Summary of Flexor Tendon Injuries of the Hand

Flexor Tendon Injuries of the Hand: A Student Guide

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Introduction

This study guide outlines practical surgical techniques, decision steps, and intraoperative principles relevant to flexor tendon surgical techniques (excluding topics explicitly covered elsewhere such as tendon injury/repair fundamentals, rehabilitation, reconstruction, grafting, tenolysis, pulley reconstruction, complications, and thumb-specific procedures). It focuses on operative exposure, tendon retrieval and handling, suture choices and placement principles, zone-based technical considerations (zones proximal to A1 and distal maneuvers except where excluded), and intraoperative strategies to optimize glide and reduce trauma.

Definition: "Endotenon" — the delicate intratendinous connective tissue layer used as an atraumatic grasp point for tendon handling.

Overview of surgical workflow

  1. Preoperative planning and positioning
  2. Exposure and extensile incisions
  3. Tendon retrieval and protection
  4. Core and circumferential suture strategy selection (principles only)
  5. Intraoperative testing of glide and excursion
  6. Hemostasis, wound closure, and postoperative splinting (basic principles)

1. Preoperative setup and positioning

  • Position the patient supine with the arm abducted at a right angle to the body.
  • Use a well-padded brachial tourniquet; inflate to about 100 mm Hg above systolic pressure after exsanguination.
  • Prepare the limb with antiseptic and ensure optical magnification (loupe or microscope) is available.
💡 Did you know?Did you know that maintaining a bloodless field with a tourniquet and meticulous bipolar cautery significantly reduces postoperative swelling and aids early rehabilitation?

2. Exposure: incision choices and extensile approaches

  • Choose an extensile approach to fully identify lacerated structures, allow possible nerve/arterial repair, and permit fasciotomy when needed.
  • Common incision options:
    • Bruner (zigzag) volar approach — good for wide exposure and skin paddle mobility
    • Mid-lateral extensile approach — favored by some for direct sheath access
    • Longitudinal palmar incisions for proximal retrieval when sheath access is limited
  • Key principle: expose enough to identify all injured structures clearly before repair begins.

Definition: "Extensile exposure" — an incision and dissection planned to be extended as needed to allow complete visualization and safe management of all injured structures.

3. Tendon retrieval and atraumatic handling

  • Grasp the tendon by the endotenon whenever possible; avoid direct grasping of the epitenon to reduce adhesion formation.
  • Techniques for retrieving retracted proximal stumps:
    • Milking the tendon (proximal-to-distal massage) to bring it into the wound
    • Use of a small pediatric feeding tube or truncated red-rubber catheter passed retrograde through the sheath (Sourmelis technique):
      • Enter sheath at laceration site, exit palm proximal to A1, suture catheter to tendon, then pull distally to deliver stump
    • Mid-palmar counterincision and catheter suture to each tendon when stumps retract proximal to A1
  • Use a 25-gauge, 5/8-inch needle to transfix and temporarily stabilize tendon position during repair.
  • Avoid repeated blind hemostat passes into the sheath; if stump cannot be retrieved, extend incision to locate it.
💡 Did you know?Fun fact: The pediatric feeding tube method reliably delivers proximal flexor stumps distally with minimal additional sheath trauma and is well-established in hand surgery practice.

4. Orientation and tendon selection when multiple slips involved

  • Always re-establish correct anatomic relationship between FDS and FDP in the palm and at the repair site.
  • In complex lacerations where orientation or repair of all slips is impractical, consider resecting one FDS slip and repairing the other to facilitate gliding and reduce bulk.
  • When laceration is proximal to the FDS decussation, base the core suture technique on tendon caliber: thicker tendons (FDP) tolerate larger-caliber, multistrand sutu
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Flexor Tendon Techniques

Klíčová slova: Flexor tendon injury and repair, Flexor tendon surgical techniques, Flexor tendon injury, Flexor tendon rehabilitation, Hand flexor tendon surgery, Thumb flexor tendon surgery, Flexor tendon reconstruction overview & techniques, Flexor tenolysis, Tendon grafting — Flexor hand procedures, Flexor tendon reconstruction surgical techniques, Flexor tendon reconstruction, Tendon grafting — Harvesting techniques, Flexor pulley reconstruction, Complications

Klíčové pojmy: Use extensile exposure with optical magnification, Grasp tendon by endotenon to minimize epitenon trauma, Retrieve retracted stumps via milking or pediatric feeding tube retrograde method, Stabilize tendon ends with a 25-gauge, 5/8-inch transfixing needle, Prefer multistrand core sutures based on tendon caliber (four-strand minimum), Use running deep circumferential suture (eg, 6-0 Prolene) to smooth repair, Test full range excursion intraoperatively and ensure sheath closure only if it improves glide, Achieve meticulous hemostasis with bipolar cautery before closure, Use sequential A4 dilation or flared catheter to pass flared FDP stumps, When orientation impractical, resect one FDS slip and repair the other to reduce bulk, Apply well-padded dorsal slab with wrist and MP slight flexion for protection, Balance suture strength against repair bulk to preserve tendon gliding

## Introduction This study guide outlines practical surgical techniques, decision steps, and intraoperative principles relevant to flexor tendon surgical techniques (excluding topics explicitly covered elsewhere such as tendon injury/repair fundamentals, rehabilitation, reconstruction, grafting, tenolysis, pulley reconstruction, complications, and thumb-specific procedures). It focuses on operative exposure, tendon retrieval and handling, suture choices and placement principles, zone-based technical considerations (zones proximal to A1 and distal maneuvers except where excluded), and intraoperative strategies to optimize glide and reduce trauma. > Definition: "Endotenon" — the delicate intratendinous connective tissue layer used as an atraumatic grasp point for tendon handling. ## Overview of surgical workflow 1. Preoperative planning and positioning 2. Exposure and extensile incisions 3. Tendon retrieval and protection 4. Core and circumferential suture strategy selection (principles only) 5. Intraoperative testing of glide and excursion 6. Hemostasis, wound closure, and postoperative splinting (basic principles) ### 1. Preoperative setup and positioning - Position the patient supine with the arm abducted at a right angle to the body. - Use a well-padded brachial tourniquet; inflate to about 100 mm Hg above systolic pressure after exsanguination. - Prepare the limb with antiseptic and ensure optical magnification (loupe or microscope) is available. Did you know that maintaining a bloodless field with a tourniquet and meticulous bipolar cautery significantly reduces postoperative swelling and aids early rehabilitation? ### 2. Exposure: incision choices and extensile approaches - Choose an extensile approach to fully identify lacerated structures, allow possible nerve/arterial repair, and permit fasciotomy when needed. - Common incision options: - Bruner (zigzag) volar approach — good for wide exposure and skin paddle mobility - Mid-lateral extensile approach — favored by some for direct sheath access - Longitudinal palmar incisions for proximal retrieval when sheath access is limited - Key principle: expose enough to identify all injured structures clearly before repair begins. > Definition: "Extensile exposure" — an incision and dissection planned to be extended as needed to allow complete visualization and safe management of all injured structures. ### 3. Tendon retrieval and atraumatic handling - Grasp the tendon by the endotenon whenever possible; avoid direct grasping of the epitenon to reduce adhesion formation. - Techniques for retrieving retracted proximal stumps: - Milking the tendon (proximal-to-distal massage) to bring it into the wound - Use of a small pediatric feeding tube or truncated red-rubber catheter passed retrograde through the sheath (Sourmelis technique): - Enter sheath at laceration site, exit palm proximal to A1, suture catheter to tendon, then pull distally to deliver stump - Mid-palmar counterincision and catheter suture to each tendon when stumps retract proximal to A1 - Use a 25-gauge, 5/8-inch needle to transfix and temporarily stabilize tendon position during repair. - Avoid repeated blind hemostat passes into the sheath; if stump cannot be retrieved, extend incision to locate it. Fun fact: The pediatric feeding tube method reliably delivers proximal flexor stumps distally with minimal additional sheath trauma and is well-established in hand surgery practice. ### 4. Orientation and tendon selection when multiple slips involved - Always re-establish correct anatomic relationship between FDS and FDP in the palm and at the repair site. - In complex lacerations where orientation or repair of all slips is impractical, consider resecting one FDS slip and repairing the other to facilitate gliding and reduce bulk. - When laceration is proximal to the FDS decussation, base the core suture technique on tendon caliber: thicker tendons (FDP) tolerate larger-caliber, multistrand sutu