ТЕМА: Сгибатели пальцев кисти - анатомия и диагностика
Сгибатели пальцев кисти - анатомия и диагностика 5 года 8 мес. назад #524
Очень показательное видео "Сухожилия сгибатели пальцев кисти - анатомия и их повреждения. Правда на английском языке, но все и так понятно.
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Сгибатели пальцев кисти - анатомия и диагностика 5 года 8 мес. назад #527
Очень показательное видео "Сухожилия сгибатели пальцев кисти - анатомия и их повреждения. Правда на английском языке, но все и так понятно.Очень полезненько, спасибо, скопираволи, будем пользоваться, студентам понравится =)))
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Сгибатели пальцев кисти - анатомия и диагностика 5 года 8 мес. назад #531
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Сгибатели пальцев кисти - анатомия и диагностика 5 года 8 мес. назад #560
Статья, посвященная анатомии, питанию, регенерации, повреждениям сухожилий сгибателей пальцев кисти.
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The objectives are to maintain the blood supply as completely as possible, obtain adequate exposure, and obtain optimal scar contracture. Bunnell developed the midlateral incision as the stationary line, either volar or dorsal to the neurovascular bundle. Littler demonstrated the diamonds of skin-to-skin contact during digital flexion. The Bruner zigzag incision avoids these areas. Preservation of the vincula is difficult if the dorsal midlateral incision is used, and hence either the Bruner or the volar midlateral incision is recommended. Midlateral incisions should not be made on surfaces exposed to much contact (eg, ulnar border of little finger, radial border of index finger). The distal extent of either incision is over the pulp of the phalanx.
Clinical clues to flexor tendon injury include loss of the normal digital cascade and the tenodesis effect observed with wrist motion. In lacerations of the flexor digitorum profundus alone, the DIP joint may be held in flexion by the intact short vinculum. Isolated flexor digitorum superficialis injury results in no overt postural deficit.
The retinacular portion of the sheath is elevated as an L-shaped flap, allowing a 2-mm cuff of tissue for subsequent repair. Furthermore, this L should be oriented such that a tendon end can be funneled into it. Flexion of the wrist is a useful intraoperative ploy that facilitates mobilization of the proximal tendon stump. Often the proximal tendon stump is hidden by a hematoma within the tendon sheath. The chiasm of Camper (flexor digitorum superficialis decussation that lies opposite the proximal digital flexion crease) is a useful anatomic marker for tendon repair within zone II.
Remember that distal to the midpoint of the proximal phalanx, the deep tendon is the flexor digitorum superficialis, and the superficial is the flexor digitorum profundus. Prior to commencing the repair, it is vital that no tension is across the tendon ends. The technique of repair is based on the length of distal tendon. Two groups of core suture exist: (1) those that criss-cross the tendon (Bunnell) and (2) those in which the suture lies parallel to the tendon fibers (Kessler, Tajima). See image below.
Two-strand repair techniques. (A) Tsuge, ( modifTwo-strand repair techniques. (A) Tsuge, ( modified grasping Kessler, (C) modified locking Kessler (ie, Pennington modified Kessler), (D) modified Pennington.
Urbaniak et al demonstrated that the former group of sutures tends to strangulate the tendon ends, with a net reduction in tensile strength. The epitenon must never be handled so that damage that predisposes to peritendinous adhesions is minimized. Terminal damage to the epitenon also jeopardizes the quality of subsequent peripheral suture. The tendon end can be grasped lightly with a toothed forceps. A 4-0 material is used for the core suture. Importantly, the first pass of the needle must be parallel to the tendon fibers. The length of bite is approximately 1 cm, with the transverse limb of the suture passing superficial to the longitudinal limbs. The core suture should not pull the tendon ends together. This is the value of overlapping the ends with transfixion needles. Employ at least 4 throws of the knot, with the ends cut at 2 mm. The protruding suture ends so as not to jeopardize subsequent healing or function. Knot slippage is said to occur in as many as 40% of repairs.
Multistrand techniques are illustrated in the image below.
Multistrand core suture techniques performed with Multistrand core suture techniques performed with single-stranded suture. (A) double modified locking Kessler, ( cruciate nonlocked, (C) cruciate cross-stitch locked, (D) 4-strand Savage, (E) augmented Becker (also called as MGH repair), (F) 6-strand Savage, (G) modified Savage, (H) triple modified Kessler.
The suture material for the peripheral running suture should be 2 gauges lighter than the core suture (6-0 nylon for adults). Like the core suture, it may be either monofilament or braided material. Monofilament material generally is preferred for both sutures. The first pass of the peripheral suture should be performed in a figure-of-eight fashion to avoid cutting out. Most importantly, it should engage only the epitenon. A shallow inverting suture is ideal, thus burying the repair. A Lembert suture can be employed if necessary. The passage of this needle should meet minimal resistance if in the correct plane. Following tendon repair, little or no bulk should be found in the tendon ends. Epitendinous techniques are illustrated in the image below.
Epitendinous suture techniques. (A) cross-stitch, Epitendinous suture techniques. (A) cross-stitch, ( Lin, (C) Halsted, (D) horizontal intrafiber, (E) simple running, (F) Simple running superficial and simple running deep.
The general recommendation is that both flexor digitorum superficialis and flexor digitorum profundus should be sutured, even in zone II. Lister recommends the use of 2 core sutures for the flat tendon of flexor digitorum superficialis. A divided flexor digitorum superficialis derotates through 90°. The management of partial lacerations is controversial.
Following the report by Weeks and Wray that partial lacerations should be managed conservatively, Kleinert et al found that failure to repair these results in triggering and delayed rupture. Current recommendations for partial tendon injuries are presented in the following table.
Table 1. Current Recommendations for Partial Tendon Injuries (Open Table in a new window)
Less than 25% Smooth edge to avoid entrapment
25-50% Peripheral running suture
Greater than 50% Core suture plus running suture
Recent debate centers on the benefit of multistrand repairs and whether a multistrand repair confers greater early tensile strength and, therefore, rapid rehabilitation over the conventional-type repair. Recent biomechanical and histological data show no differences between 2-strand and 4-strand repairs. The use of an epitendinous suture gives similar results. If care is taken with the surgical technique, adhesion formation is not necessarily increased by the use of multistrand techniques or by the placement of an epitendinous suture. More variability is introduced by individual healing response than by an increase in tendon handling by an experienced surgeon. One recent report advocated a 6-strand figure-of-eight technique, citing the ability to ensure full active extension of the proximal interphalangeal (PIP) joint in the first 4 weeks after surgery, virtually eliminating flexion contracture at the PIP joint while reducing rupture rate to 2%.[5, 6]
Resistance to failure in different repair techniques varies according to the number of locking junctions with the tendon, location, and orientation of the sutures. These factors influence the resistance to failure independent of the number of sutures used.
Recent experimental evidence in both the canine model and clinical studies suggests a stainless steel device (Teno Fix) may be promising for zone II flexor tendon repairs. A recent in vitro study found that resection of one slip of the flexor digitorum superficialis (FDS) tendon significantly reduced the work of flexion in repair of zone II injuries, while no difference in this interaction was observed among 3 different suture materials (ie, FiberWire vs Ticron vs Prolene).
The history of flexor tendon repair has been described well by Dr. Paul Manske.
Primary repair - Distal flexor digitorum profundus stump
The distal flexor digitorum profundus stump usually can be involved in a formal suture repair if longer than 1 cm.
The proximal core suture can be inserted into the distal stump if shorter than this and brought out through 2 20-gauge needles inserted through the distal pulp, 3 mm volar to the nail.
If no distal stump is present, it should be brought out through the distal phalanx and sutured over a button on the nail.
Procedures that involve extension of the tendon are contraindicated for 2 reasons: firstly, the quadriga effect on the other digits is invoked, and secondly, an extension deficit of the involved digit is always present. At most, the flexor digitorum profundus can be advanced by 1 cm.
Primary repair - Avulsion of the profundus
This is a common "rugby jersey" injury. It is most common in the ring finger. Three types are described in Table 2 below.
Table 2. Three Types of Avulsion of the Profundus (Open Table in a new window)
Type I The tendon has retracted into the palm.
Repair only can be performed within 10 days.
Type II The tendon has been tethered by the long vinculum.
Repair is feasible for as many as 3 months.
Type III A large bone fragment, which cannot pass through the sheath, has been avulsed.
It can be repaired at any time.
When reinsertion is possible, it should be performed as above, taking the sutures out through the pulp. If this is not possible, then either perform arthrodesis on the DIP joint or consider flexor tendon reconstruction.
Tendon repair out of zone II
The epitenon is not as well defined, and the peripheral running suture is unnecessary. The objective in these situations is strength of closure rather than finesse. If the deep carpal ligament needs to be divided, the wrist should be splinted in slight dorsiflexion. Alternately, the latter may be repaired. In repairs at the wrist, the best initial maneuver is to excise the glutinous mass of synovium by means of a thorough synovectomy. The distal ends easily are identified by their actions. Caution should be exercised in grasping the cut ends of the tendon (grasp only the cut surface and not the epitenon). The clues to identification of the proximal ends are as follows:
Matching the cross-sectional areas
Matching the angle of laceration
Matching the anatomic layers
Superficial flexor digitorum superficialis to middle and ring fingers
Middle flexor digitorum superficialis to index and little fingers
Deep all flexor digitorum profundus (index finger separate)
Matching the length to achieve the normal position in repose
Injuries at the musculotendinous junction should be repaired whenever possible. A figure-of-eight suture with 2 unequal loops is best.
In oblique injuries, when the injury is clean, no reason exists to render the cut transverse. Judging the correct tension in the core suture is more difficult, and this may be left untied until the peripheral suture is completed partially. Ragged ends should be resected. The tendon can be held with umbilical tape and resected with a razor blade. Double level repairs do not present a problem if more than 3 cm apart. If closer, a single core suture should be used.
Factors dictating the success of tendon reconstruction include the following:
Age: Very young and elderly patients do not fare as well.
Occupation: Often those with busy lifestyles cannot afford the time to spend at rehabilitation.
Mechanism of injury: The more widespread the zone of initial injury, the greater the scarring is likely to be. The amount of scarring is inversely proportional to the range of motion (ROM) subsequently achieved.
Quality of initial care
Previous operations: The likelihood of success lessens as the number of procedures that have preceded the proposed operation increases.
Defer performing the procedure on the patient until the skin is mobile, the joints are supple, scars mature, adequate perfusion to the digit is present, adequate sensation exists, and a stable skeleton is present. Limitation in ROM may be due to skin, sheath, or tendon on either side of the digit or the palmar plate. In pure flexor tendon adhesions, passive flexion exceeds active flexion. If extensor tendon adhesions are present, perform tenolysis on these prior to contemplating flexor tendon reconstruction. A useful approach is to examine all other structures first, leaving the flexor tendon until last.
The DIP joint contributes only 3% to the overall total arc of motion of the digit. By contrast, the PIP joint contributes 20% of the total arc. Jeopardizing the function of the PIP joint by tendon grafting may not have a favorable risk-to-benefit ratio. Instead, the flexor digitorum superficialis stump may undergo tenolysis to the middle phalanx, or arthrodesis can be performed on the DIP joint. McClinton et al reported a 13% failure rate in flexor digitorum profundus reconstruction. Therefore, the question remains as to whether benefit is found in delayed flexor digitorum profundus reconstruction, with a possible gain of 3% total arc of motion. The risk-to-reward ratio is most favorable in carefully selected, young patients in whom arthrodesis may result in growth disturbance.
The causes of flexion contracture are poor rehabilitation, bowstringing of tendons, poor splintage, and failure to create an effective repair. The severity of the contracture is measured by the extension deficit. Bowstringing tendons require additional length to achieve the same degree of flexion. This excursion is not available. The diagnosis is made by asking the patient to flex against resistance.
Tenolysis or exploration
Tenolysis usually is indicated when passive range exceeds active range and all joints have full ROM. No optimal time exists at which to perform tenolysis. It should be performed when the following are met:
Soft tissue scars are mature.
The benefit from therapy has reached a plateau.
Local anesthesia is best, since it allows the patient to participate in the operation and to visualize the intraoperative gains. A forearm tourniquet may be useful. Immediate mobilization follows surgical release. In patients not operated on under local anesthesia, immobilize the digit in flexion, since clot adhesions can be broken more easily by extension than by flexion. Prolonged postoperative anesthesia is optimal. The tendons are identified both distally and proximally in the palm. Dissection continues from either side to the point of fusion or adhesion to surrounding structures. Take care not to damage the epitenon, since this invariably leads to tendon adhesions at this point. Assess the completeness of tenolysis by the following:
Marking the tendon with ink
Observing ROM resulting from tendon excursion (limitation is due either to adhesions or inadequate pulleys)
Checking the proximal extent of the tendon as far as the musculotendinous junction (this is best performed by asking the patient to demonstrate ROM)
On completion, the tendon may be excessively long or tenuous or the pulley system may be inadequate. If the tendon is very tenuous, placing a rod alongside it may be worthwhile. If the tendon ruptures, a tendon rod is already in situ. Additional procedures include capsulotomy and skin coverage with a flap. The perfusion of the digit may be poor in the extended position, necessitating a vein graft.
Local administration of corticosteroids may lead to increased rupture, attenuation, and infection. Systemic administration is controversial. Interpositional materials generally are not used.
Postoperative mobilization should be unresisted active exercise. Caution should be exercised regarding the possibility of rupture with unprotected extension. An extensor splint may be necessary for recurrent flexion contracture. However, the risk of rupture is increased by the use of such a splint.
Contraindications to 1-stage tendon grafting include less than full ROM, inadequate skin cover, and a hostile bed. Donor options are the palmaris longus, extensor digiti quinti, and plantaris tendons. Alternately, the extensor digitorum to the index finger or the extensor digitorum longus to the second, third, or fourth toes may be used. The distal insertion is through, around, or along the distal phalanx. Lister prefers the latter, as the former 2 carry some risk of damage to the nail bed. If the flexor digitorum profundus is divided distal to the lumbrical origin, little, if any, myostatic contraction occurs. Pulling the proximal tendon out to length is important to achieve the benefit of creep. The active excursion varies for each muscle, but generally it is approximately double the passive excursion achieved on the operating table. For tendons of unequal dimension, a Pulvertaft weave is preferred for the proximal tenorrhaphy. Three slots, each at 90 degrees to each other, are used.
Two-stage tendon grafting
Two-stage reconstruction is indicated when the digit is not suitable for a 1-stage graft due to the following:
Joint requiring capsulectomy
Inadequate skin coverage
Pulleys requiring reconstruction
Scarred graft bed
Scarred graft bed is the most common indication. Some digits may be insensate, have severe flexion contractures, or occur in an uncooperative patient; in these situations, the patients are not candidates for reconstruction.
The decision to proceed with 2-stage reconstruction usually is made after failed tenolysis. Resect the flexor digitorum profundus, leaving the distal 1 cm, back to a point 2 cm distal to the lumbrical origin. Preserve the flexor digitorum superficialis from the proximal end of the chiasm of Camper distally to prevent recurvatum deformity of the PIP joint. The Hunter silicone rod or the Holter-Hauser rod may be used. The Holter-Hauser rod has a screw fixation device distally. A 4-mm rod usually is selected for adults. The proximal end of the rod is brought out proximal to the wrist crease. Complications include synovitis (15-20%), migration, extrusion, flexion contracture, and buckling of the rod. Hunter found no propensity for longitudinal contracture in the primate model. The final outcome is better when wounds are left to mature for a longer time.
Repair of the sheath is highly recommended. This usually is performed with a continuous 6-0 nylon suture. Make sure by flexing the finger that the sutures are not tethering the epitenon. Overtight closure may impede the passage of an edematous tendon. Interestingly, the best results reported were in a series in which the sheath was not closed. Strauch and others advocate the use of autogenous vein patches for sheath closure. Closure of the sheath prior to extension of the digit after tendon repair facilitates delivery of the repair beneath the A3 pulley.
"A moderate amount of intermittent movement, with as long an excursion as possible, interspersed by rest, will yield the best results" (Stirling Bunnell).
The tourniquet should be released after closure of the sheath to achieve hemostasis.
Mason demonstrated that a healing tendon has minimal tensile strength until it is stressed. Immediate mobilization of the flexor tendon repair has been demonstrated to reduce peritendinous adhesions and increase tensile strength, DNA content, eventual excursion, and uptake of synovial fluid. The options are (1) controlled passive motion, (2) active extension and rubber band flexion, and (3) immediate active motion with limited extension.
The rehabilitation protocol must be modified to the individual patient in question. The clinician should approach each patient individually and progress them with a personalized and tailored approach in close communication with the surgeon and therapist. Functional hand motion and strength are the end results of successful flexor tendon surgery and rehabilitation.
Controlled passive motion (Duran and Houser technique)
In this technique, a dorsal block splint is used (similar position to the Kleinert splint), and the fingers are immobilized in Velcro straps. The joints are flexed passively 3 times per day. This often is used in children younger than 6 y; an above-elbow cast is applied with the wrist neutral, the MP joints at 90?, and the interphalangeal (IP) joints in full extension.
Active extension and rubber band flexion (Kleinert technique)
The wrist is immobilized 20° short of full flexion, and the MP joints are in 45° flexion. Only the involved finger is incorporated in the rubber band. Free mobility of the other fingers encourages extension of the involved finger. In children older than 6 years, the Kleinert cowl splint is used, but the rubber band is not attached until the child fully understands the technique. Bear in mind that attaching the rubber band in a patient unaware if its significance renders the patient at high risk of a flexion contracture; therefore, great responsibility is associated with the use of the Kleinert band. The Kleinert-Breidenbach splint incorporates a spring-loaded roller bar in the mid palm.
Electromyographic studies since have shown that little flexor inhibition may be present during the extension phase and that opposition to extension serves little purpose. Therefore, the band only should be sufficiently taut so as to flex the finger. For each 100 of flexion at the DIP joint, the flexor digitorum profundus only moves 1 mm. Although passive motion moves joints, whether passive mobilization moves tendons is unknown. The only known way of moving tendons sufficient to prevent adhesions is by active mobilization. Recent modifications of the original Kleinert technique flex the wrist less and the MP joints more.
Immediate active motion with limited extension
More recent reports have advocated this technique and have demonstrated good results. However, the risk of tendon rupture is inevitably greater. Table 3 (below) provides a summary.
Table 3. Summary of Modifications of Immediate Active Motion With Limited Extension (Open Table in a new window)
Associated Factor Modification
Nerve or vascular repair Block full extension appropriately
Palmar plate repair Block full extension appropriately
Fracture, extensor tendon repair, or replant Early active and passive mobilization
Reversible cortical deficit, children older than 6 years Omit rubber band until sensorium clears or the child understands
Children younger than 6 years Duran technique
Patients should be observed at least twice weekly by the surgeon and more frequently by the therapist.
If the active range of motion (AROM) is full after 4 weeks, the splint may be removed and the elastic band attached to a wrist strap for a further 2-3 weeks. If the band is discarded at this time, risk of rupture is significant. Bear in mind that the patient who is mobilizing best is at greatest risk of rupture. In these patients, the rehabilitation process should be retarded.
If AROM is poor after 4 weeks, the patient is at risk of a flexion contracture. The band is discarded, and physiology becomes more active. Warn the patient about the risk of rupture. Dynamic splintage can be employed after 8 weeks without risk of rupture. Most common complications of tendon grafting include rupture, adhesion, flexion contracture, recurvatum deformity (swan neck), bowstringing, lumbrical plus, and quadriga syndrome.
The rupture rate after tenolysis is high (21% in Lister's series). This is most commonly at the proximal repair site.
A recent meta-analysis of 29 studies examining the incidence of complications following tendon repair demonstrated a 6% reoperation rate, and a 4% rate of tendon rupture and adhesion formation. The study found that use of a modified Kessler technique reduces the development of adhesions by 57%, and the presence of an epitendinous suture decreases the rate of reoperation by 84%.
The swan neck deformity results from excision of the flexor digitorum superficialis. It can be prevented by retaining the part of the flexor digitorum superficialis to which the V2 vinculum attaches. It is corrected by either capsulodesis or by the construction of a spiral oblique retinacular ligament.
Lumbrical plus occurs when the graft is too long and the tension then is taken up by the lumbrical insertion, resulting in paradoxical extension of the IP joints with forced flexion. The division of the lumbrical corrects this complication. Because the grafted finger reaches the palm prior to the other fingers, this places a block on further flexion of the other fingers (the quadriga syndrome). Reporting results
Various methods of expressing the results of tendon repair or grafting are as follows:
Littler method: Each joint's individual ROM is measured.
Boyes technique: This technique uses the pulp-to-midpalmar crease measurement (nail-to-table measurement can be added).
Total active motion (TAM): This incorporates the summed ROM of the IP joints less the extension deficit, as a fraction of 175.[13, 14] Others incorporate MP measurement. Strickland reported 50% of repairs achieved 50% of TAM. He reported 80% improvement following tenolysis, with 3% rate of rupture. Lister reports 71% improvement but with 21% rupture.
TAM-to-total passive motion (TPM) ratio: This is the postoperative TAM2 as compared to the preoperative TPM1 for tendon grafts. In flexor tendon repair, the postoperative TAM2/175 is used. Lister believes this to be the best method for reporting results. He reports 76% TAM/TPM for grafts. Strickland's formulae are as follows:
Flexor tendon repair - TAM2/175 as a percentage
Tendon grafting - TAM2/TPM1 as a percentage
Tenolysis - 100 - TPM1-TAM2/TPM1-TAM1 as a percentage
Lister technique and the Buck-Gramko technique: Both incorporate the TAM (with MP) and distance from pulp to midpalmar crease. These are used widely.
A recent retrospective review presented a new functional outcome score in which tendon function, opposition, intrinsics, deformities, and sensation are assessed to evaluate the results of both tendon and nerve repair in patients with a "spaghetti wrist" combined injury of the flexor tendons, nerves, and vessels at the wrist.[15, 16]
Lister reports 80% good or excellent results in zone II with 85% outside of zone II. The flexor digitorum superficialis was excised in only 25% of patients with zone II injuries, and in these patients only 45% achieved good or excellent results. This result is difficult to explain, but it may reflect improved blood supply or greater strength with the intact flexor digitorum superficialis. Only 12% of patients required tenolysis. Singer and Maloon report 80% excellent or good results.
Early repair has evolved as the mainstay of treatment for flexor tendon injuries. In the setting of a failed early repair or conditions in which early repair is not feasible, a delayed reconstruction remains a viable option to restore function to the affected digit.
As understanding of tendon biology and healing continues to advance, repair techniques and outcomes will also improve. Current research is directed at development of means by which to limit adhesions and scarring and to promote earlier tendon healing through the use of mesenchymal stem cells, molecular growth factors, and gene therapy.[
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Сгибатели пальцев кисти - анатомия и диагностика 5 года 8 мес. назад #564
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Сгибатели пальцев кисти - анатомия и диагностика 5 года 8 мес. назад #697
Очень понравилась отпрепарированная кисть которая выполняет самостоятельное сгибание и разгибание пальцев
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