Introduction:

• Overview
◦ flexor tendon injuries are a traumatic condition classified by the zone of injury (see
table below)
▪ basic concepts in repair are similar for different zones
▪ location of laceration directly affects healing potential
• Epidemiology
◦ incidence
▪ rare
▪ occurs in 4.83 per 100,000
• Pathophysiology
◦ mechanism of injury
▪ commonly results from volar lacerations and may have concomitant
neurovascular injury
◦ pathophysiology
▪ tendon healing
▪ occurs via 2 pathways
▪ intrinsic
▪ produced by tenocytes within the tendon
▪ extrinsic
▪ stimulated by surrounding synovial fluid and inflammatory cells
▪ implicated in the formation of scarring and adhesions
▪ occurs in 3 phases

Phases of Tendon Healing

Phase Days Histology Strength
Inflammatory 0-5 cellular proliferation none
fibroblastic proliferation with disorganized
Fibroblastic 5-28 increasing
collagen
will tolerate controlled active
Remodeling >28 linear collagen organization
motion

Anatomy:
Muscles

• Flexor digitorum profundus (FDP)

▪ functions as a flexor of the DIP joint
▪ assists with PIP and MCP flexion
▪ shares a common muscle belly in the forearm
▪ has dual innervation
▪ index and long fingers are innervated by the AIN of the median nerve
▪ ring and small fingers are innervated by the ulnar nerve

flexor digitorum superficialis (FDS)

▪ functions as a flexor of the PIP joint
 ▪ assists with MCP flexion
▪ individual muscle bellies exist in the forearm
▪ FDS to the small finger is absent in 25% of people
▪ innervated by the median nerve
▪ flexor pollicis longus (FPL)
▪ located within the carpal tunnel as the most radial structure
▪ innervated by the AIN of the median nerve
▪ flexor carpi radialis (FCR)
▪ primary wrist flexor
▪ inserts on the base of the second metacarpal
▪ closest flexor tendon to the median nerve
▪ innervated by the median nerve
▪ flexor carpi ulnaris (FCU)
▪ primary wrist flexor
▪ inserts on the pisiform, hook of hamate, and the base of the 5th metacarpal
▪ innervated by the ulnar nerve

• Camper chiasm
◦ located at the level of the proximal phalanx where FDP splits FDS
◦ Pulley system
◦ digits 1-4 contain
▪ 5 annular pulleys (A1 to A5)
▪ thicker and stiffer than cruciate pulleys
▪ A2 and A4 arise from the periosteum
▪ most important pulleys to prevent flexor tendon bowstringing
▪ A1, A3, and A5 arise from the volar plate
▪ 3 cruciate pulleys (C1 to C3)
▪ collapsible and flexible
▪ allows the annular pulleys to approximate each other during digital
flexion
◦ thumb contains
▪ 2 annular pulleys
▪ 1 interposed oblique pulley
▪ most important pulley to prevent flexor tendon bowstringing
• Blood supply
◦ 2 sources exist
▪ diffusion through synovial sheaths
▪ occurs when flexor tendons are located within a sheath
▪ it is the more important source distal to the MCP joint
▪ direct vascular perfusion
▪ nourishes flexor tendons located outside of synovial sheaths
▪ supplied by the vincular system, osseous bony insertions, reflected
vessels from the tendon sheath, and longitudinal vessels from the
palm
Classification:
Zone Definition Introduction Treatment
I distal to FDS Jersey finger
insertion
II FDS insertion Zone is unique in that FDP and FDS in Direct repair of both tendons followed by early
to distal same tendon sheath (both can be ROM (Duran, Kleinert). This zone historically
palmar injured within the flexor retinaculum). had very poor results but results have improved
crease/proxi Tendons can retract if vincula are due to advances in postoperative motion
mal A1 pulley disrupted. protocols.

III palm (A1 Often associated with neurovascular Direct tendon repair. Good results from direct
pulley to injury which carries a worse prognosis. repair can be expected due to absence of
distal aspect retinacular structures (if no neurovascular
of carpal injury). May require A1 pulley release to avoid
ligament) impingement of the repaired tendon on the
pulley.

IV carpal tunnel Often complicated by postoperative Direct tendon repair. Transverse carpal
adhesions due to close quarters and ligament should be repaired in a lengthened
synovial sheath of the carpal tunnel. fashion if tendon bowstringing is present.

V carpel tunnel Often associated with neurovascular Direct tendon repair

to forearm injury which carries a worse prognosis.

Thum TI, TII, TIII Outcomes different than fingers. Early
b motion protocols do not improve long-
term results and there is a higher re-
rupture rate than flexor tendon repair
in fingers.
Direct end-to-end repair of FPL is advocated.
Try to avoid Zone III to avoid injury to the
recurrent motor branch of the median nerve.
Oblique pulley is more important than the A1
pulley; however both may be incised if
necessary. Attempt to leave one pulley intact to
prevent bowstringing

Presentation:

• Symptoms
◦ loss of active flexion strength or motion of the involved digit(s)
• Physical exam
◦ inspection
▪ observe resting posture of the hand and assess the digital cascade
▪ evidence of malalignment or malrotation may indicate an underlying
fracture
▪ assess skin integrity to help localize potential sites of tendon injury
▪ look for evidence of traumatic arthrotomy
◦ motion
▪ passive wrist flexion and extension allows for assessment of
the tenodesis effect
▪ normally wrist extension causes passive flexion of the digits at the
MCP, PIP, and DIP joints
 ▪ maintenance of extension at the PIP or DIP joints with wrist extension
indicates flexor tendon discontinuity.
▪ active PIP and DIP flexion is tested in isolation for each digit
◦ neurovascular
▪ important given the close proximity of flexor tendons to the digital
neurovascular bundles
Treatment:
• Nonoperative
◦ wound care and early range of motion
▪ indications
▪ partial lacerations < 60% of tendon width
▪ outcomes
▪ may be associated with gap formation or triggering
• Operative
◦ flexor tendon repair and controlled mobilization
▪ indications
▪ lacerations > 60% of tendon width
◦ flexor tendon reconstruction and intensive postoperative rehabilitation
▪ indications
▪ failed primary repair
▪ chronic untreated injuries
◦ FDS4 transfer to thumb
▪ single stage procedure
▪ indications
▪ chronic FPL rupture
Techniques:
• Flexor tendon repair
◦ indications
▪ > 75% laceration
▪ ≥ 50-60% laceration with triggering
▪ epitendinous suture at the laceration site is sufficient
▪ no benefit of adding core suture
◦ fundamentals of repair
▪ easy placement of sutures in the tendon
▪ secure suture knots
▪ smooth juncture of the tendon ends
▪ minimal gapping at the repair site
▪ minimal interference with tendon vascularity
▪ sufficient strength throughout healing to permit application of early
motion stress to the tendon
◦ timing of repair
▪ perform repair within three weeks of injury (2 weeks is ideal)
▪ delayed treatment leads to difficulty due to tendon retraction
◦ approach
▪ incisions should always cross flexion creases transversely or obliquely
to avoid contractures (never longitudinal)
▪ meticulous atraumatic tendon handling minimizes adhesions
◦ technique
▪ core sutures
 ▪ # of suture strands that cross the repair site is more
important than the number of grasping loops linear
relationship between strength of repair and # of sutures
crossing repair
▪ 4-6 strands provide adequate strength for early active
motion
▪ high-caliber suture material increases strength and stiffness
and decreases gap formation
▪ locking-loops decrease gap formation
▪ ideal suture purchase is 10mm from cut edge
▪ core sutures placed dorsally are stronger

▪ circumferential epitendinous suture

▪ improves tendon gliding by reducing the cross-sectional area
▪ improves strength of repair (adds 20% to tensile strength)
▪ allows for less gap formation (first step in repair failure)
▪ simple running suture is recommended
▪ produces less gliding resistance than other techniques

▪ sheath repair
▪ theoretically improves tendon nutrition through synovial
pathway
▪ controversial
▪ clinical studies show no difference with or without sheath repair
▪ most surgeons will repair if it is easy to do
▪
▪ pulley management
▪ historically believef to be critical to preserve A2 and A4
pulleys in digits and oblique pulley in thumb
▪ recent biomechanical studies have shown that 25% of A2 and
100% of A4 can be incised with little resulting functional deficit

▪ FDS repair
▪ in zone 2 injuries, repair of one slip alone improves gliding
▪ compared to repair of both slips
◦ outcomes
▪ repair failure
▪ tendon repairs are weakest between postoperative day 6 and
12
▪ repair usually fails at suture knots
▪ repair site gaps > 3mm are associated with an increased risk of
repair failure
▪ adhesion formation
▪ increased risk with zone 2 injuries
• Wide-awake flexor tendon repair
◦ anesthesia
▪ performed under tumescent local anesthesia using lidocaine with
epinephrine
▪ dosing
▪ usually epinephrine 1:100,000 and 7mg/kg lidocaine
▪ from 1:400,000 to 1:1000 is safe
 ▪ if < 50cc is needed
▪ 1% lidocaine with 1:100,000 epi for a 70kg person
▪ if 50-100cc is needed
▪ dilute with saline (50:50) to get 0.5% lidocaine,
1:200,000 epi
▪ if 100-200cc is needed for large fields (tendon transfer,
spaghetti wrist)
▪ dilute with 150cc saline to get 0.25% lidocaine
and 1:400,000 epi
▪ for longer surgery > 2 hours
▪ add 10cc of 0.5% bupivacaine with 1:200,000 epi
▪ location
▪ proximal and middle phalanges, use 2ml
▪ distal phalanx, use 1ml
▪ palm, use 10-15ml
▪ no tourniquet, no sedation
◦ 4 advantages
▪ allows intraoperative assessment for repair gaps by getting awake
patient to actively flex digit
▪ reduces need for postop tenolysis by allowing intraoperative
assessment of whether repair will fit through pulleys
▪ allows on-the-spot debulking of bunched repairs
▪ allows division of A4 pulley and venting (partial division) of A2
pulleys
▪ allows repair of tendons inside tendon sheaths as patients can
demonstrate that the inside of the sheath has not been inadvertently
caught
▪ facilitates postop early active motion
▪ immobilize for 3 days
▪ begin active midrange motion after day 3 (form a partial fist with
45 degree flexion at MP, PIP and DIP joints, or "half a fist
45/45/45 regime")
◦ Flexor tendon reconstruction requirements
▪ supple skin
▪ sensate digit
▪ adequate vascularity
▪ full passive range of motion of adjacent joints
◦ techniques
▪ single-stage procedures
▪ only perform if the flexor sheath is pristine and the digit has full
ROM
▪ two-stage procedures
▪ Hunter-Salisbury
▪ Stage I - SR is placed to create a favorable tendon bed
▪ Stage II (3-4 months) - SR is retrieved and a tendon
graft is placed through the mesothelium-lined
pseudosheath
▪ pulvertaft weave proximally and end-to-end
tenorrhaphy distally
▪ Paneva-Holevich
 ▪ Stage I - SR is placed in the flexor sheath, pulleys are
reconstructed (as needed), and a loop between the
proximal stumps of FDS and FDP is created in the palm

▪ Stage II - SR is retrieved, FDS is cut proximally and

reflected distally through the pseudosheath and either
attached directly to FDP stump or secured with a button
▪ advantages
▪ graft (FDS) size is known at the time of silicone
rod selection
▪ less graft diameter-rod diameter mismatch
▪ FDS graft is intrasynovial
▪ fewer adhesions than extrasynovial grafts
▪ relies on only 1 tenorrhaphy site (distal or
proximal) to heal at any one time (vs. Hunter
technique where 2 tennoprhaphy sites are healing
simultaneously)
▪ disadvantages
▪ graft tensioning is at the distal end during stage II
▪ the proximal end has already healed after
stage I
▪ graft selection
▪ palmaris longus (absent in 15% of population)
▪ most common
▪ plantaris (absent in 19%)
▪ indicated if longer graft is needed
▪ extensor digitorum longus to 2nd-4th toes
▪ extensor indicis proprius
▪ flexor digitorum longus to 2nd toe
▪ FDS

▪ pulley reconstruction one pulley should be

reconstructed proximal and distal to each joint
▪ pulley reconstruction should occur first if a tendon graft is being
used
▪ methods
▪ belt loop method
▪ FDS tail method
▪
◦ outcomes
▪ subsequent tenolysis is required more than 50% of the time
• Tenolysis
◦ indications
▪ localized tendon adhesions with minimal to no joint contracture and
full passive digital motion
▪ may be required if a discrepancy between active and passive motion
exists after therapy
◦ timing of procedure
▪ wait for soft tissue stabilization (> 3 months) and full passive motion of
all joints
◦ technique
 ▪ careful technique to preserve A2 and A4 pulleys
◦ postoperative care
▪ follow with extensive therapy

Complications:
• Tendon adhesions
◦ most common complication following flexor tendon repair
◦ higher risk with zone 2 injuries
◦ treatment
▪ physical therapy

▪ tenolysis
▪ perform if 4-6 months after tendon repair and significant loss of
excursion

◦ Rerupture 15-25% rerupture rate

◦ treatment
▪ if < 1cm of scar is present, resect the scar and perform primary repair
▪ if > 1cm of scar is present, perform tendon graft
▪ if the sheath is intact and allows passage of a pediatric urethral
catheter or vascular dilator, perform primary tendon grafting
▪ if the sheath is collapsed, place Hunter rod and perform staged
grafting
• Joint contracture
◦ rates as high as 17%
• Swan-neck deformity
• Trigger finger
• Lumbrical plus finger
• Quadrigia