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Flexor Tendon Lacerations Treatment & Management

  • Author: Benjamin C Wood, MD; Chief Editor: Jorge I de la Torre, MD, FACS  more...
 
Updated: Nov 18, 2014
 

Surgical Therapy

Surgical incisions are planned so as to maintain the blood supply as completely as possible, to obtain adequate exposure, and to achieve optimal scar contracture. Bunnell developed the midlateral incision as the stationary line, either volar or dorsal to the neurovascular bundle. Littler demonstrated the diamonds of skin-to-skin contact during digital flexion. The Bruner zigzag incision avoids these areas.

Preservation of the vincula is difficult if the dorsal midlateral incision is used; accordingly, either the Bruner incision or the volar midlateral incision is recommended. Midlateral incisions should not be made on surfaces exposed to much contact (eg, the ulnar border of the little finger or the radial border of the index finger). The distal extent of either incision is over the pulp of the phalanx.

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Intraoperative Details

Primary repair

The retinacular portion of the sheath is elevated as an L-shaped flap, leaving a 2-mm cuff of tissue for subsequent repair. Furthermore, this L should be oriented in such a way that a tendon end can be funneled into it. Flexion of the wrist is a useful intraoperative ploy that facilitates mobilization of the proximal tendon stump.

Often, the proximal tendon stump is hidden by a hematoma within the tendon sheath. The chiasm of Camper (flexor digitorum superficialis [FDS] decussation that lies opposite the proximal digital flexion crease) is a useful anatomic marker for tendon repair within zone II.

Distal to the midpoint of the proximal phalanx, the deep tendon is the FDS, and the superficial tendon is the flexor digitorum profundus (FDP). Before the repair is begun, it is vital that there be no tension across the tendon ends. The technique of repair is based on the length of distal tendon. Two groups of core suture exist (see the image below):

  • Those that criss-cross the tendon (Bunnell)
  • Those in which the suture lies parallel to the tendon fibers (Kessler, Tajima)
    Two-strand repair techniques. (A) Tsuge, (B) modif Two-strand repair techniques. (A) Tsuge, (B) modified grasping Kessler, (C) modified locking Kessler (ie, Pennington modified Kessler), (D) modified Pennington.

Urbaniak et al demonstrated that the former group of sutures tends to strangulate the tendon ends, with a net reduction in tensile strength. The epitenon must never be handled, so that damage that predisposes to peritendinous adhesions is minimized. Terminal damage to the epitenon also jeopardizes the quality of subsequent peripheral suture.

The tendon end can be grasped lightly with a toothed forceps. A 4-0 material is used for the core suture. The first pass of the needle must be parallel to the tendon fibers. The length of bite is approximately 1 cm, with the transverse limb of the suture passing superficial to the longitudinal limbs. The core suture should not pull the tendon ends together. This is the value of overlapping the ends with transfixion needles.

Employ at least four throws of the knot, with the ends cut at 2 mm. The protruding suture ends so as not to jeopardize subsequent healing or function. Knot slippage is said to occur in as many as 40% of repairs.

Multistrand techniques are illustrated in the image below.

Multistrand core suture techniques performed with Multistrand core suture techniques performed with single-stranded suture. (A) double modified locking Kessler, (B) cruciate nonlocked, (C) cruciate cross-stitch locked, (D) 4-strand Savage, (E) augmented Becker (also called as MGH repair), (F) 6-strand Savage, (G) modified Savage, (H) triple modified Kessler.

The suture material for the peripheral running suture should be two gauges lighter than the core suture (6-0 nylon for adults). Like the core suture, it may be composed of either monofilament or braided material. Monofilament material generally is preferred for both sutures.

The first pass of the peripheral suture should be performed in a figure-eight fashion to avoid cutting out. Most important, it should engage only the epitenon. A shallow inverting suture is ideal, thus burying the repair. A Lembert suture can be employed if necessary. The passage of this needle should meet minimal resistance if in the correct plane. After tendon repair, little or no bulk should be found in the tendon ends.

Epitendinous techniques are illustrated in the image below.

Epitendinous suture techniques. (A) cross-stitch, Epitendinous suture techniques. (A) cross-stitch, (B) Lin, (C) Halsted, (D) horizontal intrafiber, (E) simple running, (F) Simple running superficial and simple running deep.

The general recommendation is that both the FDS and the FDP should be sutured, even in zone II. Lister recommends the use of two core sutures for the flat tendon of the FDS. A divided FDS derotates through 90°. The management of partial lacerations is controversial.

Following the report by Weeks and Wray that partial lacerations should be managed conservatively, Kleinert et al found that failure to repair these results in triggering and delayed rupture. Current recommendations for partial tendon injuries are presented in Table 1 below.

Table 1. Current Recommendations for Partial Tendon Injuries (Open Table in a new window)

Less than 25% Smooth edge to avoid entrapment
25-50% Peripheral running suture
Greater than 50% Core suture plus running suture

There has been debate regarding whether multistrand repairs are beneficial and whether a multistrand repair confers greater early tensile strength and therefore permits more rapid rehabilitation than the conventional-type repair. Biomechanical and histologic data show no differences between two-strand and four-strand repairs. The use of an epitendinous suture gives similar results.

If care is taken with the surgical technique, adhesion formation is not necessarily increased by the use of multistrand techniques or by the placement of an epitendinous suture. More variability is introduced by individual healing response than by an increase in tendon handling by an experienced surgeon.[4]

One report advocated a six-strand figure-eight technique, citing the ability to ensure full active extension of the proximal interphalangeal (PIP) joint in the first 4 weeks after surgery, virtually eliminating flexion contracture at the PIP joint while reducing the rupture rate to 2%.[5, 6]

Resistance to failure in different repair techniques varies according to the number of locking junctions with the tendon, as well as the location and orientation of the sutures. These factors influence the resistance to failure independent of the number of sutures used.[7]

Experimental evidence in both the canine model and clinical studies suggests a stainless steel device (Teno Fix) may be promising for zone II flexor tendon repairs.[8] One in vitro study found that resection of one slip of the FDS tendon significantly reduced the work of flexion in repair of zone II injuries, whereas no difference in this interaction was observed among three different suture materials (ie, FiberWire vs Ticron vs Prolene).[9]

The history of flexor tendon repair has been described well by Dr Paul Manske.[10]

Primary repair: distal FDP stump

The distal FDP stump usually can be involved in a formal suture repair if it is longer than 1 cm. If the distal stump is shorter than this, the proximal core suture can be inserted into the stump and brought out through two 20-gauge needles inserted through the distal pulp, 3 mm volar to the nail. If no distal stump is present, it should be brought out through the distal phalanx and sutured over a button on the nail.

Primary repair: avulsion of profundus

Avulsion of the profundus is a common "rugby jersey" injury. It is most common in the ring finger. Three types are described in Table 2 below.

Table 2. Three Types of Avulsion of Profundus (Open Table in a new window)

Type I The tendon has retracted into the palm.



Repair only can be performed within 10 days.



Type II The tendon has been tethered by the long vinculum.



Repair is feasible for as many as 3 months.



Type III A large bone fragment, which cannot pass through the sheath, has been avulsed.



It can be repaired at any time.



When reinsertion is possible, it should be performed as above, taking the sutures out through the pulp. If this is not possible, then either arthrodesis should be performed on the distal interphalangeal (DIP) joint or flexor tendon reconstruction should be considered.

Tendon repair out of zone II

The epitenon is not as well defined, and the peripheral running suture is unnecessary. The objective in these situations is strength of closure rather than finesse. If the deep carpal ligament must be divided, the wrist should be splinted in slight dorsiflexion. Alternately, the latter may be repaired.

In repairs at the wrist, the best initial maneuver is to excise the glutinous mass of synovium by means of a thorough synovectomy. The distal ends easily are identified by their actions. Caution should be exercised in grasping the cut ends of the tendon (ie, grasp only the cut surface and not the epitenon). The clues to identification of the proximal ends are as follows:

  • Matching the cross-sectional areas
  • Matching the angle of laceration
  • Matching the anatomic layers - Superficial FDS to middle and ring fingers; middle FDS to index and little fingers; deep all FDP (index finger separate)
  • Matching the length to achieve the normal position in repose

Injuries at the musculotendinous junction should be repaired whenever possible. A figure-eight suture with two unequal loops is best.

Untidy injuries

In oblique injuries, when the injury is clean, no reason exists to render the cut transverse. Judging the correct tension in the core suture is more difficult, and this may be left untied until the peripheral suture is completed partially. Ragged ends should be resected. The tendon can be held with umbilical tape and resected with a razor blade. Double-level repairs do not present a problem if more than 3 cm apart. If closer, a single core suture should be used.

Secondary reconstruction

Factors dictating the success of tendon reconstruction include the following:

  • Age - Very young and elderly patients do not fare as well
  • Occupation - Often, those with busy lifestyles cannot afford the time to spend at rehabilitation
  • Mechanism of injury - The more widespread the zone of initial injury, the greater the scarring is likely to be; the amount of scarring is inversely proportional to the range of motion (ROM) subsequently achieved
  • Quality of initial care
  • Previous operations - The likelihood of success lessens as the number of procedures that have preceded the proposed operation increases

The procedure should be deferred until the skin is mobile, the joints are supple, scars mature, adequate perfusion to the digit is present, adequate sensation exists, and a stable skeleton is present. Limitation in ROM may be due to skin, sheath, or tendon on either side of the digit or the palmar plate.

In pure flexor tendon adhesions, passive flexion exceeds active flexion. If extensor tendon adhesions are present, tenolysis on these should be done before flexor tendon reconstruction is contemplated. A useful approach is to examine all other structures first, leaving the flexor tendon until last.

The DIP joint contributes only 3% to the overall total arc of motion of the digit; by way of contrast, the PIP joint contributes 20% of the total arc. Jeopardizing the function of the PIP joint by tendon grafting may not have a favorable risk-to-benefit ratio. Instead, the FDS stump may undergo tenolysis to the middle phalanx, or arthrodesis can be performed on the DIP joint.

McClinton et al reported a 13% failure rate in FDP reconstruction. Therefore, the question remains as to whether benefit is found in delayed FDP reconstruction, with a possible gain of 3% total arc of motion. The risk-to-reward ratio is most favorable in carefully selected, young patients in whom arthrodesis may result in growth disturbance.

Flexion contracture

The causes of flexion contracture are poor rehabilitation, bowstringing of tendons, poor splintage, and failure to create an effective repair. The severity of the contracture is measured by the extension deficit. Bowstringing tendons require additional length to achieve the same degree of flexion. This excursion is not available. The diagnosis is made by asking the patient to flex against resistance.

Tenolysis or exploration

Tenolysis usually is indicated when passive range exceeds active range and all joints have full ROM. No optimal time exists at which to perform tenolysis. It should be performed when the following conditions are met:

  • Soft tissue scars are mature
  • The benefit from therapy has reached a plateau

Local anesthesia is best, in that it allows the patient to participate in the operation and to visualize the intraoperative gains. A forearm tourniquet may be useful. Immediate mobilization follows surgical release. In patients not operated on under local anesthesia, immobilize the digit in flexion; clot adhesions can be broken more easily by extension than by flexion. Prolonged postoperative anesthesia is optimal.

The tendons are identified both distally and proximally in the palm. Dissection continues from either side to the point of fusion or adhesion to surrounding structures. Take care not to damage the epitenon, which would invariably lead to tendon adhesions at this point. Assess the completeness of tenolysis by doing the following:

  • Mark the tendon with ink
  • Observe ROM resulting from tendon excursion (limitation is due either to adhesions or inadequate pulleys)
  • Check the proximal extent of the tendon as far as the musculotendinous junction (this is best performed by asking the patient to demonstrate ROM)

On completion, the tendon may be excessively long or tenuous, or the pulley system may be inadequate. If the tendon is very tenuous, placing a rod alongside it may be worthwhile. If the tendon ruptures, a tendon rod is already in situ. Additional procedures include capsulotomy and skin coverage with a flap. The perfusion of the digit may be poor in the extended position, necessitating a vein graft.

Local administration of corticosteroids may lead to increased rupture, attenuation, and infection. Systemic administration is controversial. Interpositional materials generally are not used.

Postoperative mobilization should be unresisted active exercise. Caution should be exercised regarding the possibility of rupture with unprotected extension. An extensor splint may be necessary for recurrent flexion contracture. However, the risk of rupture is increased by the use of such a splint.

Tendon grafting

The main donor options for tendon grafting are as follows:

  • Palmaris longus tendon
  • Extensor digiti quinti tendon
  • Plantaris tendon

Alternatively, the extensor digitorum to the index finger or the extensor digitorum longus to the second, third, or fourth toes may be used. The distal insertion is through, around, or along the distal phalanx. Lister prefers the latter, in that the former two carry some risk of damage to the nail bed.

Sasaki et al reported a case of a knife injury to the base of the right ring finger in which the FDP tendon was lacerated at the A2 pulley level.[11] The patient's left second toe flexor tendon was used as a graft to reconstruct the finger flexor tendon from palm to fingertip. Through this procedure, active ROM improved, and subsequent tenolysis resulted in restoration of function to a near-normal level. The authors concluded that the intrasynovial tendon may be used as the source of a graft to restore function in cases of tendon laceration.

If the FDP is divided distal to the lumbrical origin, little, if any, myostatic contraction occurs. Pulling the proximal tendon out to length is important to achieve the benefit of creep. The active excursion varies for each muscle, but generally, it is approximately double the passive excursion achieved on the operating table. For tendons of unequal dimension, a Pulvertaft weave is preferred for the proximal tenorrhaphy. Three slots, each at 90º to each other, are used.

Two-stage tendon grafting

Two-stage reconstruction is indicated when the digit is not suitable for a one-stage graft for any of the following reasons:

  • Skeletal instability
  • Joint requiring capsulectomy
  • Inadequate skin coverage
  • Pulleys requiring reconstruction
  • Scarred graft bed

Scarred graft bed is the most common indication. Some digits may be insensate, have severe flexion contractures, or occur in an uncooperative patient; in these situations, the patients are not candidates for reconstruction.

The decision to proceed with two-stage reconstruction usually is made after failed tenolysis. Resect the FDP, leaving the distal 1 cm, back to a point 2 cm distal to the lumbrical origin. Preserve the FDS from the proximal end of the chiasm of Camper distally to prevent recurvatum deformity of the PIP joint.

The Hunter silicone rod or the Holter-Hauser rod may be used. The Holter-Hauser rod has a screw fixation device distally. A 4-mm rod usually is selected for adults. The proximal end of the rod is brought out proximal to the wrist crease. Complications include synovitis (15-20%), migration, extrusion, flexion contracture, and buckling of the rod. Hunter found no propensity for longitudinal contracture in the primate model. The final outcome is better when wounds are left to mature for a longer time.

Sheath closure

Repair of the sheath is highly recommended. This usually is performed with a continuous 6-0 nylon suture. Flex the finger to confirm that the sutures are not tethering the epitenon. Overtight closure may impede the passage of an edematous tendon. The best results reported to date were from a series in which the sheath was not closed.[12] Strauch and others advocate the use of autogenous vein patches for sheath closure. Closure of the sheath prior to extension of the digit after tendon repair facilitates delivery of the repair beneath the A3 pulley.

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Postoperative Details

"A moderate amount of intermittent movement, with as long an excursion as possible, interspersed by rest, will yield the best results" (Stirling Bunnell).

The tourniquet should be released after closure of the sheath to achieve hemostasis.

Mason demonstrated that a healing tendon has minimal tensile strength until it is stressed. Immediate mobilization of the flexor tendon repair has been demonstrated to reduce peritendinous adhesions and increase tensile strength, DNA content, eventual excursion, and uptake of synovial fluid. The options are as follows:

  • Controlled passive motion (Duran and Houser technique)
  • Active extension and rubber band flexion (Kleinert technique)
  • Immediate active motion with limited extension

The rehabilitation protocol must be tailored to the individual patient's status and needs. The clinician should approach each patient individually and progress them with a personalized and tailored approach in close communication with the surgeon and therapist. Functional hand motion and strength are the end results of successful flexor tendon surgery and rehabilitation.[13]

Controlled passive motion

In controlled passive motion, a dorsal block splint is used (in a similar position to the Kleinert splint), and the fingers are immobilized in Velcro straps. The joints are passively flexed three times daily. This technique often is used in children younger than 6 years; an above-the-elbow cast is applied with the wrist neutral, the metacarpophalangeal (MCP) joints at 90º, and the interphalangeal (IP) joints in full extension.

Active extension and rubber band flexion

In active extension and rubber band flexion, the wrist is immobilized 20° short of full flexion, and the MCP joints are in 45° flexion. Only the involved finger is incorporated in the rubber band. Free mobility of the other fingers encourages extension of the involved finger. In children older than 6 years, the Kleinert cowl splint is used, but the rubber band is not attached until the child fully understands the technique.

Bear in mind that attaching the rubber band in a patient unaware if its significance renders the patient at high risk of a flexion contracture; therefore, great responsibility is associated with the use of the Kleinert band. The Kleinert-Breidenbach splint incorporates a spring-loaded roller bar in the midpalm.

Electromyographic (EMG) studies showed that little flexor inhibition may be present during the extension phase and that opposition to extension serves little purpose. Therefore, the band should be only taut enough to flex the finger. For each 10 º of flexion at the DIP joint, the FDP only moves 1 mm. Although passive motion moves joints, whether it moves tendons is unknown. The only known way of moving tendons enough to prevent adhesions is by active mobilization. Modifications of the original Kleinert technique flex the wrist less and the MCP joints more.

Immediate active motion with limited extension

Several reports have advocated immediate active motion with limited extension and have demonstrated good results (see Table 3 below). However, the risk of tendon rupture is inevitably greater.

Table 3. Summary of Modifications of Immediate Active Motion With Limited Extension (Open Table in a new window)

Associated Factor Modification
Nerve or vascular repair Block full extension appropriately
Palmar plate repair Block full extension appropriately
Fracture, extensor tendon repair, or replant Early active and passive mobilization
Reversible cortical deficit, children older than 6 years Omit rubber band until sensorium clears or the child understands
Children younger than 6 years Duran technique

Patients should be observed at least twice weekly by the surgeon and more frequently by the therapist.

If active ROM is full after 4 weeks, the splint may be removed and the elastic band attached to a wrist strap for a further 2-3 weeks. If the band is discarded at this time, the risk of rupture is significant. Bear in mind that the patient who is mobilizing best is at greatest risk of rupture. In these patients, the rehabilitation process should be retarded.

If active ROM is poor after 4 weeks, the patient is at risk of a flexion contracture. The band is discarded, and physiology becomes more active. Warn the patient about the risk of rupture. Dynamic splintage can be employed after 8 weeks without risk of rupture.

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Complications

The most common complications of tendon grafting include the following:

  • Rupture
  • Adhesion
  • Flexion contracture
  • Recurvatum deformity (swan neck)
  • Bowstringing
  • Lumbrical plus
  • Quadriga syndrome

The rupture rate after tenolysis is high (21% in Lister's series). This is most commonly at the proximal repair site.

A meta-analysis of 29 studies examining the incidence of complications following tendon repair demonstrated a 6% reoperation rate and a 4% rate of tendon rupture and adhesion formation. The study found that use of a modified Kessler technique reduced the development of adhesions by 57% and that the presence of an epitendinous suture decreased the rate of reoperation by 84%.[14]

The swan neck deformity results from excision of the FDS. It can be prevented by retaining the part of the FDS to which the V2 vinculum attaches. It is corrected by either capsulodesis or by the construction of a spiral oblique retinacular ligament.

Lumbrical plus occurs when the graft is too long and the tension then is taken up by the lumbrical insertion, resulting in paradoxic extension of the IP joints with forced flexion. Division of the lumbrical corrects this complication. Because the grafted finger reaches the palm before the other fingers, this places a block on further flexion of the other fingers (the quadriga syndrome).

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Outcome and Prognosis

Reporting results

Various methods of expressing the results of tendon repair or grafting have been developed, including the following:

  • Littler method
  • Boyes technique
  • Total active motion (TAM)
  • Ratio of TAM to total passive motion (TPM)
  • Lister technique
  • Buck-Gramcko technique

In the Littler method, each joint's individual ROM is measured. The Boyes technique uses the pulp-to-midpalmar crease measurement (nail-to-table measurement can be added).

The TAM method incorporates the summed ROM of the IP joints minus the extension deficit, as a fraction of 175.[15, 16] Some incorporate MCP measurement. Strickland reported 50% of repairs achieved 50% of TAM. He reported 80% improvement following tenolysis, with 3% rate of rupture. Lister reported 71% improvement but with 21% rupture.

The TAM-to-TPM ratio expresses the relation of the postoperative TAM2 to the preoperative TPM1 for tendon grafts. In flexor tendon repair, the postoperative TAM2/175 is used. Lister believes this to be the best method for reporting results. He reports 76% TAM/TPM for grafts. Strickland's formulae are as follows:

  • Flexor tendon repair - TAM2/175 as a percentage
  • Tendon grafting - TAM2/TPM1 as a percentage
  • Tenolysis - 100 – (TPM1 – TAM2)/(TPM1 – TAM1) as a percentage

Both the Lister technique and the Buck-Gramcko technique incorporate the TAM (with MP) and the distance from pulp to midpalmar crease. These are used widely.

A retrospective review presented a functional outcome score in which tendon function, opposition, intrinsics, deformities, and sensation are assessed to evaluate the results of both tendon and nerve repair in patients with a "spaghetti wrist" combined injury of the flexor tendons, nerves, and vessels at the wrist.[17, 18]

Results

Lister reported 80% good or excellent results in zone II with 85% outside of zone II. The FDS was excised in only 25% of patients with zone II injuries, and in these patients only 45% achieved good or excellent results. This result is difficult to explain, but it may reflect improved blood supply or greater strength with the intact FDS. Only 12% of patients required tenolysis. Singer and Maloon reported 80% excellent or good results.

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Future and Controversies

Early repair has evolved as the mainstay of treatment for flexor tendon injuries. In the setting of a failed early repair or conditions in which early repair is not feasible, a delayed reconstruction remains a viable option to restore function to the affected digit.

As understanding of tendon biology and healing continues to advance, repair techniques and outcomes will also improve. Current research is directed at development of means by which to limit adhesions and scarring and to promote earlier tendon healing through the use of mesenchymal stem cells, molecular growth factors, and gene therapy.[19]

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Contributor Information and Disclosures
Author

Benjamin C Wood, MD Plastic and Reconstructive Surgeon, GW Medical Faculty Associates

Benjamin C Wood, MD is a member of the following medical societies: American Cleft Palate-Craniofacial Association, American College of Surgeons, American Society for Aesthetic Plastic Surgery, American Society of Plastic Surgeons, Southeastern Society of Plastic and Reconstructive Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Joseph A Molnar, MD, PhD, FACS Medical Director, Wound Care Center, Associate Director of Burn Unit, Professor, Department of Plastic and Reconstructive Surgery and Regenerative Medicine, Wake Forest University School of Medicine

Joseph A Molnar, MD, PhD, FACS is a member of the following medical societies: American Medical Association, American Society for Parenteral and Enteral Nutrition, American Society of Plastic Surgeons, North Carolina Medical Society, Undersea and Hyperbaric Medical Society, Peripheral Nerve Society, Wound Healing Society, American Burn Association, American College of Surgeons

Disclosure: Received grant/research funds from Clinical Cell Culture for co-investigator; Received honoraria from Integra Life Sciences for speaking and teaching; Received honoraria from Healogics for board membership; Received honoraria from Anika Therapeutics for consulting; Received honoraria from Food Matters for consulting.

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.

David W Chang, MD, FACS Associate Professor, Department of Plastic Surgery, MD Anderson Cancer Center, University of Texas Medical School at Houston

Disclosure: Nothing to disclose.

Chief Editor

Jorge I de la Torre, MD, FACS Professor of Surgery and Physical Medicine and Rehabilitation, Chief, Division of Plastic Surgery, Residency Program Director, University of Alabama at Birmingham School of Medicine; Director, Center for Advanced Surgical Aesthetics

Jorge I de la Torre, MD, FACS is a member of the following medical societies: American Burn Association, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, American Society for Reconstructive Microsurgery, Association for Academic Surgery, Medical Association of the State of Alabama

Disclosure: Nothing to disclose.

Additional Contributors

Anthony E Sudekum, MD Consulting Staff, Department of Plastic Surgery, St John's Mercy Health Center of St Louis

Anthony E Sudekum, MD is a member of the following medical societies: American College of Surgeons, American Society for Surgery of the Hand, Missouri State Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the contributions of previous author D Glynn Bolitho, MD, PhD, FACS, FRCSC, FCS(SA), to the development and writing of this article.

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Flexor tendons with attached vincula.
Retinacular portion of the flexor tendon sheath.
Two-strand repair techniques. (A) Tsuge, (B) modified grasping Kessler, (C) modified locking Kessler (ie, Pennington modified Kessler), (D) modified Pennington.
Multistrand core suture techniques performed with single-stranded suture. (A) double modified locking Kessler, (B) cruciate nonlocked, (C) cruciate cross-stitch locked, (D) 4-strand Savage, (E) augmented Becker (also called as MGH repair), (F) 6-strand Savage, (G) modified Savage, (H) triple modified Kessler.
Epitendinous suture techniques. (A) cross-stitch, (B) Lin, (C) Halsted, (D) horizontal intrafiber, (E) simple running, (F) Simple running superficial and simple running deep.
Table 1. Current Recommendations for Partial Tendon Injuries
Less than 25% Smooth edge to avoid entrapment
25-50% Peripheral running suture
Greater than 50% Core suture plus running suture
Table 2. Three Types of Avulsion of Profundus
Type I The tendon has retracted into the palm.



Repair only can be performed within 10 days.



Type II The tendon has been tethered by the long vinculum.



Repair is feasible for as many as 3 months.



Type III A large bone fragment, which cannot pass through the sheath, has been avulsed.



It can be repaired at any time.



Table 3. Summary of Modifications of Immediate Active Motion With Limited Extension
Associated Factor Modification
Nerve or vascular repair Block full extension appropriately
Palmar plate repair Block full extension appropriately
Fracture, extensor tendon repair, or replant Early active and passive mobilization
Reversible cortical deficit, children older than 6 years Omit rubber band until sensorium clears or the child understands
Children younger than 6 years Duran technique
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