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Management of Extensor Tendon Injuries

Griffin M, Hindocha S, Jordan D, Saleh M, Khan W - Open Orthop J (2012)

Bottom Line: It is clear from the literature that extensor tendon repair should be undertaken immediately but the exact approach depends on the extensor zone.Complete lacerations to zone IV and VII involve surgical primary repair followed by 6 weeks of splinting in extension.Zone VIII require multiple figure of eight sutures to repair the muscle bellies and static immobilisation of the wrist in 45 degrees of extension.

Affiliation: Academic Foundation Trainee, Kingston Upon Thames, London, UK.

ABSTRACT

Extensor tendon injuries are very common injuries, which inappropriately treated can cause severe lasting impairment for the patient. Assessment and management of flexor tendon injuries has been widely reviewed, unlike extensor injuries. It is clear from the literature that extensor tendon repair should be undertaken immediately but the exact approach depends on the extensor zone. Zone I injuries otherwise known as mallet injuries are often closed and treated with immobilisaton and conservative management where possible. Zone II injuries are again conservatively managed with splinting. Closed Zone III or 'boutonniere' injuries are managed conservatively unless there is evidence of displaced avulsion fractures at the base of the middle phalanx, axial and lateral instability of the PIPJ associated with loss of active or passive extension of the joint or failed non-operative treatment. Open zone III injuries are often treated surgically unless splinting enable the tendons to come together. Zone V injuries, are human bites until proven otherwise requires primary tendon repair after irrigation. Zone VI injuries are close to the thin paratendon and thin subcutaneous tissue which strong core type sutures and then splinting should be placed in extension for 4-6 weeks. Complete lacerations to zone IV and VII involve surgical primary repair followed by 6 weeks of splinting in extension. Zone VIII require multiple figure of eight sutures to repair the muscle bellies and static immobilisation of the wrist in 45 degrees of extension. To date there is little literature documenting the quality of repairing extensor tendon injuries however loss of flexion due to extensor tendon shortening, loss of flexion and extension resulting from adhesions and weakened grip can occur after surgery. This review aims to provide a systematic examination method for assessing extensor injuries, presentation and management of all type of extensor tendon injuries as well as guidance on mobilisation pre and post surgery.

Zones of the extensor tendon muscles.
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Figure 1: Zones of the extensor tendon muscles.

Mentions: Kleinert and Verdan wrote a classification system for extensor tendon lacerations according to the eight zones of the hand, wrist and forearm which as been widely accepted [11]. Verdan defined eight zones- four odd numbered zones overlying each of the joints and four even numbered zones overlying the intervening tendon segments, increasing from distal to proximal. The type of injury, surgical approach, potential deformity varies according to the zone [11]. Zone I refers to the area from the DIP joint to the fingertip; zone II encompasses the middle phalanx; zone III refers to the PIP joint; zone IV is over the proximal phalanx; zone V refers to the MP joint; zone VI encompasses the metacarpal and zone VII is over the wrist (see Fig. 1) [11]. Rockwell et al., [12]. Explained that treatment of tendon injuries is dependent on the location and type of injury. Repair should take place very soon after the injury especially within the first 2 weeks.

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Management of Extensor Tendon Injuries

Griffin M, Hindocha S, Jordan D, Saleh M, Khan W - Open Orthop J (2012)

Zones of the extensor tendon muscles.
© Copyright Policy - open-access
Figure 1: Zones of the extensor tendon muscles.
Mentions: Kleinert and Verdan wrote a classification system for extensor tendon lacerations according to the eight zones of the hand, wrist and forearm which as been widely accepted [11]. Verdan defined eight zones- four odd numbered zones overlying each of the joints and four even numbered zones overlying the intervening tendon segments, increasing from distal to proximal. The type of injury, surgical approach, potential deformity varies according to the zone [11]. Zone I refers to the area from the DIP joint to the fingertip; zone II encompasses the middle phalanx; zone III refers to the PIP joint; zone IV is over the proximal phalanx; zone V refers to the MP joint; zone VI encompasses the metacarpal and zone VII is over the wrist (see Fig. 1) [11]. Rockwell et al., [12]. Explained that treatment of tendon injuries is dependent on the location and type of injury. Repair should take place very soon after the injury especially within the first 2 weeks.

Bottom Line: It is clear from the literature that extensor tendon repair should be undertaken immediately but the exact approach depends on the extensor zone.Complete lacerations to zone IV and VII involve surgical primary repair followed by 6 weeks of splinting in extension.Zone VIII require multiple figure of eight sutures to repair the muscle bellies and static immobilisation of the wrist in 45 degrees of extension.

Affiliation: Academic Foundation Trainee, Kingston Upon Thames, London, UK.

ABSTRACT

Extensor tendon injuries are very common injuries, which inappropriately treated can cause severe lasting impairment for the patient. Assessment and management of flexor tendon injuries has been widely reviewed, unlike extensor injuries. It is clear from the literature that extensor tendon repair should be undertaken immediately but the exact approach depends on the extensor zone. Zone I injuries otherwise known as mallet injuries are often closed and treated with immobilisaton and conservative management where possible. Zone II injuries are again conservatively managed with splinting. Closed Zone III or 'boutonniere' injuries are managed conservatively unless there is evidence of displaced avulsion fractures at the base of the middle phalanx, axial and lateral instability of the PIPJ associated with loss of active or passive extension of the joint or failed non-operative treatment. Open zone III injuries are often treated surgically unless splinting enable the tendons to come together. Zone V injuries, are human bites until proven otherwise requires primary tendon repair after irrigation. Zone VI injuries are close to the thin paratendon and thin subcutaneous tissue which strong core type sutures and then splinting should be placed in extension for 4-6 weeks. Complete lacerations to zone IV and VII involve surgical primary repair followed by 6 weeks of splinting in extension. Zone VIII require multiple figure of eight sutures to repair the muscle bellies and static immobilisation of the wrist in 45 degrees of extension. To date there is little literature documenting the quality of repairing extensor tendon injuries however loss of flexion due to extensor tendon shortening, loss of flexion and extension resulting from adhesions and weakened grip can occur after surgery. This review aims to provide a systematic examination method for assessing extensor injuries, presentation and management of all type of extensor tendon injuries as well as guidance on mobilisation pre and post surgery.

View Similar Images In: Results  - Collection
View Article: MedlinePlus - PubMed Central -  PubMed
Show All Figures - Show MeSH
getmorefigures.php?pmc=3293224&rFormat=json&query=null&req=5