Flexor Tendon Injuries Tricks of the Trade Mr Andrew Mahon Consultant Orthopaedic and Hand Surgeon University Hospital North Durham.

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