIDDLE PHALLYNXMIDDLE PHALLYNX

SIMPLE LACS SELDOM TRANSECT ALL DORSAL SIMPLE LACS SELDOM TRANSECT ALL DORSAL APP.APP.

READILY APPROX. WITH FIG. 8 NONABSORB. SUT.READILY APPROX. WITH FIG. 8 NONABSORB. SUT. IF SEGMENTAL LOSS OF PART OF THE APPARATUS IF SEGMENTAL LOSS OF PART OF THE APPARATUS

IT MAY BE BETTER TO ALLOW REMAINING INTACT IT MAY BE BETTER TO ALLOW REMAINING INTACT TENDON TO ASSUME NORMAL RESTING TENSIONTENDON TO ASSUME NORMAL RESTING TENSION

OPEN INJURIESOPEN INJURIESMID PHALANGEAL AND DIPJMID PHALANGEAL AND DIPJ

ZONE 1: CONJOINT TENDON IS WELL DEFINED ZONE 1: CONJOINT TENDON IS WELL DEFINED AND DORSALLY POSITIONEDAND DORSALLY POSITIONED

COMPLEX LACS WILL RESULT IN FLEXED DIPJ 40 COMPLEX LACS WILL RESULT IN FLEXED DIPJ 40 DEG.DEG.

INCOMPLETE LACS ==> FLEXED DIPJ 15 DEG. INCOMPLETE LACS ==> FLEXED DIPJ 15 DEG. AND EXT. WEAKNESSAND EXT. WEAKNESS

REPAIRED WITH FIG 8 NONABS.REPAIRED WITH FIG 8 NONABS.1. SEPARATE LAYER CLOSURE1. SEPARATE LAYER CLOSURE2. RUNNING STITCH WITH BOTH SKIN & 2. RUNNING STITCH WITH BOTH SKIN & TENDONTENDON

ZONE 1 AND 2 REHABZONE 1 AND 2 REHAB CONTINUOUS SPLINTING WITHOUT EXCEPTION CONTINUOUS SPLINTING WITHOUT EXCEPTION

IN FULL EXTENSION FOR 6 WEEKSIN FULL EXTENSION FOR 6 WEEKS PROTECTED AROM EXERCISES AFTER SPLINT PROTECTED AROM EXERCISES AFTER SPLINT

REMOVALREMOVAL NONCOMPLIANT PATIENTS : 0.O45 K-WIRE FOR NONCOMPLIANT PATIENTS : 0.O45 K-WIRE FOR

6 WEEKS, FOLLOWED BY PROTECTED, AROM 6 WEEKS, FOLLOWED BY PROTECTED, AROM FOR 2 WEEKSFOR 2 WEEKS

CLOSED INJURIESCLOSED INJURIES CENTRAL SLIP AND THE CONJOINT TENDON INSERT CENTRAL SLIP AND THE CONJOINT TENDON INSERT

INTO THE DORSAL BONY PROMINENCES OF THE INTO THE DORSAL BONY PROMINENCES OF THE MIDDLE AND DISTAL PHALANGESMIDDLE AND DISTAL PHALANGES

DIRECT, DEEP CONTUSIONS OR JOINT INJURIES MAY DIRECT, DEEP CONTUSIONS OR JOINT INJURIES MAY AVULSE THESE TENDONS AT THEIR INSERTIONSAVULSE THESE TENDONS AT THEIR INSERTIONS

CENTRAL SLIP INJURED: CLOSED BOUTONNIERE CENTRAL SLIP INJURED: CLOSED BOUTONNIERE DEFORMITYDEFORMITY

CONJOINT TENDON INJURED: CLOSED MALLET CONJOINT TENDON INJURED: CLOSED MALLET DEFORMITYDEFORMITY

OFTEN MISSED OR UNDERTREATEDOFTEN MISSED OR UNDERTREATED

BOUTONNIERE DEFORMITYBOUTONNIERE DEFORMITY THREE MECHANISMS OF INJURY TO PIPJOINT WILL THREE MECHANISMS OF INJURY TO PIPJOINT WILL

RESULT IN DISRUPTION OF THE CENTRAL SLIP RESULT IN DISRUPTION OF THE CENTRAL SLIP 1. DEEP CONTUSION ABOUT DORSUM OF PIPJ1. DEEP CONTUSION ABOUT DORSUM OF PIPJ2. ACUTE FORCEFUL FLEXION OF PIPJ2. ACUTE FORCEFUL FLEXION OF PIPJ3. PALMAR DISLOCATION OF PIPJ3. PALMAR DISLOCATION OF PIPJ

THESE INJURIES RESULT NOT ONLY IN CENTRAL THESE INJURIES RESULT NOT ONLY IN CENTRAL SLIP DISRUPTION BUT PALMAR MIGRATION OF SLIP DISRUPTION BUT PALMAR MIGRATION OF THE LATERAL BANDSTHE LATERAL BANDS

PULL OF INTRINSICS ARE FOCUSED ON THE DIPJ PULL OF INTRINSICS ARE FOCUSED ON THE DIPJ CAUSING DIPJ HYPEREXTENSIONCAUSING DIPJ HYPEREXTENSION

BOUTONNIERE DEFORMITYBOUTONNIERE DEFORMITY

BOUTONNIERE DEFORMITYBOUTONNIERE DEFORMITY OFTEN NOT APPARENT FOR 7-14 DAYSOFTEN NOT APPARENT FOR 7-14 DAYS INITIALLY ASSOC WITH PAINFUL SWOLLEN PIPJINITIALLY ASSOC WITH PAINFUL SWOLLEN PIPJ EARLY FINDINGSEARLY FINDINGS

1. PAINFUL SWOLLEN PIPJ1. PAINFUL SWOLLEN PIPJ2. MILD EXTENSION LAG (15-25 DEGREES)2. MILD EXTENSION LAG (15-25 DEGREES)3. DECREASED EXTENSION AGAINST 3. DECREASED EXTENSION AGAINST RESISTANCERESISTANCE

BOUTONNIERE BOUTONNIERE TREATMENTTREATMENT

KEY : MAINTAINING PIPJ IN CONSTANT COMPLETE KEY : MAINTAINING PIPJ IN CONSTANT COMPLETE EXTTENSIONEXTTENSION

POSITIONING DOES NOT REQUIRE SPLINTING DIP POSITIONING DOES NOT REQUIRE SPLINTING DIP OR MPJ IN ANY SPECIFIC POSISTIONOR MPJ IN ANY SPECIFIC POSISTION

CONTINUOUS SPLINTING 6 WEEKSCONTINUOUS SPLINTING 6 WEEKS IF ANY EVIDENCE OF RECURRANCE OF EXT LAG. IF ANY EVIDENCE OF RECURRANCE OF EXT LAG.

==> CONT. SPLINTING TOTAL OF 8 WEEKS==> CONT. SPLINTING TOTAL OF 8 WEEKS MAY OCCURE WITH AVULSION OF DORSAL LIP OF MAY OCCURE WITH AVULSION OF DORSAL LIP OF

MIDDLE PHALLYNX, REQUIRES OPEN TREATMENTMIDDLE PHALLYNX, REQUIRES OPEN TREATMENT

MALLET DEFORMITYMALLET DEFORMITY USUALLY OCCURS WHEN TIP OF FINGER IS USUALLY OCCURS WHEN TIP OF FINGER IS

STRUCK BY OR AGAINST AN OBJECT STRUCK BY OR AGAINST AN OBJECT RESULTING IN ACUTE FLEXION AT DIPJRESULTING IN ACUTE FLEXION AT DIPJ

MAY \MAY NOT OCCUR WITH AVULSION OF MAY \MAY NOT OCCUR WITH AVULSION OF SMALL FRAGMENTS OF BONESMALL FRAGMENTS OF BONE

NONOPERATIVE TREATMENT MOST WIDELY NONOPERATIVE TREATMENT MOST WIDELY USEDUSED

GOAL OF TREATMENT IS MAINTENANCE OF GOAL OF TREATMENT IS MAINTENANCE OF CONTINUOUS DIPJ EXTENSION UNTIL TENDON CONTINUOUS DIPJ EXTENSION UNTIL TENDON HEALSHEALS

MALLET DEFORMITYMALLET DEFORMITY

MALLET DEFORMITY MALLET DEFORMITY TREATMENTTREATMENT

IN COOPERATIVE PATIENT:IN COOPERATIVE PATIENT:1. CONTINUOUS SPLINTING FOR 6 WEEKS1. CONTINUOUS SPLINTING FOR 6 WEEKS2. FOLLOWED BY 2 WEEKS OF NIGHT SPLINTING2. FOLLOWED BY 2 WEEKS OF NIGHT SPLINTING3. SPLINTING MUST BE RESUMED IF EVIDENCE OF 3. SPLINTING MUST BE RESUMED IF EVIDENCE OF

RECURRENT EXTENSION LAGRECURRENT EXTENSION LAG4. OPEN CONJOINT TENDON INJURIES: 4. OPEN CONJOINT TENDON INJURIES:

TRANSFIXING DIPJ WITH 0.045 K WIRES FOR 6 TRANSFIXING DIPJ WITH 0.045 K WIRES FOR 6 WEEKSWEEKS

MALLET FINGER MALLET FINGER TREATMENTTREATMENT

SMALL DORSAL AVULSION FRAGMENTSSMALL DORSAL AVULSION FRAGMENTS1. DO NOT CONFUSE WITH HYPEREXTENSION 1. DO NOT CONFUSE WITH HYPEREXTENSION

INJURIES OF THE DIP WITH LARGE DORSAL INJURIES OF THE DIP WITH LARGE DORSAL FRAGMENTS, ASSOC WITH PALMAR SUBLUXTION FRAGMENTS, ASSOC WITH PALMAR SUBLUXTION OF DISTAL PHALANXOF DISTAL PHALANX

**TREATMENT OF SMALL DORSAL AVULSIONS **TREATMENT OF SMALL DORSAL AVULSIONS RESULTING FROM HYPERFLEXION WITH EXT RESULTING FROM HYPERFLEXION WITH EXT SPLINTING IS NONCONTROVERSIALSPLINTING IS NONCONTROVERSIAL **LARGE FX FRAGMENT FROM HYPEREXTENSION: **LARGE FX FRAGMENT FROM HYPEREXTENSION: TREATMENT SOMEWHAT CONTROVERSIAL. TREATMENT SOMEWHAT CONTROVERSIAL. MOST COMMONLY TREATED WITH ORIFMOST COMMONLY TREATED WITH ORIF

INJURY ZONE AND INJURY ZONE AND OUTCOME RELATIONSHIPOUTCOME RELATIONSHIP

ZONE 6 ( BACK OF HAND) KELLY NOTED NO ZONE 6 ( BACK OF HAND) KELLY NOTED NO POOR RESULTSPOOR RESULTS

20% POOR RESULTS AT LEVEL OF EXTENSOR 20% POOR RESULTS AT LEVEL OF EXTENSOR RETINACULUM AND OVER DORSUM OF THE RETINACULUM AND OVER DORSUM OF THE FINGERSFINGERS

ZONE 7 INJURIES AT EXTENSOR RETINACULUM ZONE 7 INJURIES AT EXTENSOR RETINACULUM HAVE IMPROVED HAVE IMPROVED

ZONE 3 &4 (PROXIMAL PHALANX AND PIPJ) ZONE 3 &4 (PROXIMAL PHALANX AND PIPJ) HAVE REMAINED PROBLEMATICHAVE REMAINED PROBLEMATIC

CONCLUSIONCONCLUSION FUNCTIONAL OUTCOMES AFTER EXTENSOR FUNCTIONAL OUTCOMES AFTER EXTENSOR

TENDON INJURIES HAVE RECEIVED LIMITED TENDON INJURIES HAVE RECEIVED LIMITED ATTENTIONATTENTION

PTS AS A GROUP WITH THIS INURY GENERALLY PTS AS A GROUP WITH THIS INURY GENERALLY EXPERIENCE DECREASE GRIP STRENGTH OF EXPERIENCE DECREASE GRIP STRENGTH OF 95% UNAFFECTED HAND95% UNAFFECTED HAND

APPROX. 95% PATIENTS EXPRESS APPROX. 95% PATIENTS EXPRESS SATISFACTIONSATISFACTION