Extensor pollicis longus

The extensor hallucis longus muscle (EGL) is a thin muscle located between the tibialis anterior muscle and the extensor digitorum longus muscle. This muscle generates the only extensor force at the interphalangeal joint and the main extensor force at the metatarsophalangeal joint. In addition, it has a slightly lower extension moment at the ankle joint than the tibialis anterior muscle. The DRP also has a smaller cross-sectional area compared to the tibialis anterior and extensor digitorum longus muscles.

Testing

Patient position: sitting or lying on back. We ask him to straighten his thumb, and we ourselves offer resistance. If there is paresis of the thumb, then the distal phalanx of the thumb does not extend, the proximal phalanx extends in the direction of abduction.

Weakness of DRBP

Thus, weakness of the DRP leads to impaired extension of the big toe at the interphalangeal and metatarsal-flank joints (once again: this is the only muscle that performs this movement).

Very soon there will be a seminar by Georgy Temichev “Diagnostics and therapy of problems of the lower extremities. Analysis of walking and running." Find out more...

During walking, initial contact with the ground (the surface of support) is made by the heel. The ground reaction force generates a plantar flexion moment of the foot, which is prevented by the muscles that perform dorsiflexion. Weakness of the DBJ reduces a person's ability to control this movement, especially of the big toe.

Patients with DFB weakness report that the big toe may bend under the foot when they pull on socks or shoes; it also leads to stumbling.

Hypertonicity DRBP

Hypertonicity of the DP joint leads to extension of the metatarsal-flank joint, which can be accompanied by flexion in the interphalangeal joint (this is also typical for other fingers), and, subsequently, “clawed” deformation of the finger.

Hyperextension of the big toe puts stress on the metatarsal-flank joint, which is accompanied by pain and callus formation when wearing shoes.

Trigger points for DRBP can cause pain in the big toe or dorsum of the foot. The pain can also be localized in the lower leg area.

Flexor hallucis longus

Injuries to the flexor tendon of the big toe are a common type of injury in risk groups such as dancers (primarily ballet dancers), gymnasts and rock climbers. These groups of people are united by a significant overload of the flexor of the big toe when performing pushes and hooks, and standing on pointe shoes. The second name for this pathology is “dancer’s tendinitis.” In the rest of the population, these lesions are extremely rare. Since the tendon of the flexor pollicis longus runs in the fibro-osseous canal behind the medial malleolus and ankle joint, it appears to be thrown over the posterior process of the talus, like a rope thrown over a pulley.

When it is chronically traumatized, degenerative changes lead to its thickening and compaction, causing compression and pinching. So-called posterior ankle impingement may occur. If nodules appear in the thickness of the tendon, a symptom such as “trigger finger” may appear, when the bent thumb “snaps”, and it can only be straightened through pain and by applying significant force. With a long-term process, cicatricial fusion of the tendon with its canal is possible, which leads to pseudo-rigid deformation of the first metatarsophalangeal joint.

First of all, it is pain along the posterior-inner surface of the ankle joint. It is possible that the thumb may “snap” when it is bent. Crunching, crepitation along the posterior-inner surface of the ankle joint during active movements. On physical examination, pain is detected when the big toe is flexed against resistance, with forced plantar flexion in the ankle joint, while there is no pain in the area of the first metatarsophalangeal joint. To diagnose damage to the flexor hallucis longus tendon, it is advisable to perform an MRI, which will reveal an accumulation of fluid around the tendon at the level of the ankle joint and a change in the signal from the tendon itself.

Differential diagnosis of tendinitis of the flexor hallucis longus tendon is carried out with tendonitis of the peroneal muscles, fracture of the posterior process of the talus, posterior talocalcaneal coalition, osteoid osteoma of the talus and calcaneus.

With ruptures of the flexor hallucis longus tendon, in addition to acute pain and swelling along the posterior-inner surface of the ankle joint, severe weakness of the plantar flexion of the big toe is determined.

In case of acute ruptures, emergency surgical restoration of tendon integrity is indicated in a group of professional athletes and dancers. For the average person, surgical treatment is recommended only in case of damage to the tendons of both the short and long flexor of the big toe.

In case of tendinitis of the flexor tendon of the thumb, conservative treatment is recommended - rest, local cold, physiotherapy, stretch exercises. In addition, it is recommended to change the approach to training, pay more attention to warming up and stretching, wearing insoles and shoes with good arch support.

If these measures are ineffective for 3 months, the question of surgical treatment arises. The tendon is released, freed from adhesions, degenerated areas are removed, and synovectomy is performed. If an accessory triangular bone is identified, it is advisable to remove it.

For good visualization, the use of a tourniquet is recommended. A semicircular incision is made parallel to the posterior edge of the inner ankle. It is necessary to carefully isolate the neurovascular bundle and take it on a holder. Access to the tendon canal can be done both anteriorly and posteriorly in relation to the bundle. At this stage, it is possible to isolate the tendon; after careful examination and palpation, all nodes and adhesions are removed. If a triangular bone is found, it must be removed.

Removing the triangular bone significantly lengthens the rehabilitation period. After isolated tenolysis of the flexor pollicis longus tendon, weight bearing and walking are resolved immediately as the pain subsides. After removal of the triangular bone, up to 8-12 weeks of non-weight-bearing walking may be required.

Tendon damage

The choice of tendon reconstruction method is made taking into account the time that has passed since the injury, the prevalence of scar changes along the tendons, and the condition of the skin at the operation site. A tendon suture is indicated when it is possible to connect the damaged tendon end to end and the soft tissue in the area of surgery is in normal condition. There is a primary tendon suture, performed within 10-12 days after the injury in the absence of signs of infection in the wound area and its incised nature, and a delayed suture, which is applied within 12 days to 6 weeks after the injury under less favorable conditions (lacerations and bruises). wounds). In many cases, in a later period, suturing is impossible due to muscle retraction and the occurrence of significant diastasis between the ends of the tendon. All types of tendon sutures can be divided into two main groups - removable and immersed.

Removable sutures, proposed in 1944 by Bunnell S., are used to fix the tendon to the bone and in areas where early movements are not so necessary. The suture is removed after the tendon has fused sufficiently firmly with the tissue at the point of fixation. Immersion seams remain in the tissues, bearing a mechanical load. In some cases, additional sutures are used to ensure a more perfect alignment of the ends of the tendons. In old cases, as well as with a primary defect, tendon plasty (tendoplasty) is indicated. The source of tendon autograft is tendons, the removal of which does not cause significant functional and cosmetic disturbances, for example, the tendon of the palmaris longus muscle, the superficial flexor of the fingers, the long extensor of the toes, and the plantaris muscle.

Injuries to the finger flexor tendons

Anatomy.

Flexion of 2-5 fingers is carried out due to two long tendons - superficial, attached to the base of the middle phalanx and deep, attached to the base of the distal phalanx. Flexion of the 1st finger is carried out by the tendon of the long flexor of the 1st finger. The flexor tendons are located in narrow, complex-shaped osteo-fibrous canals that change their shape depending on the position of the finger

Change in the shape of the osteo-fibrous canals of the 2nd-5th fingers of the hand when they are flexed

In places of greatest friction between the palmar wall of the canals and the surface of the tendons, the latter are surrounded by a synovial membrane that forms the sheath. The deep digital flexor tendons are connected through the lumbrical muscles to the extensor tendon apparatus.

Diagnostics.

If the deep digital flexor tendon is damaged and the middle phalanx is fixed, flexion of the nail is impossible; with combined damage to both tendons, flexion of the middle phalanx is also impossible.

Diagnosis of flexor tendon injuries (1, 3 – deep, 2, 4 – both)

Flexion of the main phalanx is possible due to contraction of the interosseous and lumbrical muscles.

Treatment.

There are five zones of the hand, within which anatomical features influence the technique and results of the primary tendon suture.

Brush zones

In zone 1, only the deep flexor tendon passes through the osteofibrous canal, so its damage is always isolated. The tendon has a small range of motion, the central end is often retained by the mesotenon and can be easily removed without significant expansion of the damaged area. All these factors determine good results from applying a primary tendon suture. The most commonly used transosseous tendon suture is removed. It is possible to use immersed seams.

Throughout zone 2, the tendons of the superficial and deep flexor fingers intersect; the tendons are tightly adjacent to each other and have a large range of motion. The results of tendon suture are often unsatisfactory due to scar adhesions between the sliding surfaces. This zone is called critical or “no man’s land.”

Due to the narrowness of the osteofibrous canals, it is not always possible to suture both tendons; in some cases, it is necessary to excise the superficial flexor tendon of the finger and apply a suture only to the deep flexor tendon. In most cases, this avoids finger contractures and does not significantly affect flexion function.

In zone 3, the flexor tendons of adjacent fingers are separated by neurovascular bundles and lumbrical muscles. Therefore, tendon injuries in this area are often accompanied by damage to these structures. After suture of the tendon, suture of the digital nerves is necessary.

Within zone 4, the flexor tendons are located in the carpal tunnel along with the median nerve, which is located superficially. Tendon injuries in this area are quite rare and are almost always combined with damage to the median nerve. The operation involves dissecting the transverse carpal ligament, suturing the deep digital flexor tendons, and excising the superficial flexor tendons.

Throughout zone 5, the synovial sheaths end, the tendons of adjacent fingers pass close to each other and, when the hand is clenched into a fist, they move together. Therefore, cicatricial fusion of the tendons with each other has virtually no effect on the amount of finger flexion. The results of tendon suture in this area are usually good.

Postoperative management.

The finger is immobilized using a dorsal plaster splint for a period of 3 weeks. From the second week, after the swelling subsides and the pain in the wound decreases, passive flexion of the finger is performed. After removing the plaster splint, active movements begin.

Damage to the extensor tendons of the fingers

Anatomy.

The formation of the extensor apparatus involves the tendon of the common extensor of the finger and the tendon of the interosseous and lumbrical muscles, connected by many lateral ligaments, forming a tendon-aponeurotic stretch

Extensors of the fingers and hands.

It must be remembered that the index finger and little finger, in addition to the common one, also have an extensor tendon. The middle bundles of the extensor tendon of the fingers are attached to the base of the middle phalanx, extending it, and the lateral bundles are connected to the tendons of the small muscles of the hand, attached to the base of the nail phalanx and perform the function of extending the latter. The extensor aponeurosis at the level of the metacarpophalangeal and proximal interphalangeal joints forms a fibrocartilaginous disc similar to the patella. The function of the small muscles of the hand depends on the stabilization of the main phalanx by the extensor finger. When the main phalanx is bent, they act as flexors, and when extended, together with the extensor fingers, they become extensors of the distal and middle phalanges.

Thus, we can speak of perfect extension-flexion function of the finger only if all anatomical structures are intact. The presence of such a complex interconnection of elements to some extent favors the spontaneous healing of partial damage to the extensor apparatus. In addition, the presence of lateral ligaments of the extensor surface of the finger prevents the tendon from contracting when damaged.

Diagnostics.

The characteristic position that the finger takes depending on the level of damage allows you to quickly make a diagnosis.

Diagnosis of extensor tendon damage

extensors at the level of the distal phalanx, the finger assumes a flexion position at the distal interphalangeal joint. This deformity is called a “mallet finger.” In most cases of fresh injuries, conservative treatment is effective. To do this, the finger must be fixed in a hyperextended position at the distal interphalangeal joint using a special splint. The amount of hyperextension depends on the patient’s level of joint mobility and should not cause discomfort. The remaining joints of the finger and hand must be left free. The immobilization period is 6-8 weeks. However, the use of splints requires constant monitoring of the position of the finger, the condition of the elements of the splint, as well as the patient’s understanding of the task facing him, therefore, in some cases, transarticular fixation of the nail phalanx with a knitting needle is possible for the same period. Surgical treatment is indicated when the tendon is torn from its attachment site with a significant bone fragment. In this case, a transosseous suture of the extensor tendon is performed with fixation of the bone fragment.

When the extensor tendons are damaged at the level of the middle phalanx, the triangular ligament is simultaneously damaged, and the lateral bundles of the tendon diverge in the palmar direction. Thus, they do not straighten, but bend the middle phalanx. In this case, the head of the main phalanx moves forward through a gap in the extensor apparatus, like a button passing into a loop. The finger assumes a position bent at the proximal interphalangeal joint and hyperextended at the distal interphalangeal joint. This deformation is called a “boutonniere”. With this type of injury, surgical treatment is necessary - suturing the damaged elements, followed by immobilization for 6-8 weeks.

Treatment of injuries at the level of the main phalanx, metacarpophalangeal joints, metacarpus and wrist is only surgical - primary tendon suture followed by immobilization of the hand in the position of extension in the wrist and metacarpophalangeal joints and slight flexion in the interphalangeal joints for a period of 4 weeks with subsequent development of movements.

Nerve damage to the hand

The hand is innervated by three main nerves: the median, ulnar and radial. In most cases, the main sensory nerve of the hand is the median, and the main motor nerve is the ulnar nerve, innervating the muscles of the eminence of the little finger, interosseous, 3 and 4 lumbrical muscles and the adductor pollicis muscle. Of important clinical importance is the motor branch of the median nerve, which arises from its lateral cutaneous branch immediately after exiting the carpal tunnel. This branch innervates the short flexor of the 1st finger, as well as the short abductor and opponor muscles of the Many. the muscles of the hand have double innervation, which preserves to one degree or another the function of these muscles if one of the nerve trunks is damaged. The superficial branch of the radial nerve is the least significant, providing sensation to the dorsum of the hand. If both digital nerves are damaged due to loss of sensitivity, the patient cannot use the fingers and their atrophy occurs.

The diagnosis of nerve damage should be made before surgery, since this is not possible after anesthesia.

Suturing the nerves of the hand requires the use of microsurgical techniques and adequate suture material (6\0-8\0 thread). In case of fresh injuries, soft and bone tissues are first processed, after which the nerve suture is started

Epineural suture of the nerve

The limb is fixed in a position that provides the least tension on the suture line for 3-4 weeks.

Conclusions:

Operations to restore functionally important structures of the hand are carried out in several stages, inpatient stages alternate with outpatient stages, at all stages the experience and supervision of a specialist is required. Due to the weakness of the outpatient department of government institutions, adequate care is only possible in the conditions of the “Center for Endosurgical Technologies” where there is no uncontrolled molasses of victims, here it is possible to pay attention to each patient.

It is very important to get to the right specialist immediately after an injury; in our city, not many traumatologists deal with this problem due to the complexity and low profitability of public clinics. The doctor must plan your entire treatment from beginning to end, anticipate and provide for all possible complications. The first stage is the most important; fixing something in the future is very difficult and sometimes impossible.

Hand surgery requires experience from the doctor, and patience and a winning attitude from the patient.

To sign up for a consultation: e-mail, tel.: +7 (391) 297-52-52

Anatomy

The extensor digitorum longus belongs to the muscles of the lower leg, or more precisely, to its anterior group. It is located outside the tibialis anterior muscle. The muscle goes down, turning into a narrow tendon, which is amazingly strong. Then it splits into 4 bundles: each is designed for a separate finger. It is attached at the level of the near phalanx. At the attachment point, the beam diverges into 3 small parts, which make it possible to move any part of the foot.

The mobility of the thumb is carried out by the work of several muscles simultaneously. This complex structure is necessary because it helps maintain balance and the ability to walk upright. The flexor hallucis longus is a muscle that belongs to the posterior group of the lower leg. Its growth begins in the area of the lower 2/3 of the fibula. It goes down the limb to the sole and turns into a tendon. On the foot, it grows slightly into the tendon responsible for the movements of the remaining toes. It turns out that the movements of all phalanges depend to one degree or another on his work. It is fixed on the nail phalanx.

Structure [edit]

The flexor digitorum longus runs along the posterior medial side of the shin and helps flex the toes (except the big toe).
It arises on the posterior surface of the body of the tibia, just below the plantar line up to 7 or 8 cm from its lower extremity, medial to the tibial origin of the tibialis posterior muscle; it also arises from the fascia covering the tibialis posterior muscle.

The fibers end in a tendon that runs almost the entire length of the posterior surface of the muscle. This tendon passes behind the medial malleolus in a groove common to it and the tibialis posterior muscle, but separated from the latter by a fibrous septum, each tendon being contained in a special compartment lined by a separate mucous membrane. The tibialis posterior tendon and the flexor digitorum longus tendon cross each other at a location above the medial malleolus, the tendon decussation of the tibia. [1] [2] [3]

It runs obliquely forward and lateralward, superficial to the deltoid ligament at the ankle, into the sole of the foot, where it crosses the flexor tendons of the big toe at the level of the navicular bone at a location known as Henry's node [4] (also called the plantar tendon decussation), [ 1] [2] [3] and receives strong tendon sliding from it.

It then expands and attaches to the quadratus muscle (quadratus muscle) and finally divides into four tendons, which are inserted into the bases of the last phalanges of the second, third, fourth and fifth toes, each tendon passing through an opening in the corresponding tendon. from the flexor digitorum Brevis opposite the base of the first interphalangeal joint.

Option [edit]

Flexor accessorius longus digitorum often originates from the fibula or tibia or from the deep fascia and ends in a tendon, which, passing under the lacinial ligament, connects with the tendon of the long flexor or quadratus muscle.

Trauma[edit]

After passing through the tarsal tunnel, the flexor digitorum longus tendon should bend around a bony landmark called the sustenaculum tali. Flexor digitorum longus pain can occur when you trip and fall on an uneven surface and your toes are unable to fully grip the surface. It is also possible to injure the flexor digitorum longus muscle while running on the beach on sand without shoes, leaving the muscle at the heel bone insertion vulnerable to injury. If the flexor digitorum longus muscle is painful or sprained, the patient will have difficulty walking and will experience excruciating pain in the feet and ankles. Supportive braces along with warm compresses are the most preferred treatment for flexor digitorum longus pain or sprain.

Causes of muscle dysfunction

The foot extensors may lose strength or be otherwise damaged for a number of reasons:

atrophy with age due to disruption of tissue nutrition,
pathologies in the functioning of the endocrine system,
connective tissue diseases,
fermentopathy,
polyneuritis,
complications after injuries,
too much physical activity.

The main cause of the lesion is tendinitis. This is an inflammatory disease of the tendons that can also affect nearby muscle tissue. Dystrophic destruction can become chronic, which is very dangerous and practically incurable.

Pain in the foot can also occur due to salt deposition and the formation of growths on bone tissue. The reason for this may be taking certain medications, etc.

Muscle Performance Tests

Read also: How to heal joints using magnetic therapy

The ankle extensors can lose their strength due to a number of reasons. You can check its condition and performance using simple tests that the doctor conducts during the examination:

With one hand you need to hold the metatarsus in the usual position, and with the other, carefully but firmly bend your toes. A person should strive to straighten them. If he succeeds, the highest mark is 4 or 5.
The person lies on his back, with a soft cushion placed under his knees. The metatarsus is held forcibly. At the same time, he must try to straighten his fingers. If he succeeds, the highest mark is 3.
The situation is the same. The doctor feels the tendon, while the person should try to straighten the fingers. If he succeeds, the highest mark is 1.

In a normal state, a person receives 5 points. Strength may decrease if tissues do not receive sufficient nutrition or innervation occurs.

Links[edit]

This article incorporates open access text from page 485 of the 20th edition

"Grey's Anatomy"
(1918).

^ ab Walter Thiel (1997) Photographic Atlas of Practical Anatomy - Volume 1, Part 1 - p.348
^ ab Johannes Sobotta, Reinhard Putz, Reinhard Pabst (1997) Sobotta's Atlas of Human Anatomy: Thorax, Abdomen, Pelvis, Lower Limb, p. 331
^ ab Jan Langman, Martinus Willem Woerdeman (1982) Atlas of Medical Anatomy, p. 323
Knipe, Henry. "Henry's Knot | Radiology Help Article | Radiopaedia.org". Radiopedia
. Retrieved October 20, 2021.

A set of exercises for developing the movements of the first toe