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Table of Contents
ORIGINAL ARTICLE
Year : 2018  |  Volume : 17  |  Issue : 1  |  Page : 2-7

Evaluation of uncomplicated isolated extensor tendon injury repair of hand in Amritsar (India)


1 Department of Orthopedics, Government Medical College, Amritsar, Punjab, India
2 Department of Anaethesia, Government Medical College, Patiala, Punjab, India

Date of Web Publication30-Jul-2018

Correspondence Address:
Dr. Parul Rani
19 e New Lal Bagh Colony, Patiala, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njot.njot_3_17

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  Abstract 


Introduction: Extensor tendon injury is one common hand injury occurring in young individuals. Extensor tendons are superficially located with minimal amount of subcutaneous tissue that predisposes the extensor mechanism to more complex tendon injuries. Surgical repair of extensor tendon requires an exact knowledge of anatomy, careful adherence to some basic surgical principles, sound clinical judgment, strict atraumatic surgical technique and a well planned postoperative programme. Aim and Objectives: We conducted this study to find out common causes of extensor tendon injuries, evaluation of hand function after repair of extensor tendon injuries and evaluation of effect of time elapsed between onset of injury to tendon repair on the final outcome. Methodology: The functional outcome after tendon repair was assessed by calculating Total Active range of Motion (TAM). Results: We concluded that the higher percentage of excellent and good cases is might be attributable to strong and meticulous repair in which more aggressive physiotherapy was tolerated by the patients and the tendons should be repaired preferably primarily.

Keywords: Extensor tendon, extensor zones, rehabilitation, splintage, total active range of movement


How to cite this article:
Kumar H, Rani P, Banga RK, Boparai RS, Singh J. Evaluation of uncomplicated isolated extensor tendon injury repair of hand in Amritsar (India). Niger J Orthop Trauma 2018;17:2-7

How to cite this URL:
Kumar H, Rani P, Banga RK, Boparai RS, Singh J. Evaluation of uncomplicated isolated extensor tendon injury repair of hand in Amritsar (India). Niger J Orthop Trauma [serial online] 2018 [cited 2018 Nov 15];17:2-7. Available from: http://www.njotonline.org/text.asp?2018/17/1/2/237836




  Introduction Top


The human hand is highly adaptable organ of prehension, sensation, expression and communication. It has very complex and integrated structures such as skin, muscles, tendons, nerves, vessels, bones and joints. All these components contribute to the performance of highly coordinated actions of hand. Hand injuries can cause severe disability of hand.

Injuries of hand are quite common in working individuals, and extensor tendon injury is one common hand injury occurring in young individuals in the prime of their lives.[1] Extensor tendons are superficially located with a minimal amount of subcutaneous tissues that predisposes the extensor mechanism to more complex tendon injuries.[2]

Primary treatment with restoration of normal anatomy in a single operation is required to achieve the best possible outcome.[3] Inadequate primary treatment is likely to give poor long-term results.[4] Surgical repair of extensor tendon requires an exact knowledge of anatomy, careful adherence to some basic surgical principles, sound clinical judgment, strict atraumatic surgical technique, and a well-planned post-operative programme.

The extensor tendon injuries have been divided into eight zones as recommended by Kleinert and Verdan.[5] Even-numbered zones are over bones; odd-numbered zones are over joints. Doyle considered the forearm area of extensor muscle bellies as a ninth zone.[3]

Management of tendon injuries is dependent on the location and type of injury and repair should take place very soon after the injury, especially within the first 2 weeks.[6]

Primary repair has been widely used to reunite severed tendons since the 1960s, and in recent years, early active mobilisation has been accepted as the ideal rehabilitation method. The whole new concept of tendon healing has undergone a revolutionary change, but still the perfect suture and ideal mobilisation technique elude this.

Aims and objectives

We conducted this study to find out common causes of extensor tendon injuries such as in relation to working environment, trauma and scuffle and evaluation of hand function after repair of extensor tendon injuries.

We also aimed at comparing the results achieved after extensor tendon repair in different zones and evaluation of effect of time elapsed between onset of injury to tendon repair, severity and complexity of injury on the final outcome.


  Materials and Methods Top


We conducted a prospective study on a total of 30 patients with an extensor tendon injury admitted in the Department of Orthopaedics of Government Medical College, Amritsar, from June 2011 to September 2013. Patients having concomitant flexor tendon injury were excluded from the study. In this study, only functional recovery related to the tendons was assessed.

Clinical history, general physical examination and local examination were performed, and patients were investigated for operative and anaesthetic purposes after informed written consent.

The supportive and prophylactic therapy in the form of analgesics, antibiotics, anti-tetanus injection, intravenous fluids and matched blood transfusion, wherever required, were given.

Injured hand was X-rayed to know any associated bony injury.

Before doing any operative work, the following criteria were fulfilled:

  1. Fairly good range of the passive movements at the joint acted upon by the injured tendon
  2. The absence of wound erythema and swelling suggestion inflammation or potential infection
  3. Adequate skin coverage
  4. Relative freedom from scar of the tissue in which tendon was expected to glide
  5. Satisfactory alignment of the bones and properly healed fractures
  6. Intact or restorable sensation, especially of the fingers.


Patients were subjected to general anaesthesia/regional anaesthesia. Atraumatic technique was adhered to throughout the operation. In all the patients, modified Kessler repair technique was used for the repair of extensor tendons. Non-absorbable monofilament (Prolene) suture was used.

In neglected cases, to cover the gap, free tendon grafts were used. After the repair, wound was closed with fine, interrupted non-absorbable suture. Sterile dressing was then applied along with a volar splint extending from proximal phalanx to proximal forearm. Wrist held in 30° extension and metacarpophalangeal (MP) joints flexed at least 45° and interphalangeal (IP) joint free to mobilise.

Post-operative care

Appropriate post-operative antibiotics were given. The first post-operative dressing was done on the 5th day. Stitches were removed on 12th and volar splint was changed with wrist held in 200 extension, metacarpophalangeal (MP) joint flexion at 30° and interphalangeal (IP) joints free to mobilise. Controlled active mobilisation was begun on the 1st post-operative day. The patient was instructed to carry out two exercises actively: (1) combined IP and MP joints extension and (2) joint extension with IP joint flexion. Volar splint was removed on 3rd week. First follow-up was done after 3 weeks, then after 4 weeks. Further follow-ups were done at 2 weekly intervals for 3 months.

Evaluation of results

The functional outcome after tendon repair was assessed by calculating total active range of motion (TAM) as suggested by the American Society for the Surgery of Hand. This was done by adding active flexion at MP, proximal IP and distal IP joints, after subtracting the sum of extension deficit at these joints. Recovery was calculated as per cent–regained motion compared to normal range of motion (70).



Results were evaluated according to modified Strickland's classification.

Modified Strickland, as shown, was the grading system used in the analysis.


  Observations and Results Top


Out of a total of 30 patients, 28 were males and 2 were females. Majority of them, i.e., 53.33% of case (n = 16) presented in the third decade of life. Nearly 66.67% of the cases sustained right-hand injury (n = 20). The most common etiological factor of tendon injury was individual scuffle (73.33% [n = 20]) followed by everyday life injuries seen in 20% of the cases (n = 6). Most of the injuries were seen in Zone VI and VII involving 53.33% of cases (n = 16) followed by Zone VIII and IX, i.e. 20% (n = 6).

[Table 1] shows time elapsed from the injury to primary treatment wherein 60% of the patients reported for treatment within 6 h. [Table 2] shows that only 20% (n = 6) cases approached the medical college for primary treatment while bulk of the patients were treated at other health centers. Time elapsed between the injury and operation varied from one day to three months and only 13.33% of patients (n = 4) were operated within first 24 h as shown in [Table 3].
Table 1: Time elapsed from the injury to primary treatment

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Table 2: Primary management of the patients

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Table 3: Time elapsed from the injury to operation

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It was found that bone involvement was seen in 26.67% of patients (n = 8) and joint involvement was there in 13.33% of patients (n = 4).

The results were categorised and assessed depending on the following factors: (1) time elapsed between injury and operation, (2) site of the tendon lesion, (3) effect of patient cooperation in follow-up periods and (4) effect of physiotherapy.

[Table 4] shows time elapsed from the injury to operation and the end result. It was found that patients who were operated within first 24 h, 75% of them showed excellent result and 25% had a good result. Those operated from 1 to 3 months of injury had a sharp decline with only 50% cases showing good and fair results.
Table 4: The time elapsed from the injury to operation and the end result

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Post-operative physiotherapy and adherence to the treatment plan are necessary for complete recovery. As shown in [Table 5], highly cooperative patients, i.e., 85% patients had excellent results, while uncooperative patients had only fair (75%) and poor (25%) results.
Table 5: Effect of patient cooperation in follow-up period on results

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It was found that patients with Zone IX and VIII involvement as in case [Figure 1] and [Figure 2] had excellent recovery with 100% results as shown in [Table 6]. The recovery rate started falling in cases where hand and fingers as in case [Figure 3] and [Figure 4] were involved with 55.5% and 57% excellent results, respectively.
Figure 1: Injury at zone IX showing excellent result after tendon repair following post operative protocol

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Figure 2: Injury at zone VIII showing excellent result after tendon repair following post operative protocol

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Table 6: Site of tendon lesions and end results

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Figure 3: Injury at zone VII showing poor result and stiffness of the joint after tendon repair

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Figure 4: Injury at zone VI showing good result after tendon repair following post operative protocol

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In all, nine patients had a failure. On careful scrutinisation of these cases, probable causes of failure to achieve the ideal results are shown in [Table 7].
Table 7: Complications

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  Discussion Top


Extensor tendon injuries can cause serious functional impairment if intervention is not timely. The management of these injuries demands the same skill and knowledge as required for flexor tendon injuries.[7],[8] On the dorsum of the hand and fingers, there is a relative lack of soft tissue; therefore, adhesions of the tendon to skin are common, the bone and joints being very close to the dorsal surface are injured concurrently with extensor tendons. These tendons have no vincula; their blood supply is segmental, arising from the surrounding soft tissue and paratenon. Extensive dissection devitalises these tendons and promotes scarring.

Tendon injuries were more often found in persons at their best working age (18–50 years). In the present prospective study, 87% of the patients were within this age group. A maximum number of patients were in the third decade of life (16 patients; 53.33%). Slater and Bynum [9] found similar incidence where most of the patients were between 20 and 40 years. In the present prospective study, dominant right hand was injured in 20 patients (66.67%) and so was reported by Crosby and Wehbé[10] and Pandey and Goyal.[11]

Numerous causes of tendon injuries have been mentioned in the literature by Fowler [12] and Saini et al.[13] and these vary widely in different series probably because of difference in demographic and social situations. Analysis shows that, in the third and fourth decade, the most common cause was individual scuffle. In our study also, 73.33% of patients sustained injuries to the tendons in individual scuffles followed by everyday life injuries seen in 20% of patients.

As described by Doyle [3] and Blue et al.,[4] initial treatment is of the utmost importance because it often determines the final outcome; inadequate primary treatment is likely to give poor long-term results. Surgical repair of extensor tendon requires an exact knowledge of anatomy, careful adherence to some basic surgical principles, sound clinical judgment, strict atraumatic surgical technique, and a well-planned post-operative programme.

In our study, 60% of patients reported within first 6 h, while 40% reported for treatment after 6 h. Furthermore, only 20% of patients received primary treatment in medical college (by orthopaedics team), whereas 77% patients received primary treatment from doctors other than orthopaedic specialist and 3% had taken treatment from quacks. A study conducted by Mason [14] described the following causes of negligence: (a) poor facilities at the hospital, (b) lack of experience on the part of attending surgeon, (c) poor general condition of the patient, (d) condition of the wound and (e) associated injuries.

Extensor tendons have been divided into different zones by various authors. In the present series, we used the classification of Kleinert and Verdan. The most common site of injuries was Zone of VI and VII consist total of 16 patients (53.33%), respectively, whereas VIII and IX consist total of 6 patients (20%) in this study. The study conducted by Saini et al.[13] described that 42% (n = 11) injuries were in Zone VI and 35% (n = 9) in Zone VII. This observation is understandable since these two zones are vulnerable to trauma.

We repaired the extensor tendon under supraclavicular brachial block with application of tourniquet and we faced no anaesthesia related complications. We avoided giving axillary block as it may leave an area in lateral part of arm proximally which may have to be anesthetized separately for tourniquet application.

Slater RR et al.[9] conducted a study and found that lesser the time between the injury to primary repair; better the results are. In the present study four patients were operated within first 24 hours of the injury and 75% of them had excellent end results, comparable to the study conducted by Slater RR et al.

We chose Modified Kessler technique for the repair and achieved 63.33% excellent results and 13.33% good results. Newport.[15] examined the long-term results of extensor tendon repair in 101 digits treated with traditional static splinting, achieving 45% good or excellent results. Both simple injuries and those with the addition of joint capsule injury only achieved 64% good-to-excellent results. Crosby and Wehbé[16] used dynamic splinting giving 92% good-to-excellent results. Hence, it is concluded that controlled early active mobilisation gives better results than static splinting and it is comparable to dynamic splinting protocol.

Hung et al.[17] concluded that injuries distal to knuckles (Zones II, III and IV) showed worst results with an average total active motion of only 188° (range, 95°–270°). Our study also reveals that all the patients with Zone VIII and IX achieved excellent results while lesions involving digits had variable results.


  Conclusion Top


  1. Repairs with modified Kessler technique were technically easy to perform with a relatively short learning curve
  2. The higher percentage of excellent and good cases is attributable to strong and meticulous repair in which more aggressive physiotherapy was tolerated by the patients
  3. The tendons should be repaired preferably primarily
  4. Post-operative early controlled mobilisation provides better rehabilitation in extensor tendon injuries
  5. The motivated and educated patients may be put on active motion protocols; with each subsequent visit, the load and the type of exercise may be stepped up increasing load bearing
  6. Regular follow-up of all repaired extensor tendon is advisable in 3rd week, and then next week, then every 2 weeks for at least 3 months.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Newport ML, Blair WF, Steyers CM Jr. Long-term results of extensor tendon repair. J Hand Surg Am 1990;15:961-6.  Back to cited text no. 1
    
2.
Tuncali D, Yavuz N, Terzioglu A, Aslan G. The rate of upper-extremity deep-structure injuries through small penetrating lacerations. Ann Plast Surg 2005;55:146-8.  Back to cited text no. 2
    
3.
Doyle JR. Extensor tendons: Acute injuries. In: Green, DP, Pederson, CW, Hotchkiss, RN, eds. Green's Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone; 1999:195-8.  Back to cited text no. 3
    
4.
Blue AI, Spira M, Hardy SB. Repair of extensor tendon injuries of the hand. Am J Surg 1976;132:128-32.  Back to cited text no. 4
    
5.
Kleinert HE, Verdan C. Report of the committee on tendon injuries (International federation of societies for surgery of the hand). J Hand Surg Am 1983;8:794-8.  Back to cited text no. 5
    
6.
Rockwell WB, Butler PN, Byrne BA. Extensor tendon: Anatomy, injury, and reconstruction. Plast Reconstr Surg 2000;106:1592-603.  Back to cited text no. 6
    
7.
Zubović A, Egan C, O'Sullivan M. Augmented (MGH) technique combined with static splinting in extensor tendons repairs zones III-VI: Functional outcome at three months. Chir Main 2007;26:214-8.  Back to cited text no. 7
    
8.
Evans RB. Therapeutic management of extensor tendon injuries. Hand Clin 1986;2:157-69.  Back to cited text no. 8
    
9.
Slater RR Jr., Bynum DK. Simplified functional splinting after extensor tenorrhaphy. J Hand Surg Am 1997;22:445-51.  Back to cited text no. 9
    
10.
Crosby CA, Wehbé MA. Early motion after extensor tendon surgery. Hand Clin 1996;12:57-64.  Back to cited text no. 10
    
11.
Pandey VK, Goyal A. Study of extensor injuries of hand and wrist. Indian J Orthop 1988;22:126.  Back to cited text no. 11
    
12.
Fowler SB. The management of tendon injuries. J Bone Joint Surg Am 1959;41-A: 579-80.  Back to cited text no. 12
    
13.
Saini N, Sharma M, Sharma VD, Patni P. Outcome of early active mobilization after extensor tendon repair. Indian J Orthop 2008;42:336-41.  Back to cited text no. 13
[PUBMED]  [Full text]  
14.
Mason ML. Primary tendon repair. J Bone Joint Surg Am 1959;41-A: 575-7.  Back to cited text no. 14
    
15.
Newport ML. Extensor tendon injuries in the hand. J Am Acad Orthop Surg 1997;5:59-66.  Back to cited text no. 15
    
16.
Crosby CA, Wehbé MA. Early protected motion after extensor tendon repair. J Hand Surg Am 1999;24:1061-70.  Back to cited text no. 16
    
17.
Hung LK, Chan A, Chang J, Tsang A, Leung PC. Early controlled active mobilization with dynamic splintage for treatment of extensor tendon injuries. J Hand Surg Am 1990;15:251-7.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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