局部封闭致拇伸肌腱腱帽损伤一例

患者女，43岁。2003年11月，因右拇伸肌腱狭窄性腱鞘炎，在外院行局部封闭治疗后(4次)出现拇指屈曲、伸指不能而来院就诊。临床检查：右手拇指屈曲位，拇长伸肌腱滑向内侧，掌指关节不能主动伸直，被动活动正常，手指感觉正常。诊断：右拇伸肌腱腱帽损伤。局麻下行伸肌腱复位、腱帽修复术。术中即能主动活动患指，活动时拇伸肌腱无滑脱现象出现。术后采用石膏固定，3周后去除，开始进行掌指关节屈伸功能锻炼。术后随访1年，患指功能正常。     

伸肌腱腱帽解剖与异体腱帽移植的相关性实验研究

目的 探讨伸肌腱腱帽解剖与异体腱帽移植的相关性研究。方法 对6只新鲜尸手24指指伸肌腱腱帽的动力结构和静力结构进行观察,并测定了各指伸肌腱在腱帽处的滑动范围。结果 各指腱帽桡、尺侧的长度均是桡侧长于尺侧,各指伸肌腱腱帽的滑动范围在0．9－1．5cm间,示指最大,小指最小。结论 异体腱移植可恢复伸肌腱腱帽的原有结构,可避免自体肌腱移植后的肌腱移植后的肌腱下滑而影响伸指功能的恢复。     

高频超声在手指伸肌腱闭合损伤中的诊断价值

目的 探讨高频超声诊断在手指伸肌腱闭合损伤中的诊断价值.方法 2005年4月至2008年10月,应用高频超声诊断指伸肌腱闭合损伤,对手术证实的21例患者的超声影像特征进行分析.结果 Ⅰ区伸肌腱损伤10例中,超声图像显示肌腱止点处低回声区,远节指骨基底向掌侧移位,动态观察主动伸指远节指骨无活动,其中3例合并末节指骨撕脱骨折,骨块均有移位.Ⅱ区损伤6例中,腱帽损伤完全断裂2例,表现为腱帽连续性中断,结构紊乱,局部有异常暗区,动态观察可见断端分离,伸腱滑向尺侧;腱帽损伤未断裂3例,表现为腱帽增厚,回声不均匀,结构不清;内固定损伤1例,可见内固定物在受损肌腱内穿过,肌腱滑动时受阻.Ⅲ区自发肌腱断裂5例,超声图像见肌腱内部回声不均匀,肌腱纤维混乱,肌腱连续性中断.结论 超声检查指伸肌腱闭合损伤是辅助诊断中的首选方法,为临床治疗提供依据.     

McCoY法修复陈旧性伸肌腱帽损伤7例报告

伸肌腱帽损伤常发生于掌指关节受外力猛力被动屈曲或掌指关节直接猛力撞击时，伸肌腱帽的损伤发生于掌指关节桡侧者多于尺侧，因而多数病历指伸肌腱向尺侧脱滑，并有患指的尺偏畸形，中指伸肌腱帽损伤的发生率高于其他手指。我院自2002年3月-2007年8月共利用McCoY法修复陈旧性伸肌腱帽损伤7例，效果满意，报道如下。     

介绍一种修复陈旧性锤状指的方法

锤状指是指伸肌腱第5区处肌腱形成膜状，由于外伤远指间关节过屈，将指伸肌腱帽牵拉过长，而形成患指末端过屈畸形。早期行胶布、夹板等固定有一定效果。陈旧性锤状指保守治疗无效，需手术治疗。传统方法是行关节融合或将拉长的指伸肌腱切断，然后断端重叠缝合。笔者采用不切断指伸肌腱的方法，自1996～2004年共修复46例，报告如下。     

瘢痕折叠缝合和侧腱束转位治疗陈旧性腱性锤状指

目的 探讨瘢痕折叠缝合和指伸肌腱侧腱束转位治疗陈旧性腱性锤状指的手术方法及临床疗效.方法 对30例腱性锤状指患者,根据术中所见采用不同的手术方法.其中8例采用指伸肌腱远、近断端瘢痕折叠缝合+克氏针内固定;22例采用指伸肌腱远端与近端伸肌腱单侧侧腱束转位后钢丝Kessler钮扣肌腱缝合+克氏针固定.术后均用石膏固定患指于远指间关节过伸位、近指间关节屈曲位6周.结果 术后30例患者伤口均Ⅰ期愈合,随访6～24个月,平均(13.0±4.5)个月,疗效评价采用Dargan功能评定法评分:优22例,良6例,可2例;优良率为93.3％.结论 陈旧性腱性锤状指断端间若形成松弛瘢痕连接,可采用瘢痕折叠缝合法强化;若断端分离短缩,可采用指伸肌腱单侧侧腱束转位治疗.依术中所见不同采用合适的方法治疗陈旧性腱性锤状指可取得满意的疗效.     

陈旧性腱性锤状指的显微外科手术治疗

[目的]探讨应用显微外科技术手术治疗陈旧性腱性锤状指的方法.[方法]对13例陈旧性腱性锤状指在放大3～4倍的手术显微镜下施术,显露伸指肌腱,用1枚直径1 mm克氏针固定远侧指间关节(DIP)于过伸10°～20°位,保留肌腱的瘢痕组织,切断松弛的伸指肌腱,在无张力的情况下,用7/0无创缝合线将近端位于背侧与用远段重叠缝合,使近侧伸肌腱末端与末节指骨靠拢贴紧改建肌腱止点.术后用铝板保持DIP过伸、近侧指间关节(PIP)屈曲位,4周去除铝板,6周拔出克氏针,指导患者逐步进行功能锻炼.[结果]平均随访1年,按Dargan功能评定法:优8例,良4例,可1例,优良率92%.[结论]运用显微外科技术,组织辨别清晰,操作精细准确,创伤小,修复伸肌腱正常力学结构,重建DIP伸屈力量的平衡,是治疗陈旧性腱性锤状指的有效方法.     

双微型骨锚重建伸指肌腱终腱止点的临床应用

锤状指是由于末节指骨基底背侧至中央腱束止点间伸肌健断裂或撕脱部分指骨所致。若处理不当锤状指畸形长期存在,影响手部功能及外观。针对当前骨锚在手部肌腱损伤重建的应用逐渐广泛的现状,及我科在临床应用中的经验,分别采用单、双骨锚进行止点重建。2007年7月-2009年1月随访患者8例,笔者发现采用双微型骨锚重建修复指伸肌腱终腱止点撕脱伤者疗效优于采用单微型骨锚重建修复指伸肌腱终腱止点撕脱伤者。     

“指伸肌腱终腱-止点系统”与锤状指形成原因的探讨

目的：通过对指伸肌腱终腱止点及末节指骨的解剖学观测,以物理力学方法对锤状指的形成原因做进一步的探讨。方法在成人新鲜尸体手指标本上,通过模拟手术,对指伸肌腱终腱止点及末节指骨的结构特点进行应用解剖学观测,用物理力学原理对指伸肌腱终腱及末节指骨进行受力分析。结果指伸肌腱终腱止点呈浅帽状被覆于末节指骨基底背侧的“舌”形骨嵴顶端,远侧指间关节侧面观呈规则的圆弧形,末节指骨在屈伸肌腱的牵拉下围绕一个固定的轴心在中节指骨头表面做屈伸运动;终腱或舌形骨嵴在手指纵轴线处受力最大,在垂直于手指纵轴线处受力最小。结论“指伸肌腱终腱-止点系统”的命名利于对锤状指的形成原因作进一步解释,并为锤状指治疗方法的改进提供解剖学依据。     

腱片移植治疗陈旧性锤状指

通过对手指伸腱装置的解剖与功能观察,设计了以掌长肌腱片或指背腱膜自身腱片移植修复伸指肌腱终腱手术,治疗陈旧性锤状指。1987年间试用3例,经2～3年随访,疗效满意。     

小指固有伸肌腱移位术后小指伸直障碍的防治

目的 探讨小指固有伸肌腱移位术后小指伸直障碍的应用解剖学依据及其防治方法。方法 针对小指伸肌腱行解剖学观察158例标本，并将伸向小指的指总伸肌腱束按生物力学分类为四型：即标准型、力线偏离度小型、力线偏离度大型及缺如型；针对术后小指伸直障碍，用腱间纤维联系切断术治疗3例，术中预防性治疗55例。结果 经1年以上随访，1989年8月－1996年间的54例病例中，3例术后发生小指伸直不全，经腱间纤维联系切断术后均治愈，此后，采用术中预防性治疗后未再发生小指伸直障碍。结论 小指固有伸肌腱移位术后小指伸直障碍与伸向小指的指总伸肌腱束的力线有关，按其类型分别采用腱间纤维联系切断术、腱短缩术及腱重建术，能够有效地防治小指伸直障碍的发生。     

Closed treatment of nonrheumatoid extensor tendon dislocations at the metacarpophalangeal joint

PURPOSE: Acute sagittal band injuries at the metacarpophalangeal (MCP) joint resulting in subluxation or dislocation of the extensor tendons may cause pain and swelling at the MCP joint and limit active extension of the MCP joint. These injuries often are treated with surgical repair or reconstruction. This article outlines a nonsurgical treatment protocol that uses a customized splint for acute, nonrheumatoid extensor tendon dislocations caused by injury to the sagittal bands. METHODS: We retrospectively reviewed 10 patients with 11 acute sagittal band injuries who were treated with a splint of thermally molded plastic that differentially holds the injured MCP joint in 25 degrees to 35 degrees of hyperextension relative to the adjacent MCP joints. All the sagittal band ruptures resulted in complete dislocation of the extensor digitorum communis (EDC) tendon-Rayan and Murray type III injuries. Active proximal interphalangeal and distal interphalangeal motion was begun immediately at the time of initial splinting. The average follow-up period was 14 months. RESULTS: At the time of final evaluation all patients had full range of motion in flexion and extension. Eight patients had no pain and 3 had moderate pain. Four patients (5 digits) had no extensor tendon subluxations and 3 had barely discernable subluxations. Three patients had moderate subluxation of the EDC tendon and their treatments were considered failures. One of these patients had subsequent sagittal band reconstruction. CONCLUSIONS: Our results show acute sagittal band injuries in nonrheumatoid patients resulting in dislocation of the EDC tendon can be managed nonsurgically in many patients with a customized splint called the sagittal band bridge. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.     

Geschlossene Streckhaubenverletzungen am Grundgelenk der Langfinger

Closed traumatic lesions of the extensor tendon hood of a longfinger at the metacarpophalangeal joint are rare. Surgical treatment was done in 6 cases during the last 10 years in our department; in 5 cases the dorsoradial part, in one case the dorsoulnar part of the hood was injured. The tear extended longitudinal or diagonal through the transvers fibers of the hood. Respecting the accident mechanism there have been reported tangential forces at the extensor tendon hood and forced ulnar deviation in the bended metacarpophalangeal joint. A jerky dislocation of the extensor tendon to the ulnar side of the metacarpophalangeal head during increased bending of the metacarpophalangeal joint, sometimes with ulnar abduction of the longfinger, leads usually to the diagnosis. Misdiagnoses of cases sent to our department were: ?trigger finger“ and ?recurrent dislocation of the metacarpophalangeal joint“. Once the presurgical diagnosis was ?rupture of the extensor tendon“ because of a permanent extension deficit in 30 degree position of the metacarpophalangeal joint. Treatment is always surgical with suture of the hood and immobilization of the metacarpophalangeal joint in extension position for 4 weeks. Conservative treatment can not heal up a tear of the extensor tendon hood.     

Extensor tendon dislocation in cerebral palsy.

An 18-year-old man with cerebral palsy presented with a flexion deformity of the middle finger particularly at the metacarpophalangeal joint and ulnar dislocation of the extensor tendon. Releasing the tight ulnar sagittal band and imbricating the attenuated radial sagittal band allowed centralization of the extensor tendon. For complete correction of other deformities intrinsic release and extrinsic flexor muscle lengthening were done. Extensor tendon instability in this case was due to the combined forces of the extrinsic and intrinsic muscles on the retinacular system of the extensor mechanism.     

Closed sagittal band injury due to low energy trauma

Sagittal band injury is a relatively common cause of extensor tendon subluxation caused by inflammatory disease or high-energy trauma. However, there are few reports in the literature describing sagittal band injury due to low energy trauma. In this report, we describe successful nonsurgical management of a closed sagittal band injury and extensor tendon subluxation associated with low-energy trauma. Patients in 2 cases had no rheumatoid arthritis or history of inflammatory diseases. Conservative treatment resulted in relief of symptoms and corrected the instabilities with no complications.     

Nonoperative treatment of traumatic dislocations of the extensor digitorum tendons in patients without rheumatoid disorders

Traumatic subluxation and dislocation of the extensor digitorum tendons are uncommon in patients without rheumatoid disorders. Management of the acute injury is not well defined in the orthopedic literature. Two cases of traumatic dislocations of the extensor digitorum tendon were seen acutely in young persons without rheumatoid disease. These patients were successfully managed by early closed reduction and immobilization. This treatment had yielded good hand function to date, without recurrence of the dislocation. One of these cases was particularly unusual in that the direction of the tendon dislocation was radial. This particular injury has not been previously described.     

Treatment of soft tissue injuries to the dorsum of the metacarpophalangeal joint (Boxer's knuckle)

We retrospectively reviewed the surgical treatment for 16 cases of traumatic soft tissue injury to the metacarpophalangeal joint (Boxer's knuckle). A history of trauma was present in all cases and there was an associated extensor tendon dislocation in seven cases. Eight cases were initially treated conservatively, but their symptoms persisted. Intraoperative findings included rupture of the extensor hood or joint capsule in all cases. Surgical closure of the rupture of the joint capsule resulted in a successful outcome in all cases. We consider that conservative treatment of this injury may not be effective when the joint capsule of the metacarpophalangeal joint is ruptured. We recommend arthrography of the metacarpophalangeal joint to assist in the decision as to whether to proceed with surgical or conservative treatment.     

Chronic painful subluxation of the metacarpal phalangeal joint extensor tendons

Chronic subluxation of the extensor tendons of the metacarpal phalangeal joint has been documented in six patients on active duty in the United States Navy. These patients had painful full flexion and gripping in the knuckle, especially when they were performing their jobs. No extension lag was noted. Three patients had a severed junctura tendinum between the long and index fingers, which was believed to be a contributing factor to extensor tendon subluxation. Local anesthesia was administered to these patients, and the lesions were surgically corrected by reefing of the extensor hood and the sagittal band and repair of the junctura tendinum.