LUXATED AND SEVERED TENDONS*

CHARLES R. ROUNTREE, M.D.

Assistant Professor of Orthopctlic Surgery, University of Oklahoma SchooI of \leclicinr

OKLAHOMA CITY, OKLAHOMA

T ENDON injuries are important be- cause earIy recognition and proper diagnosis is indispensabIe to adequate

to six weeks, after which function is gradu- aIIy resumed.

treatment. By Iuxation or disIocation of a tendon we impIy dispIacement of the ten- don from its normal position. By severence of a tendon we mean a partial or compIete interruption of continuity. The unsatisfac- tory resuIts which generaIIy foIIow faiIure to diagnose and properIy treat these affec- tions justifies a discussion of the principres of diagnosis and treatment.

LUXATED TENDONS

DispIacements or disIocations of tendons is by no means a common finding. The peronea1 tendons, however, are more fre- quentIy Iuxated than any other. Either one or both tendons may be invoIved. A con- genitaIIy shaIIow groove at the externa1 maIIeoIus may be an etiologic factor. In some cases the disIocation may be present at birth, but more frequently it is induced by trauma subsequently.

If the displacement has been present for some time or if conservative measures fail, an operation to repIace the tendon is indi- cated. The technic of EIIis Jones’ is simpIe and apparentIy quite efficient. The opera- tion consists of exposing the tendons in their sheaths and repIacing them in their proper position. A tongue shaped section of tendo AchiIlis is dissected downward from its IateraI border. The free end is passed through a driI1 hoIe in the external malleolus and sutured to itself, forming a sIing which prevents redislocation. In para- Iytic cases associated with a caIcaneovalgus foot, correction of the deformity is a11 that is necessary.

In a typical case the tendon can be seen and feIt to glide forward over the lower end of the fibuIa as the foot is flexed and sIightIy everted. Pain is not usuaIIy a prominent symptom, the disabiIity being caused by Ioss of mechanical efficiency of the puJ1 of the tendons. This dispIacement is often associated with caIcaneovaIgus deformities of the foot foIIowing infantiIe paralysis.

The type of treatment depends upon whether the case is seen earIy or late. If the patient is observed soon after the sIipping has occurred, the tendons can be repIaced. Reduction is maintained bv appIying a pIaster boot cast with the -foot at right angles to the Ieg and slightly everted. Fixa- tion is continued for a period of from four

Luxation (4 Long Head Biceps. Disloca- tion of the long head of the biceps muscle has been described by GiIcreest” and others. But in the experience of the writer it occurs very rarely. The etiology is trauma, either often repeated minute traumas or sudden severe movements of the arm into external rotation and abduction. The symptoms incIude pain in the region of the bicipital groove which is increased by pIacing the arm in overhead extension and external rotation. Weakness and disability, of the extremity is a common complaint. The diagnosis rests on the symptomatolog~ and proper evaluation of physica findings. There is usuaIJJ- some tenderness over the front of the shouIder in the region of the biceps tendon. Occasionally one is able to palpate the tendon outside the groo\‘c OI the empty groove itseIf, which cinches the diagnosis. Unfortunately, these signs can- not be constantly demonstrated because of the presence of o\,erJying structures. GiI- creest has described a test upon which hc

* From the Department of Orthopedic Surgery, University of Okl:rhom:l School of R/lcdicinc.

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NEW SERIES VOL. L. No. 3 Rountree-Severed Tendons American Journal of Surgery 517

places much emphasis. The patient raises his extended and externally rotated arms over head. A five pound dumbbe is heId in each hand. The examiner then places his fingers on the Iong head of the biceps as the arms are Iowered to the side of the body in the corona1 pIane. When the outstretched arm reaches an angIe of I IO to go degrees, a snap may be heard and felt in the injured shouIder which is accompanied by acute pain in the shouIder and aIso in the region of the bicipita1 groove. GiIcreest considers a positive test pathognomonic of the Iesion.

Treatment. If the case is seen soon after the accident, repIacement may be accom- plished by manipuIation; and if successfu1, the arm is immobihzed to the side of the body for two weeks. The indication for surgica1 treatment rests on the degree of disability present. If the patient is a Iabor- ing man who must use his arms in heavy work, earIy operation is the treatment of choice. The purpose of the operation is to replace the tendon in its groove and hoId it there by suture of the transverse humera ligament. GiIcreest advises cutting the tendon high in the joint and suturing the proxima1 end into the coracoid process and into the tendon of the short heady of the biceps. FoIIowing operation, a VeIpeau dressing is appIied for about two weeks after which function is graduaIIy resumed.

The condition known as snapping hip, whiIe not def’miteIy caused by a Iuxated tendon, is a somewhat analagous type of disabiIity. In the writer’s experience, the incidence of this affection is very uncom- mon. These cases are characterized by an audibIe and paIpabIe snap produced by a tight fascia1 band sIipping forward over the trochanter. Frequently the band can be seen to sIip forward. The band usuaIIy consists of a thickened portion of the iliotibia1 band or an accessory sIip of the gIuteus maximus muscIe at its insertion. Treatment is not often required because the condition is not usuaIIy painfu1. How- ever, in one of the writer’s cases, the pa- tient was aware of a snapping at the hip for severa years before pain deveIoped from

which she sought relief. When treatment is necessary it is entirely surgical. The opera- tion is best performed under IocaI anes- thetic so that the patient can reproduce the snap which makes the band easier to Iocate. While severa different operations have been proposed, apparentIy a11 that is necessary is to incise the fascia1 band trans- verseIy beIow the IeveI of the great trochanter and suture the edges to the periosteum to prevent reunion.

SEVERED TENDONS

Tendons are usuaIIy severed by sharp objects such as a knife, gIass, tin, or pieces of porceIain from broken water faucets, or they may be severed by severe muscIe puI1 foIIowing some untoward movement or vioIent exercise. The greater number of tendon injuries from incised wounds occur in the upper extremities; whereas, rupture of muscIes and tendons seems to occur more frequentIy in the Iower extremities.

The first and most important step in the treatment of any condition in which tendon involvement is obvious or suspected is a carefur examination to determine the ex- tent of the injury. The necessity for this seems cIear, and yet one not infrequently sees cases Iater on with evidence of severed tendons which were compIeteIy overIooked at the time of accident.

In connection with open or incised wounds the great danger is the distinct possibiIity of infection. When it occurs the success of the operation is in doubt and the patient’s Iife may be endangered. Obviously, therefore, one shouId never repair a tendon in the presence of infection or in a grossly contaminated wound in which infection is IikeIy to occur. As a ruIe a tendon shouId be sutured as soon as possibIe folIowing in- jury, but many factors must be considered in determining whether a primary or de- Iayed suture should be done. Among these are the character and extent of the wound, the nature and extent of the first aid treat- ment, the Iength of time which has eIapsed since injury occurred, and Iast but not

518 American Journal of Surgery Rountree-Severed Tendons IlECIHBtH, Ilj.&,,

Ieast, the skiJI and surgica1 judgment of the also beheve that some of the poor results operator. folIowing otherwise adequate surgery are

If the wound is a cIeanIy incised one, due to puIIing apart of the tendons foIIowing sustained indoors, with the patient’s skin suture. Too JittIe attention has been paid reIativeIy cJean, immediate suture may be to the proper physiologic and mechanical performed. On the other hand, in grossIy methods developed for tendon suture. The contaminated and dirty wounds a deIayed reader is referred to the exceIIent work of suture is the method of choice. As a matter Koch,3 Mason,4 and others for details of’ of generaI principIe, wounds which are more technic. than eight hours oId shouId be cIeansed as SUMMAHY thoroughIy as possibIe and the superficia1 tissue sutured IooseIy, and any tendon re-

I. The more common Iuxations of ten-

pair deferred unti1 compIete healing has dons have been briefly discussed.

occurred. 2. Severed tendons are briefly discussed

The repair of a severed tendon is a maior from a genera1 standpoint.

operatioi, and the surgeon shouId have’at his disposa1 al1 the necessary faciIities for 1. carrying out the work. We believe that a general anesthetic is preferabIe to IocaI anesthesia. It goes without saying that the ‘. operator must be thoroughIy familiar with the anatomy of the part in question. These 3’ operations are often Iong and meticuIous procedures, which tax the skiJJ of the sur- -1.

geon and the endurance of the patient. We

REFERENCES

JOKES, ~ZI_LIS. Operatiw treatment of chronic dis- location of permeal tendons. J. Bone P Joint SurR., 14: 574, 1932.

GILCKEEST, E. L. Dislocation and rIongation of the Iong head of the biceps bra&ii. Ann. Surg., 104: 118, 1936.

KOCH, SUMNER 1.. The imrnediatc treatment of injuries of the hand. Surs., Gynec. P Ohst., 52: 594, 1931.

KOCH, S. L. and Xl~so~, X~ICHAEL. L. Division of nerves and tendons of the hand. Surg., Gynec. P+ Obst., 56: I, ,933.