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Egypt Rheumatol Rehab Vol. 30, No. 2, March 2003 255 FUNCTIONAL OUTCOME AND MEDICOLEGAL IMPLICATIONS OF FLEXOR TENDON INJURIES AT THE WRIST SAFAA AL-SHANAWANY, HAMDY KHAMIES KORAYYEM*, MOWAFFAK M SAAD*, SALAH DESOUKI** AND NASSER GHOZLAN*** Forensic Medicine & Toxicology, Rheumatology & Rehabilitation*, Radiology** and Plastic Surgery*** Departments, Alexandria University Faculty of Medicine KEY WORDS: FLEXOR TENDONS AT THE WRIST, FUNCTIONAL OUTCOME, MEDICOLEGAL IMPLICATIONS. ABSTRACT Background: Flexor tendon injuries at the wrist (zone V) are commonly associated with significant morbidity. Suboptimal recovery leads to residual disability with serious medicolegal impacts. Objective: To investigate the factors influencing the functional outcome of zone V flexor tendon injuries and their medicolegal aspects. Methodology: Twenty patients with surgically repaired zone V flexor tendon injuries were included in the study. For each patient, flexion and extension composite range of motion of the digits as well as grip and pinch strengths were assessed before and after a supervised rehabilitation program. Data considering the place where injury took place, causative agent, time of surgery and postoperative complications and time of start of postoperative rehabilitation were recorded. Ultrasonographic evaluation was used to evaluate the status of tendon recovery at the end of the rehabilitation program. Results: Based on assessment of digital range of motion deficit and occupation handicap, the study showed that 40% of patients recovered with less than 20% range of motion deficit, and could resume their pre-injury working ability. Sixty percent of the studied patients ended their rehabilitation program with 20% or more loss of digital range of motion with difficulty in resuming their pre-injury working abilities. The extent of tendon injury, associated nerve involvement, delay of postoperative

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Page 1: FUNCTIONAL OUTCOME AND MEDICOLEGAL IMPLICATIONS OF …applications.emro.who.int/imemrf/egypt_rheum_regabil_2003_30_2_2… · Functional Outcome & Medicolegal Implications of Flexor

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FUNCTIONAL OUTCOME AND MEDICOLEGAL IMPLICATIONS OF FLEXOR

TENDON INJURIES AT THE WRIST SAFAA AL-SHANAWANY, HAMDY KHAMIES KORAYYEM*, MOWAFFAK M SAAD*, SALAH DESOUKI** AND

NASSER GHOZLAN*** Forensic Medicine & Toxicology, Rheumatology & Rehabilitation*,

Radiology** and Plastic Surgery*** Departments, Alexandria University Faculty of Medicine

KEY WORDS: FLEXOR TENDONS AT THE WRIST, FUNCTIONAL OUTCOME, MEDICOLEGAL IMPLICATIONS.

ABSTRACT Background: Flexor tendon injuries at the wrist (zone

V) are commonly associated with significant morbidity. Suboptimal recovery leads to residual disability with serious medicolegal impacts.

Objective: To investigate the factors influencing the functional outcome of zone V flexor tendon injuries and their medicolegal aspects.

Methodology: Twenty patients with surgically repaired zone V flexor tendon injuries were included in the study. For each patient, flexion and extension composite range of motion of the digits as well as grip and pinch strengths were assessed before and after a supervised rehabilitation program. Data considering the place where injury took place, causative agent, time of surgery and postoperative complications and time of start of postoperative rehabilitation were recorded. Ultrasonographic evaluation was used to evaluate the status of tendon recovery at the end of the rehabilitation program.

Results: Based on assessment of digital range of motion deficit and occupation handicap, the study showed that 40% of patients recovered with less than 20% range of motion deficit, and could resume their pre-injury working ability. Sixty percent of the studied patients ended their rehabilitation program with 20% or more loss of digital range of motion with difficulty in resuming their pre-injury working abilities. The extent of tendon injury, associated nerve involvement, delay of postoperative

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rehabilitation and the initial base line assessment have shown significant negative correlation with the outcome measures. Multiple linear regression analysis showed that those variables were significant predictors of the final outcome measures. Ultrasound assessment revealed complete tendon healing in 40% of patients. Tendon adhesions, deficient healing and swellings indicative of infection or hematomas were demonstrated in 60% of the studied patients.

Conclusion and Recommendations: It is recommended that structured supervised postoperative rehabilitation should be started promptly early postoperatively and that every effort is to be made to avoid postoperative complications. Predictors of final outcome may be used to plan and modify the program to ensure best results. Evaluation of patients’ disability should be accomplished in the context of their jobs and social tasks. Determination of responsibility for settlement of compensation should consider all factors contributing to the final disability.

INTRODUCTION

Fig. 1: Zone classification of flexor tendon injuries at the First Congress of International Federation of Societies for Surgeons of the Hand 1980 (Singer et al.,

1988). Injuries of the hand have an enormous impact on hand function and,

consequently on the quality of life, both occupational and social. The significant morbidity resulting from the loss of active motion in the digits is accentuated by the fact that most injuries occur at an age group below 30

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years. Zone V (Fig. 1) is among the common sites of injuries, where the flexor tendons as well as the median and / or the ulnar nerves may be involved (Singer et al., 1988 and Andrew et al., 2000).

Such injuries are usually caused by sharp objects; frequently occur in a workplace while dealing with risky machinery. Domestic accidents and assaults are also among the commonly observed injury-related circumstances. This is of special medicolegal implication because of the possibly raised claims for compensation. Therefore, outcome evaluation after flexor tendon injuries is of critical importance for assessment of the functional capacity and residual disability influencing the individuals’ potentials to carry out occupational and social tasks (Sherif, 1971; Helpern, 1977 and McCoy & Weems, 1989).

The functional outcome of flexor tendon repair is greatly influenced by the amount of adhesions allowed to form between the site of repair and surrounding tissues. No present-day management can predictably isolate the intrinsically healing tendon ends from the extrinsic ingrowth of adhesions from the surrounding tissues (Taras et al., 1999 and Chang et al., 2000).

The surgical factors as well as post-operative hand rehabilitation may be the primary determinants of the functional outcome of flexor tendon injuries. A non-traumatizing repair technique respecting the blood supply of the tendon is required for clean intrinsic healing with as few adhesions as possible. Additionally, the bulk of repair is thought to have an effect on tendon gliding (Sanders et al., 2001). Nevertheless, a delayed surgical intervention has been shown to be associated with poorer outcome. Surgical repairs currently used are limited regarding their ability to withstand the stress of early active rehabilitation; hence, prolonged period of protected rehabilitation is required (Totteham et al., 1995 and Aoki et al., 1995).

The post operative management represents a dilemma both for the surgeon and the rehabilitation team. On one hand, post-repair restriction of tendon mobility during the healing phase encourages dense adhesions binding the tendon with the surrounding tissues, reducing its functional capacity, and on the other hand, uncontrolled early mobilization may jeopardize the repair. In practice, the timing of active mobilization is still controversial, and may be guarded by the fear of repair failure (Dobbe et al., 1999).

The extent of damaged tendons and nerves may have a contribution to the functional outcome of flexor tendon injuries at the wrist. Related is the nature of the traumatizing agent that may be determinant of the extent of damage. Finally, the occurrence of infection as a complication in the course

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of management might be critical for the outcome of management (Lawrence et al., 2000).

Thus, a spectrum of factors may be operant in variable degrees in determining the functional outcome of flexor tendon injuries and the final level of disability.

In addition to the study of functional variables, ultrasound examination of the repaired tendons may be useful in revealing the status of the healing process and subsequently the patient’s prognosis (Kaplan PA et al., 1989).

Aim of Work: The aim of the present study was to investigate the factors

influencing the functional outcome of zone V flexor tendon injuries and their medicolegal aspects.

MATERIALS AND METHODS Twenty patients with zone V flexor tendons injuries were included

in the study. Ninety percent were males (mean age is 28.6 years ± 8.8 SD), while 2 patients were females (10%, mean age is 23.5 years). All patients were collected among those attending the Outpatient Clinic of the Rheumatology & Rehabilitation Department, Alexandria University Faculty of Medicine. All of them have been referred fitted with a Kleinert splint and reported being instructed on self-performing of active extension and allowing passive flexion, via rubber bands, several times a day, following surgery. Data considering the place where injury took place, causative agent, time of surgery and postoperative complications were collected. All patients were subjected to initial assessment of digital range of motion (ROM) including the metacarpophalangeal (MCP) joint, proximal interphalangeal joint (PIP) and distal interphalangeal joint (DIP) using a digit goniometer. A composite score was calculated by a modification of Strickland`s formula (Goma`a & Sultan, 1994) as follows:

Composite initial active flexion = 100290 XDIPflexionPIPActiveMCP ++

Where 290 is the sum of normal active flexion angles of the 3 joints in degrees.

Composite initial passive extension = 100540 XonDIPextensiPIPPassiveMCP ++

Where 540 is the sum of normal full extension angles of the 3 joints in degrees, considering that full extension at a single joint = 180 degrees. Grip and pinch strength were also measured with a dynamometer in kilograms.

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In addition to the functional measures, investigation of the state of the repaired tendons was done via ultrasound examination using Real Time Sonography with dynamic examination of the tendons during contraction and relaxation, using high frequency (7.5 and 10 MHz) linear transducers. Images were taken in both longitudinal and transverse planes. The continuity and echogenicity of the examined tendons were evaluated (Fornage & Riffkin, 1988)

All patients, thereafter, were enrolled in structured supervised rehabilitation sessions. Supervised exercises consisted of passive tendon gliding with tenodesis, place and hold tendon gliding with tenodesis, non-resisted place and hold grasp and release as well as partial place and hold fisting (Steinberg, 2002). The program was performed 3 sessions per week, by a single well trained therapist. The program was continued with serial evaluation of the range of motion gains, and ended when a plateau was reached. At the time, a final evaluation of the range of motion composite scores was recorded, along with the final grip and pinch strength measures.

In accordance to the concept of occupation handicap (WHO, 1980), patients were categorized according to their final outcome measure of ROM deficit into two groups: group A, including patients who recovered with less than 20% loss of active ROM, and could resume their pre-injury working abilities; and group B, including patients with 20% or more loss of active ROM, with failure to resume their pre-injury working abilities.

The obtained data were statistically analyzed using the SPSS®; v7.0. Paired-sample t-test, Pearson’s correlation, multiple linear regressions and Fisher’s exact test were used.

RESULTS The study was conducted on twenty patients with zone V flexor

tendon injuries. The majority (65%) were manual workers involved with sharp objects like glass or ceramics, as their jobs required. The sample included three students, two clerks and two housewives, as well. Injuries were accidentally sustained in 17 cases (85%), while in three other cases, the injury resulted from assault.

All injuries were reported to be caused by sharp objects. The workplace and home were the places of sustaining injury in 50% and 30% of the cases, respectively. Outdoor injuries occurred among 20% of the cases, in fights (15%) or by broken glass (5%). The injured hand was the dominant one in all cases.

All cases were surgically managed at the same day of injury. The

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mean number of injured tendons was eight with a range of 2-to-11, variably involving the flexor digitorum superficialis, profundus, flexor carpi ulnaris, radialis and flexor pollicis longus tendons. Associated nerve injuries were demonstrated in all cases. The involvement of the median nerve was found among 25% of the cases, the ulnar nerve in 30% while both nerves were injured in 45% of the cases. Infection, as a postoperative complication, was reported in eight cases (40%).

On the other hand, structured supervised postoperative rehabilitation was started between 12 and 49 days with a mean of 31.3±13.9. Six patients (30%) started the structured rehabilitation no longer than the 14th day-postoperative (early start), while the others (14 patients, 70%) started after the 14th day (late start).

In general, the functional outcome of the repaired tendons, measured as a composite score of active flexion as well as passive extension ROM of the MCP, PIP and DIP joints, showed statistically significant improvement in reference to the initial assessment before the onset of the rehabilitation management (table1). In addition, the grip strength as well as the pinch strength, both showed significant difference when the post and pre-rehabilitation mean values were compared using paired sample t-test (t= 3.361 and 3.008 respectively). Table (1): Composite ROM of the digits, initially and at final assessment (mean ± SD).

Initial Assessment Final Assessment t p X SD X SD -21.17 0.000

Fl 61.65 17.49 75.60* 19.17 -10.67 0.000 D I Ex 73.20 8.55 84.75* 10.76 -12.89 0.000 Fl 64.25 16.99 76.90* 20.50 -10.60 0.000 D II Ex 76.90 9.41 89.25* 7.93 -10.37 0.000 Fl 63.60 17.51 77.50* 20.33 -9.33 0.000 D III Ex 74.40 8.13 86.80* 9.49 -8.934 0.000 Fl 62.50 18.08 76.40* 21.32 -13.93 0.000 D IV Ex 74.40 8.39 86.40* 9.29 -13.93 0.000 Fl 63.05 19.69 74.50* 22.71 -9.874 0.000 D V Ex 78.05 8.63 89.00* 7.44 -10.63 0.000

*: significant at p≤0.05 D: Digit. F: flexion; E: extension The assumption that certain factors may influence the course and

functional outcome of repaired tendons was studied. Table (2) shows that there was a statistically significant inverse correlation between most of the

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initial values of the functional measures and the time lagging between surgery and the start of the supervised structured rehabilitation. This means that the longer the time lag before start of rehabilitation the more the chance that base line functional measures may suffer significant deficits. Table (2): Correlation between the initial measures of digits’ ROM, grip and pinch strength with the pre-rehabilitation period, number of injured tendons and nerves.

Pre-rehabilitation period

Number of injured tendons

Number of injured nerves

r p r p r p FL -0.916* 0.000 -0.942* 0.000 -0.789* 0.000 D I EX -0.638* 0.003 -0.755* 0.000 -0.611* 0.004 FL -0.915* 0.000 -0.891* 0.000 -0.721* 0.000 D II EX -0.493* 0.027 -0.693* 0.001 -0.420 0.065 FL -0.888* 0.000 -0.836* 0.000 -0.701* 0.001 D III EX -0.486* 0.030 -0.604* 0.005 -0.579* 0.007 FL -0.809* 0.000 -0.813* 0.000 -0.594* 0.006 D IV EX -0.511* 0.021 -0.656* 0.002 -0.539* 0.014 FL -0.929* 0.000 -0.887* 0.000 -0.661 0.097 D V EX -0.583* 0.007 -0.660* 0.002 -0.382 0.097

Grip strength -0.893* 0.000 -0.947* 0.000 -0.677* 0.001 Pinch strength -0.403 0.078 -0.461* 0.041 -0.410 0.072

*: significant at p≤0.05 Fl= Flexion Ex= Extension

Such correlation was also found with the extent of tendon and nerve injury, implicating that patients with higher number of injured tendons and multiple associated nerve injury were found to start rehabilitation with significant base line measures deficits. The final functional outcome measures showed a very similar pattern of correlation with the pre-rehabilitation variables, as shown in table (3), meaning that the functional outcome is significantly influenced by variables like the time lag before rehabilitation as well as the extent of tendon and nerve involvement.

Whether such variables can predict the final functional outcome was studied using multiple linear regression analysis (table 4). In general, the study showed that, for the composite final ROM of the digits, the initial base line assessment was a significant common predictor, a finding that strongly suggests that the more the initial deficit the worse may be the final outcome.

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Table (3): Correlation between the final measures of digits’ ROM, grip and pinch strength with the pre-rehabilitation period, number of injured tendons and nerves.

Pre-rehabilitation period

Number of injured tendons

Number of injured nerves

r p r p r p FL -0.930* 0.000 -0.965* 0.000 -0.772* 0.000 D I EX -0.692* 0.001 -0.774* 0.000 -0.479* 0.032 FL -0.969* 0.000 -0.926* 0.000 -0.761* 0.000 D II EX -0.566* 0.009 -0.697* 0.001 -0.366 0.102 FL -0.940* 0.000 -0.904* 0.000 -0.683* 0.001 D III EX -0.594* 0.006 -0.706* 0.001 -0.507* 0.023 FL -0.911* 0.000 -0.917* 0.000 -0.686* 0.001 D

IV EX -0.621* 0.003 -0.709* 0.000 -0.540* 0.012 FL -0.945 0.000 -0.928 0.000 -0.706* 0.001 D V EX -0.654* 0.002 -0.745* 0.000 -0.433 0.057

Grip strength -0.694* 0.001 -0.788* 0.000 -0.520* 0.016 Pinch strength -0.766* 0.000 -0.812* 0.000 -0.593* 0.006

*: significant at p≤0.05 Fl= Flexion Ex= Extension Table (4): Predictors of the functional outcome as described by the final digits’ ROM and final strength of the grip and pinch (dependent variables). Multiple linear regression analysis is used.

ANOVA Dependent variables Significant Predictors r

F p FL D I FI, number of injured tendons,

Pre-rehab period 0.994 655.172 0.000 D I

EX D I EI, Pre-rehab period 0.948 47.12 0.000

FL D II FI, Pre-rehab period 0.997 670.41 0.000 D II

EX D II EI, Pre-rehab period 0.967 77.41 0.000

FL D V FF, Pre-rehab period 0.994 436.06 0.000 D III

EX D IV EF, Pre-rehab period 0.999 2473.072 0.000

FL D IV FI, D V FF, Pre-rehab period 0.997 606.526 0.000 D IV EX D IV EI, D III EF, Pre-rehab

period 0.971 138.37 0.000

FL D V FI, D IV FF, Pre-rehab period 0.995 578.41 0.000 D V

EX D V EI, Pre-rehab period 0.920 29.24 0.000

Grip strength Number of injured tendons, number of injured nerves 0.960 33.59 0.000

Pinch strength Number of injured tendons, number of injured nerves 0.812 34.91 0.000

Significant at p≤0.05 Fl= Flexion Ex= Extension FI: initial flexion FF: final flexion EI: Initial extension EF: final extension.

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Moreover, the study showed that the pre-rehabilitation period as well as the number of injured tendons were significant predictors of the final outcome ROM measures. It is worth noticing that the number of injured tendons was a significant predictor specifically for digit 1 active flexion final outcome. With extensive number of injured tendons, the chance for the tendon of flexor pollicis longus to be involved increases, thus increasing the chance that digit I active flexion would be defective. The study also showed that the final functional outcome of certain digit flexor tendon may be predicted significantly by the initial and/or final measures of neighboring tendons. Finally, the regression study showed that the extent of tendons and nerves injured significantly predicts the final outcome of the grip and pinch strength.

Considering the occupation handicap, the studied patients at their final assessment were fitted to either one of two groups, A; with less than 20% ROM deficit (8 patients, 40%) resuming pre-injury working abilities, and group B, with 20% or more ROM deficit (12 patients, 60%) leading to work disability. The relationship between the category of occupation handicap and the delay of structured postoperative rehabilitation was studied by Fisher`s exact test, as shown in table 5. There was statistically significant relationship between the categories describing occupation handicap (by final ROM deficit), and with whether postoperative rehabilitation was delayed or not. In addition, a similar significant relationship was found with incidence of complicating infection (table 5). The postoperative rehabilitation delay as well as the occurrence of complicating infection were associated with increased incidence of handicapping deficits. Table (5): Distribution of the studied patients according to the category of occupation handicap by the start of rehabilitation and the presence of postoperative infection. Start of rehabilitation Postoperative infection Early Late Total p Present Absent Total p Group A 6 2 8 0 8 8 Group B 0 12 12 8 4 12 Total 6 14 20

0.0018 12 20

0.005

Fisher’s Exact test is significant at p ≤ 0.05

In addition to the functional measures, investigation of the repaired tendons via ultrasound was done. Tendon healing, changes in tendon thickness, echogenicity of tendon fibers were evaluated. Complete tendon healing was recorded in eight of the studied cases (40%). These patients

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were found to recover with useful hand functions. Tendon healing was evidenced by normal appearance of the tendon with just focal irregularity of the outline in four cases (Fig. 2), while healing associated with mild increase in tendon thickness was the ultrasound picture in the other four patients.

Abnormal ultrasound changes were observed in 12 patients (60%) who were clinically found to recover with non-useful hand function. The commonest observation was tendon adhesions in 50% of patients, mostly in the form of variable degrees of increased thickness together with mixed increased and decreased echogenic areas (40%). Focal swellings, also denoting adhesions, were reported in 10% of the patients (Fig. 3).

Ultrasound examination of patients having history or clinical evidences of infection (40%) demonstrated tendon swellings indicating presence of tendonitis at the site of tendon injury. On the other hand, focal hypoechoic areas adjacent to the site of injury were noticed in 15% of cases, thus confirming presence of hematomas (Fig. 4). Partial discontinuity of tendon fibers indicating deficient healing was another ultrasound finding in the incompletely – recovered patients (10%). (Fig. 5). No cases of tendon calcification were encountered.

Fig. (2): Complete tendon healing showing just irregularities of the tendon outlines.

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Fig. (3): Thickened tendon with mixed increased and decreased echogenicity.

Fig. (4): Focal hypoechoic hematoma with small internal echoes.

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Fig. (5): Discontinuity of the tendon fibers of different degrees.

DISCUSSION The studied patients were, in the great majority, males, within the 3rd

decade of age, consistent with the age and sex incidence of flexor tendon injuries reported in other studies (Naam, 1997 and Sirit-Urbina et al., 2002). Such prevalence is probably related to their high level of professional (and non-professional) activity.

The study showed significant improvement of the measured functional parameters after rehabilitation. However, only 40 % of patients restored 80% or more of their digital range of motion. Higher percentage of excellent results was reported in the literature (Rias et al., 1999; Cetin, 2001 and Coyle et al., 2002). In all of these studies, early postoperative rehabilitation was the selected strategy. Considering the impact of injury on return to work and previous activities, the study showed that 12 patients (60%) were occupationally handicapped (suffering from 20% or more ROM deficit). Several authors have also reported the serious effects of permanent and disability on the labor market (Adolfsson et al., 1996 ; Sirit-Urbina et al., 2002 and Reville et al., 2002).

In the present study, multiple variables were studied considering

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their influence on the functional outcome of repaired flexor tendon injuries in zone V. The results showed a significant inverse correlation between initial and final measures of the composite ROM and strength on one hand and the time lag between surgery and the start of the supervised protocol of rehabilitation on the other hand. A mean of 31 days was the time lagging before the start of active rehabilitation program. This is considerably long period in view of the recent accumulating recommendations for the start of early active mobilization post operatively. Aggressive supervised active mobilization through almost the full range of flexion and extension was encouraged from the first post operative day (Hatanaka et al., 2002). A number of clinical trials have shown favorable results associated with early controlled active mobilization (Sirotakova et al., 2000 and Dymarezyk, 2001). Early active mobilization not only serves to minimize adhesions but also contributes to repair strength as well as proprioceptive preservation (Dobbe et al., 1999). The long time lag may have allowed enough chance for adhesions to form, probably enhanced by the patient’s deficient independent performance of the requested Klienert`s protocol. Infection may be a factor contributing both to the elongation of the time lag prior to active mobilization program as well as to the build-up of adhesions. In the studied sample, eight cases (40%) have suffered infection of some degree during the early post-operative period.

The effect of extent of damage to the flexor tendons in zone V was studied. The number of injured tendons was found to have inverse correlation with both the initial and final outcome measures. This finding conforms to the outcome of the so called ”spaghetti wrist”, a term that describes zone V injury where flexor tendons of all fingers are injured. It has been shown that such an injury has a significant adverse effect on the functional outcome explained by its contribution to deficient recovery of the independent flexor digitorum superficialis action but not on the recovery of the digital range of motion (Yii et al., 1998).

Moreover, the extent of associated nerve injuries was found to show the same inverse correlation with the functional outcome. The association of median and/or ulnar nerve injuries may have contributed to adverse results through the resulting paralysis of the intrinsic hand muscles. Such occurrence will impose limitation on the patient’s ability to actively mobilize the digits in flexion as well as extension. Additionally, one may expect that increased extent of nerve damage is associated with increased extent of tendon injuries, based on the anatomical proximity, a combination that is unfavorable for the functional outcome. While associated nerve injury may indirectly adversely affect the outcome active range of tendon

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movements, it directly reduces the outcome measures of the grip and pinch strength considered among the functional outcome measures. It is clear that intrinsic muscle paralysis will cause direct massive reduction of the values of these two variables, thus significantly contributing to the limitation of the hand function (Jaquet et al., 2001).

From a medicolegal point of view, determination of contribution of each of these factors to the resulting disability will be of critical importance in compensation claims (Shah JP et al., 1997).

The results of the multiple linear regression analysis showed a number of significant predictors of the final functional outcome of zone V flexor tendon injuries. For most of the digits, but the initial assessment of one digit at the start of the supervised active mobilization was a significant predictor of the final functional outcome of the same digit. This finding means that high level of limitation of tendon mobility at the start of supervised active mobilization predicts worse outcome. It can also be proposed that a longer time before active supervised mobilization predicts deficient final outcome. Additionally, the regression analysis has shown the final outcome measure of some digits as significant predictor of the outcome of others. This finding in particular describes a situation of interdependence between the function of the repaired tendons. This coincides with the reported adverse effect of the zone V “spaghetti” flexor tendon injuries on the recovery of the independent function of the repaired tendons (Yii et al., 1998). Such interdependence could be explained by the anatomical proximity of the injured tendons within a narrow tunnel at the wrist.

The study of tendons with ultrasound helped to confirm complete healing or explain the unsatisfactory recovery of some patients. Ultrasonographic examination of various tendons has been reported to demonstrate post operative factors associated with poor functional recovery. Studies on Achilles tendon, patellar ligament and rotator cuff could detect calcific deposits and residual suture materials (Harcke et al., 1988 and Wiener & Seitz, 1993). In the present study, presence of adhesions and deficient tendon healing demonstrated by ultrasound explained the lack of complete recovery of patients after tendon repair in spite of the strict organized rehabilitation. Presence of infection and hematomas also played a role. Nevertheless, ultrasound could confirm proper healing and minimal adhesions associated with cases showing satisfactory functional outcome.

Conclusion and Recommendations: The present work has shown the significant negative impact of

delayed postoperative rehabilitation on the final outcome of repaired flexor

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tendons injured at zone V. Nevertheless, extensive tendon involvement, associated nerve injuries and incidence of complicating infection were all related to poorer functional outcome. Predicting the outcome quantitatively may be possible by fitting the measurements of all the related variables to a regression equation. Prior knowledge about the outcome likely to be obtained is probably useful in individualized planning and modifying the rehabilitation program. It is important to emphasize the critical need to start structured supervised rehabilitation early, postoperatively. Every possible measure should be provided to prevent postoperative complications.

Ultrasound examination is a useful non- invasive tool in confirming the state of tendon healing , assessing the unfavorable factors that may lead to diminished functional recovery and could be used to follow the tendon status throughout the postoperative period of rehabilitation.

In the medicolegal practice, evaluation of disability should be done only after the patient’s condition becomes stationary with no further improvement. It is essential to understand the socioeconomic consequences associated with the development of disability and the importance of evaluating the patients in the context of their jobs, homes and social roles.

Proper history taking and meticulous examination of the medical records are necessary, stressing on the severity of original trauma, timing of surgical repair and postoperative rehabilitation and occurrence of complications. These factors influence the outcome and subsequently share the responsibility for the resulting disability.

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النتائج الوظيفية و المضمون الطبى الشرعى الصابات األوتار القابضة عند الرسغ ***غزالن ناصر ، **دسوقى صالح ، *الحميد عبد موفق ، *آريم حمدى ، الشنوانى صفاء

، *** و جراحة التجميل** ، األشعة التشخيصية* قسم الطب الشرعى و السموم ، الطب الطبيعى . جامعة األسكندرية-آلية الطب

ؤدى في لألصابع الشفاء غير التام لألوتار القابضة ة الخامسة ي ى المنطق ة إل ة إعاق متخلف . شرعيةمع تداعيات طبية

في األوتار القابضة إلصابات الوظيفي الناتج فياستقصاء العوامل المؤثرة : هدف البحث سة ة الخام ا المنطق شرعي و جوانبه ة ال ادة و .ةالطبي ثم رق البح رى البُح: ط شرين ثأج ى ع عل

اس مدى القبض و . تمت معالجتها جراحيا المنطقة الخامسة فيمريضا بقطع األوتار القابضة تم قيل قبل و بعد القرصةالبسط المرآب لألصابع و آذلك قوة القبضة و من آل مريض . برنامج التأهي

د الجراحة لإلصابةالعامل المسبب , اإلصابة نتم جمع بيانات مكا ، وقت الجراحة، مضاعفات ما بع . يووقت بدء البرنامج التأهيل

ة، بينت الدراسة اإلعاقة مدى حرآة األصابع و فيبناء على تقدير النقص : لنتائجا المهنيل من شفوامن المرضى % 40أن لألصابع و استطاعوا الحرآي المدى في نقص % 20 مع أق

ل ا قب ل آم ى العم درتهم عل ترجاع ق ابةاس تون . اإلص يس امج ف وا البرن ن المرضى أنه ة م المائى في مدي حرآة األصابع مع صعوبة في نقص أو أآثر % 20 ب التأهيلي درتهم عل استرجاع ق

و آل من الوظيفي داللة بين قياسات الناتج إحصائي ذوتبين وجود ارتباط . اإلصابةالعمل آما قبل امج فيخير التأ أهيلي، بدء البرن د الت ا بع ار و إصابات مدى الجراحة، مضاعفات م إصابات األوت

امج الى القياسات إضافةهذه العوامل، . األعصاب المصاحبة ل البرن ة قب در أبانت ،التأهيلي األولي ة قائي الوظيفي بالناتج تنبوئية ل النه ك باستخدام التحلي يم .التراجعي اإلحصائي ، و ذل بالموجات التقي

التئام منقوص و األوتار، التصاقات .المرضىمن % 40 فيفوق الصوتية أظهر التئام تام لألوتار .من الحاالت% 60 فيانتفاخات تدل على عدوي أو تجمعات دموية ظهرت

امج : الخالصة و التوصيات دء البرن أهيلييجب ب ذل الت ة ، و يجب ب د الجراح را بع مبك في اة بالنتيجة النهائية يمكن استخدامه ئالعوامل المتنب . اعفات بعد الجراحة الجهود لمنع حدوث مض

تم يجب أن اإلعاقةتقييم . النتائجأفضل لضمان التأهيليوضع و تعديل خطة البرنامج اة ي مع مراع يجب أن يأخذ التعويضات تحديد المسئولية لتسوية . للمرضى االجتماعيةة و األهداف ي المهن األبعاد .النهائي الناتج في جميع العوامل المشارآة عتباراال في