Staged extensor tendon reconstruction in the finger

Reconstrucción de ruptura crónica del aparato extensor del dedo con autoinjerto de palmaris longus: Reporte de caso

Las lesiones crónicas del aparato extensor de los dedos son producto de una lesión inicial que no fue tratada o fue tratada inadecuadamente. Estas lesiones requieren de un adecuado y minucioso manejo para lograr un buen resultado funcional. Presentamos el caso de un paciente de 26 años con lesión traumática del aparato extensor del tercer dedo debido a un accidente de tránsito ocurrido 8 meses antes. Intraoperatoriamente, requirió abordar desde la zona I hasta la V de Verdan y reconstruir con autoinjerto de palmaris longus (PL). El paciente obtuvo un excelente resultado funcional a las 12 semanas, que persistía hasta los 9 meses de seguimiento.

Two-stage extensor tendon graft using the Paneva-Holevitch procedure: A new technique

Reconstruction of the extensor tendons remains a therapeutic challenge. Tendon transfers and grafts are a potential source of morbidity at the donor site, and the graft stock is limited. In the index finger, the tendon of the extensor indicis proprius can be anastomosed to the tendon of the extensor digitorum, and then the extensor digitorum tendon turned over after being cut at the forearm. We assessed the feasibility of this reconstruction on 12 upper limbs from 6 cadavers and we report the case of a 24-year-old patient who suffered destruction of the extensor apparatus in the index and middle fingers. For the cadaver study, in each case, the tendon could be moved onto the proximal interphalangeal joint, after having done an anastomosis downstream of the extensor retinaculum. The mean graft length was 13cm (9.7-15.2). This method was used in one clinical case with an excellent outcome. This is a simple technique that is without consequences since the tendons used are already cut, therefore saving a tendon graft. This technique should be part of our therapeutic arsenal.

Simultaneous proximal interphalangeal joint arthroplasty and extensor tendon reconstruction in adjacent fingers: case report

We present a case of a young man with heavily injured proximal interphalangeal joints and deficits of the extensor mechanism in 2 fingers treated by silicone proximal interphalangeal joint arthroplasty and 2-stage reconstruction of the extensor mechanism. The postoperative result was satisfactory with a painless, if limited, active arc of motion of the proximal interphalangeal joints of 50° in the middle finger and 35° in the ring finger.

Refinements and secondary surgery after flap reconstruction of the traumatized hand

The traumatized hand often has soft tissue loss requiring flap reconstruction. Before proceeding with flap selection, the need for future refinement and secondary surgery should be taken into consideration. Although muscle flaps may offer better contour, fasciocutaneous flaps allow easier secondary flap elevation. After the initial flap reconstruction, indications for secondary procedures may be managed according to tissue type: bone, joint, tendon, nerve, and soft tissue.

Management of extensor tendon injuries

Extensor tendon injuries are very common injuries, which inappropriately treated can cause severe lasting impairment for the patient. Assessment and management of flexor tendon injuries has been widely reviewed, unlike extensor injuries. It is clear from the literature that extensor tendon repair should be undertaken immediately but the exact approach depends on the extensor zone. Zone I injuries otherwise known as mallet injuries are often closed and treated with immobilisaton and conservative management where possible. Zone II injuries are again conservatively managed with splinting. Closed Zone III or ‘boutonniere’ injuries are managed conservatively unless there is evidence of displaced avulsion fractures at the base of the middle phalanx, axial and lateral instability of the PIPJ associated with loss of active or passive extension of the joint or failed non-operative treatment. Open zone III injuries are often treated surgically unless splinting enable the tendons to come together. Zone V injuries, are human bites until proven otherwise requires primary tendon repair after irrigation. Zone VI injuries are close to the thin paratendon and thin subcutaneous tissue which strong core type sutures and then splinting should be placed in extension for 4-6 weeks. Complete lacerations to zone IV and VII involve surgical primary repair followed by 6 weeks of splinting in extension. Zone VIII require multiple figure of eight sutures to repair the muscle bellies and static immobilisation of the wrist in 45 degrees of extension. To date there is little literature documenting the quality of repairing extensor tendon injuries however loss of flexion due to extensor tendon shortening, loss of flexion and extension resulting from adhesions and weakened grip can occur after surgery. This review aims to provide a systematic examination method for assessing extensor injuries, presentation and management of all type of extensor tendon injuries as well as guidance on mobilisation pre and post surgery.

Complex extensor tendon injuries: early active motion following single-stage reconstruction

This study presents a retrospective evaluation of patients managed with single-stage repair following complex extensor tendon injuries. Over a 2-year period, 21 extensor tendons were reconstructed in 18 patients with complex hand injuries in zones V-VII. All eight patients needed soft tissue cover. Active mobilisation was started in the first week. Total active motion (TAM) at 4 weeks was a mean of 159 degrees (SD 21.57) and at 6 weeks it was 202.6 degrees (SD 13.26). Average TAM at 8 weeks was 223.8 degrees (SD 16.46) and 249.5 degrees (SD 14.38) at 12 weeks. Grip strength at 12 weeks and 6 months was around 75% and 90% of the contralateral normal hand in most of the patients. Single-stage reconstruction of complex extensor tendon injuries seems to reduce morbidity in terms of hospitalisation, and reduced cost of treatment. It also helps to achieve better functional outcome in the early postoperative period.