Flexor Tendon Complications

Complications

 

1.  Flexor Tendon Rupture

2.  Adhesions

3.  PIPJ contractures

4.  Triggering

5.  Pulley failure

6.  Quadrigia

 

1.  Flexor Tendon Repair Rupture

 

Incidence

 

5%

 

Management Options

 

FDS only

- usually minimal impairment

 

FDP only

- may be better to fuse DIPJ

- passing tendon through FDS may give poor result

 

FDP and FDS

- repair / graft FDP

 

One Stage repair

 

Indications

1. Minimal scarring

2. Pliable joints

3. Adequate retinacular pulley system

4. Not Zone 2

 

2 Stage repair  

 

Indications

 

1.  Severe adhesions or scarred tendon bed

2.  Contractures

3.  Disruption of pulley system

4.  Missed injuries

5.  Injuries not suitable for primary repair

- usually gross contamination

 

Technique 2 Stage

 

Concept

- all anastomosis in Zone 1 and Zone 3 (not Zone 2)

 

Technique Stage 1 

 

Long Brunner incision finger

- Scarred tendon remnants excised, contractures released 

- A2/4 pulleys reconstructed if necessary

- Silastic implant sutured distally to FDP Zone 1

- proximal end zone 5 free

- need incision in palm to pass through to forearm 

 

Mobilisation regime post-op

- get finger moving / passive exercises +++

- minimise adhesions

- recreate synovial sheath for second stage

 

Pulley reconstruction

- use FDS, extensor retinaculum, PL free tendon

- A2: passed dorsal to NV bundles between phalanx and extensor tendons

- A4: superficial to extensor tendons

 

Technique Stage 2 

 

Graft options

- Palmaris longus (absent 25%)

- Plantaris (absent 20%)

- Long toe extensor (IV)

 

Timing

- performed at 3 months 

- Early, protected Post-op mobilisation

- active motion at 4 weeks

 

2.  Flexor Tenolysis

 

Diagnosis Flexor Tendon Adhesions

 

Limited active ROM > passive ROM

- tendon adhesions

 

Limited passive ROM = active ROM

- joint contracture

 

If there is a marked difference between active and passive ROM

- adhesions likely but

- need to ensure repair is intact

- feel for tendon / ultrasound

 

Timing

 

Up to 20% of patients require tenolysis

- therapy +++ for 3 - 6 months

- need to assess the amount of functional deficit of the patient

- subcutaneous tissues must be state of equilibrium (i.e. soft and supple)

 

Technique

 

Must be prepared to go on to 2-stage repair

- long brunner incision

- access tendon through sheath via less important pulleys

- early active ROM critical

 

3.  PIPJ Contractures

 

Non Operative

 

Splints

- static night time extension splints

- dynamic external fixators

 

Therapy

 

Operative

 

Access between A2 and A3 pulley

- remove cruciform pulleys

- flexor tenolysis

- release check rein ligaments

- release accessory collateral / collaterals / volar plate

- MUA

 

Results

 

Improve extension 20 - 30o

- lose equivalent amount of flexion

- change functional arc

 

4.  Triggering

 

May be triggering on A2 or A4 pulley

- Non operative treatment

 

5.  Pulley Failure and Bowstringing

 

6.  Quadriga

 

Issue

 

FDP of MF / RF / LF linked

- will only extend as much as of shortest tendon

- if limited excursion of one FDP due to repair etc

- present with limitation of all finger flexion

 

Solution

 

Release adhesions of the shortened tendon