1. In The Name of GOD

2. TENDON INJURIES & COMMON DISORDERS
A. Zarezade m.d.
Associated professor of orthopedic surgery
Isfahan university of medical sciences
(medical students teaching program)

3. Flexor Tendon Injuries

4. Introduction
Commonly result from volar lacerations and may have concomitant neurovascular injury 
Classified by the zone of injury
basic concepts in repair are similar for different zones 
location of laceration directly affects healing potential

5. Anatomy Muscles flexor digitorum profundus (FDP)
functions as a flexor of the DIP joint
assists with PIP and MCP flexion
shares a common muscle belly in the forearm

6. Anatomy Muscles flexor digitorum superficialis (FDS)
functions as a flexor of the PIP joint
assists with MCP flexion
individual muscle bellies exist in the forearm
FDS to the small finger is absent in 25% of people

7. Anatomy Muscles flexor pollicis longus (FPL)
located within the carpal tunnel as the most radial structure

8. Anatomy Muscles flexor carpi radialis (FCR) primary wrist flexor
inserts on the base of the second metacarpal
closest flexor tendon to the median nerve

9. Anatomy Muscles flexor carpi ulnaris (FCU) primary wrist flexor
inserts on the pisiform, hook of hamate, and the base of the 5th metacarpal

10. Anatomy Blood supply 2 sources exist
diffusion through synovial sheaths
occurs when flexor tendons are located within a sheath
it is the more important source distal to the MCP joint
direct vascular supply
nourishes flexor tendons located outside of synovial sheaths

11. Anatomy Campers chiasm
located at the level of the proximal phalanx where FDP splits FDS

12. Anatomy Pulley system digits 1-4 contain thumb contains
5 annular pulleys (A1 to A5)
3 cruciate pulleys (C1 to C3)
A2 and A4 are the most important pulleys to prevent flexor tendon bowstringing
thumb contains
2 annular pulley
interposed oblique pulley (most important)

13. Classification definition zone Distal to FDS insertion I
FDS insertion to distal palmar crease II
Palm (lumbrical origin)
III
Carpal tunnel IV
Wrist to forearm V

14. Presentation
Symptoms: loss of active flexion strength or motion of the involved digits
Physical exam:
inspection
observe resting posture of the hand and assess the digital cascade
evidence of malalignment or malrotation may indicate an underlying fracture
assess skin integrity to help localize potential sites of tendon injury
look for evidence of traumatic arthrotomy
range of motion
passive wrist flexion and extension allows for assessment of the tenodesis effect
normally wrist extension causes passive flexion of the digits at the MCP, PIP, and DIP joints
maintenance of extension at the PIP or DIP joints with wrist extension indicates flexor tendon discontinuity
active PIP and DIP flexion is tested in isolation for each digit
neurovascular exam
important given the close proximity of flexor tendons to the digital neurovascular bundles

15. Treatment Nonoperative Operative wound care and early range of motion
Indications: partial lacerations < 60% of tendon width
Outcomes: may be associated with gap formation or triggering
Operative
flexor tendon repair and controlled mobilization 
Indications: lacerations > 60% of tendon width
Outcomes: depends on zone of injury
flexor tendon reconstruction (tendon graft)
Indications:
failed primary repair
chronic untreated injuries
Outcomes: subsequent tenolysis is required more than 50% of the time

16. Surgical Treatments Flexor Tendon Repair of Complete Lacerations
Approach:
incisions should always cross flexion creases transversely or obliquely to avoid contractures (never longitudinal)
timing of repair:
In the cases with clean wound, primary repair is indicated (first day)
performing repair within two weeks of injury (delayed primary repair)
waiting longer leads to difficulty due to tendon retraction (secondary repair)
Outcomes:
repair failure
tendon repairs are weakest between postoperative day 6 and 12
repair usually fails at suture knots

17. Surgical Treatments (CONT.)
Flexor Tendon Repair of Partial Lacerations
Indications:
>75% laceration
≥50-60% laceration with triggering
epitendinous suture at the laceration site is sufficient
no benefit of adding core suture

18. Surgical Treatments (CONT.)
Reconstruction Technique
Requirements:
supple skin
sensate digit
adequate vascularity
full passive range of motion of adjacent joints
technique of reconstruction involving silicone rods:
Hunter-Salisbury two-stage procedure
Stage I - silicone rod is placed to create a favorable tendon bed
Stage II (3-4 months) – removing hunter rod and passing a tendon graft through the pseudo-sheath

19. Surgical Treatments (CONT.)
Reconstruction Technique
graft choices:
palmaris longus (absent in 15% of population)
plantaris (absent in 19%)
long toe extensor
Tenolysis
Indications:
localized tendon adhesions with minimal to no joint contracture and full passive digital motion 
may be required if a discrepancy between active and passive motion exists after therapy
timing of procedure: wait for soft tissue stabilization (> 3 months) and full passive motion of all joints
Technique: careful technique to preserve A2 and A4 pulleys
postoperative care: follow with extensive therapy

20. Postoperative Rehabilitation
Immobilization in wrist flexion (30-40 degrees), MCP joints in about 60 degrees flexion and IP joints in extension
Postoperative controlled mobilization has been the major reason for improved results with tendon repair
Early active motion protocols
Early passive motion protocols
Immobilize children and noncompliant patients in a long arm cast with MCP joints and wrist in a flexed position

21. Complications Tendon adhesions: Rerupture: Joint contracture:
most common complication following flexor tendon repair
Rerupture:
15-25% rerupture rate
Joint contracture:
rates as high as 17%
Trigger finger:
In cases with partial flexor tendon injury

22. Jersey Finger

23. Introduction
Refers to an avulsion injury of FDP from insertion at base of distal phalanx
Zone I flexor tendon injury
Epidemiology
ring finger involved in 75% of cases
during grip ring fingertip is 5 mm more prominent than other digits in ~90% of patients
therefore ring finger exposed to greater average force than other fingers during pull-away

24. Anatomy Muscles Flexor zones Flexor Digitorum Profundus
zone I extends from insertion of FDS distally

25. Classification

26. Presentation Physical exam
pain and tenderness over volar distal finger
finger lies in slight extension relative to other fingers in resting position
no active flexion of DIP
may be able to palpate flexor tendon retracted proximally along flexor sheath

27. Imaging
Radiographs:
may see avulsion fragment

28. Treatment
Operative
Direct tendon repair or tendon reinsertion with dorsal button
Indications: acute injury (< 10 days) in type I
ORIF fracture fragment
Indications: types II and III (in some weeks after injury)
two stage flexor tendon grafting
Indications: chronic injury in patient with full passive ROM of the DIP joint
DIP arthrodesis
indicated as salvage procedure in chronic injury with chronic stiffness

29. Extensor Tendon Injuries

30. Introduction Injury can be caused by laceration, trauma, or overuse
Epidemiology
most commonly injured digit is the long finger
zone VI is the most frequently injured zone
Mechanism
Zone I
forced flexion of extended DIP joint
Zone II
dorsal laceration or crush injury
Zone V
commonly from "fight bite"
sagittal band rupture
forced extension of flexed digit
most common in long finger

31. Classification

32. Classification (CONT.)IX

33. Imaging
Radiographs
AP and lateral of digit to verify bony avulsion (boney mallet)

34. Treatment Nonoperative: immobilization with early protected motion
Indications: lacerations < 50% of tendon in all zones if patient can extend digit against resistance
DIP extension splinting
Indications:
acute (<12 weeks) Zone 1 injury (mallet finger)
nondisplaced bony mallet
Techniques:
full-time splinting for six to eight weeks
avoid hyperextension, which may cause skin necrosis
maintain PIP motion
Outcomes: noncompliance is a common problem

35. Treatment Nonoperative (CONT.): PIP extension splinting
Indications:
closed central slip injury (zone III)
Techniques:
full-time splinting for six weeks
maintain DIP flexion
MCP extension splinting
closed zone V sagittal band rupture
full-time splinting of MCP joint for four to six weeks

38. Treatment Operative immediate I&D tendon repair
Indications: fight bite to MCP joint
tendon repair
Indications: laceration > 50% of tendon width in all zones
fixation of bony avulsion
Indications: boney mallet finger > 40% of articular surface, with P3 volar subluxation
tendon reconstruction
Indications: chronic tendon injury or when end-to-end repair is not possible
EIP to EPL tendon transfer
Indications: chronic EPL injury

39. Postoperative treatment
Splinting:
Immobilization of the wrist in degrees extension, MCP joints in about 30 degrees flexion and IP joints in extension (3 to 4 weeks)
Rehabilitation:
Passive finger extension, active limited flexion from the day after surgery

40. Complications Adhesion formation Tendon rupture Swan neck deformity
leads to loss of finger flexion
common in zone IV and VII and older patients
prevented with early protected ROM and dynamic splinting (zone IV)
Tendon rupture
causes include poor suture material or surgical technique, aggressive therapy, and noncompliance
Incidence: 5%
most frequently during first 7 to 10 days post-op
Swan neck deformity
caused by prolonged DIP flexion with dorsal subluxation of lateral bands and PIP joint hyperextension
Boutonniere deformity (DIP hyperextension)
caused by central slip disruption and lateral band volar subluxation

41. Trigger Finger

42. Introduction
Stenosing tenosynovitis caused by inflammation of the flexor tendon sheath
Epidemiology
more common in diabetics
ring finger most commonly involved
More common in women
More common after the year 40
Mechanism
caused by entrapment of the flexor tendons at the level of the A1 pulley
fibrocartilaginous metaplasia of tendon and pulley found in pathology
Associated conditions
diabetes mellitus
rheumatoid arthritis

45. Classification

46. Presentation Symptoms Physical exam finger clicking
pain at distal palm near A1 pulley
finger becoming "locked in flexed position
Physical exam
tenderness to palpation over A1 pulley 
a palpable bump may be present near the same location

47. Treatment Nonoperative Operative
night splinting, activity modification, NSAIDS
Indications: first line of treatment
steroid injections
Indications: the best initial treatment
technique
give 1 to 2 injections in flexor tendon sheath
diabetics do not respond as well as non-diabetics
Operative
surgical debridement and release of the A-1 pulley
Indications:  in cases that fail nonoperative treatment

48. De Quervain's Tenosynovitis

49. Introduction
A stenosing tenosynovial inflammation of the 1st dorsal compartment which includes:
abductor pollicis longus (APL)
extensor pollicis brevis (EPB)
Epidemiology
demographics
woman > men
years old
body location: most commonly in the dominant wrist
risk factors
Overuse: golfers and racquet sports
post-traumatic
postpartum

50. Introduction (CONT.) Pathophysiology Prognosis pathoanatomy
thickening and swelling of extensor retinaculum causes increased tendon friction
NOT considered an inflammatory process
Prognosis
most cases resolve with non-operative management 
high recurrence rate

52. Anatomy Extensor tendon compartments
Compartment 1 (De Quervain's Tenosynovitis)
APL
EPB
Compartment 2 (Intersection syndrome)
ECRL
ECRB
Compartment 3
EPL
Compartment 4
EIP
EDC
Compartment 5 
EDM
Compartment 6 (Snapping ECU)
ECU

53. Presentation Symptoms Physical exam gradual onset
radial sided wrist pain
pain exacerbated by gripping and raising objects with wrist in neutral
Physical exam 
inspection
tenderness over 1st dorsal compartment at level of radial styloid
motion
usually normal wrist motion
pain with resisted radial deviation
provocative tests
Finkelstein maneuver
On grasping the patient’s thumb and quickly abducting the hand ulnar-ward, the pain over the styloid tip is severe

54. Imaging Radiography: may be used to rule out
basilar arthritis of the thumb
carpal arthritis

55. Treatment Nonoperative
Rest, NSAIDS, thumb spica splint, steroid injection
Indications: first line of treatment
Technique:
NSAIDS, rest and immobilization usually first step
steroid injections into first dorsal compartment usually second step
Outcomes
overall corticosteroids found to be superior to splinting 
concomitant splinting and/or NSAIDs after steroids injection does not improve outcomes

56. Treatment Operative surgical release of 1st dorsal compartment
Indications:
severe symptoms 
usually consider after 6 months of failed nonoperative management 
Technique:
radial based incision proximal to the wrist
protect the superficial radial sensory nerve
Surgical release of 1st dorsal compartment

57. complications Sensory branch of radial nerve injury Neuroma formation
Failure to decompress with recurrence
may be caused by failure to recognize and decompress EPB or APL lying in separate sub-sheath/compartment
Complex regional pain syndrome

58. Thanks for Your Attention