10/12/2015

Extensor Tendon Injuries: Ensuring the Best Outcome Brad Palmer, MD Allegheny General Hospital Pittsburgh, PA

Disclosures • Nothing to Disclosure • in the past 12 months, neither my spouse nor myself have had a financial relationship with a commercial interest (any entity producing, marketing, re-selling, or distributing health care goods or services consumed by or used on patients; with the exception of providers of clinical service directly to patients)

Extensors of the Fingers • Extrinsic – EDC, EIP,EDQ, EPL, EPB

• Intrinsic – Interossei, lumbricals

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Extensor Hood

Extensor Mechanism: A complex interweave of tendon fibers controlled by 4 or 5 muscles

Conjoined Tendon

Central Slip

Interossei (2)

Extrinsic(1 or 2) Terminal tendon

Lumbrical (1) Lateral Band 5

Zones • Odd numbers are located over joints • Even numbers are over bone • thumb has unique classification

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Zone VI • • • •

Over metacarpals Less risk of adhesions Multiple repair techniques Repaired with a core suture +/- an epitendinous suture

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Repair Techniques • • • • • •

No clear consensus Bunnell Becker Modified Kessler Figure of 8 Horizontal mattress

Biomechanical Studies

4-0 Prolene

Newport ML, Williams CD. Biomechanical Characteristics of Extensor Tendon Suture Techniques. J Hand Surg Am. 1992;17A:1117-1123.

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Biomechanical Studies • Modified Brunnell – Statistically strongest: highest load to 2mm gap and ultimate failure

• Modified Kessler • Figure of 8 • Horizontal Mattress

Newport ML, Williams CD. Biomechanical Characteristics of Extensor Tendon Suture Techniques. J Hand Surg Am. 1992;17A:1117-1123.

Biomechanical study • Comparison of 3 techniques

Brunnell +epitendinous

Becker +epitendinous

Running-InterLocking Horizontal Mattress(RIHM)

Lee SK, Dubey A, Kim BH, Zingman A, Landa J, Paksima N. A Biomechanical Study of Extensor Tendon Repairs: Introduction to the Running-Interlocking Horizontal Mattress Extensor Tendon Repair Technique. J Hand Surg Am. Jan 2010:35(1):19-23.

Running Locking Horizontal Mattress

Step 1

Step 2

Lee SK, Dubey A, Kim BH, Zingman A, Landa J, Paksima N. A Biomechanical Study of Extensor Tendon Repairs: Introduction to the Running-Interlocking Horizontal Mattress Extensor Tendon 12 Technique. J Hand Surg Am. Jan 2010:35(1):19-23. Repair 17

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Results • RIHM suture: – Significantly stiffer(8506 N/m vs. 5971 N/m and 6719 N/m) – Significantly less shortening(1.7mm vs. 6.2mm and 6.3mm)

• Ultimate load to failure – No significant difference(53N,48N,51N) Lee SK, Dubey A, Kim BH, Zingman A, Landa J, Paksima N. A Biomechanical Study of Extensor Tendon Repairs: Introduction to the Running-Interlocking Horizontal Mattress Extensor Tendon Repair Technique. J Hand Surg Am. Jan 2010:35(1):19-23.

Post op Splinting • • • •

33 patients treated with static splinting splint for 3 to 4 weeks 6 months of follow-up 95% excellent or good results

Purcell, T., Eadie, P.A., Murugan, S., O'Donnell, M., and Lawless, M. Static splinting of extensor tendon repairs. J Hand Surg Br. 2000; 25: 180–182

Dargen Criteria • Excellent – No extensor lag with flexion of pulps to mid-palm

• Good – Extensor lag 2cm Sylaidis, P., Youatt, M., and Logan, A. Early active mobilization for extensor tendon injuries. the Norwich regime. J Hand Surg Br. 1997; 22: 594–596

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Static Splints • 33 simple extensor tendon repairs treated with static splinting • Good to excellent results in 64% • Mean follow up 5 years

Newport, M.L., Blair, W.F., and Steyers, C.M. Jr. Long-term results of extensor tendon repair. J Hand Surg Am. 1990; 15: 961–966

Static Splints • 35 extensor tendon repairs • 40% good to excellent results • Follow up of 12 months

Chow, J.A., Dovelle, S., Thomes, L.J., Ho, P.K., and Saldana, J. A comparison of results of extensor tendon repair followed by early controlled mobilisation versus static immobilisation. J Hand Surg Br. 1989; 14: 18–20

Dynamic Splints • Nonrandomized trial prospective trail • 100% excellent/good results with Dynamic splints • 40% in static group

Chow, J.A., Dovelle, S., Thomes, L.J., Ho, P.K., and Saldana, J. A comparison of results of extensor tendon repair followed by early controlled mobilisation versus static immobilisation. J Hand Surg Br. 1989; 14: 18–20

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Active Motion with Volar Block • 24 simple repairs zones IV to VII • Start active motion POD#1 • Splint for 4 weeks – Then night 2 weeks

• 92% excellent or good result

Sylaidis, P., Youatt, M., and Logan, A. Early active mobilization for extensor tendon injuries. the Norwich regime. J Hand Surg Br. 1997; 22: 594–596

Active Motion with Volar Block

3-0 Prolene Modified Kessler

Relative Motion Extension Splint • Wrist at 25o of extension • Repaired digit 15o of relative extension compared to other digits • Wrist splint discontinued at 4 weeks

Sharma JV, Liang NJ, Owen JR, Wayne JS, Isaacs JE. Analysis of Relative Motion Splint in the Treatment of Extensor Tendon Injuries. J Hand Surg Am. Sept 2006:31(7):1118-1122.

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Relative Motion Extension Splint • 140 patients • Extensor zones IV to VII • 96% excellent or good results

Howell, J.W., Merritt, W.H., and Robinson, S.J. Immediate controlled active motion following zone 4-7 extensor tendon repair. J Hand Ther. 2005; 18: 182–190

Comparisons • Prospective Randomized Trial • Dynamic splinting vs Static Splinting – 8 weeks • Improved Total Active Motion (TAM) • Improved grip strength

– 6 months • No differences Mowlavi, A., Burns, M., and Brown, R.E. Dynamic versus static splinting of simple zone V and zone VI extensor tendon repairs: a prospective, randomized, controlled study. Plast Reconstr Surg. 2005; 115: 482–487

Comparisons • • • •

Prospective Randomized Trial 100 patients Dynamic Splinting vs Volar Block with motion No differences at 8 weeks – 97% vs 94% excellent or good results

Khandwala, A.R., Webb, J., Harris, S.B., Foster, A.J., and Elliot, D. A comparison of dynamic extension splinting and controlled active mobilization of complete divisions of extensor tendons in zones 5 and 6. J Hand Surg Br. 2000; 25: 140–146

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Return to activities/work • Relative Motion Extension splinting – 18 days

• Volar Block with active motion – 6 weeks

• Dynamic extension splints – 10 weeks

Canham CD, Hammert WC. Rehabilitation Following Extensor Tendon Repair: Evidence Based Medicine. J Hand Surg Am. Aug 2013:38(8):1615-1617.

Take Home Points • DES, Active motion, RME protocols provide early and possibly later improvements • RME for 3 or less digits • Active motion with volar block for 4 digits • Pediatric and unreliable patients – Static splint

• Repair technique

Contact • [email protected]

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