Extensor Tendon Repair

imagesFor repair of a partial or complete tendon injury


imagesPartial laceration of the extensor tendons proximal to the metacarpophalangeal (MCP) joint may or may not require repair; those at or distal to the MCP joint level must be repaired


CONTRAINDICATIONS



imagesDelayed closure and/or referral to a hand specialist or orthopedic surgeon may be more appropriate in the following circumstances:


   imagesSevere contamination or acute infection


   imagesInjuries due to human teeth (clenched fist injury or “fight bite”)


   imagesDelayed presentation of injury


   imagesExtensive injury requiring prolonged use of tourniquet (longer than 20–30 minutes)


   imagesPenetration of laceration into a joint capsule


imagesThese cases may be taken to the operating room for surgical exploration, irrigation, and intravenous (IV) antibiotics


RISKS/CONSENT ISSUES



imagesPain


imagesBleeding


imagesInfection (theoretical risk of iatrogenic infection)


imagesRisk of injuring other structures—tendons, vessels, nerves


imagesLaceration may need to be extended to allow adequate exploration or access to the surgical field



imagesGeneral Basic Steps


   imagesPatient preparation (ring removal, tourniquet, irrigation)


   imagesLocal anesthesia or nerve block


   imagesThorough wound evaluation


   imagesTendon repair


   imagesApply appropriate splint


LANDMARKS



The anatomic location of open extensor tendon injuries in the wrist or hand drives treatment decisions and emergency department (ED) management. The Verdan classification system divides the hand and wrist into eight zones (TABLE 51.1 and FIGURE 51.1), which helps determine if tendon repair should be attempted in the ED.


TECHNIQUE



imagesPreparation


   imagesRemove all rings immediately!


   imagesRadiographs, as indicated, should be employed to assess for associated fracture, foreign body, or joint space disruption


   imagesPlace the patient in a comfortable position, preferably supine, with the injury site easily accessible


   imagesObtain proper lighting to optimize wound exploration, which should include thorough assessment for tendon injury and foreign bodies


   imagesSterile technique should be employed


   imagesAdequate anesthesia should be administered once the initial neurovascular examination is complete. Lidocaine 1% to 2% with epinephrine can be used in the hand except in areas supplied by end arteries. Local infiltration or an appropriate nerve block can be used.


   imagesThe wound should be thoroughly irrigated and free of contamination. Debridement of grossly contaminated tissue may be necessary.


   imagesGood hemostasis is critical to wound exploration and tendon repair


      imagesElevate the arm for 1 minute to facilitate drainage of blood before applying a tourniquet


      imagesInflate a blood pressure cuff to 260 to 280 mm Hg and clamp the cuff tubes to avoid air leak, or use commercial tourniquets for arm or finger


      imagesApply the tourniquet for no longer than 20 minutes










TABLE 51.1.


THE VERDAN CLASSIFICATION SYSTEM














































Zone


Finger


Thumb


I


DIP joint


IP joint


II


Middle phalanx


Proximal phalanx


III


PIP joint


MCP joint


IV


Proximal phalanx


Metacarpal


V


MCP joint


CMC joint


VI


Metacarpals


 


VII


Carpals


 


VIII


Proximal wrist and distal forearm


 


DIP, distal interphalangeal; IP, interphalangeal; PIP, proximal interphalangeal; MCP, metacarpophalangeal; CMC, carpometacarpal.



images


FIGURE 51.1 Extensor tendon repair landmarks.

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Aug 9, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Extensor Tendon Repair

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