Extensor Tendon Injuries: ED Management and Follow-up

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Extensor Tendon InjuriesED Management and
Follow-up

• Jon Friesen, CCFP-EM Resident
• Guest Consultant Dr. Earl Campbell
• May 16, 2002

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outline

• why extensor tendon injuries?
• anatomy
• injury zones
• basic principleswhats the evidence?
• extensor tendon zone i-vi injuries
• ED management, splinting, and follow-up
• hand OT/PT resources in Calgary

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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 were doing?

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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 dont know how were doing!

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why anatomy matters

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

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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

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Verdans zones of injury

• 8 zones of injury
• each zone has
• particular injuries
• variations in acute management
• different splinting requirements
• not all extensor tendon injuries are the same!!

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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 4.0-5.0

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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!

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suture techniques

• Bunnel suture
• advantages
• strong
• disadvantages
• time constraints
• technical skills
• need good tendon cross-sectional area

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suture techniques

• Kessler suture
• advantages
• strong
• disadvantages
• time constraints
• technical skills
• need good tendon cross-sectional area

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suture techniques

• horizontal mattress suture
• advantages
• easy to do, even on thinner tendons
• disadvantages
• decreased strength

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suture techniques?

• practicality in the ED
• 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

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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
• lacslt30-50, wound closure and splint for
  shortened period w/early mobilization
• lacsgt30-50, repair and treat as complete
• all partial zone i-v injuries should be repaired?
• variable amongst surgeons

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shredded ends

• important to consider in injuries where primary
  tendon repair is indicated
• fine trimming acceptable
• excursion of extensors lt 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

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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

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zone 1 mallet finger

• common injury
• closed vs. open in ed
• goal of rx
• lt10 degrees extension lag
• good flexion
• prevention of swanneck deformity

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mallet finger who to refer

• closed
• tendon avulsion with bony fragment involving gt30
  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

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closed mallet finger

• classification
• 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 gt30 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

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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 (lt2w), ½ w/delayed (gt4w)
• 0 change in outcomes with regards to extensor
  lag, rx of dorsal lip s lt30, or splint type
• conclusion splinting equally effective in both
• implication we can manage both in the ed

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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

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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

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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

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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
  lt50

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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

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closed zone 3 clinical pearls

• central slip rupture is not a simple dx!
• have high degree of suspicion if
• pip extensor lag gt15-20 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!

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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

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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

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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

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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

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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??

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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

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open zone 3 injuries

• splinting as for closed injuries
• if lateral bands lacerated, splint DIP for 4w
• antibiotics
• use if joint capsule penetration present

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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

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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

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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

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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

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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

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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

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open zone 5 who to refer

• fight bite
• sagittal band/dorsal hood involvement
• may repair if comfortable with anatomy
• associated open fractures
• tendon abrasions

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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

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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

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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

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open zone 5 splinting

• tendon lac
• splint wrist in 40-45 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

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open zone 5 f/u OT/PT

• static splinting x 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

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open zone 5 f/u OT/PT

• at 5w
• 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

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open zone 5 thumb

• what about thumb zone 5?
• 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

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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

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zone 6 injuries

• ed rx
• tendon is well formed and thick
• suturing as for zone 5 lacs
• splinting
• as for zone 5 lacs
• f/u OT/PT
• as for zone 5 lacs

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hand resources OT PT

• FHH hand clinic
• [phone]
• ask to speak to a hand pt to book patient
• Lindsay Park (2 hand pts)
• [phone]
• must indicate you want a hand pt to reception and
  they will book for you

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hand resources OT PT

• PLC
• [phone]
• ideally they want pt seen by plastics 1st
• RVH
• [phone] Ph
• [phone] Fax
• fill out form, refer from ED
• OT/PT will contact pt based on priority
• can refer from peripheral center as well

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hand resources OT PT

• what about kids?
• ACH
• [phone] Ph
• [phone] Fax
• fill out form, refer from ED
• OT/PT will contact pt w/i 48h