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Extensor tendon injury
& associated deformities
Dr Sumer Yadav
Mch – Plastic and Reconstructive surgery
sumeryadav2004@gma...
ANATOMY OF EXTENSOR
FORE ARM
 Proximal group: The
ECU,EDM,EDC,ECRL,ECRB tendons
originate adjacent to the lateral epicond...
sumeryadav2004@gmail.com
sumeryadav2004@gmail.com
sumeryadav2004@gmail.com
Muscles of the Forearm lateral
(Extensor Surface)
 Outcropping Group
Extensor Pollicis Brevis/
Abductor Pollicis Longus
E...
ARRANGEMENT OF
EXTENSOR TENDONS AT
WRIST
 The Extensor tendons gain entrance to hand
from the fore arm through a series o...
sumeryadav2004@gmail.com
sumeryadav2004@gmail.com
sumeryadav2004@gmail.com
EXTENSOR MECHANISM IN
FINGER
 At the MP joint, the Extensor mechanism flattens into a broad
hood and envelops the dorsal ...
sumeryadav2004@gmail.com
sumeryadav2004@gmail.com
sumeryadav2004@gmail.com
MECHANICS OF HAND
 Two set of muscles, INTRINSIC (originating in the hand itself &
innervated by the Ulnar and Medial ner...
FULL FLEXION EXTENSION
ARC
sumeryadav2004@gmail.com
sumeryadav2004@gmail.com
TENODESIS EFFECT
Dynamic Tenodesis is defined as the concept
of movement at one joint transmitting power to
an adjacent jo...
ZONES OF INJURY
ZONE FINGER
THUMB
I DIP joint IP joint
II Middle Phalanx Proximal Phalanx
III PIP joint MCP joint
IV Proxi...
Each zone in the fingers refers to an identical
location. The thumb lacks a middle phalanx.
Consequently the thumb zones ...
sumeryadav2004@gmail.com
CLINICAL EVALUATION
Testing for EDC, EIP & EDM
musculotendinous function
The proprius tendon to the index &
little finger ...
TESTING PROPRIUS
TENDONS
With the middle & ring fingers flexed into
the palm, the Proprius tendon can
extend the index and...
EPB tendon can be checked by
placing a finger in the anatomical
snuff box and asking the patient to
extend the thumb in a ...
Evaluation of wrist extensors
& deviators
sumeryadav2004@gmail.com
Testing the EPL tendon
sumeryadav2004@gmail.com
ZONE I INJURY
 Occurs at the DIP joint of the finger or
the IP joint of the thumb
 Mechanism of injury is usually forced...
MALLET FINGER
Mechanism : a blow from a thrown ball
strikes the tip of the finger--- ‘forced flexion’.
It tears the extens...
sumeryadav2004@gmail.com
sumeryadav2004@gmail.com
MALLET FINGER
 Management : continuous splint immobilization for 4 to 6
weeks in full extension
 Indications for surgery...
Zone I injury: Surgical
Intervention
Placement of a permanent buried suture
can be avoided by :
A. The tendon ends are inc...
Zone I injury: Surgical
Intervention
Technique of extensor tendon repair at
the DIP joint , in which the skin and the
tend...
SORL Reconstruction
 A. A Mallet deformity with
compensatory swan neck deformity
B&C. The Tendon graft is fixed to the
d...
ZONE II INJURY
 Extensor tendon width is greater in zone II than zone
I & the extensor mechanism has two lateral bands
wh...
Doyle’s repair : Sharp laceration of zone II repaired with a running suture
and over sewn by a Silverskiold cross stitch
s...
Immobilization Of Zone I & II
injuries
Aluminum splint
Stack splint
sumeryadav2004@gmail.com
ZONE III INJURY
 Disruption of the extensor apparatus at or just
proximal to the PIP joint results in a loss of extensor
...
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...
sumeryadav2004@gmail.com
Chronic Boutonniere
Deformity
 Burton & Melchior classification:
Stage 1: supple, passively correctable
deformity
Stage 2...
Treatment plan in Boutonniere
deformity
 Acute closed Boutonniere injuries: extension
splinting of PIP joint
 Acute open...
Burton & Melchior’s guidelines
for Boutonniere surgery
 Boutonniere reconstruction are most successful on
supple joints. ...
A Bunnell splint is applied to maintain extension at the PIP joint. The strap over
the PIP joint is progressively tightene...
Reconstruction of Boutonnière
A. The boutonniere deformity with the lateral
bands & ORL volar to the PIP joint
B. Dorsal z...
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 troug...
Snow’s technique of central slip
reconstruction ( distally based flap)
Aiche’s technique of central slip
reconstruction (c...
Littler’s tendon graft
technique: a thin graft is
woven through the base of
the middle phalanx and
through the extensor
te...
Extensor Tenotomy for Supple
Boutonniere deformity
Dolphin or Fowler procedure: The
lateral bands are released distal to
t...
Post burn Boutonniere
Defomity
 Primary damage is that of the central slip, leading to
the sliding of the lateral bands b...
Pseudo Boutonniere
Deformity
 Flexion deformity of PIP joint, often
following an axial load injury
 Hyper extension inju...
ZONE IV INJURY
 Partial zone IV injury is more common than a
complete laceration because the extensor
mechanism is flat &...
Dynamic splint in zone IV
injuries
sumeryadav2004@gmail.com
ZONE V INJURY
 A complete division of the extensor mechanism in
this zone is uncommon owing to the width of the
tendon
 ...
HUMAN BITE INJURIES
 Partial extensor tendon injuries over the MP joint
(zone V) are often caused by a punch to an
oppone...
Closed Sagittal band injuries
(Extensor tendon subluxation)
 Result from direct blow, from forced MP joint flexion
or fro...
Methods of Extensor hood reconstruction
sumeryadav2004@gmail.com
ZONE VI INJURY
 Have a better prognosis than distal injuries
because decreased surface area & increased
subcutaneous tiss...
ZONE VII INJURY
 There is almost always an associated injury
to the extensor Retinaculum
 Point in favor of excision of ...
Chronic injuries of zone VII
 Most common cause is attritional rupture e.g.
EPL rupture after distal radius fracture or w...
Reconstruction after EPL
rupture
Reconstructive options:
1. The Palmaris longus tendon is used
as a intercalated graft
2. ...
ZONE VIII INJURY
 Includes ruptures of musculotendinous
junction and muscle belly lacerations
 Repair of these injuries ...
ZONE IX INJURY
 Penetrating trauma in this region can be
accompanied by nerve injuries making
assessment difficult
 A pr...
Swan Neck Deformity
Hyper extension of PIP with
flexion of DIP
sumeryadav2004@gmail.com
sumeryadav2004@gmail.com
Swan Neck Deformity
 Cause : Volar plate rupture at the PIP with often
accompanying triangular ligament rupture.
 Pathol...
SURGICAL ASPECTS
ZONE SUTURE TECHNIQUE SUTURE MATERIAL
I & II Splint only none
Skin with tendon (simple) 5-0 monofilament
...
Regional anaesthesia
 Brachial plexus block ( above the
clavicle):
Inter scalene – anterior or posterior
Supra clavicular...
Regional anaesthesia
Infra clavicular approach- Para
coracoid, lateral
 Axillary block
sumeryadav2004@gmail.com
LOCAL BLOCKS
 Wrist blocks
Median nerve block
Superficial branch of Radial block
Ulnar nerve block
sumeryadav2004@gmail.c...
LOCAL BLOCKS
Technique of giving a dorsal digital
block
DIGITAL NERVE BLOCKS
Ring block
Volar block
Dorsal block
Flexor te...
TOURNIQUET
A penrose drain can be used as a
finger tourniquet
For the upper limb as a whole a
tourniquet is kept at a pres...
Techniques
A.Horizontal mattress; B.Figure of 8; C.Kessler’s; D.Modified Bunnell
D
sumeryadav2004@gmail.com
Thin flat tendons repaired in
pairs
When the core diameter of two tendon slips makes a core grasping
suture technically di...
Suture technique for flat broad
tendons
Flat , broad tendons of zone III, IV & V are repaired by A. core suture, B. cross
...
IMPORTANT POINTS IN
EXTENSOR TENDON
REPAIR
 Extensor tendon suture technique vary according to
the location of the injury...
COMPLICATIONS
 Most common complication after tendon repair is the
formation of adhesions between the repair site,
adjace...
PHYSIOTHERAPY
 Zone I & II injuries are treated with a static
Splint. Only 1 to 2 mm of tendon excursion is
necessary for...
sumeryadav2004@gmail.com
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extensor tendons injury and deformity

  1. 1. Extensor tendon injury & associated deformities Dr Sumer Yadav Mch – Plastic and Reconstructive surgery sumeryadav2004@gmail.com
  2. 2. 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. sumeryadav2004@gmail.com
  3. 3. sumeryadav2004@gmail.com
  4. 4. sumeryadav2004@gmail.com
  5. 5. sumeryadav2004@gmail.com
  6. 6. Muscles of the Forearm lateral (Extensor Surface)  Outcropping Group Extensor Pollicis Brevis/ Abductor Pollicis Longus Extensor pollicis longus  Medial Group Extensor Carpi radialis L/B Bracioradialis sumeryadav2004@gmail.com
  7. 7. 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 sumeryadav2004@gmail.com
  8. 8. sumeryadav2004@gmail.com
  9. 9. sumeryadav2004@gmail.com
  10. 10. sumeryadav2004@gmail.com
  11. 11. 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 sumeryadav2004@gmail.com
  12. 12. sumeryadav2004@gmail.com
  13. 13. sumeryadav2004@gmail.com
  14. 14. sumeryadav2004@gmail.com
  15. 15. 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 sumeryadav2004@gmail.com
  16. 16. FULL FLEXION EXTENSION ARC sumeryadav2004@gmail.com
  17. 17. sumeryadav2004@gmail.com
  18. 18. TENODESIS EFFECT Dynamic 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 extension The 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 sumeryadav2004@gmail.com
  19. 19. ZONES OF INJURY ZONE FINGER THUMB I DIP joint IP joint II Middle Phalanx Proximal Phalanx III PIP joint MCP joint IV Proximal Phalanx Metacarpal V MCP joint Carpometacarpal joint/ Radial Styloid VI Metacarpal VII Dorsal Retinaculam VIII Distal forearm IX Mid & Proximal forearm sumeryadav2004@gmail.com
  20. 20. 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 injury More than 50% of injuries have an associated injury such as fracture, dislocation or flexor tendon injury sumeryadav2004@gmail.com
  21. 21. sumeryadav2004@gmail.com
  22. 22. CLINICAL EVALUATION Testing for EDC, EIP & EDM musculotendinous function The 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 sumeryadav2004@gmail.com
  23. 23. TESTING PROPRIUS TENDONS With the middle & ring fingers flexed into the palm, the Proprius tendon can extend the index and little fingers sumeryadav2004@gmail.com
  24. 24. 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 sumeryadav2004@gmail.com
  25. 25. Evaluation of wrist extensors & deviators sumeryadav2004@gmail.com
  26. 26. Testing the EPL tendon sumeryadav2004@gmail.com
  27. 27. 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 sumeryadav2004@gmail.com
  28. 28. 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 sumeryadav2004@gmail.com
  29. 29. sumeryadav2004@gmail.com
  30. 30. sumeryadav2004@gmail.com
  31. 31. 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 sumeryadav2004@gmail.com
  32. 32. 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 sumeryadav2004@gmail.com
  33. 33. Zone I injury: Surgical Intervention Technique of extensor tendon repair at the DIP joint , in which the skin and the tendon are simultaneously approximated sumeryadav2004@gmail.com
  34. 34. SORL Reconstruction  A. A Mallet deformity with compensatory swan neck deformity B&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 phalanx SORL reconstruction is advocated for correction of a swan neck deformity which is secondary to a mallet finger sumeryadav2004@gmail.com
  35. 35. 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 sumeryadav2004@gmail.com
  36. 36. Doyle’s repair : Sharp laceration of zone II repaired with a running suture and over sewn by a Silverskiold cross stitch sumeryadav2004@gmail.com
  37. 37. Immobilization Of Zone I & II injuries Aluminum splint Stack splint sumeryadav2004@gmail.com
  38. 38. 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 sumeryadav2004@gmail.com
  39. 39. Boutonniere Deformity Right hand Ring finger sumeryadav2004@gmail.com
  40. 40. 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 jointsumeryadav2004@gmail.com
  41. 41. sumeryadav2004@gmail.com
  42. 42. 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 sumeryadav2004@gmail.com
  43. 43. 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 sumeryadav2004@gmail.com
  44. 44. 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 sumeryadav2004@gmail.com
  45. 45. 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
  46. 46. Reconstruction of Boutonnière A. The boutonniere deformity with the lateral bands & ORL volar to the PIP joint B. Dorsal zigzag incision C. 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 events F. The PIP joint is fixed with a transarticular K wire G. The mechanics of the reconstruction sumeryadav2004@gmail.com
  47. 47. Central slip laceration with sufficient tendon to repair with core suture & over sew with silverskiold epitendinous suture sumeryadav2004@gmail.com
  48. 48. 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 sumeryadav2004@gmail.com
  49. 49. 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
  50. 50. 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 sumeryadav2004@gmail.com
  51. 51. 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 sumeryadav2004@gmail.com
  52. 52. 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 sumeryadav2004@gmail.com
  53. 53. 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 sumeryadav2004@gmail.com
  54. 54. 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 sumeryadav2004@gmail.com
  55. 55. Dynamic splint in zone IV injuries sumeryadav2004@gmail.com
  56. 56. 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 sumeryadav2004@gmail.com
  57. 57. 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 sumeryadav2004@gmail.com
  58. 58. 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 sumeryadav2004@gmail.com
  59. 59. Methods of Extensor hood reconstruction sumeryadav2004@gmail.com
  60. 60. 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 sumeryadav2004@gmail.com
  61. 61. 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 sumeryadav2004@gmail.com
  62. 62. 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 sumeryadav2004@gmail.com
  63. 63. Reconstruction after EPL rupture Reconstructive options: 1. The Palmaris longus tendon is used as a intercalated graft 2. EIP is transferred to the distal end of EPL 3. The Palmaris longus is transferred around the radial side of the wrist to the EPL sumeryadav2004@gmail.com
  64. 64. 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 sumeryadav2004@gmail.com
  65. 65. 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 immobilizationsumeryadav2004@gmail.com
  66. 66. Swan Neck Deformity Hyper extension of PIP with flexion of DIP sumeryadav2004@gmail.com
  67. 67. sumeryadav2004@gmail.com
  68. 68. 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 sumeryadav2004@gmail.com
  69. 69. SURGICAL ASPECTS ZONE SUTURE TECHNIQUE SUTURE MATERIAL I & II Splint only none Skin with tendon (simple) 5-0 monofilament Tendon suture (Cross stitch) 6-0 monofilament Pull out tendon 4-0 monofilament III,IV & V Grasping tendon suture 4-0 braided synthetic +/- simple or cross stitch 6-0 monofilament VI,VII & VIII Grasping core suture 4-0 braided synthetic + epitenon 6-0 monofilament Multiple slips to same digit 4-0 braided synthetic sutured together sumeryadav2004@gmail.com
  70. 70. Regional anaesthesia  Brachial plexus block ( above the clavicle): Inter scalene – anterior or posterior Supra clavicular – Classic, Plump bob, Para scalene, Inter strernocleidomastoid, Subclavian perivascular sumeryadav2004@gmail.com
  71. 71. Regional anaesthesia Infra clavicular approach- Para coracoid, lateral  Axillary block sumeryadav2004@gmail.com
  72. 72. LOCAL BLOCKS  Wrist blocks Median nerve block Superficial branch of Radial block Ulnar nerve block sumeryadav2004@gmail.com
  73. 73. LOCAL BLOCKS Technique of giving a dorsal digital block DIGITAL NERVE BLOCKS Ring block Volar block Dorsal block Flexor tendon sheath sumeryadav2004@gmail.com
  74. 74. TOURNIQUET A penrose drain can be used as a finger tourniquet For 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 sumeryadav2004@gmail.com
  75. 75. Techniques A.Horizontal mattress; B.Figure of 8; C.Kessler’s; D.Modified Bunnell D sumeryadav2004@gmail.com
  76. 76. 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 SUTURE sumeryadav2004@gmail.com
  77. 77. Suture technique for flat broad tendons Flat , broad tendons of zone III, IV & V are repaired by A. core suture, B. cross stitch suture techniques sumeryadav2004@gmail.com
  78. 78. 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. sumeryadav2004@gmail.com
  79. 79. 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 sumeryadav2004@gmail.com
  80. 80. 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 sumeryadav2004@gmail.com
  81. 81. sumeryadav2004@gmail.com
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extensor tendons injury and deformity

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