Flexor Tendon InjuriesTricks of the Trade

Mr Andrew MahonConsultant Orthopaedic and Hand

SurgeonUniversity Hospital North Durham

History

• Demographics– Age, Hand Dominance, Occupation, Hobbies

• Mechanism– Blade, Glass, Power Tools, Closed Avulsion

• Time of Injury

• Tetanus

• Fitness for theatre

Examination

• Look at the Hand!!– Posture, Colour

• Wounds– Tidy, Untidy, Contaminated

• Test Sensation

• Know how to examine tendons

Question 1

• Linburg – Comstock anomaly

Question 2

• How do you assess the injured hand in a young child?

Examination - Children

• Look

• Sweating – pen test

• Wrinkling test

• Tenodesis

• Direct pressure over tendons / muscles

Don’t Under-estimate the Injury!

Question 3

• What is the injury?

Leddy and Packer

Take an X-Ray

Surgery

• Skin

• Associated structures

• Flexor sheaths

• FDS

• FDP

Skin - Incisions

• Need adequate exposure

• Avoid scar contracture

Associated Structures

• Inspect Nerves and Vessels

Question 4

• Which are the most important pulleys in the flexor sheath?

Question 4

• Which are the most important pulleys in the flexor sheath?

• A2

• A4

Flexor Sheath

• Lister’s Windows

• A4 Pulley

Deliver the Tendon

Zone 1 Repair

• < 1cm reattach to bone– Button– Suture anchor

• > 1cm tenorraphy

Tendon Repair Techniques

• Core suture– 2, 4, 6, 8 strands

• Circumferential (epitendinous) suture– Running– Halsted– Silfverskiold

Core Sutures

Core Sutures

• Kessler

Core Sutures

4 strand cruciate

Strickland

Question 5

• What is the most important factor affecting core suture strength?

Question 5

• What is the most important factor affecting core suture strength?

• The number of suture strands crossing the repair site

Question 6

• What is the optimum suture bite length for a core suture?

Question 6

• What is the optimum suture bite length for a core suture?

• 7mm to 1 cm

• Aim for 1cm

Circumferential Sutures

• Adds to repair strength

• Reduces bulk at repair site

Sequence of Repair

• In finger repair FDS first

Goals of Repair (Zone 2)

• Strong enough for active motion

• No gapping• Free glide through

pulleys• Minimal handling to

reduce adhesions Untidy Repair

Rehabilitation

• Controlled active movement (Belfast)

Rehabilitation

• Kleinert– Active extension– Passive flexion

Rehabilitation

Question 6

• What is the optimum wrist position for immobilisation following flexor tendon repair?

Question 6

• What is the optimum wrist position for immobilisation following flexor tendon repair?

• Slight extension– (Savage)

Rehabilitation

• Dorsal splint– MCPs 70 - 90°– Full extension allowed at PIPs

• Full time 6 weeks

• At night / in crowds until 12 weeks

• No resisted exercises until 8 weeks

• Driving 10 weeks