extensor tendon injurieshta-ca.org/wp-content/uploads/2016/02/12-ajw-ext... · extensor injuries:...
TRANSCRIPT
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EXTENSOR TENDON INJURIES
6TH ANNUAL MEETING:
HAND THERAPY ASSOCIATION OF NORTHERN
CALIFORNIA
Andrew J. Watt MD
The Buncke Clinic
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DISCLOSURES:
I have no personal or financial interest in the products contained
within this presentation.
All identifiable photos utilized with permission.
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GOALS & OBJECTIVES:
• To review the Anatomy and Biomechanics of the Extensor
Mechanism
• To understand the Management of Acute and Chronic
Deformities Resulting from Injuries to the Extensor
Mechanism
– Techniques
– Indications
– Contraindications
– Optimizing Success
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ANATOMY OF THE
EXTENSOR MECHANISM:
• All Extensor Musculature Innervated By Branches of the Radial Nerve (C6-C8)
• 2 Dorsal Forearm Compartments
– Superficial:
• Origin From Lateral Humeral Epicondyle
• ECRL, ECRB, ECU, EDC & EDM
– Deep:
• Origin from Radius, Ulna, IOM
• APL, EPB, EPL, EIP
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ANATOMY OF THE
EXTENSOR MECHANISM:
• 2 Notable Anatomic
Variations:
1. Accessory Extensor Carpi
Radialis Intermedius (12%)
2. Extensor Medii Proprius (10%)
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ANATOMY OF THE
EXTENSOR MECHANISM: • Extensor Retinaculum:
– Radial Palmar Radius to Pisiform/Triquetrum
• Extensor Compartments: Fibro-osseous tunnels
1. APL, EPB
2. ECRL, ECRB
3. EPL
4. EDC, EIP
5. EDM*
6. ECU
* 5th compartment is unique as a fibrous tunnel without bony attachment
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ANATOMY OF THE
EXTENSOR MECHANISM: • Juncturae Tendinae (Connexus
Intertendinei)
– Vary in thickness from filamentous band to tendinous band
– A, B, C
– 3 Primary Biomechanical Functions
1. Stabilization
2. Force Distribution
3. Coordination of Tendon Movements
A B C
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ANATOMY OF THE
EXTENSOR MECHANISM:
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ANATOMY OF THE
EXTENSOR MECHANISM:
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ANATOMY OF THE
EXTENSOR MECHANISM:
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ANATOMY OF THE EXTENSOR
MECHANISM: FUNCTIONAL
SUMMARY
Proximal Phalanx: EDC tendon via the sagittal bands
Middle Phalanx: Central slip in conjunction with lateral bands
Distal Phalanx: Terminal extensor tendon
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ANATOMY OF THE EXTENSOR
MECHANISM: TRANSVERSE
RETINACULAR LIGAMENT
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BIOMECHANICS OF THE
EXTENSOR MECHANISM • Tendon Length is Critical
– Less Excursion compared
with flexor tendons
• Active 2-3cm
• Combined 5cm
• Primarily proximal to
wrist
– Heavily reliant on
“Tenodesis” effect (position
of wrist)
– Intricate balance within the
finger
• Intrinsic
• Extrinsic
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EXTENSOR INJURIES:
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EXTENSOR INJURIES:
EPIDEMIOLOGY
• Patillo & Rayan
– 125 tendons
• Predominately Male: 83%
• Mean Age: 34.2
• Dominant Extremity: 60%
• Zone V laceration most
common injury
• Distribution of Injury:
– Thumb: 25.7%
– Long Finger: 24.8%
– Small Finger: 10.5%
• Complex injuries more
common distal to the MCP
• Lacerations more common
proximal to the MCP
Patillo D, Rayan GM. Open Extensor Tendon Injuries: An Epidemiologic Study Hand Surgery, Vol 17, No. 1 (2012) 37-
42.
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EXTENSOR INJURIES:
ZONES OF INJURY • 1: Overlies DIPJ
• 2: Overlies Middle Phalanx
• 3: Overlies PIPJ
• 4: Overlies Proximal Phalanx
• 5: Overlies MCPJ
• 6: Overlies Metacarpal
• 7: Overlies Carpus, Underlies Extensor Retinaculum
• 8: Overlies Distal Forearm
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EXTENSOR TENDON
INJURIES: ZONE 1
• Acute Injury: Mallet Finger
– Injury to the terminal tendon
• Doyle Classification
– Type 1: Closed
– Type 2: Open
– Type 3: Open with loss of
skin & tendon substance
– Type 4: Mallet Fracture
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EXTENSOR TENDON
INJURIES: ZONE 1
• Management Considerations:
– Nature of Injury
• Open vs. Closed
• Soft tissue Envelope
– Reliability & Preference of
Patient
• Closed Treatment:
– 15° Hyperextension x 6
weeks (if bony), 8 weeks if
soft tissue
– Night splint x 6 weeks
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EXTENSOR TENDON
INJURIES: ZONE 1
• Surgical Indications
– Open Injuries
– Associated Soft Tissue Loss
– Fracture Fragment >30-
50%*
– Subluxation of the distal
interphalangeal joint.
– Occupation requiring
frequent use of hands or
inability to tolerate (or
comply) with a splinting
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EXTENSOR TENDON
INJURIES: MALLET FRACTURE TECHNIQUE
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EXTENSOR TENDON
INJURIES: ZONE 2 • Acute Injury:
– Laceration of the extensor tendon over the middle phalanx
– Often associated with skin and skeletal injury
• Management:
– Operative Repair
– DIP joint immobilized with K-wire x 6 weeks
– AROM, PROM at PIP and MCP allowed
– Night extension splint x additional 6 weeks
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EXTENSOR TENDON
INJURIES: ZONE 3 • Acute Injury: Central Slip
Disruption
– Closed vs. Open
– Volar PIP Joint Dislocations
• Presentation:
– PIP swelling
– Mild extensor lag with weak extension against resistance
– + Elson Test
• Management:
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EXTENSOR TENDON
INJURIES: ZONE 3 • Management:
– Closed:
• PIP extension splint x
6 weeks
• Night splint x 4-6
weeks
– Open:
• Laceration
• Avulsion +/- Fracture
• Tendon Loss
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EXTENSOR TENDON
INJURIES: ZONE 3 • Management:
– Reconstruction with
Tendon Loss
• Palmaris Graft with
suture anchor
• Lateral Band
Centralization
• Central Slip
Turndown (Snow
Repair)
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EXTENSOR TENDON
INJURIES: ZONE 3 • Management:
– Reconstruction with
Tendon Loss
• Palmaris Graft with
suture anchor
• Lateral Band
Centralization
• Central Slip
Turndown (Snow
Repair)
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EXTENSOR TENDON
INJURIES: ZONE 4 • Acute Injury:
– Uniformly an open injury
– Laceration of the extensor tendon over the
proximal phalanx
• Management:
– Tendon is broad and flat
• Partial laceration
• Stronger repair
• Prone to Adhesions
– Amenable to Early Mobilization so long as
skeletal stability is present or achieved
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EXTENSOR TENDON
INJURIES: ZONE 5 • Acute Injury:
Most Common Level of
Injury
– Laceration
– Fight Bite
– Sagittal Band Injury
• Management:
– Laceration = Repair & Early
Mobilization
– Sagittal Band Injury
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EXTENSOR TENDON
INJURIES: ZONE 5 • Sagittal Band Injury:
– Mechanism: Blunt trauma to the MCP joint
– Almost exclusively the radial sagittal band
– Presentation:
• Extensor Lag
• Tenderness over sagittal band
• +/- Subluxation
• “Snapping” associated with discomfort
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EXTENSOR TENDON
INJURIES: ZONE 5
• Sagittal Band Injury:
– Mechanism: Blunt
trauma to the MCP joint
– Almost exclusively the
radial sagittal band
– Presentation:
• Extensor Lag
• Tenderness over
sagittal band
• +/- Subluxation
Description Treatment
Type I Contusion
without tear
RMES until
nontender
Type II Partial
Subluxation
RMES x 6-8
weeks
Type III Complete
Subluxation
MCP Ext
splint x 6
weeks
RMES = relative motion extension splint
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EXTENSOR TENDON
INJURIES: ZONE 5
• Sagittal Band Injury:
– Surgical Indications & Management
• Failure of nonoperative management
– Type II & III injuries
• Delayed presentation (>3-4 weeks post injury)
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EXTENSOR TENDON
INJURIES: ZONE 5
• Sagittal Band Reconstruction:
• Multiple reconstructive options
• Kang & Carlson (2010)
– Palmaris Longus Tendon
Graft
– 1.6mm Bone Tunnel
– Immobilize 1 week
– RMES x 4-6 weeks
Kang L, Carlson MG. Extensor Tendon Centralization at the Metacarpophalangeal Joint: Surgical
Technique, JHS (35A), 1194-1197.
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EXTENSOR TENDON
INJURIES: ZONE 5
• Sagittal Band Reconstruction:
• Multiple reconstructive options
• Kang & Carlson (2010)
– Palmaris Longus Tendon
Graft
– 1.6mm Bone Tunnel
– Immobilize 1 week
– RMES x 4-6 weeks
Kang L, Carlson MG. Extensor Tendon Centralization at the Metacarpophalangeal Joint: Surgical
Technique, JHS (35A), 1194-1197.
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EXTENSOR TENDON
INJURIES: ZONE 5
• Sagittal Band Reconstruction:
• Multiple reconstructive options
• Kang & Carlson (2010)
– Palmaris Longus Tendon
Graft
– 1.6mm Bone Tunnel
– Immobilize 1 week
– RMES x 4-6 weeks
Kang L, Carlson MG. Extensor Tendon Centralization at the Metacarpophalangeal Joint: Surgical
Technique, JHS (35A), 1194-1197.
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EXTENSOR TENDON
INJURIES: ZONE 5
• Sagittal Band Reconstruction:
• Multiple reconstructive options
• Kang & Carlson (2010)
– Palmaris Longus Tendon
Graft
– 1.6mm Bone Tunnel
– Immobilize 1 week
– RMES x 4-6 weeks
Kang L, Carlson MG. Extensor Tendon Centralization at the Metacarpophalangeal Joint: Surgical
Technique, JHS (35A), 1194-1197.
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EXTENSOR TENDON
INJURIES: ZONE 6-8
• Acute Injury:
– Typically open, sharp
lacerations
– Tendon Loss in degloving
injuries
• Management:
– Primary Repair
– Tendon Grafting
– Tendon Transfers
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CHRONIC EXTENSOR
DEFORMITIES
• Swan Neck Deformity
– Results from Chronic Disruption
or Lengthening of the Terminal
Tendon
• Boutonniere Deformity
– Results from Chronic Disruption
or Attenuation of Central Slip
– Both Represent Flexion
Deformities with Subsequent
Hyperextension (compensation)
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SWAN NECK DEFORMITY
• Inciting Causes:
– Mallet Injury
– PIP Laxity
• Attenuation of Volar
Plate
• FDS rupture or loss
– Intrinsic Tightness +/- MCP
subluxation
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SWAN NECK DEFORMITY
• Characteristics:
– Loss of DIP extension
– Imbalance of Extension force at the PIP joint.
– Hyperextension and diminished active and passive flexion at the PIP joint
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SWAN NECK DEFORMITY
Disruption of Terminal Tendon
1. Closed Injury
2. Laceration
3. Infection
4. Inflammatory Arthritis
Lateral Bands Retract Proximally
* Exert at greater extension force on the PIP joint
Volar Plate Attenuation
Hyperextension of the PIP joint
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SWAN NECK DEFORMITY
• Treatment Considerations:
– Timing of Injury / Deformity
• Acute (<2 weeks)
• Subacute (2-8 weeks)
• Chronic (>8 weeks)
– Condition of Soft Tissues
– PIP Joint
• Supple or Fixed
• Arthritis
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SWAN NECK DEFORMITY
• Acute Injury (<2 weeks)
• Critical Distincton
– PIP in origin
• Dorsal Blocking Splint x
4 weeks
• Fixation of PIP fracture
– DIP in origin
• Closed: Mallet Tx
• Open: Repair +
Transarticular K-wire
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SWAN NECK DEFORMITY
• Subacute Injury (2-8 weeks)
• Critical Distinction is whether or
not the PIP joint is supple
– Supple: Tx like acute injury
– Stiff: PIP Dorsal Block +
DIP transarticular K-wire
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SWAN NECK DEFORMITY
• Chronic Injury (>8 weeks)
• Treatment is much more complex
and results are much less
predictable.
• Must address 3 critical
components:
– DIP flexion
• Tendon Repair
• Arthrodesis
– PIP joint Hyperextension
– PIP joint (+/- arthrosis)
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BOUTONNIERE DEFORMITY
• Mason 1930
• “It is the middle portion of the
dorsal aponeurosis which
ruptures, the two lateral slips
now loosen from their
attachment about the joint slip
palmarward, and the joint
comes to lie between them as
in a “buttonhole.”
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BOUTONNIERE DEFORMITY
• Characteristics:
– Weakness and loss of
extension at PIP joint
– Hyperextension and
diminished active and
passive flexion at the DIP
joint
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BOUTONNIERE DEFORMITY
Disruption of Central Slip
1. Closed Injury
2. Laceration
3. Infection
4. Inflammatory Arthritis
Disruption of Triangular Ligament
1. Injured with Central Slip
2. Attenuated
Volar Migration of Lateral Bands
* Move volar to the axis of rotation of the PIP joint.
Mechanically become a flexor of the PIP joint rather than an extensor
Contracture of ORL, CL & Volar Plate
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BOUTONNIERE DEFORMITY
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BOUTONNIERE DEFORMITY
• Treatment Considerations:
– Timing of Injury / Deformity
• Acute (<2 weeks)
• Subacute (2-8 weeks)
• Chronic (>8 weeks)
– Condition of Soft Tissues
– PIP Joint
• Supple or Fixed
• Arthritis
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BOUTONNIERE DEFORMITY
• Acute Injury (<2 weeks)
• Closed
– PIP extension splint with DIP free
– 4 weeks
• Open Laceration (Zone 3)
– Open Repair: Primary, Graft, Suture Anchor or Reconstruction
• Fracture
– Open Repair
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BOUTONNIERE DEFORMITY
• Subacute Injury (2-8 weeks)
• Critical Distinction is whether or
not the PIP joint is supple
– Supple: Tx like acute injury
– Stiff: Static Progressive
Extension splint or Serial
Cast
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BOUTONNIERE DEFORMITY
• Chronic Injury (>8 weeks)
• Treatment is much more complex
and results are much less
predictable.
• Must address 3 critical
components:
– Triangular ligament
attenuation
– Volar Migration of Lateral
Bands
– PIP joint (+/- arthrosis)
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THANK YOU