Anatomical Considerations in the Primary Treatment of Tendon Injuries of the Hand

Abstract

The hand has been divided into anatomical areas of injury so that specific problems in repair might be presented as clearly as possible. Hand wounds, even those which on the surface appear trivial, must be evaluated with knowledge of underlying anatomical structures so that proper diagnosis and treatment can be instituted. Injuries to circulation, skin, skeletal structures, and nerve pathways demand definitive treatment in that order. Tendon injuries, although lowest in the scale of tissue priorities, challenge surgical judgment and skill more than does injury to any other tissue. The restoration of function to injured tendons demands careful planning in the anatomy and physiology of repair, proper suigical facilities, and the atraumatic technique pioneered by Dr. Sterling Bunnell. Illustrations are presented to serve as a guide in primary treatment of severed tendons. The type of repair is dictated largely by the character and location of the wound. Simple wound closure followed by secondary reconstruction or grafting is often the procedure of choice, particularly in no man's land and the deep thenar area of the flexor mechanism. All extensors, as a general rule, can be repaired primarily, except where there is loss of tendon substance or skin coverage. In properly selected cases, the skilled hand surgeon may elect to carry out a more definitive type of repair as a primary procedure. It must be remembered that extensive dissection and additional exploratory incisions can be extremely hazardous in the injured and potentially infected hand, even under the best of circumstances. When primary treatment fails because of compromised circulation, infection, or scarring, the success of secondary reconstructive procedures will be jeopardized. Secondary reconstruction of tendon function does not always imply tendon-grafting. The most conservative surgery which gives the best assurance of good function with the least risk should be used. Other operative procedures which should be kept in mind are: delayed suture, tendon advancement, tendon substitution or transfer, tendon-lengthening, tenodesis, and arthrodesis.