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54 Cards in this Set
- Front
- Back
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Flexor Digitorum Profundus
Origin Insertion Innervation Action |
Origin: ulna and interosseous membrane
Insertion: P3 of IF, LF, RF, SF Innervation: Ulnar to RF/SF Anterior Interosseous branch of Median to IF/LF Action: Flexes the DIPjt |
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Which muscle has a common muscle belly... FDP or FDS?
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FDP has a common muscle belly. The IF may have indpendent flexion throught its own muscle belly or be interdigitated with the common belly
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What can cause a quadregia effect?
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if the FDP: 1) unable to glide from adhesions
2) tacked down after DIP amputation 3) Advanced more than 1cm during a repair, the adjacent FDP tendon will experience difficulty gliding proximally All result in decreased active DIP flexion of the adjacent fingers to the injured finger |
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Flexor DigitoriumSuperficialis
Origin Insertion Innervation Action MMT |
Origin: 2 heads from Medial epi
Insertion: P2 of IF,LF,RF,SF Innervation: Median Nerve Action: PIP flexion, assist w/ MP Flexion MMT: Support all digits and have pt attempt to flex PIPjt |
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FDS of the SF is absent in approx ____ of population
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21% of population
Asymmetry present in 26% |
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At the level of the carpal, which muscle lies deeper, FDS or FDP?
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FDP is deep to FDS in FA through carpal tunnel to level of P1
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Within the carpal tunnel, the tendons of FDS are in what order?
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FDS of RF and LF lies volar to FDS of IF and SF
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What is it called where the FDS splits for the FDP?
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Chiasma of Champer
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What happens at the Chiasma of Champer?
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FDS splits at level of the P1 to pass around and underneath the FDP to form an opening for the FDP to emerge and insert on the P3
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Flexor Pollicis Longus
Origin Insertion Innervation Action MMT |
Origin: Radius and Interosseous membrane
Insertion: Base of distal phalanx of thumb Innervation: Anterior interosseous branch of Median Nerve Action: Flexes thumb IP MMT: hold thumb MP joint in ext and pt attempts IP flexion |
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Lindburg's Sign
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FPL interedigitated with the FDP of IF
Pt pt actively flex thumb IP, IF IP flexes |
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Thickenings of the Synovial Sheaths
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Pulleys.
Fibrous bands that overlay the synovial sheath in segmental fashion |
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Function of the flexor pulleys
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Keep the flexor tendons in place longitudinally
Prevent bowstringing of the flexor tendons |
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Two types of flexor pulleys
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Annular Pulleys
Cruciate LIgaments |
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Critical pulleys
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A2
A4 |
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Odd number pulleys cross what?
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Joints
A1 MP A3 PIP A5 DIP |
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Thick, rigid, Transverse pulleys?
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Annular
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Thin and flexible pulleys?
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Cruciate ligaments
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Location of Cruciate ligaments?
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C1: between A2 & A3
C2: between A3 & A4 C3: distal to A4 pulley |
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Pulley at the level of the wrist
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Transverse retinacular ligament
Acts as a pulley to prevent bowstringing |
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How many flexor tendon zones are there?
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5
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Flexor Zone I
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From insertion of the FDS on P2.
Includes ONLY FDP tendon |
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Flexor Zone II
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From the beginning of A1 pulley just proximal to MP jt
to FDS insertion |
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Flexor Zone III
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From the distal edge of transverse carpal ligament to
proximal edge of A1 pulley |
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Flexor Zone IV
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From proximal edge of transverse carpal ligament to distal edge of tranverse carpal ligament
*withing carpal tunnel |
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Zone V
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From the musculotendinous junction of the flexor tendons to proximal edge of the transverse carpal ligament
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How many flexor zones of the thumb?
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5
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Zone TI
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Distal to the IP joint of thumb
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Zone TII
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From the A1 pulley to IPjt of thumb
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Zone TIII
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Over the thenar eminance
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Zone TIV
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From proximal edge of transverse carpal ligament to distal edge of transverse carpal ligament
*within carpal ligament |
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Zone TV
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From the musculotendinous junction of the flexor tendons to proximal edge of transverse carpal ligament
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Normal Tendon Excursions for
FDP FDS FPL |
FDP 32mm
FDS: 24mm FPL: 27mm |
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Which surface of flexor tendons is relatively avascular?
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Volar
and a "watershed area" between the vinculum |
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What provides blood supply to flexor tendons?
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Vinculum longus and brevis
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Synovial Diffiusion
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Synovial fluid pumped into tendons through compressive forces of the tendon sheath against the pulley during motion
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Extrinsic tendon Healing
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Described as tendon healing by fibroblast adhesion formation between tendon and surronding tissue.
Study by Potenza and Peacock. developed the "one wound' concept |
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Intrinsic Tendon Healing
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Tendon's ability to heal through intrinsic means using both intrinsic vascularity and synovial diffusion, WITHOUT adhesions.
Studies by Matthew & Richards, Lundborg, Manske, Gelberman |
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Factors that affect tendon Healing
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Age
Nutrition Controlled Stress (mobilization) Biochemcial response Mechanism/Type of injury |
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Tendon strength is noted to decrease when following a repair?
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First week following repair (Mason & Allen)
Progressive increase in strength after the first 2-3 weeks |
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Immediate controlled stress to a healing tendon reverses or strengthens in the initial weakening process?
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reverses
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Maximum colagen synthesis occurs at _____ weeks and does what to the tensile strength?
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3 weeks
Increases the tendon's tensile strength |
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Flexor tendon tensile strength demands
PROM Light grip Strong Grip Tip Pinch |
PROM 500 gm
Light grip 1500 gm Strong grip 5000 gm Tip pinch 9000gm (IF FDP) |
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Clinical purposes of Controlled Stress to the healing tendons
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1. Promote intrinsic healing and therefore decrease adhesion formation and need for extrinsic healing
2. Encourage longitudinal orientation of adhesions associated with extrinsic healing during collagen synthesis 3. Decrease joint stiffness |
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Physiologic response of the healing tendon to controlled stress
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1. Improved tensile strength
2. Improved tendon excursion 3. Improved repair site cellularity 4. Improved pentratin of synovial fluid into the tendon to enhance nutrition and intrinsic healing 5. Reorginaiztion, elongation, reorientatin of extrinsic scar |
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Consideration for application of controlled stress
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1. type of injury
2. Levle of injury (zone II) 3. Repair technique (number & type of sutures) 4. Patient factors ( age, cognitive status, compliance) |
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Precise transmission of controlled stress to flexor tendon
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Provide enough stress to move tendon a controlled amount (3-5mm determined by Gelberman and Duran) BUT avoid gapping or rupture.
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Explain the amount of stress on a tendon with Immobilization.
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LIttle to no controlled stress on a repaired tendon
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Explain the amount of stress in an Immediate Passive Mobilization protocol
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designed to place controlled stress on the healing tendon with active IP extension and passive flexion
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Explain the amount of stress in an Immediate Controlled Active mobilization protocol
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Place an evengihger level fo controlled stress on the repaired musculotendinous unit, resulting in definite proximal gliding of the repaired tendon
Requires a stronger surgical repair with minimal complications to safely apply an early controlled active mobilization protocol. |
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If adhesions are significantly limiting tendon gliding, active motion and progression toward resistance are initiated EARLIER/LATER than if tendon gliding is good
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Earlier
With good tendon gliding, PROTECT the tendon from resistance and potential rupture for a longer period of time |
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If passive extension to any joint is performed within the first 4-5 weeks following flexor tendon repair, What position should the other joints be in and why?
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It is done with all other joints supported in Flexion, to give the flexor tendon slack and prevent gapping or rupture through excessive traction
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Flexor Protocol used for children under 12, cognitively impaired or non compliant patients
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Immobilization
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Immobilization Flexor Protocol
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EARLY stage (0-3 or 4 wks)
DBS Wrist 10-30 flex MPs 40-60 flex IPs in ext Therapy for passive flexion of digits in therapy, maintain shoulder/elbow ROM, wound/skin care INTERMEDIATE stage (3-4 to 5-6 wks) Splint odified to wrist neutral Remove splint hourly for exercises -Passive flexion & ext w/ wrist in 10 ext -Active flexion using tendosis of hand/wrist -If more than 50 deg diff is present b/w passive and active flexion, move to the LATE stage. If less is noted, cont with intermediate phase until 6 wks post op LATE stae (5 to 6 wks) -D/c DBS, Can use a NOC resting pain w/ wrist neutral and fingers in comfortable ext if flex muscle tendon shortening has occurred -Begin gentle blocking ex, except to SF -After 1 wk of gentle blocking, may initiate light resistance. -IF TENDON GLIDING IS GOOD, DEALY ANY RESISTANCE |
