Flexor Tendon Injuries Tricks of the Trade Mr Andrew Mahon Consultant Orthopaedic and Hand Surgeon...
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Transcript of Flexor Tendon Injuries Tricks of the Trade Mr Andrew Mahon Consultant Orthopaedic and Hand Surgeon...
Flexor Tendon InjuriesTricks of the Trade
Mr Andrew MahonConsultant Orthopaedic and Hand
SurgeonUniversity Hospital North Durham
History
• Demographics– Age, Hand Dominance, Occupation, Hobbies
• Mechanism– Blade, Glass, Power Tools, Closed Avulsion
• Time of Injury
• Tetanus
• Fitness for theatre
Examination
• Look at the Hand!!– Posture, Colour
• Wounds– Tidy, Untidy, Contaminated
• Test Sensation
• Know how to examine tendons
Question 1
• Linburg – Comstock anomaly
Question 2
• How do you assess the injured hand in a young child?
Examination - Children
• Look
• Sweating – pen test
• Wrinkling test
• Tenodesis
• Direct pressure over tendons / muscles
Don’t Under-estimate the Injury!
Question 3
• What is the injury?
Leddy and Packer
Take an X-Ray
Surgery
• Skin
• Associated structures
• Flexor sheaths
• FDS
• FDP
Skin - Incisions
• Need adequate exposure
• Avoid scar contracture
Associated Structures
• Inspect Nerves and Vessels
Question 4
• Which are the most important pulleys in the flexor sheath?
Question 4
• Which are the most important pulleys in the flexor sheath?
• A2
• A4
Flexor Sheath
• Lister’s Windows
• A4 Pulley
Deliver the Tendon
Zone 1 Repair
• < 1cm reattach to bone– Button– Suture anchor
• > 1cm tenorraphy
Tendon Repair Techniques
• Core suture– 2, 4, 6, 8 strands
• Circumferential (epitendinous) suture– Running– Halsted– Silfverskiold
Core Sutures
Core Sutures
• Kessler
Core Sutures
4 strand cruciate
Strickland
Question 5
• What is the most important factor affecting core suture strength?
Question 5
• What is the most important factor affecting core suture strength?
• The number of suture strands crossing the repair site
Question 6
• What is the optimum suture bite length for a core suture?
Question 6
• What is the optimum suture bite length for a core suture?
• 7mm to 1 cm
• Aim for 1cm
Circumferential Sutures
• Adds to repair strength
• Reduces bulk at repair site
Sequence of Repair
• In finger repair FDS first
Goals of Repair (Zone 2)
• Strong enough for active motion
• No gapping• Free glide through
pulleys• Minimal handling to
reduce adhesions Untidy Repair
Rehabilitation
• Controlled active movement (Belfast)
Rehabilitation
• Kleinert– Active extension– Passive flexion
Rehabilitation
Question 6
• What is the optimum wrist position for immobilisation following flexor tendon repair?
Question 6
• What is the optimum wrist position for immobilisation following flexor tendon repair?
• Slight extension– (Savage)
Rehabilitation
• Dorsal splint– MCPs 70 - 90°– Full extension allowed at PIPs
• Full time 6 weeks
• At night / in crowds until 12 weeks
• No resisted exercises until 8 weeks
• Driving 10 weeks