ANATOMY OF FLEXOR TENDONS

OF HAND AND MANAGEMENT OF

FLEXOR TENDON INJURIES
 ANATOMY
The tendons of the nine digital
flexors enter the proximal
aspect of the carpal tunnel
The most superficial tendons
are the FDS tendons to the long
and ring fingers.
Immediately beneath them are
the FDS tendons to the index
and little fingers.
In the deepest layer are four
tendons of the FDP and the
FPL.
 Anatomy
Flexor tendon system consists of intrinsic and
extrinsic components
Extrinsics:
FDP: flexing the DIP joint
FDS: Flexing the PIP Joint
FPL: Flexing the IP joint of the thumb
Intrinsics:
Lumbricals: Flex the MCP joints and Extend the IP joints
 FDP inserts on base
of distal phalanx
FDS inserts on sides
of middle phalanx
FPL inserts on
proximal portion of
the distal phalanx
DIGITAL FLEXOR SHEATH
Closed synovial system membranous
- retinacular
Memb visceral and parietal layers
Retinacular cruciform, annular and tranverse patterns.
Function 1) smooth gliding
2) fulcrum for flexion
3) nutrition
 FDP and FDS tendons have fibrous sheaths on the palmar
aspect of the digits
Extent: anterior to MCPJ to the distal phalanges;
DIGITAL FLEXOR SHEATH

Consist of SYNOVIAL SHEATH and PULLEYS(inter woven

condensed fibrous bands
SYNOVIAL sheath is thin layer of continous smooth paratenon,
covering the inner surface of fibrous sheath.
Provide smooth surface for tendon gliding
Provide nutrition to tendon
PULLEY SYSTEM is unique consists of annular pulley and
cruciate pulleys
pulleys
5 annular pulleys and 3 cruciate pulleys
Annular pulleys are heavier,condensed and rigid
A1 A3 A5 originates from palmar plate of MCP PIP DIP joints. A2
A4 from proximal and middle phalynx
A2 is the broadest one,and encompasses the bifurcation of fds
Maintain the anatomical path of tendons close to bone and joints,
optimising the mechanical efficiency of digital flexion
 Thumb has 3 pulleys ;A1, oblique and A2
A1 and oblique are fuctionaly imp
A1 pulley located palmar to MCP jnt,
Oblique pulley over proximal phalynx .
A2 near the site of incertion of FPL
 Function: increase the
mechanical efficiency by
preventing bowstringing
PULLEY BIOMECHANICS
Campers Chiasma

FDS lies superficial to FDP upto bifurcation of FDS at

the level of MCP J. Then FDS tendon becomes 2 slips
coursing laterally and then deeper to the FDP
tendons .This FDS bifurcation is in the A2 pulleys area .
this part of FDS also serves to constrain the FDS tendon.
Deep to FDP tendon the FDS slips rejoin to form
CAMPERS chiasma and distally Insert as two separate
slips on the volar aspect of the middle phalanx.
Tendon Morphology
70% collagen (Type I)
Extracellular components
Elastin
Mucopolysaccharides (enhance water-binding
capability)
Endotenon around collagen bundles
Epitenon covers surface of tendon
Paratenon visceral/parietal adventitia
surrounding tendons in hand
Tendon Nutrition
Vascular
Longitudinal vessels
Enter in palm
Enter at proximal synovial fold
Segmental branches from digital arteries
Long and short vinculae
Vessels at osseous insertions
Synovial fluid diffusion
Imbibition
Tendon Nutrition

Avascular zones
FDS (over proximal
phalanx
FDP (over middle
phalanx)
Nutrition vital for rapid
healing, minimization
of adhesion and
restoration of gliding
Vincular System
Flexor tendon receives
blood supply within
the tendon sheath
Each tendon is
supplied by a short
Vinculum (Vinculum
Breve) and a long
Vinculum (Vinculum
Longus
VBP arises from distal transverse
digital artery at DIP
VBS & VLP from Central
Transverse digital artery at PIP
VLS arises just distal to MCP
from proximal transverse
 Flexor tendon healing
2 forms:

Intrinsic healing:

From prolifaration of tenocytes and extracellular matrix

from intrinsic cells. occurs without direct blood flow to the
tendon
Intrinsic healing is innately weaker then extrinsic healing
If intrinsic capacity is disabled such as in excessive trauma,
or in case of post surgical immobilisation extrinsic healing
is favoured
 Extrinsic healing:

occurs by proliferation of fibroblasts from the peripheral

epitendon; adhesions occur because of extrinsic healing of the
tendon and limit tendon gliding within fibrous synovial sheaths
Phases of Intrinsic healing
1.Inflammatory (0-5 days) : strength of the repair is
reliant on the strength of the suture itself
2.Fibroblastic (5-28 days) : or so-called collagen-
producing phase
3.Remodelling (>28 days)
ZONES
Sterling Bunnell Proximal, Middle, Distal

Modified by Claude E. Verdan- 5 Zones

I Profundus tendon from insertion of FDS in P2 to insertion

of FDP in P1.
II Bunnells No Mans Land upto proximal edge of A1 pulley
or distal palmar crease..
III distal edge of carpal ligament to A1 pulley the Lumbrical
zone
IV Carpal tunnel with 9 tendons and median nerve.
V tendon origin to proximal edge of carpal tunnel.
Sub-divisions of Zone 2 - Tang
2A : Distal margin of FDS insertion to proximal margin
2B: From proximal margin of insertion to distal border of
A2 pulley
2C: A2 pulley area, narrowest part
2D: Proximal border of A2 to proximal margin of A2
 ZONE II-NO MANS LAND

From metacarpal head to middle phalanx

Called so because initial attempts for tendon repair
here produced poor results
FDS and FDP within one sheath
Adhesion formation risk is amplified at campers
chiasma
Tendon injury -Etiology
Open/ closed injuries
Open injuries ass. With neurovascular def.
Closed forced extension and active flexion
FDP avulsion - Jersey finger
Fracture ends
Tendon injury-Pathophysiology
Synovial fluid gives nutrition
Stiff joints limit motion
Adhesions restrict excursion
Pulley system loss esp of A2, A4 cause bowstringing.
Bowstringing increases moment arm requiring greater
excursion for given flexion
This leads to weak grip and stiff joints
Clinical examination
Initial Finger position
Natural position composite cascade
FDP DIP jt extended
First to get cut will be FDP
Both FDP FDS flat extended
Partial lacern presents with pain when flexed against
resistance.
FDS examination
Adjacent finger DIPs, PIPs, and MCPs are held in full
extension to eliminate FDP action
Ask patient to actively flex at PIP
Perform each finger seperately
Can not rule out partial tendon injury
FDP examination
Isolate DIP joint by grasping middle phalanx
Ask patient to flex DIP
FPL
Stabilise the MCP
joint

Ask the pt to flex IP

joint
Imaging studies
X-ray for fractures, foreign bodies
Ultrasound and MRI for correct delineation of annular
pulleys.
 Goals of reconstruction
anatomical repair

multiple strand repair to permit active range of motion

rehabilitation

Pully reconstruction to minimize bow-stringing

atraumatic surgical technique to minimize adhesions

strict adherence to rehabilitation protocol.

Minimal dissection and handling

Tendon apposition without gapping
Early protected mobilization
 Timing of flexor tendon repair:

Primary: repair within 24 hours (contraindicated in case of high grade

contamination i.e. human bites, infection)

Delayed Primary: 1-10 days when the wound can be still pulled open
without incision

Early Secondary: 2-4 weeks.

Late Secondary : after 4 weeks

 No repair if less than <25% laceration,

only epitenon repair in 25-50% lacerations,

core suture plus epitenon repair when >50% laceration

Dorsal blocking splint for 6-8 weeks as conservative

measure
 Repair Techniques
Ideal
Gap resistant
Strong enough to tolerate forces generated by early
controlled active motion protocols
10-50% decrease in repair strength from day 5-21 post repair in
immobilized tendons
This is effect is minimized (possibly eliminated) through application
of early motion stress
Uncomplicated
Minimal bulk
Minimal interference with tendon vascularity
Suture Materials
Core Non-absorbable 4/0 suture
Different configurations
6/0 monofilament running epitenon
suture.
3-0 prolene or mersilene suture
Incisions
Bunnel midlateral incision
Littler diamonds of skin contact in flexion
Brunner zig-zag incision
Midlateral incision
Flex jt. Points on crease ends. Line joining them marks
incision.
put incision anterolateral to n/v bundle they lie 2mm
volar to incision.
Suture Configurations
Core sutures
Epitenon sutures reduce bulk and increase strength

Core sutures
- careful handling and alignment of tendons
- more dorsal suture placement better outcome
- More sutures crossing the interaction site, more strength
- lacerations involving more than 60 % cross-section of the tendon
should be repaired
- 4-0 sutures like polyester most commonly used
Core Sutures
Current literature supports several conclusions
regarding core sutures
Strength proportional to number of strands
Locking loops increase strength but may collapse and
lead to gapping
Knots should be outside repair site
Increased suture caliber = increases strength
Braided 3-0 or 4-0 probably best suture material
Dorsally placed suture stronger and biomechanically
advantageous
Equal tension across all strands
Core Suture Techniques

Bunnell stitch
Crisscross stitch

Robertson and Al-Qattan

Mason-Allen stitch Interlock stitch
Kessler stitch Modified Kessler

Tajima modification
Of kessler stitch with
double loop at repair
site
Sheath repair

Advantages:
barrier to the formation of extrinsic adhesions
quicker return of synovial nutrition
better tendon-sheath biomechanics
Disadvantages:
technically difficult
may narrow and restrict tendon gliding
ZONE 1
contains: A4, C3, and A5 pulley
A4 pulley must be preserved
most injuries are due to lacerations
loss of active flexion of distal phalanx
hyperextension instability of distal IP
unstable pinch
If trapped at Campers chiasma, PIP mobility affected
 ZONE 1
Repair primarily
Tendon advancement and primary repair to bone
Advance 1 cm
More than 1 cm; quadriga effect
Old cases: tendon grafting, arthrodesis, tenodesis
Quadriga
over advancement of the FDP following tendon rupture
or repair
proximal FDP adhesions
arthrodesis of PIP joint of ring and long fingers
weak grasp in remaining fingers due to FDP tethering by
scar at amputation site
if one FDP is tethered, the others can not shorten
loss of flexion in other digits and patient may be unable
to make a full fist
Tendon Advancement
Previously advocated for zone 1 repairs, as moving the repair
site out of the sheath was felt to decrease adhesion formation
Disadvantages
Shortening of flexor system
Contracture
Quadregia effect
Little excursion distally, therefore adhesions near insertion less of an
issue
FDP Avulsions
Commonly male athletes
Forced extension at DIP during maximal flexion (jersey
finger)
Often missed due to normal xray and intact flexion at
MP and PIP
Opportunity for FDP reinsertion lost if treatment delayed
 Leddy classification
Type I: retraction into the palm
Repair in 7-10 days due to disrupted vascularity
Type II: retraction to PIP joint(small bony
fragment retracts to A3 level)
Vincula intact, prohibit further retraction
Repair up to 6 weeks
Type III: avulsed with volar lip of P3
Can not retract past A4 pulley (DIP joint)
Repair up to 6 weeks
Type IV: tendon avulsed off bony fragment
 Pull out wire technique-osteoperiosteal flap distal to VP
30 prolene thru distal edge in Bunnel weave pattern
drill hole thru P3 exiting thru sterile matrix
with Keath needle pass suture thru hole
tie prolene over felt or button
After healing prolene can be pulled out
Pull out wire technique
Zone II: no mans land
Historically poor results
Adhesions, limited motion
Fraught with complications
ZONE 2
Fibro osseous tunnel
FDS becomes deep splitting to enclose the FDP and
reunite beneath in the Campers chiasma only to
redivide again to attach to the middle phalanx
n/v injury should be examined for
FDS is repaired first - FDP repaired next.
Suturing should be intratendonous configuration
Sheath repair is done next
ZONE 2
retaining FDS increases the gliding resistance of FDP
and hence resection of the FDS atleast one of the two
slips should be performed.
The single most important factor preventing smooth
excursion of the FDP is a repaired FDS.
ZONE 3
tendons essentially free of tendon sheath
may affect lumbricals - damaged lumbrical is either
repaired or excised depending on severity
lumbricals are intact, it is left adjacent to FDP repair; - it
is not wrapped around the repaired flexor
- lumbrical contracture is avoided if this muscle is not
tightened
if both tendons are lacerated, both are repaired
ZONE 4
combined nerve - tendon procedure may be delayed for
21 days
Associated with partial or complete laceration of median
nerve
nerves should be repaired first and the tendons last
tension is removed from nerve suture line by flexing
wrist 30 deg and MP joints 60 deg
ZONE 5
Common site suicidal cuts
Matching of ends is the problem
Glutinous mass of blood stained synovium
Perform a thorough synovectomy
Distal ends identified easily
Proximal ends: all pass thru a space that occupies only
3 cm to the ulnar side of median nerve.
ZONE 5
TENDONS LIE IN 3 LAYERS
No two tendons have identical cross
section
Angle of laceration will be diff for each
Approximation of identical tendon ends
should restore the normal balanced posture
of hand and without undue tension
Repair has a better prognosis
When multiple tendons injured avoid
epitenon sutures
THUMB
Zone 1: contains A2 and Oblique pulleys
Most injuries occur at level of ip crease FPL insertion area
Extend skin laceration
Z cut on the sheath
Proximal edge often retracts into the thenar eminence or
wrist lacks vinculum, lumbrical!!
Tendon sheath is narrow in the thenar region
Zone 2 : thenar muscles and recurrent branch of median
nerve injury possible.
 Tenolysis
Tendon transfer
Primary tendon graft
Two stage tendon graft
Tenolysis

Release of nongliding adhesions for salvage in

poorly functioning digits with previous tendon injury
Avoid in marginal digits
May not tolerate additional vascular/neurologic
injury
May need concomitant collateral ligament release,
capsulotomy
Single Stage Tendon Grafting

Indications
injuries resulting in segmental tendon loss.
Delay in repair that obviates primary repair, such as laceration
that have been neglected for 3 to 6 weeks and show tendon
degenerations
Zone 2 injury where large section of tendon have been
damaged and surgeon believes delayed grafting is better option
Delay presentation of FDP avulsion injury associated with
significant tendon retraction
Supple joints with adequate passive ROM
Principles include
Place only one graft in each finger
Never sacrifice intact FDS
Use a graft of smaller caliber
Perform the junctions outside the tndon sheath
Ensure adequate graft tension

Graft donors
Palmaris longus
Plantaris
Long toe extensors
 Before surgery wound should be well healed with no extensive
scarring
Joint should be free of contracture and maximum passive
range of motion should have been attained
Circulation is satisfactory
At least one digital nerve in affected digit is intact

Pts with joint contracture should undergo hand therapy

regimen to achieve maximum possible passive range of
motion
In case of extensive scarring, pulley incompetence, joint
contracture single stage grafting is contraindicated.
 PULLEY RECONSTRUCTION

Must be done during the first stage

Well-healed pulley reconstruction facilitates early mobilization
and gliding of tendon graft
Reconstruction during the second stage increases the
likelihood of pulley rupture and adhesion formation
Material used
Autogenous grafts: PL, Plantaris, to extensors, EIP, Extensor
retinaculum, fascia lata
Postoperative Management
Different Methods

Active Extention-Rubber Band Flexion Method: e.g. Kleinert , and Brooke-

Army

Immobilization

Controlled Passive Motion Methods: e.g. Durans protocol

Strickland: Early active ROM

Kleinert Protocol
Combines dorsal extension block with rubber-band
traction proximal to wrist

Originally, included a nylon loop placed through

the nail, and around the nail is placed a rubber
band

This passively flexes fingers, & the patient actively

extends within the limits of the splint
 Duran protocol
At surgery, a dorsal extension-block
splint is applied with the wrist at 20-30
of flexion, the MCP joints at 50-60 of
flexion, and the IP joints straight
Complications
Joint contracture
Adhesions
Rupture
Bowstringing
Infection
 Thank you