From Big Medical Encyclopedia

TENDINOUS SEAM — a way of operational connection of the injured sinews. Most often NL apply at injuries of sinews at the level of a forearm and a brush.

On terms of imposing distinguish primary, early secondary (delayed) and late secondary NL. Primary stitch is put in the first 24 hours after damage if there are no signs of an inflammation of a wound. The early secondary seam which is gaining ground is applied after healing of a skin wound in terms from 2 to 6 weeks from the moment of damage. Late secondary NL make during from 6 to 8 weeks after damage. In later terms resort to plastics of sinews (see. Sinews ).

NL impose under local, conduction, intra bone anesthesia (see. Anesthesia local ) or under anesthesia (see) depending on the volume of operation. There are more than 40 ways of imposing of NL. The seam shall be simple, minimum break blood circulation in a sinew, keep the smooth sliding surface of a sinew, strong hold its ends. Most tendinous seams of Kyuneo, Bloch — Bonnet, V. I. Rozov, a removable seam of Bannell meet these requirements. Adaptation seams with fixing of the ends of a sinew thread or a fine needle deserve attention.

Fig. 1. The diagrammatic representation of different types of an intra barreled tendinous seam (the dotted line showed a suture material in a sinew): and — across Kyuneo (the sinew is stitched at first in transverse direction, then is crosswise in the form of a lacing); — according to Bloch — Bonnet (the sinew is stitched at first in transverse direction, then it is crosswise); in — across Rozov (the sinew is stitched at first in transverse direction, then along an axis); — on Bannella with unloading of a proximal piece of a sinew (1 — the button which is temporarily fixing a seam, 2 — a removable intra barreled seam, 3 — a loop for the subsequent removal of a seam).

By Kyuneo's method (fig. 1, a) NL impose vnutristvolno by means of a fine end with two straight needles on the ends. Otstupya 2 cm from the end of a sinew, one needle stitch a sinew in transverse direction, then serially each needle stitch a sinew crosswisely in the form of a lacing. The last vykol needles is the share of the plane of section of a sinew. Similarly put a stitch on other end of a sinew then threads are tied.

NL according to Bloch — Bonnet (fig. 1, b) and across Rozov (fig. 1, c) are simple, a little traumatic and strong. They differ with the fact that at the first of them thread after cross underrunning of a sinew is carried out on the plane of its section crosswisely, and at the second — is longitudinal. Bannell's seam — removable, providing intra barreled carrying out thread with unloading of a proximal piece of a sinew. At the same time thread is carried out crosswisely through a proximal piece of a sinew and bring her along tendinous fibers. In the same direction thread is entered into a distal piece of a sinew and removed sideways from it. Units fix over skin by means of a node on a button (fig. 1, d). For removal of a seam cut one of units and extend it for the loop brought to skin proksimalno.

The suture material for NL shall be thin, strong and cause the smallest reaction of fabrics. Use nylon, capron, amide thread, chrome more often - a molybdenum and tantalic wire (see. Suture material ).

For imposing of NL use tools from special set of Rozov.

Before operation it is necessary to specify in what situation there was a finger at the time of wound since damage at the bent fingers conducts to the shift of distal stumps of sinews, and at the proximal stumps unbent to shift. For the best access to the injured sinew the wound needs to be expanded. Removal in a wound of the displaced central ends of sinews is facilitated during the imposing of rubber bandage on an upper third of a forearm. If at the same time to bend a brush, then the proximal end of a sinew can be found easier in a wound. Otherwise make an additional section on a palm, remove a proximal stump of a sinew in a wound and, having put on it a stitch, by means of the conductor from Rozov's set, carry out from a palm on a finger and sew it with a distal piece. At damage only of a deep sgibatel of fingers the central end of his sinew is spent between legs of a sinew of a superficial sgibatel of fingers and hemmed to the distal end or if it short, paraossalno or transossalno to a distal phalanx. At damage of both sgibatel of fingers at the level of a palm or fingers recover a sinew only of a deep sgibatel of fingers, excising the distal end of superficial. For search of the ends of the injured sinews at the level of a forearm and a palm there is a need for a section of a retinaculum of sgibatel (a palmar ligament of a wrist), to-ry it is not necessary to recover. At a seam of sinews it is necessary to protect the ring-shaped and crucial ligaments playing a role of «blocks» during the sliding of sinews. After NL fingers and a brush fix on 2 — 3 weeks a plaster splint in the provision of moderate bending. In a splint passive bending of a finger is begun in 6 — 8 days after operation, and active — in 10 — 14 days.

At a separation of a proximal sinew of a long head of a biceps of a shoulder it is hemmed transossalno to a humeral bone or to a sinew of a big pectoral muscle. The injured distal sinew is hemmed to a beam bone. The immobilization is carried out by a plaster splint during 3 — 4 weeks, then appoint thermal procedures, massage, to lay down. gymnastics.

At a rupture of a sinew the four-head of a muscle of a hip observes its razvolokneniye. In fresh cases recovery in its way of imposing of P-shaped (mattress) seams with the subsequent immobilization a back plaster splint in the provision of extension during 4 weeks is possible.

Fig. 2. The diagrammatic representation of lengthening of a sinew on Bannella: and — the line of a section of a sinew (it is shown by a dotted line); — the ends of a sinew are sewed (lengthening is reached it).

The net result of a seam of sinews of sgibatel is worse, than razgibatel. By bad outcomes of NL conduct unions of a sinew with surrounding fabrics, the probability of development to-rykh increases at errors in technology of operation, use of a rough suture material, postoperative complications. Unions are resulted by tenogenny flexion contractures of fingers (see. Contracture ). In similar cases the operation directed to allocation of a sinew from hems and excision of hems is shown (see. Tenolysis ). If it is not possible to achieve sufficient extension of a finger and free sliding of a sinew, the last is excised and make plastics a free transplant or sew a polyvinyl chloride tube for creation of an artificial tendinous vagina. The last way is especially shown after complications of tendinous felon (see).

At localization of hems on a forearm when their excision does not result in desirable result, it is necessary to make lengthening of a sinew by a S-shaped section it on Bannella (fig. 2).

Bibliography: Grigorovich K. A. Surgical treatment of injuries of nerves, page 154, JI., 1981; Dubrov Ya. G. Injury of sinews of a brush, Ortop. and travmat., No. 5, page 75, 1975; The Multivolume guide to orthopedics and traumatology, under. edition of N. P. Novachenko, t. 3, page 255, M., 1968; Bunnell S. Bunnell’s surgery of the hand, Philadelphia — Toronto, 1970; Flynn J. E. Hand surgery, p. 184, Baltimore, 1966; Pompner K. Gedeckte Strecksehnenverletzung am Fingerend-glied, Zbl. Chir., Bd 100, S. 238, 1975; VerdanC. et Poulenas I. L’est-hetique en chirurgie de la main, Rev. med. Suisse rom., t. 94, p. 989, 1974.

L. H. Bryantseva.