Hand CASE 34
CASE 34
A patient sustains a laceration at the level of the middle phalanx of the long finger.
He has an abnormal cascade and undergoes wound exploration. He is noted to have a laceration of the FDP tendon in zone 2. He undergoes repair of both tendons with a four-strand repair and epitendinous suture. He presents 3 days after injury for wound check (Fig. 4–18).
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Figure 4–18
What is the most appropriate splint for him postoperatively?
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A volar splint in the position of function with the wrist extended 30 degrees, MPs flexed 60 degrees, and IPs straight
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Volar splint with wrist in neutral, MPs flexed 60 degrees, and IPs free
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Dorsal blocking splint with wrist flexed 30 degrees, MPs flexed 60 degrees, IPs straight
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Dorsal blocking splint with wrist flexed 30 degrees, MPs extended, IPs flexed 50 degrees
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Outrigger splint with wrist in neutral and elastic allowing for passive extension and active flexion
Discussion
The correct answer is (C). After flexor tendon repair, a dorsal blocking splint is applied to prevent the digit from extending and placing tension on the repair. The Kleinert splint is also utilized and combines a dorsal blocking splint with a rubber band secured volarly to allow for active extension and passive flexion. The wrist and MPs are placed in flexion, the IPs in extension. A volar splint is avoided because the patient can flex the digit against a volar splint. An outrigger splint is used for radial nerve palsy to allow active flexion and passive extension.
The patient is enrolled in a therapy protocol postoperatively. Which of the following is true regarding therapy?
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Therapy should begin 10 to 14 days postoperatively at the time of suture removal
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Passive range of motion protocol is associated with a decreased tendon rupture rate compared to active
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Passive range of motion protocol is associated with decreased tendon adhesion compared to an active motion protocol
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The tensile strength of the repaired tendon is adequate for active loading beginning at 8 weeks
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Gap formation between the repaired tendon ends is associated with a poor prognosis
Discussion
The correct answer is (B). Active motion protocols are associated with less tendon adhesion but a higher rate of tendon rupture. Therapy should begin early after surgery-ideally within 48 hours. The tensile strength of the repaired tendon is adequate for active loading at 4 to 5 weeks postoperatively. Gap formation is not associated with a poor prognosis.
The patient is lost to follow up after a personal issue and presents 3 months later highly motivated to progress with his treatment. He complains of difficulty using the long finger. On physical examination, he has 70 degrees of active flexion of his MP joint and no active flexion of the PIP and DIP joints. He has 80 degrees of passive flexion of his PIP and DIP joints. There is no palpable flexor tendon with attempted flexion of the digit.
What is the appropriate next step?
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Ultrasonography therapy to treat tendon adhesions
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Passive motion flexor tendon repair protocol
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Active motion flexor tendon repair protocol
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Tenolysis followed by an active motion protocol
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Excising the flexor tendons and placement of a silicone rod
Discussion
The correct answer is (E). Based on the physical examination, the patient has sustained a tendon rupture. The MPs are likely flexing secondary to lumbrical contraction. The IPs do not have active motion, and the tendon is not palpable on
attempted excursion, which would be expected if the tendon were intact but adhesed to the surrounding structures. Flexor tendon repair therapy protocols would not be expected to change this patient’s clinical course. Ultrasonography does not have a role after tendon rupture. The only appropriate option is reconstruction.
Objectives: Did you learn...?
Select the appropriate splint after flexor tendon repair? Describe appropriate postoperative therapy?
Identify tendon rupture and its treatment?