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Flexor Tendon Injuries for Orthopaedic Exams
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Flexor Tendon Injuries for Orthopaedic Exams
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Language: EN.
Segment:0 .
OK good evening, guys. Welcome to the teaching of this Wednesday FRCS teaching from the mentor group. Sorry, that last couple of weeks missed out teaching, but faculty were all very busy with various stuff. So tonight we have Kashif with us. He's the presenter.
He is an upper limb surgeon from the London area and he is going to tell us about, you know, present us that an extensor tendon injuries from an FRCS perspective. Also with us, Sean, as always, and also sarfraz, who recently passed his international forces exam. So we welcome him and he's very keen to help us.
And that's great. After this session, there will be some hot seat vivo questions, so please, guys, anyone who's interested in taking part in the waiver, please raise the hand symbol next to your name and it's first come, first served basis, basically. OK over to you. Hi, guys. I think Ali is a flexor-pronator tendon is only not extensor because getting voted will be extensive.
So do the flexor-pronator today. And then we'll try to do the rest of the hand injuries in the next session. So starting with the flexor tendons, so. So tender is derived from the Latin word 10, 10 in India, that meaning to straight and these tender alludes their role as flexible cables, transporting forces through the fingers from the common flag, their origin in order to provide strength and motion at the finger and restore its.
So there's a little bit about the enemy of the flexor tendons and pulley system, the desirable part of this sorry little bitty slide sign, well, part of the flag sheet is sentimentally taken to form another and police and these police keep the tendon in close proximity to the bone and prevent both stringing. So another police are from a 1 to a four hour sorry affair and crucial police from see 1 to see three.
Most important police are a 2 and a 4. Little about the blood supply of the tendon, so tendon has a direct and indirect nutrition, so direct, indirect is through the different from the synovial sheath and direct to the vascular direct through the vascular supply, which derive from four main sources. So larger vessels from the territories, vessels from the synovial reflection in the palm vessels from the OSIRIS tendon insertion and those entering through the vein equally.
Like flexor tendon injuries are divided, according to the zones, zone 1 is the distal tubule the afdb's insertion zone to a. Approximately it is up to the mccreath zone 3 is in the pump zone 4 is under the carpal tunnel. Zone 5 is proximal to the carpal tunnel and because zone 2 is the most important, although it was called no lane, but not anymore, and some the is divided into three zones one, two and three.
So whenever patient present to you with the flexor-pronator injury, usually they present with the loss of active flexion, either strength or motion of the involved digit. So when you inspect those, you will be need to see the resting position, posture of the hand and digital cascade, which you can see here. This is a normal digital cascade which you need to observe if you see any evidence of muscle alignment or rotation that may indicate underlying fracture, and you have to assess the integrity of the skin, which can help to localize the potential side of the tendon injury.
Then you need to check the range of motion of the fingers with the passive wrist flexion and extension that allows you to observe that tenodesis effect when it is to go into the extension. Normally they just go into reflection FCPA and if there is, if tenodesis effect is negative, that means there is an injury.
And when you are going to when you are going to check the patient, you have to check the still neurovascular strategy very carefully regarding digital nerves because they are very important and you have to check that vascular regularity of the digits as well. Either with a digital Allen test. So treatment of the flexor-pronator injury, they are divided, whether this is a partial laceration to the tendon or whether it's a complete laceration.
So it is a partial laceration less than 60% of the tendon, which you don't need to repair, that you need wound care and early range of motion for those type of injuries. And usually outcome is good if there is a gap formation and are triggering, then you can address later. But if the situation is more than 60% of the attendant weight, then you have to do the repair of the tendon and then followed by the controlled mobilization.
In and then an injury more than 60% outcome depends on the zone of the injury versus the zone to. So surgical technique for the approach in Syria should always cross the flexion creases. Transfers really are not never longitudinal, because that causes a contractor oil Giants. Timing of the repair is very important. So usually a repair is performed within two weeks of the injury.
Two weeks is within two weeks. The ideal time is the time goes up, the outcome goes down. So there are a lot of different techniques described by different authors. It depends how you are trained, but modified Kessler technique is the most common technique which is used when the report suggests you have to go. And then there the epicondylitis repair.
Number of such restraints that craft the repair site is more important than the number of grasping loops in the repair technique, usually for 4 to six strands, provide adequate strength for early active range of motion and locking loops decreases the gap formation or the repair side. Ideally, suture purchase should be 10 millimeters from the cut from the age of the age of the tendon.
And according to some studies, also just placed dorsally are strong at number two place, and you need to make sure there should be meticulous a traumatic handling because that minimizes your agents. Once you're done, the court suggests, then you need to go for the circumferential epicondylitis repair.
It improves the tendon gliding and it also improves the strength of the repair are around 20% of the tensile strength. And it allows that less give formation, which is a first step in the repair failure, usually simple running such a technique is recommended for the epicondylitis suture. Then third, repair is a sheet repair, which is a bit controversial, but theoretically, it improved the tendon nutrition through Samuel pathway.
Once you've done that tendon repair, then you have to do the pulley management. If there is a rupture of the police, which you can find some time with lacerations, try to preserve a 2 and a police A4 bullet in the digits and apply equally in that, which is very important. If you have a zone to injury, only one slap.
Alone is enough to repair rather than repairing the boat slips, because it 1 1 SLAP repair improve the gliding boat slips. Repair failure is usually tied and repair is weakest between day 6 and day 12. And usually repair fails eight suture nodes and gave formation is very important in the repair failure.
I will come to that a little bit after a few slides, but let me finish this. So there is a little bit controversial between 75% lacerations and lacerations between 50% to 60% If you have less than 75% litigation, some authors suggest you don't need to go for course, suture repair. Just do the epicondylitis repair. And if you have 50% to 60% less with a triggering of the finger, then you have to, then you have to do again, pretending suturing only not the Kessler suture.
And there is a new emerging technique, especially in the hand surgery department, to do the repair and under local anesthesia in awake patients, so that you can assess the strength of your repair and you can check. Is there any thickening of the fingers? Took advantage of the awake repair Allen intraoperatively assessment for repair gaps by getting a patient to actively flex the digits.
It reduces the need for post-operative penalizes by allowing intraoperative assessment of whether repair will fit through the police or not. And it also allowed us on the spot developing debunking of the budget repair. If you are, if you have your repair, it's too bulky. And with this technique, you can also divide it, allow the Division of the air, please fully and venting of the air to cool it if needed.
With this technique, patient can demonstrate that inside of the sheet, head will not inadvertently cut when you are repairing that if you cut the sheet with the tendon that causes the idioms. And it also allows early postoperative motion you can. You need to immobilize these patients only for three days and then you can start mid-range motion, which is half of fist like 45 45 45.
All three words. So I was talking about the formation of the gifts, so studies suggest that if their formation is less than 3 mm, then outcome is good. But if a give formation is more than three mm, according to few studies, then outcome is bad. That that repair will ultimately fail if there is a gap formation of more than three intraoperatively or if it is going to develop post-operatively.
So this was a technique for a primary repair, if you have a patient which need a reconstruction. Then there are few requirements which patients need to meet for the reconstruction of the tendons, the skin should be supple. Digits should be censored. There should be adequate visibility of the digit and finger should have full range of motion of the joints. There there are quite few techniques for the reconstruction, but the most common technique is the Hunter technique, which is to stretch technique, where in stage one silicone rod is placed to create a favorable tendon bait and then stage to it after three to four months.
Once there is a super sheet formation, then you can do the tendon graft. Usually this technique, usually the reconstruction is done by a technique where the. And then a tendon is weaved through the flexor tendon, and then it is suture. So far for the reconstruction growth choices are either you can use the pomus longer, although you have promised longer in 15% of the cases, you can use plant tariffs.
If the longer graft is needed, you can use the long term extensions. Fully reconstruction is very important, as I mentioned in one of my earlier slide, at least one should one police should be reconstructed proximal and distal to each joint. The post-operative rehabilitation, early control mobilization is very important and very successful and gives the very successful results there are quite a few different protocols, but most common protocols, which is used as a Judon and a.
A climate protocol with a dual protocol, it is a low force and low excursion protocol, and in this protocol, patient goes for active finger extension with patient assisted passive finger flexion, while in climate protocol is again a low force and low excursion. But in this, in this technique, patient actively extend the fingers. But there is a dynamic splint assisted passive finger flexion.
So patient patient is in the splint with a dynamic patient, so the patient is in dynamic splint. So finally, the complications of the flexor tendon repairs, so tendon agents are very common and they say early active, early active mobilization protocols are very important to reduce the chances of adyen re rupture rates are 15 to 25 percent, so you need to warn the patient there are always chances of rupture joint contractures around 17% So on neck deformity is one of the complications.
Trigger finger if you are a repair is too bulky. And then your tendon may cut in the police vehicle plus finger for your attention is not correct and fatigue effect again for your attention is not correct in the tendons. So that was all about the flexor tendon injuries, the rest of the hand injuries, probably I will go with another session, probably either next week or week after.
Thank you, kashif, if any questions, please. Yeah, sure, sure. I have some questions, I think can I speak about the basic physiology of the tendons, the anatomy and nutrition and surgical management all very nicely, concisely and in a few minutes. Which is a fair question about how does one leg deformity develop? And I think obviously there are many mechanisms for this, but.
And I think you're discussing acute ruptures, isn't it? Yeah, so acute rupture is one of the causes, yeah, Yeah. Deformity, and I'm sure you guys understand this. It's a long term, not an acute complication. No, no, no, it's not. It is a long term complication. Yeah so you need to make it clear to the examiners that it is a long term complication. The deformity.
I mean, it's like any question if you're struggling in the exam to answer it, just say what you know, described the deformity. As far as I would answer this or what do I know about it, is that what the primary cause? Of swan neck deformity is the boilerplate injury at the PIP joint in rheumatoid arthritis. Yeah however, in flexor tendon injuries, the problem is that there will be.
And opposed extension at the hip joint. Yeah so the unopposed extension of the PIP joint on the long term causes attrition of the ligaments, which lead to the deformity. Um, I have to revise the names of the ligaments and everything, but it's not something I deal with every day, but that's the principle. Yeah so basically unopposed in a tendon injury.
Swan neck deformity developed because of unopposed and opposed action of the extensions of the central slap. And then you can build up build up on that one first more. My question is that the rehabilitation you covered it very nicely. I think, yeah, they wanted a little bit. Yeah, so coming to yeah, for the further rehabilitation because every hospital have different protocols.
Yes, you need to know your hospital protocol. Do you run? And that is the most common protocol, which which is ask about. And there are few steps you need to know which I mentioned in my slides. But again, you need to know what is protocol in your hospital because in my hospital, where I have done my head rotation, they follow the modified Norwich protocol.
Yeah which is what you want to know is that the principle, what's the main principle regardless of the names? Yeah so the basic so the basic principle, which I have already mentioned in my slide, let me finish this extrinsic. And so healing the blood and cells needed for the healing are supplied by adhesions between tendons and surrounding tissue. So that is extrinsic healing.
Yes, blood and cells needed for tendon healing. Yeah, they are supplied by the Indians, so extrinsic healing is with Indians. While the intrinsic healing that is with the. And so the intrinsic healing that is healing like we have intrinsic primary, primary healing in the bone. Yeah, same healing is independent intrinsic healing.
Yeah, it's like direct and indirect. Indirect repair. Yeah direct and indirect healing, Yes. And therefore, can we infer that intrinsic healing is better? Yes intrinsic healing is better because you don't have much evidence. And that's why we repair. You have idioms that will go into this extensive healing. Thank you.
That's thank you for clarifying this point. So coming back to the rehabilitation? So what do you need to do? You need. You need early controlled motion, so you need passive and active motion as well. So active motion will be the extension of the fingers and passive motion is done with the flexion of the fingers. The flexion of the finger will be always passive.
And extension of the finger will be active. And this is all in the controlled environment with hand therapists. This need to be done under the supervision of the hand therapist. Yeah I mean, I think that's exactly I mean, in principle, what you two rehabilitation protocol, two schools for rehabilitation protocols in hand. Yeah active range of movements.
Yeah, or passive range of movements. Yeah, absolutely. But really, because these two protocols, which are very common in the UK, different in China, they imply control motion. So it's that they're active movements and passive movements. So active movement is with finger extension and passive movement.
It's finger flexion. Yeah and to aid that, obviously there will be respective blocking splints. Yes, it is. Yes so blocking is plenty for both. Yeah and the blocking splint principle is to avoid overstretching of the repair. Yes, so you have to block with a certain degree of deflection. So as we are talking about flexor tendons, the blocking splint will be on the dorsal side.
Yeah, Yeah. Dorsal block. Yes generally, these are the principles of these. I don't know if you need to know more because we already spent 1 minute at least talking about it, and there's not much time to talk more. So just talk principles, mainly in the exam. I think we don't need to dig, to be honest. If you're being asked about rehabilitation protocols, you've already discussed how to repair a tendon.
Yes, exactly. I think that's one of the first point us to any other important thing you need to draw. What goes suture technique you are going to do? Yeah what sort of people they do? Modified Kessler, so you need to have practice on the paper how to do that. Yeah, and that's a very good point, actually. You can easily get caught out.
They'll say, draw me how you're going to do modify Kessler. Absolutely it's one of those drawings that could be asked. Yes so first of all, very important to understand. Yes, it's a chronic result of a chronic injury. It's it doesn't happen acutely. It's something that develops over time. That's true. What's also important to understand is that it's about one type of injury that causes the swelling.
However, the principle behind it is a hyperextension. Forces over the pip joints overwhelm the flexion of the PIP joint. So there are a number of causes. Number one is the primary lesion, which is usually the volar plate laxity, which means that the flexor side is not working as efficiently on the pip as the extensor side or a ligament.
Sorry, a tendon injury on the flexor side in your development as well, we'll do the same thing that creates your typekit extension of the joint. The secondary injuries are usually got to do with an imbalance between your flexor and extensor. One of the ones that do develop is malate injury, where the transfer of the extension of the PIP joint is transferred.
So Depew joint is now transferred to the PIP joint. So the pi traject is being forced into hyperextension while the flexor-pronator is affected. Other causes are ph.d.'s, rupture and intrinsic contracture, where their forces are being transferred again to cause a hyperextended injury problem. And if you get an MCP subluxation, especially volar, then that again causes extension of the PIP joint because if you open a joint now has a sort of extension of a longer labor and therefore more force, or they're more attentive as they're going up.
OK, so it's a little digital arteries there that can be repaired with 9o, but you need a microscope and again, digital nerves are repaired with a minor non-edible suture. Again, you need either loops or you need a microscope. So the unit where I worked, we have a microscope, but then every surgeon, they have their own loops, which which is a 2.4 magnification.
Yes, because when you are exploring the finger, then you need to make sure that because the sensitive sensation is very important. So you need to make sure you need to repair the digital nerve if they are injured. Finger can be viable on one digital artery, so if you have one intact digital artery, then you don't need to go for repair if you don't have expertise.
If you have expertise, then yeah, that's fine. You can go for that. Thank gosh, if there is not a question from me. Yeah is also an exam question being asked how if you how do you retrieve FDP tendon if you don't find it easily presented to you when you're trying to repair it? So how do you get affected, Yeah.
So you should go a few days or a couple of weeks after the acute rupture? So what you can do, you can put the smallest artificial save our mosquito inside the police. And you can find if you can't find, then you have to extend the incision. So because I have done one with my boss where we have to go into the forum. Because it was, as you mentioned, it was I think it was around 10 days or two weeks old, injury and patient was not in the splint, so you would keep moving the hand and fingers.
So the tendon was in the forearm. So we started from zone 2 and then we go on to the four of. So if you're presented with a question like that in the exam, you can't find the FDP say my response always with a patient who is chronically injured is talk about it forever imaging that will help you establish where it is before you go to theater. But unfortunately, imaging doesn't add much with the findings of the proximal tendon.
And imaging is very much obturator dependent. And absolutely, I absolutely agree, but I'm suggesting I'm not suggesting that this is the real life answer. What I'm suggesting is sort of showing that you are thinking about this could be significant attracted you staying as safe as you can. That's the principle you do anything you can. Sometimes you can repeat it in two stages.
If it is a chronic injury, you can make a tunnel and then do the repair at a later stage. Is there something you see in kashif? No, because there are two stage repairs for only reconstruction. If a patient is coming to you within three weeks time, you need to. You need to prepare the patient for the extension of the incision.
So you will start from wherever you are suspecting. And then if you can't find the tendon, you have to extend the and progressively. Because the results of reconstruction are to state are not as good as primary repair. But I think that within three weeks, if it comes after three weeks, yeah, then it will be then it will be a reconstruction. Yeah, thank you.
I think we're starting it now into a level 9 questions. So that's good. So OK, guys. So regarding Viva, we move on to the Viva if you guys are happy. So I'll stop recording.
Segment:0 .
OK good evening, guys. Welcome to the teaching of this Wednesday FRCS teaching from the mentor group. Sorry, that last couple of weeks missed out teaching, but faculty were all very busy with various stuff. So tonight we have Kashif with us. He's the presenter.
He is an upper limb surgeon from the London area and he is going to tell us about, you know, present us that an extensor tendon injuries from an FRCS perspective. Also with us, Sean, as always, and also sarfraz, who recently passed his international forces exam. So we welcome him and he's very keen to help us.
And that's great. After this session, there will be some hot seat vivo questions, so please, guys, anyone who's interested in taking part in the waiver, please raise the hand symbol next to your name and it's first come, first served basis, basically. OK over to you. Hi, guys. I think Ali is a flexor-pronator tendon is only not extensor because getting voted will be extensive.
So do the flexor-pronator today. And then we'll try to do the rest of the hand injuries in the next session. So starting with the flexor tendons, so. So tender is derived from the Latin word 10, 10 in India, that meaning to straight and these tender alludes their role as flexible cables, transporting forces through the fingers from the common flag, their origin in order to provide strength and motion at the finger and restore its.
So there's a little bit about the enemy of the flexor tendons and pulley system, the desirable part of this sorry little bitty slide sign, well, part of the flag sheet is sentimentally taken to form another and police and these police keep the tendon in close proximity to the bone and prevent both stringing. So another police are from a 1 to a four hour sorry affair and crucial police from see 1 to see three.
Most important police are a 2 and a 4. Little about the blood supply of the tendon, so tendon has a direct and indirect nutrition, so direct, indirect is through the different from the synovial sheath and direct to the vascular direct through the vascular supply, which derive from four main sources. So larger vessels from the territories, vessels from the synovial reflection in the palm vessels from the OSIRIS tendon insertion and those entering through the vein equally.
Like flexor tendon injuries are divided, according to the zones, zone 1 is the distal tubule the afdb's insertion zone to a. Approximately it is up to the mccreath zone 3 is in the pump zone 4 is under the carpal tunnel. Zone 5 is proximal to the carpal tunnel and because zone 2 is the most important, although it was called no lane, but not anymore, and some the is divided into three zones one, two and three.
So whenever patient present to you with the flexor-pronator injury, usually they present with the loss of active flexion, either strength or motion of the involved digit. So when you inspect those, you will be need to see the resting position, posture of the hand and digital cascade, which you can see here. This is a normal digital cascade which you need to observe if you see any evidence of muscle alignment or rotation that may indicate underlying fracture, and you have to assess the integrity of the skin, which can help to localize the potential side of the tendon injury.
Then you need to check the range of motion of the fingers with the passive wrist flexion and extension that allows you to observe that tenodesis effect when it is to go into the extension. Normally they just go into reflection FCPA and if there is, if tenodesis effect is negative, that means there is an injury.
And when you are going to when you are going to check the patient, you have to check the still neurovascular strategy very carefully regarding digital nerves because they are very important and you have to check that vascular regularity of the digits as well. Either with a digital Allen test. So treatment of the flexor-pronator injury, they are divided, whether this is a partial laceration to the tendon or whether it's a complete laceration.
So it is a partial laceration less than 60% of the tendon, which you don't need to repair, that you need wound care and early range of motion for those type of injuries. And usually outcome is good if there is a gap formation and are triggering, then you can address later. But if the situation is more than 60% of the attendant weight, then you have to do the repair of the tendon and then followed by the controlled mobilization.
In and then an injury more than 60% outcome depends on the zone of the injury versus the zone to. So surgical technique for the approach in Syria should always cross the flexion creases. Transfers really are not never longitudinal, because that causes a contractor oil Giants. Timing of the repair is very important. So usually a repair is performed within two weeks of the injury.
Two weeks is within two weeks. The ideal time is the time goes up, the outcome goes down. So there are a lot of different techniques described by different authors. It depends how you are trained, but modified Kessler technique is the most common technique which is used when the report suggests you have to go. And then there the epicondylitis repair.
Number of such restraints that craft the repair site is more important than the number of grasping loops in the repair technique, usually for 4 to six strands, provide adequate strength for early active range of motion and locking loops decreases the gap formation or the repair side. Ideally, suture purchase should be 10 millimeters from the cut from the age of the age of the tendon.
And according to some studies, also just placed dorsally are strong at number two place, and you need to make sure there should be meticulous a traumatic handling because that minimizes your agents. Once you're done, the court suggests, then you need to go for the circumferential epicondylitis repair.
It improves the tendon gliding and it also improves the strength of the repair are around 20% of the tensile strength. And it allows that less give formation, which is a first step in the repair failure, usually simple running such a technique is recommended for the epicondylitis suture. Then third, repair is a sheet repair, which is a bit controversial, but theoretically, it improved the tendon nutrition through Samuel pathway.
Once you've done that tendon repair, then you have to do the pulley management. If there is a rupture of the police, which you can find some time with lacerations, try to preserve a 2 and a police A4 bullet in the digits and apply equally in that, which is very important. If you have a zone to injury, only one slap.
Alone is enough to repair rather than repairing the boat slips, because it 1 1 SLAP repair improve the gliding boat slips. Repair failure is usually tied and repair is weakest between day 6 and day 12. And usually repair fails eight suture nodes and gave formation is very important in the repair failure.
I will come to that a little bit after a few slides, but let me finish this. So there is a little bit controversial between 75% lacerations and lacerations between 50% to 60% If you have less than 75% litigation, some authors suggest you don't need to go for course, suture repair. Just do the epicondylitis repair. And if you have 50% to 60% less with a triggering of the finger, then you have to, then you have to do again, pretending suturing only not the Kessler suture.
And there is a new emerging technique, especially in the hand surgery department, to do the repair and under local anesthesia in awake patients, so that you can assess the strength of your repair and you can check. Is there any thickening of the fingers? Took advantage of the awake repair Allen intraoperatively assessment for repair gaps by getting a patient to actively flex the digits.
It reduces the need for post-operative penalizes by allowing intraoperative assessment of whether repair will fit through the police or not. And it also allowed us on the spot developing debunking of the budget repair. If you are, if you have your repair, it's too bulky. And with this technique, you can also divide it, allow the Division of the air, please fully and venting of the air to cool it if needed.
With this technique, patient can demonstrate that inside of the sheet, head will not inadvertently cut when you are repairing that if you cut the sheet with the tendon that causes the idioms. And it also allows early postoperative motion you can. You need to immobilize these patients only for three days and then you can start mid-range motion, which is half of fist like 45 45 45.
All three words. So I was talking about the formation of the gifts, so studies suggest that if their formation is less than 3 mm, then outcome is good. But if a give formation is more than three mm, according to few studies, then outcome is bad. That that repair will ultimately fail if there is a gap formation of more than three intraoperatively or if it is going to develop post-operatively.
So this was a technique for a primary repair, if you have a patient which need a reconstruction. Then there are few requirements which patients need to meet for the reconstruction of the tendons, the skin should be supple. Digits should be censored. There should be adequate visibility of the digit and finger should have full range of motion of the joints. There there are quite few techniques for the reconstruction, but the most common technique is the Hunter technique, which is to stretch technique, where in stage one silicone rod is placed to create a favorable tendon bait and then stage to it after three to four months.
Once there is a super sheet formation, then you can do the tendon graft. Usually this technique, usually the reconstruction is done by a technique where the. And then a tendon is weaved through the flexor tendon, and then it is suture. So far for the reconstruction growth choices are either you can use the pomus longer, although you have promised longer in 15% of the cases, you can use plant tariffs.
If the longer graft is needed, you can use the long term extensions. Fully reconstruction is very important, as I mentioned in one of my earlier slide, at least one should one police should be reconstructed proximal and distal to each joint. The post-operative rehabilitation, early control mobilization is very important and very successful and gives the very successful results there are quite a few different protocols, but most common protocols, which is used as a Judon and a.
A climate protocol with a dual protocol, it is a low force and low excursion protocol, and in this protocol, patient goes for active finger extension with patient assisted passive finger flexion, while in climate protocol is again a low force and low excursion. But in this, in this technique, patient actively extend the fingers. But there is a dynamic splint assisted passive finger flexion.
So patient patient is in the splint with a dynamic patient, so the patient is in dynamic splint. So finally, the complications of the flexor tendon repairs, so tendon agents are very common and they say early active, early active mobilization protocols are very important to reduce the chances of adyen re rupture rates are 15 to 25 percent, so you need to warn the patient there are always chances of rupture joint contractures around 17% So on neck deformity is one of the complications.
Trigger finger if you are a repair is too bulky. And then your tendon may cut in the police vehicle plus finger for your attention is not correct and fatigue effect again for your attention is not correct in the tendons. So that was all about the flexor tendon injuries, the rest of the hand injuries, probably I will go with another session, probably either next week or week after.
Thank you, kashif, if any questions, please. Yeah, sure, sure. I have some questions, I think can I speak about the basic physiology of the tendons, the anatomy and nutrition and surgical management all very nicely, concisely and in a few minutes. Which is a fair question about how does one leg deformity develop? And I think obviously there are many mechanisms for this, but.
And I think you're discussing acute ruptures, isn't it? Yeah, so acute rupture is one of the causes, yeah, Yeah. Deformity, and I'm sure you guys understand this. It's a long term, not an acute complication. No, no, no, it's not. It is a long term complication. Yeah so you need to make it clear to the examiners that it is a long term complication. The deformity.
I mean, it's like any question if you're struggling in the exam to answer it, just say what you know, described the deformity. As far as I would answer this or what do I know about it, is that what the primary cause? Of swan neck deformity is the boilerplate injury at the PIP joint in rheumatoid arthritis. Yeah however, in flexor tendon injuries, the problem is that there will be.
And opposed extension at the hip joint. Yeah so the unopposed extension of the PIP joint on the long term causes attrition of the ligaments, which lead to the deformity. Um, I have to revise the names of the ligaments and everything, but it's not something I deal with every day, but that's the principle. Yeah so basically unopposed in a tendon injury.
Swan neck deformity developed because of unopposed and opposed action of the extensions of the central slap. And then you can build up build up on that one first more. My question is that the rehabilitation you covered it very nicely. I think, yeah, they wanted a little bit. Yeah, so coming to yeah, for the further rehabilitation because every hospital have different protocols.
Yes, you need to know your hospital protocol. Do you run? And that is the most common protocol, which which is ask about. And there are few steps you need to know which I mentioned in my slides. But again, you need to know what is protocol in your hospital because in my hospital, where I have done my head rotation, they follow the modified Norwich protocol.
Yeah which is what you want to know is that the principle, what's the main principle regardless of the names? Yeah so the basic so the basic principle, which I have already mentioned in my slide, let me finish this extrinsic. And so healing the blood and cells needed for the healing are supplied by adhesions between tendons and surrounding tissue. So that is extrinsic healing.
Yes, blood and cells needed for tendon healing. Yeah, they are supplied by the Indians, so extrinsic healing is with Indians. While the intrinsic healing that is with the. And so the intrinsic healing that is healing like we have intrinsic primary, primary healing in the bone. Yeah, same healing is independent intrinsic healing.
Yeah, it's like direct and indirect. Indirect repair. Yeah direct and indirect healing, Yes. And therefore, can we infer that intrinsic healing is better? Yes intrinsic healing is better because you don't have much evidence. And that's why we repair. You have idioms that will go into this extensive healing. Thank you.
That's thank you for clarifying this point. So coming back to the rehabilitation? So what do you need to do? You need. You need early controlled motion, so you need passive and active motion as well. So active motion will be the extension of the fingers and passive motion is done with the flexion of the fingers. The flexion of the finger will be always passive.
And extension of the finger will be active. And this is all in the controlled environment with hand therapists. This need to be done under the supervision of the hand therapist. Yeah I mean, I think that's exactly I mean, in principle, what you two rehabilitation protocol, two schools for rehabilitation protocols in hand. Yeah active range of movements.
Yeah, or passive range of movements. Yeah, absolutely. But really, because these two protocols, which are very common in the UK, different in China, they imply control motion. So it's that they're active movements and passive movements. So active movement is with finger extension and passive movement.
It's finger flexion. Yeah and to aid that, obviously there will be respective blocking splints. Yes, it is. Yes so blocking is plenty for both. Yeah and the blocking splint principle is to avoid overstretching of the repair. Yes, so you have to block with a certain degree of deflection. So as we are talking about flexor tendons, the blocking splint will be on the dorsal side.
Yeah, Yeah. Dorsal block. Yes generally, these are the principles of these. I don't know if you need to know more because we already spent 1 minute at least talking about it, and there's not much time to talk more. So just talk principles, mainly in the exam. I think we don't need to dig, to be honest. If you're being asked about rehabilitation protocols, you've already discussed how to repair a tendon.
Yes, exactly. I think that's one of the first point us to any other important thing you need to draw. What goes suture technique you are going to do? Yeah what sort of people they do? Modified Kessler, so you need to have practice on the paper how to do that. Yeah, and that's a very good point, actually. You can easily get caught out.
They'll say, draw me how you're going to do modify Kessler. Absolutely it's one of those drawings that could be asked. Yes so first of all, very important to understand. Yes, it's a chronic result of a chronic injury. It's it doesn't happen acutely. It's something that develops over time. That's true. What's also important to understand is that it's about one type of injury that causes the swelling.
However, the principle behind it is a hyperextension. Forces over the pip joints overwhelm the flexion of the PIP joint. So there are a number of causes. Number one is the primary lesion, which is usually the volar plate laxity, which means that the flexor side is not working as efficiently on the pip as the extensor side or a ligament.
Sorry, a tendon injury on the flexor side in your development as well, we'll do the same thing that creates your typekit extension of the joint. The secondary injuries are usually got to do with an imbalance between your flexor and extensor. One of the ones that do develop is malate injury, where the transfer of the extension of the PIP joint is transferred.
So Depew joint is now transferred to the PIP joint. So the pi traject is being forced into hyperextension while the flexor-pronator is affected. Other causes are ph.d.'s, rupture and intrinsic contracture, where their forces are being transferred again to cause a hyperextended injury problem. And if you get an MCP subluxation, especially volar, then that again causes extension of the PIP joint because if you open a joint now has a sort of extension of a longer labor and therefore more force, or they're more attentive as they're going up.
OK, so it's a little digital arteries there that can be repaired with 9o, but you need a microscope and again, digital nerves are repaired with a minor non-edible suture. Again, you need either loops or you need a microscope. So the unit where I worked, we have a microscope, but then every surgeon, they have their own loops, which which is a 2.4 magnification.
Yes, because when you are exploring the finger, then you need to make sure that because the sensitive sensation is very important. So you need to make sure you need to repair the digital nerve if they are injured. Finger can be viable on one digital artery, so if you have one intact digital artery, then you don't need to go for repair if you don't have expertise.
If you have expertise, then yeah, that's fine. You can go for that. Thank gosh, if there is not a question from me. Yeah is also an exam question being asked how if you how do you retrieve FDP tendon if you don't find it easily presented to you when you're trying to repair it? So how do you get affected, Yeah.
So you should go a few days or a couple of weeks after the acute rupture? So what you can do, you can put the smallest artificial save our mosquito inside the police. And you can find if you can't find, then you have to extend the incision. So because I have done one with my boss where we have to go into the forum. Because it was, as you mentioned, it was I think it was around 10 days or two weeks old, injury and patient was not in the splint, so you would keep moving the hand and fingers.
So the tendon was in the forearm. So we started from zone 2 and then we go on to the four of. So if you're presented with a question like that in the exam, you can't find the FDP say my response always with a patient who is chronically injured is talk about it forever imaging that will help you establish where it is before you go to theater. But unfortunately, imaging doesn't add much with the findings of the proximal tendon.
And imaging is very much obturator dependent. And absolutely, I absolutely agree, but I'm suggesting I'm not suggesting that this is the real life answer. What I'm suggesting is sort of showing that you are thinking about this could be significant attracted you staying as safe as you can. That's the principle you do anything you can. Sometimes you can repeat it in two stages.
If it is a chronic injury, you can make a tunnel and then do the repair at a later stage. Is there something you see in kashif? No, because there are two stage repairs for only reconstruction. If a patient is coming to you within three weeks time, you need to. You need to prepare the patient for the extension of the incision.
So you will start from wherever you are suspecting. And then if you can't find the tendon, you have to extend the and progressively. Because the results of reconstruction are to state are not as good as primary repair. But I think that within three weeks, if it comes after three weeks, yeah, then it will be then it will be a reconstruction. Yeah, thank you.
I think we're starting it now into a level 9 questions. So that's good. So OK, guys. So regarding Viva, we move on to the Viva if you guys are happy. So I'll stop recording.
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