Cut Wrist & Flexor tendon injury

Cut Wrist & Flexor tendon injury Ramy El Nakeeb, MD. Orthopaedic Department Damanhour Medical institute

ANATOMY • FDS • FDP • FPL • Lumbricals origin from radial side of FDP

FDS divides and passes around the FDP tendon, the two portions of the FDS reunite at “Camper’s Chiasma” CAMPER’s CHIASMA

PULLEYS Preserve A2 and A4 pulley to prevent bowstringing. NOTE: There is a mistake in this diagram: The C1 pulley is DISTAL to the A2 pulley!

TENDON EXCURSION • 9 cm of flexor tendon excursion with wrist and digital flexion • only 2.5 cm of excursion is required for full digital flexion with the wrist stabilized in neutral position

BLOOD SUPPLY • Segmental branches of digital arteries which enter the tendon through: • vincula • osseous insertions • Synovial fluid diffusion

VINCULAE

ZONES

The goals of the surgical treatment is to achieve a primary tendon repair of sufficient tensile strength to allow application of a postoperative mobilization and rehabilitation protocol.

It is well-known by hand surgeons that the catastrophic potential of a volar wrist laceration can result in a functionless extremity. Tendon repair can be expected to heal and maintain individual gliding function when primary repair is coupled with early and aggressive occupational therapy.

Tendon Injury in Cut Wrist • Zone of injury • Complications • Management • In the Emergency Room • First aid • Calm the patient • Examination • Surgical repair • Rehabilitation • Cut wrist in a child

Cut wrist injuries were defined as lacerations occurring between the distal wrist crease and the flexor musculotendinous junctions. It may involve as many as 16 different structures, including 12 tendons, 2 nerves, and 2 arteries.

Adhesion formation • In many instances, it is unrealistic to expect a tendon to heal without any adhesions, some loose adhesions may develop after surgery even with exercise. • Adhesions influence tendon movement depending on their density. • loose adhesions arise from the subcutaneous tissue • adhesions of moderate density • dense adhesions arise from the bony floor or volar plates • A fourth type are adhesions between the repaired tendons.

Repair rupture • Among all the consequences of flexor tendon surgery, repair ruptures are of prime concern to hand surgeons, because they require secondary operations. The following factors may trigger the ruptures: Overload of the repaired tendons Tendon edema or bulky tendons Triggering in pulleys or edges of opened sheath

Joint stiffness • Clean-cut flexor tendon injuries themselves, however, usually do no trauma to finger joint structures. It is the postoperative protective finger position that causes joint contracture.

Nerve injury • May lead to insenate hand • Loss of intrensic function

Vascular injury • Cold intolerance • ischemia

A Case of Cut Wrist

First aid: Cut wrist • Tendon injury • Nerve injury • Vascular injury Emergency????

Vascular injury Pleeeease Do not clamp & No stitches ischemia bleeding • Removal of tourniquet • elevation of the hand as high above the heart as possible. • packing of the wound and direct pressure Did not stop Bleeding from a partially severed vessel

Now you can calm the patient

Cut wrist • Why not directly into the OR ? 1. you can miss something 2. you can avoid operating and transfer the case if no proper facilities or expertise are available. 3. A superficial wound ????

Examination • What to search for in your examination ? • Diagnosis of tendon injury

TENODESIS EFFECT • Passive extension of the wrist does not produce the normal “tenodesis” flexion of the fingers if flexors are injured

FDS: Clinical Exam

FDP: Clinical Exam

FDP RUPTURE • No active DIP motion (present passive DIP motion)

Nerve injury : Motor ulnar and radial, median sensory.

I must have with me: • Basic instruments.

Magnification and microsurgery instruments

BRUNNER INCISION

Extension of the wound

Extension of the wound 2

Extension of the wound 3

Identification and tagging • 1.Distal structures • 2. Proximal structures should be identified from deep to superficial and tagged……..N.B. Follow the Hematoma • 3. FDS 3 4 5 2

numerous studies have demonstrated the superiority of the four-strand core suture overthe two-strand core suture and the greater strengths achieved with six- and eight-strandcore suture techniques. • The limiting factor to more widespread use of modern multistrand suture techniques remains the surgeon’s ability toperform the repair using atraumatic techniquesuch that trauma to the tendon stumps and the circumferential visceral epitenon is minimized.

How to choose which kind of repair ?? the epitendinous suture

2 Suture material: non absorbable Suture caliber :4-0 3-0, (the mode of failure was affected by the configuration and the caliber of suture used) The needle

Nerve Repair The purpose of performing a nerve suture is to align, as accurately as possible, the corresponding fascicular components of the proximal and distal nerve segments. The evolution of surgical techniques has passed through many stages. One important step was the introduction of the operating microscope, which made it possible to identify and manipulate nerve structures with improved accuracy.

Nerve injury crushing Clean cut Do not clamp Apparent Not apparent Direct sutures Trim+ direct repair, if under tension primary grafting Direct sutures will give bad results

Vascular repair

Cut Wrist & Flexor tendon injury