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Zones I-III Repair

Authors:

Planning

B

Preoperative Plan

1

Execute surgical walkthrough

  • describe the steps of the procedure verbally prior to the start of the case

2

Description of potential complications and steps to avoid them

C

Room Preparation

1

Surgical Instrumentation

  • loupe magnification

2

Room setup and Equipment

  • standard operating table
  • hand table

3

Patient Positioning

  • patient placed in the supine position with hand on hand table
  • place tourniquet high on the affected extremity

Technique

D

Zone I Repair

1

Expose the lacerated tendon

2

Perform primary repair of the tendon

  • place a running cross stitch or figure of eight stitch with 5-0 absorbable suture in the tendon
  • avoid shortening the tendon

3

Place a K wire

  • place the DIP joint in neutral
  • support the repair by placing a 0.045 inch Kwire across the DIP joint

4

Close the skin

E

Zone II Repair

1

Expose the lacerated tendon

2

Bluntly dissect down to the lacerated tendon

3

Perform primary repair

  • perform primary tendon repair with a running 4-0 or 5-0 cross stitch suture

4

Close the skin

5

Stabilize the repair

  • splint the DIP joint or pin the joint in extension for 6 weeks
F

Zone III Primary Repair

1

Make a skin incision at the site of the repair

2

Expose the site of repair

  • bluntly dissect to the site of repair

3

Perform a primary repair of the central slip

  • use a running stitch with 4-0 or 5-0 suture to repair the central slip

4

Repair the lateral bands

  • repair the lateral band or bands with single 4-0 or 5-0 monofilament

5

Close the skin

G

Zone III Reconstruction in Cases with Tendon Loss

1

Choose type of procedure to perform

  • Consider v-y advancement of the central tendon or a turndown of the central slip proximal to the laceration to cover the defect

2

Make and extend the incision

  • extend the skin incision proximally almost to the MCP joint
  • incise a V in the central slip with the apex just distal to the MCP joint
  • make the distal end the width of the tendon
  • take care to not damage the overlying epitenon

3

Advance the tendon distally

  • minimize disruption to the loose alveolar tissue between the tendon and the periosteum as much as possible

4

Close the incised V

  • close the V into a Y with a 4-0 or 5-0 suture

5

Repair the distal end of the advanced central slip

  • use a running stitch with 4-0 or 5-0 suture for the repair

6

Close the skin

7

Immobilize the repair

  • use static splinting or pinning of the PIP joint in full extension
J

Wound Closure

Patient Care

K

Preoperative H & P

1

Perform basic medical and orthopaedic history and physical

  • check neurovascular status
  • check range of motion

2

Perform operative consent

  • describe complications of surgery including
  • painful neuroma
  • altered sensation
  • CRPS
L

Perioperative Inpatient Management

1

Write comprehensive postoperative orders

  • pain management

2

Orders appropriate inpatient occupational and physical therapy

  • for compliant patients
  • 0 to 30 degrees of active PIP flexion and extension is allowed starting a few days after surgery
  • do this with a palmar flexion block splint with a free wrist and MCO joint

3

Discharges patient appropriately

  • write for pain meds
  • schedule follow up appointment in 1 week
M

Outpatient Evaluation and Management

1

Obtain focused history and performs focused exam

  • concomitant and associated orthopaedic injuries
  • differential diagnosis and physical exam tests

2

Prescribes and manages nonoperative treatment

  • attempts trial of physical therapy
  • orders appropriate orthosis

3

Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • describes accepted indications and contraindications for surgical intervention

4

Provides postoperative management and rehabilitation

  • Zone I and II 2 week postoperative visit
  • remove sutures
  • diagnose and management of early complications
  • Zone I and II 6 week postoperative visit
  • remove the pin
  • continue splinting for rigorous activity and at night for six weeks
  • Zone III 2 week postoperative visit
  • remove sutures
  • postoperative rehabilitation for children and less compliant adults
  • continue immobilization for 2 weeks
  • Zone III 4 week postoperative visit
  • postoperative rehabilitation for children and less compliant adults
  • remove pin or splint
  • protected motion program
N

Advanced Evaluation and Management

1

Provides post-op management and rehabilitation

O

Complex Patient Care

1

Comprehensive pre-op planning/alternatives.

2

Modify and adjust post-op plan as needed

 

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