Flexor tendon lacerations in zone V

Flexor Tendon Injury and Repair. The Influence of Synovial Environment on the Early Healing Response in a Canine Model

BACKGROUND

Environmental conditions strongly influence the healing capacity of connective tissues. Well-vascularized extrasynovial tendons typically undergo a robust wound-healing process following transection and repair. In contrast, avascular intrasynovial tendons do not mount an effective repair response. The current study tests the hypothesis that flexor tendons, as a function of their synovial environment, exhibit unique inflammatory, angiogenic, and metabolic responses to injury and repair.

METHODS

Flexor tendons present a distinct opportunity to test the study hypothesis, as they have proximal regions that are extrasynovial and distal regions that are intrasynovial. In an internally controlled study design, the second and fifth forepaw flexor tendons were transected and repaired in either the extrasynovial or the intrasynovial anatomical region. Histological, gene expression, and proteomics analyses were performed at 3 and 7 days to define the early biological events that drive synovial environment-dependent healing responses.

RESULTS

Uninjured intrasynovial tendons were avascular, contained high levels of proteoglycans, and expressed inflammatory factors, complement proteins, and glycolytic enzymes. In contrast, extrasynovial tendons were well vascularized, contained low levels of proteoglycans, and were enriched in inflammation inhibitors and oxidative phosphorylation enzymes. The response to injury and repair was markedly different between the 2 tendon regions. Extrasynovial tendons displayed a robust and rapid neovascularization response, increased expression levels of complement proteins, and an acute shift in metabolism to glycolysis, whereas intrasynovial tendons showed minimal vascularity and muted inflammatory and metabolic responses.

CONCLUSIONS

The regional molecular profiles of intact and healing flexor tendons revealed extensive early differences in innate immune response, metabolism, vascularization, and expression of extracellular matrix as a function of the synovial environment. These differences reveal mechanisms through which extrasynovial tendons heal more effectively than do intrasynovial tendons.

CLINICAL RELEVANCE

To improve outcomes after operative repair, future treatment strategies should promote features of extrasynovial healing, such as enhanced vascularization and modulation of the complement system and/or glucose metabolism.

Quantitative examination of isolated finger flexion associated with function of the flexor digitorum superficialis

[Purpose] Isolated finger flexion associated with function of the flexor digitorum superficialis has been qualitatively assessed using standard and modified tests. The purpose of this study was to quantify isolated finger flexion in healthy participants. [Participants and Methods] We assessed 100 volunteers (mean age: 44.6 years) without upper limb dysfunction using the standard and modified flexor digitorum superficialis tests. The sum of the isolated active flexion angles of the metacarpophalangeal and proximal interphalangeal joints of the test finger was also calculated, with the other three fingers held in an extended position with our original jig. [Results] The mean isolated flexion angles were, respectively, 152.4° and 154.8° for the right and left index fingers, 161.1° and 160.4° for the middle fingers, 160.6° and 158.2° for the ring fingers, 129.4° and 134.6° for the independent flexor digitorum superficialis function, 85.8° and 74.7° for the common flexor digitorum superficialis function, and 75.8° and 71.2° for absent flexor digitorum superficialis function in the small finger. The functional variations of the flexor digitorum superficialis of the small fingers showed symmetry in 65.0% of the fingers but asymmetry in 35.0%. [Conclusion] The data obtained in this study provide normal reference values for the examination of independent movement disorders of the fingers.

FREQUENCY, DISTRIBUTION AND TREATMENT OF ACUTE FLEXOR TENDON INJURIES IN ZONE V OF HAND

Background: Flexor tendons injuries are common emergency procedures The objectives of this study were to determine the frequency, distribution and results of treatment of acute flexor tendon injuries in zone V of hand in our population. Material and Methods: This descriptive cross-sectional was conducted in the Department of Orthopedic, Gomal Medical College, D.I.Khan, Pakistan from January 2015 to December 2017. Sample size was 30, selected through consecutive technique. Patients having flexor tendon injuries in zone v, admitted through emergency department were included in this study. Demographic variable were sex and age-groups. The research variable were tendon involved, nerves involved, artery involved, mechanism of injury, wound size, duration of injury, season, type of injury, hand involved and results of treatment. All variables, being categorical were analyzed by frequency and percentages using SPSS version 16.0. Results: Out of 30 patients, 22(73.33%) were male. Twenty four (80%) patients were between 21 to 40 years age. Mechanism of injury was glass in 16(53.33%) cases, knife in 10(33.33%) cases. Twenty (66.66%) cases presented in summer. Flexor digitorum sublimus was injured in 21(70.0%), FCR in 11(36.66%), FPL in 8(26.66), FDP in 6(20.0%) and FCU in 4(13.33%) cases. Median nerve was involved in nine (30%) cases. Radial artery was involved in eight (26.66%) cases. Wound size was 2 cm in 24(80%) cases. Sixteen (53.33 %) cases came with self-inflicted injuries. Twenty (66.66 %) cases came after 12 hours. Twenty five (83.33%) patients achieved good to excellent results. Conclusion: Flexor digitorus sublimus was the most common tendon injured in non-dominant hand, especially in young males. Median nerve and radial artery were commonly injured structures mostly with glass. Majority patients presented more than 12 hours after injury, having wound size of 2cm. Mostly the injuries were self-inflicted and occurred in summer season.

An Extensive Volar Forearm Laceration - The Spaghetti Wrist: A Systematic Review

Purpose

'Spaghetti wrist' is an extensive laceration that involves multiple structures in the volar wrist, including tendons, nerves and arteries. This injury is frequently encountered in trauma units, but despite its complex nature, management is often handled by junior surgeons.Furthermore, the guidance on how to approach these injuries is limited, with a relatively poor evidence base on management and outcomes.

Methods

In this article, we perform a systematic review of the literature on the management and outcomes of the spaghetti wrist injury. Patient demographics, definitions of spaghetti wrist, mechanism of injury, operative and rehabilitative techniques and surgical outcomes are discussed.

Results

Results from this study show significant physical, functional, psychological and financial impacts of spaghetti wrist injuries. Operative technique appears relatively consistent; even though reporting of injuries and outcomes was heterogeneous, no current classification system is in common usage.

Conclusions

An increased focus on the standardisation of assessment, management and rehabilitation and on overcoming the obstacles to care will serve as a guidance to the operative and post-operative management of the spaghetti wrist injury. The use of a single definition and classification system has been proposed to standardise outcome measures and improve inter-observer reliability.

Type of study/level of evidence

Systematic Review: Level IIa evidence.

Functional outcome of flexor tendon repair of the hand at Zone 5 and post operative early mobilization of the fingers

Objective: There are few reports on outcome following flexor tendon repair of the hand in zone 5. We hypothesized that early mobilization of the fingers is possible if the suture site of repaired tendon is strong enough. The aim of this study was to assess the results of flexor tendon repair in this zone using modified Kessler method reinforced by peripheral running suture and a post operative early active and passive mobilization of the fingers.

Methodology: This prospective study was carried out between April 2006 and Feb 2010, and 171 digits flexor tendons cut in 42 patients were repaired by modified Kessler technique reinforced by running peripheral suture. Early active mobilization and gentle passive motion of the fingers was allowed in a dorsal wrist splint the day after surgery. Wrist Immobilization was performed for one month. Function of the tendons was assessed by Buck-Gramcko score at nine month follow up.

Results: Mean age of the patients was 25.4 years (range 17-46 y). Twenty nine flexor policis longus, 77 flexor digitorum superficialis and 65 flexor digitorum profundus tendons of digits were repaired. Middle and index fingers were most commonly involved. Median and ulnar nerve repair was done in 17 and 12 cases respectively. Good to excellent results were seen in of 79.34% of FPL and 74.65% of other finger flexors. One case of FPL rupture was seen. Tenolysis of FDS was performed in one case. Recovery in thenar muscle function was good, fair and poor in 5, 2 and 10 cases after median nerve repair, while all 12 patients with ulnar nerve lesion showed some degrees of clawing of 4^th and 5^th fingers.

Conclusion: Most patients following flexor tendon repair at zone 5 obtained good results. Early motion of the fingers seems to improve outcome in these patients. Concomitant nerve cut in particular of ulnar nerve were associated with a high rate of poor results.

Anatomic and functional improvements achieved by rehabilitation in Zone II and Zone V flexor tendon injuries

OBJECTIVE

The aim of this study was to compare anatomic and functional improvements in zone II and zone V flexor tendon injuries and to determine the effect of injury level on disability.

DESIGN

Seventeen patients (53 digits) with zone V and 14 patients (25 digits) with repaired zone II flexor tendon injuries were enrolled in this study. All patients were treated with Modified Kleinert protocol and followed up for a median of 60 mos. The anatomic improvement was assessed by total active motion scoring system of the American Society for Surgery of the Hand. Quick Disability of the Arm, Shoulder, and Hand (Quick DASH) questionnaire and the grip strength value were used for the evaluation of functional improvement.

RESULTS

Two groups were similar with respect to age (P = 0.147), sex (P = 0.889), type of repair (P = 0.453), and follow-up period (P = 0.499). According to total active motion scoring system, good to excellent results (75%-100% of the normal total active motion value) were achieved in 52% of the digits with zone II and 83% of digits with zone V flexor tendon injuries (P = 0.004). The recovery in the grip strength, in comparison with the uninjured hand, has been found to be 71% and 53% in zone II and zone V injuries, respectively (P = 0.112). There was no difference between Quick DASH index scores of two groups (P = 0.721). The grip strength percentage (r = -0.435; P = 0.014) and total active motion recovery results (r = -0.541; P = 0.002) of the patients were moderately correlated with Quick DASH scores.

CONCLUSIONS

Early passive mobilization in patients with zone V injuries resulted in higher percentage of good to excellent results when compared with zone II injuries. However, this does not translate into recovery in grip strength and disability. This study suggests that although the level of the injury is an important factor for the anatomic improvement, it may not be the predictor of functional improvement.

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.

Treatment of acute flexor tendon injury: zones III-V

Many of the principles of flexor tendon repair and rehabilitation can be applied to zones III-V. Injuries in zones III-V are rarely isolated and neurovascular involvement is common. Because of the often extensive and unknown degree of injury, there should be a low threshold for surgical wound exploration. Primary repair of injured tendons and neurovascular structures is recommended by way of a systematic approach. Good to excellent outcomes in range of motion and tendon function can be expected; however, functional outcomes of associated nerve injuries are varied, with younger patients generally demonstrating the best results (Fig. 2E).

The assessment of flexor tendon function after primary tendon repair

Because the actual methods of assessment and the grading of these methods in favor at any one time have changed so much over the last 50 years, the usefulness of the considerable experience in this field for practitioners today is much reduced. Agreement on the systems of assessment to be used for the different parts of the flexor system would allow a better exchange of knowledge worldwide at this time and a more useful cumulative experience for the next 50 years. If an acceptable method of assessment of any particular injury and its treatment can be agreed on by all, two stages remain for us to audit our work. The first is identifying how much we must downgrade the expectations of the assessment to accommodate the imperfections of our treatments. Most patients would consider an "excellent" result to be a return to normal. Currently, using, for example, the first Strickland system of assessment, we are happy to call any result of primary repair of a zone 2 flexor tendon division greater than 85% of normal, "excellent." How much we should reasonably downgrade our assessments is a variable that one hopes would reduce with accumulated experience, but one that makes repeated adjustment of our methods of assessment essential. Having set the level of the "excellent," "good," "fair," and "poor" qualifying bands relative to normal digital function, it only remains to take our measuring instruments out of their boxes and measure!

Median, ulnar, and combined median-ulnar nerve injuries: functional outcome and return to productivity

BACKGROUND

Forearm and wrist injuries are a common cause of morbidity and are often associated with suboptimal recovery of hand function. This study describes and compares outcome after median, ulnar, or combined median-ulnar nerve injuries.

METHODS

Three hundred thirteen wrist and forearm nerve injuries operated on between 1980 and 1997 in a large university hospital were reviewed in relation to complications, return to work, and sensor and motor recovery. Of these 313 patients, 220 (age range, 5-73 years) met the inclusion criteria.

RESULTS

Motor recovery, progress of sensory reinnervation, and number of severed structures were related to the type of injury (p < 0.05). Multiple linear regression analysis revealed a relation between the appearance of sensory reinnervation and motor recovery (beta = 0.02; 95% confidence interval, 0.01-0.04; p = 0.01). A probability of 24% of work loss, after a mean follow-up of 17.7 months, was found. Poor sensory and motor recovery were associated with work disability (odds ratio [OR], 2.9; p = 0.002; and OR, 2.9; p = 0.007, respectively). No relationship was found between type of injury and return to work (p = 0.47). Level of injury (OR, 2.6; p = 0.01), type of work (OR, 3.1; p = 0.002), number of complications (p < 0.001), and hand-therapy (OR, 0.24; p = 0.001) were found to influence return to work.

CONCLUSION

It may be concluded that peripheral nerve injuries at the forearm level can result in substantial functional loss and have major social consequences. This study identified factors influencing return to work that can be used to optimize postoperative treatment strategy.

A prospective study of flexor tendon repair in zone 5

A prospective study of postoperative mobilization of flexor tendon repairs in zone 5 was conducted over a 2-year period between 1994 and 1996 using a controlled active motion (active extension-active flexion) regimen of mobilization. Fifty-two patients, who had a total of 151 flexor digitorum superficialis (FDS) and 103 flexor digitorum profundus (FDP) divisions, were available for review at a mean follow-up of 10 months. Of the 161 fingers with division of one or both flexor tendons, 66% exhibited independent FDS function and 90% achieved good or excellent results of digital range of motion. No rupture of an FDP tendon repair occurred during the study period. The data allowed us to define a new method of classifying the results of treatment of these injuries in terms of the injured wrists as a whole and not simply as a series of isolated observations for each individual finger with divided flexor tendons. The results of recovery of independent FDS action and range of finger movement achieved for injuries in which the flexors of all four fingers had been divided indicate a statistically significant interdependence of injuries of finger flexors of adjacent fingers at the wrist. Multivariate analysis showed the presence of a "spaghetti wrist" injury to have a significant adverse effect on the recovery of the independent FDS action but not on the recovery of the digital range of motion.

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 occurred in a zone 2 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.