EXTENSOR TENDON INJURIES

1
EXTENSOR TENDON INJURIES
2
EXTENSOR TENDON INJURIES

• EXTENSOR TENDONS ARE PREDISPOSED TO LACERATION
• 1. DUE TO SUPERFICIAL LOCATION ON DORSUM
• OF HAND
• 2. MINIMAL AMOUNT OF SUBCUT. TISSUE
• BETWEEN TENDONS AND OVERLYING SKIN
• RESULTS OF TREATMENT ARE NOT ALWAYS AS
• FAVORABLE AS ONCE ASSUMED

3
EXTENSOR MECHANISM
4
ANATOMY

• EXTENSOR TENDON ON THE DORSUM OF THE HAND TO THE
  LEVEL OF THE MCPJ ARE COMPOSED OF
  MUSCULOTENDINOUS UNITS
• TENDONS RADIAL gt ULNAR
• EPB,EPL,EIP,EDC,EDQM
• GAIN ACCESS BY PASSING THROUGH FIBRO-OSSEOUS
  TUNNELS AT THE WRIST LEVEL, AND AT THIS LEVEL ARE
  COVERED BY TENOSYNOVIUM

5
ANATOMY

• NEAR THE MIDPORTION OF THE METACARPALS, JUNCTURA
  TENDINUM PASS DISTALLY AND OBLIQUELY BETWEEN THE
  ULNAR THREE EDC TENDONS
• COMPARTMENTS PREVENT EXT. TENDONS FROM
  BOWSTRINGING DORSALLY DURING ACTIVE FINGER
  EXTESION, PARTICULLARLY WHEN WRIST IS EXTENDED
• JUNCTURA RESULT IN GROUPED EDC EXTENSION,
  ESPECIALLY AT THE ULNAR ASPECT OF THE HAND

6
ANATOMY

• AT THE MPJ LEVEL THE EIP AND EDC TO THE INDEX
  JOIN TOGETHER THE TENDONS AND ARE CENTRALIZED
  OVER THE DORSUM OF THE MPJ BY SAGITAL BANDS
• TRANSVERSE FIBERS CONNECT THE LATERAL MARGINS OF
  THE EXT TENDONS TO THE PALMAR PLATES OF THE MPJ
  AND TO THE PERIOSTEUM OF THE PROXIMAL PHALLYNX
• DISTAL TO THE SAGITTAL BANDS ARE TRANSVERSE AND
  OBLIQUE FIBERSgtINITIAL CONTRIBUTIONS OF THE
  INTEROSSEOUS MM TO THE DORSAL APPARATUS

7
ANATOMY

• DISTAL TO THE MPJ THE DIGITAL EXTENSOR MECHANISM
  CONSISTS OF BOTH INTRINSIC AND EXTRINSIC
  MUSCULOTENDINOUS UNITS
• AT THE MPJ LEVEL ALL COMPONENTS OF INTRINISIC
  MUSCLES ARE PALMAR TO THE AXIS OF ROTATION AND
  SERVE AS MPJ FLEXORS
• DISTAL TO THE MPJ EXTRINSIC AND INTRINSIC TENDONS
  JOIN TOGETHER FORMING THE DORSAL APPARATUS
• CONTINUATION OF THE EXTRINSIC EXTENSOR IS THE
  CENRAL SLIP WHICH INSERTS ON THE BASE OF THE
  MIDDLE PHALLYNX

8
ANATOMY

• INTRINSIC TENDONS FORM THE LATERAL BANDS WHICH
  SEND FIBERS MEDIALLY TO FORM PART OF THE CENTRAL
  SLIP
• LATERAL BANDS JOIN ON THE DORSUM OF THE MIDDLE
  PHALLYNX FORMING THE CONJOIN TENDON AND INSERTS
  ON THE BASE OF THE DISTAL PHALLYNX

9
VERDENS EXTENSOR ZONES
10
OPEN INJURIESDISTAL FOREARM AND WRIST (ZONE 8
7)

• DEEP LACERATIONS USUAL CAUSE AT THIS LEVEL
• TENDONS MAY RETRACT WELL PROXIMAL INTO THE
  FOREARM
• LACERATIONS OF THE SUPERFICIAL RADIAL BRANCHES
  AND LATERAL ANTEBRACHIAL CUTANEOUS NERVES ARE
  COMMONLY ASSOC.
• SURGICAL APPROACH REQUIRES LONGITUDINAL EXPOSURE
• 4-0 NONABSORBABLE SUTURE WITH KNOTS BURIED

11
DISTAL FOREARM AND WRISTZONE 8 7 CONT.

• SPECIFIC PROBLEMS OCCUR AT THE LEVEL OF THE
  EXTENSOR RETINACULUM
• 1. COMPARTMENTS ARE WELL DEFINED BY A
• RETINACULUM AND SEPTA BOTH OF WHICH
• APPROXIMATE TENDONS CLOSELY
• 2. COMPARTMENTS MAY HAVE TO BE OPENED,
• OR A PORTION EXCISED TO RETRIEVE
• RETRACTED ENDS AND ACCOMMODATE BULK
• OF TENDON REPAIR

12
OPEN INJURIESZONE 8 7 POST-OP CARE

• WRIST SPLINTED 20 DEGREES EXT. AND MP JOINTS
  NEUTAL 10 DAYS
• SPLINT CHANGED TO ALLOW MPJ 30-40 DEGREES 4 WEEKS
• SPLINT REMOVED TO BEGIN PROTECTED AROM UNTIL 6
  WEEKS POST-OP
• MULTIPLE TENDON INJURIES
• 1. DYNAMIC EXTENSION SPLINTING AS SOON AS
• LOCAL WOUND PERMITS.
• 2. STATIC HAND AND WRIST SPLINT 4 WEEKS
• AFTER SURGERY
• 3. PERIODIC REMOVAL WITH AROM 6 WEEKS P/O

13
OPEN INJURIESZONE 6

• TENDONS VERY SUPERFICIAL
• ASSOC INJURIES WITH PARATENON AND PERIOSTEUM
  RESULT IN INC. ADHESIONS
• ASSCO LACS OF BRANCHES OF SUP RADIAL AND DORSAL
  ULNAR N.
• TENDONS ARE ROUND OR OVAL AND WILL ACCEPT KESSLER
  STITCH, 4-0 NONABSORBABLE

14
OPEN INJURIESZONE 6 POST OP

• STATIC SPLINT WRIST 30 DEG EXT, MP NEUTRAL 10
  DAYS
• SPLINT CHANGE AT 10 DAYS, FLEXING MPJ AT 30
  DEGREES
• 4 WEEKS PERIODIC REMOVAL OF SPLINT, AROM
• D/C SPLINT AT 6 WEEKS
• SPLINT ALL THREE ULNAR DIGITS IF ONE OR MORE
  INJURED, IF THUMB TREATED INDEP.

15
OPEN INJURIESMETACARPOPHALANGEAL JOINT LEVEL
(ZONE 5)

• LACERATIONS READILY ENTER THE JOINT
• MUST CONSIDER HUMAN BITE AT THIS LEVEL
• RADIOGRAPHS TO ASSESS METACARPAL HEAD ARE
  ESSENTIAL
• OPEN JOINT INJURIES SECONDARY TO HUMAN BITES
  REQUIRE THOROUGH DEBRIDEMENT AND PARENTERAL
  ANTIBIOTICS
• TENDON ENDS DO NOT RETRACT AT THIS LEVEL
• LACERATION MAY BE PROXIMAL TO SKIN LAC DUE TO
  FLEXED MPJ

16
OPEN INJURIESMETACARPOPHALANGEAL JOINT LEVEL
(ZONE 5)

• LACERATIONS READILY ENTER THE JOINT
• MUST CONSIDER HUMAN BITE AT THIS LEVEL
• RADIOGRAPHS TO ASSESS METACARPAL HEAD ARE
  ESSENTIAL
• OPEN JOINT INJURIES SECONDARY TO HUMAN BITES
  REQUIRE THOROUGH DEBRIDEMENT AND PARENTERAL
  ANTIBIOTICS
• TENDON ENDS DO NOT RETRACT AT THIS LEVEL
• LACERATION MAY BE PROXIMAL TO SKIN LAC DUE TO
  FLEXED MPJ

17
OPEN INJURIESMETACARPOPHALANGEAL JOINT LEVEL
(ZONE 5)

• LACERATIONS READILY ENTER THE JOINT
• MUST CONSIDER HUMAN BITE AT THIS LEVEL
• RADIOGRAPHS TO ASSESS METACARPAL HEAD ARE
  ESSENTIAL
• OPEN JOINT INJURIES SECONDARY TO HUMAN BITES
  REQUIRE THOROUGH DEBRIDEMENT AND PARENTERAL
  ANTIBIOTICS
• TENDON ENDS DO NOT RETRACT AT THIS LEVEL
• LACERATION MAY BE PROXIMAL TO SKIN LAC DUE TO
  FLEXED MPJ

18
OPEN LACERATIONSMETACARPOPHALANGEAL JOINT ZONE 5

• OBLIQUE LACERATIONS MAY INCLUDE SAGITTAL BANDS,
  SHOULD BE CAREFULLY SUTURED TO PREVENT LATERAL
  MIGARATION OF THE EDC
• SIMPLE LACERATIONS WHICH EXTEND INTO JT.
• 1. CAREFUL INSPECTION AND ID OF JOINT
• CLOSURE AS SEPARATE LAYTER 4-0
• ABSORBABLE SUTURE
• 2. JOINT CONTAMINATED PORTION OF CAPSULE
• EXCISED AND LEFT OPEN, WICK 48HRS, IV ABX

19
OPEN INJURIESZONES 3 4 PIP JOINT LEVEL

• DORSAL APPARATUS THIS AND CIRCUMFERENTIALLY
  ORIENTED
• SIMPLE LACERATIONS SELDOM RESULT IN COMPLETE
  LACERATIONS OF DORSAL APP.
• ENDS DO NOT RETRACT
• SIMPLE INJURIES RE-APPROX WITH 5-0 NONABS
• IF PARTIAL SUBSTANCE LOSS OF DORSAL APP. 1.
  BETTER TO ALLOW REMAINING TENDON TO
  ASSUME NORMAL RESTING TENSION THAN TO
  APPROX. UNDER TENSION

20
OPEN LACERATIONSPIPJ LEVEL ZONES 4 3

• LACERATIONS DISTALLY INTO ZONE 3 MAY EXTEND INTO
  PIPJ
• ZONE 3 LACERATIONS OCCUR WHERE THE EXTENSORS AND
  LATERAL BANDS COMBINE TO FORM THE CENTRAL SLIP
• OPEN INJURIES OF THE CENTRAL SLIP MAY CAUSE ACUTE
  BOUTONIERE DEFORMITY
• PROGRESSION TO ADVANCED BOUTONNIERE DEFORMITY
  SHOULD NOT BE UNDERESTIMATED
• EXPLORATION OF CENTRAL SLIP IS MANDATORY
• PROTECTIVE SPLINTING ADVISED

21
OPEN LACERATIONS ZONE 4 5

• PARTIAL OR COMPLETE SIMPLE LACERATIONS, REPAIR
  WITH 5-0 NONABS. FIG-8 WITH NOT BURIED
• IF DISTAL STUMP TOO SMALL TO ACCEPT SUTUREgt
  ATTATCH PROXIMAL CENTRAL SLIP DIRECTLY TO DORSAL
  FLARE OF MIDDLE PHALANX WITH T-VERSE DRILL HOLES
• IF EXT. TENDON LAC EXTENSIVE PRECLUDING DIRECT
  REPAIR, MAY RECONSTRUCT USING PORTION OF THE
  LATERAL BANDS

22
OPEN LACERATIONSZONE 4 3

• PIVOTAL POINT IN REHAB FOR ZONE 4 3 INJURIES IS
  PREVENTION OF EARLY PIP FLEXION POSTURE
• INCREASED TENSION IN THE REPAIRS AND PALMAR
  MIGRATION OF THE LATERAL BANDS MUST BE AVOIDED
  gt WILL OCCUR IF PIPJ IS ALLOWED TO FLEX
• COMPLEX INJURIES/NONCOMPLIANT PATIENT MAY REQUIRE
  K-WIRES TO TRANSFIX PIPJ IN EXTENSION

23
OPEN LACERATIONSZONE 4 3

• K-WIRES NEED TO BE REMOVED 3 WEEKS
• EXTERNAL SPLINTING ADDITIONAL 3-4 WEEKS
• RUBBER-BAND OR SPRING LOADED REVERSE KNUCKLE
  BENDERS ARE USED TO MAINTAIN EXTENSION WHILE
  ALLOWING ACTIVE FLEXION EXERCISES AFTER TOTAL OF
  6 WEEKS INTERNAL/EXTERNAL STATIC SPLINTING
• ALL SPLINTING IS DISCONTINUED AT 8 WEEKS
• IF PLASTER SPLINTING WRIST EXT 30 DEG. MP FLEXED
  30 DEG. AND PIPJ IS IN NEUTRAL

24
OPEN INJURIESMIDDLE PHALANGEAL AND DIPJZONES 2
1

• LATERAL BANDS BLEND DORSALLY TO FORM THE
  CONJOINT TENDON, THEY ARE THIN AND ORIENTED
  AROUND THE DORSAL HALF OF THE MIDDLE PHALLYNX
• SIMPLE LACS SELDOM TRANSECT ALL DORSAL APP.
• READILY APPROX. WITH FIG. 8 NONABSORB. SUT.
• IF SEGMENTAL LOSS OF PART OF THE APPARATUS IT MAY
  BE BETTER TO ALLOW REMAINING INTACT TENDON TO
  ASSUME NORMAL RESTING TENSION

25
OPEN INJURIESMID PHALANGEAL AND DIPJ

• ZONE 1 CONJOINT TENDON IS WELL DEFINED AND
  DORSALLY POSITIONED
• COMPLEX LACS WILL RESULT IN FLEXED DIPJ 40 DEG.
• INCOMPLETE LACS gt FLEXED DIPJ 15 DEG. AND EXT.
  WEAKNESS
• REPAIRED WITH FIG 8 NONABS.
• 1. SEPARATE LAYER CLOSURE
• 2. RUNNING STITCH WITH BOTH SKIN TENDON

26
ZONE 1 AND 2 REHAB

• CONTINUOUS SPLINTING WITHOUT EXCEPTION IN FULL
  EXTENSION FOR 6 WEEKS
• PROTECTED AROM EXERCISES AFTER SPLINT REMOVAL
• NONCOMPLIANT PATIENTS 0.O45 K-WIRE FOR 6 WEEKS,
  FOLLOWED BY PROTECTED, AROM FOR 2 WEEKS

27
CLOSED INJURIES

• CENTRAL SLIP AND THE CONJOINT TENDON INSERT INTO
  THE DORSAL BONY PROMINENCES OF THE MIDDLE AND
  DISTAL PHALANGES
• DIRECT, DEEP CONTUSIONS OR JOINT INJURIES MAY
  AVULSE THESE TENDONS AT THEIR INSERTIONS
• CENTRAL SLIP INJURED CLOSED BOUTONNIERE
  DEFORMITY
• CONJOINT TENDON INJURED CLOSED MALLET DEFORMITY
• OFTEN MISSED OR UNDERTREATED

28
BOUTONNIERE DEFORMITY

• THREE MECHANISMS OF INJURY TO PIPJOINT WILL
  RESULT IN DISRUPTION OF THE CENTRAL SLIP
• 1. DEEP CONTUSION ABOUT DORSUM OF PIPJ
• 2. ACUTE FORCEFUL FLEXION OF PIPJ
• 3. PALMAR DISLOCATION OF PIPJ
• THESE INJURIES RESULT NOT ONLY IN CENTRAL SLIP
  DISRUPTION BUT PALMAR MIGRATION OF THE LATERAL
  BANDS
• PULL OF INTRINSICS ARE FOCUSED ON THE DIPJ
  CAUSING DIPJ HYPEREXTENSION

29
BOUTONNIERE DEFORMITY
30
BOUTONNIERE DEFORMITY

• OFTEN NOT APPARENT FOR 7-14 DAYS
• INITIALLY ASSOC WITH PAINFUL SWOLLEN PIPJ
• EARLY FINDINGS
• 1. PAINFUL SWOLLEN PIPJ
• 2. MILD EXTENSION LAG (15-25 DEGREES)
• 3. DECREASED EXTENSION AGAINST RESISTANCE

31
BOUTONNIERE TREATMENT

• KEY MAINTAINING PIPJ IN CONSTANT COMPLETE
  EXTTENSION
• POSITIONING DOES NOT REQUIRE SPLINTING DIP OR MPJ
  IN ANY SPECIFIC POSISTION
• CONTINUOUS SPLINTING 6 WEEKS
• IF ANY EVIDENCE OF RECURRANCE OF EXT LAG.
• gt CONT. SPLINTING TOTAL OF 8 WEEKS
• MAY OCCURE WITH AVULSION OF DORSAL LIP OF MIDDLE
  PHALLYNX, REQUIRES OPEN TREATMENT

32
MALLET DEFORMITY

• USUALLY OCCURS WHEN TIP OF FINGER IS STRUCK BY OR
  AGAINST AN OBJECT RESULTING IN ACUTE FLEXION AT
  DIPJ
• MAY \MAY NOT OCCUR WITH AVULSION OF SMALL
  FRAGMENTS OF BONE
• NONOPERATIVE TREATMENT MOST WIDELY USED
• GOAL OF TREATMENT IS MAINTENANCE OF CONTINUOUS
  DIPJ EXTENSION UNTIL TENDON HEALS

33
MALLET DEFORMITY
34
MALLET DEFORMITY TREATMENT

• IN COOPERATIVE PATIENT
• 1. CONTINUOUS SPLINTING FOR 6 WEEKS
• 2. FOLLOWED BY 2 WEEKS OF NIGHT SPLINTING
• 3. SPLINTING MUST BE RESUMED IF EVIDENCE OF
  
• RECURRENT EXTENSION LAG
• 4. OPEN CONJOINT TENDON INJURIES
• TRANSFIXING DIPJ WITH 0.045 K WIRES FOR 6
  
• WEEKS

35
MALLET FINGER TREATMENT

• SMALL DORSAL AVULSION FRAGMENTS
• 1. DO NOT CONFUSE WITH HYPEREXTENSION
• INJURIES OF THE DIP WITH LARGE DORSAL
• FRAGMENTS, ASSOC WITH PALMAR SUBLUXTION
• OF DISTAL PHALANX
• TREATMENT OF SMALL DORSAL AVULSIONS
• RESULTING FROM HYPERFLEXION WITH EXT
• SPLINTING IS NONCONTROVERSIAL
• LARGE FX FRAGMENT FROM HYPEREXTENSION
• TREATMENT SOMEWHAT CONTROVERSIAL.
• MOST COMMONLY TREATED WITH ORIF

36
INJURY ZONE AND OUTCOME RELATIONSHIP

• ZONE 6 ( BACK OF HAND) KELLY NOTED NO POOR
  RESULTS
• 20 POOR RESULTS AT LEVEL OF EXTENSOR RETINACULUM
  AND OVER DORSUM OF THE FINGERS
• ZONE 7 INJURIES AT EXTENSOR RETINACULUM HAVE
  IMPROVED
• ZONE 3 4 (PROXIMAL PHALANX AND PIPJ) HAVE
  REMAINED PROBLEMATIC

37
CONCLUSION

• FUNCTIONAL OUTCOMES AFTER EXTENSOR TENDON
  INJURIES HAVE RECEIVED LIMITED ATTENTION
• PTS AS A GROUP WITH THIS INURY GENERALLY
  EXPERIENCE DECREASE GRIP STRENGTH OF 95
  UNAFFECTED HAND
• APPROX. 95 PATIENTS EXPRESS SATISFACTION