Thursday, June 26, 2008

Extensor Tendon Repair

Because there is little to protect the extensor tendons (thin skin, minimal subcutaneous tissue), they can be easily injured by knives, saws, teeth (hitting someone), etc. The extensor tendon anatomy can be reviewed here online, or in more depth offline using a good anatomy or hand surgery text.

These injuries will often include fractures or soft tissue injuries (lacerations, crush, loss of skin, etc). This post is only a brief overview of the repair of "isolated" extensor tendon laceration at the time of injury, not reconstructively later. This post will in no way make the reader an expert on extensor tendon injury/repair, but will give you a general understanding (maybe).

Injuries of the extensor tendon are defined by zones. The tendon injuries in finger Zones II-IV and VII tend to fare worse than injuries in the other zones.

Zone I --

  • DIP joint of the fingers
  • IP joint of the thumb

Zone II--

  • Middle Phalanx of the fingers
  • Proximal Phalanx of the thumb

Zone III--

  • PIP joint of the fingers
  • MP joint of the thumb

Zone IV--

  • Proximal phalanx of the fingers
  • Metacarpal of the thumb

Zone V--

  • MP joint of the fingers
  • CMC joint/radial styloid of the thumb

Zone VI -- Dorsum of the hand

Zone VII -- Dorsal retinaculum

Zone VIII -- Distal forearm

Primary suture of extensor tendon lacerations in all zones is the accepted standard. Indications for the need to repair include:

  • Tendon laceration greater than 50%
  • Tendon laceration less than 50% with significantly decreased strength compared with contralateral finger (the finger next to the one injured)
  • Tendon laceration associated with significant overlying skin loss, joint space penetration, or bony fracture

Reasons not to do a primary repair include:

  • Skilled physician unavailable in which case simple closure of the skin to aid in prevention of infection until the patient can be seen by a hand surgeon, sooner rather than later in a perfect world.
  • Contaminated injury, particularly open zone 5 "fight bite" injury. The injury due to hitting someone in the mouth.
  • Presence of bony fracture, open joint space, or significant overlying skin loss (requires an orthopedist or hand surgeon for repair) See the injury posted by Shadowfax last week.

Treatment by zone of injury

Zone I -- Mallet Finger, see my post from last year

  • Management ranges from simple immobilization to aggressive open reduction and internal fixation.
  • Extension splinting of just the DIP joint has become
    the standard of care for most mallet injuries. Splinting is continuous for a period of 6 to 8 weeks and may be continued longer. (photo credit)
  • Indications for operative treatment are controversial. The three most often indications include (1) open injuries, (2) those individuals who are noncompliant or unable to tolerate
    a splint, and (3) in cases where there exists a large dorsal fragment with palmar subluxation of the distal phalanx.

Zone II -- Injuries are typically seen with sharp lacerations, saw injuries, and crush injuries.

  • Acute lacerations with extensor lag present on examination need to be explored and repaired.
  • If there is active extension with some weakness against resistance, it can be treated with splinting for 3 to 4 weeks.
  • A running core suture oversewn with a epitendinous stitch is recommended for the repair.

Zone III --

  • The treatment of acute injuries is designed to prevent the boutonniere deformity.
  • Injury in this zone often involves a laceration to the central slip. Reapproximation of the central slip should be undertaken.
  • Closed injuries should be treated with splinting alone. (photo credit)

Zone IV --

  • Partial lacerations encompassing greater than 50 percent and complete lacerations are repaired with a modified Kessler technique or modified Bunnell suture using a 5-0 non-absorbable suture. (photo credit)
  • Postoperatively, the patient is placed in a volar positioning splint.
  • For the first 3 weeks, passive extension is allowed in the splint.
  • At week 4, gentle active extension is monitored.
  • No passive flexion is allowed at any time for the first 4 weeks. After 4 weeks active flexion is initiated and graded resistive exercises are added to the regimen.

Zone V --

  • The injuries here may divide the sagittal band allowing the tendon to shift laterally. If this is not repaired, the patient may have difficulty with extension of the the proximal phalanx.
  • Use of the modified Kessler or modified Bunnell is a good choice.
  • The patient is placed in a dynamic extension splint for early mobilization. During the initial 4 weeks, the patient is allowed to perform active flexion to 30 degrees of MCP joint motion with passive extension by means of rubber band traction.
  • The range of motion is increased gradually over the ensuing several weeks to full by the 5th week.
  • After 5 weeks, the dynamic extension splint can be discontinued, provided there is no extensor lag or other complications present to interfere with motion.
  • Once the splint is discontinued, the patient may begin active extension and flexion.
  • Eventually, graded resistive exercises are begun to augment strength and mobility.

Zone VI --

  • Injuries through or just distal to the juncturae tendinum may be difficult to diagnose because of the minimal extensor lag associated with these injuries.
  • Injuries occurring proximal to the juncturae may result in retraction of the proximal tendon stump. This makes repair technically more challenging.
  • Here the tendons are very superficial, covered only with thin paratenon and scant subcutaneous tissue. Degloving injuries are not uncommon and may require grafting, or local versus distant flap coverage.
  • Modified Bunnell using 4-0 nonabsorbable suture is a good way to repair the tendons in this zone.
  • Postoperative dynamic splinting and therapy is similar to Zone V.

Zone VII --

  • Injuries in this zone may have the worst prognosis as the injuries may produce mass healing of tendons to the underlying joint capsule and surrounding retinaculum. All of that may impair tendon excursion (sliding/movement) after healing and frequently results in a tenodesis of the tendons at the wrist.
  • Injuries in the wrist will often require releasing the retinaculum for visualization and repair. As much of the extensor retinaculum should be preserved as possible to prevent bowstringing of the tendons.
  • Modified Bunnell or modified Kessler using a 4-0 nonabsorbable suture
  • Early dynamic splinting may prevent or minimize postoperative adhesions. Often the same postop regimen as for Zone 4 is used.

Zone VIII --

  • Injuries in the forearm may involve extensor muscle bellies, tendons, or the musculotendinous junctions.
  • Actual muscle injuries should be repaired with liberal figure-of-8 stitches.
  • Static mobilization for 5 to 6 weeks with the wrist extended to approximately 45 degrees is recommended.

Thumb Zones I - III

  • Repair is similar to that of the fingers.
  • A thumb spica splint is used initially. During the first 3 weeks, the wrist is positioned to 30 degrees of extension. The thumb, CMC, MCP, and IP joints are all held in an extended
    manner.
  • At week 3, gentle active extension of those joints is initiated.
  • At weeks 4 to 5, there is continued gentle active extension with the addition of gentle active flexion of the same joints.
  • At week 6 and beyond, graded resistive exercises are initiated.


You may want to read Doc Shazam's post on Extensor Tendon Repair in Honduras --Part 3, or start with Part I and Part II and get the entire story.

REFERENCES

Extensor Tendon Repair; eMedicine Article, July 22, 2007; Adam J Rosh, MD, MS and Nancy S Kwon, MD,MPA

Mallet Fracture; eMedicine Article, June 17, 2008; Michael E Robinson, MD

Boutonniere Deformity; eMedicine Article, Jan 11, 2008; Randle L Likes, DO and Sean D Ghidella, MD

Extensor Mechanism of Fingers; Duke Orthopaedics Wheeless' Textbook of Orthopaedics Online

Extensor Mechanism Anatomy, Biomechanics and Closed Rupture of Digital Extensor Tendons; E-Hand.com; Charles Eaton, MD

Doyle, J. R. Extensor tendons: Acute injuries. In D. P. Green (Ed.), Green's Operative Hand Surgery, 5th Ed. Philadelphia: Elsevier Churchill Livingstone, 2005.

Extensor Tendon Injuries: Acute Management and Secondary Reconstruction; Plastic and Reconstructive Surgery:Volume 121(3)March 2008pp 109e-120e; Kevin R. Hanz, M.D.; Michel Saint-Cyr, M.D.; Maynard J. Semmler, O.T.R.; Rod J. Rohrich, M.D.

7 comments:

DrB said...

I have been (happily) surprised at how well mallets respond to splinting, regardless of time from injury. I had a "little old lady" who suddenly realized--2 YEARS--after an injury that she didn't like the way her finger drooped. I wasn't too keen on surgerizing her, so I splinted her. She was compliant, and had a beautiful outcome!! Now, I splint just about everyone. 6 weeks 24/7, then 6 weeks night-time.
(btw, I know my blog's been focused on my pigeons lately, but I will write something surgical at some point--I had a post on CTS before, and some recipes :)

rlbates said...

drb, glad to have another female surgeon around. Glad to have another surgeon around -- period.

Theresa said...

I'm always in awe of your surgical posts, they are so comprehensive and textbook-like, but so much more accessible to non-surgeons than most textbooks. Thank you for taking the time.

TBTAM said...

I think you need to publish these posts as a textbook.

Thanks for the info.

Minde said...

Thank you so much! This is exactly what I was looking for! I was wondering whether I had to refer this out.
Many thanks from an occ health PA, and fellow seamstress (clothing, though!)
Exceptionally well written!
Minde

caroline said...

I am not a doctor. However, I have had to take the initiative to find medical information for my situation on my own. Your website is extremely helpful.

I have a question because some of the terminology is not familiar to me.

I believe that I have been misdiagnosed with bilateral trigger finger. But, cortisone injections into the joint in the palm of my hand had no effect. Nerve tests are normal.

I believe that I actually have sagittal band tear (or possibly rupture) in zone V.

What is a modified Kessler or Bunnell? Can I locate and purchase a dynamic extension splint without the assistance of a doctor?

Finally, how do I find information about doctors who specialize in this particular type of hand problem? I would like to go to the best and most experienced doctor (just as I did for my ACL replacement.)

Thank you,
Caroline
dleecubfan@yahoo.com

rlbates said...

Caroline, you need to see a doctor who specializes in hand surgery. I don't think you can purchase a dynamic extension splint without the assistance of a doctor or the referal to a hand therapist.