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Flexor Tendon Complications
997 Plays2 years ago
Miranda and Josh talk about complications that can occur after a flexor tendon repair, including some of the more common complications but also some infrequent complications, which include lumbrical plus and the quadriga effect.
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Transcript
Introduction to Flexor Tendon Repair Complications
00:00:07
Speaker
Hi, I'm Josh McDonald. And I'm Miranda McKittery and we are Hand Therapy Academy. Today we're going to talk about flexor tendon repair complications. Some of the things we see the most and maybe what we do for them. Miranda, what would you say is one of the flexor tendon repair complications that you see most often?
Common Complication: PIP Joint Contracture
00:00:23
Speaker
I think the number one most common complication I see is probably a PIP joint contracture. So from tendon adhesions and just to stiff, especially in the zone when we're talking about a zone two injury.
00:00:37
Speaker
Yeah. Yeah. How about you? I think you're right. I think that's the one we see the most
Setting Realistic Patient Expectations
00:00:41
Speaker
often. And I think setting good expectations for patients is important early on, particularly if it's like a small finger, those are just stiff, stubborn, small tendons, every ounce of space is accounted for. And so when you add scar into that, um,
00:00:56
Speaker
Getting patients to understand like yes we want the perfect outcomes but if we get like a minus five degree extension lag because the contractors are minus ten maybe that's okay. But yeah that's setting good expectations initially is important right and i always say if you know if you can kind of anticipate what your complications and problems
Anticipating Complications in Treatment
00:01:16
Speaker
are.
00:01:16
Speaker
you can share them with your patients, but also you can kind of guide your treatment, right? You're like, oh, I know this is most likely to be a PIP joint contracture, so I'm going to really focus on doing that synergistic or that tenodesis with the full, you know, making sure that they get that full PIP joint extension and then doing the protected reverse joint blocking.
Uncommon Complications Overview
00:01:35
Speaker
So I feel like with the PIP joint contractures, you can really anticipate or that type of complication you can anticipate, but then there's some of those complications that
00:01:45
Speaker
You can't, you don't really anticipate, right? Some of those more obscure, rare ones.
Understanding Quadrigia
00:01:51
Speaker
So I kind of want to talk about those and what are some of those rare, obscure things you might see.
00:01:59
Speaker
So one of them is going to be a quadrige. And we don't see it a ton, but when you are allowed to start doing a little bit more range of motion, maybe week three or four where you're starting to get a little bit more down towards that full fist, if you see the injured digit doing more flexion range of motion into that flexion position than the other digits, it might be that that flexor tendon was put on too much tension.
00:02:24
Speaker
And so it bottoms out before the others have a chance to come down with it. So a quadrige is oftentimes either too much tension on that tendon, or maybe the repair was a little short. And a lot of times we're the first ones that see that, and then we got to refer them back to the doctor and say, listen, their tendon's coming down, or the fingers come down okay, but the others aren't, and it presents like quadrige.
Impact of Quadrigia on Grip Strength
00:02:46
Speaker
Yeah, and the problem I feel like with those, I don't see those very often either. Maybe every few years,
00:02:54
Speaker
But the problem with those is that they lose so much grip strength. And no matter what you do, they're not going to be getting their grip strength back because you can't physiologically make that tendon longer. Yeah. And if it's a barrier enough to their function, it might require going back for more surgery, unfortunately.
00:03:13
Speaker
right, you know, a tendon graft or something like that to make it a little bit longer.
Complication: Lumbrical Plus Finger
00:03:18
Speaker
So I think that's a really hard one when you have a patient that has that because it is oftentimes leads to additional surgery that maybe they weren't planning on.
00:03:27
Speaker
Yeah, yeah. Another one is a lumbrical plus finger and it's almost kind of the opposite if there's a laceration to that FDP or if the repair is too loose or too slacked, the load of the FDP muscle belly imparts load first to the lumbricals. And so it will tighten the lumbrical and cause that paradoxical extension. So when they're trying to flex the FDP,
00:03:55
Speaker
isn't applying load out to the tip of the finger, it's instead applying load to that lumbrical and can give you that extension. And that's something that, again, if that happens when they're trying to flex and the finger goes into extension, not just lagging and it's not coming down, but it actively extends. That's something where they may need to go back in for surgical repair. Yeah. And sometimes I feel like with the lumbrical plus finger, uh, when they go into that paradoxical extension, it almost looks like a tendon rupture, right?
00:04:23
Speaker
because you're like, they're not bending at the PIP when they go into their fist. It's kind of a weird presentation. So with that one, I'll check them, you know, in full extension, I'll joint block the patient, I'll be like, oh, their tendons are intact, they look good. But they're actually going into extension when they come down into the full, you know, when they're trying to make the full fist and that finger just shoots out straight. And that's another complication that as a therapist, we can't fix.
Therapy Limitations and Need for Surgery
00:04:50
Speaker
Yeah. Well, no matter how much you try, you know, you want to see that patient more, there's nothing we can really do to tighten that structure. Right. So like I had one guy that he was attending graft and the graph just happened to be too long. So.
00:05:05
Speaker
And there was just nothing we could do and we ended up having to go in and have the tendon shortened. And then your back is square one where you're treating it like a tendon repair. Yeah. Our nature is to be problem solvers and we want to help our patients and help them through things. But there's some things that walk in the door that we say, this is just outside my scope. There's just nothing. I mean, if it is too long or too short, I can't change that inherent muscle tendon unit length. That may need some surgical intervention.
Exploring Tinolysis Outcomes
00:05:32
Speaker
Right. And so with those patients, you know, you might still be seeing them if they have a stiff joint or something of that nature, because you're trying to get them ready for the next surgery. So it might not mean that you're not going to be still helping with them with things. It kind of depends on where they're at in their recovery, but it might mean that you're helping him get the joints looser and you're going to help them to optimize the surgical outcomes for that next procedure.
00:05:55
Speaker
But then at the same time, you might be thinking, okay, well, how many visits does this patient have, right? So we know insurance, with insurances, we're really limited too. So if they only have 20 visits, how are we gonna, you know, get them through this next phase? Yeah, yeah. And you talked before about, you know, if you know that a patient's presenting like they're trending, because we're watching the numbers on a Gilgroth pyramid progression, and we say, you know, all there, that PIP is getting a little stuck, we can shift that. I've had patients that look great,
00:06:25
Speaker
And on week three, they come in and something changed. And they got stuck. I've had a patient who went in for tinaliasis and a second time through something about week three, he got stuck. And it's just how his body scarred in. He was getting keloids externally. And I think that's probably what's happening internally. And you don't always know and can have that anticipation. So you're right. You help them through as best you can for prepping for the next surgery, putting in the best situation for that. But we don't always have a good advance notice ahead of time.
00:06:54
Speaker
Yeah. So you mentioned a little bit about athenolysis. And for those who don't know, that's where they go in afterwards and they scrape the scar off of the tendon, basically to move the tendon and have it move a little more freely. And with that procedure, there's a short amount of time where the tendon is a little bit a vascular, right? So they might not have good blood flow. So they're a little bit at a risk for rupture immediately following the surgery. But then it's almost like they do really well that first like two weeks. You're like, this is,
00:07:25
Speaker
third week, they do, they start doing poorly again, and then they usually catch back up and do well again. So whenever I have a patient that's going to undergo a Tinolysis, I always tell them, Hey, you know, you're going to be excited the first couple of weeks, we have that motivation, it's moving well, and then it starts getting
Post-Tinolysis Recovery Expectations
00:07:40
Speaker
stuck again. And you're like, I want you to be prepared for that, because that's the week when you're going to have to not give up, right? That's when they start getting fatigue too, with the exercises.
00:07:49
Speaker
because it's pretty strict. Yeah, and they figure, I'm out of the woods now and they can back off a little bit and that's exactly the wrong time to back off. Yeah. Yeah. So I always prep them like, this is not going to be easy. You know, the first week's going to seem great, but after that it's going to get hard again. Yeah. And that teen alliances, when they go in for it, again, about setting expectations, they say that whatever range of motion you have going in, active range of motion, you're going to have 50% more range of motion when the process is done at that eight or 12 week mark post-operative. So don't,
00:08:19
Speaker
we don't want them to come out expecting like, oh, I might have a full like, you're not going in for 100%. We're going in for a little bit more, which is why I need to do the therapy leading into
Criteria for Further Surgery
00:08:28
Speaker
it. Because if we can get you as much active as possible, you'll have likely better outcomes. But we're still not going to be expecting this 100% return after the surgery. It's not that kind of fix. Right? It's not. That's what I think people think it is. And it's not it's hot. It's a tough recovery.
00:08:44
Speaker
Yeah. And so when patients are debating that, I don't want to sell them on one way or the other. I talk to them about, what are you lacking now? And I say, you tell me a number. What percent of function do you have? 100%, 80%, 20%? And they give me a number. And I say, OK, if you're going into that surgery with 85% function,
00:09:05
Speaker
you have a certain amount that you could lose. You could come out of that surgery the same, worse or better. The same, no point doing it. Worse, there's an awful lot of room for worse. But if you're at 20% function, there's an awful lot of room for better. So there's those patients that say, like, I want to be 100%, I'm not going to rest until I am. Say, you could come out of this with more scar because it's a new incision and your body's still healing. And so it's setting those realistic expectations to say, if you're at 90% and you think you're there, it's probably not worth it.
00:09:34
Speaker
Right.
Case Study: Flute Player's Journey
00:09:35
Speaker
And so for me, I had one patient, he was, you know, he was, he was recovering very well. Um, but he just didn't have that last like DIP flexion. And I was like, well, you know, that doesn't really matter. And he's like, but it does to me because I'm a flute player. The only thing I want to do is play my flute again. And I can't do that with my finger, how it is. And so I'm like, well, you know, for anybody else that might not warrant another surgery, but for him, it was definitely something meaningful that he wanted to get back to. So it's definitely an individualized case by case.
00:10:04
Speaker
you know, make sure you know your patients. Yeah. Did he get the movement back? Um, yeah, he, he actually had a couple more teen license procedures. Eventually he did get it, but it did require more than just one. Okay. So apparently flute players have good insurance. Yes. At least this one. Okay.
Future Discussions and Contact Information
00:10:25
Speaker
Yeah. Okay. It was definitely an interesting case.
00:10:27
Speaker
Well, we could do a whole separate podcast on all of the, uh, all of the complications and stuff that go into teen alliances. Maybe we'll do another one of those someday down the road, but, um, lots of complications. Hopefully you have an idea now of maybe which ones we can have an effect and an impact on, which ones we can't, and which ones we kind of bridge that gap until they have that next procedure. So hopefully you found this one helpful. Yeah. For questions, you can email us info at hand therapy academy or check out our Instagram at hand therapy academy.