Tendon injuries of the hand

Tendon injuries are the second most common injuries of the hand and therefore an important topic in trauma and orthopedic patients. Most injuries are open injuries to the flexor or extensor tendons, but less frequent injuries, e.g., damage to the functional system tendon sheath and pulley or dull avulsions, also need to be considered. After clinical examination, ultrasound and magnetic resonance imaging have proved to be important diagnostic tools. Tendon injuries mostly require surgical repair, dull avulsions of the distal phalanges extensor tendon can receive conservative therapy. Injuries of the flexor tendon sheath or single pulley injuries are treated conservatively and multiple pulley injuries receive surgical repair. In the postoperative course of flexor tendon injuries, the principle of early passive movement is important to trigger an "intrinsic" tendon healing to guarantee a good outcome. Many substances were evaluated to see if they improved tendon healing; however, little evidence was found. Nevertheless, hyaluronic acid may improve intrinsic tendon healing.     

Principles of tendon repair

Tendon injuries in the hand are common; they are usually open injuries requiring surgical intervention. In this article we discuss tendon injuries in terms of approach to repair beginning at the time of diagnosis through to the rehabilitation programmes and outcome measures commonly used in the UK. In general tendon injuries should be considered using Verdan's zones for both extensor and flexor injuries. Flexor tendons require a high strength repair and usually warrant a core suture with epitendinous reinforcement bearing in mind the importance of not disrupting glide with unnecessary suture bulk. Extensor tendons more proximally can be treated in the same way but distally require only a running suture in the flattened tendon ends. All tendon injuries require a period of protected mobilization with splinting aiming to protect the repair but reduce stiffness in other joints.     

The most frequent tendon injury: the "mallet finger". Review, therapeutic concept and results]

This study covers treatment and after-treatment of 126 extensor tendon injuries of the DIP-joint in 125 patients over a period of 4 years. Tendon injuries were classified into 4 types and the final results were evaluated using a modified Riedeberger and Zeumer scale. In recent subcutaneous tendon injuries conservative therapy is indicated, depending on the primary extension deficit (less than 20 degrees modified Stack splint, greater than 20 degrees Mommsen plaster of Paris or special dressing). Chip fractures should be stabilized by pull-out suture.     

Traumatic simultaneous rupture of both flexor tendons in a finger of an athlete

We report a case of traumatic simultaneous disruption of both finger flexor tendons in a professional athlete. The novelties in this report are (1) the location of the rupture (FDS at midsubstance and FDP at insertion) and (2) the proposition that a normal but diminutive FDS tendon is a contributing factor in the rupture. We recommend that simultaneous rupture of the normal flexor tendons be treated in a similar manner as tendon lacerations. Primary repair, if possible, is the treatment of choice in these acute injuries. Tendon grafting should be reserved for subacute or chronic cases in which restoration of active finger flexion is needed.     

Therapeutic concept and results of treatment of subcutaneous extensor tendon rupture of the finger end joint

This study covers treatment and after-treatment of 95 extensor tendon injuries of the DIP-joint in 94 patients over a period of 3 years. Tendon injuries were classified into 4 types according to Suckert et al. and the final results were evaluated using a modified Riedeberger and Zeumer scale. In recent subcutaneous tendon injuries conservative therapy is indicated, depending on the primary extension deficit (less than 20 degrees = modified Stack splint, greater than 20 degrees = Mommsen plaster of Paris or special dressing). Chip fractures should be stabilized by pull-out suture.     

Lacerations and ruptures of the flexor or extensor hallucis longus tendons

Lacerations and ruptures of the flexor hallucis longus or extensor hallucis longus tendon are frequently managed with operative repair. Tendon injuries of the hallux are not all alike; careful consideration should be given to the mechanism and site of injury, the timing of presentation, and the presence of other injuries. Not all tendon injuries of the hallux require repair. The effectiveness of a repair will depend on the goals of surgery, which may include pain relief, active joint motion, or correction of deformity. When goals are clearly defined, a satisfactory result can be expected in most patients.     

Prise en charge d’une avulsion du flexor pollicis longus et flexor profundus indicis par transferts tendineux en urgence. À propos d’un cas

Tendon injuries are common in hand wounds and their functional consequences are not negligible. In emergency, tendon repairs techniques are well codified to restore function. These tendon repairs can be made in one session, in two sessions, or even use tendon transfers. Tendon transfers are not usual in the emergency but more common in the treatment of sequelae or failure of primary repair. We report one case of transfer to restore thumb flexion in emergency.     

Traumatische und degenerative Läsionen der Sehnen an der Hand

Tendon lesions are the second most common injury in the hand and therefore an important factor in orthopedic patients. Most injuries are open injuries to the flexor or extensor tendons; nevertheless, also less frequent injuries such as damage to the functional system of tendon sheath and pulley or dull avulsions need to be considered. Besides the clinical examination, ultrasound and MRI have proven to be important diagnostic tools. In the postoperative course of flexor tendon injuries, the principle of early passive movement is important to trigger "intrinsic" tendon healing to guarantee a good outcome.     

Subcutaneous rupture of the flexor hallucis longus tendon: a case report

It is well known that rupture of the flexor hallucis longus tendon can be associated with open injuries and that closed rupture of the flexor hallucis longus tendon is rare. Tendon injuries of the foot can occur secondary to direct, indirect, or repetitive injury. Repetitive tendon injuries can cause tendinitis or stenosing tenosynovitis. Tendinitis is associated with internal tendon injury that can present with tendon thickening, mucinoid degeneration, nodule development, or in situ partial tears. Stenosing tenosynovitis is the development of tendon adhesions within the tendon sheath that interfere with tendon gliding, known as trigger toe. The flexor hallucis longus tendon is susceptible to injury along its entire course. A total of 35 cases of complete or partial closed ruptures of the flexor hallucis longus tendon have been reported. We present the case of complete subcutaneous rupture of the flexor hallucis longus tendon associated with trauma at the proximal phalangeal head.     

Management of flexor hallucis longus tendon injuries

Acute trauma is being seen with increasing frequency by the podiatric surgeon. Tendon pathology may be obvious, as noted through impaired function of a part, or it may be more subtle, suggesting merely localized tenderness. Lack of appropriate management of such injuries can result in major biomechanical alterations. This author describes flexor hallucis longus tendon injuries and their follow-up care.     

Influence of tendon injuries on the clinical outcome of ankle and hindfoot fractures

BackgroundAssociations of tendon injuries with ankle and hindfoot fractures is a current concern and recent research has linked specific fractures with specific tendon injuries, despite its functional impact being unknown. The purpose of this study is to assess that impact.MethodsComputed tomography scans of patients with ankle and hindfoot fractures were reviewed for tendon injuries. Patients were clinically evaluated with the Visual Analogue Scale (VAS) and the Manchester–Oxford Foot Questionnaire (MOXFQ), via a telephonic interview.ResultsEighty-five patients were included in the study. The mean age was of 49.9 ± 16.5 (14–80) years and there were 43 females (50,6%). Mean follow-up was of 43,7 ± 15,1 (24,4–82,2) months. Tendon injuries were identified in 23 patients (27,1%) and the most common lesion was tendon entrapment. The tibialis posterior tendon (TP) was injured in 18 patients (21,2%) and comprised 58,1% of all tendon injuries. Tendon injuries were mostly associated with pilon fractures, which was the most common fracture type (44,7%). There was no clinical difference between patients with a tendon injury [VAS of 4,3 ± 2,6 (0–8) and MOXFQ score of 35,1 ± 22,4 (5–80)], and those without [VAS of 3,9 ± 2,5 (0–10) and MOXFQ of 34,3 ± 26,0 (0–95), respectively (p = 0,281 and 0,689)].ConclusionTendon injuries were present in 27% of patients with ankle and hindfoot injuries. The most frequently injured tendon was the TP in association with pilon fractures, with entrapment being the most common lesion. These lesions, however, do not seem to reflect in a worse functional outcome at two years of follow-up.     

Wide-Awake Primary Flexor Tendon Repair,Tenolysis, and Tendon Transfer

Tendon surgery is unique because it should ensure tendon gliding after surgery. Tendon surgery now can be performed under local anesthesia without tourniquet, by injecting epinephrine mixed with lidocaine, to achieve vasoconstriction in the area of surgery. This method allows the tendon to move actively during surgery to test tendon function intraoperatively and to ensure the tendon is properly repaired before leaving the operating table. I applied this method to primary flexor tendon repair in zone 1 or 2, tenolysis, and tendon transfer, and found this approach makes tendon surgery easier and more reliable. This article describes the method that I have used for tendon surgery.     

Primärversorgung von Sehnenverletzungen der Hand

Tendon injuries of the hand are common and their treatment is surgically challenging. Precise knowledge of the anatomy of the extensor and flexor tendons in the hand is necessary to be able to perform a detailed clinical examination and to estimate adequately the extent of injury. Depending on the injury pattern, various conservative and surgical treatment options must be considered. Concerning the overall concept of the supply of tendon injuries of the hand, follow-up treatment is crucial to achieve an optimal functional outcome. It should be noted, however, that the results are influenced by the following: extent of the injury, mechanism, exact anatomical location, associated injuries, and finally the participation of the patient in the follow-up treatment.     

Flexor pollicis longus tendon injuries in children.

Tendon injuries to the thumb are uncommon in children. Nine children (mean age 6.1 years) with isolated complete injuries to the flexor pollicis longus (FPL) were treated with primary suture and controlled mobilisation at a major referral centre between 1985 and 1992. Five injuries occurred in zone II, two in zone III and two in zone V. One child developed sepsis and there were no cases of tendon rupture. Good or excellent results (Buck-Gramcko criteria) were achieved in seven of the nine children. Pinch grip after repair was similar to the non-injured hand. Primary repair and early controlled mobilisation of FPL leads to satisfactory results in children.     

不可逆桡神经损伤的手功能重建

目的评估不可逆桡神经损伤后肌腱移位重建伸腕、伸拇及伸指功能的效果。方法1987年1月～2005年2月，用Riordan肌腱移位术治疗不可逆桡神经损伤25例。其中桡神经主干损伤19例，桡神经深支损伤6例；均伴伸拇及伸指功能障碍，肌力0～1级，前臂肌萎缩。肌腱移位术距神经损伤或修复时间为4个月～8年。结果术后23例经3～60个月随访，根据陈德松等制定的桡神经损伤后肌腱移位术疗效判定标准，优10例，良9例，手功能恢复基本满意；可2例，差2例，其中1例为移位肌腱张力不足，3例为移位肌腱粘连所致。结论Riordan肌腱移位术可作为不可逆桡神经损伤功能重建的首选方法。     

Tendon reconstruction for the rheumatoid hand

Tendon involvement in rheumatoid arthritis is frequent and might even be the first sign of the disease. In long-standing untreated conditions, especially in combination with bony erosions, tenosynovitis may lead to tendon fraying and finally tendon rupture. Tendon reconstruction includes tendon grafting and tendon transfer. Direct repair is almost never possible in patients with rheumatoid arthritis, because the inflammatory process produces extensive tendon damage over a long distance. In patients with significant impaired joint function, additional joint treatment should be planned at the same time as tendon reconstruction.     

Philosophy of flexor tendon surgery

Tendon surgery should be based upon an understanding of tendon healing mechanisms and the fate of tendon grafts. It is also essential to understand those factors that produce adhesions to tendons and how to avoid or minimize such adhesions.     

The use of growth factors on tendon injuries.

Tendon injuries continue to be a vexing clinical problem faced by the upper extremity surgeon. These injuries often lead to disability and dissatisfaction for both the patient and treating physician. Advances throughout the century have focused largely on improvements in surgical techniques and therapy protocols. Recently, attention has been turned to the biologic pathways by which tendons heal and the growth factors involved in this process have been identified. There is great hope that these growth factors may one day be used to treat tendon injuries. This article provides a summary of the use of growth factors on tendon injuries including contemporary research, delivery methods, and future directions in this field.     

Tendon transfers for radial, median, and ulnar nerve injuries: current surgical techniques

Tendon transfers are performed predominantly to restore hand function or balance due to injuries of the radial, median, and ulnar nerves. Current surgical techniques for the most common tendon transfers for reconstruction of radial, median, and ulnar nerve palsies are demonstrated. These techniques can also be applied to restore flexion and extension of the fingers and thumb after injuries to the extrinsic flexor and extensor muscles and tendons of the forearm or intrinsic muscles of the hand.     

Ersatzoperationen bei Ausfall motorischer Funktionen an der Hand

Nerve injuries in the upper extremity can result in severe disability. In the last three decades, progress in microsurgical techniques has improved the outcome for nerve injuries and if the prognosis is reasonably good, nerve repair should usually be performed prior to tendon transfer procedures. However, above all proximal lesions of peripheral nerves such as high radial nerve palsy still often yield unsatisfactory results, despite a technically well-executed nerve repair. Prognosis further depends on the time interval since the injury and also on the age of the patient, as the regenerative process is delayed in older patients. The indication for tendon transfers strongly depends on the personal and professional profiles of the individual patient. Tendon transfer procedures alleviate the suffering from functional hand impairment providing a superior alternative to permanent external splints. Tendon transfers are usually secondary procedures for replacing function after evaluation of the functional motor loss. Numerous transfer procedures have been described for every nerve trunk of the upper extremity, their prognosis depending mainly on the extent and pattern of nerve loss, local effects of the trauma (e.g. involvement of soft tissues, joints), and the physiological characteristics of the transferred muscle. Even if the results of the tendon transfers may finally be less satisfactory in cases of complex nerve damage than in isolated motor nerve lesions, they offer a valuable functional benefit, often being the only possibility to restore hand function. Although regrettably underused, tendon transfer improve upper extremity function in more than 70% of patients with cervical spinal cord injury. Reconstruction of key elements such as wrist extension, key grip between the thumb and the index finger, or digital flexion and extension leads to highly improved use of the tetraplegic hand and thus provides new mobility and independence from the help of others. This article presents an overview of the most common procedures to restore hand function in peripheral nerve injuries and tetraplegia in order to provide a systematic approach for decision making.