1. Extensor Tendon Injuries: ED Management and Follow-up
Jon Friesen, CCFP-EM Resident
Guest Consultant: Dr. Earl Campbell
May 16, 2002

2. outline why extensor tendon injuries? anatomy injury zones
basic principles…what’s the evidence?
extensor tendon zone i-vi injuries:
ED management, splinting, and follow-up
hand OT/PT resources in Calgary

3. why extensor tendon injuries?
acute injuries we see and initially manage
initial rx NB to hand functional outcome
poorly described in EM texts and literature
hit and miss in clinical education/practice
do we really know what we’re doing?

4. how good are we?
one study (!!) that examines follow-up of extensor tendons done by EM docs
Evans JD; 1995
EM housestaff in UK repaired 65 extensor tendon lacs
follow-up within 6 mos. re: functional outcome
results (as per Miller system): 80% good to excellent results in proximal injuries vs. 18% good to excellent results in distal injuries
weaknesses: unconventional splinting of distal injuries, poor physio f/u, small numbers
conclusion: we don’t know how we’re doing!

5. why anatomy matters complex anatomy different from flexors
role of juncturae
role of paratenon
EDM, EIP
extrinsics vs. intrinsics

6. why anatomy matters digits are v. complex! clinical relevance
disruption of anatomy at one joint has consequences for function of adjacent joints
initial management very important to injury outcome

7. Verdan’s zones of injury
each zone has:
particular injuries
variations in acute management
different splinting requirements
not all extensor tendon injuries are the same!!

8. what about suture material?
based on experience and expert opinion
absorbable vs. non-absorbable synthetics
non-absorbs most often used, but may cause knot irritation at site of repair
absorbs less prone to producing knot irritation, but ? strength
size:

9. suture techniques? little data re: extensor tendon repairs
may be more important as dynamic splinting becomes “en vogue” in extensor injuries
Newport ML and CD Williams; 1992
compared simple mattress, figure-of-eight, Kessler, and Bunnell suture techniques
Bunnell and Kessler stronger, but not much difference with regards to tendon shortening or decreased ROM
difficult to apply to all extensor tendon injuries!

10. suture techniques Bunnel suture advantages: disadvantages: strong
time constraints
technical skills
need good tendon cross-sectional area

11. suture techniques Kessler suture advantages: disadvantages: strong
time constraints
technical skills
need good tendon cross-sectional area

12. suture techniques horizontal mattress suture advantages:
easy to do, even on thinner tendons
disadvantages:
decreased strength

13. suture techniques? practicality in the ED: general guidelines:
time constraints
limited opportunity to use new techniques
barbaric equipment for fine repairs in the ER
general guidelines:
zones i-v: figure-of-8, horizontal mattress
zone vi, thumb extensors: Kessler, Bunnel

14. incomplete lacerations
flexor tendon studies:
studies suggest that 0 repair and early mobilization produces comparable outcomes to conventional rx in Zone II injuries
applicable to extensor injuries? what zones?
recommendations based on expert opinion:
lacs<30-50%, wound closure and splint for shortened period w/early mobilization
lacs>30-50%, repair and treat as complete
all partial zone i-v injuries should be repaired?
variable amongst surgeons

15. shredded ends
important to consider in injuries where primary tendon repair is indicated
fine trimming acceptable
excursion of extensors < flexors
overzealous trimming results in:
undue wound tension post-suturing
flexion loss during rehabilitation
general rule: if gap not breachable, or undue tension on wound distorts anatomy, refer to plastics for repair/tendon grafting

16. what about antibiotics?
little evidence specific to simple tendon lacs
ACEP Guidelines:
abx indicated for both hand and tendon lacs
Stone JF, 1998
retrospective review of 140 pts w/simple flexor lacs
timing to repair and abx not associated w/increased infx
can these results be extrapolated to extensor repair?
surgeon dependent
absolute indications:
bites, crush injuries, associated open fractures, joint capsule disruption

17. zone 1: mallet finger common injury closed vs. open in ed goal of rx:
<10 degrees extension lag
good flexion
prevention of swanneck deformity

18. mallet finger: who to refer
closed:
tendon avulsion with bony fragment involving >30% of the articular surface
associated w/volar distal phalanx subluxation or #
associated w/transepiphyseal plate # in kids
swanneck deformity
active pts: refer for k-wire fixation
open:
abrasion w/tendon erosion
associated w/open #

19. closed mallet finger classification: ed management:
type 1: distal extensor mechanism rupture, no fracture
type 2: tendon avulsion w/ small bony fragment of distal phalanx
type 3: tendon avulsion with bony fragment involving >30% of the articular surface
ed management:
dorsal/volar splint w/DIP extension; PIP free x 6w
important to emphasize NO DIP FLEXION
splint care: remove daily to avoid skin erosion

20. closed mallet finger
early vs. delayed presentation for closed injuries:
Garberman et al.; 1994
small study of 40 pts with closed mallet finger, ½ with early (<2w), ½ w/delayed (>4w)
0 change in outcomes with regards to extensor lag, rx of dorsal lip #s <30%, or splint type
conclusion: splinting equally effective in both
implication: we can manage both in the ed

21. open mallet finger ed management:
tendon suture vs. skin closure and splint
if suturing:
use figure-of-8, keep in mind tendon is friable
suture tendon and skin in one bite
suture removal in 10-12d
splinting as for closed injuries

22. mallet finger: f/u & OT/PT
continuous splint x 6w
at 6w, begin guarded DIP flexion
flex DIP 10-20x q1h
20-25 degrees for 1st week
if no lag after 1st week, 35 degrees and progress as limited by pain
if lag, reapply splint x 2w
night splinting x 2w

23. what about mallet thumb?
extremely rare due to thickness of EPL tendon
closed:
management identical to mallet finger for closed deformities
open:
clean lacs should be sutured as described for open mallet finger
follow-up and OT/PT as for mallet finger

24. zone 2: middle phalanx injuries
most injuries are either partial lacs/crush injuries
referral criteria similar to open mallet
suture technique:
lateral bands are very friable and difficult to suture
suture type: figure-of-8
epl on thumb: use core-type suture
splinting and follow-up as for mallet finger
wound care and splinting x 7-10d for partial lacs <50%

25. zone 3: the PIP worst prognosis of extensor tendon injuries
closed vs. open in ed
consider central slip and lateral bands
goal of rx: maximize flexion and extension, prevention of Boutonniere deformity

26. closed zone 3: clinical pearls
central slip rupture is not a simple dx!
have high degree of suspicion if:
pip extensor lag >15-20 degrees while MCP and wrist in full flexion
decreased strength to resistance or pain to pip extension
tenderness over pip and appropriate mechanism of injury
may present with acute Boutonniere deformity
need to assess laxity of lateral bands via passive PIP extension
assess PIP stability!

27. closed zone 3: who to refer
displaced avulsion # at base of middle phalanx
axial/lateral instability of PIP
ie. post-reduction of volar dislocation
irreducible volar dislocation
Boutonniere deformity not correctable by passive PIP extension
time to rx less important than joint laxity

28. closed zone 3 injuries ed management: continuous splint x 6w
volar splint with DIP and MCP free to move
when splint removed, PIP MUST BE HELD IN EXTENSION
splint care: remove daily to avoid skin erosion

29. closed zone 3 injuries if associated volar dislocation:
reduce by applying traction w/MCP and PIP in full flexion
if this fails, try adding in wrist extension for extensor relaxation
reassess PIP stability

30. open zone 3: clinical pearls
anatomy is complex!!
high degree of suspicion for joint capsule penetration in lacs over PIP
look closely for lateral band lacs
lacs rarely involve entire dorsal apparatus
failure to repair may result in Boutonniere deformity

31. open zone 3: who to refer
distal central slip stump too short for tendon suturing
abrasion w/tendon erosion
associated w/open #
lateral band laceration??
PIP joint capsule penetration??

32. open zone 3 injuries: ed rx
wound irrigation and exploration is NB
lacs require suturing
suture technique: figure-of-8
suture type: 5.0 non-absorbable/absorbable
suture lateral bands as well

33. open zone 3 injuries splinting as for closed injuries antibiotics
if lateral bands lacerated, splint DIP for 4w
antibiotics
use if joint capsule penetration present

34. zone 3 injuries: f/u & OT/PT
much more complex than DIP, get hand physio involved at 6w
at 6w: exercises 10-20x q1h
active PIP extension w/MCP in flexion to encourage intrinsic extension
gentle active flexion (to pain) w/wrist and MCP extension
reapply splint between hand physio sessions
if extensor lag develops, decrease flexion and reapply splint

35. zone 3 injuries: f/u & OT/PT
at 8w
continue active flexion, gentle resistance applied
splint at night or d/c splint
at 10w
increase resistance exercises
progress to full grasp

36. zone 3 thumb injuries: the MCP
may involve EPB and/or EPL
closed:
rare injuries: refer to plastics for management
open:
thicker tendons; use Kessler suture for open lacs
repair both EPB and EPL
splint with CMC neutral, MCP 0 degrees, and IP 0 degrees
complex OT/PT: refer for follow-up

37. zone 4 injuries: proximal phalanx
tendon is very broad at this level
lacs tend to be partial
if 0 loss of extension, splint as for PIP x 3-4w and then begin active motion
suture complete lacs
may be able to use Kessler suture
treat as for PIP lacs, but mobilize at 3-4w b/c of higher degree of “scarring down” at this zone
f/u and OT/PT as for PIP injuries
thumb injuries: rx as for zone 3 thumb injuries

38. zone 5: the MCP
consider importance of dorsal hood and sagittal bands in addition to tendon
closed vs. open injuries
open injuries are considered “fight bite” until proven otherwise

39. closed zone 5
injuries are rare and usually due to a crush mechanism over the MCP
classic: tendon dislocation and relocation with passive extension
suspect sagittal band/dorsal hood disruption when painful flexion at MCP occurs
who to refer: all injuries
ed management:
splint w/MCP in extension at place of tendon relocation
leave other MCPs free to move

40. open zone 5: who to refer fight bite
sagittal band/dorsal hood involvement
may repair if comfortable with anatomy
associated open fractures
tendon abrasions

41. open zone 5: fight bite early presentation: ie. non-infected
irrigation and exploration required
if any disruption of joint capsule/tendon, start abx and refer to plastics
if underlying structures OK, start abx and ensure close f/u in 24-48h
wound closure in 5-7d post-abx
abx prophylaxis: clavulin x 5d
splint: as for other zone 5 lacs

42. open zone 5: ed rx irrigation and wound debridement
tendon is thick at this point
ends tend not to retract
suture material: 4.0 nonabsorbable
suture techniqure: Kessler suture vs. figure-of-8

43. open zone 5: ed rx what about dorsal hood lacs?
need to be repaired to prevent central tendon subluxation
what about sagittal band lacs?
need to be repaired for same reason

44. open zone 5: splinting tendon lac:
splint wrist in degrees extension, MCPs 20 degrees flexion, and IPs in 0 degrees
time: 4-5w
isolated dorsal hood/sagittal band lac:
avoiding abduction/adduction exercises is key
buddy tape adjacent finger
begin flexion/extension in 3-5 days

45. open zone 5: f/u & OT/PT static splinting x 4w at 4w:
may take off IP splint to allow mobility periodically
hand physio NB!!
at 4w:
gentle active extension at MCP
alternating flexion of MCP and IPs
wrist extension and flexion to neutral
splint worn b/t sessions, IPs now free

46. open zone 5: f/u & OT/PT at 5w: at 7w:
claw postion to encourage extrinsic extension
intrinsic + to stretch collateral ligaments
alternate finger and wrist flexion
night splinting only, unless extensor lag persists
at 7w:
resisted exercises

47. open zone 5: thumb what about thumb zone 5? ed rx: splint: f/u and pt:
involves CMCJ, EPB and/or APL
also consider radial artery/nerve branch lacs
ed rx:
refer if APL avulsed off bone
repair as for zone 5 digit injuries
splint:
thumb in extension and moderate abduction
f/u and pt:
refer to hand physio

48. zone 6 injuries better prognosis than injuries to distal counterparts
open injuries prevail
who to refer:
associated w/open #s, crush injuries
significant tendon retraction
infection

49. zone 6 injuries ed rx: splinting: f/u & OT/PT
tendon is well formed and thick
suturing as for zone 5 lacs
splinting:
as for zone 5 lacs
f/u & OT/PT

50. hand resources: OT & PT FHH hand clinic Lindsay Park (2 hand pts)
(403)
ask to speak to a hand pt to book patient
Lindsay Park (2 hand pts)
(403)
must indicate you want a hand pt to reception and they will book for you

51. hand resources: OT & PT PLC RVH (403) 291-8785
ideally they want pt seen by plastics 1st
RVH
(403) Ph
(403) Fax
fill out form, refer from ED
OT/PT will contact pt based on priority
can refer from peripheral center as well

52. hand resources: OT & PT what about kids? ACH (403) 229-7912 Ph
(403) Fax
fill out form, refer from ED
OT/PT will contact pt w/i 48h