Presentation on theme: "Extensor Tendon Injuries: ED Management and Follow-up"— Presentation transcript:
1 Extensor Tendon Injuries: ED Management and Follow-up Jon Friesen, CCFP-EM ResidentGuest Consultant: Dr. Earl CampbellMay 16, 2002
2 outline why extensor tendon injuries? anatomy injury zones basic principles…what’s the evidence?extensor tendon zone i-vi injuries:ED management, splinting, and follow-uphand OT/PT resources in Calgary
3 why extensor tendon injuries? acute injuries we see and initially manageinitial rx NB to hand functional outcomepoorly described in EM texts and literaturehit and miss in clinical education/practicedo we really know what we’re doing?
4 how good are we?one study (!!) that examines follow-up of extensor tendons done by EM docsEvans JD; 1995EM housestaff in UK repaired 65 extensor tendon lacsfollow-up within 6 mos. re: functional outcomeresults (as per Miller system): 80% good to excellent results in proximal injuries vs. 18% good to excellent results in distal injuriesweaknesses: unconventional splinting of distal injuries, poor physio f/u, small numbersconclusion: we don’t know how we’re doing!
5 why anatomy matters complex anatomy different from flexors role of juncturaerole of paratenonEDM, EIPextrinsics vs. intrinsics
6 why anatomy matters digits are v. complex! clinical relevance disruption of anatomy at one joint has consequences for function of adjacent jointsinitial management very important to injury outcome
7 Verdan’s zones of injury each zone has:particular injuriesvariations in acute managementdifferent splinting requirementsnot all extensor tendon injuries are the same!!
8 what about suture material? based on experience and expert opinionabsorbable vs. non-absorbable syntheticsnon-absorbs most often used, but may cause knot irritation at site of repairabsorbs less prone to producing knot irritation, but ? strengthsize:
9 suture techniques? little data re: extensor tendon repairs may be more important as dynamic splinting becomes “en vogue” in extensor injuriesNewport ML and CD Williams; 1992compared simple mattress, figure-of-eight, Kessler, and Bunnell suture techniquesBunnell and Kessler stronger, but not much difference with regards to tendon shortening or decreased ROMdifficult to apply to all extensor tendon injuries!
10 suture techniques Bunnel suture advantages: disadvantages: strong time constraintstechnical skillsneed good tendon cross-sectional area
11 suture techniques Kessler suture advantages: disadvantages: strong time constraintstechnical skillsneed good tendon cross-sectional area
12 suture techniques horizontal mattress suture advantages: easy to do, even on thinner tendonsdisadvantages:decreased strength
13 suture techniques? practicality in the ED: general guidelines: time constraintslimited opportunity to use new techniquesbarbaric equipment for fine repairs in the ERgeneral guidelines:zones i-v: figure-of-8, horizontal mattresszone vi, thumb extensors: Kessler, Bunnel
14 incomplete lacerations flexor tendon studies:studies suggest that 0 repair and early mobilization produces comparable outcomes to conventional rx in Zone II injuriesapplicable to extensor injuries? what zones?recommendations based on expert opinion:lacs<30-50%, wound closure and splint for shortened period w/early mobilizationlacs>30-50%, repair and treat as completeall partial zone i-v injuries should be repaired?variable amongst surgeons
15 shredded endsimportant to consider in injuries where primary tendon repair is indicatedfine trimming acceptableexcursion of extensors < flexorsoverzealous trimming results in:undue wound tension post-suturingflexion loss during rehabilitationgeneral rule: if gap not breachable, or undue tension on wound distorts anatomy, refer to plastics for repair/tendon grafting
16 what about antibiotics? little evidence specific to simple tendon lacsACEP Guidelines:abx indicated for both hand and tendon lacsStone JF, 1998retrospective review of 140 pts w/simple flexor lacstiming to repair and abx not associated w/increased infxcan these results be extrapolated to extensor repair?surgeon dependentabsolute indications:bites, crush injuries, associated open fractures, joint capsule disruption
17 zone 1: mallet finger common injury closed vs. open in ed goal of rx: <10 degrees extension laggood flexionprevention of swanneck deformity
18 mallet finger: who to refer closed:tendon avulsion with bony fragment involving >30% of the articular surfaceassociated w/volar distal phalanx subluxation or #associated w/transepiphyseal plate # in kidsswanneck deformityactive pts: refer for k-wire fixationopen:abrasion w/tendon erosionassociated w/open #
19 closed mallet finger classification: ed management: type 1: distal extensor mechanism rupture, no fracturetype 2: tendon avulsion w/ small bony fragment of distal phalanxtype 3: tendon avulsion with bony fragment involving >30% of the articular surfaceed management:dorsal/volar splint w/DIP extension; PIP free x 6wimportant to emphasize NO DIP FLEXIONsplint care: remove daily to avoid skin erosion
20 closed mallet fingerearly vs. delayed presentation for closed injuries:Garberman et al.; 1994small study of 40 pts with closed mallet finger, ½ with early (<2w), ½ w/delayed (>4w)0 change in outcomes with regards to extensor lag, rx of dorsal lip #s <30%, or splint typeconclusion: splinting equally effective in bothimplication: we can manage both in the ed
21 open mallet finger ed management: tendon suture vs. skin closure and splintif suturing:use figure-of-8, keep in mind tendon is friablesuture tendon and skin in one bitesuture removal in 10-12dsplinting as for closed injuries
22 mallet finger: f/u & OT/PT continuous splint x 6wat 6w, begin guarded DIP flexionflex DIP 10-20x q1h20-25 degrees for 1st weekif no lag after 1st week, 35 degrees and progress as limited by painif lag, reapply splint x 2wnight splinting x 2w
23 what about mallet thumb? extremely rare due to thickness of EPL tendonclosed:management identical to mallet finger for closed deformitiesopen:clean lacs should be sutured as described for open mallet fingerfollow-up and OT/PT as for mallet finger
24 zone 2: middle phalanx injuries most injuries are either partial lacs/crush injuriesreferral criteria similar to open malletsuture technique:lateral bands are very friable and difficult to suturesuture type: figure-of-8epl on thumb: use core-type suturesplinting and follow-up as for mallet fingerwound care and splinting x 7-10d for partial lacs <50%
25 zone 3: the PIP worst prognosis of extensor tendon injuries closed vs. open in edconsider central slip and lateral bandsgoal of rx: maximize flexion and extension, prevention of Boutonniere deformity
26 closed zone 3: clinical pearls central slip rupture is not a simple dx!have high degree of suspicion if:pip extensor lag >15-20 degrees while MCP and wrist in full flexiondecreased strength to resistance or pain to pip extensiontenderness over pip and appropriate mechanism of injurymay present with acute Boutonniere deformityneed to assess laxity of lateral bands via passive PIP extensionassess PIP stability!
27 closed zone 3: who to refer displaced avulsion # at base of middle phalanxaxial/lateral instability of PIPie. post-reduction of volar dislocationirreducible volar dislocationBoutonniere deformity not correctable by passive PIP extensiontime to rx less important than joint laxity
28 closed zone 3 injuries ed management: continuous splint x 6w volar splint with DIP and MCP free to movewhen splint removed, PIP MUST BE HELD IN EXTENSIONsplint care: remove daily to avoid skin erosion
29 closed zone 3 injuries if associated volar dislocation: reduce by applying traction w/MCP and PIP in full flexionif this fails, try adding in wrist extension for extensor relaxationreassess PIP stability
30 open zone 3: clinical pearls anatomy is complex!!high degree of suspicion for joint capsule penetration in lacs over PIPlook closely for lateral band lacslacs rarely involve entire dorsal apparatusfailure to repair may result in Boutonniere deformity
31 open zone 3: who to referdistal central slip stump too short for tendon suturingabrasion w/tendon erosionassociated w/open #lateral band laceration??PIP joint capsule penetration??
32 open zone 3 injuries: ed rx wound irrigation and exploration is NBlacs require suturingsuture technique: figure-of-8suture type: 5.0 non-absorbable/absorbablesuture lateral bands as well
33 open zone 3 injuries splinting as for closed injuries antibiotics if lateral bands lacerated, splint DIP for 4wantibioticsuse if joint capsule penetration present
34 zone 3 injuries: f/u & OT/PT much more complex than DIP, get hand physio involved at 6wat 6w: exercises 10-20x q1hactive PIP extension w/MCP in flexion to encourage intrinsic extensiongentle active flexion (to pain) w/wrist and MCP extensionreapply splint between hand physio sessionsif extensor lag develops, decrease flexion and reapply splint
35 zone 3 injuries: f/u & OT/PT at 8wcontinue active flexion, gentle resistance appliedsplint at night or d/c splintat 10wincrease resistance exercisesprogress to full grasp
36 zone 3 thumb injuries: the MCP may involve EPB and/or EPLclosed:rare injuries: refer to plastics for managementopen:thicker tendons; use Kessler suture for open lacsrepair both EPB and EPLsplint with CMC neutral, MCP 0 degrees, and IP 0 degreescomplex OT/PT: refer for follow-up
37 zone 4 injuries: proximal phalanx tendon is very broad at this levellacs tend to be partialif 0 loss of extension, splint as for PIP x 3-4w and then begin active motionsuture complete lacsmay be able to use Kessler suturetreat as for PIP lacs, but mobilize at 3-4w b/c of higher degree of “scarring down” at this zonef/u and OT/PT as for PIP injuriesthumb injuries: rx as for zone 3 thumb injuries
38 zone 5: the MCPconsider importance of dorsal hood and sagittal bands in addition to tendonclosed vs. open injuriesopen injuries are considered “fight bite” until proven otherwise
39 closed zone 5injuries are rare and usually due to a crush mechanism over the MCPclassic: tendon dislocation and relocation with passive extensionsuspect sagittal band/dorsal hood disruption when painful flexion at MCP occurswho to refer: all injuriesed management:splint w/MCP in extension at place of tendon relocationleave other MCPs free to move
40 open zone 5: who to refer fight bite sagittal band/dorsal hood involvementmay repair if comfortable with anatomyassociated open fracturestendon abrasions
41 open zone 5: fight bite early presentation: ie. non-infected irrigation and exploration requiredif any disruption of joint capsule/tendon, start abx and refer to plasticsif underlying structures OK, start abx and ensure close f/u in 24-48hwound closure in 5-7d post-abxabx prophylaxis: clavulin x 5dsplint: as for other zone 5 lacs
42 open zone 5: ed rx irrigation and wound debridement tendon is thick at this pointends tend not to retractsuture material: 4.0 nonabsorbablesuture techniqure: Kessler suture vs. figure-of-8
43 open zone 5: ed rx what about dorsal hood lacs? need to be repaired to prevent central tendon subluxationwhat about sagittal band lacs?need to be repaired for same reason
44 open zone 5: splinting tendon lac: splint wrist in degrees extension, MCPs 20 degrees flexion, and IPs in 0 degreestime: 4-5wisolated dorsal hood/sagittal band lac:avoiding abduction/adduction exercises is keybuddy tape adjacent fingerbegin flexion/extension in 3-5 days
45 open zone 5: f/u & OT/PT static splinting x 4w at 4w: may take off IP splint to allow mobility periodicallyhand physio NB!!at 4w:gentle active extension at MCPalternating flexion of MCP and IPswrist extension and flexion to neutralsplint worn b/t sessions, IPs now free
46 open zone 5: f/u & OT/PT at 5w: at 7w: claw postion to encourage extrinsic extensionintrinsic + to stretch collateral ligamentsalternate finger and wrist flexionnight splinting only, unless extensor lag persistsat 7w:resisted exercises
47 open zone 5: thumb what about thumb zone 5? ed rx: splint: f/u and pt: involves CMCJ, EPB and/or APLalso consider radial artery/nerve branch lacsed rx:refer if APL avulsed off bonerepair as for zone 5 digit injuriessplint:thumb in extension and moderate abductionf/u and pt:refer to hand physio
48 zone 6 injuries better prognosis than injuries to distal counterparts open injuries prevailwho to refer:associated w/open #s, crush injuriessignificant tendon retractioninfection
49 zone 6 injuries ed rx: splinting: f/u & OT/PT tendon is well formed and thicksuturing as for zone 5 lacssplinting:as for zone 5 lacsf/u & OT/PT
50 hand resources: OT & PT FHH hand clinic Lindsay Park (2 hand pts) (403)ask to speak to a hand pt to book patientLindsay Park (2 hand pts)(403)must indicate you want a hand pt to reception and they will book for you
51 hand resources: OT & PT PLC RVH (403) 291-8785 ideally they want pt seen by plastics 1stRVH(403) Ph(403) Faxfill out form, refer from EDOT/PT will contact pt based on prioritycan refer from peripheral center as well
52 hand resources: OT & PT what about kids? ACH (403) 229-7912 Ph (403) Faxfill out form, refer from EDOT/PT will contact pt w/i 48h
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