Flexor Tendon Laceration



10.1055/b-0034-97733

Flexor Tendon Laceration

Justin B. Cohen & Thomas H. H. Tung
A 20-year-old right hand–dominant man presents to the emergency department with a laceration sustained while he was trying to open a broken mason jar. (Image shows patient attempting to flex at the interphalangeal joint of the thumb.)


Description




  • Laceration over the volar first web space, extending onto the thenar eminence and resulting in injury to the flexor tendon in zones T2 and T3.



  • Physical examination reveals inability to actively flex the thumb at the interphalangeal (IP) joint. No other range of motion (ROM), sensory, or strength deficits noted.



Work-up



History




  • Mechanism of injury (e.g., sharp, blunt, avulsion).



  • Position of hand and affected digit at time of injury (flexed vs extended).



  • Time elapsed since injury.



  • Hand dominance.



  • Occupation.



  • Previous hand injuries.



  • Any associated injuries and medical comorbidities.



Physical examination




  • Cascade of the hand




    • In the resting position, the fingers are flexed, with the degree of flexion increasing from the radial to the ulnar side.



    • Disruption of the cascade due to abnormal extension of a digit signifies flexor tendon injury.



  • Tenodesis effect




    • Passive extension of the wrist causes flexion at the metacarpophalangeal (MCP) and IP joints.



    • Abnormal extension of a digit signifies flexor tendon injury.



  • Assess flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) function separately along with flexor pollicis longus (FPL).




    • FDS: Flexion of finger at proximal interphalangeal (PIP) joint while holding all other digits in extension.



    • FDP: Flexion of finger at distal interphalangeal (DIP) joint while holding PIP joint in extension.



    • FPL: Flexion of the thumb at IP joint while holding proximal phalanx and MCP joint in extension.



  • Sensory and vascular examination.



  • Partial tendon laceration results in weakness, limited movement, triggering of pain with flexion.



Pertinent imaging or diagnostic studies




  • X-ray of hand with three views (anteroposterior, lateral, oblique): Evaluate for bony injury and foreign bodies.



Treatment




  • Advanced trauma life support (ATLS) protocol.



  • Antibiotics and tetanus prophylaxis.



  • If unable to perform flexor tendon repair immediately, any visible tendons may be tagged with suture and the skin may be closed.




    • The patient should be splinted with the wrist and MCP joints in flexion to minimize retraction.



Flexor tendon repair




  • Timing




    • Ideally, flexor tendons should be repaired as soon as possible. Immediate exploration is warranted if nerve or arterial damage is suspected.




      • In order to avoid staged tendon grafting for zone 2 injuries, flexor tendons should be repaired within 72 hours. Longer delays in repair have been reported for injuries outside of zone 2 with variable outcomes.



    • Delays > 6 weeks require tendon substitution procedures (tendon grafts, tendon transfers) or salvage procedures (tenodesis, capsulodesis, arthrodesis).



  • Flexor tendon repairs should be performed in the operating room with a tourniquet.

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Jun 18, 2020 | Posted by in General Surgery | Comments Off on Flexor Tendon Laceration
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