8 Extensor Tendon Repair

10.1055/b-0038-161076

8 Extensor Tendon Repair

Dariush Nikkhah, Amir H. Sadr

8.1 Extensor Tendon Repair

The patient presented with a glass laceration over the thumb metacarpophalangeal joint (MCPJ) and had an inability to extend the thumb on the retropulsion test (Fig. 8‑1). They were booked for local anesthetic exploration and repair of the extensor pollicis longus (EPL) (Fig. 8‑2, Fig. 8‑3, Fig. 8‑4, Fig. 8‑5, Fig. 8‑6). Most distal extensors can be done under local anesthetic; however, once you get to proximal zones 6 and 7, it can become trickier under local anesthetic as the tendons retract.

Fig. 8.1 Thumb demonstrates an abnormal posture suggestive of EPL division.

Fig. 8.2 Access is gained with broad longitudinal flaps.

Fig. 8.3 The extensor tendon is marked with ink approximately 10 mm. This reminds the surgeon to take appropriate bites for the core suture.

Fig. 8.4 A two-strand core 3.0 PDS modified Kessler is used initially and tied. We advocate PDS use over Prolene to prevent the nonabsorbable knots of the Prolene irritating the thinner dorsal skin.

Fig. 8.5 **(a,b)** This is followed by a continuous 6.0 epitendinous PDS. An alternative complex epitendinous suture is a Silfverskiöld repair that provides additional strength compared to simple epitendinous repairs.

Fig. 8.6 **(a,b)** Final closure with 5.0 Vicryl Rapide and EPL repair is protected in forearm-based thumb spica-based plaster of Paris.

Extensor tendon injuries are more common than flexor tendon injuries due to their less protected anatomical location. Some surgeons underestimate the management of these injuries which require the same skill and attention to detail as flexor tendon surgery to avoid poor results. Verdan classified extensor tendon injuries in zones 1 to 9. The odd numbers 1, 3, 5, and 7 lie over the joints with zone 1 lying over the distal interphalangeal joint (DIPJ). The importance of this is that in zones 1 to 3 the tendon is flatter and may not easily accommodate a core stitch. Ideally, if it is possible, one should do a core repair with an additional epitendinous repair. The Silfverskiöld repair is a useful technique in flat extensor tendons and provides a strong repair (Fig. 8‑7, Fig. 8‑8, Fig. 8‑9, Fig. 8‑10, Fig. 8‑11).

Fig. 8.7 **(a–c)** EPL division, tendon ends are first cleaned before repair. Back wall epitendinous repair is done with 5.0 Prolene. This draws the tendon together and is a very useful technique especially when there is a large gap. It enables easier core stitch placement.

Fig. 8.8 **(a,b)** Core suture of modified Kessler 3.0 PDS is then followed by Silfverskiöld cross-stitch repair where the surgeon stitches toward himself or herself.

Fig. 8.9 The surgeon sutures toward himself or herself in order to complete the repair.

Fig. 8.10 Completed Silfverskiöld cross-stitch repair.

Fig. 8.11 Illustration of Silfverskiöld cross-stitch repair.

Note: In zones 1 and 2, most of the proximal pull on the terminal extensor comes from the lumbricals via the lateral bands. Thus, flexing the digit at the MCPJ and proximal interphalangeal joint (PIPJ) can facilitate a tight repair by detensioning the lateral bands. Conversely, in zone 3 (and more proximally), extending the digit relaxes the proximal extensor digitorum communis (EDC) tendon to aid suture repair of the central slip.

Zone 9, which includes muscle belly, is best repaired with either Vicryl horizontal mattress sutures or a Monocryl pulley stitch.

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