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SUTURA DE TENDÓN
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SUTURA DE TENDÓN

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Sutura de tendón.

Son numerosas las ocasiones en que el médico de familia se encuentra con incisiones menores a las que debe dar respuesta, realizando los diferentes tipos de sutura, adecuadas según la zona afectada. Las incisiones en la mano y los dedos son frecuentes en las tareas domésticas y en el ambiente laboral. Es en estas incisiones donde el médico de familia debe tener especial cuidado en la exploración del miembro, por el gran riesgo de afectación de componente neurovascular y motor.

Nos centraremos en la sutura de los tendones afectados en estas incisiones y en su manejo, sin olvidar la gran importancia que tiene en estos casos una exploración exhaustiva de la sensibilidad y la motricidad distal a la incisión, siempre antes de aplicar el anestésico.

En ocasiones puede ser dificultoso observar la anatomía de la zona, en el caso de estar ante una sección parcial con fuerza conservada, pero nunca debemos menospreciar la exploración y tenemos que hacerlo constar siempre en la historia clínica. Cabe recordar que la afectación tendinosa suele ser más frecuente en las incisiones palmares y, por tanto, en los tendones flexores. Esta técnica requiere seguridad y un entrenamiento previos, con supervisión de un especialista a ser posible. Ante cualquier duda, debe derivarse al paciente a los servicios hospitalarios.

¿Qué material es preciso?

– Guantes estériles.

– Gasas y tallas estériles (fenestrada si es posible).

– Equipo de sutura (en este caso pinzas, con y sin dientes),

mango, hoja de bisturí y tijeras.

– Seda del número apropiado al grosor de la zona incisa

para sutura externa y reabsorbible para tejido interno.

– Aguja intramuscular (21 G 0,8  40 mm), subcutánea

(25 G 0,5  16 mm) y jeringas.

– Farmacoterapia anestésica (mepivacaína al 1 o 2%, mejor

con adrenalina).

– Lámpara y taburete regulado (es importante la comodidad

y la buena visualización).

Procedimiento

En primer lugar, deberemos limpiar y desinfectar correctamentela herida con suero fisiológico y povidona yodada (solución jabonosa para la parte interna de la herida y solución a 1 g/10 ml para los bordes de la herida). Es frecuente que el enfermo acuse dolor durante este proceso, por lo que se puede aplicar anestesia local, pero siempre habiendo realizado previamente una exhaustiva exploración de sensibilidad y motricidad de la zona distal a la incisión. La anestesia locorregional y troncular es muy útil en estas situaciones y nos permitirá realizar en segunda instancia, una vez montado el campo estéril, una exploración más minuciosa del interior de la herida, con la finalidad de retirar cuerpos extraños y revisar las estructuras anatómicas. Puede ser útil realizar una isquemia voluntaria con manguito de presión en casos concretos, con la finalidad de disminuir el sangrado y observar con más detalle el campo quirúrgico. En el caso que nos ocupa observaremos la sección tendinosa (fig. 1), que debe corresponderse con el territorio afectado en la exploración física. Como se observa en las figuras 2 y 3, realizaremos una o 2 incisiones que abrirán el campo operatorio (desbridaremos un poco si es necesario), que nos permitirán explorar y trabajar con mayor comodidad. En este momento debemos tener cuidado de no provocar iatrogenia en una zona en la que puedan pasar otras estructuras y actuar de la forma más conservadora posible. Aunque es opcional, resulta muy útil poner unos puntos a la piel desbridada que posteriormente se retirarán.

Para el manejo del tendón aconsejamos usar las pinzas sin dientes, ya que causan menor lesión de las estructuras internas. Una vez realizados estos procedimientos, podemos empezar con la sutura propia del tendón (con seda reabsorbible); para ello realizamos, en primer lugar, un punto central de aproximación, que nos permitirá retirar su anclaje. En este momento se procede a realizar una sutura en forma de cuadrado3-5, que unirá los bordes laterales del tendón, una a cada lado del punto de aproximación, y reforzará los bordes proximal y distal de éste.

Una vez suturado el tendón, comprobaremos la calidad de lasutura con portaagujas o pinzas y retiraremos los puntos de anclaje. El resultado final es la sutura del tejido desbridado y de la incisión de la piel . Puntos de sutura provisionales en piel desbridada.

 

Errores más frecuentes

1. No realizar una exploración suficientemente exhaustiva del miembro afectado.

2. Observar la integridad del tendón afectado con buena movilidad de la extremidad, descartando la lesión con una afectación parcial del tendón.

3. Realizar la técnica de sutura del tendón sin el material adecuado o la práctica y la seguridad que requiere.

 

Duran Rabés J et al. Sutura de un tendón seccionado FMC. 2008;15(4):250-2 251

 

 

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