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Extensor Tendon Repair

  • Author: Adam J Rosh, MD; Chief Editor: Erik D Schraga, MD  more...
 
Updated: Apr 29, 2015
 

Overview

The extensor tendons of the hand are in a relatively superficial position; consequently, they are highly susceptible to injury from lacerations, bites, burns, or blunt trauma. Extensor tendon injuries are commonly diagnosed in the emergency department (ED). Certain injuries can be repaired in the ED,[1] whereas others should be repaired by a hand surgeon.

The dorsum of the hand, wrist, and forearm are divided into the following nine anatomic zones to facilitate classification and treatment of extensor tendon injuries (see the image below)[2, 3, 4] :

  • Zone 1 (distal interphalangeal [DIP] joint)
  • Zone 2 (middle phalanx)
  • Zone 3 (proximal interphalangeal [PIP] joint)
  • Zone 4 (proximal phalanx)
  • Zone 5 (metacarpophalangeal [MCP] joint)
  • Zone 6 (dorsum of hand)
  • Zone 7 (wrist)
  • Zone 8 (distal forearm)
  • Zone 9 (proximal forearm)
    Zones of hand and forearm. Zones of hand and forearm.

Extensor tendon injuries may require operative intervention, depending on the complexity of the injury and the zone of the hand involved.[5] For treatment of injuries to specific zones of the hand, see Technique. The goal of repair is to restore tendon continuity and function. Optimal preparation and technique are critical for minimizing adhesions and scar tissue formation and ensuring the best possible outcome.

Extensor tendon injuries are often more difficult to treat than flexor tendon injuries owing to several issues specific to extensor tendons. The extensor mechanisms of the hand are in a superficial position, not enclosed in tendon sheaths (as are flexor tendons), and often have limited retraction after injury.

Extensor tendons also tend to be thinner and flatter than the structure of flexor tendons, as well as being in very close proximity to bony structures. This leaves them highly susceptible to adhesions and shortening, which can severely impair function and range of motion.

In addition, injuries that are proximal to the anatomic juncturae tendinum may still have preserved extensor function. Additionally, up to 90% of an extensor tendon can be lacerated and still retain preserved function to gravity.[6, 4, 7]

Brief anatomic overview

Several anatomic structures contribute to the extensor mechanism, including the extrinsic muscles of the forearm, intrinsic muscles such as the interosseous and lumbricals, and fibrous structures.

The extrinsic tendons pass through the extensor retinaculum on the dorsum of the wrist. This structure is divided into six compartments, each of which has tendons that pass through. The third compartment is of particular importance in injury patterns. Injuries to the distal radius can result in rupture of the extensor pollicis longus (EPL), which passes through this compartment. Of significance, the sixth compartment contains the extensor carpi ulnaris, which serves as a major stabilizer for the distal radioulnar joint as well as extends the wrist.[4, 6]

The extensor apparatus of the digits have three separate insertion sites. Proximally, they are attached at the level of the metacarpal heads by a sagittal band, which centers the tendon and prevents hyperextension. The most important insertion site is at the base of the middle phalanx. There is a third insertion point distally.

It is also important to be aware of insertion sites of the extensor tendons during repair. (See the image below.)

Extensor tendon insertion sites. LL = musculi lumb Extensor tendon insertion sites. LL = musculi lumbricales; IO = musculi interossei; EPL = musculus extensor pollicis longus; EPB = musculus extensor pollicis brevis; ED = musculus extensor digitorum communis; ECRLB = musculus extensor carpi radialis longus et brevis; ECU = musculus extensor carpi ulnaris; APL = musculus abductor pollicis longus. Extrinsic muscles are colored in yellow, intrinsic muscles in blue. Image courtesy of Dr Roberto Schubert, Radiopaedia.org, http://radiopaedia.org/cases/flexor-and-extensor-insertions-at-the-hand-and-wrist.

For more information about the relevant anatomy, see Hand Anatomy and Wrist Joint Anatomy.

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Indications

Indications for extensor tendon repair include the following:

  • Tendon laceration greater than 50%
  • Tendon laceration less than 50% with significantly decreased strength in comparison with contralateral finger
  • Tendon laceration associated with significant overlying skin loss, joint space penetration, or bony fracture

Repair can be accomplished immediately in the ED or after a delay of up to 7 days following the injury.[8] If repair is delayed, irrigate and debride the wound, approximate the skin loosely with interrupted sutures, and place the hand in a volar splint.[9] Simple lacerations can be repaired in the ED; however, lesions proximal to zone 6 should ideally be treated in an operating room; such injuries tend to require significant exposure of the tissues for appropriate reapproximation of the tendon.[4]

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Contraindications

Extensor tendon repair should not be attempted in the ED or acute care setting in any of the following circumstances:

  • Unavailability of an appropriately skilled physician
  • Contaminated injury, particularly open zone 5 "fight bite" injury
  • Presence of bony fracture, open joint space, or significant overlying skin loss (requires an orthopedist or hand surgeon for repair)
  • Injuries proximal to zone 6 - Caution is required with these injuries owing to frequent necessity for significant exposure of area to achieve adequate repair

In these cases, the repair should be performed by an experienced hand surgeon, preferably in the operating room.

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Anesthesia

Adequate anesthesia is required for thorough wound exploration and tendon manipulation. Use lidocaine 1% or bupivacaine 0.25% without epinephrine (see Local Anesthetic Agents, Infiltrative Administration). Use local or digital nerve block for finger injury (see Hand, Anesthesia: Blocks). Use field or regional nerve block for hand injury (see Local Anesthesia and Regional Nerve Block Anesthesia).

For operative surgical repairs, wide-awake surgery is becoming increasingly popular and well accepted. During this approach, patients are not sedated, analgesia is with lidocaine-epinephrine (local only), and a tourniquet is not used. In this technique, the patient is able to move his or her fingers during the operative repair, enabling verification of adequate repair intraoperatively.[10, 11, 12]

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Equipment

Equipment used for anesthesia includes the following:

  • Povidone-iodine solution (see the image below)
  • Syringe, 10 mL
  • Needle, 25 or 27 gauge
  • Local anesthetic solution
    Povidone-iodine solution, 1% lidocaine, 10-mL syri Povidone-iodine solution, 1% lidocaine, 10-mL syringe, and 25-gauge needle.

Equipment used for wound irrigation and preparation includes the following:

  • Sterile normal saline (0.9% NaCl) solution, 500 mL
  • Irrigation set (see the image below)
  • Syringe, 60 mL
  • Angiocatheter, 16 gauge
  • Intravenous tubing
  • Face shield
  • Blood pressure cuff
  • Bright overhead lighting
    Irrigation equipment. Irrigation equipment.

Equipment used for tendon and skin repair includes the following:

  • Sterile gloves
  • Sterile drapes
  • Gauze pads, 4 × 4
  • Needle holder
  • Skin hooks, 2
  • Retractors
  • Sharp and blunt-nosed scissors
  • Small hemostats, several
  • Single-toothed forceps
  • Nonabsorbable, synthetic, and braided suture (4-0, 5-0, and 6-0)
  • Nylon suture (4-0 or 5-0) for skin repair - Avoid silk suture (high tissue reactivity) and chromic suture (dissolves before the tendon adequately heals)

Equipment used for wound care and splinting includes the following (see the image below):

  • Topical antibiotic ointment
  • Gauze pads
  • Elastic gauze bandage or tape
  • Splint material
  • Shears to cut aluminum splint
    Shears, aluminum splint, tape. Shears, aluminum splint, tape.
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Positioning

Place the patient supine on a procedure table or a gurney with an attached armboard. Make sure the patient is in a comfortable position to limit movement during the procedure. Place the patient’s hand level with his or her body or heart.

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Technique

Preparation

Explain the procedure, risks, and benefits to the patient and obtain informed consent. Place the patient in the appropriate position with bright overhead lighting. Administer anesthesia as described above.

To control blood flow, elevate the affected limb for approximately 1 minute to allow blood flow to drain by gravity.

Place either a digital tourniquet or a blood pressure cuff on the middle to upper arm and inflate to 50-100 mm Hg above the systolic pressure. For comfort, several layers of cast padding may be applied under the tourniquet or blood pressure cuff.

Once inflated, wrap the cuff with rolled gauze. Tape the gauze to prevent it from unraveling off the inflated cuff. Use a hemostat to clamp the cuff tubes to avoid a slow leak from the inflated cuff. A blood pressure cuff tourniquet is well tolerated for approximately 20 minutes and should never be left in place for longer than 2 hours.

Once blood flow is controlled, débride the wound and liberally irrigate with 500-1000 mL of normal saline. Once irrigation is complete, the wound is considered sterile. Apply sterile drapes to create a sterile field and prepare the necessary instruments and suture material at the bedside.

Handling of tendons

Always handle tendons delicately. Avoid crushing forces or excessive punctures with forceps and needles. Only use forceps on the exposed, cut end of the tendon whenever possible. Always consult an orthopedist or hand surgeon for complex injuries.

Size and thickness of extensor tendons vary greatly from the proximal to more distal zones. Proximally, tendons are thick and round. Distally, tendons become thinner and flatter. Suturing techniques should be tailored to the location of the lesion.[4]

Repair for specific injury patterns

The repair depends on the location and nature of the injury (see the image below).

Zones of hand and forearm. Zones of hand and forearm.

Zone 1

Injury in zone 1 (distal interphalangeal joint [DIP]) often results in mallet finger deformity. It can be open but is more likely caused by forceful flexion of the DIP joint in an extended digit. This causes rupture of the tendon or avulsion from its insertion on the distal phalanx. Untreated, the patient can develop retraction of the central band, resulting in swan-neck deformity.[6, 7]

Open injury is treated as follows:

  • Dermatotenodesis
  • Mallet finger splint/Kirschner wire (K-wire) fixation (see the video below)
    Video clip of splint application.

Closed injury is treated as follows:

  • Conservative management/splinting recommended
  • Immobilization of the DIP joint in slight hyperextension while sparing the proximal interphalangeal (PIP) joint for at least 6 weeks without removal of the splint
  • Surgical treatment for closed injuries is indicated/considered if avulsed fracture fragment is greater than one third of the joint surface [4]
  • Type 1 (no avulsion) and type 2 (small avulsion with laceration at or proximal to the DIP with loss of tendon continuity) - Mallet finger splint
  • Type 3 (intra-articular avulsion fracture with dorsal displacement, loss of skin/subcutaneous cover/tendon substance) - Orthopedic or hand surgeon performs operative repair

Zone 2

Injury in zone 2 (middle phalanx) is often sustained with direct sharp laceration/crush injuries. Less than 50% laceration of the tendon is considered stable, and no intervention is recommended.

Laceration of greater than 50% of the tendon should be repaired with figure-eight suture or suture of similar tensile strength; some authors advocate use of a Silversköld cross-stitch for zone 2 repairs (see below). Avoiding shortening of the tendon in zone 2 should be paramount, as it can result in altered flexion at the DIP joint. Some authors advocate the use of a running interlocking horizontal mattress suture for distal injuries in zones 2-5.[13, 14]

Open injury is treated as follows:

  • Dermatotenodesis
  • Mallet finger splint/K-wire fixation (see the video below)
    Video clip of splint application.

Closed injury is treated as follows:

  • Type 1 (no avulsion) and type 2 (small avulsion) - Mallet finger splint
  • Type 3 (intra-articular avulsion fracture with dorsal displacement) - Orthopedic or hand surgeon performs operative repair

Zone 3

Injury in zone 3 (PIP joint) results in boutonniere deformity, typically 10-14 days after the initial injury, secondary to disruption of the central slip at the PIP joint.[15] The central tendon is most commonly injured.[9]

  • Open injury - Orthopedic or hand surgeon performs operative repair
  • Closed injury - Dorsal boutonnière splint

Feuvrier et al described four extensor tendon central slip defects treated in an emergency setting with Oberlin's bypass procedure, which uses a free tendon graft intercalated between the extensor indicis proprius and the base of the middle phalanx.[16] At 9 months, functional outcomes were comparable (average mobility, 0-13-72°). The two patients who were working at the time of injury were able to return to work in month 3. At final follow-up (>5 years), average active mobility was 0-5-76.5°.

Zone 4

The extensor tendon becomes broader over the proximal phalanx, so partial lacerations are often observed, and zone 4 (proximal phalanx) injuries are commonly associated with fractures of the proximal phalanx. Therefore, always test the tendon against resistance during examination.

Open injury is treated as follows:

  • Modified Kessler or modified Bunnell using 5-0 nonabsorbable suture
  • Splint/K-wire fixation
  • Volar splint for 6 weeks in extension

Zone 5

Closed ruptures (both traumatic and spontaneous) of the sagittal bands are often seen in patients with rheumatoid arthritis. Open "fight bite" injury often is a partial laceration including the central extensor tendon and sagittal bands. These tendon lacerations can be easily missed because remaining intact tendon can often maintain extensor function. Complete lacerations are unusual, owing to the broad width of the extensor apparatus here. Keep in mind that if injured in flexion, the tendon injury may be located proximal to the skin laceration.

Open injury in zone 5 (metacarpophalangeal [MCP] joint) is treated as follows:

  • Radiograph the injury, explore and irrigate, administer antibiotics, cover wounds with bulky dressing, apply a volar splint
  • Orthopedist or hand surgeon performs delayed closure

Closed injury is treated as follows:

  • Splint MCP joint in neutral position (vs operative repair)

Zone 6

Zone 6 (dorsum of hand) is the most superficial region of the hand. Injury is associated with a good prognosis for repair, owing to the broad structure, extrasynovial nature of the tendon, and lack of association with joint spaces. Treatment involves the following:

  • Modified Bunnell using 4-0 nonabsorbable suture or a 3-0 core stitch with an epitendinous running suture
  • Volar splint

Zone 7

Zone 7 (wrist) is an uncommon site, and injury in this zone is often associated with open lacerations or closed ruptures and distal radius fractures (extensor pollicis longus [EPL] tendon in particular). It often involves the extensor retinaculum and is at risk for developing adhesions after repair.[9] Typically, an orthopedist or hand surgeon performs operative repair.

Zones 8 and 9

Injuries in zones 8 and 9 (dorsal and proximal forearm) are often associated with musculotendinous junctions and muscle bellies. Multiple figure-eight sutures or similar tensile strength sutures are used to repair muscle bellies. An orthopedist or hand surgeon performs operative repair. Static immobilization of the wrist in 30-45° of extension is maintained for at least 4-5 weeks postoperatively.

Suture techniques

Appropriate suture techniques include the modified Kessler stitch and the modified Bunnell stitch (see the image below).

Suture techniques for tendon repair. Suture techniques for tendon repair.

Modified Kessler stitch

Place a single suture into the cut end core of the tendon, entering about one third of the diameter of the tendon. Weave the suture through the lateral tendon margin. Wrap the suture around the tendon, and re-enter on the dorsal radial side of the tendon perpendicularly and 1-2 mm closer to the tendon end.

Pull the suture through the tendon to exit on the ulnar side. Wrap the suture along the tendon and enter the dorsal aspect of the ulnar half of the tendon. Thread the needle through the length of the tendon, and exit at the cut end of the tendon in alignment with the original insertion site.

Repeat the same stitch on the opposing cut half of the tendon, entering ipsilaterally. Once this is complete, the two free ends of the suture are on the same side of the tendon. Apply delicate tension to the sutures and gently approximate the two tendon ends together. Tie the suture ends with a square knot that remains buried between the tendon ends.

Modified Bunnell stitch

Place a single suture into the cut end core of the tendon, entering about one third of the diameter of the tendon. Pass the needle diagonally through the tendon, exiting on the ulnar side. Wrap the suture around the tendon, and re-enter on the dorsal ulnar side of the tendon.

Pull the suture directly through the tendon to exit on the dorsal radial side of the tendon. Re-enter the radial side of the tendon. Pass the needle diagonally through the tendon, crossing the initial stitch, to exit on the ulnar side of the tendon in alignment with the original insertion site.

Repeat the same stitch on the opposing cut half of the tendon, entering ipsilaterally. Once this is complete, the two free ends of the suture are on the same side of the tendon. Apply delicate tension to the sutures and gently approximate the two tendon ends together. Tie the suture ends with a square knot that remains buried between the tendon ends.

Dermatotenodesis

Place a single suture into the lateral distal end of the cut skin, and include a bite from the proximal skin wound. Anchor the suture with a knot, leaving enough material to complete the stitch. Enter the skin medial to the knot and pull the suture through 1 mm from the knot.

Place a stitch through the distal skin so that the needle passes through the dorsal side of the tendon. Bring the needle through to exit the dorsal side of the proximal tendon, incorporating the dorsal skin. Repeat the same stitch so that the needle exits the proximal half.

Place a single suture into the medial distal end of the cut skin, and include a bite from the proximal skin wound. Pull the suture to approximate skin edges. Place the last suture to anchor to the knot. (See the image below.)

Dermatotenodesis. Dermatotenodesis.

For more information on suturing, see Suturing Techniques.

Splinting techniques

Splinting techniques vary according to the zone of injury.[4, 15, 17, 18]

Dorsal splint for zone 1 injury (mallet finger splint)

Measure and cut an aluminum, foam-backed splint so that the splint sits just distal to the PIP joint and ends at the distal tip of the nail. Place the splint on the finger, keeping the DIP joint in slight hyperextension. Avoid excessive hyperextension at the DIP joint, which may cause skin sloughing. Tape the splint to the finger. The DIP is held in slight extension for no less than 6 weeks. (See the images below.)

Mallet finger splint. Mallet finger splint.
Mallet finger splint. Mallet finger splint.

Dorsal splint for zone 3 injury (boutonnière splint)

Measure and cut an aluminum, foam-backed splint so that the splint lies just distal to the MCP joint and ends just proximal to the DIP joint. Place the splint on the finger, keeping the MCP joint in full extension. Tape the splint to the finger. (See the images below.)

Boutonnière splint. Boutonnière splint.
Boutonnière splint. Boutonnière splint.
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Pearls

Obtain a thorough history and perform a complete physical examination. History should include mechanism of injury, position of the digit during injury, handedness, and occupation of patient. It is also important to determine cleanliness of the wound. Physical examination of extensor tendon injuries should always include strength/function against resistance, two-point discrimination, and adequate wound exploration and exposure.

Testing of especially the radial nerve, but also median and ulnar nerve function, is imperative during physical examination to determine extent of injury.

Assume all dorsal wrist, hand, and digit lacerations have an underlying tendon injury until proven otherwise.

Obtain a radiograph of the injury when a fracture or foreign body is suspected.

Be familiar with the anatomy of the region.[19]

Provide a well-lit and optimally prepared surgical field.

Handle all tissue delicately to avoid adhesion and scar tissue formation.

Consult a specialist whenever possible.

Consider prophylactic antibiotics.

Never close a contaminated wound.

All patients should be referred to a rehabilitation program following repair. Early mobilization is associated with improved outcomes.[20]

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Complications

General complications include infection and tendon rupture.

Zone 7 and 8 complications include the following:

  • Multiple tendon lacerations
  • Risk of adhesions following tendon repair that decrease wrist mobility and impair finger movement [21]
  • Decreased wrist mobility
  • Retraction from the initial site of injury

Zone 6 complications include retraction from the initial site of injury (less likely than zones 7 and 8) and excess shortening of the tendon following repair.

Zone 5 complications include infection (injury often secondary to human bite) and subluxation of the extensor digitorum communis.

Zone 4 complications include damage to the gliding layer located between the tendon and bone.

Zone 3 complications include boutonnière deformity.

Zone 1 and 2 complications include mallet deformity, swan-neck deformity, and skin ulceration secondary to splint.[8, 22]

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Contributor Information and Disclosures
Author

Adam J Rosh, MD Assistant Professor, Program Director, Emergency Medicine Residency, Department of Emergency Medicine, Detroit Receiving Hospital, Wayne State University School of Medicine

Adam J Rosh, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Nancy S Kwon, MD Assistant Professor of Clinical Surgery, Consulting Staff, Department of Emergency Medicine, New York University Medical Center and Bellevue Hospital Center

Nancy S Kwon, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John M Wilburn, MD Resident Physician, Department of Emergency Medicine, Wayne State University, Detroit Medical Center, Detroit Receiving Hospital

Disclosure: Nothing to disclose.

Francesca R Civitarese, DO Resident Physician, Department of Emergency Medicine, Detroit Medical Center, Detroit Receiving Hospital

Francesca R Civitarese, DO is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Osteopathic Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Luis M Lovato, MD Associate Clinical Professor, University of California, Los Angeles, David Geffen School of Medicine; Director of Critical Care, Department of Emergency Medicine, Olive View-UCLA Medical Center

Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Additional Contributors

Gil Z Shlamovitz, MD, FACEP Associate Professor of Clinical Emergency Medicine, Keck School of Medicine of the University of Southern California; Chief Medical Information Officer, Keck Medicine of USC

Gil Z Shlamovitz, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the assistance of Lars J Grimm, MD, MHS, with the literature review and referencing for this article.

References
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  2. Kleinert HE, Verdan C. Report of the Committee on Tendon Injuries (International Federation of Societies for Surgery of the Hand). J Hand Surg [Am]. 1983 Sep. 8(5 Pt 2):794-8. [Medline].

  3. Sameem M, Wood T, Ignacy T, Thoma A, Strumas N. A systematic review of rehabilitation protocols after surgical repair of the extensor tendons in zones V-VIII of the hand. J Hand Ther. 2011 Oct-Dec. 24(4):365-72; quiz 373. [Medline].

  4. Megerle K , Germann G. Extensor Tendon Injuries. Neligan PC, ed. Plastic Surgery: 6-Volume Set, Third Edition. 3rd ed. Elsevier Inc; 2013. 210-27.

  5. Hanz KR, Saint-Cyr M, Semmler MJ, Rohrich RJ. Extensor tendon injuries: acute management and secondary reconstruction. Plast Reconstr Surg. 2008 Mar. 121(3):109e-120e. [Medline].

  6. Griffin M, Hindocha S, Jordan D, Saleh M, Khan W. Management of extensor tendon injuries. Open Orthop J. 2012. 6:36-42. [Medline]. [Full Text].

  7. [Guideline] Davenport M. Injuries to the Arm, Hand, Fingertip, and Nail. Tintinalli JE, Sapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli's Emergency Medicine. 7th ed. New York, NY: McGraw-Hill; 2011. Vol 1: 47.

  8. Hart RG, Uehara DT, Wagner MJ. Emergency and Primary Care of the Hand. American College of Emergency Physicians; 2001. 175-88.

  9. Tang JB. Tendon injuries across the world: treatment. Injury. 2006 Nov. 37(11):1036-42. [Medline].

  10. Lalonde D, Bell M, Benoit P, Sparkes G, Denkler K, Chang P. A multicenter prospective study of 3,110 consecutive cases of elective epinephrine use in the fingers and hand: the Dalhousie Project clinical phase. J Hand Surg Am. 2005 Sep. 30(5):1061-7. [Medline].

  11. Lalonde DH. Wide-awake flexor tendon repair. Plast Reconstr Surg. 2009 Feb. 123(2):623-5. [Medline].

  12. Bezuhly M, Sparkes GL, Higgins A, Neumeister MW, Lalonde DH. Immediate thumb extension following extensor indicis proprius-to-extensor pollicis longus tendon transfer using the wide-awake approach. Plast Reconstr Surg. 2007 Apr 15. 119(5):1507-12. [Medline].

  13. Dy CJ, Rosenblatt L, Lee SK. Current methods and biomechanics of extensor tendon repairs. Hand Clin. 2013 May. 29(2):261-8. [Medline].

  14. Altobelli GG, Conneely S, Haufler C, Walsh M, Ruchelsman DE. Outcomes of digital zone IV and V and thumb zone TI to TIV extensor tendon repairs using a running interlocking horizontal mattress technique. J Hand Surg Am. 2013 Jun. 38(6):1079-83. [Medline].

  15. Hart RG, Uehara DT, Kutz JE. Extensor tendon injuries of the hand. Emerg Med Clin North Am. 1993 Aug. 11(3):637-49. [Medline].

  16. Feuvrier D, Loisel F, Pauchot J, Obert L. Emergency repair of extensor tendon central slip defects with Oberlin's bypass technique: feasibility and results in 4 cases with more than 5 years of follow-up. Chir Main. 2014 Oct. 33(5):315-9. [Medline].

  17. Hammond K, Starr H, Katz D, Seiler J. Effect of aftercare regimen with extensor tendon repair: a systematic review of the literature. J Surg Orthop Adv. 2012 Winter. 21(4):246-52. [Medline].

  18. Neuhaus V, Wong G, Russo KE, Mudgal CS. Dynamic splinting with early motion following zone IV/V and TI to TIII extensor tendon repairs. J Hand Surg Am. 2012 May. 37(5):933-7. [Medline].

  19. Kostopoulos E, Casoli V, Verolino P, Papadopoulos O. Arterial blood supply of the extensor apparatus of the long fingers. Plast Reconstr Surg. 2006 Jun. 117(7):2310-8; discussion 2319. [Medline].

  20. Newport ML, Tucker RL. New perspectives on extensor tendon repair and implications for rehabilitation. J Hand Ther. 2005 Apr-Jun. 18(2):175-81. [Medline].

  21. Tang JB. Tendon injuries across the world: treatment. Injury. 2006 Nov. 37(11):1036-42. [Medline].

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Povidone-iodine solution, 1% lidocaine, 10-mL syringe, and 25-gauge needle.
Irrigation equipment.
Equipment for tendon repair.
Polypropylene and nylon sutures.
Shears, aluminum splint, tape.
Mallet finger splint.
Mallet finger splint.
Boutonnière splint.
Boutonnière splint.
Suture techniques for tendon repair.
Dermatotenodesis.
Video clip of splint application.
Zones of hand and forearm.
Extensor tendon insertion sites. LL = musculi lumbricales; IO = musculi interossei; EPL = musculus extensor pollicis longus; EPB = musculus extensor pollicis brevis; ED = musculus extensor digitorum communis; ECRLB = musculus extensor carpi radialis longus et brevis; ECU = musculus extensor carpi ulnaris; APL = musculus abductor pollicis longus. Extrinsic muscles are colored in yellow, intrinsic muscles in blue. Image courtesy of Dr Roberto Schubert, Radiopaedia.org, http://radiopaedia.org/cases/flexor-and-extensor-insertions-at-the-hand-and-wrist.
 
 
 
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