Case Presentation Wednesday, November 13th , 2013

REHABILI A I!N !" PA IEN P!# A1 P$LLE% RELEA#E & EN'!N LEN( HENIN( & I))!BILI*A I!N WI H P!# ERI!R #LAB +,LEINER '$E ! C!N(ENI AL RI((ER "IN(ER

By: dr. Yuliana Supervised by: dr. Marina, Sp.KFR

'EPAR )EN !" PH%#ICAL )E'ICINE AN' REHABILI A I!N "AC$L % !" )E'ICINE, PA'.A'.ARAN $NI/ER#I % HA#AN #A'I,IN H!#PI AL BAN'$N( 2013

IN R!'$C I!N The hand, as the human executing rgan, is in the center ! daily li!e activities in pr !essi ns and sp rts. "n this utstanding p siti n, the hand is al#ays exp sed t in$uries and veruse. %ith the change ! ur s ciety !r m a industrial s ciety t a service&based s ciety, surprisingly, an assumed decrease in hand in$uries has n t been detected, pr bably due t an increase in private activities, such as sp rts and d &it&y ursel! # r'.( %hile trigger !inger in the pediatric p pulati n is a c mm n path l gical c nditi n. S metimes multiple c ngenital bilateral trigger !inger in children is ass ciated t genetic dis rders. ) nservative treatment is rec mmended ! r * m nths t + years, acc rding t the age ! the patient. Surgical treatment is indicated a!ter , year ! age. The m st c mm n n n perative treatments per! rmed are passive !lexi n&extensi n stretching ! the !ingers and splint therapy. EPI'E)I!L!(% Trigger digit-s estimated incidence rate is ! .../0 t ..,0. T# percents ! the upper limb c ngenital an malies are trigger digits1 alth ugh s me auth rs believe that this is an ac2uired rather than a c ngenital an maly. The thumb is much m re !re2uently a!!ected than the ther digits. The disease presents #ith a !lexi n de! rmity ! the interphalangeal $ int ! the !inger. "t is m re c mm nly unilateral. 3nli'e adults, in children the m st a!!ected digits d n t trigger but remain in l c'ed !lexi n. The path l gy ! the disease is the l c'ing ! the !lex r tend n ver 4( pulley, #ith changes in b th the pulley and tend n.+ "$NC I!NAL #%# E) "LE0!R EN'!N#, EN'!N #HEA H, AN' P$LLE% The system ! !lex r tend ns is n t l 'ed at individually but as a !uncti nal unit ! tend ns, tend n sheath and pulleys. 4 di!!erentiati n bet#een the thumb and the index !inger is als necessary. B th !lex r tend ns ! the l ng !ingers, the !lex r digit rum pr !undus 5F678 and m. !lex r digit rum super!icial 5F6S8 run c mm nly thr ugh the carpal tunnel and pulleys and subse2uently intersect at the chiasm. The !lex r tend n ! the thumb 5m. !lex r p llicis l ngus8 runs thr ugh the carpal tunnel n the radial side ! the ! rearm and, strengthened by + pulleys, the muscle passes thr ugh an ste !ibr us channel t the basis ! the distal phalanx 5Figure (8.

Figure (. The pulley system ! the l ng !ingers 5m di!ied acc rding t Schmidt and 9an:8. The annular ligaments and crucial ligaments are seen as a re&en! rcement system ! the !lex r tend ns al ng the ste !ibr us channels ! the !ingers and hereby are !ixed t the phalanges., F ur t / annular 54(&4/8 and , #ea'er crucial ligaments 5)(&),8 are distinguished 5Figure (8. The pattern and arrangement ! these ligaments vary. 4ll pulleys have di!!erent !uncti ns in stabilising the !lex r tend ns at the palmar sides ! the phalanges. ;,/ The main !uncti n ! the !lex r tend n digital pulley system is t maintain the !lex r tend ns cl se t the b ne, thus c nverting linear translati n and ! rce devel ped in the !lex r muscle&tend n unit int r tati n and t r2ue at the !inger $ ints.* The 4+ crucial ligament plays the m st imp rtant r le in guidance ! the !lex r tend ns, #hereas pini ns c ncerning the 4, and 4; vary c nsiderably 5Figures +8. 4 smaller r le in strength transmissi n and tend n de!lecti n is per! rmed by the 4( and 4/.*

Figure +. ) mplete pulley system during a stress test in the bi mechanical lab rat ry. The pulley system suppresses the tend n excursi n and the strength ! the !lex r tend ns is redirected e!!iciently in !lexi n and hyperextensi n t reach the !ull range ! m ti n. The mm.
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lumbricalis and mm. inter ssei are excepti ns as they themselves and end in the tendin us h

riginate !r m the !lex r tend ns

d ! the extens r tend ns. Their !uncti n is !lexi n in the

metacarp phalangeal $ int 5M)78, extensi n in the pr ximal 57"78 and distal interphalangeal $ int 56"78. Bl d supply ! the !lex r tend ns is guaranteed thr ugh the <vincula tendinae= in the regi n ! the sse us inserti n ! the tend n as #ell as in the ste !ibr us channel. >en us drainage is per! rmed thr ugh the same system. >erdan subse2uently divided the !lex r and extens r tend ns int di!!erent regi ns ! interest regarding in$uries, pr gn sis and nutriti n.(,? EN'!N HEALIN( @ist l gically, tend ns c nsist ! extremely l ng c llagen us !ibers that are arranged int bundles. Similar t a r pe ladder, elastic !ibers and vessels are entangled in bet#een th se bundles.A T pr vide the necessary slippage, a peritendeum r a tend n sheath c vers tend ns. 7ulleys strengthen these structures al ng the phalanges. Fricti n plays an imp rtant r le in the rigin ! in$uries and chr nic in!lammat ry diseases ! the tend ns, their sheath and pulleys. ;,/,B,(. F ll #ing an in$ury, the healing pr cess emerges !r m the peritendeum and the peritendin us tissue1 there! re a distincti n ! an extrinsic t an intrinsic healing pr cess has t be made.A,(.,(( )haracteristic ! r an extrinsic healing pr cess is a distinctive in!lammat ry resp nse ! ll #ed by pr li!erati n and rem deling. Fibr blasts ! the paraten n play an imp rtant r le in migrati n #hich leads t adhesi ns. "mm bili:ati n supp rts the adhesi n pr cess. (.&(; The intrinsic healing pr cess, supp rted by m vement ! the tend n, is characteri:ed by immigrati n ! <!ibr blast&li'e ten cytes=, #hich pr duce the c llagen us tissue and carry ut the rem deling pr cess.A,(.&(; "! the in!lammat ry resp nse is minimal, the clinical utc me is better. This is the rati ! the #idely rec mmended early passive m vement therapy, #hich leads t better nutriti n and strength ! the tend n. The ! ll #ing !act rs predict the tend n healing: age, verall health c nditi n, scar ! rmati n disp siti n, m tivati n, in$ury ris' based n >erdan-s : nes, ? in$ury type, syn vial c ntainment as #ell as the surgical techni2ue. (. Three phases ! tend n healing are de!ined. Firstly, a migrati n ! peripheral cells and invasi n ! bl d vessels ccur and sec ndly, the tend n and surr unding tissues heals. Rem deling happens in the third phase ! healing due t m vement and !uncti n ! the tend n.(/ The tend n gains its daily li!e l ading capacity a!ter (+ #ee's ! healing and sp rting activities are all #ed ; m nths a!ter in$ury at the earliest. The rem deling pr cess can last up t (+ m nths. IN.$R% PA ERN pen r cl sed, sharp r blunt, traumatic, c ngenital

"n$ury patterns are di!!erentiated int

r degenerative lesi ns, as #ell as in$ury t the d rsal r palmar part. Further subdivisi ns are
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sse us tend n lesi ns, c mplex lesi ns #ith c nc mitant trauma r in$ury ! the tend n sheath and pulley system. )l sed tend n in$uries are 2uite c mm n(* 5Figure ,8. 4vulsi ns, !irst menti ned by v n Cander in (BAB, m stly a!!ect the inserti n ! the F67 tend n at the distal phalanx. 3sually this in$ury is seen n the ;th !inger, as the F67 tend n is embedded in bet#een the d uble&sided lumbrical tend ns, as sh #n by Mans'e and 9es'er in cadaver dissecti n.(? %e can veri!y this in$ury, especially in r c' climbers, based n chr nic degenerative damages t the tend n?,(A. These in$uries !ten result in p r p st perative utc mes.(B

Figure ,. )l sed !lex r tend n rupture ! the !lex r digit rum pr !undus at the level ! the middle phalanx 5r c' climber8. F ur !act rs determine the pr gn sis ! avulsi n in$uries: the extent ! the retracti n ! the tend n, the remaining bl d supply, the time interval bet#een trauma and surgery and the presence and si:e ! an sse us !ragment. (* 4cc rding t 9eddy and 7ar'er, three di!!erent in$ury types #ith varying pr gn sis and therapy exist.(*,(A )haracteristics ! r type ( are retracti ns ! the tend n int the palm, the >inculae are ruptured, the bl d supply is interrupted and surgery is needed #ithin ? d t (. d a!ter trauma. "n type + in$uries, the tend n retracts t the 7"7 $ int nly and is held by an intact vinculum. There! re, the bl d supply is n t c mpr mised and surgery can be delayed #ith ut ris'ing a p r utc me. Type , in$uries are sse us ruptures ! the F67 d pr gn sis. ccur in high tend n at the distal phalanx. Than' t the intact vinculum, these in$uries have a g blunt disrupti ns ! the lumbricalis rigins at the !lex r tend n n the palm level d stress !inger activity 5e.g., r c' climbing8 5Figure ,8. Dpen tend n in$uries are c mm n !indings in trauma and rth pedic patients and need primary surgical treatment. 4 di!!erentiati n bet#een c mplete r partial rupture has t be made. 4 lesi n ! less than *.0 ! the tend n-s diameter sh uld be treated c nservatively. (( Multiple bi mechanical in vivo and ex vivo studies pr ved that c nservatively treated partial tend n ruptures sh #ed a higher tear&resistance 5P E .../8 c mpared t the surgically treated nes. )hr nic degenerative tend n ruptures as seen in rheumatic patients must be distinguished !r m these traumatic ruptures. 4 c mbined entity #e see in ur patients, m stly in r c' climbers, is a chr nic tendin sis and degenerati n and then !inally an acute tear. @igh intensive stress c mbined #ith chr nic ten syn vitis 5peritendin sis8 and tendin sis 5end tendinitis8 can lead t a rupture !
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Blunt trauma, in terms ! ruptures, als happen t the tend n sheath and the pulleys.+.,++ Rarely,

the tend n, even alth ugh nly min r stress #as applied. (B 4dditi nal t the p

r bl d supply !

the tend n, micr trauma and micr sc pic structural damage can lead t a m dest pr gn sis. HERAP% Surgery sh uld be per! rmed under plexus r general anesthesia #ith the use ! a t urni2uet. Surgery sh uld be per! rmed in the perating r m using peri perative antibi tic

pr phylaxis. 4s !lex r tend n in$uries are !ten c mbined #ith in$uries t the vessels and nerves, these structures must be th r ughly displayed. 4 palmar <Bruner= incisi n is ! ll #ed by a m di!ied 5Cechner8 Kirchmayr&Kessler suture #ith n n abs rbable plaited ;&. yarn. F r !ine adaptati n <running&sutures=, a m n !il *&. yarn is used, either abs rbable r n n abs rbable 5e.g., 76S8. "! annular pulleys need t be released, a d uble d r #ing shaped incisi n is per! rmed and sec ndarily rec nstructed as an extensi n plastic. Fxtensive retracted pr ximal tend n stumps can be pr duced and re!ixed, using an additi nal incisi n t insert a !lexible catheter thr ugh the tend n sheath&pulley system and !ix the tend n stump t it, t pull the tend n !urther distally.+, Blunt !lex r tend n disrupti ns are sutured, sse us avulsi ns are re!ixed trans sseus 5using a peri steal !lap i! necessary8. 4 primary arthr desis ! the 6"7 sh uld be c nsidered in excessive degenerative tend n lesi ns. "! tend n tissue is resected, the tend n must be lengthened using a C&plastic r a ! rearm tend n recessi n.+, F r c ngenital trigger !inger, c nservative treatment ! this path l gy by using a !inger extensi n splint indicates a negative utc me. "t is di!!icult ! r a ne#b rn r y ung child t maintain #earing a !inger splint. %aiting * m nths d es n t imply residual !inger de!icit pr blems r a permanent !inger !lexi n c ntracture. Surgical treatment is usually necessary in c ngenital thumb trigger !inger cases. %e !eel that this surgery sh uld be per! rmed as s n as the small patient-s physical c nditi n c uld supp rt the surgery by using general anesthesia. 3sually, #e rec mmend that the surgery be per! rmed nce the ne#b rn has reached (A m nths ! age.+ The surgery c nsists ! !reeing up the F79, #hich is d ne by ma'ing a small transverse incisi n at the l cati n ! the palpable n dule at the !inger !lexi n ! ld. Dne pr ceeds by care!ully dissecting layer by layer and !reeing up the digit-s c llateral nerves, s that they can glide !reely and super!icially. Dnce the vascular nerve bundle has been separated #ith the appr priate instruments, the pulley is incised t exp se the tend n and n dule. Dnce this has been d ne, the surge n sh uld gently extract the tend n utside ! the pulley and chec' that it glides !reely. G attempt sh uld be made t excise the n dule.+

I))!BILI*A I!N PR!(RA) 3sing c mplete imm bili:ati n p st peratively is the m st c nservative appr ach t rehabilitati n a!ter a !lex r tend n repair, and this meth d still h lds a place in hand rehabilitati n. HHG matter h # s phisticated ur therapeutic and surgical care bec mes, there pr bably #ill al#ays be a need ! r imm bili:ati n ! !lex r tend n repairs in s me circumstances--. 4n imm bili:ati n pr gram may be indicated a!ter a !lex r tend n repair ! r the ! ll #ing reas ns: children and adults #h are unable t c mprehend and ! ll # thr ugh #ith a c mplex m bili:ati n pr t c l, ass ciated in$uries t the ad$acent structures, such as !racture, and dis rders and health c nditi ns that a!!ect tissue healing, such as rheumat id arthritis.+, Table (. "mm bili:ati n pr gram.

Figure ;. 6i!!erential gliding exercises.

Figure /. F67 and F6S bl c'ing exercises. ,LEINER PR!(RA) "n the (B*.s, Kleinert and thers intr duced an early c ntr lled passive m ti n pr t c l using a d rsal pr tective splint 5#rist, ,. !lexi n and M)7, ,.I;. !lexi n8 #ith elastic tracti n !r m the !ingernail t the v lar ! rearm. The elastic !lexi n pull acts as the repaired !lex r tend n unit #ith ut !lex r muscle c ntracti n. 4ctive extensi n ! the digit is per! rmed t the limits ! the d rsal bl c'ing splint. Because ! !lexi n c ntractures at the pr ximal interphalangeal 57"78 $ int and l ss ! active distal interphalangeal 56"78 m ti n, t# m di!icati ns became standard: a palmar pulley #as added t impr ve 6"7 !lexi n, and at night the elastic tracti n is detached and the !ingers strapped int extensi n #ithin the splint t prevent 7"7 $ int !lexi n c ntractures. Table + utlines the basic Kleinert pr t c l.+, Table +. Kleinert 7r gram.

Figure *. Kleinert splint #ith palmar pulley. '$RAN PR!(RA) "n the (B?.s 6uran and @ user intr duced a c ntr lled passive m ti n pr t c l using a similar d rsal pr tective splint #ith ut elastic tracti n. The pr gram #as designed in resp nse t their measurement that ,I/ mm ! tend n glide # uld prevent restrictive adhesi n in : ne "". 7assive 6"7 extensi n #ith 7"7 and M)7 $ int !lexi n #as ! und t glide the F67 a#ay !r m the F6S suture sites. 7assive 7"7 $ int extensi n #ith M)7 and 6"7 !lexed glides b th tend ns a#ay !r m the in$ury site. Table , utlines the basic 6uran pr t c l.+, Table ,. 6uran 7r gram.

EARL% AC I/E )! I!N PR!(RA) Since the late (BA.s and early (BB.s early active m ti n pr t c ls devel ped in resp nse t experimental and clinical studies that dem nstrate bene!icial e!!ects ! early 5as early as +; h urs p st perative8 active m ti n. Farly active m ti n pr t c ls depend techni2ues.+, n str ng repair

Table ,. Farly active m ti n pr gram 5Stric'landJ"ndiana @and )enter8.

PR!(N!#I# AN' C!)PLICA I!N# The m st c ncerning c mplicati ns in !lex r tend n surgery are adhesi ns and suture dehiscence, maybe due t prematurely active m vement.(. This is an expressi n ! <extrinsic tend n healing=, characteri:ed by a distinctive in!lammat ry phase #ith migrati n peritendin us !ibr blasts.(+,(, F r an intrinsic healing, an intact system ! ! tend n sheath and

pulleys is essential, #hich pr duces a syn vial !luid&li'e envir nment that supp rts the healing pr cess until the vascular system is regenerated. Scrubbing ! the tend n al ng the tend n sheath pumps nutritive syn vial !luid int the ten cytes and adhesi ns are prevented.(. Many papers rep rt excellent utc mes in ?.0 a!ter !lex r tend n sutures, similarly t Brug, #h rep rts ?(.A0 excellent, (,0 g Kramc' &Sc re, in a study d and A.A0 p r results, acc rding t the Buc'& Keldmacher, even #ith ptimal r premises. ! +/A patients. 4cc rding t

premises, less than B.0 excellent utc mes are t be expected and nly (,0 #ith p

Besides adhesi ns and ! ll #ing essential intense physi therapy, Luengel treatment and ten lysis, dreaded c mplicati ns are c ntractures, sec ndary ruptures, pulley mal!uncti n, snapping !inger

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and in!ecti n. 7ulley mal!uncti n either by rupture r insu!!icient initial rec nstructi n indicates sec ndary pulley plastic.,,(.,++ ) ncerning the timing ! trigger !inger surgery, several auth rs rec mmend early release at presentati n,+; #hile thers pr p se success!ul res luti n #ith release even a!ter the age ! / years.(; "! the de! rmity is unaddressed ! r a l ng time h #ever, there is a ris' ! !lexi n c ntracture1 acc rding t ne rep rt this c mplicati n ensued be! re the age ! ; years in up t d 5,08 gr ups. 7 ssible reas ns include /.0 ! cases.; "n the current study, !lexi n de! rmity persisting p st peratively #as n ted in a greater percentage ! the in!antile 5A08 than the childh a higher chance ! inc mplete release in very tiny in!antile thumbs, r due t adhesi ns. "n additi n t having l #er anaesthesia ris's, residual de! rmity #as enc untered less !re2uently in sub$ects lder than ( year. "n summary, surgery sh uld pr ceed a!ter the child is ( year ld, #hile splinting is rec mmended ! r the peri d ! c nservative treatment.+; C!NCL$#I!N Tend n pr blems ! the hand, especially !lex r tend ns, are seri us pr blems that sh uld be treated by a s'illed surge n. ) nsistent initial therapy is as imp rtant ! r a g #ell as physi therapy and ccupati nal therapy. d verall utc me as is pr per a!tercare. )l se c perati n ! the surge n and the patient is essential, as

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CA#E
Child ,&year& ld girl, right handed, lives in )aringin Bandung. She came t 7MMR 6epartment

n March +/th +.(+ #ith a re!erence !r m Drth paedic 6epartment ut ! the diagn sis ! 7 st release 4( pulley N tend n lengthening 5F6SNF67 """8 N imm bili:ati n #ith p steri r slab 5Kleinert8 due t c ngenital trigger !inger ! ,rd digit ! le!t hand. ANA)NE#I# Chie1 Com23aint4 5February +,rd +.(+8: )ann t extend the middle !inger ! le!t hand. History o1 2resent I33ness 4

@er m ther stated that triggering had been n ticed since birth. There #as n hist ry ! perinatal trauma, viral r bacterial in!ecti ns, r rheumat l gic r metab lic dis rders, and the girl-s devel pment had been n rmal #ith ut any ther an maly. @er m ther !ten d es passive !lexi nJextensi n t her middle !inger. 4t the beginning it #as n t t sti!! t d it but in the past ( year it became harder t straighten the middle !inger. The patient c mplains ! pain #hen her m ther tries t extend her middle !inger. 4!ter that her parents decided t bring her t @asan Sadi'in h spital t get any !urther treatment. History o1 2sy5hoso5ia34 She is the +nd child ! + children. She lives in a h use ! ab ut +/ m + #ith her !ather, her m ther, and her br ther. F r medical c st, she uses medical assurance 5Oam'esmas8. She #as ta'en t RS@S by her m ther #ith public transp rtati n #ith transp rt c st ar und Rp.(.....,&. G # she d es n t care ab ut her c nditi n yet alth ugh s me ! her lder !riends !ten as' ab ut her !inger c nditi n. @er parents are # rried ab ut her !inger c nditi n c nsidering she #ill gr # and bec me a girl and have t !ind a husband. PH%#ICAL E0A)INA I!N +"ebr6ary 23rd 2012) nsci usness ) mmunicati n Gutriti n 7 sture : ) mp s mentis, ade2uate c ntact : Receptive language : g Fxpressive language : g : G rmal d d

: G rm #eight 5#eight P (/ 'g, height P A+ cm8

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)obi3i7ation Trans!er 4mbulati n Balance /ita3 si8n4 Bl d pressure : ?.JB. mm@g @R RR Temp : B+xJmnt : +;xJmnt : ,*.A ) : independent : independent : Sitting Balance g Standing Balance g d d

Interna3 #tat6s @ead Gec' Th rax : de! rmity &, c n$ungtiva: anemic & J& , sclera: icteric &J& : O>7 d esn-t elevate, lymph n des aren-t palpable : symmetric shape and m vement 9ung : >BS sinistraPdextra, r nchi &J&, #hee:ing &J& @eart : le!t margin ! the heart 9M)S, heart s und "&"" n rmal murmur &, gall p & 4bd men Fxtremities : !lat, liver and spleen aren-t palpable, n rmal b #el s und. : edema &J&, cyan sis IJ&

Ne6ro3o8i5a3 #tat6s )ranial Gerve " I Q"" : G rmal )6s563os9e3eta3 #tat6s a:r Head and Ne59 6e! rmity Range ! M ti n MMT : 5&8 : Full :/ "n!lammati n sign : 5&8

a:r $22er e;tremities de! rmity : & JN !lexi n c ntracture ! middle !inger ! le!t hand
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in!lammati n sign : & J & range ! m ti n : #rist extensi n 5active8 FullJFull 5passive8 FullJFull #rist !lexi n 5active8 FullJFull 5passive8 FullJFull M)7 extensi n 5active8 FullJFull 5passive8 FullJFull M)7 !lexi n 5active8 FullJFull 5passive8 FullJFull 7"7 extensi n 5active8 FullJ& 5passive8 FullJ+. 7"7 !lexi n 5active8 FullJFull 5passive8 FullJFull 6"7 extensi n 5active8 FullJFull 5passive8 FullJFull 6"7 !lexi n 5active8 FullJFull 5passive8 FullJFull Spasticity MMT Sensibility :&J& : Right 3pper Fxtremity : //// 9e!t 3pper Fxtremity : //// : n rmal Triceps NNJNN Brachi radialis NNJNN 7ath l gical re!lex : &J& @and dexterity : 7inch g 7almar g 9ateral g @ ) rdinati n 'g Krasp g 7r pi septi! :g dJg dJg dJ g dJ g dJ g dJ g d d d dJg d d d d 7hysi l gical re!lex : Biceps NNJNN

: !inger t n se test g

a:r Lo<er E;tremities de! rmity : &J&

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in!lammati n sign : &J& range ! m ti n Spasticity MMT Sensibility : Full J Full : &J& : ////J//// : n rmal J n rmal 47R NNJNN 7ath l gical re!lex : Babins'y &J& ) rdinati n : heel t shin test g :g dJg d dJg d 7r pi septi! /e8etative #tat6s

7hysi l gical re!lex : K7R NNJNN

: Bladder and b #el !uncti n G rmal

#$PP!R IN( E0A)INA I!N "ebr6ary 23rd 2012

"ebr6ary 2=th 2012

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)ar5h >th 2012

A##E##)EN )linical 6iagn sis : 7 st 4( pulley release N tend n lengthening N imm bili:ati n #ith p steri r slab 5Kleinert8 due t c ngenital trigger !inger ! the ,rd digit ! le!t hand 9 cati n 6iagn sis Fti l gy 6iagn sis "6n5tiona3 'ia8nosis "mpairment 6isability PR!(N!#I# Lu ad vitam Lu ad sanati nam Lu ad !uncti nam PR!BLE)#
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: le!t middle !inger : ) ngenital trigger !inger ! the ,rd digit ! le!t hand

: S !t tissue : "469

: ad b nam : ad b nam : ad b nam

Medical pr blem 7 st 4( pulley release N tend n lengthening N imm bili:ati n #ith p steri r slab 5Kleinert8 due t c ngenital trigger !inger ! the ,rd digit ! le!t hand 9imited range ! m ti n ! 7"7 $ int ! ,rd digit ! le!t hand

Rehabilitati n pr blem "469

(oa3 #hort erm T ma'e the parents understand ab ut their child-s c nditi n T increase $ int !lexibility T increase endurance ! r grasping

Lon8 erm T be able t use her le!t hand ! r "469

)E'ICAL PR!(RA) 1? Post A1 2633ey re3ease & tendon 3en8thenin8 & immobi3i7ation <ith 2osterior s3ab +,3einert- d6e to 5on8enita3 tri88er 1in8er o1 the 3rd di8it o1 3e1t hand S : D : She can n t extend her le!t middle !inger since birth, perated in March Ath +.(+ Still can n t !ully extend her le!t middle !inger actively Fr m R ntgen ta'en n February +;th +.(+, there is n de! rmity r b ne disc ntinuity ! the b ne p st perati n scar 5N8 n palmar side ! le!t hand, / and + cm, adhesi n 5&8 K : 7 : "ncrease $ int !lexibility and endurance ! r grasping Fducate the parents ab ut tend n healing pr cess

2? Limited ran8e o1 motion o1 PIP @oint o1 3rd di8it o1 3e1t hand S : D : K : 7 : She can n t extend 7"7 $ int ! ,rd digit ! le!t hand !ully RDM ! the le!t middle !inger extensi n is ,.&*. "ncrease RDM ! 7"7 $ int ! ,rd digit ! le!t hand 5!uncti nal RDM8 4ctive RDM exercise ! r 7"7 $ int ! ,rd digit ! le!t hand
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REHABILI A I!N PR!(RA) 1? IA'L +8ras2in8, 23ayin8 <ith toys, ho3din8 83assS : 7 st 4( pulley release N tend n lengthening N imm bili:ati n #ith p steri r slab 5Kleinert8 ! le!t hand #ee' , )an n t extend 7"7 $ int ! ,rd digit ! le!t hand !ully 7atient can d his daily activities independently m stly by using right hand nly r by help !r m her parents D : "469 scale P / m stly by using right hand nly 9imited RDM ! 7"7 $ int ! ,rd digit ! le!t hand MMT ! r le!t middle !inger are ; K : 7 : 4chieve !uncti nal RDM ! 7"7 $ int ! ,rd digit ! le!t hand "469 by using b th hands "469 exercise by using b th hands 5bimanual activity8 4ctive RDM exercise ! r 7"7 $ int ! ,rd digit ! le!t hand "ncrease RDM ! 7"7 $ int ! ,rd digit ! le!t hand 'I#C$##I!N Treatment can be p stp ned until a!ter age (, as sp ntane us regressi n pr bably ccurs in ab ut ,.0 ! cases. "n children, s metimes, digits d n t trigger, but remain l c'ed in the !lexed p siti n. There is still c ntr versy as t #hether the c ngenital trigger digit is a c ngenital r an early ac2uired c nditi n. Dne study rep rted that the mean age at nset ! trigger !inger in children is (( m nths 5range: birth t , years8. "n this case, her parents claimed that the trigger !inger #as present since birth. 6inham and Meggitt ! und that in (+0 ! their pediatric patients trigger thumbs healed sp ntane usly #ithin a peri d ! six m nths. 6e Smet et al. and T rdai and Fng'vist rep rted s me cases ! trigger !ingers in children in #h m the pr blem #as res lved #ith ut an perati n. 7argali and @abib:adeh rep rted n a very rare c nditi n ! bilateral trigger !inger in a /&year& ld child #hich res lved c mpletely #ith physi therapy 5A sessi ns8 and n n&ster idal anti& in!lammat ry drugs 5GS4"6s8 ! r +. days. M st auth rs rec mmend surgical treatment, particularly i! trigger !inger persists a!ter c nservative treatment. Secti n ! the 4( pulley ! the !lex r tend n is the m st c mm n surgical treatment per! rmed ! r trigger !inger, but the timing ! surgery is still debated. M utet et al. described a case ! a ,&year& ld girl a!!ected by ten c ngenital trigger !ingers. The girl #as treated surgically by a transverse incisi n in b th palms and release ! all 4( pulleys. The auth rs rep rted that the !inal result #as g d. Dda et al. described a case
18

! a B&year& ld b y treated ! r multiple

c ngenital bilateral trigger digits in additi n t the thumb. Triggering #as m st c nstant in the middle and ring !ingers and bserved nly ccasi nally in the index and little !ingers. Surgical treatment #as per! rmed nly n b th middle and ring !ingers. K d $ int m ti n #ith ut triggering #as rep rted a!ter surgical release ! the pulleys. "t is believed that in trigger !inger surgical treatment is indicated in all cases in #hich c nservative treatment !ailed. %ith care!ul surgical techni2ue, the incidence ! c mplicati ns sh uld be l #. The m st c mm n c mplicati n rep rted a!ter surgery is damage t digital nerve. 4dhesi ns and subse2uent sti!!ness may devel p #ith excessive handling pr tected and 'ept clean. RE"ERENCE# (. > igt ). RTend n in$uries ! the handS. )hirurg +..+1 ?,: ?;;&*;1 2ui: ?*/&?. +. ) lb urn O, @eath G, Manary S, 7aci!ic 6. F!!ectiveness ! splinting ! r the treatment ! trigger !inger. O @and Ther. +..A1 +(5;8: ,,*&;,. ,. SchT!!l >R, SchT!!l ". "n$uries t the !inger !lex r pulley system in r c' climbers: current c ncepts. O @and Surg 4m +..*1 ,(: *;?&/;. ;. SchT!!l ", Dppelt K, OUngert O, Sch#ei:er 4, Bayer T, Geuhuber %, SchT!!l >. The in!luence ! c ncentric and eccentric l ading n the !inger pulley system. O Bi mech +..B1 ;+:+(+;&A. /. SchT!!l ", Dppelt K, OUngert O, Sch#ei:er 4, Geuhuber %, SchT!!l >. The in!luence ! the crimp and sl pe grip p siti n n the !inger pulley system. O Bi mech +..B1 ;+: +(A,&?. *. R l !! ", SchT!!l >R, >ig ur ux 9, Luaine F. Bi mechanical m del ! r the determinati n ! the ! rces acting n the !inger pulley system. O Bi mech +..*1 ,B: B(/&+,. ?. >erdan )F. 7rimary and sec ndary repair ! !lex r and extens r tend n in$uries. "n: @and Surgery, Flynn OF 5ed8. %illiams M %ill'ins: Baltim re, (B**1 ++.&;+. A. %erdin F, Schaller @F. R) mbined !lex r tend n and nerve in$ury ! the handS. Drth pade +..A1 ,?: (+.+&B. B. Sch#ei:er 4, Fran' D, Dchsner 7F, Oac b @4. Fricti n bet#een human !inger !lex r tend ns and pulleys at high l ads. O Bi mech +..,1 ,*: *,&?(. (.. Taras OS, Kray RM, )ulp R%. ) mplicati ns ! !lex r tend n in$uries. @and )lin (BB;1 (.: B,&(.B. ((. B yer M", Stric'land O%, Fngles 6, Sachar K, 9eversedge FO. Flex r tend n repair and rehabilitati n: state ! the art in +..+. "nstr ) urse 9ect +..,1 /+: (,?&*(. (+. Stric'land O%. The scienti!ic basis ! r advances in !lex r tend n surgery. O @and Ther +../1 (A: B;&((.1 2ui: (((.
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! the tend n

pr l nged p st perative m bili:ati n. "n!ecti ns and pain!ul scars are unc mm n i! the incisi n is

(,. )h ue'a O, @eminger @, Mass 67. )yclical testing ! : ne "" !lex r tend n repairs. O @and Surg 4m +...1 +/: ((+?&,;. (;. Stein T, 4li 4, @amman O, Mass 67. 4 rand mi:ed bi mechanical study ! : ne "" human !lex r tend n repairs analy:ed in a linear m del. O @and Surg 4m (BBA1 +,: (.;,&/. (/. %erber K6. RFlex r tend n in$uries ! the handS. 3n!allchirurg +../1 (.A: A?,&A(1 2ui: AA+. (*. 4r n #it: FR, 9eddy O7. )l sed tend n in$uries ! the hand and #rist in athletes. )lin Sp rts Med (BBA1 (?: ;;B&*?. (?. Mans'e 7R, 9es'er 74. 4vulsi n ! the ring !inger !lex r digit rum pr !undus tend n: an experimental study. @and (B?A1 (.: /+&/. (A. SchT!!l >. R c' )limbing. "n: Sp rts "n$uries, Fngelhardt M 5ed8. Flsevier: Munich&Oena, +.((. (B. SchT!!l >R, SchT!!l ". Finger pain in r c' climbers: reaching the right di!!erential diagn sis and therapy. O Sp rts Med 7hys Fitness +..?1 ;?: ?.&A. +.. SchT!!l >, SchT!!l ". "s lated cruciate pulley in$uries in r c' climbers. O @and Surg Fur > l +.(.1 ,/: +;/&*. +(. B llen SR. "n$ury t the 4+ pulley in r c' climbers. O @and Surg Br (BB.1 (/: +*A&?.. ++. SchT!!l ", Baier T, SchT!!l >. Flap irritati n phen men n 5F9"78: eti l gy ten syn vitis a!ter !inger pulley rupture. O 4ppl Bi mech +.((1 +?: +B(&*. +,. >uce' vich K, Kallard K, Fiala K. Rehabilitati n a!ter Flex r Tend n Repair, Rec nstructi n, and Ten lysis. @and )lin +( 5+../8 +/?I*/. +;. 9eung DY, "p FK, % ng T), %an S@. Trigger thumbs in children: results ! surgical release. @ ng K ng Med O +.((1(?:,?+&/. ! chr nic

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