Flexor Tendon Surgery

Transcript:

Let’s take a look at flexor tendon surgery. First, let’s take a look at the anatomy. What are the flexor tendons? Well, the flexor tendons are the tendons that come up through the fingers along the palm side, come out of the carpal tunnel, all the way to the tip of the fingers. The muscles are here and they cause contractions of those tendons, allowing you to bend the tendons into the palm. But they’re very important sheaths that the tendons, that they’re two tendons that go to the tips of the fingers and one to the thumb, and they go through a little system of bands or what we call pulleys. And there’s several pulleys in the fingers that are critical to the function similar to a rope going through pulleys it allows the mechanical advantage of the tips of the fingers to curl into the palm, very critical. So, ultimately, let’s take a look at the next image that shows these pulleys from the side view. You have two tendons in this finger, one goes out and attaches to the base of the middle failen that bends the middle joint and then the other the profundus tendon goes all the way to the tip of the the last joint that allows that bend and these work again in unison to allow that fingertip to come into the palm. So let’s take a look now at the actual uh two tendons in that come down as I said, one comes in goes to the middle joint or the PIP joint, it ex it splits off into a wide to either side of that joint and then the profundus tendon comes all the way to the tip of the digit. So let’s take a look now at the actual mechanism of injury, the most common injury is a knife or uh or laceration, skill saw, you name it, that cuts through the skin can easily cut these tendons. And usually there’s, in many cases, an associated artery or nerve that’s cut, with immediate loss of feeling to the finger. So when the tendons are paired, so should these other structures. So let’s take a look now at what’s happening with the tendon laceration, tendons are coming through the pulley system here. This is actually called No Man’s Land in the middle of the finger where these two tendons are together, because in the old days, people wouldn’t even try to repair these because they had terrible results. Now, with meticulous tendon repairs done right away, the results are very good. So let’s take a look now as we go deeper down through the pulley, both tendons are cut, and in the next image you’ll see the tendon start to pull apart. As you can see here, the tendon goes into the palm and goes out towards the tip of the finger leaving the sizable gap that these tendons we have to when we go in surgically will cut open the finger usually from the tip all the way to the palm so we can fish this T this tendon all the way back to the point where it needs to be repaired. So it’s a meticulous repair. So let’s take a look now at an actual open patient right here with the two flexor tendons at the tip of the arrow, you can see have been cut, and we again flex the tip of the digit so we can get those tendons in close proximity for a good repair. So let’s take a look now at the next most common type of injury, it’s called a jersey finger, where a football player or a rugby player is grabbing a jersey and that tendon, as it’s contracting, rips away from the tip of the bone. But the other tendon that bends the middle finger, or the PIP middle joint, or the PIP joint is there, you just can’t bend the tip of the finger. So let’s take a look at what’s actually happening. You can see here an extended digit at the tip patient comes in they can’t bend the tip and as we go down to the next image here you can actually see what’s happened, the tendon has torn away from the right out towards the insertion into the bone or sometime usually off of the bone and then it retracts usually uh up into the upper part of the digit or in actually into the palm. So when we go in, let’s take a look now at the actual tendon, a typical tendon repair. We take a suture and we weave this suture through in a very meticulous fashion through both ends of the tendon and pull it together. And then, as you can see here from the next image, you can see the repair. These loops here are where we’ve done the what we call the core suture, that is usually a very robust stitch that’s hidden within the substance of the tendon. Then we take a very fine suture and run it around the outside, called an epitenonous repair, just to tidy up those edges because we want that tendon to glide smoothly back and forth between those, between those little through the tunnel or through those little pulleys. So let’s take a look at actual tendon repair. You can see this what called fiber loop it’s a very strong suture we use now similar to Kevlar the bulletproof vest and and this we run this in a double strand as opposed to the the older fashioned sutures much stronger allowing for a much quicker recovery because the sooner these tendons can move the much less adhesions are scarring and ultimately the higher success rate. So let’s take a look at an actual tendon repair, as you can see right here, the tendon is nicely repaired. You can see the pulley just at the base of that, where the tendon is fixed. Once we repair the tendon and any other structures like the nerve or artery, then we sew the skin shut, put you in a big, bulky splint that’s on for several days. Then the critical point starts the rehabilitation or recovery phase, that is the most critical that we need to talk about now. Now we’re going to talk about the very important critical rehabilitation for flexor tendon surgery, joining us is Jeanie Robinson, who’s the head of California Hand Therapy here in Beverly Hills. Jeanie, flexor tendon injury on this side of the hand, I guess anywhere from the wrist out to the fingertips, this is critical. So to walk us through what this device is and when it all starts. Sure, absolutely. This actually starts immediately after the surgery, so this splint is put on as early as three days after the surgery. So the patient will actually have the stitches in when we start their therapy. Okay, so walk us through what you’re going to have me do if I have a cut 10m or in your case, you’re wearing this, what are you going to have yourself do. Okay, so what we usually start with is we start with passive range of motion. So if the Tenon was just repaired, it’s going to be pretty weak, and it’s not usually going to be able to withstand a lot of force, so we wouldn’t want the patient making an active fist on their own. So what we have them do is we have them do some passive exercises. So we have them take the injured finger and we have them bend it with their other hand, and that does a couple of things. So that’s going to help make sure that the finger joints stay nice and loose, and it’s also going to provide a little bit of t lighting so that scar tissue adherence will be less likely. Okay, so after that goes on for how long, and then what’s the next step after that? So that goes on for about three weeks, and at three weeks, we start the patient with some early graded active motion. So what we have the patient do is they again passively place their hand into a fist, and then we have the patient let go and hold that. So it’s a place and hold exercise, and usually what I have the patient imagine is they imagine that they have a butterfly in their hand. So the amount of tension you want to have is you want to pretend that there’s a butterfly in your hand that you don’t want to let the butterfly go, but at the same time, you don’t want to kill the butterfly. So that’s the amount of tension that you want when you do these exercises. Makes sense. So then, five to six weeks you’re out of this, the splints removed, then what do you do? So then we’re going to start some uh again we’ll have the patient use a little bit more force to make a fist and then also they’re going to start some tendinitis lighting exercises. So basically we’re going to have the patient go through different uh different fists to maximize the tend and gliding of the repair. That’s great. So, total time a cut a tendon, everything goes well, no adhesions, when can I get back to full activities? Uh, usually full activities would be about 12 weeks for the tendon to be able to withstand, say, grabbing a heavy weight, or um, you know, opening a door, putting gas in your car, I would say that would be about 12 weeks. Now, if there are sometimes people who cut more than one tendon, more than one finger, does it change anything, or is it still the same rehab? Um, you know, the more complex the repair is, the patient typically will need a little bit more rehab. There might be more swelling, there might be more chance of scar tissue formations, so that might be a little bit longer. Great, well, thanks for joining us and for more on this and many other conditions, please check out our website. Thank you.