Equipment
Many emergency departments (EDs) and acute care facilites use prepackaged laceration kits. These may contain much (though typically not all) of the equipment needed for the repair of extensor tendons. Additionally, at some facilities, sterile instrumentation may have to be requested from the operating room (OR).
Equipment used for anesthesia includes the following:
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Povidone-iodine solution (see the image below)
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Syringe, 10 mL
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Needle, 25 or 27 gauge
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Local anesthetic solution
Equipment used for wound irrigation and preparation includes the following:
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Sterile normal saline (0.9% NaCl) solution, 500 mL
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Irrigation set (see the image below)
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Syringe, 60 mL
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Angiocatheter, 16 gauge
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Intravenous tubing
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Face shield
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Blood pressure cuff
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Bright overhead lighting
Equipment used for tendon and skin repair includes the following:
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Sterile gloves
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Sterile drapes
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Gauze pads, 4 × 4
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Needle holder
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Skin hooks (2)
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Retractors
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Sharp and blunt-nosed scissors
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Small hemostats, several
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Single-toothed forceps
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Nonabsorbable, synthetic, and braided suture (3-0, 4-0, or 5-0) - Typical examples of appropriate brands of suture material are TiCron and Ethibond
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Nylon suture (4-0 or 5-0) for skin repair - Silk suture (which has high tissue reactivity) and chromic suture (which dissolves before the tendon heals adequately) should be avoided; the exception is in young children and infants, in whom the use of chromic suture for skin closure is acceptable, given their healing rates and their poor psychological reaction to suture removal in the clinic
Equipment used for wound care and splinting includes the following (see the image below):
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Topical antibiotic ointment
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Gauze pads
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Elastic gauze bandage or tape
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Splint material (fiberglass, plaster, or aluminum foam)
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Shears
Patient Preparation
Anesthesia
Adequate anesthesia is required for thorough wound exploration and tendon manipulation. Local digital or field blocks are typically adequate for this purpose in the acute care setting.
Lidocaine 1% or 2% or bupivacaine 0.25% or 0.5% without epinephrine (see Local Anesthetic Agents, Infiltrative Administration) is preferred. Some hand surgeons are becoming increasingly comfortable with using manufacturer-prepared local anesthetics with epinephrine (in a 1:100,000 ratio). [13, 14] However, unless the physician is comfortable and experienced with their use, these preparations should be avoided out of concern for the possibility of causing ischemic injury to a digit whose blood supply may already be compromised by an acute injury. Epinephrine should not be used in the setting of tobacco use or peripheral vascular disease.
Local or digital nerve block is warranted for finger injuries (see Hand, Anesthesia: Blocks). Field or regional nerve block should be used for hand injuries (see Local Anesthesia and Regional Nerve Block Anesthesia).
For operative surgical repairs, wide-awake surgery is well accepted. In this approach, patients are not sedated, analgesia is with lidocaine-epinephrine (local only), and a tourniquet is only occasionally used as needed. The acronym WALANT (Wide Awake Local Anesthetic and No Tourniquet) is often used for this technique. A prime benefit of WALANT is that the patient is able to move his or her fingers during the operative repair, which enables intraoperative verification of the adequacy of the repair. [13, 14, 15]
The patient should be placed supine on a procedure table or a gurney with an attached armboard. It is important to make sure that the patient is in a comfortable position so as to limit movement during the procedure. The patient’s hand should be level with his or her body or heart.
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Povidone-iodine solution, 1% lidocaine, 10-mL syringe, and 25-gauge needle.
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Irrigation equipment.
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Equipment for extensor tendon repair.
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Polypropylene and nylon sutures.
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Shears, aluminum splint, tape.
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Mallet finger splint, side view.
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Mallet finger splint, end view.
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Boutonnière splint, side view.
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Boutonnière splint, view from above and to side.
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Extensor tendon repair. Suture techniques.
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Extensor tendon repair. Dermatotenodesis.
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Extensor tendon repair. Video clip of splint application.
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Division of dorsum of hand and forearm into anatomic zones.
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Extensor tendon repair. 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.
