Extensor Tendon Surgery

Transcript:

Let’s take a look at extensor tendon surgery. First off, let’s take a look at the anatomy. The extensor tendons come from the forearm down across the wrist on the top surface and come down and extend the fingers, straighten the fingers out, flexors bend the fingers, extensors straighten the fingers. So we’re going to concentrate on the extensors. They come down across the wrist through several compartments, and they can be injured anywhere along this line. So the tendons come across the knuckles and then out in the finger gets a little complex. The extensors insert at the base of the middle phalange at the PIP joint or that middle joint and then they split off into two lateral bands that go out and extend that very last joint or the DIP joint and the key is with these with the extensor mechanism in the finger is it extends those two joints simultaneously so any injury whether it’s a laceration or a tendon rupture that can affect that that synchronization uh between those two tendons and really and cause certain deformities. So let’s take a look now at the mechanisms of injury. Kobe Bryant dunking the ball um jamming fingers volleyball players uh basketball players that grab uh balls in their hand can jam the fingers and then there’s simple injuries that can uh cause torn tendons such as just simply with a mallet finger, we’ll see in a minute, can just simply tucking the sheet uh under your bed can can just abruptly bend the joint in a different position causing these very fine causing these very fine tendons to tear away from the bone causing deformities. So let’s take a look at actually some of the of the injuries. Mallet finger, as you can see here. So a mallet finger is looks like a mallet, the the last joint or the DIP joint is flexed and that again occurs usually from tearing the tendon away from the bone. Let’s look at this in more detail on the next image. You can see the extensor tendon, it’s really just like a paper thin tendon that’s coming right across this joint attaches to the bone. So what happens is you tear the tendon as you can see from this red line and now you can see the broken tendon so it it the the tendon can no longer straighten the joint and this actually is pretty painless unless of course there’s more of a crush injury where sometimes the bone tears away from the bone as opposed just the tendon tearing away from the bone. So, how is this treated? Let’s take a look. It’s called a Stack splint now S T A C K Stack splint and these can be these can come different sizes. They’re already prefabricated and the therapist we usually send you to a therapist and they’ll put these on and sometimes they’ll make more of a custom one that’s lower profile and the key is we want to hold that joint slightly hyperextended so the tendon can has a chance to heal back to the bone. So as you can see here the splint is in place, it takes about six to eight weeks in place and if it comes off at any point during that healing period you got to start all over but this can be effective up to several months from the time of the injury but the the sooner you get the splint on, the sooner the healing period. So let’s take a look now at what the next deformity called a Boutonniere deformity. So at the PIP joint the middle joint now your the tendon becomes torn and forms this Boutonniere deformity flexion at the PIP joint and hyperextension at the DIP joint as you can see here. So let’s look a little deeper into what actually is happening. You can see the extensor slip or the central slip right on top of the PIP joint becomes torn and as a result the joint starts to flex the middle joint. As you can see in the next image, the lateral bands or these tendon this tendon along the outside of the joint starts to actually migrate towards the palm side of the digit and actually becomes a flexor of the PIP joint and then it becomes too tight, remember they’re working in unison and the DIP joint starts to hyperextend. So, how do we treat this? Well conservatively usually and we’ll put a brace on as you can see in the next image and it’s a a PIP extension brace and this holds that joint the middle joint straight but it allows flexion at the distal joint because that’s important to get those those tendons back in balance. In some cases though if it’s late late to come to the doctor that joint may be fixed meaning we have to go in and relieve the contracture just to get it straight so those tendons have a chance to heal. Now let’s take a look at the most common tendon injury. You got it comes from cutting, slicing, saws, anything sharp, penetrating objects that can cut the skin can cut these little tendons and so commonly what happens is um from even from cooking, most common injury is actually getting an avocado pit out of an avocado is that it involves this awkward maneuver with the tip of the knife and it can skure the digit or the the area of the hand or wrist causing a tendon laceration. So let’s actually take a look at a tendon laceration. This gentleman had a saw injury cut across the tops of the knuckles about the at the base of the index and middle fingers. You can see here this gap, this is the white structure that I’m holding between the forceps or tweezers is is the tendon laceration. You can actually see down into the knuckle joint. So what do we do? We put several little fine sutures in place to actually sew that back together as you can see in the next image, nice tidy repair right here. We close the skin and then place the patient in a splint uh for several days and at the initial post-operative evaluation, that’s the time that the hardest part of rehabilitation begins. So let’s take a look now at the post-operative therapy, which is one of the most critical points. Today we’re joined by Jeannie Robinson, who’s the head therapist at California Hand Therapy here in Beverly Hills, who’s going to walk us through the recovery and rehabilitation that’s so critical to extensor tendon surgery. So I see you have this on, tell us what are the indications, where is the tendon cut in the hand to warrant this gizmo? Okay, so the tendon is cut in zone four, zone five. This is specifically to the index finger extensor tendon um so this is made so that we can start some early active motion. So, early active motion is going to help promote the tendon gliding. Okay, and so zone again, the zone is between roughly this strap and the knuckle here, would be the zones between the wrist and the knuckle, is where you would wear this, right? Exactly. Okay, and so walk us through kind of the time period that you have to like you’ll start wearing this right soon after surgery, but how long are you in this? Typically, you’re going to be in the splint for about four weeks. So what this does is allows some graded motion, right now the splint is set so that we can move the index finger to about 30° flexion at the MP joint and so each week we’re going to allow the mo the motion of that MP joint to be a little greater uh so typically this is worn for about four weeks and then after four weeks, the patient is allowed to make a full fist. So make a full composite fist with wrist extension and then about five weeks, they can move into full composite uh fist with wrist flexion, right? Uh, and then after that, about six weeks, we can start doing some strengthening. Okay, so total recovery what, 3 to four months or how? Um, I would say, you know, 12 weeks until the patient can do everything that they normally did before the injury. Great. All right. Earlier, we also talked about Boutonniere deformities. This can be from laceration or, more commonly, from just blunt trauma, jamming the finger. And so she’s going to walk us through this, a splint for a Boutonniere injury. So tell us, you know, about this, what’s involved, and how long I have to wear this? Okay, so the important thing about this brace is that you have to wear it all the time. We don’t want any motion at all at the PIP joint which is the middle joint uh and typically you’re going to have to wear it for about six to eight weeks and often times I’ll make a second splint for the patient to sleep in that just holds the whole the whole finger or just the, not the whole finger. So really, this is just immobilizing the uh PIP joint. Um, so we actually want some motion at the tip, so you want to do this? Exactly. And that how often do I do this during the day? Uh, I have my patients do it every hour. Okay. And then after this comes off, what’s the, you know, just regular, it’s obviously going to be stiff then. How long does it take usually? What’s the average recovery time to get over this kind of injury? I would say average recovery maybe about six to eight weeks. Okay, great. And then we have one more injury we talked about earlier. Again, usually it’s not from a laceration, it can be it’s called a mallet finger where you tear the terminal tendon out here just just before the fingernail and the finger droops. Um this is as we talked about earlier, there’s a Stack splint that that we showed a picture of earlier that kind of comes in different sizes like shoe wear and sometimes it doesn’t fit properly and so a lot of times they’ll do a custom splint because it fits better, it’s lower profile. So tell me again, how does this go? Is this the way it goes on? Yeah, that’s perfect. Can you tape it or you got it? Yeah, we tape it because we really want this to stay on the finger and because it’s on such a small part of the finger, velcro is really not going to cut it, right? Because if it comes off, it kind of starts all over, you that’s true. Yeah, if this comes off, if the finger bends it all, then you have to start from day one again. And how long do you leave the patient in this typically? I six to eight weeks just depending on the healing, right? All right. This has been very helpful, and uh, for this and many other conditions, please check out our website. All right, thank you.