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ORIGINAL ARTICLE
Year : 2015  |  Volume : 28  |  Issue : 1  |  Page : 149-153

Evaluation of the results of management of acute extensor tendon injuries of the hand


Department of Orthopaedic Surgery, Menoufia University, Shebin El Kom

Date of Submission10-Jul-2014
Date of Acceptance11-Sep-2014
Date of Web Publication29-Apr-2015

Correspondence Address:
Mohammed Ahmed Kadah
Department of Orthopaedic Surgery, Menoufia University, Shebin El Kom Teaching Hospital, Shebin El Kom

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.155973

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  Abstract 

Objectives
The aim of this study was to prospectively assess the results after primary extensor tendon repair and to analyze the factors affecting the results, such as the zone of injury, multiplicity of digits and zones affected, splint type, social class of patients, and the associated bone injury.
Background
Acute extensor tendon injuries of the hand is a common lesion due to the superficial nature of the extensor tendons and its adjacency to bone, which makes it more liable to injury than flexor tendons.
Materials and methods
During a period of 14 months, 30 hands with acute extensor tendon injuries in 29 patients (as one patient had bilateral hand affection) were studied prospectively regarding cause of injury and affected zone (s) and finger (s). Two of them were lost in follow-up postoperatively. The final results were based on 28 hands in 27 patients, where primary extensor tendon repair was carried out. The patients were followed up for an average duration of 8.5 months ranging 3-14 months and were evaluated according to Miller's scoring system.
Results
The final results of 46 digits with acute extensor tendon injury were reported. The excellent and good results represented 74.9% of the all final results. The best results were obtained in thumb and in zone TV and the worst results were seen in the ring finger and zone III. Multidigits and multifingers was associated with the worst results.
Conclusion
Multidigits and multiinjury zones involved have a poor effect on final results of extensor tendon injury. The results of zones III gave the worst results compared with other zones. More poor results were found in extensor tendons associated with bone injury. Postoperative splinting after extensor tendon repair is still under debate. From the economic point of view, a static regimen may be preferred, as it is much cheaper besides it requires little supervision by the physician.

Keywords: Extensor tendon injuries, hand injury, tendon repair


How to cite this article:
Kadah MA. Evaluation of the results of management of acute extensor tendon injuries of the hand. Menoufia Med J 2015;28:149-53

How to cite this URL:
Kadah MA. Evaluation of the results of management of acute extensor tendon injuries of the hand. Menoufia Med J [serial online] 2015 [cited 2019 Jul 17];28:149-53. Available from: http://www.mmj.eg.net/text.asp?2015/28/1/149/155973


  Introduction Top


Surgeons who treat hand injuries have developed a great respect for injuries to the flexor tendons; there is widespread knowledge about pitfalls and complications encountered in the management of these injuries [1],[2]. Injuries to the extensor mechanism, in contrast, may seem relatively simple to treat but this is not so [3]. Extensor injuries have not been given the same degree of attention, despite the advice of many authors [1],[2],[3],[4]. The management of injuries to the extensor mechanism demands the same amount of skills and knowledge required for the care of flexor tendon injuries. The extensor mechanism in fingers in comparison with that of flexors is thinner, less substantial, and less likely to hold sutures well [5]. At the wrist and forearm, however, the extensors' substance and cross-sectional area are much more like the flexor tendons. Injuries to the extensor tendons are common due to their relatively exposed and superficial location. The dorsal aspect of wrist and hand is covered with a thin layer of supple skin with minimal subcutaneous tissue [5]. A significant complication of injury to extensor tendons is loss of finger flexion, and this may be greater than the extensor lag [2]. Neglected or chronic extensor tendon injuries can lead to fixed deformities that can be very difficult to treat [4]. The more recent debate has been between dynamic splintage and controlled active mobilization. Prospective randomized studies have shown no difference between dynamic splintage and protected early active mobilization, and they have suggested that the latter should be used due to its simplicity and lower cost and therapist input [6]. The aim of this study was to prospectively assess the results after primary extensor tendon repair and to analyze the factors affecting the results, such as the effect of the zone of injury, multiplicity of digits and zones affected, splint type, social class of patients, and the effect of associated bone injury.


  Materials and methods Top


A total of 30 hands with acute extensor tendon injuries in 29 patients (one patient with both hands affected), admitted to Menoufia University hospital and Shebin El-kom teaching hospital from December 2011 to January 2013, were studied prospectively with a former approval of the ethics committee in faculty of medicine of Menoufia University. Two of them were lost in follow-up postoperatively; hence, the final material results were based on 28 hands in 27 patients. The age of the 29 patients in this study varied from 4 to 52 years with a mean of 30.5 years [Table 1]. There were 21 hands with single-finger affection and nine hands with more than one finger affection [Table 2]. Anesthesia was applied before intraoperative detection of injured structures. Wounds were washed out with normal saline solution, and the patient received prophylactic antibiotics. Associated fractures were fixed with K-wires. Primary extensor tendon repair was carried out using the modified Kessler technique, associated with augmentation sutures when possible, using prolene sutures (0-3 and 0-4) [Figure 1]. In this study, there were 21 cases with single-finger affection and nine cases with more than one finger affection. The most common injured fingers in this study were the index and ring fingers (each representing 29.16% of all injured fingers). Associated bone injury was noted in 20% of cases, and skin and tendon loss was noted in one case. After the repair, patients were immobilized using volar static splinting. In one case, it was replaced by a dynamic splint after 3 days. The postoperative splinting varied according to the affected zones and number of affected fingers; splinting application ranged from 3 to 8 weeks with a mean of 3.27 weeks. Rehabilitation was initiated on the immediate postoperative basics. Protected motion protocol was applied for the joints distal to the injury when possible; associated bone injury delayed the rehabilitation program. Rehabilitation period ranged from 2 to 4) months with a mean of 2.7 months. All injuries were categorized according to Verdan's classification system [Figure 2] [zone I: distal interphalangeal joint; zone II: middle phalanx; zone III: proximal interphalangeal (PIP) joint; zone IV: proximal phalanx; zone V: metacarpophalangeal joint; zone VI: dorsal hand; zone VII: dorsal retinaculum; and zone VIII: distal forearm]. At follow-up, the range of motion was measured in metacarpophalangeal, PIP, and distal interphalangeal joints of the injured digit with a goniometer according to Miller's criteria classification [Table 3] based on total active motion [Table 4] [7],[8].
Table 1: Age distribution in this study

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Table 2: Distribution of fingers affection

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Table 3: Miller's criteria for assessing extensor tendon function

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Table 4: Normal TAM

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Figure 1: (a– d) Complete cut of extensor digitorum of all fingers, cut extensor indicis, and extensor digiti mini in zones VII and VIII caused by a sharp knife was repaired by the modifi ed Kessler technique with augmentation using prolene (0– 3 and 0– 4).

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Figure 2: Verdan's classification of extensor tendon injury zones.

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Statistical analysis was performed using the SPSS program (IBM Company, Armonk, New York, USA). The following tests were used: (a) the mean (X), (b) P-value test, and (c) the t-test. The analysis of variance test was used to compare between mean (X2 ) and SD. P-value less than 0.05 denoted a statistically significant difference.


  Results Top


In this series, there were 30 hands (48 digits) affected. There were 26 male patients (89.6%) and three female patients (10.3%); the bilateral case affection was a male patient. The age of patients in this study varied from 4 to 52 years with a mean of 30.5 years. The dominant hand was the site of injury in 17 patients (56.66%). The occupation of patients varied greatly, but commonly the study met with manual workers 65.66% and farmers 20%. Sharp tools injuries represented the main cause of trauma representing 96.6% of causes. Treatment consisted of primary repair of the extensor tendon injury in 28 hands within the first 24 h and delayed primary repair in the other two hands 3 days after initial trauma. The patients were followed up for an average duration of 8.5 months (range 3-14 months). There were 21 hands with single-finger affection and nine hands with more than one finger affection. The most common injured fingers in this study were the index and ring fingers, representing 58.32% of all injured fingers. Zone VI was the most common affected representing 30% of all injured zones. Two patients (two digits) were lost in follow-up. The overall final results were evaluated according to Miller's criteria classification based on total active motion evaluation. Excellent results were found in 32.1% of cases, good results in 42.8%, fair results in 17.8%, and poor results in 1.7% of cases. According to finger affection in this study, all thumb injuries had excellent and good results. The fair results were found commonly in the little finger representing 50%, and the poor results were found commonly in the ring finger representing 14.28%. In this study, age was classified into two groups (≤30 years and >30 years) and the results according to the age group were nonsignificant. More excellent and good results were found when only one finger was affected than multifingers affection, but the difference was nonsignificant. The excellent results were obtained more often in zone TV as 100% had excellent and good results. Good results were obtained more often in zones I, II, and V, and the worst results were obtained more often in zone III either single or combined with another zone. Excellent and good results were more found when only one zone was affected, and the results were significant. More excellent results were found when no associated bone injury occurred, but the difference was nonsignificant. The final results according to the type of splint were estimated by comparison of the results found in patients who had the same injury zone and who were treated by a different type of splint. When only dynamic splint was applied in zone VII, the patient had fair result, whereas of three other patients treated by a static splint, one got excellent results and other two had good results, but the difference was nonsignificant; nonsignificant difference was found between patients who had primary repair and those who had delayed primary repair. In this study, cases according to social class were classified into two groups; students and educated employed patients were considered in one category (high) and other patients were considered in the other category (low), but the difference between the two groups was nonsignificant. Complications that were encountered in this study were adhesions, extension lag, infection, and stiffness. Combined complications were also noted, such as adhesions resulted in extension lag and stiffness and infection resulted in delayed physiotherapy and stiffness. The overall patients with combined complications were five patients representing 17.8%. In this study, three patients representing 10.7% of all patients suffered from adhesions, which resulted in extension lag in two patients (zone VI and VII) and stiffness in one patient (zone III). Two patients had postoperative wound infection representing 7.1% of all patients. Infection was treated by antibiotics and anti-inflammatory drugs; one patient was completely recovered with no finger affection and the other patient had PIP joint stiffness (zone III). Tendon extension lag was noted in two patients representing 7.1% of patients. They had multidigits affection (four digits). Both patients were noted in zones VI and VII, as they suffered from adhesions causing difficult gliding of the extensor tendons beneath the fibro-osseous tunnel. The affected fingers were managed by physiotherapy until adequate improvement and satisfaction of the patients were obtained. Stiffness was noted in two patients representing 7.1% of patients. Both were injured at zone III; they did not show any desire for a further management of the affected PIP joint as it did not interfere with their work ability. One of the all complicated patients had associated bone injury (represented 20% of all complicated patients). He suffered from both infection and stiffness (represented 22.22% of all complication frequency). The accompanied zones of injury with complications were: zone III in two cases, zones VI and VII in two cases, and one case of infection in zone V.


  Discussion Top


There have been conflicting reports regarding the results of extensor tendon repair. Despite the efforts of many authors, no globally accepted system has evolved. This makes it virtually impossible for surgeons to compare reported results with each other in a meaningful manner [7]. The comparison of studies on extensor tendon repairs is limited by the heterogeneity of patients included, techniques, and the postoperative treatment regimens [7]. The exclusion of major crushed hand injuries and cases with associated flexor tendon injuries allowed to focus on the impact of the extensor tendon injuries on the ultimate hand function and to be particular upon the efficiency of the extensor tendon repair and forthcoming applied rehabilitation program. In this study, the number of patients who underwent final evaluation was 28 representing 46 digits; the overall results were excellent in 32.1%, good in 42.8%, fair in 17.8%, and poor in 7.1%. In this study, the mean age was 30.5 years ranging from 4 to 52 years; in other studies, the mean age was close. In Evans study [9], the mean age was 32 years ranging from 16 to 61 years. There was lesser mean age of 22.5 years ranging from 10 to 55 years in Khachaba's study [10]. The study by Fitoussi et al. [11] was conducted on children with mean age of 9.5 years ranging from 12 months to 15 years. In the studies by Kayalar et al. [12], Khachaba [10], Fitoussi et al. [11], Allieu et al. [13], Evans et al. [9], and Newport et al. [14], they noted the mean age of patients in their studies but they did not consider it as a significant factor influencing the final results. In this study, the results according to the age groups were not significant. Reporting sex distribution of cases varied in the literatures; as some studies neglected reporting it, others considered reporting it. In this study, there were 27 male patients representing 93% of cases and three female patients representing 7% of cases. Studies that considered sex distribution noted male patients as the most affected sex with extensor tendon injury; it may be 100% of male patients as in Khachaba study [10] or 81.25% male patients as in Fitoussi et al. [11] study. The high percentage of male patients' affection is logically due to the hard nature of activities that male patients participate more in. In this study, it was noticed that excellent results were more found in primary tendon repair than in delayed primary tendon repair, but still good results could be obtained in delayed primary repair as long adequate management was performed. Besides that, other factors can affect the final results of the patients. The relationship between the zone of injury and outcome is an important concept; the literatures reviewed poor results observed at the level of the extensor retinaculum and over the dorsum of the fingers. Reparative techniques evolved and results at the extensor retinaculum level (VII) have improved, but the results of injuries at the proximal phalangeal and PIP joint level (zones III and IV) have remained problematic [7],[9],[11]. This is due to the fact that the extensor tendon in zone III has a complex structure where intrinsic and extrinsic mechanisms are joined. An adhesion forming on the PIP joint of the extensor side results in the limitation of finger flexion or extension loss. This situation reduces the functional capacity of the hand [8]. In this study, the zone with worst results was zone III, as poor results represented 33.3% of affected patients in this zone, which is compliant with other studies by Khachaba [10], Fitoussi et al. [11], Allieu et al. [13], Evans et al. [9], and Newport et al. [14]. In this study, final results of zone VII were excellent and good in 75% of patients, which reflects the improvement of final results in this zone as reported in other studies by Khachaba [10], Allieu et al. [13], Evans et al. [9], and Newport et al. [14]. It has been also noticed that patients with multiple injury zones have worse prognosis than other patients who have only one injured zone as reported by Allieu et al. [13] and Newport et al. [14]. Early studies that discussed extensor tendon management addressed the common condition of extensor tendon laceration combined with an associated bone injury. Kelly [15] noted that poor results were four times more common with associated fractures than without. Hauge [16] reported 76% good or excellent results in those without fracture, but only 39% such results in those with fracture. Other studies by Khachaba [10], Fitoussi et al. [11], Allieu et al. [13], Evans et al. [9], and Newport et al. [14] also confirmed the importance of associated bone injury as an effective harm factor to the final results of extensor tendon injury management [8-12]. In this study, excellent results were found in 39.13% of patients without associated injuries, whereas there was no excellent result in patients with associated bone injuries. Poor results were found in 4.5% of patients without associated injuries, whereas it was 20% in patients with associated bone injuries, which reflects the distinct efficacy of associated bone injuries in functional outcome of extensor tendon repair, but the results according to associated bone injury in this study were not significant. The debate about static and dynamic splinting in extensor tendon injury and the superiority of any did not resolve, although many studies show no significant functional difference between the dynamic and static regimes [1,2]. In this study, a static splint was applied at the end of the operation immediately according to the zone of injury affected. Because of economic reasons, the main regimen of splint type was the static one (96.66%). The splints were applied for a mean period of 3.3 weeks ranging from 3 to 5 weeks. This was compliant with other studies by Kayalar et al. [12], Khachaba [10], and Newport et al. [14]. Other studies by Fitoussi et al. [11] and Allieu et al. [13] gave a wider range of 3-6 weeks. This variation was mainly due to the difference in severity of injury in reported cases in each study. The results according to the type of splint in this study were not significant; yet, it has to be considered the insignificant representation of dynamic splinting in this study as one case represented 3.34%.


  Conclusion Top


  1. The early primary repair of extensor tendon injury is attended with more excellent results.
  2. Multidigits and multiinjury zones involved have a poor effect on final results of extensor tendon injury management.
  3. The results of injuries at the PIP joint level (zones III) have remained problematic, as in this study and many other previous studies it gave the worst results compared with other zones.
  4. Extensor tendon injury with associated bone injury still represents a challenge to hand surgeons in earlier and recent studies.
  5. The postoperative splinting after extensor tendon repair is still under debate. From the economic point of view, a static regimen may be preferred, as it is much cheaper besides it requires little supervision by the physician.



  Acknowledgements Top


Conflicts of interest

None declared.

 
  References Top

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2.
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9.
Evans JD, Wignakumar V, Davis TR, Dove A Results of extensor tendon repair performed by junior accident and emergency staff. Injury 1995; 26:107-109.  Back to cited text no. 9
    
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11.
Fitoussi F, Badina A, Ilhareborde B, Morel E, Ear R, PenneçotGF. Extensor tendon injuries in children. J Pediatr Orthop 2007; 27 :863-866.  Back to cited text no. 11
    
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Allieu Y, Cbammas M, Romian M. Acute traumatic injuries of the digital extensor mechanism. In: Tubiana R, Gilbert A eds. Tendon, nerve and other disorders London, New York: Taylor & Francais; 2005:2-70.  Back to cited text no. 13
    
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Newport ML, Blair WF, CM Steyers. Long-term results of extensor tendon repair. J Hand Surg Am 1990; 15 :961-966.  Back to cited text no. 14
    
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Kelly AP. Primary tendon repairs; a study of 789 consecutive tendon severances. J Bone Joint Surg Am 1959; 41 -A:581-598.  Back to cited text no. 15
    
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