9 - Flexor tendon injuries and reconstruction

Abstract

Anatomy and function of the flexor tendons, especially those to the thumb and fingers, are complex and delicate. The tendons in the digits glide in a tunnel confined by a series of dense annular pulleys. Traumatic laceration is the most common cause of tendon injuries, and an acutely lacerated tendon should be repaired primarily or at delayed primary stage (a few days or 2–3 weeks after trauma). Multistrand core sutures and a peripheral suture are used by the majority of surgeons for primary flexor tendon repair within the digital sheath. When the A2 or A4 pulleys block gliding of the repaired tendons, some surgeons advocate venting a part of the A2 pulley or the entire A4 pulley when other pulleys are intact. After repair, an extension–flexion test should be performed to ensure tendon repairs do not gap and that the tendon glides smoothly. Postoperatively, the tendons should be mobilized early in adult patients. Major complications include repair ruptures and adhesion formation. Patients with a lengthy tendon defect should be treated with free tendon grafting at a later stage. When the tendon bed or pulley system is destroyed, staged tendon reconstruction is indicated with a silicone tendon spacer placed during the first stage surgery followed by tendon autograft in the second stage.