2. Cut Wrist & Flexor tendon injury Ramy El Nakeeb, MD. Orthopaedic Department Damanhour Medical institute

3. FDS FDP FPL Lumbricals origin from radial side of FDP ANATOMY

4. CAMPER’s CHIASMA FDS divides and passes around the FDP tendon, the two portions of the FDS reunite at “Camper’s Chiasma”

6. Preserve A2 and A4 pulley to prevent bowstringing. NOTE: There is a mistake in this diagram: The C1 pulley is DISTAL to the A2 pulley! PULLEYS

7. TENDON EXCURSION - 9 cm of flexor tendon excursion with wrist and digital flexion - only 2.5 cm of excursion is required for full digital flexion with the wrist stabilized in neutral position

8. BLOOD SUPPLY Segmental branches of digital arteries which enter the tendon through: – vincula – osseous insertions Synovial fluid diffusion

9. VINCULAE

10. ZONES

12. Cut wrist injuries were defined as lacerations occurring between the distal wrist crease and the flexor musculotendinous junctions. It may involve as many as 16 different structures, including 12 tendons, 2 nerves, and 2 arteries.

13. The goals of the surgical treatment is to achieve a primary tendon repair of sufficient tensile strength to allow application of a postoperative mobilization and rehabilitation protocol.

14. It is well-known by hand surgeons that the catastrophic potential of a volar wrist laceration can result in a functionless extremity. Tendon repair can be expected to heal and maintain individual gliding function when primary repair is coupled with early and aggressive occupational therapy.

15. Tendon Injury in Cut Wrist Zone of injury Complications Management 1.In the Emergency Room First aid Calm the patient Examination 2.Surgical repair 3.Rehabilitation 4.Cut wrist in a child

16. Tendon Injury in Cut Wrist Zone of injury Complications Management 1.In the Emergency Room First aid Calm the patient Examination 2.Surgical repair 3.Rehabilitation 4.Cut wrist in a child

17. Cut wrist injuries were defined as lacerations occurring between the distal wrist crease and the flexor musculotendinous junctions. It may involve as many as 16 different structures, including 12 tendons, 2 nerves, and 2 arteries.

18. Tendon Injury in Cut Wrist Zone of injury Complications Management 1.In the Emergency Room First aid Calm the patient Examination 2.Surgical repair 3.Rehabilitation 4.Cut wrist in a child

19. Adhesion formation In many instances, it is unrealistic to expect a tendon to heal without any adhesions, some loose adhesions may develop after surgery even with exercise. Adhesions influence tendon movement depending on their density. 1. loose adhesions arise from the subcutaneous tissue 2. adhesions of moderate density 3.dense adhesions arise from the bony floor or volar plates 4.A fourth type are adhesions between the repaired tendons.

20. Repair rupture Among all the consequences of flexor tendon surgery, repair ruptures are of prime concern to hand surgeons, because they require secondary operations. The following factors may trigger the ruptures: 1.Overload of the repaired tendons 2.Tendon edema or bulky tendons 3.Triggering in pulleys or edges of opened sheath

21. Joint stiffness Clean-cut flexor tendon injuries themselves, however, usually do no trauma to finger joint structures. It is the postoperative protective finger position that causes joint contracture.

22. Nerve injury May lead to insenate hand Loss of intrensic function

23. Vascular injury Cold intolerance ischemia

24. A Case of Cut Wrist

26. Tendon Injury in Cut Wrist Zone of injury Complications Management 1.In the Emergency Room First aid Calm the patient Examination 2.Surgical repair 3.Rehabilitation 4.Cut wrist in a child

27. 1.Tendon injury 2.Nerve injury 3.Vascular injury First aid: Cut wrist Emergency????

28. Vascular injury bleeding ischemia tourniquetRemoval of tourniquet elevation of the hand as high above the heart as possible. packing of the wound and direct pressure Bleeding from a partially severed vessel Did not stop Pleeeease Do not clamp & No stitches

29. Now you can calm the patient

30. Why not directly into the OR ? 1. you can miss something 2. you can avoid operating and transfer the case if no proper facilities or expertise are available. 3. A superficial wound ???? Cut wrist

31. Examination What to search for in your examination ? Diagnosis of tendon injury

32. TENODESIS EFFECT Passive extension of the wrist does not produce the normal “tenodesis” flexion of the fingers if flexors are injured

33. FDS: Clinical Exam

34. FDP: Clinical Exam

35. FDP RUPTURE No active DIP motion (present passive DIP motion)

36. Nerve injury : Motor ulnar and radial, median sensory.

37. Tendon Injury in Cut Wrist Zone of injury Complications Management 1.In the Emergency Room First aid Calm the patient Examination 2.Surgical repair 3.Rehabilitation 4.Cut wrist in a child

38. I must have with me: Basic instruments. Basic instruments.

39. Magnification and microsurgery instruments

40. Suture material: non absorbable Suture caliber :4-0 3-0, (the mode of failure was affected by the configuration and the caliber of suture used) The needle

41. Suture material: non absorbable immediately after a tendon repair, the tendon contributes nothing to the strength of repair. During that time, the suture itself and suture technique are the sole contributors to the strength of repair. Although stainless steel is the strongest material that can be used at the time of repair, it has serious disadvantages. It is difficult to work with and makes a bulky knot. Conversely, all absorbable sutures become too weak too soon to be of value. At this time, nonabsorbable, synthetic fibers that are relatively strong, such as Supramid or prolene, are the most desirable materials available.

42. Suture material: 1.Monofilament polyglyconate (Maxon®). 2.Monofilament stainless steel 3.Braided polyester (Ticron®) 4.Braided polyglycolic acid (Dexon®) 5. Multifilament stainless steel 6.Monofilament polybutestor (Novafil®) 7.Polypropylene (Surgilene®) 8.Monofilament nylon (Dermalon) Suture caliber :4-0 3-0, (the mode of failure was affected by the configuration and the caliber of suture used) The needle

43. BRUNNER INCISION

44. Extension of the wound

45. Extension of the wound 2

46. Extension of the wound 3

47. 2 34 5 1.Distal structures 2. Proximal structures should be identified from deep to superficial and tagged……..N.B. Follow the Hematoma 3. FDS Identification and tagging

48. Attempts to improve the early postoperative strength of the repair construct have focused on biomechanic and biologic attempts to modify the early postoperative repair site. 1.Configuration of the core suture 2.To alter the number of suture strands passing across the repair site 3.The use of core sutures of different caliber and materials 4.Variation in the pattern and depth of placement of the circumferential epitenon suture

49. numerous studies have demonstrated the superiority of the four-strand core suture overthe two-strand core suture and the greater strengths achieved with six- and eight- strandcore suture techniques. The limiting factor to more widespread use of modern multistrand suture techniques remains the surgeon’s ability toperform the repair using atraumatic techniquesuch that trauma to the tendon stumps and the circumferential visceral epitenon is minimized.

50. Locked Vs grasping suture The relationship between the longitudinal and transverse intratendinous components of the core suture defines whether the suture is "locking" or "grasping." When the transverse component passes within the tendon superficial to the longitudinal component, the suture "locks" a bundle of tendon fibers. When the transverse component passes deep to the longitudinal component, however, the suture does not "lock" a bundle of tendon fibers but pulls through the tendon.

51. How to choose which kind of repair ?? the epitendinous suture

52. 2 Suture material: non absorbable Suture caliber :4-0 3-0, (the mode of failure was affected by the configuration and the caliber of suture used) The needle

53. Nerve Repair The purpose of performing a nerve suture is to align, as accurately as possible, the corresponding fascicular components of the proximal and distal nerve segments. The evolution of surgical techniques has passed through many stages. One important step was the introduction of the operating microscope, which made it possible to identify and manipulate nerve structures with improved accuracy.

54. Nerve injury crushing Clean cut Apparent Not apparent Direct sutures Trim+ direct repair, if under tension primary grafting Direct sutures will give bad results Do not clamp

57. Vascular repair

58. Tendon Injury in Cut Wrist Zone of injury Complications Management 1.In the Emergency Room First aid Calm the patient Examination 2.Surgical repair 3.Rehabilitation 4.Cut wrist in a child

59. Complete your work

60. Rehabilitation of cut wrist injury Immobilization program: uncooperative, associated injury. Controlled motion program (passive) 1.Kleinert program 2.Duran program Early active motion

61. STIFFNESS RUPTURE

62.  Too much motion  To little motion RUPTURE STIFFNES

63. Because of improvements in strong, graping suture techniques, a trend has developed in tendon rehabilitation from immobilization to early controlled motion protocols. Studies have shown that early controlled forces applied to the healing tissues: 1.improve recovery of tensile strength. 2.decrease adhesions. 3.improve tendon excursion 4.promote intrinsic healing

64. Kleinert program In the 1960s, Kleinert and others introduced an early controlled passive motion protocol using a dorsal protective splint (wrist, 30 flexion and MCP, 30–40( flexion) with elastic traction from the fingernail to the volar forearm two modifications became standard: a palmar pulley was added to improve DIP flexion, and at night the elastic traction is detached and the fingers strapped into extension within the splint to prevent PIP joint flexion contractures.

65. Duran program dorsal protective splint without elastic traction. The program was designed in response to their measurement that 3–5 mm of tendon glide would prevent restrictive adhesion in zone II. Passive DIP extension with PIP and MCP joint flexion was found to glide the FDP away from the FDS suture sites. Passive PIP joint extension with MCP and DIP flexed glides both tendons away from the injury site.

66. Early active motion Active motion from day one in a protective dorsal splint, better supervised in the first 3 weeks. The amount of force applied must be less than the tensile strength of the repair to prevent gapping or rupture. 4 strand technique, or a stronger configuration is required,

68. 1. The patient in undependable 2. Hand Therapist 3. Financial reasons 4- The recurrent sessions of physiotherapy require a good movable splint Why don’t we follow the international programs for rehabilitation??

69. 1. The patient in undependable 2. Hand Therapist 3. Financial reasons

70. 4. The recurrent sessions of physiotherapy require a good movable splint

71. 3

72. Tendon Injury in Cut Wrist Zone of injury Complications Presentation and Examination Management 1.First aid 2.Surgical anatomy 3.Technique of repair 4.Rehabilitation 5.Cut wrist in a child

73. Flexor tendon injuries in children differ from adults in their diagnosis and postoperative rehabilitation principles. The child may be uncooperative, so indirect methods of tendon integrity must be used for diagnosis. A high index of suspicion necessitates surgical exploration. Although surgical approach and repair techniques are identical to those in adults, postoperative immobilization for 3–4 weeks is used instead of an early motion protocol.