2. Flexor Tendon Injuries
• Restoration of satisfactory digital function
after flexor tendon lacerations remains
one of the most challenging problems in
hand surgery
• Prior to the 1960’s tendons lacerated in
“no man’s land” were not repaired in favor
of delayed grafting
3. Tendon Morphology
• 70% collagen (Type I)
• Extracellular components
– Elastin
– Mucopolysaccharides (enhance water-binding
capability)
• Endotenon – around collagen bundles
• Epitenon – covers surface of tendon
• Paratenon – visceral/parietal adventitia
surrounding tendons in hand
• Synovial like fluid environment
4. Anatomy
• Extrinsic flexors
– Superficial group
• PT, FCR, FCU, PL
• Arise from medial
epicondyle, MCL,
coronoid process
5. Anatomy
• Extrinsic Flexors
– Intermediate group
• FDS
• Arises from medial
epicondyle, UCL,
coronoid process
• Usually have independent
musculotendinous origins
and act independantly
6. Anatomy
• Extrinsic flexors
– Deep group
• FPL – originates from
entire medial third of
volar radius
• FDP – originates on
proximal two thirds of the
ulna, often has common
musculotendinous origins
10. Tendon Nutrition
• Vascular
– Longitudinal vessels
• Enter in palm
• Enter at proximal synovial fold
– Segmental branches from digital arteries
• Long and short vinculae
– Vessels at osseous insertions
• Synovial fluid diffusion
– Imbibition (pumping mechanism)
11. Tendon Nutrition
• Dorsal vascularity
• Avascular zones
– FDS (over proximal
phalanx
– FDP (over middle phalanx)
• Nutrition vital for rapid
healing, minimization of
adhesion and restoration
of gliding
12. Tendon Healing
• Inflammatory phase (0-5 d); fibroblastic
phase (5d – 6wks); remodelling (6wks-
9mos)
• Intrinsic vs extrinsic healing
• Balance between the two determines
amount of extrinsic adhesion vs intrinsic
tendon healing
18. Diagnosis
• Physical exam
• Abnormal resting posture
• Absent FDP / FDS function
• Associated digital nerve and digital vessel
injury
• Discuss nature of injury and postoperative
course with patient
19. Zones of Injury
FDS Insertion
Flexor Sheath
(proximal)
TCL
(distal edge) Carpal Tunnel
20. Flexor Tendon Repair
Timing
• Delayed equal or better than emergent
repair
– Acute or subacute acceptable
– Tendon deterioration/shortening after several
wks
– Delay several days if wound infected
21. Incisions
• Factors
– Avoid crossing joints
at 90 deg.
– Preference
– Existing lacerations
– Need to expose other
structures
22. Repair Techniques
• Ideal
– Gap resistant
– Strong enough to tolerate forces generated by
early controlled active motion protocols
• 10-50% decrease in repair strength from day 5-21
post repair in immobilized tendons
• This is effect is minimized (possibly eliminated)
through application of early motion stress
– Uncomplicated
– Minimal bulk
– Minimal interference with tendon vascularity
23. Core Sutures
• Current literature supports several conclusions
regarding core sutures
– Strength proportional to number of strands
– Locking loops increase strength but may collapse and
lead to gapping
– Knots should be outside repair site
– Increased suture callibre = increases strength
– Braided 3-0 or 4-0 probably best suture material
– Dorsally placed suture stronger and biomechanically
advantageous
– Equal tension across all strands
24. Sheath Repair
• Advantages
– Barrier to extrinsic adhesion formation
– More rapid return of synovial nutrition
• Disadvantages
– Technically difficult
– Increased foreign material at repair site
– May narrow sheathand restrict glide
• Presently, no clear cut advantage to
sheath repair has been established
25. Partial Lacerations
• Controversy in past as partial lacerations
were felt to predispose to entrapment,
triggering and rupture
• Repair if > 50%
• Some advocate repair of partial
lacerations > 60%
26. Tendon Advancement
– Previously advocated for zone 1 repairs, as
moving the repair site out of the sheath was
felt to decrease adhesion formation
– Disadvantages
• Shortening of flexor system
• Contracture
• Quadregia effect
• Little excursion distally, therefore adhesions near
insertion less of an issue
28. Summary
• Strong gap resistant repair
• 4 strand, locking epitendinous (or
equivalent), 3-0 suture needed for early
active motion
– 4-0 suture, modified Kessler, running
epitendinous suture adequate for more
conservative protocols
• No sheath repair
• Large grasping/locking loops
29. FDP Avulsions
• Commonly male athletes
• Forced extension at DIP during maximal
flexion (jersey finger)
• Often missed due to normal xray and
intact flexion at MP and PIP
– Opportunity for FDP reinsertion lost if
treatment delayed
31. FDP Avulsions
- Type 1: zig-zag exposure
- Tendon delivered
through pulley system
with catheter passed
retrograde
- Fixed to base of phalanx
with monofilament
suture through distal
phalanx and nail plate
and tied over button
- Fix within 7-10 days
before tendon
degeneration and
myostatic shortening
occurs
32. FDP Avulsions
- Type 2: small bony
fragment retracts to
A3 level
- Can fix up to 6 wks
post injury (less
shortening)
- May convert to type 1
if tendon slips through
A3 pulley and into
palm
- Use same technique
as for type 1
33. FDP Avulsions
- Type 3: large bony
fragment retracts to
A4 level
- Bony reduction and
fixation of fragment
34. Children
• Usually not able to reliably participate in
rehabilitation programs
• No benefit to early mobilization in patients
under 16 years
• Immobilization > 4 wks may lead to poorer
outcomes
36. Single Stage Tendon Grafting
Zone 2
• Indications
– Delayed treatment making end to end repair
impossible
• Patient factors prevent repair
• Late referral, missed tendon laceration or avulsion
– Supple joints with adequate passive ROM
37. Single Stage Tendon Grafting
Zone 2
• Technique
– 1 cm distal FDP stump left intact
– 1 cm of FDS insertion left intact (decreased
adhesion formation vs granulating insertion
site)
– Tenodesis of FDS tail to flexor sheath (10-20
deg of flexion) optional
• Hyperextension at PIP in absence of FDS tendon
occurs occasionally
38. Single Stage Tendon Grafting
Zone 2
• Technique
– Graft donors
• Palmaris longus
• Plantaris
• Long toe extensors
• (FDS)
• (EIP)
• (EDM)
39. Single Stage Tendon Grafting
Zone 2
• Technique
– Graft passed through pulley system
• Atraumatic technique
– Distal fixation with tension set proximally or
proximal fixation first
– Multiple methods for fixation of graft ends
41. Single Stage Tendon Grafting
Zone 2
• Technique
– proximal
juncture
Pulvertaft weave creates a
stronger repair vs end to end
techniques, and allows for
greater ease when setting
tension
42. Single Stage Tendon Grafting
Zone 2
• Setting tension
– GA
• With wrist neutral
• Fingers fall into semi flexed position (slightly less
than ulnar neighbour), allowing estimation of
tension
– Local anesthesia, active flexion
– Electrical stimulation
• Bunnel – “tendons shrink”
• Pulvertaft – “tendons stretch”
43. Secondary Reconstruction
Zone 1
• Zone 1 (functioning FDS)
– Eg. Late presentation of FDP avulsion
– DIP fusion
– Tendon graft
• Risks damaging FDS function through
injury/adhesions in a very functional finger
• ? Young patients, supple joints, need for active
DIP flexion
44. Secondary Reconstruction
Zones 3, 4 and 5
• Usually associated with 3 – 5 cm gap
– Interposition graft
– FDS to FDP transfer
– End to side profundus juncture
45. Two Stage Reconstruction
• Primary grafting likely to give poor result,
but salvage of functioning finger still
desirable
• Sub-optimal conditions
– Extensive soft tissue scarring
• Crush injuries
• Associated fractures, nerve injuries
– Loss of significant portion of pulley system
46. Two Stage Reconstruction
• Patient selection
– Motivated
– Absence of neurovascular injury
– Good passive joint motion
• Balance benefits of two additional
procedures in an already traumatized digit
with amputation/arthrodesis
47. Two Stage Reconstruction
• Stage 1
– Excision of tendon remnants
• Distal 1 cm of FDP left intact, remainder excised to
lumbrical level
• FDS tail preserved for potential pulley
reconstruction
– Incision proximal to wrist
• FDS removed/excised
• Hunter rod then placed through pulley system and
fixed distally (suture or plate and screw –
depending on implant)
48. Two Stage Reconstruction
• Stage 1
– Rod extends proximally to distal forearm in
plane between FDS and FDP
– Test glide
– Reconstruct pulleys as needed if implant
bowstrings
49. Two Stage Reconstruction
• Stage 1
– Postop
• Start passive motion at 7 days
• Continue x 3mos to allow pseodosheath to form
around implant
• Before stage 2 joints should be supple, and
wounds soft
50. Two Stage Reconstruction
• Stage 2 – implant removal and tendon
graft insertion
– Distal and proximal incisions opened
– Implant located proximally and motor selected
(FDP middle/ring/small, FDP index)
– Graft harvested, sutured to proximal implant
and delivered distally
• Fixed to distal phalanx with pull out wire over
button
51. Two Stage Reconstruction
• Stage 2 – implant removal and tendon
graft insertion
– Proximally sutured to motor with pulvertaft
weave
• FDS transfer from adjacent digit described
• Obviates need for graft
• Difficulty with length/tension
• Postop
• Early controlled motion x 3 wks, then slow
progression to active motion
52. Pulley Reconstruction
• Pulley loss
– Bowstringing = tendon taking shortest
distance between remaining pulleys
– Biomechanical disadvantage
• Excursion translates into less joint motion
– Adhesions/rupture at remaining pulleys due to
increased stress
– A2 and A4 needed (minimum)
• Most biomechanically important
• Some authors advocate reconstructing a 3 or 4
pulley system for optimal results
53. Pulley Reconstruction
• Most done in conjunction with a two stage
tendon reconstruction
• Can be done with single stage tendon
graft
• generally if extensive pulley reconstruction
is required it is better to do a two stage
procedure
54. Pulley Reconstruction
• Methods
– Superficialis tendon
• Insertion left intact
• Remnant sutured to original pulley rim, to
periosteum, or to bone through drill holes
– Tendon graft
• Sutured as above
• Passed through hole drilled in phalanx (risk of
fracture)
• Wrapped around phalanx (requires 6-8 cm of graft)
56. Pulley Reconstruction
• Methods
– Extensor retinaculum
• Excellent gliding surface
• Difficult to harvest the 8-6 cm required for fixation
around phalanx
– Artificial materials
• Dacron, PTFE, nylon silicone
• Due to abundant atogenous material and
disadvantages of artificial materials, this has not
become common clinical practice
• May be stronger in long term vs autogenous
57. Tenolysis
– Release of nongliding adhesions for salvage
in poorly functioning digits with previous
tendon injury
– Avoid in marginal digits
• May not tolerate additional vascular/neurologic
injury
– May need concomitant collateral ligament
release, capsulotomy
– Prepare patient for possible staged
reconstruction
58. Tenolysis
• Timing
– 3-6 mos. Post repair (minimum)
– Plateau with physiotherapy
• Anesthesia
– Local with sedation
• Allows patient participation
• Tests adequacy of release
• Motivates patient
59. Tenolysis
• Technique
– Zig zag incisions
– Adhesions divided maintaining non-limiting
adhesions
– Pulleys reconstructed as needed
• If extensive or not possible convert to staged
reconstruction
– Immediate motion postop.
Notas do Editor
At the wrist level ten structures pass through the carpal tunnel
4xfds, 4xfdp, fpl and median nerve
Bordered by:hamate, triquetrum and pisiform and ulnarly
Scaphoid and trapezium radially
Roof = flexor retinaculum
Consists of three components – the the deep forearm facsia, the transverse carpal ligament (which traverses from the scaphoid tuberosity and trapezial beak radially to the hook of the hamate and pisiform ulnary) and the distal aponeurosis btw the thenar and hypothenar muscles
Pulleys
A2 and a4 (most biomechanically important) arise from periosteum of proximal aspect of proximal phalanx, and middile aspect of middle phalanx (respectively)
A1 a3 and a5 (joint pulleys) arise from volar plates of mp, pip and dip joints respectively
Intervening cruciate pulleys (c1 c2 and c3) are thin and collapse to allow annular pulley approximation during flexion
In the palm FDS is superficial to FDP
In the proximal sheath fds divides to allow fdp to pass through and go on to insert at the base of the distal phalanx
Fds the reunites at camper’s chiasm before dividing into two slips of insertion on the base of the middle phalanx
Zone 1: distal to FDS insertion
Zone 2: FDS insertion proximal beginning of flexor sheath
Previously “no man’s land”
Zone 3: distal edge of TCL to flexor sheath origin
Zone 4: carpal tunnel
Zone 5: distal portion of forearm
Generally a combination of zig zag or mid lateral incisions are used
Depend on
Direction of initial laceration
Need to expose other injured structures
Surgical preference
Little advantage to limiting exposure
Avoid crossing jt creases at rigth angles
Type 1: zig-zag exposure
Tendon delivered through pulley system with catheter passed retrograde
Fixed to base of phalanx with monofilament suture through distal phalanx and nail plate and tied over button
Fix within 7-10 days before tendon degeneration and myostatic shortening occurs
Type 2: small bony fragment retracts to A3 level
Can fix up to 6 wks post injury (less shortening)
May convert to type 1 if tendon slips through A3 pulley and into palm
Use same technique as for type 1
Type 3: large bony fragment retracts to A4 level
Bony reduction and fixation of fragment
Type 1: zig-zag exposure
Tendon delivered through pulley system with catheter passed retrograde
Fixed to base of phalanx with monofilament suture through distal phalanx and nail plate and tied over button
Fix within 7-10 days before tendon degeneration and myostatic shortening occurs
Type 2: small bony fragment retracts to A3 level
Can fix up to 6 wks post injury (less shortening)
May convert to type 1 if tendon slips through A3 pulley and into palm
Use same technique as for type 1
Type 3: large bony fragment retracts to A4 level
Bony reduction and fixation of fragment
Type 1: zig-zag exposure
Tendon delivered through pulley system with catheter passed retrograde
Fixed to base of phalanx with monofilament suture through distal phalanx and nail plate and tied over button
Fix within 7-10 days before tendon degeneration and myostatic shortening occurs
Type 2: small bony fragment retracts to A3 level
Can fix up to 6 wks post injury (less shortening)
May convert to type 1 if tendon slips through A3 pulley and into palm
Use same technique as for type 1
Type 3: large bony fragment retracts to A4 level
Bony reduction and fixation of fragment
Type 1: zig-zag exposure
Tendon delivered through pulley system with catheter passed retrograde
Fixed to base of phalanx with monofilament suture through distal phalanx and nail plate and tied over button
Fix within 7-10 days before tendon degeneration and myostatic shortening occurs
Type 2: small bony fragment retracts to A3 level
Can fix up to 6 wks post injury (less shortening)
May convert to type 1 if tendon slips through A3 pulley and into palm
Use same technique as for type 1
Type 3: large bony fragment retracts to A4 level
Bony reduction and fixation of fragment