Flexor Tendon Injury

Dr. Bestin
• Hippocrates- called it nerve
• Galen- Not to suture - Convulsions
• Mayer- blood supply and avascular zones of
tendon
• Bunnel- No man’s land
• Verdan- Zones of flexor tendon repair
• Kleinert - revolutionized the primary repair of
acute flexor tendon injuries in the digital
sheath.( modified Bunnels)
 Tendon Anatomy
• Has no inherent contractile property
• Links muscle to bone causing joint motion.
• Microscopy: collagen bundles arranged in
spiral pattern
• Type 1 collagen with minimal T3, T4 and
elastin.
 Anatomy
• Verdan classified flexor tendon injuries based
on the location.
• 1A- very distal FDP tendon (<1cm), not able to pass
core suture
• 1B- 1A to distal margin of A4 pulley
• 1C- FDP tendon within A4 pulley

• 2A- area of FDS insertion

• 2B- proximal margin of FDS insertion to distal
margin of A2
• 2C- area covered by A2 pulley
• 2D- proximal margin of A2 pulley to proximal
reflection of digital sheath
• 9 Flexor tendons arranged as 3 layers as they
approach the carpal tunnel

1-FDS MF,RF
2-FDS IF, LF
3-FPL FDP
• At the base of fingers FDS divides (A2 pulley
area) to allow FDP to pass through them.
• The 2 slips of FDS course laterally and
DEEPER to FDP
• FDS rejoins at the campers chiasm and and
insert to middle of middle phalanx to flex PIP
• Lumbricals originate from FDP, passes volar to
MCP joint and Dorsal to IP joint and inserts to
proximal phalanx… FlexesMCP, extends IP.

• FDP inserts to base of distal phalanx.

 Nutrition
• Extrinsic- Synovial fluid

• Intrinsic- Longitudinal vessels in endotendon

Vessels at osseous insertion
Vincula
• Digital fibro osseous sheath
• Synovial lined canal
• Originates from periosteum
• Encloses, nourishes, lubricates flexor tendons
• From DIP to Distal palmar crease
• Pulleys:
• Thickened synovial sheath. They keep the tendon
attached to bone.
• Prevents bowstringing.
• 5 Annular, 3 Cruciate, 1 palmar aponeurosis pulley
• A2 , A4 preserved to prevent bow stringing.
• Even 25% deficiency in critical pulleys- bowstringing
• A1- MC site of stenosing tenosynovitis- trigger finger
• Thumb has 2 annular pulleys ( proximal and
distal phalanx) and an oblique pulley between
them.
• Incising ½ or 2/3 of A2 pulley or entire A4
pulleys- NO bowstringing
• Decreases resistance to tendon motion
 Flexor tendon healing
• Intrinsic and Extrinsic
• Intrinsic – proliferation of tenocytes and
production of ECM by intrinsic cells

• Extrinsic- growth of tissues or cell seeding

from outside. ( adhesions)
 Biomechanics
• Excursion- The distance a tendon slides along
its path.
• Affected by contractures, adhesions
• Increased by exercise, stretch
• FDP – 32 mm
• FDS – 24 mm
• With wrist motion, FDP -50mm, FDS 49 mm.
• MOMENT ARM
• The distance the tendon lies from the joint-
moment arm
• As the moment arm increases, less tension is
required to move the joint, but the range of
motion of the joint is reduced.
• Moment arm vs Tension- Torque delivery
• An increase in moment arm from 1.0 to
1.5 cm results in a loss of joint motion of 30 deg.
• By keeping moment arms smaller, the pulleys
decrease some of the available force for joint
movement but make it easier for precise
control of the fingers.
 Biomechanics
• Force in normal hand movements -35 N
• Two strand repair with epitendinous - 20-30N
• 4 strand repairs – 40 N
• 6 strand repair – 50-60 N
 Principles of Repair
• Repair is to be strong to resist gap formation (3mm).
• Technique must be smooth
• Tendon edges mustn’t be bunched up.
• Repair within 72 hrs
• Adequate exposure ( Bruners/ Mid lateral)
• Avoid excessive manipulation of the tendon
• Cut ends must be grasped only at the core to prevent
epitenon injury- adhesions.
Factors affecting strength of repair
 Diagnosis
• Assume every structure is damaged
• History:Mechanism
• Disruption of normal flexion cascade
• Impaired sensation
• Test FDS, FDP
• Pain or weakness in flexion- partial cut
• Xray
• Usg
 Repair
• Primary – 24 hrs
CI- contamination ( human bite, infection,
bony injuries of joints, extensive soft tissue
loss)
• Delayed Primary- 1-14 days
• Early secondary- 2- 5 weeks
• Late secondary- >5 weeks
( tendon grafting, tendon transfer,
tenodesis)
 Zone 1
• Only FDP
• Expose proximal and distal cut ends
• Try suturing
• If less than 1cm of distal FDP stump, proximal
tendon is advanced to decorticated distal
phalanx and sutured dorsally over the nail with
a button.
Zone 2
• Proximal end may need to retrieved from
palm.
• Atraumatic tendon handling
• Ragged edges to be debrided
• 3-0 or 4-0 core
• 6-0 epitendon
• Repair strength decreases by 50 % between
day 5- 21
• incision of one single annular pulley (A1, A3,
or A4) or a critical part (up to two-thirds of its
length) of the A2 pulley does not significantly
affect tendon gliding when all other pulleys or
the synovial sheath are intact.
 Zone 3 4 5
• Better prognosis
• Neurovascular injury common
• Spaghetti wrist- (10/15)
adverse effect on recovery of FDS
• Partial tendon laceration less than 60 %
diameter need core suturing.
• Tendon edges to be trimmed to lessen
entrapment and epitendinous stitches done.
 Post op
• Early active mobilization is the present trend.
• Should not exceed critical rupture force
• Passive motion without resistance -500g
• Light grip- 1500g
• Strong grip- 5000g
• Active extension to prevent PIP contracture
and passive flexion are encouraged from POD
1
• After 2-3 wks- place and hold no power
and protected passive motion to maintain joint
mobility and avoid contractures PIP

After 4 wks : active tendon gliding

Protective splinting upto 8 wks
Exercises continued upto 12 wks
 Belfast Sheffield
• Splint wrist 20 F, MP 80 F, IP Extension
• 24 hrs after repair in zone 3
• 48hrs after zone 2
• Four hourly 2 repetitions
• Full passiveF, Active F, Active E
• 1st week goal: Full PF, Full AE,
AF 30PIP 10 DIP
• 4-6 wks: splint discontinued, treat flexion
contractures with dynamic extension splint.
• Protected passive IP joint extension is done
with MP in flexion.
 Complications
• Disruption of repair: Repair strength decreases
by 50 % between 1-3 weeks if tendon is not
stressed.
• Quadriga effect: excessive FDP tendon
shortening causing flexion deformity of
repaired finger with incomplete flexion of
other fingers.
• Excessive tendon length: Lumbrical Plus
finger- extension of IP joints
• Adhesions
• Joint stiffness
• Tenolysis is done usually 3-6 moths after
repair.
• Diagnosed when passive motion > active
motion.