[MUSIK] [MUSIK] [MUSIK] [MUSIK] >> This slide shows the anatomy of extensor tendons. These transfer the strength of the under-arm musculature to the fingers. This slide shows in diagrammatic form the course of the extensor tendons along the finger below the corresponding pulleys. The most frequent cause is to be found in cuts on the back of the hand or the dorsal fingers. Such extensor tendon complaints can unfortunately also be caused by minor injuries. They occur as cases of trauma during falls or twisted fingers as well as from injuries incurred during sports played with a ball. [MUSIK] >> Hello, >> welcome. >> Hello. >> My name is Dr. Vester. What can I do for you? >> Well, I was playing volley ball when the ball somehow or other hit my finger and then I started to feel pain. >> I’ll just have a look at your hand. >> Yes. >> OK. [UNHÖRBAR] Right. Let’s start here. Does that hurt at all? >> No. >> Here? >> No. >> And here, everything OK as well? >> Yes. >> Okay. Is everything OK with the fingers here? >> Hmm. >> Right, so it is just that one. What about here? Does that hurt at all? >> Hmm. >> Does that hurt at all? >> Hmm. >> Okay. How about here? >> Yes. >> Okay. Could you just lean against me, please? Yes, that is good. Stretch upwards here, please. >> I can’t do that. >> OK. Stretch here, please. Yes, that is easier to do, right? Good. How about there? What is the feeling in your finger like? >> Good. >> OK here as well? OK, let's have a look - blood flow is good. You can see for yourself, at the back here, yes, the small finger so to say, there, the head is hanging a bit like this and I also cannot get it to if I stretch it, then it is OK, but somehow or other you cannot stretch it in the same way. And I fear that, because you cannot stretch the distal phalanx, you may well have suffered an avulsion of the extensor digitorum. >> The clinical examination is intended to identify the degree of the sectioning. An x-ray image should also be taken so as to exclude any osseous avulsion injuries. The tendon can be examined under conductive anaesthesia in the event of any uncertainties being apparent. The extensor tendon transfers the strength of the under-arm musculature to the fingers. In principle, an avulsion can be incurred at any site. Within this, a distinction is made between intraligamentary and osseous avulsion injuries. Sectioning frequently forms an intraligamentary injury. Osseous avulsions and avulsion fractures most frequently occur in the end joint and in the middle joint. In order to ensure the optimum form of treatment, the first thing required is to assign the avulsion to to the appropriate zones. Zone I-III can be treated non-operatively with immobilisation. Surgical reconstruction is required from Zone III onwards. Mallet finger is a typical form of deformity in extensor tendon ruptures. In this, the extensor tendon is avulsed at the level of the distal interphalangeal joint. The term button hole deformity is used to describe an extensor tendon rupture at the level of the proximal interphalangeal joint. [NO AUDIO] [NO AUDIO] >>The impact made by a ball can easily result in an avulsion of the extensor digitorum in this way. This can cause a tear within the tendon or also tear off here at the bone where the tendon is attached. >> OK. - What does that mean really? >> I’ll show you here, using this model. You can see here; this is your thumb, this is your little finger and these structures you can see here are the extensor tendons for the fingers. They allow you to stretch your hands as it were. There are superficial ones which run on top and there are deep extensor tendons. These start here at the distal phalanx. OK? The one responsible for movement in the distal phalanx therefore starts here. The tendons can tear, either in an intraligamentary way, that is to say within the structure of the tendon, or tear off from the bone with their point of attachment at the bone, together with a small piece of bone. This would then be called an osseous avulsion of the extensor digitorum. >> OK. >> In order to find out now whether you have an osseous avulsion or whether a tear has occurred in the tendon itself, I would recommend we make an x-ray image of the finger. >> Mhmm, okay. And will it be necessary to operate then, or...? >> It was more usual in the past to provide non-operative treatment, that is to say not to operate, meaning the finger was simply immobilised in an extensor splint with the hope that the tendons would grow together again. That does also work very well, albeit not always and the danger of the tendon tearing again is really very great, as it is simply not very stable. As a basic rule, we therefore recommend a surgical procedure be undertaken. This means that a higher level of stability is basically achieved and the functional outcome, that is the ability to move the finger, is simply better. Particularly if an osseous avulsion is involved, that is to say if a piece of the bone is missing as well. >> Okay. >> First of all, however, we’ll take an image and then talk things over further. >> Mhmm. >> Please go out of this room to the x-ray area and we’ll then talk again afterwards. [NO AUDIO] >> The indication for a surgical procedure is given either with an osseous avulsion or a tear from Zone III upwards. The surgical procedure foresees treatment by means of small hook plates. [KNOCK] >> Please come in. - Hullo, so you’re back again? Please, take a seat. - I already have your image here as well. So that is the image of your little finger. You can see that that is how the distal phalanxes of the finger are normally configured. Yes, everything is nice and round here, but here you can see what looks like a wedge and which somehow does not seem to belong here. >> Mhmm. >> This side should usually look like this side. >> Okay. And that is the place where the extensor tendon is attached. The tendon has been torn away from the bone in this small section. >> Okay. >> That is why I would really tend towards advising you to allow us to operate. What we do is to place a small hook plate on top of this. I can show you how this is done with the help of the model. This is now another finger, but it looks something like this. It is really mini-, mini-sized and this is placed again onto the tendon and the bone from above and is screwed in place there and the tendon is inserted again at its normal, original place. >> Ah, I see and that then stays in place there? >> Yes, that be left inside. It is so small, it does not generally cause any disturbance. It is not a major operation. You will also not need any anaesthetic. It can also be conducted under what is termed very high local anaesthesia. This means that you will simply be given a small injection with local anaesthetic here and here, and then the finger simply becomes numb. >> Okay. >> Until that time, we would fit a splint, an extensor splint like this so as to ensure that the finger remains extended. See? You will then undertake physiotherapy, that is to say early functional exercising of the finger so that you can learn how to extend the finger again. That will take some time and you will therefore be occupied by this for some five or six weeks and will also not be able to play any basket ball in this period. >> I play volley ball. >> No volley ball either. We would therefore, as it were, not recommend playing any form of ball games at all - OK? - so as to ensure that everything can heal well. >> Yes. Okay. >> You will have to adapt to not being able to play for at least six weeks. >> Does the operation need to be conducted immediately? >> This is not an emergency operation on the operating table quickly this evening but rather a tendon is simply a structure which retracts a bit like a rubber band. OK? If we now wait for three weeks, the enthesis will no longer be positioned here but perhaps down here, >> ähmm, meaning I would propose that we do this next week. >> Mhmm, mhmm, okay. >> These x-ray images reveal a typical avulsion injury in the region of the fifth finger. These images show the postoperative x-ray checks following treatment of an osseous avulsion of the extensor digitorum. What can be clearly recognised is how the small hook plate retains the osseous fragment to the joint. [NO AUDIO] >> In principle, there are nevertheless still risks involved, as with any operation. >> It can, for example, bleed, vessels can be injured, nerves can be injured. Any nerves/vessel lesion is relatively improbable as the nerves and vessels on the fingers run outwards in a parietal direction and not where the operation is conducted. OK? This means that is relatively improbable, but it can, of course, always happen at any time. The more likely danger is that the tendon tears again, either tears off from the bone or the small plate becomes loose and pulls it off or this occurs within the tendon structure. >> And now what happens? >> Another operation would be needed, that is to say revision and then another operation would be conducted. >> Yes, good. >> Ok? My suggestion would therefore be that we conduct the operation next week. The sister will fit a splint for you in the next room and we’ll then see each other again next week. >> Yes, thank you very much. Good-bye. [NO AUDIO] >> In summary, what can be established is that extensor tendon injuries can have varying causes. We distinguish between intraligmentary and osseous lacerations. The treatment to be administered depends on the level and type of the avulsion or on whether an osseous avulsion has occurred or not. Extensor tendon injuries can be treated non-operatively by means of immobilisation and surgically by means of small hook plates. Deformities of the fingers often occur with chronic ruptures. Many thanks for having listened so attentively. [MUSIC] [MUSIC] [MUSIC]