Introduction Relevant

anatomy Clinical evaluation,investigation Treatment Rehab Outcome,prognosis conclusion

tendon injuries are frequently underestimated The less protected environment and the superficial anatomical location, extensor tendon injuries are encountered more frequently than flexor tendon injuries Disruptions to the extensor system are common and can be associated with poor patient outcomes when not treated appropriately
Extensor

 1.APL,EPB 2.ECRL,ECRB 3.EPL 4.EIP,EDC 5.EDM 6.ECU

mechanism of injury associated injuries Lacerations, swellings,bruise and locations Finger cascade Finger exam individually Neurovascular assessment Radiographs mandatory
History;

#s, dislocations

 Injury

to the terminal tendon at the DIP joint is considered a mallet finger. forced flexion during active extension Doyle classification
Type I injuries are closed, whereas type II are open. Type III injuries are open, with loss of skin and tendon substance. Type IV injuries involve large mallet fractures.

 Classically,

type I mallet fingers are treated with DIP extension splinting for 6 weeks. If active DIP extension is still limited, fulltime immobilization might need to be continued for up to a total of 3 months. When active DIP extension is maintained following immobilization, a nighttime extension splint is continued for an additional 4 to 6 weeks.

 the

surgical indications includes;

open injuries, instability of the DIP joint, fracture fragment greater than 30% to 50%.

repair can be performed using a variety of suture techniques with K-wire fixation of the DIP joint to protect the repair. The terminal tendon can also be successfully repaired with a pullout suture/button or a suture anchor.
Primary

II injuries occur over the middle phalanx and usually o/a laceration. Incomplete tendon injuries can be treated nonsurgically with a short, 1-to 2-week course of splinting, if;
Zone

greater than 50% of the tendon is intact, no extensor lag exists, Active extension occurs without weakness.

Complete

tendon injuries should be treated with primary repair K-wire through the DIP joint in extension.

REHAB Strict immobilization with the DIP in extension for 6 weeks. Active and passive ROM of PIP and MCP joints After 6 weeks, daytime active motion is permitted, as long as active DIP joint extension is maintained. nighttime extension splinting is continued for an additional 6 weeks.

III injuries involve disruption of the central slip. these injuries can be subtle, and high index of suspicion is necessary Patients usually present with
Zone

PIP joint swelling, mild PIP joint extension lag, and weak PIP joint extension against resistance. Elson test, positive [rigidity of the DIP joint during attempted PIP extension from a flexed position]

 Treatment

of zone III injuries is similar to that of zone I injuries. Closed injuries can be managed by extension splinting of the PIP joint, assuming that full passive PIP joint extension and full passive DIP joint flexion can be achieved PIP joint immobilization for 6 weeks, followed by 6 weeks of night-time splinting.

Surgical treatment of central slip injuries is reserved for;

open injuries, displaced avulsion fractures of the middle phalanx, PIP instability, and failed nonsurgical treatment.

Surgical options include

primary repair for open lacerations and suture anchor repair for avulsions and distal central slip injuries.

postop rehabilitation protocol same as nonsurgical management, with static extension splinting for 4 to 6 wks

to zone II injuries, Most often secondary to lacerations. injuries are frequently partial. Thorough physical examination that focuses on weakness to PIP joint extension is necessary to determine treatment. If there is no loss of extension nonsurgical tx with splinting and early motion is recommended. However, if there is a loss of active extension, surgical exploration and tendon repair should be performed
Similar

 The

stronger the suture techniques will allow early mobilization better outcome

Zone V injuries occur over the MCP joint, which is the most common location for extensor mechanism disruption. fight bite tendon injury is often of secondary importance compared to the risk of infection. Although the tendon is often only partially lacerated, the MCP joint is usually inoculated with mouth bacterial flora and eventually becomes septic. This requires surgical debridement, broad-spectrum intravenous antibiotics,and splinting.

 Nonfight

bite injuries also occur at this level Blunt trauma to the MCP joint can cause rupture of the sagittal bands, with subsequent extensor tendon subluxation Rayan and Murray classification
Type I injuries involve a contusion without a tear. Type II is associated with subluxation of the extensor, with its border extending past the midline but maintaining contact with the metacarpal head condyle. Type III involves a dislocation of the tendon between the metacarpal heads.

 Treatment

depends on the chronicity of the

injury. Acute injuries can be treated with extension splinting of the MCP joint for 6 weeks Chronic injuries with 1 repair

Zone VI injuries occur over the metacarpals and are usually associated with better outcomes than more distal injuries o/a
fewer associated joint injuries, decreased adhesion formation and less chance of tendon imbalances.

Diagnosis can be challenging because the patient might still be able to extend the MCP joint via
the EIP, EDM, and/or juncturae tendinum.

a high index of suspicion necessary to thoroughly evaluate for extension weakness.

 Because

of the increased tendon diameter, surgical treatment should consist of a core suture.
the modified Becker and running, interlocking, horizontal mattress suture techniques are considered to allow earlier mobilization

VII injuries involve damage to the extensor retinaculum. partial release of extensor retinaculum necessary for visualization.
Zone

step-cut or z-cut so that it can be successfully closed after the tendon repair.

dissection

should proceed into normal anatomy to correctly identify cut tendon ends and other potentially injured structures such as sensory nerves. After all tendon ends are matched, repair should proceed with a core suture.

 Chronic

tears or ruptures in zone VII are difficult to manage. E.g EPL rupture after nonsurgical treatment of a minimally displaced distal radius fracture These injuries are not amenable to primary repair, and therefore, tendon transfer or grafting is the treatment of choice.

tendon injuries at the forearm level usually involve the musculotendinous junction or the muscle belly. the quality of tissue available for repair is the biggest problem . search within the central aspect of the muscle belly for tendon tissue to repair. The most proximal injuries might have only a thin piece of fascia that overlies the muscle to provide tissue to suture.
Extensor

repair of these injuries is usually performed using multiple figure-of-eight stitches with slowly absorbing suture.[vicryl] Besides injury to the tendon itself, lacerations in this region can be accompanied by nerve injuries, so a careful examination must be performed.
Surgical

Extensor injuries over the fingers (zones I to IV) had less motion at follow-up than extensor tendon injuries over the metacarpals, wrist, and distal forearm (zones V to VIII).

 most

common complication after tendon repair is the formation of adhesions between the repair site, adjacent skin, and bone. These adhesions can restrict joint flexion as well as extension. Therapy is designed to improve tendon gliding. If loss of motion persists 4 to 6 months after repair, an extensor tendon tenolysis may improve motion. Capsulotomy flexor tendon tenolysis when ROM is limited in flexion

 While

extensor injuries often result in loss of extension, this is seldom disabling. However, these injuries frequently result in loss of flexion, which is greater in severity and frequency than loss of extension. extensor tendon injuries deserve careful attention in diagnosis, treatment, and rehabilitation to offset potential loss of fxn

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