Flexor Tendon Laceration


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.)


  • 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.



  • 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.


  • 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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