A 30-year old female presented to the emergency room with a laceration and bleeding in her right hand after falling on glass. She was right hand dominant and worked in telemarketing. Physical examination would focus on the extent of the laceration and potential injury to flexor tendons and nerves. Flexor tendon injuries can lead to loss of finger flexion and grip strength if not repaired properly. The goals of reconstruction are to anatomically repair the tendons with limited motion restrictions and adhere to post-operative rehabilitation to regain function and prevent complications like adhesions.

1. HMC Plastic
& reconstruction
mansoor khan
Dec, 2011
Injuries & Repair of
Flexor Tendons of the Hand !!

2. Presentation: Questions to consider:
A 30-year old female presents to the 1. What aspects of the physical
Emergency room after falling on a piece examination would you focus on?
of glass. She complains of 2. What anatomic structures may
pain, numbness and bleeding of her have been disrupted given this type
right hand. She is right hand dominant of injury?
and works for a local telemarketing firm.

3. “
glistening structure
between muscle
& bone which
”
transmit force from
muscle to the bone

4. Tendons
tertiary bundles
fasciles
fibers
fibrils endotenon
collagen

7. F
L
E
X
O
R
D
I
G
I
T
S
U
B
L
I
M
I
S

8. F
L
E
X
O
R
D
I
G
I
T
p
R
O
F
U
N
D
U
S

9. F
L
E
X
O
R
P
O
L
L
I
C
I
S
L
O
N
G
U
S

10. L
U
M
B
E
R
I
C
A
L
S

12. PULLEYS

18. Skin laceration with loss of normal cascade of the
fingerd in resting position!!

19. Loss of active flexion
at DIP in FDP laceration!!

20. Loss of normal
tenodesis effect!!

21. Passive flexion
with forearm squeez!!

24. Complain of numbness
preceeded by execissive bleed
Concider neurovascular insult!!

25. Goals of reconstruction:
Coaptation of tendons, anatomical repair with a
limited accordion effect at the repair site, multiple
strand drepair to permit active range of motion
rehabilitation
Pully reconstruction to minimize bow-
stringing, atraumatic surgical technique to
minimize adhesionns, strict adherence to
rehabilitation protocole.

26. Timing of flexor tendon injuries:
Primary: repair within 24 hours
(contraindicated in case of high grade
condtamination i.e. human bites, infection)
Delayed Primary: 1-14 days when the wound
can be still pulled open without incision
Early Secondary: 2-5 weeks.
Late Secondary : after 5 weeks i.e. tendon
substitution techniques/salvage process.

27. Leddy classification of zone I flexor
tendon injuries!!
Type I: tendon retracted into palm
(fullness in palm)
Type II: tendon traped in the
sheath at PIP (unable to flex PIP)
Type III: tendon traped in A4 pully

28. Type II injury!!

29. Type I injury!!

30. Direct repair:
if laceration is more than 1 cm
from FDP insertion
Tendon advancement:
if the laceration is less then 1
cm from insertion.

31. Tendon-to-bone attachment!!

32. Wilson
One method of attaching tendon to bone. A, Small area of cortex is raised with osteotome.
B, Hole is drilled through bone with Kirschner wire in drill. C, Bunnell crisscross stitch is placed
in end of tendon, and wire suture is drawn through hole in bone. D, End of tendon is drawn
against bone, and suture is tied over button.

33. Kleinert method of
tendon advancement!!

34. Tendon advancement shortens the FDP & completes
the grip before the normal fingerd and limit their
flexion and thus week grip
Quadrigia effect!!

35. Laceration during flexion leads to
retraction of cut ends of the
tendons!!

36. Complications: complete
disruption, entrapment, triggering.
Assess for entrapment, debride if risk of
entrapment
No drepair if less than <25% laceration, only
epitenon repair in 25-50% lacerations, core suture
plus epitenon repair when >50% laceration
Dorsal blocking splintage for 6-8 weeks as
consevative measure
Partial lacerations of the tendons!!

37. Commonly used incidions for flexor
tendon exploration!!

38. Brunner incision !!

41. Because the blood supply to the FDP
tendon is jeopardized if the FDS is not
also fixed (due to the vinculae anatomy)
Repair both tendons:

42. Complications:
Adhesions & stiffness requiring
tenolysis in 18-25% cases
Tenolysis is indicated after 3 months if
no improvement is noted for 1-2
months extensive physiotherapy.

43. Lumbrical muscle bellies usually are not sutured
because this can increase the tension of these
muscles and result in a “lumbrical plus” finger
(paradoxical proximal interphalangeal extension
on attempted active finger flexion).
Zone 3 injuries

44. Tendon repair strength:
Core suture:
Material, caliber, number of
strands, knot location, dorsal vs ventral
location
Epitendinous suture:
Depth, locking, cross hatching, simple

45. T
H
R
E
E
B
A
S
I
C
T
Y
P
E
S

48. Silfverskiöld

49. Fish-Mouth End-to-End Suture (Pulvertaft)

50. End-to-Side method
tendon repair!!

51. Active range of motion rehabilitation
Kleinert !!

52. Place and hold
post-operative exercised!!

53. Differential passive exercises for
FDP & FDS!!

54. Post-operative passive exercises
Duran’s

55. Lumbrical plus!!

56. Risk factors for adhesions:
Composite tendon/tissue
damage
Gap formation
Ischaemia due to over
mobalizations of tendon ends
Immobalization
Persistant inflammation
Secondary trauma