Extensor Tendon Repair


Extensor Tendon Repair


Introduction


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Figure 1Illustration of the eight extensor tendon zones. T = thumb.

(Reproduced with permission from Hunt TR, Wiesel SW : Operative Techniques in Hand, Wrist, and Forearm Surgery, ed 1. Philadelphia, PA, Wolters Kluwer Health, 2010.)


Patient Selection


Contraindications




  • Closed extensor tendon injury amenable to splint treatment


  • Extensive comorbid conditions or neurologic dysfunction

Preoperative Imaging




  • Plain radiographs to assess bony avulsion type disruptions, joint subluxation, or other associated injuries


  • MRI or CT rarely indicated


  • Occasionally ultrasonography may be helpful


  • Physical examination remains the mainstay of diagnosis

Procedure


Zone I—Type 1 Mallet Injuries




  • Terminal extensor tendon disruption is common that can occur with an open laceration or closed injury from a flexion force to an extended finger


  • Treat with full-­time extension splinting for 6 to 8 weeks followed by weaning period of part-­time splinting for additional 4 to 6 weeks



Surgical Technique: Closed Pin Fixation of the DIPJ




  • Perform under local anesthesia with fluoroscopy


  • K-­wires (0.045 ″ or 0.035 ″ diameter) in an axial or oblique direction across the joint


  • For axial direction, start wire at the distal tuft, just under nail plate


  • Wire should be in the intramedullary canal and stop just at the subchondral bone of the base of the middle phalanx to avoid PIP joint penetration


  • Withdraw wire a few millimeters and cut at the skin level; tap into position just below the skin

Zone I—Type II Open Mallet Injury


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Figure 2 A, Photograph showing open mallet injury in a child. B, Photograph showing suture repair and pin fixation.


Surgical Technique: Suture Techniques


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Figure 3Illustration of RIHM (running-­interlocking horizontal mattress) technique. A, How to perform the new extensor tendon running-­interlocking horizontal mattress repair technique: Begin the simple running suture at the near end. B, How to perform the new extensor tendon running-­interlocking horizontal mattress repair technique: Run the interlocking horizontal mattress suture by starting at the far end. The suture needle passes underneath the prior crossing suture to lock each throw. Finish the suture and tie at the near end.

(Reproduced with permission from Lee SK, Dubey A, Kim BH, et al: A biomechanical study of extensor tendon repair methods: Introduction to the running-­interlocking horizontal mattress extensor tendon repair technique. J Hand Surg Am2010;35[1]:19-­23.)



  • Extensor mechanism is thin and does not tolerate shortening or lengthening


  • Recent evidence supports use of dorsal epitendinous suture called the running-­interlocking horizontal mattress (RIHM) suture technique (Figure 3)


  • Core sutures techniques such as modified Kessler and Bunnell are appropriate for tubular and substantial extensor anatomy in Zone V-­VII

Zone I—Type III Open Mallet Injury With Soft Tissues Loss




  • More complex open injury with multiple structure damaged


  • May require tendon graft, or if the joint is significantly injured, an arthrodesis may be required

Zone I—Type IV B Mallet Injury



Zone I–Type IV C Mallet Injury With Subluxation


May 13, 2023 | Posted by in Uncategorized | Comments Off on Extensor Tendon Repair

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