CASE REPORT

EXTENSOR DIGITORUM TENDON RUPTURE OF MANUS DEXTRA

Diajukan untuk memenuhi tugas dan melengkapi salah satu syarat dalam menempuh Program
Pendidikan Profesi Dokter bagian Ilmu Bedah
di RSUD Dr. H. Soewondo Kendal

Disusun oleh:
Septi Dwi Sulistyowati
30101507559

Pembimbing:
dr. Wisnu Murti, Sp.OT

FAKULTAS KEDOKTERAN
UNIVERSITAS ISLAM SULTAN AGUNG
SEMARANG
2019
 HALAMAN PENGESAHAN

Nama : Septi Dwi Sulistyowati

NIM : 30101507559

Fakultas : Kedokteran

Universitas : Universitas Islam Sultan Agung ( UNISSULA )

Tingkat : Program Pendidikan Profesi Dokter

Bagian : Ilmu Bedah

Judul : EXTENSOR DIGITORUM TENDON RUPTURE OF MANUS DEXTRA

Semarang, November 2019

Mengetahui dan Menyetujui

Pembimbing Kepaniteraan Klinik

Bagian Ilmu Bedah RSUD Dr. H.Soewondo Kendal

Pembimbing,

dr. Wisnu Murti, Sp.OT.

 CHAPTER I
INTRODUCTION

The extensor tendon system of the wrist, hand, and fingers is surprisingly complex.
The six extensor compartments of the wrist and the intrinsic muscles of the hand comprise 23
musculotendinous units. Open and closed injuries to these structures are more common than
injuries to the flexor structures and range from very subtle, seemingly minor traumas to overt
complex injuries with failure and/or loss of multiple tissue types.
Failure to diagnose and treat these injuries, including those in the superfcially subtle
categories, can lead to significant loss of motion and function. The zones of injury have been
assigned beginning distally with odd numbered zones located over the respective distal
interphalangeal (DIP), proximal interphalangeal (PIP), metacarpophalangeal (MCP), and
wrist joints, while the even numbered zones are located over the underlying intervening
osseous structures.
A few general anatomical points are critical to be aware of when evaluating patients
with potential injuries to the extensor mechanism. (1) Variations in extensor anatomy are
common, such as extensor digiti minimi (EDM) duplication, absence of extensor digitorum
communis (EDC) to the small fnger. (2) The juncturae tendinum connect the EDC tendons of
the ulnar four digits and are more common and more substantial (tendon like) on the ulnar
part of the hand. An injury to the extensor mechanism proximal to a juncturae can be masked
on examination by the ability to extend the injured digit at the MCP joint through an intact
juncturae to an adjacent tendon. (3) Because of the superfcial location of the extensors partial
and complete injuries can and do occur with seemingly minor lacerations. (4) Injuries may be
initially compensated for by the duplications and interconnections of the extensor mechanism
but a clinically signifcant deformity can develop with time. (5) A high percentage of these
injuries have associated bone, skin, or joint injury.
A major component of the care of tendon injuries is rehabilitation with controlled
early motion. While exceptions exist, the vast majority of flexor tendon injuries are currently
treated with early motion. In the extensor system, the biomechanical characteristics of repair
do not as routinely allow for the same degree of early mobilization. In general, the
biomechanical strength of utilized repairs is dependent on the zone of injury. Hence the most
important factors in determining the treatment of extensor tendon injuries include the
anatomical zone, the chronicity of the injury, and any pathology of the adjacent tissues
(principally skin, bone, and joints).
 CHAPTER II
LITERATURE REVIEW

A. ANATOMY OF TENDON
Tendons are fibrous connective tissue located between the muscles and bone whose
role is to transmit force generated by skeletal muscle in a manner which maintains posture
and joint movement. When muscles contract, tendons pull on bones. This causes parts of the
body (such as a finger) to move.
The muscles that move the fingers and thumb are located in the forearm. Long
tendons extend from these muscles through the wrist and attach to the small bones of the
fingers and thumb. The tendons on the top of the hand straighten the fingers. These are
known as extensor tendons. The tendons on the palm side bend the fingers. These are known
as the flexor tendons.

TENDON STRUCTURE
Macroscopically, tendons present as mother of pearl in colour, with a viscous-elastic
consistency with high mechanic resistance; in fact, being more rigid than muscles, tendons
have a greater tensile strength and therefore can support greater loads while deforming less,
which means that force generated by the muscles is transmitted without the dissipation of
energy due to stretching. Form is dictated by function and vice versa; muscles responsible for
precision movements, such as those in the fingers, end in long and slender tendons, while
muscles that do a lot of work, such as the flexors and extensors of the thigh, have thick robust
tendons.
The tendon is wrapped in a membrane or synovial sheath, which facilitates tendon
movement, avoids friction and maintains the position of the tendon during muscular
contraction. Furthermore tendons which have fibres with one predominant orientation, such
as the Achilles tendon, are covered with an external sheath called the paratenon which
consists of peritendineal sheets of loose fibrillar tissue which are predominantly formed of
collagen types I–III and elastic fibres. The number of these sheets varies as a function of the
type of tendon and anatomical location.
The function of the paratenon is then to reduce tendon friction during movement.
Immediately below the paratenon lies the epitenon, a thin sheath composed of dense
connective tissue, and together the paratenon and epitenon make up the peritenon (Fig. 1.5).
Internally adjacent to the epitenon lies the endotenon, a thin connective tissue membrane
which functions to encompass and group collagen fibrils into bundles of varying dimensions
and to organise the distribution of nervous system and vascular structures within the tendon.
Alternatively, tendons that are subject to greater degrees of bending during movement, such
as the flexor tendons of the fingers, are enclosed within a richly vascularised synovial sheath.
The presence of synovial liquid between the external wall of the tendon and the internal wall
of the sheath ensures minimal friction between the tendon and the bone.
 The area where the tendons insert into the bone is called the osteotendinous junction
(enthesis) and comprises four zones: the tendon, fbrocartilage, mineralised fbrocartilage and
bone. The areas where the tendon meets the muscle is called the myotendinous junction; here
the collagen fbrils make contacts with muscle cells forming folds which increase the contact
surface area between muscle and tendon hence reducing the applied stress during muscular
contraction. Structurally the tendon is formed by numerous collagen bands covered externally
by the peritenon. Internally we see tertiary, secondary and sub-fascicular bands as well as
single collagen fibres, wrapped by and separated from others by the endotenon. The basic
building blocks of the tendon are collagen fbres themselves composed of many collagen
fibrils which have a diameter of 20–150 nm depending on the functional role of the tendon.
The majority of fibres are aligned with the main axis of the tendon, which makes the
tendon very load resistant; this property is associated with the average diameter of the
collagen fibres. Within the tendons, aggregates of collagen fibrils form fibres, which
themselves form the bands of varying dimensions that are together called tendons. More
precisely, a group of collagen fibrils form a primary band, or sub-band, and many of these
primary bands surrounded by the endotenon form a secondary band or fascicle. A group of
secondary bands form a tertiary band and many tertiary bands together constitute the tendon,
enclosed within the endotenon.

BIOCHEMICAL COMPOSITION OF THE TENDON

From a biochemical perspective, the tendon is a complex structure comprising
collagen fibres immersed in a proteoglycan matrix. The acellular portion of the tendon is
composed of a water-rich matrix (60–65% water) made up of proteoglycans and
glycosaminoglycans, elastin and collagen fibrils.
 TENDON VASCULARISATION
The tendons are vascularised by the perimysium, the periosteum and the paratenon;
the flow of blood is slow (0.5 ml per 100 g tissue per minute) and is concentrated on the
external surface of the tendon. For this reason the tendon is considered a poorly vascularised
tissue and therefore is subject to prolonged regeneration times.

TENDON INNERVATION
The tendon is scarcely innervated, and the nerve branches form a course parallel to
the main axis of the tendon with transversal and oblique anastomoses. In some cases, these
branches terminate in contact with corpuscular receptors (Golgi, Pacini corpuscles, Ruffni
corpuscles and GolgiMazzoni corpuscles) that are involved in proprioceptive sensitivity and
myotatic reflexes, while others terminate in free branched ends which are mostly found in the
peritendinous sheets involved in nociception.

CLINICALLY RELEVANT ANATOMY

Extensor tendons are located at the dorsal region of the hand and fingers. The
function of these tendons is to extend the wrist and the fingers. According to Kleinert
and Verdan (1983), there are eight anatomic zones in which the extensor mechanism is
divided;

Zone I: DIP joint

Zone II: middle phalanx
Zone III: PIP joint
Zone IV: proximal phalanx
Zone V: MCP joint
Zone VI: metacarpals
Zone VII: wrist (carpus and extensor
retinaculum)
Zone VIII: distal third of the forearm
 FINGER MOVEMENT
Finger extension involves simultaneous actions of
both extrinsic and intrinsic extensor muscles. Extrinsic
muscles originate in the elbow and forearm and include the
following: extensor digitorum, extensor indicis, and
extensor digiti minimi. The primary function of these
muscles is extension of the metacarpophalangeal (MCP)
and interphalangeal joints. The intrinsic muscles that
originate and insert within the hand are the lumbrical and
interosseous muscles. The function of these muscles is
primarily to extend the interphalangeal joints and
secondarily to contribute to flexion of the MCP joint. These
groups of extrinsic and intrinsic muscles are coordinated by
a series of stabilizing retinacular structures, which facilitate
balanced transmission of muscular force. These structures
are found in the dorsum of the carpum (extensor
retinaculum), the hands (intertendinous connections), and
the fingers (extensor hood, retinacular and triangular
ligaments).

EXTENSOR TENDONS
The extensor tendons pass under the extensor retinaculum at the wrist and
are divided into six fibroosseous compartments over the dorsal aspect to the wrist
(Fig. 11–4). The dorsal compartments and the retinaculum act to stabilize the
extensor tendons and prevent bow stringing. The six fibroosseous compartments
containing the nine extensor tendons are presented below:
 a. Abductor Pollicis Longus and Extensor Pollicis Brevis.
The abductor pollicis longus inserts at the dorsal base to the thumb
metacarpal and the extensor pollicis brevis inserts at the base to the proximal
phalanx to the thumb. These tendons can be tested by asking the patient to
forcefully spread the hand. The abductor pollicis longus is palpated just distal to the
radial styloid. The extensor pollicis brevis is palpated under tension over the dorsum
to the thumb metacarpal.
b. Extensor Carpi Radialis Longus and Brevis.
These tendons insert at the dorsal base to the index and middle metacarpal,
respectively. They are evaluated by asking the patient to make a fist and extend the
wrist forcibly. These tendons are outmost importance to the function and strength to
the hand because they are the primary extenders to the wrist.
c. Extensor Pollicis Longus.
The extensor pollicis longus passes around Lister tubercle on the dorsal
aspect to the radius and inserts on the distal phalanx to the thumb. It forms the ulnar
border of the anatomic snuffbox and can be easily seen by extending the thumb.
Only this tendon can extend the thumb and forcibly hyperextend it at the IP joint. It
is tested by asking the patient to hyperextend the distal phalanx of the thumb against
resistance.
d. Extensor Digitorum Communis and Extensor Indicis Proprius.
These tendons are tested by asking the patient to flex the IP joints into a tight
claw and actively extend the MCP joint. This permits the examiner to visualize the
extensor digitorum communis. Asking the patient to first make a fist and then
extend the index finger, while the other fingers remain flexed, tests the extensor
indicis proprius.
e. Extensor Digiti Minimi.
The extensor digitorum minimi is in the next compartment and can be tested
at the same time as the extensor indicis proprius. Ask the patient to first make a fist,
and then extend the index and the little fingers while the long and ring fingers
remain flexed.
f. Extensor Carpi Ulnaris.
This tendon inserts at the dorsal base of the the fifth metacarpal and is
evaluated by asking the patient to ulnar deviate the hand while the examiner
palpates the taut tendon over the ulnar side of the wrist just distal to the ulnar head.
DEFINITION/DESCRIPTION
An extensor tendon injury is a cut or tear to one of the extensor tendons. Due
to this injury, there is an inability to fully and forcefully extend the wrist and/or
fingers.

EPIDEMIOLOGY /ETIOLOGY
The extensor tendons of the hand are located superficially, so they are very
susceptible to injuries. An-other reason is the lack of subcutaneous tissue between
the tendons and the overlying skin. Possible mechanisms are sharp object direct
lacerations, burns, blunt trauma, bites, crush injuries, avulsions and deep abrasions.
Closed injuries arise usually under situations of extreme load. This results in ripping
the tendons apart from their attachment of the bone.

CHARACTERISTICS/CLINICAL PRESENTATION
Dependent on the zone of injury, different characteristics are shown.
 Zone I: Mallet finger
 Zone II: no complete rupture of the tendon, but partially injured
  Zone III: Disruption of the central slip, also called a Boutonnière deformity
or jammed finger. This is characterised by a flexed position of the PIP joint
and an extension or hyperextension of the DIP joint.
 Zone IV: injuries are frequently partial, with or without loss of extension at
the PIP joint
 Zone V: fight bite injuries (open injuries) or non-fight bite injuries (e.g.
blunt trauma): a possible effect of such an injury is a rupture of the sagittal
bands, attended with following extensor tendon subluxation. This is
presented as a difficulty to actively straighten the flexed MCP joint.
 Zone VI: the MCP joint can still be extended via the juncturae tendinum.
 Zone VII: physical injury to the extensor retinaculum.

TENDON HEALING
The maintenance and viability of tendons are largely dependent on the structural
molecules that constitute the extracellular matrix (ECM) (Butler et al. 2004). The
tenocytes are the primary regulator of the ECM and tendon homeostasis (Galloway et al.
2013). These fbroblast-like cells are interconnected with one another and with adjacent
collagen fibers, enabling recognition of mechanical changes in the ECM (Wang 2006).
The tenocytes are able to respond to load and mechanical changes by modulating the
degradation and formation of ECM (Wang 2006). The preservation of ECM homeostasis
is critical in the tendon healing process and its capacity to respond to injury.
The ECM is composed predominantly of type I collagen, which is the primary
constituent of the native tendon (Hogan et al. 2011). The longitudinal and parallel
arrangement of type I collagen enables the ECM to respond to tensile loads (Karousou et
al. 2008). Proteoglycans also play a role in the ECM’s capacity to resist tensile and
compressive forces (Karousou et al. 2008). Indeed, the collagen network of the ECM is
mechanosensitive and is stabilized by mechanical strain (Bhole et al. 2009). Bhole et al.
showed, using dynamic differential imaging, that nonstrained collagen fbril was
resorbed faster than collagen fbrils subjected to strain (Bhole et al. 2009). Normal
physiologic loads on the tendon unit are necessary to maintain the ECM homeostasis
and structural integrity (Nabeshima et al. 1996; Flynn et al. 2010).
Stages of Tendon Healing
The biologic cascade that modulates tendon healing is divided in three distinct
stages, each governed by different cell types (Sharma and Maffulli 2006) (Fig. 4.1). The
inflammatory stage is initiated by the traumatic event surrounding tendon injury,
precipitating the hematoma and the agglomeration of platelets, releasing a slew of
chemotaxic molecules, cytokines, and growth factors. The phagocytic cells, monocytes,
neutrophils, and microphages, migrate to the site of injury via dilated vessels and begin
the process of breaking down the blood clot and extracellular matrix. The process of
angiogenesis is introduced by macrophages where a new network of vasculature matures
in the healing tissue (Gelberman et al. 1992). The ECM is notably stabilized by the
increasing amount of collagen type III, which are not yet aligned in parallel. The
inflammatory stage lasts between 3 to 7 days following tendon injury. The amount of
collagen will steadily increase during the first 5 days where the tendon callus will reach
its largest size (Oliva et al. 2011).
 The proliferative stage follows with an increasing amount of intrinsic fbroblast in
the ECM. These cells emerge from the endotenon and epitenon and play a primordial
role in resorbing and producing new collagen (Muller et al. 2015). At this stage, the
immature healing ECM is still stabilized by a soaring amount of type III collagen, and
this phase lasts for about 6 weeks. During the remodeling stage, the biomechanical
strength of the tendon is at its greatest. The collagen is reorganized in a longitudinal,
parallel fashion, while the collagen type III is replaced by collagen type I. The ECM will
continue to mature for the next year with a rising amount of longitudinal and cross-
linked collagen, while the callus volume of the tendon will decrease and the tendon
biomechanical strength will continue to improve (Hogan et al. 2011). The healed tendon
is biomechanically weaker than the uninjured tendon, with less cross-linking and smaller
diameter collagen, and is more susceptible to reinjury (Hyman and Rodeo 2000).
Dyment et al. corroborated these findings in a histologic and biomechanical study in the
mice model, where they demonstrated that the healed tendon regains 63% of its original
strength after an 8-week time period (Dyment et al. 2012).

DIFFERENTIAL DIAGNOSIS
 Mallet Finger refers to a drooping end-joint of a finger. This happens when
an extensor tendon has been cut or torn from the bone. It is common when a
ball or other object strikes the tip of the finger or thumb and forcibly bends
it.
  Boutonnière Deformity describes the bent-down (flexed) position of the
middle joint of the finger. Boutonniere can happen from a cut or tear of the
extensor tendon.
 Cuts on the back of the hand can injure the extensor tendons. This can
make it difficult to straighten your fingers
 Trigger finger (no passive movement possible)
 PIN syndrome: tenodesis effect present - not present with rupture ]

DIAGNOSTIC PROCEDURES
Radiographs are recommended because associated injuries of surrounding
structures are common. For example, it can be that a piece of bone is pulled off with
the tendon. The rupture of the tendon isn’t visible at a radiograph because it’s a soft
tissue.

OUTCOME MEASURES
 Disability of Arm, Shoulder, and Hand questionnaire (DASH)
 Quick DASH –This outcome measure is a shortened version of the DASH
and is used to determine the patient’s physical function and symptoms.
 Gartland and Werley Score – This is one of the most widely used outcome
measures used in the clinic to evaluate wrist and hand function.

EXAMINATION
Examination of extensor tendon injuries contains different points of interest.
First, the wound characteristics should be evaluated e.g.such as size and location to
give the physical therapist has an idea of which structures may have been damage d.
Next, the function of the fingers and wrist will be tested in three ways: passively,
actively and then with resistance. It is important that each finger is tested separately
because the juncturae tendinum between the communis tendons can mask a
dysfunction. Furthermore, complete neurovascular examinations should be done.

MEDICAL MANAGEMENT
Patients with an extensor tendon injury can be treated in two ways, surgically
or conservatively (namely splinting). The choice of treatment depends on the degree
of the injury. In general, open injuries and entire ruptures demand surgical
treatment. Closed injuries and partial lacerated tendons require splinting, static as
well as dynamic splinting is used. The mechanism of the dynamic splint is based on
the withdraw of elastic bands, in contrast with the static splint where there is no
load on the joints.

1. NONOPERATIVE
o Immobilization with early protected motion.
Indications: lacerations < 50% of tendon in all zones if patient can
extend digit against resistance
o DIP extension splinting
 Indications: acute (<12 weeks) Zone 1 injury (mallet finger),
nondisplaced bony mallet, chronic mallet finger (>12 weeks) if joint
supple, congruent
o PIP extension splinting
Indications: closed central slip injury (zone III)
o MCP extension splinting
Indications: closed zone V sagittal band rupture

2. OPERATIVE
o Immediate Incision & Drainage
Indications: fight bite to MCP joint
o Tendon repair
Indications: laceration > 50% of tendon width in all zones
o Fixation of bony avulsion
Indications : boney mallet finger with P3 volar subluxation
o Tendon reconstruction
Indications: chronic tendon injury or when repair not possible

SURGICAL TECHNIQUES
a) Tendon Repair
Incision technique: utilize laceration, when present, and extend
incision as needed to gain appropriate exposure, longitudinal incision may
be utilized across joints on the dorsum of digits, unlike the palmar side.
Suture technique: # of suture strands that cross the repair site is more
important than the number of grasping loops. In general strength increases
with increasing number of sutures crossing the repair site, thickness of the
suture, and locking of the stitchs. 4-6 strands provide adequate strength for
early active motion.
Circumferential epitendinous suture: Optional for reinforcement
Repair failure: tendon repairs are weakest between postoperative day
6 and 12. Repair usually fails at knots

b) Tendon Reconstruction
Usually done as two stage procedure, first a silicon tendon implant is
placed to create a favorable tendon bed. Wait 3-4 months and then place
biologic tendon graft. Only perform single stage reconstruction if flexor
sheath is pristine and digit has full ROM
Available grafts include:
o Palmaris longus (absent in 15% of population): most common
o Plantaris (absent in 19%): indicated if longer graft is needed
o Long toe extensor

c) Tenolysis
Indications: adhesion formation with loss of finger flexion. Wait for
soft tissue stabilization (> 3 months) and full passive motion of all joints.
Postoperative: follow with extensive therapy
3. REHABILITATION
a. Early active short-arc motion (SAM)
Indications: after zone III central slip repair
Advantages over static immobilization: increases total arc of motion,
decrease duration of therapy, increase DIP motion, creates 4mm of
tendon excursion and prevents adhesions.
b. Relative motion splint (yoke splint): positions the involved MCP
joint in hyperextension relative to adjacent digits.
Indications: after zone 4-7 extensor tendon repair
Advantages over static immobilization and dynamic splinting:
increased early active range of motion, decreases strain on tendon and
prevents adhesions, easy for patient compliance, earlier return to
work

COMPLICATIONS
 Adhesion formation : Leads to loss of finger flexion. Common in
zone IV and VII and older patients. Prevented with early protected ROM
and dynamic splinting (zone IV).
Treatment: Extensor tenolysis with early motion indicated after
failure of nonoperative management, usually 3-6 months. Tenolysis
contraindicated if done in conjunction with other procedures that require
joint immobilization

 Tendon rupture: causes include poor suture material or surgical

technique, aggressive therapy, and noncompliance.
Incidence: 5%, most frequently during first 7 to 10 days post-op.
Treatment: Early recognition may allow revision repair. Tendon
reconstruction for late rupture or rupture with excessive scarring.

 Swan neck deformity: caused by prolonged DIP flexion with dorsal

subluxation of lateral bands and PIP joint hyperextension.
Treatment: Fowler central slip tenotomy, spiral oblique ligament
reconstruction
 Boutonniere deformity (DIP hyperextension): caused by central slip
disruption and lateral band volar subluxation.
Treatment: Dynamic splinting or serial casting for maximal passive
motion, Terminal extensor tenotomy, PIP volar plate release.
 CHAPTER III
PATIENT’S STATUS
I. IDENTITY
a. Name : Mr. S
b. Age : 35 years old
c. Sex : Male
d. Religion : Islam
e. Job : Labour
f. Address : Tambakrejo
g. Room : Kenanga
h. Register number : 5879xx
i. Date of Admission : September, 23th 2019

II. HISTORY TAKING

Autoanamnesis and and alloanamnesis with the patient and the patient’s
family held on September, 23th 2019 in Kenanga room and supported by
medical records.

PRIMARY SURVEY :
 A (Airway) : Airway and cervical spine stabilisation (Clear)
 B (Breathing) : Adequate breathing (respiration rate:
20x/minutes)
 Circulation (C) : Adequate circulation (TD:110/70 mmHg, HR:
80x/minutes)
 Disability (D) : E4M6V5, GCS 15, pupil refleks +/+ isokor
 Exposure (E) : No other injury

Chief complaint : Pain on the right fingers.

Present status :
Patient came to the emergency room of RSUD Soewondo Kendal
accompanied by her family, complained pain on his right fingers since 30
 minute ago before admission, after being injured by the tobacco grinder
machine while he was working. The patient also complained that he was
unable to extended his right fingers, especially the 3rd and 4th fingers and he
had continuous bleeding.

Medical condition history:

- Previous trauma : denied
- Previous surgery : denied
- History of asthma and allergies : denied
- History of heart disease : denied
- History of hypertension : denied
- History of diabetes : denied

Family history:
- History of asthma and allergies : denied
- History of heart disease : denied
- History of hypertension : denied
- History of diabetes : denied

Socioeconomic status:
The cost of treatment is paid by health insurance.
III. Physical Examination
Held on September, 24th 2019 at 07.00 in Kenanga room of Dr. H. Soewondo
Kendal Hospital
 General Condition : Looks weak
 Vital Signs
1. Blood pressure : 110/70 mmHg
2. Heart rate : 80x / minutes, regular
3. Temperature : 36oC
4. Respiration Rate : 20 x / minutes

PHYSICAL ASSESSMENT
 General Appearance : clean in appearance, well groomed, and cooperative
 Skin : brown, skin turgor normal
 Head : mesocephal, injuries (-)
 Eyes : isokor pupil (d : 3mm/3mm), light reflex (+/+), palpebral conjungtival
pallor (-/-), sclera jaundice (-/-)
 Ears : Discharge (-/-), battle sign (-), raccoon eyes (-)
 Nose : septal deviation (-),blood discharge (-/-)
 Mouth : Normal, cyanosis (-)
 Neck : symmetrical, deviation of the trachea (-), enlarged lymph nodes (-),
enlarged thyroid gland (-)

COR
 Inspection : Ictus cordis (-)
 Palpation : Ictus cordis palpable at SIC V, 2 cm medial to the linea
midclavicularis sinistra, pulsus sternal lift (-), pulsus epigastric (-), pulsus
parasternal (-).
 Percussion : heart border
Bottom left: SIC V, 2 cm medial linea midclavicularis sinistra
Top left : SIC II linea sternalis sinistra
Top right : SIC II linea sternalis dextra
 Waist heart: SIC III linea parasternalis sinistra
Impression : normal heart size, cardiomegaly (-)
 Auscultation : heart sound I-II regular, gallop (-), murmur (-)

PULMO :
Anterior Posterior
Inspection: Inpection:
Static: normochest(+/+), Static: normochest(+/+),
simetris (+/+), retraction (-/-). simetris (+/+), retraction (-/-)
Dynamic: symmetrical
Palpation: Palpation:
Symmetric (+), nothing Symmetric (+), nothing
widening between the ribs, widening between the ribs,
retraction (-/-), sterm fremitus retraction (-/-), sterm fremitus
dx=sin dx=sin
Percussion: Sonor (+/+) Percussion: Sonor (+/+)
Auscultation: vesicular (+/+), Auscultation: vesicular (+/+),
ronchi (-/-), wheezing (-/-) ronchi (-/-), wheezing (-/-)

ABDOMEN
Inspection : normal, rounded, abdominal mass (-), cicatrix (-)
Palpation : rigidity (-), pain (-), hepar and lien are not papble
Percussion : tympany (+)
Auscultation : bowel sounds (+) Normal

EXTREMITIES :
Right Left
Motoric Upper 5 5
Lower 5 5
Sensoric Upper Normal Normal
Lower Normal Normal
 Hand region
Look Skin color Brown Brown
Oedema + -
Wound + -
Deformity + -
Feel Skin temperature Normal Normal
Tenderness + -
Crepitation + -
Pulsation + +
Extension of finger Limited +
Flexion of finger + +
Active
Abduction of finger + +
Adduction of finger + +
Movement
Extension of finger Limited +
Flexion of finger + +
Passive
Abduction of finger + +
Adduction of finger + +

LOCALIZED STATUS
Localized Status of the right hand region
 Look: Active movement:
Skin colour : normal Limitation (+) and pain (+) in
Edema : (+) extention of the right hand.
Angulation : (-) Passive Movement:
Pale and wrinkled : (-) Limitation (+) and pain (+) in
Wound : (+) extention of the right hand.
 Feel:
Skin temperature : normal
Pain : (+)
Crepitation : (+)
Artery pulsation : (+)
 Movement:
 IV. ADDITIONAL EXAMINATION RESULTS
1. LABORATORY EXAMINATION (September, 23rd 2019)
HEMATOLOGY
ROUTINE BLOOD TEST 13,5 gr/dl 11,5-16,5
• Hemoglobin 6,7 x 10^3/uL 4-10
• Leucocytes 219 x 10^3/uL 150-500
• Thrombocytes 43,2% 35-49
• Hematocrit
PROTHROMBIN TIME (PT) 12,9 sec 11,3-14,7
APTT 27,7 sec 27,4-39,3
KIMIA KLINIK
Random Blood Glucose 107 mg/dL 75-115
Ureum 50 mg/dL 10-50
Creatinine 0,73 mg/dL 0,5-1,1
SEROLOGY
HBsAg Negative Negative

2. RADIOLOGY
Before operation (September, 23th 2019)

V. DIAGNOSIS
Extensor digitorum tendon rupture of manus dextra
Digiti 3, 4 manus dextra fracture
VI. INITIAL PLAN
a. Initial Planning : Therapeutic Medical treatment
 Infus RL 20 tpm
 Ketorolac inj. 2x30 mg
 Cefotaxime inj. 2x1 gr
b. Initial Planning : Operative
Tendon repair
c. Initial Planning : Monitoring
General status & vital sign, additional examination (laboratory examination, x ray),
Range of Movement.
d. Initial Planning : Education
Educate patient to do some simple exercise after the treatment was received.

VII. PROGNOSIS
 Quo ad vitam : ad bonam
 Quo ad sanam : ad bonam
 Quo ad fungsionam : ad bonam

VIII. CONCLUSION
 CHAPTER IV
CONCLUSION

Extensor tendon injuries are one of the common injuries in the hand. Careful attention
to the anatomical details of the zone of injury and complicated mechanical balance of the
extensor system will determine whether surgical or nonsurgical treatment is indicated. As
each component of extensor tendon over the fingers tolerate little loss of tendon substances,
in repairing the extensor tendon, care should be taken to ensure minimal shortening of the
tendon substance to maintain intricate mechanical balance of the extensor apparatus.
Though strength of repair is not as important as for flexor tendons, a mechanically
reliable repair method should be considered. Extensor tendons injured at the distal parts of
the fingers, such as over the DIP or PIP joint areas may develop joint deformities easily,
leading to chronic mallet fnger or boutonniere deformities. Correct splinting or surgical
intervention at acute stage is important to prevent development of these deformities. In many
surgical cases, postoperative early motion protocols help restore digital range of motion and
return patients to occupational and daily activities more rapidly. Adhesions may develop,
especially over the fingers or at the extensor retinaculum, which may require secondary
tenolysis.
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