屈指肌腱鞘管阻滞的实验研究与临床观察

一种新的手指阻滞方法─—屈指肌腱鞘管阻滞。通过向屈指肌腱路管内注射２～３ｍｌ麻醉药，迅速达到阻滞效果。检测了１０例正常人阻滞前、后手指感觉传导速度，并对１５只Ｗｉｓｔａｒ大白鼠后趾作显微解剖及组织学研究。结果阻滞后正常人手指感觉传导速度被完全传导阻滞；麻醉药直接通过鞘膜扩散，全面地浸润其表面的指神经。临床应用４９３例（６２５指），４９１例（６２３指）阻滞满意，尚未见并发症。     

Anesthésie locale digitale par la gaine des fléchisseurs

A series a 350 cases of local anaesthesia of the finger using the flexor tendon sheath is reported. The patients were ranked ASA 1 or 2 and the youngest was 12 months old. This technique was used for day case surgery, such as nail trauma and tumours, wound exploration, tumour and cyst removal, tenolysis and neurolysis. The needle was inserted on the palmar aspect of the metacarpophalangeal joint, into the digital flexor tendon of the corresponding finger. Thereafter the needle was withdrawn very slightly in order to inject the local anaesthesia solution within the sheath, and not the tendon. The volumes were respectively 1 ml in children and 3 to 4 ml in adults of either 2 % lignocaine or 0.5 % bupivacaine without adrenaline. As palmar injections are painful a freezing spray solution was used prior to insertion of the needle. There was no anaesthesia of the dorsal digital nerves, as opposed to the findings of the author of the first series. This technique, which can be qualified as being easy and reliable, could be a valuable alternative for the ring or interdigital blocks, which carry a significant risk of vascular and neurological complications.     

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.     

Successful infiltration of the flexor tendon sheath.

Twenty cadaveric fingers and five thumbs were injected through a midaxial approach, a palmar approach superficial to the flexor tendon, and a palmar approach deep to the tendon, to assess the ability of these approaches to infiltrate the flexor tendon sheath successfully. With care to observe proper positioning of the needle, we were able to achieve essentially equivalent success in infiltration with most of these approaches. However, the midaxial approach to the thumb flexor sheath was unsuccessful.     

The mechanical effect of partial resection of the digital fibrous flexor sheath

In the context of primary flexor tendon repair, a study has been made to determine how much of the flexor sheath may be opened without causing mechanical disadvantage to the finger. In five cadaver hands, measurement of profundus tendon excursion, distance from nail to distal palmar crease, profundus flexion force, and tendon bow-stringing, showed that there was no material change of these parameters when up to four contiguous pulleys were divided. Along with other individual pulleys, A2 and A4 cannot be regarded as inviolate.     

Operative findings in camptodactyly of the little finger.

In five of six cases of camptodactyly in which an abnormality of the flexor tendon was examined at operation, the flexor digitorum superficialis tendon was hypoplastic and there was no continuity of the normal tendon between the muscle belly and bony insertion. The proximal end of the flexor digitorum superficialis tendon was attached to the palmar aponeurosis and the flexor tendon sheath of the ring finger in two patients, to the palmar aponeurosis in one, to the undersurface of the transverse carpal ligament in one and to the flexor tendon sheath of the ring finger in one. The tenodesis effect of the abnormal tendon of the flexor digitorum superficialis is considered to play an important role in the cause and rapid increase of the deformity of camptodactyly.     

改良屈肌腱鞘浸润麻醉在手足指（趾）手术中的应用

目的探讨应用改良屈肌腱鞘浸润麻醉进行手足指（趾）手术的治疗效果。方法对32例手足指（趾）,全部采用改良屈肌腱鞘浸润麻醉进行手术。结果所有病例均经1次注入鞘管成功。麻醉用药剂量单指（趾）平均1.5～3ml。起效时间平均2～3min,持续时间平均2～3h。术中对刷洗、双氧水冲洗、切皮、清创、咬除骨质、缝合等刺激耐受良好,无疼痛感。麻醉范围：拇指（趾）掌指（跖趾）关节以远部分,第2～5指（趾）掌指（跖趾）关节以远部及相邻指（趾）半指（趾）,各指（趾）近节背侧效果稍差,拇指（趾）近节背侧几无麻醉作用。结论改良屈肌腱鞘浸润麻醉操作简单、起效迅速、用药经济安全、无任何副作用,特别适用于手足指（趾）手术的麻醉方法。     

Symptomatic restrictive thumb-index flexor tenosynovitis: incidence of musculotendinous anomalies and results of treatment

During a 5-year period, 33 patients with pain in the palmar aspect of the wrist and forearm with and without features of carpal tunnel syndrome were diagnosed as having restrictive thumb-index flexor tenosynovitis. The pathognomonic sign in this condition was the simultaneous flexion of the index finger with active flexion of the thumb across the palm. Treatment included either steroid injection into the tendon sheath of the flexor pollicis longus or surgical exploration of the palmar aspect of the distal forearm and wrist region. Twenty-six wrists in 24 patients were surgically explored, and all had hypertrophic tenosynovium between the flexor pollicis longus and index profundus tendons. More than half of the explored wrists had a tendinous connection between the flexor pollicis longus and the flexor profundus of the index digit. Of 17 wrists with follow-up of more than 6 months, 13 were improved by surgical management. Steroid injection did not have a long-term effect.     

Anatomical demonstration of the nerve-supply to the flexor tendon

A dissection of four unembalmed human fingers demonstrated a branch from the digital nerve which enters the flexor tendon sheath at the same place as the transverse branch of the digital artery. We conclude that this branch supplies the nerve fibres found within the vinculum.     

Repair and healing of the divided digital flexor tendon

A series of 275 repairs is reviewed. Primary or delayed primary repair of the divided digital flexor tendon is advocated. Preoperative splinting and careful operative technique to avoid damage to the blood supply of the divided tendon are necessary. The tendon repair is followed by closure of the fibrosynovial sheath and postoperative splintage. By this means acceptable results are obtained.     

Comparison of MRI and local anesthetic tendon sheath injection in the diagnosis of posterior tibial tendon tenosynovitis

BACKGROUND: The modalities currently available to clinicians to confirm the clinical suspicion of posterior tibial tendinitis include MRI, CT, sonography, tenography, and local anesthetic tendon sheath injections. There are no reports in the literature comparing local anesthetic tendon sheath injection to MRI as tools for diagnosing posterior tibial tenosynovitis. METHODS: The authors reviewed the records of all patients with stage 1 posterior tibial tendon dysfunction between the dates of September 1, 2001, to November 21, 2004. Fifteen patients (17 ankles) had a local anesthetic injection into the posterior tibial tendon sheath and MRI for clinically suspected tenosynovitis of the posterior tibial tendon. RESULTS: Seventeen (100%) of 17 ankles had complete relief of symptoms after the local anesthetic tendon sheath injections. Fifteen (88%) of 17 ankles had abnormally increased fluid signal within the posterior tibial tendon sheath seen on MRI. Two of two ankles (100%), after having negative MRI findings, had complete relief with a local anesthetic tendon sheath injection. In addition, conservative treatment failed in these two patients, and they subsequently had tenosynovectomy with gross confirmation at surgery of inflammatory changes within the tendon sheath. These two patients had complete symptom relief after tenosynovectomy. CONCLUSIONS: Local tendon sheath injections and MRI are both reliable diagnostic tools. Injection of the posterior tibial tendon is an accurate, safe, and sensitive modality useful in patients in whom MRI studies are negative in the face of continued clinical suspicion.     

Flexor tendon lengthening by tenotomy at the musculotendinous junction

The author presents his experience with an established technique of flexor tendon lengthening by tenotomy at the musculotendinous junction. This technique can be used for digital stiffness of forearm origin when active extension is possible on flexion of the wrist. There must not be adherence in the carpal tunnel or in the digital sheath, and active flexion must be preserved. It can also be used for digital stiffness in addition to other techniques. This kind of lengthening has some advantages: there are no sutures in the tendon itself, and it allows early reeducation in association with dynamic extension splinting. Active flexion is preserved immediately and there is good tendon healing. It is possible to lengthen selectively the superficial flexor or the deep flexor and in some cases both. Results are presented according to cause.     

Flexor tendon pulley reconstruction

The flexor tendon pulley mechanism causes the tendons to work with maximum efficiency. Without its competency,flexor tendons will bowstring causing significant losses of digital motion and strength. Without an intact pulley system, increased flexor tendon excursion is required to affect joint motion and flexion contractures may develop over time. Recent investigators have described the properties of the intact flexor pulley system as well as those of flexor pulley reconstructive techniques. Reconstruction of the flexor pulley system should take into account both strength and length of the construct and in most cases a loop of either flexor tendon graft or wrist extensor retinaculum is used. Other methods are available including the use of the palmar plate as well as the superficialis tendon.     

Transthecal digital block: digital anaesthesia through the sheath of the flexor tendon

We studied the effectiveness of a local injection of 1 ml of 2% mepivacaine into the sheath of the flexor tendon in 64 fingers and found it to be a safe procedure giving satisfactory anaesthesia.     

Histology and ultrastructure of the human flexor tendon sheath

Twenty human flexor tendons and their sheaths were studied to determine the gross, microscopic, and ultrastructural morphology of their surfaces. Specimens were obtained at the time of autopsy or at the time of reconstructive and reparative surgery. The flexor tendon sheath consists of a noninterrupted layer of parietal synovium reinforced externally at intervals by dense bands of collagen, the annular and cruciform pulleys, and the palmar plates of the respective finger joints. The sheath contents are independently covered by a second similar layer of visceral synovium. These two layers are continuous at the proximal cul-de-sac, the vincula origins, and the tendon insertions. While the synovial cells lining the pulleys and tendons differ quantitatively from those of the membranous portion of the sheath, they are morphologically identical. The presence of a visceral synovial layer covering each tendon may indicate a key role of the synovial cell in tendon healing.     

Flexor Tendon Injuries: II. Operative Technique

The repair of flexor tendons (zones I and II) is a technique-intensive surgical undertaking. It requires a strong understanding of the anatomy of the tendon sheath and the normal relationship between the pulleys and the flexor digitorum superficialis and flexor digitorum profundus tendons in the digit. Meticulous exposure, careful tendon retrieval, and atraumatic repair are extremely important, and the repair should be of sufficient strength to resist gapping and permit the early postrepair application of motion forces. Whenever possible, the tendon sheath should be preserved or repaired, and a smooth gliding surface should be reestablished. The author describes an effective method of tendon retrieval and a simplified technique for a four-strand tendon repair with a supplementary peripheral running-lock suture. The repair is considered to maintain sufficient strength throughout healing to allow a postrepair rehabilitation protocol that will impart passive and modest active stress forces to the repaired tendons. Complications include tendon rupture, digital joint flexion contractures, and adhesions that restrict tendon gliding and ultimately necessitate tenolysis.     

Blood supply of the digital sheath

One hundred upper extremities from fresh human cadavers aged 20 to 80 years were injected with coloured latex or Indian ink and gelatin. Under the dissecting microscope two main and one occasional source of vascularization of the digital sheath were identified. Originating from the digitopalmar arches, from the proper palmar digital arteries and occasionally from the arcus palmaris superficialis, a complex arterial system supplies the various parts of the digital sheath. The best vascularized area is the floor of the sheath, while the pulleys and the palmar surface of the sheath are less well vascularized. These data may be of interest to those involved in reconstruction of the tendons of the digital flexor muscles.     

Nahttechniken und Nahtmaterial in der Beugesehnenchirurgie

Adhesions and scar formation between flexor tendons and the surrounding tissue can currently only be prevented by mobilization oft he flexor tendon. Active treatment concepts are more favorable than passive mobilization. The main risks of flexor tendon repair are rupture of the tendon suture, gradually progressive dehiscence and inhibition of tendon gliding within the tendon sheath. Currently, there is no consensus with respect to the optimal suture technique and suture material. Nevertheless, there are some noteworthy principles, such as the use of suture material with a greater diameter, locked suture techniques, sutures with four or more strands as well as simple circular running sutures. A technically acceptable compromise, even for persons with less practice, is currently a 4-thread suture in combination with a circular running suture, which guarantees sufficient stability for active postoperative treatment without causing resistance.     

Anatomy and function of the palmar aponeurosis pulley

The transverse fibers of the palmar aponeurosis are attached by vertical septa to the underlying transverse metacarpal ligament and thus form a pulley over the flexor tendons. It is a constant and substantial retinacular structure that overlays the synovial sheath. Because of its proven function, position and breaking strength, I believe it should be considered part of the flexor tendon pulley system.     

Palmar dislocation of the metacarpophalangeal joint of the finger

We report a case of palmar dislocation of a finger metacarpophalangeal joint. Disruption of all the supporting structures of this joint and rupture of the flexor tendon sheath caused marked instability. Treatment was by open reduction and repair of the collateral ligaments.