Zone Definition Introduction Treatment

I distal to Jersey finger 

FDS
insertion
II FDS Zone is unique in that FDP and Direct repair of both tendons followed by early ROM
insertion FDS in same tendon sheath (Duran, Kleinert). This zone historically had very poor
to distal (both can be injured within the results but results have improved due to advances in
palmar flexor retinaculum). Tendons postoperative motion protocols.
crease/pro can retract if vincula are
ximal A1 disrupted.
pulley
III palm (A1 Often associated with Direct tendon repair. Good results from direct repair can
pulley to neurovascular injury which be expected due to absence of retinacular structures (if
distal carries a worse prognosis. no neurovascular injury). May require A1 pulley release
aspect of to avoid impingement of the repaired tendon on the
carpal pulley.
ligament)
IV carpal Often complicated by Direct tendon repair. Transverse carpal ligament should
tunnel postoperative adhesions due to be repaired in a lengthened fashion if tendon
close quarters and synovial bowstringing is present.
sheath of the carpal tunnel.

V carpel Often associated with Direct tendon repair

tunnel to neurovascular injury which
forearm carries a worse prognosis.

Thum TI, TII, TIII Outcomes different than
b 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

FLEXOR TENDON INJURIES (ZONES)

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
◦ 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 
▪ important given the close proximity of flexor tendons to the digital
neurovascular bundles

Digital Cascade: The Cascade Sign is used to assess rotational deformity of the fingers due to the
presence of metacarpal and phalangeal fractures. Overlapping or askew
fingers could be due to internal derangement of the bones of the fingers due
to trauma.
Procedure
Patient should be awake and cooperative to perform the Cascade Sign test.
1. Patient should be seated with elbow flexed at 90 degrees and the forearm supinated.
2. Tell patient to close his hand without making a fist. The patient should close all his fingers
and let the thumb remain open.
3. Examine the hand. Normally, the fingers will come together over the hypothenar muscles
and scaphoid bone.
4. After the examination, let the patient open his hand.
Patient is instructed to close hand without making a fist.
Interpretation
Positive Cascade Sign Test
A positive Cascade Sign ia when fingers overlap or are askewed. This could indicate that there is
carpal internal derangement due to trauma.
Clinical Notes
Patients that have faulty cascading fingers could have problems with gripping or holding objects.
This could affect their daily way of living. It is therefore a must to assess the
grip strength of the patient as well.

Tenodesis grasp and release (effect) is an orthopedic observation of a passive hand grasp and

release mechanism, affected by wrist extension or flexion, respectively. It is caused by the manner
of attachment of the finger tendons to the bones and the passive tension created by two-joint
muscles used to produce a functional movement or task (tenodesis). Moving the wrist in extension
or flexion will cause the fingers to curl or grip when the wrist is extended, and to straighten or
release when the wrist is flexed.

Wrist extension tenodesis effect Wrist flexion tenodesis effect

Imaging
• Radiographs
◦ may have associated fracture
• Ultrasound
◦ used to assess suspected lacerations
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 
◦ flexor tendon reconstruction and intensive postoperative rehabilitation 
▪ indications
▪ failed primary repair
▪ chronic untreated injuries
◦ FDS4 transfer to thumb
▪ single stage procedure
▪ indications
▪ chronic FPL rupture
Techniques
• Flexor tendon repair
◦ indications
▪ > 75% laceration
▪ ≥ 50-60% laceration with triggering
▪ epitendinous suture at the laceration site is sufficient 
▪ no benefit of adding core suture
◦ fundamentals of repair
▪ easy placement of sutures in the tendon
▪ secure suture knots
▪ smooth juncture of the tendon ends
▪ minimal gapping at the repair site
▪ minimal interference with tendon vascularity
▪ sufficient strength throughout healing to permit application of early motion
stress to the tendon
◦ timing of repair
▪ perform repair within three weeks of injury (2 weeks is ideal)
▪ delayed treatment leads to difficulty due to tendon retraction
◦ approach
▪ incisions should always cross flexion creases transversely or obliquely to
avoid contractures (never longitudinal)
▪ meticulous atraumatic tendon handling minimizes adhesions
◦ technique
▪ core sutures
▪ # 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
▪
▪ circumferential epitendinous suture
▪ improves tendon gliding by reducing the cross-sectional area

▪ improves strength of repair (adds 20% to tensile strength)

 ▪ allows for less gap formation (first step in repair failure)
▪ simple running suture is recommended
▪ produces less gliding resistance than other techniques

▪ sheath repair 
▪ theoretically improves tendon nutrition through synovial pathway
▪ controversial
▪ clinical studies show no difference with or without sheath
repair
▪ most surgeons will repair if it is easy to do
▪
▪ pulley management
▪ historically believef to be critical to preserve A2 and A4 pulleys in
digits and oblique pulley in thumb
▪ recent biomechanical studies have shown that 25% of A2 and 100%
of A4 can be incised with little resulting functional deficit

▪ FDS repair 
▪ in zone 2 injuries, repair of one slip alone improves gliding
▪ 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
▪ repair site gaps > 3mm are associated with an increased risk of repair
failure
▪ adhesion formation
▪ increased risk with zone 2 injuries
• Wide-awake flexor tendon repair  
◦ anesthesia
▪ 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 > 2 hours 
▪ 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")
◦ Flexor tendon reconstruction requirements
▪ supple skin
▪ sensate digit
▪ adequate vascularity
▪ full passive range of motion of adjacent joints
◦ techniques
▪ single-stage procedures
▪ only perform if the flexor sheath is pristine and the digit has full
ROM
▪ two-stage procedures
▪ Hunter-Salisbury 
▪ Stage I - SR is placed to create a favorable tendon bed
▪ Stage II (3-4 months) - SR is retrieved and a tendon graft is
placed through the mesothelium-lined pseudosheath
▪ pulvertaft weave proximally and end-to-end
tenorrhaphy distally
▪ Paneva-Holevich 
▪ 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 the pseudosheath and either attached directly
to FDP stump or secured with a 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
▪ relies on only 1 tenorrhaphy site (distal or proximal) to
heal at any one time (vs. Hunter technique where 2
tennoprhaphy sites are healing simultaneously)
 ▪ disadvantages
▪ graft tensioning is at the distal end during stage II
▪ the proximal end has already healed after stage
I
▪ graft selection
▪ palmaris longus (absent in 15% of population)
▪ most common
▪ plantaris (absent in 19%)
▪ indicated if longer graft is needed
▪ extensor digitorum longus to 2nd-4th toes
▪ extensor indicis proprius
▪ flexor digitorum longus to 2nd toe
▪ FDS

▪ pulley reconstruction one pulley should be reconstructed proximal

and distal to each joint
▪ pulley reconstruction should occur first if a tendon graft is being used
▪ methods
▪ belt loop method
▪ FDS tail method
▪
◦ outcomes
▪ subsequent tenolysis is required more than 50% of the time
• 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
• Protocols
◦ Immobilization
▪ indicated for children and non-compliant patients 
▪ casts/splints are applied with the wrist and MCP joints positioned in flexion
and the IP joints in extension
◦ Early passive motion 
 ▪ Duran protocol
▪ low force and low excursion
▪ active finger extension with patient-assisted passive finger flexion and
static splint

▪ Kleinert protocol
▪ low force and low excursion
▪ active finger extension with 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
◦ Early active motion
▪ moderate force and potentially high excursion
▪ dorsal blocking splint limiting wrist extension
▪ perform “place and hold” exercises with digits