A man was chopping an avocado at home, slipped, and cut into his finger. You see him in the fracture clinic. He is having difficulty moving the finger.
Answer each question out loud before you reveal the model answer.
I would test the injured finger in isolation. The tendons include FDS and FDP. FDP can be tested by isolating the DIPJ and asking the patient to flex the tip of the finger. FDS cannot be completely isolated but can be tested by maximal flexion of the MCPJ and asking them to bend the finger.
FDS- volar aspect of middle phalanx
FDP- proximal aspect of volar distal phalanx
1: Distal to FDS insertion
2: 'no man’s land' FDS insertion to A1 pulley
3: A1 pulley to distal aspect of carpal tunnel
4: over the carpal tunnel
5: proximal to carpal tunnel in forearm
Because here the tendons are in a synovial sheath and therefore when injured scarring can occur, and healing is troublesome.
Pulleys prevent bow stringing of the tendons.
A1: over MCPJ
A2: over proximal phalanx
C1: proximal to PIPJ
A3: over PIPJ
C2: distal to PIPJ
A4: over middle phalanx
C3: proximal to DIPJ
A5: Over DIPJ
A=annular
C=cruciate
A2 and A4 are very important in preventing bow stringing anatomically (they are the most important!)
Remember odd As are over joints.
This requires surgical intervention. I would consent and mark him for an exploration of the wound and tendon repair. I would discuss with a hand consultant.
My surgical plan would be to extend the wound as appropriate and identify the neurovascular bundles and protect them. I would then assess the tendons and repair them as appropriate. If completely lacerated, I would repair FDP first (single tendon). I would use a 4 strand repair such as the Adelaide repair and a circumferential repair also which adds 20% of the strength to the repair. After I would attempt to repair the 2 slips of FDS. However I am aware that this repair may be quite bulky, and would check to see if the tendons were gliding through the pulleys. If not I would only repair one strand of FDS in a similar fashion.
Early active mobilisation in order to prevent adhesion formation. Immediately post operatively I would make sure they have a dorsal blocking splint with the wrist in 20 degrees of flexion and MCPJ at 70 degrees of flexion. This would be on for 2 weeks. After I would make sure they have a hand therapy splint like this for 6 months to wear at night. The splint stops over stretching of the tendon and early failure. Full remodelling of the tendon takes this amount of time.
81 clinical topics and every other station of the interview.