Long-term outcome of paediatric flexor tendon injuries of the hand

Accepted Manuscript Long-Term Outcome of Paediatric Flexor Tendon Injuries of the Hand Georg Singer, Thomas Zwetti, Ruth Amann, Christoph Castellani, Holger Till, Barbara Schmidt PII:

S1748-6815(17)30148-1

DOI:

10.1016/j.bjps.2017.03.014

Reference:

PRAS 5283

To appear in:

Journal of Plastic, Reconstructive & Aesthetic Surgery

Received Date: 23 November 2016 Revised Date:

28 February 2017

Accepted Date: 29 March 2017

Please cite this article as: Singer G, Zwetti T, Amann R, Castellani C, Till H, Schmidt B, Long-Term Outcome of Paediatric Flexor Tendon Injuries of the Hand, British Journal of Plastic Surgery (2017), doi: 10.1016/j.bjps.2017.03.014. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Long-Term Outcome of Paediatric Flexor Tendon

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Injuries of the Hand

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Georg Singer, Thomas Zwetti, Ruth Amann, Christoph Castellani, Holger

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Till, Barbara Schmidt

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Department of Paediatric and Adolescent Surgery, Auenbruggerplatz 34, Medical

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University of Graz, 8036 Graz, Austria

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Corresponding author Georg Singer, MD Department of Paediatric and Adolescent Surgery Medical University of Graz Auenbruggerplatz 34 8036 Graz phone: 0043/316/385/13762 fax: 0043/316/385/13775 e-mail: [email protected]

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ACCEPTED MANUSCRIPT Abstract

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The ideal rehabilitation regimen of paediatric flexor tendon injuries of the hand

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is discussed controversially. In this study the clinical outcome of paediatric patients

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with flexor tendon injuries treated with a dynamic postoperative protocol was

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assessed. All children treated with flexor tendon injuries of the hand and a dynamic

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postoperative protocol between 1999 and 2011 were included. Patients were invited

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for a follow-up examination consisting of clinical examination and the TAM and Buck-

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Gramcko scores and the linear measurement system. 144 patients (mean age 9.1

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years, range 1-17 years) were treated with 267 flexor tendon injuries (128 flexor

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digitorum superficialis (FDS), 126 flexor digitorum profundus (FDP) and 13 flexor

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pollicis longus (FPL)) of 191 digits. 44% (n=62) of the patients (n=49 male; n=13

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female) with 88 digits (thumb n=4, index finger n=17, middle finger n=25, ring finger

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n=20, small finger n=22) with 123 injured tendons (FDS n=62, FDP n=57, FPL n=4)

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were included in the follow-up study at a mean post-operative interval of 7.2 years

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(range 1-13 years). Using the TAM score an excellent and good outcome could be

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achieved in 41% and 48% of the patients, respectively. The zone of injury did not

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influence the objective outcome measures. Subjective and objective outcomes were

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not statistically different between young children (≤6 years) and older children (>6

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years). The present study demonstrates good to excellent outcome in a large cohort

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of paediatric patients with flexor tendon injuries of the hand treated with an active

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mobilisation protocol irrespective of patient age.

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Keywords: flexor tendons; children; outcome; dynamic rehabilitation

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ACCEPTED MANUSCRIPT Introduction

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With an annual incidence of 3.6 per 100,000, flexor tendon injuries (FTIs) of the 1

hand are rare injuries in paediatric patients

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prevalence. Most injuries occur at home when falling on glass. Due to limited

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cooperation the diagnosis of FTIs is more challenging in younger children compared

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to adults

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ascertain the diagnosis.

and sometimes even exploration under general anaesthesia is required to

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. Generally, boys have a higher

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Primary tendon repair in children follows the same principles as in adults.

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However, there is still disagreement among paediatric hand surgeons concerning the

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ideal postoperative rehabilitation regimen 3. While early mobilisation represents an

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accepted treatment protocol following these lesions in adults, many authors advocate

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a strict immobilisation programme for up to several weeks in young children due to

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difficulties in performing active and passive hand exercises at this age

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contrary, other surgeons postulate a dynamic rehabilitation comparable to adults

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irrespective of patient age claiming that early motion exercises stimulate tendon

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healing and decrease adhesions 6, 7.

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. In

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A variety of different scores has been used to assess the outcome following

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flexor tendon repair in children. However, the subjective long-term satisfaction

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following surgical reconstruction of flexor tendon injuries of paediatric patients has

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rarely been addressed yet.

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The aims of the present study therefore were 1) to present a retrospective

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analysis of FTIs of the hand of a large cohort of children treated with a dynamic

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rehabilitation protocol and 2) to assess the subjective and objective long-term

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outcomes of these patients with respect to different age groups.

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ACCEPTED MANUSCRIPT Patients and Methods

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Following approval of the local ethical committee (EK 24-171 ex 11/12) all

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children treated with complete lacerations of FTIs of the hand between 1999 and

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2011 were included. Data was analysed with regard to gender, age at surgery,

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number of injured tendons and affected digits, additional injuries and complications.

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The exact location of the injury was categorised according to Verdan´s classification

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excluded from further analysis.

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. Patients with amputated structures and involvement of extensor tendons were

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Surgical Technique and Rehabilitation Protocol

All procedures were performed under general anaesthesia and operated by one

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of three consultants experienced in paediatric hand surgery. The injured tendons

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were reconstructed using a two strand core suture according to the Kirchmayr-

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Zechner technique with either a 3/0 or 4/0 non-absorbable suture. 5/0 or 6/0

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absorbable sutures were used as peripheral running suture depending on the

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tendon´s size. For zone 2 injuries with laceration of the flexor digitorum superficialis

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(FDS), both slips of the FDS were repaired. In cases with a gliding resistance of the

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suture during full intraoperative movement of the finger through the A2 pulley, either

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an incision or a Z-lengthening of the A2 pulley was performed.

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At the end of the operation a dorsal forearm cast was applied with 5° flexion of

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the wrist joint. Rubber bands were fixed to the nails of the affected fingers using

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cyanoacrylate

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interphalangeal (IP) joints in flexion at rest. The approximate flexion of the fingers

adhesive

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were 70-80° in the MCP joint, 90° in the proximal i nterphalangeal (PIP) joint and

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about 45° in the distal interphalangeal (DIP) joint . Mobilisation of the affected fingers was started on the first postoperative day

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with controlled active extension and passive flexion exercises of the MCP and IP

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joints with a minimum of five times a day. Exercises were supervised by an

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occupational or a physical therapist and consisted of passive extension of the DIP

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joint with extended MCP and 90° flexed PIP joint, a ctive extension of the PIP and DIP

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joints with 90° flexed MCP joint and active extensi on of all three finger joints. Children

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who were able to comply with the instructions performed these exercises by

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themselves under the supervision of an occupational or physical therapist. In patients

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who were unable to actively extend the fingers due to young age, careful passive

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extension of the fingers was performed and the above described exercises were

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performed by a therapist. The parents were also instructed to perform the exercises.

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On the second postoperative day the first cast was replaced by a dorsal

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thermoplastic splint in 0° to 5° flexion of the wri st joint with rubber bands on the

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affected fingers (Figure 1). Patients and/or their parents were instructed to repeat the

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exercises by themselves on an hourly basis during daytime always accompanied by

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a therapist. Between the therapy sessions the fingers were immobilised using the

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thermoplastic splint and the rubber band fixed to the nails to prevent inadvertent

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grasping.

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Patients were only discharged when they and/or their parents were able to

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perform the taught passive tendon gliding exercises. Following discharge from

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inpatient care, the patients were seen once a week by a multi-professional team

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consisting of an occupational and/or physical therapist and a paediatric hand

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surgeon. Splinting and exercises were continued for 5 weeks postoperatively. 5

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performed. Sports activities were restricted and slowly increased from the 9th

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postoperative week onward. Full loading was allowed three months postoperatively.

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In patients who developed an extension deficit of the affected fingers a splint was

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applied during night hours.

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Follow-up

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In order to assess the long-term outcome patients were contacted by mail and

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asked to return to our outpatient department. Active flexion and extension deficits

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(DIP, PIP and MCP joints; IP and MCP joints for thumbs) were assessed using a

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plastic goniometer. Data are presented as means ± standard deviation. In order to

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objectively compare the follow-up results, the following functional evaluation systems

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were applied: TAM score 9, Buck-Gramcko-Score

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system (LMS) 11.

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and the linear measurement

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Following clinical assessment patients and/or their parents were asked to rate

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their subjective satisfaction with functional and cosmetic outcome (VASf and VASc 0-

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100).1 Additionally, the quick-DASH score was determined as described before 12.

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The Kruskal-Wallis-Test was used to analyse the influence of the zone of injury

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on the different objective outcome scores. Since children younger than 6 years were

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expected to demonstrate a lower degree of cooperation the cohort was sub-divided

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into two age groups (≤ 6 years and > 6 years). The Kolmogorov-Smirnov-Test

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confirmed non-parametric distribution of the outcome scores (TAM, Buck-Gramcko,

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LMS, VASf, VASc, and the quick DASH score) justifying the Mann-Whitney-U test for

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group comparison. P-values <0.05 were considered statistically significant. The

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manuscript adheres to the Strobe guidelines for cohort studies.

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ACCEPTED MANUSCRIPT Results

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Between 1999 and 2011, 144 patients were treated with 267 flexor tendon

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injuries. 77% (n=111) were male and 23% (n=33) were female. The mean age was

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9.1 years (range 1-17 years). Figure 2 depicts the number of patients according to

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age. The right side was injured in 76 patients (40%), the left side in 68 patients

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(60%). The injuries were repaired after a median of 1 day following the accident

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(range 0-28 days, SD 5 days). 90% of the injuries were repaired within 2 days.

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In total, 191 digits were affected (thumb n=13; index finger n=45; middle finger

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n=48; ring finger n=39; small finger n=46). While in 80% of the patients (n=115) only

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one finger was affected, 20% of the patients (n=29) sustained FTIs involving more

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than one finger. The flexor digitorum profundus (FDP) tendon was affected in 50

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fingers (26%), the flexor digitorum superficialis (FDS) tendon in 52 fingers (27%) and

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a combination of FDP and FDS tendon injuries was seen in 76 fingers (40%).

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From the 267 injured flexor tendons, 128 involved the FDS, 126 the FDP and 13

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the flexor pollicis longus (FPL). The numbers of tendon lacerations at zone 1, 2, 3

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and 5 were 42, 144, 38 and 43, respectively. No FTIs at zone 4 were encountered.

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The injuries were caused by broken glass in the majority of the cases (n=58,

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40%). 47 (33%) patients sustained an injury with a knife and 16 children (11%) with

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other tools. In 20 cases (14%) other accidents including sports injuries caused the

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FTI and in 3 cases (2%) the exact cause of injury could not be retrieved.

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Concomitant neurovascular transections were diagnosed in 43 out of 144

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patients (30%). Due to extension deficits following the rehabilitation protocol splinting

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was necessary in 30% of the children (n=43). However, it was not required in 62% of

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the patients (n=82). For the remaining 8% (n=12) the information could not be

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retrieved retrospectively. Adhesions necessitating re-operations occurred in 7 patients (4.9%, mean age

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8.9 years, range 3-15 years). Tenolysis was performed after a mean of 28 weeks

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following the initial operation. Six patients (4.2%) had a re-rupture during the course

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of treatment necessitating operative revision.

Follow-up

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62 patients (n=49 male; n=13 female, 43% of all patients with FTIs of the hand

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treated between 1999 and 2011) could be re-evaluated at a mean follow-up of 7.2

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years ranging from 1 to 13 years. The mean age at injury was 7.3 years (range, 1 to

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17 years). Figure 2 depicts the distribution of age at injury of the patients at follow-

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up.

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In total, 88 digits (thumb n=4, index finger n=17, middle finger n=25, ring finger

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n=20, small finger n=22) with 123 injured tendons (FDS n=62, FDP n=57, FPL n=4)

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were injured in these patients. The number of tendon lacerations at zone 1, 2, 3 and

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5 was 19, 44, 13 and 12, respectively.

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The average active flexion of the PIP and DIP joints was 96° ± 10° and 67° ±

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19°, respectively. Additionally, the patients prese nted with a mean extension deficit of

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6° ± 16° of the PIP joint and 2° ± 5° of the DIP jo int. For the four thumbs the mean

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active flexion of the IP joint was 69° ± 15° and th e extension deficit was 0° in all 4

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patients.

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ACCEPTED MANUSCRIPT Table 1 shows the outcome according to the TAM-score, Buck-Gramcko score,

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and the linear measurement system. The mean VASc was 84 (median 100; range 0-

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100), the mean VASf was 90 (median 95; range 10-100) and the mean quick DASH

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score was 3.3 (median 2.3; range 0-20.45). Figure 3 demonstrates that the zone of

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the injury did not influence the objective outcome measures.

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In order to evaluate whether the age at injury might influence the outcome of

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flexor tendon injuries, patients were divided into two age groups, i.e. children younger

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and older than six years (30 patients ≤ 6 years with 42 injured fingers, 32 patients > 6

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years with 46 injured fingers). Table 2 shows that none of the scores investigated

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showed significant differences between the age groups.

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ACCEPTED MANUSCRIPT Discussion

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In the present study a retrospective analysis of paediatric flexor tendon injuries

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of the hand was performed. Follow-up examination was possible in almost half of the

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patients after a mean of 7.2 years. Generally, excellent and good outcome was

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achieved. Similar to previously published reports injuries were predominately located

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in zone 2 and were caused by glass and knife injuries in the majority of the cases 1.

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Using an active rehabilitation programme in all patients similar long-term results in

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younger children when compared to older children were demonstrated.

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Inadequate management of FTIs in children can result in loss of hand function.

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Therefore, a careful pre-operative examination and a subtle operative technique are

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prerequisites for good outcome. In younger children the clinical examination in case

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of a suggestive wound can be frustrating due to limited cooperation. Additionally, a

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separate evaluation of the FDS und FDP tendon cannot be performed sufficiently to

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rule out lacerations in this age group. As a consequence, FTIs are easily overlooked

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and late presentation is more common compared to adults 13.

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Children display a tremendous healing potential after flexor tendon injuries.

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Even though there is no experimental evidence for this assumption, animal models

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performed in foetal lambs suggest that younger age is associated with faster healing

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combined with fewer adhesions

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blood supply per square centimetre tendon surface due to shorter vincula and a

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greater ability to remodel scars

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flexor tendon repair in paediatric patients has been shown when compared to adults

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. These advantages can be attributed to a better

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ACCEPTED MANUSCRIPT In addition to the challenges in diagnosis and surgical technique a carefully

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monitored post-operative rehabilitation programme is of pivotal importance to enable

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optimal results. However, rehabilitation still remains a controversial issue in the

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management of paediatric FTI especially in younger children. While there is

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undivided agreement that teenagers should undergo mobilisation immediately

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postoperatively 2, a variety of different treatment regimens has been published for

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younger children. Many authors advocate immobilisation by cast

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to palm suture to prevent the patient from inadvertent grasping within the cast

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even botulinum toxin injections to the muscle bellies of the injured tendons to induce

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temporary muscle weakness

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fourth week has been shown to result in a deterioration of function

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good to excellent long-term outcome has been demonstrated in children treated with

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strict postoperative immobilisation. Ebinger et al. describe good results in the majority

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of 17 patients younger than six years of age treated with casting for three weeks at a

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mean of 3.7 years following the injury 3. The present report demonstrates comparable

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results in the same age group treated with an active rehabilitation programme. Other

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authors also advocate an early mobilisation protocol irrespective of age. Moehrlen

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and coworkers have treated 49 flexor tendon injuries in 39 children with an age

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adapted active rehabilitation programme and report uniformly good results, a low

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complication rate and no significant differences of the different age groups 7. Similar

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to Moehrlen et al we could not find any significant differences in the outcome

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measures when comparing children older and younger than 6 years. The results of

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the present study of paediatric patients with FTIs of the hand support an active post-

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operative rehabilitation regimen independent of patient age. Nevertheless, the

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comparable results of active and passive rehabilitation may indicate that rubber band

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fixation and early mobilisation may not be necessary in children. However, to

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conclusively answer this question a prospective randomised study would be

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necessary, ideally also applying a multi-centre approach.

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Regarding post-operative complications the authors of a recent meta-analysis in

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adult patients included 39 studies with a total of 3,852 flexor tendon repairs and

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report adhesions and re-ruptures with an incidence of 4% each

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rate and the 5% adhesion rate in the present study are comparable to these findings.

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However, a meta-analysis of FTI in paediatric patients has not been performed yet.

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. The 4% re-rupture

Historically, Verdan´s zone 2 has been termed “no man´s land” because overall

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results of flexor tendon repair in this zone were disappointing. Still, overall results of

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flexor tendon injuries in zone 2 seem to be worse in adults when compared to other

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zones

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results: One study comparing 16 digits injured in zone 1 and 25 digits injured in zone

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2 revealed worse results in zone 2 similar to adult data

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patients with 45 involved fingers, however, could not confirm these findings 1. Similar

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to the latter our follow-up study could not demonstrate an influence of the injured

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zone on the outcome.

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. Previous reports in children addressing this issue report controversial

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Limitations of the present study include the retrospective analysis of the initial

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patient cohort and the absence of a group of children treated with a strict

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immobilisation protocol serving as a control group. In order to definitely answer the

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question whether mobilisation or immobilisation of FTIs in younger children

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represents the superior rehabilitation a prospective, randomised trial would be the

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best approach. This is difficult owing the rarity of FTIs in young children and would

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require a multi-centre approach. Also, our rather low follow-up rate carries the risk to

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miss adverse effects. Additionally, the fact that the patients included in the follow-up

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study were slightly younger compared to the initial cohort of patients could potentially

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ACCEPTED MANUSCRIPT lead to a better overall outcome. Emigration for further education or job can be

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assumed as the most possible reason for loosing contact with the older patients

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despite several efforts made by email or phone. However, we were able to

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demonstrate comparable outcomes when dividing the patients included in the follow-

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up study into two age groups. Another limitation of the present study is that the DASH

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score has been developed and validated for adults. However, no valid score for

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measuring the outcome of children sustaining injuries of the upper extremity is

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available.

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This study with a rehabilitation protocol consisting of early mobilisation

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demonstrates good patient compliance paired with good results. Our data are

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comparable to adult investigations with early mobilisation regimes. Our results

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furthermore advocate treatment of paediatric FTIs in designated paediatric surgical

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centres because a low incidence, difficult diagnosis and adequate therapy demand a

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multi-disciplinary experienced team to achieve a satisfactory long-term function of the

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hand.

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ACCEPTED MANUSCRIPT Conflict of Interest: None

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Source of Funding: None

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ACCEPTED MANUSCRIPT Figure Legends

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350 Figure 1: On the second postoperative day a thermoplastic splint was applied on the

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dorsal side in 0° to 5° flexion of the wrist joint with rubber bands on the affected

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fingers.

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Figure 2: Age distribution of 144 patients treated with 267 flexor tendon injuries

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between 1999 and 2011 (dark grey bars) and of 62 patients at a mean follow-up of

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7.2 years (light grey bars).

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Figure 3: The zone of injury according to Verdan did not influence the subjective

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outcome measures of 62 patients with flexor tendon injuries of the hand (panel A

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TAM score; panel B LMS; panel C Buck-Gramcko-Score). Note that no injuries in

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Zone 4 were encountered.

EP AC C

363

TE D

359

18

ACCEPTED MANUSCRIPT 364

Table 1: Outcome of paediatric FTIs of the hand of 62 patients with 88 injured

365

fingers. Note that the LMS score does not include the outcome of FPL injuries.

TAM Score

Buck-Gramcko-

LMS Score

Score

RI PT

366

n=88

n=88

Excellent

36

82

Good

42

2

Fair

6

3

Poor

4

M AN U

SC

74 9

1 0

AC C

EP

TE D

367

1

n=84

19

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Table 2: Comparison of objective and subjective outcome scores between children

369

younger and older than 6 years; Patients ≤ 6 years n=30 with 42 injured fingers and

370

patients > 6 years n=32 with 46 injured fingers.

Patients > 6 years

[mean ± SD]

[mean ± SD]

90 ± 14

92 ± 15

p-value

0.363

14.7 ± 1.4

14.5 ± 1.8

0.302

LMS Score

9.5 ± 1.1

0.6 ± 1.1

0.464

VASf

92 ± 12

87 ± 23

0.823

VASc

88 ± 17

80 ± 27

0.443

2.88 ± 3.82

3.79 ± 5.45

0.577

M AN U

Buck-Gramcko Score

quick DASH

EP

TE D

SD…standard deviation

AC C

372

Patients ≤ 6 years

SC

TAM Score

RI PT

371

20

AC C

EP

TE D

M AN U

SC

RI PT

ACCEPTED MANUSCRIPT

AC C

EP

TE D

M AN U

SC

RI PT

ACCEPTED MANUSCRIPT

AC C

EP

TE D

M AN U

SC

RI PT

ACCEPTED MANUSCRIPT