import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Location**: Palmar-lateral, 2-3mm from midline at each digit level. **Protection**: Raise full-thickness flaps, identify nerves BEFORE deep dissection, spreading technique parallel to nerve, loupe magnification essential. **Location**: Alongside proper digital nerves palmar-laterally. **Protection**: Same as nerves - spreading technique, gentle retraction, cauterize only bleeding branches (not main vessels). **Location**: Over proximal phalanx, 17-20mm length, most critical pulley. **Protection**: Must preserve at least 50% - loss causes 30-40% power loss and bowstringing. Open sheath between pulleys, not through A2. **Location**: Over middle phalanx, 7-10mm length. **Protection**: Preserve at least 50% - loss combined with A2 causes severe bowstringing. Repair with 6-0 suture if released more than 25%. **Location**: Central and superficial in carpal tunnel, directly under transverse carpal ligament. **Protection**: Identify before tendon access, release TCL on ulnar side, protect with retractor during tendon retrieval. **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) ### Verdan Zone Classification | Zone | Location | Structures | Key Considerations | |------|----------|------------|-------------------| | **Zone 1** | FDS insertion to fingertip | FDP only | May need bone reinsertion if very distal | | **Zone 2** | A1 pulley to FDS insertion | FDP + FDS + pulleys | "No man's land" - highest complexity | | **Zone 3** | Carpal tunnel exit to A1 | FDP + FDS + lumbricals | Good exposure, no pulleys | | **Zone 4** | Carpal tunnel | FDP + FDS + median nerve | CTR for access, protect median nerve | | **Zone 5** | Proximal to carpal tunnel | Muscle-tendon junction | Adequate exposure, may need forearm incision | **Thumb Zones**: T1 (distal to IP), T2 (A1 to IP), T3 (thenar eminence) ### Annular and Cruciate Pulleys | Pulley | Location | Length | Critical? | Can Divide? | |--------|----------|--------|-----------|-------------| | **A1** | MCP joint | 8-10mm | No | Yes - often divided | | **A2** | Proximal phalanx | 17-20mm | **YES** | No - preserve 50%+ | | **C1** | PIP level | Variable | No | Yes | | **A3** | PIP joint | 3-5mm | No | Yes | | **C2** | Between A3-A4 | Variable | No | Yes | | **A4** | Middle phalanx | 7-10mm | **YES** | No - preserve 50%+ | | **C3** | Between A4-A5 | Variable | No | Yes | | **A5** | DIP joint | 3-5mm | No | Yes | **Critical Rule**: Loss of more than 50% of A2 or A4 causes bowstringing and 30-40% power loss. ### Core Suture Options | Technique | Strands | Strength | Indication | |-----------|---------|----------|------------| | Modified Kessler | 2 | ~2kg | Historical only, inadequate for early motion | | Savage | 4 | ~4kg | Modern minimum standard | | Cruciate | 4 | ~4kg | Excellent 4-strand option | | Augmented Savage | 6 | ~6kg | Allows more aggressive early motion | | 8-strand techniques | 8 | ~8kg | Strongest, for early active motion | **Suture Material**: 3-0 or 4-0 braided non-absorbable (FiberWire, Ethibond, braided nylon) **Epitendinous**: 5-0 or 6-0 monofilament, running locked around circumference - adds 10-50% strength ### Early Protected Motion Options | Protocol | Description | Advantages | Disadvantages | |----------|-------------|------------|---------------| | **Duran** | Passive flexion, active extension | Simple, low rupture risk | Requires therapist | | **Kleinert** | Elastic band traction | Dynamic, patient-driven | Flexion contracture risk | | **Place-and-Hold** | Passive position, brief hold | Progressive loading | Complex compliance | | **Early Active** | Active flexion from day 3-5 | Best adhesion prevention | Requires 6-8 strand repair | **Frequency**: 10 repetitions every 1-2 hours while awake - frequency is CRITICAL for adhesion prevention. ### Dorsal Blocking Splint Position | Joint | Position | Rationale | |-------|----------|-----------| | Wrist | 20-30° flexion | Relaxes flexor tendons | | MCP | 60-70° flexion | Protects repair from tension | | IP | 0-20° flexion | Prevents flexion contracture | **Timeline**: - Day 1-5: Begin early protected motion - Week 4-6: Begin gentle active flexion - Week 6-8: Light resistance exercises - Week 8-12: Progressive strengthening - **NO passive IP extension for 6 weeks** (ruptures repair) **Key**: Supervised hand therapy ESSENTIAL for Zone 2 repairs. ### 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). **Technical Tip**: EXAM KEY: 'Flexor tendon ZONE CLASSIFICATION is critical: Zone 1 = FDP only, distal to FDS insertion. Zone 2 = \"no man's land\" from A1 pulley to FDS insertion, both tendons in tight sheath with critical pulleys - historically poor results, modern techniques improved outcomes. Zone 3 = palm, good exposure. Zone 4 = carpal tunnel, median nerve risk. Zone 5 = forearm, muscle-tendon junction. I test EACH tendon: FDP (stabilize PIP, flex DIP), FDS (block adjacent fingers, flex PIP). Timing critical: Primary repair ideal <12 hours, acceptable up to 24 hours if clean wound. Contaminated wounds need staged approach. Chronic >3 weeks cannot do primary repair - too much retraction and scarring, need graft or two-stage. Zone 2 repairs require: experienced surgeon, multi-strand core suture (4-6-8 strand minimum), early protected motion protocol postop. Must have proper equipment including loupe magnification, fine instruments, tendon retrieval tools, appropriate suture (3-0 or 4-0 braided for core, 5-0 or 6-0 monofilament for epitendinous).' - Delayed or missed diagnosis = tendon retraction, muscle shortening, cannot do primary repair (need graft) - Operating on contaminated wound = high infection risk, may lose entire tendon - Attempting Zone 2 repair without expertise or proper equipment = high failure rate (adhesions or rupture) - Not testing both FDP and FDS = missing one tendon injury (common error) - Missing associated nerve injury = poor functional outcome despite tendon repair - Attempting primary repair on chronic laceration (>3 weeks) = failure due to retraction and scarring ### 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. **Technical Tip**: EXAM KEY: 'Anesthesia choice depends on complexity and patient. General anesthesia preferred for Zone 2 repairs - provides muscle relaxation facilitating tendon retrieval, allows longer operative time, patient comfort. WALANT suitable for simple Zone 1, 3, 5 repairs. I position patient supine, arm on hand table. Tourniquet essential for visualization - arm tourniquet 250-300mmHg. Exsanguinate with elevation (avoid Esmarch if worried about tendon displacement). LOUPE MAGNIFICATION critical for precision - 2.5-3.5x minimum for Zone 2 repairs. Microscope for very distal repairs. Have proper instruments: fine forceps, tenotomy scissors for delicate work, tendon retrievers (silicone catheter or feeding tube), appropriate suture (3-0 or 4-0 braided non-absorbable for core - FiberWire, Ethibond, or braided nylon; 5-0 or 6-0 monofilament for epitendinous - Prolene or nylon). Plan tourniquet time <120 minutes if possible.' - Inadequate anesthesia = patient movement during delicate repair (catastrophic) - Tourniquet >120 minutes without break = compartment syndrome risk, tourniquet pain even under GA - No loupe magnification for Zone 2 = suboptimal technique, higher complication rate - Wrong suture material = repair failure (absorbable suture loses strength, too thin suture cuts through) - Esmarch exsanguination = may push tendon proximally making retrieval harder ### 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. **Technical Tip**: EXAM KEY: 'Incision planning is zone-dependent. ZONE 2 (no man's land): BRUNER ZIGZAG - apices at flexion creases with 60° angles not 90°, prevents scar contracture across joints while providing excellent exposure. Extend proximal and distal to laceration for pulley access and tendon retrieval. This is gold standard for Zone 2. ZONE 1: midlateral or volar Bruner, avoid direct volar over DIP (painful scar). ZONE 3: longitudinal or curved in palm following creases. ZONE 4: standard carpal tunnel incision. ZONE 5: volar forearm longitudinal. Key principles: never cross joints at 90° (contracture), Bruner angles 60°, adequate exposure critical - extend incisions generously, don't compromise access. Incorporate existing traumatic laceration into surgical incision design.' - Crossing flexion crease at 90° = scar contracture (significant functional loss) - Inadequate incision length = poor exposure, difficult repair, higher complication rate - Transverse palmar incision (Zone 3) = crosses multiple neurovascular bundles, worse than longitudinal - Direct volar incision over DIP joint (Zone 1) = painful scar, hypersensitivity, poor padding ### 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. **Technical Tip**: EXAM KEY: 'After skin incision, I raise full-thickness skin flaps carefully - avoid thin flaps (vascular compromise). Identify neurovascular bundles IMMEDIATELY: proper digital nerves and arteries run palmar-laterally, 2-3mm from midline in fingers, pink-white nerves with red arteries alongside. I use SPREADING technique with fine scissors parallel to nerves rather than cutting - safer. Grayson's ligaments palmar to nerves - divide carefully to mobilize flaps. Zone 3 (palm): multiple structures - common digital nerves, superficial arch branches, lumbricals - protect all. Zone 4 (carpal tunnel): median nerve superficial and central - must identify and protect, may need carpal tunnel release for tendon access. Zone 5 (forearm): identify median nerve, ulnar nerve, radial artery before proceeding. Loupe magnification essential throughout. Self-retaining retractors for exposure, gentle traction only (nerve injury risk from excessive traction).' - Digital nerve injury (most common complication) - laceration or traction injury causes numbness, neuroma, may need repair or grafting - Digital artery injury - bleeding, hematoma, digit ischemia if both arteries injured (rare) - Thin skin flaps = vascular compromise, necrosis - Excessive retraction = nerve traction injury (neurapraxia, may be permanent) - Median nerve injury in Zone 4 = major complication (thenar weakness, sensory loss), requires microsurgical repair ### 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. **Technical Tip**: EXAM KEY: 'In Zone 2, pulley management is CRITICAL. I identify pulley system: A1, A2 (critical, overlies P1), C1, A3, C2, A4 (critical, overlies P2), C3, A5. A2 and A4 MUST preserve at least 50% to prevent bowstringing - loss >50% causes 30-40% power loss. I open sheath in WINDOWS between pulleys: can safely divide A1, A3, and ALL cruciate pulleys (C1, C2, C3). This gives excellent exposure while preserving A2 and A4. If absolutely need more exposure, can release up to 50% of A2 or A4 (one side only) but MUST repair if >25% released. I extend sheath opening proximally as needed to retrieve tendons. Zone 3-4-5: no pulleys, direct tendon access after superficial dissection. Zone 4 may need carpal tunnel release for exposure (divide transverse carpal ligament).' - A2 or A4 pulley damage >50% = bowstringing (loss of mechanical advantage, weak grip, PIP hyperextension, functional impairment), requires pulley reconstruction - Not repairing A2/A4 if >25% released = delayed bowstringing - Inadequate sheath opening = cannot retrieve tendons or perform repair, temptation to force leading to complications - Dividing pulleys indiscriminately without knowing which are critical = bowstringing - Excessive pulley release preventing tendon gliding (needs intact pulley system for excursion) ### 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. **Technical Tip**: EXAM KEY: 'Tendon retrieval is critical step. Distal stumps usually visible. Proximal stumps often retracted significantly - FDP retracts MORE than FDS (deeper, lumbrical pull). Retrieval techniques: (1) Milking forearm muscles proximally-to-distally. (2) FEEDING TUBE METHOD (my preferred) - pass 8Fr feeding tube or silicone catheter from distal to proximal through sheath, identify in palm/forearm through small window incision, suture proximal stump to catheter, pull back delivering stump distally. (3) Separate proximal incision if cannot retrieve. (4) Wrist flexion relaxes tendons. Must identify BOTH tendons in Zone 2: FDS superficial (splits into 2), FDP deep (single). Verify by traction (FDP = DIP flexion, FDS = PIP flexion). CRITICAL: chronic injuries >3 weeks with severe retraction CANNOT do primary repair - need staged reconstruction (Hunter rod then graft stage 2) or primary grafting. Don't force tendon retrieval - causes tendon damage or musculotendinous avulsion. Gentle handling essential - tendons are delicate.' - Unable to retrieve proximal stump = aborted primary repair, need staged reconstruction or graft - Forceful traction = tendon shredding, weakened repair site, or musculotendinous junction avulsion - Wrong tendon retrieved = missing injury to other tendon (common in Zone 2 - FDS vs FDP confusion) - Lumbrical muscle excursion with excessive FDP pull = 'lumbrical plus' deformity (paradoxical IP extension with attempted flexion) - Chronic retraction >3 weeks attempting primary repair = failure due to muscle shortening and tendon scarring (need graft) - Tendon damage during retrieval through tight pulleys or carpal tunnel ### 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. **Technical Tip**: EXAM KEY: 'I trim tendon ends minimally to healthy tissue - only remove obviously damaged tissue. Minimize shortening - goal is gap <3mm after repair. I use 45° BEVEL technique (oblique cut) - increases healing surface area and improves biomechanics compared to transverse cut. Assess tendon quality: healthy tendon is white, fibrous, good substance. Poor quality (macerated, diseased, infected) may need graft not primary repair. Remove all loose fragments and frayed tissue. ZONE 1 special consideration: if very distal FDP laceration (<1cm from insertion), consider PRIMARY REINSERTION to bone (transosseous tunnels, sutures through bone, tie over button) rather than tendon-to-tendon repair. ZONE 2: prepare both FDP and FDS. If FDS damaged and bulky, may resect one slip to reduce bulk (preserve radial slip) - modern approach prioritizes FDP repair, FDS if space allows. Preserve intact vincula (vascular pedicles) if possible during dissection - aids healing.' - Excessive trimming = gap >10mm = high tension repair = high rupture risk or cannot repair (need graft) - Inadequate trimming of damaged tissue = weak repair site, higher rupture rate - Attempting repair of poor quality tendon = failure, should consider graft - Missing damaged segment within tendon = rupture at that site postop - Disrupting intact vincula unnecessarily = devascularization of repair site ### 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). **Technical Tip**: EXAM KEY: 'CORE SUTURE is most critical step. Modern standard: MINIMUM 4-STRAND core suture, 6-8-strand better. Each strand adds ~1kg tensile strength. 4-strand = 4kg allows early protected motion. 2-strand (old Kessler) only 2kg - inadequate, high rupture rate 10-30% with modern early motion. I use 3-0 or 4-0 braided non-absorbable suture (FiberWire, Ethibond, or braided nylon). Technique: locking loops (modified Kessler, Savage, or cruciate) with bites 7-10mm from cut end, 2-3mm deep into tendon substance. Goal: tendon-to-tendon apposition with gap <3mm. Bury knots away from repair site. 6-8-strand techniques provide strongest repair (6-8kg) allowing more aggressive early motion with rupture rate <5%. Zone 2 repairs MUST be 4-strand minimum - this is gold standard. Check gap after core suture - should be <3mm (epitendinous suture will close further).' - Inadequate strands (<4) = high rupture risk 10-30% with early motion protocols - Suture too close to cut end (<7mm) = pull-out failure - Suture too far from end (>10mm) = grasps excessive tendon, gapping - Epitenon-only suture (not through tendon substance) = inadequate purchase, rupture - Gap >3mm after core suture = adhesion formation increases exponentially - Bulky repair = triggering, catching on pulleys, rupture from impingement - Knot in repair site = bulk, triggering ### 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). **Technical Tip**: EXAM KEY: 'Epitendinous suture is CRITICAL - not just cosmetic. Adds 10-50% repair strength, smooths surface for better gliding, closes gap. I use 5-0 or 6-0 monofilament (Prolene or nylon) running locked technique around FULL circumference (360°). Start at core knot, catch epitenon only (superficial layer) with small 1-2mm bites, lock at quadrants (90° intervals) for security. Complete full circle. Goals: smooth surface (palpate - should feel smooth, no step-off), gap <1-2mm, strength augmentation. After epitendinous suture, repair is complete. Smooth contour essential for gliding through pulleys without catching. Some surgeons skip epitendinous (rely on strong core only) but this is sub-optimal - modern evidence supports epitendinous as critical component. Total repair strength = core (4-8kg depending on strands) + epitendinous (add 10-50% = ~0.5-2kg additional).' - Skipping epitendinous suture = 10-50% loss of strength, rough surface increases adhesions - Too tight epitendinous = bunching, bulk, triggering - Too loose epitendinous = gapping, sutures tear through epitenon - Incomplete circumference (not 360°) = gap persists at missed areas - Braided suture for epitendinous = more friction, gliding impairment ### 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. **Technical Tip**: EXAM KEY: 'Zone 2 FDS decision is controversial. Traditional teaching: repair BOTH FDP and FDS for maximum strength. Modern approach: FDP repair ESSENTIAL, FDS repair if space allows but may resect one or both slips if bulk concern. I assess intraoperatively: after completing FDP repair, test bulk by passive motion through pulley system. If smooth gliding and adequate space: repair FDS (same 4-strand technique). If tight, catching, or FDS badly damaged: resect one FDS slip (keep radial if possible) or both slips. FDP alone provides ~60-70% grip strength of combined FDP+FDS, but excellent DIP flexion and reduced adhesion risk from less bulk. No consensus in literature - both approaches have good outcomes. Patient factors: heavy manual laborer may benefit from FDS repair (more strength), office worker may benefit from FDS resection (better motion, less adhesions). Modern strong 6-8-strand FDP repair may obviate need for FDS repair.' - Bulky FDP+FDS repair = triggering, catching on pulleys, repair rupture from impingement, adhesions - Repairing only FDS and missing FDP laceration = loss of DIP flexion (functional disaster) - Resecting both FDS slips unnecessarily = ~30-40% PIP flexion loss (may impact grip for heavy work) - Damaged FDS repair adding bulk without strength benefit = worst outcome ### 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. **Technical Tip**: EXAM KEY: 'Before closing, I MUST test repair with passive ROM through full arc. I observe repair directly in wound while gently flexing and extending finger passively. Assess: (1) Smooth gliding through A2 and A4 without catching - if catching, identify cause and revise. (2) Gap <3mm throughout motion - if gap opens >5mm indicates excessive tension or weak repair. (3) Pulley interaction - repair should pass smoothly, bulky repair may catch requiring slimming or more pulley release (up to 50% A2/A4). (4) Smooth passive motion without resistance - tight spots need revision. (5) Adequate ROM - should achieve >50% normal passive ROM immediately (full ROM may be limited by edema/sutures but should be reasonable). Profundus check rule: repair site should pass from palm (extended position) through A2 into finger (flexed position) - if cannot pass A2, either insufficient tendon length or A2 too tight. Make any adjustments NOW before closing - much harder to revise postop. Accepting catching or resistance = high adhesion rate and poor outcome.' - Catching repair on pulley = rupture or adhesions, must revise before closing - Gap >5mm = adhesion formation increases exponentially, poor outcome - Excessive tension = rupture risk, must revise or consider graft - Not testing before closure = missed problems requiring reoperation - Accepting inadequate gliding 'it will improve' = usually false, adhesions form and worsen ### 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. **Technical Tip**: EXAM KEY: 'If I released >25% of A2 or A4 pulley for access, I MUST repair to prevent bowstringing. I use 6-0 absorbable suture (Vicryl) interrupted horizontal mattress reapproximating edges. Goal: reconstruct at least 50% of pulley width. Test tendon gliding after repair - should pass smoothly without constriction. Cruciate pulleys (C1, C2, C3) do NOT need repair - safe to divide. A1, A3, A5 optional repair. If complete A2 or A4 loss (>50%), cannot adequately repair acutely - options are accept (may develop mild bowstringing), immediate reconstruction (advanced, use FDS slip or graft), or delayed reconstruction if develops. I document all pulley management in operative note - critical for future reference.' - Not repairing A2 or A4 release >25% = delayed bowstringing postop (weeks to months), functional loss, may need reconstruction - Over-tightening pulley repair = tendon constriction, adhesions, triggering - Inadequate pulley reconstruction <50% = insufficient bowstringing prevention - Complete A2 and A4 loss = severe bowstringing, major functional loss, complex reconstruction 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. **Technical Tip**: EXAM KEY: 'Sheath closure controversial after Zone 1-2 flexor tendon repair. Two approaches: (1) Close loosely with interrupted 6-0 absorbable suture - maintains synovial environment but must be very loose, not tight (tight closure strangulates repair, increases adhesions). (2) Leave open - reduces compartment pressure, evidence suggests possible better motion, sheath reconstitutes over time. No strong evidence favoring either - both give good results. I tend to leave sheath open or partially open, especially if any concern about tight closure compressing repair. If I close, it's very loose with gaps, not watertight. Principle: never tight circumferential sheath closure (adhesions and repair strangulation). Zones 3-4-5 have no sheath so not applicable.' - Tight sheath closure = compartment effect, strangulates repair, increases adhesions and rupture risk - Circumferential tight closure = worst outcome (adhesions, stiffness, possible rupture) - Sutures through repair site during sheath closure = weakening of repair ### 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. **Technical Tip**: EXAM KEY: 'I close skin with interrupted 4-0 or 5-0 nylon sutures - non-absorbable allows removal 10-14 days. Bruner incision: vertical mattress at apices (prevents dog-ears), simple interrupted on straight segments. No tension, good edge apposition. If TOURNIQUET used, MUST release before final skin closure to check hemostasis - wait 2-3 minutes, cauterize any bleeding, then complete closure. This is critical - prevents postop hematoma when tourniquet pressure released. WALANT already hemostatic. Alternative: subcuticular absorbable (Monocryl) for better cosmesis but requires perfect hemostasis (hematoma risk). Avoid buried deep sutures near tendon repair (adhesion risk if suture migrates).' - Tension on closure = skin ischemia, dehiscence - Not releasing tourniquet before closure = missed bleeding vessels, postop hematoma when tourniquet released (adhesions, infection risk) - Hematoma under subcuticular closure = may not be apparent until large, difficult to drain - Sutures near tendon repair = adhesion formation if migrate ### 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. **Technical Tip**: EXAM KEY: 'Postop protocol is CRITICAL for success - equal importance to surgical technique. I apply dorsal blocking splint: wrist 20-30° flexion, MCPs 60-70° flexion, IPs extended. This position maximally RELAXES flexor tendons protecting repair from tension. EARLY PROTECTED MOTION PROTOCOL is modern gold standard - prevents adhesions while protecting repair. Start within 1-5 days (sooner better): Duran (passive flexion by therapist, active extension), Kleinert (elastic band dynamic traction), place-and-hold, or early active motion if very strong 6-8-strand repair. Perform 10 reps every 1-2 hours while awake - frequency critical. Progression: 3-4 weeks protected motion continues, 4-6 weeks begin gentle active flexion, 6-8 weeks light resistance, 8-12 weeks progressive strengthening. CRITICAL: NO passive IP extension for 6 weeks (ruptures repair). Early motion prevents adhesions (most common complication) - strong multi-strand repair allows safe motion. Patient education absolutely essential - non-compliance = rupture or adhesions. Supervised hand therapy highly recommended for all Zone 2 repairs.' - Wrong splint position (wrist/MCPs extended) = tension on repair, rupture risk - No early motion = adhesions, stiffness, poor functional outcome (most common problem) - Passive IP extension before 6 weeks = repair rupture (catastrophic) - Inadequate patient education = non-compliance (too much activity = rupture, too little = adhesions) - No hand therapy = poor adherence to protocol, suboptimal outcomes - Removing splint too early (<4 weeks) = rupture risk - 2-strand repair with early motion = high rupture rate (need immobilization 3 weeks or better repair technique) 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 1. Strickland JW. Development of flexor tendon surgery: twenty-five years of progress. J Hand Surg Am. 2000;25(2):214-235. 2. Tang JB. Clinical outcomes associated with flexor tendon repair. Hand Clin. 2005;21(2):199-210. 3. Elliot D, Giesen T. Primary flexor tendon surgery: the search for a perfect result. Hand Clin. 2013;29(2):191-206. 4. Boyer MI, Strickland JW, Engles D, Sachar K, Leversedge FJ. Flexor tendon repair and rehabilitation: state of the art in 2002. Instr Course Lect. 2003;52:137-161. 5. Tang JB, Amadio PC, Boyer MI, et al. Current practice of primary flexor tendon repair: a global view. Hand Clin. 2013;29(2):179-189. 6. Dy CJ, Hernandez-Soria A, Ma Y, Roberts TR, Daluiski A. Complications after flexor tendon repair: a systematic review and meta-analysis. J Hand Surg Am. 2012;37(3):543-551.e1. 7. Peck FH, Bücher CA, Watson JS, Roe A. A comparative study of two methods of controlled mobilization of flexor tendon repairs in zone 2. J Hand Surg Br. 1998;23(1):41-45. 8. Dowd MB, Figus A, Harris SB, Southgate CM, Foster AJ, Elliot D. The results of immediate re-repair of zone 1 and 2 primary flexor tendon repairs which rupture. J Hand Surg Br. 2006;31(5):507-513. 9. Sirotakova M, Elliot D. Early active mobilization of primary repairs of the flexor pollicis longus tendon with two Kessler two-strand core sutures and a strengthening circumferential suture. J Hand Surg Br. 2004;29(6):531-535. 10. Amadio PC. Friction of the gliding surface: implications for tendon surgery and rehabilitation. J Hand Ther. 2005;18(2):112-119.

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

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