Management of extensor tendon injuries

Experience With Vaughan-Jackson Syndrome at Eastern Regional Referral Hospital, Bhutan: Diagnosis and Its Treatment

Vaughan-Jackson syndrome is a clinical diagnosis that does not require advanced investigations. Timely intervention with tendon suturing or reconstruction, along with addressing the offending structures, can result in a successful functional outcome.

Management of partial extensor tendon lacerations of the hand and forearm: A national survey of practice in the United Kingdom

BACKGROUND

Partial extensor tendon lacerations of the hand and forearm are common. There is a lack of evidence to guide their management and it is also unclear at what threshold surgeons would consider repair necessary. This study aimed to identify national surgical management of partial extensor tendon lacerations of the hand and forearm (zones 2-8) and assess surgeons' willingness to randomise in a future trial.

METHODS

A 34-item online survey was developed by the steering group and, via a trainee-led collaborative model, was disseminated to plastic and orthopaedic surgeons in the UK. Summary data were calculated for each survey item, and the variations between zones and specialties were explored using linear regression.

RESULTS

142 complete responses were recorded (response rate 71%). On average, respondents said that 46% tendon division was the maximum they would manage in clinical practice without surgical repair. There was no significant difference in this percentage between zones or surgical specialties. Importantly, the majority (83%) of surgeons would be willing to randomise patients in a clinical trial to repair versus no-repair, within 29%-61% tendon division, demonstrating clinical equipoise.

CONCLUSIONS

There is significant variation in UK practice regarding the surgical management of partial extensor tendon lacerations of the hand and forearm and clinical equipoise exists regarding the decision to repair or not. A definitive randomised trial is warranted to identify the optimum management of this common injury.

Complex regional pain syndrome type II localized to the index finger. A case report translating scientific evidence into clinical practice

BACKGROUND

Complex regional pain syndrome type II (CRPS-II) is a rare condition associated with peripheral nervous system lesions. Its localized distribution in the fingers is unique, and its treatment is unclear.

CASE DESCRIPTION

A 56-year-old male presented to the emergency department with a saw-cut index finger injury with associated tendon and nerve injuries. After surgery, he was admitted to physical therapy (PT) with persistent pain, joint stiffness, allodynia, and trophic changes compatible with CRPS-II localized in the index finger. The diagnosis was confirmed after applying the Budapest Criteria, and PT was progressive and individualized according to the patient's needs, including graded motor imagery, mobilizations, exercises, and education.

OUTCOMES

After 12 weeks of PT, a clinically significant decrease in pain intensity and improvements in mobility and index finger and upper limb functionality was observed, reducing CRPS symptomatology.

DISCUSSION

This report provides information about a unique case of a localized form of CRPS-II. After reviewing the literature on clinical cases of both CRPS-II and localized forms of CRPS, we highlight that the clinical features of this patient and his positive therapeutic response support the importance of translating the scientific evidence on CRPS into clinical practice.

The Direct Tendon Suture and Paratenon Repair Technique for Acute Tendinous Mallet Finger: A Case Series

(1) Introduction: Tendinous mallet finger is a frequent deformity that occurs after an extensor tendon injury during sports or daily life activities. Despite the existence of numerous non-operative and operative techniques to address this deformity, there is a controversy on its optimal management. In this study, we aimed to present a direct tendon suture technique using the distal interphalangeal (DIP) joint open approach for treating tendinous mallet finger injury. (2) Methods: Between 2019 and 2021, 19 patients with closed non-fracture tendinous mallet fingers underwent the direct tendon and paratenon repair technique. After skin incision, we opened the paratenon with lazy S shape incision and found the ruptured proximal and distal tendon ends. We reapproximated the tendons using a simple interrupted suture with Prolene #6/0. After that, we meticulously performed paratenon repair using PDS #6/0 for preventing readherence. Temporary trans-articular Kirschner wire fixation was used for 4 weeks. (3) Results: All patients were followed-up for 3-8 months (mean: 4.8 months). The mean final extension lag was 6.5 degrees, and the overall rate of cases with excellent and good outcomes using Crawford's criteria was 85%. (4) Conclusions: In conclusion, this surgical approach could be a reliable alternative for the treatment of tendinous mallet finger injuries.

One-stage reconstruction of the massive overlying skin defect combined with total loss of extensor tendon in zones V and VI using a reverse pedicled radial forearm tendinocutaneous flap: A case report

Our case report involved a 36-year-old man who sustained injury during manual labor caused by a machine press. The patient had extensive fourth-degree burns in the right dorsal hand with total loss of extensor tendons in zones V and VI of the index, middle, and ring finger. We performed a reverse radial forearm tendinocutaneous flap (the radial artery flap permits the inclusion of three "strips" of vascularized tendons: brachioradialis, flexor carpi radialis, and palmaris longus) to cover his hand defects. Six months after the operation, the active extension of the index, middle, and ring metacarpophalangeal joints had recovered well. The patient is satisfied with the outcome.

[Treatment of extensor tendon injuries of the hand]

The extensor apparatus of the hand is a complex system consisting of extrinsic and intrinsic muscles, which in combination enable the individual extension of the fingers. Extensor tendon injuries of the hand are frequent injuries and the operative or conservative treatment options are determined by the localization and involvement of osseus structures. For an optimal outcome of the treatment of extensor tendon injuries, correct diagnostics and a consistent hand aftercare are absolutely essential. The crucial decision making regarding the further procedure starts with the initial patient treatment, ideally on the day of trauma.

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.

Thumb ultrasound: Technique and pathologies

Ultrasound is ideally suited for the assessment of complex anatomy and pathologies of the thumb. Focused and dynamic thumb ultrasound can provide a rapid real-time diagnosis and can be used for guided treatment in certain clinical situations. We present a simplified approach to scanning technique for thumb-related pathologies and illustrate a spectrum of common and uncommon pathologies encountered.

Degenerative lesion of the extensor tendon V finger: Ultrasound imaging in diagnosis and therapeutic possibilities

Traumatic injuries of the extensor tendons of the hand are common and are more frequent predisposed to tendon injuries due to the presence of chronic tendon damage. We present the case of a 61-year-old woman, tailor by profession, who showed acute rupture (80 %) with degenerative etiology of the extensor tendon of the V finger of the fifth level according to Kleinert and Verdan classification.

Hand tendon injuries

This article provides a comprehensive overview of hand tendon injuries. It has been tailored towards healthcare professionals who will be the first to assess these injuries and instigate appropriate management. It discusses the essential hand anatomy to be aware of, how to assess tendon injuries, their initial management and also the definitive surgical interventions used, if required. Rehabilitation techniques are also discussed, as this is also key to good functional outcomes. Missed injuries, or delay in their diagnosis and referral to specialist hand surgeons, can cause a large amount of morbidity for patients and therefore it is important that they are picked up in a timely manner.

Zone V Extensor Tendon Repair with a Palmaris Longus Tendon Autograft and Human Umbilical Membrane

Extensor tendon repairs, although common, can be difficult injuries to treat. Their treatment is tailored to the zone of the hand that is affected since varying biomechanical forces are applied to the tendon at each zone. Prompt treatment is necessary to prevent potential complications associated with these injuries. This is particularly true of Zone V extensor tendon injuries, as their mechanism is commonly a highly infectious human bite. We present the case of a human fight bite resulting in a Zone V extensor tendon injury. The delayed presentation of this case resulted in an untreated infection that caused an abscess with associated extensor tendon necrosis and rupture. Given the large gap length between the ends of the tendons, tendon repair was performed using a palmaris longus autograft. Even when these are done in a controlled setting, adhesions are common. The compromised wound bed caused irritation, erosion, and subsequent rupture of the extensor tendon of the hand. In an effort to avoid common complications such as adhesion, the repair was then wrapped with human umbilical membrane (AVIVE® Soft Tissue Membrane, AxoGen Inc., Alachua, FL) to separate adjacent tissue and reduce inflammation. Even without access to formal physical therapy, our patient had excellent functional outcomes at his final follow-up visit. The patient was able to make a loose composite fist, had no extensor lag at the MCP joints, and had extensor lag of 15 degrees at the PIP joints of digits 4-5.

The Effect of Extensor Tendon Adhesions on Finger Motion

PURPOSE

To quantify the amount and pattern of finger range of motion loss at the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints with a simulated extensor tendon adhesion at the level of the proximal phalanx or metacarpal.

METHODS

In 10 cadaveric specimens, traction sutures were placed in the forearm extensor digitorum communis and flexor digitorum profundus tendons of the middle and ring fingers. Active motion was simulated by suspending weights from the traction sutures via pulleys. The angles of the MCP, PIP, and DIP joints were measured at the position of maximum flexion and extension. Extensor tendon adhesions were simulated alternately at the proximal phalanx and metacarpal levels of the middle and ring fingers, using suture anchors. Repeat measurements were taken using the same amount of force.

RESULTS

There was an average total loss of flexion of 38° and of extension of 6° with a proximal phalanx adhesion, with a greater contribution of flexion loss at the PIP joint. The loss of flexion was 17° and of extension was 50° with a metacarpal adhesion, with a loss of extension mostly at the MCP joint.

CONCLUSIONS

The results of this study identified clear patterns of motion loss that are associated with isolated simulated adhesions in different locations along the extensor mechanism. The greatest motion loss occurred at the joint immediately distal to the simulated adhesion.

CLINICAL RELEVANCE

Although extrapolation of these findings to clinical relevance remains unclear, the ability to predict the level of adhesion by the pattern of motion restriction may allow for a targeted tenolysis procedure. This would reduce the amount of soft tissue dissection required, which in turn, could be expected to reduce the degree of repeat adhesion formation.

Therapeutic management of closed central slip injuries: Outcome of a service evaluation

Introduction

Closed central slip injuries can be difficult to manage and there is a lack of published research to support evidence-based clinical decision making in practice. This article presents the results of a service review in a busy trauma hospital hand therapy department.

Method

Following a literature review and retrospective review of outcomes, new clinical guidelines for central slip injuries were developed. These were implemented with 22 patients referred to hand therapy for conservative management of closed central slip injuries during a one-year period.

Results

The majority of patients (72%) had either an excellent or good outcome using the Strickland-Glogovac outcome measure and an average total active motion of 90% compared to their unaffected hand.

Conclusions

The outcomes following implementation of new treatment guidelines following the service review are in line with the small amount of published data currently available. They provide detailed guidelines for the conservative management of closed central slip injuries in a busy out-patient setting.

Tendon Adhesions: A Novel Method of Objectively Measuring Adhesions by Assessing Tendon Glide Through a Soft Tissue Envelope in a Rat Model

PURPOSE

To develop a rat model of extra-synovial tendon adhesions that will enable accurate testing of scar barriers and adhesion inhibiting treatments to facilitate future research.

METHODS

Thirty-six 6-month-old male Sprague-Dawley rats were randomized to one of the 3 groups of 12. In Group A, the middle one-third portion of the left Achilles tendon was excised. In Group B, the tendon and soft tissue bed was abraded with steel wool. In Group C, a silk suture was sewn along the tendon. The right hind limbs served as controls. At 4 weeks, biomechanical testing was performed on the bilateral hind limbs. The Achilles tendon was cut at the gastrocnemius-tendon junction proximal to the "adhesion zone" (or analogous level in the control limb). The calcaneal insertion of the Achilles was attached to a tensiometer. The force needed to pull the tendon out of its soft tissue envelope at a fixed rate was measured.

RESULTS

Three rats were excluded because of complications during data collection. Pair-wise comparison testing was performed, comparing the mean peak force to pull the Achilles tendon from its soft tissue envelope in 33 control limbs and the contralateral limb from each group. The average peak force for the cut tendon group (A) was 20.1 N, 18.8 N in the steel wool group (B), and 21.1 N in the suture group (C). The average peak force in the control limbs was 15.6 N. There was a significant difference noted in peak forces between the control limbs and each experimental group.

CONCLUSIONS

A consistent and statistically increased force was necessary to pull a rodent Achilles tendon from an adhesion-induced tissue bed compared with controls. No statistical difference was detected between experimental groups.

CLINICAL RELEVANCE

Our study demonstrates an objective method of biomechanical tendon adhesion assessment in a rat model.

MRI of the Extensor Tendons of the Wrist

OBJECTIVE

This article reviews the normal anatomy of the extensor tendons of the wrist as well as the clinical presentation and MRI appearances of common tendon abnormalities, such as tears, tenosynovitis, intersection syndromes, and associated or predisposing osseous findings. Treatment options are also discussed.

CONCLUSION

We review the anatomy and normal MRI appearance of the clinically important dorsal extensor tendons of the wrist, in addition to the spectrum of abnormalities associated with these tendons.

Rupture of the extensor hood of the fifth toe: a rare injury

Closed injuries of the extensor hood of the lesser toes are rare and seldom reported in the literature. We present the case of a woman aged 25 years who presented to the orthopaedic fracture clinic with a 2-week history of pain in the left fifth toe and inability to extend following a ballet dancing session. Investigations showed no fracture on plain radiographs, but an ultrasound scan demonstrated rupture to the extensor hood of the little toe. Successful surgical repair of the extensor hood was performed, and the patient made a good recovery with return to dancing activities.

Comparison of impairment and restitution of hand function in a group of patients with total damage to the extensor pollicis longus and in a group of patients with damage to the flexor pollicis longus tendon after surgical treatment

The thumb constitutes 40% of the whole hand function, and damage to the extensor pollicis longus (EPL) and/or the flexor pollicis longus (FPL) tendons of the thumb results in its significant limitation. The main factors contributing to damage of the EPL and/or FPL tendons are mechanical injuries - cuts and spontaneous ruptures. The aim of the study was to compare values of thumb and whole hand function loss and restoration as a result of the implemented physical therapy in patients with total damage to the EPL tendon with the values obtained by the study group 2 comprised of patients with damage to the FPL tendon. The study involved 25 patients of the Specialized Hand Therapy Center in Krakow. 15 of them had ruptured continuity of the EPL tendon (study group), and 10 suffered damage to the FPL tendons (control group). The study included measurements of active motion of the thumb and wrist and superficial sensation. On the basis of these tests, functional impairment was measured using the methodology according to Swanson. The study included assessment of muscle strength in terms of global and precision grips using a dynamometer. Statistically signifcant functional improvement was noted for the thumb and whole hand as well as muscle strength in both groups. The values of functional loss differed between the two groups. The indicators of functional improvement were greater in patients with damage to the EPL tendon. Functional physical therapy is an important factor determining the return of function in the thumb and whole hand after total damage to the EPL and FPL tendons. Szczechowicz J., Jamka K., Pieniążek M. Comparison of impairment and restitution of hand function in a group of patients with total damage to the extensor pollicis longus and in a group of patients with damage to the flexor pollicis longus tendon after surgical treatment. Med Rehabil 2016; 20(3): 5-12. DOI: 10.5604/01.3001.0009.5009

Comparison of Roll Stitch Technique and Core Suture Technique for Extensor Tendon Repair at the Metacarpophalangeal Joint level

Background:

Proper suturing technique is needed to ensure good outcome in extensor tendon surgery. Different techniques have been reported for the repair of extensor tendon injuries at the level of the metacarpophalangeal joint (MCPJ). These reports were in vitro studies on cadaver models. Repair techniques must be clinically tested, to determine results.

Objectives:

The purpose of this in vivo study was to compare results of extensor tendon repair, using roll stitch and core suture techniques.

Patients and Methods:

Forty two fingers, in 38 patients (aged 15- 45 years), with simple complete extensor tendon injuries in the MCPJ area, were identified and operated by a single surgeon. The patients were divided into two groups, according to the technique used for tendon repair. The first group consisted of 21 digits, in 19 patients, who were repaired with roll stitch technique, while the second group consisted of 21 digits, in 19 patients, who were repaired with core suture technique. The same splint and rehabilitation regimen (early passive range of motion) were given to all patients. The splints were removed at 6 weeks after surgery and range of motion of the operated fingers was measured and compared to uninjured hands, after 12 weeks.

Results:

Five patients were lost to follow up or excluded from the study. There was no rupture of the repaired tendons in the groups. There was no statistically significant difference in mean MCPJ flexion, proximal interphalangeal joint (PIPJ) flexion, distal interphalangeal joint (DIPJ) flexion and total range of motion of the fingers, between the two groups. However, extension lag was significantly more common in the second group (11 of 19 digits) compared the first group (four of 17 digits).

Conclusions:

Roll stitch technique had superior outcome compared to the modified Kessler technique, when performed in the MCPJ area. Level of evidence: Therapeutic (Level III)

Management of complications of periarticular fractures of the distal interphalangeal, proximal interphalangeal, metacarpophalangeal, and carpometacarpal joints

Fractures involving the bones of the hand are among the most common injuries in the United States. A significant portion of these fractures are periarticular. Although the great majority of these fractures are treated successfully by nonoperative means, complications arise. We present a comprehensive review of prevention and management of complications of periarticular fractures of the distal interphalangeal, proximal interphalangeal, metacarpophalangeal, and carpometacarpal joints.

A brief review of extensor tendon injuries specific to the pediatric patient

Extensor tendon injuries in the pediatric population require careful evaluation and treatment. This article focuses on the differences in injury type and treatment of pediatric versus adult extensor tendon injuries. A detailed history and physical examination is crucial in the management of extensor tendon injuries of the young patient. Treatment of pediatric extensor tendon injuries depends largely on the site of injury. A majority of these injuries may be treated with splinting or primary repair. Treatment methods that require high compliance must be adjusted for the young child.

Unusual combination of lesions of the traumatic hand: closed central slip laceration of the extensor and interphalangeal thumb joint's dislocation (a case report)

From the functional standpoint, the hand is one of the most important organs of the body. However, its significance depends largely upon the pincer action of the thumb-index. The management of traumatic lesions of the hand is nowadays’ subject of numerous scientific discussions. We present here the case of a patient with a recent laceration of the central slip of the extensor tendon with boutonniere deformity linked to a dislocated interphalangeal thumb of the same hand with a loss of force of the clip thumb and index finger. This combination is a rare lesional of the traumatic hand that has not been previously reported in any orthopedic literature. It was observed after adopting the orthopedic treatment that the range of motion of its joint was at the same level as its healthy side without observing any redislocations during the 6-month follow-up period.

Finger movement function after ultrasound-guided percutaneous pulley release for trigger finger: effects of postoperative rehabilitation

OBJECTIVE

To develop and test a postoperative rehabilitation protocol for use by individuals with trigger finger undergoing ultrasound-guided percutaneous pulley release.

DESIGN

Nonrandomized controlled trial.

SETTING

Hospital and local community.

PARTICIPANTS

Individuals suffering from trigger finger with joint contracture (N=21) were recruited and grouped into an intervention group (n=9) or a control group (n=12).

INTERVENTIONS

All the participants underwent the same surgical procedure performed by the same surgeon. A 4-week postoperative rehabilitation program was designed based on the wound healing process. The intervention group received postoperative rehabilitation after the surgery, whereas the control group received no treatment after the surgery.

MAIN OUTCOME MEASURES

The finger movement functions were quantitatively evaluated before and 1 month after the surgery using a 3-dimensional motion capture system. The fingertip workspace and joint range of motion (ROM) were evaluated while the participant was performing a sequential 5-posture movement, including finger extension, intrinsic plus, straight fist, full fist, and hook fist.

RESULTS

The intervention group demonstrated significantly more improvements than the control group in the fingertip workspace (49% vs 17%), ROM of the distal interphalangeal (DIP) joint (16% vs 4%), ROM of the proximal interphalangeal (PIP) joint (21% vs 5%), and total active ROM (17% vs 5%).

CONCLUSIONS

This pilot study evaluated a postoperative rehabilitation protocol for trigger finger and demonstrated its effects on various finger functions. Participants who underwent the rehabilitation program had significantly more improvements in the fingertip workspace, ROM of the DIP and PIP joints, and total active ROM.

Distal digital replantation

BACKGROUND

Hand surgeons have been hesitant to perform distal digital replantation because of the technical challenges and the perception of a high cost-to-benefit ratio. Recent studies, however, have shown high survival rates and excellent functional and aesthetic results, providing renewed enthusiasm for distal replantation.

METHODS

The authors reviewed the literature and summarize key points regarding the surgical treatment, perioperative care, and outcomes of distal digital replantation. They describe specific techniques and considerations for surgical repair in each of four distal zones as described by Sebastin and Chung.

RESULTS

Zone 1A replantation involves an artery-only anastomosis of a longitudinal pulp artery. Venous anastomosis first becomes possible in zone 1B. Zone 1C involves periarticular amputations where arthrodesis of the distal interphalangeal joint is usually indicated. Repair of the artery, vein, and nerve is technically optimal in zone 1D, where venous anastomosis should be performed. Overall, survival rates for distal digital replantation are similar to those reported for more proximal replantation. The literature reports good outcomes regarding nail salvage, fingertip sensibility, and range of motion, with restoration of length and aesthetic appearance.

CONCLUSIONS

Distal replantation performed at institutions that specialize in microsurgery and specifically tailored to the level of injury is associated with good survival, function, and patient satisfaction and superior aesthetic outcome. More prospective data are needed to evaluate the cost of treatment, psychological outcomes, and functional outcomes of distal replantation compared with revision amputation.

Alternate technique in managing adhesions after zone 3 extensor tendon repair: a case report

Extensor tendon injuries are given less importance than the flexor tendon injuries; however, the extensor mechanism is more complicated than flexor tendon system, and regaining satisfactory function is a challenge. It has been reported that loss of digital flexion would affect grasp and power grip imposing greater functional loss than digital extensor lag. Zone 3 extensor tendon management is complex because of excessive scar formation limiting composite digital flexion and extension. The adhesions are more common if the tendon is immobilized for long period. The purpose of this care report is to describe the alternate technique in managing adhesion after prolong immobilization in zone 3 extensor tendon injuries.