I gave this talk on flexor tendon injury to a group of orthopaedic surgeons. Find out more about hand and arm problems at http://www.noelhenley.com.

1. Flexor Tendon
Injuries
C. Noel Henley, MD

2. Flexor Tendon
Injuries
IU Orthopaedic Surgery
C. Noel Henley, MD

3. Flexor Tendon
Injuries
IU Orthopaedic Surgery
April 5, 2006
C. Noel Henley, MD

4. Talk Summary

5. Talk Summary
• Introduction

6. Talk Summary
• Introduction
• Basic science
– anatomy
– nutrition
– biomechanics
– healing
• Surgical considerations
– lacerations
– avulsions
• Rehabilitation

7. Introduction

8. Introduction
• History

9. Introduction
• History
– no repair possible in the digit

10. Introduction
• History
– no repair possible in the digit
– “no man’s land”

11. Introduction
• History
– no repair possible in the digit
– “no man’s land”
• Current evidence

12. Introduction
• History
– no repair possible in the digit
– “no man’s land”
• Current evidence
– 1970s: repair is possible without delayed grafting,
reconstruction

13. Introduction
• History
– no repair possible in the digit
– “no man’s land”
• Current evidence
– 1970s: repair is possible without delayed grafting,
reconstruction
– Now: adhesion-free, primarily healed tendon repair is
possible

14. Introduction

15. Introduction
• General goals of repair

16. Introduction
• General goals of repair
– primary tendon repair – avoid grafting

17. Introduction
• General goals of repair
– primary tendon repair – avoid grafting
– sufficient strength for passive motion rehab which will
allow for

18. Introduction
• General goals of repair
– primary tendon repair – avoid grafting
– sufficient strength for passive motion rehab which will
allow for
• minimum adhesion formation

19. Introduction
• General goals of repair
– primary tendon repair – avoid grafting
– sufficient strength for passive motion rehab which will
allow for
• minimum adhesion formation
• restoration of gliding surface

20. Introduction
• General goals of repair
– primary tendon repair – avoid grafting
– sufficient strength for passive motion rehab which will
allow for
• minimum adhesion formation
• restoration of gliding surface
• facilitation of repair site healing

21. Anatomy

22. Anatomy
• FDS

23. Anatomy
• FDS
– O: volar humerus, radius, ulna

24. Anatomy
• FDS
– O: volar humerus, radius, ulna
– divided muscle belly in mid forearm (FA)

25. Anatomy
• FDS
– O: volar humerus, radius, ulna
– divided muscle belly in mid forearm (FA)
• super cial – long and ring ngers (LF, RF)

26. Anatomy
• FDS
– O: volar humerus, radius, ulna
– divided muscle belly in mid forearm (FA)
• super cial – long and ring ngers (LF, RF)
• deep – index and small ngers (IF, SF)

27. Anatomy
• FDS
– O: volar humerus, radius, ulna
– divided muscle belly in mid forearm (FA)
• super cial – long and ring ngers (LF, RF)
• deep – index and small ngers (IF, SF)
• FDP

28. Anatomy
• FDS
– O: volar humerus, radius, ulna
– divided muscle belly in mid forearm (FA)
• super cial – long and ring ngers (LF, RF)
• deep – index and small ngers (IF, SF)
• FDP
– O: anteromedial ulna, IO membrane

29. Anatomy
• FDS
– O: volar humerus, radius, ulna
– divided muscle belly in mid forearm (FA)
• super cial – long and ring ngers (LF, RF)
• deep – index and small ngers (IF, SF)
• FDP
– O: anteromedial ulna, IO membrane
– dorsal to FDS in volar FA

30. Anatomy
• FDS
– O: volar humerus, radius, ulna
– divided muscle belly in mid forearm (FA)
• super cial – long and ring ngers (LF, RF)
• deep – index and small ngers (IF, SF)
• FDP
– O: anteromedial ulna, IO membrane
– dorsal to FDS in volar FA
– four tendons usually arise from common belly

31. Anatomy

32. Anatomy
• In the hand

33. Anatomy
• In the hand
– ve zones

34. Anatomy
• In the hand
– ve zones
• V: musculo-tendinous junction to
proximal edge of carpal canal

35. Anatomy
• In the hand
– ve zones
• V: musculo-tendinous junction to
proximal edge of carpal canal
• IV: beneath (dorsal to) the
transverse carpal ligament

36. Anatomy
• In the hand
– ve zones
• V: musculo-tendinous junction to
proximal edge of carpal canal
• IV: beneath (dorsal to) the
transverse carpal ligament
– IF, SF FDS are dorsal to LF, RF FDS
here

37. Anatomy

38. Anatomy
• Zones (cont.)

39. Anatomy
• Zones (cont.)
– III: distal edge of transverse
carpal ligament to origin of
bro-osseous sheath at the
distal palmar crease

40. Anatomy
• Zones (cont.)
– III: distal edge of transverse
carpal ligament to origin of
bro-osseous sheath at the
distal palmar crease
– II: origin of bro-osseous
sheath to FDS insertion

41. Anatomy
• Zones (cont.)
– III: distal edge of transverse
carpal ligament to origin of
bro-osseous sheath at the
distal palmar crease
– II: origin of bro-osseous
sheath to FDS insertion
– I: distal to FDS insertion

42. Anatomy

43. Anatomy
• Super cialis

44. Anatomy
• Super cialis
– FDS divides into two slips, wrapping around
FDP; reunite at Camper’s chiasma

45. Anatomy
• Super cialis
– FDS divides into two slips, wrapping around
FDP; reunite at Camper’s chiasma
– continues to insert along the proximal half of the
middle phalanx (P2)

46. Anatomy

47. Anatomy
• Profundus

48. Anatomy
• Profundus

49. Anatomy
• Profundus
– passes through chiasma to insert at proximal base
of distal phalanx (P3)

50. Anatomy
• Profundus
– passes through chiasma to insert at proximal base
of distal phalanx (P3)
– FDP = primary digital exor

51. Anatomy
• Profundus
– passes through chiasma to insert at proximal base
of distal phalanx (P3)
– FDP = primary digital exor
– FDS + intrinsics combine for forceful exion

52. Anatomy

53. Anatomy

54. Anatomy

55. Anatomy
• Sheath

56. Anatomy
• Sheath
– visceral and parietal synovial layers
enclose the tendons

57. Anatomy
• Sheath
– visceral and parietal synovial layers
enclose the tendons
– Pulleys

58. Anatomy
• Sheath
– visceral and parietal synovial layers
enclose the tendons
– Pulleys
• A2 and A4 arise from periosteum of
proximal P1 and midportion of P2 (prox-
prox and mid-middle)

59. Anatomy

60. Anatomy
• Sheath

61. Anatomy
• Sheath
– Pulleys

62. Anatomy
• Sheath
– Pulleys
• A1, A3, and A5 arise from volar plates of
MCP, PIP, and DIP joints respectively

63. Anatomy

64. Anatomy
• Sheath

65. Anatomy
• Sheath
– Pulleys

66. Anatomy
• Sheath
– Pulleys
• cruciate pulleys collapse to allow annular
pulley apposition during exion

67. Nutrition

68. Nutrition
• Two sources of tendon nutrition

69. Nutrition
• Two sources of tendon nutrition
– vascular

70. Nutrition
• Two sources of tendon nutrition
– vascular
– synovial

71. Nutrition
• Two sources of tendon nutrition
– vascular
– synovial
• Vascularity sources

72. Nutrition
• Two sources of tendon nutrition
– vascular
– synovial
• Vascularity sources
– longitudinal vessels

73. Nutrition
• Two sources of tendon nutrition
– vascular
– synovial
• Vascularity sources
– longitudinal vessels
– proximal synovial fold vessels

74. Nutrition
• Two sources of tendon nutrition
– vascular
– synovial
• Vascularity sources
– longitudinal vessels
– proximal synovial fold vessels
– segmental branches from paired digital vessels
(vincular system)

75. Nutrition
• Two sources of tendon nutrition
– vascular
– synovial
• Vascularity sources
– longitudinal vessels
– proximal synovial fold vessels
– segmental branches from paired digital vessels
(vincular system)
– insertional vessels at FDP, FDS insertions

76. Nutrition

77. Nutrition

78. Nutrition

79. Nutrition
• Avascular segments

80. Nutrition
• Avascular segments
– FDP and FDS: over proximal phalanx

81. Nutrition
• Avascular segments
– FDP and FDS: over proximal phalanx
– FDP: short zone over middle phalanx

82. Nutrition
• Avascular segments
– FDP and FDS: over proximal phalanx
– FDP: short zone over middle phalanx
• Synovial uid diffusion

83. Nutrition
• Avascular segments
– FDP and FDS: over proximal phalanx
– FDP: short zone over middle phalanx
• Synovial uid diffusion
– imbibition

84. Nutrition

85. Nutrition

86. Nutrition

87. Nutrition
• Vascularity

88. Nutrition
• Vascularity
– damage to vascular and uid nutritional systems
may further hamper healing of repaired exor
tendons

89. Nutrition
• Vascularity
– damage to vascular and uid nutritional systems
may further hamper healing of repaired exor
tendons
– their integrity must be respected during all
reparative efforts

90. Nutrition

91. Nutrition

92. Biomechanics

93. Biomechanics
• Excursion

94. Biomechanics
• Excursion
– 9 cm of excursion for composite wrist, full digital
exion

95. Biomechanics
• Excursion
– 9 cm of excursion for composite wrist, full digital
exion
– 2.5 cm required for full digital exion with wrist
at neutral

96. Biomechanics

97. Biomechanics
• Moment arm

98. Biomechanics
• Moment arm
– increased distance of tendon from joint center of
rotation = higher moment arm = less motion per
muscle contraction force

99. Biomechanics

100. Biomechanics
• Moment arm

101. Biomechanics
• Moment arm
– pulley system constraint governs these parameters

102. Biomechanics
• Moment arm
– pulley system constraint governs these parameters
– loss of portions of pulley system may alter balance
between exor, intrinsic, and extensor tendons

103. Biomechanics
• Moment arm
– pulley system constraint governs these parameters
– loss of portions of pulley system may alter balance
between exor, intrinsic, and extensor tendons
– loss of A2 or A4 pulleys may diminish motion/power
or lead to contractures of IP joints

104. Tendon Healing

105. Tendon Healing
• Phases

106. Tendon Healing
• Phases
– in ammatory – 48-72 hours

107. Tendon Healing
• Phases
– in ammatory – 48-72 hours
• repair strength reliant upon suture itself

108. Tendon Healing
• Phases
– in ammatory – 48-72 hours
• repair strength reliant upon suture itself
– collagen-producing phase – 5 days to 4 weeks

109. Tendon Healing
• Phases
– in ammatory – 48-72 hours
• repair strength reliant upon suture itself
– collagen-producing phase – 5 days to 4 weeks
• strength accelerates rapidly here

110. Tendon Healing
• Phases
– in ammatory – 48-72 hours
• repair strength reliant upon suture itself
– collagen-producing phase – 5 days to 4 weeks
• strength accelerates rapidly here
– remodeling phase – until 112 days

111. Tendon Healing
• Phases
– in ammatory – 48-72 hours
• repair strength reliant upon suture itself
– collagen-producing phase – 5 days to 4 weeks
• strength accelerates rapidly here
– remodeling phase – until 112 days
• Predominance of extrinsic over intrinsic
healing leads to more adhesions

112. Tendon Healing
inflammatory

113. Tendon Healing
inflammatory

114. Tendon Healing
collagen-producing

115. Tendon Healing
collagen-producing

116. Tendon Healing
remodeling

117. Tendon Healing
remodeling

118. Tendon Healing

119. Tendon Healing
• Adhesion formation and control

120. Tendon Healing
• Adhesion formation and control
– Contributing factors

121. Tendon Healing
• Adhesion formation and control
– Contributing factors
• trauma (from injury and surgery)

122. Tendon Healing
• Adhesion formation and control
– Contributing factors
• trauma (from injury and surgery)
– tendon surface crushing

123. Tendon Healing
• Adhesion formation and control
– Contributing factors
• trauma (from injury and surgery)
– tendon surface crushing
– vincula disruption

124. Tendon Healing
• Adhesion formation and control
– Contributing factors
• trauma (from injury and surgery)
– tendon surface crushing
– vincula disruption
• tendon ischemia

125. Tendon Healing
• Adhesion formation and control
– Contributing factors
• trauma (from injury and surgery)
– tendon surface crushing
– vincula disruption
• tendon ischemia
• tendon immobilization

126. Tendon Healing
• Adhesion formation and control
– Contributing factors
• trauma (from injury and surgery)
– tendon surface crushing
– vincula disruption
• tendon ischemia
• tendon immobilization
• repair gapping

127. Tendon Healing
• Adhesion formation and control
– Contributing factors
• trauma (from injury and surgery)
– tendon surface crushing
– vincula disruption
• tendon ischemia
• tendon immobilization
• repair gapping
• excision of tendon sheath components

128. Tendon Healing

129. Tendon Healing
• How is healing related to motion?

130. Tendon Healing
• How is healing related to motion?
– passive mobilization enhances healing by
stimulating tendon wound maturation and scar
remodeling* , 110
*Gelberman R, Goldberg V, An KN, et al: Tendon, in Woo SLY, Buckwalter JA
(eds): Injury and Repair of the Musculoskeletal Soft Tissues. Park Ridge, Ill:
American Academy of Orthopaedic Surgeons, 1988, pp 5-40.

131. Tendon Healing
• How is healing related to motion?
– passive mobilization enhances healing by
stimulating tendon wound maturation and scar
remodeling* , 110
– use a strong, gap-resistant suture technique +
controlled-motion stress postoperatively
*Gelberman R, Goldberg V, An KN, et al: Tendon, in Woo SLY, Buckwalter JA
(eds): Injury and Repair of the Musculoskeletal Soft Tissues. Park Ridge, Ill:
American Academy of Orthopaedic Surgeons, 1988, pp 5-40.

132. Tendon Healing
• How is healing related to motion?
– passive mobilization enhances healing by
stimulating tendon wound maturation and scar
remodeling* , 110
– use a strong, gap-resistant suture technique +
controlled-motion stress postoperatively
– 3-5 mm of excursion needed at repair site to
prevent adhesions 144
*Gelberman R, Goldberg V, An KN, et al: Tendon, in Woo SLY, Buckwalter JA
(eds): Injury and Repair of the Musculoskeletal Soft Tissues. Park Ridge, Ill:
American Academy of Orthopaedic Surgeons, 1988, pp 5-40.

133. Tendon Repair

134. Tendon Repair
• Contraindications

135. Tendon Repair
• Contraindications
– severe multiple tissue injuries to ngers, palm

136. Tendon Repair
• Contraindications
– severe multiple tissue injuries to ngers, palm
– gross wound contamination

137. Tendon Repair
• Contraindications
– severe multiple tissue injuries to ngers, palm
– gross wound contamination
– signi cant skin loss over the exor system

138. Tendon Repair
• Contraindications
– severe multiple tissue injuries to ngers, palm
– gross wound contamination
– signi cant skin loss over the exor system
• Reduce fractures, repair neurovascular injuries
concomitantly

139. Tendon Repair
• Contraindications
– severe multiple tissue injuries to ngers, palm
– gross wound contamination
– signi cant skin loss over the exor system
• Reduce fractures, repair neurovascular injuries
concomitantly
• Repair tendons acutely/subacutely to avoid
deterioration of tendon ends and extrinsic muscle
shortening

140. Examination

141. Examination
• High index of suspicion for multiple structures
injured through a small laceration or crush injury

142. Examination
• High index of suspicion for multiple structures
injured through a small laceration or crush injury
• Complete neurovascular exam

143. Examination
• High index of suspicion for multiple structures
injured through a small laceration or crush injury
• Complete neurovascular exam
– division of two digital nerves indicates arterial division as
well

144. Examination
• High index of suspicion for multiple structures
injured through a small laceration or crush injury
• Complete neurovascular exam
– division of two digital nerves indicates arterial division as
well
– dysvascularity could compromise repair or skin ap
healing +/- cold intolerance

145. Examination

146. Examination
• Alterations in posture

147. Examination

148. Examination
• Alterations in posture

149. Examination

150. Examination
• Tenodesis effect

151. Examination

152. Examination
• Functional testing (FDS, FDP)

153. Examination
• Functional testing (FDS, FDP)

154. Examination

155. Examination
• Functional testing (FDS)

156. Examination

157. Examination
• Functional testing (FDP)

158. Surgery

159. Surgery
• Planning

160. Surgery
• Planning
– inform the patient of the injury severity and potential
need for more surgery

161. Surgery
• Planning
– inform the patient of the injury severity and potential
need for more surgery
– incisions

162. Surgery
• Planning
– inform the patient of the injury severity and potential
need for more surgery
– incisions
• keep tendon retraction in mind

163. Surgery
• Planning
– inform the patient of the injury severity and potential
need for more surgery
– incisions
• keep tendon retraction in mind
• no bonus points for small incisions

164. Surgery
• Planning
– inform the patient of the injury severity and potential
need for more surgery
– incisions
• keep tendon retraction in mind
• no bonus points for small incisions
• maintain ap viability

165. Surgery
• Planning
– inform the patient of the injury severity and potential
need for more surgery
– incisions
• keep tendon retraction in mind
• no bonus points for small incisions
• maintain ap viability
• avoid skin/scar contracture

166. Surgery - planning

167. Surgery - planning
• Volar incisions

168. Surgery - planning
• Volar incisions • Mid-axial incision

169. Surgery - principles

170. Surgery - principles
• Ideal repair

171. Surgery - principles
• Ideal repair
– easy placement of sutures in the tendon

172. Surgery - principles
• Ideal repair
– easy placement of sutures in the tendon
– secure suture knots

173. Surgery - principles
• Ideal repair
– easy placement of sutures in the tendon
– secure suture knots
– smooth junction of tendon ends

174. Surgery - principles
• Ideal repair
– easy placement of sutures in the tendon
– secure suture knots
– smooth junction of tendon ends
– minimal gapping at the repair site

175. Surgery - principles
• Ideal repair
– easy placement of sutures in the tendon
– secure suture knots
– smooth junction of tendon ends
– minimal gapping at the repair site
– minimal interference with tendon vascularity

176. Surgery - principles
• Ideal repair
– easy placement of sutures in the tendon
– secure suture knots
– smooth junction of tendon ends
– minimal gapping at the repair site
– minimal interference with tendon vascularity
– sufficient strength for early motion stress to the tendon

177. Surgery

178. Surgery
• Core suture considerations

179. Surgery
• Core suture considerations
– strength of a repair is proportional to the number of
suture strands crossing the repair site

180. Surgery
• Core suture considerations
– strength of a repair is proportional to the number of
suture strands crossing the repair site
– increasing crossing strands increases difficulty and risk of
tendon damage, vascularity compromise

181. Surgery
• Core suture considerations
– strength of a repair is proportional to the number of
suture strands crossing the repair site
– increasing crossing strands increases difficulty and risk of
tendon damage, vascularity compromise
– repairs usually rupture at the suture knots

182. Surgery
• Core suture considerations
– strength of a repair is proportional to the number of
suture strands crossing the repair site
– increasing crossing strands increases difficulty and risk of
tendon damage, vascularity compromise
– repairs usually rupture at the suture knots
– locking loop con gurations usually allow less gapping
than grasping types

183. Surgery
• Core suture considerations
– strength of a repair is proportional to the number of
suture strands crossing the repair site
– increasing crossing strands increases difficulty and risk of
tendon damage, vascularity compromise
– repairs usually rupture at the suture knots
– locking loop con gurations usually allow less gapping
than grasping types
– larger caliber sutures increase repair strength

184. Surgery

185. Surgery
• Core suture methods

186. Surgery

187. Surgery
• Suture material

188. Surgery
• Suture material
– absorbable materials seem attractive

189. Surgery
• Suture material
– absorbable materials seem attractive
• less foreign body reaction long-term

190. Surgery
• Suture material
– absorbable materials seem attractive
• less foreign body reaction long-term
• less stress-shielding of the host tissue

191. Surgery
• Suture material
– absorbable materials seem attractive
• less foreign body reaction long-term
• less stress-shielding of the host tissue
– optimal rates of material absorption, strength reduction
are unknown

192. Surgery
• Suture material
– absorbable materials seem attractive
• less foreign body reaction long-term
• less stress-shielding of the host tissue
– optimal rates of material absorption, strength reduction
are unknown
– 3-0, 4-0 braided polyester is most commonly used

193. Surgery

194. Surgery
• Circumferential (peripheral) sutures

195. Surgery
• Circumferential (peripheral) sutures
– may provide a 10-15% increase in exor tendon repair
strength

196. Surgery
• Circumferential (peripheral) sutures
– may provide a 10-15% increase in exor tendon repair
strength
– reduces gapping between ends

197. Surgery
• Circumferential (peripheral) sutures
– may provide a 10-15% increase in exor tendon repair
strength
– reduces gapping between ends
– methods

198. Surgery
• Circumferential (peripheral) sutures
– may provide a 10-15% increase in exor tendon repair
strength
– reduces gapping between ends
– methods
• running lock loop (Lin)

199. Surgery
• Circumferential (peripheral) sutures
– may provide a 10-15% increase in exor tendon repair
strength
– reduces gapping between ends
– methods
• running lock loop (Lin)
• horizontal mattress method (Mashadi)

200. Surgery
• Circumferential (peripheral) sutures
– may provide a 10-15% increase in exor tendon repair
strength
– reduces gapping between ends
– methods
• running lock loop (Lin)
• horizontal mattress method (Mashadi)
• Halsted continuous horizontal mattress method (Wade)

201. Surgery
• Circumferential (peripheral) sutures
– may provide a 10-15% increase in exor tendon repair
strength
– reduces gapping between ends
– methods
• running lock loop (Lin)
• horizontal mattress method (Mashadi)
• Halsted continuous horizontal mattress method (Wade)
• cross-stich technique (Silfverskiold)

202. Surgery

203. Surgery

204. Surgery

205. Surgery

206. Surgery

207. Surgery

208. Surgery
• Strickland conclusion: Any 4-strand core suture +
running lock or horizontal mattress circumferential
suture should permit light composite grip during the
entire healing period

209. Surgery

210. Surgery
• Sheath repair

211. Surgery
• Sheath repair
– cumulative work of several investigators fails to give clear
direction

212. Surgery
• Sheath repair
– cumulative work of several investigators fails to give clear
direction
– advantages

213. Surgery
• Sheath repair
– cumulative work of several investigators fails to give clear
direction
– advantages
• provides a barrier to extrinsic adhesions

214. Surgery
• Sheath repair
– cumulative work of several investigators fails to give clear
direction
– advantages
• provides a barrier to extrinsic adhesions
• quicker return of synovial nutrition

215. Surgery
• Sheath repair
– cumulative work of several investigators fails to give clear
direction
– advantages
• provides a barrier to extrinsic adhesions
• quicker return of synovial nutrition
• serves as a mold for the remodeling tendon

216. Surgery
• Sheath repair
– cumulative work of several investigators fails to give clear
direction
– advantages
• provides a barrier to extrinsic adhesions
• quicker return of synovial nutrition
• serves as a mold for the remodeling tendon
• results in better sheath-tendon biomechanics

217. Surgery
• Sheath repair
– cumulative work of several investigators fails to give clear
direction
– advantages
• provides a barrier to extrinsic adhesions
• quicker return of synovial nutrition
• serves as a mold for the remodeling tendon
• results in better sheath-tendon biomechanics
– disadvantages

218. Surgery
• Sheath repair
– cumulative work of several investigators fails to give clear
direction
– advantages
• provides a barrier to extrinsic adhesions
• quicker return of synovial nutrition
• serves as a mold for the remodeling tendon
• results in better sheath-tendon biomechanics
– disadvantages
• difficult

219. Surgery
• Sheath repair
– cumulative work of several investigators fails to give clear
direction
– advantages
• provides a barrier to extrinsic adhesions
• quicker return of synovial nutrition
• serves as a mold for the remodeling tendon
• results in better sheath-tendon biomechanics
– disadvantages
• difficult
• may restrict tendon gliding

220. Surgery

221. Surgery
• Partial lacerations

222. Surgery
• Partial lacerations
– lacerations of 50% or less do not need to be sutured

223. Surgery
• Partial lacerations
– lacerations of 50% or less do not need to be sutured
– Grewal: nonrepaired partial lacerations had higher
ultimate load and stiffness than repaired tendons

224. Surgery
• Partial lacerations
– lacerations of 50% or less do not need to be sutured
– Grewal: nonrepaired partial lacerations had higher
ultimate load and stiffness than repaired tendons
– entrapment, rupture, triggering of unrepaired partial
severed tendons has been reported (Schlenker)

225. Surgery

226. Surgery
• Zone I injury – FDP avulsion

227. Surgery
• Zone I injury – FDP avulsion
– occurs w/ forcible extension during strong DIP
exion

228. Surgery
• Zone I injury – FDP avulsion
– occurs w/ forcible extension during strong DIP
exion
– three types (Leddy and Packer) – relevant to
nding the fragment/tendon end and to repair
timing

229. Surgery
• Zone I injury – FDP avulsion
– occurs w/ forcible extension during strong DIP
exion
– three types (Leddy and Packer) – relevant to
nding the fragment/tendon end and to repair
timing
– tendon repair to cancellous bone provides the
best result

230. Surgery
• Zone I injury – FDP avulsion
– occurs w/ forcible extension during strong DIP
exion
– three types (Leddy and Packer) – relevant to
nding the fragment/tendon end and to repair
timing
– tendon repair to cancellous bone provides the
best result
• done with sutures exiting dorsally tied over a button

231. Surgery
• Zone I injury – FDP avulsion
– occurs w/ forcible extension during strong DIP
exion
– three types (Leddy and Packer) – relevant to
nding the fragment/tendon end and to repair
timing
– tendon repair to cancellous bone provides the
best result
• done with sutures exiting dorsally tied over a button
• OR with suture anchors

232. Surgery – FDP avulsion

233. Surgery – FDP avulsion
• Leddy and Packer classi cation

234. Surgery

235. Surgery
• FDP laceration – Zone I

236. Surgery
• FDP laceration – Zone I
– laceration distal to FDS insertion = Zone I injury

237. Surgery
• FDP laceration – Zone I
– laceration distal to FDS insertion = Zone I injury
– distal stump < 1 cm long = perform FDP advancement
and tendon to bone repair

238. Surgery
• FDP laceration – Zone I
– laceration distal to FDS insertion = Zone I injury
– distal stump < 1 cm long = perform FDP advancement
and tendon to bone repair
– > 1 cm distally = repair primarily

239. Surgery
• FDP laceration – Zone I
– laceration distal to FDS insertion = Zone I injury
– distal stump < 1 cm long = perform FDP advancement
and tendon to bone repair
– > 1 cm distally = repair primarily
• laceration may be near A4  difficult repair

240. Surgery
• FDP laceration – Zone I
– laceration distal to FDS insertion = Zone I injury
– distal stump < 1 cm long = perform FDP advancement
and tendon to bone repair
– > 1 cm distally = repair primarily
• laceration may be near A4  difficult repair
• advancement of FDP > 1 cm may result in the quadrigia effect

241. Rehabilitation (zone ii)

242. Rehabilitation (zone ii)

243. Rehabilitation (zone ii)

244. Rehabilitation (zone ii)

245. Talk Summary

246. Talk Summary
• Basic science
– anatomy
– nutrition
– biomechanics
– healing
• Surgical considerations
– lacerations
– avulsions
• Rehabilitation

247. OITE

248. OITE
2004 #10
A partial laceration of the exor tendon should be repaired when the
percentage of tendon lacerated is more than
1. 10%
2. 20%
3. 40%
4. 60%
5. 80%

249. OITE
2004 #10
A partial laceration of the exor tendon should be repaired when the
percentage of tendon lacerated is more than
1. 10%
2. 20%
3. 40%
4. 60%
5. 80%

250. OITE

251. OITE
2005 #246

252. OITE
2005 #246

253. OITE
2005 #246
A 21 year-old left-handed college student was playing rugby 3 days ago and
felt the sudden onset of pain in his right ring nger when another
played pulled away from him. A clinical photo is shown in Figure 86.
What is the most likely diagnosis?

254. OITE
2005 #246
A 21 year-old left-handed college student was playing rugby 3 days ago and
felt the sudden onset of pain in his right ring nger when another
played pulled away from him. A clinical photo is shown in Figure 86.
What is the most likely diagnosis?

255. OITE
2005 #246
A 21 year-old left-handed college student was playing rugby 3 days ago and
felt the sudden onset of pain in his right ring nger when another
played pulled away from him. A clinical photo is shown in Figure 86.
What is the most likely diagnosis?
1. Volar plate avulsion of the proximal interphalangeal joint

256. OITE
2005 #246
A 21 year-old left-handed college student was playing rugby 3 days ago and
felt the sudden onset of pain in his right ring nger when another
played pulled away from him. A clinical photo is shown in Figure 86.
What is the most likely diagnosis?
1. Volar plate avulsion of the proximal interphalangeal joint
2. Avulsion of the distal exor digitorum profundus tendon

257. OITE
2005 #246
A 21 year-old left-handed college student was playing rugby 3 days ago and
felt the sudden onset of pain in his right ring nger when another
played pulled away from him. A clinical photo is shown in Figure 86.
What is the most likely diagnosis?
1. Volar plate avulsion of the proximal interphalangeal joint
2. Avulsion of the distal exor digitorum profundus tendon
3. Musculotendinous rupture in the forearm

258. OITE
2005 #246
A 21 year-old left-handed college student was playing rugby 3 days ago and
felt the sudden onset of pain in his right ring nger when another
played pulled away from him. A clinical photo is shown in Figure 86.
What is the most likely diagnosis?
1. Volar plate avulsion of the proximal interphalangeal joint
2. Avulsion of the distal exor digitorum profundus tendon
3. Musculotendinous rupture in the forearm
4. Stretch injury to the ulnar nerve at the wrist

259. OITE
2005 #246
A 21 year-old left-handed college student was playing rugby 3 days ago and
felt the sudden onset of pain in his right ring nger when another
played pulled away from him. A clinical photo is shown in Figure 86.
What is the most likely diagnosis?
1. Volar plate avulsion of the proximal interphalangeal joint
2. Avulsion of the distal exor digitorum profundus tendon
3. Musculotendinous rupture in the forearm
4. Stretch injury to the ulnar nerve at the wrist
5. Ulnar artery thrombosis

260. OITE
2005 #246
A 21 year-old left-handed college student was playing rugby 3 days ago and
felt the sudden onset of pain in his right ring nger when another
played pulled away from him. A clinical photo is shown in Figure 86.
What is the most likely diagnosis?
1. Volar plate avulsion of the proximal interphalangeal joint
2. Avulsion of the distal exor digitorum profundus tendon
3. Musculotendinous rupture in the forearm
4. Stretch injury to the ulnar nerve at the wrist
5. Ulnar artery thrombosis

262. OITE

263. OITE
2005 #246

264. OITE
2005 #246

265. OITE
2005 #246
A 21 year-old left-handed college student was playing rugby 3 days ago and
felt the sudden onset of pain in his right ring nger when another
played pulled away from him. A clinical photo is shown in Figure 86.
What is the most likely diagnosis?

266. OITE
2005 #246
A 21 year-old left-handed college student was playing rugby 3 days ago and
felt the sudden onset of pain in his right ring nger when another
played pulled away from him. A clinical photo is shown in Figure 86.
What is the most likely diagnosis?

267. OITE
2005 #246
A 21 year-old left-handed college student was playing rugby 3 days ago and
felt the sudden onset of pain in his right ring nger when another
played pulled away from him. A clinical photo is shown in Figure 86.
What is the most likely diagnosis?
1. Volar plate avulsion of the proximal interphalangeal joint

268. OITE
2005 #246
A 21 year-old left-handed college student was playing rugby 3 days ago and
felt the sudden onset of pain in his right ring nger when another
played pulled away from him. A clinical photo is shown in Figure 86.
What is the most likely diagnosis?
1. Volar plate avulsion of the proximal interphalangeal joint
2. Avulsion of the distal exor digitorum profundus tendon

269. OITE
2005 #246
A 21 year-old left-handed college student was playing rugby 3 days ago and
felt the sudden onset of pain in his right ring nger when another
played pulled away from him. A clinical photo is shown in Figure 86.
What is the most likely diagnosis?
1. Volar plate avulsion of the proximal interphalangeal joint
2. Avulsion of the distal exor digitorum profundus tendon
3. Musculotendinous rupture in the forearm

270. OITE
2005 #246
A 21 year-old left-handed college student was playing rugby 3 days ago and
felt the sudden onset of pain in his right ring nger when another
played pulled away from him. A clinical photo is shown in Figure 86.
What is the most likely diagnosis?
1. Volar plate avulsion of the proximal interphalangeal joint
2. Avulsion of the distal exor digitorum profundus tendon
3. Musculotendinous rupture in the forearm
4. Stretch injury to the ulnar nerve at the wrist

271. OITE
2005 #246
A 21 year-old left-handed college student was playing rugby 3 days ago and
felt the sudden onset of pain in his right ring nger when another
played pulled away from him. A clinical photo is shown in Figure 86.
What is the most likely diagnosis?
1. Volar plate avulsion of the proximal interphalangeal joint
2. Avulsion of the distal exor digitorum profundus tendon
3. Musculotendinous rupture in the forearm
4. Stretch injury to the ulnar nerve at the wrist
5. Ulnar artery thrombosis

272. OITE
2005 #246
A 21 year-old left-handed college student was playing rugby 3 days ago and
felt the sudden onset of pain in his right ring nger when another
played pulled away from him. A clinical photo is shown in Figure 86.
What is the most likely diagnosis?
1. Volar plate avulsion of the proximal interphalangeal joint
2. Avulsion of the distal exor digitorum profundus tendon
3. Musculotendinous rupture in the forearm
4. Stretch injury to the ulnar nerve at the wrist
5. Ulnar artery thrombosis

273. OITE

274. OITE
2003 #10
Active mobilization following exor tendon repair is best accomplished
with the wrist in
1. exion and the metacarpophalangeal joints in exion.
2. exion and the metacarpophalangeal joints in extension.
3. neutral and the metacarpophalangeal joints in extension.
4. neutral and the metacarpophalangeal joints in exion.
5. extension and the metacarpophalangeal joints in exion.

275. OITE

276. OITE
2003 #10
Active mobilization following exor tendon repair is best accomplished
with the wrist in
1. exion and the metacarpophalangeal joints in exion.
2. exion and the metacarpophalangeal joints in extension.
3. neutral and the metacarpophalangeal joints in extension.
4. neutral and the metacarpophalangeal joints in exion.
5. extension and the metacarpophalangeal joints in
exion.

277. OITE

278. OITE
2003 #126
What is the major advantage of allowing early active motion of a repaired
zone II exor tendon injury?
• 1- Increased tendon excursion
• 2- Greater repair strength
• 3- Less postoperative pain
• 4- Better patient compliance
• 5- Faster tendon healing

279. OITE

280. OITE
2003 #126
What is the major advantage of allowing early active motion of a repaired
zone II exor tendon injury?
• 1- Increased tendon excursion
• 2- Greater repair strength
• 3- Less postoperative pain
• 4- Better patient compliance
• 5- Faster tendon healing

281. OITE

282. OITE
2005 #21
e ideal exor tendon rehab protocol that minimizes peritendinous
adhesions includes
1. Casting for 6 weeks
2. A synergistic wrist and digit motion rehabilitation protocol
3. Dorsal blocking splint with unrestricted active nger exion
4. Dynamic extension outrigger splinting
5. Early aggressive active motion and a strengthening program

283. OITE

284. OITE
2005 #21
e ideal exor tendon rehab protocol that minimizes peritendinous
adhesions includes
1. Casting for 6 weeks
2. A synergistic wrist and digit motion
rehabilitation protocol
3. Dorsal blocking splint with unrestricted active nger exion
4. Dynamic extension outrigger splinting
5. Early aggressive active motion and a strengthening program

285. OITE

286. OITE
2005 #103
A 3 year-old child undergoes repair of lacerated exor tendons of the
ring and little ngers in zone II. Postoperative rehabilitation should
consist of
1. Passive exion and extension exercises
2. Passive exion and active extension exercises
3. Active exion and extension exercises
4. Cast immobilization for 4 weeks
5. Cast immobilization for 8 weeks

287. OITE

288. OITE
2005 #103
A 3 year-old child undergoes repair of lacerated exor tendons of the
ring and little ngers in zone II. Postoperative rehabilitation should
consist of
1. Passive exion and extension exercises
2. Passive exion and active extension exercises
3. Active exion and extension exercises
4. Cast immobilization for 4 weeks
5. Cast immobilization for 8 weeks

289. OITE

290. OITE
2002 #70
A 4 year old girl undergoes repair of both exor tendons in zone II.
Initial postoperative physical therapy should consist of
1. passive mobilization only.
2. active extension and passive exion mobilization.
3. active place and hold mobilization.
4. immobilization.
5. unrestricted active mobilization.

291. OITE

292. OITE
2002 #70
A 4 year old girl undergoes repair of both exor tendons in zone II.
Initial postoperative physical therapy should consist of
1. passive mobilization only.
2. active extension and passive exion mobilization.
3. active place and hold mobilization.
4.immobilization.
5. unrestricted active mobilization.

293. Bibliography
Trumble, ed. Hand Surgery Update 3., 2003.
Green, ed. Green’s Operative Hand Surgery, 5th ed., 2003.
Canale, ed. Campbell’s Operative Orthopaedic Surgery, 10th ed., 2003.

294. Bibliography
Trumble, ed. Hand Surgery Update 3., 2003.
Green, ed. Green’s Operative Hand Surgery, 5th ed., 2003.
Canale, ed. Campbell’s Operative Orthopaedic Surgery, 10th ed., 2003.

295. Bibliography

296. Bibliography
Schmidt. Surgical Anatomy of the Hand. 2004