extensor tendons injury and deformity

Extensor tendon injury

& associated deformities Dr Sumer YadavMch – Plastic and Reconstructive surgery

sumeryadav2004@gmail.com

ANATOMY OF EXTENSOR FORE ARM Proximal group: The

ECU,EDM,EDC,ECRL,ECRB tendons originate adjacent to the lateral epicondyle of the humerus and are innervated proximally

Distal group: The EPL,EIP,AbPL & EPB originate in the distal half of the forearm. There fore, a proximal laceration with loss of function in distal group probably represents a motor nerve injury.

Muscles of the Forearm lateral (Extensor Surface)

Outcropping Group Extensor Pollicis Brevis/

Abductor Pollicis Longus

Extensor pollicis longus

Medial GroupExtensor Carpi radialis

Bracioradialis

ARRANGEMENT OF EXTENSOR TENDONS AT WRIST The Extensor tendons gain entrance to

hand from the fore arm through a series of six canals, 5 fibro-osseus & 1 fibrous( the 5th dorsal compartment containing EDM)

The Communis tendons are joint distally near the MP joint by fibrous inter connections called Junturae Tendinum

The Proprius tendons( EIP&EDM) are independent finger extensors and they lie on the ulnar side of the their respective EDC tendons

EXTENSOR MECHANISM IN FINGER At the MP joint, the Extensor mechanism flattens into a

broad hood and envelops the dorsal third of proximal & middle phalanges

Fibers of the common extensor tendon blend with the fibers of lateral bands to form the central slip which inserts in the base of the middle phalanx & effects PIP joint extension

The central slip is kept in its dorsal position by the Transverse Retinacular ligament

The lateral bands are held dorsal to the axis of the PIP joint by fibers of the Triangular ligament

SORL originates on the palmer plate & flexion sheath beneath the PIP joint .These fibers move dorsally to insert in the terminal tendon. With PIP extension , fibers of the SORL tighten to assist DIP extension

MECHANICS OF HAND Two set of muscles, INTRINSIC (originating in the hand itself

& innervated by the Ulnar and Medial nerves) and EXTRINSIC (originating in the forearm & innervated by the Radial nerve) act synergistically

The extensor system prepares the hand for grasp & pinch by positioning the hand in various degrees of extension.

The most frequent activities of daily living occur in positions close to the position of function like holding a cup or writing with a pen. More specialized activities like grasping a large or a very small object occur at the extremes of extension & flexion

An Extensor tendon laceration results in the decrease in the extensor force distal to the injury. This force is then transferred to the joint proximal to the injury, resulting in a net increase of extensor force at that joint, which causes a change in that joint position leading to characteristic deformities

FULL FLEXION EXTENSION ARC

TENODESIS EFFECTDynamic Tenodesis is defined as the concept of movement at one joint transmitting power to an adjacent joint( usually distal)As the wrist flexes , the extensor tendons tighten and the flexor tendons relax, both actions serving to produce extension of the MP joints. The intrinsic tendons tighten with MP extension, augmenting PIP extensionThe lateral bands & the ORL are lax with PIP flexion and tighten with PIP extension. The Tenodesis effect of the ORL can be demonstrated by checking passive flexion of the DIP joint with the PIP joint in flexion and extension

ZONES OF INJURYZONE FINGER THUMBI DIP joint IP jointII Middle Phalanx Proximal PhalanxIII PIP joint MCP jointIV Proximal Phalanx MetacarpalV MCP joint Carpometacarpal

joint/ Radial StyloidVI Metacarpal VII Dorsal RetinaculamVIII Distal forearmIX Mid & Proximal forearm

Each zone in the fingers refers to an identical location. The thumb lacks a middle phalanx. Consequently the thumb zones I to V refer to different anatomic location relative to the fingers 60% of Tendon injuries occur in zone V to VIII ( MP joint to distal fore arm)Outcome is more favorable in zone V to VIII injury as compared to zone I to IV injuryMore than 50% of injuries have an associated injury such as fracture, dislocation or flexor tendon injury

CLINICAL EVALUATION

Testing for EDC, EIP & EDM musculotendinous functionThe proprius tendon to the index & little finger are capable of independent extension.Their function together can be evaluated with the middle & ring finger flexed into the palm , the proprius tendons can extend the ring & little finger

TESTING PROPRIUS TENDONS

With the middle & ring fingers flexed into the palm, the Proprius tendon can extend the index and little fingers

EPB tendon can be checked by placing a finger in the anatomical snuff box and asking the patient to extend the thumb in a flat position APL tendon can be checked by asking the patient to abduct the thumb against resistance

Evaluation of wrist extensors & deviators

Testing the EPL tendon

ZONE I INJURY Occurs at the DIP joint of the finger

or the IP joint of the thumb Mechanism of injury is usually

forced flexion of an actively extended distal joint

aka Mallet finger, Base ball finger, Dropped finger, or Extension lag

MALLET FINGER Mechanism : a blow from a thrown ball

strikes the tip of the finger--- ‘forced flexion’.

It tears the extensor tendon from its insertion +/- dorsal tip of distal phalanx

Clinically , there is extensor lag with localized DIP joint tenderness . The athlete is unable to extend the DIP

Investigation : radiographs to rule out fracture with volar subluxation

MALLET FINGER Management : continuous splint immobilization for 4

to 6 weeks in full extension Indications for surgery: open injuries, closed injuries

in a person who will be unable to work with a splint on e.g. health care worker and a large dorsal fragment with palmar subluxation of the distal fragment

Complications : skin ulceration is most common. Compensatory Swan neck deformity is known to occur.

Chronic Mallet injuries with compensatory swan neck deformity are reconstructed with SORL reconstruction techniques . Those chronic deformities which are painful, arthritic, and interfere with hand function are treated with DIP fusion

Zone I injury: Surgical Intervention

Placement of a permanent buried suture can be avoided by :

A. The tendon ends are incorporated with the interrupted skin sutures

B. The proximal end of the divided tendon is advanced into the insertion site with the use of a pull out suture tied over a bolster on the finger pad

Zone I injury: Surgical Intervention

Technique of extensor tendon repair at the DIP joint , in which the skin and the tendon are simultaneously approximated

SORL Reconstruction A. A Mallet deformity with compensatory swan neck deformityB&C. The Tendon graft is fixed to the distal phalanx with a pull out suture.The graft is passed between the flexor tendon sheath & the neurovascular bundles palmar to the PIP joint. The graft is tensioned & anchored into the shaft of the proximal phalanxSORL reconstruction is advocated for correction of a swan neck deformity which is secondary to a mallet finger

ZONE II INJURY Extensor tendon width is greater in zone II than

zone I & the extensor mechanism has two lateral bands which extend the distal phalanx

Lacerations of less than 50% of the tendon cut can be treated by skin closure alone, rest are repaired by a pull out suture technique

Typically seen in conjunction with sharp lacerations, saw injuries, and crushing injuries

The DIP is splinted in extension for 4 to 6 weeks Turrent Exostosis is a mass of bone formed

secondary to a periosteum injury in a zone II laceration. This mass limits DIP flexion and resection is the treatment of choice

Doyle’s repair : Sharp laceration of zone II repaired with a running suture and over sewn by a Silverskiold cross stitch

Immobilization Of Zone I & II injuries

Aluminum splint

Stack splint

ZONE III INJURY Disruption of the extensor apparatus at or just proximal to

the PIP joint results in a loss of extensor power at the PIP joint

Forced flexion of the PIP joint damages the central slip of the extensor tendon

After central slip disruption the triangular ligament stretches over time shifting the lateral bands in a volar direction

The head of the proximal phalanx ‘buttonholes’ through the extensor mechanism, creating the Boutonniere deformity

Lateral bands falling volar become PIP joint flexors instead of extensors while continuing to exert an extensor force on the DIP joint

Boutonniere deformity can be acute –(closed or open) and chronic

Boutonniere Deformity Right hand Ring finger sumeryadav2004@gmail.com

Patho mechanics of Boutonniere deformity: A. Attenuation of the central slip results in unopposed flexion at the PIP joint; B. With PIP flexion the lateral bands drift palmar( due to decreased support from the stretched triangular ligament) to the axis of rotation at the PIP joint sumeryadav2004@gmail.com

Chronic Boutonniere Deformity Burton & Melchior classification: Stage 1: supple, passively

correctable deformity Stage 2: fixed contracture:

contracted lateral bands Stage 3: fixed contracture: joint

fibrosis, collateral ligament & palmar plate contractures

Treatment plan in Boutonniere deformity Acute closed Boutonniere injuries:

extension splinting of PIP joint Acute open Boutonniere injuries: primary

repair ( Doyle’s, Snow’s, Aiche’s methods) Chronic Boutonniere deformity: Stage 1 &

2- therapy regimen of active assisted extension of the PIP joint combined with passive flexion of the DIP joint . Stage 3 – options include Tenotomy, Tendon grafting, Tendon relocation

Burton & Melchior’s guidelines for Boutonniere surgery Boutonniere reconstruction are most successful on

supple joints. If necessary, a joint release can be performed as a first stage.

An Arthritic joint usually precludes soft tissue reconstruction. The surgeon should consider either a PIP joint fusion or Arthroplasty with extensor tendon reconstruction

Boutonniere deformity rarely compromise PIP flexion & grip strength. Do not trade extension at the PIP joint for a stiff finger & a weak hand

Goal of Boutonniere reconstruction is to rebalance the extensor system by reducing extensor tone at the DIP joint and increasing tone at the PIP joint

Splinting is an important component of the post operative care; it may be necessary for several months

A Bunnell splint is applied to maintain extension at the PIP joint. The strap over the PIP joint is progressively tightened until the PIP joint is fully extended. The patient is encouraged to flex the DIP joint.sumeryadav2004@gmail.com

Reconstruction of Boutonnière

A. The boutonniere deformity with the lateral bands & ORL volar to the PIP joint

B. Dorsal zigzag incisionC. The ORL is separated from the lateral

bands & a tenotomy of the lateral bands is done distal to the central slip insertion

D. If active PIP extension is still not possible, the lateral bands are suture together, dorsal to the PIP joint

E. Sequence of eventsF. The PIP joint is fixed with a

transarticular K wireG. The mechanics of the reconstruction

Central slip laceration with sufficient tendon to repair with core suture & over sew with silverskiold epitendinous suture

When the tendon laceration is distal, leaving a small stump of central slip; the core suture can be passed through a trough in the base of the middle phalanx

Snow’s technique of central slip reconstruction ( distally based flap)

Aiche’s technique of central slip reconstruction (central halves of lateral bands)sumeryadav2004@gmail.com

Littler’s tendon graft technique: a thin graft is woven through the base of the middle phalanx and through the extensor tendon to restore extensor tone to the PIP joint

Extensor Tenotomy for Supple Boutonniere deformity

Dolphin or Fowler procedure: The lateral bands are released distal to the insertion of the central slips . The lateral resulting proximal migration of the extensor mechanism reduces tension at the DIP joint & increases extensor tension at the PIP joint

Post burn Boutonniere Defomity Primary damage is that of the central slip, leading

to the sliding of the lateral bands below the axis of rotation of the PIP joint

The lateral bands thus become PIP joints Flexors rather than extensors, and the PIP joint is flexed up to 90 degrees

The absence of Central slip allows the system to move proximally resulting in excessive pull on DIP joint causing its hyper extension

Before surgery its necessary to its necessary to eliminate the related contractures of other hand joints

There is a constant battle between the options of Tendoplasty vs Arthrodesis

Pseudo Boutonniere Deformity Flexion deformity of PIP joint, often

following an axial load injury Hyper extension injury to PIP joint Volar plate avulsion on X-ray with

volar PIP joint tenderness More common than Boutonniere

deformity Protected immobilization required

ZONE IV INJURY Partial zone IV injury is more common than

a complete laceration because the extensor mechanism is flat & it curves around the proximal phalanx

Often associated with a proximal phalanx fracture

Treatment is repair with modified Kessler’s suture using 4-0 braided polyester

Within 1 week of repair the patient is started on passive extension & active flexion

Dynamic splint in zone IV injuries

ZONE V INJURY A complete division of the extensor mechanism

in this zone is uncommon owing to the width of the tendon

A partial laceration with division of the central tendon is common because of the tendon’s prominence over the metacarpal head

The central tendon is repaired with a grasping suture & the hand is splinted in wrist extension & 30 degrees of MP flexion. The IP joint is allowed active motion

Sagittal band injury can also occur in zone V, can be either open or closed . Treatment of open injuries is straight forward exploration & repair

HUMAN BITE INJURIES Partial extensor tendon injuries over the MP joint

(zone V) are often caused by a punch to an opponent’s mouth, so called clench fist injury or fight bites

The tendon injury is proximal to the skin laceration because the MP joint is flexed at the time of injury

Bacterial growth consists of Streptococcus, Staphylococcus, Bacteroides & E.Corrodens

Treatment consists of prompt surgical exploration of the wound. The extensor tendon should be split longitudinally and the MP joint opened, cultured,& irrigated with antibiotic solution. Repair of lacerations is deferred ( usually 7 to 10 days) until the infection is cleared

Closed Sagittal band injuries (Extensor tendon subluxation) Result from direct blow, from forced MP joint

flexion or from daily activities such as flicking the finger or crumpling the paper

Symptoms range from pain & loss of MP joint motion to extensor tendon snapping or catching during finger flexion

Acute injuries that are 2 -3 week old can be treated with extension splinting of the MP joint

Patients who fail splint treatment or who have an injury more than 3 weeks old should be treated with direct repair of the Sagittal band

Methods of Extensor hood reconstruction

ZONE VI INJURY Have a better prognosis than distal injuries

because decreased surface area & increased subcutaneous tissue lessens adhesion formation and also there is greater tendon excursion with no complex tendon imbalances

Modified Bunnel or Kessler’s core suture supplanted with epitendinous sutures is the standard treatment

Complications after zone VI repair are loss of flexion, loss of extension, & tendon rupture in the order of frequency

ZONE VII INJURY There is almost always an associated injury

to the extensor Retinaculum Point in favor of excision of Retinaculum are

that it improves exposure & prevents friction between bulky repairs and the retinaculum while its preservation prevents bow stringing or subluxation of the extensor tendons

Treatment is same as zone VI in acute cases

Chronic injuries of zone VII Most common cause is attritional rupture

e.g. EPL rupture after distal radius fracture or with Rheumatoid Arthritis

Management is difficult as there is no Para Tenon in this region leading to retraction of the proximal tendon. Also, since the ends are frayed, end to end repair is not possible without unacceptable shortening of the musculotendinous unit & a loss of flexion

Tendon transfer or a graft is the standard treatment

Reconstruction after EPL rupture

Reconstructive options:1. The Palmaris longus tendon is

used as a intercalated graft2. EIP is transferred to the distal

end of EPL3. The Palmaris longus is

transferred around the radial side of the wrist to the EPL

ZONE VIII INJURY Includes ruptures of musculotendinous

junction and muscle belly lacerations Repair of these injuries is complicated

by the difficulty of placing sutures in the thin fascia overlying the muscle

When repair is not feasible, a side to side tendon transfer provides the best means to restore tendon function

ZONE IX INJURY Penetrating trauma in this region can be

accompanied by nerve injuries making assessment difficult

A proximal forearm laceration with a loss of distal muscle group function is probably a motor nerve injury rather than a tendon division

Multiple interrupted absorbable sutures are used to repair the Epimysium & fibrous intramuscular septum.

Suture repair of muscle lacerations have virtually no tensile strength. Post op treatment is 4 weeks of cast immobilization

Swan Neck Deformity

Hyper extension of PIP with flexion of DIP

Swan Neck Deformity Cause : Volar plate rupture at the PIP with often accompanying

triangular ligament rupture. Pathology :Lateral bands drift dorsally and exacerbate the

hyperextension at the PIP joint. They become ineffective in extension at the DIP joint and the unopposed action of the profundus causes flexion at the DIP joint.

Clinically : Causes “jamming” dislocations Immediately noticeable, if not immobilized will become surgical

finger. Treatment: involves SORL reconstruction

SURGICAL ASPECTSZONE SUTURE TECHNIQUE SUTURE MATERIALI & II Splint only none Skin with tendon (simple) 5-0 monofilament Tendon suture (Cross stitch) 6-0 monofilament Pull out tendon 4-0 monofilamentIII,IV & V Grasping tendon suture 4-0 braided synthetic +/- simple or cross stitch 6-0 monofilamentVI,VII & VIII Grasping core suture 4-0 braided synthetic + epitenon 6-0 monofilament Multiple slips to same digit 4-0 braided synthetic sutured together

Regional anaesthesia Brachial plexus block ( above

the clavicle): Inter scalene – anterior or posterior Supra clavicular – Classic, Plump bob, Para scalene, Inter strernocleidomastoid, Subclavian perivascular

Regional anaesthesia Infra clavicular approach- Para

coracoid, lateral Axillary block

LOCAL BLOCKS Wrist blocks Median nerve block

Superficial branch of Radial block

Ulnar nerve block

LOCAL BLOCKS

Technique of giving a dorsal digital block

DIGITAL NERVE BLOCKS Ring block Volar block Dorsal block Flexor tendon sheath

TOURNIQUET

A penrose drain can be used as a finger tourniquetFor the upper limb as a whole a tourniquet is kept at a pressure of 150 -250 mm of Hg for a period ranging from 45 mins to 2 hours

Techniques

A.Horizontal mattress; B.Figure of 8; C.Kessler’s; D.Modified Bunnell

Thin flat tendons repaired in pairs

When the core diameter of two tendon slips makes a core grasping suture technically difficult , the two sips can be incorporated into one repair, A. FIGURE OF EIGHT, B. MODIFIED GRASPING SUTUREsumeryadav2004@gmail.com

Suture technique for flat broad tendons

Flat , broad tendons of zone III, IV & V are repaired by A. core suture, B. cross stitch suture techniquessumeryadav2004@gmail.com

IMPORTANT POINTS IN EXTENSOR TENDON REPAIR Extensor tendon suture technique vary according to the

location of the injury & the size of the tendon. Distal to the MP joint, in zone I to V, the extensor tendon

is wide and flat. In zone VI to VIII, the tendon is narrow and thick.

A grasping technique is used when the tendon is large enough to allow placement of sutures.

Suture technique should be chosen to maximize strength & minimize shortening of the tendon.

Extensor retinaculum when involved should be preserved

The highest priority of extensor tendon injury is not regaining full extension. The goal is to increase motion in the functional range of the patient’s normal activities.

COMPLICATIONS Most common complication after tendon repair

is the formation of adhesions between the repair site, adjacent skin and the bone. The adhesions can restrict joint flexion as well as extension.

Treatment includes Tenolysis, Capsulotomy or Collateral ligament release

Gapping Disruption Non healing skin site Scarring Decreased Joint mobility

PHYSIOTHERAPY Zone I & II injuries are treated with a static

Splint. Only 1 to 2 mm of tendon excursion is necessary for DIP flexion, a fact that makes adhesions at the injury site less of a problem.

Early motion rehabilitation protocols are recommended for injuries in zone III to VIII

The patient actively flexes the finger followed by passive extension with rubber band traction

Children & non cooperative patients are best treated with immobilization

extensor tendons injury and deformity

Health & Medicine

Transcript of extensor tendons injury and deformity

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