Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Soft tissue injuries of the hand. But unfortunately, Miss Claire's wife all had a last minute uh change. So we're not gonna do that. So, uh we've got Miss Sonia Gardner who's one of the consultant, plastic surgeons at Bromfield Hospital. Um, who's gonna talk about flexor tendon injuries. Um Then I'm gonna talk about extensor tendon injuries. And then we've got Michael Whitlock as one of the hand therapists at Saint Andrews Center at Bloomfield, who's gonna talk about a flexor and extensive tendon rehab. So, and then, you know, feel free to ask questions at any point in time and then we can try and keep it interactive as much as possible, right? So I'm going to hand it over to Sonia if there any, uh we should be able to see her slides if there any issues. Just let me know. Yeah, can you will see and just, you'll just have to shout out if you want to ask anything because I don't know how to see you and see the screen. Um So just let me know, just shout out and you can interrupt me if you need to. Ok. So we're going to talk about flex tendon injuries today. So, just an outline of the presentation, we'll discuss some anatomy, then we'll talk about how we assess these injuries and then concentrate on aspects related to the prime reflex tendon repair. So we won't deal with secondary tendon surgery. That's a whole topic in itself. Um What kind of repair techniques we use, the management of the tendon teeth and the pulleys and really how we've evolved over time and the techniques have changed according to the evidence base. And then we'll touch on rehabilitation because I know you've got that talk separately. A bit of flexon anatomy. As you all know, you've got an FDS and an FDP. Each thing, you've got an F FPL to your thumb and you know, the FDS of the little is absent in about 10 to 15% of cases. So that's something to be aware of when you've got an injury and you're about to open the finger. You can see here, I don't know if you can see my cursor, but you can see initially approximately the F DSI see position for the FDP. And then it changes its location, it divides and then it rejoins by this campus chiasm. And it's worth just thinking about the importance of the F DS. And we know when we harvest the F DS and we use it for tendon transfers and other things that we can cause problems with the finger. Um And we can risk things like swan necking. So there is some, you know, reason to have the F DS and it confers some pip stability in addition to its function, like see the digit, we also need to think about the blood supplies. So the blood supply to your flexor tendons come from your venular. And there's a short and long to both the F DS and the FDP, you've also got blood supply coming through your muscular tendons junction and also at the insertion sites where it's attaching to the bone. So just to be aware of this, because it also affects when you've got particularly tendon injuries and your closed flexor tendon ruptures, you know, it will affect how much it migrates approximately. So how much you have to really open on the finger to retrieve it. We also need to talk about our pulley system. So these are your fiber osseous sheaths that your tendons sit in, made up of your annular cruciate pulleys and your annular pulley are really your kind of more fixed, stronger substances. And your cruciate are very flimsy and they allow the annular po to concerti it together when fingers flex. Of course, it's really important when we're managing these injuries to think about the tendon sheath and the pulleys there, they're there because they confer that biomechanical advantage, the flexion and we want to prevent bow stringing a couple of papers just to think about for your flex at tendon sheath and your pulley system. So, there's a paper by Doyle in 1988. So these are some of your classic papers for your flex at tendons. And he looked at the flex at tenon sheath. And he also noted that there was this Palmer aponeurosis, this Pa Pulley that sits proximal to the A one in his biomechanical studies. He showed that that Pa Pulley did have some significant function. So it's not something we generally think about. But I think in his paper, he talks about if you lose a one and a two and then comparing it to losing a one, a two and the palmar aponeurosis pulley, you get more bow rigging. So the palmar apopsis does confer some biomechanical advantage, then just thinking about the thumb as well. So this is a key paper by Vivien Leigh and we classically get taught that it's the A one oblique and the A two pulley. But there's also this V pully that sits just distal to the A one. So it's a variable pully. And actually, it's thought that the A one and the V are the most critical pulley for the thumb. And they're the ones that you really need to think about preserving. If you can, we'll talk a bit more about how we manage the police. A bit later, we also need to talk about the flexor tendon zones. I'm sure you're all aware about this. So the Verdens flexor tenon zones in the finger. So your zone one from the end to F DS insertion, then to the A one pulley and the proximal part and you've got the palm to the carpal tunnel, the distal part and to the proximal part and then coming up into the wrist for your zone five and kind of similarly for your thumb. So, it's important when you're particularly recording in your operation records for the hand therapist, I'm sure they find it very useful to know exactly where you've operated. And it's not just the, that general subdiv the subdivisions, it's not just the divisions that I've just shown you. So for zone one, Moman and Elliott did further subdivisions and for zone two T has subdivided further and it's probably the subdivisions of zone two. That's particularly important when we're thinking about how we're going to manage to flex the tendon injuries. Because if you've got an injury in this two C area, which is really under the um in the A two pulley, this is a very, very tight space. So this is the kind of area you're thinking about venting the pulley and you can really vent up to two thirds of the pulley quite safely. And it's also an area where you probably think about just repairing the FDP and not the F DS because you don't want something so bulky to affect glide. But if you've got an injury more approximately the two D section, then you're pretty much safe to kind of vent your a one if you need to and then repair both. So, something to think about helped you plan your surgery also are closed ruptures. So we have the Packer classification. Sure, you're aware of this, um, describe 1 to 3 and kind of progressively, you know, you got one going into the palm, then two at your A three and then FDP with a bit of bone at your A four and then four and five have been later um added on. So four is when the tendon is separate from the fracture fragments, you've got two things to deal with. And then five is when you start getting these comminuted dystrophin fractures, which actually can be quite challenging to treat because you've got multiple things to deal with. You need to fix your fractures and you need to get the tendon back on and you need to manage the rehab of these patients afterwards to try and get some movement. Has anyone got any questions? Everything? All right. So far, I assume, yes, I don't hear anything. Um So how do we assess these injuries? Well, in an exam situation, any trauma patient, you have to say your ATLS, you know, assuming this is an isolated injury and then focusing on the hand, be prepared for your general hand focused history. So age occupation, hand dominant mechanism of injury is obviously extremely important and you want to know what position the hand was in when they did the injury if the hand is fully flexed at the time of the flexor tendon injury, then when you're exploring the thing, you're more likely to expect the division of the flexor tendon to be distal to the skin. And that affects how you're going to plan your incisions to open or is it closed? Is it open, you know, your closed injuries? Is it a Leddy Packer injury or are we dealing with closed ruptures in the setting? Things like rheumatoid or distal Raia. So we're not just dealing with the classical trauma patients that we think of. And then obviously, when you're examining, you would assess all the fingers and assess your vascular status of the hand, your FTS ftp independently, you know, do your x rays check there's no bony injury, all the necessary medications tailored to the patient. And then usually your initial management, if there's an open injury, it's going to be a tetanus antibiotics, wash the wound, splint them appropriately for comfort if you need to and then plan for surgery. And these just fade across. I show you some of the presentations that you see. So when we're planning for surgery, obviously really important to outline the risks and the pathway that the patient is going to go through. And actually probably one of the most challenging things sometimes that you have when patients turn up on the trauma list is that they've been consented by someone, but it hasn't been made clear to them that, you know, this flex atend and injury is potentially the amount of action off work for three months. And you know, for the heavy workers and that's really important. You don't want it to come to the shock. It needs to be at that first visit that it's laid out the sequela and what their rehab is going to be like general consent that you need to tell the patients about scars, wound healing, infection or the usual stuff that more specific to the hand with altered sensation, cold intolerance and CRPS. And then more specific to your tendons, it's mainly ruptures and adhesions that we worry about. And then as I said, make it clear how long are they going to need off work when they can drive and so on and then planning your anesthesia obviously could be general regional. And now more popularized by Don is the wall technique which you know, allows us to be a bit more independent from the from the regional anesthetic. But also I think comes with a bit of a learning curve if you haven't done it before, but it can be very useful. So how are you going to plan your incisions? This just gives you a bit of an array of different kinds of incisions that you can use. I mean, most classically you'd use a mid lateral or a Brunner type incision that you can see here. I quite like the mid lateral just because then you have a bit of better covering of your tendon and your nerves and vessels if you've got them to address as well. But you know, Bruno is fine if that's what you're used to, you just want to raise nice thick skin flaps so that they heal well and you plan them appropriately so you can see what you need to. Someone said they can't see the screen. We're just checking. Does anyone have any other issues with seeing the screen? Because I can see it? I can see. Ok, fine. So I am guessing no one else has any issues. I will ask the other person to see whether they need to restart it. Um ok. Alright, sorry on um and then this I don't know if you're familiar with this technique. I think it was originally described by Tang but there's I've got a little video that I can show you that is a push pull technique from retrieving your flexor tenons from the palm that stops you having to open up everything. Let me just see if we can. Can you say this with dear you two? Does anyone yell out? Yes, I can see it. Yeah. Yeah, we can see it. Yeah. Yeah, sorry. Can you see that? Yeah, I can I just continue with it. I think most people are saying yes, I can't hear anyone now. Hello? You can. Oh sorry it the video was muted. Let me just mute the visits up. Ok. Sorry, my mistake. So this is quite a nice technique where you're dealing quite distally. But then you can just make an incision in the palm and then you literally just get two forceps and you push it up and as you push it up, you grab the bit proximal to it and push it up again. And it means you keep it in the sheath, you minimize how much you've minimize your skin incisions. And ever since I showed me this, I've used it ever since and it's much quicker as well. Less to suit you at the end, you less edema. And it's a nice little technique and you can see how otherwise some he's just demonstrating here in the video. Otherwise you would have opened up all this area to try and retrieve it and it stops you having to use other feeding tubes and suture loops that can be quite fiddly and sometimes frustrating. Ok, back to this. So now we talk about the actual repair itself. So we need to talk about how we're going to repair the tendon. Are you going to use a couture? What type of cou are you going to use a number of strands that you're going to use? You're going to use an Epitendinous. What suits your material you're going to use then thinking about the tendon sheath and the pulleys. What's safe to vent? What are you going to vent? How are you going to manage the sheath and then we'll touch on the rehab and really all these things go together. So as our ability to get stronger tender repairs has increased, so too is our ability to increase our rehab. And really, that's how early active mobilization has evolved. This is quite a nice paper that it's very recent 2022 modern of surgery in European. And it's kind of some of the big names in flex tenon repair surgery, Jim Bo. And they talk about how they do their, they manage their individual patients with flex tenon injuries. So they talk about how they repair and how they do the rehab. So probably worth a read. It gives you a nice overview about current practice. This is quite a very important paper. So it's talked about the biomechanical aspects and the forces along intact tendons. So generally, if you're going to have full active finger movement that transmits forces about 35 newtons and surprisingly tip pinches a lot. Timp pinch is up to 120. So first when you started, really, people were just using two strand techniques and that really only compares about 15 newtons. So when we think about what we want to achieve, when we're trying to get these fingers moving early actively, and it's not really good enough. And I think the only thing that really saved all these two strands who were having lots and lots of ruptures was that we use an epitendinous with it and that probably confers another 20 units, sorry, 20 newtons. So that's something to worth thinking about. And that's why we're all moved to four strand and some people use six strands because they confer 40 newtons plus. And if you've got 40 newtons plus, then you can, you know, tolerate this unresisted, active finger movement and you can tolerate early active mobilization. So that's really where everything has come from. And you've got to think about what suture you're going to use. So it needs to obviously be strong, biomechanically sound. You know, think about the morphology of the core suture, the number of strands, the knots that you're going to use. You don't want something too bulky, you want something biologically inert because you want to make sure things heal and it doesn't interfere with the tendon healing and it's got to be user friendly. You know, if we're going to change to different suture materials, surgeons want to use it. I think most people and myself included, generally use Prolenes with a round bodied needle. Some people like ether bond. But I think with these kind of heavily braided sutures, they glide less and it's probably harder to prevent gapping as you're bringing your tendon together. And then there is also a move to use the very strong sutures like the tina fix. But I think they're a bit less user friendly. So that's why people haven't adopted it and probably harder to get lots of strands in a small tendon. This is something to worth thinking about. So there was a paper by a BAC 1975 a long time ago. Sorry about that. And they looked at the tensile strength of the tendon um, after it had been repaired, flexor tendons and what they found, they used dog flexor tendons and they found that the mechanism of failure changed according to how long it was since the repair. So very early on. So day one, it could withstand about 40 newtons. And then the tendon repair failed because the suture snapped. But once you got to day five, you know, it was a lot weaker and the suture tended to pull out. So that was really because the tendon was softening. So initially, it fails because the suture fails, your repair fails. And then later on, it's because your tendon has softened and weakened, which really raises the question, whether does it really matter what we use? Because then that limiting factor that's causing a rupture is more likely to be the tendon itself rather than any suture that we're using a type of suture. So then thinking more about the core suture, you want something that's going to grip the tendon ends at the distance from the cut ends, but prevent the suture pulling through it when it's subjected to that longitudinal tension. There's a huge array of different types of core sutures. I like to use an Adelaide. But I think you just find something that you like and you need to use at least a four strand. Now, you know, you could be pressed to, you know, you could be heavily criticized for using less than a four unless this particular circumstance. And then you generally want you using a three or a four suture. And that's because as you start getting thicker sutures, then your knot is going to become bulkier and that might affect your glide or affect tendon healing when it's sitting in the center. This is kind of a landmark change in flex tendon repairs. So savage brought out a six strand repair and then suddenly the rupture rates came down. So probably before these rupture rates were always sitting about 5 to 6%. And then this increase in the number of strands reduced the rupture rate to 3%. And that's we talked all about the strength of the core. They really had over 40 newtons and this was sitting, they say about 86. So really this was quite a turning point in flexor tendon repair surgery because after this, a lot of the focus all went to four strand six strand and that's really where it's gone from there. And as I said before, probably the only thing saving the two strand techniques was the epi tenderness which we'll talk about. Now, I think, or we'll talk about the Adelaide first. So this is the one that I like. Um, it just kind of comes together quite nicely. It's a four strand, it's got these locking sutures and these are things that have been deemed important in biomechanical studies to confer strength with flexor tendon repairs. So, having a good suture purchase. So that means the distance from the cut of the tendons ideally wants to be about a centimeter, having these locking sutures and then also slightly shortening your tendon segment at your repair site and that helps you resist gapping. So, you know, for example, when Doon does his under warrant, I know that he tests the repair and he's what he's looking is looking to see if there's any gapping. If there is, then it needs to be redone because that's gonna increase the risk of failure if there is any gapping. Um So now, you know, we talked about how, you know, we're mostly doing four strand, but really a lot of the literature is going in the direction of six strand course. And I've got another video as well of this because it might be something you're not familiar with and you, OK. So this is a, a six strand and it uses a loop and it uses a for a loop nylon suture. So this is just a demo. So you kind of do a loop and you lock it. And I mean, this kind of repair now based in the literature that was like a zero rupture rate. So it kind of looks like that's the direction that flex attendant repairs are going in and then I'll do, I'll try to speed this up. You don't just, it's just gonna be a box type suture being done. You can see and then coming in half and then this will be tied off. So you've got four strands now from the two loops and obviously you'd not have a gap here. They're just doing this to demonstrate the repair and then that's tied off and then to get your six, they put another feature in the center, just get that's tied off as well. OK. OK. Yeah. So, you know, and there's discussion whether it matters whether or not within the tendon ends or not, and it hasn't really showed that it affects healing, whether it's inside or right, and it's outside, there's not good evidence that it affects glide. So I don't think there's a clear direction from that standpoint and then the epitendinous suture. So really the role of that epitendinous suture that goes around the tendon is to try and help with the glides. If you've got ragged parts, you can tuck them in. Um And, but then you think about you've got more suture material going around the tendon, is that going to increase resistance on the suture surface? So that's when people say they don't use it. And then there's the argument, does it increase strength? But if we're starting to use more multiple multistrand repairs, the six strand repairs and is there a point in adding any more suture material. So with um the Tang method, he just uses some sparse epitendinous around just to tuck things in probably the main strength is coming from that six round core. Um But then there's more in the literature with individuals such as Giesen that are using the M 10 the six strand and they're not using any tenderness and it doesn't seem to be equating to increase rupture rates. So again, this could be the direction we're going in six strand with no epi tender, but I think it's also very surge dependent. Um I mean, I haven't moved to something like this yet. I'm using the four strand Adelaide. And I think changing your repair technique, obviously, there's a learning curve and you're trying to put more suture materials sometimes in quite small space. This is just uh if you put your mics on and if you just want to shout out just some light relief, an M CQ. Yeah. OK. Anyone high number of crossing? Yeah, perfect. So kind of where everything we've shown all the evidence is going towards the core strands. Really the most important, more strands help give you more strength, reduced risk of rupture the tendon as we've talked about might confer some strength, it's probably not critical. Now, as we're using 46 strands, knots don't seem to make much difference. The presence of a gap does, but the strands have more of an effect on strength and locking, um sorry, locking loops do as well. But again, to a lesser effect. So when you're just dealing with MC Qs like this, just go for the clear one that you know, definitely increases the strength the most. So we just touch on tendon healing. So you have to think about intrinsic and extrinsic intrinsic tendon healing by proliferation of the tenocytes and production of the extracellular matrix by the intrinsic cells. And we're talking about your blood supply coming from your vincular diffusion from the nutrient and the synovial fluid. Then when we talk about extrinsic healing, it's cell seeding outside the tendon and it's very much dependent on the fibrous attachment between the sheath and the tendon. So you're going to get more extrinsic healing if you've got a very badly damaged tendon or you have to immobilize the patients. So they've got a fracture as well as a flexor tendon repair. Um And it's going to obviously, if you've got a very badly damaged tendon in your finger, it's going to limit your intrinsic healing and then they give you usual phases of hearing inflammation, proliferation, remodeling. So, what am I thinking about? I'm sorry, very sensitive screen when we're thinking about the tendon sheath, that's really changed the thoughts about how to manage the tendon sheath. So, in the forties and sixties, they would excise the whole sheath and they thought that you just needed adhesions and scarring to get the tendon to heal because it was all about extrinsic healing. Then the seventeens, they showed that the tendon healed in that so over environment so that they were meticulously closing every bit of the sheath. And that must have meant that there was a lot of adhesions as well and things got stuck. And then more recently, they've shown that blood vessels go along the epotenon. So that's more in line with intrinsic healing and then our ability to um join that with early active mobilization. So what do we do with the pulleys where we touched on the s when we looked at the pulley anatomy, but generally, you know, you might need to open a couple of centimeters. You want to try not to, you know, avoid opening and going crazy. You want to avoid, you know, you just do the minimal dissections. You can do a good tender repair and make sure that there's good glide generally in the digits, you can vent the whole of a four if you need to A two is probably more important if you can vent about a half to two thirds. But if you can avoid venting a two do so. And as you all know, a two and a four are the most critical the pulleys that the largest, the strongest. And we think confer, you know, reduce the risk of bow stringing if you keep them. And we also talked previously about how you can plan what you're going to repair, if you're not going to repair FD or just one slip or go into how tight your space is. And if you're in the two C, then you might just repair your FDP and you might need to even some of the at pulley. You can also think about if you're in a very tight space. I think Davey Elliott has published a lot in the flex in the literature and he talked about using a hemi FDP. So there is a mindset that you should try and do everything you can to do prime reflex, a tendon surgery because we get better outcomes than any secondary tendon surgery. I'm putting in rods or tendon grafts. And then when you think about it, using half an FDP is probably equivalent or might even be a bit bigger than using a Palmaris Longus, which we would use as a second stage. So doing everything you can tendon lengthening immediate grafting if your sheath is good to try and reduce the risk of having to put the patient to that prolonged two stage rehab and probably not having as good outcome at the end. And then with your thumb, general teaching is to keep one annul part of oblique. And we talked before, it's probably the A one and the AV V that are the most important. This is just put in more for the hand therapist because it's a pet peeve, but we repair these tendons and then they don't know what's been repaired where it's been repaired, what's happened to the pulleys. So you just want to give a good summary of everything that's been done. What digits are affected, the zone of injury? We talked about the percentage injury and what's been repaired. So if it's less than 50% you're better off, just if it's more than 50% sorry, you're better off or more than 50% in touch, you're better off leaving things alone. What kind of repair you've used? Have you vented pulley with any special circumstances? You know, very damaged tendons, bony injury as well and so on, all these things can affect how they rehab the patients. And this is quite a nice paper by David Elliot. Kind of talks a little about the evolution of tendon repairs, tendon repairs and pulley management, how we've got to this stage, just wanna have a look at that. So I'm just going to touch a little bit about rehab because you've got separate lecture on that. Um But we like so many things, we tend to go full circle. So more early 19 100s, they realized that you needed a good strength repair to allow you to get moving. But then they really went away from this and be in the forties and the fifties. They were just immobilizing the hand so they could heal with adhesions. And they also went through a phase where everyone had secondary flexor tendon surgery and they weren't really doing primary surgery on any. Then in the sixties, the mindset change really coming out of Louisville and Switzerland. And then they really moved to immediate repair and early active mobilization because they were showing they were getting better outcomes in terms of range of movement. And they realized that you don't need that extrinsic healing to get your tendon healed. You've got that you can rely on and get the patient moving. So hand therapy regimes. So initially, there was the traction, which are these rubber bands, you can see the top right hand corner as you can see that they're connected to the fingers and to the kind of polar aspect of the wrist. Um And you know, really the patients, they've got kind of a regime of passive flexion, the bands, bring the fingers down and they would actively extend. But the main issue with these rubber bands is that they'd get P I PJ contractures. So then they started moving away from the bands and then there was ad and hauser in the 19 seventies as well and they went for just a passive mobilization. But what we use today, which you're all aware of is based on the Belfast regime, what we use in this country generally and that's your early active mobilization. So generally with this, you accept a slightly increased risk of rupture rates for getting patients moving and getting an increased range of movement. And actually in the initial papers for the Belfast regime, they had quite high rupture rates even up to kind of 9 10%. But that was more because they were again using the two strands. So now we're in a very different situation, but we're using the multistrand. So we're actually using repair techniques that allow us to do this early after immobilization. And you can just see an array of splints there in the mid where there's this Manchester Short Splint that some centers use. Um And again, this paper just shows by star 2013 General Plan Surgery America and shows that you get better outcomes, slightly increased rupture rates, but generally better outcomes by using early active mobilization regimes. Ok. So it's like frozen, apologies. Know my screen just frozen, but I think it was generally it there might have been an M CQ at the end. Can you still hear me? Yeah, we can hear you. Yeah. Sorry. My screen shut. But I think it was very near the end. Does anyone have any questions about anything? Anything I wanted to talk more about? Sure. No. Ok. I might just have to switch off my computer and stop sharing. Otherwise you might be just stuck with the slide for the rest of your, I'm sure you don't want to read this paper that badly for having. I hope it was useful. Um And I think you're going to hear a bit more about rehabilitation and regimes. She'll, she'll mirror this talk nicely. Yeah. No, thanks very much. Sonia. Does anyone have any questions for Sonia before? She looks off? I think she's got clinic this afternoon. No, no. Ok. I think Sonia, um Michael might come in with much back. It's just come back. Um Do you want me to just see, can you see your system? I can still see the, I think I was just going to talk about the Splint we use but I think you might talk. So we use a controlled active mobilization Splint. Why don't we just end with an M CQ for a light relief? Yeah. Can't see a change of your screen. I can't see it. You want me to stop screen sharing and start again or see how we can stop? Yeah, I see. Screen sharing has stopped now. Now can you say something? The OK. No, I can't see. Let's see that it's up. OK. All right guys. All right. Thanks very much on you. You're welcome. Bye everyone. I hope the rest of the afternoon is helpful. Bye. Mm Right. So if everyone can hand me, uh we're gonna try and go to my screen share. Can everyone see my screen? Yeah. Yeah. Right. So I'm gonna talk about extensor tendon trauma. Um It be slightly different from the plastics point of view. Um I don't know if Sonia sort of mentioned, does anyone know why flexor tendons go to the plastic surgeon to the extensor tendons? Don't always necessarily go to them any guesses. Ok. Bone here. Yeah. The extensor tendon repairs are more forgiving than Flexor tendon repairs. Well, that's one thing. So, yeah. So, you know, when you talk about the pull out strength and you look at all the classical papers, most of them focus on flexor tendon injuries as opposed to extensor tendon, um, injuries. But there's another more sort of pertinent reason. Does anyone know, I think because they can retract more uh proximal? So how does that make a life? How does that make a difference? Incision wise, soft tissue covered, uh possibly, but you know, extensor tendons can retract as well. If you do an E PL repair, the E PL tends to retract approximately past the, the wrist level as well. But the main one, I mean, in my head, the main reason is that flexor tendon injuries are also strongly associated with nerve and arterial nerve and vessel damage. Yeah, because that's why the anatomy is important because whenever you get a flexor tendon injury, it's usually a laceration and, and you will in, you know, inadvertently get nerve and um nerve as well as arterial injury. And you need to assess that when you, if you ever see someone with a flexor tendon injury, whereas for the extensor side, you don't tend to get that that often. So I think that was, that's sort of the main reason, right. So we move on, we'll go through the basic anatomy. So we'll cover uh the tendons of the wrist and we'll go towards the fingers and then we'll work our way back down. Um So this is basically you can see, uh the extensor tendons crossing the wrist level. You have your extensor retinolum, um and you have the different sheaths, which we'll go through in a second and then they sort of then split up and then go towards the fingers. What's important is the junctura tendinum. Um Does any, can anyone has it a guess what the juncture tendinum sort of function is? Why are those important? You want her scar exam here? Ok. It's a fiber tissue which it attaches to extensor tendons in between them. So if you have one injured, basically the tendon, which is still attached, if the, if the injury is distal to that attachment of your to a tendon, the, the tendon, the extension still can work by um by being basically pulled by extensor to the other finger. Yeah. So, I mean that, so that's so in a clinical setting, that's rather important because you might have someone who comes in with a extensor tendon injury and then you, they can still extend it and you think that's fine, but you just have to have a low thre a high threshold to sort of so a lower threshold to sort of explore because of the fact that it might be the function of the juncture tendon and that you're seeing as opposed to the fact that, you know, the tendon is still um not, not, not torn. So that can, you know, sort of confound things slightly as well. So that's why it's important to sort of know that uh anyone apart from Maria want to answer what the compartments are. So this is at the risk level. So there are six compartments who can tell me, I mean, number six is already named there, who can name the other ones. This is a common exam question for the Fr CS. So who can name me the tendons in the in the compartments? N compartment number six is already named, that's EC U in there which goes through on the groove on the on the ulnar. What about the other compartments? Compartment? One APL and B Yeah. Yeah, 3d E CRL MB. Yeah, three EP. Yeah. So A DC and AD yeah and 5 a.m. Yeah, that's fine. So you know, make sure you guys sort of know this inside out and sort of practice that as well because in the they can ask you to draw this as well. All right, and it's important to know the different sort of injuries that can happen uh in each compartment. And as far as this, you know, compartment one, you look at the current compartment two, you look at intersection syndrome three, you have, you got your EP RR and so forth. Um We're gonna cover trauma today's um and we'll cover sort of degenerative conditions late in the next year, I think. But it's still sort of important to know. Right. Then we're gonna look at the anatomy of the finger. So this is a bit more complex, but it's really sort of important to understand how, what, what happens, um, at this level because a, it tells you what the function is. B, it tells you what are the important structures and c, it tells you how you're gonna sort of manage them. So you've got your EDC uh coming through and then you, you is maintained over the metacarpal by the sagittal band. And the function of the sagittal band is really to keep the extensor tendon centralized over the MP. Uh Because if you look at it, there's no bony connection into the uh into the base of the proximal phalanx. So it doesn't really have a direct pull. But because of the Sagittal band, it can then allow the MPG flex uh M PGA extension to happen. Then as it goes over the middle phalanx, um you start, it starts splitting up into, into your left, the, the lateral slips which then coalesce with the, with the attachments from the lumbrical and the inter side to form your lateral bands. Um And that's important because the function of the inter rosa and the lumbrical part of it is to help extend the P IP and the D IP. So they are quite integral to the function of the extension of the finger. Um And then on the side, if you, if you look at that, you've got your transverse retinacular ligament, your oblique retinacular ligament and on top, you have your triangular ligament. What's the function of the transverse retinacular ligament? One prevents dorsal subluxation of the tendon. Yeah, good. And therefore the triangular ligament is to prevent volar subluxation of the lateral band. Yeah. So when you assess sort of chronic injuries, you know, you need to look at those things because all the deformities that you might get in injuries are precipitated by any potential injuries. The oblique retinacular ligament has um you know, there, it's debated on, on its exact function is there are some papers that suggest if you excise them, there is uh no functional loss, but it sort of helps to um extend the, maintain the extension of the P IP and the D I PJ simultaneously. So, and the other thing to note for the lateral bands are quite interesting as when you go into flexion, they, the axis goes go up and when you extend it, it goes more dorsal. But then the two ligaments help to hold that in place. All right. So that's the sort of basic anatomy that we're sort of looking at. Central slip inserts into the base, um uh central slip inserts into the base of the middle phalanx. Um And then the two, the lateral bands then sort of coalesce held by the triangular ligament, then go into the base of your D I PJ. OK. So that's sort of the basic anatomy. Now, um as with flexor tendons, they are in different zones of injury. Uh the zones of injury is slightly more uh different. So we've got one which is at the D I PJ two over the uh middle phalanx. Uh three is basically your insertion of the central slip. Four is over the proximal phalanx five is over the M CPG area. Six is overlying the dorsum. Oh, sorry, the dorsum of the hand and then your, you know, seven is over your wrist joint and eight is more proximal and the thumbs have their separate zones as well corresponding to the joints and where things insert. So we'll look at injury zone by zone because I think that's one way of doing that and then we'll assess the thumb separately. So this, we see very commonly mallet fingers. So what is a mallet? How do you get a mallet injury? It usually force flexion of an extended D I PJ. So very often you get patients. So you're saying they were doing the bit sheet, so they were flicking the bit sheet, pulling clothes out and they just felt something go um or it can be quite traumatic um as well. So I usually sort of split them up into a tendinous injury and a bony injury because that changes the way I sort of manage it on the x rays, you can see what the avulsion, bony avulsion looks like. And then WW the other one on the right hand side is just um a pure tendinous one. You don't need any other imaging really to diagnose this. Um Again, classification system Doyle, you know, type one is close injury with or without small dorsal avulsion fracture. Type two is an open injury. Type three is also an open injury but that um has significant skin loss and tendon substance loss. And then type four is what we call your sort of mallet fracture. Um You have your pediatric ones, um which is like a semo fracture involving the growth pain and then you can subclassify that into B or C depending on the articular surface fragment. Um In the past, there used to be talk about um when you would have to surgically treat them depending on the size of the articular surface. But I think it's got to do more with what your reduction is. If you can reduce the fragment in a split and hold it into a good anatomical position, then you don't necessarily need to fix it. So with, um, if it's purely tenderness, normally you get a stack splint, which you can see that's usually uh available in most A&E S or fracture clinics and that, that keeps the distal phalanx and hyperextension. So you're reducing the gap between the insertion of the um terminal tendon um into the base of the distal phalanx. And if all the L fails, you can use a Zimmer Splint or something just to keep it in a, in a similar position. Now, what's important is you need to tell them to keep it in the Splint, um, 24 hours a day for eight weeks really, really important because if not patients will, uh, will think they can take it off for washing and doing other things And then that sort of um then makes the deformity worse again and then they have to restart it. There are ways they can take out the splint to do things and the hand therapist will advise them. And then followed by that, you usually need about six weeks of night splinting um to make sure that um they can at least start mobilization during the day cause they'll end up being very, very stiff. Um So in terms of surgical treatment, so if you have an open injury, so if it, then you probably need to do a wash out and depending on how much tendon loss there is, or skin loss, there is, then the management sort of changes. So if there's minimal, I, if there's minimal um loss of the tendon, you can do a primary suture and then close it. Um And then you could put a Ky in just to protect it. If there's significant loss of tendon, you have to try and see whether the tendon is gonna go back in, you might need to consider tendon grafting. Um You might even need to consider flaps for skin coverage depending on how much skin loss there is. So, we're not gonna cover all of that today. Um So bony, bony injuries again, if it's undisplaced and you can reduce it and it holes in a, in a mallet splint or a Zimmer splint, you can keep that on for six weeks and that, that should heal. But if not, there are a variety of methods. So the classical teaching is what we call the Ishiguro technique, which is essentially like a sort of a, a dorsal blocking or a Kanji sort of technique. You flex the distal phalanx first and you put ak wire in into the middle phalanx and just superior uh just a dorsal to that fragment there. And then what you're doing that blocks that fragment and then what you're doing is that you're extending the distal phalanx to try and reduce it. And then you're putting another wire just through the tip of the distal phalanx into the middle phalanx. So you're just trying to basically reduce it and then use it as a dorsal blocking splint and that's what the x rays would sort of look like. Um, companies like meats. Um They have like a little hook pt that you can put in, but um I've never used one. It's, you just have to be a bit cautious because the soft tissue coverage in the area is not fantastic. Um, and if you've got an open injury, you do not want to be putting that little claw plate on, uh, complications if you don't. So complications, you know, you can get an extensor lag even after treating them with splinting. But if the extensor leg is not significant, most patients can sort of deal with that. You can get stiffness, uh, you can get a chronic mallet. So with chronic mallets, um it's usually because they haven't done the therapy properly or very often you can get delayed presentation. Um I often see patients two or three months down the line following um tendinous mallet injury and I still start with splinting. Um um and go back to the same regimen and in a, in about 50 to 60% of them, it still works. So it's worthwhile trying to do that because with chronic malad, it's quite difficult. The ends of the tendon would be sort of um degenerate and you're gonna have a massive gap there. So trying to reattach it will be quite challenging. Some people do a tono demode which they put, they attach the tendon to a bit of the skin and they suture it altogether on mask. So that's one option or, or some people use like an endo button to try and grab it and just put it over that. But again, there, there is a high risk of wound breakdown and infection from there if you leave, um, the mallet injury, there's a risk of developing swan neck deformity. So that's the main complication. So what happens is that because you've got an injury to the terminal tendon that is overactivity and then you get stretching out of the volar plate of the P I PJ. Um And then your lateral band sort of almost become a flexor instead. Um, as this tend to, as they tend to uh sublux volarly. And then that's why you get that sort of deform deformity. And there's also um a risk of posttraumatic osteoarthritis and very often if they've got significant pain and a chronic mallet injury, then one option is to consider a fusion of the D I PJ. So that's sort of mallet injuries. Any questions before I move on to zo the rest of the zones? No. OK. Uh Zone two, there's not much about that. Zone two tends to be usually uh a laceration. So that's at the level and it's sort of just repairing what you can. So there's different uh suture techniques, most of them sort of epitendinous sort of sutures at this level. It's very, sometimes it can be very difficult to do uh multistrand repair because the tendons tend to be quite flat zone, three central slip injuries. So they can present with pain over the P I PJ. Sorry. Yeah. Mhm. They don't say anything. No. OK. Um So they can present with pain and swelling over the P I PJ mechanism is either a laceration to an open injury or you can have a jammed finger. So basically you stub your finger against something which can cause both injuries at the D I PJ, as well as the P I PJ. Uh Elon's test is quite important to sort of assess um that and basically what you're looking for is that you get them to bend the P I PJ over a couch or a table and you ask them to forcefully extend it. And then if the central slip is still intact, then the most of the force is going through the central slip. So the lateral bands then are not activated and your D I PJ remains floppy. Whereas if there's a central slip injury, because now the force is not going through the central slip, it's going by the lateral bands into the D I PJ. And that's why your D I PJ goes very tight. So let me just play the video to test for a central slip rupture. The patient is asked to flex their finger to 90 degrees at the proximal interphalangeal joint and place it over the edge of the table or the plant. The clinician will then palpate at the middle phalanx while asking the patient to extend at the proximal interphalangeal joint. A positive test is the clinician reporting little to no pressure over the middle phalanx while the distal phalanx is going into extension. Currently, there are no diagnostic accuracy studies indicating the clinical utility or value of this test. Yeah. All right. So that's Ellison's test. So, in terms of closed injuries, you can splint them an extension for about six weeks. You don't need to necessarily do anything, uh, bony avulsions. Um, you can consider a hook plate as well as we mentioned before, if it's an open injury. Um, then you know the fact that the P I PJ is underneath that there's a high chance of the P I PJ being affected. So you should do an open wash out of the joint and then you should do a tendon repair. And some uh authors will suggest even K wiring it in extension just to uh hold that in position. Again, there are multiple ways of um repairing tendons. Uh This level again is very flat. So you're not gonna get your four strand or six strand repair. A modified tesla is usually enough and sometime, and if you can get an epitendinous stitch like in diagram F there, then that's quite useful as well. Um complications. So, bonia deformity. So what happens is that you get over time, the central slip results in on a post flection in the P IP. And then that basically causes a volar plate contracture and then your lateral bands tend to drift and then you basically get a hyperextension deformity in in the area. As now the lateral bands are pulling on, on the distal phalanx more because there's, there's not much pull at the, uh at the base of the middle phalanx anymore. Zone four, similar to zone two injuries, either laceration or in conjunction with a proximal pha length fracture, treat the proximal phalanx fracture first. And then again, either a modified Kessler or a epitendinous stitch usually is enough to repair it at that level. And we'll get Michael to talk through the um hand therapy components of it. Zone five, very commonly. So we get fight bite injuries or traumatic sagittal band ruptures. So starting with fight bite injuries, obviously, the impact of the knuckle into someone's mouth, um can cause a deep laceration over the M CPJ things to be aware of is that if you look at the diagram on the right. So you have your line of injury here when it's flexed and your wound will be here. But when, once you extend the finger, your tendon then retracts proximately and your, your injury to the tendon is actually proximal to where your wound is. So where one common mistake people make is that when they go in and they just open the wound slightly and they debride it and clean it and they look at the tendon and they can't see any injury and they leave it. But that's because you've missed the injury. You need to either extend your incision proximately or you know, flex it to see the tendon, the extensor tendon come back into the wound. So that's really quite important to assess that. And obviously, the joint, the joint capsule tends to be damaged as well. You should do a wash out of the joint as well. Um So it's important to be aware of that because the uh the your skin injury doesn't line up with where the injury is and the human bites um tend to be very infe can get very infected. So, you know, you need to have a low threshold to wash these out. Um I would also get an X ray. You can have the bony avulsions. In some cases, you can also have a bit of someone's tooth left inside there that's been shown in some x-rays. So get your x-rays, take the patient debride, it, make the wound bigger, debride, the skin edges, explore, um explore the tendon to see where the injury is and make sure you wash out the joint as well and let's leave the patient on IV antibiotics. So it's quite important that these fight bites as well that you assess them properly. Uh Sagittal band ruptures tend to be more sort of forceful resistant flexion or extension and they call it the flicking fee, flicking flea sort of movement or you can get a direct impact or a laceration, they can look normal on extension. But when you flex the fingers, you can see the sagittal band, um you can see the extensor tendon moving uh to one of the gutters, the radial sagittal band tends to be the one that's injured most often. And again, classifications, you can get a sagittal back injury without an extensive tendon instability. Um or you can get them with a tendon subluxation like here or you can get complete tendon dislocation. And once that happens, one of the patients will normally present with an inability um to actually initiate extension. We talked about the main function. One of the main functions of the Sagittal band was to keep the extensor tendon centralized and help in MMM PJ flexion extension. And that's what um you'll find that the patients struggle to do. And you see that quite of often in rheumatoid patients, um you can have what we call a yolk splint. So basically you keep that in uh extension, you're allowing the rest of the fingers to move, you're allowing the, uh for example, here in the middle finger, you're allowing flexion at the P I PJ and the D I PJ, but you're just preventing uh flexion at the M CPJ um surgical. So primary, you can have just, you know, directly go in and suture, the, the tear. So you can have a criss cross going uh going up, this is known as the kettle C suture and later on, if primary repair is not um possible, then you're looking at tendons uh centralization. Um You can either do any of these uh where you use a bit of the EDC tendon to go through, uh and then swing around uh the go through the lateral bands and then back onto itself to suture, suture itself. There's a, there's about five different techniques. Um I tend to just use a slip of the EDC and go round and then back onto itself. And that tends to work in terms of centralizing um the extensor tendon and you don't then have to repair the sagittal band because you'll get a lot of scarring there. You might have to release a bit um of the sagittal fibers on one side or else it doesn't go all the way back as well, proximal zones. Um So, you know, zone six disruption of the metacarpal that has a slightly higher risk of nerve and vessel injury. Zone seven, you at the wrist joint, you need to think about repairing the retinaculum or as you're gonna get bowstringing and zone eight is further up the arm. You know, you're talking about penetrating trauma into the area where this muscle belly um neurological injuries, you know, you need more uh tendon repairs at that level and even tendon transfers later on if need be all right, APL tendon rupture, um very common of the distal radius fractures or wrist surgery. Um In distal radius fractures, you actually get a higher rate of um E pl rupture uh when they're treated non operatively. And that is usually because you, you've got a distal radius fracture. There's a lot of swelling. Um, the E PL in, in its own tunnel is going over listless cubicle. You can get disruption of listless cubicle and that can cause an attrition rupture. If there's any incongruency or sharp edges there or if there's just too much pressure, there can be an injury and then there can be a ischemic episode within the tendon sheath itself which then leads to delayed rupture. Um And very often the patients only have a delayed rupture once they start moving it after they've been in cast for 4 to 6 weeks, or you can get it from a laceration in terms of repair, you can do primary repairs, but we often see these quite late and because they're quite attritional, you end up having to probably do uh E IP to E PL tendon transfer. So where? So obviously, with the E IP, can anyone tell me how you assess for the E IP function? Clinically one? You do that the thing, all you know, you, you extend the, the index while you're having the uh middle and ring uh flex. And you usually ha keep the little finger extended as well. Yeah, and then you assess for power of the index. Yeah. But um so let me stop sharing the screen for a bit. So basically if you, if you make a face, you're tensioning your edc. So if you try to lift your ring finger, it only goes up to that mu much because it's sharing a common, uh, muscle belly. Yeah. And everything is fully, uh, fully extended. Whereas, you know, if you raise up your index finger, you know, goes up higher and similarly for the little finger as well, because both the little finger and the index finger have a, have a second tendon. Yeah. And where are we looking? So, when we're looking at it in, in surgery, where are we looking at it? Uh, Where do we find it? Anyone? Oh, it's, so we make the decision over the second meal here. It's all to the, to the A DC. Yeah, that's right. So it's all not to the EDC and that's always worth mentioning, but obviously check it. So you make an incision here, you cut the, you, you identify, cut it there, you make another incision over the wrist to pull it out. Then you go through subcutaneous and then you make an incision along here, find the distal stump of the E PL, ignore the proximal stump. You, it would have retracted quite far. And then what you end up doing is normally a pulver weave. So with the PVI T we've, what you're doing is that you're basically going, you're going, you're weaving through the distal stump and every pass is at 90 degrees to each other. So, and then you normally stitch it um at the junction of where the weaves go in and some people as well. I tend to do it. I usually put one stitch in this area in the corner so that you're trying to prevent it from being disrupted, this is a far stronger um then doing a direct tendon uh repair, uh it heals better, the power is better. You just have to make sure you've got adequate tensioning of it, you know, so you want to actually extend the thumb while you're, while you're putting the repair so that the patient actually has a functional um extension of the thumb afterwards. OK? I mean, that is what we need to know about extensor tendon request just briefly, like I mentioned, in terms of um the number of strands, I think the number of strands um is determined by how thick your tendon is. Most of the extensor tendons tend to be quite flat at those levels. Um Small studies have shown that the pull out strength is much lower. Um uh So the pull out uh you need, you don't need as much pull out strength. So, you know, as flexor tendons, so your repair doesn't have to be as robust every tenon as repairs are also important. Um And then in terms of rehabilitation, we'll get Michael to go through all of that. But the sort of specific protocols and you just have to, again, it's all about being controlled because it's sort of day six to day 12 where you chances of ex for any sort of tendon repair to fail as high as, as that's when the tendons are weakest in their healing phase. Right. Questions any questions? No. Can you guys all hear me? Yeah. OK. Right. Let me see where Michael is cause he's supposed to be doing the next stage.