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Flexor Tenolysis Workup

  • Author: Cato T Laurencin, MD, PhD; Chief Editor: Harris Gellman, MD  more...
Updated: Nov 02, 2015

Laboratory Studies

No specific laboratory tests are indicated.


Imaging Studies

The major utility of imaging studies prior to flexor tenolysis is to evaluate whether the patient has a failure of tendon reconstruction, elongated callus, or tendon adhesions that lead to the clinical presentation.[11]

Initially, radiographs should be taken to ensure proper anatomical alignment of the skeletal elements.[2] Ultrasound has proven effective to assess both the presence and location of a ruptured tendon repair.[12, 13] Additionally, the mechanism of ultrasound allows dynamic assessment of flexor tendon injuries, and thus ultrasound is recommended for evaluation of zone 1 (DIP joint) tendon injuries. Ultrasound, however, is not effective in discerning pure adherence from elongated callus, and thus the type of surgical intervention required.[11] Additionally, ultrasound of the ligaments in zone 2 (MCP and PIP joints) are a difficult endeavor and strongly operator dependent.[11]

MRI has proven to be effective as a noninvasive imaging procedure to differentiate between tendon rupture and tendon adhesions in zone 2.[11] Imaging artifacts from implanted devices, including metal plates or screws, can limit the effectiveness of MRI in evaluating tendon injuries.


Histologic Findings

In a rabbit model of tendon repair, once a tendon is injured, within 24 hours a noticeable increase in cellularity, predominantly from neutrophils, is seen. In the same model, cells in the tendon sheath are seen to migrate into the tendon, and cells from the periphery of the tendon are seen to migrate to the interior of the tendon core within 7 days.[4] By 7 days, alpha smooth muscle actin expression is high, which marks the presence of myofibroblasts and pericytes in the wound area. From 7 to 21 days, cells are both depositing and remodeling collagen bundles, which correlate with a peak in heat shock protein 47 around day 21. As intrinsic healing of affected tendons progresses, alignment of collagen fibers along the axis of contraction, as well as a decrease in inflammatory cellularity, is usually seen, with a peak in apoptosis around 84 days in rabbits.[4, 11]

In human subjects, studies that closely track cell origin and type are lacking, but when looking at histological sections of adhesions, noninflammatory cells resemble myofibroblasts and secrete types I and III collagen, and epitenon cells are also involved in the process of both collagen production and collagen debris clearance.

Contributor Information and Disclosures

Cato T Laurencin, MD, PhD University Professor, Albert and Wilda Van Dusen Endowed Distinguished Professor of Orthopedic Surgery, and Professor of Chemical, Materials, and Biomolecular Engineering, University of Connecticut School of Medicine

Cato T Laurencin, MD, PhD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.


Clarke Nelson University of Connecticut School of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Thomas R Hunt III, MD Professor and Chairman, Joseph Barnhart Department of Orthopedic Surgery, Baylor College of Medicine

Thomas R Hunt III, MD is a member of the following medical societies: American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, Southern Orthopaedic Association, AO Foundation, American Academy of Orthopaedic Surgeons, American Association for Hand Surgery, American Society for Surgery of the Hand, Mid-America Orthopaedic Association

Disclosure: Received royalty from Tornier for independent contractor; Received ownership interest from Tornier for none; Received royalty from Lippincott for independent contractor.

Chief Editor

Harris Gellman, MD Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M Miller School of Medicine, Clinical Professor, Surgery, Nova Southeastern School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, Arkansas Medical Society

Disclosure: Nothing to disclose.

Additional Contributors

Michael S Clarke, MD Clinical Associate Professor, Department of Orthopedic Surgery, University of Missouri-Columbia School of Medicine

Michael S Clarke, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Arthroscopy Association of North America, American Academy of Pediatrics, American Association for Hand Surgery, American College of Surgeons, American Medical Association, Clinical Orthopaedic Society, Mid-Central States Orthopaedic Society, Missouri State Medical Association

Disclosure: Nothing to disclose.


W Jay Gorum II, MD Consulting Surgeon, Gorum Orthopedics and Associates

W Jay Gorum II, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

  1. Derby BM, Wilhelmi BJ, Zook EG, Neumeister MW. Flexor tendon reconstruction. Clin Plast Surg. 2011 Oct. 38(4):607-19. [Medline].

  2. Azari KK, Meals RA. Flexor tenolysis. Hand Clin. 2005 May. 21(2):211-7. [Medline].

  3. Eggli S, Dietsche A, Eggli S, Vögelin E. Tenolysis after combined digital injuries in zone II. Ann Plast Surg. 2005 Sep. 55(3):266-71. [Medline].

  4. Wong JK, Lui YH, Kapacee Z, Kadler KE, Ferguson MW, McGrouther DA. The cellular biology of flexor tendon adhesion formation: an old problem in a new paradigm. Am J Pathol. 2009 Nov. 175(5):1938-51. [Medline].

  5. Dy CJ, Daluiski A, Do HT, Hernandez-Soria A, Marx R, Lyman S. The epidemiology of reoperation after flexor tendon repair. J Hand Surg Am. 2012 May. 37(5):919-24. [Medline].

  6. Caulfield RH, Maleki-Tabrizi A, Patel H, Coldham F, Mee S, Nanchahal J. Comparison of zones 1 to 4 flexor tendon repairs using absorbable and unabsorbable four-strand core sutures. J Hand Surg Eur Vol. 2008 Aug. 33(4):412-7. [Medline].

  7. Potenza AD. Critical evaluation of flexor-tendon healing and adhesion formation within artificial digital sheaths. J Bone Joint Surg Am. 1963 Sep. 45:1217-33. [Medline].

  8. Matthews P, Richards H. Factors in the adherence of flexor tendon after repair: an experimental study in the rabbit. J Bone Joint Surg Br. 1976 May. 58(2):230-6. [Medline].

  9. Lindsay WK, Thomson HG. Digital flexor tendons: an experimental study. Part I. The significance of each component of the flexor mechanismhin tendon healing. Br J Plast Surg. 1960 Jan. 12:289-316. [Medline].

  10. Lindsay WK, Thomson HG, Walker FG. Digital flexor tendons: an experimental study. Part II. The significance of a gap occurring at the line of suture. Br J Plast Surg. 1960 Apr. 3:1-9. [Medline].

  11. Drapé JL, Silbermann-Hoffman O, Houvet P, Dubert T, Thivet A, Benmelha Z. Complications of flexor tendon repair in the hand: MR imaging assessment. Radiology. 1996 Jan. 198(1):219-24. [Medline].

  12. Corduff N, Jones R, Ball J. The role of ultrasound in the management of zone 1 flexor tendon injuries. J Hand Surg Br. 1994 Feb. 19(1):76-80. [Medline].

  13. McGeorge DD, McGeorge S. Diagnostic medical ultrasound in the management of hand injuries. J Hand Surg Br. 1990 May. 15(2):256-61. [Medline].

  14. Whitaker JH, Strickland JW, Ellis RK. The role of flexor tenolysis in the palm and digits. J Hand Surg Am. 1977 Nov. 2(6):462-70. [Medline].

  15. Walcher K, von Lüdinghausen M, Kuzmany J, Matzen KA, Küsswetter W. [Experimental "hormonal tenolysis" by cortisone therapy (author's transl)]. Arch Orthop Unfallchir. 1976 Feb 26. 84(1):1-12. [Medline].

  16. Wrenn RN, Goldner JL, Markee JL. An experimental study of the effect of cortisone on the healing process and tensile strength of tendons. J Bone Joint Surg Am. 1954 Jun. 36-A(3):588-601. [Medline].

  17. Hunter JM, Schneider LH, Dumont J, Erickson JC 3rd. A dynamic approach to problems of hand function using local anesthesia supplemented by intravenous fentanyl-droperidol. Clin Orthop Relat Res. 1974 Oct. (104):112-5. [Medline].

  18. Feldscher SB, Schneider LH. Flexor tenolysis. Hand Surg. 2002 Jul. 7(1):61-74. [Medline].

  19. Schneider LH. Tenolysis and capsulectomy after hand fractures. Clin Orthop Relat Res. 1996 Jun. (327):72-8. [Medline].

  20. Strickland JW. Flexor tenolysis. Hand Clin. 1985 Feb. 1(1):121-32. [Medline].

  21. Constantinescu MA, Greenwald DP, Amarante MT, Nishioka NS, May JW Jr. Effects of laser versus scalpel tenolysis in the rabbit flexor tendon. Plast Reconstr Surg. 1996 Mar. 97(3):595-601. [Medline].

  22. Foucher G, Lenoble E, Ben Youssef K, Sammut D. A post-operative regime after digital flexor tenolysis. A series of 72 patients. J Hand Surg Br. 1993 Feb. 18(1):35-40. [Medline].

  23. Wheeldon T. The use of cellophane as a permanent tendon sheeth. J Bone Joing Surg Am. 1939. 21:

  24. Karakurum G, Buyukbebeci O, Kalender M, Gulec A. Seprafilm interposition for preventing adhesion formation after tenolysis. An experimental study on the chicken flexor tendons. J Surg Res. 2003 Aug. 113(2):195-200. [Medline].

  25. Strickland JW. Flexor tendon injuries. Part 5. Flexor tenolysis, rehabilitation and results. Orthop Rev. 1987 Mar. 16(3):137-53. [Medline].

  26. Strickland JW. Flexor tendon injuries. Part 2. Flexor tendon repair. Orthop Rev. 1986 Nov. 15(11):701-21. [Medline].

  27. Wiig ME, Dahlin LB, Fridén J, Hagberg L, Larsen SE, Wiklund K, et al. PXL01 in sodium hyaluronate for improvement of hand recovery after flexor tendon repair surgery: randomized controlled trial. PLoS One. 2014. 9 (10):e110735. [Medline]. [Full Text].

  28. Branford OA, Klass BR, Grobbelaar AO, Rolfe KJ. The growth factors involved in flexor tendon repair and adhesion formation. J Hand Surg Eur Vol. 2014 Jan. 39 (1):60-70. [Medline]. [Full Text].

  29. Turner JB, Corazzini RL, Butler TJ, Garlick DS, Rinker BD. Evaluating adhesion reduction efficacy of type I/III collagen membrane and collagen-GAG resorbable matrix in primary flexor tendon repair in a chicken model. Hand (N Y). 2015 Sep. 10 (3):482-8. [Medline].

Flexor tendons with attached vincula. FDS, flexor digitorum superficialis; FDP, flexor digitorum profundus.
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