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Flexor Tendon Injuries/Rehab

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abdullah kattan

on 21 July 2011

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Transcript of Flexor Tendon Injuries/Rehab

Flexor Tendon Injuries and Rehabilitation

Hand Rounds TWH
July 21st 2011
Abdullah Kattan Anatomy Blood Supply Zones of Injury Types of Repair Rehabilitation Protocols Pulley Ststem 5 Annular (A) Pullies:
- A1, A3, A5 are over joints and arise from the VP of
MCP, PIP & DIP respectively
- A2 & A4 most important to preven bowstringing,
and are over proximal and middle phalanges,
from preiostium
3 Cruaciate (C) Pullies:
- between annular pullies, allow the sheath to
collapse (accodion)
PA (palmar aponeuorisis) pulley:
- transverse and vertical fibers of palmar fascia
- important when other proximal components of
sheath are lost - Mainly on the dorsum

1. Longitudinal vessels within paratenon
2. Vessels enter at level of proximal synovial fold in palm
3. Segmental branches from paired digital arteries entering sheaths by
means of long and short vincula
4. Vessels entering at osseous insertions Nutrition Tendon Healing Intrinsic healing:
from withing the tendon
tenocytes and blood supply from vinculae, longitudinal vessles and diffusion
minimal adhesions
3 phases (inflamatory, collagen production, remodeling)
Extrinsic healing:
from outside the tendon with vascular ingorwth and fibroblasts and inflammatory cells
forms adhesions Distal to
insertion Beginning of flexor tendon sheath at distal palmar crease to insertion of FDS
“No man’s land" Distal edge of transverse carpal ligament to distal palmar crease Carpal tunnel Proximal to carpal tunnel in distal forearm Insertion of FPL Neck of MC
to neck of PP Thenar muscles Carpal tunnel Core Suture Epitendinous Sutures Tendon Sheath Synovial lined fibro-osseous tunnel
Begins at MC neck and ends distal to DIPJ
Codensatinos form the pullies
- smooth tendon gliding
- maintains tendon close to volar surface of the bone
- prevent bowstringing
- synovial fluid for nutrition Direct vascular supply

Synovial diffusion (more important) Decrease bulk
Decrease gap formation
Increase tensile strength
(10-50%) Goals of Treatment Repair of adequate tensile strength to apply post op rehabilitation protocol
- to inhibit adhesions and restore gliding
- facilitate healing 4 and 6 strand core sutures have greater tensile strength at time zero and 6 weeks post op
atraumatic technique to avoid injury to the tendon stumps and epitenon
Locking provides more strength
Knot position --> no effect on strength Fibroblasts and Type I collagen
Collagen cross linkage varries along the length
Strongest at midportion --> tendon-bone instertion --> musclulotendenous junction FDP Moves all 3 finger joints
Most of the strenght
Single muscle belly
DIP flexion by insertion into DP
PIP flexion by moment arm on PIP
MCP flextion propagation of momentum at DIP and PIP FDS 4 muscle bellies
Lies closer to the bone --> smaller moment arm than FDP at PIP
With PIP flextion --> FDS terminal branches bowstrin and add more moment arm --> more power
FDP/FDS are used in different proportions between digits
- D3 FDS is 75% stronger than D2 & D4
- D5 FDS is 50% the strength of D3
- 28% of tension on a flexed D2 and 50% in D3 FDS Loss may lead to some weakess in grip
Superficialis minus finger
- loss of balance at PIP --> hyperextension deformity
- compensatory DIP flexion deformity with FDS tension
--> swan neck Evolution Immobilization
Early passive motion
Early active motion

All three are still used
Good clinical decision making AND COMMUNICATOION with the hand therapist Immobilization Children
Adults unable to comprehend and follow through
Associated injuries Kleinert Controlled Motion Programs Improved surture techniques

Improves tensile strength
Decreases adhesion
Improves excursion
Promotes intrisice healing Zone II Unique anatomy (Camper's chiasm, vinculae, A2,A4)
Edema, scar
Patient compliance 1960 s
Controlled passive motion (PM) with elastic traction
Passive flexion , active extension
Dorsal protective splint (wrist 30 flex, MCP 30-40 flex, elastic traction from nails to volar forearm)
Palmar pulley to improve DIP flexion
Detatch elastics at night and tape in xetension Duran 1970 s
Controlled PM with dorsal protection without traction
3-5 mm of tendon glide in zone II prevents adhesions
Passive flexion and extension Early Active Motion EAM 1980 s- 1990 s
Experimental studies demonstrated beneficial effect of EAM
Depends on strong repair techniques
Force must be less that tensile strength of repair to prevent gapping or rupture
Recommended for 4 strand repairs with epitendinous suture
Good patient motivation/comprehension, edema comtrol, good wound healing If good tendon excursion is achieved quickly "keep the breaks on", if poor tendon excursion "accelorate" excursion rupture
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