2012.4.27

서울 현대병원 정 순영

Flexor Tendon In-jury

Anatomy of Flexor Tendon

Hand Anatomy

*Origin

2 muscle bellies

- medial epicondyle

- radial shaft

* tendons arise form separated muscle bundles

act independently

FDS

FDP

* Origin

ulna & interosseous membrane

* commom muscle origin for several tendons

Hand Anatomy

act simultaneous flexion of multiple digits

ZonesHand Anatomy

Pulley SystemHand Anatomy

Hand Anatomy

Tendon Nutrition

1. Synovial fluid :produced within tenosyn-ovial sheath2. Blood supply provide by vincular circula-tion

Hand Anatomy

Vascular supply to flexor tendon

Tendon sheath

Suprative tenosy-ovitis Kanavel’s 4 cardinal sign

Hand Anatomy

Vincular system

Nutrition of tendon

Suspensory ligament of ten-

don

Stabilization of tendon

Flexor Tendon Excursion

9cm : wrist & digital flexion 2.5cm : full digital flexion with wrist neutral posi-tion

DIP ( FDP ) & PIP ( FDS,FDP ) joint motion 10 degrees : 1.5mm ex-cursion MP motion : no flexor tendon excursion

Welcome to Real World !

What can I do for you?

Physical Examina-tion

Is it necessary ?

FDS intact

FDS + FDP severance

Timing of Flexor Tendon Re-pair

* primary tendon repair : < 12 hrs

( 24 hrs )

* delayed primary repair : 24 hrs ~

10 days

* early secondary repair : 10 days ~

4 weeks

* late secondary repair : > 4 weeks

MyofibrosisPrefer tondon graft

How ?

( suture technique )

To obtain exposure

Flexor tendon retrieval

Sourmelis and McGrouther’s Method

A. Conventional Bunnel stich

B. Crisscross stich C. Mason-Allen( Chicago )

stich D. Kessler grasping stich E. Modified Kessler stitch

with single knot at re-pair

F. Tajima modification of Kessler stitch with dou-ble knots at repair site

- Tajima core sutures in place- Back wall running-lock peripheral epitendinous stitch- Mattress core suture- Completion of running-lock peripheral epitendinous suture

Ultimate Strength and Repair Tech-nique*Proportional to number of strands

- 6 and 8 strand repairs

strongest

steep learning curve

4-strand repair adequate strength without complexity of 6 ~ 8

strands

• increased bulk and resistance to glide• increased tendon healing and adhesion for-

mation• May not be necessary for forces of early ac-

tive motion

Flexor tendon repair : strength vs force

Suture knot location

Inner side

Outer side

: interference with healing

: interference with tendon gliding

Repairing the sheath ?

*Providing a barrier for adhesion formation

*Restoring synovial fluid nutrition

*Restoring the sheath mechanics

Technically difficult

Increased foreign material at repair

site

May narrow sheath and restrict

glide

VS

Tendon Healing

*Intrinsic tendon healing

: differentiation of fibroblasts from epitenon ( tenocyte )

: collagen synthesis occurred primarily within the endotenon cells

: vascularity of tendon bed - important

*Extrinsic tendon healing

: activity of peripheral fibroblast

: peripheral adhesions

No Adhesion

Take Home Mes-sage !!

Phases of tendon healing

* Inflammatory phase

: phagocytosis

3 ~ 5 days

* Fibroblastic or collagen-producing phase

: neovascularization, peripheral adhesion

5 ~ 3-6 weeks

* Remodeling or maturation phase

: arrangement of fiber

6 ~ 9monts

Tendon weakest at 10 ~ 14 days Take Home Mes-

sage !!

Something SpecialZone I : distance < 1cm direct insertion into distal phalanx ( Advancement repair )

Uneven tension : too tight

lengthen of tendon at wrist tendon graft

Quadriga effect

Something Special : FPL

• Can be advanced without disturbing its blood supply ( does not have vinculum )

• Lengthening of tendon at writ by Z plasty may be re-quired

Post-Operative Rehabili-tation

Stressed tendons

* Heal faster

* Gain tensile strength faster

* Have fewer adhesions

* Better excursions

Take Home Mes-sage !!

Post OP Protocols

* Kleinert : Active extension,

Passive flexion by rubber bands

* Duran : controlled passive motion

* Strickland : early active ROM

Goal : Full active ROM at 10 ~ 12 weeks

Duran proto-col Wrist 30 flexion

MP joint 50~70 flexion IP joint allow to exten-sion

Kleinert Protocol

Wrist 35 flexionMP joint 60~70 flexion IP joint full extension Elastic band : proximal 8~10cm from wrist joint

The ideal treatment

of flexor tendon in-

juries under almost

every circumstance is

primary repair

Hope the Best Prepare the Worst

Too little motion Too much motion

Stiffness Rupture

Secondary Surgery

*Severe injury

*Make excessive amounts of scar tissue

*Have not co-operated with therapy

: low pain thresholds

social circumstances

stupidity

Mostly complication of primary re-pair : ruptured & adherent primary re-pairs

Healings of either “ bad injuries ” or “ bad patients ”

Reconstruction of Flexor Ten-dons

One stage

Universal tendon spacer

By 4 ~ 6 weeks, pseudosheath forma-tion

two stage

Pulley reconstruc-tion

*The skin is pliable

*Any wounds are well healed

*Edema has subsided

*The joints allow a full passive range of mo-

tion

*Sensation in finger is normal ( at least

one )A2 & A4 pulley systems also should be intact

Prerequisites

Donor tendons for Graft-ing* palmaris longus

* plantaris tendon

* long extensors of toes

Pulvertaft interlace su-ture

Take Home Mes-sage !!

cascading

Determining tension in a reconstructed flexor sys-

tem

Thumb located In front of indexIP joint : 30 degree flexion

FPL tension adjustment

Wrist neutral position

Isolated FDP loss but good retention of FDS function

Tendon reconstruction risks worsening finger function

Tenodesis Arthrode-sis

Lumbrical plus finger

*Paradoxical extension of the IP joints while attempting to flex the fingers

*Most commonly caused by FDP laceration distal to the origin of limbricals

3rd finger m/c involve

Tenodesis of FDP to terminal tendon Reinsertion to distal phalanx Lumbrical release

Tx

Flexor tenolysis after repair and grafting

* at least 3 months pass

* some situations 4 ~ 6 months may be re-quired to make an accurate assessment of pa-tient’s progress

Take Home Mes-sage !!

Extensive shortage of skin

Do you know ?

What I want to be

Thank you for your at-tention