Flexor tendon injuries of hand

FLEXOR FLEXOR TENDON TENDON

INJURIES OF INJURIES OF HANDHAND

Nutrition and repairNutrition and repair

1. synovial fluid in the sheath1. synovial fluid in the sheath 2. vincular circulation2. vincular circulation

vincula longa and brevia each for vincula longa and brevia each for profundus and superficialisprofundus and superficialis

Repair-Repair-

Intrinsic mechanismIntrinsic mechanism

Extrinsic mechanismExtrinsic mechanism

ExaminationExamination

Position and attitude of the hand-Position and attitude of the hand- Unnatural position of hyper Unnatural position of hyper

extension of the finger suggests extension of the finger suggests injury to both tendonsinjury to both tendons

Passive examination-Passive examination- extension of wristextension of wrist flexion of the wristflexion of the wrist Compression of forearm musclesCompression of forearm muscles Pressure on the fingertipsPressure on the fingertips

FDP and FDSFDP and FDS

ZONES OF THE HANDZONES OF THE HAND

ZONESZONES ZONE 1- distal to the insertion of ZONE 1- distal to the insertion of

superficialissuperficialis ZONE 2- no mans land b/w the distal palmar ZONE 2- no mans land b/w the distal palmar

crease and insertion of the sublimiscrease and insertion of the sublimis ZONE 3- lumbrical region b/w distal palmar ZONE 3- lumbrical region b/w distal palmar

crease and the distal end of transverse crease and the distal end of transverse carpal ligamentcarpal ligament

ZONE 4- zone covered by the flexor ZONE 4- zone covered by the flexor retinaculumretinaculum

ZONE 5- proximal to the flexor retinaculumZONE 5- proximal to the flexor retinaculum

RULES OF REPAIRRULES OF REPAIR

All flexor tendons when severed should be repaired All flexor tendons when severed should be repaired irrespective of whatever is the zone.irrespective of whatever is the zone.

Ideally fix the fracture and repair the tendon and Ideally fix the fracture and repair the tendon and digital primarily.digital primarily.

When delayed repair is done may need a tendon When delayed repair is done may need a tendon graftgraft

Flexor tendon sheath should be repaired over the Flexor tendon sheath should be repaired over the tendontendon

A2 and A4 pulleys of the flexor sheaths should be A2 and A4 pulleys of the flexor sheaths should be preserved to prevent bowstringing and flexon preserved to prevent bowstringing and flexon deformitydeformity

PULLEYS OF THE FLX PULLEYS OF THE FLX SHEATHSHEATH

ZONE 1ZONE 1

Repair primarilyRepair primarily To distal stump or advance 1 cmTo distal stump or advance 1 cm More than 1 cm quadriga effect.More than 1 cm quadriga effect. Type 1: 7-10 days retracted in the palm. Type 1: 7-10 days retracted in the palm.

Repair with a pull out wire technique.Repair with a pull out wire technique. Type 2: few months retracted till PIPType 2: few months retracted till PIP Type 3: retracted upto DIP.Type 3: retracted upto DIP. Old cases: tendon grafting, arthrodesis, Old cases: tendon grafting, arthrodesis,

tenodesis tenodesis

Pull out wire techniquePull out wire technique

ZONE 2 ZONE 2

Called bunnells zone or no mans land Called bunnells zone or no mans land zone.zone.

Notorious for bad results, adhesions Notorious for bad results, adhesions are a big problem. Area of pulleysare a big problem. Area of pulleys

Repair both tendons at the same timeRepair both tendons at the same time Tendons are sutured malrotatedTendons are sutured malrotated Suturing should be intratendonous Suturing should be intratendonous

configuration.configuration.

ZONE 3ZONE 3

Lumbrical zoneLumbrical zone Primarily suturedPrimarily sutured Do not suture the belly of the Do not suture the belly of the

lumbricals as it increases the tension lumbricals as it increases the tension of the musclesof the muscles

Lumbrical plus syndrome- Lumbrical plus syndrome- paradoxical extension on attempted paradoxical extension on attempted flexionflexion