Zone is unique in that FDP and FDS in same tendon sheath (both can be injured within the flexor retinaculum). Tendons can retract if vincula are disrupted.
Direct repair of both tendons followed by early ROM (Duran, Kleinert). 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). May require A1 pulley release to avoid impingement of the repaired tendon on the pulley.
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 if tendon bowstringing is present.
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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Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC.
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
Select Answer to see Preferred Response
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
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
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.
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
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
Flexor tendons of the fingers within Zone 2 receive their primary nutritional supply from:
Diffusion from the synovial sheath
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
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
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
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?