Acute tendon injury of the hand and its repair

1. Acute Tendon injury of the
Hand and its Repair
Dr Okpako Isaac Oghenero
Senior Registrar Plastic and Reconstructive Surgery
UATH
29/02/2024

2. Outline
• Introduction
• Epidemiology
• Classification of tendon injuries
• Functional Anatomy
• Function of the hand
• Zones of the hands
• Classification of tendon injuries
• Tendon healing
• Clinical presentation
• Diagnosis
• Investigation
• Principles of surgery
• Principles of tendon repair
• Flexor tendon repair
• Extensor tendon repair
• Rehabilitation
• Assessment of repair
• Factors affecting tendon repair
• Conclusion

3. Introduction
• The hand is the part of the upper limb distal to the wrist
• The hand is essential for carrying out daily task
• And even more important for our largely service based society
• The role of the hand can not be underestimated in sports and many
professions
• Acute tendon injuries are those occurring within 2 weeks of injury

4. Epidemiology
• In the US the incidence of tendon injuries according to Johanna P. J. is
33.2 injuries per 100,000 person-years in a 10 year retrospective
study done from 2001- 2010

5. Classification of tendon injuries
• Acute tendon injuries
• Less than 2 weeks
• Subacute
• between three to six weeks
• chronic
• more than six weeks

6. Functional anatomy
• All tendons of the hands arise either from the distal arm or from the
forearm and they arise commonly as common tendon sheath which
shortly becomes muscle and along its course to the hand changes to
tendons
• Or it may arise as muscle from its origin and changes to tendon along
its course to the hand

7. Functional anatomy
• Flexors
• The flexors are grouped into those to the medial 4 fingers and that to the
thumb
• The flexor digitorum profundus and flexor digitorium superficialis are
tendons to the medial 4 fingers and both run together in the carpal tunnel
and pulleys and insert as the campers chiasm for each fingers
• The flexor pollicis longus run on the radial side of the carpal tunnel
through 2 pulleys to insert at the base of the distal phalanx of the thumb

8. Functional anatomy
• Extensors
• There are 4 tendons viz
• extensor digitorium to the medial 4 finger connected to each other by
intertendineous connections on the dorsum of the hand and runs in the 4th
extensor compartment with extensor indices
• Extensor indices to the index finger
• Extensor digiti minimi to the little finger runs in the 5th extensor compartment
• The extensor pollicis longus run through the 3rd extensor compartment and the
extensor pollicis brevis runs in the 1st compartment to reach the thumb
• At the level of the proximal interphalangeal joint these tendons separate to two
lateral and a central band forming the extensor hood which inserts to the distal
phalanx

9. Functions of the hand
• The hand is essential for
• grip (power and pinch grip)
• Pull and push movement
• Essential in non verbal
communication
• Can assist in making some diagnosis
of some health condition

10. Zones of the hand
Flexor tendon zones Extensor tendon zones

11. Classification of acute tendon injuries
• Open or closed – based on exposure of the tendons to the external
environment e.g of closed mallet fingers
• Nature of the Injured part – Sharp or blunt
• Part involved – hand, distal forearm, musculotendineous junction
• Surface involved – dorsal or palmer
• Complexity – simple, complex, complicated
• Avulsion – partial and complete

12. Tendon healing
• Following an injury, the healing commences from the peritendeum and the
peritendinous tissue;
• There are two types of healing intrinsic and extrinsic healing
• In intrinsic healing; healing commences from the paratenon and it is characterized by
the migration of fibroblast-like tenocytes”, which produce the collagenous tissue
necessary to heal (First phase) type III
• There is also the formation of new blood vessels by invasion of surrounding blood
vessel (second phase) and finally remodelling (third phase)
• These processes is facilitated by gliding of the tendons
• Extrinsic healing involves invasion of the injured tendon by surrounding sheath or
synovium

13. Clinical presentation
• Flexor tendon injuries
• History
• trauma
• Cut
• Inability to hold on to objects
• Loss of joint motion especially when finger closed injuries are involved
• Examination
• Loss of normal flexor cascade
• Loss of flexion function to the affected tendon
• Carefully palpating the flexor tendon sheath may elicit tenderness proximally
at the site of tendon retraction.

14. Clinical presentation
• Extensor tendon injuries
• History
• trauma
• Cut
• Inability to hold on to objects
• Loss of joint motion especially when finger closed injuries are involved
• Examination
• Loss of normal flexor cascade
• Loss of active digital extension function to the affected tendon
• Carefully palpating the flexor tendon sheath may elicit tenderness proximally
at the site of tendon retraction.

15. Diagnosis
• Diagnosis of tendon injuries are largely clinical however some
investigation can help in questionable cases
• MRI
• CT scan
• Ultra sound scan

16. Investigation
• To confirm diagnosis
• Largely clinical
• Imaging (MRI, CT USS)
• Extent of injury
• X-rays
• To prepare patient for surgery
• FBC
• Eucr

17. Principles of surgery
• Repair should be done under magnification
• Surgery should be performed under regional or general anaesthesia with the use
of a tourniquet.
• Surgery should be performed in the operating room using perioperative
antibiotic prophylaxis. As flexor tendon injuries are often combined with injuries
to other structures
• Appropriate use of instrument
• Meticulous dissection and gentle handling of tendons

18. Principles of tendon repair
• Handle tendon ends as little as possible
• Reattachment of cut ends together
• Repair should be strong enough to allow early mobilization
• sufficient suture purchase of 7–10 mm
• Repairs should be done with core and/or peripheral sutures, many surgeons
prefer to combine both as this increase the chances of repair success.
• Proper apposition of cut edges
• Non bunched up repair
• Early rehabilitation

19. Types of acute tendon repair
• Primary repair
• Within 24 hrs
• Delayed primary repair
• Within 2 weeks
• Secondary repair
• After two weeks

20. •Flexor tendon repair

21. •Flexor tendon repair
•Types of repair
•Core and
•peripheral

22. Types of repairs
•Core repair
• ∘ 2-strand repair
• – Kessler, with two knots on the outside of the tendon.
• – Modified Kessler, with a single knot within the repair site.
• ∘ 4-strand repair
• – Cruciate
• – Adelaide (modified Savage)
• ∘ 6-strand repair
• – Savage.

23. Types of repair
• Peripheral/epitedineous repair
• Aim
• Align tendon ends prior to core suture (back wall first).
• Tidy up tendon ends following core suture.
• Contribute significant strength to the repair.
• • Examples of peripheral sutures include:
• Strickland simple continuous suture
• Silfverskiöld cross-stitch
• Halsted continuous horizontal mattress

24. • ∘ Strength of repair is dependent on:
• – Gauge of suture – 3/0 is stronger than 4/0.
• – Number of strands crossing the repair – four are stronger than two.
• – Configuration of the peripheral suture.
• – Tendon-suture interaction – grasping sutures pull through easily; locking
sutures ‘lock’ a bundle of tendon fibres, minimising suture pull-out.

25. •Extensor tendon repair

26. Extensor tendon repair
• Extensor tendon morphology changes as one progresses towards the distal
phalanx with the proximal aspect more round and distal aspect more flat
• Forearm and wrist: tendons are thick; capable of holding core sutures.
• Finger: tendons become broad and thin; do not take core sutures well. • Suggested
techniques of repair:
• Zone 1: running suture that may incorporate the skin (dermotenodesis).
• Zone 2: running suture reinforced with Silfverskiöld cross-stitch.
• Zones 3–5: modified Kessler core reinforced with Silfverskiöld.
• Zones 6–8: As for zones 3–5; the cross-stitch can be circumferential

27. Rehabilitation
• Immobilization and mobilization
• Immobilization
• this is recommended for children or for adults not suitable for mobilization
• Mobilization
• Early passive mobilization
• No active movement is allowed

28. Flexor rehabilitation
• Early active extension with passive flexion
• This involves use of kleinert traction or thermoplastic splint that permits active extension
and passive flexion
• Early active mobilisation
• Strength of repair is increased by early active flexion.
• The ‘Belfast’ regime is widely used in the United Kingdom in modified forms.
• Active mobilisation is started 48 hours after the operation.
• Exercises are repeated two-hourly throughout the day:
• Two passive movements, then two active movements of the finger(s).
• The aim is full passive flexion in the splint within the first week.
• Range of active motion is gradually increased

29. Rehabilitation protocol for extensor tendon injury
• Zone 1: mallet injury. Splint with slight hyperextension of the DIPJ for 6–8 weeks.
• Zone 2: similar to zone 1.
• Zone 3: static PIPJ immobilisation in extension for 6 weeks. DIPJ is free to flex to ensure
lateral bands do not shorten, leading to boutonnière.
• Zone 4: distal injuries follow zone 3; proximal injuries follow zone 5.
• Zones 5–7: the ‘Norwich’ regime is widely used in the United Kingdom.
• Volar splint – wrist 45∘ extension, MCPJs flexed >50∘, IPJs extended.
• Controlled active mobilization begins on day 1.
• Exercises are repeated four times each, four times a day, for the first 4 weeks:
• 1 Combined IPJ and MCPJ extension.
• 2 MCPJ extension with IPJ flexion (hook grip).
• After 4 weeks, the splint is worn at night only; MCPJ flexion is commenced.
• Full power grip should be possible by week 6

30. Assessment of repair
• Functional assessment
• Qualitative assessment
• Functional assessment
• Grip and pinch strength,
• Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire,
• Michigan hand questionnaire.
• Shortcomings; may not be sensitive enough for isolated tendon injuries.

31. Assessment of repair – qualitative
measurement
• • The total active motion (TAM) evaluation system as proposed by the
ASSH:
• TAM =total active flexion−total extension deficit (for MCPJ, PIPJ and
DIPJ)
• This flatters suboptimal zone II repairs because the MCPJ is unaffected.
• • Strickland’s system addresses this shortcoming by assessing IPJs
only:
• (Active flexion of PIPJ and DIPJ − Extension deficit of PIPJ and DIPJ 175)/ ×
100% •

32. Factors affecting repair
• Local and systemic
• Local factors
• Duration of the injury
• Type of injury e.g partial laceration/ complete laceration
• Concomitant other injuries
• Multiple tendon injuries
• Systemic factors
• Nutrition
• Steroid abuse
• uncontrolled diabetes mellitus

33. Conclusion
• Acute Tendon injury should be repaired as quick as possible and
rehabilitation is as vital in returning the hand to function

34. •Thank you

35. References
• Charles H T: Grabbs and Smith’s Plastic
surgery 7th edition 2014, Lippincott
Williams & Wilkins,
• Jeffery E J: essentials of plastic surgery 2nd
edition y Taylor & Francis Group, LLC
• Adrain R, Hywel D. key notes of plastic
surgery 2nd edition 2015, John Wiley &
Sons, Ltd
• de Jong JP, Nguyen JT, Sonnema AJ, Nguyen
EC, Amadio PC, Moran SL. The incidence of
acute traumatic tendon injuries in the hand
and wrist: a 10-year population-based
study. Clin Orthop Surg. 2014 Jun;6(2):196-
202. doi: 10.4055/cios.2014.6.2.196. Epub
2014 May 16. PMID: 24900902; PMCID:
PMC4040381.
• Jin B T, Donald L, Leila H , Ahmed F S, Koji
M and Zhang J P:Flexor tendon repair:
recent changes and current methods,
Journal of Hand Surgery (European
Volume) 2022, Vol. 47(1) 31–39,
2021Bailey and Love’s short practice of
surgery, 26th Edition,
• Crowe CS, Massenburg BB, Morrison SD,
et al. Inj Prev 2020;26:i115–i124
• Schwartz principles of surgery, 10th
edition, Ed F. Charles Brunicardi.
• Badoe and Jaja- Principle and practice of
surgery including pathology in the tropics,
4th edition.