I. What is tendon?
Tendon is commonly known as “tendon”, tendon is the continuation of the muscle, the other end is connected to the bone. The appearance of tendons in the hand is creamy white and shiny. The finger flexor tendons are oval in cross-section and the finger extensor tendons are oval in cross-section above the dorsum of the hand and lamellar in the dorsum of the fingers. Their total length is more than 20cm.
1.The role of tendon
The function of the tendon is to transmit the contraction force of the muscle to the bone and produce the movement of the joint. The tendon itself is inelastic and has the ability to slide in the body. The sliding varies greatly from one part to another, and in the wrist, the finger flexor tendon slides up to 4cm or more. Li Gang, Department of Rehabilitation Medicine, Qiqihar First Hospital
2.Characteristics of tendon
Tendon tension is very strong, a flexor tendon can withstand tens of kilograms of tension. Tendons are very easy to be cut and injured. When the tendon is tense, a slight knife cut injury can make the tendon in the hand completely rupture.
3.Tendon injury
There are many tendons in the hand, and in life and work, the tendons of the hand are easily injured. The most common of its injury mechanism is glass injury, followed by knife cut. In emergency cases, the proportion of hand trauma involving tendons is more than 50%, and simple tendon injuries account for about 30%.
The more common clinical tendon injuries are seen in the following situations.
Classical case type I: the patient struck the glass with his fist in an emotionally uncontrollable state, resulting in a tendon injury.
The second classical case: the patient broke a glass or bottle of wine on a drinking table, resulting in tendon injury to the hand.
This type of tendon injury may be a complete rupture of the tendon or an incomplete rupture, and may be accompanied by nerve damage, vascular damage, and bone and joint damage, as well as the entry of broken glass into the wound.
Tendon injury is a more serious injury. However, neurovascular injuries are more serious. Nerve injuries can be disabling, and even if surgically repaired, they can still leave serious functional deficits; simple vascular injuries, which can lead to hemorrhage, are surgically repaired and do not leave sequelae. In actual cases, when tendon injuries are severe because of anatomical reasons, they are usually accompanied by nerve and vascular injuries. Cases of nerve and vascular injury alone are rare.
Each tendon (except the long palmar tendon) has a functional role. After an injury to a tendon, most patients will experience a functional deficit. For example, the inability to straighten or bend a particular finger, etc. Therefore, tendon rupture must be repaired.
4.Tendon exploration
Exploratory procedures are very common in surgery. It is used when the surgeon has a strong suspicion of damage to certain important tissue structures. In addition to skin debridement and suturing, tendon exploration is also performed when there is clinical suspicion of tendon injury. Tendon-based procedures, both anesthesia and surgery, are a level higher and cost from a few hundred dollars to nearly two thousand dollars. Many patients do not want to undergo tendon exploration for various reasons.
A tendon, like a cord, even if it is only attached to a tenth of it, it can drive the finger to flex and extend. Therefore, an incomplete injury to the tendon can only be determined under direct vision! There is no other means of examination. A professional physician who suspects the possibility of tendon injury in this injury should examine the tendon for injury and the extent of the injury under direct vision, under brachial plexus anesthesia, after debridement, through the existing wound or an extended wound.
However, not all cases explored will have tendon damage or require tendon repair. Tendon repair is not always necessary in the following two cases.
(1) Simple rupture of the long palmar tendon (this is a tendon that has already deteriorated functionally).
(2) A rupture of the extensor tendon that does not exceed 1/3 of the cross-section.
It takes tens to a hundred days from tendon injury to functional recovery and will be extremely costly to the patient’s work and life.
Most of the more serious tendon injuries, such as injuries in certain areas, multiple tendon injuries, non-sharp object type injuries, tendon defects, etc., require late surgery and will still leave functional defects forever after surgery.
Second, the causes and prevention of tendon adhesions
Tendon adhesions are a normal and inevitable result. When the tendon heals, the injury point will form a scar connection with the surrounding tissue, and this scar connection is called an adhesion zone. Adhesive bands restrict the (bidirectional) gliding of the tendon in the body and need to be improved with functional exercises or pulled off completely. Tendon adhesions that form after a more severe hand tendon injury usually require tendon adhesion release after functional exercises.
Although tendon adhesions are inevitable and cannot be avoided during the tendon healing process, there are minor and major adhesions. Tendon adhesions restrict tendon gliding, and postoperative functional exercises are required to reduce the negative effects of tendon adhesions. In addition, the use of an absorbable medical film for tendon repair can reduce the degree of tendon adhesions through physical isolation. The use of absorbable medical film during tendon adhesion release can reduce the chance of tendon adhesions again.
Third, the treatment of the hand after trauma
After hand trauma, you should immediately apply pressure and bandage to stop bleeding, or go to a nearby hospital immediately. In the primary hospital, except for a single skin laceration that can be sutured in place, all cases with tendon injury and suspected injury are best referred to a specialist hospital for surgery. Patients with more bleeding should not be transferred long distances without pressure bandaging to stop the bleeding. The best way to stop bleeding is to apply pressure bandages, and the key to this is not to be afraid of the pain of the injured person. Wrapping rope around the wrist is generally not necessary, but if used, it must be tightened, otherwise it will aggravate the bleeding and must be loosened every hour.
Tendon injuries caused by trauma to the hand, or tendon injuries with wounds, should be operated on immediately. However, the so-called immediate surgery does not mean scrambling for time and causing unnecessary panic, but generally within 6 to 8 hours after the injury.
Simple tendon injury, post-surgery hospitalization is to more convenient access to medical care, hospitalization is not necessary (except for compound injuries with bone, blood vessels, nerves and other tissues).
Fourth, the precautions after tendon surgery
1.In the hospital, the doctor will definitely inject the patient with tetanus antitoxin before and after the surgery, such as after the transfer, the patient should be clear whether the injection has been given in the last hospital.
2, before, during and after the surgery, the doctor will give the patient antibiotics. The best time to use intravenous antibiotics is from before surgery, and the infusion can be continued during surgery (intravenous access is necessary during surgery). Generally, intravenous medication is used for 3 days after surgery and then switched to oral medication for 3 to 5 days, adjusted according to the size of the wound and the degree of contamination.
3, after surgery every other day must go to the hospital to change the medication, the next review change time by the doctor who received this time to decide. Tendon injury surgery, half a month after surgery to remove the stitches, 3 to 4 weeks after surgery to go to the cast. Before the stitches are removed, the medication is usually changed 2~3 times, and the cast is fixed after each change. If the cast is very unyielding or has broken, it needs to be replaced. For a single tendon injury, the cast is externally fixed for three weeks, and for multiple tendon injuries, the cast is usually removed only after four full weeks.
4, from the injection of anesthetic to the recovery of anesthesia after surgery, the longest can reach more than ten hours, the sign is that the wound began to pain, and then the muscle can be contracted. If there is no return of sensation for more than fifteen hours after surgery, attention should be drawn to it.
5. The tendons of the hand are protected with a cast after repair. Any part that is fixed by a cast should never be moved! The parts that are not covered by the cast are encouraged to move.
For flexor tendon injury, the finger is fixed in flexion by the cast; for dorsal tendon injury, the finger is fixed in extension, which allows the ruptured tendon to heal on its own without tension.
It is strictly forbidden to flex the finger to feel whether the tendon has been attached or not! It is strictly forbidden to remove the cast by oneself!
6. It is normal for the wound site to have a small amount of blood leakage after surgery. If there is a lot of bleeding on the gauze, it is wet all the time, or even dripping blood downward, you should go to the hospital immediately.
7.If the pain is abnormally severe after surgery, the temperature of the fingertip is low and the color is dark, it may be caused by severe swelling of the wound or limb and the wound bandage is too tight. You should loosen the bandage on the outer layer of the cast before going to the hospital or go directly to the hospital.
8. In the philosophy of Western medicine, there is no special contraindication in diet.
V. Functional exercises
Tendon healing does not mean that the tendon can function. For the tendon to function, the tendon needs to be able to slide without resistance in the body. The tendon healing process is inevitably accompanied by tendon adhesions, which prevent the tendon from sliding. Functional exercises are designed to loosen and break these scarred adhesions through hand movements, restoring the tendon’s gliding properties and transmitting muscle contraction.
Functional exercises need to be started at the right time, and after they are started, they should be done in a gradual manner as prescribed by the doctor. If functional exercises are started too early or done too aggressively, the tendon rupture point will not be healed yet and the chance of tendon rupture will become greater. If you start too late or are too conservative, the tendon adhesion scar bands become hard and large and cannot be pulled loose. The best way to do functional exercises is to have a medical professional provide one-on-one instruction and treatment to the patient, along with some complementary therapies.
It is the physical rehabilitation department that undertakes this work within the hospital. However, very few patients actually receive treatment in the physical rehabilitation department throughout the entire process. The main reason for this is that patients do not pay enough attention to functional exercises after tendon injuries. The rehabilitation of this type of injury is a long-term process, usually taking about 2 months, and most patients are not guaranteed time.
Methods of functional exercises.
1, from the day the cast is removed to start functional exercises.
First, active flexion and extension activities should be performed for two weeks. The so-called active flexion and extension activity is to use the affected limb’s own strength to do flexion and extension activities. The force starts from light to heavy, and the maximum force can be used at the end of two weeks. The purpose of active flexion and extension activities is to strengthen the forearm muscles, move the stiff joints, and loosen the adhesions formed when the tendon rupture point heals through the activities. Active activities cannot be performed with other forces. It is also important to protect your fingers from injury when you are not active, so as not to scrape your fingers on other objects.
2.At the beginning of the activity, the fingers will not move, as if the fingers do not obey, but persist, you will find that there will be progress every day.
Do flexion and extension activities, each to a direction of force, to feel pain, and persist in this state for more than half a minute, can be repeated to do, every day in multiple groups, at least four times a day morning, noon, night and before bed, each time more than an hour. Focus on quality not quantity! Before the event, such as soaking the injured hand with hot water for fifteen minutes, the effect will be better. Pay attention to prevent burns. The limbs should become swollen after the activity, which is normal.
3, the daily practice, first of all, to consolidate the previous day’s results, followed by a further.
Specifically described as, first to adapt to the pain overcome the previous day, and then challenge the new pain. Only in this way can we get good results. Too conservative and you may be delayed; too aggressive and you may pull the tendons out. In reality, it is very difficult to accidentally rupture a tendon when you follow the normal method. The two-week period of active functional exercises is boring, painful and energy consuming, and it is not easy to do well.
4. In milder cases, after two weeks of active flexion and extension exercises, more than 50% functional recovery can generally be obtained. However, for heavier cases, passive functional exercises are also needed.
The so-called passive functional exercise is to use external force to passively flex or straighten the joint to loosen or break the adhesion band of the proximal tendon. For example, using the other hand or another person’s hand, or a traction support. Injuries to the flexor tendons (for example, in the wrist), by passively straightening the finger joints, the tendons are pulled toward the fingertips, while pulling in the opposite direction can only rely on continued, stronger active activity; injuries to the dorsal tendons, by passively flexing the joints, the tendons are pulled toward the fingertips, and pulling in the opposite direction also relies on active activity.
5.Passive functional exercises usually start from the seventh week.
Cases that require passive activity are heavier, involve multiple fingers, and are operated finger by finger. Although the tendon should normally be fully healed by six weeks, it is still strictly forbidden to flex or straighten the fingers at once with violent force. Each force should be applied at a resistance for half a minute, when the patient should and must feel pain, otherwise the force may not be sufficient. The force used is progressive each day. A breakthrough sensation may be felt at one time, and as long as the finger can still move actively in the other direction, it means that the tendon is not broken, but the adhesive band is completely pulled.
6. Doing passive activities for the patient is a tiring task and the patient may also feel pain due to the pain, but can only persist.
Passive activities cannot replace active activities. All functional exercises, for patients with unilateral injury, should be done for three months.
Soaking the hand in hot water before activity is more effective. It is normal for the swelling of the injured hand to increase after activity. Traction brace can reduce the amount of labor for passive activities. But need to emphasize again, focus on quality not quantity, no pain and strain of the activity is ineffective!
7, if accompanied by bone and joint and other tissue damage, although in the method is roughly the same, but the specific point of time and precautions, but also according to the specific situation. In lighter cases, through functional exercises, satisfactory results can be obtained and the treatment ends there; while in heavier cases, the later surgical treatment – tendon release – is inevitable. The timing of tendon release is usually about six months after the first surgery.
Sixth, tendon adhesion release surgery
Tendon release is a surgical procedure to completely sever the adhesions between the tendon and its channels. Tendon release can improve finger flexion and extension mobility and finger flexion and extension strength. Adhesive bands are present between the tendon and the surrounding tissue, restricting the tendon’s glide and depleting the strength to flex or extend the finger. Adhesive bands may be present not only at the point of injury but also throughout the length of the tendon. As a result, the surgical incision is usually longer than the scar line left by the previous surgery. The fewer the involved tendons, the more adequate the functional exercises after the repair surgery, and the better the results after the release procedure.
Before performing a tendon release, the outpatient surgeon performs a preoperative evaluation to determine if the tendon release can improve the patient’s hand function and if the local conditions are suitable for the release procedure. Tendon release surgery must be performed in an inpatient setting, and 24 to 48 hours after surgery, the patient should begin full flexion and extension activities of the injured hand under the direction of the physician to prevent the formation of new adhesion bands.
(I) Functional exercises after tendon adhesion release surgery
Under the guidance and assistance of the physician, the first activity is 24~48 hours after the surgery. Two to three times a day, two to three times per flexion or extension of the finger is sufficient. The principle of functional exercises is also: quality not quantity. However, it sounds easier to do than it is difficult, mainly because of the need to overcome severe pain, and secondly, to eliminate concerns (fear of bleeding, wound bursting open or tendon rupture, etc.).
(B) Precautions after tendon release surgery
1.It must be the patient himself to overcome the pain to perform the flexion and extension finger exercises with his own strength, and there is no substitute for others.
2. Under the premise of quality assurance, it is not necessary to increase the number of exercises in the first few days by oneself. Otherwise, it will increase the burden on the wound and worsen the swelling, which is not conducive to practice.
3.When you first start the activity, it is true that the wound has not yet grown well, and it is normal for it to bleed during the activity and swelling to increase after the activity.
4.If you can’t practice actively for fear of pain, new adhesions will be formed again in three days.
(C) Risks of tendon release surgery
1.Rupture of tendon during flexion and extension exercises after surgery! The chance of occurrence is less than 1%. In this case, the tendon should be sutured again and then released six months later. The root cause of this situation is that after the last tendon rupture was sutured, the rupture point did not heal well.
2.Tendon release surgery is often changed to tendon suture surgery: The tendon is intended to be released, but during the surgery it is seen that the tendon is not growing at all or is not growing well, and needs to be re-sutured. It is loosened again after six months.
When performing the loosening surgery, you can also encounter such a situation, the tendon is mostly healed, but worry about the post-operative activities when rupture, then whether to continue to loosen or change to re-suture, the surgeon is often in a dilemma, at this time, the need is the doctor’s experience and mutual understanding between doctors and patients.
3. The nerve bundle is accidentally injured during surgery causing numbness in the finger.
4.The sutures burst open during activity and need to be re-sutured.
5.Wound bleeding during activity and increased swelling after activity, resulting in poor postoperative wound healing.
(D) Situations not suitable for tendon release
1.Children, elderly, weak or extremely pain-averse patients often cannot afford to overcome pain for active activities after surgery.
2.Patients with very poor local skin and soft tissue conditions. For example, postoperative extensive local compound injuries due to laminating contusions.
3.Patients with stiff joints, regardless of the cause.