Flexor tendon injuries

Dr Tanmayee Thite
Department of Hand surgery -CMCH
 Historical perspectives & Contributions.
 Anatomy & Physiology.
 Biomechanics & Clinical applications.
 Techniques & Rehabilitation.
 Complications.
“No man’s land”
-Bunnell

“Critical zone”
-Boyes
  Verdan et al 1960-1987 First report of successful primary tendon
repair within digital sheath

 Kleinert -1967 report on repair of ZONE II injuries to ASSH

 Bruner 1967-1975- Skin incisions Zigzag volar approach to digital

sheath

 Kessler et al 1969-1987 - Core suture technique

Contributions
 Lundborg- “intrinsic” tendon healing, detailed vascularity.

 Leddy et al 1977-1993- Classification of FDP avulsions

 Strickland 1982-present - studies of flexor tendon repair and et al

rehabilitation

 Silfverskiöld 1983-1994- Tendon repair site gap formation and et al

rehabilitation
Pre 1960 era
 No antibiotics
 No magnification/
instruments
 Concepts of healing and
repair in evolving stage
 Post operative mobilization
concept
Post 1960 era
 Prophylaxis
 Microscope/instrumentation,
suture materials
 Newer concepts of healing,
 Controlled active motion and
rehabilitation.
Goals
 Accurate coaptation ensuring successful postoperative
rehabilitation.
 Repair that inhibits peritendinous adhesions, stimulates
restoration of the gliding surface, allows for primary (INTRINSIC)
healing.
 Restoration of normal range of finger motion.
 Soluble
tropocollagen

Insoluble collagen
molecules forming
microfibrils,
Tendon
anatomy fibrils

fibers.
(bound by epi- &
endotenon.)
Tendon  Intrinsic healing: proliferation of tenocytes and production of
extracellular matrix by intrinsic cells.
healing :  Extrinsic healing: growth of tissues or cell seeding from outside
the tendon.

“Concept of  Conceptually, extrinsic healing does not equal adhesion formation.

However, it is extrinsic healing in the form of restrictive adhesions
intrinsic that hampers tendon function.

healing"
(A) Mobilized tendon
that is healing by cellular
ingrowth from the
epitenon.

(B) Immobilized
tendon healing by
adhesion and endotenon
cellular in- growth.
 Flexor digitorum superficialis
 The FDS muscle has two heads of origin. The ulnar head arises
from the anterior aspect of the medial epicondyle, the ulnar
collateral ligament of the elbow, the medial aspect of the coronoid
process, and the proximal ulna. The radial head arises from the
proximal radius immediately distal to the insertion of the
supinator muscle and lies deep to the prona- tor teres.
 At the level of the mid-forearm, the FDS muscle divides and sends
tendons to the middle and ring fingers (superficial) and the index
and small fingers (deep)
 Flexor digitorum profundus
 The FDP muscle belly arises from the volar and medial aspects of
the proximal three fourths of the ulna and from the interosseous
membrane.

 The flexor pollicis longus (FPL) tendon arises from the volar aspect
of the middle third of the radial shaft and from the lateral aspect
of the interosseous membrane.
Carpel tunnel

 The tendons of the nine digital flexors enter the proximal aspect of the
carpal tunnel in a fairly constant relationship.
 Most superficial tendons : FDS tendons to the long and ring fingersthen
index and little fingers. Deepest layer :four tendons of the FDP & FPL
  Periosteal attachments
 Vincula
Tendon  Synovial diffusion between vinculae
nutrition  Palmar and digital arteries
*Vincula of FDS to FDP : prevents migration , assists nutrition,
preservation advocated during repairs; FDS repair indicated along
with FDP when both injured i/v/o its supply to FDP through vincula
.
  Flexor tendons glide within the digital synovial flexor sheath that
has interwoven condensed fibrous bands (“pulleys”).
 The synovial sheath is a thin layer of continuous smooth
paratenon covering the inner surface pulleys (condensed, rigid,
Flexor sheath : and heavier annular bands) and cruciate pulleys (filmy cruciform
Synovial + bands)
Retinacular  The A1, A3, and A5 pulleys originate from the palmar plates of the
MCP, PIP and DIP joints; A2 and A4 pulleys originate from the
aspects middle portion of the proximal and middle phalanges respectively.
 The palmar aponeurosis pulley (A0). Loss of motion associated
with transection of the A1 or A2 pulley is insignificant as long as
the PA pulley remains intact.
 Flexor tendon zones of fingers:

Anatomy 1st : Distal to FDS insertion; FDP, A5 & C3 pulleys

2nd : proximal to A1 to FDS insertion; both tendons, A2,C1,A3,C2 ,A4
3rd :distal to transverse carpal ligament at orgin of lumbricals from FDP/
superficial palmar arch to A1 pulley entrance.
4th : below the transverse carpal ligament.
5th : Musculotendinous junction to prox part of TCL.

Thumb:

1st : Tip to neck of prox ppx- FPL insertion,

2nd : prox of A1 to neck of prox ppx- A1, oblique & A2 pulleys.
3rd: flexor retinaculum to prox margin of A1
4th & 5th correspond to those of fingers

The subdivisions of zone 1 by Moiemen and Elliot are:
• 1A: the very distal FDP tendon (usually <1 cm), not
possible to insert a core suture
• 1B: from zone 1A to distal margin of the A4 pulley
• 1C: the FDP tendon within the A4 pulley.
 The subdivisions of zone 2 by Tang are:
 • 2A: the area of the FDS tendon insertion
 • 2B: from the proximal margin of the FDS
insertion to the distal margin of the A2 pulley
 • 2C: the area covered by the A2 pulley
 • 2D: from the proximal margin of the A2
pulley to the proximal reflection of digital
sheath.
 At carpal tunnel region, FDS of middle and ring volar /superficial.
 At midportion of proximal phanlanx (A2 pulley region), FDS splits and lies dorsal to FDP and
rejoins to form Camper’s chiasm (fibrous interweaved connection between two slips) & inserts in
prox+mid parts of middle phalanx as two separate slips.
 FDP & FPL insert in their respective volar distal phalanx bases.
Clinical
assessment of
FDS,FDP & FPL
Tendon repair
and
Biomechanics
  Forces generated during normal hand action range from 1 to 35 N.
 Conventional two-strand core repairs plus running peripheral
sutures yield a maximal strength from 20 to 30 N;this is lower than
Biomechanics forces generated during normal hand actions and explains why
some repairs are disrupted during postoperative motion exercise.
and Gliding  Studies showed that failure forces of four-strand repairs are
around or beyond 40 N
 Six-strand repairs fail with loads over 50–60 N.
  A core suture purchase of at least 0.7 to 1.0 cm is necessary to
generate maximal holding power.
 Light tension in the core sutures is necessary to resist gapping at
the repair site.
Biomechanics  A locking tendon–suture junction is generally better than a
and Gliding grasping junction in terms of holding power. Diameter of the
suture locks must reach or exceed 2 mm.
 Core suture purchase (>1.2 cm) and locking repairs for an obliquely
cut tendon. Strength >> Increasing suture calibers. Clinically, the
caliber of suture used in adults is either 3-0 or 4-0.
  Repairs with cross- or circle-locks appear slightly stronger than
Kessler-type repairs with Pennington locks. Pennington locks
provide a looser junction than cross- or circle-locks.
 Also , the repair fails more easily in the flexed finger under
curvilinear loads.

Biomechanics
and Gliding
  Incision of the A2 pulley ½ or 2/3 rd’s length (< 2cm) / entire A4
pulley / entire A3 = no bowstringing and little loss of digital flexion.
 Partial A2 incision decreases resistance to tendon motion and
Biomechanics lessens the chance of repair failure.
and Gliding  Lengthy sheath cut adjacent to the A3 pulley, containing the C1 or
C2, causes tendon bowstringing.
Timing of
repair
Indications

• Clean-cut tendon injuries

• Tendon cut with limited peritendinous damage, no defects in soft-
tissue coverage
• Regional loss of soft-tissue coverage or fractures of phalangeal
shafts are borderline indications
• Within several days or at most 3 or 4 weeks after tendon laceration

Contraindications

• Severe wound contamination..human bites, cellulitis

• Bony injuries involving joint components or extensive soft-tissue
loss
• Destruction of a series of annular pulleys and lengthy tendon
defects
• Experienced surgeons are not available
 • The midlateral incision prevents scar formation directly over the
tendon, is less likely to breakdown during physiotherapy but
requires surgical dissection directly over the neurovascular
bundle.
• Bruner's zigzag incision provides excellent surgical exposure but
there may be scar formation directly over the tendon and may
break in case of infection thereby affecting the physiotherapy.
Approach /
Incisions
Leddy and
Packer
classification
of FDP
avulsions
Zone I injury
repair
Atleast 1 cm required for
end to end
or traditional pull out or
anchor techniques.

Tendon securing in bony

footprint is necessary
Multiple core
suturing
techniques
  Acute repair of zone 2 flexor tendon injuries is indicated when
there is a clean- cut injury with the following:
 Complete or Partial tendon injury involving greater than 50% of
the tendons of FDP/FDS .
Zone II injury  A tendon defect of up to 1 cm can be repaired by end-to-end
suturing.
 Greater losses (up to 2 to 3 cm) may need an intramuscular tendon
lengthening via forearm incisions, and larger tendon gaps will
need tendon grafting.
  Debridement
 Retrival of tendon ends ( Sourmelis and McGrouther feeding tube
Selective release method)
of pulley’s  Assessement of excursion and release of adhesions
 Core and peripheral suture repairs.
 In palm, tendon release first followed by nerve and artery
 In forearm, arterial repair first,tendon repairs second, and the
nerve repairs last.
 The tendon repairs are started from the deepest tendon that is
lacerated, and the progression of repairs is to the most superficial
tendon that is lacerated.
  Excursion, measured in millimeters, is best described as the total
amount of glide that a point on the tendon travels during range of
Post operative motion.
rehabilation  Widely excepted -Duran and Houser protocol, 3 to 5 mm of tendon
excursion was sufficient to prevent restrictive adhesions after
repair.
Boyes grading
for decision of
staged
reconstruction
- Staged
reconstruction
beyond 2nd grade.
Carroll first described the
use of silicone rod for use
in two stage flexor tendon
reconstruction in 1963.

The technique was

modified by Hunter in
1970.

The indications for

secondary tendon
reconstruction are:
failed primary repair,
neglected injuries,
segmental tendon loss
and complicated injuries
• Palmaris longus is the most commonly preferred graft ,is absent in 25% of the population.
The approximate useable length is 16cm hence short length if repair is done in forearm.

• Plantaris is the second most commonly used tendon. It is absent in 20% of the
population.The approximate usable length is 35 cm and because of its thinness it can be
passed easily through the newly constructed tendon sheath.

• The long extensors of foot (middle three extensors) and flexor digitorum longus of second
toe have been used with little morbidity of the toes, however they are difficult to pass with
newly constructed sheath.
.
• Flexor digitorum longus of 2nd toe is the only intrasynovial tendon, (adhesions are expected
to be lower) because of intrasynovial property,is usually 12-13 cm long .

• Extensor indicis proprius is another graft that can be used with little morbidity of the second
metacarpophalangeal joint.
  Rupture of tendon/ repair.
 Stuck or adherent tendon.
 Musculotendinous shortening especially FPL thumb.

Complications  Extensor tethering.

Incidence 5% each in  Joint contractures.

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