Flexor Tendon Injuries Tricks of the Trade Mr Andrew Mahon Consultant Orthopaedic and Hand Surgeon University Hospital North Durham

History Demographics –Age, Hand Dominance, Occupation, Hobbies Mechanism –Blade, Glass, Power Tools, Closed Avulsion Time of Injury Tetanus Fitness for theatre

Examination Look at the Hand!! –Posture, Colour Wounds –Tidy, Untidy, Contaminated Test Sensation Know how to examine tendons

Question 1 Linburg – Comstock anomaly

Question 2 How do you assess the injured hand in a young child?

Examination - Children Look Sweating – pen test Wrinkling test Tenodesis Direct pressure over tendons / muscles

Don’t Under-estimate the Injury!

Question 3 What is the injury?

Leddy and Packer

Take an X-Ray

Surgery Skin Associated structures Flexor sheaths FDS FDP

Skin - Incisions Need adequate exposure Avoid scar contracture

Associated Structures Inspect Nerves and Vessels

Question 4 Which are the most important pulleys in the flexor sheath?

Question 4 Which are the most important pulleys in the flexor sheath? A2 A4

Flexor Sheath Lister’s Windows A4 Pulley

Deliver the Tendon

Zone 1 Repair < 1cm reattach to bone –Button –Suture anchor > 1cm tenorraphy

Tendon Repair Techniques Core suture –2, 4, 6, 8 strands Circumferential (epitendinous) suture –Running –Halsted –Silfverskiold

Core Sutures

Kessler

Core Sutures 4 strand cruciate Strickland

Question 5 What is the most important factor affecting core suture strength?

Question 5 What is the most important factor affecting core suture strength? The number of suture strands crossing the repair site

Question 6 What is the optimum suture bite length for a core suture?

Question 6 What is the optimum suture bite length for a core suture? 7mm to 1 cm Aim for 1cm

Circumferential Sutures Adds to repair strength Reduces bulk at repair site

Sequence of Repair In finger repair FDS first

Goals of Repair (Zone 2) Strong enough for active motion No gapping Free glide through pulleys Minimal handling to reduce adhesions Untidy Repair

Rehabilitation Controlled active movement (Belfast)

Rehabilitation Kleinert –Active extension –Passive flexion

Rehabilitation

Question 6 What is the optimum wrist position for immobilisation following flexor tendon repair?

Question 6 What is the optimum wrist position for immobilisation following flexor tendon repair? Slight extension –(Savage)

Rehabilitation Dorsal splint –MCPs ° –Full extension allowed at PIPs Full time 6 weeks At night / in crowds until 12 weeks No resisted exercises until 8 weeks Driving 10 weeks