This document discusses flexor tendon injuries and repairs in the hand. It covers tendon anatomy, zones of injury, types of repairs, and postoperative rehabilitation protocols. Flexor tendon injuries most commonly occur in males aged 15-30 years old. There are two main postoperative protocols - passive flexion protocol with splinting for 6-9 weeks or early active tension protocol with splinting for 4 weeks and early active exercises. Precise surgical technique and strict adherence to rehabilitation are needed for successful results.

2. INVOLVE
 LACERATIONS ,RUPTURES
 MALES COMMONLY
 B/W 15 -30 YEARS
ZONES OF INJURY INFLUENCE THE TYPE OF
REPAIR AND POST OPERATIVE REGIMEN

3.  CARPAL TUNNEL :
 HERE MIDDLE AND RING FINGER TENDONS LIE
SUPERFICIAL TO SMALL AND INDEX FINGER
TENDONS
 34 GREATER THAN 25

4.  EACH FINGER HAS FDP AND FDS TENDON
 SHEATH BEGINS AT THE LEVEL OF
METACARPAL NECK
 DIGITAL ARTERY BRANCHES OR VINCULA
ASSIST TENDON NUTRITION

5. ONCE INSIDE DIGITAL SHEATH,THE FDS FORMS CAMPERS
CHIASM BY SPLITTING INTO TWO SLIPS THAT ATTACH ON
THE PALMAR SIDE OF MIDDLE PHALANX.
FDS PASSES THRU THIS TO ATTACH ON THE VOLAR ASPECT
OF DISTAL PHALANX
CAMPERS CHIASM

6.  A2 AND A4 ARE MOST IMP
TO PREVENT BOW
STRINGING OF THE
TENDONS
 WITHOUT PULLEYS
TENDONS CAN NO LONGER
GLIDE JUXTAPOSED TO
PHALANGES AND GREATER
AMOUNT OF FORCE WILL BE
NEEDED TO OBTAIN THE
SAME AMOUNT OF FLEXION

7.  ONLY FPL
 CONTAINS 2
ANNULAR
PULLIES AND ONE
OBLIQUE PULLIES

8. TENDON ZONES

9.  REGION B/W MIDDLE ASPECTS OF MIDDLE
PHALANX TO FINGER TIPS
 CONTAINS ONLY ONE TENDON-FDP
 TENDON LACERATION OCCURS CLOSE TO ITS
INSERTION
 TENDON TO BONE REPAIR IS REQUIRED THAN
TENDON REPAIR

10.  TYPE 1:RETRACT INTO THE PALM
 TYPEII:RETRACT TO THE LEVEL OF PIP JOINT
 TYPE III:TO LEVEL OF DIP JOINT

11.  FROM METACARPAL HEAD TO MIDDLE
PHALANX
 CALLED SO COZ INITIAL ATTEMPTS FOR
TENDON REPAIR HERE PRODUCED POOR
RESULTS
 FDS N FDP WITHIN ONE SHEATH
 ADHESION FORMATION RISK IS AMPLIFIED AT
CAMPERS CHIASM

12.  B/W TRANSVERSE CARPAL LIGAMENT AND
PROXIMAL MARGIN OF TENDON SHEATH
FORMATION
 LUMBRICALS ORIGIN HERE PREVENTS
PROFUNDUS TENDONS FROM OVER ACTING
 DELAYED TENDON REPAIRS ARE SUCCESFULL
EVEN AFTER SEVERAL WEEKS OF INJURY

13.  LIES DEEP TO DEEP TRANSVERSE LIGAMENT
 TENDON INJURIES ARE RARE

14.  LIES PROXIMAL TO TRANSVERSE CARPAL
LIGAMENT

15. INSPECTION
 THERE IS A NORMAL ARCADE TO HAND WITH
INDEX FINGER SHOWING LEAST AND LITTLE
FINGER SHOWING MAX FLEXION
 IF AFFECTED FINGER SHOWS MORE
EXTENSION THAN OTHER DIGITS,CHANCE OF
TENDON INJURIES ARE HIGH,

16. FDP
 Hold the
metacarpophalangeal
and proximal
interphalangeal joints of
the finger being tested
,in extension.
 Ask the patient to flex
the finger at the distal
interphalangeal joint.
 If the patient cannot
flex the finger, the
flexor digitorum
profundus tendon is cut
or non-functional.

17.  Hold the fingers in
extension except the
finger being tested.
 Ask the patient to flex
the finger at the
proximal
interphalangeal joint.
 If the patient cannot
flex the finger, the
flexor digitorum
superficialis tendon is
cut or non-functional.

18.  STABILISE THE MCP
JOINT
 ASK THE PT TO
FLEX IP JOINT

19.  TO EXCLUDE UNDERLYING INJURIES LIKE
FRACTURES.

20.  REPAIR WITHIN 1ST TWO WEEKS,LATE REPAIR
DECREASE THE ULTIMATE MOBILITY OF THE
FINGERS
 STRENGTH AND ABILITY TO PREVENT GAPPING
DEPENDS ON THE NO OF SUTURES THAT CROSS
THE REPAIR SITE
 TENDON GAPPING IS THE HALLMARKOF TENDON
FAILURE
 DORSALLY PLACED SUTURES HELPS TO MINIMISE
GAPPING

21.  EPITENON SUTURES HELPS TO IMPROVE THE
STRENGTH AND QUALITY OF TENDON
REPAIRS
 NO NEED FOR TENDON SHEATH REPAIR
 PARTIAL TENDON LACERATIONS OF LESS
THAN 60% OF CROSS SECTIONAL AREA OF
TENDON SHOULD BE TREATED WITHOUT
TENORRHAPHY AND EARLY MOBILISATION

22.  IN TRANSVERSE
LACERATIONS,
LONGITUDINAL INCISIONS
ARE PUT ON OPPOSITE
SIDES EXTENDING
PROXIMALLY AND
DISTALLY
 OBLIQUE SKIN
LACERATIONS CAN BE
EXTENDED IN A ZIG ZAG
FASHION

23.  WOUND EXTENDED PROXIMALLY AND DISTALLY
 PROXIMAL TENDON RETRIEVED,CORE SUTURES
ARE PLACED
 KEITH NEEDLES USED TO PASS THE SUTURES
AROUND THE DISTAL PHALANX EXITING
THROUGH NAIL PLATE DISTALLY
 REMAINING DISTAL END OF TENDON SUTURED
TO THE RE-ATTACHED PROXIMAL PORTION

24.  REPAIR BOTH TENDON LACERATIONS
 TENDON SHEATH MAY BE OPENED FOR
EXPOSURE BUT A2 AND A4 ARE PRESERVED
AS MUCH AS POSSIBLE
 FDS IS REPAIRED FIRST FOLLOWED BY FDP

25.  If both tendons are lacerated,
both are repaired, end to end
with
circumferential re-enforcing
sutures
 May affect lumbricals inaddition
to flexor tendons
 Damaged lumbrical is either
repaired or excised depending
on severity of injury and the

26.  Lacerations of flexor tendons within the
carpal canal are typically associated with
partial or complete laceration of median
nerve
 Here median nerves should be repaired first
and the tendons last

27.  In this area there may be concomitant ulnar
nerve & artery damage as well as radial artery
& median nerve damage.
 Primary repair of the arteries is usually
indicated
 If wound is contaminated, arteries are
repaired and delayed repair of tendons and
nerves is planned

28. TWO PROTOCOLS ARE FOLLOWED
1. PASSIVE FLEXOR TENDON PROTOCOL
2. EARLY ACTIVE TENSION PROTOCOL

29.  0-3 WEEKS:NO ACTIVE FINGER
FLEXION,DORSAL BLOCK SPLINT IS APPLIED
 3-6 WEEKS:SPLINTING CHANGES WITH WRIST
IN NEUTRAL POSITION ,PASSIVE FLEXION AND
ACTIVE EXTENSION EXERCIZES STARTTED
 6-9 WEEKS:WEANING FROM SPLINT,LIGHT
FUNCTIONAL ACTIVITIES STARTTED.

30.  9-12 WEEKS:JOINT CONTRACTURES IF
PRESENT ARECORRECTED.RESISTIVE
EXERCIZES ARE BEGUN.
 12-16 WEEKS:PROGRESS TO FULL RESISTIVE
EXERCIZES
 BEYOND 16 WEEKS:RESIDUAL DEFICITS IF ANY
CORRECTED

31.  24-48 HRS POST OP:DORSAL BLOCK
SPLINTING,PASSIVE AND ACTIVE EXTENSIONS
STARTTED WITHIN THE SPLINT
 24-72 HRS POST OP TO 4 WEEKS:ACTIVE
EXERCIZES IN A HINGED TENODESIS SPLINT
AND DORSAL BLOCK SPLINT RE-APPLIED
AFTER EACH EXERCIZE SESSION

32.  4-6 WK POST OP:ACTIVE EXERCIZES DONE
OUTSIDE THE SPLINT
 6-8 WKS POST OP:SPLINT DISCONTINUED
 8-9 WKS POST OP:LIGHT STRENGTHENING
EXERCIZES BEGUN
 10-14 WKS POST OP:PROGRESSIVE RESISTIVE
STRENGTHENING EXERCIZES BEGUN.
 BEYOND 14 WKS:RETURN TO FULL
UNRESTRICTED ACTIVITY AT 14 WKS

33.  SUCCESSFUL RESULTS REQUIRE PRECISE
SURGICAL TECHNIQUE AND STRICT
ADHERENCE TO REHABILITATION PROGRAM.