The role of ultrasound in the management of zone 1 flexor tendon injuries

The role of ultrasound in the management of zone 1 flexor tendon injuries

THE ROLE OF ULTRASOUND IN THE MANAGEMENT ZONE 1 FLEXOR TENDON INJURIES N. CORDUFF, R. JONES OF and J. BALL From the Departments of Surgery and Ra...

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THE ROLE

OF ULTRASOUND IN THE MANAGEMENT ZONE 1 FLEXOR TENDON INJURIES N. CORDUFF,

R. JONES

OF

and J. BALL

From the Departments of Surgery and Radiology, Royal Hobart Hospital, Hobart, Tasmania, Australia

We have reviewed 22 flexor tendon repairs in zone 1 undertaken in Hobart, Tasmania, during the period 1986 to 1991. The repairs were assessed using both ultrasound and Strickland’s clinical criteria. The results are presented, and the two methods of assessment compared. A new method of grading results is proposed based on the ultrasound findings. We have demonstrated that ultrasound has an important role to play in assessing tendon repairs, both in the on-going management and as an objective method of measuring the results of repair. Journal of Hand Surgery (British and European Volume, 1994) 19B: 76-80 A tidy injury is one involving a clean laceration, and an untidy injury is associated with crush, skin loss, fracture or joint injury. The ultrasound and clinical examinations were performed between 4 months and 4 years after the tendon repair. All the patients were examined by the same radiologist using an Acuson ultrasound machine. A 7.5 MHtz linear array probe was used in all cases with a 2 x 9 cm stand-off gel pad (Aquaflex ultrasound gel pad). All tendons were scanned in sagittal and transverse planes and the scans were recorded on video and conventional X-ray film. Real time video recordings were made in neutral and with active flexion of the DIP joint where this was possible, and with passive flexion where it wasn’t. The Strickland formula was then applied to all patients (Strickland, 1985). The movements at the distal and proximal interphalangeal joints of the finger were measured and a numerical value derived from the following formula:

The management of patients with poor results after flexor tendon repair in zone 1 may be inappropriate because of diagnostic difficulties. The principal dilemma is the differential diagnosis of a poorly functioning tendon. This can include tendon rupture or adherence to a bed of scar tissue (Strickland, 1989). To evaluate the role of ultrasound in the management of tendon repairs we have reviewed the results of zone 1 repairs performed in Hobart, Tasmania, over the last 5 years. 22 patients responded to our request to attend for assessment and ultrasound examination. All the repairs were examined using high resolution ultrasound and classified using the Strickland formula. Lack of a reliable method to measure results of tendon repair has made comparison of techniques unsatisfactory (So et al, 1990; Kleinert and Verdan, 1983). We have found that the Strickland formula can indicate a good result even in the presence of tendon rupture because of good PIP movement. However, preliminary studies by Khaleghian et al (1984) and McGeorge and McGeorge (1990) demonstrated how ultrasound can be used to assess a tendon repair and diagnose complications. We have used ultrasound to examine the tendon repair, and have devised a new method of grading the results based on ultrasound findings. The Strickland formula was also used to measure the results, and for comparison with ultrasound.

TAM (PIP + DIP) -Extensor 175

lag

x 100 = percentage of

normal PIP + DIP joint motion. where TAM is total active motion PIP is proximal interphalangeal joint DIP is distal interphalangeal joint The numerical value derived from the Strickland formula is the basis for four grades as shown in Table 1. The formula cannot differentiate between the DIP and PIP joints. False results may be obtained when increased movement at the PIP joint compensates for decreased movement at the DIP joint. We have compared the two methods of assessment.

METHODS The repairs were undertaken as primary procedures and done by senior surgeons. A modified Kessler suture (Kim, 1981; Strickland, 1989) of monofilament nylon or prolene was employed and reinforced with a continuous circumferential suture of fine monofilament nylon or prolene. An avulsion injury or division within 1Omm of the tendon insertion required a pull through method passing the suture through the distal phalanx, and tying the suture over a button on the fingertip. After 3 to 5 days, mobilization using the Kleinert rubber band method was commenced under the supervision of a hand therapist. The patients were classified into two groups according to the type of injury-tidy or untidy (Rank et al, 1973).

Table l-Grouping Grade Excellent Good Fair Poor

16

of results using the Strickland formula % of return 75-100 50-74 25-49 O-24

ULTRASOiJND

IN FLEXOR

TENDON

INJURIES

RESULTS Of the 22 patients studied, ten (46%) had untidy injuries, and 12 (54%) had tidy injuries. Using the Strickland formula our results gave 41% excellent and 36% good grades with only 5% falling into the poor grade (Fig 1). As expected, tidy injuries gave better results as derived by the Strickland formula (Fig 2). The ultrasound findings fell into five well defined groups and these groups were used to describe our results (Table 2). In contrast to the clinical Strickland formula, the ultrasound findings showed a more even spread of results between the groups (Fig 3). 27% with a normal appearance comprised group 1. 32% of tendons exam-

EXCELLENT

9

41%

8

36%

FAIR

4

18%

POOR

1

5%

II

7

Fig 3

I

Results of tendon repairs assessed groups are defined in Table 2.

UNTIDY

Fig 1

/ ,

32%

using

ultrasound.

The

ined were thickened but well-defined and gliding well. This was consistent with an oedematous tendon, and following treatment with coban bandaging the movement in these fingers was found to improve. 9% fell into group 3 with an appearance consistent with gap formation. The tendon repair appeared atrophic, with stretched scar, but was still gliding. 18% of the tendons were diffusely thickened, ill-defined and had poor glide. These repairs were stuck down in scar and comprised

22 PATIENTS

GOOD

22 PATIENTS

Results of tendon repairs Strickland formula.

assessed using a clinical method,

‘IDY

= 10

NUMBER

= 12

the

L

TIDY NUMBER = 12

UNTIDY NUMBER = 10

NUMBER

I

II

III

IV

v ULTTRASOUND GROUPS

ULTRP.SO”ND GROUPS

Results of tendon repairs assessed using ultrasound.

Fig 4

EXC. GOOD

FAIR POOR

STRICKLAND

Fig 2

EXC. GOOD

GRADES

FAIR POOR

STRICKLAND

GRADES

Results of tendon repairs comparing tidy and untidy injuries, assessed using a clinical method, the Strickland formula.

comparing tidy and untidy injuries, The groups are defined in Table 2.

EXCELLENT

‘: 5 F: 4 I: k 52 z

Table 2--Grouping Group

=0

of results based on ultrasound findings

I

r

Ultrasoundfinding Normal intact tendon Normal glide Thickened tendon, well-dehned Gliding well Atrophic appearance, stretched Gliding Diffusely thickened, ill-defined Poor glide Ruptured tendon

$ F d 8 82 4 z’

scar

7

II Ill IV ULTRASOUNDGROUPS

v

FAIR

: 4

0 I

Fig 5

II

Ill

IV

v

The uItrasound findings in each grade of the Strickland formula assessment, so comparing the two methods. The ultrasound groups are defined in Table 2.

THE JOURNAL OF HAND SURGERY VOL. 19B No. 1 FEBRUARY 1994

78

group 4. Three tendon repairs (14%) were ruptured and formed group 5. Still films from the ultrasound are shown in Figs 6-10. The findings are clearer when using real-time ultrasound. As with the clinical method of Strickland the better results were seen in tidy injuries (Fig 4). Figure 5 compares the results of the two methods of assessment. Each grade of the Strickland formula is grouped with its corresponding ultrasound finding. Two of the three tendon ruptures were found in Strickland’s “good” and “fair” grades. In addition tendons stuck

down in scar (group 4) were distributed between the “good” and “fair” grades. In practice ultrasound would appear to be more useful in determining the condition of the repair. DISCUSSION

Over the past 40 years advances have been made in the management of flexor tendon injuries. Many different techniques in surgical repair and post-operative therapy have been proposed. However, a reliable method of

mP

b Fig 6

(a) Group 1. (See Table 2). Normal phalanx. dp = distal phalanx.

intact

tendon

with normal

glide. (b) Drawing

of the image shown in (a). t = tendon.

mp =middle

mp

Fig 7

(a) Group 2. (See Table 2). Thickened tendon, mp = middle phalanx. dp = distal phalanx.

but gliding

well and well defined.

(b) Drawing

of the image shown

in (a). t= tendon.

ULTRASOUND

Fig 8

IN FLEXOR

TENDON

19

INJURIES

(a) Group 3. (See Table 2). Atrophic middle phalanx. dp = distal phalanx.

appearance,

stretched

:ar. but gliding. SC

(b) Drawing

of the image shown

$11(a). i= tendon.

mp=

b Fig 9

(a) Group 4. (See Table 2). Diffusely phalanx. dp = distal phalanx.

thickened,

ill defined,

poor glid e. (b) Drawing

assessment of results has yet to be found. Only through an accurate assessment of the tendon repairs can one review results, and thus compare different techniques in management. The problem of assessment was brought out by the report of the Committee on Tendon Injuries (Kleinert and Verdan, 1983). The need for a universal method of evaluation of results was clear. Previous proposals include the older methods of Boyes (1950) and of White (1956), which measure the distance between the pulp of the terminal phalanx and the distal palmar crease; the

of the Image shown

in :a). := tendon.

mp= middle

system recommended by the -American Society for Surgery of the Hand (ASSH; Kleinert and Verdan, 1983), which measures total active or passive motion at the MP, PIP, and DIP joints, minus any extension deficit; and the Strickland formula (1985), which measures total active movement at the DIP and PIP joints. A prospective study by So et al (1990) looked at five popular clinical methods of assessment; Buck-Gramcko (1976), linear measurement, Grossman (I 986), ASSH and Strickland. They found discrepancies between them. All these methods look at finger movement as a whole,

80

THE JOURNAL OF HAND SURGERY VOL. 19B No. 1 FEBRUARY 1994

b Fig 10 (a) Group 5. (See Table 2). Ruptured tendon. (b) Drawing of the image shown in (a). t = tendon. mp =middle phalanx. dp = distal phalanx.

and as there are so many variables it is difficult to assess the result of the tendon repair alone. We have used ultrasound to look at the tendon.repair, and propose a new method of grading results which gives an accurate picture of the repair itself, with clinical relevance. We looked at a series of zone 1 flexor tendon results in order to evaluate this new method of assessment. In comparing ultrasound and the Strickland formula we have demonstrated how ultrasound provides a potentially more accurate picture of the condition of a repaired tendon. We recommend this new grading system to assess and compare different treatment protocols, such as active and passive exercise regimens. Ultrasound can be used to elucidate the reasons for slow recovery, allowing appropriate management. We have found ultrasound invaluable in differentiating between the repair bound down in scar tissue and the undetected late secondary rupture. Gap formation can also be detected. Unnecessarily prolonged physiotherapy can be avoided and one can decide when surgical intervention is suitable. We found that a further clinical improvement can be made in group 2 by using elastic bandaging. The active movement at the DIP improved. We are at present doing further work to see if this is a result of reducing oedema in the tendon. In conclusion we propose a new method of assessing results of flexor tendon repairs using ultrasound. We have described a grading system, groups 1 to 5, based on clear differences in findings on ultrasound. The value of this in the management of zone 1 flexor tendon repairs has been demonstrated, and a further study is

needed to demonstrate other zones.

its application

to injuries in

References BOYES, J. H. (1950). Flexor tendon grafts in the finger and thumb: An evaluation of end results. Journal of Bone and Joint Surgery, 32A: 488-499,531. BUCK-GRAMCKO, D., DIETRICH, F. E. and GOGGE, S. (1976). Evaluation criteria in follow-up studies of flexor tendon therapy. Handchirurgie, 8: 2: 65-9. GROSSMAN, J. A. I., WILKINS, L., MAURER, G., and TUBIANA, R. An analysis of methods for evaluating the results of flexor tendon surgery and proposal of a universal system. Papers presented at the Third Congress of International Federation of Societies for Surgery of the Hand, Tokyo, 1986: 12-13. KHALEGHIAN, R., TONKIN, L. .I., DE GEUS, J. J. and LEE, J. P. K. (1984). Ultrasonic examination of the flexor tendons of the fingers. Journal of Clinical Ultrasound, 12: 9: 547-551. KIM, S. K. (1981). Further evolution of the grasping technique for tendon repair. Annals of Plastic Surgery, 7: 2: 113-l 19. KLEINERT, H. E. and VERDAN, C. (1983). Report of the committee on tendon injuries. Journal of Hand Surgery, 8: 5(2): 794-798. McGEORGE, D. D. and McGEORGE, S. (1990). Diagnostic medical ultrasound in the management of hand injuries. Journal of Hand Surgery, 15B: 2: 256-261. RANK, B. K., WAKEFIELD, A. R., and HUESTON, J. T. Surgery of Repair as Applied to Hand Injuries 4th Edn. Edinburgh, Churchill Livingstone, 1973: 96-97. SO, Y. C., PUN, W. K., LUK, K. D. K. and NG, C. (1990). Evaluation of results in flexor tendon repair: A critical analysis of five methods in 95 digits. Journal of Hand Surgery, 15A: 2: 258-264. STRICKLAND, J. W. (1985). Results of flexor tendon surgery in zone II. Hand Clinics, 1: 1: 167-179. STRICKLAND, J. W. (1989). Flexor tendon surgery. Part 1: Primary flexor tendon repair. Journal of Hand Surgery, 14B: 3: 261-272. WHITE, W. L. (1956). Secondary restoration of finger flexion by digital tendon graft. An evaluation of seventy-six cases. American Journal of Surgery. 91: 662-668.

Accepted:21 May 1993 N. Cord&, Departmentof Victoria.

Plastic

Surgery,

Royal

Melbourne

Australia.

0 1994 The British

Society

for Surgery

of the Hand

Hospital,

Parkville,

Melbourne,