Tendon Injuries

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Tendon Injuries
ACUTE INJURY Anatomy Tendon Nutrition Types of Injury
Contraindications Zones Incisions Technique
TENDON
Wrist Post-operative Complications
RECONSTRUCTION
ACUTE FLEXOR TENDON REPAIR [Back To Top]
Anatomy [Back To Top]
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Annular & Cruciate pulleys prevent bow stringing of flexor tendons.
Thumb - Oblique pulley over proximal phalanx.
Tendon Nutrition [Back To Top]
The vinculae are remnants of mesotenon & provide the blood

supply & nutrition to the flexor tendons.
The vincular system is supplied by the transverse communicating

branches of the common digital artery.
Nutrition of the tendons is also derived from the synovial sheaths -

thus early mobilisation post-op is important.
Types of Injury [Back To Top]
The position of the hand at the time of injury determines the tendon
retraction:
Flexed fingers - distal tendon retracts
Extended fingers - proximal tendon retracts
Contraindications to Repair
[Back To Top]
1. Wounds liable to
infection
2. Inability of patient to
cooperate with
rehabilitation
Failed primary repair is worse

than no repair! If only one
tendon is cut the functional
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result will be better than a poor repair.
Zones [Diagram] [Back To Top]
The tight A4 pulley makes repair

FDS insertion to FDP
Zone 1 difficult. Aim to advance FDP stump
insertion
to reattach to terminal phalanx.
Zone 1 to proximal part
Zone 2 two slips of FDS; Vincula
of A1 pulley
easily repaired with good results. Don't
Zone 2 to distal edge of
Zone 3 suture lumbrical muscle around tendon
flexor retinaculum
repair.
Zone 4 within carpal tunnel
Can use mattress sutures if many
Zone 5 proximal to carpal tunnel
tendons need repair.
FPL tendon lacerations often retract
Thumb FPL insertion to A2 into the thenar area or wrist; - unlike the
T1 pulley fingers, the FPL often lacks a vinculum
and does not have a lumbrical, and
Thumb Zone 1 to distal part A1 therefore the tendon is free to retract;
T2 pulley Repair requires an incision prox. to
carpal tunnel & ' pull-through '
Thumb also damage thenar muscles & recc. br.
Zone 2 to carpal tunnel
T3 median nerve.
Incisions [Back To Top]
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Safe Volar Hand Incisions
For retracted tendons:
Try milk the tendon with the wrist flexed.

Small incision a the distal palmar crease just proximal to A1 pulley. Pass a silastic cannula from the
distal wound through the sheath to the proximal wound. Attach the proximal tendon to the cannula &
pull through to distal wound.
Technique [Back To Top]
Core Non-absorbable 4/0 suture - Modified Kessler

technique.
6/0 monofilament running epitenon suture.
Close sheath, if possible.
Multiple Flexor Tendons at the Wrist (Zone 5)

[Back To Top]
Order of Repair:
1. FPL
2. FDP tendons
3. FDS to middle & ring fingers
4. FDS to index & little fingers
5. Ulnar nerve
6. Ulnar artery
7. Median nerve
8. FCU
9. FCR
10. Radial artery - ligated.
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Post-operative program [Back To Top]
Belfast Regimen:
(J. Hand Surg. 14B:383-391. 1989)
At 48hrs post-op remove dressings &

apply splint
Thermoplastic splint : wrist
20deg., MCP 70deg., 2/3 up
forearm, straps on palmar
crease, wrist & forearm.
First 6 weeks:
Fingers- Every 2hrs.- [1] Passive
flexion (2x/ individual finger)- [2]
Active extension (2x/ mass
action)- [3] Active flexion (2x/
mass).
Thumb- Every 3hrs.- as above.
After 6 weeks:
Remove splint & progress to
active flexion of individual joints.
6-8 weeks: use hand, no heavy liting.
8-10 weeks: slowly incr. activity, stretches into extension, fine work.
10-12 weeks: Driving, heavier work.
> 12 weeks: Full funtion (60% strength back at 16 weeks).
Complications [Back To Top]
1. Rupture
2. Infection
3. Adhesions - prevented by early passive ROM
4. Joint contractures - too tight repair or from prolonged splintage
5. Bow stringing - from damaged pulleys
SECONDARY FLEXOR TENDON REPAIR & RECONSTRUCTION [Back To Top]
Defined as delayed primary repair performed > 3wks after injury.
Contracture of the muscle-tendon unit has usually occurred & tendon graft often required.
Prerequisites for tendon reconstruction:
1. Adequate skin & soft tissue cover

2. Skeletal alignment
3. Good passive ROM of joints
4. Adequate sensation & circulation of finger
Methods:
1. Delayed direct repair

2. single stage flexor tendon grafting
3. two-stage grafting
4. tenodesis or arthrodesis
5. tendon transfer
6. Amputation
Two-stage Flexor Tendon Reconstruction
Contraindications:
1. Infection
2. Too much damage to support an implant or allow decent tendon gliding
3. Motivated patient
4. Experienced surgeon
5. Experienced Hand Therapist
First Stage:
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Aims:
1. Joint contractures must be released

2. Tenolysis of scarred tendons
3. Finger must have free & full passive ROM
4. Digital nerve repair or grafting
5. Provide healthy skin (may require a flap)
6. Full flexion on traction of the silastic rod at the wrist
7. Preserve A1, A2 & A4 pulleys
Second Stage:
2 - 3 months after first stage.
Tendon Graft options:
1. Palmaris Longus
2. Plantaris - best for multiple tendon grafts
3. Long toe extensors - 2nd, 3rd or 4th toes
4. EIP
5. Fascia Lata
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Tendon Transfer - Principles http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
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Tendon Transfer - Principles

Definition
A tendon transfer is a procedure in which the tendon of insertion or of origin of the functioning muscle is mobilised, detached or divided
and reinserted into a bony part or onto another tendon, to supplement or substitute for the action of the recipient tendon
Indications for tendon transfers
1. Irreparable nerve damage
2. Loss of function of a musculotendinous unit due to trauma or disease
3. In some nonprogressive or slowly progressive neurological disorders
Basic principles of tendon transfer
1. Mobile Joints / Correction of joint, skin and soft tissue contractures
If necessary, capsulotomy, or free flap may be necessary prior to tendon transfer
2. Adequate power of transferred tendon
Power of a muscle is determined by its cross sectional area
Only muscles with power of 4+ should be considered donors as they always lose 1 MRC grade of power
3. Sufficient amplitude (excursion / freedom of movement) in the transferred tendon
The amplitude of a muscle is a function of the sarcomere length
It is a fixed value for any muscle, but can be increased by
Freeing the muscle from its fascial attachments
Changing a muscle from monoarticular to biarticular, the amplitude is increased by movement of the extra joint that the tendon crosses
Amplitude can be limited by scarring and adhesions
As a guide, amplitudes are as follows
W rist motors 33mm
Finger extensors 50mm
Finger flexors 70mm
4. Maximal work capacity of the transfer
Power x amplitude = work capacity (Kg.M)
5. The transferred tendon should be of adequate length
A graft can be used as an extension, but all anastomoses are sources of adhesions
6. A satisfactory line of pull should be achieved
The less turns or bends through which the tendon has to pass, the less friction can reduce power and amplitude
7. An adequate glide of the transferred tendon is necessary, through unscarred natural planes
8. Functional integrity must be preserved
The transferred musculotendinous unit must be expendable
If a tendon is split and inserted into different sites only the tighter of the two will function and the other will not
In extensive paralysis
Restore function from proximal to distal
In general function is restored using the following scheme
1. Stabilisation of the shoulder
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2. Flexion of elbow
3. Extension of wrist
4. Flexion of fingers
5. Reestablishment of thumb grip in opposition or lateral thumb grip
6. Finger extension
7. Restoration of function of the interrossei
Surgical considerations in tendon transfers
1. Timing
If no chance of functional recovery, transfers should be performed ASAP
Following nerve injury repair, the date of expected recovery can be calculated by measuring the distance between the injury to the most
proximal muscle supplied, assuming a rate of regeneration of 1mm/day. If reasonable return of function not present for 3 mnths after the
expected, consider tendon transfer.
Early tendon transfers - within 12 weeks of injury
2. Planning
Make a list of deficient functions
Make a list of available donor muscles
3. Techniques
1. Multiple short transverse incisions rather than long longitudinal incisions
2. Careful tendon handling
3. Good soft tissue coverage over the tendon junctures
4. Joining the tendons
1. End to end anastomoses
2. End to side anastomoses
3. Side to side anastomoses
4. Tendon weave procedures can all be used
5. Achieving proper tension - No general rule, but reasonable to place limb in the position of maximal function of the tendon transfer and
suture without tension
Nerve Injuries & Tendon Transfers in the Upper Limb
Review by Robert Boome, Consultant Peripheral Nerve Surgeon
Tendon Transfers - summary table
Low injury (wrist) High injury (elbow)
MEDIAN NERVE:
Thumb Opposition (loss of FBP) (note thumb opposition is For index and middle finger flexion
combination of flexion and adduction)
FDP of index and middle finger sutured side to side to FDP
1. Ring finger FDS transfer to APB via a pulley of ring and little fingers, +/- ECRL tendon transfer to FDP for
made in the FCU tendon at the level of the extra strength
pisiform. [Picture]
2. MCP +/or IP joint fusion For flexion of IP joint of thumb -Brachioradialis transfer to FPL
For thumb opposition -Extensor indices transfer to Abductor

pollicis brevis
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ULNAR NERVE:
For Adductor pollicis and FPB (thumb opposition) +For loss of FCU - Use ECRL transfer for power
1. Absent FPB = Ring finger FDS transfer to APB via a pulley

made in the FCU tendon at the level of the pisiform.
[Picture].
2. If FPB working and adductor not = use extensor indices
transfer through interosseous membrane to adductor pollicis
For loss of action of interrosei and ulnar 2 lumbricals
1. Split tendon transfers of FDS + /- EIP & EDQ, to radial

dorsal extensor apparatus (tenodesis procedures)
2. Or stabilise MCP joint with Zancolli capsulodesis where the
volar capsule is tightened to produce slight flexion of MCP
joint (not very successful).
COMBINED MEDIAN & ULNAR NERVES:

very difficult problem
For function of the interrossei and lumbricals, to restore flexion
of MCP joint and extension of IP joints - Brands ECRB graft For function of the long flexors & interrossei and lumbricals, to
with a plantaris graft to increase length, attached to insertion of restore flexion of MCP joint and extension of IP joints - Zancolli
intrinsics Capsulodesis of MCP joints, ECRL to FDP, BR to FPL, ECU (with
free graft) to EPL
Thumb opposition - FDS (ring finger) via FCU pulley to EPL
[Picture] Thumb fusions
Thumb adduction (pinch) - EIP to Adductor pollicis
RADIAL NERVE:
(Radial wrist extensors functioning:)
wrist extension - Pronator Teres to ECRB
MCP joint extension - FCR / FCU to EDC or FDS to EDC
extension and abduction of the thumb - PL rerouted to EPL
If radial nerve might still recover keep EPL in continuity and bring
palmaris longus upward
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Ulnar Nerve Palsy Signs http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
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Ulnar Nerve Palsy Signs
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Vascular Disorders http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
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Vascular Disorders
Aneurysms of the Vascular
Vascular Tumours
Upper Extremity Malformations
Thoracic Outlet Occlusive Vascular
Vasospastic Disorders
Syndrome Disorders
Author: James Carmichael
Aneurysms [Back To Top]
Pulsatile , tender mass

Vasospastic symptoms
Digit ischaemia and/or gangrene from Embolic showers from mural thrombi
Adjacent nerve compression
May be erythematous and mimic an abscess
Systolic bruit or thrill
Allen's test may be positive if the aneurysm is occluded, also perform digital Allen's test
Treatment
Surgery recommended due to risk of thrombosis and peripheral embolism

Reconstruction versus resection
Choice guided by adequacy of digital blood flow after resection
Vascular Malformations [Back To Top]
Arteriovenous Malformations
High flow lesion
May start small in childhood and be triggered to enlarge after trauma

Spontaneous bleeding may occur
Clinical Findings
Possible thrill
Ischaemic ulcers distal to the lesion
Investigation
Doppler: continuous murmur

MRI: high versus low flow
Contrast arteriography
Treatment
Resection may be dangerous

Consider embolisation therapy but carries a high risk of digital ischaemia
Ligation of feeding vessels of no help proximal ligation only increases collateralisation
High-flow arteriovenous malformations are difficult to treat, & staged partial Excisions
are mostly palliative
YAG laser, used in direct contact with tissue for incision & thermal coagulation has
allowed subtotal excision of complicated haemangiomas of the hand previously thought
to be untreatable
Laser will not stop bleeding from blood vessels with lumen diameters greater than 1
mm
Venous Malformations
Venous malformations, although present at birth, often are not noticed until 1 year of age
They engorge when dependent, decompress when elevated, and enlarge with trauma,
puberty, pregnancy, or use of oral contraceptives
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Frequently confused with haemangiomas
Present at birth
Slow steady growth
Do not involute
Discrete and diffuse subtypes
Diff Dx
1. AVM
2. Haemangioma
Investigation
MRI: can distinguish between high flow (AVM) and low flow lesions (venous
malformations);
Closed system venography
Treatment:
Low-flow venous and lymphatic malformations treated conservatively by compression

garments or surgically by staged debulking
Surgery complicated by bleeding or lymphatic leaks, haematoma or seroma formation,
skin necrosis, scarring, ulceration, contractures, and distension of channels in the
same or adjacent areas
Vascular Tumours [Back To Top]
Haemangiomas
Benign, vascular tumour that occurs in children, usually in limbs or trunk
Most common form of haemangioma has infiltrative margins composed of both large and small
vessels
Despite their vascular origin, haemangiomas do not metastasise or undergo malignant

transformation
Pyogenic granuloma
variant of capillary haemangioma
appears on the fingertip following a minor laceration
consists of benign vascular granulation tissue
May be pedunculated or polypoid
Purplish red colour & friable
Rx = surgical excision
Glomus Tumour
Glomus body is a neuromyoarterial apparatus. Controlled arteriovenous anastomosis or shunt

between terminal vessels, function is to regulate peripheral blood flow in the digits.
Majority of the lesions occur in females between 30-50 years
Clinical features:
Frequently involves nail bed with classic triad of recurrent excruciating pain, tenderness
and cold sensitivity
Placing involved digit in ice water will usually reproduce pain within 60 sec
Nail bed ridging (and possibly a small blue spot at the base of the nail can be seen)
Multiple tumours in 25% of patients
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May have no visible or palpable signs except for a bluish discoloration
Radiographs:
X-rays for apposition loss: perforating lesion of the phalanx, may also show a shelled
out lesion dorsal lesion
Treatment:
In terms of excision the tumour is usually well encapsulated and can be shelled out
Thoracic Outlet Syndrome [Back To Top]
Most often affects subclavian artery, vein, and lower trunk (C8 /T1) of brachial plexus
Both the subclavian artery and the brachial plexus traverse between the anterior and middle
scalene muscles. Most symptoms arise from neural compression
Age 18-40 (never before puberty rare after 50yr)
Aetiology :
cervical rib (< 10 % of pts with cervical ribs will have symptoms), fibrous bands, anterior
scalene muscle constriction, 2 o to clavicular # ( xs callus/ hypertrophic non-union),
pancoast tumour
In some cases, thoracic outlet syndrome will be accentuated by recurrent anterior
shoulder instability, and this may be the cause of the "dead arm syndrome"
General Examination:
Tenderness or mass in supraclavicular fossa

Neurological Examination
Compression of the inferior trunk C8/T1
Sensory changes in the ring and little finger
Intrinsic weakness
Vascular Examination
Radial pulse obliteration is not itself specific, but loss of pulse with reproduction
of symptoms is a positive test
Provocative tests
1. Adson's test
Arm of the affected side adducted with forearm supinated

Turn head toward the affected side
Extend neck and hold breath
Positive test is obliteration of the radial pulse
2. Reverse Adson's test
As above but head turned away from the affected side
3. Wright's test ( Hyperabduction stress test)
Axillary vessels and plexus bent 90 o at the junction of the glenoid and humeral head
Place extremity in full abduction, external rotation and reach back as far possible. Turn
head away and check for decrease or loss of radial pulse
Creation of a bruit in the supraclavicular area is further evidence
4. Roos ' overhead exercise test
Above head repeated forearm exercise may reproduce symptoms
Investigations:
X-ray - Cervical ribs may be seen but more commonly the cause is a fibrous band
which will not show up on X-rays
CXR to rule out pancoast tumour
MR scan to exclude cervical disc disease
Treatment
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Non-operative (for at least 4 months)
Postural re-education
Activity modification
Weight loss
Operative (rarely required)
Excision of first rib with fibrous band and anterior scalene muscle via supraclavicular ,
subclavicular or axillary approach
Occlusive vascular Disease [Back To Top]
Tend to be unilateral conditions unlike the vasospastic conditions which tend to be bilateral
Embolic Disease
20% of all arterial emboli occur in the upper limb
70% are of cardiac origin with the remainder originating from aneurysms or from Thoracic
Outlet Syndrome.
Treatment is by embolectomy followed by anticoagulation, if this is not possible consider

thrombolysis .
Post Traumatic Vascular Occlusion
The most common example in the upper extremity is the hypothenar hammer syndrome
where local trauma causes thrombosis of the ulna artery at Guyon's canal.
The resulting ischaemia is worsened by an associated increase in sympathetic tone

causing peripheral vasospasm.
The thrombosis can also embolise where it is most likely to affect the ring finger
Treatment:
Resection of the thrombosed segment with or without sympathectomy and / or

reconstruction
Effort Thrombosis of Axillary Vein
Rare condition but suspect in throwing athlete with upper extremity oedema as this may
indicate effort thrombosis of axillary vein
Arteritis and Systemic Disorders
The following should be considered as possible causes of upper limb occlusive disease:
Thromboangitis obliterans ( Buergers Disease):- smoking induced vasculitis that is treated

when smoking stops
Giant Cell Arteritis : Can affect the subclavian and axillary arteries
Polyarteritis nodosa : Necrotising arteritis that preferentially affects the bifurcations of small
vessels (e.g. the digital arteries)
Connective Tissue diseases (RA, SLE etc) Can cause vascular occlusion through
immune complex deposition
Atherosclerosis
Vasospastic Disorders [Back To Top]
Raynaud's
Raynaud's phenomenon:
Episodic Digital Ischaemia
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Associated with connective tissue diseases, vibration, neurological disorders, arterial

occlusive disorders and blood dyscrasias
Raynauds Syndrome:
When the syndrome occurs as part of a disease e.g.:
o Connective tissue disease
o Occlusive arterial disease
o Neurovascular compromise (e.g. Thoracic outlet syndrome)
o Haematological abnormalities (e.g. polycythaemia )
o Occupational Trauma (e.g. Vibration white finger)
o Drugs
o CNS disease
o Misc (e.g. RSD or Malignancy
Raynaud's disease:
Primary vasospastic disorder without a demonstrable or associated disease occurring mainly in

young women. Diagnosis is by Allen and Brown's criteria:
Intermittent
Bilateral
No clinical arterial occlusion
Gangrene or atrophy is rare and limited to distal digit
>2yr history
No associated disease
Investigations:
TFT's - these patients will often have a subtle hypothyroidism

Cryoglobulins - many patients with significant amounts of cryoglobulins are
asymptomatic others develop purpura , Raynaud's phenomenon, cyanosis, and tissue
necrosis when exposed to cold
Patients with mixed cryoglobulinemia frequently have vasculitis , glomerulonephritis ,
lymphoproliferative disorders, or chronic infection, particularly with hepatitis B virus
Treatment:
Protection from the cold/ heated gloves (the most effective treatment overall)
Stop smoking
Digital and/or cervical sympathectomy
Pharmacological
1. Alpha blocking agents ( dibenzyline )
2. Myovascular relaxants (nicotinic acid, cyclospasmol )
3. Catecholamine and or serotonin depletors ( reserpine )
4. Nifedipine
5. Nicardipine
6. T3
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Wrist Arthroscopy http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
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Wrist Arthroscopy
Positioning &
Indications Complications Portals Images
Preparation
Indications: [Back To Top]
1. Chronic wrist pain for > 3months

2. Guide to planning further treatment
3. Carpal instability
Confirm diagnosis & additional associated damage
Arthroscopic reduction & percutaneous pinning of scapholunate dissociation
4. TFCC tears - Diagnose & debride
5. Remove loose bodies
6. Excision of Dorsal wrist ganglion
7. Synovial biopsy
8. Synovectomy
9. Keinbock's disease - staging
Arthroscopic debridement of the head of the capitate may unload the lunate allowing
revascularisation (Lena et al.)
10. Fracture reduction of distal radius fractures & treat associated TFCC tears.
11. Bone grafting of lunate cysts & scaphoid fractures.
Complications: [Back To Top]
Complication rate is only 0.5%
Warhold & Ruth reviewed 205 wrist arthroscopies & found:
1. one stitch abscess

2. one inclusion cyst
3. 2 cases of CRPS
Potential complications:
1. traction related
2. complications incurred during the establishment of portals
3. procedure-specific complications
4. others
Positioning and Preparation: [Back To Top]
Finger traps (to index and long fingers) tied to drip-stand
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Elbow to be flexed 90 deg

Counter traction is applied to the arm with use of a second 10 lb weight attached to sling over
tourniquet on upper arm.
Mark out the dorsal wrist veins before wraping out and elevating the tourniquet
Gravity assistant inflow
Initially inject saline to distend the capsule
2.4mm or 2.7mm wrist scope
Wrist Portals: [Back To Top]
arthroscopic portal: - 3/4 portal: (between ECRL & EPL) - lies 1 cm distal to the Lister's tubercle; -
insert the scope in line with the dorsal radial slope;
Instument portal: 6U portal: placed just ulnar to ECU - note the proximity of the dorsal ulnar cutaneous
branch
instrumentation portal 2: 4/5 portal: (between EDC & EDM)
mid-carpal portal: MC portal: lies in the scaphocapitate interval; - inserted 1cm ulnarwards & 1cm distal
to 3/4 portal; It is radial to the third ray, distal to the proximal row, just radial to the EDC to the index
finger.
1/2 portal: between the ECRB & APL; - note that the radial artery courses along the volar aspect of this
interval.
Images: [Back To Top]
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Further Reading:
Wrist Arthroscopy - Wrightington Hospital

Thurston AJ. Current Orthopaedics. 13:120-30.1999.
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Wrist Instability http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Wrist Instability
Anatomy Classification CID CIND Axial
CIC CIA Investigations Carpal Angles Treatment
Carpal Anatomy [Back To Top]
2 carpal rows:
1. Distal
Trapezium, trapezoid, capitate, hamate bound together by strong interosseous

(intrinsic) ligaments to form distal row, which moves together as a single unit
2. Proximal
Scaphoid, lunate and triquetrum form the proximal row. It has no muscle
attachments and is inherently unstable in compression without its ligamentous
attachments. Acts as a link between the relatively rigid distal row and the radioulnar
articulations.
Intrinsic ligaments
These have their origin and insertion within the same carpal row
Distal row
To bind all the distal carpal bones together
Proximal row
Scapholunate ligament
Lunotriquetral ligament
Extrinsic ligaments
Volar
Stronger, and arranged in 2 distinct "V" shapes centred on the lunate and the capitate
The radioscapholunate ligament is now known to be a vascular pedicle rather than a
true ligament
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Dorsal
Weaker and centred on the triquetrum
Classification (Mayo) [Back To Top]
Instability may be static or dynamic
Carpal Instability Dissociative (CID) [Back To Top]
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Relates to instability between individual carpal bones of the same row
Carpal Instability Non-Dissociative (CIND) [Back To Top]
Relates to instability between carpal rows or transverse osseous segments, and can be
caused by ligament injury or bony fracture (or both)
Axial instability [Back To Top]
Involves a longitudinal force of disruption resulting in either dislocation or fracture

dislocation
Trans - if pathway of force is through a bone
Peri - if pathway of force is around a bone
Carpal Instability Complex (CIC) [Back To Top]
Several patterns exist which are a combination of CID and CIND lesion
It is better to describe the individual components of these injuries as it is a guide to
treatment
Most frequently represented by perilunate injury
Mayfield classified these in 4 stages:
I scapholunate ligament injury

II capitolunate ligament injury
III lunotriquetral ligament injury
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IV dislocation of the lunate
Carpal Injury Adaptive (CIA) [Back To Top]
Secondary changes in the carpus, which results from a non-union or malunion of the
distal radius or carpal bones
Clinical Features [Back To Top]
History
Fall on outstretched hand

Often presents late as a sprained wrist which fails to resolve
Examination
Detailed palpation of all the landmarks

Grip strength often diminished
Special tests
Scapholunate ballotment
Kirk-Watson's test
Lunotriquetral ballotment
Reagan's with 2 hands
Kleinman's with one hand (thought to be more sensitive)
Investigations [Back To Top]
X-ray
PA/lat (wrist must be neutral)/clenched fist/ulnar deviation/radial deviation/oblique

Static instability, if present will show up on the x-ray
Dynamic instability may not be seen even on the clenched fist view
MR/CT/dynamic fluoroscopy/ arthrography may be of value in limited circumstances
Arthroscopy
Direct visualisation of the radiocarpal and midcarpal joints gives a good picture of
instability as the ballotment tests can be performed whilst watching the carpal bones
but the carpus is not under physiological loads
Dorsal Intercalated Segment Instability (DISI) [Back To Top]
When the lunate is rotated dorsally and the scapholunate angle is greater than 70 o
This is a description of the deformity but does not describe the pathological process
Causes: SLL injury, scaphoid #, Keinboch's and perilunate injury
Volar Intercalated Segment Instability (VISI) [Back To Top]
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When the lunate is flexed and the scapholunate angle is less than 30 o
Much less common than DISI
Most commonly caused by LTL injury
Treatment [Back To Top]
CID
Scaphoid fracture or non-union (can lead to SNAC )
treat # or malunion
Scapholunate ligament injury (can lead to SLAC ) [ Case Study ]
Acute
Early open repair + K-wire stabilisation up to 3 weeks
Delayed open repair can be performed up to 6 months
Repair is by either direct suture, pull through sutures or suture anchors
Chronic
Bony procedures - scapho-trapezio-trapezoid fusion (STT)
Soft tissue - dorsal capsulodesis (Blatt procedure) or FCR tenodesis
(Brunelli Procedure)
Established Scapholunate advanced collapse (SLAC)
Scaphoid excision and 4 corner fusion (capitate, hamate, lunate, triquetrum)

Proximal row carpectomy
Radial styloidectomy
Wrist denervation (division of the anterior and posterior interosseous nerves at the
wrist)
Lunotriquetral ligament injury
Rarely recognised acutely but if so then acute open repair of the ligament
Lunotriquetral fusion
FCU tenodesis
5 of 6 10/6/2007 12:29 PM
Acute perilunate dislocation
Immediate closed reduction followed by open repair of the ligaments via dorsal
approach
CIND
Acute - direct repair of the ligaments
CIC
Treat the individual components of the injury
CIA
Normally related to radial malunion therefore perform a corrective distal radial

osteotomy
[ Close Window ]
6 of 6 10/6/2007 12:29 PM
Wrist Osteoarthritis http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Wrist Osteoarthritis
From: JK Stanley. Current Orthopaedics. 13:290-6.1999.
May be Generalised or Localised (STT, SLAC, SNAC, rhizarthrosis)
Cause Notes Treatment
1. Idiopathic
fuse scaphoid & lunate to
distal radius; radio-lunate
Malunion distal die punch injury of scaphoid or
fusion; involvement of
radius lunate fossa; 4 part #; pilon injury
midcarpal jt. = proximal row
carpectomy
limited wrist fusion = excise
distal pole of scaphoid & fuse
Scaphoid
SNAC wrist prox. pole to lunate to
nonunion
capitate (or ? radial
styloidectomy?)
'hump back' deformity = scaphoid
united in flexed position; may be
Scaphoid rotational malunion also;
osteotomy risky
malunion scaphoid does not support lat.
column thus incr. load central &
medial columns
medial column injuries ->
Carpal bone
capito-hamate & hamo-lunate
#'s
impaction
Kienbock's prox. row carpectomy or wrist
Arthrosis = Lichtman stage 4
2. disease arthrodesis
Mechanical Preiser's
AVN of scaphoid
disease
AVN Capitate
70% of people have a facet on
the medial aspect of the lunate
Hamo-lunate Hamate head excision
which can impinge on the head
Impaction (arthroscopic)
of hamate in full ulnar deviation;
diagnosed arthroscopically
STT OA ass. with chondrocalcinosis; pain
STT arthrodesis
[Radiograph] on radial deviation of wrist;
from malunion distal radius #s; Sauve-Kapandji procedure
DRUJ OA
injury to sigmoid notch [Picture]
scaphoid excision & 4 corner
Carpal
SLAC fusion
instability
(capito-hamo-triquetro-lunate)
from scapho-lunate interosseous
Dorsal rim
lig. incompetence; diagnosed
impaction
arthroscopically; precursor of
syndrome
SLAC & SNAC
Piso-triquetral
causes loose bodies in wrist joint
OA
3. Metabolic Gout
Pseudogout
4. RA
Inflammatory
Psoriasis
Scapholunate Advanced Collapse (SLAC):
common pattern of OA
may be end-stage of scapho-lunate dissociation
The structures maintaining scapho-lunate alignment fail from trauma or degeneration.
1 of 3 10/6/2007 12:33 PM
Lunate extends & scaphoid flexes -> reduces carpal height

Later proceeds to radio-carpal OA & lunocapitate & lunohamate OA
Treat with scaphoid excision + 4-corner fusion (lunocapitate & triquetrohamate)
Scaphoid Non-union Advanced Collapse (SNAC):
Develops from a longstanding scaphoid non-union.

The proximal pole of scaphoid acts like a lunate
OA develops betw. distal scaphoid fragment & radial styloid (not between radius &
proximal fragment)
Notes on some Treatments:
Neurectomy:
Limited neurectomy (Berger technique)

70% of patients have 70% pain relief at 7 years
Arthroplasty:
for low demand patients (RA) with good bone stock.

metalloplastic
Loosening = 15% over 10 years
small dislocation rate
DRUJ Procedures:
1. Darrach
Procedure
Darrach's
original
procedure
was
to
resect
the
distal
ulna
but
retain
a
strip
of
bone
2 of 3 10/6/2007 12:33 PM
on the ulnar side with the styloid & the ligaments joining this to the carpus.
(forerunner of Bower's hemiresection & soft tissue interposition)
Theoretically get subluxation of the carpus to the ulnar side.
Get instability of the stump causing discomfort in young active people.
2. Sauve-Kapandji Procedure:
Preferred option
Prevents 'ulnar subluxation' of carpus (radiocarpal joint)
Good forearm function in 80%
20% complain of troublesome clicking in forearm rotation.
may be ECU slipping over prox. ulnar stump.
may be ulnar stump abutting on distal radius
Can try tendon sling procedures
[ Close Window ]
3 of 3 10/6/2007 12:33 PM

Tendon Injuries

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Tendon Injuries

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Tendon Injuries http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...

ACUTE INJURY Anatomy Tendon Nutrition Types of Injury

Contraindications Zones Incisions Technique

ACUTE FLEXOR TENDON REPAIR [Back To Top]

Anatomy [Back To Top]

Annular & Cruciate pulleys prevent bow stringing of flexor tendons.

Thumb - Oblique pulley over proximal phalanx.

Tendon Nutrition [Back To Top]

The vinculae are remnants of mesotenon & provide the blood

The vincular system is supplied by the transverse communicating

Nutrition of the tendons is also derived from the synovial sheaths -

Types of Injury [Back To Top]

Flexed fingers - distal tendon retracts

Extended fingers - proximal tendon retracts

Failed primary repair is worse

result will be better than a poor repair.

Zones [Diagram] [Back To Top]

The tight A4 pulley makes repair

Incisions [Back To Top]

Safe Volar Hand Incisions

For retracted tendons:

Try milk the tendon with the wrist flexed.

Technique [Back To Top]

Core Non-absorbable 4/0 suture - Modified Kessler

6/0 monofilament running epitenon suture.

Close sheath, if possible.

Multiple Flexor Tendons at the Wrist (Zone 5)

Post-operative program [Back To Top]

(J. Hand Surg. 14B:383-391. 1989)

At 48hrs post-op remove dressings &

Complications [Back To Top]

SECONDARY FLEXOR TENDON REPAIR & RECONSTRUCTION [Back To Top]

Defined as delayed primary repair performed > 3wks after injury.

Prerequisites for tendon reconstruction:

1. Adequate skin & soft tissue cover

1. Delayed direct repair

Two-stage Flexor Tendon Reconstruction

1. Joint contractures must be released

2 - 3 months after first stage.

Tendon Graft options:

Tendon Transfer - Principles

Indications for tendon transfers

1. Irreparable nerve damage

2. Loss of function of a musculotendinous unit due to trauma or disease

3. In some nonprogressive or slowly progressive neurological disorders

Basic principles of tendon transfer

1. Mobile Joints / Correction of joint, skin and soft tissue contractures

If necessary, capsulotomy, or free flap may be necessary prior to tendon transfer

2. Adequate power of transferred tendon

Power of a muscle is determined by its cross sectional area

3. Sufficient amplitude (excursion / freedom of movement) in the transferred tendon

The amplitude of a muscle is a function of the sarcomere length

It is a fixed value for any muscle, but can be increased by

Freeing the muscle from its fascial attachments

Amplitude can be limited by scarring and adhesions

As a guide, amplitudes are as follows

W rist motors 33mm

Finger extensors 50mm

Finger flexors 70mm

4. Maximal work capacity of the transfer

Power x amplitude = work capacity (Kg.M)

5. The transferred tendon should be of adequate length

6. A satisfactory line of pull should be achieved

8. Functional integrity must be preserved