"Flexor Tendon Injuries", Dr. Mark A. Deitch, M.D.

, Johns Hopkins University, Presented at the Orthopaedic

Review Course, Baltimore, June, 2003

Flexor Tendons
Anatomy

Flexor Tendon
Injuries

Muscles
Superficial: Pron teres, FCR, FCU, PL
Intermediate: FDS
Deep: FDP, FPL

FDS
Mark A. Deitch, MD
Chief, Hand & Microvascular Surgery
Johns Hopkins Bayview Medical Center
June 25, 2003

Tendon Anatomy
Endotenon
Connective tissue surrounding fascicles
Allows longitudinal movement between
fascicles

Epitenon
Covers surface of tendon

Independent action

FDP
Simultaneous flexion of multiple digits

Tendon Anatomy
Mesotenon
Present in certain anatomic locations
Bifoliate layer
Joins epitenon
Ex: digital flexors

Paratenon
External layer covering tendon
i.e., Patellar tendon

FDS/FDP
Anatomic Relationship
Wrist: FDS
superficial to FDP
A1 pulley
FDS splits, wraps
around FDP

Campers Chiasma

Tendon Nutrition
Forearm
Longitudinal vessels
Paratenon

Digital sheath
Vascular via vincula
Diffusion from
synovial fluids

2 slips rejoin behind

FDP, then split again
to insert in P2

"Flexor Tendon Injuries", Dr. Mark A. Deitch, M.D., Johns Hopkins University, Presented at the Orthopaedic
Review Course, Baltimore, June, 2003

Flexor Pulleys (Fingers)

Flexor synovial
sheath

Flexor Pulleys (Thumb)

A1
MP joint

Begins at MC neck
Low friction gliding
Nutrition

Oblique
P-1

A3

5 annular pulleys
3 cruciate pulleys
Palmar pulley

Attaches to DIP

Flexor Tendon Zones

Flexor Zones (Thumb)

Distal to insertion
Zone I of FDS

Zone I FPL insertion

MC neck to
Zone 2 middle phalanx
(sheath)

Zone 2

Zone 3 Thenar muscles

Distal transverse
Zone 3 carpal ligament to
MC neck

Zone 4 Carpal tunnel

Zone 4 Carpal tunnel

Zone 5

Zone 5 Proximal to
carpal tunnel

Proximal to
carpal tunnel

Biomechanical Properties
A2 + A4 pulley most important
Bowstringing: increase moment arm
Requires increased FDP excursion
Moment arm
Excursion
Joint Rotation

Neck of P-1 to
MC neck

Constrained by
pulley system

Phases of Tendon Healing

Inflammatory
3.5 days after repair
Strength = suture repair

Proliferative
5 days to 3-6 wk after repair
Incr fibroblasts, collagen synthesis
Increased strength

Remodeling
3-6 wk to 6-9 months
Longitudinal reorientation of collagen

"Flexor Tendon Injuries", Dr. Mark A. Deitch, M.D., Johns Hopkins University, Presented at the Orthopaedic
Review Course, Baltimore, June, 2003

Factors Influencing Adhesion

Formation:

Tendon Healing
Intrinsic Healing
Diffusion of nutrients
Fewer adhesions

Extrinsic Healing
Cellular
contributions
Presence of intact
vincular system
improves healing
More adhesions

Contraindications to Primary
Repair

Trauma to tendon & sheath

Tendon ischemia
Tendon immobilization
Gapping
Excision of components of tendon
sheath

Diagnosis based on physical

examination

Severe multiple tissue injuries

Severe wound contamination
Skin loss over flexor system not
amenable to immediate flap coverage

Principle of Tendon Repair

Primary: < 3 weeks after injury
Atraumatic treatment of tendon ends
Lacerated tendon will retract away from
the laceration site
Consider skin incisions carefully!!
Anesthesia
Bier block

Suturing Technique
Suture characteristics
Non
- reactive, pliable, strong

Materials
Braided or non
- braided nonabsorbable

Technique
Kessler, Bunnell, Pulvertaft weave,
Strickland, Tajima, Tsuge

Axillary block
General

"Flexor Tendon Injuries", Dr. Mark A. Deitch, M.D., Johns Hopkins University, Presented at the Orthopaedic
Review Course, Baltimore, June, 2003

Analysis of Core Sutures

Strength is proportional to size of
suture and # strands crossing repair
Repair usually fails at knots
Larger the suture, greater strength

Suture
Techniques

3
- 0or -4 0

Fewer knots is better

Locking sutures may lead to gapping

Suturing Technique
Strength comparison (Urbaniak et al, 1975)

Initial
5 days
10 days
15 days

Bunnell
3930 gm
630 gm
1200 gm
2700 gm

Kessler
3970 gm
1830 gm
1300 gm
2800 gm

Epitendinous suture adds strength to tensile

strength regardless of core suture technique
(Pruitt et al, 1991)

Primary vs. Delayed Primary

Repair
Definition:
Primary repair
<24 hours after injury

Delayed primary repair

>24 hours after injury
Direct end to end

Primary repair is preferable

Delayed primary repair at <3 weeks
does not adversely affect results

Post-surgical Flexor Tendon

Rehabilitation
Early controlled mobilization
(Gelberman et al, 1988)
Strengthens repair
Decreases adhesions and increases
motion

Methods
Active extension with passive flexion
(Kleinert et al, 1967)

Controlled active and passive motion

(Duran/Houser, 1975)

Treatment (Zone I)
Injury: Laceration of FDP
Repair: primary or delayed primary
1cm: direct end to end
<1 cm: advancement with reinsertion into
distal phalanx

Postop: controlled dynamic splinting

Complications:
Flexion contracture
Tendon rupture

"Flexor Tendon Injuries", Dr. Mark A. Deitch, M.D., Johns Hopkins University, Presented at the Orthopaedic
Review Course, Baltimore, June, 2003

Treatment (Zone I, Thumb)

Anatomy
Oblique and A2 pulley
Oblique pulley can be excised if A1 intact

Repair
Same as digits
Also: FPL fractional lengthening

Treatment (Zone II)

Repair of FDS and FDP
Independent motion
Stronger flexion

Treatment (Zone II)

History
No primary repair, debridement, secondary
grafting
Verdan (1960) and Kleinert(1967) promoted
primary repair of zone II injuries

Both FDS and FDP should be repaired

Postop: dynamic splinting with
controlled motion

Treatment (Zone II Thumb)

Anatomy
One tendon in sheath (FPL)
A1 and oblique pulley

Repair
Surgery more difficult
Adhesions at repair site
Bulk of repair

Treatment (Zone III)

Primary or delayed primary

Preserve A1 or oblique pulley

Postoperative
Protective dorsal splinting
Dynamic splinting

Treatment (Zone IV)

Anatomy
9 tendons, one nerve

Both FDS and FDP

Assoc injuries

Associated N/V injury

Repair everything
May need to delay motion to protect
N/V repair

Median n, palmar arch, ulnar motor branch

"Flexor Tendon Injuries", Dr. Mark A. Deitch, M.D., Johns Hopkins University, Presented at the Orthopaedic
Review Course, Baltimore, June, 2003

Treatment (Zone V)
Anatomy

Profundus Tendon Avulsion

Avulsion from P3

Proximal to wrist crease: multiple

structures

Primary or Delayed primary

>3
- 4weeks: myostatic contraction
Makes end to end repair impossible

Forced extension of DIP with FDP

contraction

Athletes
Ring finger most common
Dx often missed
Sx: Pain, swelling, lump in finger or
palm
Loss of DIP flexion

Jersey Finger

FDP Testing

FDP Avulsion
Classification (Leddy & Parker)

FDP Avulsion
Classification (Leddy & Parker)

Type I
Retracts to palm, prox to A1
No vincular attachment
No flexion at DIP, excellent PIP flexion
Tender mass in palm
Repair within -7 10 days

Type II
Most common
Tendon retracts to PIP joint
Vincula at PIP intact

Occasionally small bone fleck

Pain, swelling, tenderness at PIP
Repair early, but may delay up to 3 months
May convert to Type I

"Flexor Tendon Injuries", Dr. Mark A. Deitch, M.D., Johns Hopkins University, Presented at the Orthopaedic
Review Course, Baltimore, June, 2003

FDP Avulsion
Classification (Leddy & Parker)

FDP Avulsion
Late Treatment

Type III
Large bony fragment prox to DIP joint
Tendon caught at A4 pulley
Both vincula intact
Swelling, ecchymosis, tenderness at P2,3
No flexion at DIP
Repair early with ORIF

Delayed Free Tendon Grafting

Rationale

No treatment if stable, good motion

DIP arthrodesis if unstable
Late reconstruction with graft

Free Tendon Graft

Technique
Harvest tendon

Primary repair impossible

Delayed presentation with contracture
Poor wound base

Prerequisite
Benign wounds (3
- 4weeks healing)
Normal full PROM

Free Tendon Graft

Method of Proximal Juncture
Bunnell crisscross suture
Grasping suture (Kessler)
Pulvertaft weave
Outside flexor sheath
3 passes in perpendicular planes
Stronger than end
- to
- end repair
Easier to establish tension

Atraumatic handling and passage

through pulleys
Proximal and distal repairs

Donor Tendons
Palmaris Longus
Present in 85% population
Wide variation in size/length
Enough for one palm
- to
- fingertip graft

Plantaris
Present in 80
- 93%
Multiple grafts or one long graft

Long toe extensors (2,3,4)

FDS (same hand); EIP; EDM; allograft

"Flexor Tendon Injuries", Dr. Mark A. Deitch, M.D., Johns Hopkins University, Presented at the Orthopaedic
Review Course, Baltimore, June, 2003

Free Tendon Grafts

Complications
Adhesions
Rupture
Hyperextension at PIP
if FDS slip used

Staged Tendon Reconstruction

Indications
Extensive injury
Failed primary tendon repair
Late presentation
Extensive scarring of tendon bed
Loss of retinacular pulley system

Staged Tendon Repair

Complications

Staged Tendon Repair

Stage I
Excision of damaged flexor tendons
Implantation of silastic rod
Induces formation of pseudosheath
Active and passive implants

Stage II
3 months after Stage I

Implant synovitis
Infection
Extrusion of silastic rod
Breakdown of repair
Pulley breakdown
Late flexion deformity

Removal of silastic rod

Replacement with free tendon graft

Pulley Reconstruction
Prevent bowstringing
Loss of pulley decreases efficiency of
flexor tendons
A2, A4 most important
Reconstruct with palmaris longus