1. Flexor tendon injuries can occur in any of the 5 zones defined by Kleinert and Verdan and require different surgical approaches depending on the location and severity of the injury. 2. Primary repair within 12-24 hours of injury provides the best functional outcomes while delayed or secondary repairs have higher risks of adhesion formation. 3. Flexor tendon repair techniques aim to accurately approximate the tendon ends with core sutures while minimizing handling and restoring the normal gliding relationship between tendons. Postoperative rehabilitation is crucial. 4. Flexor tendon grafting is indicated for injuries with segment

1. PRESENTER: DR. SOUVIK
/DR.NAVEEN
MODERATOR:DR VIVEK SINGH

2.  Extrinsic flexors
• Superficial group
 PT, FCR, FCU, PL
• Intermediate group
 FDS
• Deep group
 FPL –
 FDP –

3. Condensations of the fibrous retinacular
sheath form the flexor pulleys
Cruciform pully:allow digital flexion to
occur without significant deformation of
annular pulley system
Annular pulley : stiffer and thicker
A1
A2
A3
A4
A5

4.  Contains only one tendon-FDP
 Tendon laceration occurs close to its insertion
 Tendon to bone repair is required
Green DP, JBJS 2002
Kleinert and verdan classified into 5 anatomic
zones

5.  From metacarpal head to middle phalanx
 FDS n FDP within one sheath
 Adhesion formation risk is amplified at campers chiasm
ZONE III
•B/W transverse carpal ligament and proximal margin of tendon
sheath formation
•Lumbricals origin here prevents profundus tendons from over acting

6.  Lies deep to deep transverse ligament
 Tendon injuries are rare
Lies proximal to transverse carpal ligament in the forearm
ZONE V

7. History
Clinical examination
Special tests

8.  H/o trauma by sharp objects
 completely transected :no active flexion
and loss of tenodesis effect
 Loss of inherent flexor tone and
extended posture at PIP and DIP
 Functional tests of FDS and FDP
 light touch and static two-point discrimination
 Capillary refill of the volar digital pulp and the nail bed

9. Types :
 Primary: first 12-24 hours of injury
 Delayed primary repair : 24 hours to 10 days
 Secondary repair: 10 to 14 days,
 Late secondary repair: after 4 weeks
Ref campbell 12 th ed

10.  Emergency repair needed if altered digital perfusion present
 Clean wound caused by sharp object.

11. Indicated if a/w
 extensive crushing with bony comminution
 severe neurovascular injury
 severe joint injury and skin loss requiring a coverage procedure
 Primary repair gives better functional outcomes than secondary
repairs
 Ref: Tang JB :Injury. 2006 Nov

12.  Incisions should not compromise viability of skin flaps shd not
create contractures or cosmetically unsightly scars
 Zigzag (Brunner) or midaxial incisions and midlateral incisions

13.  Core Non-absorbable 4/0 suture
 4-0 or 3-0 prolene or mersilene suture may be used
 5-0 or 6-0 monofilament running epitenon suture.
Ref: J Bone Joint Surg Am. 1998.
 Singer G,

14.  Direct repair (primary tenorraphy): laceration >1 cm from FDP
insertion
 Entire A4 annular pulley preserved
 proximal tendon
Retrieved by feeding
tube and passed
underneath A4 pulley

15. Traditional pull-out suture methods :
Free ends of sutures are passed through or around distal phalanx to be
tied over dorsum of fingernail by tie over button.
Removed after 6 weeks.
Internal suture methods: suture
anchors or other methods to affix
the tendon directly to the bone

16.  Dissection proceeds with identification
and protection of the digital nerves and arteries
 It is necessary to open either the C1 (between A2 and A3) or C2
(between A3 and A4) cruciate-synovial sheath
 Always restore the normal relation between the two tendons

17. Pearls
 Multistrand core suture method with running circumferential suture
preferred
 Enter sheath between distal A2 and proximal A4.
 Proximal stump retrieval by milking, feeding tube, or direct exposure
 Deliver distal stump by passive DIP hyperflexion
 Repair by transfixation using 25-gauge, 5/8 inch needle
 Use two or four strand core suture technique

18. Newer ones: Strickland, cruciate,
Becker, Savage, and Winters

19. Core suture loops
 When transverse component passes within tendon
superficial to the longitudinal component, suture “locks” a
bundle of tendon fibers.
 When transverse component passes deep to longitudinal
component, but the suture does not “lock” a bundle of
tendon fibers, but pulls through the tendon by grasping it.

20.  Postoperative POP and dressing applied with wrist
flexed (20 to 30 degrees) and MP joints flexed (50 to 70
degrees), and PIP and DIP joints at zero or slight flexion
 Graded rehabilitation protocol(Duran ,Kleinert)
 Unrestricted activity at 4 to 6 months after surgery

21.  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 location of the laceration
 Lumbricals muscle bellies usually are not sutured, cause lumbrical
plus finger

22.  A/w median ,ulnar nerve or ulnar or radial vessel injury.
 Here vessels and nerves should be repaired first and the tendons
last

23.  Partially severed tendon should not be repaired if at least 40% of
the tendon remains intact
 J Hand Surg 2000;25A:1118-1121 :

24.  Extensile exposure in a controlled setting with optical
magnification allows the extent of the injury to be defined.
▪ Tendon retrieval is done using atraumatic techniques and
windows through noncrucial areas of the flexor tendon sheath.
▪ Handling of the tendon should be minimal.
▪ The tendon must be accurately oriented.
▪ The core tendon sutures should be placed to allow for
accurate coaptation of the tendon ends. The suture method
should provide a stable, smooth repair that is freely gliding
within the tendon sheath.
▪ Circumferential suture is used to “finish” the repair and
add strength to the repair.
▪ Sheath closure is necessary only if it improves tendon
gliding.
 Acknowledgments

27.  Indications: 1.Injuries resulting in segmental tendon loss.
2. Neglected >3 to 6 weeks with tendon degeneration and scar
within the tendon sheath.
3. Large section of tendon has been damaged in zone 2 injury

4.Delayed presentation of FDP avulsion injuries associated with
significant tendon retraction.

28.  Grade 1 Good: Minimal scar with mobile joints and no trophic
changes
 Grade 2 Cicatrix: because of injury , failed primary repair or
infection
 Grade 3 Joint damage: with restricted range of motion
 Grade 4 Nerve damage: resulting in trophic changes
 Grade 5 Multiple damage: Involvement of multiple fingers with
combination of above problems
From Boyes JH: J Bone Joint Surg Am 32:489-499, 1950.

29. One graft in each finger.
Never sacrifice intact flexor digitorum superficialis (FDS).
Graft of small caliber.
Perform the junctions outside of the tendon sheath.
Ensure adequate graft tension.

30.  Palmaris longus[1] tendon present in approximately 85%
of all individuals of sufficient length and size .
 Plantaris [2] when graft length is important.
present in about 93% of population
 EDL[3]
 EI [3]
 EDM[3]
 FDS of unaffected finger[4]
 Ref: 1. MARTIN I. BOYER.JBJS 2002
 2.Morrison WA J Hand Surg [Br] 1992
 3. Harvey FJ, J Hand Surg [Am] 1983
 4.Snow JW: Plast Reconstr Surg 1968

31.  Tendon weave in any area outside the flexor sheath
 Stronger than the end-to-end suture techniques
 Allow to modulate graft tension
Ref:Pulvertaft RG: JBJS Am 1980; 42:1363-
1371.
Rank BK: 2nd ed. Edinburgh, E & S
Livingstone, 1988.

32.  Profundus stump not available:
 Profundus stump available:

33. ▪ 1 cm FDP stump ,1 to 2 cm FDS tendon near insertion
▪ Obtaining flexor graft
▪ Graft threaded under pulleys with suture passer(pediatric
feeding tube/red rubber catheter
▪ Distal juncture created
▪ Proximal juncture into the FDP tendon just distal to the
lumbrical origin. (≥3 interweaves)
Sourmelis SG: J Hand Surg Br 1987;

34. ▪ In patients with DIP joint hyperextension, tenodesis
or arthrodesis can be offered.
 Postoperative Care
▪ Static dorsal blocking splint (4 to 6 weeks) with the
wrist neutral, MP joints at 45 degrees, and IP joints
neutral.
▪ Treat flexion contractures with passive stretching
and splinting (6 to 8 weeks).

35.  Passive tendon implants at first surgery, placement of
tendon graft at second surgery
 Indications ▪ Crushing injuries a/w # or skin damage
▪ Damaged pulley system
▪ Excessive scarring of the tendon bed
▪ Failure of previous operations
▪ Contracted joints

36.  1-cm FDP stump kept & proximal FDP tendon
transected at the level of the lumbrical origin.
 Through distal forearm incision identify the involved
FDS tendon, draw it into the wound, and transect it
near the musculotendinous junction
 Appropriate size of the silicone implant.
 Assess pulley system

37.  Pass implant from proximal palm to distal forearm
between the FDP and FDS
Distal juncture suture applied
 ROM checked
 If implant assumes bowstring posture, pulley
reconstruction done by Bunnell encircling
method/ Kleinert technique

38. Postoperative Care :Splint with wrist in 35 degrees of
flexion, MP joints at 60 to 70 degrees of flexion, and IP
joints extended.
▪Start passive motion on first postoperative visit
▪Contracture releases may benefit from dynamic splinting
(6 to 8 weeks).

39.  Indication: Patient who underwent stage I of flexor reconstruction
process
 Interval between stages I and II :2-3 months.
 Hand must be soft, and joints well mobilized.

40. Surgical principles:
 Implant distal and proximal ends located
 Tendon graft obtained
 Graft sutured to proximal end
of implant, and pull it distally
through sheath.
 Fix distal juncture and
proximal juncture.(in palm or
distal forearm)

41. Proper tension of graft maintaining necessary
 Postoperative Care
▪ Apply a short arm dorsal blocking splint
▪ Protected passive range of motion early
▪ Dynamic splinting for contractures.