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Flexor Tendon Injuries
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Introduction
Muscles insert in bones via tendons
Tendons
white fibrous cords that are lined with aloose tissue (paratenon) & whichsometimes run through a fibrous tube(tendon sheath)
have the ability to glide over bone andthrough tissues
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Introduction
Muscle contraction transmitted via
tendons causing intervening joints to
move Muscles that bend the fingers and
wrist "flexor"
Muscles that straighten the fingersand wrist "extensors"
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Anatomy
Flexor systems : Fingers 2 tendons
thumb 1 tendon
Blood supply viaMesotenon VincularSystem
Retinacular pulleysystem
to keep the flexortendons approximatedto the underlying bonystructures
Mechanical leverage forfull fingers motion
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Vascularization
tendons are able to obtain theirnutrients from two different sources :
direct blood supply
the synovial fluid
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Zone of Fingers
Flexor TendonsVerdanclassification :
1. Zone I :extends fromdistal ins/ of FDS to theins/ of FDP
2. Zone II:extends from
the midportion of themiddle phalang to theneck of MC
3. Zone III:extends fromthe prox neck of MC to thedistal edge transverse
carpal ligament4. Zone IV:the region
under the transversecarpal ligament
5. Zone V:proximal to thecarpal canal
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Zone of Flexor
Tendons in Thumb
Verdanclassification : Zone I :distal at the
insertion of the flexortendon
Zone II:from the neck ofprox.phalang to the neck ofMC (within the flexorretinaculum of the thumb)
Zone III :the area of thethenar muscle
Zone IV :the region ofcarpal canal
Zone V :proximal totheproximal edge of the carpalligament
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Tendon Injuries
caused by : involving sharp things (open injury)
overstressed in sports (closed injury)
damage to single or multiple tendons
immediate loss of its function
need cerefully assessment
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Position
The normal cascade
Hand Posture when relaxedthe thumb-tip held slightly
flexed
fingers held in a cascade
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Active movement
use the tendon by moving or tensing the relevant joint
flexion of the fingers loss of active movement
at the tip of the ring finger (closed FDP rupture)
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Passive movement
assessed by gentlepressure over themuscles in theforearm somemovement of therelevant tendon
an alternative wayto move thewrist
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Tendon Healing
An early time :
Process in which paratendinous tissuesinvaded the healing area
Determining factors :
Age
Mechanism & extent of the injuryLevel of the tendon laceration
Individual healing respons
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Tendon Healing
Two mechanisms Intrinsic healingmediated by the epitenon
with cell migration into the depths of the repairsite
Extrinsic healingdependent upon ingrowthof cells from outside the tendon
The extrinsic is less desirable
adhesion formation (lacerated edge of thetendon)
leading to restricted tendon gliding
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Classification
BoyesPreoperative Classification : Grade I : Good
Minimal scar w/ mobile joints
No trophic changes Grade II : Cicatrix
Heavy skin scarring due to injury / surgery
Deep scarring due to failed primary repair /
infection Grade III : Joint Damage
Injury to the joint
Restricted ROM
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Classification
Grade IV : Nerve Damage
Injury to the digital nerves
Trophic changes in the finger
Grade V : Multiple Damage Involvement of multiple fingers
Combination of problems
(cicatrix-joint damage-nerve damage)
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Tendon Reconstruction
The soonerreconstructive the more
likely will return to full function
The latereconstructive :
missed injuries
severely contaminated wounds
severely damaged soft tissues
patients not tolerate by acute treatment
failure of primary reconstructive efforts
considered 3 weeksafter injury
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Flexor Tendon Reconstruction
Type of incision
Principle :
1. Timing
2. Staging
3. Technique
4. Suture & Matl
5. Post Op Prog
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Options for Late Reconstructive
direct repair
tenolysis
one- or two-stage grafting tendon transfer
tendon advancement with or without
tendon lengthening
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Direct Repair
contraction of the musculotendinous
scar tissue within the flexor sheath
in the thumb (even >3 months after
injury) some loss of excursion & IP jointmotion is well-tolerated
has no lumbricales
its flexor sheath has only three pulleys
only one flexor tendon within the sheath
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Direct Repair
In the fingers upto 4 weeks frominjury
If tendon retractionis significant, oneoption islengthening
With or without atendon graft ortransfer
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Tenolysis
Indication : surgical release of
non-gliding &
localized adhesion limitation of active
motion
risk of further
decreased thevascular supply &innervation
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Tenolysis
After repair treating a stiff digit(combination of joint contracture &adhesion)
Adhesions in the repair site orresult of edema & immobility of anuninjured digit
not performed prior to 3 monthsfrom repair
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Tendon Grafting
Indication : (i) the ends have retracted apart and
shortened
(ii) the tendons become stuck to the sheath
(iii) the sheath narrows Donor Site :
PL
Plantaris
Foot Flexor & Extensor EIP
FDS
Allograft
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Tendon Transfer
Principles : Mobile Joints, skin & soft tissue
contractures
Adequate power
Sufficient
Maximal work capacity of Power
An adequate length
A satisfactory line of pull should beachieved
An adequate glide
Functional integrity must be preserved
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Tendon Transfer
Surgical Consideration : Timing Planning Technique Joinning the tendons
Achieving proper tensile
Failed of Reconstruction : Infection Tendon exposed
Stiffness Rupture Scar Nerve damage
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Rehabilitation
Mobilization affects the mechanism oftendon healing :
motion interrupts the tendon and the periphery
motion stimulates the epitenon & promotesdifferentiation between the tendon and thesheath
Early mobilization resulting in tensilestrength improved tendon gliding
Tendon mobilization stimulates intrinsichealing & limits extrinsic healing
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Rehabilitation
Program For 4 :
4 passiveflexions
4 active flexions
4 activeextensions
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Thanks