Flexor Tendon Repairs - All Zones (Zone 1-5)

Patient Position: Supine with arm on hand table, shoulder abducted 90°. Arm tourniquet (250mmHg) or WALANT for simple cases. Loupe magnification (2.5-3.5x) strongly recommended, microscope for very distal repairs.

Surgical Approach: Zone-dependent: Bruner zigzag (Zone 1-2), midlateral/volar zigzag (Zone 3-4), volar forearm (Zone 5). Extend incisions as needed for exposure.

Incision: Zone-dependent: Bruner zigzag (Zone 1-2), longitudinal palm (Zone 3), standard CTR (Zone 4), volar forearm (Zone 5)

Step 1: Preoperative Assessment, Zone Classification & Planning

Preoperative Assessment, Zone Classification & Planning: IMMEDIATE ASSESSMENT: Document laceration details: location (zone), depth (complete vs partial), structures injured, wound contamination (clean vs contaminated), time since injury (<12 hours ideal for primary repair, up to 24 hours acceptable if clean, >24 hours consider delayed primary), associated injuries (nerve, artery, bone/joint, skin loss). ZONE CLASSIFICATION (Kleinert & Verdan): ZONE 1 (distal to FDS insertion) = FDP ONLY, from FDS insertion to fingertip, includes DIP joint. ZONE 2 ('NO MAN'S LAND') = from A1 pulley (distal palmar crease/MP joint) to FDS insertion (middle phalanx), BOTH FDP and FDS in tight sheath with critical pulleys A2 and A4, historically poor results (now good with modern techniques). ZONE 3 (palm) = from carpal tunnel distal edge to A1 pulley, lumbrical origins, adequate room for repair. ZONE 4 (carpal tunnel) = within carpal tunnel, median nerve at risk, tight space. ZONE 5 (forearm) = proximal to carpal tunnel, muscle-tendon junctions, adequate exposure. THUMB ZONES: TI (distal to IP joint), TII (from A1 to IP), TIII (thenar eminence). CLINICAL EXAMINATION: Test FDP: stabilize PIP in extension, ask patient to flex DIP - FDP function. Test FDS: block adjacent fingers in extension (eliminates FDP via quadriga effect), ask to flex PIP - FDS function. Test sensation: two-point discrimination <6mm normal, >15mm suggests nerve injury. IMAGING: X-ray to rule out fracture, foreign body (glass). PLANNING: Primary repair if <12-24 hours and clean. Delayed primary if contaminated (clean wound first, return 3-7 days). Secondary reconstruction (grafting, two-stage) if chronic >3 weeks. Zone 2 lacerations require experienced hand surgeon, modern multi-strand techniques, early motion protocol. Ensure availability: proper instruments (fine forceps, scissors, suture), loupe magnification, tendon retrieval tools (silicone catheter/feeding tube), appropriate suture (3-0/4-0 braided for core, 5-0/6-0 monofilament for epitendinous).

Step 2: Anesthesia, Positioning & Tourniquet

Anesthesia, Positioning & Tourniquet: ANESTHESIA OPTIONS: (1) GENERAL ANESTHESIA: For complex repairs, pediatric patients, anxious patients, long cases. Allows full muscle relaxation facilitating tendon retrieval. (2) REGIONAL: Bier block (IVRA), axillary block, supraclavicular block - excellent for hand/forearm, requires anesthesiologist. (3) WALANT (Wide Awake Local Anesthesia No Tourniquet): For simple Zone 1, 3, or 5 repairs in cooperative patients. Lidocaine 1% with 1:100,000 epinephrine. Advantage: can test tendon repair actively intraop. Limitation: more difficult tendon retrieval without muscle paralysis. POSITIONING: Supine, arm on hand table, shoulder abducted 90°, elbow extended. Consider arm holder for stability during long case. Surgeon and assistant positioned comfortably. TOURNIQUET: Arm tourniquet 250mmHg (100mmHg above systolic) or 300mmHg if large arm. Exsanguinate with elevation or Esmarch bandage (avoid Esmarch if concern about tendon retraction with compression). Pad tourniquet to prevent skin injury. TIMING: Plan for tourniquet inflation <90-120 minutes if possible (complex Zone 2 repairs may require longer - warn patient, use padding, consider tourniquet release and reinflation if >120 min). MAGNIFICATION: Loupe magnification (2.5-3.5x) HIGHLY RECOMMENDED for all zones, essential for Zone 1-2. Microscope (10-16x) for very distal repairs or microsurgical technique. INSTRUMENTS: Fine forceps (Adson, Bishop-Harmon), tenotomy scissors, nerve hooks, mosquito clamps for retrieval, tendon passers, fine needle holders.

Step 3: Incision Planning & Skin Approach - Zone Specific

Incision Planning & Skin Approach - Zone Specific: ZONE 1: Midlateral or volar (Bruner) incision on radial side of digit, extending from laceration proximally to DIP joint, distally to near fingertip. Avoid direct volar incision over DIP (poor padding, painful scar). ZONE 2: BRUNER ZIGZAG incision - gold standard. Zigzag with apices at flexion creases (PIP, DIP, distal palmar crease), angles 60° not 90°, provides excellent exposure while preventing scar contracture. Extend proximal and distal to laceration to expose pulleys and allow tendon retrieval. If laceration already present: incorporate into Bruner design. Alternative: midlateral incision on radial side (less exposure but useful for limited laceration). ZONE 3: Longitudinal or gently curved incision in palm, following natural skin creases if possible. Avoid transverse incision (crosses too many digital neurovascular bundles). Extend from carpal tunnel area to base of affected digit. ZONE 4: Longitudinal or slightly oblique incision over carpal tunnel, in line with ring finger axis (Kanavel's line). Standard carpal tunnel release incision. Extend distally into palm (Zone 3) if needed. ZONE 5: Longitudinal volar forearm incision following the flexor compartment. Start 3-4cm distal to elbow flexion crease, extend distally to wrist. Keep incision slightly ulnar to midline to avoid median nerve superficial branch. Can extend distally into carpal tunnel if needed. PRINCIPLES: (1) Bruner zigzag angles 60° at creases (prevents contracture), (2) Never cross flexion crease at 90° angle (contracture risk), (3) Incisions can be extended extensively for exposure - don't compromise access to save 1cm of incision, (4) Incorporate traumatic laceration into planned incision.

Step 4: Superficial Dissection & Protection of Neurovascular Bundles

Superficial Dissection & Protection of Neurovascular Bundles: TECHNIQUE: Sharp incision through skin (15-blade), then careful dissection to deep structures. Raise FULL-THICKNESS skin flaps (skin plus subcutaneous fat) carefully - avoid thin flaps (vascular compromise) or undermining (hematoma risk). IDENTIFY NEUROVASCULAR BUNDLES: Proper digital nerves and arteries run palmar-laterally, approximately 2-3mm from midline at various levels in finger. Pink-white nerves with accompanying arteries (usually two arteries per nerve - one on each side). Use SPREADING TECHNIQUE with fine scissors or mosquito clamp rather than cutting - spread parallel to neurovascular bundles. PROTECT STRUCTURES: Grayson's ligaments (palmar to NV bundles attaching skin to sheath) - divide carefully to mobilize skin flaps without injuring nerves. Cleland's ligaments (dorsal to NV bundles) - generally safe. In PALM (Zone 3): Multiple structures at risk - common digital nerves, superficial palmar arch branches, lumbrical muscles. Identify and protect each. In CARPAL TUNNEL (Zone 4): Median nerve central and superficial - identify and protect before accessing tendons. May need carpal tunnel release for exposure (divide transverse carpal ligament longitudinally on ulnar side). In FOREARM (Zone 5): Less risk to major structures but identify median nerve, ulnar nerve, radial artery location before proceeding. RETRACTION: Use self-retaining retractors (Weitlaner or Gelpi) or skin hooks - gentle retraction. Assistant helpful for retracting structures. Avoid excessive traction on neurovascular bundles (nerve injury). LOUPE MAGNIFICATION essential for identifying small structures.

Step 5: Flexor Sheath Opening & Pulley Management (Zone 1-2)

Flexor Sheath Opening & Pulley Management (Zone 1-2): ZONE 1-2 SPECIFIC: Open flexor sheath to access tendons. IDENTIFY PULLEY SYSTEM first: A1 (MP joint level), A2 (proximal phalanx - longest, CRITICAL), C1 (cruciate, PIP level), A3 (PIP joint), C2 (cruciate), A4 (middle phalanx - CRITICAL), C3, A5 (DIP). A2 and A4 are CRITICAL BIOMECHANICALLY - must preserve at least 50% of each to prevent bowstringing. SHEATH OPENING STRATEGY: Open sheath BETWEEN pulleys in 'windows'. Can safely divide: A1 (if needed for proximal access), A3 (over PIP), C1, C2, C3 (all cruciate pulleys). Create windows between A2 and C1, between C1 and A3, between A3 and C2, between C2 and A4. Use fine scissors to open sheath longitudinally in windows. PRESERVE A2 and A4: If more exposure absolutely needed, can release UP TO 50% of A2 or A4 (release radial or ulnar side, preserve at least 50%). If >25% of A2 or A4 released, MUST repair with 6-0 absorbable suture at end of case. PROXIMAL EXTENSION: May need to extend sheath opening proximally into palm (Zone 3) or even carpal tunnel (Zone 4) to retrieve retracted proximal tendon stumps. ASSESS LACERATION: Once sheath open, identify distal tendon stumps (usually visible at laceration site). Note level of laceration within zone. Look for proximal tendon stumps (may have retracted). ZONE 3-4-5: Flexor sheath not present in these zones. Direct access to tendons after superficial dissection. Zone 3: tendons more superficial in palm. Zone 4: need to release carpal tunnel (divide transverse carpal ligament longitudinally on ulnar side) for exposure. Zone 5: tendons deep to muscle bellies - identify musculotendinous junctions.

Step 6: Tendon Retrieval - Proximal and Distal Stumps

Tendon Retrieval - Proximal and Distal Stumps: DISTAL STUMPS: Usually visible at laceration site or just distal. Zone 1: FDP stump may have retracted into finger. Zone 2: both FDP and FDS stumps. May need to open sheath distally in additional windows. Gentle traction with fine forceps or mosquito clamp to deliver stumps into wound. PROXIMAL STUMPS: Often retracted significantly, especially FDP (retracts more than FDS due to deeper position and lumbrical muscle pull). RETRIEVAL TECHNIQUES: (1) MILKING: Have assistant milk forearm muscles from proximal to distal (hand surgeon) to push tendon stumps distally. Effective for minimal retraction. (2) FEEDING TUBE/SILICONE CATHETER (most common): Pass small feeding tube (8Fr) or silicone catheter through sheath from DISTAL to PROXIMAL (easier than proximal to distal). Thread catheter through A1 into palm and proximally. Identify catheter in palm or forearm through separate incision. Suture proximal tendon stump to catheter tip. Pull catheter back distally delivering tendon stump through sheath into wound. (3) PROXIMAL WINDOW: If cannot retrieve, create additional proximal incision in palm (Zone 3) or even wrist/forearm (Zone 4-5). Identify retracted tendon stump, pull into distal wound with suture or tendon passer. (4) WRIST FLEXION: Flex wrist and fingers to relax tendons and reduce retraction distance. May facilitate retrieval. IDENTIFY CORRECT TENDONS: FDS is superficial (splits into 2 slips at Camper's chiasm). FDP is deep (single tendon, inserts distal phalanx). In Zone 2, BOTH must be identified and repaired. Color: freshly lacerated tendon is whitish with visible fiber bundles. Retracted chronically may be scarred/discolored. Verify by traction - pulling FDP tendon should flex DIP, pulling FDS should flex PIP. AVOID EXCESSIVE TRACTION: Gentle handling - excessive force shreds tendon or avulses musculotendinous junction. If tendon severely retracted (chronic injury, >3 weeks), primary repair not possible - consider STAGED RECONSTRUCTION (Hunter rod, silicone implant placed, form pseudosheath, second stage tendon graft 3 months later) or PRIMARY GRAFTING if viable bed.

Step 7: Tendon End Preparation

Tendon End Preparation: TRIM DAMAGED TISSUE: Inspect tendon ends. Crushed, macerated, or severely contaminated tissue must be trimmed back to healthy tendon. Use sharp scalpel or fine scissors. MINIMIZE SHORTENING: Trim only what is necessary - excessive trimming creates gap and tension on repair. Ideal gap <3mm. If gap would be >10mm after trimming, may need intercalary graft or staged reconstruction. BEVEL TECHNIQUE: Trim ends at 45° BEVEL (oblique cut) rather than transverse - increases surface area for healing (more contact between tendon ends), improves biomechanics. Some surgeons prefer transverse cut for simplicity - both acceptable. ASSESS TENDON QUALITY: Good quality tendon: white, fibrous bundles visible, good substance. Poor quality: macerated, thin, diseased (rheumatoid), infected. Poor quality may need graft rather than primary repair. REMOVE LOOSE FRAGMENTS: Any loose tendon fragments, frayed tissue, debris must be removed - potential for adhesion formation. ZONE-SPECIFIC CONSIDERATIONS: Zone 1 (FDP only): if laceration very distal (<1cm from insertion), consider PRIMARY REINSERTION rather than tendon-to-tendon repair. Drill transosseous tunnels in distal phalanx, pass sutures through bone, tie over button on fingertip. Zone 2 (FDP+FDS): prepare both tendons. If FDS heavily damaged and repair would be bulky, may resect one FDS slip (preserve radial slip if possible) to reduce bulk in tight sheath. Modern approach: FDP repair ESSENTIAL, FDS repair if space allows. Zone 3-4-5: usually adequate tendon length, straightforward preparation. PRESERVE VINCULA: Vincula are vascular pedicles to tendons (vinculum longum and breve for both FDS and FDP). Laceration disrupts these but preserve intact vincula if possible during dissection. Improves healing.

Step 8: Core Suture Technique - Multi-Strand Repair (4-6-8 Strands)

Core Suture Technique - Multi-Strand Repair (4-6-8 Strands): MODERN PRINCIPLE: MINIMUM 4-STRAND core suture for early motion protocols. 6-strand or 8-strand even better. Each strand adds approximately 1kg tensile strength. 2-strand (old technique) = ~2kg strength, inadequate for active motion (rupture rate 10-30%). 4-strand = ~4kg, allows early protected motion (rupture rate 3-10%). 6-8-strand = 6-8kg, allows more aggressive early motion (rupture rate <5%). SUTURE MATERIAL: Non-absorbable, braided or monofilament. 3-0 or 4-0 size. Options: FiberWire (braided polyblend, very strong), Ethibond (braided polyester), braided nylon, Prolene (monofilament - less friction). Most use braided for better knot security and strength. TECHNIQUE OPTIONS: (1) MODIFIED KESSLER (2-strand): Classic technique, two locking loops. Simple but only 2 strands - inadequate for modern protocols. (2) SAVAGE (4-strand): Four locking loops, two sutures. Good 4-strand technique. (3) CRUCIATE (4-strand): Cross-weave pattern, four strands. Excellent 4-strand option. (4) AUGMENTED KESSLER or SAVAGE (6-strand): Add additional sutures to 4-strand technique. (5) 8-STRAND techniques: Various configurations (double cruciate, augmented Savage). More complex but strongest. SUTURE CONFIGURATION: Each suture locks within tendon substance (not just epitenon). Bites should be: 7-10mm from cut end (too close = pulls out, too far = excessive grasping), 2-3mm deep into tendon (through substance not just surface), locking technique (loop locks on itself) for better purchase. Sutures cross repair site - should achieve tendon-to-tendon apposition with minimal gap (<3mm). KNOTS: Bury knots within tendon or at one end (not in repair site - bulky). Multiple throws (5-6) for security with braided, fewer (3-4) for monofilament. ASSESS REPAIR: After core suture placement, assess gap with gentle traction. Should be <3mm. If gap >3mm, revise technique or accept (epitendinous suture will reduce gap further). Test strength gently - should hold ~4-8kg depending on strands (don't actually test to failure, just gentle traction to feel security).

Step 9: Epitendinous (Running Peripheral) Suture

Epitendinous (Running Peripheral) Suture: CRITICAL ADDITION: Epitendinous suture is NOT just cosmetic - adds 10-50% to repair strength (studies vary), smooths repair surface reducing friction and adhesions, reduces gap. TIMING: Performed AFTER core suture placement. SUTURE MATERIAL: Fine monofilament, 5-0 or 6-0 size. Prolene or nylon. Monofilament preferred over braided - less friction, glides better through pulleys. TECHNIQUE: RUNNING LOCKED suture around full circumference of repair. Start at core suture knot site. Run continuously catching EPITENON only (superficial layer of tendon, not deep substance) with small bites (1-2mm). Lock suture at intervals - typically at 90° intervals (4 quadrants) or every 2-3mm. Continue around ENTIRE circumference - full 360°. Finish near starting point, tie to initial knot or make new knot. GOALS: (1) Smooth repair surface - palpate with instrument, should feel smooth contour without step-off or roughness (glides better through pulleys). (2) Gap closure - epitendinous suture reduces gap, ideally to <1-2mm. (3) Strength augmentation - adds 10-50% to core suture strength. TECHNIQUE VARIATIONS: Some surgeons do simple running (no locks), others lock every bite, others lock at quadrants only. Locking is stronger (prevents bunching and unraveling if suture breaks) but slightly bulkier. ASSESS REPAIR: After epitendinous suture, repair should be: smooth contour, minimal gap (<2mm), good strength (gentle traction test), appropriate bulk (not too bulky for pulley passage). If too bulky, may need to revise by removing suture, thinning repair, or accepting (test gliding later).

Step 10: FDS Decision & Repair (Zone 2 Specific)

FDS Decision & Repair (Zone 2 Specific): ZONE 2 DILEMMA: Both FDP and FDS are lacerated and in tight sheath with critical pulleys. Historically, taught to repair BOTH tendons for maximum strength. Modern controversy: bulky repair from both tendons risks adhesions, triggering, and catching on pulleys. CURRENT APPROACH: FDP repair is ESSENTIAL (only tendon providing DIP flexion). FDS repair is BENEFICIAL if space allows but optional if bulk is concern. DECISION ALGORITHM: (1) If FDS laceration clean and space adequate (test by placing repair through pulley system with passive motion): Repair FDS with same technique as FDP (4-strand core + epitendinous). Maximum strength. (2) If FDS laceration ragged or extensive, or if combined FDP+FDS repair too bulky: Consider PARTIAL FDS RESECTION. Resect one FDS slip (preserve radial slip if possible - provides better PIP flexion). Reduces bulk by ~30-40%. Repair FDP only or FDP + remaining FDS slip. (3) If sheath extremely tight or pulleys released for access: Consider COMPLETE FDS RESECTION (both slips). Repair FDP only. Function: Some PIP flexion loss (FDP provides weak PIP flexion, ~30-40% of FDS strength), but excellent DIP flexion and reduced adhesion risk. STUDIES: Outcomes similar between FDP-only vs FDP+FDS repair in Zone 2 - some show better motion with FDP-only (less bulk), others show better grip with FDP+FDS (more strength). No consensus. EXAMINE INTRAOP: After FDP repair completed, test bulk by placing repair through A2/A4 area with passive motion. If catching or tight, consider FDS resection. If smooth gliding, repair FDS. MODERN TREND: Increasing acceptance of FDP-only repairs in Zone 2 to reduce bulk, especially if modern strong multi-strand FDP repair (6-8 strands) provides sufficient strength.

Step 11: Test Repair Gliding & Passive ROM

Test Repair Gliding & Passive ROM: CRITICAL STEP before closure: Test repair by passive finger motion through full range. TECHNIQUE: Gently flex and extend digit passively (surgeon moves finger, patient relaxed or under GA). Observe repair site directly in wound throughout ROM. ASSESS: (1) GLIDING: Repair should glide smoothly under preserved pulleys (A2, A4) without catching, triggering, or resistance. If catching: identify cause (bulky repair? pulley edge? synovium?), revise as needed (slim repair, trim pulley edge, remove synovium). (2) GAP: Repair site gap should remain <3mm throughout full flexion and extension. If gap opens >5mm, suggests repair under excessive tension or inadequate repair - may need revision, intercalary graft, or accept reduced motion arc. (3) PULLEY INTERACTION: Watch repair pass through A2 and A4 - should be smooth. Bulky repair may catch or trigger - may need to slim repair or release more pulley (up to 50% of A2/A4). (4) RESISTANCE: Passive motion should feel smooth without excessive resistance. Tight repair or pulley constriction creates resistance - palpate with instrument to identify tight point. (5) RANGE: Assess ROM achieved - ideal is full extension to full flexion (0-90° at PIP, 0-70° at DIP depending on zone). May have reduced passive ROM immediately postop (tendon edema, sutures) but should be >50% normal. PROFUNDUS CHECK RULE: When finger extended, flexor tendon repair site should lie proximal to A2 (in palm or proximal). When finger fully flexed, repair site should pass through A2 into finger (distal to A2). If repair site cannot pass A2 with flexion, indicates either insufficient tendon length or excessive A2 constriction. ADJUST: If issues identified, make adjustments before closure: slim repair, release more pulley, revise suture technique, accept reduced ROM, or consider need for graft.

Step 12: Pulley Repair (if released)

Pulley Repair (if released): If A2 or A4 pulley was released for access (>25% of width), MUST repair to prevent bowstringing. TECHNIQUE: Use 6-0 absorbable suture (Vicryl, PDS) or non-absorbable (Prolene, nylon). Interrupted horizontal mattress sutures reapproximating pulley edges. Usually 2-4 sutures sufficient. GOAL: Reconstruct at least 50% of pulley width. Pull edges together but don't over-tighten (constricts tendon gliding). Test gliding after repair - tendon should pass through reconstructed pulley smoothly. If too tight, adjust by loosening sutures or releasing more pulley (accept reconstruction of less than full width as long as >50%). CRUCIATE PULLEYS (C1, C2, C3): Do NOT need repair - these can be divided without consequence. A1, A3, A5 PULLEYS: Usually do not need repair even if divided, but some surgeons repair for completeness. Not critical. COMPLETE PULLEY LOSS: If A2 or A4 completely destroyed (>50% or entire pulley), cannot adequately repair. Options: (1) Accept (may develop mild bowstringing, some function loss), (2) Immediate pulley RECONSTRUCTION (advanced technique - use slip of superficial flexor, extensor retinaculum, or palmaris graft weaved around phalanx), (3) Delayed reconstruction if bowstringing develops. Most common: accept immediate loss, reconstruct later if problematic bowstringing. DOCUMENTATION: Note in operative report which pulleys divided, repaired, or reconstructed. Important for future surgeons if revision needed.

Step 13: Sheath Management & Closure Controversy

Sheath Management & Closure Controversy: FLEXOR SHEATH CLOSURE: After tendon repair completed, consider whether to close flexor sheath (Zone 1-2). CONTROVERSY: Two schools of thought. (1) CLOSE SHEATH LOOSELY: Proponents argue sheath closure maintains synovial environment, prevents tendon desiccation, guides healing, contains tendon. Technique: interrupted 6-0 absorbable sutures loosely approximating sheath edges. Do NOT close tightly (strangulates repair, increases adhesions). Leave gaps (not watertight). (2) LEAVE SHEATH OPEN: Proponents argue open sheath reduces compartment pressure, prevents adhesions, allows nutrition from surrounding tissues, tendon heals regardless. Sheath will reconstitute over time. EVIDENCE: No strong evidence favoring either approach - outcomes similar. Slight trend toward better motion with open sheath (less adhesions) but also more bowstringing if pulleys inadequate. CURRENT PRACTICE: Many surgeons leave sheath open or partially open, especially if tight closure would compress repair. If close, must be very loose closure with gaps. Avoid circumferential tight closure. ZONE 3-4-5: No sheath to close in these zones. Not applicable.

Step 14: Skin Closure

Skin Closure: CLOSURE TECHNIQUE: Interrupted non-absorbable sutures preferred over running (allows selective removal if infection, less purse-string). 4-0 or 5-0 nylon or Prolene. BRUNER INCISION (Zone 2): Vertical mattress sutures at zigzag apices (provides eversion, prevents dog-ears), simple interrupted along straight segments. Usually 6-12 sutures total depending on length. MIDLATERAL or LONGITUDINAL: Simple interrupted or vertical mattress throughout. PALM/FOREARM: Simple interrupted, may use subcuticular layer with 4-0 absorbable (Vicryl) for deeper closure to reduce tension. PRINCIPLES: No tension (undermines healing), good edge apposition, slight eversion acceptable. Avoid buried sutures near tendon repair (potential for adhesions if suture migrates). ALTERNATIVE: Subcuticular running 5-0 Monocryl (absorbable) for better cosmesis - requires excellent hemostasis underneath to prevent hematoma. Useful for patients unlikely to return for suture removal. TOURNIQUET RELEASE: If used, release tourniquet BEFORE final skin closure to check hemostasis (critical step). Cauterize any bleeding vessels. Then complete skin closure. WALANT: Already hemostatic, no tourniquet to release.

Step 15: Splinting & Postoperative Protocol - Critical for Success

Splinting & Postoperative Protocol - Critical for Success: SPLINTING is ESSENTIAL: Dorsal blocking splint (also called 'protective splint' or 'Kleinert position splint'). CONFIGURATION: Wrist 20-30° flexion, MCPs 60-70° flexion, IPs in full extension (0°) or slight flexion (10-20°). This position RELAXES flexor tendons maximally (shortens distance from muscle origin to insertion), protecting repair from tension. Include forearm in splint for wrist control. Dorsal placement (not volar) allows palmar sensation and feedback. ALTERNATIVE POSITION: 'Safe position' - wrist neutral or slight extension, MCPs 90° flexion, IPs extended. Also protective but some prefer Kleinert position for better relaxation. DURATION: 4-6 weeks continuously (remove only for supervised exercises). EARLY PROTECTED MOTION PROTOCOL (CRITICAL): Modern gold standard, prevents adhesions while protecting repair. Start 1-5 days postop (sooner better). PROTOCOLS: (1) DURAN PROTOCOL (true passive): Therapist or patient passively flexes IPs (tendon glides distally) then actively extends IPs against dorsal block (tendon glides proximally back to resting). No active flexion for 3-4 weeks. (2) KLEINERT PROTOCOL: Elastic band traction (rubber band from fingernail to wrist pulls finger into flexion). Patient actively extends against band and block. Passive flexion from elastic. Dynamic splinting. (3) PLACE-AND-HOLD: Therapist passively flexes digit to various positions, patient holds position briefly (activates muscle minimally), then relaxes. Progressive. (4) EARLY ACTIVE MOTION (EAM): Requires strong repair (6-8 strands). Gentle active flexion allowed at 3-5 days. More aggressive but requires expertise. FREQUENCY: 10 repetitions every 1-2 hours while awake. Critical to prevent adhesions. PROGRESSION: 3-4 weeks: continue protected motion. 4-6 weeks: begin gentle active flexion (remove dorsal block, allow active flexion exercises). 6-8 weeks: begin active flexion against light resistance (therapy putty, sponge). 8-12 weeks: progressive strengthening, return to normal activities. NO PASSIVE IP EXTENSION for 6 weeks (ruptures repair). CRITICAL PRINCIPLE: Early motion prevents adhesions (most common complication). Strong multi-strand repair (4-8 strands) allows safe early motion. If weak repair (2-strand), may need immobilization 3 weeks before motion (higher adhesion rate). PATIENT EDUCATION: Absolutely critical patient understands protocol and complies. Non-compliance = rupture (too much activity) or adhesions (too little motion). Consider supervised therapy for all complex repairs.

Dorsal blocking splint (wrist 20-30° flex, MCP 60-70° flex, IP extended) continuously 4-6 weeks. Early protected motion starting 1-5 days postop (Duran, Kleinert, or place-and-hold) 10 reps every 1-2 hours. NO passive IP extension 6 weeks. Progress: 4-6wk begin active flexion, 6-8wk light resistance, 8-12wk strengthening. Hand therapy essential. Full recovery 3-6 months.

References

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