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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
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)
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
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
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Average 4.3 of 27 Ratings
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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?
Repair with core suture purchase 5mm from the cut edge only. No epitendinous suture
Repair with core suture purchase 10mm from the cut edge only. No epitendinous suture
Repair with core suture purchase 5mm from the cut edge. Circumferential simple running epitendinous suture.
Repair with core suture purchase 10mm from the cut edge. Circumferential Silfverskiold epitendinous suture.
Repair with core suture purchase 10mm from the cut edge. Circumferential simple running epitendinous suture.
Select Answer to see Preferred Response
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).
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.
Gulihar A, Hajipour L, Dias JJ
Hand Surg. 2012 17(2):155-60. PMID: 22745077 (Link to Abstract)
Lee SK, Goldstein RY, Zingman A, Terranova C, Nasser P, Hausman MR
J Hand Surg Am. 2010 Jul;35(7):1165-71. PMID: 20541326 (Link to Abstract)
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Average 3.0 of 14 Ratings
Which of the following statements is true regarding zone II flexor tendon injuries?
At this level, FDS and FDP are located within separate tendon sheaths
FDS repair has not been shown to improve outcomes
Improved gliding is seen with repair of 1 slip of FDS compared to repairing both slips
Repairing FDS does not affect post-operative digit strength
FDP repair has not been shown to improve outcomes
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.
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.
Zhao C, Amadio PC, Zobitz ME, An KN
J Hand Surg Am. 2002 Mar;27(2):316-21. PMID: 11901391 (Link to Abstract)
Average 3.0 of 11 Ratings
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:
Synergistic motion protocol
Low force and low tendon excursion passive range of motion
Early digit active range of motion protocol
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.
J Am Acad Orthop Surg. 1995 Jan;3(1):55-62. PMID: 10790653 (Link to Abstract)
Average 3.0 of 30 Ratings
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?
Trim the frayed tendon edges and begin early range of motion
Trim the frayed tendon edges and cast in an intrinsic positive position for 2 weeks
Peritendinous 6/0 and Core 4/0 suture repair
Core 4/0 suture repair
Core 6/0 suture repair
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.
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.
Bishop AT, Cooney WP 3rd, Wood MB.
J Trauma. 1986 Apr;26(4):301-12. PMID: 3959135 (Link to Abstract)
McGeorge DD, Stilwell JH.
J Hand Surg Br. 1992 Apr;17(2):176-7. PMID: 1588198 (Link to Abstract)
Average 3.0 of 28 Ratings
The median nerve lies immediately ulnar to which of the following structures at the level of the distal radioulnar joint?
Flexor carpi radialis
Flexor carpi ulnaris
Flexor digitorum profundus
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.
Average 2.0 of 101 Ratings
Flexor tendons of the fingers within Zone 2 receive their primary nutritional supply from:
Diffusion from the synovial sheath
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.
Average 2.0 of 29 Ratings
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?
The size of the core suture
Number of core strands crossing the repair site
Use of epitendinous suture
Active range of motion during the immediate postoperative period
Repair of the flexor tendon sheath
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.
Hatanaka H, Manske PR
Clin. Orthop. Relat. Res.. 2000 Jun;(375):267-74. PMID: 10853178 (Link to Abstract)
Average 4.0 of 19 Ratings
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?
Low force and low excursion
Moderate force and potentially high tendon excursion
Low force and high tendon excursion
High force and high tendon excursion
High force and low tendon excursion
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).
Lilly SI, Messer TM
J Am Acad Orthop Surg. 2006 Jul;14(7):387-96. PMID: 16822886 (Link to Abstract)
Average 2.0 of 25 Ratings
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:
2 strand core suture technique and gentle active flexion and extension exercises with wrist in extension
2 strand core suture technique and cast immobilization for 8 weeks
4 strand core suture technique and gentle active flexion and extension exercises with wrist in extension
4 strand core suture technique and cast immobilization for 4 weeks
4 strand core suture technique and cast immobilization for 8 weeks
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.
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:
No tendon repair with early protected range of motion
No tendon repair with splint immobilization for 2 weeks
Tendon repair with 2 strand repair and early protected range of motion
Tendon repair with 2 strand repair with splint immobilization for 2 weeks
Tendon repair with 4 strand repair and early active range of motion
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.
J Hand Surg Am. 2000 Nov;25(6):1118-21. PMID: 11119672 (Link to Abstract)
Average 3.0 of 21 Ratings
HPI - Dec 6th, 2015 - Deep laceration to palm of hand (zone III/IV). Ruptured all 8 flexor tendons (except for thumb), severed median and ulnar nerves.
Dec 15th, 2015 - Six-hour long repair; nerve grafting. Immobilized post-op for one week, then transitioned to a splint + passive-active motion.
January 5th, 2016 - Sutures removed, active motion allowed.
February 18th, 2016 - Decent range of motion, a lot of scarring in the palm present. The middle finger is doing best, able to touch the palm. Very good range of motion at all DIP joints. (Please see the attached video).
February 19th, 2016 - At 8 weeks and 2 days post-repair, sudden loss of middle finger tip flexion (DIP). Most likely re-rupture. The range of motion at PIP joint worsens as well. Previous best finger now becomes the worst with the least ROM.
March 1st, 2016 - At about 10 weeks post-repair, able to bend the tip of middle finger if and only if the PIP joint is held down. (Again, video attached). Most likely it was possible all along, just haven't tried/put enough force into it.
What is the possible cause of this new onset middle-finger DIP stiffness?
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