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Flexor Tenolysis Workup

  • Author: Cato T Laurencin, MD, PhD; Chief Editor: Harris Gellman, MD  more...
 
Updated: Nov 02, 2015
 

Laboratory Studies

No specific laboratory tests are indicated.

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Imaging Studies

The major utility of imaging studies prior to flexor tenolysis is to evaluate whether the patient has a failure of tendon reconstruction, elongated callus, or tendon adhesions that lead to the clinical presentation.[11]

Initially, radiographs should be taken to ensure proper anatomical alignment of the skeletal elements.[2] Ultrasound has proven effective to assess both the presence and location of a ruptured tendon repair.[12, 13] Additionally, the mechanism of ultrasound allows dynamic assessment of flexor tendon injuries, and thus ultrasound is recommended for evaluation of zone 1 (DIP joint) tendon injuries. Ultrasound, however, is not effective in discerning pure adherence from elongated callus, and thus the type of surgical intervention required.[11] Additionally, ultrasound of the ligaments in zone 2 (MCP and PIP joints) are a difficult endeavor and strongly operator dependent.[11]

MRI has proven to be effective as a noninvasive imaging procedure to differentiate between tendon rupture and tendon adhesions in zone 2.[11] Imaging artifacts from implanted devices, including metal plates or screws, can limit the effectiveness of MRI in evaluating tendon injuries.

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Histologic Findings

In a rabbit model of tendon repair, once a tendon is injured, within 24 hours a noticeable increase in cellularity, predominantly from neutrophils, is seen. In the same model, cells in the tendon sheath are seen to migrate into the tendon, and cells from the periphery of the tendon are seen to migrate to the interior of the tendon core within 7 days.[4] By 7 days, alpha smooth muscle actin expression is high, which marks the presence of myofibroblasts and pericytes in the wound area. From 7 to 21 days, cells are both depositing and remodeling collagen bundles, which correlate with a peak in heat shock protein 47 around day 21. As intrinsic healing of affected tendons progresses, alignment of collagen fibers along the axis of contraction, as well as a decrease in inflammatory cellularity, is usually seen, with a peak in apoptosis around 84 days in rabbits.[4, 11]

In human subjects, studies that closely track cell origin and type are lacking, but when looking at histological sections of adhesions, noninflammatory cells resemble myofibroblasts and secrete types I and III collagen, and epitenon cells are also involved in the process of both collagen production and collagen debris clearance.

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Contributor Information and Disclosures
Author

Cato T Laurencin, MD, PhD University Professor, Albert and Wilda Van Dusen Endowed Distinguished Professor of Orthopedic Surgery, and Professor of Chemical, Materials, and Biomolecular Engineering, University of Connecticut School of Medicine

Cato T Laurencin, MD, PhD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Clarke Nelson University of Connecticut School of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Thomas R Hunt III, MD Professor and Chairman, Joseph Barnhart Department of Orthopedic Surgery, Baylor College of Medicine

Thomas R Hunt III, MD is a member of the following medical societies: American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, Southern Orthopaedic Association, AO Foundation, American Academy of Orthopaedic Surgeons, American Association for Hand Surgery, American Society for Surgery of the Hand, Mid-America Orthopaedic Association

Disclosure: Received royalty from Tornier for independent contractor; Received ownership interest from Tornier for none; Received royalty from Lippincott for independent contractor.

Chief Editor

Harris Gellman, MD Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M Miller School of Medicine, Clinical Professor, Surgery, Nova Southeastern School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, Arkansas Medical Society

Disclosure: Nothing to disclose.

Additional Contributors

Michael S Clarke, MD Clinical Associate Professor, Department of Orthopedic Surgery, University of Missouri-Columbia School of Medicine

Michael S Clarke, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Arthroscopy Association of North America, American Academy of Pediatrics, American Association for Hand Surgery, American College of Surgeons, American Medical Association, Clinical Orthopaedic Society, Mid-Central States Orthopaedic Society, Missouri State Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

W Jay Gorum II, MD Consulting Surgeon, Gorum Orthopedics and Associates

W Jay Gorum II, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

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Flexor tendons with attached vincula. FDS, flexor digitorum superficialis; FDP, flexor digitorum profundus.
 
 
 
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