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COMPLICATIONS IN
HAND SURGERY
COMPLICATIONS
OF INJURY
Complications of tendon
injuries
Missed tendon injuries
can occur when either the patient or the initial examining physician fails
to appreciate subtle findings.
Partial tendon
lacerations (partend.htm) should
be suspected when the patient has apparent full motion, but has pain
when attempting to use the tendon against resistance. Consequences
of partial tendon lacerations include delayed rupture, scarring
with tendon adhesions, triggering and weakness.
Missed finger extensor
mechanism injuries may occur because the broad expanse of the extensor
mechanism can initially maintain posture until softening from the healing
process allows the remnants of support to give way. Terminal tendon
injuries at the distal interphalangeal joint, and central slip injuries
at the proximal interphalangeal joint should be suspected when there is
a regional injury and pain with attempted extension against resistance,
even if the patient has a full active unresisted motion.
Missed finger flexor tendon
injuries are less common than missed extensor tendon injuries because
of change in the resting posture of the hand
(cuttend.htm). Isolated superficialis
tendon injury with an intact profundus tendon produces a subtle change
in finger posture, and is easily missed. Profundus tendon avulsion
injuries (profavul.htm)
are
often unappreciated by the patient, who believes that the finger is simply
"jammed", and delays medical evaluation until the best window of opportunity
for treatment has passed. If there is significant proximal retraction after
profundus avulsion, the flexor tendon sheath fills with blood, and within
a matter of days shrinks enough that reinsertion is either impossible or
does not result in functional movement.
Missed dorsal hand extensor
tendon injuries may occur with little initial functional deficit, either
through action of adjacent tendinous junctures, or in the index or small
fingers if only one of two (proprius and communis) tendons has been cut.
Extensor
pollicis longus tendon injuries may be missed because of trick motion
through the action of the thumb intrinsic muscles on the thumb extensor
mechanism, which may allow interphalangeal joint extension to neutral despite
a divided extensor pollicis longus tendon.
Common complications
of tendon injuries of the hand include stiffness, contractures, tendon
rupture, recurrent adhesions and weakness, and depend on the exact level
of injury.
The worst results
of flexor tendon injuries occur in injuries located in the flexor
tendon sheath extending from the metacarpal head to the middle portion
of the middle phalanx - referred to as "zone II" or "no man's land". Even
under ideal management, only about half of injuries at this level recover
good to excellent function, and fewer have a satisfactory outcome following
staged flexor tendon reconstruction with a tendon graft (CJ).
Quadrigia
syndrome refers to limited excursion of the middle, ring, and small
fingers due to tethering connections between the profundus tendons of these
fingers. This may follow a simple flexor tendon injury or be due
to adhesions following amputation.
The worst results of extensor
tendon injuries occur when injuries are located over the dorsum of
the proximal phalanx or the proximal interphalangeal joint. Loss
of proximal interphalangeal joint motion may take the form of a fixed contracture,
swan neck deformity, or boutonniere finger. Thin soft tissue cover and
poor tolerance of any length change both contribute to poor results at
this level.
Complications of the treatment
of tendon injuries
Tendon adhesions
and are the most common problem following tendon repair. Rupture
of a flexor tendon repair occurs in at least four percent of patients following
primary flexor tendon repair in zone II with postoperative controlled passive
motion (CJ). Stiffness may be due to
either or both problems, and it may be impossible to determine the nature
of loss of motion, even with MRI.
Mallet finger: Nearly
half of patients treated for mallet finger develop some type of complication
of treatment. Complications following surgery are more common,
more serious (e.g. deep infection), and more frequently permanent than
those arising from splinting alone (BG).
Bowstringing due to
incompetence of the flexor tendon pulley system may follow injury or iatrogenic
injury during efforts to expose, retrieve, and repair the tendon.
External ring splints to support the tendon pulley system are commonly
used, but have not shown to be mechanically effective in preventing bowstringing.
Staged flexor tendon reconstruction
using temporary silastic tendon spacers followed by tendon grafts carry
all the risks of primary tendon repair. In addition, staged reconstruction
is more likely to result in flexion contractures, and greatly extend
the necessary length of incapacitation.
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American
Society
for
Surgery
of the
Hand
assh.org
The Best
Resource
For Your
Hands,
Period.
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