Flexor tendon

injuries
Dr. Gautam Kalra
Senior resident
Dept of plastic and Reconstructive surgery
CONTENTS
 History
 Anatomy
 Tendon Healing
 Zones of Flexor tendons and characters of
each zone
 Management of each Zone
 Surgical technique
 Post Tendon Repair protocols
 Recent advances
 Conclusion
Introduction

 Tendons are composed of dense connective tissues that

transmit forces generated by muscles to move the joints
or to create action power.

 Flexor tendon injuries are some of the most commonly

encountered forms of hand trauma.

 Ideal management of these injuries is of utmost

importance to a plastic surgeon.
History

 The first operation on a tendon is credited to the Arabian surgeon

Avicenna / Ibn Sina” (980-1037 AD)

 In 1752, Albrecht von Haller published his work on the sensibility and
irritability of tissues. He established the insensibility of tendons and
laid the foundation for primary tendon repair

 In the early 1900s, Sterling Bunnell set the foundation for modern
tendon surgery.

 Primary repair was pioneered by Verdan and Kleinert in 1960s.

Anatomy
FDS
Origin-
Medial epicondyle,
Proximal ulna and
radius

Insertion:
Middle 1/3rd of
Middle phalanx
F
F C
D U
S
FPL
Origin-
FDP
Oblique line of the
Origin: Proximal
flexor surface of
and anterior
radius
aspect of ulna.
Insertion:
INSERTION:
Palmar surface of
Base of Volar
the base of distal
aspect of terminal
phalanx
phalanx of finger

FPL – arise
from the
Ulnar side of a
unipennate
muscle belly
9 digital tendons +
median nerve
Retinacular System

1.Transverse Carpal Ligament

2.Palmar Fascia and aponeurosis

3.Palmar and digital pulley system

PULLEY SYSTEM
CONDENSATION OF FLEXOR TENDON SHEATH FORMS THE FLEXOR PULLEY

5 Heavier Annular pulleys (A1-A5)

3 Flimsy Cruciform Pulleys (C1- C3)

ANNULAR PULLEY CRUCIFORM PULLEY

THICKER
STIFFER AND KEEPS
TENDONS CLOSE TO BONE
Economises tendon
excursion
Thinner
Collapsible
Accordion effect to allow
digital flexion, without
deforming annular pulley
 0.5-0.7cm

1.5-1.7cm
FUNCTION OF CHIASMA
• Provides pathway for FDP tendon
• Increases stability and balance of the PIP joint
• Prevents hyper-extension of the PIP joint
MEMBRANOUS COMPONENT
OF PULLEY SYSTEM
 VISCERAL AND PERIETAL LAYERS
 ALLOWS GLIDING OF TENDONS
 Nourished by synovial fluid
BLOOD SUPPLY OF TENDONS

 3 SOURCES OF BLOOD SUPPLY

 MUSCULOTENDINOUS JUNCTION
 BONY INSERTIONS
 MESENTERIC VESSELS

 MESENTERIC VESSELS
 PROXIMAL SYNOVIAL SHEATH VESSELS
 VINCULAR SYSTEM (VBP, VLP. And VBS, VLS)
Vincular system receives blood supply
from transverse branches of digital
artery

VINCULA BREVIA VINCULA LONGA

2 triangular folds, one each
to FDS and FDP
one to FDS- connecting
tendon at PIP Jt.
More delicate and filliform
For FDS-2 in number usually
run parallel, at Proximal
phalanx

One to FDP- connecting For FDP- 1 in number, at the

tendon at DIP jt. level of distal end of PPx
Zone of injury (Verdan`s
Zone)
 Zone 1: from the insertion of the FDS
tendon to the terminal insertion of
the FDP tendon
 Zone 2: from the proximal reflection
of the digital synovial sheath to the
FDS insertion
 Zone 3: from the distal margin of the
transverse carpal ligament to the
digital synovial sheath
 Zone 4: area covered by the
transverse carpal ligament
 Zone 5: proximal to the transverse
In the thumb, zone 1 is distal to the carpal ligament.
interphalangeal (IP) joint, zone 2 is from
the IP joint to the A1 pulley, and zone 3 is
the area of the thenar eminence.
 CHARACTERISTIC OF EACH
ZONE
ZONE CHARACTERSTIC
1 One tendon in a Osseo-facial tunnel
2 Two tendons in a tight Osseo-facial tunnel
3 Tendons under palmar aponeurosis
4 Nine tendons in an Osseo-facial tunnel
5 Tendons lying freely in distal form (musculo
tendinous junction)

Zone 2 and Zone 4 where more than one tendon are present in an Osseo-facial
tunnel are prone for problems after repair
SUB DIVISIONS OF ZONES

 ZONE 1a
 Very distal FDP tendon (<1cm), not
possible to insert a core suture
 Zone 1b
 From Zone 1a to distal margin of A4 pulley
 Zone 1c
 FDP within A4 pulley
ZONE 2 Sub-divisions (by Tang)
 2A- The area of the FDS tendon insertion

 2B - From the proximal margin of the FDS insertion to the

distal margin of A2 Pulley

 2C – Area covered by the A2 pulley

 2D- from the proximal margin of the A2 pulley to the proximal

reflection of the digital sheath
 Flexor tendon healing
TWO THEORIES
Extrinsic
Intrinsic (LUNDBERG) POTENZA AND PEACOCK

 Proliferation of  Healing with adhesion

tenocytes formation
 Production of  Neovascularization
extracellular matrix
 Fibroblast proliferation

 CELL MIGRATION AND

TENOCYTE
 SYNOVIUM IS IMPORTANT
PROLIFERATION
ZONE I
 Single tendon injury In Osteo-facial tunnel.
 Most important stability of repair and attatchment to
terminal phalanx
 C/F- Loss of DIP flexion
 Types of injury-
 Injury to tendon prox. To insertion
 Avulsion from insertion.
TRANS-Osseous technique
Intra-osseous technique with pull out suture
Anchor suture technique
JERSEY FINGER
 AVULSION injury OF FDP
 Occurs in football hence the name.
 Closed traumatic avulsion of the insertion of FDP with or
Without a bony fracture.
Zone II

 Was previously known as No mans land

 Both FDP and FDS are liable to damage

within a tight fibro osseous canal
TENDON RETRACTION,
retrieval and arrest
 Injury distal to VBS AND VLP stay at A2
pulley

 Injury to FDS and FDP proximal to VBS

AND VLP  retracts to A1 pulley
 Zone II

 Ends retrieval

 Atraumatic handling

 Ragged cut ends are

sharpened with scalpel or fine
scissors.

 Hypodermic needle for

fixation
ZONE III
 Between distal palmar crease and carpal tunnel
 Contains two tendons
 *Lumbrical origin (assoc. injury)
 Accompanying injury to the palmar arch
ZONE IV
 Entails injury in the carpal tunnel
 9 tendons in tight osseo-facial tunnel and Median nerve
 Origin of thenar and hypothenar muscles from flexor
retinaculum
ZONE V
 Multiple tendons involved
 Median and ulnar nerve can be involved
 Ulnar and radial artery can be involved
 Principles of repair are similar to Zone II

 Spaghetti wrist injuries were defined as in which atleast 10 out of fifteen

longitudinal structures are transected.
Timing of repair

 Primary repair- 24hrs

 Delayed primary- within 1-10 days
 Secondary repair- 10days to 4 Weeks
Primary flexion tendon injury repair
indication

 Clean-cut tendon injuries

 Tendon cut with limited peritendinous damage, no
defects in soft-tissue coverage
contraindication

 Severe wound contamination.

 Assoc. # not stabilized.
 Other life threatening injuries.
 Animal bites (biological contamination).
 Bony injuries involving joint components or extensive
soft-tissue loss.
 Destruction of a series of annular pulleys and lengthy
tendon defects.
Delayed primary ( upto 3
weeks)
 Once Signs of inflammation and edema have subsided
 Retraction of tendon has not yet started
 Chances of tight repair
Secondary repair- after 4 Weeks

 Repair of cut ends not possible due to retraction.

 Neglected injuries.
 Retraction and adhesions precludes reapproximation
 Reapproximation is permissible only with extreme
positioning of fingers and wrist in flexion.
 Injury of flexor tendon at multiple levels.
 Lack of adequate soft tissue cover.

 Tendon reconstruction might be an option.

Core suture Techniques
Two strand- modified Kessler

4 strand- Strickland`s technique

 2 strands- 20-30N
 4 strands- 40-50N
Suture purchase

7-10 mm

 Purchase length has bearing on strength

 7mm to 1cm is optimal
 Recommended to have loops atleast 2mm

SUTURE CALIBRE
• as per tendon size
• 4-0 for core
• 5-0 for circumferential
• Number of core sutures across the repair is
more determinant of strength
Peripheral sutures

 Running
 Interlocking
 Interrupted

5-0/6-0
STRENGTH OF REPAIR

 INITIALLY
 Depends on repair technique
 Later
 Depends on strength of healing.

CORE 0 week 1 week 3 week 6 week

SUTURE (-50%) (-33%) (+20%)
TECH.
2 strand 2500gm 1200gm 1700gm 2700gm
4 strand 4300gm 2150gm 2800gm 5200gm
SUTURE TENSION

• Tension of repair should be tight enough to hold

both the ends together (<3mm)
• Gap >3mm gives poor result
Adhesion prevention

 Meticulous surgery
 early postoperative motion
Post Tendon Repair Therapy Protocols

 Following are representative protocols for each of the

three basic approaches to flexor tendon post repair
management:
 Immobilization,
 Early passive mobilization
 Early active mobilization
 Combined passive-active mobilization
 Choice between one protocol and another is a matter of
assessment of
 Patient compliance
 ability to attend therapy regularly
 Surgery :strength of suture
 factors impairing healing or gliding
 Therapist :experience and skill.

 Early mobilization protocols- alert, motivated patients,

understand exercise programs and precautions.
Immobilization protocol
Differential gliding exercises
Early Passive Mobilization

 Kleinert
 Duran and Houser

 In 1975, Duran- used passive flexion of fingers and

designed to cause excursion of 3-5mm of tendon
excursion – limit formation of peritendinous adhesions
OUR EXPERIENCE with zone 2
injury
48 hours after Surgery
At 4 weeks post surgery, we
started active movements
At 6 weeks, only night splintage
and continued active movements
At 8 weeks with full recovery
Early Active Mobilization

 Belfast and Sheffield

 Strickland/Cannon
 Silfverskiold and May
 Evans and Thompson
THANKYOU