Case 54 Flexor Tendon Laceration

Reena A. Bhatt

Case 54 Flexor Tendon Laceration

Case 54 (a, b) A 50-year-old female presents to the emergency department with a laceration sustained while cutting an avocado. The patient is attempting to flex in the second image.

54.1 Description

  • Abnormal resting cascade of the hand involving the left small finger

  • Laceration over the volar distal palm, distal to the distal palmar crease, likely in proximal zone 2

  • Images show lack of active flexion of the distal interphalangeal joint (DIP) and proximal interphalangeal (PIP) joint and loss of cascade

  • Rule out injuries to nerves, lumbricals, vessels, or tendons to small and ring fingers as well

54.2 Work-Up

54.2.1 History

  • Mechanism of injury (sharp, blunt, or avulsion)

  • The position of the hand at the time of injury (flexed vs. extended position)

  • Numbness or tingling (question whether patient had local anesthetic injected)

  • Significant bleeding at time of injury

    • Suggests arterial and digital nerve injury

  • Time elapsed since injury (e.g., 2 days vs. 2 months)

  • Right hand dominant versus left hand dominant

  • Any additional or associated injuries

  • Occupation and hobbies

  • Prior injuries or associated medical problems especially to hands

  • Comorbidities and social history (drug/alcohol abuse)

54.2.2 Physical Examination

  • Resting cascade of the hand: Interphalangeal joints should maintain flexion with arc increasing as examination moves ulnarly

  • Tenodesis (especially important to check with child/obtunded patient)

    • Passive wrist extension results in flexion of the fingers

    • Lack of flexion of the lacerated finger demonstrates discontinuity of flexor tendons

  • Level of laceration and likely zone of injury (e.g., laceration over center of middle phalanx, likely zone 1 and flexor digitorum profundus [FDP] only repair)

  • Separately assess active flexor action for all fingers

    • Flexor digitorum superficialis (FDS): The examiner maintains other digits in extension while attempting flexion of injured finger to isolate the FDS

    • FDP: The examiner maintains the PIP in extension while attempting flexion of the DIP

    • Flexor pollicis longus (FPL): In the setting of an injured thumb/palm, the examiner maintains the metacarpophalangeal joint (MCP) in extension while attempting flexion of the interphalangeal joint (IP)

  • Sensibility: Radial and digital nerve injuries

  • Perfusion of the digit: Absence of perfusion would prompt emergent intervention

54.2.3 Pertinent Imaging or Diagnostic Studies

  • Standard three-view X-rays (anteroposterior, lateral, and oblique) of the hand should be obtained to assess for fracture or foreign bodies

54.3 Patient Counseling

  • Patient should be counseled on critical importance of postoperative compliance with splinting and hand therapy. Potential complications should be reviewed

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Jul 17, 2021 | Posted by in General Surgery | Comments Off on Case 54 Flexor Tendon Laceration
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