http://upload.orthobullets.com/topic/6031/images/flexor_zones.jpg
http://upload.orthobullets.com/topic/6031/images/campers chiasm.jpg
Introduction
  • Commonly result from volar lacerations and may have concomitant neurovascular injury 
  • Classified by the zone of injury (see table below)
    • basic concepts in repair are similar for different zones 
    • location of laceration directly affects healing potential
 
Phases of Tendon Healing
Phase
Days
Histology
Strength
Inflammatory
0-5
cellular proliferation none
Fibroblastic
5-28
fibroblastic proliferation with disorganized collagen increasing
Remodeling
>28
linear collagen organization will tolerate controlled active motion 
 
Anatomy
  • Muscles
    • flexor digitorum profundus (FDP)  
      • functions as a flexor of the DIP joint
      • assists with PIP and MCP flexion
      • shares a common muscle belly in the forearm
    • flexor digitorum superficialis (FDS)  
      • functions as a flexor of the PIP joint
      • assists with MCP flexion
      • individual muscle bellies exist in the forearm
        • FDS to the small finger is absent in 25% of people
    • flexor pollicis longus (FPL) 
      • located within the carpal tunnel as the most radial structure
    • flexor carpi radialis (FCR) 
      • primary wrist flexor
      • inserts on the base of the second metacarpal
      • closest flexor tendon to the median nerve 
    • flexor carpi ulnaris (FCU) 
      • primary wrist flexor
      • inserts on the pisiform, hook of hamate, and the base of the 5th metacarpal
  • Blood supply
    • 2 sources exist
      • diffusion through synovial sheaths
        • occurs when flexor tendons are located within a sheath  
        • it is the more important source proximal to the MCP joint
      • direct vascular supply
        • nourishes flexor tendons located outside of synovial sheaths 
  • Campers chiasm 
    • located at the level of the proximal phalanx where FDP splits FDS 
  • Pulley system  
    • digits 1-4 contain
      • 5 annular pulleys (A1 to A5)
      • 3 cruciate pulleys (C1 to C3)  
        • A2 and A4 are the most important pulleys to prevent flexor tendon bowstringing
    • thumb contains
      • 2 annular pulley
      • interposed oblique pulley (most important)  
Classification 
 
Zone
Definition
Introduction
Treatment
I
Distal to FDS insertion  Jersey finger 
II
FDS insertion to distal palmar crease

Zone is unique in that FDP and FDS in same tendon sheath (both injured within the flexor retinaculum) 

Direct repair of both tendons followed by early ROM (Duran, Kleinert). Be sure to preserve A2 and A4 pulley. This zone historically had very poor results but results have improved due to advances in postoperative motion protocols

III
Palm

Often associated with neurovascular injury which carries a worse prognosis

Direct tendon repair. Good results from direct repair can be expected due to absence of retinacular structures (if no neurovascular injury)

IV
Carpal tunnel

Often complicated by postoperative adhesions due to close quarters and synovial sheath of the carpal tunnel

Direct tendon repair. Transverse carpal ligament should be repaired in a lengthened fashion

V
Wrist to forearm

Often associated with neurovascular injury which carries a worse prognosis

Direct tendon repair
Thumb
TI, TII, TIII

Outcomes different than fingers. Early motion protocols do not improve long-term results and there is a higher re-rupture rate than flexor tendon repair in fingers

Direct end-to-end repair of FPL is advocated. Try to avoid Zone III to avoid injury to the recurrent motor branch of the median nerve. Oblique pulley is more important than the A1 pulley; however both may be incised if necessary. Attempt to leave one pulley intact to prevent bowstringing

 
Presentation
  • Symptoms
    • loss of active flexion strength or motion of the involved digit(s)
  • Physical exam
    • inspection
      • observe resting posture of the hand and assess the digital cascade
      • evidence of malalignment or malrotation may indicate an underlying fracture
      • assess skin integrity to help localize potential sites of tendon injury
      • look for evidence of traumatic arthrotomy
    • range of motion
      • passive wrist flexion and extension allows for assessment of the tenodesis effect
        • normally wrist extension causes passive flexion of the digits at the MCP, PIP, and DIP joints
        • maintenance of extension at the PIP or DIP joints with wrist extension indicates flexor tendon discontinuity
      • active PIP and DIP flexion is tested in isolation for each digit
    • neurovascular exam
      • important given the close proximity of flexor tendons to the digital neurovascular bundles
Treatment
  • Nonoperative
    • wound care and early range of motion
      • indications
        • partial lacerations < 60% of tendon width
      • outcomes
        • may be associated with gap formation or triggering
  • Operative
    • flexor tendon repair and controlled mobilization 
      • indications
        • lacerations > 60% of tendon width   
      • outcomes
        • depends on zone of injury
    • flexor tendon reconstruction and intensive postoperative rehabilitation
      • indications
        • failed primary repair
        • chronic untreated injuries
      • outcomes
        • subsequent tenolysis is required more than 50% of the time
    • FDS4 transfer to thumb
      • single stage procedure
      • indication
        • chronic FPL rupture
Surgical Technique
  • Flexor Tendon Repair of Complete Lacerations
    • approach
      • incisions should always cross flexion creases transversely or obliquely to avoid contractures (never longitudinal)
    • timing of repair
      • perform repair within three weeks of injury (2 weeks ideal)
      • waiting longer leads to difficulty due to tendon retraction
    • technique
      • # of suture strands that cross the repair site is more important than the number of grasping loops
        • linear relationship between strength of repair and # of sutures crossing repair
        • 4-6 strands provide adequate strength for early active motion  
        • high-caliber suture material increases strength and stiffness and decreases gap formation
        • locking-loops decrease gap formation
        • ideal suture purchase is 10mm from cut edge 
        • core sutures placed dorsally are stronger
        • meticulous atraumatic tendon handling minimizes adhesions
      • circumferential epitendinous suture
        • improves tendon gliding
        • improves strength of repair (adds 20% to tensile strength)
        • allows for less gap formation (first step in repair failure)
        • simple running suture is recommended
      • sheath repair is controversial
        • theoretically improves tendon nutrition through synovial pathway
        • clinical studies show no difference with or without sheath repair
        • most surgeons will repair if it is easy to do
      • pulley management
        • critical to preserve A2 and A4 pulleys in digits and oblique pulley in thumb
      • FDS repair 
        • in zone 2 injuries, repair of one slip alone improves gliding when compared to repair of both slips
    • outcomes
      • repair failure
        • tendon repairs are weakest between postoperative day 6 and 12
        • repair usually fails at suture knots
  • Flexor Tendon Repair of Partial Lacerations
    • indications
      • >75% laceration
      • ≥50-60% laceration with triggering
        • epitendinous suture at the laceration site is sufficient  
        • no benefit of adding core suture
  • Wide-Awake Flexor Tendon Repair   
    • performed under tumescent local anesthesia using lidocaine with epinephrine
      • dosing
        • usually epinephrine 1:100,000 and 7mg/kg lidocaine
        • from 1:400,000 to 1:1000 is safe
        • if <50cc is needed
          • 1% lidocaine with 1:100,000 epi for a 70kg person
        • if 50-100cc is needed
          • dilute with saline (50:50) to get 0.5% lidocaine, 1:200,000 epi
        • if 100-200cc is needed for large fields (tendon transfer, spaghetti wrist)
          • dilute with 150cc saline to get 0.25% lidocaine and 1:400,000 epi
        • for longer surgery >2h 
          • add 10cc of 0.5% bupivacaine with 1:200,000 epi
      • location
        • proximal and middle phalanges, use 2ml
        • distal phalanx, use 1ml
        • palm, use 10-15ml
    • no tourniquet, no sedation
    • 4 advantages
      • allows intraoperative assessment for repair gaps by getting awake patient to actively flex digit
      • reduces need for postop tenolysis by allowing intraoperative assessment of whether repair will fit through pulleys
        • allows on-the-spot debulking of bunched repairs
        • allows division of A4 pulley and venting (partial division) of A2 pulleys
      • allows repair of tendons inside tendon sheaths as patients can demonstrate that the inside of the sheath has not been inadvertently caught
      • facilitates postop early active motion
        • immobilize for 3 days
        • begin active midrange motion after day 3 (form a partial fist with 45 degree flexion at MP, PIP and DIP joints, or "half a fist 45/45/45 regime")
  • Reconstruction Technique 
    • requirements
      • supple skin
      • sensate digit
      • adequate vascularity
      • full passive range of motion of adjacent joints
    • techniques of reconstruction involving silicone rods
      • Hunter-Salisbury two-stage procedure
        • Stage I - silicone rod is placed to create a favorable tendon bed
        • Stage II (3-4 months) - retrieve SR and pass a tendon graft through the mesothelium lined pseudosheath
        • only perform a single-stage reconstruction if the flexor sheath is pristine and the digit has full ROM
        • pulvertaft weave proximally and end-to-end tenorrhaphy distally
      • Paneva-Holevich two-stage technique  
        • Stage I - SR is placed in the flexor sheath, pulleys are reconstructed (as needed), and a loop between the proximal stumps of FDS and FDP is created in the palm
        • Stage II - SR is retrieved, FDS is cut proximally and reflected distally through pseudosheath and attached directly to FDP stump/or secured with button 
        • advantages
          • graft (FDS) size is known at the time of silicone rod selection
            • less graft diameter-rod diameter mismatch
          • FDS graft is intrasynovial (fewer adhesions than extrasynovial grafts)
          • only relying on 1 tenorrhaphy site (distal or proximal) to heal at any one time (vs Hunter technique where 2 tennoprhaphy sites are healing simultaneously)
        • disadvantage
          • graft tensioning is at the distal end during stage II
            • the proximal end has already healed after stage I
    • graft choices
      • palmaris longus (absent in 15% of population)
        • most common
      • plantaris (absent in 19%)
        • indicated if longer graft is needed
      • long toe extensor
    • pulley reconstruction 
      • one pulley should be reconstructed proximal and distal to each joint
      • methods include belt loop method and FDS tail method
  • Tenolysis
    • indications
      • localized tendon adhesions with minimal to no joint contracture and full passive digital motion 
      • may be required if a discrepancy between active and passive motion exists after therapy
    • timing of procedure
      • wait for soft tissue stabilization (> 3 months) and full passive motion of all joints
    • technique
      • careful technique to preserve A2 and A4 pulleys
    • postoperative care
      • follow with extensive therapy
Postoperative Rehabilitation
  • Postoperative controlled mobilization has been the major reason for improved results with tendon repair
    • especially in zone II
    • leads to improved tendon healing biology
    • limits restrictive adhesions and leads to increased tendon excursion
  • Early active motion protocols
    • moderate force and potentially high excursion
    • dorsal blocking splint limiting wrist extension
    • perform “place and hold” exercises with digits
  • Early passive motion protocols
    • Duran protocol
      • low force and low excursion
      • active finger extension with patient-assisted passive finger flexion
    • Kleinert protocol
      • low force and low excursion
      • active finger extension, dynamic splint-assisted passive finger flexion
    • Mayo synergistic splint  
      • low force and high tendon excursion
      • adds active wrist motion which increases flexor tendon excursion the most
  • Immobilize children and noncompliant patients
    • Children should be immobilized following repair 
    • Casts or splints are applied with the wrist and MCP joints positioned in flexion and the IP joints in extension
Complications
  • Tendon adhesions
    • most common complication following flexor tendon repair
  • Rerupture 
    • 15-25% rerupture rate
    • treatment
      • if <1cm of scar is present, resect the scar and perform primary repair
      • if >1cm of scar is present, perform tendon graft
        • if the sheath is intact and allows passage of a pediatric urethral catheter or vascular dilator, perform primary tendon grafting
        • if the sheath is collapsed, place Hunter rod and perform staged grafting
  • Joint contracture
    • rates as high as 17%
  • Swan-neck deformity  
  • Trigger finger 
  • Lumbrical plus finger  
  • Quadrigia 
 

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Questions (10)

(OBQ13.225) A 28-year-old man sustained a complete laceration of the flexor digitorum profundus of his index finger while cutting a watermelon 3 days ago. A clinical photograph is shown in Figure A. The surgeon plans to repair the tendon using a 4-strand core suture technique. Which method of tendon repair will give him the best results in terms of load to failure and gliding resistance? Review Topic

QID:4860
FIGURES:
1

Repair with core suture purchase 5mm from the cut edge only. No epitendinous suture

2%

(58/2831)

2

Repair with core suture purchase 10mm from the cut edge only. No epitendinous suture

3%

(81/2831)

3

Repair with core suture purchase 5mm from the cut edge. Circumferential simple running epitendinous suture.

21%

(591/2831)

4

Repair with core suture purchase 10mm from the cut edge. Circumferential Silfverskiold epitendinous suture.

14%

(388/2831)

5

Repair with core suture purchase 10mm from the cut edge. Circumferential simple running epitendinous suture.

60%

(1695/2831)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

Repair with core suture purchase 10mm from the cut edge, coupled with circumferential simple running epitendinous suture will give him the best load to failure and gliding resistance.

The strength of tendon repairs depend on the number of strands crossing the repair site. Ideally, repairs should have 4-6 strands to allow for early active motion. A running epitendinous suture is recommended to improve tendon gliding and repair strength.

Gulihar et al. compared 3 different epitendinous suture techniques. They found that compared with an intact tendon, gliding resistance increased 100% with the Halsted repair, 80% with the Silfverskiold repair and 60% with a running suture. They thus recommend a simple running suture when an epitendinous suture is needed.

Lee et al. compared core suture purchase at 3, 5, 7 and 10mm from the cut edge. The 10mm-repair group had the highest 2-mm gap force and ultimate failure load. They recommend 10-mm suture purchase for optimal performance and to allow early active motion.

Figure A shows a laceration to the volar aspect of the index finger in flexor zone II. Illustration A shows a core suture purchase distance from the cut edge (represented by "X", where 10mm is the ideal distance). Illustration B shows 3 different epitendinous suture techniques (A, simple running; B, Silfverskiold; C, Halsted).

Incorrect Answers:
Answers 1, 3: Suture purchase 5mm from the cut edge is inferior to purchase at 10mm from the cut edge.
Answer 2: An epitendinous suture adds to repair strength and improves gliding compared with no epitendinous suture.
Answer 4: The Silfverskiold technique has increased gliding resistance compared with a simple running suture.

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(OBQ12.182) Which of the following statements is true regarding zone II flexor tendon injuries? Review Topic

QID:4542
1

At this level, FDS and FDP are located within separate tendon sheaths

13%

(183/1428)

2

FDS repair has not been shown to improve outcomes

13%

(181/1428)

3

Improved gliding is seen with repair of 1 slip of FDS compared to repairing both slips

64%

(908/1428)

4

Repairing FDS does not affect post-operative digit strength

5%

(76/1428)

5

FDP repair has not been shown to improve outcomes

5%

(66/1428)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

In zone II flexor tendon injuries, repairing only one slip of FDS has been shown to improve gliding when compared to repair of both slips.

Zone II flexor tendon injuries have notoriously had poor outcomes secondary to high rates of adhesion formation at the pulleys. However, new advances in post-operative rehabilitation have significantly improved outcomes to the point where it is no longer considered "no man's land." Management of the FDS has been a source of controversy. In the past, the FDS was occasionally excised to theoretically make more room for the FDP. This has now been largely abandoned and the FDS is repaired whenever possible. Whether or not to repair both slips of FDS remains controversial, with in vitro data suggesting that gliding resistance is improved if only one slip is repaired.

Zhao et al. review the effect of partial vs. complete FDS excision following repair of FDP for zone II flexor tendon injuries. Preserving the whole FDS resulted in a significantly larger increase in gliding resistance after FDP repair than did full or partial FDS removal, which were not significantly different from each other.

Illustration A shows the zones of flexor tendon injury. Note that zone II injuries occur between the FDS insertion and the distal palmar crease. Illustration B shows the anatomy of the flexor tendons in detail. Video V shows a technique for repair of zone II injuries.

Incorrect Answers:
Answer 1: In zone II, the FDS and FDP are located within the same tendon sheath.
Answer 2: While the FDS was excised in the past, clinical outcomes have recently been shown to be improved with repair of either one or both slips.
Answer 4: Repairing FDS has been shown to increase digit strength.
Answer 5: Repair of FDP has been shown to improve long-term clinical outcomes.

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(OBQ10.170) A 24-year-old male cuts his left middle finger with a knife while chopping vegetables. Physical exam reveals a zone 2 flexor tendon laceration. He undergoes a 2-strand core suture repair with epitendinous suture. This particular repair is strong enough for each of the following rehabilitation protocols EXCEPT: Review Topic

QID:3263
1

Kleinert protocol

3%

(49/1686)

2

Duran protocol

4%

(72/1686)

3

Synergistic motion protocol

5%

(84/1686)

4

Low force and low tendon excursion passive range of motion

5%

(84/1686)

5

Early digit active range of motion protocol

82%

(1385/1686)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

Early active range of motion protocols are thought to decrease adhesions but risk rerupture or gap formation.

Strickland et al notes that the generation of muscle forces to either assist digit flexion or perform “place and hold” exercises require at least a 4-strand core suture with epitendinous repair. This patient only had a 2-strand repair.

The Kleinert and Duran protocols are both forms of low force and low tendon excursion programs, that include passive digit flexion range of motion. Kleinert includes a dorsal block splint with the wrist in 45° of flexion and elastic bands secured to the patient’s nails and a more proximal attachment point. Once the interphalangeal joints are actively fully extended, recoil of the elastic bands flexes them down passively. The Duran protocol utilizes the other hand to passively flex the affected DIP and PIP joints and a higher amount of patient compliance is needed. Synergistic motion regimens allow passive digit flexion combined with active wrist extension, followed by active digit extension coupled with active wrist flexion to produce low forces and high tendon excursions at the involved digit.


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(OBQ09.97) You are seeing a 26-year-old man after he was involved in a knife fight. He has pain when flexing and extending his index finger. You explore a 2 centimeter wound in zone 2 and find his flexor tendons to the index are 40% lacerated. What is the preferred method of treatment? Review Topic

QID:2910
1

Trim the frayed tendon edges and begin early range of motion

77%

(1586/2070)

2

Trim the frayed tendon edges and cast in an intrinsic positive position for 2 weeks

6%

(117/2070)

3

Peritendinous 6/0 and Core 4/0 suture repair

13%

(266/2070)

4

Core 4/0 suture repair

3%

(64/2070)

5

Core 6/0 suture repair

1%

(29/2070)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

This patient has a partial flexor tendon laceration involving < 60% of the width of the tendon, therefore, the preferred management would be to trim the frayed tendon edges and begin early range of motion.

Flexor tendon injuries are classified into five anatomic zones. Injuries in zone II, which ends at the insertion of the FDS tendon at the middle phalanx, are particularly challenging because the tendon gliding must be restored within a tight fibro-osseous sheath while minimizing the formation of adhesions in surrounding tissues.

Bishop et al. developed a nonweightbearing canine model to examine partial tendon lacerations and found early motion improved tendon excursion and stiffness, resulting in more normal tendon morphology. They concluded that partial tendon lacerations less than 60% cross-sectional area be treated without tenorrhaphy and with early mobilization.

McGeorge et al. compared the results of repair versus non-repair in patients with zone II tendon lacerations and concluded that tendons lacerated by 60% or less should not be repaired.

Illustration A depicts the palmar view of the hand highlighting the anatomical classification of flexor tendon injuries. Illustration B shows a lateral view of a finger demonstrating the relationship between FDP and FDS within zone II.

Incorrect Answers:
Answer 2: Casting is not indicated in this patient. Early range of motion is preferred as it allows for improved tendon excursion and morphology.
Answer 3, 4 & 5: Flexor tendon repair is not indicated in this patient as it is recommended in patients with lacerations >60% of the tendon width.

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(OBQ08.165) The median nerve lies immediately ulnar to which of the following structures at the level of the distal radioulnar joint? Review Topic

QID:551
1

Flexor carpi radialis

77%

(1180/1540)

2

Flexor carpi ulnaris

2%

(38/1540)

3

Radial artery

4%

(67/1540)

4

Flexor digitorum profundus

15%

(225/1540)

5

Pronator teres

1%

(16/1540)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

The median nerve sits immediately ulnar to the flexor carpi radialis (FCR). This anatomic relationship is demonstrated by the fact that a median nerve injury is most likely to be associated with a deep laceration of flexor carpi radialis (FCR) at the level of the wrist. Additionally, the risk associated in dissecting between the flexor carpi radialis and palmaris longus is injury to palmar cutaneous branch of the median nerve.

Illustration A shows the relative position of the median nerve to FCR at the level of the pronator quadratus on cross section anatomy.
Illustration B shows a cross-sectional MRI at the level of the wrist.

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(OBQ08.227) Flexor tendons of the fingers within Zone 2 receive their primary nutritional supply from: Review Topic

QID:613
1

Vinculae

29%

(453/1545)

2

Phalangeal periosteum

1%

(12/1545)

3

Musculotendon junction

1%

(10/1545)

4

Tendon insertion

0%

(7/1545)

5

Diffusion from the synovial sheath

68%

(1053/1545)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

The vascularity of tendon varies depending on the type of tendon (e.g. with or without a sheath) and the location. Sheathed tendons (e.g. flexor tendons of the hand) have a dual blood supply via both vascular perfusion but also have regions that are relatively avascular where they receive nutrition through synovial diffusion. This is the case in zone 2 of the digital flexor tendons where the primary nutritional supply is from synovial diffusion through the parietal paratenon which allows for passive nutrient delivery to the flexor tendon within the sheath. The digital flexor tendons also receive minor direct arterial perfusion in zone 2 through the vinicular system, osseous bony insertions, reflected vessels from the tendon sheath and longitudinal vessels from the palm, but this is not the major blood supply.

Tendons not enclosed by a sheath receive their blood supply directly from vessels entering from the tendon surface or from the tendon-to-bone insertion.

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(OBQ06.274) A 32-year-old male sustains a 100% tear of his flexor tendon in the Zone 2 region after cutting his finger with a knife. You plan a one-stage repair of the flexor tendon. Which of the following variables has the greatest effect on increasing the strength of the tendon repair? Review Topic

QID:285
1

The size of the core suture

1%

(20/1727)

2

Number of core strands crossing the repair site

93%

(1599/1727)

3

Use of epitendinous suture

3%

(45/1727)

4

Active range of motion during the immediate postoperative period

2%

(28/1727)

5

Repair of the flexor tendon sheath

2%

(27/1727)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

The single most effective intervention for increasing strength of a flexor tendon repair is to increase the number of core sutures crossing the repair site.

Hatanaka and Manske found that locking loops were better than grasping loops, and that a higher core suture diameter led to an increase in strength. It is well known that adding an epitendinous suture increases the repair up to 10-50% in strength depending on the depth of the suture. There is no evidence that fixing the flexor sheath after repair increases the strength of the repair nor does it lead to improved outcome. Postoperative active range of motion would increase excursion thus decreasing the number of potential adhesions. Active range of motion of a repaired tendon can facilitate intrinsic over extrinsic tendon healing and increase tendon tensile strength, but the magnitude of this effect is secondary to the number of sutures crossing the repair site.


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(OBQ05.21) A 34-year-old man sustains a finger flexor tendon laceration and undergoes operative repair. Which of the following statements best describes the tendon motion rehabilitation protocol as depicted in Figures A where the splint holds the wrist at 45 degrees of flexion? Review Topic

QID:58
FIGURES:
1

Low force and low excursion

45%

(757/1675)

2

Moderate force and potentially high tendon excursion

5%

(77/1675)

3

Low force and high tendon excursion

41%

(692/1675)

4

High force and high tendon excursion

2%

(29/1675)

5

High force and low tendon excursion

6%

(105/1675)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

The rehabilitation protocol depicted in Figure A is the Kleinert protocol which is categorized as a low force and low excursion rehabiliation. This uses a dorsal blocking splint with the wrist in 45° of flexion and elastic bands secured to the patient’s nails and a more proximal point on the splint. Once the interphalangeal (IP) joints are actively fully extended, recoil of the elastic bands flexes them down passively. The Duran protocol (Illustration A) is similar but the wrist is in 20° of flexion and relies on the patient to alternately passively extend the DIP and PIP joints with the other joints of the finger flexed. Early active motion protocols that include "place and hold" finger exercises are considered moderate force and potentially high excursion protocols.

The review article by Lilly and Messer reports that synergistic motion protocols are low force and high tendon excursion and are the best at minimizing peritendonous adhesions. In this splint, passive digit flexion is combined with active wrist extension, followed by active digit extension coupled with active wrist flexion (Illustration B and C).

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(OBQ05.103) A 4-year-old boy sustains a flexor tendon laceration in Zone 2 of his 4th digit when he attempts to grab a knife. Optimal surgical management and postoperative rehabilitation consists of: Review Topic

QID:989
1

2 strand core suture technique and gentle active flexion and extension exercises with wrist in extension

4%

(71/1833)

2

2 strand core suture technique and cast immobilization for 8 weeks

1%

(24/1833)

3

4 strand core suture technique and gentle active flexion and extension exercises with wrist in extension

21%

(381/1833)

4

4 strand core suture technique and cast immobilization for 4 weeks

64%

(1168/1833)

5

4 strand core suture technique and cast immobilization for 8 weeks

10%

(177/1833)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

4 strand core suture technique and cast immobilization for 4 weeks is the preferred postoperative rehabiltation in a 4 year old child.

Ordinarily, adult flexor tendon repair postoperative rehab protocols call for early light active digital flexion with wrist in gentle flexion as long as the tendon has been repaired with a 4 or 6 strand core suture technique and strong epitendinous suture. However, this method cannot succeed without the cooperation of a mature and motivated patient. Children or the mentally disabled are often lacking some of these prerequisites. Therefore, a flexor tendon repair in a child should be treated like a flexor tendon repair with interposed graft in an adult. Immobilization for a minimum of 3 – 4 weeks with a posterior molded plaster splint or cast from the tips of the fingers to just above the elbow. Wrist is flexed 35 degrees, MCPs flexed 60 – 70 degrees and IP joints relaxed in extension. Active motion can be started after the cast is removed at 4 weeks.


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Question COMMENTS (6)

(OBQ04.10) A 23-year-old presents with a knife laceration in the flexor zone 2 of the hand. Examination of the wound is performed and a laceration of the flexor tendon one-half the width of the tendon is identified. There is no triggering present as the patient's finger is passively extended and flexed fully. The most appropriate treatment is: Review Topic

QID:121
1

No tendon repair with early protected range of motion

74%

(698/943)

2

No tendon repair with splint immobilization for 2 weeks

6%

(52/943)

3

Tendon repair with 2 strand repair and early protected range of motion

9%

(85/943)

4

Tendon repair with 2 strand repair with splint immobilization for 2 weeks

2%

(22/943)

5

Tendon repair with 4 strand repair and early active range of motion

9%

(82/943)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

Nonsurgical treatment with early protected range of motion is indicated for flexor tendon lacerations one-half the width of the tendon. The article by Al-Qattan recommends that partial flexor tendon lacerations should be fixed if the laceration is greater than 60%. Furthermore, the patient should be witnessed under digital block that they have full extension and flexion without triggering which would be another indication to operate. Rehabilitation consists of early ROM, wrist and MP flexed in dorsal splint, PIP and DIP extended, Passive digital flexion with wrist flexed, and wait until eight weeks postop to begin strengthening. This concept was also tested in question 9 of the 2007 OITE with the cited reference by McGeorge and Stillwell comparing the results of repair with non-repair in humans for zone 2 injuries and concluded that tendons lacerated by 60% or less should not be repaired.


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