Complications
1. Flexor Tendon Rupture
2. Adhesions
3. PIPJ contractures
4. Triggering
5. Pulley failure
6. Quadrigia
1. Flexor Tendon Repair Rupture
Incidence
5%
Management Options
FDS only
- usually minimal impairment
FDP only
- may be better to fuse DIPJ
- passing tendon through FDS may give poor result
FDP and FDS
- repair / graft FDP
One Stage repair
Indications
1. Minimal scarring
2. Pliable joints
3. Adequate retinacular pulley system
4. Not Zone 2
2 Stage repair
Indications
1. Severe adhesions or scarred tendon bed
2. Contractures
3. Disruption of pulley system
4. Missed injuries
5. Injuries not suitable for primary repair
- usually gross contamination
Technique 2 Stage
Concept
- all anastomosis in Zone 1 and Zone 3 (not Zone 2)
Technique Stage 1
Long Brunner incision finger
- Scarred tendon remnants excised, contractures released
- A2/4 pulleys reconstructed if necessary
- Silastic implant sutured distally to FDP Zone 1
- proximal end zone 5 free
- need incision in palm to pass through to forearm
Mobilisation regime post-op
- get finger moving / passive exercises +++
- minimise adhesions
- recreate synovial sheath for second stage
Pulley reconstruction
- use FDS, extensor retinaculum, PL free tendon
- A2: passed dorsal to NV bundles between phalanx and extensor tendons
- A4: superficial to extensor tendons
Technique Stage 2
Graft options
- Palmaris longus (absent 25%)
- Plantaris (absent 20%)
- Long toe extensor (IV)
Timing
- performed at 3 months
- Early, protected Post-op mobilisation
- active motion at 4 weeks
2. Flexor Tenolysis
Diagnosis Flexor Tendon Adhesions
Limited active ROM > passive ROM
- tendon adhesions
Limited passive ROM = active ROM
- joint contracture
If there is a marked difference between active and passive ROM
- adhesions likely but
- need to ensure repair is intact
- feel for tendon / ultrasound
Timing
Up to 20% of patients require tenolysis
- therapy +++ for 3 - 6 months
- need to assess the amount of functional deficit of the patient
- subcutaneous tissues must be state of equilibrium (i.e. soft and supple)
Technique
Must be prepared to go on to 2-stage repair
- long brunner incision
- access tendon through sheath via less important pulleys
- early active ROM critical
3. PIPJ Contractures
Non Operative
Splints
- static night time extension splints
- dynamic external fixators
Therapy
Operative
Access between A2 and A3 pulley
- remove cruciform pulleys
- flexor tenolysis
- release check rein ligaments
- release accessory collateral / collaterals / volar plate
- MUA
Results
Improve extension 20 - 30o
- lose equivalent amount of flexion
- change functional arc
4. Triggering
May be triggering on A2 or A4 pulley
- Non operative treatment
5. Pulley Failure and Bowstringing
6. Quadriga
Issue
FDP of MF / RF / LF linked
- will only extend as much as of shortest tendon
- if limited excursion of one FDP due to repair etc
- present with limitation of all finger flexion
Solution
Release adhesions of the shortened tendon