Flexor Tendon Injuries

125

Chapter
William F. Wagner, MD, and
James W. Strickland, MD

1. Should acute flexor tendon lacerations be repaired primarily?

The concept that tendons can be immediately repaired in zones I and II with the expectation of restoring a favorable
amount of tendon excursion has advanced from doubtful theory to general acceptance. Almost all studies have shown
superior results compared with flexor tendon grafting. Advantages of primary tendon repair include the fact that the
tendon is returned to its normal length, the period of disability necessitated by wound healing and later grafting is
reduced, the tendency for joint stiffness is decreased, and the results of secondary lysis, when necessary, should be
better.

2. What is the orientation of the flexor digitorum profundus and flexor digitorum
superficialis tendons at the level of the proximal phalanx?
Once within the flexor sheath, the flexor digitorum superficialis (FDS) tendon begins to flatten. It then splits and divides
around the flexor digitorum profundus (FDP) tendon. The two slips of the FDS tendon reunite deep to the FDP tendon,
with half of the fibers decussating and the other half continuing distally on the same side. The reuniting of fibers of the
FDS tendon is known as the chiasm of Camper. Beyond the chiasm, the FDS tendon splits into radial and ulnar slips,
which insert into the middle three fifths of the middle phalanx (Fig. 125-1).

3. Where does the flexor tendon sheath begin and end in the digit? Where are the
various pulleys or thickened areas of the flexor sheath located?
In the fingers the flexor sheath arises at the level of the volar plate of the metacarpophalangeal (MCP) joint and ends at
the proximal volar base of the distal phalanx. The flexor sheath comprises thickened areas of arcing fibers, referred to as
annular pulleys, which alternate with thin, flexible areas of crisscrossing fibers called cruciate pulleys. The first annular
pulley arises from the volar plate of the MCP joint and the second annular pulley from the middle third of the proximal
phalanx. The first cruciate pulley extends from the distal end of the second annular pulley to the proximal end of the
third annular pulley, which arises primarily from the volar plate of the proximal interphalangeal (PIP) joint. The second
cruciate pulley is located between the third and fourth annular pulleys, and the fourth annular pulley arises from the
middle portion of the middle phalanx. The third cruciate pulley is located between the fourth and fifth annular pulleys,
and the fifth annular pulley arises from the volar plate of the distal interphalangeal (DIP) plate and proximal volar base of
the distal phalanx. It is not always possible to identify all of the described pulleys of the flexor sheath (Fig. 125-2).

4. What are the two ways in which flexor tendons receive nutrition?
Vascular injection studies have long shown the significant role of perfusion via small blood vessel networks called
vincula, which arise from the digital arteries and ultimately connect into an intratendinous vascular network. Other
studies have noted that synovial diffusion is the significant nutrient pathway.

5. What two areas of cellular activity contribute to flexor tendon healing?

Tendons heal by a combination of extrinsic and intrinsic cellular activity. The more intrinsic the cellular activity is, the
fewer the adhesions. Extrinsic cellular activity primarily relates to peripheral adhesions that are frequently associated

FDS

FDP Camper’s chiasm FDS

Figure 125-1.  Early in the flexor sheath, the flexor digitorum superficialis (FDS) tendon divides and passes around the flexor digitorum
profundus (FDP) tendon. The two portions of the FDS reunite at Camper’s chiasm.

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