1. Tendon injuries Robert Spławski MD, PhD Paweł Surdziel MD, PhD Robert Spławski MD, PhD Paweł Surdziel MD, PhD Department of Traumatology and Hand Surgery University of Medical Sciences in Poznan Head of Department: Prof. Władysław Manikowski Head of Department: Prof. Władysław Manikowski

2. Historical notes Tendon surgery is as old as surgery itself

3. 2698 BC – Yu-Fu 460BC – Hippocrates 280 BC – Herophilos from Chalkedon 129-199 – Galen 980-1037 – Avicenna 1641- Ambrosius Pare 1880 - Nikoladoni 1881 – Gluck 1882 – Henck Historical notes

4. Hippocrates – if injury of Achilles tendon occurs it would cause acute fever, convulsins etc. Avicenna - tenth century strongly advocated tendon suture World War I and II stimulated the development of modern hand surgery

5. Tendon consists of : Cells – fobroblastsCells – fobroblasts Extracellular matrixExtracellular matrix mainly collagen fibers, elastin fibers mainly collagen fibers, elastin fibers ground substance (proteoglicans, glycosaminoglycans, structural proteins, plasma proteins and other small molecules) ground substance (proteoglicans, glycosaminoglycans, structural proteins, plasma proteins and other small molecules)

6. Collagen typI – composed of three chains 70% glicine, 15% proline and 15% hydroxyproline Collagen molecules are combined in a right-handed triple helix. The stabilisation between helixs is maintain by hydrogens bonds.

7. Collagen molecule micro fibrils Fibril of collagen tendon epitendon endotendon

8. Blood supply

9. 1 artery, 1 veins, a lot of nervs 2 fascicls – 1 artery, 1vein, 2-3 nervs 2 arteris, 2 veins, a lot of small arteries 5 fascicles – 1 artery i 2 veins Blood supply

11. Flexor tendon nutrition

12. Tendon healing

14. Zones of flexor tendon injury

20. Primary flexor tendon suture Delayed flexor tendon suture Secondary repair /late reconstruction/ - one stage tendon reconstruction - two stage tendon reconstruction

21. Treatment Zone I Reinsertion after avilsion injury End to end suture Zone II End to end suture Zone III End to end suture

22. Treatment 1.Active extension-passive flexion Kleinert method of rehabilitation 2.Controlled passive motion -Duran-Houser method /active motion after 5 weeks/ 3.Controlled active motion method.

23. Active extension-passive flexion

25. PM

26. CAM

27. Tendon reconstruction Primary end to end tendon suture. To 3-4 weeks. Secondary - staged techniques single stage – good conditions two stage – after complicated injuris 1-st stage – endoprothesis 2-nd stage – tendon graft.

28. Secondary tendon repair 1.One stage reconstruction FTG /free tendon graft/ 1.1. Bunnel graft zone I-IIII° wg Boys`a 1.2. Matev graft zone I-V 1.3. Interposition graft III-V 2. TFTI (temporary flexor tendon implant) 2.1. Short graft I-III 2.2. Long tendon graft I-V

29. Tendon reconstruction Tendon grafts Short – zone 1-3 Long – zone 1-5

49. Prostowniki

50. Mallet finger Type I- closed trauma, with or without small avulsion fracture Type II- laceration, loss of tendon continuity Type III- II+deep abrasion Type IV- A-transepiphiseal plate fracture; B- fracture of artic. surf. 20-50%; C- fracture of artic. surf. >50%, or subluxation aDIP Zone I

52. Zone II 1.Open injury – tendon suture; immobilization in hyperextension for 6 weeks. 2.Closed injury- split in hyperextension in aPIP

53. Zones III, IV,V Open injury: -tendon suture, immobilization aPIP 0° to 5-6 weeks - exercise -Zone V – wrist immobilization in flexion 40°. MP joints in flexion 10-20°. Closed injury: - splint for 6 weeks

54. Zones VI-IX End to end tendon suture. Immobilization – wrist in hyperextension 40-45° for 4-5 weeks

55. Controlled active flexion –passive extension