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Extensor Tendon Injuries: ED Management and Follow-up

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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 outline why extensor tendon ... – PowerPoint PPT presentation

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Title: Extensor Tendon Injuries: ED Management and Follow-up


1
Extensor Tendon InjuriesED 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 principleswhats 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 were 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 dont know how were 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
Verdans 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 4.0-5.0

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
  • lacslt30-50, wound closure and splint for
    shortened period w/early mobilization
  • lacsgt30-50, 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 lt 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
  • lt10 degrees extension lag
  • good flexion
  • prevention of swanneck deformity

18
mallet finger who to refer
  • closed
  • tendon avulsion with bony fragment involving gt30
    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 gt30 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 (lt2w), ½ w/delayed (gt4w)
  • 0 change in outcomes with regards to extensor
    lag, rx of dorsal lip s lt30, 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
  • 20-25 degrees for 1st week
  • if no lag after 1st 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
    lt50

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 gt15-20 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 40-45 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) 670-1432
  • ask to speak to a hand pt to book patient
  • Lindsay Park (2 hand pts)
  • (403) 221-8340
  • must indicate you want a hand pt to reception and
    they will book for you

51
hand resources OT PT
  • PLC
  • (403) 291-8785
  • ideally they want pt seen by plastics 1st
  • RVH
  • (403) 943-3575 Ph
  • (403) 943-3332 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) 229-7912 Ph
  • (403) 541-7501 Fax
  • fill out form, refer from ED
  • OT/PT will contact pt w/i 48h
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