flexor tendon injury

1. Flexor Tendon
Injuries
Dr . Alexson Soney

2. INTRODUCTION
• Despite advancement in our understanding of flexor tendon biology,
repair & rehabilitation, a successful outcome after intrasynovial
flexor tendon injury can be difficult to achieve.
• This requires a thorough understanding of the biologic principles of
tendon injury & healing, a detailed knowledge of normal and
pathologic flexor tendon anatomy, an attention to meticulous surgical
technique, a careful postoperative rehabilitation protocol & surgeon,
therapist & patient who are motivated to enact that protocol.

3. Definition
• Tendons are composed of dense connective tissues that transmit
forces generated by muscles to move the joints or to create action
power.

4. ANATOMY
MUSCLES OF FOREARM
• Anterior Compartment:
• Has a common flexor origin from medial epicondyle humerus
• Divided in 2 compartments
• 1. SUPERFICIAL
• a) Pronator Teres
• b) Flexor Carpi Ulnaris
• c) Palmaris Longus
• d) Flexor Carpi Radialis
• e) Flexor Digitorum Superficialis (sublimus)

5. • DEEP:
a) Flexor Digitorum Profundus
b) Flexor Pollicis Longus
c) Pronator Quadratus

6. PRONATOR TERES
• Insertion: midway long the lateralsurface of the radius
• Action: pronation,flexion of forearm
• N.Supply:Median.N (C6c7)

7. FLEXOR CARPI RADIALIS
• INSERTION:base of the 2nd mc bone and slip to the bace of the 3rd
MC bone
• ACTION: flexion and abduction of wrist
• N.SUPPLY: Median.N (C6 , C7)

8. PALMARIS LONGUS
• INSERTION: anterior aspect of the distal flx.retinaculum and palmar
aponeurosis
• ACTION: flx.the wrist, and tightens the palmar.aponeurosis
• N.SUPPLY: Median. N (c6,c7)

9. FLEXOR CARPI ULNARIS
• ORIGIN:humoral head: med epicondyle , Ulnar head:med.margin of
the olecrenon,posterior border of the ulna
• INSERTION: pisiform, hook of hamate, base of the 5th MC &
flx.retinaculum
• ACTION:flexes and adducts the hand
• N.SUPPLY: Ulnar.N (C7,C8)

10. FLEXOR DIGITORUM SUPERFICIALIS
• ORIGIN: humeroulnar head: med.epicondyle of the humerus, coronoid
process. Radial head: sup.half of anterior aspect of the radius
• INSERTION : bodies of the Middle phalanges of the medial 4 digits
• ACTION: flx.of all joints it crosses
• N.SUPPLY :Median .N (C7,C8,T1)

11. FLEXOR DIGITORUM PROFUNDUS
• ORIGIN:prox.3/4 of the medial and anterior aspect of the ulna and from
interosseous memb.
• INSERTION:base of The Diatal phalanges of the medial 4 digits
• ACTION: flx.DIP,,PIP,MP, wrist
• N.SUPPLY:
Medial-ulnar.N (C8,t1)
Lateral-AIN Of Median.N (C8,t1)

12. FLEXOR POLLICIS LONGUS
• ORIGIN: upper 3/4 of anterior surface of radius
• INSERTION: base of distal phalanx of the thumb
• ACTION: flexion of proximal & distal phalnx of the thumb
• N.SUPPLY:AIN (C7,C8,T1)

14. • At the level of the metacarpal neck, the tendons enter the synovial
sheath, at which point the FDS splits into halves that course dorsally
around the FDP tendon. These halves then rejoin at the Camper
chiasm, then split again to insert independently on the middle
phalanx.

15. Pulleys
The flexor tendon sheath begins at the level of the metacarpal neck,
and consists of 5 annular and 3 cruciate pulleys.
• The A1, A3, and A5 pulleys arise from the volar plates of the
metacarpophalangeal (MCP), proximal interphalangeal (PIP), and
distal interphalangeal (DIP) joints, respectively.
• The A2 and A4 pulleys arise from the volar portion of the proximal
and middle phalanges.
• The first cruciate pulley (C1) is between A2 and A3, C2 is between A3
and A4, and C3 is between A4 and A5.

17. TENDON NUTRITION:
 Mainly from 2 basic sources
1. The synovial fluid produced within tenosynovial
sheath
2. Blood supply provided through longitudinal
insertions, & vincular circulation.
 Each tendon has long and short vinculum,
which are supplied by a transverse “ladder
branch” of the digital arteries
 Each vinculum enters the tendon on its dorsal
surface, resulting in the dorsal aspect of the
tendon being the most well vascularized.

18. Flexor tendon zone
• Kleinert and verdan classified into 5 anatomic zones
ZONE I: contains only FDP tendons
• Extends from just distal to insertion of sublimis tendon to site
of insertion of FDP tendon.
ZONE II: critical area of pulleys (bunnell’s “no man’s land”)
• Contains both FDP & FDS tendons
• Between distal palmar crease & insertion of sublimis tendon.
• Tang subdivided zone II in 4 parts
1. Iia - The area of the FDS tendon insertion
2. Iib -Area covered by the A2 pulley
3. IIc : it is area in which satisfactory functional recovery is most
difficult to achieve after 10 repair of both FDP & FDS tendons.
• 4. Iid -from the proximal margin of the A2 pulley to the
proximal

19. ZONE III: comprises area of lumbrical origine
• Between distal margin of transverse carpal
ligament & beginning of critical area of
pulleys or 1st annulus.
ZONE IV:
• Zone covered by transverse carpal ligament
ZONE V:
• Zone proximal to transverse carpal ligament
and include forearm

20. • In the thumb, zone 1 is distal to the interphalangeal (IP) joint, zone 2
is from the IP joint to the A1 pulley, and zone 3 is the area of the
thenar eminence.

21. CHARACTERISTIC OF EACH ZONE
1 - One tendon in a Osseo-facial tunnel
2 - Two tendons in a tight Osseo-facial tunnel
3 - Tendons under palmar aponeurosis
4 - Nine tendons in an Osseo-facial tunnel
5 - Tendons lying freely in distal form
• Zone 2 and Zone 4 where more than one tendon are present in an
Osseo-facial tunnel are prone for problems after repair

23. PATIENT EVALUATION:
• The initial evaluation of a patient with a flexor tendon injury is important
for formulating a diagnosis establishing a treatment plan counselling the
patient regarding expected outcomes.
• The mechanism of injury has implications for quality of the tendon
status of the surrounding soft tissues.
• A sharp laceration is more likely to have a cleanly cut tendon end and
less soft tissue damage than a crushing or avulsion type mechanism

24. • 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

25. Each flexor tendon must be examined
independently
• Stabilizing the middle phalanx of the injured
digit and asking the patient to actively flex the
Dip joint isolates the FDP.
• The FDS is examined by holding the adjacent
digits in extension and asking the patient to flex
the injured digit at the PIP Joint.

26. • TENDON HEALING:
• Believed to occur through activity of extrinsic & intrinsic mechanisms
• Occurs in 3 phases
1. Inflammatory : 48 to 72 hrs
2. Fibroblastic : 5 days to 4 weeks
3. Remodeling : 4 weeks to about 3.5 months
• Extrinsic mechanism occurs through activity of peripheral fibroblasts &
seems to be dominant mechanism contributing to formation of scar &
adhesions.
• Intrinsic healing seems to occur through activity of fibroblastic derived
from tendon.

27. Flexor tendon healing
TWO THEORIES
Intrinsic (LUNDBERG)
• Proliferation of
tenocytes
• Production of
extracellular matrix
• CELL MIGRATION AND
TENOCYTE
PROLIFERATION
Extrinsic
POTENZA AND PEACOCK
• Healing with adhesion
formation.
• Neovascularization.
• Fibroblast proliferation.
• SYNOVIUM IS
IMPORTANT

30. Flexor tendon repair
• Types :
1. Primary: first 12-24 hours of injury - Emergency repair needed if
altered digital perfusion present Clean wound caused by sharp
object.
2. Delayed primary repair : 24 hours to 10 days
3. Secondary repair: 10 to 14 days,
4. Late secondary repair: after 4 weeks

31. • Secondary repair ;-
• 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

32. Surgical incision
• Incisions should not compromise viability of skin flaps should not
create contractures or cosmetically unsightly scars
• Zigzag (Brunner) or midaxial incisions and midlateral incisions

33. • During tendon suturing, handling should be gentle & delicate, causing as little
reaction & scaring as possible.
• Pinching & grasping of uninjured surfaces should be avoided, as it can contribute
to adhesions formation.
• Strickland stressed 6 characteristics of an ideal tendon repair:
1. Easy placement of sutures in tendon
2. Secure suture knots
3. Smooth juncture of tendon ends
4. Minimal gapping at repair site
5. Minimal interference with tendon vascularity
6. Sufficient strength throughout healing to permit application of early motion
stress to tendon.

34. SUTURE MATERIAL:
• Although monofilament stainless steel has highest tensile strength,
Difficult to handle Tends to pull through the tendon , Makes a large
knot , Can be used satisfactorily in distal forearm
• Catgut & polyglycolic acid group(dexon, vicryl) becomes weak too
early after surgery
• Synthetic sutures of caprolactum family & nylon maintain their
resistance to disrupting forces longer than polypropylene (prolene) &
polyester suture.
• Polydioxanone has been shown to be strong as polypropylene

35. SUTURE CONFIGURATIONS:
Various tendon repair types can be divided into 3
groups:
• Group 1: exemplified by simple sutures; suture
pull is parallel to tendon collagen bundle,
transmitting stress of repair directly to opposing
tendon ends.
• Group 2: exemplified by bunnell suture; stress is
transmitted directly across juncture by suture
material & depends on strength of suture.
• Group 3: exemplified by pulvertaft technique (fish
mouth weave); suture are placed perpendicular to
tendon collagen bundles & applied stress.

36. • Interrupted sutures were found to weakest & unsuitable in most tendon
repair.
• Fish-mouth or end weave repairs are strongest & most suitable for tendon
graft & tendon transfer junctures in distal forearm & palm, where
intermediate suture configurations(bunnell, kessler) didn’t differ
significantly in strength.
• 4-strand, 6- strand & 8-strand core sutures
• create stronger repairs
• Reduce possibility of gap formation
• Permit greater active forces to be applied to repaired tendons, allowing
earlier active motion.

41. TENDON-TO-BONE ATTACHMENT:

43. ZONE I
• Single tendon injury In Osteo-facial tunnel.
• Most important stability of repair and attatchment to terminal phalanx
• C/F- Loss of DIP flexion
• Types of injury-
• Injury to tendon prox. To insertion
• Avulsion from insertion.

44. TRANS-Osseous technique
Intra-osseous technique with pull out suture
Anchor suture technique

45. Zone I : Flexor tendon Avulsions
• Classification given by Leddy and Packer
Type 1: Avulsed FDP tendon retracts in palm with disruption of vincular
system (VLP + VBP)
• Needs repair (<2 weeks)
Type II:
• FDP retracts till level of PIP
• VLP Intact
• repaired within 6 weeks from time of injury

46. Type III: FDP doesn’t retract proximal to A4 pulley because of large
bone-fragment
• Need fixation with kirschner wire or screw
• Strickland (Cross kwire) or Moiemen and Elliot intraosseous wire tech.
Type IV: Fracture and avulsion of FDP from bony stump (DOUBLE
AVULSION)
• This has been added
• Repair of fracture done first and then tendon is advanced and fixed to
distal phalanx
• Screw fixation of fracture and pullout suture of tendon can be done

47. Zone II (NO MAN` land by Bunnell)
• Unique features
• Nerve and vessels may be injured ( after the tendon repair is
completed)
• Associated Fractures (fix # before tendon repair)
• Both FDS and FDP cut
• Only FDS or FDP cut / one slip of FDS cut
• Partial cut

48. FDS ALONE REPAIR
• Risk of failure
• Can be done in late presentation or old infected cases
• If both slips of FDS and FDP injured under A2.
FDS + FDP repair
• Can be done if Suture line of FDS and FDP do not coincide
• Repair site proximal or distal to A2
Partial CUT
• <25%- no repair
• 25-75%- only coaptive sutures
• >75 %- full repair

49. SUBDIVISION OF ZONE 2
• 2A- The area of the FDS tendon insertion
• 2B - From the proximal margin of the FDS insertion to the distal
margin of A2 Pulley
• 2C – Area covered by the A2 pulley
• 2D- from the proximal margin of the A2 pulley to the proximal
reflection of the digital sheath

50. Zone IIA- Area of FDS insertion
• FDS tendon split in 2, and flattened tendon
Zone IIB- Between FDS insertion and distal margin of A2
• Pulley here can be vented and both FDS and FDP repaired
Zone IIC- underneath A2 pulley
• Ensuring proper gliding is difficult
• Pulley may be partly vented or only one slip FDS or only FDP repair
Zone IID- Proximal to A2
• Pulley system can be vented and both FDS and FDP can be repaired

51. • Ends retrieval
• Atraumatic handling
• Ragged cut ends are
sharpened with scalpel or
fine scissors.
• 3-0/ 4-0 suture
• Hypodermic needle for
fixation

52. ZONE III
• Between distal palmar crease and carpal tunnel
• Contains two tendons
• *Lumbrical origin (assoc. injury)
• Accompanying digital nerves and vessels

53. ZONE IV
• Entails injury in the carpal tunnel
• 9 tendons in tight osseo-facial tunnel and Median nerve
• Origin of thenar and hypothenar muscles from flexor retinaculum

54. ZONE V
• Multiple tendons involved
• Median and ulnar nerve can be involved
• Ulnar and radial artery can be involved
• May be underlying fracture of ulna
• Need a sequential plan of exploration and repair

55. SUBZONES of Zone V
• V a- tendinous portion of the flexor muscles in forearm
• V b- Muscular part of flexor muscle, distal to nerve supply. Muscle
and small tendinous slips within are repaired
• V c- proximal forearm muscle, with entry zone of nerves

56. SPAGHETTI WRIST
• Spaghetti wrist injuries were defined as those
occurring between the distal wrist crease and the
flexor musculotendinous junctions involving at least
three completely transected structures, including at
least one nerve and often a vessel.

57. Biomechanics of tendon
repairs

59. STRENGTH OF REPAIR
INITIALLY
• Depends on repair technique
Later
• Depends on strength of healing.
CORE
SUTURE
TECH.
0 week 1 week
(-50%)
3 week
(-33%)
6 week
(+20%)
2 strand 2500gm 1200gm 1700gm 2700gm
4 strand 4300gm 2150gm 2800gm 5200gm

60. Two strand- modified
Kessler
4 strand- Strickland`s
technique

61. Suture purchase
• Purchase length has bearing on strength
• 7mm to 1cm is optimal
• Recommended to have loops atleast 2mm 7-10 mm
• SUTURE CALIBRE
• as per tendon size
• 3-0 or 4-0 for core
• 5-0 or 6-0 for circumferential
• Number of core sutures across the repair is more determinant of strength

62. SUTURE TENSION
• Tension of repair should be tight enough to hold both the ends
together (<3mm)
• Gap >3mm gives poor result

63. Adhesion prevention
• Meticulous surgery
• Early postoperative motion
• The prime cause of adhesions is tendon repair by Poor technique

64. FLEXORTENDON RECONSTRUCTION

65. Single Stage Flexor Tendon Grafting ; FDP and
FDS Tendon Disrupted
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.

66. Boyes Preoperative Classification
• 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.

67. Surgical principles
• 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.

68. Graft choices
1. Palmaris longus tendon present in approximately 85% of all
individuals of sufficient length and size .
2. Plantaris when graft length is important. present in about 93% of
population
3. EDL
4. EDM
5. FDS of unaffected finger

69. • 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).

70. Two staged reconstructions
stage 1
• Passive tendon implants at first surgery, placement of tendon graft at
second surgery
Indications
1. Crushing injuries a/w # or skin damage
2. Damaged pulley system
3. Excessive scarring of the tendon bed
4. Failure of previous operations
5. Contracted joints

71. • 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

72. • 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

73. • 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).

74. Stage 2
Indication:
1. Patient who underwent stage I of flexor reconstruction process
2. Interval between stages I and II :2-3 months.
3. Hand must be soft, and joints well mobilized.
4. No infection

75. 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)
• Proper tension of graft maintaining
necessary

76. Postoperative Care
• Apply a short arm dorsal blocking splint
• Protected passive range of motion early
• Dynamic splinting for contractures.

77. Post Tendon Repair Therapy Protocols
• Following are representative protocols for each of the three basic
approaches to flexor tendon post repair management:
• Immobilization,
• Early passive mobilization
• Early active mobilization
• Combined passive-active mobilization

78. Early stage (from 0 to 3-4 weeks)
• Splint
• The dorsal forearm-based postoperative splint
or cast holds the wrist in 10 to 30 degrees of
flexion, the MCP joints in 40 to 60 degrees of
flexion, and the IP joints in full extension.
• The splint is worn 24 hours a day except for
therapy visits one to two times a week, when
the splint may be removed by the therapist.

79. • Exercise
• One or two times a week, the splint is removed by the therapist for
gentle protected PROM (passive ROM).
• The therapist holds adjacent joints in flexion while extending and
flexing each joint.
• Often, after prolonged protection in MP flexion, patients develop
intrinsic tightness. Therefore, in addition to protected isolated ROM
of all joints, protected intrinsic stretch exercises are performed (wrist
flexed maximally while MP joints are held in neutral and IP joints are
gently flexed passively).

81. TENDON GLIDING EXERCISES
10 reps each every 4 hours
• DUCK position
• HOOK position
• Squeeze/ tight fist position
• Trace position
• Fan out Position

82. • After 3 or 4 days of these exercises, tendon function is evaluated. The
therapist measures active and passive flexion (TAM and TPM), totaling
the degrees of flexion achieved at MP and IP joints for total active and
passive flexion.
• If there is a discrepancy of more than 50 degrees between total active
and total passive flexion (TPM – TAM > 50), poor gliding and heavy
adhesion formation are assumed and the patient is moved on to the
next phase of therapy.
• If the discrepancy is less than 50 degrees, the patient continues with
the current phase of therapy until 6 weeks after repair.

83. IMMOBILIZATION – Late Stage
Starts at 4-6 weeks
• SPLINT-
• The dorsal blocking splint is discontinued
• Exercises
• Gentle tendon blocking exercises for isolated FDP and FDS glide:4-6 times a
day with 10 reps*
• Tendon gliding exercises are continued
• If after 1 week of starting this plase, Flexion has not improved the program
is upgraded to towel gripping and putty squeezing
• Manually block tendons or bunnel blocking splint

84. • DISADVANTAGE OF IMMOBILIZATION PROTOCOL
• Outcomes may not be optimal
• Difficult to mobilize these repairs later on because of heavy adhesion
formation.

85. • In order To Overcome These Problems
Significant point
• Tendon excursion shall be maintained
• By Passive movements or active movements
• Hence Early passive mobilization and early active mobilization
• These movements will get excursion but at the same time increases
load on tendons and hence on repair sites.

86. Early Passive Mobilization
1. Kleinert
2. Duran and Houser
• In 1975, Duran- used passive flexion of fingers and designed to cause
excursion of 3-5mm of tendon excursion – limit formation of peritendinous
adhesions
• Each protocol has many variations on these two approaches described in
literature.
• In both approaches, a forearm-based dorsal blocking splint, applied at
surgery, blocks the MP joints and wrist in flexion to place the flexor tendons
on slack, and the IP joints are left free or allowed to extend to neutral within
the splint.
• Dynamic traction maintains the fingers in flexion to further relax the tendon
and prevent inadvertent active flexion.

87. The dynamic traction may be provided by
• rubber bands
• elastic threads
• springs
The traction is applied to the fingernail by:
• placing a suture through the nail in
surgery
• gluing to the fingernail a dress hook

88. DURAN AND HOUSER
EARLY STAGE (0-4.5 weeks)
• Splint, applied immediately after surgery The
wrist is held in 20 degrees of flexion and the
MCP joints in a relaxed position of flexion.
• Exercise.
• With MCP joint and PIP jt. Flexed, the DIP is
extended passively, thus moving FDP repair
distally away from and FDS repair.
• Then with DIP AND MCP JOINT flexed, the PIP is
extended, both repairs glide distally away from
the site of repair and surrounding tissues.

89. INTERMEDIATE PHASE ( from 4.5 weeks to 8
weeks)
• Splint is replaced with a wrist band to which
rubber band traction is attatched
• Exercise-
• Active extension exercises begin within the
limitations imposed by the wrist band
• Active flexion (blocking, FDS gliding and
fisting) is initiated on removal of the wrist
band at 5.5 weeks.
LATE STAGE (STARTS AT 7.5-8 weeks)
• Resisted flexion after 7.5 – 8 weeks is
initiated

90. KLEINERT
• Splint.
• Applied immediately after surgery
• The dorsal blocking splint blocked the wrist in 45 degrees of flexion
and the MCP joints in 10 to 20 degrees.
• Rubber band traction was directed to the fingernail from the wrist or
just proximal to the wrist.
• Exercise. Every hour, the patient actively extends the fingers to the
limits of the splint 10 times, allowing the rubber bands to flex the
fingers.
• Continued for 3 weeks

91. INTERMEDIATE STAGE (3-5 Weeks)
• Splint-
• The rubber band from the injured digit is attached to a wrist band for 3weeks
through the 5 weeks.
• EXERCISE
• All active movements to the wrist and hand are encouraged, although injured
digit is still tethered through 5 weeks.
• At 5 weeks, gentle active flexion may begin
Late Stage (Starts at 6 weeks)
• Resistance exercises begins
• Elastic flexion pull acts as it as the repaired flexor tendon unit without flexor
muscle contraction.
• Passive Flexion achieved and active extension of digit.

93. Drawbacks Of Kleinert Program
• Flexion contracture at PIP jt.
• Elastic traction can be detached and the finger strapped in extension
within the splint.
• Washington regimen- use single strand rubber band so that full
extension is easier to achieve
• Loss of active DIP motion
• Pull of rubber band in linear direction- no flexion at DIP jt.
• Improved by using a palmar pulley

94. ORIGINAL KLEINERT
• Wrist flexion 45 DEGREE
• MCP flexion 10-20 degree
• Direct rubber band tractionfrom
wrist/distal forearm to fingernail
MODIFIED KLEINERT
• Wrist flexion 20 degree
• MCP flexion 40 degree
• Directed traction through palmar
pulley

95. SUMMARY
• Flexor tendon injury remains a challenging problem in hand surgery due
to intimate anatomy of the FDP, FDS & pulley system.
• Repair need to be strong enough to begin early range of motion, while
avoiding bulkiness within confines of pulley system.
• Currently, although many repair configurations are acceptable, it is
recommended that at minimum 4-strand core suture repair with
epitendinous suture is used.
• Although every attempts should be made to repair both FDP & FDS
tendon, sacrificing one limb of FDS is acceptable should a repair become
too bulky with A2 pulley.

96. • Venting of pulley system should be done prudently to allow smooth
gliding of repaired tendon while avoiding excessive release.
• Compliance with postoperative motion protocols is vital in securing a
successful results.
• Future advances in the biology of tendon healing may aid in better
outcomes, but ultimately, the healing of the tendon repair is
dependent on the surgeon, the patient & the therapist

97. Thank you