Damage to tendon

1. Damage to the tendon
apparatus of the hand . Tendon
suture
Name: Balaganapathy
Group: LD1(ino)c-18

2. What are tendons?
Tendons are white, fibrous bands that connect a muscle to a bone and allow
joints to move.
The human body features thousands of tendons.
Where are the tendons that move your hand?
There are two sets of tendons that attach to various parts of your hand:
• The flexor tendons are on the palm side of your hand. Flexor tendons
bend the fingers and thumb, allowing you to make a fist and pick up
objects.
• The extensor tendons are on the back of your hand. Extensor tendons
straighten the fingers and thumb, allowing the hand to release objects or
loosen a grip.
Many of the muscles connected to these tendons start all the way from the
elbow!
In total, there are nine flexor tendons and 12 extensor tendons that go into
your hand.

3. How do common hand tendon
injury occur ?
You can injure a tendon a number of different ways, including:
• Handling sharp objects, like knives, box cutters, and sheet
metal
• Using industrial equipment, like table saws, snow blowers,
and lawn mowers
• Falling while holding fragile objects, like glass bottles and
ceramic bowls
• Jamming or forceful pulling, including jamming your finger
playing basketball or getting your finger stuck in a rope
• Sustaining direct trauma, like throwing a punch or falling
into a door

4. Symptoms of hand tendon
injury
Hand tendon injuries can present several different ways, depending on the type and severity of the
injury.
Common symptoms of a hand tendon injury include:
• Inability to fully bend or straighten a finger or thumb
• Pain with movement
• Swelling
• Drooping of the finger

5. Common diagnosis of tendon injury
• Mallet finger, where the tip of the finger droops and can’t
be straightened due to a stretched or torn tendon.
• Jersey finger, which is an injury to a flexor tendon
commonly seen in football, rugby, and other contact
sports.
• Boutonniere deformity, which results in a bent fingertip
and the inability to straighten the middle joint of the finger.
• Flexor or extensor tendon lacerations, which are caused
by sharp objects cutting through the skin and into the
tendon.

6. When hand tendon repair is needed
Hand tendon repair is needed when 1 or more tendons in your hand rupture (break or split) or are cut, leading to the
loss of normal hand movements.
If your extensor tendons are damaged, you'll be unable to straighten 1 or more fingers. If your flexor tendons are
damaged, you'll be unable to bend 1 or more fingers.
Tendon damage can also cause pain and swelling (inflammation) in your hand.
Sometimes, damage to the extensor tendons can be treated without the need for surgery, using a rigid support
called a splint that's worn around the hand.
Common causes of tendon injuries include:
• cuts – cuts across the back or palm of your hand can result in injury to your tendons
• sports injuries – extensor and flexor tendons can be injured when playing sports like rugby, and the pulleys
holding flexor tendons can rupture if you do a lot of strenuous gripping like in rock climbing
• animal and human bites – these type of bites can cause tendon damage, and a person may damage their
hand tendon after punching another person in the teeth
• crushing injuries – jamming a finger in a door or crushing a hand in a car accident can divide or rupture a
tendon
• rheumatoid arthritis – rheumatoid arthritis can cause tendons to become inflamed which, if severe, can lead to
them rupturing

7. How tendon injuries treated
Sometimes, torn tendons can heal after a period of immobilization.
This may be achieved via a cast or a custom-made splint to keep the joint in place. The custom splint
is made by an occupational or physical therapist.
Tendons that are completely cut typically require surgery.
A hand surgeon will determine the best course of treatment
Tendon repair may involve a surgeon making a cut (incision) in your wrist, hand or finger so they can
locate the ends of the divided tendon and stitch them together.
Extensor tendons are easier to reach, so repairing them is relatively straightforward

8. Before the cut tendons in your
hand are repaired, X-rays of
your hand and forearm may be
taken.
This is to check for fragments of
glass that may have cut the tendon
and any other damage, such as a
fracture, that may also need to be
repaired.
Tendon repair isn't usually
regarded as emergency surgery,
but is generally carried out as
quickly as possible after the injury
– usually within a few days.
This is because the longer the
tendons remain ruptured, the more
scarring will develop on the end of
the tendons. This could reduce the
range of your hand movement
after surgery.
Depending on the nature of your
injury, you may be given antibiotics
and a tetanus jab before surgery to
prevent your hand becoming
infected.

9. Extensor tendon repair
Extensor tendon repair is usually carried out either under a regional or a general anaesthetic.
For a regional anaesthetic, an injection is used to make part of your body totally numb.
For hand surgery, regional anaesthetic is injected into the base of the neck or the top of the shoulder to numb the whole arm.
If your tendon was damaged as the result of a wound, the wound will be thoroughly cleaned.
A cut (incision) may be made in your hand to make the wound larger and the 2 ends of the ruptured tendon will be stitched
together.
The wound will be closed with stitches and a rigid splint (a support to protect your hand) made of plaster will usually be fitted to
stop you moving your hand and damaging the repaired tendons.
If nothing else has been damaged, extensor tendon repair surgery can take around 30 minutes to complete.

10. Flexor tendon repair
Flexor tendon repair is also usually carried out under either a regional or general anaesthetic.
A tourniquet will be wrapped around your upper arm to stop the blood circulating so that bleeding at the
wound doesn't make it difficult to see the relevant structures.
A tourniquet is a cord or tight bandage that's used to squeeze the arm and temporarily cut off the blood
supply.
The surgeon will then extend the wound, or make an incision if there's no wound, to locate the damaged
tendons.
They'll bring the 2 ends of the damaged tendon together before stitching them to each other.
The wound in the hand will be closed with stitches and a rigid plaster splint will usually be applied to
protect the repaired tendons.
A simple flexor tendon repair takes 45 to 60 minutes, but complex surgery for more severe injuries could
take much longer.

12. Tendon transfer
• It sometimes isn't possible to reattach the
2 ends of the ruptured tendon. This may
be because the ends of the tendon are
too frayed.
• In these circumstances, surgery may be
carried out to detach a tendon from 1 of
your healthy fingers (each finger has 2
flexor tendons connected to it) and
reattach it to the damaged finger or
thumb. This is known as a tendon
transfer.

13. After the Operation
• If you had a general anaesthetic, you'll wake up in the recovery room after your operation. You may have
an oxygen mask on your face and feel a bit drowsy.
• If you had a regional or local anaesthetic, you'll be able to go back to the ward sooner, but your arm will
be numb and floppy for several hours.
• It's normal for your hand to be elevated in a sling (a large, supportive bandage) to help reduce swelling.
• Following the operation, your hand is likely to be bruised and swollen and, when the anaesthetic wears
off, it'll be painful.
• You may need to take painkillers, such as ibuprofen, paracetamol or codeine, for up to 2 weeks.
• Before leaving hospital, you'll be advised to keep your hand above the level of your heart whenever
possible to help reduce swelling.
• For example, you may be advised to raise your arm on cushions while seated or to hold your arm up to
your other shoulder while standing and walking.
• You won't be able to drive for several weeks after the operation, so you'll need to arrange for someone to
pick you up and take you home from the hospital.
• If you live on your own and had a general anaesthetic, you may be advised to stay in hospital overnight.
• You may also need to stay overnight if you need hand therapy in hospital before you go home.

14. After hand Tendon surgery
Your surgeon may prescribe occupational or physical therapy for
rehabilitation of the repaired tendon.
The therapist will be someone who specializes in the treatment of the
hand, wrist, and elbow.
You will be fitted with a custom splint to protect the repair for
approximately 6 weeks.
During that period, only controlled range of motion is allowed and
exercises are progressed each week based on the surgical protocol; this
means normal use of the hand is greatly restricted.
Each injury is unique, and therefore each rehabilitation process will be
different.
Your therapist will guide you through the appropriate precautions

15. Returning to Work and Activities
The repaired tendon will usually be back to full strength after about 12 weeks, but it can take up to 6
months to regain the full range of movement.
Some people may never be able to move the affected finger or thumb as much as before it was damaged.
In general, most people are able to:
• resume light activities, such as using a keyboard or writing with a pen, after 6 to 8 weeks
• drive a car, motorcycle or heavy goods vehicle (HGV) after 8 to 10 weeks
• resume medium activities, such as light lifting or shelf stacking, after 8 to 10 weeks
• resume heavy activities, such as heavy lifting or building work, after 10 to 12 weeks
• resume sporting activities after 10 to 12 weeks
Your hand therapist or surgeon will be able to give you a more detailed estimate of your likely recovery
time.
It's vital that you follow all the instructions and advice given to you regarding the use of your hands during
your recovery period.
If you attempt to use the repaired tendons before they have fully healed, it could cause the repair to rupture
(break or split).

16. Possible complications
As with any surgery, there’s the potential for complications after hand tendon
surgery, including:
• Damage to the repair if precautions are not properly followed
• Infection
• Limited motion due to scar tissue adhesion

17. Prevention
Many people who sustain hand tendon injuries would consider them to be a complete accident – but while
there are some truly unpreventable injuries, in many cases, hand injuries occur due to carelessness or
unsafe practices.
Always take the proper precautions when handling sharp objects and heavy machinery.
In addition, keep the following tips in mind:
• Take extra care when using saws and other cutting machinery – check once, twice, three times that
your hands are clear of the blade and as protected as possible.
• Do not stab that avocado pit with a knife – use a spoon!
• Do not stick your hand in the snow blower or lawn mower, even if the power is off.
• Do not carry six beer bottles and walk any kind of distance – tripping could have serious
consequences.
• Do not use a butter knife to separate frozen pork chops. Believe it or not, butter knives are sharper
than you think.
• Punching a glass door is a bad idea – please find different ways to channel that anger!

18. Tendon suture
• The choice of tendon suture techniques can be determined according to the severity of tendon injury
and the technique and conditions of the surgeon. In recent years, microsurgical stitchings have been
used, aiming to minimize the impact on blood supply of the tendon to promote tendon healing and
reduce adhesion.
• There are many techniques on tendon repairing, such as Bunnell stitching, Kessler stitching , etc…

19. Bunnell Stitching
• 1.
First clamp the tendon rupture end using hemostatic forceps, and pull it tight. At 1.5 cm from the
rupture end, use the straight needle to cross the 3-0 polypropylene (PROLENE) bidirectional
suture across the tendon (Fig. 7.30a).
• 2.
Approximately 1 mm above the entry point, pass the two straight needles obliquely at 6 mm site
(Fig. 7.30b).
• 3.
Cut off the tendon rupture end with a blade approximately 5 mm to the exit point (Fig. 7.30c).
• 4.
Insert the straight needle obliquely approximately 1 mm above the exit point, and pass through
the tendon rupture end (Fig. 7.30d).
• 5.
Tighten the suture passing through the tendon rupture end (Fig. 7.30e).
• 6.
After trimming the other rupture end with a blade, pass the two straight needles obliquely from
the rupture end to both sides 5 mm away from the rupture end (Fig. 7.30f).
• 7.
Cross the two straight needles obliquely at 1 mm at the exit point and pass them out at 6 mm,
and then pass the straight needles transversely 1 mm above the exit point (Fig. 7.30g).
• 8.
Tighten the knot (Fig. 7.30h).

21. Tsuge Loop Stitching
Comments:
• 1.
Using a special looped suture with needle is easy to operate and
can suture in a small incision (Fig. 7.32);
• 2.
There is less damage and the blood supply in the tendon is
impacted less, and the tendon heals quickly;
• 3.
Good and reliable matching of both rupture ends, with less and
limited postoperative adhesion;
• 4.
It can be used to repair flexor and extensor tendons in various
zones.

22. Modified Kessler Stitching
• 1.
Fix both tendon ends with needles. Use a 3-0
polypropylene bidirectional suture (PROLENE),
and firstly cross one end of the tendon at 8–10 mm
to the end, then insert the double straight needle
into the tendon slightly obliquely at 2–3 mm above
the exit point, and pass through the tendon cross
section after being parallel to the tendon.
• 2.
Perform the procedure above on the other end of
the tendon.
• 3.
Bring the two rupture ends of the tendon together,
tighten the suture and knot.
• 4.
After core suturing of the tendon, make external
continuous peripheral suturing around the
anastomotic site at the rupture end with 5-0 or 6-0
monofilament (Fig. 7.31a–e)

23. Stitching and Double Cross Stitching
Comments:
• 1.
Easy to operate (Fig. 7.33), and time
saving, but with poor tensile strength;
• 2.
Applicable only in emergency suturing.
Extensor Tendon Repair Technique
After core suturing of the tendon, make
continuous peripheral suturing around the
anastomotic site at the ruptured end
Fish Mouth Stitching
Comments:
• 1.
It can be used for repairing the ruptured
flexor tendons in forearm or palm;
• 2.
It can be used in repairing with tendon
transfer;
• 3.
It is more applicable in suturing two
ruptured ends in different sizes

24. Weaving Stitching
Repair of Extensor Tendon Insertion Rupture
Repair of Middle Phalanx Level Extensor Tendon Rupture
Repair of Proximal Interphalangeal Joint Level Extensor
Tendon Rupture

25. Repair of Metacarpophalangeal Level Extensor Tendon Rupture
Repair of Flexor Tendon Insertion (Zone I Dp1) Rupture
Repair of Middle Phalanx Level Flexor
Tendon Insertion (Zone II Dp2) Rupture
Repair of Proximal Phalanx Level Flexor
Tendon Insertion (Zone II Dp2) Rupture

26. Repair of Wrist Level Flexor Tendon Insertion (Zone IV
Dp4) Rupture
Repair of Palm Level Flexor Tendon Insertion (Zone III
Dp3) Rupture