WEBVTT 00:00.000 --> 00:30.000 position:50% align:top line:0% *This machine-generated transcript may have errors. If remediation or a manually-generated transcript is needed, please contact NLM Support at https://support.nlm.nih.gov.* 00:30.840 --> 00:37.370 The 00:37.380 --> 00:40.050 operation of a flexor tendon graft 00:40.610 --> 00:42.700 is a very commonly done procedure. 00:43.440 --> 00:46.130 The reason is that injuries to the flexor 00:46.130 --> 00:48.550 tendons in this area of the 00:48.550 --> 00:49.390 palm. 00:49.400 --> 00:51.460 Between the distal crease 00:51.470 --> 00:54.360 here and the middle flexion 00:54.360 --> 00:56.910 crease of the fingers is an 00:56.910 --> 00:59.330 area that has been called no man's land. 00:59.590 --> 01:02.110 Now in this area we have to flexor 01:02.110 --> 01:04.810 tendons held in place by a 01:04.810 --> 01:07.560 thick fibrous surrounding sheath, 01:08.100 --> 01:09.450 sometimes called a pulley, 01:10.640 --> 01:13.440 and when the damage occurs to the tendons in this 01:13.440 --> 01:13.960 area, 01:14.540 --> 01:17.190 if they're injured by laceration or 01:17.190 --> 01:19.650 scarring from an operation of a 01:19.650 --> 01:20.260 repair, 01:20.920 --> 01:23.410 then flexion of the finger is impaired. 01:24.510 --> 01:24.730 Now, 01:24.730 --> 01:26.880 in order to reproduce a flexor 01:27.340 --> 01:28.830 mechanism in the finger, 01:29.170 --> 01:31.980 it's necessary to substitute for the whole 01:31.980 --> 01:32.560 tendon. 01:33.130 --> 01:33.840 In other words, 01:33.840 --> 01:36.680 a tendon from the lumber ical origin in the palm to the 01:36.680 --> 01:37.360 insertion. 01:38.040 --> 01:40.750 So we must remove all of the old 01:40.750 --> 01:41.450 tendons, 01:41.770 --> 01:44.360 the scarred area as well as the remaining parts of the 01:44.360 --> 01:46.230 tendon as well. 01:46.740 --> 01:47.320 Likewise, 01:47.320 --> 01:50.250 the synovial sheath that covers this tendon. 01:50.910 --> 01:53.310 Now the pulleys should be repaired if 01:53.310 --> 01:54.070 necessary, 01:54.070 --> 01:55.160 or reconstructed. 01:56.600 --> 01:59.540 The principle of this operation is based on the work of banel 02:00.340 --> 02:03.060 and consists of the full length tendon graft 02:03.740 --> 02:06.740 going from the lumberjack large in in the palm 02:07.240 --> 02:10.000 through the finger to insert into the bone of the 02:10.000 --> 02:11.160 terminal phalanx. 02:11.940 --> 02:14.460 Now at the same time that this graft is inserted, 02:14.600 --> 02:17.540 we reconstruct pulleys and also repair 02:17.540 --> 02:19.050 the nerves if they're damaged. 02:20.810 --> 02:23.420 The usual incision is mid lateral in the finger. 02:23.580 --> 02:26.560 In other words it's dorsal to the flexion creases of 02:26.560 --> 02:29.410 the finger and a curved incision in the 02:29.410 --> 02:32.160 palm paralleling the flexor creases here. 02:33.500 --> 02:36.410 Now in the following scenes you will 02:36.410 --> 02:39.360 see an operation of a tendon graft into a finger. 02:39.740 --> 02:40.110 Dr. 02:40.110 --> 02:43.020 Stark will do the operating procedure and while 02:43.020 --> 02:45.970 he's doing it I will try to point out the important steps 02:46.320 --> 02:47.200 in the operation. 02:48.440 --> 02:51.030 This is the hand of a patient who severed both flexor 02:51.030 --> 02:52.850 tendons in the right middle finger. 02:53.640 --> 02:56.360 You'll notice that she can flex the 02:56.360 --> 02:59.320 metacarpal financial joint for the intrinsic muscles 02:59.320 --> 03:02.240 are still functioning but she cannot flex the middle 03:02.250 --> 03:04.160 and distal joints of the fingers. 03:05.040 --> 03:07.840 Both flexor tendons have been severed in the proximal 03:07.840 --> 03:08.250 segment, 03:08.940 --> 03:10.600 passive motions are normal. 03:11.240 --> 03:12.860 The joints are completely limber. 03:13.240 --> 03:16.230 She has a palmer's longest in the forearm which we will use 03:16.230 --> 03:16.860 for the grass. 03:23.240 --> 03:26.200 Operations of this type are not done until 03:26.200 --> 03:29.080 the tissues are soft and supple and the joints are 03:29.080 --> 03:30.560 completely mobile. 03:31.140 --> 03:33.710 Here you see a full range of passive motion 03:33.930 --> 03:34.650 of the digits. 03:38.900 --> 03:41.860 Incisions in the finger are made mid lateral. 03:42.540 --> 03:45.230 Here you see the dorsal points of the 03:45.230 --> 03:46.300 flexor creases. 03:46.620 --> 03:48.860 The incision should be dorsal to this. 03:49.120 --> 03:51.920 If it is made anterior you're apt to develop a 03:51.920 --> 03:53.120 flexion contracture. 03:53.640 --> 03:56.590 All the operations are done under the ischemia of a tourniquet and the 03:56.590 --> 03:58.860 arm is first wound with a rubber bandage 03:59.940 --> 04:02.390 and then the cuff is inflated on the upper arm. 04:03.640 --> 04:06.460 The mid lateral incision is made the full length of the finger 04:07.210 --> 04:10.070 and by undermining the skin carefully at the level of the middle 04:10.070 --> 04:10.600 joint. 04:11.100 --> 04:13.940 Small retractors can be placed and the finger 04:13.940 --> 04:16.670 held firmly for the rest of the 04:16.680 --> 04:17.290 dissection. 04:18.400 --> 04:21.360 The deeper part of the incision here now goes through a layer of 04:21.370 --> 04:24.240 fashion which may be part of Cleveland's ligament 04:24.270 --> 04:27.060 or part of the transfers 04:27.740 --> 04:29.060 retina macular system. 04:29.640 --> 04:32.370 This is divided carefully and we will place 04:32.630 --> 04:34.540 sutures in this layer of tissue. 04:34.540 --> 04:35.060 Later 04:40.300 --> 04:41.860 is the incision is deepened, 04:42.070 --> 04:44.860 the flexor tendons and the sheep come into view 04:46.110 --> 04:48.750 and on the volar flap the neurovascular bundle 04:48.750 --> 04:50.880 remains here. 04:50.880 --> 04:53.750 You will see some adhesions between the subcutaneous 04:53.760 --> 04:56.730 tissues and the sheath and here 04:56.730 --> 04:58.640 carefully towards the tip of the finger. 04:59.010 --> 05:01.820 We make sure that we do not damage the 05:01.820 --> 05:04.260 digital nerve which tends to go a little more 05:04.260 --> 05:04.910 dorsal. 05:05.100 --> 05:07.050 In this area of the hand 05:09.740 --> 05:12.710 there's also a deep layer of fashion at the level of the distal joint. 05:12.710 --> 05:14.450 Similar to that at the middle joint. 05:14.590 --> 05:17.040 And this is divided but not necessarily 05:17.300 --> 05:19.060 sutured as a separate layer. 05:19.140 --> 05:21.780 Later when we 05:21.780 --> 05:24.080 expose the flexor tendons now in the finger. 05:26.240 --> 05:26.440 MS. 05:26.440 --> 05:28.900 Buller flap containing the 05:28.900 --> 05:31.810 neurovascular bundle is held out of 05:32.020 --> 05:34.910 the way and we have a complete exposure 05:34.910 --> 05:36.830 of the contents of the finger, 05:36.840 --> 05:39.750 we could even repair a digital nerve on the opposite side. 05:41.240 --> 05:43.780 We want to save these pulleys these national 05:43.780 --> 05:45.970 bands which hold the tendons in place. 05:46.260 --> 05:48.180 But we want to remove all the remaining 05:48.940 --> 05:51.850 she and scar and tendons 05:52.440 --> 05:55.400 here we're removing the tenant and its insertion dividing 05:55.400 --> 05:55.880 the vehicle. 05:55.880 --> 05:58.610 Um But being very careful to not damage the 05:58.610 --> 05:59.360 volar plate. 05:59.940 --> 06:01.850 For if any scar occurs here, 06:01.860 --> 06:04.640 the tendon will become adherent will not glide 06:04.970 --> 06:07.660 and we will have difficulty in getting a good range of 06:07.660 --> 06:08.060 motion. 06:08.840 --> 06:11.480 It's not necessary to preserve the entire 06:11.480 --> 06:11.960 pulley. 06:15.620 --> 06:17.910 This pulley in the middle segment has been narrowed, 06:19.140 --> 06:21.930 but it is necessary to save some 06:21.930 --> 06:24.920 pulley in both the middle and the proximal segments of 06:24.920 --> 06:25.460 the finger. 06:27.340 --> 06:29.130 The supplements 10ant is removed. 06:29.140 --> 06:30.550 Clear out to its insertion. 06:31.040 --> 06:33.960 We do not believe that you should leave the decolonization of 06:33.960 --> 06:36.840 the fibers or the chasm of camper as 06:36.840 --> 06:37.660 it is called. 06:38.140 --> 06:40.650 But should remove the tendon completely here, 06:40.650 --> 06:43.150 you will notice that the proximal pulley is being 06:43.150 --> 06:45.360 opened in a portion of it being removed. 06:47.540 --> 06:50.460 If the pulleys are so badly damaged and scarred 06:50.760 --> 06:52.230 that they have to be removed, 06:52.310 --> 06:55.250 then we believe that reconstruction of the pulley by free graphs 06:55.250 --> 06:57.970 should be carried out at the same time as the flexor 06:57.970 --> 06:58.660 tendon graft 07:01.640 --> 07:04.510 all of the scar tissue was divided with sharp 07:04.510 --> 07:05.190 dissection 07:10.230 --> 07:13.160 and the entire contents of this area removed 07:13.640 --> 07:15.670 all excessive sheath and scar, 07:15.810 --> 07:18.660 leaving only these pulleys here a little strand of 07:18.670 --> 07:21.050 tissue at the middle joint has been left 07:22.610 --> 07:25.020 Notice that the 10ant is now fairly free 07:25.810 --> 07:27.610 as far as the finger is concerned. 07:27.610 --> 07:30.110 But we will see later there are still some 07:30.120 --> 07:31.560 adhesions in the pond. 07:32.740 --> 07:35.500 Now the attachment is made for the tendon to the 07:35.500 --> 07:36.360 distal phalanx. 07:36.740 --> 07:38.480 Here we turn up an osteoporosis, 07:38.480 --> 07:41.240 osteo flat distal to the joint 07:41.380 --> 07:44.030 so that there's a good angle of approach of the tendon to 07:44.030 --> 07:45.950 provide flexion of this terminal segment. 07:50.840 --> 07:53.150 A drill is passed through the nail 07:54.490 --> 07:56.760 to exit in this hole in the phalanx, 07:56.880 --> 07:59.810 and this will provide us with the channel through which a wire can 07:59.810 --> 08:00.460 be passed, 08:00.840 --> 08:03.510 and later on the tendon suture itself 08:03.510 --> 08:04.950 drawn through this area, 08:05.440 --> 08:08.230 This enables us to bring the tendon right into 08:08.230 --> 08:09.550 the raw bony surface. 08:13.200 --> 08:15.750 This guide wire is a simple loop of wire 08:16.200 --> 08:19.070 to facilitate the later passage of the tendon suture 08:19.070 --> 08:19.560 itself. 08:25.540 --> 08:27.400 Here again are the three pulleys, 08:27.580 --> 08:30.460 essential mechanical feature so 08:30.460 --> 08:33.250 that the tendon will flex the finger completely. 08:40.490 --> 08:43.490 Now we're ready to expose the tendons in the palm 08:43.490 --> 08:46.460 incisions here are made paralleling the flexor creases 08:47.140 --> 08:49.720 and make them of adequate size to gain 08:49.720 --> 08:52.650 exposure and do a careful excision of 08:52.650 --> 08:55.560 scar as well as an adequate repair 08:55.620 --> 08:58.260 of the tendon and the graft in this area. 08:58.840 --> 09:01.460 We expect to make our tendon suture 09:01.790 --> 09:04.360 at this level as far proximal as possible, 09:04.660 --> 09:07.510 so that the lum brickell origin will cover the 09:07.510 --> 09:10.320 point of the junction between the graft and the 09:10.330 --> 09:10.750 tendons. 09:11.440 --> 09:14.130 We usually excise a small portion of the palmer upon 09:14.130 --> 09:17.120 neurosis and very carefully remove all of 09:17.120 --> 09:19.770 the thickened sheath and perry tenderness tissues 09:19.780 --> 09:20.950 here in the palm, 09:21.610 --> 09:24.150 you will notice now as these tendons are exposed 09:24.540 --> 09:27.150 that there is a thin filmy layer of 09:27.640 --> 09:30.510 scar surrounding them and though they 09:30.510 --> 09:32.860 appear to be fairly free, 09:33.440 --> 09:36.080 they are adherent at the level of the metacarpal 09:36.080 --> 09:36.560 pulley. 09:37.140 --> 09:40.020 Once this is freed the tendons and he 09:40.020 --> 09:42.980 lifted up notice the little adhesions holding 09:42.980 --> 09:45.950 one to the other and to the deeper structures. 09:54.390 --> 09:56.990 The point of greatest adherence of the tenant is in this 09:56.990 --> 09:58.050 metacarpal pulley. 09:58.050 --> 10:00.680 And here we are careful to excise all of the thick and 10:00.680 --> 10:01.660 surrounding sheet. 10:06.400 --> 10:09.060 The supplements and the profundis tenants are separated 10:09.060 --> 10:11.980 here so that later we can withdraw this supplements 10:11.980 --> 10:14.540 in the forearm and cut it off at the muscular tendon. 10:14.540 --> 10:15.160 This junction. 10:16.240 --> 10:19.150 This will also enable us to free the profundis in the 10:19.150 --> 10:19.700 palm, 10:20.010 --> 10:23.010 removing all of this thickened carotene in this tissue 10:23.300 --> 10:26.260 in the film of scar which lies over the 10:26.260 --> 10:27.160 lumber ical muscle, 10:28.340 --> 10:31.270 the lumber ical here is being freed so that our junction can 10:31.270 --> 10:33.460 be made as far proximal as possible, 10:37.840 --> 10:40.640 notice the full amplitude of motion that is now present. 10:40.890 --> 10:43.590 We have found we can use the profundis as the motor 10:43.690 --> 10:46.060 even many years after the original injury, 10:46.840 --> 10:49.620 a short incision just above the wrist will expose the 10:49.620 --> 10:51.030 palmer as long as tendon. 10:51.450 --> 10:54.370 And also enable us to take out the proximal 10:54.370 --> 10:55.560 portion of the supplements. 11:03.340 --> 11:06.230 Years ago we thought if we attached the proximal supplements 11:06.230 --> 11:09.190 to the profundity of the same finger that had added to the strength 11:09.190 --> 11:09.660 of grip, 11:10.220 --> 11:13.180 we have found it since that this 11:13.180 --> 11:15.660 causes more problems than it tends to solve. 11:15.670 --> 11:18.260 So now we simply divide the tendon as far 11:18.260 --> 11:21.060 approximate as possible and allow the end to retract 11:22.940 --> 11:25.420 the palmer's longest is to be removed through two 11:25.420 --> 11:26.080 incisions, 11:26.090 --> 11:28.630 this one at the wrist and another higher in the forearm. 11:29.510 --> 11:32.480 It's not necessary to make a longitudinal incision 11:32.750 --> 11:35.740 and remove the so called parity non along with the 11:35.740 --> 11:36.760 palmer's longest. 11:37.640 --> 11:40.350 Perhaps if the finger was badly scarred, 11:40.360 --> 11:42.810 this might add something to the 11:42.820 --> 11:43.520 result. 11:43.730 --> 11:46.580 But we have found that in most cases it is best to 11:46.590 --> 11:47.680 remove the tendons, 11:47.680 --> 11:50.530 simply just avoiding damage 11:50.530 --> 11:51.360 to its surface, 11:51.940 --> 11:54.790 not making any attempt to remove any surrounding tissue 11:54.790 --> 11:57.720 with it in the proximal 11:57.720 --> 11:58.660 portion of the form. 11:58.660 --> 12:00.760 The tendon lies deep to the fashion of course, 12:01.280 --> 12:03.760 and that the fashion must be opened in order to 12:03.930 --> 12:05.070 isolate the tendon. 12:08.140 --> 12:10.900 The palmer's longest is used by preference as a graft. 12:10.900 --> 12:11.950 If it is not present, 12:11.950 --> 12:14.680 we could use the proximal portion of the suppleness of the 12:14.680 --> 12:17.480 same digit or we could use one of the toe 12:17.480 --> 12:18.120 extensive. 12:19.150 --> 12:21.840 We feel that the planned terrorist tendon is too small in 12:21.840 --> 12:22.360 diameter. 12:27.030 --> 12:30.000 Suture has now passed through the distal end of the palmer as long 12:30.000 --> 12:30.600 as tendon. 12:30.680 --> 12:32.760 This is the panel pull a wire suture. 12:33.340 --> 12:34.330 It's number 34. 12:34.330 --> 12:36.770 Wire Woven back and forth through the Tendon 12:37.520 --> 12:40.070 with a pullout loop to enable it to be 12:40.070 --> 12:42.620 withdrawn later At the end of three 12:42.620 --> 12:43.110 weeks. 12:43.360 --> 12:45.360 When the future is no longer necessary. 12:55.840 --> 12:58.780 It's well to avoid any kinks in the wire when it's being 12:58.780 --> 13:01.260 placed for a kink in the wire will weaken it 13:01.740 --> 13:04.500 and may cause it to rupture later 13:04.500 --> 13:05.760 under some stress. 13:08.930 --> 13:11.910 Now these two ends of the wire which have been brought out the end of 13:11.910 --> 13:12.560 the tendon, 13:13.040 --> 13:15.520 will be passed through the terminal phalanx, 13:15.520 --> 13:18.500 utilizing the guide wire that we placed before 13:19.700 --> 13:21.290 and by traction on this wire. 13:21.290 --> 13:23.960 We draw the raw end of the tendon into the 13:23.970 --> 13:25.150 opening and the bone. 13:25.240 --> 13:27.080 We have tendon to bone attachment, 13:27.090 --> 13:28.370 not tending to scar, 13:28.370 --> 13:30.710 not tending to tendon or tending to 13:30.710 --> 13:31.460 curiosity. 13:31.950 --> 13:34.800 We feel that this method gives adequate 13:34.810 --> 13:35.640 fixation, 13:35.960 --> 13:38.650 and if the tenant is held in place for three weeks, 13:38.660 --> 13:41.440 healing will be sufficient to withstand the 13:41.440 --> 13:42.250 pull of the tendon. 13:43.010 --> 13:45.760 The wire after being passed through the fingernail is tied over a 13:45.760 --> 13:48.150 button and then the proximal loop, 13:48.160 --> 13:51.140 the pullout loop is brought out the finger on the volar 13:51.140 --> 13:54.050 surface in line with the opening in the bone 13:55.440 --> 13:58.430 traction on this later will withdraw the suture material. 14:00.140 --> 14:03.100 Now the 10ant has passed through the police and will 14:03.100 --> 14:06.000 be placed in the palm and then making 14:06.000 --> 14:07.020 traction on it. 14:07.400 --> 14:10.190 We can duplicate the motion of the finger 14:10.480 --> 14:12.930 and show that there are no adhesions and no 14:12.930 --> 14:15.900 limitations in the joints and that the tendon 14:15.900 --> 14:18.560 will be enabled to flex the finger completely 14:40.400 --> 14:43.250 notice the great amplitude that is necessary and a 14:43.250 --> 14:46.010 flexor tendon to fully flex a 14:46.010 --> 14:46.550 digit. 14:49.940 --> 14:52.640 Here is the suture in the fashion at the level of the middle 14:52.640 --> 14:54.590 joint which we talked about before 14:55.700 --> 14:58.660 this suture is placed before the proximal suture line in the 14:58.660 --> 15:01.460 tendon because we want to put the finger in a few degrees of 15:01.460 --> 15:01.960 flexion, 15:02.450 --> 15:05.380 and if we made our proximal tendon attachment we 15:05.380 --> 15:07.510 would no longer have control in this position. 15:09.040 --> 15:10.060 Now the problem, 15:10.940 --> 15:13.620 how do you determine the tension or the length of the 15:13.620 --> 15:14.040 graft? 15:14.040 --> 15:14.860 In other words, 15:15.340 --> 15:18.160 we feel that if the risk is put in a neutral position 15:18.720 --> 15:19.810 and you look at the hand, 15:19.810 --> 15:21.960 the normal fingers will be in semi flexion. 15:22.640 --> 15:25.390 If we adjust the tension or the length of the graft 15:25.400 --> 15:28.330 so that the involved digit is in slightly more 15:28.330 --> 15:29.520 flexion than the others. 15:29.770 --> 15:32.450 This will be the approximate correct position. 15:33.540 --> 15:36.520 Once this has been determined the remaining portions of the 15:36.520 --> 15:37.910 tendons are excised, 15:38.060 --> 15:40.820 making sure that the junction will be as far approximate as 15:40.820 --> 15:41.390 possible. 15:42.140 --> 15:44.870 And then these two Tendon ends will be united with the 15:44.870 --> 15:47.260 number 34 buried wire suture 15:47.610 --> 15:50.590 placed again according to the method 15:50.590 --> 15:52.160 that was described by Banel. 15:53.240 --> 15:55.510 The future is woven in and out of the tendon, 15:57.440 --> 15:59.310 avoiding any kinks in the wire 16:01.640 --> 16:04.110 and the tendons approximated end to end. 16:04.640 --> 16:07.600 We feel this is possible even though there is a slight difference in 16:07.600 --> 16:09.950 the size of the graft and the profundis tendon. 16:10.310 --> 16:12.680 It is only if there is a large difference in 16:12.680 --> 16:15.290 diameter that one need go to other 16:15.290 --> 16:17.840 methods of approximations such as poverty. 16:19.840 --> 16:22.790 Simple end to end suture provides adequate healing, 16:23.840 --> 16:26.570 adequate strength and will withstand the 16:26.580 --> 16:29.050 full pull of the muscles at a later date. 16:35.040 --> 16:37.680 Now the future has been placed in the proximal end in the 16:37.680 --> 16:38.250 profundity, 16:38.740 --> 16:40.960 and here it will be placed in the ground. 16:44.240 --> 16:46.960 Notice how the future has passed through the cut end of the tendon 16:47.340 --> 16:47.850 first, 16:48.940 --> 16:51.460 and then out through the tendon more distantly. 16:54.540 --> 16:56.160 The damaged portion in the clamp, 16:56.540 --> 16:57.350 it's been cut off. 16:57.800 --> 16:59.490 The tenant ends are approximated, 16:59.490 --> 17:01.360 they are actually over approximated. 17:01.740 --> 17:03.770 There's an accordion like effect here. 17:07.010 --> 17:09.830 The ruins of the wire are pressed down into the tendon, 17:10.210 --> 17:13.030 and you will notice that our junction is now almost 17:13.040 --> 17:15.710 automatically covered with alum brickell 17:15.710 --> 17:16.200 muscle. 17:18.040 --> 17:20.960 There's no objection to placing a few fine sutures in 17:20.960 --> 17:22.200 the american muscle, 17:23.040 --> 17:25.970 but if you do this you must pull the lum 17:25.970 --> 17:28.570 brickell distillate before it's attached on the 17:28.570 --> 17:29.060 tendon. 17:29.540 --> 17:32.310 Otherwise you will interrupt and interfere 17:32.490 --> 17:34.770 with the smooth functioning of the finger later 17:35.940 --> 17:36.280 here, 17:36.280 --> 17:39.030 one or two fine sutures are simply placed to hold the 17:39.030 --> 17:41.960 lumber ical around the proximal junction. 17:46.440 --> 17:48.460 At this point the tourniquet is removed. 17:48.740 --> 17:51.510 Bleeding points are litigated after maintaining pressure for 17:51.510 --> 17:52.320 several minutes, 17:52.770 --> 17:55.250 and the hand is covered with fluff. 17:55.260 --> 17:58.210 Cause stocking it, 17:58.640 --> 18:01.270 some sheet wadding and a posterior plaster 18:01.280 --> 18:02.230 bandage. 18:02.280 --> 18:05.230 Now we want to split this hand with the wrist and palm 18:05.230 --> 18:06.010 reflection, 18:06.410 --> 18:08.970 and we want to prevent extension of the finger, 18:08.980 --> 18:11.970 but we do not want anything on the volar surface of 18:11.970 --> 18:14.770 that finger that will impair its flexion. 18:15.140 --> 18:17.280 If the patient should unconsciously or 18:17.280 --> 18:19.440 involuntarily flex this finger, 18:19.610 --> 18:22.520 we do not want any of this flexion to be 18:22.520 --> 18:25.450 against resistance because this means 18:25.650 --> 18:28.550 tension on our fresh suture line, 18:29.340 --> 18:31.110 so the splint is posterior, 18:31.230 --> 18:33.550 but the entire volar surface of the finger 18:33.780 --> 18:34.770 remains free. 18:35.790 --> 18:37.920 We want to be able to see the tip of the finger, 18:39.340 --> 18:42.300 see that the circulation is maintained and be sure 18:42.300 --> 18:44.910 that there is nothing here that the finger will flex 18:44.910 --> 18:47.560 against in case of involuntary motion. 18:59.600 --> 19:02.600 This position of the hand with the wrist and palm 19:02.600 --> 19:05.100 reflection will be maintained for the first three 19:05.100 --> 19:05.610 weeks. 19:06.340 --> 19:08.170 Then the pull out wire is removed 19:08.810 --> 19:11.730 now the hand will still be 19:11.730 --> 19:14.410 kept in the wrist and palm reflection, 19:14.410 --> 19:16.950 but the patient will be allowed to remove the splint 19:17.540 --> 19:19.460 carefully protecting this position, 19:20.340 --> 19:21.960 wash the hand with luke warm, 19:21.960 --> 19:24.920 soapy water and to start gentle 19:24.930 --> 19:25.950 active motion. 19:26.640 --> 19:29.550 It is important that the joints have a full range of 19:29.550 --> 19:32.360 motion and may be necessary to 19:32.360 --> 19:35.160 help him buy some passive manipulation. 19:36.910 --> 19:39.170 We maintain the protection by not 19:39.540 --> 19:42.460 Dorsey flexing the wrist Until the end of 19:42.460 --> 19:43.270 the 4th week. 19:44.040 --> 19:44.270 Now, 19:44.270 --> 19:47.210 at about the end of the fourth week or the early in the fifth 19:47.210 --> 19:49.740 week there are two maneuvers that are 19:49.740 --> 19:52.550 important and it may help to provide a 19:52.550 --> 19:54.270 better range of motion in the tendon. 19:54.740 --> 19:55.550 First of all, 19:56.040 --> 19:58.790 if the finger is held with the metacarpal financial 19:58.790 --> 20:01.780 joint in full extension and the 20:01.780 --> 20:04.400 patient asked to flex voluntarily 20:04.730 --> 20:07.230 all of the forces now being placed upon the 20:07.230 --> 20:09.270 tendon to slip it through the finger. 20:10.780 --> 20:13.630 The second maneuver is to passively flex the 20:13.630 --> 20:16.460 metacarpal financial joint and the 20:16.460 --> 20:17.780 interface Langil joint, 20:18.120 --> 20:20.550 and then to passively 20:20.660 --> 20:23.470 hyper extend the distal joint and then 20:23.470 --> 20:26.460 gradually extend the middle joint of the finger. 20:26.940 --> 20:29.830 This tends to slip the tendon through the 20:29.830 --> 20:32.620 finger and thus break up a few 20:32.620 --> 20:33.470 adhesions. 20:34.200 --> 20:34.750 Now, 20:35.000 --> 20:37.620 at the 5th week we can also advise 20:37.980 --> 20:39.960 a little stronger active flexion, 20:40.540 --> 20:43.230 But this should be guarded until the 6th week. 20:43.230 --> 20:43.860 At least. 20:44.440 --> 20:47.370 We would prefer that a man not do any type of heavy 20:47.370 --> 20:50.060 work until after the sixth week and 20:50.060 --> 20:52.770 perhaps even the eighth week would be even better. 20:53.840 --> 20:54.350 Now. 20:54.840 --> 20:57.640 Now the results of a tendon graft will depend 20:57.640 --> 20:58.950 upon many factors. 20:59.640 --> 21:00.480 First of all, 21:00.490 --> 21:02.460 the proper choice of patients. 21:03.140 --> 21:04.670 Age makes a great difference. 21:05.340 --> 21:06.510 The type of the tissue, 21:06.510 --> 21:07.770 the amount of scarring, 21:08.740 --> 21:10.410 the length of time sits injury. 21:10.560 --> 21:11.770 Perhaps another factor, 21:13.140 --> 21:16.060 but the proper choice of procedure 21:16.440 --> 21:19.150 and the necessary proper technique in 21:19.150 --> 21:19.960 carrying it out. 21:21.320 --> 21:23.790 Then adequate postoperative 21:23.800 --> 21:25.360 care and follow up. 21:25.840 --> 21:28.640 And finally a patient who is 21:28.640 --> 21:31.420 willing to undergo a certain amount of 21:31.420 --> 21:34.290 discomfort and exercise in order 21:34.290 --> 21:36.560 to obtain the most desired results. 21:45.040 --> 21:45.210 Mm. 21:45.210 --> 21:46.080 Hmm.