Flexor tendon injuries

155 Pages·2005·6.998 MB·English

by  Daniel P Mass, Craig S Phillips

Volume 21, Issue 2, Pages 123-278 (May 2005)
Flexor Tendon Injuries
Edited by Daniel P. Mass, Craig S. Phillips

articles 1 - 19
1 fmv-viii: TOC
Pages v-viii

2 fmix: forthcoming issues
Page ix

3 Flexor Tendon Injuries
Pages xi-xii
Daniel P. Mass and Craig S. Phillips

4 History of Flexor Tendon Repair
Pages 123-127
Paul R. Manske

5 Biomechanics of the Flexor Tendons
Pages 129-149
Howard J. Goodman and Jack Choueka

6 Flexor Tendons: Anatomy and Surgical Approaches
Pages 151-157
Christopher H. Allan

7 Flexor Tendon Biology
Pages 159-166
Martin I. Boyer

8 Zone I Flexor Tendon Injuries
Pages 167-171
Brian A. Murphy and Daniel P. Mass

9 Acute Flexor Tendon Repairs in Zone II
Pages 173-179
Robert W. Coats II, Julio C. Echevarría-Oré and Daniel P. Mass
10 Treatment of Acute Flexor Tendon Injury: Zones III–V
Pages 181-186
George S. Athwal and Scott W. Wolfe

11 Complex Injuries Including Flexor Tendon Disruption
Pages 187-197
Jon D. Hernandez and Peter J. Stern

12 Clinical Outcomes Associated with Flexor Tendon Repair
Pages 199-210
Jin Bo Tang

13 Flexor Tenolysis
Pages 211-217
Kodi K. Azari and Roy A. Meals

14 Delayed Treatment of Flexor Tendon Injuries Including Grafting
Pages 219-243
James W. Strickland

15 Flexor Tendon Pulley Reconstruction
Pages 245-251
Vishal Mehta and Craig S. Phillips

16 Pediatric Flexor Tendon Injuries
Pages 253-256
Timothy G. Havenhill and Roderick Birnie

17 Rehabilitation after Flexor Tendon Repair, Reconstruction, and Tenolysis
Pages 257-265
Kathy Vucekovich, Gloria Gallardo and Kerry Fiala

18 The Future of Flexor Tendon Surgery
Pages 267-273
Jeffrey Luo, Daniel P. Mass, Craig S. Phillips and T.C. He

19 Index
Pages 275-278

FLEXORTENDON INJURIES
CONTENTS
Preface xi
Daniel P. Mass and Craig S. Phillips
History of Flexor Tendon Repair 123
Paul R. Manske
The firstissueofHandClinics published20yearsagowasdevotedtoflexortendon in-
juries.Thiswasmostappropriate,becausenosubjectinhandsurgeryhassparkedmore
interestordiscussion.Thatinauguralissueincludedexcellentpresentationsonthebasic
scienceoftendoninjuries(anatomy,biomechanics,nutrition,healing,adhesions)andthe
clinicalpracticeoftendonrepair.Ofinterest,therewasnopresentationonthefascinating
history of flexor tendon surgery. It is most appropriate, therefore, that this current
update of the flexor tendon begins with a historical review of the evolution of flexor
tendon repair.
Biomechanics of the Flexor Tendons 129
Howard J. Goodman and Jack Choueka
Thisarticleexaminesbasictendonbiomechanics,theanatomyandmechanicsofdigital
flexortendons,andthedigitalflexorpulleysystem.Italsoexploresthevariousmodels
thathavetried tosimulate themotionoftheflexortendons andseveraltesting modal-
ities that have been used. Finally, clinical applications are considered, including the
biomechanics of flexor tendon repairs and tendon transfers. As we reach limits in the
careofflexortendoninjuries,researchintomolecular,biochemical,andmicromechanical
methods of tendon repairwill become theforefront offutureinvestigation.
Flexor Tendons: Anatomy and Surgical Approaches 151
Christopher H. Allan
The extrinsic flexor tendons of the hand represent the terminal functional units of the
forearmmotorstothedigits,andarenamedbasedonthelocationofthoseforearmmus-
cles. The flexor digitorum profundus (FDP; profound ¼ deep) tendons arise from the
deeper layer of flexor muscles, while the flexor digitorum superficialis (FDS) tendons
are the continuation of the more superficial muscle layer. The flexor pollicis longus
(FPL) also arises from the deeper muscle layer, and is the only thumb flexor with a
tendon occupying a sheath. Flexor tendons are enclosed in synovial sheaths which
lubricatethemandminimizefrictionastheypassbeneaththetransversecarpalligament
andwithinthedigits.Thesesynovialsheathsdemarcatedifferentzonesalongthecourse
of thetendons.
Æ Æ
VOLUME21 NUMBER2 MAY2005 v
Flexor Tendon Biology 159
Martin I. Boyer
Significant advances in the understanding of intrasynovial flexor tendon repair and
rehabilitation have been made since the early 1970s. The concept of adhesion-free,
or primary tendon healing – that tendons could heal intrinsically without the in-
growth of fibrous adhesions from the surrounding sheath has been validated both
experimentallyandclinicallyinstudiesoverthepast25years.Recentattemptstounder-
stand and improvethe results of intrasynovial flexor tendon repairhave focused upon
restoration of the gliding surface, augmentation of early post-operative repair site
biomechanical strength and on the elucidation of the molecular biology of early post-
operativetendonhealing.Thegoalsofthesurgicaltreatmentofpatientswithintrasyno-
vialflexortendonlacerationsremainunchanged:toachieveaprimarytendonrepairof
sufficienttensilestrengthtoallowapplicationofapost-operativemobilizationrehabili-
tation protocol. This program should inhibit the formation of intrasynovial adhesions
and restore thegliding surface,whilefacilitating the healingof therepair site.
Zone I Flexor Tendon Injuries 167
Brian A. Murphy and Daniel P. Mass
Zone I flexor tendon injuries entail injuries to the flexor digitorum profundus (FDP)
tendon.Theseinjuriesoccurdistaltothesuperficialisinsertionoverthemiddlephalanx
orproximaldistalphalanx,andassuchareisolatedinjuriestotheFDP.Themechanism
most commonly is closed avulsion from the distal phalanx or a laceration, but other
mechanismssuchasopenavulsionorcrushinjurycanoccur.Onphysicalexamination,
thecascadeofthefingerswillbedisrupted,anddistalinterphalangeal(DIP)jointflexion
mustbeisolatedtodetermineiftheFDPtendoniscontinuous,asothermechanismsare
presentto enablefingerflexion at theother joints.
Acute Flexor Tendon Repairs in Zone II 173
Robert W. Coats, II, Julio C. Echevarr´ıa-Ore´, and Daniel P. Mass
Flexor tendon repair in zone II is still a technically demanding procedure, but the out-
comeshavebecomemorepredictableandsatisfying. Ofkeystoneimportanceforobtain-
ing the goals of strength and gliding are a surgically atraumatic technique, adequate
suture material, a competent of the pulley system, and the utilization of early motion
rehabilitationprotocols. Theoverallgoalofhandandfingerfunctionalsoimpliestimely
addressingofneurovascularinjuries. Newdeviceshaveshownadequatestrengthinthe
lab, but are bulky and untested for work of flexion. Insufficient clinical data and high
cost maypreventwidespreaduse.
Treatment of Acute Flexor Tendon Injury: Zones III–V 181
George S. Athwal and Scott W. Wolfe
FlexortendoninjuriesinzonesIII–Vrarelyoccurinisolationandmayinvolvethewrist
flexors, radial and ulnar arteries, and median and ulnar nerves. The treating surgeon
must examine fully the injured extremity to determine the extent of injury. Primary
repair of injured tendons and neurovascular structures is recommended by way of a
systematic approach.
Complex Injuries Including Flexor Tendon Disruption 187
Jon D. Hernandez and Peter J. Stern
Thetreatmentoftendoninjuryincombinedcomplexinjuriestothehandwillbedictated
by the presence of concomitant injuries. Early range of motion is desirable. To achieve
this, fractures must be stabilized and the soft tissue envelope and vascular integrity
maintained or reconstituted. In those instances where these conditions cannot be met,
vi CONTENTS
the surgeon and patient should be prepared for secondary surgeries including recon-
structionand/ortenolyis.Althoughnerveintegrityisnotnecessaryforearlyfunctional
successfollowingtenorrhaphy,nerveinjuriesshouldberepairedorgraftedprimarilyas
the injury permits. In cases where vascular compromise is encountered, the options of
revascularizationversusprimaryamputationshouldbediscussedwiththepatient.With
anunderstandingofthetreatmentprinciplesthecomplicationsassociatedwithcomplex
tendon injuries can be minimized. It is important to stress that optimal functional
outcome ismultifactorial and includes aphysician-therapist team-oriented approach.
Clinical Outcomes Associated with Flexor Tendon Repair 199
Jin Bo Tang
Review of the outcomes of clinical flexor tendon repairs reported over the 15 years
showed advances in the outcomes with excellent or good functional return in more
than three-fourth of primary tendon repairs following a variety of postoperative
passive/active mobilization treatment. Strickland and Glogovac criteria are the most
commonly adopted method to assess function. Repair ruptures, adhesion formations,
and stiffness of finger joints remain frustrating problems in flexor tendon repairs and
rehabilitation. Four approaches are suggested to improve outcomes of the repairs and
to solve these difficult problems, which include stronger surgical repairs, appropriate
pulleys or sheath management, optimization of rehabilitation regimens, and modern
biological approaches.
Flexor Tenolysis 211
Kodi K. Azari and Roy A. Meals
Flexortenolysisisachallengingprocedurewithvaluableclinicalusefulnessintheresti-
tutionandenhancementofdigitalfunctionintheappropriatepatient.Intheabsenceof
complications,improvementindigitalflexioncanbeexpected.Therequisitesforsuccess
are a skilled surgeon,a motivated and well-informed patient, and a carefully executed
hand therapyprogram.
Delayed Treatment of Flexor Tendon Injuries Including Grafting 219
James W. Strickland
Thisarticlereviewsthehistory,indications,andcurrenttechniquesforthelatetreatment
offlexortendoninjuries.Conventionalfreetendongrafting,flexortenolysis,andstaged
flexor tendon reconstruction are discussed with ample illustrations and clinical photo-
graphs of surgical procedures. Controversial issues are presented and the article is
referencedextensively.
Flexor Tendon Pulley Reconstruction 245
Vishal Mehta and Craig S. Phillips
Reconstruction of the flexor tendon pulley system remains a challenging technical and
intellectual exercise. Many different techniques have been developed and modified to
increasetheefficiencyofthereconstructedpulleysystem.Thisarticleprovidesanover-
viewoftheanatomyandfunctionofthepulleysystemandaconcisereviewofpopular
reconstructive options. Familiarity with the nuances of each of these techniques allows
the treatingsurgeontochoose the optimalprocedure foreachclinical situation.
Pediatric Flexor Tendon Injuries 253
Timothy G. Havenhill and Roderick Birnie
Flexortendoninjuriesinchildrendifferfromadultsintheirdiagnosisandpostoperative
rehabilitationprinciples.Thechildmaybeuncooperative,soindirectmethodsoftendon
integritymustbeusedfordiagnosis.Radiographsmaybeusefulforassociatedfracture
CONTENTS vii
or retained foreign bodies. A high index of suspicion necessitates surgical exploration.
Whilesurgicalapproachandrepairtechniquesareidenticaltothoseinadults,postoper-
ative immobilization for 3-4 weeks is utilized instead of an early motion protocol. De-
layed diagnosis is more common in the pediatric population, and recognition and
managementofpostoperativecomplicationscanbedifficultsincethechildmaybeun-
able to cooperate orcomplywith thetreatment.
Rehabilitation after Flexor Tendon Repair, Reconstruction, and Tenolysis 257
Kathy Vucekovich, Gloria Gallardo, and Kerry Fiala
Much attention and study of the reparation and rehabilitation of flexor tendon injuries
has been in place over the past several decades. This article is a literature review of
the advancement of flexor tendon repair rehabilitation, specifically the immobilization,
controlled motion, and early active motion programs. Rehabilitation programs after
stagedreconstructionandtenolysisarereviewed.Thepurposeofthisarticleistobetter
enabletherehabilitationspecialisttomakeclinicallysounddecisionsintheprogression
and treatmentofeach patient who hasundergone flexortendon surgery.
The Future of Flexor Tendon Surgery 267
Jeffrey Luo, Daniel P. Mass, Craig S. Phillips, and T.C. He
Clinicaloutcomesfollowingflexortendonrepairhavemadesignificantimprovementsin
thelast50years.Inthattime,standardtreatmenthasevolvedfromsecondarygraftingto
primary repair with postoperative rehabilitation protocols. Unfortunately, excellent re-
sults are not yetuniversally attained following treatment.Improving understanding of
tendon healing at the cellular, molecular, and genetic levels likely will enable surgeons
to modulate the normal repair process. We now look toward biologic augmentation of
flexortendonrepairstoaddresstheproblemsofincreasingtensilestrengthwhilereduc-
ing adhesionformation following injuryand operative repair.
Index 275
viii CONTENTS
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and Alexander Y.Shin,MD, GuestEditors
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Peter J.L.Jebson, MD,Guest Editors
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HandClin21(2005)xi–xii
Preface
Flexor Tendon Injuries
DanielP.Mass,MD CraigS.Phillips,MD
GuestEditors
The Hand Clinics debuted 20 years ago with repair,’’ often overwhelming and confusing the
a review on flexor tendon injuries. There have treating surgeon. The goal of this issue of the
been no subsequent issues dealing with this Hand Clinics is to combine long-standing dogma
controversial complex topic, which has produced with recent advances associated with flexor ten-
morearticles in the peer-reviewed hand literature don repair in all zones to increase understanding
than any other single topic. Since Sterling Bun- of these often complex problems. The diverse
nell’s articles advocating not operating on ten- content of this issue includes 15 articles encom-
donsin‘‘no-man’sland,’’therehasbeenongoing passing the history of flexor tendon repairs,
debate about when and how to repair flexor tendon/pulley biomechanics, the most recent su-
tendons. The question of whether tendons heal ture techniques, andthe abilitytoalter the flexor
intrinsically or require peripheral adhesions to tendonmilieuthroughmolecularmanipulationin
healisstill unanswered. an effort to enhance healing and functional out-
Duetotheunforgivingnatureofflexortendon comes associatedwithflexor tendonrepairs.
repairs, these injuries have become the sole The literature is filled with recommendations
domain of the hand surgeon. Human flexor for flexor tendon repair, yet evidence-based out-
tendons remain unique in their anatomy (micro- comestudiesarestilllacking.Clinicalstudieshave
and macroscopic), biomechanics, intimacy with beenprimarilycasereportsorsmallserieswithno
the fibro-osseous sheath, and proximity to the comparison groups. Intellectual understanding
neurovascularstructuresofthedigit,aswellasthe andtechnicaldetailareparamountwhenoptimiz-
response to trauma and their ability to heal ing function after restoring flexor tendon conti-
through both extrinsic and intrinsic healing. The nuity, yet they are useless when not combined
dichotomy of regaining tendon strength and with an appropriate, well-supervised postopera-
gliding while avoiding adhesions or rupture after tiverehabilitationcourse.Forthisreasonwehave
repair remains an intellectual and technical chal- includedanarticlehighlightingthedifferentpost-
lenge today, 76 years after Bunnell advocated operative protocolsafterflexor tendon repair.
removing the flexor tendon from the digit and Theinsightaffordedbytheindividualauthors
grafting the defect after zone II injury. Due to of this issue provides a concise yet thorough
average functional outcomes, considerable re- overviewofallinjuriestotheflexortendonsystem.
searchhasemergedoverthelast15yearsdirected It is with pride that this anniversary issue be
towardidentifyingthe‘‘idealzoneIIflexortendon dedicated to those who have spent many hours
0749-0712/05/$-seefrontmatter(cid:1)2005ElsevierInc.Allrightsreserved.
doi:10.1016/j.hcl.2005.01.002 hand.theclinics.com
xii PREFACE
attempting to solve the mysteries associated with CraigS. Phillips, MD
improvingresults afterflexor tendonrepair. ReconstructiveHandandMicrovascular Surgery
The Illinois BoneandJointInstitute
Daniel P.Mass, MD EvanstonNorthwestern Healthcare
SectionofOrthopaedic Surgery and Glenview, ILUSA
Rehabilitation Medicine
E-mailaddress: [email protected]
UniversityofChicagoPritzkerSchoolofMedicine
University of ChicagoHospitals
5841SouthMaryland Avenue, MC3079
Chicago, IL60637,USA
E-mailaddress:[email protected]