Beugesehnenverletzung der Hand

At last, flexor tendon injuries of the hand and digit are no longer nearly impossible to treat. Many recent studies have reported a more than 75% success with excellent results, in particular in zone 2, in some cases reaching 98% satisfactory outcomes. The challenge inherent in treating and rehabilitating the zone 2 flexor tendon injury remains, however, even for the skilled hand surgeon. We must remain diligent, obeying principles outlined earlier by the first surgeons willing to attempt these repairs, while carefully gleaning the helpful and critical recommendations of the now sophisticated researchers in the subject of flexor tendon repair and rehabilitation.     

An evaluation of the influence of practitioner-led hand clinics on rupture rates following primary tendon repair in the hand.

Practitioner-led hand clinics were introduced in our unit in the year 2000 as a response to the high and increasing number of postoperative hand trauma patients coming to consultant clinics. The aim of this study was to evaluate the influence of these clinics on rupture rates following primary tendon repair in the hand. The study specifically examined:zone II flexor tendon repairsflexor pollicis longus (FPL) tendon repairsextensor pollicis longus (EPL) tendon repairs.Prospective data collection were undertaken for these particular operations over a 17-month study period. Prior to the introduction of the practitioner-led hand clinics previous audits had demonstrated rupture rates of 30% zone II flexor tendon repairs, 16% for FPL repairs and 5% for EPL repairs. Rupture rates after the introduction of practitioner-led hand clinics fell in all of the study categories-to 17% for zone II flexor tendon repairs, 4% for FPL repairs and 0% for EPL repairs. It is suggested that improved continuity of care by experienced hand therapists may have contributed to the observed improvements in outcome.     

Functional outcome in patients with zone V flexor tendon injuries

Introduction Zone V flexor tendon injuries may involve major nerves and arteries as well as the wrist and finger flexors. Although these injuries are not infrequent, few studies have reported functional outcomes. The purpose of this study was to evaluate the functional outcome in patients with flexor tendon repairs in zone V.Materials and methods Eighteen patients with repaired zone V flexor tendon injuries were followed up for an average of 20 months. The postoperative rehabilitation program consisted of a combined regime of modified Kleinert and modified Duran techniques. Outcome parameters were hand function according to the Buck-Gramcko assessment system, grip and key pinch strength values, and return to work status.Results Functional results were excellent in 92.8% of the digits, good in 1.4%, and poor in 5.8%. Grip strength recovered to an average of 77% and pinch strength to 74% of the uninjured hand. Two tendon ruptures occurred in a patient, and tenolysis was required in 3 patients. Of 15 patients who were employed at the time of injury, 13 returned to their original occupations.Conclusion Satisfactory functional results can be obtained when proper surgical technique is coupled with careful postoperative management in patients with zone V flexor tendon injuries.     

Hunter手术治疗Ⅱ区屈肌腱陈旧性损伤

目的：探讨治疗Ⅱ区屈肌腱损伤的较佳方法。方法：采用一期手术切除指深、浅屈肌腱,保留或重建滑车,植入Hunter硅胶棒,2－6月后行二期手术,游离移植肌腱方法治疗Ⅱ区陈旧性屈肌腱损伤69例106指。结果：术后平均随访19例,TAM标准评价取得了84％的优良率。结论：硅胶棒植入手术治疗Ⅱ区屈肌腱陈旧性损伤,可有效避免肌腱移植术后经常发生的肌腱粘连,是一种较好手术方法。     

Two-stage flexor tendon reconstruction in zone II using Hunter's technique

Tendon injuries in the digital flexor sheath area (zone II) are the most difficult to treat and remain a focus of both clinical attention and basic investigations. Although some new techniques have been developed, the clinical results are still not satisfying, especially in old injuries. This retrospective study was designed to investigate the results of delayed zone II flexor tendon repair using Hunter rods. Between July 1974 and June 1998, 81 patients at our institution underwent 2-stage reconstruction using Hunter's technique. Sixty-one patients with 106 fingers were included in this study. Digital flexor tendon resection and Hunter rod implantation were performed in the first-stage operation. Combined digital nerve injuries and damaged pulleys were repaired or reconstructed at the same time. Plaster was used to immobilize the hand for 3 weeks. During the second-stage operation, performed 2 to 6 months later, palmaris longus or plantaris were grafted into the pseudosheath formed surrounding the Hunter rods. The proximal end of the transplanted tendon was fixated with flexor digitorum profundus tendon using the Pulvertaft method, and the distal end was fixated to the distal phalanx using Bunnell's pullout wire method. Early controlled motion was performed in all cases. Evaluation based on total active motion was good to excellent in 84%, fair in 12%, and poor in 4% of patients. Flexor tendon reconstruction using Hunter technique is an effective way to restore digital function in delayed zone II flexor tendon injuries.     

Primary flexor tendon suture in the "no man's land" of the hand

If the conditions of the wound are favourable, flexor tendon divisions in zone 2 should be sutured and functionally treated early according to Kleinert's method. Different modifications of the Kirchmayr-suture can be used. Out of 24 primarily and delayed primarily repaired flexor tendon divisions 22 showed very good results. When applying this method for the early secondary treatment of flexor tendon divisions 8 cases out of 14 showed very good results. The flexor tendon repair in the region of the tendon sheath of the fingers is difficult and can therefore only be performed by a skilled hand surgeon. Success depends on the quality of postoperative supervision and physiotherapy practised.     

Primary care of flexor tendon injuries

The approach to the acute flexor tendon injury is an area of hand surgery that has seen considerable change in the last 25 years. Direct repair in the early postinjury period, at all levels of injury, is the accepted procedure provided wound conditions permit. The procedures performed along with the tendon repair in zone 2 are based on both clinical experience as well as laboratory evidence, but additions such as sheath closure have not been completely proven to improve the clinical result. At this time, both flexor tendons are repaired in zone 2 and the flexor sheath is repaired. All patients are mobilized in a protected mobilization program. The last modification is probably the chief reason that results from flexor repairs are improving at this time.     

Outcomes of the therapy of old injury of finger flexor tendons

193 fingers of 131 patients have been treated at the level of the I, II and III zones due to inveterate tendon damages. In case of isolated damage of deep flexor tendon of the II-V fingers at the level of the I zone there were made palliative operations of 12 fingers: tenodesis and arthrodesis of distal interphalangeal articulation in functionally advantageous position. They failed to achieve successful outcome with one finger. In 17 cases long flexor tendon of the I finger had been restored by different methods; in all cases there were achieved good and excellent outcomes. Three fingers (IV, V) with the tendon, damaged at the II zone level, were subjected to plasty by free autotransplant. The outcomes are as follows; satisfactory--2, bad--I. At the remaining 161 finger (II-V) deep flexor tendon has been restored by different methods with utilization of autotendon with its natural blood circulation or revascularized one. There was formed an artificial tendon sheath in some methods. Positive outcomes, as evaluated by the system of the American association of hand surgeons, were achieved in 138 (85.7%) cases, by Buch-Gramcko system--in 143 (88.8%) cases.     

Ⅱ、Ⅲ区陈旧性拇长屈肌腱损伤的重建

目的探讨重建Ⅱ、Ⅲ区陈旧性拇长屈肌腱损伤的手术疗效。方法对20例Ⅱ、Ⅲ区陈旧性拇长屈肌腱损伤的患者，根据手术方式分成两组：A组10例，采用环指指浅屈肌腱移位修复拇长屈肌腱；B组10例，采用掌长肌腱移植修复。结果术后随访10～18个月，平均12个月。按照屈肌腱术后评定标准(Kleinert)评定，A组优良率为90％，B组优良率30％。A组明显优于B组。结论对伤后时间超过8周的Ⅱ、Ⅲ区拇长屈肌腱损伤首选修复方法是行环指指浅屈肌腱移位术。     

Impact of flexor digitorum superficialis on gliding function of the flexor digitorum profundus according to regions in zone II

PURPOSE: Structures and gliding characteristics of the flexor tendons vary remarkably according to regions of zone II in the hand. We studied the impact of the flexor digitorum superficialis (FDS) on the work of flexion and excursion efficiency of the flexor digitorum profundus (FDP) tendon in different regions of zone II. METHODS: Twenty-one fresh-frozen human fingers were used as an experimental model. The FDP was pulled to flex the finger with a tensile machine. The work of flexion of the finger and gliding excursion of the tendon were recorded in the fingers with the FDS intact, after excision of the FDS proximal to, under, or distal to the A2 pulley. RESULTS: The FDS tendon exerts notably different effects on the work of flexion and excursion efficiency of the FDP in subregions of zone II. Removal of the FDS under the A2 pulley affected the FDP most manifestly, causing a 12% decrease in the work of flexion and a loss of the excursion efficiency at the metacarpophalangeal joint. Removal of the FDS proximal to the A2 pulley had a less notable effect on the work of flexion. Removal of the FDS distal to the pulley did not markedly alter the biomechanics of the FDP. CONCLUSIONS: Removal of the FDS tendon in the area of the A2 pulley reduces the work of flexion most notably and causes a loss of excursion efficiency. Removal of the FDS tendon distal to the A2 pulley does not change the work of flexion, and removal of the FDS tendon proximal to the A2 pulley has a notable but less pronounced effect on the FDP tendon.     

Flexor tendon injuries in children

Flexor tendon injuries in adults differ from those in children. 38 children (22 male and 16 female) with a mean age of 6.7 years were treated for flexor tendon injuries by primary suture and controlled mobilization between 1985 and 1992. 53 flexor tendons were injured (average 1.5 digits per patient) and the injury most commonly affected the little finger (23 patients). 60% of injuries occurred in zone 2. Using Lister's criteria, 82% achieved excellent or good results. Repair of both FDS and FDP was better than repair of FDP alone, even in zone 2. There were three tendon ruptures(all classified as poor results) and one other poor result occurredin a zone injury with an associated ulnar nerve palsy. The outcome after flexor tendon repair in children is better than in adults in our hands because rapid healing of tendons occurs in children. No child has yet required tenolysis because in children adhesions are more pliable. Both flexor tendons should be repaired irrespective of the zone of injury. A functional hand can be expected after flexor tendon repair in children.     

手屈肌腱损伤Ⅰ期显微修复及功能康复97例 临床报告

目的：探讨手屈肌腱损伤Ⅰ期显微修复的方法及疗效。方法：本组97例182条肌腱损伤,其中男59例,女38例;平均年龄32岁（6-65岁）;玻璃割伤22例,刀伤32例,电锯伤29例,挤压伤14例;Ⅰ区12例,Ⅱ区35例,Ⅲ区28例,Ⅳ区8例,V区14例。合并血管神经损伤68例,合并骨折53例,均I期采用改良Kessler法缝接肌腱,术后早期循序渐进康复锻炼。结果：本组97例均获随访,时间3-24个月,按TAM法评定疗效,优48例,良39例,可8例,差2例。结论：修复肌腱损伤应彻底清创,无创操作,具备牢固光滑的肌腱吻合技术及自始至终贯穿功能康复理念。     

Long-term results after primary repairs of zone 2 flexor tendon lacerations in children younger than age 6 years

In young children, methods of primary flexor tendon repair in the digital canal are controversial. The authors reviewed 12 children younger than age 6 years with zone 2 flexor tendon repairs. The mean follow-up period was 8 years. In all cases, the flexor digitorum profundus tendons were repaired according to the Kessler modified technique and the hands were immobilized by an above-elbow cast. As for postoperative complications, there were no fingers with tendon rupture and two fingers with tendon adhesion. One finger needed tenolysis. The total active motion (TAM) in the interphalangeal joints evaluated with the Strickland formula averaged 155 degrees, and the TAM percentage averaged 89% (range 74%-100%). Eleven patients had an excellent result and one had a good result. The percentage phalangeal length averaged 99% (range 96%-100%). Functional motion and nearly normal growth of the finger can be expected after primary zone 2 flexor tendon repairs in children younger than age 6 years.     

The Incidence of Acute Traumatic Tendon Injuries in the Hand and Wrist: A 10-Year Population-based Study

Background

Acute traumatic tendon injuries of the hand and wrist are commonly encountered in the emergency department. Despite the frequency, few studies have examined the true incidence of acute traumatic tendon injuries in the hand and wrist or compared the incidences of both extensor and flexor tendon injuries.

Methods

We performed a retrospective population-based cohort study of all acute traumatic tendon injuries of the hand and wrist in a mixed urban and rural Midwest county in the United States between 2001-2010. A regional epidemiologic database and medical codes were used to identify index cases. Epidemiologic information including occupation, year of injury, mechanism of injury and the injured tendon and zone were recorded.

Results

During the 10-year study period there was an incidence rate of 33.2 injuries per 100,000 person-years. There was a decreasing rate of injury during the study period. Highest incidence of injury occurred at 20-29 years of age. There was significant association between injury rate and age, and males had a higher incidence than females. The majority of cases involved a single tendon, with extensor tendon injuries occurring more frequently than flexor tendons. Typically, extensor tendon injuries involved zone three of the index finger, while flexor tendons involved zone two of the index finger. Work-related injuries accounted for 24.9% of acute traumatic tendon injuries. The occupations of work-related injuries were assigned to major groups defined by the 2010 Standard Occupational Classification structure. After assigning these patients'' occupations to respective major groups, the most common groups work-related injuries occurred in construction and extraction occupations (44.2%), food preparation and serving related occupations (14.4%), and transportation and material moving occupations (12.5%).

Conclusions

Epidemiology data enhances our knowledge of injury patterns and may play a role in the prevention and treatment of future injuries, with an end result of reducing lost work time and economic burden.     

The aetiology of acute rupture of flexor tendon repairs in zones 1 and 2 of the fingers during early mobilization.

Five hundred and eight patients with 840 acute complete flexor tendon injuries in 605 fingers in zones 1 and 2 underwent surgery and postoperative mobilization in a controlled or early active motion (active flexion-active extension) regimen over a period of 7.5 years. Sixty-eight patients with 79 finger flexor divisions who did not complete the rehabilitation programme were excluded. Of the 440 patients with 728 complete tendon divisions in 526 fingers included in the study, 23 patients ruptured 28 tendon repair(s) in 23 fingers, an overall rupture rate of 4%. One hundred and twenty-nine fingers with zone 1 injuries had a rupture rate of 5%. Three hundred and ninety-seven fingers with zone 2 injuries had a rupture rate of 4%. This study analyses the 23 patients with flexor tendon rupture(s) to identify causative factors. In approximately half of these patients, tendon rupture followed acts of stupidity. The implications of this are discussed. There was no significant relationship between tendon rupture and the age or sex of the patients, smoking or delay between injury and tendon repair and there was no particular prevalence of zone 2C level injuries among the fingers in which tendon rupture occurred.     

Healing of canine tendon in zones subjected to different mechanical forces.

The effect of external force environment on the healing of a partial thickness injury to canine flexor tendon was studied. A 50% laceration was made in either the fibrocartilaginous (compressive) zone or in the tendinous (tensile) zone of canine flexor digitorum profundus tendons. After three or six weeks, the tendons were harvested. An optical method for determining zone-specific material properties showed that, in response to injury, the structural stiffness decreased in the tensile zone of the tendon but increased in the compressive zone. The mechanical properties and failure mechanism of canine tendon and their changes in response to injury vary according to tendon zone, and differences in the healing process in mechanically specialised zones of the flexor tendon are discussed.     

Pulley plasty versus resection of one slip of the flexor digitorum superficialis after repair of both flexor tendons in zone II: a biomechanical study

BACKGROUND: The outcome of repair of zone-II lacerations of the flexor digitorum superficialis and flexor digitorum profundus tendons remains suboptimal. We investigated the effects of two strategies to improve postoperative gliding in a human cadaveric hand. METHODS: The second, third, and fourth digits were harvested from ten fresh-frozen human cadaveric hands. Complete lacerations and repairs were made to the profundus and superficialis tendons at a location where both repair sites would pass beneath the A2 pulley with the proximal interphalangeal joint in 45 degrees of flexion. The gliding resistance of the flexor digitorum profundus tendon was measured following pulley plasty and following excision of one slip of the flexor digitorum superficialis. The breaking strength of the remaining slip of the flexor digitorum superficialis tendon was then measured. RESULTS: Pulley plasty and resection of one slip of the flexor digitorum superficialis tendon both significantly decreased gliding resistance compared with repair of both slips (p < 0.001). There was no difference in the mean gliding resistance between the pulley plasty and one-slip resection groups. The flexor digitorum superficialis slip was stronger after repair with a Becker suture (28.8 +/- 9.0 N) than after repair with a modified Kessler (16.4 +/- 4.5 N) or a zigzag suture (15.0 +/- 5.7 N). CONCLUSION: Both pulley plasty and resection of one slip of the flexor digitorum superficialis reduce gliding resistance after tendon repair in zone II of the hand.     

The effect of flexor sheath integrity on nutrient uptake by primate flexor tendons

The effect of flexor sheath excision versus sheath incision and repair on the uptake of 3H-proline by profundus tendons in zone II was examined. Proline uptake was measured at 7 days in eight monkeys with intact flexor tendons (group I) and at either 3 or 7 days in eight monkeys with the tendons transected and repaired (group II). In both groups, the flexor sheaths of the digits of the right hand were excised, whereas those of the left hand were incised and repaired. For both the intact and the transected and repaired flexor tendons, it was found that 3H-proline uptake was not improved with sheath closure. The extracellular tissue fluid appeared to be capable of providing nutrients to the tendon in amounts equal to that of the synovial fluid. Therefore, closure of the sheath after primary flexor tendon repair does not appear to be necessary for tendon nutrition, according to the data obtained from experimental studies on the nonhuman primate.     

The Omega "Omega" pulley plasty. A new technique to increase the diameter of the annular flexor digital pulleys

The authors report a new technique of pulley plasty of the flexor digital system. It is not an operative procedure to reconstruct a damaged pulley but an original way to expand the volume of an intact pulley in order to adapt its volume to the diameter of the repaired flexor tendon. The flexor tendons ruptures in Verdan zone II and particularly in Tang zones IIA and IIB are often accompanied by an osteofibrous tunnel injury. Initially, the tendon sheath closure was advised after tendons repair. This sheath recovery had to have an effect on tendons nutrition by establishing the synovial cavity continuity and particularly to protect the tendons from adhesions formation. The closure of the digital tube was rapidly shown to be unnecessary creating an obstacle to the tendons movements without any effect on tendons healing. In primary tendon management, the tendon repair is associated with an increase of the tendon diameter. An incongruence appears with the surrounding digital tube with gliding resistance complicating the tendon injury recovery. In secondary tendon injury management, the flexor digital tube is subject to healing and inflammatory process. This situation with the absence of the flexor tendon generates a retraction with a collapse of the digital tunnel over the injured area. This incongruence between the repaired flexor tendons and the narrowed digital tube required a release of the retracted zone to restore an adequate volume. The only way reported is the "Venting" of a part or the total length of the pulley. This procedure even if it resolves the tendon gliding resistance, is still unacceptable. Indeed it destroys an important anatomical structure of the flexor tendon dynamic system. The flexor pulley Omega plasty "Omega" consists in releasing the lateral palmar attachment of the pulley enhancing its internal volume and increasing the flexor tendon gliding area. The digital tube is composed by the succession of five annular and three cruciform pulleys. The cruciform pulleys are thin and flexible. They retract during the digital flexion assuring the continuity of the digital tube, while the annular pulleys are thicker and fill a biomechanical function. There are two types of annular pulleys: the joint pulleys as A1, A3 and A5; they are attached to the palmar plates of the MP, PIP and DIP joints respectively. During the digital movement, they retract approximately 50% of their length. The osseous pulleys as A2 and A4 are fixed over the lateral and palmar borders of the first and the second phalanx respectively. It is on these pulleys that the Omega plasty is practised. The operative procedure is simple. It consists on a periosteal dissection over the one lateral border of the phalanx. The liberation is undergone palmarly releasing the lateral attachment of the pulley. It respects the anatomical continuity of the pulley and its mechanical properties. Indeed, the continuity of the pulley is fully respected with the periosteal flap of the digital tube floor maintaining sufficient attachment to the pulley to resist to the flexor tendon forces. The level of the flexor tendon injury and the digit position during the initial trauma will determine the level of tendon resistance and where the pulley plasty must be made. If the flexor zone II injury occurred with the digit in an extension position, the tendon conflict appears with the A2 pulley, while it arises with the A4 pulley if the digit was in flexed position. The Omega plasty creates the ideal conditions for an optimal flexor tendon movement recovery. It is a simple and a reproducible procedure. It doesn't distort the mechanical properties of the pulley and the digital tube. We used this pulley Omega plasty fifteen times in twelve patients. In 60% of the cases, the injury concerned the dominant hand, and in 67% of the cases, it was a work accident. In eight of our cases, the omega plasty was done in emergency at the same time of flexor tendon repair, while in the other seven cases, the pulley Omega plasty accompanied the late flexor tendon repair forgotten during the initial trauma management. In ten cases, the plasty concerned the A4 annular pulleys, while in the other five cases, it concerns the A2 annular pulleys. Four cases necessitate a secondary tenolysis three months after the tendon repair. Two patients moved out and cannot be included in our results. On the thirteen-remainder cases, nine retrieved a full digital flexion particularly those who underwent digital tenolysis, while the other four cases retrieved a satisfying digital function in spite of the partial DIP flexion. In our hand, the pulley Omega plasty "Omega" becomes almost a systematic procedure in conjunction with the flexor tendon repair. It offers the ideal conditions for a tendon healing and a physiological flexor tendons motion recovery.     

Therapiestandards nach Beugesehnen- und Nervenverletzungen der Hand

Background

There is little evidence for the ideal aftercare of combined nerve and flexor tendon injuries of the hand. The aim of this study was to elicit whether concomitant nerve injuries are changing the individual treatment plans after flexor tendon repair in a survey of German centres for hand surgery.

Methods

A questionnaire about aftercare of isolated and combined nerve and flexor tendon injuries of the hand was distributed to members of three German Societies of hand, trauma and plastic surgery.

Results

Isolated flexor tendon injuries in zones II to IV are treated by early mobilization in all centres, whereas isolated digital nerve repair is usually followed by immobilization (10% no immobilization, 22.5% up to 1 week, 52.5% for 2 weeks and 15% for 3 weeks). The duration of immobilization increases with lesions of the median or ulnar nerves by about 1 week. In 55% of cases concomitant nerve injury does not influence the early onset of dynamic splinting and mobilization after flexor tendon injuries.

Conclusion

There seem to be no uniform treatment guidelines for flexor tendon repair if concomitant nerve injury is present. Against the background of the current literature early controlled mobilization after tendon and nerve repair seems to be justified.