Flexor Tendon Laceration 882.2

synonyms:

Flexor Tendon ICD-9

• 727.64 (Rupture of tendon, nontraumatic; flexor tendons of hand and wrist)
• 882.2 (Open wound of finger with tendon involvement)

Flexor Tendon Etiology / Epidemiology / Natural History

Flexor Tendon Anatomy

• The two flexor tendons begin to run in one shealth at the distal palmar crease, known as surgical "no mans land."

Flexor Tendon Clinical Evaluation

Flexor Tendon Xray / Diagnositc Tests

• A/P and lateral views of the hand are usually normal, but are indicated to rule out fracture or foreign body.
• Evaluate the resting posture of the digits which will indicate which digits are affected.
• FDP tendons are tested by
• FDS tendons are tested by

Flexor Tendon Classification / Treatment

• Zone I: distal to mid aspect of the middle phalynx
• Zone II: proximal to zone I to the level of the distal palmar crease
• Zone III: proximal to zone II to the distal edge of the flexor retanaculum. 
• Zone IV: within the carpal tunnel
• Zone V: proximal to the carpal tunnel.

Flexor Tendon Flexor Tendon Repair Keys

• Delayed repair within the first the7 days is eqivalaent to emergent repair.
• The strength of any repair is determined by the number of sutures stands crossing the repair. 
• Synthetic braided sutures are best for repair.
• Ibuprofen or indomethacin improve funtional recovery.

Flexor Tendon Repair Technique

• CPT 26350 (repair or advancement of flexor tendon, not in zone 2 without free graft, each tendon)
• Pre-operatvie antibiotic.
• Supine with hand table. All bony prominences well padded.
• Anesthesia (GETA, LMA, axillary block.)
• Prep and drap in standard sterile fashion.
• Zig-zag or midaxial incision based on original laceration location and associated injuries needing repair.
• Disection with 2.5 / 3.5 loop magnification.
• Identify tendon ends. This can usally be accomplished by squeezing the muscle belly in the forearm, flexing the wrist and/or fingers. Zone 2 injuries often require a seperate palmar insertion to find the proximal tendons and paasge of a small catheter form distal to proximal and tieing the tendons to the catheter for passage. Once located the tendon ends are tagged or held in place by passing a 25-gauge needle transversely through the tendon and sheath.
• The annular pulleys shoulde be preserved, especially the A2 and A4 pulleys. Repairs are generally performed through one of the cruciate/synovial windows.
• Repair tendons with modified Kessler stich using 3-0 braided non-absorbable suture.
• Place a horizontal mattress stitch to complete a 4 stranded repair.
• Run horizontal locking stitch around the perimeter as an epitendinour repair.
• Repair flexor sheath with 6-0 nylon.

Flexor Tendon Associated Injuries / Differential Diagnosis

• Metacarpal fracture
• Phalangeal fracture
• Nerve injury: should be repaired b at time of flexor tendon repair.
• Vascular injury: associated digital artery injuries should be repaired especially if both digital arteries are injuryed. Failure to repair can lead to painful cold intolerance and poor tendon healing due to poor perfusion.

Flexor Tendon Complications

• Joint contracture / stiffness
• Infection
• Re-rupture / failure of repair

Flexor Tendon Follow-up Care

• dynamic traction splint with silk suture threw nail. first 4 weeks followed by inceasing AROM with physical therapy.
• Early passive flexion and active extesion rom prevents adhesions and increases ROM (beware of gap formation more than 2mm which will result in a failed repair).
• Children less than 5 y/o: immobilize for 3-4 weeks to protect repair and prevent gap formation. (O'Connell et al; J Hand Surg 1994;19A:48-52)

Flexor Tendon Review References

• Stewart KM: Review and comparison of current trends in the postoperative management of tendon repair. Hand Clin 1991;7:447-460.
• Wakefield AR: Hand injuries in children. JBJS 1964;46:1226°