Flexor Tendon Injuries

Introduction
Muscles insert in bones via tendons
Tendons

white fibrous cords that are lined with a

loose tissue (paratenon) & which
sometimes run through a fibrous tube
(tendon sheath)
have the ability to glide over bone and
through tissues

Introduction
Muscle contraction transmitted via
tendons causing intervening joints to
move
Muscles that bend the fingers and
wrist "flexor"
Muscles that straighten the fingers
and wrist "extensors"

Anatomy

Flexor systems :
Fingers 2 tendons
thumb 1 tendon

Blood supply via

Mesotenon Vincular
System

Retinacular pulley
system
to keep the flexor
tendons approximated
to the underlying bony
structures
Mechanical leverage for
full fingers motion

Vascularization

tendons are able to obtain their

nutrients from two different sources :
direct blood supply
the synovial fluid

Zone of Fingers
Flexor Tendons
Verdan classification :
1.
Zone I : extends from
distal ins/ of FDS to the
ins/ of FDP
2.
Zone II :extends from
the midportion of the
middle phalang to the
neck of MC
3.
Zone III :extends from
the prox neck of MC to the
distal edge transverse
carpal ligament
4.
Zone IV : the region
under the transverse
carpal ligament
5.
Zone V : proximal to the
carpal canal

Zone of Flexor
Tendons in Thumb
Verdan classification :

Zone I : distal at the

insertion of the flexor
tendon
Zone II : from the neck of
prox.phalang to the neck of
MC (within the flexor
retinaculum of the thumb)
Zone III : the area of the
thenar muscle
Zone IV : the region of
carpal canal
Zone V : proximal to the
proximal edge of the carpal
ligament

Tendon Injuries

caused by :
involving sharp things (open injury)
overstressed in sports (closed injury)

damage to single or multiple tendons

immediate loss of its function
need cerefully assessment

Position

The normal cascade

Hand Posture when relaxed

the thumb-tip held slightly
flexed
fingers held in a cascade

Active movement

use the tendon by moving or tensing the relevant joint

flexion of the fingers loss of active movement
at the tip of the ring finger (closed FDP rupture)

Passive movement

assessed by gentle
pressure over the
muscles in the
forearm some
movement of the
relevant tendon
an alternative way
to move the
wrist

Tendon Healing

An early time :
Process in which paratendinous tissues
invaded the healing area
Determining factors :
Age
Mechanism & extent of the injury
Level of the tendon laceration
Individual healing respons

Tendon Healing

Two mechanisms
Intrinsic healing mediated by the epitenon
with cell migration into the depths of the repair
site
Extrinsic healing dependent upon ingrowth
of cells from outside the tendon

The extrinsic is less desirable

adhesion formation (lacerated edge of the
tendon)
leading to restricted tendon gliding

Classification

Boyes Preoperative Classification :

Grade I : Good
Minimal scar w/ mobile joints
No trophic changes

Grade II : Cicatrix
Heavy skin scarring due to injury / surgery
Deep scarring due to failed primary repair /
infection

Grade III : Joint Damage

Injury to the joint
Restricted ROM

Classification
Grade IV : Nerve Damage
Injury to the digital nerves
Trophic changes in the finger

Grade V : Multiple Damage

Involvement of multiple fingers
Combination of problems
(cicatrix-joint damage-nerve damage)

Tendon Reconstruction

The sooner reconstructive the more

likely will return to full function

The late reconstructive :

missed injuries
severely contaminated wounds
severely damaged soft tissues
patients not tolerate by acute treatment
failure of primary reconstructive efforts
considered 3 weeks after injury

Flexor Tendon Reconstruction

Type of incision
Principle :
1. Timing
2. Staging
3. Technique
4. Suture & Matl
5. Post Op Prog

Options for Late Reconstructive

direct repair
tenolysis
one- or two-stage grafting
tendon transfer
tendon advancement with or without
tendon lengthening

Direct Repair

contraction of the musculotendinous

scar tissue within the flexor sheath
in the thumb (even >3 months after
injury) some loss of excursion & IP joint
motion is well-tolerated
has no lumbricales
its flexor sheath has only three pulleys
only one flexor tendon within the sheath

Direct Repair

In the fingers up
to 4 weeks from
injury
If tendon retraction
is significant, one
option is
lengthening
With or without a
tendon graft or
transfer

Tenolysis

Indication :
surgical release of
non-gliding &
localized adhesion
limitation of active
motion
risk of further
decreased the
vascular supply &
innervation

Tenolysis
After repair treating a stiff digit
(combination of joint contracture &
adhesion)
Adhesions in the repair site or
result of edema & immobility of an
uninjured digit
not performed prior to 3 months
from repair

Tendon Grafting

Indication :
(i) the ends have retracted apart and
shortened
(ii) the tendons become stuck to the sheath
(iii) the sheath narrows

Donor Site :

PL
Plantaris
Foot Flexor & Extensor
EIP
FDS
Allograft

Tendon Transfer

Principles :
Mobile Joints, skin & soft tissue
contractures
Adequate power
Sufficient
Maximal work capacity of Power
An adequate length
A satisfactory line of pull should be
achieved
An adequate glide
Functional integrity must be preserved

Tendon Transfer

Surgical Consideration :

Timing
Planning
Technique
Joinning the tendons
Achieving proper tensile

Infection
Tendon exposed
Stiffness
Rupture
Scar
Nerve damage

Failed of Reconstruction :

Rehabilitation

Mobilization affects the mechanism of

tendon healing :
motion interrupts the tendon and the periphery
motion stimulates the epitenon & promotes
differentiation between the tendon and the
sheath

Early mobilization resulting in tensile

strength improved tendon gliding

Tendon mobilization stimulates intrinsic

healing & limits extrinsic healing

Rehabilitation

Program For 4 :
4 passive
flexions
4 active flexions
4 active
extensions

Thanks