Delayed flexor tendon repair in no man's land

Thirty-seven digital flexor tendon injuries in 31 patients were treated by closure of the skin and delayed repair from 24 hours to 21 days later. All skin wounds healed without serious complication, and there were no infections. On examination at a minimum of 4 months after repair, 36% had total active motion (TAM) of22(1', 32%from 200° to 22(1', 6%from 18(1' to 200° and 26% with less than 18(1'. Under proper conditions, repair offlexor tendons can be carried out with the expectation of results comparable to more complex reconstruction procedures.

Lawrence H. Schneider, M.D., James M. Hunter, M.D., Tom R. Norris, M.D., and PaulO. Nadeau, M.D., Philadelphia. Pa.

Many surgeons believe that repair of a severed flexor tendon in no man's land, even under otherwise favorable conditions, should not be done if the injury period exceeds a rigid time limit. This was established at 4 to 6 hours by Mason! and Koch 2 and later extended to as long as 24 hours by Verdan. 3 In patients present­ing with injuries after this time interval, most surgeons preferred to wait and to reconstruct the flexor mecha­nism when the wounds were healed. Unfortunately, many of the patients we see do not reach our institution within the so-called" golden period." With knowledge of the technique of "delayed emergency" advanced by Iselin4 and that some authors were delaying their re­pairs:;'7 without encountering problems in wound heal­ing, we began to repair injured flexor tendons as they presented to our referral service, up to 3 weeks after in­jury. We did these repairs only in patients with clean, healing wounds with a minimum of soft tissue damage. We advocate repair of severed tendons at any level when patients are seen on the day of injury and when conditions are suitable. The attempt now is to eliminate the rigid time factor in selected situations so that advan­tages of direct repair can be extended to a larger group of patients.

Technique

The wounds of injury were treated, after cleansing, by skin edge excision, where needed, and by closure on

From the Hand Service, Department of Orthopaedic Surgery. Thomas Jefferson University Hospital. Philadelphia. Pa.

Received for publication Feb. 7, 1977.

Revised for publication Aug. 22, 1977.

Reprint requests: L. H. Schneider, M.D., Hand Rehabilitation Cen­ter, Ltd. 243 S. Tenth St. Philadelphia, PA 19107.

the day of injury. At that time appropriate tetanus prophylaxis was administered. Antibiotics were not used routinely. In this series the tendons were repaired 1 to 3 days after the patients came under our care. This ranged from 1 day to 3 weeks after injury.

The anaesthesia used was general-brachial plexus block or nerve blocks administered at the wrist level. The wound of injury was opened and extended if neces­sary. The zig-zag volar approach was preferred. 8 In the dissection, as much as possible of the uninjured sheath­pulley system was preserved until the exact level of the repair could be determined. Usually it was necessary to sacrifice a portion of the pulley system to allow free gliding of the repaired area. The profundus tendon was repaired using a Bunnell crisscross suture of No. 4-0 monofilament steel. If the tendon ends were ragged in appearance, they were aligned using a circumferential stitch of No. 6-0 nylon. 9 The distal end of the superfi­cialis tendon was pulled distally, transsected, and al­lowed to retract proximally. In one case, where the su­perficialis also was repaired, buried, nonabsorbable No. 4-0 Dacron was used. Approximately 1 cm of sheath was removed in either direction from the juncture, ensuring gliding room but still preserving adequate pulley support for the flexor tendon. Digital nerves then were repaired and the skin was closed. A posterior plaster slab over the dressing held the wrist at about 30° of flexion with the metacarpophalangeal joint at about 60° of flexion. The interphalangeal joints were flexed only minimally.

Although we have experimented with early motion techniques incorporating rubber band devices,9, 10 at present we keep the hand at rest for 3 weeks before we begin gentle active motion. At 4 weeks exercise to mobilize the tendon becomes more vigorous and often

452 THE JOURNAL OF HAND SURGERY November, 1977 Vol. 2, No.6, pp. 452-455

Vol. 2 No.6 November, 1977

Table I. Time interval between day of injury and day of repair

I 10 5 days 6 10 10 days IlIa 21 days

Group I TAM 200 6 4

Group II TAM 20010219 5 3 2

Group III TAM 18010 199 2 0 0

Group IV TAM <180 4 3

Legend: TAM. total active motion

includes the use of wood blocks and various dynamic splint devices .

Material

Between July, 1972, and September, 1976,68 pa­tients with injuries to their flexor tendons in no man's land, i.e., from the level of the metacarpophalangeal joint to the mid-middle phalanx level, were treated on our service . Of these patients, 41 patients with 51 fingers involved were subjected to the delayed repair technique described, I day to 3 weeks after injury. The remainder underwent primary repair on the day of in­jury or late reconstruction . There were 31 patients with 37 digits suitable for review. In six fingers only the profundus tendon was lacerated completely, so these were excluded fro'll this report. In the remaining 31 fingers both tendons had been severed. There were 16 men and nine women, ranging in age from 4 to 59 years. The average age was 27 years. Three patients were below the age of 15 years .

In 17 of the 31 fingers there was also injury to the digital nerves-both nerves in five fingers and only one nerve in 12 fingers .

Results

All patients were followed for 4 or more months ex­cept for two whose tendon junctures ruptured at 35 and 22 days after operation and were obvious failures.

All patients' skin wounds healed without significant complication. Two superficial wound problems cleared with local wound care . The slight delay in skin healing in these two cases did not influence the result.

Return of full gliding function is the goal of flexor tendon repair. To measure this function, range of mo­tion of the involved fingers was recorded, using the total active motion system suggested by the End-Result Evaluation Committee of The American Society for Surgery of The Hand. Measurement of active flexion of

Delayed flexor lendon repair in no man's land 453

Fig. 1. A, A 20-year-old woman severed all flexor tendons in the fingers at the proximal interphalangeal joint level on a blade of a power meat slicer. Digital nerves were severed in the long, ring, and little fingers . The skin was sutured on the day of injury and delayed repair of the four profundi and the digital nerves was carried out on the third day . Band C, Flex­ion and extension 2 years after repair.

each of the three joints of the involved finger was totaled . From this was subtracted any extension deficit, giving a single figure for total active motion. The results then were grouped using this numerical value as folIows:

Group I-total active motion 220 Group II-total active motion 200 to 219 Group III-total active motion 180 to 199 Group IV-total active motion < 180 Eleven fingers (36%) were classified as group I re-

454 Schneider el ul.

Fig. 2. A, A 24-year-old man lacerated the superficialis and profundus tendons of his ring and little fingers on a machette. Delayed repair of both profundus tendons was done 6 days after injury. Band C, Flexion and extension 6 months after repair.

The Journal of HAND SURGERY

Fig. 3. A, A 19-year-old man severed both flexor tendons in his little finger on the lid of a tin can. Appearance of the wound 6 days after injury. Band C, Motion at 4 months after repair of profundus tendon only.

suits. Eight of these could touch the distal palmar crease. Ten fingers (32%) were found to be in group II, whereas two fingers (6%) were in group III. There were eight fingers with group IV results (26%) and these were regarded as failures of treatment.

The results were charted against the time interval be­tween the day of injury and the day of repair (Table I).

In five patients (20%) tenolysis was performed 3 to 6

Vol. 2 No.6 November. 1977

Fig. 4. A, An 18-year-old student lacerated her index finger on a broken dinner plate 8 days prior to this photograph. Both flexor tendons were severed just proximal to the proximal in­terphalangeal joint. Repair of the profundus tendon was car­ried out 8 days after injury. This injury had a crushing ele­ment and in the postrepair period marginal wound necrosis developed. Band C, Motion seen 6 months after operation.

months later by techniques described elsewhere. ll , 12

Four were from group IV and one from group III. We consider tenolysis as a possible necessary accompani­ment to flexor tendon repair, and we advise all patients of this possibility, but for the purpose of this review we recorded results before tenolysis was carried out.

There were two failures due to rupture of the tendon juncture. One occurred on the 35th day after a repair which had been done 4 days after the injury. The pa­tient has refused further treatment. The other patient,

Delayed flexor tendon repair in no man's land 455

whose tendon was repaired 2 days after injury, ruptured the tendon junction 22 days later. Attempted secondary repair could not restore function and he has had no fur­ther treatment.

Summary and conclusion

Review of the results in 25 patients in whom 31 fingers had both flexor tendons severed in no man's land suggests that the results of this method are similar to those obtained when the tendons are repaired imme­diately or reconstructed later by tendon grafts. The use of this method allowed definitive treatment to be given by more experienced personnel at an elective time and reduced the pressure on the emergency room surgeon to undertake a procedure under less suitable conditions. Wound complications were minimal.

In selected cases this method makes available the ad­vantages of direct tendon repair any time in the first 3 weeks after injury.

REFERENCES

I. Mason ML: Primary and secondary tendon suture. Surg Gynecol Obstet 70:392-402, 1940

2. Koch SL: Division of the flexor tendons within the digi­tal sheath. Surg Gynecol Obstet 78:9-22, 1944

3. Verdan CE: Practical considerations for primary and sec­ondary repair in flexor tendon injuries. Surg Clin North Am 44:951-970, 1964

4. Iselin M: "delayed emergencies" in fresh wounds of the hand. Proc R Soc Med 51:713-714, 1958

5. Madsen E: Delayed primary suture of flexor tendons cut in the digital sheath. J Bone Joint Surg 52-B:264-267, 1970

6. Salvi V: Delayed primary suture in flexor tendon divi­sion. Hand 3:181-183,1971

7. Arons MD: Purposeful delay of the primary repair of cut flexor tendons in "some man's land" in children. Plast Reconstr Surg 53:638-641, 1974

8. Carter SJ, Mersheimer WL: Deferred primary tendon repair. Ann Surg 164:913-916, 1966

9. Bruner JM: The zig-zag volar-digital incision for flexor tendon surgery. Plast Reconstr Surg 4:571-574, 1967

10. Kleinert HE, Kutz JE, Cohen MJ: Primary repair of zone 2 flexor tendon lacerations, in Symposium on tendon sur­gery in the hand, A.A.O.S., St. Louis, 1975, the C. V. Mosby Co.

II. Young RES, Harmon JM: Repair of tendon injuries of the hand. Ann Surg 151 :562, 1960

12. Hunter JM, Schneider LH, Dumont J, et al: dynamic approach to problems of hand function. Clin Onhop 104:112-115,1974

13. Schneider LH, Hunter JM: Aexor tenolysis, in Sym­posium on tendon surgery in the hand, A.A.O.S., St. Louis, 1975, The C. V. Mosby Co.