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54 Cards in this Set

  • Front
  • Back
Flexor Digitorum Profundus
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
Which muscle has a common muscle belly... FDP or FDS?
FDP has a common muscle belly. The IF may have indpendent flexion throught its own muscle belly or be interdigitated with the common belly
What can cause a quadregia effect?
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
Flexor DigitoriumSuperficialis
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
FDS of the SF is absent in approx ____ of population
21% of population

Asymmetry present in 26%
At the level of the carpal, which muscle lies deeper, FDS or FDP?
FDP is deep to FDS in FA through carpal tunnel to level of P1
Within the carpal tunnel, the tendons of FDS are in what order?
FDS of RF and LF lies volar to FDS of IF and SF
What is it called where the FDS splits for the FDP?
Chiasma of Champer
What happens at the Chiasma of Champer?
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
Flexor Pollicis Longus
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
Lindburg's Sign
FPL interedigitated with the FDP of IF

Pt pt actively flex thumb IP, IF IP flexes
Thickenings of the Synovial Sheaths
Fibrous bands that overlay the synovial sheath in segmental fashion
Function of the flexor pulleys
Keep the flexor tendons in place longitudinally
Prevent bowstringing of the flexor tendons
Two types of flexor pulleys
Annular Pulleys
Cruciate LIgaments
Critical pulleys
Odd number pulleys cross what?
Thick, rigid, Transverse pulleys?
Thin and flexible pulleys?
Cruciate ligaments
Location of Cruciate ligaments?
C1: between A2 & A3
C2: between A3 & A4
C3: distal to A4 pulley
Pulley at the level of the wrist
Transverse retinacular ligament
Acts as a pulley to prevent bowstringing
How many flexor tendon zones are there?
Flexor Zone I
From insertion of the FDS on P2.
Includes ONLY FDP tendon
Flexor Zone II
From the beginning of A1 pulley just proximal to MP jt
to FDS insertion
Flexor Zone III
From the distal edge of transverse carpal ligament to
proximal edge of A1 pulley
Flexor Zone IV
From proximal edge of transverse carpal ligament to distal edge of tranverse carpal ligament
*withing carpal tunnel
Zone V
From the musculotendinous junction of the flexor tendons to proximal edge of the transverse carpal ligament
How many flexor zones of the thumb?
Zone TI
Distal to the IP joint of thumb
Zone TII
From the A1 pulley to IPjt of thumb
Over the thenar eminance
Zone TIV
From proximal edge of transverse carpal ligament to distal edge of transverse carpal ligament
*within carpal ligament
Zone TV
From the musculotendinous junction of the flexor tendons to proximal edge of transverse carpal ligament
Normal Tendon Excursions for
FDP 32mm
FDS: 24mm
FPL: 27mm
Which surface of flexor tendons is relatively avascular?

and a "watershed area" between the vinculum
What provides blood supply to flexor tendons?
Vinculum longus and brevis
Synovial Diffiusion
Synovial fluid pumped into tendons through compressive forces of the tendon sheath against the pulley during motion
Extrinsic tendon Healing
Described as tendon healing by fibroblast adhesion formation between tendon and surronding tissue.

Study by Potenza and Peacock. developed the "one wound' concept
Intrinsic Tendon Healing
Tendon's ability to heal through intrinsic means using both intrinsic vascularity and synovial diffusion, WITHOUT adhesions.

Studies by Matthew & Richards, Lundborg, Manske, Gelberman
Factors that affect tendon Healing
Controlled Stress (mobilization)
Biochemcial response
Mechanism/Type of injury
Tendon strength is noted to decrease when following a repair?
First week following repair (Mason & Allen)

Progressive increase in strength after the first 2-3 weeks
Immediate controlled stress to a healing tendon reverses or strengthens in the initial weakening process?
Maximum colagen synthesis occurs at _____ weeks and does what to the tensile strength?
3 weeks

Increases the tendon's tensile strength
Flexor tendon tensile strength demands
Light grip
Strong Grip
Tip Pinch
PROM 500 gm
Light grip 1500 gm
Strong grip 5000 gm
Tip pinch 9000gm (IF FDP)
Clinical purposes of Controlled Stress to the healing tendons
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
Physiologic response of the healing tendon to controlled stress
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
Consideration for application of controlled stress
1. type of injury
2. Levle of injury (zone II)
3. Repair technique (number & type of sutures)
4. Patient factors ( age, cognitive status, compliance)
Precise transmission of controlled stress to flexor tendon
Provide enough stress to move tendon a controlled amount (3-5mm determined by Gelberman and Duran) BUT avoid gapping or rupture.
Explain the amount of stress on a tendon with Immobilization.
LIttle to no controlled stress on a repaired tendon
Explain the amount of stress in an Immediate Passive Mobilization protocol
designed to place controlled stress on the healing tendon with active IP extension and passive flexion
Explain the amount of stress in an Immediate Controlled Active mobilization protocol
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.
If adhesions are significantly limiting tendon gliding, active motion and progression toward resistance are initiated EARLIER/LATER than if tendon gliding is good

With good tendon gliding, PROTECT the tendon from resistance and potential rupture for a longer period of time
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?
It is done with all other joints supported in Flexion, to give the flexor tendon slack and prevent gapping or rupture through excessive traction
Flexor Protocol used for children under 12, cognitively impaired or non compliant patients
Immobilization Flexor Protocol
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.