How To Repair Extensor Hood Toe
Extensor Tendon Lacerations to the Foot
A immature man is brought into an emergency department after an electric lawn edger cut through his piece of work kick and into the dorsum of his correct human foot. He has a clearly contaminated five cm x i cm laceration on the lateral side, and an underlying tendon is exposed. Sensation is diminished around the wound and he is unable to actively extend his fifth toe past a neutral position. How would yous diagnose and repair his extensor tendon injury?
Evaluate Systematically: Every Foot, Every Time
Requirements to clothing protective footwear in the workplace have decreased the incidence of occupational injury. Most work-specific footwear, however, leaves the dorsum of the pes vulnerable to blunt, penetrating, and cutting injuries. 1,two A missed airtight injury with tendon damage can pb to permanent disability and deformity. 1,3,4 This is why it's crucial that ED providers consider the possibility of impairment to the tendon,even in the absence of a deep laceration or visible damage to the footwear.
Anatomy
There are ii sets of superficial tendons on the dorsum of the foot. The tendons of the extensor digitorum longus (EDL) and extensor hallucis longus (EHL) muscles are most superficial. Deep to these are the tendons of the extensor digitorum brevis (EDB) and extensor hallucis brevis (EHB) (Effigy 1). The origin, insertion, and functions of each are reviewed in Tabular array 1. v
Effigy 1. Extensor tendons of the dorsal foot. EDL and EHL are seen in blueish. EDB and EHB are seen in green. (Photo by James Powell)
| Musculus | Origin | Insertion of Tendon | Function |
| Tibialis Inductive | Lateral tibia and adjacent interosseous membrane | Medial cuneiform and base of the showtime metatarsal | Dorsiflexion and inversion of the human foot |
| Extensor digitorum longus (EDL) | Medial fibula and adjacent interosseous membrane | Digital expansions insert onto the dorsal bases of the middle and distal phalanges of toes 2 – 5 | Extension of toes two – v and dorsiflexion of the foot |
| Extensor hallucis longus (EHL) | Medial fibula and adjacent interosseous membrane | Dorsal base of operations of distal phalanx of bang-up toe | Extension of great toe and dorsiflexion of the foot |
| Extensor digitorum brevis (EDB) andExtensor hallucis brevis (EHB) | Superolateral calcaneus | Lateral sides of the tendons of EDL for toes ii – 4 and base of operations of proximal phalanx of dandy toe | Extend digit at metatarsophalangeal articulation |
Table 1. Summary of the origin, insertion, and role of the muscles of the dorsal foot
Key Points from the Physical Exam
Range of Motion Matters!
Because it is piece of cake to get distracted by a deep and gory laceration, have a systematic arroyo to evaluating the motor role of the pes. Be certain to examination:
- Extension and flexion of each digit
- The ability to hyper-extend a digit at the metatarsophalangeal joint
- Dorsiflexion of the ankle
Compare these findings to the unaffected foot. The inability to dorsiflex the ankle may represent a driblet-human foot deformity. Remember that toes are not equally dexterous as fingers, and so a lack of hyperextension may be normal.
2 Things to Palpate
Audit and palpate all the tendons of the foot. Tendons should be palpable – a non-palpable tendon may be stand for a transection! In this case, look for a painless mass proximal to the injury. 3 Be certain to palpate distal pulses. If you cannot palpate a pulse, your next footstep is to evaluate with a Doppler.
Managing an Extensor Tendon Laceration of the Foot
Field Grooming
Obtaining a bloodless field will help with identifying a tendon laceration and any neurovascular damage. If hemostasis cannot exist be achieved by the use of lidocaine plus epinephrine and initial direct pressure lonely, a tourniquet-based approach tin can be taken:
- Apply cast padding around the ankle.
- Loosely wrap a pneumatic tourniquet (e.g. sphygmomanometer) over the cast padding.
- Drag the limb for at least 1 minute to assist with venous drainage.
- Inflate the cuff until the pressure level reaches > 260 mmHg. Clamping the cuff tubes with a hemostat may aid to forestall a pressure leak.
- Wrap the cuff with agglutinative or padding to prevent cuff unraveling.
Tourniquet force per unit area is typically tolerated for effectually 20 minutes. Sedation can be used to ensure comfort if more than time is needed. 6 The maximum length of tourniquet time before an increment in the risk of complications is approximately ane to 4 hours. Transient nerve palsies are associated with pressure at the tourniquet site, rather than the duration of use. vii,eight To better exposure, you tin consider extending the incisions at the border of the injury, perpendicular to the long-centrality of the wound. This turns the laceration line into a 'Z' shape, and then the edges tin be sutured open. (Figure 2).
Figure two. Extension of a laceration using 2 incisions fabricated perpendicular to the long-axis of the wound, and held in place with sutures or skin hooks.
LacerationRepair.com provides an fantabulous video of the to a higher place technique:
Careful Inspection of the Wound
Inspection includes evaluation for:
- Tendon injury (while moving the digits into flexion and extension)1
- Foreign bodies
- Any surrounding nerve or vessel injury
A plain radiograph can be helpful in identifying any fragments of drinking glass inside the wound. The sensitivity for radiopaque foreign bodies is almost 98%. 1 It is of import to place nearby nerves before repairing a lacerated tendon. Adventitious trauma or transection of a nerve tin can consequence in distal sensory loss and potentially a painful neuroma.
Extensor Tendon Repair
Extensor tendon lacerations often will require suture repair (Table 2).
Table 2. Indications for Suture Repair of an Extensor Tendon Laceration
| Percent Tendon Laceration | Recommendation |
| 100% (complete transection) | Suture repair of tendon |
| ≥ fifty% of tendon's cross-sectional surface area | Suture repair of tendon |
| < 50% of tendon's cross-exclusive surface area | Suture repair of tendon vs conservative management* |
*Consider patient factors: e.g. follow up, compliance, functional goals.
If a repair is performed, an approach similar to one used for repairing an extensor tendon on the paw (zone VI) can exist applied successfully. 4,6 An ideal repair would utilize a braided, non-absorbable suture, (iii-0 or 4-0), using a technique that buries the knot, such as a figure-of-viii pattern. A previous ALiEM post reviewed how to repair extensor tendon injuries of the hand and at that place is some overlap in technique.
Wound Surface Repair
Regardless of whether the extensor tendon is repaired, the wound surface should be repaired. For patients who are are referred to an orthopedist or podiatrist for delayed primary tendon repair, but re-approximate the epidermal layer of the wound. For patients whose tendons are repaired in the ED, be aware that there is a fine sheath of paratenon effectually the tendon. This tin can exist treated every bit a part of the surrounding connective tissue in terms of a layered closure. 9 Because the extensor tendons of the foot lack a synovial sheath, deep sutures that shut the connective tissue over the tendon, followed past superficial skin closure will be sufficient to prevent adhesions. 6 Good results have been demonstrated in the repair of each of the extensor tendons of the foot. 4
Splinting
All patients with suspected or confirmed extensor tendon lacerations should exist splinted in a short leg posterior splint in 90 degree (toes in neutral position) for 3-4 weeks to prevent further damage. 3,vi Some physicians, however, prefer splinting with the toes in slight extension so that in that location is less theoretical stress on the extensor tendon. iv Others recommend continuous dynamic splinting, or a combination of static splinting followed by dynamic splinting for six to 8 weeks, offer earlier range of motion and weight bearing while yet restricting stress on the affected tendon. 10
Disposition
Repaired tendon injury or non-repaired partial (<50%) tendon injury: The patient should non weight-bear upon the splinted leg and follow up with an orthopedic surgeon or podiatrist, depending your hospital'south resources. 6 Typically this will be in 3-7 days.
Suspected tendon injury simply are unable to locate it: The patient should not weight-bear on the splinted leg and urgent follow up with an orthopedic surgeon or podiatrist in one-three days. half-dozen In most cases, tendon repair delayed upwards to x days will issue in similar outcomes as primary closure on initial evaluation.
Back to the Case
After irrigation and exposure, a partial ten% extensor tendon laceration was discovered on the lateral side of the EDL tendon of the 5th digit, proximal to its insertion (Figure three). Because the patient admitted he would non attach to a plan for non-weight bearing, nosotros felt that the extra force of a suture may assist to prevent farther transection. The tendon was repaired with a 3-0 braided not-absorbable figure-of-8 suture. The connective tissue was closed around the tendon with four-0 absorbable deep sutures, and the epidermis was closed using 4-0 non-absorbable horizontal mattress sutures (Figure 4). The patient was given crutches and asked to be non-weight begetting every bit much as possible until follow up in 7-ten days for suture removal and reassessment.
Figure iii. Patient's right dorsolateral foot, showing the exposed EDL tendon of the 5th digit and a partial (10%) injury at the tip of the forceps (Photo by James Powell – used with patient permission)
Figure four. Patient's right dorsolateral foot showing the airtight wound. Detect the 'Z' shape due to extension of the apices for exposure. (Photo by James Powell – used with patient permission)
Have Home Points
- Extensor tendon injuries of the dorsal foot are common in the setting of dorsal human foot penetrating trauma.
- Many extensor tendon injuries, including those of the extensor digitorum longus and extensor digitorum brevis, tin be finer repaired in the emergency department.
- Extensor tendon lacerations greater than 50% of its cross sectional area should exist repaired.
- Primary closure of extensor tendon lacerations tin can occur within 72 hours. Therefore, if proper assessment cannot be performed, clean and shut the wound and adjust follow-up inside 72 hours for delayed primary repair.
- The suture size and technique are identical to repairing a Zone Half dozen injury of the extensor tendons on the hand. Utilize a 3-0 non-absorbable braided suture, using a figure-of-eight technique.
- The patient should be not-weight bearing on the affected pes. The foot should be splinted in a posterior leg splint with a neutral to extended position of the toes.
How To Repair Extensor Hood Toe,
Source: https://www.aliem.com/extensor-tendon-lacerations-foot/
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