Tendons

Tendon & Ligament

 Definition :
Tendon Ligament
 from Latin ‘ligare‘-‘to bind’.
• or sinew, from Greek ‘teinein’
 Tough, flexible fibrous connective tissue
- ‘to stretch’.
which connects two bones or cartilages
• Dense,regularly arranged groups of collagen

bundles that attach muscle to bone

 Anatomy :
Tendon Ligament

• Covered with either synovium or paratenon  Surrounding epiligamentous coat—analogous

( more vascular, sleeve function ) to the epitenon of tendons and carries

neurovascular structures
• Fibers (individual fascicles) and bundles are
surrounded by endotenon and epitenon (type
III collagen), endure less friction and carry the
nerves, arteries, veins and lymphatics of tendons.
 Embryology :
Tendon & Ligament

• The syndetome is the embryonic structural

origin of tendons & ligaments from the somite
and originates from the dorsolateral edge of
the sclerotome.
Histology :
Tendon
• Tendon cells or Tenocytes
• Tenocytes synthesize the
extracellular matrix
• arranged in direction of muscle
loading in arrays
Ligament
 fibroblasts which are surrounded by matrix.
 responsible for matrix synthesis and they are
relatively few in number
 collagen bundles aligned along the long axis of the
ligament and displaying an underlying "waviness" or
crimp along the length.
Insertion into bone:
Tendon Ligament
• By means of fourtransitional tissues  Transition in four phases (zones):
• Tendon  Ligament
• Fibrocartilage
 Fibrocartilage
• Mineralized fibrocartilage (Sharpey fibers
 mineralized fibrocartilage
interdigitate with periosteum)
 bone
• Bone
Composition :
Tendon Ligament
• Collagen (75% dry weight; 95%  Primarily type I collagen (80% of dry

type I collagen, 5%type III collagen weight)

• Proteoglycans (decorin and biglycan—  Water

5%dry weight)  Elastin (1% dry weight)

• Decorin—most predominant
 Lipids
proteoglycan in tendons. Regulates
tendondiameter and provides cross-  Proteoglycans (1% dry weight)
links between collagen fibers.
• Aggrecan—present at points of tendon
compression
Functions:
Tendon Ligament
 It maintains correct bone and joint geometry
• Carry tensile forces from muscle to
 Ligaments + Associated joint capsules combinely
bone
function as passive joint stabilizers

• They carry compressive forces when  Secondary function: Proprioception.

wrapped around bone like a pulley

• They facilitate skeletal muscle

movement (movement in joints)

• Proprioception.

• Secondary function: Storage of energy

 Healing :
Tendon Ligament
STAGES OF TENDON HEALING STAGES OF LIGAMENT HEALING
• Hemostasis Platelets initiate coagulation
cascade Fibrin clot and fibronectin interaction  Inflammation acute mediators (PMNs and
chemotaxis to stabilize torn tendon edges then macrophages),with production of type III
• 5-15 min
collagen and growth factors
• Inflammation Fibroblasts produce type III
collagen, macrophages help initiate healing  Proliferative — around 1 to 3 weeks, with
and remodeling
replacement by type I collagen (weakest)
• 1-7 days
• Organogenesis Tissue modeling via large  Remodeling and maturation
amounts of disorganized collagen and
angiogenesis
• 7-21 days (weakest at 7 to 10 days)
• Remodeling - replacing type III collagen to
type I collagen
• Upto 18 mths (Maximum strength achieved at 6
months)
Important Properties :

• Exercise strengthens tendons

• Immobilisation, Intraarticular ligamentousinjury • Old age • Smokers • NSAID use • Diabetes

mellitus • Alcohol use • Decreasein growth factors • Limited gene expression • Local injection of

corticosteroids has detrimental effects.

• Heat decreases tensility/strength .

• Strength varies with hydration, pH, tempreature

• viscoelastic structures exhibiting both elastic and viscous behaviour.

• Tendons can bear 5-10% more tension as compared to bone

 … …

 crimped structure of the collagen fibre bundles permits stretching by 10–15% before failure.

 absorb more strain energy per unit weight than any other biological material

 very effective shock absorbers

 "load relax" - loads/stresses decrease within the ligament if they are pulled to constant

 "creep" - deformation (or elongation) under a constant or cyclically repetitive load.

 Contain mechanoreceptors and nerve endings = proprioception, which is referred to as the conscious

perception of limb position in space.

Clinical Importance :

• Synovium-covered tendons (flexor tendons): allow for gliding motion, with

vincula that carry the blood supply

• Areas not contacted by vincula receive nutrition via diffusion through paratenon.

• Synovial fluid between the two layers of the synovial sheath

• Achilles, patellar, and supraspinatus tendons are prone to rupture at hypovascular

areas.

Eg. Achilles tendon is hypovascular 4 to 6 cm proximal to calcaneal insertion.

Clinical Importance… :

• Surgical tendon repairs:

• weakest at 7 to 10 days

• Most of original strength regained at 21 to 28 days

• Maximum strength achieved at 6 months,(reaching 2/3rd)

• Injury is more common in females.

• Most common ligaments injured — in the knee and ankle

• Mid substance ligament tears are common in adults.

• Avulsion injuries are more common in children. (also heals faster)

Clinical Importance… :

• Factors that impair ligament healing:

• Alcohol use
• Intraarticular ligamentousinjury

• Decrease in growthfactors
• Old age

• Limited gene expression

• Smokers

• Local injection of corticosteroids

• NSAID use

• Diabetes mellitus
Principle of Tendon
Repair
 Tendon
• Healthy tendon are brilliant white in color and have a fibro-elastic texture
• They can be rounded cords , straps like bands , or flattened ribbons
• Consist of matrix and cellular elements
 90-95 % of cellular elements are tenoblast and tenocytes
 5-10 % of the cellular elements of tendon consist of chondrocytes at the bone
attachment and insertion site ,synovial cells and vascular cells
• Epitenon :fine ,loose connective tissue
sheath containing vascular, lymphatic
and nerve supply to tendon , covers
the whole tendon
• Endotenon :thin reticular network of
connective tissue investing each
tendon fiber
• Paratenon: loose areolar connective
tissue lies superficial to epitenon.
Physiological aspects of tendon
• The oxygen consumption of tendon and ligament are 7.5 times lower
than that of skeletal muscles
• low metabolic rate and well developed anaerobic energy generation
capacity are essential to carry loads for long periods ,reducing the risk
of ischemia and subsequent necrosis
• Low metabolic rate results in slow healing after injury
 Blood supply to tendon
• Two basics sources
1. the synovial fluid produced within the tenosynovial sheath
2.the blood supply provided through longitudinal vessels in
paratenon ,intraosseous vessels at the tendon insertion and vincular circulation

Tendon vascularity is compromised at the junctional zones and sites of torsion ,

friction or compression
 Tendon injury
• Can be acute or chronic
• Caused by intrinsic or extrinsic factors
• Mode of injury :
 severed by laceration or cut injury
 sports injury
 tendon rupture
 tendinopathy
Predisposing factors
• Intrinsic Extrinsic
A. Previous injury training errors
B. Increasing age cold weather

C. genetic predisposition training surface

D. Tendon structure
E. Obesity
F. Diabeties
G. Medication :fluoroquinolones , steroids
 Healing of tendon in two forms

A. Intrinsic healing
B. Extrinsic healing (occurs by proliferation of fibroblasts from epitenon
 Zones of Extensor tendon of hand

• Divided in 9 zones
• Anatomic variation in the extensor tendon are
common
• The most common pattern single extensor indicis
proprius inserting the ulnar side of the index EDC
• single EDC to index finger, long finger, ring finger but
absent EDC to little finger and a double extensor digiti
quinti with double insertion
 Juncturae tendium

• Type I:thin filamentous between EDC

(m) and index EDC (i)finger
• Type II:thicker juncturae between EDC
tendon of ring and long finger
• Type 3 (subtype y):y shaped tendon
between EDC of ring and long finger .
• Type 3 (subtype r):more oblique R
shaped juncturae between EDC r and
EDQ
Extensor apparatus digits
 Basics tendon repair
• Strickland stressed six characteristics of an ideal repair
i. Easy placement of sutures in the tendon
ii. Secure suture knots
iii. Smooth junction of tendon ends
iv. Minimal gapping at the repair ends
v. Minimal interference with tendon vascularity
vi. Sufficient strength through out healing to permit application of early motion stress to
the tendon
Techniques
• Redrive the tendon ends through the sheath in an atraumatic manner
• Maintain the integrity of A2 and A 4 pulley
• Extend the original laceration for better exposure- zigzag or midlateral
• Avoid linear scar that cross flexion crease
• Milk the forearm with the wrist and MCP joint in flexion
• Do not attempt blind retrieval more than twice
• Use pediatric feeding tube to retrieve tendon stump
Suture technique
o Suture material
 Non reactive
Pliable
Small caliber
Strong
Easy to handle
Common material :ethibond , nylon , prolene
• A 4.0 suture is estimated to be 66% stronger than 5-0 suture and 3-0
suture is 52% stronger than a 4-0 suture
Timing of repair

• Primary tendon repair are done within first 12-24 hours

• Delayed repair within 10 days of injury
• Secondary repair after 14 days
 Partial flexor tendon laceration

• A tendon with 60% laceration can retain 50 % or more of its strength

So must be treated the same as complete transection
Repaired with core suture with continuous epitendinous suture with 6-0 nylon suture

• A tendon with 90% laceration can retain only slightly more than 25 % of its
strength
Should be evaluated for the risk of trigerring
If chances of trigerring is high , should be smoothly debrided and the flexor sheath is
repaired
 flexor Zone I
• Repaired primarily by direct suture to its distal stump or by
advancement and direct insertion in to the distal phalynx when the
distance is 1 cm or less
• Excessive trimming and advancement can result in a finger that is held
in flexed position compared with other finger
• May lead to quadriga effect
Zone II
• Bunnell’s no man’s land
• Repair profundus only if both are lacerated
• Should explore injury through a window made in the tendon sheath
between A2 and A4 pulley
Zone III
• Zone of lumbricals
• Repair both FDS and FDP preferentially FDP
• Do not suture lumbricals as it may lead to lumbricals plus finger
Zone IV
• Release partially or completely transverse carpel ligament
• Do not flex the wrist beyond the neutral if TCL is completely released
• As it leads to subluxation of repaired tendon out of their normal bed
and than bowstringing them under the sutured skin
• Release the TCL in a Z lengthening configuration to overcome the
above effect.
 Zone V
• All tendon and nerves lacerated are repaired
• An isolated laceration of the palmaris longus does not absolutely require
repair
 Extensor zone I
• Mallet finger deformities usually result from closed avulsion of the insertion of the
tendon
• Closed avulsion can be treated by splinting alone
• An open transection of the central slip insertion is repaired with a roll stitch or a
dermotenodermal suture
Classification of mallet finger deformity by
Doyle
•Type I:closed injury, with or without a small avulsion fracture
•Type II: open injury ,tendon laceration
•Type III:open injury , with loss of skin and tendon substance
•Type IV:mallet fracture
A :transphyseal fracture in children
B : Hyperflexion injury with 20-50 % involvement of articular surface
C : hyperflexion injury with more than 50 % involvement of articular surface and with early or late volar subluxation
of the distal phalynx
Extensor zone III
• Boutonniere deformity is common due to rupture of the central slip of
extensor expansion
• Boutonniere deformity that are diagnosed early in closed wounds
before fixed contractures can be managed conservatively
• Conservative management consist of splinting the proximal PIP joint
in full extension while permitting the DIP joint to be in actively flexed
• If Boutonniere deformity is traumatic ,central slip should be exposed
and repaired surgically
 STAGES OF BOUTONNIERE
DEFORMITY
• STAGE 1: supple , passively correctable deformity
• Stage 2:fixed contracture with contracted lateral bands
• Stage 3:fixed contracture with joint fibrosis ,collateral ligament and volar
plate contractures
• Stage 4:stage III plus PIPJ arthritis
 Zone v

• Includes area of MCP joint

• For clean laceration ,repair of tendon with a core suture reinforced with cross
stitch is indicated
• Traumatic dislocation of extensor tendon towards the ulnar aspect of MCP joint
occurs
• Detected with in first few days, dislocation can be treated effectively with
splinting of the MCP joint in extension for 3-4 weeks followed by buddy taping to
adjacent finger on the radial side for 3-4 weeks
Rayan and Murray classified sagittal band
injury in 3 types
• Sagittal band dislocation is repaired with ulnar based loop formed from extensor
tendon passed in distal to proximal direction around radial collateral ligament and
sutured to extensor tendon
Complication tendon repair

• Quadriga effect: advancement of FDP more than 1 cm

reduces ability to flex the uninjured digits due to FDP tethering
• Lumbrical plus finger:
Develops when pull of profundus musculotendinous unit is applied through
lumbricals muscle rather than tendon graft
Occurs when tension in tendon graft is not appropriately set and graft is
relatively long
Forceful flexion leads to extension of IP joint ‘paradoxic extension’
Transection of involved lumbrical tendon to the radial side of involved finger
Post operative care of tendon repair
• Wrist and hand are held in posterior splint
• Wrsit is positioned in 20-45 degree of flexion with MCP joint in 50-70
degree of flexion
• Involved finger is held in flexion by elastic band attached at wrist level and
at finger nail by wire through nail
• Permits active finger extension and protected passive flexion
• 3-5 mm of excursion of tendon is allowed via passive movement of finger
tip
• After 3 weeks the dorsal splint is removed and a wrist band with a hook
for the rubber band is used for a additional 3 weeks
• Wrist band splint is discontinued at 6-8 weeks
• 8-10 weeks , strengthening exercise are allowed
• 10-12 weeks normal function of hand is permitted
TENDON REPAIR TECHNIQUES
OUTLINES
• PURPOSE OF TENDON REPAIR
• SUTURE MATERIALS FOR TENDON REPAIR
• CORE SUTRUE AND TENDON SHEATH REPAIR
• COMMONL USED TENDON REPAIR TECHNIQUES FOR IN HAND
• ACHILLES TENDON REPAR
• PATELLAR TENDON REPAIR
• QUADICEPS TENDON REPAIR
• COMPLICATIONS
BASIC TENDON REPAIR
TECHNIQUES
• The purpose of tendon suture is
-to approximate the ends of a tendon
-or to fasten one end of a tendon to adjoining tendon or to bone
- and to hold this position during healing.
• When tendons are being sutured, handling should be gentle and
delicate, causing as little reaction and scarring as possible.
• Pinching and grasping of the uninjured surfaces should be avoided
because this can contribute to the formation of adhesions.
In general, studies have shown that four, six, and eight core sutures with
epitendinous repair best accomplish the objectives of achieving a predictable
clinical outcome of near ideal functional restoration.
SUTURE MATERIAL
A variety of satisfactory suture materials are available for tendon repair.
1. monofilament stainless steel: highest tensile strength, difficult to
handle, tends to pull through the tendon, and makes a large knot.
2. Absorbable sutures: eg. Catgut(natural) and the polyglycolic acid
group(synthetic) eg Dexon, Vicryl; become weak too early after
surgery to be effective in tendon repair
3. Synthetic sutures: caprolactam family (Supramid), nylon,
polypropylene (Prolene), polyester suture.
4. Polydioxanone(PDS)- absorbable, synthetic; shown to be as strong as
polypropylene, maintained better strength over 28 days.
• In clinical situations, most surgeons find that the braided polyester
sutures (Ticron, Fiberwire,Mersilene) provide sufficient resistance to
disrupting forces and gap formation, easy to handle, and have
satisfactory knot characteristics; consequently, these sutures are
widely used.
• In most situations, a 3-0 suture may be useful to repair tendons in the
forearm, palm, and larger digits, whereas a 4-0 suture may handle
better in smaller digits
Epitendinous repair usually is done with 5-0 or 6-0 monofilament
suture eg.Prolene.
• An abundance of research has shown that four-strand, six-strand, and
eight-strand core sutures create stronger repairs, reduce the
possibility of gap formation.
• Continuous epitendinous sutures, placed circumferentially around
the repair site, decrease the bulk of the repair site, minimizing the risk
of triggering.
• Also enhances the strength of the core suture repair, supports 50% of
the load to failure, and resists gap formation.
 Core Sutures
Current literature supports several conclusions regarding
core sutures
– Strength proportional to number of strands 
– Locking loops increase strength but may collapse and lead to
gapping 
– Knots should be outside repair site
– Increased suture callibre = increases strength
– Braided 3-0 or 4-0 probably best suture material
– Repairs are stronger when the core sutures are placed dorsally
– Equal tension across all strands
Sheath Repair
Advantages
– Barrier to extrinsic adhesion formation
– More rapid return of synovial nutrition
– better tendon-sheath biomechanics
Sheath Repair
Disadvantages
– Technically difficult
– Increased foreign material at repair site
– May narrow sheath and restrict glide
Presently, no clear cut advantage to sheath repair has been established
Core suture techniques

Crisscross stitch
 FISH-MOUTH END-TO-END SUTURE (PULVERTAFT)

• A tendon of small diameter can be sutured to one of large diameter by the this
method.
• commonly is used to suture tendons of unequal size.
A, Smaller tendon is brought
through larger tendon and anchored with one
or two sutures after tension is adjusted.

B, Tendon is brought through more proximal

hole and is anchored again with one or two
sutures after tension is adjusted.
C, After excess is cut flush with larger tendon,
exit hole can be closed with one or two sutures.
D, Excess of larger tendon is trimmed as shown
to permit central location of smaller tendon.
This so-called fish mouth is closed with sutures.
 Roll stitch

• The roll stitch is especially

useful for suturing extensor
tendons over or near the
metacarpophalangeal
joints.
End to side repair
• End-to-side repair frequently is used in tendon transfers when one
motor must activate several tendons.
 TENDON-TO-BONE ATTACHMENT
• usually for distal phalanx
• For repair or grafting frequently requires a pull-out technique.
• For tendon-to-bone repairs, the techniques used most often have included the
Kessler and a modified Bunnell crisscross suture
SUTURE ANCHOR TENDON
ATTACHMENT
• shown to be as effective as a pull-out wire or suture but
• without complications with the fingernail that can occur with the
pull-out technique.
• Two suture anchors are placed in the distal phalanx from distal-volar
to proximal-dorsal

Suture anchor tendon attachment

suture anchor placement in the distal phalanx and
suture technique.
Repair of Achilles tendon rupture
Is largest tendon in body
Lack of tendon sheath
• peak age for Achilles tendon rupture in both men and women is
between 30 and 40 years of age.
• Several intrinsic and extrinsic risk factors for Achilles rupture
Clinical features
• Felt like a shot/kick OR heard pop at back of heel
• Isolated tenderness or swelling
• Palpable defect
• Thompsons squeeze test positive
• Matles test positive
• Obrien needle test positive
 Primary repair of acute Achilles
tendon upture
• posteromedial longitudinal skin incision 8 to 10 cm long; make it about 1 cm
medial to the tendon
• Approximate the ruptured ends of the tendon with No. 5 nonabsorbable tension
suture, using a modified Kessler, Krackow stitch through the stump 2.5 cm from
the rupture
• Use a tendon stripper and harvest the plantaris tendon
• Place the harvested plantaris tendon in a fascial needle and pass it
circumferentially, first through the posterior and then through the anterior part of
the tendon 2 cm from the rupture.
 KRACKOW technique
• posteromedial incision approximately 10 cm
long about 1 cm medial to the tendon
• Approximate the ruptured ends of the tendon
with a no.5 nonabsorbable suture(ethibond)
• Check the repair for stability after the sutures
are tied.
• Close the peritenon and subcutaneous tissues
with 4-0 absorbable sutures.
 LINDHOLM technique
• patient prone
• posterior curvilinear incision- from the
midcalf to the calcaneus.
• Debride the ragged ends and appose them
with a box type of mattress suture of heavy
nonabsorbable suture material or wire
• Fashion two flaps from the proximal tendon
and gastrocnemius apponeurosis
• Twist each flap 180 degrees on itself , as it is
turned distally over the rupture
• Suture each flap to the distal stump
DYNAMIC LOOP SUTURE TECHNIQUE
FOR ACUTE ACHILLES RUPTURE
• Expose the Achilles tendon and the tuberosity of
the calcaneus
• Identify and retract the sural nerve
• Detach the peroneus brevis tendon from its
insertion at base of the fifth metatarsal.
• Dissect the tuberosity of the calcaneus and drill a
hole
• Pass the peroneus brevis tendon drilled hole
• Reinforcing the site of rupture, and suture it to the
peroneus brevis itself, producing a dynamic loop
 Repair of chronic rupture of Achilles
tendon
1. primary repair- uncommon

2.Augmentation-free fascia tendon graft –plantaris, peroneus brevis

-fascia advancement eg V-Y quadriceps plasty, gastrocnemius-
soleus turndown graft

3.Local tendon transfer-FHL,FDL,peroneus longus/brevis,plantaris,TP

4.Syynthetic of allograft augmentation

 USING PERONEUS BREVIS AND
PLANTARIS TENDONS-white and kraynick and Teuffer

Technique for chronic rupture of Achilles tendon.

A, Exposure of Achilles tendon and tuberosity
through posterolateral incision.
Peroneus brevis is passed through hole drilled in
tuberosity and sutured to Achilles tendon.

B, Plantaris tendon is passed through ruptured

ends of tendon
 TRANSFER OF THE PERONEUS BREVIS TENDON
FOR NEGLECTED ACHILLES TENDON RUPTURES

Peroneus brevis transfer for chronic Achilles

tendon rupture.
A, Longitudinal incisions- 5cm long, 2 cm
proximal and just medial to palpable stump.
2nd incision -3 cm long,2 cm distal and just
lateral to lateral margin of distal stump
.
Harvest the peroneus brevis tendon graft
B, Completed transfer.
 V-Y REPAIR OF NEGLECTED ACHILLES
TENDON RUPTURES
V-Y advancement may be required if
more than 80% of the tendon width
is involved.
It also is useful when 1 to 3 cm of
tendon must be resected.
V-Y repair of neglected rupture of Achilles
tendon
. A, Incision.
B, Design of V flap.
C, Y repair and end-to-end anastomosis
REPAIR OF NEGLECTED TENDON RUPTURES
USING GASTROCNEMIUS-SOLEUS TURNDOWN
GRAFT

Bosworth technique for repairing old ruptures of Achilles

tendon
SUTURE REPAIR OF PATELLAR
TENDON RUPTURE
-With a rongeur, make a small horizontal trough
at the inferior pole of the patella.
-Place three horizontal No. 5 nonabsorbable
mattress sutures through the patellar tendon
stump and bring the tendon through holes
drilled in the patella,
drawing the tendon securely to the inferior
pole of the patella.
Technique of repair of fresh rupture of patellar
This can be accomplished with a
Tendon- ruptured through attachment.
suture passer or Beath pin.

Bury the nonabsorbable suture knots superior to the

patella deep to the quadriceps tendon
Technique of repair of fresh rupture of patellar tendon
- Ruptured through tendon substance

Interlocking suture are placed in the proximally

and distally base bundles.

sutures are secured through parallel vertical

holes drilled in patella and transverse hole
drilled in tibial tuberosity.

Repair the individual bundles side-to-side after

appropriate tendon length is determined.
RUPTURE OF TENDON OF QUADRICEPS
FEMORIS MUSCLE
• generally result from eccentric contraction of the extensor mechanism
against a sudden load of body weight with the foot planted and the knee
flexed.

• usually ruptures at the osteotendinous junction in older patients and

Mid tendon or musculotendinous area in younger patients.

• Hypovascular zone in the quadriceps tendon 1 to 2 cm from the superior

pole of the patella, corresponding to the site of spontaneous ruptures
reported in the literature.
 Technique for repair of fresh rupture of
quadriceps femoris tendon

. A, Two parallel interlocking sutures are

placed in quadriceps tendon.
Small trough is made in anterior aspect of superior
pole of patella. Horizontal mattress sutures are placed
in vastus intermedius stump.

B, Sutures in vastus intermedius

are pulled anteriorly through rectus and are tied while
tendon is held in anatomic position, using sutures
placed distally through drill holes; sutures are then tied
distally.
Codivilla tendon lengthening and repair of quadriceps tendon- in chronic rupture

• If shortening makes apposing the ends of the

tendon impossible, tendon lengthening can be
helpful.
• An inverted V is cut through the full thickness of the
proximal segment of the quadriceps tendon, with
the inferior ends of the V ending 1.5 to 2.0 cm
proximal to the rupture.
• The triangular flap thus fashioned is split into an
anterior part of one third of its thickness and a
posterior part of two thirds.

• anterior part of the flap is turned distally and is

sutured
Complications
• Infection
• Joint contracture
• Adhesions
• Rupture
• Triggering of finger
• Bowstringing- flexor tendon injury of hand
• Quadriceps rupture:Loss of motion especially flexion, Extensor
mechanism weakness, quadriceps atrophy and extensor lag.
 FLEXOR TENDONS
Tendon nutrition
is believed to derive from two basic sources:
(1) the synovial fluid produced within the tenosynovial
sheath and
(2) the blood supply provided through
longitudinal vessels in the paratenon,
intraosseous vessels at the tendon insertion, and vincular
circulation
• An ischemic area is present in the flexor digitorum superficialis
beneath the A2 pulley at the proximal phalanx.

Two zones of ischemia are present in the flexor digitorum profundus—

beneath the A2 pulley and beneath the A4 pulley.
Tendon healing
• is believed to occur through the activity of extrinsic and intrinsic
mechanisms,
• occurring in three phases:
1. Inflammatory (48 to 72 hours),
2. Fibroblastic (5 days to 4 weeks), and
3. Remodeling (4 weeks to about 3.5 months).
The extrinsic mechanism
occurs through the activity of peripheral fibroblasts
seems to be the dominant mechanism contributing
to the formation of scar and adhesions.
Intrinsic healing
• seems to occur through the activity of the fibroblasts derived
from the tendon.
REHABILITATION PROTOCOL-
MODIFIED DURAN METHOD
FOR FLEXOR TENDON REPAIR.
• 0-3 days -Dosally placed splint with wrist at plamar flexion of ~20-
45* , MCP ~50*flexion, IP in full extension
• 2 WEEKS POST-OP: Sutures removed. Active hold in composite fist in
splint.
• 3½ WEEKS POST-OP: Gentle active flexion and extension of all fingers
within the limits of the splint – avoid making a tight fist.
• 4 WEEKS POST-OP:Remove splint. Active wrist motion . Composite
active flexion and extension of digits.
• 4½ WEEKS POST-OP: Non-resistive” functional activities such as
picking up foam, rice, etc.

• 5 WEEKS POST-OP:If finger is stiff with limited range of motion and

tendon excursion, discontinue splint in low risk activity. Continue with
splint at night and with high risk activity.
• 6 WEEKS POST-OP:Blocking exercises. Stabilize on sides of digit. Do
not stabilize on volar as this will serve as an isometric force.

• 8 TO 10 WEEKS POST-OP: Gradual increase in resistive exercises

continues. Dynamic extension splints as needed for PIP contractures
Extensor tendon repair-Rehabilitation
• Volar splint with wrist positioned at 40-45 dorsiflexion
• WEEK 3: Continue with exercises while in splint for active flexion and
passive extension
• WEEK 4: Out of splint active composite fist.
Active wrist flexion gradually increases with fingers relaxed.
Full MP and IP extension. Continue with splint while not
exercising.
• WEEK 5:Active range of motion out of splint.
• WEEK 6: Discontinue splint.
• WEEK 7: Initiate blocking.
• WEEK 8: Re-evaluate. Graded strengthening. Dynamic splint as
needed.
• WEEKS 10-12: No restrictions.
Achilles tendon repair rehabilitation
• 0-2 weeks: Posterior slab/splint; non–weight bearing with crutches
(immediately postoperative or after injury)
• 2-4 weeks :Aircast walking boot with 2-cm heel lift.
Protected weight bearing with crutches.
Active plantar flexion and dorsiflexion to neutral,
inversion/eversion below neutral
• 4-6 weeks Weight bearing as tolerated. Continue activities as above
• 6-8 weeks: Remove heel lift from boot. Weight bearing as tolerated.
Dorsiflexion stretching, slowly graduated resistance exercises. (open
and closed kinetic chain, functionalactivities)
• 8-12 weeks: Wean off boot. Return to crutches and/or cane as
necessary and gradually wean off. Continue to progress range of
motion, strength, proprioception.
• >12 weeks: Continue to progress range of motion, strength,
proprioception. Sport-specific training
Patellar and quadriceps tendon repair
rehabilitation
• A cylindrical castor brace with knee in extension.
• Weight bearing with crutches as tolerated
• Straight leg raise are begun at 3 weeks.
• Cast/brace removed at 6 weeks and controlled motion brace with
ROM 0-45* fitted.
Extensor Tendon Injuries
 Tendons
Dense, regularly arranged groups of parallel
collagen bundles that attach muscle to bone.

Anatomy
 Type 1 collagen grouped into microfibrils,
then subfibrils, then fibrils, surrounded by
endotenon.
 Fibroblasts and fibrils surrounded by a
peritenon forms fascicle.
 Groups of fascicles surrounded by an
epitenon forms tendon.
 Tendons
Tendon inserts into bone by means of four transitional
tissues (force dissipation)
Tendon
 Fibrocartilage
 Mineralized fibrocartilage (Sharpey’s fibers)
Bone

Blood supply
Vascular tendons have a paratenon (no sheath) that surrounds
them and supplies blood.
Avascular tendons (in a sheath) have a vinculum to supply blood.
 Tendons
Healing
Initiated by fibroblasts and macrophages
Early healing is with type III collagen which later
converted to type I collagen.

 Surgical repairs: weakest at 7 to 10 days

 Most of original strength regained at 21 to 28 days
 Maximum strength achieved at 6 months
 Extensor Tendons
Anatomy

• The extensor tendons pass from the forearm onto the

dorsum of the hand through the six compartments beneath
the extensor retinaculum.

• From the radial (lateral) side to the ulnar (medial) side of

the retinaculum, the compartments contain following
numbers of tendons: two, two, one, five, one, and one.
Extensor Tendons
 Extensor Tendons
Anatomical variations in the extensor tendons are common.

In the first dorsal compartment, septation occurs in 20% to 60%.

The abductor pollicis longus may have multiple slips in 56% to 98% of
dissections.
Extensor Tendons
 Extensor Tendons
•Because of their superficial location, they are often involved with
injuries to the dorsum of the hand.

•The extensor tendons are thin, broad and flat in structure and,
therefore, are vulnerable to rupture and adhesions.

•The extensor tendons receive their blood supply through vascular

mesenteries – mesotendons – that are analogous to the vincula of the
flexor tendons.

• Extensor tendon injuries are defined by nine zones for the extrinsic
finger extensors and five zones for the thumb
extensors. The zones are as follows:
Extensor zones of hand
 Extensor Tendons
Diagnosis

• Mechanism of injury
• The exact position of a cut will indicate which structures
may have been injured.
• Assessment of passive movement of the digits
• Assessment of active movement of the digits and wrist.
• Radiographs to asses for associated fracture
• Surgical exploration of the wound
 Extensor Tendons
Doyle techniques for extensor tendon repair:

• Zone 1 (DIP joint): Running suture incorporating skin and tendon.

• Zone 2 (middle phalanx): Running 5-0 stitch near cut edge of tendon,
completed with “basket-weave” type of cross-stitch.

• Zones 3 through 5 in fingers, and zones 2 and 3 in thumb: Modified

Kessler suture of 4-0 synthetic material in the thickest portion of the
tendon. A 5-0 cross-stitch tied to itself.

• Zones 6 and 7: Same as for zones 3 through 5 except the cross-

stitch is run around the entire circumference of the tendon, if feasible.
 Post operative management
Zones 1 and 2:- 6 wks of immobilization with either splint or K-wire
fixation of DIP joint.

Zones 3 through 5:- 4 wks of immobilization with wrist in 40 degree

of extension, slight flexion at MP joint and extension at PIP joint.

The main concern after repair is to maintain the integrity of the

repair while limiting adhesion formation.
 Complications of ext
tendon repair
Adhesions are the most frequent complication of extensor tendon
repair and can cause an extension lag and loss of flexion.

Extensor tenolysis is considered if progress is considered to be

unsatisfactory after 6 months.

In the ideal situation, full passive motion should be present before

tenolysis.
Extensor Tendons
 Extensor Tendons
ZONE I
• Zone I is at the level of the
distal interphalangeal joint.

• Mallet finger injury is characterized by discontinuity of the

terminal extensor tendon resulting in an extensor lag at the DIP
joint with or without compensatory hyperextension at PIP joint
(swan neck deformity).

• It can be due to open transection or closed rupture with or

without associated fracture of distal phalanx.
 EXTENSOR TENDON RUPTURE
For a closed type I mallet finger the
treatment usually is nonsurgical.

The DIP joint is constantly held in

hyperextension on a splint for 6 to 8
weeks and at night only for 1
additional week
 ACUTE TRANSECTION OF EXTENSOR TENDON

Type II and III mallet open injury of the extensor tendon insertion
requires repair of the tendon.

A roll suture or dermotenodermal suture usually is applied to hold

the insertion for healing.

The repair can be protected with a transarticular K- wire.

The wound is closed, and the finger is splinted for 8 weeks and k-
wire removed at 4 wks
 CHRONIC MALLET FINGER
(SECONDARY REPAIR)

After 12 weeks, if the distal phalanx droops severely, but passive extension in the
distal interphalangeal joint still is satisfactory, surgery may be indicated.

TECHNIQUE

V-shaped or U-shaped incision, convex distally, with the tip 5 mm proximal to the
nail base on the dorsum of the finger.
 CHRONIC MALLET FINGER
(SECONDARY REPAIR)

Flap is developed gently in the plane between the tendon and the
subcutaneous fat.
Elevate the flap proximally to expose the extensor tendon with its
intervening scar.
Resect sufficient scar.
Immobilize the joint with a K-wire.
Repair the extensor tendon with 4-0 monofilament nylon or wire as
a pull-out roll stitch .
Support the finger with a volar splint.
 POSTOPERATIVE CARE

The sutures are removed at 10 to 14 days, and the distal

joint is maintained in extension.

 K-wire is removed after 4 to 6 weeks, and the repair is

protected with a splint for 8 weeks.

Normal activities are progressively resumed.

 Fowler technique to
correct chronic mallet
finger
 Fowler technique to correct chronic mallet finger

The Fowler central slip tenotomy relies on a mature terminal

tendon that has healed with slight elongation resulting in a
persistent extensor lag.

A boutonniere deformity is not created during central slip tenotomy

is because of triangular ligament.
 Extensor Tendons
Correction of an old mallet
finger deformity can also be
done by tendon transfer
or tendon graft.

MILFORD TECHNIQUE
OF TENDON TRANSFER
 Extensor Tendons
TENDON GRAFT FOR
CORRECTION OF
OLD MALLET FINGER
DEFORMITY
 Extensor Tendons
ZONE II
Zone II is the area over the middle phalanx.
The flat tendon in this area may limit the suture
configuration.
The Kleinert modification of the Bunnell suture and the
modified Kessler sutures can be used for repair of
extensor tendons in zone II.
 Extensor Tendons
ZONE III

Zone III is the area of the proximal interphalangeal

joint.

Rupture or acute transection of the central slip or lateral band ( or both)

resulting PIP joint extensor lag and DIP Joint hyperextension termed a
Boutonniere deformity.
 Boutonniere deformity
 If left untreated, collateral ligaments and volar plate of the PIP joint become
contracted.

The lateral bands of the extensor expansion subluxate volarly and also become
contracted. This results in an established buttonhole deformity.

The contracted oblique retinacular ligaments and the lateral bands force the
distal interphalangeal joint into hyperextension.
 Boutonniere deformity
Repair of central slip of the extensor expansion causing
buttonhole deformity.

• Expose the extensor mechanism dorsally with a lazy-S or bayonet

incision.

• Place the PIP joint in full extension with K-wire.

• Repair the disruption of the central slip with a roll stitch of 4-0
monofilament nylon or wire.
CHRONIC BUTTONHOLE DEFORMITY
(SECONDARY REPAIR AND
RECONSTRUCTION)
 Extensor Tendons
ZONE IV

• Zone IV includes the area over the proximal phalanx.

• commonly incomplete injury to the tendon occurs because of the broad tendon
covering the phalanx.

• If full active PIP joint extension is present, closed treatment with splinting suffice.
 Extensor Tendons
If proximal interphalangeal joint extension is limited, exploration of the wound is
needed to determine the extent of injury.

A core stitch of the modified Bunnell configuration of Kleinert or the modified

Kessler stitch.

Postoperative extension splinting is maintained for 6 to 8 weeks, and a “short

arc” range-of-motion started.
 Extensor Tendons
ZONE V

Zone V includes the area at the metacarpophalangeal joint.

For a clean laceration, repair of the tendon with a core suture reinforced with a
cross stitch is indicated.

If the tendon injury occurs as the result of a tooth injury, repair of the tendon is
delayed until the infection is controlled.
 Extensor Tendons
ZONE VI

Zone VI is the area of the metacarpals of the fingers.

Wound is explored who cannot hyperextend the metacarpophalangeal.
 Pulling through the juncturae tendinum may conceal a complete transection of
extensor tendons in zone VI.
 Adequate exposure is required to retrieve tendons that may retract proximally.
 Extensor Tendons
ZONE VII

Zone VII is the area of the wrist under the dorsal carpal ligament (extensor
retinaculum).
At this level, the tendons have mesotenon. They are retained by the dorsal carpal
ligament, which acts as a pulley.
More extensive incisions and dissection may be required to retrieve lacerated
tendons.
Access to the tendons may require elevation of the extensor retinaculum.
 Extensor Tendons
ZONE VIII

Zone VIII is the area of the distal forearm, proximal to

the extensor retinaculum (dorsal carpal ligament).
In this zone, many extensor tendons are covered by
their respective muscles.
Careful dissection is required to identify the proximal
portion of the muscle belly.
The tendinous portion of the musculotendinous unit
can be sutured to the muscle belly 3-0 mattress .
 Extensor Tendons
ZONE IX
Lacerations of the extensor muscle bellies in the
proximal forearm may be associated with vessel and
nerve injuries.

The muscle bellies usually require several mattress or

figure-of-eight sutures to hold the muscle together.

 If difficulty is encountered with suturing techniques,

tendon grafts may be used.
 EXTENSORS OF THE THUMB
ZONES TI AND TII

Closed injuries to the EPL is treated with prolonged

splinting for 8 or more weeks, as for mallet finger
injuries in the fingers.

Associated fractures of the distal phalanx involving 50%

or more of the joint or fractures with distal fragment
subluxation require reduction and internal fixation.
 EXTENSORS OF THE THUMB
ZONES TIII AND TIV

Zone TIII is at the metacarpophalangeal joint; zone TIV

is over the thumb metacarpal.
Injuries to the extensor pollicis brevis in these zones
usually are repaired.
When the tendon has been divided at these zones its
proximal segment retracts rapidly.
By 1 month after injury, a fixed contracture of the
muscle usually developed.
 Extensor Tendons
ZONE TV

The extensor pollicis longus, extensor pollicis brevis,

and abductor pollicis longus tendons may be injured in
this zone.

The superficial radial nerve also is at risk for injury.

Tendons injured in the first dorsal compartment usually

are mobilized to minimize adhesion formation.
Thank you