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Extensor Tendon Injuries: ED Management and Follow-up Jon Friesen, CCFP-EM Resident Guest Consultant: Dr. Earl Campbell May 16, 2002.

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Presentation on theme: "Extensor Tendon Injuries: ED Management and Follow-up Jon Friesen, CCFP-EM Resident Guest Consultant: Dr. Earl Campbell May 16, 2002."— Presentation transcript:

1 Extensor Tendon Injuries: ED Management and Follow-up Jon Friesen, CCFP-EM Resident Guest Consultant: Dr. Earl Campbell May 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-up hand OT/PT resources in Calgary

3 why extensor tendon injuries? acute injuries we see and initially manage initial rx NB to hand functional outcome poorly described in EM texts and literature hit and miss in clinical education/practice do we really know what we’re doing?

4 how good are we? one study (!!) that examines follow-up of extensor tendons done by EM docs Evans JD; 1995 –EM housestaff in UK repaired 65 extensor tendon lacs –follow-up within 6 mos. re: functional outcome –results (as per Miller system): 80% good to excellent results in proximal injuries vs. 18% good to excellent results in distal injuries –weaknesses: unconventional splinting of distal injuries, poor physio f/u, small numbers conclusion: we don’t know how we’re doing!

5 why anatomy matters complex anatomy different from flexors role of juncturae role of paratenon EDM, EIP extrinsics vs. intrinsics

6 why anatomy matters digits are v. complex! clinical relevance –disruption of anatomy at one joint has consequences for function of adjacent joints –initial management very important to injury outcome

7 Verdan’s zones of injury 8 zones of injury each zone has: –particular injuries –variations in acute management –different splinting requirements not all extensor tendon injuries are the same!!

8 what about suture material? based on experience and expert opinion absorbable vs. non-absorbable synthetics –non-absorbs most often used, but may cause knot irritation at site of repair –absorbs less prone to producing knot irritation, but ? strength size:

9 suture techniques? little data re: extensor tendon repairs may be more important as dynamic splinting becomes “en vogue” in extensor injuries Newport ML and CD Williams; 1992 –compared simple mattress, figure-of-eight, Kessler, and Bunnell suture techniques –Bunnell and Kessler stronger, but not much difference with regards to tendon shortening or decreased ROM difficult to apply to all extensor tendon injuries!

10 suture techniques Bunnel suture advantages: –strong disadvantages: –time constraints –technical skills –need good tendon cross-sectional area

11 suture techniques Kessler suture advantages: –strong disadvantages: –time constraints –technical skills –need good tendon cross-sectional area

12 suture techniques horizontal mattress suture advantages: –easy to do, even on thinner tendons disadvantages: –decreased strength

13 suture techniques? practicality in the ED: –time constraints –limited opportunity to use new techniques –barbaric equipment for fine repairs in the ER general guidelines: –zones i-v: figure-of-8, horizontal mattress –zone 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 injuries –applicable to extensor injuries? what zones? recommendations based on expert opinion: –lacs<30-50%, wound closure and splint for shortened period w/early mobilization –lacs>30-50%, repair and treat as complete –all partial zone i-v injuries should be repaired? –variable amongst surgeons

15 shredded ends important to consider in injuries where primary tendon repair is indicated fine trimming acceptable excursion of extensors < flexors overzealous trimming results in: –undue wound tension post-suturing –flexion loss during rehabilitation general 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 lacs ACEP Guidelines: –abx indicated for both hand and tendon lacs Stone JF, 1998 –retrospective review of 140 pts w/simple flexor lacs –timing to repair and abx not associated w/increased infx –can these results be extrapolated to extensor repair? surgeon dependent absolute 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 lag –good flexion –prevention of swanneck deformity

18 mallet finger: who to refer closed: –tendon avulsion with bony fragment involving >30% of the articular surface –associated w/volar distal phalanx subluxation or # –associated w/transepiphyseal plate # in kids –swanneck deformity –active pts: refer for k-wire fixation open: –abrasion w/tendon erosion –associated w/open #

19 closed mallet finger classification: –type 1: distal extensor mechanism rupture, no fracture –type 2: tendon avulsion w/ small bony fragment of distal phalanx –type 3: tendon avulsion with bony fragment involving >30% of the articular surface ed management: –dorsal/volar splint w/DIP extension; PIP free x 6w –important to emphasize NO DIP FLEXION –splint care: remove daily to avoid skin erosion

20 closed mallet finger early vs. delayed presentation for closed injuries: –Garberman et al.; 1994 small study of 40 pts with closed mallet finger, ½ with early ( 4w) 0 change in outcomes with regards to extensor lag, rx of dorsal lip #s <30%, or splint type conclusion: splinting equally effective in both implication: we can manage both in the ed

21 open mallet finger ed management: –tendon suture vs. skin closure and splint –if suturing: use figure-of-8, keep in mind tendon is friable suture tendon and skin in one bite suture removal in 10-12d –splinting as for closed injuries

22 mallet finger: f/u & OT/PT continuous splint x 6w at 6w, begin guarded DIP flexion –flex DIP 10-20x q1h degrees for 1 st week if no lag after 1 st week, 35 degrees and progress as limited by pain if lag, reapply splint x 2w –night splinting x 2w

23 what about mallet thumb? extremely rare due to thickness of EPL tendon closed: –management identical to mallet finger for closed deformities open: –clean lacs should be sutured as described for open mallet finger follow-up and OT/PT as for mallet finger

24 zone 2: middle phalanx injuries most injuries are either partial lacs/crush injuries referral criteria similar to open mallet suture technique: –lateral bands are very friable and difficult to suture –suture type: figure-of-8 –epl on thumb: use core-type suture splinting and follow-up as for mallet finger –wound 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 ed consider central slip and lateral bands goal 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 flexion –decreased strength to resistance or pain to pip extension –tenderness over pip and appropriate mechanism of injury may present with acute Boutonniere deformity –need to assess laxity of lateral bands via passive PIP extension assess PIP stability!

27 closed zone 3: who to refer displaced avulsion # at base of middle phalanx axial/lateral instability of PIP –ie. post-reduction of volar dislocation irreducible volar dislocation Boutonniere deformity not correctable by passive PIP extension –time 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 move –when splint removed, PIP MUST BE HELD IN EXTENSION –splint 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 flexion –if this fails, try adding in wrist extension for extensor relaxation reassess PIP stability

30 open zone 3: clinical pearls anatomy is complex!! high degree of suspicion for joint capsule penetration in lacs over PIP look closely for lateral band lacs lacs rarely involve entire dorsal apparatus failure to repair may result in Boutonniere deformity

31 open zone 3: who to refer distal central slip stump too short for tendon suturing abrasion w/tendon erosion associated w/open # lateral band laceration?? PIP joint capsule penetration??

32 open zone 3 injuries: ed rx wound irrigation and exploration is NB lacs require suturing –suture technique: figure-of-8 –suture type: 5.0 non-absorbable/absorbable suture lateral bands as well

33 open zone 3 injuries splinting as for closed injuries –if lateral bands lacerated, splint DIP for 4w antibiotics –use if joint capsule penetration present

34 zone 3 injuries: f/u & OT/PT much more complex than DIP, get hand physio involved at 6w at 6w: exercises 10-20x q1h –active PIP extension w/MCP in flexion to encourage intrinsic extension –gentle active flexion (to pain) w/wrist and MCP extension –reapply splint between hand physio sessions –if extensor lag develops, decrease flexion and reapply splint

35 zone 3 injuries: f/u & OT/PT at 8w –continue active flexion, gentle resistance applied –splint at night or d/c splint at 10w –increase resistance exercises –progress to full grasp

36 zone 3 thumb injuries: the MCP may involve EPB and/or EPL closed: –rare injuries: refer to plastics for management open: –thicker tendons; use Kessler suture for open lacs –repair both EPB and EPL splint with CMC neutral, MCP 0 degrees, and IP 0 degrees complex OT/PT: refer for follow-up

37 zone 4 injuries: proximal phalanx tendon is very broad at this level lacs tend to be partial –if 0 loss of extension, splint as for PIP x 3-4w and then begin active motion suture complete lacs –may be able to use Kessler suture –treat as for PIP lacs, but mobilize at 3-4w b/c of higher degree of “scarring down” at this zone f/u and OT/PT as for PIP injuries thumb injuries: rx as for zone 3 thumb injuries

38 zone 5: the MCP consider importance of dorsal hood and sagittal bands in addition to tendon closed vs. open injuries open injuries are considered “fight bite” until proven otherwise

39 closed zone 5 injuries are rare and usually due to a crush mechanism over the MCP classic: tendon dislocation and relocation with passive extension suspect sagittal band/dorsal hood disruption when painful flexion at MCP occurs who to refer: all injuries ed management: –splint w/MCP in extension at place of tendon relocation –leave other MCPs free to move

40 open zone 5: who to refer fight bite sagittal band/dorsal hood involvement –may repair if comfortable with anatomy associated open fractures tendon abrasions

41 open zone 5: fight bite early presentation: ie. non-infected –irrigation and exploration required –if any disruption of joint capsule/tendon, start abx and refer to plastics –if underlying structures OK, start abx and ensure close f/u in 24-48h –wound closure in 5-7d post-abx abx prophylaxis: clavulin x 5d splint: as for other zone 5 lacs

42 open zone 5: ed rx irrigation and wound debridement tendon is thick at this point ends tend not to retract suture material: 4.0 nonabsorbable suture 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 subluxation what 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 degrees –time: 4-5w isolated dorsal hood/sagittal band lac: –avoiding abduction/adduction exercises is key –buddy tape adjacent finger –begin flexion/extension in 3-5 days

45 open zone 5: f/u & OT/PT static splinting x 4w –may take off IP splint to allow mobility periodically –hand physio NB!! at 4w: –gentle active extension at MCP –alternating flexion of MCP and IPs –wrist extension and flexion to neutral –splint worn b/t sessions, IPs now free

46 open zone 5: f/u & OT/PT at 5w: –claw postion to encourage extrinsic extension –intrinsic + to stretch collateral ligaments –alternate finger and wrist flexion –night splinting only, unless extensor lag persists at 7w: –resisted exercises

47 open zone 5: thumb what about thumb zone 5? –involves CMCJ, EPB and/or APL –also consider radial artery/nerve branch lacs ed rx: –refer if APL avulsed off bone –repair as for zone 5 digit injuries splint: –thumb in extension and moderate abduction f/u and pt: –refer to hand physio

48 zone 6 injuries better prognosis than injuries to distal counterparts open injuries prevail who to refer: –associated w/open #s, crush injuries –significant tendon retraction –infection

49 zone 6 injuries ed rx: –tendon is well formed and thick –suturing as for zone 5 lacs splinting: –as for zone 5 lacs f/u & OT/PT –as for zone 5 lacs

50 hand resources: OT & PT FHH hand clinic –(403) –ask to speak to a hand pt to book patient Lindsay 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 –(403) –ideally they want pt seen by plastics 1 st RVH –(403) Ph –(403) Fax –fill out form, refer from ED –OT/PT will contact pt based on priority –can refer from peripheral center as well

52 hand resources: OT & PT what about kids? –ACH (403) Ph (403) Fax fill out form, refer from ED OT/PT will contact pt w/i 48h

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