Phẫu Thuật Gân Bàn Tay (Tendon Surgery of the Hand)

188
Section 2:  Primary Flexor Tendon Surgery
have been the cause of the slight drop in the excellent
and good results in this group of patients compared
with our previous results.8 Possibly of more significance
is the fact that this technique is difficult to use in clinical
practice and may be too complicated for those routinely
doing these repairs worldwide.
FPL REPAIR WITH NO
RUPTURES: ELSEWHERE
In the early 2000s, an additional three studies of primary
repair of the FPL tendon were published,2,49,50 two of
which reported no mechanical ruptures of FPL repairs
using various conventional two-strand core sutures and
simple circumferential repair,2,49 albeit in small numbers
of patients (Table 16-1). These studies may identify a
factor that is currently given little attention because of
concentration on stronger sutures, namely the quality
of the rehabilitative service. At a time when stringent
financial pressures are being forced on clinicians
worldwide, this may be of political importance to the
well-being of this group of patients. Unfortunately,
strengthening of suture techniques is considerably easier
for most surgeons than achieving any increase in hand
therapy availability and expertise.
SIMPLER FPL REPAIR WITH NO RUPTURES:
ST. ANDREW’S 2004–2009
Our most recent study51 reported the results of an addi­
tional 50 FPL primary tendon repairs performed since
January 2004 using Tang’s technique of three Tsuge
sutures as the “core” suture,52,53 with no circumferential
suture (Figure 16-4). The Tsuge system of suturing
flexor tendon repairs54,55 is as strong as the more con­
ventional core and circumferential suture combinations,
of achieving a four-strand core suture. This combination
of sutures achieved a 0% rupture rate. However, the bulk
of a combination of a multistrand core suture and a
complex circumferential suture may increase the resis­
tance to movement of the repaired tendon.48 This may
Figure 16-1  The modified splint with inclusion of the fingers used for early active mobilization in St Andrew’s of FPL repairs
since 1994. A, Mobilization of the fingers with the thumb resting. B, Early mobilization of the thumb using Kapandji’s
method. C, Later mobilization of the thumb to near-full flexion.
A
B
C
Figure 16-2  Diagram showing the technique of stronger
circumferential suturing described by Silfverskiöld and
Anderson (1993) and used in St. Andrew’s for FPL repair,
1996–2004.
Figure 16-3  Diagram showing the technique of four strand
repair using two Kessler core sutures described by Smith
and Evans (2001) and used in St Andrew’s for FPL repair,
1999–2004.
Double Kessler core suture

189
Chapter 16:  Primary Repair of the Flexor Pollicis Longus Tendon
suture,3 this difference was not statistically significant.
More recently, Tang modified his technique of inserting
the three Tsuge sutures58 and, then, further modified
the technique to a four-strand Tsuge-type of repair to
make the repair easier and faster59 (Table 16-2). We
have no experience of these newer techniques and
cannot comment on them in a clinical setting, but
the results reported by these authors in their animal
studies would suggest that these variations are similar
in effectiveness to the original technique that was used
in our study.
which are commonly used in Europe and may be more
simple to insert.56 This group, again, had a 0% rupture
rate and showed that the three Tsuge suture technique
described by Tang and his colleagues is of adequate
strength to prevent rupture of primary repairs of the FPL
tendon during early active mobilization using the
“Belfast” regimen.57 It is also considerably easier to carry
out a repair by this technique. Although the results of
this latest cohort of repairs were better than those fol­
lowing repair with a combination of a four-strand
Kessler core suture and a Silfverskiöld circumferential
Table 16-1  Summary of Major Studies of Primary Repair of the FPL Tendon, 1989–2009
Authors
Rehabilitation
Techniques
Number of
Tendons
Zones
Study
Period
(Years)
Excellent and Good
Results
Mechanical
Rupture Rate (%)
Percival and
Sykes (1989)
Immobilized
25
1, 2, 3
4
44% (White76)
8
Kleinert
mobilization
26
1, 2, 3
60% (White76)
8
Noonan and
Blair (1991)
Kleinert
mobilization
30
1, 2, 3, 4, 5
6
71% Interphalangeal
joints normal
82% Metacarpophalangeal
joints normal
—
Nunley et al
(1992)
Kleinert
mobilization
38
1, 2
2
Average IP 35%
3
Thomazeau
et al (1996)
Immobilization
10
1, 2, 3, 4, 5
Kleinert
mobilization
3
1, 2, 3, 4, 5
5
85% (Tubiana7)
5
Passive
mobilization
7
1, 2, 3, 4, 5
Sirotakova and
Elliot (1999)
Early Active
Mobn (Group 1)
30
1, 2
8.5
70% (White76) 73%
(Buck-Gramcko77)
17
Early Active
Mobn (Group 2)
39
1, 2
67% (White76) 72%
(Buck-Gramcko77)
15
(3) Early Active
Mobn (Group 3)
49
1, 2
76% (White76) 80%
(Buck-Gramcko77)
8
Kasashima
et al (2002)
Immobilization
16
1, 2, 3
12
50% (JSSH 1994)*
0
Kleinert
mobilization
13
1, 2, 3
77% (JSSH 1994)*
0
Peck et al
(2003)
Kleinert
mobilization
23
1, 2
1.5
Not reported
4
Baer et al
(2003)
Mantero Early
Active Mobn
22
1, 2
6
91% (Buck-Gramcko)†
0
Sirotakova and
Elliot (2004)
Early Active
Mobn
48
1, 2
3.5
73% (White76) 77%
(Buck-Gramcko77)
0
Giessen et al
(2009)
Early Active
Mobn
50
1, 2
2.75
78% (White76) 82%
(Buck-Gramcko77)
0
*JSSH, assessment of the Japanese Society for Surgery of the Hand (similar to the White Assessment, uses IP range of motion only).
†This figure includes results of both finger and thumb flexor repairs. Although the authors indicate that the results were poorer in the
thumbs, they only give an overall result of excellent and good results for all cases.

190
Section 2:  Primary Flexor Tendon Surgery
FPL REPAIR WITH NO RUPTURES: OTHER
SIMPLE ALTERNATIVES
Another method of simplifying the flexor repair while
adding to its strength is to use a larger caliber of core
suture.60,61 However, sutures become cumbersome to tie
and the knot is bulky at the flexor tendon junction
Figure 16-4  A, Illustration of the 1977 modification by
Tsuge of his own suture, which is used in B, the triple Tang
technique used in St. Andrew’s for FPL repair, 2004–2007.
A
B
Table 16-2  Summary of the Five Groups of Primary FPL Tendon Repairs Carried Out in the St. Andrew’s Hand
Unit (1989–2007)
Number of
Tendons
Zones of
Injuries
Excellent and
Good Results (%)*
Rupture
Rate (%)
Group 1: Two-strand Kessler core suture, simple
circumferential suture, thumb only splint and early
active mobilization
30
1 and 2
70/73
17
Group 2: Two-strand Kessler core suture, simple
circumferential suture, thumb and finger splint and
early active mobilization
39
1 and 2
67/72
15
Group 3: Two-strand Kessler core suture, Silfverskiöld
circumferential suture, thumb and finger splint and
early active mobilization
49
1 and 2
76/80
8
Group 4: Four-strand Kessler core suture, Silfverskiöld
circumferential suture, thumb and finger splint and
early active mobilization
48
1 and 2
73/77
0
Group 5: Tang technique of triple Tsuge suture, no
circumferential suture, thumb and finger splint and
early active mobilization
50
1 and 2
78/82
0
*The first figures shown are the excellent or good results according to the White (1956) method and the second figures are the excellent or
good results according to the Buck-Gramcko et al (1976) method of assessment.
beyond a 3-0 suture size. The Mantero technique,62
probably based on a distal technique of flexor tendon
suture fixation first described by Brunelli 20 years
earlier,63 avoids the problem of suture knotting within
the flexor tendon sheath. It leaves less knotted suture
material in the repaired part of the tendon than do
Kessler repairs, so it is particularly suitable for use with
larger core sutures. This technique was, perhaps, the very
earliest attempt at early active mobilization without
rubber bands. It comprises a two-strand core suture with
suture fixation to the proximal part of the tendon using
half of a Kessler suture and distal fixation over a button
at the tip of the digit. Although the Mantero technique
has been used more recently with 3-0 sutures,49 the
original Mantero technique used a 2-0 suture.62 Both the
technique and this suture size are still used routinely in
many parts of southern Europe, including Mantero’s
unit.43,64-70 This technique is applicable to primary repair
of zone 1 and 2 divisions of the FPL, so it provides an
alternative means of adding strength while simplifying
the FPL suture.
MANAGEMENT OF THE RETRACTED FPL
When retraction is obvious at surgery, proximal tendon
lengthening within the muscle31,71 or by “Z” lengthening
of the tendon at the musculotendinous junction30,72
may improve the results. It has certainly been our own
experience that, even after short delays, apposition of
the FPL tendon ends is sometimes only possible by
considerable flexion of the interphalangeal (IP) joint of
the thumb. These repairs have then proved liable to

191
Chapter 16:  Primary Repair of the Flexor Pollicis Longus Tendon
References
additional 24 hours. Eleven achieved good results and
four achieved fair results using both methods of assess­
ment, suggesting that immediate re-repair, although not
easy, is the treatment of choice for most patients who
present quickly after rupture of an FPL repair, as it is for
finger flexor tendon repairs that rupture.4,57,74,75
rupture during early postoperative mobilization, unless
one limited the speed and extent of rehabilitation and
accepted the possibility of an unsatisfactory result with
a very flexed IP joint. In these cases, we have used FPL
tendon lengthening within the muscle by simple trans­
verse division of the tendon in its intramuscular part at
one or two places as a tension relieving maneuver
(Figure 16-5), as described by Le Viet.71 Routine tendon
lengthening of all FPL repairs is another possible way of
reducing the FPL rupture rate. Rouhier described this in
1950 as an alternative to tendon grafting.31 The Rouhier
technique is well recognized and, occasionally, still used
in France73 but is not commonly considered, or used,
elsewhere. The FPL tendon is detached from its muscle
along its intramuscular course and a tendon slide is
carried out within the muscle, allowing the FPL to act
as its own graft to close any gap without tension at the
site of tendon division. Once the repair has been com­
pleted, the tendon is sutured back to the muscle belly
more distally than its original attachment. Although we
have no experience of this technique, one would expect
it to allow considerable lengthening of the proximal FPL
tendon. It may be a useful means of tendon lengthening
for difficult cases when repair is delayed but it is pos­
sibly too elaborate for use in reducing the tension on
an immediate repair. The Le Viet technique71 of making
a complete transverse division of the tendon one or
more times within the muscle belly is technically easier
to carry out than intratendinous slide lengthening,
whether in the muscle or at the wrist. It only increases
the tendon length by 1 cm or so, but this can be suffi­
cient to reduce the active tension on the repair more
distally in the thumb during early mobilization.
THE SUCCESS OF FPL RUPTURE RE-REPAIR
All 15 ruptures of the FPL in these studies presented
within 48 hours and were re-repaired within an
Figure 16-5  Use of the technique of intramuscular division
of the tendon described by Le Viet (1986) to overcome a
retracted FPL at primary repair. A, A single intramuscular cut
of the tendon. B, A double cut.
A
B
1. Murphy FG: Repair of laceration of flexor pollicis longus
tendon, J Bone Joint Surg (Am) 9:1121–1123, 1937.
2. Kasashima T, Kato H, Minami A: Factors influencing prognosis
after direct repair of the flexor pollicis longus tendon: multi­
variate regression model analysis, Hand Surg 7:171–176, 2002.
3. 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 strengthened circumferential
suture, J Hand Surg (Br) 29:531–535, 2004.
4. Harris SB, Harris D, Foster AJ, et al: The aetiology of acute
rupture of flexor tendon repairs in zones 1 and 2 of the fingers
during early mobilization, J Hand Surg (Br) 24:275–280,
1999.
5. Lundborg G: The vascularization of the human flexor pollicis
longus tendon, Hand 11:28–33, 1979.
6. Hergenroeder PT, Gelberman RH, Akeson WH: The vascular­
ity of the flexor pollicis longus tendon, Clin Orthop Relat Res
162:298–303, 1982.
7. Tubiana R, Gordon S, Grossman J, et al: Évaluation des résul­
tats après réparations des tendons fléchisseurs des doigts. In
Tubiana R, editor: Traité de Chirurgie de la Main, Paris, 1985,
Masson, pp 281–286.
8. Sirotakova M, Elliot D: Early active mobilisation of primary
repairs of the flexor pollicis longus tendon, J Hand Surg (Br)
24:647–653, 1999.
9. Bell JL, Mason ML, Koch SL, et al: Injuries to flexor tendons
of the hand in children, J Bone Joint Surg (Am) 40:1220–1230,
1958.
10. Boyes JH: Flexor tendon grafts in the fingers and thumb,
J Bone Joint Surg (Am) 32:489–499, 1950.
11. Foss Hague M: The results of tendon suture of the hand, Acta
Orthop Scand 24:258–270, 1955.
12. Harrison SH: Repair of digital flexor tendon injuries in the
hand, Br J Plast Surg 14:211–230, 1961.
13. Koch SL: Division of the flexor tendons within the digital
sheath, Surg Gynecol Obstet 78:9–22, 1944.

192
Section 2:  Primary Flexor Tendon Surgery
14. McCullough FH: Repair of the flexor pollicis longus tendon.
U.S. Armed Forces Med J 2:1579–1591, 1951.
15. McKenzie AR: Function after reconstruction of severed long
flexor tendons of the hand. A review of 297 tendons, J Bone
Joint Surg (Br) 49:424–439, 1967.
16. Peacock EE: Some technical aspects and results of flexor
tendon repair, Surgery 58:330–342, 1965.
17. Pulvertaft GR: Repair of tendon injuries in the hand-Hunterian
Lecture, Ann R Coll Surg Engl 3:3–14, 1948.
18. Pulvertaft GR: Tendon grafts for flexor tendon injuries in the
fingers and thumb, J Bone Joint Surg (Br) 38:175–194, 1956.
19. Strandell G: Tendon grafts in injuries of the flexor tendons in
the fingers and thumb. End results in a consecutive series of
74 cases, Acta Chirurg Scand 111:124–141, 1956.
20. Kelly AP: Primary tendon repairs, J Bone Joint Surg (Am)
41:581–598, 1959.
21. Koch SL: Division of the flexor tendons within the digital
sheath, Surg Gynecol Obstet 78:9–22, 1944.
22. Kyle JB, Eyre-Brook AL: The surgical treatment of flexor
tendon injuries in the hand, Br J Surg 41:502–511, 1954.
23. Miller H: Repair of severed tendons of the hand and wrist,
Surg Gynecol Obstet 75:693–698, 1942.
24. O’Shea MC: The treatment and results of 87 severed tendons
and 57 severed nerves of the hand and forearm, Am J Surg
43:346–366, 1939.
25. Posch JL: Primary tendon repair, Surg Clin North Am 28:1323–
1340, 1948.
26. Rank BK, Wakefield AR: Flexor tendon repair in the hand, Aust
N Z J Surg 19:135–139, 1951.
27. Siler VE: Primary tenorrhaphy of the flexor tendons in the
hand, J Bone Joint Surg (Am) 32:218–225, 1950.
28. Van’t Hof A, Heiple KG: Flexor-tendon injuries of the fingers
and thumb, J Bone Joint Surg (Am) 40:256–262, 1958.
29. Verdan CE: Primary repair of flexor tendons, J Bone Joint Surg
(Am) 42:647–657, 1960.
30. Nigst H, Megevand RP: La réparation du long fléchisseur du
pouce. Technique de l’élongation du tendon, Helvetica Chir
Acta 4/5:456–459, 1956.
31. Rouhier G: La restauration du tendon du long fléchisseur du
pouce sans sacrifice du tendon primitif, J Chir 66:537–542,
1950.
32. Urbaniak JR, Goldner LJ: Laceration of the flexor pollicis
longus tendon: Delayed repair by advancement, free graft or
direct suture, J Bone Joint Surg (Am) 55:1234–1148, 1973.
33. Urbaniak JR: Repair of the flexor pollicis longus, Hand Clin
1:69–76, 1985.
34. Noonan KJ, Blair WF: Long-term follow-up of primary flexor
pollicis longus tenorrhaphies, J Hand Surg (Am) 16:653–662,
1991.
35. Nunley JA, Levin LS, Devito D, et al: Direct end-to-end repair
of flexor pollicis longus tendon lacerations, J Hand Surg (Am)
17:118–121, 1992.
36. Percival NJ, Sykes PJ: Flexor pollicis longus tendon repair: a
comparison between dynamic and static splintage, J Hand
Surg (Br) 14:412–415, 1989.
37. Thomazeau H, Attali JY, Dréano T, et al: Plaies récentes et
isolées du flexor pollicis longus (20 cas) Revue à long term,
Rev Chir Orthop 82:590–597, 1996.
38. Becker H, Orak F, Duponselle E: Early active motion follow­
ing a bevelled technique of flexor tendon repair: Report on
fifty cases, J Hand Surg 4:454–460, 1979.
39. Duran RJ, Houser RG: Controlled passive motion following
flexor tendon repair in zones 2 and 3. In AAOS Symposium
on Tendon Surgery in the Hand, St Louis, 1975, Mosby, pp
105–114.
40. Early MJ, Milward TM: The primary repair of digital flexor
tendons, Br J Plast Surg 35:133–139, 1982.
41. Gault D: A review of repaired flexor tendons, J Hand Surg (Br)
12:321–325, 1987.
42. Kessler I, Nissim F: Primary repair without immobilisation of
flexor tendon division within the digital sheath, Acta Orthop
Scand 40:587–601, 1969.
43. Mantero R, Bertolotti P, Badoino C, et al: Revisione critica di
20 anno di esperienza sul trattamento delle lesioni dei fles­
sori, Riv Chir Mano 12:87–110, 1974/5.
44. Lister G, Kleinert H, Kutz J, et al: Primary flexor tendon repair
followed by immediate controlled mobilisation, J Hand Surg
2:441–451, 1977.
45. Elliot D, Moiemen NS, Flemming AFS, et al: The rupture rate
of acute flexor tendon repairs mobilized by the controlled
active motion regimen, J Hand Surg (Br) 19:607–612, 1994.
46. Silfverskiöld KL, Andersson CH. Two new methods of tendon
repair: an in vitro evaluation of tensile strength and gap for­
mation, J Hand Surg (Am) 18:58–65, 1993.
47. Smith AM, Evans DM: Biomechanical assessment of a new
type of flexor tendon repair, J Hand Surg (Br) 26:217–219,
2001.
48. Kubota H, Aoki M, Pruitt DL, et al: Mechanical properties of
various tendon suture techniques, J Hand Surg (Br) 21:474–
480, 1996.
49. Baer W, Jungwirth N, Wulle C, et al: Die Beugesehnennaht
nach Mantero eine Alternative, Handchir Mikrochir Plast Chir
35:363–367, 2003.
50. Peck FH, Kennedy SM, Watson JS, et al:An evaluation of the
influence of practitioner-led hand clinics on rupture rates
following primary tendon repair in the hand, Br J Plast Surg
57:45–49, 2004.
51. Giesen T, Sirotakova M, Elliot D: Flexor pollicis longus
primary repair: further experience with the Tang technique
and controlled active mobilisation, J Hand Surg (Eur) 34:
758–761, 2009.
52. Tang JB, Shi D, Gu YQ, et al: Double and multiple looped
suture tendon repair, J Hand Surg (Br) 17:699–703, 1994.
53. Tang JB, Gu YT, Rice K, et al: Evaluation of four methods of
flexor tendon repair for postoperative active mobilisation,
Plast Reconstr Surg 107:742–749, 2001.
54. Tsuge K, Ikuta Y, Matsuishi Y: Intra-tendinous tendon suture
in the hand, Hand 7:250–255, 1975.
55. Tsuge K, Ikuta Y, Matsuishi Y: Repair of flexor tendons
by intratendinous tendon suture, J Hand Surg 2:436–440,
1977.
56. Elliot D: Primary flexor tendon repair-operative repair, pulley
management and rehabilitation: invited personal view,
J Hand Surg (Br) 27:507–513, 2002.
57. Small JO, Brennen MD, Colville J: Early active mobilisation
following flexor tendon repair in zone 2, J Hand Surg (Br)
14:383–391, 1989.
58. Wang B, Xie RG, Tang JB: Biomechanical analysis of a modi­
fication of Tang method of tendon repair, J Hand Surg (Br)
28:347–350, 2003.
59. Cao Y, Tang JB: Biomechanical evaluation of a four-strand
modification of the Tang method of tendon repair, J Hand
Surg (Br) 30:374–378, 2005.
60. Barrie KA, Tomak SL, Cholewicki J, et al: Effect of suture
locking and suture caliber on fatigue strength of flexor tendon
repairs, J Hand Surg (Am) 26:340–346, 2001.
61. Taras JS, Raphael JS, Marczyk SC, et al: Evaluation of suture
caliber in flexor tendon repair, J Hand Surg (Am) 26:1100–
1104, 2001.
62. Mantero R, Bertolotti P, Badoini C: Il pull-out in “no man’s
land” e al canale digitale nelle lesioni dei flessori (metodo
personale), Riv Chir Mano 11:119–130, 1973/4.
63. Brunelli G: Tenorrafia semplificata con materiale estraibile,
Minerva Ortoped 5:321–323, 1954.

193
Chapter 16:  Primary Repair of the Flexor Pollicis Longus Tendon
71. Le Viet D: Flexor tendon lengthening by tenotomy at the
musculotendinous junction, Ann Plast Surg 17:239–246,
1986.
72. Vigliani F, Martinelli B: Repair of rupture of flexor pollicis
longus by ‘Z’ lengthening at the wrist, Ital J Orthop Tr 2:171–
179, 1981.
73. Ebelin M, Le Viet D, Lemerle JP, et al: Chirurgie secondaire
du long fléchisseur du pouce, Ann Chir Main 4:111–119,
1985.
74. Allen BN, Frykman GK, Unsell RS, et al: Ruptured flexor
tendon tenorrhaphies in zone 2: repair and rehabilitation,
J Hand Surg (Am) 12:18–21, 1987.
75. Dowd MB, Figus A, Harris SB, et al: The results of immediate
re-repair of zone 1 and 2 primary flexor tendon repairs which
rupture, J Hand Surg (Br) 31:507–513, 2006.
76. White WL: Secondary restoration of finger function by digital
tendon grafts, Am J Surg 91:662–668, 1956.
77. Buck-Gramcko D, Dietrich FE, Gogge S: Bewertungskriterien
bei Nachuntersuchungen von Beugesehnenweiderherstellun­
gen, Handchir 8:65–69, 1976.
64. Brunelli G, Monini L: Technique personelle de suture des
tendons fléchisseurs des doigts avec mobilisation immédiate,
Ann Chir Main 1:92–96, 1982.
65. Brunelli G, Vigasio A, Brunelli F: Slip-knot flexor tendon
suture in zone 2 allowing immediate mobilisation, Hand 3:
352–358, 1983.
66. Emery FE: Immediate mobilization following flexor tendon
repair, J Trauma 17:1–7, 1977.
67. Grandis C, Rossello MI: Dieci anni di esperienza con il pull-
out intertendineo nella chirurgia dei tendini flessori al canale
digitale (zona 1-2). Ten years experience with intertendinous
pull-out in flexor tendon surgery at the digital canal (zones
1-2), Riv Chir Mano 25:43–49, 1988.
68. Guinard D, Montanier D, Thomas D, et al: The Mantero flexor
tendon repair in zone 1, J Hand Surg (Br) 24:148–151, 1999.
69. Mantero R, Bertolotti P: La mobilisation précoce dans le trait­
ement des lésions des tendons fléchisseurs au canal digital,
Ann Chir Main 30:889–896, 1976.
70. Wulle C: Flexor tendon suture in zone 1 and distal zone 2 by
the Mantero technique, Ann Hand Upper Limb Surg 11:200–
206, 1992.

194
CHAPTER
17 
TREATMENT OF FLEXOR
TENDON INJURIES AT OR
PROXIMAL TO THE WRIST
David Elliot, MA, FRCS, BM, BCh
A
Zone 5 Flexor Tendon Repairs
the ulnar nerves, division of which is almost inevitable
if the main longitudinal structures are divided. These
can, occasionally, cause significant problems of end-
neuroma pain if ignored at primary surgery.3-5
The wounds are generally transverse, or nearly so,
across the wrist. Access is easiest by converting the
wound to an “H” or “Z.” Whatever is done with the skin,
it is unusual to have healing problems with the skin as
whatever extension incisions of the primary laceration
are made surgically to aid access, the flaps so designed
(without thought) will be broad-based, short fasciocu­
taneous flaps with the radial and ulnar arteries feeding
directly into their bases. It is rare to be unable to achieve
safe primary wound closure for this reason.
The tendon repairs are carried out largely using the
techniques used in zone 2, so this will not be discussed
further, except to say that the anatomy mostly allows for
larger core and circumferential sutures than in zones 1
and 2. The tendon repairs are, theoretically, easier than
in the fingers because the tendons are not confined
within a tendon sheath. However, the multitude of
structures and the associated nerve and, sometimes,
arterial injuries make flexor wrist injuries daunting and
long operations for junior training surgeons and these
injuries should not be dismissed by seniors as “good
training cases,” to be left without help to junior sur­
geons. The many structures to be repaired can turn these
operations into marathons in inexperienced hands! It
is, also, often the case that the individual tendons are
not cut transversely but obliquely, with different tendons
cut at different levels relative to the carpal canal or, even,
within the carpal tunnel by shards of glass. The tendons
may be “shredded” longitudinally, making textbook
repairs difficult. Where multiple structures are divided
or surgery is lengthy and, particularly, when the tendon
repairs approximate to the proximal edge of the carpal
ligament on full digital extension, the carpal tunnel
OUTLINE
Recent reports concerning management of zone 5
flexor tendon injuries have identified this injury as
more significant in terms of digital motor dysfunction
than previously thought. Recent research has shown
that, despite a small risk of losing differential tendon
gliding when the superficialis tendons are repaired,
repair of both sets of tendons is beneficial and to be
recommended.
Arguably, flexor tendons are more commonly injured in
the flexor aspect of the distal forearm (zone 5) than in
any other zone, yet less is written about the manage­
ment after tendon divisions in this zone than in any
other. This may relate directly to a comment by Kleinert
and his colleagues over 30 years ago that “tendon gliding
in this area should not be a problem.”1
CLINICAL FEATURES
These cases are an everyday feature of upper limb trauma
units. The mechanisms of injury include laceration by
broken glass (alcohol-related in many instances), sharp
machinery at work, knives, and self-inflicted injuries.
The flexor aspect of the distal forearm transmits eigh­
teen longitudinal structures superficial to the wrist and
carpal joints, with the pronator quadratus lying trans­
versely across the wrist area between the skeleton and
these longitudinal structures. Any, or all, of these struc­
tures can be injured. Most emergency surgery is con­
cerned with the (longitudinal) running flexor tendons,
radial and ulnar arteries, and the median and ulnar
nerves. A “spaghetti” wrist is defined as one with a flexor
laceration in which at least 10 of the 15 longitudinal
structures (11 tendons, 2 arteries, and 2 nerves, exclud­
ing the palmaris longus) have been transected.2 Often
forgotten are the palmar branches of the median and

195
Chapter 17A:  Zone 5 Flexor Tendon Repairs
following failure to repair the FDS tendon in zone 5,
although of less significance, is suggested by a single
case report.13 The possibility of adhesions causing limi­
tation of finger excursion and/or loss of independent
FDS action, despite early mobilization, was not
researched at that time.
The literature on injuries to the flexor aspect of the
distal forearm immediately prior to 2000 is scant.11,13-16
Two of these reports were small and concentrated their
reviews mainly on the injuries to the median and ulnar
nerves and not on the outcome of the finger flexor
tendon injuries.11,16 In 1985, Puckett and Meyer reviewed
37 patients who suffered a minimum of three and an
average of eight completely transected longitudinal
structures at the wrist.15 One-third of their patients had
“spaghetti” wrists. The hands were mobilized postop­
eratively using a Kleinert regimen. Tendon function was
considered to be excellent when digital range of motion
was 85% to 100% of normal or finger flexion brought
the fingertip within 1.0 cm of the distal palmar crease;
good with 70% to 84% of normal digital range of
motion or the fingertip within 2.0 cm of the distal
palmar crease; fair with 50% to 60% of normal digital
range of motion; or poor with fixed contractures or
adhesions. Thirty-three (97%) of 34 wrists available for
assessment were reported to have good or excellent
ranges of digital motion and one patient to have a fair
range of motion. The method by which the overall
results were derived from the assessment of the indi­
vidual fingers was not given. No tendon ruptures
occurred in their series.
In 1992, Stefanich et al13 reported independent FDS
action in only 30% of a retrospective series of 23 patients
who underwent zone 5 flexor tendon repairs that were
mobilized using Kleinert’s early mobilization (active
extension-passive flexion) regimen. In this series, five
patients had transection of a single digital (finger or
thumb) flexor tendon and 18 patients had transections
of multiple digital flexor tendons. The total active
motion (TAM) of the associated digits as well as for the
corresponding unaffected digits was calculated, as sug­
gested by the American Society for Surgery of the Hand,
but, unfortunately, the associated scoring system of
excellent/good/fair/poor was not recorded. Instead the
average TAM (as a percentage of the uninjured contra­
lateral digit) was given for the whole group of 23 patients
for each of the five digits. Sixteen of the 23 patients
regained full digital flexion of all digits but the number
of digits in these patients that had not suffered flexor
tendon injury was not stated. There was an average PIP
extension deficit of 8° and distal interphalangeal exten­
sion deficit of 4°. Two patients (9%) had extremely
limited motion. Rupture of one flexor pollicis longus in
one patient and rupture of one ring finger flexor digito­
rum profundus (FDP) in an additional patient occurred
should be decompressed to avoid both the development
of secondary carpal tunnel syndrome6 and loss of exten­
sion as a result of the tendon repairs impinging on the
carpal ligament on full extension of the wrist and digital
joints.
Following surgery, these injuries are mobilized using
the same regimes as zone 2 injuries and these are not
discussed further. When the carpal ligament has been
divided, the fingers are mobilized with the wrist splinted
in the neutral position or slight extension. In other cir­
cumstances, a straight wrist or only slightly flexed wrist
position may be preferred, but it should be remembered
that the 30° flexed wrist position originally advocated
for rehabilitation is little different from the Phalen test
we use to irritate the median nerve when diagnosing
carpal tunnel syndrome and may precipitate this
problem postoperatively if the carpal ligament remains
intact.
One point about rehabilitation of zone 5 flexor
tendon repairs that is unique to this zone is that there
will be no intrinsic proximal interphalangeal (PIP) joint
extensors of the ulnar fingers if the ulnar nerve has also
been divided. This requires that the metacarpophalan­
geal (MCP) joints of these fingers be held in flexion
during the 4-week postoperative splinting period to acti­
vate PIP extension by the long extensor tendons, if PIP
joint contractures are to be avoided.7
It is also frequently forgotten by surgeons what may
be being asked of a patient with a spaghetti, or near-
spaghetti, wrist. At 1 to 3 days after surgery, the patient
is being expected to move a large number of swollen
tendons, possibly bristling with unabsorbable suture
ends and tightly bound down by swollen fasciocutane­
ous flaps across repaired median and/or ulnar nerves.
This is painful! Mobilization may be hindered by lack
of adequate analgesia, making the therapist’s job impos­
sible and the ultimate result less than perfect.
THE FLEXOR DIGITORUM SUPERFICIALIS
TENDONS: TO REPAIR OR NOT
Until the introduction of early mobilization of flexor
tendon repairs in the latter half of the twentieth century,
it was believed that repair of divided flexor digitorum
superficialis (FDS) tendons following wrist lacerations
in which both the superficial and deep digital flexor
tendons had been divided caused adhesions with limi­
tation of excursion of the associated fingers.8,9 However,
the superficial digital flexors increase the grip of the
hand and make pinch and flexion of the PIP joint more
stable, in addition to providing superior individual
finger flexion.10 For these reasons and, possibly, reas­
sured by the comment that “tendon gliding in this area
should not be a problem,”1 repair of the superficial
digital flexors became routine with the advent of early
mobilization.1,10-12 The possibility of PIP hyperextension

196
Section 2:  Primary Flexor Tendon Surgery
action after repair of the FDS at the wrist in this study
may include fewer failures of mobilization than is sug­
gested by our figures as it has been shown that the
superficialis tendon of the little finger, although present
at the wrist, cannot achieve flexion of this finger in one-
third of normal individuals.18,19
For the first time, an analysis was presented to math­
ematically to analyze these injuries in terms of the effect
on overall hand function rather than by consideration
of the individual fingers that had sustained division of
flexor tendons at the wrist. This showed that there was
a statistically significant interdependence of the flexor
systems of the different fingers in those wrists with inju­
ries to the flexors of all four fingers. This indicates that
the consequences of this injury in respect of hand func­
tion are more complex than the mere sum of its con­
stituent tendon injuries and future attempts to assess
the zone 5 injury need to change to reflect this
complexity.
Since our study, few reports on zone 5 have been
written.20-24 Two of these studies lend support to the
benefit of active, as opposed to passive, mobilization of
zone 5 flexor repairs.22,23 In 2005, Wilhelmi et al reviewed
168 zone 5 tendon flexor divisions24 repaired using their
own core suture technique and mobilized early using a
technique of protected active motion similar to that
reported by Silfverskiöld and his colleagues from Göte­
borg in Sweden25 in 29 patients treated over 4 years.
Despite the emphasis of the authors on the strength and
benefits of their particular suture technique, three rup­
tured tendons occurred in one patient. Of more interest
was the use of a technique of mobilization that opti­
mized differential gliding between the FDS and FDP
tendons. This allowed these authors to achieve good or
excellent results in 97 (99%) of 103 fingers and inde­
pendent FDS action in 88 (91%) of 103 fingers. These
authors stressed loss of extension in patients with con­
comitant ulnar nerve injuries as responsible for their
few less than perfect results.
The benefits of FDS function favor repair of the FDS
tendons in zone 5 flexor tendon injuries. There would
appear to be no logical basis for not repairing the FDS
tendons at the wrist as the use of a supervised active
mobilization regimen in the early postoperative period
is likely to achieve a high proportion of good and excel­
lent results in terms of finger movement and a good
chance of retaining independent action of the superfi­
cial finger flexors.
in their series. This report reintroduced the question of
adhesion of the flexor tendons after repair of both
tendon groups in zone 5 and the possibility that loss of
digital excursion and/or independent FDS action is
more common than had been assumed.
Subsequent to this small study,13 we carried out a
larger prospective study17 over a 2-year period to examine
the results of routine repair of both finger flexor tendons
in zone 5 followed by early postoperative mobilization
using the variant of the controlled active mobilization
(active extension-active flexion) regimen described pre­
viously and used routinely in our unit.14 In this study,
after mobilizing the injured hands using an early active
motion regimen, good or excellent results were achieved
in 90% of fingers that had repair of completely divided
flexor tendons in zone 5 and independent FDS action
was achieved in 66% of the fingers. No tendon ruptures
occurred in this series. The group of patients with “FDS
injuries only” fared better than those with ‘“FDS and
FDP” injuries in terms of independent FDS action, the
difference being statistically significant. This most prob­
ably reflects the difference in magnitude of the total
injury to the wrist between those with more superficial
injuries and deeper injuries, rather than simply a differ­
ence between division of one or two tendon groups.
Multivariate analysis showed that the presence of a “spa­
ghetti” wrist injury had a significant adverse effect on
the overall hand recovery in terms of independent FDS
action but had no significant adverse effect on the
overall hand recovery in terms of digital range of motion.
While the extensive scar tissue likely to follow a “spa­
ghetti” wrist injury might be expected to eliminate dif­
ferential gliding of the tendons, the resultant tendon
mass appeared to be capable of moving the fingers
through a full, or near full, range of motion in most
cases. Age was not a significant factor in determining
recovery of either independent FDS action or range of
digital motion. A statistically significant association
between recovery of independent FDS action and recov­
ery of the digital range of motion appears to confirm
that wrists that do well with respect to one modality will
do well with respect to the other. Those fingers with FDS
tendons lying close to the FDP tendons at the wrist—
namely, the index and little—are more likely to lose
independent FDS action after division and repair of
their tendons at the wrist. The little finger had the lowest
incidence of independent FDS action in this study.
However, those little fingers without independent FDS
References
1. Kleinert HE, Kutz JE, Atasoy E, et al: Primary repair of flexor
tendons, Orthop Clin North Am 4:865–876, 1973.
2. Katz RG: Discussion. Results of treatment of extensive volar
wrist lacerations; the spaghetti wrist, Plast Reconstr Surg
75:720–721, 1985.
3. Atherton DD, Leong JCS, Anand P, et al: Relocation of painful
end neuromas and scarred nerves from the zone II territory
of the hand, J Hand Surg (Eur) 32:38–44, 2007.
4. Evans GRD, Dellon AL: Implantation of the palmar cutane­
ous branch the median nerve into the pronator quadratus for

197
Chapter 17A:  Zone 5 Flexor Tendon Repairs
16. Rogers GD, Henshall AL, Sach RP, et al: Simultaneous lacera­
tion of the median and ulnar nerves with flexor tendons at
the wrist, J Hand Surg (Am) 15:990–995, 1990.
17. Yii NW, Urban M, Elliot D: A prospective study of flexor
tendon repair in zone 5, J Hand Surg (Br) 23:642–648, 1998.
18. Austin GJ, Leslie BM, Ruby LK: Variations of the flexor digi­
torum superficialis of the small finger, J Hand Surg (Am)
14:262–267, 1989.
19. Baker DS, Gaul JS, Williams VK, et al: The little finger
superficialis–clinical investigation of its anatomic and func­
tional shortcomings, J Hand Surg (Am) 6:374–378, 1981.
20. Bircan C, El O, Akalin E, et al: Functional outcome in patients
with zone V flexor tendon injuries, Arch Orthop Trauma Surg
125:405–409, 2005.
21. Gibson TW, Schnall SB, Ashley EM, et al: Accuracy of the
preoperative examination in zone 5 wrist lacerations, Clin
Orthop Relat Res 365:104–110, 1999.
22. Korstanje JW, Schreuders TR, van der Sijde J, et al: Ultrasono­
graphic assessment of long finger tendon excursion in zone
V during passive and active tendon gliding exercises, J Hand
Surg (Am) 35:559–565, 2010.
23. Panchal J, Mehdi S, Donoghue JO, et al: The range of excur­
sion of flexor tendons in zone V; a comparison of active and
passive flexion mobilisation regimes, Br J Plast Surg 50:517–
522, 1997.
24. Wilhelmi BJ, Kang RH, Wages DJ, et al: Optimizing indepen­
dent finger flexion with zone V flexor repairs using the Mas­
sachusetts General Hospital flexor tenorraphy and early
protected motion, J Hand Surg (Am) 30:230–236, 2005.
25. Silverskiöld K, May E: Flexor tendon repair in zone II with a
new suture technique and an early mobilization program
combining passive and active flexion, J Hand Surg (Am)
19:53–60, 1994.
treatment of painful neuroma, J Hand Surg (Am) 19:203–206,
1994.
5. Sood MK, Elliot D: Treatment of painful neuromas of the
hand and wrist by relocation into the pronator quadratus
muscle, J Hand Surg (Br) 23:214–219, 1998.
6. Figus A, Iwuagwu FC, Elliot D: Subacute nerve compressions
after trauma and surgery of the hand, Plast Reconstr Surg
120:705–712, 2007.
7. Elliot D: Primary flexor tendon repair: operative repair, pulley
management and rehabilitation, J Hand Surg (Br) 27:507–
513, 2002.
8. Carroll RE, Match RM: Common errors in the management
of wrist lacerations, J Trauma 14:553–562, 1974.
9. Verdan C: Practical considerations for primary and secondary
repair in flexor tendon injuries, Surg Clin North Am 44:951–
970, 1964.
10. Kleinert HE, Meares A: In quest of the solution to severed
flexor tendons, Clin Orthop Relat Res 104:23–29, 1974.
11. Hudson DA, de Jager LT: The spaghetti wrist. Simultaneous
laceration of the median and ulnar nerves with flexor tendons
at the wrist, J Hand Surg (Br) 18:171–173, 1993.
12. Strickland JW: Flexor tendon repair, Hand Clin 1:55–68,
1985.
13. Stefanich RJ, Putnam MD, Peimer CA, et al: Flexor tendon
lacerations in zone V, J Hand Surg (Am) 17:284–291,
1992.
14. Elliot D, Moiemen NS, Flemming AFS, et al: The rupture
rate of acute flexor tendon repairs mobilised by the con­
trolled active motion regimen, J Hand Surg (Br) 198:607–
612, 1994.
15. Puckett CL, Meyer VH: Results of treatment of extensive volar
wrist lacerations; the spaghetti wrist, Plast Reconstr Surg 75:
714–721, 1985.

198
Jun Tan, MD, and Jin Bo Tang, MD
B
Methods and Outcomes of Zone 5
Flexor Tendon Repairs
longitudinal incision suffices. The distal tendon ends
are easily brought into the operative field after wrist
flexion and the wrist is held in flexion by an assistant
during surgery. Because of frequent lacerations in nerve
trunks, particular care must be taken to identify the
tendons and nerves and to suture the corresponding
ends correctly. Careful attention to their locations in the
wound, diameters and the shape of the lacerated struc­
tures, and the oblique angle of their cross sections help
produce a proper match of the tendon ends.
Adhesion formations between tendon injuries and
overlying skin and fascia are frequent, but subsequent
limitations to active finger motion vary. In a majority of
cases, adhesions between the tendons and loose
paratenon are not problematic, because the adhesions
are not as restrictive as those between the tendon and
fibroosseous sheath or the firm flexor retinaculum.
Severe adhesions can arise between multiple tendons
and affect the motion of multiple digits, subsequently
requiring secondary tenolysis.
The median and ulnar nerves and the radial and ulnar
arteries are frequently involved. The median nerve is
more frequently cut than the ulnar nerve, and the lacera­
tions to the ulnar artery are more frequent than those
to the radial artery. Because the ulnar nerve and artery
are located so close together in the distal forearm, injury
to the artery is almost always accompanied by injury to
the nerve. In the presence of intact radial artery and
positive Allen’s test, the severed ulnar artery may not
require anastomosis, but the ulnar nerve should always
be repaired primarily if no lengthy defect presents.
We reviewed the records of 52 patients (52 wrists)
treated in our clinic and found that 43 wrists (83%) had
complete lacerations to median or ulnar nerves, with
median nerve cut in 31 (59%) and ulnar nerve cut in 21
(40%). Both median and ulnar nerves were lacerated in
nine wrists (17%). Twenty-nine (56%) had complete
or major severance of ulnar (40%) artery, radial (26%)
artery, or both (10%). Lacerations in anterior cutaneous
branches of median or ulnar nerves (which need no
repair) were seen in almost all cases. We repaired all
severed median and ulnar nerves primarily with direct
end-to-end suture along with tendon repairs.
We should emphasize that cases necessitating second­
ary tenolysis and secondary surgery are not rare. We
OUTLINE
Flexor tendons in zone 5 are located in the distal and
middle parts of the forearm. A severe injury can
produce “spaghetti wrist,” namely, lacerations of 10 or
more structures, including tendons, nerves, and vessels.
In this chapter, we present our current methods for
repair of zone 5 flexor tendon injuries and follow-up
of 52 patients. Recovery of active digital motion and
grip strength are generally good, but functional loss
caused by accompanying nerve injuries is a concern.
Repairs by experienced surgeons produce better recov­
ery. Outcomes of “spaghetti” injury are worse than
those of less severe injuries.
The region of the distal and middle forearm, which
extends from the proximal border of the transverse
carpal ligament to the musculotendinous junctions of
the forearm flexors, contains zone 5 flexor tendons. In
the forearm, the flexor digitorum profundus (FDP) has
a single muscle belly and travels distally to separate into
a radial bundle and an ulnar bundle. The radial bundle
forms the FDP tendon to the index finger, and the ulnar
bundle forms the FDP tendons of the middle, ring, and
small fingers. The flexor digitorum superficialis (FDS)
separates into individual tendon units and muscle
bellies. No synovial sheath covers the tendons in this
region.
Tendon lacerations in this zone are easy to diagnose;
with rare exceptions, all the injuries are repaired primar­
ily. Secondary surgeries are reserved for tenolysis or
nerve grafting. Wound contamination can be a serious
concern if the patients are injured by dirty tools or oily
machines. Thorough irrigation of the wounds and
débridement of wounds are particularly necessary,
together with intravenous administration of antibiotics
to prevent wound infection.
We perform primary, rather than “delayed” primary
repairs, for tendons injured in zone 5, because these
wounds are open and in many cases are extensive. The
tendon ends are easily found during surgery. The
proximal tendon ends may retract, but not over a
long distance. Additional incisions are in most cases
not required to locate the retracted tendon ends. If
proximal tendon ends retract too proximally, a single

199
Chapter 17B:  Methods and Outcomes of Zone 5 Flexor Tendon Repairs
department, including the current authors. We repaired
flexor tendons using one of three methods: a two-strand
modified Kessler method (with either 4-0 or 3-0 sutures),
a four-strand cruciate method (with either 4-0 or 3-0
sutures), or a six-strand Tang (or M-Tang) method1,2
(with 4-0 looped nylon sutures), supplemented with a
simple running or locking circumferential suture (with
a 5-0 or 6-0 nylon suture). Choice of repair methods
remains a personal preference; over the last a few years,
we have tended to use four- or six-strand repairs, and
two-strand Kessler repairs were used only sometimes.
When multiple tendons were repaired in a single patient,
a mixture of simple or more complicated methods were
used, which reduces the total operation time.
Postoperative Care
After surgery, a cast or a thermoplastic splint with the
wrist in flexion of 20° to 30° and the fingers in slightly
flexed position is used to protect the hand (Figure
17[B]-2). We used a motion protocol similar to that
used for zone 2 tendon repair1 but under less stringent
perform 10 to 15 cases of secondary surgeries for zone 5
flexor tendons (and their accompanying nerve repairs)
annually. Around three-fourths of the patients are
referred from local hospitals where primary repair is
done. The secondary surgeries are indicated in one of
the following situations: (1) adhesions form between
multiple tendons, (2) tendon adhesion with skin
wounds, (3) nerves are not sutured during primary
surgery, or (4) infrequently, loss of proper finger flexion,
due to improper match of the tendon ends (e.g., wrong
tendon-to-tendon match, or tendon is sutured to a
nerve). Among the zone 5 injures that are treated primar­
ily in our unit, 7% of the wrists need secondary tenolysis
due to formation of adhesions among multiple tendons.
In our unit, we routinely repair lacerated nerve trunks
primarily, and tendons are carefully identified to ensure
proper match, but this is not always the case in the
hospitals when injuries are handled by surgeons with
inadequate training. In such cases, the complications
rate of zone 5 tendon repairs can be higher, including
(1) improper primary treatment of the tendons, such as
mismatching of the tendon ends or suturing nerves to
tendons, (2) failure to repair the lacerated nerves, and
(3) extensive adhesion formations involving multiple
tendons.
PATIENTS AND OUTCOMES
Patients
In 2010, we reviewed the medical charts of the patients
admitted after surgery for primary repairs of zone 5
tendon injuries over the previous 6 years. We were
unable to include a small number of patients who had
lacerations to a single tendon in forearms because they
were discharged immediately after surgery. Cases of
massive soft tissue loss, extensor tendon injuries, hand
fractures, or replantation surgery were excluded, as were
patients younger than 12 years. A total of 69 patients
with intact medical records were reviewed. Follow-up
was available for 52 patients. The average follow-up
period was 2 years 8 months (range, 11 to 78 months).
There were 41 males and 11 females, with a mean age
of 35 years (range, 15 to 57 years).
The flexor tendons to 163 digits (14 thumbs, 35 index,
44 middle, 42 ring, and 28 small fingers) were involved.
There were 14 flexor pollicis longus (FPL) tendon cuts,
82 FDP tendon cuts, and 147 FDS tendon cuts.
Of the 52 patients, 16 (30.7%) had “spaghetti”
wrists (i.e., at least 10 structures lacerated, involving
tendons, nerves, and arteries, not including cutaneous
nerve branches and palmaris longus tendon) (Figure
17[B]-1).
Surgical Methods
All patients were treated with primary surgery within 12
hours after trauma by staff hand surgeons in our
Figure 17(B)-1  The distal part of the left forearm of a
36-year-old patient was cut with a knife, presenting a
“spaghetti” injury involving complete cut of 11 tendons, two
nerves (median and ulnar), and ulnar artery.
Figure 17(B)-2  A thermoplastic splint is applied with the
wrist in flexion of 20° to 30° and the fingers in slightly
flexed position after surgery.

200
Section 2:  Primary Flexor Tendon Surgery
Patients under 35 years of age were more likely to
have satisfactory outcomes than were patients over 35
years of age (p < 0.01). Outcomes in the nondominant
hand were significantly worse than when the dominant
hand was involved (p < 0.01). Outcomes in the fingers
with a mixture of FDS and FDP injuries were worse than
those of only FDS injuries (p < 0.01). Gender and
follow-up time (from 11 months to 6.5 years) were not
associated with any significant differences in the out­
comes of digital range of motion and independent FDS
action.
Worse outcomes were significantly associated with
repairs performed by surgeons with lower levels of
expertise4 (Figure 17[B]-3).
Sixteen cases had “spaghetti” wrists. Grip and pinch
strength, DASH, active range of digital motion, and
independent FDS motion of the spaghetti wrists were
significantly worse as compared with non-spaghetti
wrists (p < 0.01). Grip and pinch strength of spaghetti
wrists recovered to only about one-third of the unin­
volved side (Table 17[B]-1).
SUMMARY
We were able to perform primary tendon repairs in all
the cases brought to us. Over the past 6 years, no cases
were unsuitable for primary repair, which would have
necessitated delayed or secondary tendon repairs. None
of the cases developed serious wound infection. Patients
with an extensive wound were given intravenous anti­
biotics, and particular care was taken to irrigate the
wound. We consider that thorough wound irrigation
and débridement are an important part of treatment.
supervision. Typically, patients begin the early passive-
active motion on postsurgical day 3 or 4 under the
supervision of surgeons and therapists while they are
still hospitalized. During the first 3 weeks, in each exer­
cise session, passively placing the fingers into flexion
and extension position is initiated first, followed by
active motion over the amplitude at which the motion
does not encounter marked resistance.
Within the first 3 weeks, when multiple tendons are
lacerated or the tendon repairs are accompanied by
direct nerve approximation, we do not encourage
patients to move actively through the full range of finger
motion. Instead, we encourage them to move in a rela­
tively small range, just enough to move the tendons in
the forearm, avoiding pain, potential bunching of the
repaired tendons, or disturbance to the nerves by
tendons. The patients move to the extent they feel com­
fortable. Flexion of the wrist is a component of the
motion protocol.
At the end of week 3, a dorsal extension block splint
is applied to keep the wrist at 30° extension. From the
third to fifth weeks, the dorsal splint is discontinued
gradually and further active and passive finger flexion is
emphasized. After 5 weeks, the splint is discarded. After
6 to 7 weeks, the patients return to normal activities.
Differential FDS and FDP motion exercise can be started
from the second or third weeks, and continue for 3 to
4 weeks.
Exercise can be controlled more loosely than zone 2
repairs. The number of exercise sessions each day varies
among patients. Generally, at least four or five sessions
are encouraged daily, but it is not necessary to perform
exercise hourly. Each session consists of about 20 to 30
repetitions of motion; active motion precedes passive
motion.
Outcomes
Consistent with the results reported previously, we
found that tendon repairs in zone 5 generally yield quite
satisfactory results, but we also noted that patients with
severe injuries or whose repairs were carried out by
junior surgeons had a higher percentage of digits func­
tionally ranked as “fair” or “poor.”
Graded using Strickland and Glogovac criteria3 for
the range of active digital motion among 163 digits of
52 patients, excellent results were achieved in 123 digits
(75.5%), good in 23 (14.1%), fair in 12 (7.4%), and
poor in 5 (3%). The good and excellent rate was 89.6%.
No repairs ruptured. Independent FDS action was dem­
onstrated in 103 (70.1%) of the 147 fingers with FDS
injuries. Grip strength recovered to an average of 68%
and tip pinch strength to 65% of the uninjured hand,
respectively. Mean DASH (Disabilities of the Arm,
Shoulder and Hand) score was 11.9 (SD 11.0, range 1.7
to 40).
Figure 17(B)-3  The graph showing correlation between
expertise levels of surgeons and functional outcomes. The
outcomes in terms of active range of digital motion treated
by more experienced surgeons (Levels 3 and 4) are better
than junior surgeons (Level 2)* or residents (Level 1).** The
numbers shown in the bars are number of fingers evaluated.
0
10
20
30
40
50
60
70
Good
Fair
Poor
80
90 100
% Functional recovery
2
1
3
22
10
7
2
*
**
5
11
66
31
3
Excellent
I
II
III
IV
Level of expertise

201
Chapter 17B:  Methods and Outcomes of Zone 5 Flexor Tendon Repairs
tendon ends are crushed. We consider repairs to the FDS
tendon a positive option, favoring gain in grip strength.
Nevertheless, no clinical data indicate whether lacerated
FDS tendon repairs are absolutely necessary or whether
only a part of the lacerated FDS tendons need to be
repaired. If the FDS tendons are to be selectively repaired
to reduce operation time or reduce the chance of adhe­
sions, we usually repair the FDS to the index and middle
fingers.
One of us (the senior author) proposed classification
and documentation of the level of expertise of sur­
geons4; we considered zone 5 injuries a perfect test
ground in which to apply such criteria to analyze pos­
sible associations between expertise levels and treat­
ment outcomes. In fact, outcomes were correlated
positively with expertise levels. While the results of zone
5 tendon repairs are generally considered favorable, we
found that this injury is more likely to have a better
outcome in more experienced hands within our unit.
When treated by experienced surgeons, patient out­
comes were rated as good or excellent in nearly all cases;
the few cases with poor results were all treated by junior
staff members.
Accompanying nerve injuries in this area present a
greater concern than tendon lacerations. Loss of hand
function is mostly due to incomplete recovery of associ­
ated nerve injuries (Figure 17[B]-4). Inadequate active
finger extension is not infrequently, caused by incom­
plete functioning of the intrinsic muscles.
The “spaghetti” wrist consists of severe trauma to
the soft tissues of the wrist.8 Previous studies indicated
that a spaghetti wrist was associated with poor indepen­
dent FDS action.1,3-6 Our results are consistent with pre­
vious findings. Spaghetti wrist trauma produces a severe
adverse effect on overall hand function. Grip and pinch
strength of such wrists recovered to only about one-
third that of the contralateral side. After median or ulnar
nerve injuries, intrinsic muscles do not function nor­
mally, which contributes to decreased grip strength and
the inability to perform fine hand actions.
Proper identification of nerves and tendons during
surgery is important to ensure correct surgical repair.
Particularly, junior surgeons can confuse two different
structures.
Our follow-up findings indicate that it is not abso­
lutely necessary to use four- or six-strand repairs for
zone 5 tendon injuries, but this has become a preference
in our unit in recent years. We suggest that stronger
repair methods be used, rather than the weaker conven­
tional Kessler repairs. Alternatively, it is also proper to
use 3-0 suture rather than 4-0 suture to enhance repair
strength. We do not have recommendations about the
particular one or two methods that should be used in
zone 5; methods vary. In our unit, we use a cruciate
repair or a six-strand M-Tang repair. At a hand surgery
center in a neighboring city, surgeons use a four-strand
U-shaped method (another method developed by the
senior author5) with 4-0 looped suture together with a
running peripheral suture. The surgeons achieved gener­
ally good and excellent results in more than 25 cases
without repair ruptures over the past 3 years (Zun Shan
Ke, MD, personal communication, 2011). We have not
used the U-shaped method in zone 5 repairs; a six-
strand M-Tang method has been adopted.
In our cases, 89% of the digits have good or excellent
active range of digital motion, and 70% fingers exhib­
ited independent FDS action. An overall good and excel­
lent rate of 90% was reported by Yii et al,6 though they
used American Society for Surgery of the Hand (ASSH)
criteria; those are in fact different from the criteria in
our follow-up. The thumb was not included into the
grading by Yii et al. Our cases appeared to have more
severe vascular injuries. In the past reports, the propor­
tion of independent FDS action varied from 30% to
85% of the fingers after zone 5 tendon repairs.7-14
Regarding the number of tendons to repair, all the
wrist flexors except the palmaris longus tendon should
be repaired. While FDP and FPL tendon repairs are nec­
essary, it may not be necessary to repair all the FDS
tendons, particularly if the wounds are untidy and
Table 17(B)-1  Comparison of Outcomes Between the Wrists With “Spaghetti” and “Non-Spaghetti” Zone 5
Tendon Injuries
Injuries
No. of
Patients
Digital Range of Motion*
Independent
FDS Action
(Digits)*
Grip
Strength
(%)*
Pinch
Strength
(%)*
DASH
Scores
Excellent
Good
Fair
Poor
Total
Digits
Spaghetti
16
42
(62.7)
15
(22.4)
8
(11.9)
2
(3.0)
67
36 (59.0)
50 ± 26
47 ± 25
21 ± 12
Non-
spaghetti
36
81
(84.4)
8
(8.3)
4
(4.2)
3
(3.1)
96
67 (77.9)
75 ± 18
75 ± 20
8 ± 8
Grip and pinch strengths of the injured side were recorded as percentage of the contralateral side. Numbers in parentheses are percentages.
Digital range of motion was examined by the nonparametric Mann-Whitney U test; other comparisons were done with student t test.
*Of significant difference between two types of injuries.

202
Section 2:  Primary Flexor Tendon Surgery
Figure 17(B)-4  Findings of a patient with spaghetti wrist injury 2 years 8 months after primary tendon and ulnar nerve
repair. The patient recovered full digital extension (A), and full flexion (B). Note the patient was unable to abduct the little
finger (A [arrow]) due to incomplete recovery of ulnar nerve function. There were mild hypotrophy of intrinsic muscles and
flattened hypothenar area (A). Incomplete function of intrinsic muscles presented as a prominent problem. Recovery of grip
strength was also incomplete.
A
B
References
1. Tang JB: Indications, methods, postoperative motion and
outcome evaluation of primary flexor tendon repairs in Zone
2, J Hand Surg (Eur) 32:118–129, 2007.
2. Tang JB: Clinical outcomes associated with flexor tendon
repair, Hand Clin 21:199–210, 2005.
3. Strickland JW, Glogovac SV: Digital function following flexor
tendon repair in Zone II: A comparison of immobilization
and controlled passive motion techniques, J Hand Surg (Am)
5:537–543, 1980.
4. Tang JB: Re: Levels of experience of surgeons in clinical
studies, J Hand Surg (Eur) 34:137–138, 2009.
5. Cao Y, Tang JB: Biomechanical evaluation of a four-strand
modification of the Tang method of tendon repair, J Hand
Surg (Br) 30:374–378, 2005.
6. Yii NW, Urban M, Elliot D: A prospective study of flexor
tendon repair in zone 5, J Hand Surg (Br) 23:642–648, 1998.
7. Bircan C, EI O, Akalin E, et al: Functional outcome in patients
with zone V flexor tendon injuries, Arch Orthop Trauma Surg
125:405–409, 2005.
8. Puckett CL, Meyer VH: Results of treatment of extensive volar
wrist lacerations: the spaghetti wrist, Plast Reconstr Surg
75:714–721, 1985.
9. Noaman HH: Management and functional outcomes of com­
bined injuries of flexor tendons, nerves, and vessels at the
wrist, Microsurg 27:536–543, 2007.
10. Weinzweig N, Chin G, Mead M, et al: “Spaghetti wrist”:
management and results, Plast Reconstr Surg 102:96–102,
1998.
11. Jaquet JB, van der Jagt I, Kuypers PD, et al: Spaghetti wrist
trauma: functional recovery, return to work, and psychologi­
cal effects, Plast Reconstr Surg 115:1609–1617, 2005.
12. Stefanich RJ, Putnam MD, Premier CA, et al: Flexor tendon
lacerations in zone V, J Hand Surg (Am) 17:284–291, 1992.
13. Wilhelmi BJ, Kang RH, Wages DJ, et al: Optimizing indepen­
dent finger flexion with zone V flexor repairs using the
Massachusetts General Hospital flexor tenorrhaphy and early
protected active motion, J Hand Surg (Am) 30:230–236,
2005.
14. Katz RG: Discussion. Results of treatment of extensive volar
wrist lacerations: the spaghetti wrist, Plast Reconstr Surgt 75:
720–721, 1985.

203
CHAPTER
18 
FLEXOR TENDON REPAIRS
WITH NOVEL SUTURES
AND DEVICES
Ombretta Spingardi, MD, Mario Igor Rossello, MD,
and Renzo Mantero, MD
A
Mantero’s Technique for
Tendon Repair
with consequent acquired and permanent deformity
and stiffness of the joints was remarkably decreased.
INDICATIONS
Any clean-cut injury of the flexor digitorum profundus
(FDP) tendon in zone 2 or the flexor pollicis longus
(FPL) tendon in zone 2 can be repaired with this tech­
nique. This method is also indicated for FDP tendon
injuries in proximal zone 1, where direct end-to-end
tendon repair is necessary.1,4-6 However, we do not use
this method in the case of complex trauma (e.g., ampu­
tation or tendon injury associated with exposed frac­
ture), because early motion is not possible, and the
button on the top of the finger carries a risk of causing
ischemia in situations in which digital circulation is
already poor.
When both the FDS and FDP tendons are injured,
the FDS tendon can be repaired with any end-to-end
repair method in association with FDP repair by our
method.
SURGICAL TECHNIQUES
Under regional anaesthesia, two cut tendon ends are
exposed through a Bruner’s skin incision. A needle (size:
20G) used for spinal anesthesia is inserted from the
fingertip and passed through the distal FDP tendon
stump, from distal to proximal. Then, a 2-0 nylon thread
is passed in the proximal tendon stump for 1 to 1.5 cm
from the cut creating an Ω-shaped loop. The needle is
then cut and the two ends of the suture are passed in
the distal tendon stump by the previously inserted
needle. The thread is pulled out from the tip of the
finger and its two ends are secured over a mother-of-
pearl button with multiple knots (Figures 18[A]-1 to
18[A]-6). For all repairs, ensuring correct coaptation of
OUTLINE
We present our experience with pull-out repairs of
flexor digitorum profundus (FDP) tendon injuries in
zone 2. Since 1973, we have repaired zone 1 and 2
tendon injuries with the Bunnell technique of pull-out
suture through the fingertip, together with immediate
active digital mobilization of patients. We followed a
sample of patients with zone 2 FDP tendon lacerations
treated between 2005 and 2008, and no patients had
rupture of the repairs. We assessed the outcomes of
one group of 46 patients (46 digits) by evaluating
subjective and objective function; 33 digits (72%) had
good or excellent results. We also compared the results
in 22 digits treated with the pull-out method to those
in 22 digits after two-strand surgical repairs. We noted
faster recovery of active finger flexion and grip strength
after the pull-out method. Poor results were seen only
when tendon mobilization was begun too late or was
insufficient.
Flexor tendon surgery has made much progress since
the 1970s due to accrued knowledge of the biology of
tendon tissue repair and great improvement in suture
techniques and postoperative mobilization concepts.
However, tendon repair in zone 2 still is a problem due
to the high risk of adherence and consequent limitation
of range of active motion, even when early postopera­
tive protected motion is adopted.
The pull-out technique was described by Bunnell in
the beginning of the 20th century for tendon repair.
Mantero and colleagues1-3 started using the technique
in 1973 in association with immediate postoperative
active motion. With this regimen, the occurrence of
tendon adherence and an hypertrophic cutaneous scar

204
Section 2:  Primary Flexor Tendon Surgery
Figure 18(A)-1  Illustration of the pull-out technique. The
needle is passed through the distal part of the tendon after
an Ω-shaped loop is made in the proximal tendon stump.
Distal
tendon
stump
Proximal
tendon
stump
Figure 18(A)-2  Passing the thread through the distal
tendon stump.
Distal
tendon
stump
Proximal
tendon
stump
Figure 18(A)-3  A case of zone 2B flexor tendon injury in a
child and skin incisions to expose the tendons.
Figure 18(A)-4  The retracted proximal tendon stump was
exposed and pulled distally under the A2 pulley.
Figure 18(A)-5  The Ω-shaped suture was placed in the
proximal stump of the tendon.

205
Chapter 18A:  Mantero’s Technique for Tendon Repair
POSTOPERATIVE CARE
Immediate active motion is the keystone to success with
this technique and it has to start as soon as possible.1-4
In particular, full extension of the proximal interphalan­
geal (PIP) joint must be achieved in the first few days
after surgery. On the first day, the dressing is reduced
and the patient can start active digital motion with the
wrist in a protected position (wrist in flexion). Daily
homework is given to the patient, so that he or she can
be autonomous, not only in moving but also in clean­
ing and renewing the dressings if necessary. One week
later, the wound is checked and any remaining swelling
is controlled. If possible, a smaller dressing is placed to
allow a wider range of motion. The range of active
digital flexion is increased gradually (Figure 18[A]-7).
At about 21 days, it is important to observe whether
there are any early clinical signs of block of tendon
gliding or joint motion. If nothing abnormal is found,
more vigorous and full active digital flexion exercises are
performed.
The patient returns every 6 to 8 days to have the dress­
ing changed and for a wound check. In more recent
Figure 18(A)-6  The thread was passed through the distal
stump of the tendon and tired over a mother-of-pearl button
on the fingertip.
Figure 18(A)-7  Seventeen days after pull-out suture repair
of the FDP tendons in the ring and little fingers. Active
flexion and extension exercise are shown.
A
B
the two tendon ends with good tension is very impor­
tant and depends on the surgeon’s experience. A running
suture with 4-0 suture is added to tighten the tendon
edges. Previously, we used a 4-0 Prolene suture and
noted some foreign body reactions caused by sutures
during long-term follow-up, and suture remnants had
to be removed. We prefer to use absorbable (such as
PDS) sutures presently.
Tendons cut distal to the A2 pulley (in zones 2A
and 2B) can be more easily repaired with this method,
because the distal tendon is shorter and has fewer con­
strictive pulleys. Therefore, it is easier to insert the needle
from the fingertip through the entire distal tendon
stump. For tendons cut at or proximal to the A2 pulley,
the needle will pierce a greater length of the distal tendon
stump with both DIP and PIP joints slightly flexed. After
piercing, the internal guide of a spinal needle is retracted
so that the passage of the 2-0 nylon thread is allowed. We
prefer to use two different passages through the tendon
stump for the thread; it ensures greater tightness of the
system as the suture tension is more evenly spread along
all parts of the tendon during motion.
Whenever possible, the pulley system is respected.
When the A2 or A3 pulley is partially or totally damaged
or when the pulleys must be partially incised to avoid
any impingement of the tendon repair site on the edge
of the pulley, these pulleys are not repaired. When more
pulleys are injured, reconstruction is strongly recom­
mended, especially for A2 and A4 pulleys, to avoid
tendon bowstringing. We prefer to use a flap of extensor
retinaculum (Lister technique) or one of the FDS tendon
slips (when the FDS tendon is not repaired), sutured to
the pulley remnants. A suction drain is placed and the
skin is sutured with absorbable sutures. The drain is
removed 1 day later, and a thinner dressing is made so
that a wider range of active digital motion is allowed.

206
Section 2:  Primary Flexor Tendon Surgery
sessions, (3) less pain and disability, and (4) earlier
recovery in grip strength. The ultimate total range of
active digital motion was not significantly different, and
repair ruptures were not recorded in either group.
We had no case of deep infection or tendon rupture.
A few patients had superficial infection on the fingertip,
due to prolonged contact of the button on the skin.
The wound healed within a few days after use of local
and oral antibiotics and daily careful disinfection. An
infrequent but serious complication is a permanent
residual loss of extension of the PIP joint, due to late
start of active mobilization. This often occurred in low-
compliant patients. However, they seldom requested
surgical treatment (tenolysis) because the extension
deficits were often only mild and were not bothersome,
creating no serious limitation of function.
DISCUSSION
Because the pull-out technique is not popular outside
of southern Europe, it is difficult to compare our results
with reports in the literature. However, we agree with
Wulle5 that the best results of the pull-out repair method
are achieved in young patients with early tendon motion
exercise, even when injuries of the arteries and/or nerves
coexist. Elder patients have a worse prognosis.
Except for cases involving bone injuries, to which
early motion cannot be applied, all zone 2 tendon cuts
deserve to be treated with this easy, reliable, and fast
method. This pull-out repair method can be used for
FDP tendon injuries in zones 1 and for FPL tendon
injuries in the thumb.1-6,9,10 Owing to reliable strength,
years, we have preferred to use absorbable sutures for
skin closure to avoid the need for removal of suture
stitches, which can be painful or quite unpleasant, espe­
cially for young patients. From 30 to 35 days after surgery,
the pull-out suture is cut and the button is removed. The
scab on the tip of the finger, where the button has created
a small bedsore, will fall off within 2 to 3 days with daily
antiseptic cleaning. A rehabilitation program is started
after pull-out removal, with progressive strengthening
active digital flexion from 8 weeks. The average time to
return to work is 10 weeks after injury.
OUTCOMES
We conducted two studies on patients who were treated
with the pull-out technique. Both studies contained
only a portion of the patients who were treated in this
period. The patients included in the two studies were
those living in close proximity to our city, so they could
come to our department for regular follow-up. In the
first study, we followed 46 patients with injuries to 46
FDP or FPL tendons in zone 2 treated with this method
between 2005 and 2008. At postoperative weeks 3, 6,
and 12, we evaluated the total active range of motion
of the distal inter­phalangeal (DIP), PIP, and metacarpo­
phalangeal (MCP) joints; visual analog scale;7 DASH
(Disabilities of the Arm, Shoulder, and Hand) score;
grip strength; and Kapandji test8 (for thumb motion
evaluation during opposition to long fingers). Being
impossible to equally compare all these data, as all the
tests have different numerical ranges, we decided to
make them homogeneous by calibrating their minimum
and maximum values from 0 to 30. According to all the
data provided from the different evaluation systems, we
could obtain poor, fair, good, and excellent results—
“poor” for mean values between 0 and 7, “fair” for
values between 7 and 15, “good” for values between 16
and 21, and “excellent” for values between 22 and 30.
We recorded poor results in 13 patients (28%), fair
results in none, good results in 28 patients (61%), and
excellent results in 5 patients (11%) (Figure 18[A]-8).
Similar to literature data,5 tendon injuries in the ring
and little fingers led to the worst recovery of range of
motion of the hand. No repairs ruptured.
The second study that we carried out between 2005
and 2008 compared two different treatments: (1) 22
patients (22 FDP tendons injured in zone 2) treated by
pull-out technique followed by active digital flexion and
extension exercise and (2) 22 patients (22 FDP tendons
in zone 2) treated with two-strand repair methods
(Tsuge, Kleinert, Kessler, or Kessler-Tajima) followed by
either Kleinert or Duran early motion programs. Our
referring hand therapist evaluated all the patients at 4,
6, 8, and 12 weeks after surgery. We recorded impres­
sively superior results for the patients treated with the
pull-out method: (1) faster recovery of the active range
of digital motion, (2) lower number of rehabilitative
Figure 18(A)-8  Complete recovery of active finger flexion
after surgical repair of FDP tendon of the little finger with
the pull-out method.

207
Chapter 18A:  Mantero’s Technique for Tendon Repair
this method also allows use of early motion of the
repaired finger in children. Nevertheless, this method
has not been used popularly so far, possibly because
putting a button on the top of a finger is not considered
“smart” or, more simply, because it is an old technique
and hence “out of fashion.” We believe that these
ideas are prejudicial. Although this method is rarely
included in descriptions of currently prioritized surgical
techniques of repair of flexor tendons, it should be
considered.
The advantages of this technique are easy technical
execution, cheap (and easy to find) surgical materials,
reliability of repair strength, and no need to wear a
splint. The pull-out system is of particular merit in the
case of tendon injuries in multiple fingers because it
allows active motion of these fingers. Rupture of the
suture or infection of the tip of the finger is rare, even
if the patient is not quite compliant. Postoperatively few
dressings are needed; at 30 to 35 days, the thread passing
though the fingertip is cut and the button is removed.
References
1. Mantero R, Bertolotti P, Badoino C: Il pull-out in “no man’s
land” e al canale digitale nelle lesioni dei flessori (metodo
personale), Riv Chir Mano 11:119–130, 1973–1974.
2. Mantero R, Bertolotti P: La mobilizzazione precoce nel trat­
tamento dei tendini flessori al canale digitale, Revista Esp Chir
Mano 5:35–43, 1975.
3. Mantero R, Bertolotti P: La mobilisation précoce dans le trait­
ement del lesions des tendons fléchisseurs au canal digital,
Ann Chir Main 30:889–896, 1976.
4. Grandis C, Rossello MI: Dieci anni di esperienza con il pull-
out intertendineo nella chirurgia dei tendini flessori al canale
digitale (zona 1–2), Riv Chir Mano 25:43–49, 1988.
5. Wulle C: Flexor tendon suture in zone 1 and distal zone 2 by
the Mantero technique, Ann Hand Upper Limb Surg 11:200–
206, 1992.
6. Guinard D, Montanier F, Thomas D, et al: The Mantero
flexor tendon repair in zone 1, J Hand Surg (Br) 24:148–151,
1999.
7. Ohnhaus EE, Adler R: Methodological problems in the mea­
surement of pain: a comparison between verbal rating scale
and the visual analogue scale, Pain 1:379–384, 1975.
8. Kapandji A: Clinical test of apposition and counter-apposition
of the thumb, Ann Chir Main 5:67–73, 1986.
9. Elliot D, Southgate CM: New concepts in managing the long
tendons of the thumb after primary repair, J Hand Ther 18:
141–156, 2005.
10. Schaller P: Repair of the flexor pollicis longus tendon with
the motion-stable Mantero technique, Scand J Plast Reconstr
Surg Hand Surg 44:163–166, 2010.

208
Antonio Merolli, MD, FBSE, Lorenzo Rocchi, MD, and
Francesco Catalano, MD
B
Teno Fix for Tendon Repair
We present clinical findings on our early patients
treated with Teno Fix, including detailed follow-up. We
also performed mechanical tests of two devices from our
hospital inventory.
A BIOMECHANICAL STUDY
The Teno Fix is a stainless steel device (ASTM F138-00)
composed of two intratendinous spindle–coil com­
plexes (the “anchor”) joined by a multifilament 2-0
stainless steel suture (the “wire”). The anchor is
composed of a spiralling cork-screw-like coil around
a hollow spindle core (Figure 18[B]-1A). The early
anchor that we used was 2.0 mm in diameter and
4.0 mm in length; a smaller anchor is now available.
Two stop-beads are used for tensioning the wire. One is
secured by the manufacturer, while the other must be
crimped intraoperatively by the surgeon (with the help
of a dedicated instrument). This latter step seemed to
us to be the weak point of the device, since in clinical
practice the strength of the stop grain is crucial for the
mechanical performance of the device. For this reason,
we tested two devices randomly chosen from the stan­
dard inventory of the hand clinic.
To evaluate the load needed to pull out the lower and
upper stop grains from the wire and the load at which
the wire itself starts rupturing, a metal plate with a suit­
able hole was used to constrain each grain, allowing us
to test the effective strength of the grain-wire assembly.
A wire length of 15 mm (common in clinical practice)
was chosen. Two grips were used to hold the plate con­
straining the grain and the end of the wire. The tests
were performed in a tensile mode at 1 mm/min, using
a material testing machine (Model 5566; Instron Corp,
Norwood, Massachusetts) with a load cell of 100 N
(Figure 18[B]-1B).
Results showed a typical load-displacement curve
that was linear until a maximum load value was reached
(Figure 18[B]-1C). Maximum load values of 56.7 and
58.9 N were recorded (greater than the mean stated by
the manufacturer). Although the wires became damaged
in tests, it was notable that the stop grains were not
pulled out (Figure 18[B]-1D).
We believe these data support the conclusion that the
device withstands loads in excess of those likely to be
encountered in clinical practice. They also support the
conclusion that crimping the grain intraoperatively is a
suitable procedure.
OUTLINE
We present our experience with the Teno Fix Tendon
Repair System (Ortheon Medical, Winter Park, Florida)
device for primary flexor tendon repair in digits. We
treated 22 patients presenting with laceration of a
single flexor digitorum profundus or superficialis
tendon or flexor pollicis longus tendon within the
digital sheath in zone 2; the mean follow-up was 16
(range, 6 to 26) months. Of the 22 patients, the results
according to the Strickland’s total active motion crite­
ria were excellent in 12, good in 6, and fair in 4.
Radiography revealed rather smooth gliding of the
repaired tendon after surgical implantation of the
device. However, in our series, the results of four
patients were not satisfactory, and the device was
removed from three of them. The other patients did
not complain of discomfort, nor have they required
secondary surgery for removal of the device after
tendon healing, with the longest follow-up being 7
years. This device is practical clinically and can produce
strong tendon repairs that withstand early active finger
motion. Use of this device may ensure a quicker recov­
ery and return to work after surgery. However, we also
present possible reasons for unsatisfactory recovery in
four cases in our series.
Our main motivation for testing the Teno Fix Tendon
Repair System device (Ortheon Medical, Winter Park,
Florida) in the clinic is the way it interfaces with the
fibers of the tendon. Specifically, Teno Fix does not
apply tractional force to a small number of fibers con­
stricted inside a knot; instead, it distributes traction
more evenly along a greater number of fibers. Despite
being compressed into the small volume of the anchor­
ing system, those fibers maintain their physiological axis
of elongation.
The Teno Fix device has been marketed as a practical
clinical tool, able to produce strong tendon repairs that
withstand early active finger motion.1-6 It is advisable to
mobilize the tendon with either passive or active flexion
as soon as possible, to prevent adhesions. Late initiation
of finger mobilization would increase the risk of an
incomplete functional recovery.7-10
*Conflict of interest: The authors have no financial relation­
ship with the manufacturer or the distributors of the device.

209
Chapter 18B:  Teno Fix for Tendon Repair
CLINICAL TECHNIQUES AND OUTCOMES
We report on treating 22 patients presenting primary
flexor tendon injuries within the digital sheath in zone
2. Results were assessed after a mean of 16 (6 to 26)
months of follow-up.
Clinical end points assessed included a comparison
in range of active motion according to the Strickland
and Glogovac method9,10 of the distal and proximal
interphalangeal (DIP and PIP, respectively) joints of the
finger as well as a recording of the linear measurement
of pulp–to–distal palmar crease distance.11 We adopted
the Strickland criteria in the documentation of out­
comes of flexor tendon repair in zones 1 and 2, because
we find these criteria more practical than the total active
motion (TAM) method advocated by the American
Society for Surgery of the Hand (ASSH). In fact, some
degree of joint stiffness is always present after tendon
repair, making patients with normal TAM rare. With the
Strickland method, excellent functional status requires
a sufficiently large total range of active digital motion
but not necessarily the same range as on the contralat­
eral side.12
Patients
There were 14 men and 8 women, with a mean age of
32 (range, 18-46) years, presenting with a complete
tendon transsection caused by a sharp blade injury, in
flexor digital sheath zone 2 (the subdivision zones
defined by Tang12-14 were followed). Lesions were treated
on the thumb (3 patients) and index (12 patients),
middle (3 patients), ring (1 patient), and little (3
patients) fingers. The study reports the complete experi­
ence of the authors, and no patient was lost to follow-up
before end results were determined.
Inclusion Criteria
All patients were treated within 12 hours of injury, and
the injured flexor tendons were treated primarily. Four
kinds of lesions were included in this case series: (1)
complete transsection of the flexor digitorum profundus
(FDP) tendon without or with only minor negligible
lesion of the flexor digitorum superficialis (FDS) tendon
at zones 2B or 2C; (2) complete transsection of the FDP
tendon without concomitant lesion of the FDS tendon,
at zone 2A; (3) complete transsection of the FDS alone,
at zone 2D (the authors propose surgical intervention
in young and active patients; the reason is that even if
finger motion remains normal when only the FDP is
present, cumulative grip strength is reduced); and (4)
complete transsection of the flexor pollicis longus (FPL)
tendon at zone 2.
Exclusion Criteria
In the interest of simplification, patients with injuries
of both flexor tendons or accompanying injuries (of the
Figure 18(B)-1  A, The spindle–coil complex (the “anchor”)
positioned on the needle of its delivery tube. B, The second
stop-bead, with the multifilament wire already in place,
held by the dedicated crimping instrument. C, A load-
displacement curve shows a linear trend, with a sawtooth
denoting the partial breaking of wire filaments. D, At the
time of failure under load, the wires were broken, but stop
grains were not pulled away from the wire.
A
B
D
0
0
0.1
0.2
C
0.3
0.4
0.5
0.6
0.7
0.8
Displacement (mm)
10
20
30
40
50
60
Load (N)

210
Section 2:  Primary Flexor Tendon Surgery
hole in the core, until the bead comes into contact with
the complex. After the wire has passed through the
second anchor and the second stop-bead (allocated into
the preloaded crimping instrument), the stumps are
gently redirected into the tendon sheath and under the
pulleys, to be held together under proper tension. The
second stop-bead is crimped and the excess wire is cut
away. A continuous epitendinous 6-0 nylon suture com­
pletes the repair, while the longitudinal tenotomies are
sutured by buried knots. We never found it necessary to
close the sheath, although we repaired the pulleys
whenever necessary.
Postoperative Care
The most attainable active digital flexion to the palm
was allowed beginning on the first postoperative day.
Extension was limited by placing the hand in a plaster
cast with both the wrist and metacarpophalangeal
(MCP) joints flexed at 30° until the 14th postoperative
day. Afterward, the plaster cast and the skin suture were
vessels or joints) or fractures were excluded. Because of
the diameter of the anchors, children were excluded
from the study as well as some adult patients presenting
lesions in comparably small fingers (most often, the
little finger).
Operative Techniques
Under brachial plexus block anesthesia, after the skin
has been incised according to Bruner, the injured tendon
stumps are exposed. A longitudinal palmar split is made
about 10 mm from the cut edge, to accommodate the
obturator and the delivery tube, which contains the
anchor–coil complex. The tendon sheath at this level is
often disrupted by the trauma; however, a limited lon­
gitudinal incision can be made if necessary. Either proxi­
mal or distal stumps can be chosen as the first point of
entry, according to clinical need (Figure 18[B]-2A).
Once the complex has been gently twisted into place,
the straight needle with the stainless steel suture and the
built-in stop-bead (the “wire”) is passed through the
Figure 18(B)-2  A, FDP tendon cut in the index finger in a patient. We chose the proximal stump as the first point of entry.
B and C, Despite an initial effort at early active and passive motion, after 20 days, rehabilitation was discontinued and rigidity
of the index finger ensued. D, We removed the device after 5 months and performed a cruciate repair.
A
B
D
C

211
Chapter 18B:  Teno Fix for Tendon Repair
DISCUSSION
Advantages
An ideal tendon repair should be simple and reproduc­
ible in execution, of immediately high strength, take up
only a small amount of space within the sheath, produce
negligible gaps, allow vascularization, and tolerate early
active tendon mobilization. Many proposed techniques
are adequate in tensile strength but are technically
demanding, requiring excessive tendon manipulation
and possibly increasing the tendon bulk.14-17 Teno Fix
respects the vascular perfusion provided by the vincula
vessels. Tendon repairs with this device do not directly
involve the surfaces of the tendon cut and do not require
knots to be placed between tendon cut surfaces. This
characteristic facilitates the closure of the epitenon,
favoring reestablishment of tendon continuity.19,20
We noted that this device has a unique feature: the
intratendinous complex inserted in the tendon belly
allows the tendon collagen fibers, caught between the
coil and the core, to maintain their physiological elon­
gation. This happens without excessive twisting and/or
constriction of the tendon fibers, which is more likely
in repairs using ordinary surgical sutures. Surgical suture
repairs may interfere with vasculature of the tendon
and produce a well-demarcated acellular zone in tied
knots.21
We compared results in the literature from clinical
series of traditional treatment of flexor tendon injuries
in zone 2 with our results with Teno Fix. They are in the
same range when the Strickland criteria and percentage
of rupture are considered.22 However, Teno Fix appears
to have faster functional recovery and return to work. In
our series, the average time needed to return to work
was only 34 days.
We did not receive any complaints or requests for
removal of the device in the long term, and our oldest
case now dates back 7 years. We believe it is not neces­
sary to remove the device after successful healing because
of the possible damage to healed tendons, presenting a
risk that far outweighs the benefits of not having an
artificial device in place.
Disadvantages
Because of the diameter of the anchors, use of the Teno
Fix is not indicated in children or some adult patients
presenting with lesions in comparably small fingers, like
the little finger. Regarding possible risk of infection due
to the presence of a metallic device, in our opinion the
Teno Fix is not indicated in treatment of dirty lesions or
generally in complex multiple lesions. Because it requires
good-quality tissue in the stumps receiving the anchors,
the device is not indicated in case of fraying cut tendons.
Finally, the need for full patient compliance with the
rehabilitation program suggests that the device should
not be used with uncooperative patients. All these are
removed. A dorsal splint in neutral wrist position was
applied until the 28th day for limiting wrist extension.
Complete active motion of all the fingers was allowed
(apart from flexion against resistance and forced passive
extension).
The patients were monitored on outpatient visits
weekly during the first month and then at 2, 6, 12, and
24 months. Anterior and lateral x-ray films in flexion
and extension were taken on the 14th and 60th postop­
erative days.
Outcomes
Of the 22 patients, function was excellent in 12, good
in 6, and fair in 4 by the Strickland criteria 12 months
after surgery. The four patients who scored a “fair” had
an unsatisfactory outcome, and in three of them the
device was removed; the details are given below. The first
patient fell accidentally after surgery, provoking a forced
hyperextension and the eventual tendon rupture around
the anchors; the device did not rupture but was removed.
The second patient required the removal of the device
because of a low-grade sepsis that gave persistent pain;
the use of Teno Fix was probably a poor choice for this
patient, who presented with a torn and poorly vascular­
ized wound at the time of surgery. The third patient was
extremely noncompliant and did not follow any reha­
bilitation instructions. The fourth patient, despite an
initial effort at early active motion (Figure 18[B]-2B
and C), failed to continue a rehabilitation program, and
ended up with a rigidly extended finger. The device was
removed (Figure 18[B]-2D). As with all other removals
of the device, we performed a traditional cruciate repair
for the tendon. However, failure to comply with a reha­
bilitation regimen resulted in novel rigidity.
In the remaining 18 patients (i.e., six FDP cuts at
zones 2B or 2C, 5 FDP cuts at the border of zone
2A, 4 FDS cuts at zone 2D, and 3 FPL cuts), we found
notable that patients returned to work after a mean
of 34 (±12) days, a comparatively short period. We
extended use of this device in treating disruption of the
FPL tendon of the thumb and outcomes were excellent
(Figure 18[B]-3A and B).
Dynamic x-ray films in full flexion and full extension
showed that the device did not interfere with the
pulleys, since no blockage of the repaired tendon
occurred under them. This proved true with a critical
pulley like the A4 in distal zone 2A lesions (Figure
18[B]-3C) and with another critical pulley like the A2
(Figure 18[B]-3D).
In 14 cases of the series, radiographs taken 2 months
after surgery showed that the anchors had slid closer to
the junction site (see Figure 18[B]-3C). This has been
interpreted as a sign of effective tendon scarring, which
involves a physiological contracture of the stump tissue.
However, in the other cases anchors were not displaced,
even in the long term (see Figure 18[B]-3D).

212
Section 2:  Primary Flexor Tendon Surgery
with a rehabilitation regimen, a requirement in recovery
from tendon surgery. In the other two patients with
unsatisfactory outcomes, we stress that the reasons for
removal (forced hyperextension and low-grade sepsis)
were not directly associated with the device itself. The
drawbacks and limitations revealed in our case series
should be taken into consideration when this device is
used in future cases.
Acknowledgments
We would like to thank Professor Luigi Ambrosio and
Dr. Antonio Gloria from the Institute of Biomedical
Composite Materials (Naples, Italy) for their coopera­
tion in performing mechanical tests. Figures 18-1A and
18-3, A–D, are used with permission from Springer
Verlag, Heidelberg-New York.
clear disadvantages that argue against the use of Teno
Fix in these clinical settings. In our series, this treatment
was not the right choice for four patients, giving us fair
results and a reoperation rate no lower than in recent
reports of primary flexor tendon repairs in zone 2.
We should acknowledge that in our case series, only
a single flexor tendon was injured, which calls for a
relatively simple clinical response. We do not know
whether this device would work well for patients with
simultaneous injuries of both FDS and FDP tendons. In
addition, four of our cases did not recover satisfactory
function. Three of those four required removal of the
device, and we then performed a traditional four-strand
cruciate repair to provide some kind of treatment.
However, we must also note that two of the four patients
with unsatisfactory outcomes were unable to comply
Figure 18(B)-3  A and B, Good results were obtained in the thumb, as shown in this patient 22 months after surgery.
C, Dynamic x-ray films taken after 2 months showed that the anchors (a, anchor; sb, stop-beads) had slid toward the junction
site in the majority of patients. This is interpreted as a sign of effective tendon healing and scarring, which involves a
physiological contracture of the stump tissue. D, In the other cases, anchors were not displaced, even after 2 years.
A
C
AP
LL
sb
sb
a
a
B
D

213
Chapter 18B:  Teno Fix for Tendon Repair
References
1. Lewis N, Quitkin HM: Strength analysis and comparison of
the Teno Fix Tendon Repair System with the two-strand modi­
fied Kessler repair in the Achilles tendon, Foot Ankle Int
24:857–860, 2003.
2. Su BW, Protopsaltis TS, Koff MF, et al: The biomechanical
analysis of a tendon fixation device for flexor tendon repair,
J Hand Surg (Am) 30:237–245, 2005.
3. Su BW, Solomons M, Barrow A, et al: Device for zone-II flexor
tendon repair. A multicenter, randomized, blinded, clinical
trial, J Bone Joint Surg (Am) 87:923–935, 2005.
4. Su BW, Raia FJ, Quitkin HM, et al: Gross and histological
analysis of healing after dog flexor tendon repair with the
Teno Fix device, J Hand Surg (Br) 31:524–529, 2006.
5. Su BW, Solomons M, Barrow A, et al: A device for zone-II
flexor tendon repair. Surgical technique, J Bone Joint Surg
(Am) 88(Suppl 1 Pt 1):37–49, 2006.
6. Wolfe SW, Willis AA, Campbell D, et al: Biomechanic com­
parison of the Teno Fix tendon repair device with the cruciate
and modified Kessler techniques, J Hand Surg (Am) 32:356–
366, 2007.
7. Kitsis CK, Wade PJ, Krikler SJ: Controlled active motion fol­
lowing primary flexor tendon repair: a prospective study over
9 years, J Hand Surg (Br) 23:344–349, 1998.
8. Peck FH, Bucher CA, Watson JS: A comparative study of two
methods of controlled mobilization of flexor tendon repairs
in zone 2, J Hand Surg (Br) 23:41–45, 1998.
9. Strickland JW, Glogovac SV: Digital function following flexor
tendon repair in Zone II: A comparison of immobilization
and controlled passive motion techniques, J Hand Surg (Am)
5:537–543, 1980.
10. Strickland JW: Flexor tendon surgery. Part 1: primary flexor
tendon repair, J Hand Surg (Br) 14:261–272, 1989.
11. Boyes JH: Flexor tendon grafts in the fingers and thumb: an
evaluation of end results, J Bone Joint Surg (Am) 32:489–499,
1950.
12. Tang JB: Clinical outcomes associated with flexor tendon
repair, Hand Clin 21:199–210, 2005.
13. Tang JB, Shi D: Subdivision of flexor tendon “no man’s land”
and different treatment methods in each sub-zone. A prelimi­
nary report, Chin Med J 105:60–68, 1992.
14. Tang JB, Shi D, Gu YQ, et al: Double and multiple looped
suture tendon repair, J Hand Surg (Br) 19:699–703, 1994.
15. Wade PJ, Wetherell RG, Amis AA: Flexor tendon repair: sig­
nificant gain in strength from the Halsted peripheral suture
technique, J Hand Surg (Br) 14:232–235, 1989.
16. Trail IA, Powell ES, Noble J: The mechanical strength of
various suture techniques, J Hand Surg (Br) 17:89–91,
1992.
17. Barrie KA, Tomak SL, Cholewicki J: Effect of suture locking
and suture calibre on fatigue strength of flexor tendon repairs,
J Hand Surg (Am) 26:340–346, 2001.
18. Strickland JW: Flexor tendon repair, Hand Clin 1:55–68,
1985.
19. Strickland JW: Development of flexor tendon surgery:
twenty-five years of progress, J Hand Surg (Am) 25:214–235,
2000.
20. Ketchum LD: Suture materials and suture techniques used in
tendon repair, Hand Clin 1:43–53, 1985.
21. Wong JKF, Cerovac S, Ferguson MWJ, et al: The cellular effect
of a single interrupted suture on tendon, J Hand Surg (Br)
31:358–367, 2006.
22. Rocchi L, Merolli A, Genzini A, et al: Flexor tendon injuries
of the hand treated with Teno FixTM: mid-term results,
J Orthop Traumatol 9:201–208, 2008.

214
CHAPTER
19 
TREATMENT OF RUPTURE
OF PRIMARY FLEXOR
TENDON REPAIRS
David Elliot, MA, FRCS, BM, BCh
strength. Two curious facts should make us wary of
this search for the perfect suture configuration. Savage
reported one rupture in 20 fingers and 3 thumbs with
zone 2 complete flexor divisions repaired with a six-
strand suture, a rupture rate in the fingers of 5% or
a rupture rate of 3% overall.2 Harris et al,4 reporting
results from my own unit from June 1989 to December
1996, recorded 17 ruptures in a series of 397 fingers
(4%) with zone 2 complete flexor divisions using a two
strand modified Kessler core suture. So simply putting
in more complex sutures is possibly not the answer, or
not the only answer.
A very interesting laboratory study from Professor
McGrouther’s laboratory in Manchester5 showed that
even a single suture passed through a tendon signifi­
cantly affects the cell population of the tendon around
it: the suture foreign body causes the tenocytes to move
away. So, perhaps, we are, unwittingly, making tendon
repair breakdown more likely as we put more foreign
suture material into the tendon.
THE PATIENT
This may be the reason why we cannot get past an inevi­
table rupture rate, although it is probably more likely
that it is simply human nature that is defeating us. In
1999, we highlighted the role of patient irresponsibility
in the etiology of rupture of primary flexor tendon
repairs.4 This study included 526 fingers in 440 patients
with primary flexor tendon repairs in zones 1 and 2 who
underwent surgery and postoperative mobilization in a
controlled or early active motion. Twenty-three patients
ruptured 28 tendon repair(s) in 23 fingers, an overall
rupture rate of 4%. Eleven of these, just less than half,
occurred as a result of patients using the hand, in or out
of their splint, against therapy advice. It is likely than
this figure is an underestimate of this problem of patient
noncompliance in this population worldwide.
THE SHEATH
In a laboratory study, Tang et al6 identified a further
possible factor in the etiology of these ruptures. These
OUTLINE
Clinical series of primary flexor tendon repairs world­
wide, using a variety of suture materials and suture
configurations, all include a small, but ever present,
rupture rate. That the assumption that stronger sutures
will “cure” the problem may be false is discussed and
the role of the sheath and of the patient considered.
Immediate re-repair of ruptures has been carried out
for many years without analysis of the success of this
procedure. This chapter discusses a study of the effec­
tiveness of immediate re-repair of ruptures of the
primary repair. It identifies that this works adequately
for all digits but the little finger. Possible modifica­
tions of the method of re-repair used in this study
which might improve the results are discussed and an
alternative management plan for the little finger is
considered.
Rupture of the tendon repair, or detachment of the rein­
serted tendon, if recognised immediately, should be treated
with prompt re-exploration and repair.
Leddy, 19821
With a few exceptions, most studies published during
the past 25 years discussing acute flexor tendon repair
and early mobilization report a rupture rate of between
3% and 9%. In studies of less than 100 patients, which
are the norm for this field, these figures indicate negli­
gible differences in the number of patients with rup­
tured tendon repairs in different units using a multitude
of core and circumferential suture techniques and many
variations of the three basic regimes of early postopera­
tive mobilization.
THE SUTURE
Survey of the many new suture techniques used through­
out the past 20 years confirms that the Savage six-strand
suture2,3 is still the strongest suture, although it is diffi­
cult to use. One could argue that 20 years have been
spent trying to achieve a simpler suture with equal

215
Chapter 19:  Treatment of Rupture of Primary Flexor Tendon Repairs
rehabilitation of the initial tendon division, were rela­
tively small and the studies were not focused on the
results of re-repair.
THE RESULTS OF RUPTURE RE-REPAIR
In view of the paucity of data on the results of immedi­
ate re-repair, we carried out a study to examine the cir­
cumstances of the 62 fingers in 61 patients who ruptured
primary zone 1 and 2 finger flexor tendon repairs in
our unit over a 14-year period, from 1989 to 2003, and
reported the outcome of immediate re-repair of the rup­
tured tendons in those fingers in which re-repair was
undertaken.7 This study remains the major work on this
subject to date.
There are some absolute contraindications to attempt­
ing re-repair after rupture, such as poor general health
precluding either regional or general anesthesia, infec­
tion of the involved finger, and a mental status of the
patient incompatible with cooperation with therapy.
Most other contraindications are relative but may
constitute logical reasons not to attempt to re-repair a
rupture of a primary finger flexor tendon repair in a
particular individual or in a particular finger. These
include advanced or very young age, the general medical
status of the patient, the suitability and compliance of
the patient, other pathologies or injuries of the affected
hand or digit, rupture of the flexor digitorum profundus
(FDP) tendon in the presence of a functioning flexor
digitorum superficialis (FDS) tendon with a good range
of motion of the proximal interphalangeal joint, palmar
skin loss of the affected digit or excessive stiffness, and/
or swelling of the digit. It is commonly thought that
re-repair should be performed no more than 48 to 72
hours from rupture, although there are no data to
support this cut-off time. After 5 weeks from the primary
repair, the digit is often at that stage of the healing
process when it is hard and “wooden” and re-repair is
difficult and may endanger other structures in the opera­
tive field. The re-repair is also very likely to stick post­
operatively. In our study, the average time to rupture of
the primary repairs was 18 days (range, 3 to 61 days),
so most ruptures fall within the time when this factor
does not prevent re-repair. Patients may also decline
further surgery for various reasons. In our study, two
patients in whom only the FDP repair had ruptured,
leaving an “FDS-only” finger with full proximal inter­
phalangeal (PIP) joint flexion, declined to undergo
re-repair. A third patient, who ruptured both tendon
repairs, declined re-repair for business reasons. He, sub­
sequently, underwent a two-stage tendon graft proce­
dure at a more convenient time with a good result.
Although it is usually possible to re-repair the rup­
tured tendon(s) if correct decisions have been made
preoperatively, it can become obvious at surgery that
this will be difficult, impossible or unwise. It is impor­
tant that the patient be informed of this possibility
authors suggested that repair rupture is most likely to
occur at sites where tendons glide over a rim of a major
pulley or over gliding curves of a small diameter, char­
acteristics found typically in zone 2B repairs and repairs
of tendons in little fingers. In our study, described later,
32 of a total of 42 fingers (77%) requiring re-repair of
the flexor tendons occurred in zone 2B and/or in little
fingers.7
TIMING OF OCCURENCE OF THE RUPTURE
The times after primary repair at which the ruptures
occurred are shown in Table 19-1, which contains infor­
mation from our unit in 62 fingers in 61 patients who
ruptured primary zone 1 and 2 finger flexor tendon
repairs. The average time to rupture of the primary
repairs was 18 days (range, 3 to 61 days). The highest
incidence of rupture of primary finger flexor tendon
repairs was seen in the second week after surgery. The
incidence of rupture was higher in the first 5 weeks after
surgery than in the later 4 weeks (weeks 6 to 9).
IMMEDIATE RE-REPAIR OF RUPTURES
Little has been published specifically about the manage­
ment of ruptured primary flexor tendon repairs. For 20
years, the quotation at the beginning of this chapter has
been the teaching on the management of rupture of
primary flexor tendon repairs of the fingers in zones 1
and 2 during the early part of the rehabilitation program.
While most experienced clinicians would agree with this
opinion, this statement was made without published
evidence to support it. The available literature in the
period immediately following Leddy’s statement sug­
gested that he was correct.4,8-11 However, the numbers of
ruptures and re-repairs in these studies, which were pri­
marily concerned with the surgical management and
Table 19-1  Timing of Ruptures of Primary Finger
Flexor Tendon Repair in a Total of 62 Fingers
Time After Primary
Repair (Wk)
Mechanical
Ruptures
(n = 57)
Infective
Ruptures
(n = 5)
<1
6
2
1-2
23
0
2-3
9
2
3-4
7
1
4-5
6
0
5-6
2
0
6-7
2
0
7-8
1
0
8-9
1
0

216
Section 2:  Primary Flexor Tendon Surgery
cases, general medical problems in two cases, dense
scarring in the flexor sheath and frayed tendon ends in
two cases, a large gap between the tendon ends preclud­
ing direct suture of the tendon without undue tension
in one case, and an overly long delay of 9 days between
tendon rupture and presentation in one case. This list
emphasizes some of the more common considerations
of management.
Immediate re-repair of the flexor tendons was per­
formed in 44 fingers (71%) in 43 (70%) patients. All
were carried out within 48 hours from the rupture. Two
fingers in two patients were excluded from analysis of
the effectiveness of immediate re-repair because the sub­
sequent poor results were considered an unfair repre­
sentation of the result of the immediate re-repair
procedure. One patient developed chronic regional pain
syndrome (CRPS) type 1 postoperatively and one had
severe osteoarthritis of multiple joints in all of his
fingers. Five patients re-ruptured their re-repairs in five
fingers and so were excluded from analysis of the effec­
tiveness of immediate re-repair.
In the remaining 37 fingers in 36 patients, the results
were assessed using the original Strickland method13
(Table 19-2). This group of patients included 31 men
(average age, 36 years; range, 30 to 58 years) and five
women (average age, 23 years; range, 16 to 32 years).
Eighteen fingers had primary repair of both the profun­
dus and superficialis flexor tendons (FDP, FDS). In nine
of these fingers, both tendon repairs had ruptured. In
eight of these, both tendons were re-repaired, while only
preoperatively. The tendons may be too swollen,
although this can often be overcome by single tendon
repair and excision of the whole, or half, of the FDS
tendon. The proximal end of the tendon may have
retracted too far. This is most commonly a problem of
the long flexor tendon of the thumb but can occur with
finger flexor tendons. It can often be overcome by
lengthening the proximal tendon, using either the Le
Viet technique12 or conventional tendon lengthening at
the wrist, although this was not necessary in our series.
The alternatives to immediate re-repair should be
discussed carefully with the patient preoperatively both
to allow informed consent and in case re-repair proves
impossible. Making a discussion intraoperatively will be
impossible if general anesthesia has been used initially
or after failure of regional anesthesia. Where immediate
re-repair is clearly impossible preoperatively, or it
becomes apparent during surgery that re-repair is impos­
sible, the options include (1) doing nothing further; (2)
single-stage tendon grafting; (3) the first stage of two-
stage tendon grafting, i.e., insertion of a silicone rod;
and (4) tendon transfer. Doing one of these may convert
the failure of the primary intention to re-repair the
flexor tendon(s) into a useful operation.
In our series, it was not possible to carry out immedi­
ate re-repair in 18 fingers (29%) in 18 (30%) patients,
approximately one-third of cases. The reasons for not
re-repairing the ruptured tendon repairs in these cases
included infection in five cases, poor previous compli­
ance with therapy in four cases, patient choice in three
Table 19-2  Results of Immediate Re-Repair of Ruptures of Primary Flexor Tendon Repairs and Distribution of
Ruptures of Primarily Repaired Tendons Among Different Fingers at the St Andrew’s Centre for Plastic Surgery,
Chelmsford, UK
Locations
Excellent
Good
Fair
Poor
Second Rupture
Total
Results by fingers
All fingers
9 (24%)*
10 (27%)
5 (14%)
13 (35%)
5
42
Index
2
4
1
1
0
8
Middle
4
3
0
4
1
12
Ring
1
0
0
1
0
2
Little
2
3
4
7
4
20
Results by locations in fingers
Zone 1
1 (20%)
2 (40%)
0 (0%)
2 (40%)
—
5
Zone 2
8 (25%)
8 (25%)
5 (16%)
11 (34%)
—
32
Zone 2A
0
1
0
0
—
1
Zone 2B
5
5
4
7
—
21
Zone 2C
2
2
1
3
—
8
Zone 2D
1
0
0
1
—
2
*The percentages shown are only for the 37 fingers which were rehabilitated successfully.

217
Chapter 19:  Treatment of Rupture of Primary Flexor Tendon Repairs
and/or additional unadvised use of the hand after
re-repair, provided the resulting repair is not so thick as
to preclude free gliding within the sheath. However, the
size of the re-repair is more likely to be a problem in
this respect than at the time of primary repair as the
fingers involved are already edematous from the primary
injury and repair. This limitation was initially identified
in primary repair when increasingly complicated cir­
cumferential repairs were used,16 and our clinical experi­
ence supports this finding. For reasons discussed
previously, simply putting in more complex sutures may
not be the answer, or not the only answer.
Given the above, single tendon re-repair may also be
more appropriate after double tendon rupture. In this
study, both previously repaired tendons ruptured in
nine fingers. Both were re- repaired in eight fingers. This
policy may be one of perfection that should be modi­
fied. However, five (62.5%) of these eight fingers had
excellent or good results. It is certainly easier to repair
one tendon only as the tendons are swollen and the
tendon ends are more frayed and less easily handled at
re-repair than primary repair. Removing the FDS tendon
from the finger to reduce the likelihood of the tendons
sticking under the A2 pulley is a further step to reducing
the possibility of tendon adhesion. This is unlikely to
result in PIP swan-necking as these fingers mostly have
shortened PIP palmar plate ligaments as a result of their
postinjury/operative state. The extensibility of this joint
can easily be tested intraoperatively and appropriate
tenodesis of the distal part of the superficialis tendon
across the proximal interphalangeal joint carried out, if
necessary.
THE LITTLE FINGER
In previous studies, we have found difficulty achieving
good results in the little finger after primary repair.17
This experience is repeated in this series of re-repair of
ruptures of the primary repairs. The percentage of rup­
tures of primary repairs was very much greater in the
little finger (46%) than in the other fingers and second
rupture was almost exclusively a problem of the little
finger, with four of the five re-ruptures occurring in the
little finger (see Table 19-2). The number of excellent
or good results after immediate re-repair of ruptured
primary repairs in the index and middle fingers was
higher than in the ring and little fingers and only 5 of
20 re-repairs in the little finger achieved excellent or
good results. Certainly, there are technical difficulties to
repairing the small tendons and to rehabilitation of this
finger and, possibly, higher risks to the repair in the
border digit.
As mentioned earlier, Tang et al6 suggested that repair
rupture is most likely to occur at sites where tendons
glide over gliding curves of a small diameter, a charac­
teristic found typically in repairs of tendons in little
fingers. These figures support a policy of no re-repair in
FDP was re-repaired in one finger, with no reason being
given by the operating surgeon as to why FDS was not
re-repaired. In the other nine of these fingers, rupture of
the FDP repair only occurred and immediate re-repair of
the FDP was performed. Nineteen fingers, including five
zone 1 injuries, had primary repair of FDP only, so only
this tendon repair ruptured. All nineteen underwent
re-repair of this tendon alone. Of the 37 re-repairs, nine
(24%) had excellent, 10 (27%) had good, 5 (14%) had
fair, and 13 (35%) had poor results (see Table 19-2).
Earlier studies mentioning the results of immediate
re-repair of zone 1 and 2 finger flexor tendon injuries
after rupture of primary repairs during rehabilitation
suggest that immediate re-repair can achieve an excel­
lent or good result in just over 60% of cases. This study,
specifically examining this option of treatment in a
larger number of fingers, does confirm that immediate
re-repair is feasible in cases which present within 48
hours of rupture but only achieved excellent or good
results in just over 50% of the fingers. While flexor
tendon grafting may achieve better results in the hands
of some surgeons and in some patients, it should be
remembered that these patients include many who are
unlikely to achieve excellent or good results by any
method of treatment.4
RUPTURE OF THE RE-REPAIR
In this study, second rupture was also associated with a
high incidence of noncompliance. That only 50% of the
patients in this series achieved excellent or good results
after immediate re-repair of ruptures of previous tendon
repairs may be a realistic expectation for this subgroup
of patients. Nevertheless, this, and the fact that 5 of the
41 patients in this study ruptured the re-repairs again
(see Table 19-2), is a poor result that brings into ques­
tion a universal policy of immediate re-repair of all
ruptured primary finger flexor tendon repairs and alter­
natives should be considered.
POSSIBLE MODIFICATIONS OF THE RE-REPAIR
In our study, all of the tendons were re-repaired using
the same technique, which had been used in the primary
repair, namely the modification of the two-strand
Kirchmayr/Kessler core suture14,15 in which the suture is
tied with a single intratendinous knot, and a continuous
circumferential suture. Core sutures of 3-0 or 4-0 poly­
propylene (Prolene) and a continuous circumferential
suture of 5-0 or 6-0 nylon (Ethilon) or polypropylene
were used in all tendons, with the suture sizes being
chosen according to tendon size. The repairs were mobi­
lized postoperatively using the same technique as used
after the primary repair, namely a variation of the
controlled, or early, active motion regimen previously
described in 1989 in Belfast,9,11 for a minimum of 8
weeks. Use of stronger suturing techniques might seem
appropriate to withstanding the forces of rehabilitation

218
Section 2:  Primary Flexor Tendon Surgery
the finger. Review at 6 months will identify functional
problems requiring tendon grafting in individual cases
but these are likely to be rare. Where the little finger has
no means of flexing after rupture of a primary repair, we
would advise that a rod be inserted into the finger and
secondary grafting scheduled when the finger is soft and
supple, as the alternative of re-repair has a 4 : 20 (20%)
chance of a second rupture, necessitating further treat­
ment within a few weeks, and a 7 : 20 (35%) chance of
creating a little finger that is a hindrance because of loss
of sufficient extension and hooking and/or insufficient
flexion ability to provide good grip function and prevent
objects dropping out of the ulnar side of the hand.
Although these conclusions are empirical, they are no
less worthwhile and useful in formulating a treatment
strategy for the management of primary flexor tendon
repairs which rupture. When evidence that stronger
re-repairs give better results in the little finger is avail­
able, this policy may require modification.
patients who rupture primary flexor tendon repairs of
the little finger. Unfortunately, even when only the FDP
tendon of the little finger has ruptured, doing nothing
may not be an option as the FDS tendon may be absent,
or too weak, to provide sufficient PIP joint flexion for
useful function. In this difficult finger, particularly in a
less than ideal patient, we would not contemplate single
stage tendon grafting. In making a decision to insert
a rod when the patient presents with a rupture of a
primary repair in a little finger, it is often possible to
identify those patients who are most likely to do badly
if they are known to the therapy department, having
spent time—or not—mobilizing the primary repair.
CONCLUSION
Most ruptures outside of the little finger should be
re-repaired if possible. Little finger ruptures with a strong
intact FDS tendon can provide adequate little finger
flexion and usually do not have significant hooking of
References
1. Leddy JP: Flexor tendons: acute Injuries. In Green DP,
editor: Operative Hand Surgery, New York, 1982, Churchill
Livingstone, p 1359.
2. Savage R: In vitro studies of a new method of flexor tendon
repair, J Hand Surg (Br) 10:135–141, 1985.
3. Savage R, Risitano G: Flexor tendon repair using a “six strand”
method of repair and early active mobilisation, J Hand Surg
(Br) 14:396–399, 1989.
4. Harris SB, Harris D, Foster AJ, et al: The aetiology of acute
rupture of flexor tendon repairs in zones 1 and 2 of the fingers
during early mobilization, J Hand Surg (Br) 24:275–280,
1999.
5. Wong JK, Cerovac S, Ferguson MW, et al: The cellular effect
of a single interrupted suture on tendon, J Hand Surg (Br)
31:358–367, 2006.
6. Tang JB, Xu Y, Wang B: Repair strength of tendons of varying
gliding curvature: a study in a curvilinear model, J Hand Surg
(Am) 28:243–249, 2003.
7. Dowd MB, Figus A, Harris SB, et al: The results of immediate
re-repair of zone 1 and 2 primary flexor tendon repairs which
rupture, J Hand Surg (Br) 31:507–513, 2006.
8. Allen BN, Frykman GK, Unsell RS, et al: Ruptured flexor
tendon tenorrhaphies in zone 2: repair and rehabilitation,
J Hand Surg (Am) 12:18–21, 1987.
9. Elliot D, Moiemen NS, Flemming AFS, et al: The rupture
rate of acute flexor tendon repairs mobilized by the con­
trolled active motion regimen, J Hand Surg (Br) 19:607–612,
1994.
10. Moiemen NS, Elliot D: Primary flexor tendon repair in zone
1, J Hand Surg (Br) 25:78–84, 2000.
11. Small JO, Brennen MD, Colville J: Early active mobilisation
following flexor tendon repair in zone 2, J Hand Surg (Br)
14:383–391, 1989.
12. Le Viet D: Flexor tendon lengthening by tenotomy at the
musculotendinous junction, Ann Plast Surg 17:239–246,
1986.
13. Strickland JW, Glogovac SV: Digital function following flexor
tendon repair in Zone II: a comparison of immobilization
and controlled passive motion techniques, J Hand Surg (Am)
5:537–543, 1980.
14. Kessler I, Nissim, F: Primary repair without immobilization
of flexor tendon division within the digital sheath, Acta
Orthop Scand 40:587–601, 1969.
15. Kirchmayr L: Zur Technik der Sehnennaht, Z Chir 40:906–
907, 1917.
16. Kubota H, Aoki M, Pruitt DL, et al: Mechanical properties of
various circumferential tendon suture techniques, J Hand Surg
(Br) 21:474–480, 1996.
17. Elliot D: Invited personal view. Primary flexor tendon repair:
operative repair, pulley management and rehabilitation,
J Hand Surg (Br) 27:507–513, 2002.

219
OUTLINE
Traumatic avulsion of flexor tendons is not uncom­
mon. Often observed in athletes, this lesion concerns
mainly an avulsion of the flexor digitorum profundus
tendon on the distal phalanx of the ring finger.
Although clinically typical, diagnosis is often missed.
Prognosis factors identified are the level of retraction
of the tendon, the status of the vinculae, the delay
between injury and treatment, and the presence
and size of a phalangeal bony fragment. Acutely,
direct reinsertion of the profundus tendon on the
distal phalanx gives satisfactory results. Long-standing
lesions with tendon retraction and impaired tendon
vascular supply should not be treated by reinsertion
to avoid finger stiffness. No surgery is recommended
when impairment of function is slight, the proximal
interphalangeal (PIP) joint perfectly mobile, and the
distal interphalangeal (DIP) joint stable. If the PIP
joint is stiff, the retracted flexor digitorum profundus
tendon is resected, followed by tenodesis or capsu­
lodesis of the DIP joint. One-stage tendon graft is
reserved for cases in which the loss of strength and
range of active finger flexion are not acceptable, but
the PIP and DIP joints have normal passive motion.
Closed traumatic avulsion of the insertion of flexor
tendons is a relatively common injury, particularly in
athletes. The majority of injuries involve the profundus
tendon at its insertion1-4 and, less frequently, the super­
ficialis5,6 or both tendons.7-10 Avulsion of the flexor digi­
torum superficialis (FDS) tendon can be directly from
the middle phalanx5 or can be associated with a middle
phalangeal cortical bone avulsion.6 Avulsion of the
flexor digitorum profundus (FDP) tendon occurs most
commonly at the bony insertion on the distal phalanx,
with or without bone fracture.1,2 The injury has been
reported to occur in all fingers, but the ring finger is
CHAPTER
20 
CLOSED AVULSION OR
RUPTURE OF FLEXOR TENDONS
Pierre Mansat, MD, PhD, and Michel Mansat, MD
A
Traumatic Avulsion of
Flexor Tendons
involved in more than 75% of cases.1,2,4 Satisfactory
results of surgical repair are usually obtained in most
cases if the diagnosis is made quickly. However, impair­
ment of the function of the finger can result from a late
diagnosis. In these chronic cases, the results of surgical
treatments are often unpredictable.
BACKGROUND
In 1960, Gunter11 reported avulsion of the FDP tendon
occurring in eight rugby players. In 1970, Carroll and
March12 reviewed 35 cases and emphasized the particu­
lar involvement of the ring finger and the irreversibility
of the injury once the tendon had retracted into the
palm. The “grasping jersey” mechanism of this trauma
was specified by Folmar et al13 and Chang et al.14 A clas­
sification into three types according to the amount of
tendon retraction has been proposed initially by Leddy
and Packer in 19771 and then in France by Mansat and
Bonnevialle in 19852 after review of a series of 19 cases.
In 1981, Smith15 described a fourth type, with avulsion
of the profundus tendon in association with a bone frac­
ture of the distal phalanx. Al-Qattan, in 2001,16 added a
type V with tendon and bony avulsion and transverse
fracture of the distal phalanx. Only case reports have
been published of traumatic rupture of the FDS.5,6,13,17
MECHANISM OF INJURY
Many of these injuries occur in rugby or American
football, when the finger is forcibly extended during a
maximum contraction of the profundus flexor muscle.
The injury occurs when a player is attempting to make
a tackle and the little finger slips off the opposite player’s
pants or jersey (Figure 20[A]-1). As this occurs, the ring
finger is caught in the pants or jersey. Because of the
mechanism of injury, the lesion has been termed “jersey
finger” or “rugby finger.”2,18-20 Other etiologies have
been reported, including blast injury21 and closed blunt
trauma.22

220
Section 2:  Primary Flexor Tendon Surgery
disrupted, resulting in loss of blood supply to the
tendon.
 Type II, the tendon retracts back to the level of the
proximal interphalangeal (PIP) joint, being held
there by the intact long vinculum.
 Type III, there is usually a large bony fragment that
is avulsed from distal phalanx and holds the
tendon from proximal retraction by catching on
the A4 pulley. The tendon and vinculae remain
intact.
Mansat and Bonnevialle2 have found it more logical
to classify this injury according to the extent of retrac­
tion of the avulsed FDP tendon from a more benign
form to a more severe form:
 Type I, proximal retraction of the avulsed FDP
tendon to the level of the bifurcation of the FDS
tendon, but the long vinculum remains intact.
 Type II, marked retraction of the avulsed FDP
tendon into the palm, with avulsion of the vincu­
lae and loss of the tendon vascular support.
 Type III, Intraarticular fracture of the distal phalanx
and dorsal subluxation of the DIP joint; the
tendon still attaches to the bony fragment and
proximal retraction of the FDP tendon is very
limited. The bony fragment is entrapped in the
distal part the digital sheath tunnel.
 Type IV, the tendon is avulsed from the fractured
fragment of the distal phalanx and retracts; the frac­
ture is intraarticular, involving articular surface.15
 Type V, avulsion of an osseous fragment connect­
ing to the insertion of the FDP tendon. There is a
The ring finger is most susceptible to avulsion of the
FDP tendon.1 Several studies have shown that the inser­
tion of the profundus tendon is anatomically weaker in
the ring finger than in the middle finger.19,23 The FDP of
the ring finger is tethered in the palm by a bipennate
lumbrical muscle,19 and the anatomic arrangement of
the extensor tendons in the ring finger may also relate
to the susceptibility of the ring finger to rupture.1
When the four long fingers are grasping an object with
force, they bear strong traction, which causes acute hyper­
extension of the distal interphalangeal (DIP) joints. The
index, whose muscular belly is independent, can release
its grip before the others. Because the muscular part of
the profundus is united to the surrounding structures
and because of the existence of tendinous connections,
the ring finger is submitted to the constraint along with
the middle and little fingers. Because of the shorter size
of the little finger, it closes up before the others. This
leaves the middle and ring fingers to oppose this strong
hyperextension force. The distal insertion of the ring
finger, being weaker than that of the middle finger, gives
away first.2
CLASSIFICATION
The amount of injury to the extrinsic vascular supply of
the distal flexor tendon is proportional to the degree of
retraction of the avulsed tendon. The short vinculum,
located at the neck of the middle phalanx and at the
DIP joint, is injured when the FDP tendon is avulsed
from the distal phalanx. However, the tendon may be
still supplied by the long vinculum located on the FDS
tendon closed to its chiasma, which extends to the FDP
tendon. The intactness of this long vinculum determines
the severity of the injury.24-26
Leddy and Packer classified the FDP tendon avulsion
injury in the finger into three types1 (Figure 20[A]-2):
 Type I, the avulsed FDP tendon is retracted into the
palm. The vincular system has been completely
Figure 20(A)-1  Mechanism of injury of a “rugby finger.”
Figure 20(A)-2  Leddy and Packer’s classification.1
Type I
Type II
Type III

221
Chapter 20A:  Traumatic Avulsion of Flexor Tendons
tendon.27 The only differential diagnosis is a torn volar
plate of the DIP joint as described by Bowers and
Fatjgenbaum.28
Isolated, closed avulsion of the FDS tendon at its
insertion can present diagnostic and therapeutic chal­
lenges. The injury is often associated with flexion defor­
mity and diminished extension of the involved digit.
This presentation is readily explained by the anatomy
of the digital flexor tendon and annular pulley system.
Once torn from its insertion on the middle phalanx, the
superficialis tendon retracts proximally. It stops at the
level of the A1 pulley where Camper’s chiasma acts as
noose to ensnare the FDP tendon. If diagnosis is delayed,
concomitant fracture of the distal phalanx beside
the avulsion.16
In some rare cases, both flexor tendons can be avulsed
on the same finger.7-10
DIAGNOSIS
The problem of this injury is that it is often missed
initially. In the Mansat and Bonnevialle series, only 50%
of the cases had been diagnosed within the first 3 weeks.2
The history of the mechanism of injury is typical. While
playing rugby, American football, or other sports, the
patient feels a searing pain in the ring finger when grasp­
ing the opposite player’s jersey, sometimes with ecchy­
mosis (Figure 20[A]-3). The patient may notice loss of
active DIP joint flexion (or PIP joint flexion for an FDS
tendon avulsion) (Figure 20[A]-4). Pain localization
may give an indication of the amount of retraction of
the avulsed tendon. According to Mansat and Bonnevi­
alle’s classification,2 in type I, patients have pain, swell­
ing, and loss of motion of the PIP joint as well as no
active flexion of the DIP joint. In type II, the patient may
have tenderness over the insertion area of the FDP
tendon on the distal phalanx, and there also may be
tenderness and swelling in the palm where the tendon
has retracted. In type III, the patient has marked swell­
ing, ecchymosis, and pain over the distal aspect of the
middle phalanx just proximal to the DIP joint, as well
as no active flexion at the DIP joint. Radiographs are
often negative in type I and II lesions. However, in types
III, IV, and V, a lateral radiograph shows a large bony
fragment just proximal to the DIP joint with or without
distal phalanx fracture (Figure 20[A]-5). The use of
ultrasound has been proposed to localize the avulsed
Figure 20(A)-3  Ecchymosis along the finger.
Figure 20(A)-4  Loss of active flexion of the DIP joint after
rupture of the FDP tendon in a ring finger.
Figure 20(A)-5  A lateral x-ray film showing a bony
fragment avulsed from the base of the distal phalanx.

222
Section 2:  Primary Flexor Tendon Surgery
rupture.4 Transosseous suture repair is preferred, using
a standard pull-out wire and button technique,1,2 a
double-arm reinsertion technique,29 or micro-anchors4,30
(Figure 20[A]-7). In the Brustein et al study,31 the
micro-bone suture anchor provided a stronger tendon-
to-bone repair compared to pull-out wire and button
or a mini-anchor. However, McCallister et al32 have
shown no difference between pull-out wire and button
technique and mini-anchors for zone 1 flexor tendon
repair in respect of clinical outcome, although signifi­
cant improvement was found in the time to return to
work following repairs using suture anchor technique.
There was less potential morbidity associated with the
anchor technique compared to the pull-out wire and
button technique. The main problems reported with the
pull-out technique were discomfort, pain, suture wire
rupture, difficulty in daily care of the bolster, infection,
skin necrosis, and nail bed injury.33 The use of a braided
polyester suture instead of a monofilament suture is
recommended, as it is more resistant to cyclic testing.34
Care should be taken not to injure the volar plate of the
DIP joint when reinserting the tendon.
In type II, the exposure is identical to that for a type
I injury. If the tendon is not identified just distal to the
A2 pulley, it must have retracted into the palm. Then, a
slightly curved incision is made just proximal to the
distal palmar crease; this allows exposure of the flexor
sheath proximal to the A1 pulley. A small incision is
made in the sheath, and the distal end of the profundus
tendon is identified. Next, a small catheter is inserted
into the sheath through the incision in the distal finger
and passed to the level of the A1 pulley. The profundus
inflammation and adhesion formation further entrap
the profundus tendon.5 Lateral radiograph can show a
bony fragment at the middle phalanx.6
TREATMENT
Several factors have been identified which influence the
prognosis and treatment of injury of the FDP tendon:
(1) the level of retraction of the tendon, (2) the status
of the vinculae, (3) the delay between injury and treat­
ment, and (4) the presence and size of a phalangeal
bony fragment.2,18
The definition of “acute” cases varies from one sur­
geon to another. For Mansat and Bonnevialle,2 a delay
of 3 weeks is the limit, whereas for Tropet et al,3 10 days
is the maximum. For Leddy and Packer,1 the delay is not
the major factor but more the level of tendon retraction
at diagnosis. If the tendon is not retracted, a direct repair
can be performed up to 3 months after injury; on the
other hand, if the tendon is retracted into the palm,
direct repair may not be possible after 10 days have
elapsed. Usually, final decision is made during surgery.
The treatment of an acute injury, according to Mansat
and Bonnevialle’s classification,2 is described below. The
decision to repair or reattach the tendon to the distal
phalanx depends on the degree of retraction.
In type I, the optimal treatment for this injury is early
reinsertion of the tendon to the distal phalanx. The
exposure is through a zigzag incision on the finger,
exposing the flexor sheath from the area of the insertion
to just proximal to the PIP joint. An opening is created
in the sheath just distal to the A2 pulley to identify the
retracted tendon (Figure 20[A]-6). The tendon is found
and threaded beneath the flexor tendon sheath to the
level of the distal phalanx in a nontraumatic manner.
A raised osteoperiosteal flap is then created at the
insertion site on the distal phalanx, and the profundus
tendon is reinserted. If some tendon materials remain
on the distal phalanx direct tendon-to-tendon suture
must be avoided because of a high risk of secondary
Figure 20(A)-6  Surgical exposure for a type I lesion.
Figure 20(A)-7  Repair of the FDP tendon by means of
pull-out or barb-wire suture (A), or micro-anchors (B).
A
B

223
Chapter 20A:  Traumatic Avulsion of Flexor Tendons
tendon is then sutured to the catheter, which is pulled
distally, threading the profundus tendon back beneath
the pulleys and through the superficialis chiasma to the
level of the PIP joint. The tendon is then passed in a
similar fashion beneath the C1, A3, C2, A4, and C3
pulleys to the level of the distal phalanx. The tendon is
reattached to the phalanx with the methods for a type I
injury. However, if reinsertion on the phalanx is difficult
and under tension, resection of the tendon with stabi­
lization of the DIP joint in slight flexion is preferred.
Using the distal remnant of the profundus tendon may
help to create a simple tenodesis protected by a tempo­
rary K-wire. Fusion is an alternative to tenodesis.2
In type III, treatment consists of open reduction and
internal fixation of the bone fragment. Correct reduc­
tion of the joint line is necessary to obtain good motion
without pain. Internal fixation can be performed with
K-wires,2,4,15,35,36 micro-screws,20,37,38 or a micro-plate39,40
(Figure 20[A]-8).
In types IV and V, the bony fragment is openly
reduced and fixed followed by repair of the avulsed
profundus tendon, as described for type I and II injuries,
depending on the level of retraction.15,16
For old injuries, management is variable and indi­
vidualized for each case. Decision-making is based on
functional impairment (PIP joint stiffness, loss of
strength), patient’s needs and expectation, and total
ranges of active and passive motion of the PIP and DIP
joints. Those patients who are asymptomatic should be
left alone. Rarely do patients have limitation of motion
at the PIP joint 6 months after injury; however, if there
is instability of the DIP joint with weakness of pinch
or recurrent dorsal dislocation, arthrodesis or tenodesis
of the joint should be considered18 (Figure 20[A]-9).
Fusion provides joint stability and does not interfere
with the function of the superficialis tendon. If there is
a tender lump in the palm, the retracted tendon end can
be excised at the time of fusion. Generally, Mansat and
Bonnevialle2 advocated (1) no surgery when impair­
ment is slight (non-manual workers), the PIP joint is
perfectly mobile, and the DIP joint is stable; and (2)
simple resection of the retracted FDP tendon if the PIP
joint is stiff, in association with tenodesis of the DIP
joint. There is a risk of PIP and DIP joint stiffness if
reinsertion is performed, even in type I injury. One-stage
tendon graft with palmaris longus tendon should be
reserved for patients for whom strength and function
impairment of the ring finger are not acceptable but who
have normal passive motion of PIP and DIP joints
(Table 20[A]-1).
FDS tendon avulsion can be reinserted or sutured
totally or partially with repair of one slip through a
palmar zigzag incision centered on the PIP joint if diag­
nosed early. However, for long-standing cases, the inci­
sion must be extended into the palm. The retracted end
of the tendon is found at the level of the A1 pulley.
Figure 20(A)-8  Treatment of a type III lesion. A, Osteosyn­
thesis of the fracture with a screw. B and C, Tendon repair
with a micro-anchor. D and E, Clinical results at follow-up.
A
B
C
D
E

224
Section 2:  Primary Flexor Tendon Surgery
Peritendinous adhesions and scar tissue were excised
along with the FDS tendon.5 If a bony fragment is
attached to the tendon, it is removed with the tendon.6
POSTOPERATIVE CARE
Postoperatively, in type I and II lesions after reinsertion
of the FDP tendon to the distal phalanx, a dorsal splint
is used to hold the wrist in slight flexion, the MCP joints
in 75° of flexion, and the PIP and DIP joints in relative
extension (Figure 20[A]-10). Passive flexion exercises
are started early in the postoperative course. Active exer­
cises are begun at 3 weeks when the splint is removed.
The pull-out wire and button are removed 3 to 4 weeks
postoperatively, and the remaining rehabilitation is
similar to that for other flexor tendon injuries.
In type III, IV, and V lesions, immobilization of the
DIP joint of 45 days is necessary for consolidation of the
fracture. Then passive and active mobilization is begun.
OUTCOMES
For acute lesions of the FDP tendon, surgical repair is
always indicated, and satisfactory results varied from
70% for Gaston et al4 to 80% for Mansat and Bonne­
vialle2 and 100% for Leddy and Packer1 and Tropet
Figure 20(A)-10  Dorsal splinting to place the MCP joint in
flexion and PIP and DIP joints in extension.
Figure 20(A)-9  Type I lesion treated by resection of the
FDP tendon (A), and tenodesis of the remnant of the FDP
tendon at the DIP joint (B).
A
B
Table 20(A)-1  Operative Methods for Avulsion of the
FDP Tendon
Type*
Operative Treatment:
Acute (<3 Wk)
Operative Treatment:
Late (>3 Wk)
I
Direct repair
(+micro-anchors)
FDP resection + DIP
joint capsulodesis or
tenodesis
FDP resection + DIP
joint capsulodesis or
tenodesis
FDP resection + DIP
joint arthrodesis
FDP resection + DIP
joint arthrodesis
Tendon graft
II
Direct repair
(+micro-anchors)
Direct repair
(+micro-anchors)
FDP resection + DIP
joint capsulodesis or
tenodesis
FDP resection + DIP
joint arthrodesis
Tendon graft
III
Osteosynthesis
(±suture of the
tendon)
Osteosynthesis
(±suture of the
tendon)
*Classifications by Leddy and Packer.1
et al.3 For type II lesions according to Mansat and Bonn­
evialle’s classification, reinsertion of the FDP tendon on
the distal phalanx must be performed without tension
to obtain satisfactory results.2 If not, the finger becomes
stiff with limitation of active motion of the DIP and PIP
joints. For type III, IV, and V lesions, the prognosis

225
Chapter 20A:  Traumatic Avulsion of Flexor Tendons
For patients seen more than 3 weeks after injury, the
FDP tendon was resected in one case, the FDP tendon
was resected with a DIP joint capsulodesis in 4 cases,
and tendon grafting using the palmaris longus was per­
formed in one case.
Patients were reviewed at an average of 7 years
(3 months to 13 years) from treatment (Table 20[A]-2).
Four of the 10 patients had a complete recovery (range
of motion and strength), 3 had an incomplete recovery
(range of motion of the DIP joint between 60° and 80°
of flexion, normal strength), and one had an unsatisfac­
tory result (range of motion of the DIP joint of 20° and
loss of strength). Two ruptures were observed within the
first month postoperatively: one type I lesion with
tendon reinsertion using a barb-wire suture, and one type
II lesion with direct tendon suture. In the 3 patients with
type III lesion, one was lost to follow-up, one had a
complete recovery, and one developed osteoarthritis of
the DIP joint (Figure 20[A]-11).
depends on the quality of articular surface reduction,
often with loss of few degrees of active motion of the
DIP joint.4
For chronic lesions, if the patient has no or slight
impairment, conservative management is the best
option. If the patient complains of digital pain, with
flexion deficit of the PIP joint, resection of the avulsed
tendon must be proposed. If there is instability of the
DIP joint, capsulodesis, or arthrodesis of the DIP joint
can be added. Tendon grafting should be limited to
young and active patients with specific needs. Preopera­
tive normal passive motion of the PIP and DIP joints is
a prerequisite to a good result. The patient must be
aware that a tendon graft usually does not allow com­
plete recovery of DIP active flexion. McClinton et al,41
reviewing 100 cases of tendon graft for isolated FDP
tendon laceration, obtained 48° of average DIP active
flexion. Liu and Yang,42 reviewing 15 cases of tendon
graft for isolated FDP tendon rupture, obtained an
average of 33° of DIP active flexion. Main complica­
tions were loss of PIP joint extension (more than 30°
in 27% of the cases of Liu et al,42 less than 10° in 55%
of the cases, and more than 10° in 9% of the cases of
McClinton et al41).
OUR PERSONAL EXPERIENCE
We recently reviewed our experience of treating avulsion
of the FDP tendon in 20 patients.4 These included 17
men and 3 women (average age, 31 years; range, 20 to
52 years). In 12 cases, the injury was related to sports
injury (football or rugby), and in 8 cases, to domestic or
work-related trauma. The ring finger was involved in 14
cases, the middle finger in 3 cases, and the little finger
in 3 cases. In 14 cases the patients were seen within 3
weeks from the injury. According to Leddy and Packer’s
classification,1 the lesion was staged as type I in 5 patients,
type II in 6, and type III in 3. In 6 cases, the patient was
seen more than 3 weeks from the initial trauma. These
lesions were classified as type I in 5 and type II in 1.
For the 14 patients seen acutely (within 3 weeks), all
type I and II injuries except one were treated surgically.
The FDP tendon was reattached to the distal phalanx
using a micro-anchor in 4 cases, a pull-out suture in 4,
and barb-wire fixation in one case. In one case, a direct
tendon-to-tendon suture was performed with a distal
remnant of the FDP on the distal phalanx. In one case
of type I lesion, the FDP tendon was resected. Postop­
eratively, early mobilization was proposed using a dorsal
splint with the MCP joint in flexion and the PIP and
DIP joints in extension. Passive flexion exercises were
started immediately in 6 patients and after 2 weeks in
4 patients. Active exercises were begun at 4 weeks when
the splint was removed. An osteosynthesis of the distal
phalanx was performed in type III lesions, using K-wire
to fix the avulsed bone in all 3 cases, along with a pull-
out suture of the FDP tendon in one case. The fingers
were immobilized with a splint for 4 weeks.
Figure 20(A)-11  A, Another example of type III lesion.
B, Subsequent development of malunion of the avulsed
bone fragment. C, Secondary arthritis of the DIP joint.
A
B
C

226
Section 2:  Primary Flexor Tendon Surgery
delay between injury and treatment, and the presence
and size of a phalangeal bony fragment affect the final
results of treatment. In acute cases (less than 3 weeks
after injury), direct reinsertion of the FDP tendon on the
distal phalanx gives satisfactory results. Long-standing
lesions with tendon retraction and impaired tendon
vascular supply should not be treated by reinsertion, to
avoid finger stiffness. No surgery is recommended when
function loss is slight, the PIP joint is mobile, and the
DIP joint is stable. If the PIP joint is stiff, the retracted
FDP tendon should be resected, followed by tenodesis
or capsulodesis of the DIP joint. One-stage tendon graft
should be reserved for patients whose strength and range
of active finger flexion are not acceptable but passive
motion of the PIP and DIP joints are normal.
Of the 5 patients seen lately with resection of the
FDP tendon, 3 of 5 were satisfied with their surgery
despite an ongoing loss of strength. The patient with a
tendon graft had poor results, with 10° of extension
deficit and 60° of flexion of the PIP joint, and had a
stiff DIP joint.
SUMMARY
Diagnosis of the closed FDP tendon can often be missed.
History of the mechanism of injury as well as the clinical
presentation is typical; tracing pain along the finger,
ecchymosis, and loss of active DIP joint flexion can be
helpful in making a diagnosis. Radiographs are essential
to diagnose a fracture of the distal phalanx. The level of
retraction of the tendon, the status of the vinculae, the
Table 20(A)-2  Treatment Results of Avulsion of the FDP Tendon in Our Unit
Methods of Treatment
Number of Patients
and Types
Results*
Complications
Surgery: <3 wk after injury
  Transosseous reinsertion (micro-anchors)
3, Type I
1, Type II
2 Excellent
1 Good
1 Poor
0
  Transosseous reinsertion (pull-out)
4, Type II
2 Excellent
2 Good
0
  Transosseous reinsertion (barb-wire)
1, Type I
1 Poor
Rupture
  Direct FDP repair
1, Type II
1 Poor
Rupture
  FDP resection
1, Type I
Lost to follow-up
—
  Osteosynthesis (K-wire)
2, Type III
1 Excellent
1 Lost to follow-up
0
  Osteosynthesis (K-wire + pull-out)
1, Type III
1 Poor
DIP joint osteoarthritis
Surgery: >3 wk after injury
  FDP resection + capsulodesis
4, Type I
3 Good
1 Fair
Capsule lengthening and
Loss of strength
  FDP resection
1, Type I
1 Fair
Loss of strength
  Tendon graft
1, Type II
1 Poor
PIP/DIP joint stiffness
*Assessed with Strickland and Glogovac criteria.
References
1. Leddy JP, Packer JW: Avulsion of the profundus tendon inser­
tion in athletes, J Hand Surg (Am) 2:66–69, 1977.
2. Mansat M, Bonnevialle P: Avulsion traumatique du fléchis­
seur commun profond. A propos de 19 cas, Ann Chir Main
4:185–196, 1985.
3. Tropet Y, Nicolet F, Berthoz L, et al: La rupture traumatique
des tendons fléchisseurs. A propos de douze observations,
Ann Chir Main 5:59–62, 1986.
4. Gaston A, Allavena C, Mansat P, et al: Avulsion traumatique
du fléchisseur profond des doigts. A propos de 20 cas, Chir
Main 28:288–293, 2009.
5. Stern JD, Mitra A, Spears J: Isolated avulsion of the flexor
digitorum superficialis tendon, J Hand Surg (Am) 20:642–
644, 1995.
6. Ferraro SP Jr, Schenck RR: Isolated closed rupture of the bony
insertion of the flexor digitorum superficialis tendon: An
unusual case, J Hand Surg (Am) 23:837–839, 1998.
7. Cheung KM, Chow SP: Closed avulsion of both flexor tendons
of the ring finger, J Hand Surg (Br) 20:78–79, 1995.
8. Lanzetta M, Conolly WB: Closed rupture of both flexor
tendons in the same digit, J Hand Surg (Br) 17:479–480,
1992.

227
Chapter 20A:  Traumatic Avulsion of Flexor Tendons
28. Bowers WH, Fajgenbaum DM: Closed rupture of the volar
plate of the distal interphalangeal joint, J Bone Joint Surg (Am)
61:146, 1979.
29. Messina A, Messina JC: Double armed reinsertion suture
(DARS) of the profundus flexor tendon with immediate
active mobilization of the finger. 63 cases, Ann Chir Main
Memb Super 16:245–251, 1997.
30. Bonin N, Obert L, Jeynet L, et al: Réinsertion du tendon
fléchisseur par ancre de suture: Etude prospective continue
avec mobilisation active précoce, Chir Main 22:305–311,
2003.
31. Brustein M, Pellegrini J, Choueka J, et al: Bone suture anchors
versus the pullout button for repair of distal profundus
tendon injuries: A comparison of strength in human cadav­
eric hands, J Hand Surg (Am) 26:489–496, 2001.
32. McCallister WV, Ambrose HC, Katolik LI, et al: Comparison
of pullout button versus suture anchor for zone I flexor
tendon repair, J Hand Surg (Am) 31:246–251, 2006.
33. Kang N, Marsh D, Dewar D: The morbidity of the button-
over-nail technique for zone 1 flexor tendon repairs. Should
we still be using this technique? J Hand Surg (Eur) 33:566–
570, 2008.
34. Latendresse K, Dona E, Scougall PJ, et al: Cyclic testing of
pullout sutures and Micro-Mitek suture anchors in flexor digi­
torum profundus tendon distal fixation, J Hand Surg (Am)
30:471–478, 2005.
35. Buscemi MJ Jr, Page BJ 2nd: Flexor digitorum profundus avul­
sions with associated distal phalanx fractures, Am J Sports Med
15:366–370, 1987.
36. Boussouga M, Jaafar A, Bousselmane N, et al: Avulsion of
flexor digitorum profundus combined with articular fracture
of distal phalanx: A case report, Chir Main 26:250–252, 2007.
37. Eglseder WA, Russell JM: Type IV flexor digitorum profundus
avulsion, J Hand Surg (Am) 15:735–739, 1990.
38. Trumble TE, Vedder NB, Benirschke SK: Misleading fractures
after profondus tendon avulsions: A report of 6 cases, J Hand
Surg (Am) 17:902–906, 1992.
39. Chen CY, Li TS, Liu YT, et al: Miniplate hooking method for
repair of type III flexor digitorum profundus avulsion injury
with a small bone fragment: Case report, J Hand Surg (Am)
34:1449–1453, 2009.
40. Kang N, Pratt A, Burr N: Miniplate fixation for avulsion inju­
ries of the flexor digitorum profundus insertion, J Hand Surg
(Br) 28:363–368, 2003.
41. McClinton MA, Curtis RM, Wilgis EF: One hundred tendon
grafts for isolated flexor digitorum profundus injuries, J Hand
Surg (Am) 7:224–229, 1982.
42. Liu TK, Yang RS: Flexor tendon graft for late management of
isolated rupture of the profundus tendon, J Trauma 43:103–
106, 1997.
9. Og˘ün TC, Ozdemir HM, Senaran H: Closed traumatic avul­
sion of both flexor tendons in the ring finger, J Trauma
60:904–905, 2006.
10. Tan V, Mundanthanam G, Weiland AJ: Traumatic simultane­
ous rupture of both flexor tendons in a finger of an athlete,
Am J Orthop (Belle Mead, NJ) 34:505–507, 2005.
11. Gunter JH: Traumatic avulsion of the insertion of the flexor
digitorum profundus, Aust NZ J Surg 30:1–9, 1960.
12. Carroll RE, Match RM: Avulsion of the flexor profundus
tendon insertion, J Trauma 10:1109–1118, 1970.
13. Folmar RC, Nelson CL, Phalen GS: Ruptures of the flexor
tendons in hand of non-rheumatoid patients, J Bone Joint Surg
(Am) 54:579–584, 1972.
14. Chang WH, Thomas OJ, White WL: Avulsion injury of the
long flexor tendons, Plast Reconstr Surg 50:260–264, 1972.
15. Smith JH Jr: Avulsion of a profundus tendon with simultane­
ous intraarticular fracture of the distal phalanx-case report,
J Hand Surg (Am) 6:600–601, 1981.
16. Al-Qattan MM: Type 5 avulsion of the insertion of the flexor
digitorum profundus tendon, J Hand Surg (Br) 26:427–431,
2001.
17. Boyes JH, Wilson JN, Smith JW: Flexor-tendon ruptures in the
forearm and hand, J Bone Joint Surg (Am) 42:637–646, 1960.
18. Aronowitz ER, Leddy JP: Closed tendon injuries of the hand
and wrist in athletes, Clin Sports Med 17:449–467, 1998.
19. Lunn PG, Lamb DW: “Rugby finger”—avulsion of profundus
of ring finger, J Hand Surg (Br) 9:69–71, 1984.
20. Shabat S, Sagiv P, Stern A, et al: Avulsion fracture of the flexor
digitorum profundus tendon (‘Jersey finger’) type III, Arch
Orthop Trauma Surg 122:182–183, 2002.
21. Toussaint B, Lenoble E, Roche O, et al: Avulsion sous-cutanée
des tendons fléchisseurs profonds et superficiels des IV et V
doigts par blast, Ann Chir Main Memb Super 9:232–235, 1990.
22. You JS, Chung YE, Kim D, et al: Rupture of the flexor digito­
rum profundus tendon caused by closed blunt trauma.
J Emerg Med 41:e91–e92, 2011.
23. Manske PR, Lesker PA: Avulsion of the ring finger flexor digi­
torum profundus tendon: An experimental study, Hand 10:
52–55, 1987.
24. Edwards EA: Organisation of the small arteries of the hand
and digits, Am J Surg 99:837–846, 1960.
25. Smith JW: Blood supplies of tendons, Am J Surg 109:272–276,
1965.
26. Leffert RD, Weiss C, Athanasoulis CA: The vincula; with par­
ticular reference to their vessels and nerves, J Bone Joint Surg
(Am) 56:1191–1198, 1974.
27. Cohen SB, Chabbra AB, Anderson MW, et al: Used of ultra­
sound in determining treatment for avulsion of the flexor
digitorum profundus (rugger jersey finger): A case report, Am
J Orthop (Belle Mead, NJ) 33:546–549, 2004.

228
Hiroshi Yamazaki, MD, PhD, Hiroyuki Kato, MD, PhD,
and Shigeharu Uchiyama, MD
B
Tendon Rupture After Fractures
or Carpal Disorders
tendon and the FDP tendon of the little finger were
most frequently affected in 10 patients with flexor
tendon ruptures. Yamazaki et al15 reported 21 patients
with closed rupture of the flexor tendons caused by
carpal bone and joint disorders and described useful­
ness of radiocarpal arthrography as a diagnostic tool.
In this section, characteristic clinical and roentgeno­
graphic features of closed rupture of the flexor tendon
secondary to fractures or carpal disorders are reviewed.
Pathophysiology and reconstruction are discussed.
METHODS AND OUTCOMES
Patients
We analyzed 21 patients with closed rupture of the
flexor tendons caused by carpal bone and joint disor­
ders.15 The mean patient age was 68 (range, 35 to 89)
years. Fourteen patients were men and seven were
women. Fifteen of the 21 patients were manual laborers.
The pathological conditions included nonunion of the
hook of the hamate in six patients, pisotriquetral joint
arthritis in seven patients, nonunion of the scaphoid in
four patients, the presence of a rough surface of the
hook of the hamate in two patients, Kienböck disease
in one patient, and the presence of an intraosseous
ganglion of the lunate in one patient. Affected digit was
the thumb in four patients, index finger in one patient,
ring and little fingers together in one patient, and little
finger in fifteen patients. Patients with tendon rupture
caused by direct invasion by synovitis associated with
rheumatoid arthritis or infection were excluded. Radio­
carpal arthrography was performed in 14 of the 21
patients and capsular perforation demonstrated by con­
trast medium leakage into the carpal canal in 11 patients
(Figure 20[B]-1). A free palmaris longus tendon or
plantaris tendon graft was interposed between the prox­
imal and distal stumps of the ruptured tendon in 17
patients. Tendon transfer of the flexor digitorum super­
ficialis (FDS) tendon of the ring finger to the FDP
tendon of the little finger was performed in two patients.
End-to-side tendon transfer using the FDP tendon of the
long finger with interposition of the palmaris longus
OUTLINE
Closed flexor tendon ruptures can be caused by some
pathologies of the carpal bones and joints, such as
fracture of the hook of the hamate, Kienböck’s disease,
scaphoid nonunion, and pisotriquetral disorders. We
analyzed 21 patients with closed rupture of the flexor
tendons caused by carpal bone and joint disorders. In
most patients the closed flexor tendon rupture occurred
when mild resistance forces were applied to the finger
or spontaneously. The mechanism of the tendon rup­
tures is attrition from passage back and forth over a
rough bone surface. We found it difficult to identify
the causes of these tendon ruptures using plain radio­
graphs, especially in the elderly or in manual laborers
who have preexisting abnormal lesions, such as osteo­
arthritis, instability of the carpus, and radiographic
evidence of previous trauma. Radiocarpal arthrogra­
phy was useful in identifying the site of the lesion
responsible for the flexor tendon ruptures. The radio­
graphic signs of lesions from which contrast medium
leaked subsequently corresponded to the disruption
site of the periosteum or joint capsule at surgery. Our
preferred management is free tendon graft reconstruc­
tions followed by early controlled mobilization, and
we suggest that the projected bony parts be resected
and the capsule/periosteum repaired to prevent recur­
rence of tendon rupture.
Most flexor tendon ruptures result from avulsion of the
flexor digitorum profundus (FDP) tendon at its inser­
tion. Although not common in contrast to rheumatoid
arthritis, closed flexor tendon ruptures caused by hidden
pathologies of the carpal bones and joints have been
reported, namely fracture of the hook of the hamate,1-4
Kienböck’s disease,5 scaphoid nonunion,6,7 pisotrique­
tral osteoarthritis,8,9 pisotriquetral instability,10 lunate
fracture,11 and chronic lunate dislocations.12 Boyes et al13
reported that 10 of 80 flexor tendon ruptures (12.8%)
had occurred in the carpal tunnel and that 2 of the
10 had associated abnormalities of the carpal bones.
Folmar et al14 reported the flexor pollicis longus (FPL)

229
Chapter 20B:  Tendon Rupture After Fractures or Carpal Disorders
Figure 20(B)-1  Radiocarpal arthrogram showing leakage
(arrow) of contrast medium into the flexor tendon sheath in
pisotriquetral joint arthritis.
tendon to the FDP tendons of the little and ring finger
was performed in one patient.
Operative Techniques
During operation, a curved and zigzag incision was
made on the palm between distal palmar crease and
proximal crease. The patients underwent release of the
carpal tunnel for exposure of carpal pathologies and the
ruptured tendon stumps. We used this method to check
the neighboring tendon, which often frayed. The volar
capsule/periosteum of the carpus was perforated at the
site of the tendon ruptures. The free or sharp bone frag­
ment was excised. At the site of mobile nonunion and
osteoarthritis, sclerotic cortical surface of the bone was
curetted and filled with cancellous bone graft. The edges
of the palmar capsule defect were approximated and
sutured. In free tendon grafting, the palmaris longus or
the plantaris tendon was harvested. The proximal stump
was well pulled until myostatic contracture was released.
The FDP tendon was reconstructed only in the finger in
which both the FDP and FDS tendons were ruptured.
The remnant tendon was trimmed out, and the inter­
positional or transferred tendon was sutured to the
refreshed stump with interlacing or Pulvertaft weave
suture. The junction of the graft with the stump was
placed away from the carpal area for preventing adhe­
sion of the tendon stump within the carpal tunnel. The
tourniquet was then deflated, and correct tension was
achieved by observation of the resting position of the
finger and the interphalangeal (IP) joint during passive
flexion and extension of the wrist. One patient in whom
the transverse carpal ligament was sutured developed
carpal tunnel syndrome subsequent to surgery and we
now do not recommend repairing this ligament.
Postoperative Care
After tendon reconstruction, early controlled mobiliza­
tion with a modified Kleinert elastic band technique was
used for 3 to 4 weeks. The Duran method was also per­
formed to prevent contracture of IP joint. Thereafter, the
hand was protected by a dorsal splint only and active
flexion exercise was encouraged. Active finger use was
permitted at 12 weeks postoperatively. Dorsal blocking
splint with rubber band was not used in the thumb. The
affected thumb was immobilized for 3 weeks, and active
exercise was started after that.
Outcomes
Postoperative total active range of motion (TAM) in the
finger after 13 free tendon graft reconstructions averaged
213° (range, 170° to 265°) (Table 20[B]-1). The TAM
of the thumb IP joint after free tendon graft reconstruc­
tion in three cases improved from 0° to 33° on average
(range, 10° to 40°). In nine patients, the postoperative
grip strength ratio averaged 84% (range, 57% to 126%).
Illustrative Case
A 73-year-old woman noticed the distal IP (DIP) joint
of the little finger gradually became incapable of active
flexion. Radiography in an oblique lateral view in supi­
nation and computed tomography (CT) imaging (Figure
20[B]-2) showed pisotriquetral joint arthritis. In the
operation, the FDP tendon of the little finger was seen
to be ruptured and adherent to the FDS tendon of that
finger. The pisiform was removed (Figure 20[B]-3), and
a free tendon graft from the palmaris longus tendon was
interposed between the stumps. Modified Kleinert early
mobilization was carried out. One year after the opera­
tion, percent TAM was 92% and outcome according to
the American Society for Surgery of the Hand criteria
was good. No pain was present at the wrist. The grip
strength ratio was 89%.
DISCUSSION
A detailed history and clinical examination allow diag­
nosis of rupture of the flexor tendon to be made.
However, especially in chronic cases, diagnosis of
rupture of the flexor tendon is often delayed or missed.
In most patients, the closed flexor tendon rupture occurs
when mild resistance forces applied to the finger or
spontaneously. In some cases, flexor tendon attrition
and rupture cause discomfort within the region of the
synovial sheath of the digit.
Some patients have past history of trauma to the wrist,
and others have no recollection of obvious injury. The
symptoms at the wrist resulting from fractures or carpal
bone disorders are often free or mild, and disability is

230
Section 2:  Primary Flexor Tendon Surgery
Table 20(B)-1  Patient Data, Tendon(s) Ruptured, Findings of Arthrography, and Recovery of TAM After
Treatment
Age
(Yr)/Sex
Disorder/Hand
Involved
Finger(s)/
Ruptured
Tendon(s)
Site of Contrast
Medium Leakage
on Radiocarpal
Arthrography
Treatment
Functional
Recovery* (% TAM
and Grade)
35/M
Hamate hook
nonunion/R
Little/FDP
Not examined
Tendon graft
100%, Excellent
51/M
Hamate hook
nonunion/R
Little/FDP
Not examined
Tendon graft
71%, Fair
55/M
Hamate hook
nonunion/R
Little/FDP, FDS
Not examined
Tendon graft
88%, Good
58/M
Hamate hook
nonunion/R
Little/FDP
Not examined
Tendon graft
75%, Fair
63/M
Hamate hook
nonunion/L
Little/FDP, FDS
Triquetrohamate
joint
Tendon transfer
83%, Good
73/M
Hamate hook
nonunion/L
Little/FDP, FDS
Not examined
Tendon graft, tenolysis
85%, Good
50/F
Hamate hook
projection/R
Little/FDP, FDS
Not examined
Tendon graft
Not available
76/M
Hamate hook
projection/L
Little/FDP, FDS
No leakage
Tendon graft
85%, Good
67/F
Pisotriquetral OA/R
Little/FDP
Pisotriquetral joint
Tendon graft
75%, Fair
70/F
Pisotriquetral OA/L
Little/FDP
Pisotriquetral joint
Tendon graft
81%, Good
70/M
Pisotriquetral OA/L
Little/FDP
Pisotriquetral joint
Tendon graft
83%, Good
73/F
Pisotriquetral OA/R
Little/FDP
Pisotriquetral joint
Tendon graft, tenolysis
83%, Good
73/F
Pisotriquetral OA/L
Little/FDP
Pisotriquetral joint
Tendon transfer
92%, Good
80/F
Pisotriquetral OA/L
Little/FDP, FDS
Pisotriquetral joint
Tendon graft
77%, Good
89/M
Pisotriquetral OA/R
Little/FDP
Pisotriquetral joint
Tendon graft
85%, Good
65/M
Scaphoid nonunion/R
Thumb/FPL
Not examined
Tendon graft
Good†
72/M
Scaphoid nonunion/L
Thumb/FPL
Nonunion site
no operation
Not available
72/M
Scaphoid nonunion/R
Thumb/FPL
Nonunion site
Tendon graft
Fair†
83/M
Scaphoid nonunion/R
Thumb/FPL
Nonunion site
Tendon graft
Good†
76/F
Kienböck disease/R
Little, ring/FDP
Radiolunate joint
End-to-side, tenolysis
87%, Good; 75%,
fair
71/F
Intraosseous ganglion
of the lunate/R
Index/FDP, FDS
Radiolunate joint
Tendon graft,
arthrodesis
65%, Fair
M, male; F, female; OA, osteoarthritis. R, right; L, left.
*Evaluated by the TAM method advocated by ASSH, except †by Buck-Gramcko method.
sometimes minimal. These disorders are often neglected
until the closed flexor tendon rupture occurs, because
routine anteroposterior and lateral roentgenograms of
the wrist fail to detect them.3,16 In approximately 14%
of hamate hook fracture, nonunion of the hook may
escape discovery, until it eventually causes closed rupture
of the flexor tendon of the little or ring finger.17 When
these historical and physical features exist, closed flexor
tendon rupture should raise suspicion of concealed dis­
orders of the carpal bones and joints. Other nonosseous
causes include anomalous tendon,18 nonspecific synovi­
tis,19 and crystal-induced tenosynovitis.20
The mechanism of these tendon ruptures is attrition
from gliding back and forth over a rough bone surface,
the latter having perforated the dorsal wall of the carpal
tunnel.14,21 The tendon that ruptured depended on the

231
Chapter 20B:  Tendon Rupture After Fractures or Carpal Disorders
rupture caused by carpal bone and joint disorders,
detection of the underlying pathological lesion before
surgery is also extremely important for the treatment,
because the surgical approach to the lesion is needed to
prevent flexor tendon re-rupture. To prevent recurrence
of tendon rupture, the sharp bone must be resected and
the capsule/periosteum repaired. The nonunion and
osteoarthritis with instability often require bone graft­
ing. Plain radiography of the wrist is often unhelpful,
unless special views are taken. Radiography in a carpal
tunnel view, radiography in an oblique lateral view
in supination, conventional tomography,16 and CT
imaging3 can help make diagnosis of the pathologies.
MRI was also useful to the diagnosis. However, it is
often difficult to differentiate the causative lesion of
the tendon rupture from the other abnormal lesions
by these diagnostic imaging studies, especially in the
elderly or in manual laborers who have preexisting
carpal abnormalities, including osteoarthritis, instabil­
ity of the carpus, and radiographic evidence of previous
trauma. Radiocarpal arthrography was very useful in
identifying the site of the lesion responsible for the
flexor tendon rupture. Similarly, using arthrography, we
identified extensor tendon rupture as a result of osteo­
arthritis of the distal radioulnar joint.24 Radiocarpal
arthrography was performed in 13 patients of flexor
tendon rupture in our series, and capsular perforation
demonstrated by contrast medium leakage into the
carpal tunnel in 11 patients. A high percentage of cases
in our investigation displayed contrast medium leakage
(see Figure 20[B]-1), and the radiographic lesions from
which contrast medium leaked corresponded to the
site of disruption of the periosteum or capsule seen at
surgery. Their adjacent tendons were disrupted. Gener­
ally, the lesion from which contrast medium leaks will
indicate location of the tear in the soft tissues and,
hence, the bony cause of the tendon rupture.
The goals of surgery are to reconstruct flexor tendon
function and to prevent flexor tendon re-rupture. The
affected tendon(s) invariably have frayed stumps, with
a long defect between the ends. Thus, direct suture
is impossible. The options of tendon reconstruction
include DIP joint arthrodesis, tenodesis, cross transfer of
flexor tendons from adjacent fingers, buddying to adja­
cent flexors, and free tendon graft. Milek and Boulas25
reported surgical results in four patients, three of whom
were treated by tendon transfer and one by tendon graft.
They attributed variation in the results largely to differ­
ences of the patients’ ages and recommended side-to-
side tendon suture. We prefer an interposition tendon
graft, since use of the tendon of another finger for a
tendon transfer may compromise function of that finger.
Motion of the DIP joint is reconstructed only by means
of free tendon grafting. We obtained mean digital TAM
of 213° after 13 free tendon graft reconstructions fol­
lowed by early controlled mobilization.15 In our series,
location of the bone perforation into the carpal tunnel.
The affected digit provides useful information about the
location of the carpal disorders. Disorders with an ulnar
location, such as fracture of the hook of the hamate and
arthritis involving the pisotriquetral joint, may abrade
the FDP tendon of the little finger, particularly. The
neighboring FDS tendon of the little finger and the FDP
tendon of the ring finger may subsequently be affected.
The FPL tendon lies over the ulnar surface of the scaph­
oid, and nonunion of the scaphoid may cause FPL
tendon rupture. The lunate forms the dorsal wall of the
carpal tunnel and contacts the FDP tendon of the index
finger, the tendon located most dorsally in the carpal
tunnel. Therefore, a lunate abnormality in which bone
penetrates the volar capsule is most likely to cause attri­
tion of flexor tendons of the index finger.
Ultrasound, magnetic resonance imaging (MRI),20,22
and three-dimensional CT imaging23 have been reported
to be useful tools for diagnosing flexor tendon injury
and pinpointing the site of rupture, which is crucial for
preoperative planning and thus avoiding unnecessary
surgical exploration. In patients with flexor tendon
Figure 20(B)-3  Intraoperative findings. The rough surface
of the pisiform is apparent. The FDP of the little finger is
ruptured at the lesion.
Figure 20(B)-2  A CT scan of the wrist showing
pisotriquetral joint arthritis.

232
Section 2:  Primary Flexor Tendon Surgery
reduce grip strength. In our series, tendon reconstruc­
tion does not improve grip strength.
Postoperative management following free tendon
grafting is, therefore, important. Free tendon grafting for
FDP reconstruction incurs the risk of postoperative con­
tracture in the interphalangeal joint. It is our belief that
postoperative immobilization after free tendon grafting
may lead to adhesion that compromises function, so we
adopted immediate early controlled mobilization with
a modified Kleinert elastic band technique. Early mobi­
lization after FDP reconstruction ensures larger gliding
excursion of the grafted tendon.
the mean patient age was 68 years. Although most
patients were older adults, results were satisfactory after
tendon grafting and outcome did not depend on patient
age or the interval between tendon rupture and recon­
struction. We believe that free tendon grafting is reason­
able, though this technique has the risk of adhesion and
re-rupture, and the postoperative early controlled mobi­
lization could be complicated.
Tendon graft should be done early to prevent myo­
static contracture in the affected digit. If the tendon
rupture was neglected, myostatic contracture may result
in undue tension of the tendon graft at surgery and
References
1. Clayton ML: Rupture of the flexor tendons in carpal tunnel
(non-rheumatoid) with specific reference to fracture of the
hook of the hamate, J Bone Joint Surg (Am) 51:798–799, 1969.
2. Minami A, Ogino T, Usui M, et al: Finger tendon rupture
secondary to fracture of the hamate. A case report, Acta Orthop
Scand 56:96–97, 1985.
3. Stark HH, Chao EK, Zemel NP, et al: Fracture of the hook of
the hamate, J Bone Joint Surg (Am) 71:1202–1207, 1989.
4. Yamazaki H, Kato H, Nakatsuchi Y, et al: Closed rupture of
the flexor tendons of the little finger secondary to non-union
of fractures of the hook of the hamate, J Hand Surg (Br)
31:337–341, 2006.
5. Niwa T, Uchiyama S, Yamazaki H, et al: Closed tendon
rupture as a result of Kienböck disease, Scand J Plast Reconstr
Surg Hand Surg 44:59–63, 2010.
6. McLain RF, Steyers CM: Tendon ruptures with scaphoid
nonunion. A case report, Clin Orthop Relat Res 117–120,
1990.
7. Saitoh S, Hata Y, Murakami N, et al: Scaphoid nonunion and
flexor pollicis longus tendon rupture, J Hand Surg (Am)
24:1211–1219, 1999.
8. Lutz RA, Monsivais JJ: Piso-triquetral arthrosis as a cause of
rupture of the profundus tendon of the little finger, J Hand
Surg (Br) 13:102–103, 1988.
9. Saitoh S, Kitagawa E, Hosaka M: Rupture of flexor tendons
due to pisotriquetral osteoarthritis, Arch Orthop Trauma Surg
116:303–306, 1997.
10. Corten EM, van den Broecke DG, Kon M, et al: Pisotriquetral
instability causing an unusual flexor tendon rupture, J Hand
Surg (Am) 29:236–239, 2004.
11. Minami A, Ogino T, Usui M: Delayed rupture of a flexor
tendon secondary to fracture of the lunate, Ital J Orthop Trau­
matol 11:233–236, 1985.
12. Stern PJ: Multiple flexor tendon ruptures following an old
anterior dislocation of the lunate. A case report, J Bone Joint
Surg (Am) 63:489–490, 1981.
13. Boyes JH, Wilson JN, Smith JW: Flexor-tendon ruptures in the
forearm and hand, J Bone Joint Surg (Am) 42:637–646, 1960.
14. Folmar RC, Nelson CL, Phalen GS: Ruptures of the flexor
tendons in hands of non-rheumatoid patients, J Bone Joint
Surg (Am) 54:579–584, 1972.
15. Yamazaki H, Kato H, Hata Y, et al: Closed rupture of the flexor
tendons caused by carpal bone and joint disorders, J Hand
Surg (Eur) 32:649–653, 2007.
16. Murray WT, Meuller PR, Rosenthal DI, et al: Fracture of the
hook of the hamate, Am J Roentgenol 133:899–903, 1979.
17. Boulas HJ, Milek MA: Hook of the hamate fractures. Diagnosis,
treatment, and complications, Orthop Rev 19:518–529, 1990.
18. Bois AJ, Johnston G, Classen D: Spontaneous flexor tendon
ruptures of the hand: Case series and review of the literature,
J Hand Surg (Am) 32:1061–1071, 2007.
19. Prosser GH, Sterne GD, Nancarrow JD: Intratendinous
rupture of flexor digitorum profundus caused by non-specific
synovitis, Br J Plast Surg 55:77–79, 2002.
20. Matloub HS, Dzwierzynski WW, Erickson S, et al: Magnetic
resonance imaging scanning in the diagnosis of zone II flexor
tendon rupture, J Hand Surg (Am) 21:451–455, 1996.
21. Hallett JP, Motta GR: Tendon ruptures in the hand with par­
ticular reference to attrition ruptures in the carpal tunnel,
Hand 14:283–290, 1982.
22. Kumar BA, Tolat AR, Threepuraneni G, et al: The role of
magnetic resonance imaging in late presentation of isolated
injuries of the flexor digitorum profundus tendon in the
finger, J Hand Surg (Br) 25:95–97, 2000.
23. Sunagawa T, Ochi M, Ishida O, et al: Three-dimensional CT
imaging of flexor tendon ruptures in the hand and wrist,
J Comput Assist Tomogr 27:169–174, 2003.
24. Yamazaki H, Uchiyama S, Hata Y, et al: Extensor tendon
rupture associated with osteoarthritis of the distal radioulnar
joint, J Hand Surg (Eur) 33:469–474, 2008.
25. Milek MA, Boulas HJ: Flexor tendon ruptures secondary to
hamate hook fractures, J Hand Surg (Am) 15:740–744, 1990.

233
Rohit Arora, MD, and Markus Gabl, MD
C
Rupture of the Pulleys
edge of the A2 pulley is especially high in rock climbers
using the “crimp grip.”5,7,8 In this position, the proximal
interphalangeal (PIP) joints are flexed 90° and the
distal interphalangeal (DIP) joints are hyperextended
(Figure 20[C]-1). The superficial and profundus flexor
tendons are at maximum possible contractile ability
in order to maintain the finger position under the
climbers’ body weight load.9 Pulley injuries (“climber’s
finger”) mostly occur as a result of grim grip when sud­
denly the climber slips off with the hand holding rock
niches, and the load to the finger is increased. Closed
flexor tendon pulley ruptures can also occur in other
situations in which a flexed finger is subjected to high
and rapidly applied forces, causing a sudden finger
extension3—for example, while lifting a heavy object or
while opening a door or drawer as seen in our patients.
The ring and middle fingers are usually injured while
the index and little fingers are less exposed.10 Generally,
reconstruction of both the A2 and A4 pulleys, the most
essential pulleys, is recommended.11
A number of surgeons reported various surgical
methods of pulley reconstruction, using various sources
of graft material like autogenous tendons,12,13 the exten­
sor retinaculum,6,14 the palmar plate of the PIP joint,14
or synthetic materials.15,16 Loop techniques are believed
to be stronger than nonencircling methods of pulley
reconstruction.16 The encircling procedures are believed
to interfere with the function of the extensor tendon
system.16
We present a retrospective review of 23 patients with
closed traumatic rupture of the flexor pulleys treated
with two techniques of nonencircling pulley reconstruc­
tion in our unit, with special reference to the long-term
functional outcome after pulley reconstruction.
METHODS AND OUTCOMES
Patients
Between 1996 and 2003, a total of 56 patients with
closed traumatic lesions of the finger pulleys were
treated in our unit. Patients with partial pulley ruptures
were treated conservatively. Twenty-three patients,
including 3 women and 20 men, with a mean age of 40
(range, 24 to 59) years, with a complete A2 pulley
rupture or with a combined A2 and A3 pulley rupture
were reviewed. Of the 23 patients, 14 had isolated rup­
tures of the A2 pulley and 9 had combined ruptures of
the A2 and A3 pulleys. The C1 pulley was ruptured in
OUTLINE
We present our experience with a total of 23 patients
with closed traumatic lesions of the flexor pulleys that
required surgical reconstruction. The A2 pulleys were
reconstructed with use of one of the two methods. In
extensor retinaculum grafting, a strip of extensor reti­
naculum together with the periosteum from the floor
of the extensor tunnel is harvested. After bilateral
holes are drilled in the palmar aspect of the phalanx
at the distal and proximal ends of the A2 pulley, the
graft is fixed by the periosteum to the bone of the
phalanx. The ligamentous portion of the graft is
sutured to the remnants of the pulley system. It is
important to fix the graft adequately to the remnants
of the sheath. In palmaris longus tendon grafting, a slip
of the tendon is passed through holes created in the
remnants of the A2 pulley, and the graft is sutured to
itself or to the fibrous rim at each end of the pulley.
Postoperatively, the fingers were immobilized with a
palmar splint extending from the distal interphalan­
geal to the proximal palmar crease for 4 weeks. The
range of active digital motion, pinch strength, and grip
power of the hand improved to the levels close to
those of the contralateral uninjured hand with both
methods. Extensor retinaculum as an intrasynovial
tissue may have less resistance to tendon gliding than
a palmaris longus graft.
Detailed anatomic and mechanical investigations of the
finger flexor tendon sheath and pulley system have
allowed better understanding of biomechanical impor­
tance of the cruciate and annular pulleys.1 Pulleys main­
tain the digital flexor tendons close to the axes of the
joints and secure efficiency in finger flexion by provid­
ing the most efficient use of flexor tendon excursion.2 If
the pulleys are injured, the tendons are displaced volarly
(bowstringing), leading to a decreased maximum range
of active joint flexion and power and to an increased
risk of developing fixed flexion contractures.3
In acute cut injuries, flexor tendons are frequently cut
through a laceration in the pulley system; partial or
complete injuries of the pulleys are common. Closed
ruptures of the flexor tendon pulleys are rare injuries
and most of them are reported to occur during rock
climbing.4-6
Biomechanical studies demonstrated that the mech­
anical load between finger flexor tendons and the distal

234
Section 2:  Primary Flexor Tendon Surgery
These patients complained of reduced finger dexterity
while performing their daily activities and work. The
persisting impairment of finger function and strength
in these patients was the indication for surgery. Bow­
stringing was noted in all patients (Figure 20[C]-3).
Additionally, magnetic resonance imaging (MRI) and
ultrasound were performed and the diagnosis of closed
rupture of annular pulleys was verified at surgery in all
patients. Ultrasound is very useful in diagnosis.17,18
Rupture of the pulley system was indicated by tendon
bowstringing, assessed using high-resolution ultraso­
nography (Acuson Sequoia 512, 15L8W; Siemens
Medical Solutions, Erlangen, Germany) (Figure 20[C]-
4). MRI was performed in the sagittal and coronal
planes with a 1.5-T superconductive Magnetom (Vision,
Siemens Medical Solutions) to assess the bowstringing
(Figure 20[C]-5).19
Operative Techniques
We used two methods of nonencircling pulley recon­
struction in the patients. The age, sex, affected fingers,
and ruptured pulleys of the patients with two treatment
methods are shown in Table 20[C]-1. One group con­
sisted of 13 patients who had pulley reconstruction
using a graft from the extensor retinaculum of the wrist
(Figure 20[C]-6). As described by Gabl et al,6 a strip of
extensor retinaculum approximately 10 mm in width
together with the periosteum from the floor of the
extensor tunnel was used for reconstruction of the A2
pulley (Figure 20[C]-7). After drilling bilateral burr
holes in the palmar aspect of the phalanx at the distal
and proximal ends of the A2 pulley, the graft was fixed
by the periosteum to the bone of the phalanx, placing
the synovial layer innermost (Figure 20[C]-8). Addi­
tionally, the ligamentous portion of the graft was sutured
to the remnants of the pulley system. The other group
consisted of 10 patients who were treated with a free
tendon graft of the palmaris longus tendon for recon­
struction of the A2 pulley (Figure 20[C]-9). The pulley
Figure 20(C)-3  Significant bowstringing in a patient with
ruptures of A2, A3, and A4 pulleys.
Figure 20(C)-1  Crimp grip used by rock climbers to make
the best use of small niches in the rocks for safe support.
Figure 20(C)-2  Intraoperative findings of complete
ruptures of the A2 (*) and C1 pulleys in a rock climber.
*
all patients (Figure 20[C]-2). Fifteen injuries were
caused by rock climbing and all of these patients
described inability to perform their sports at their previ­
ous level. Three injuries occurred while lifting a heavy
object and five occurred while opening a door or drawer.

235
Chapter 20C:  Rupture of the Pulleys
was made by passing a slender slip of tendon graft
through perforations made in the remnants of the origi­
nal A2 pulley, and the tendon graft was sutured to itself,
or to the fibrous rim at each end, with two sutures,
resulting in a shoelace-like reconstruction, as described
by Kleinert and Bennett13 (Figure 20[C]-10).
Postoperative Care
Postoperatively, patients of both treatment groups were
immobilized with a palmar splint extended from the
DIP to the proximal palmar crease for 4 weeks. The
metacarpophalangeal (MCP) joint and the PIP joint
Figure 20(C)-4  A, Preoperative longitudinal
ultrasonography scans showing pulley injury (A2, C1, A3)
with bowstringing of tendon and increased distance (arrow)
between phalanx and tendon. B, Postoperative longitudinal
ultrasonography scans after pulley reconstruction (A2) using
an extensor retinaculum graft showing decreased distance
(arrow) between phalanx and tendon.
A
B
Table 20(C)-1  Patient Demographics for Two Groups of Patients
Graft Materials
Total Patients
Sex (M/F)
Age (Yr)
Fingers
Pulleys Ruptured
Extensor retinaculum
13
11 : 2
41 (26–51)
10 Middle, 3 ring
A2 in 8, A2 + A3 in 5
Palmaris longus
10
9 : 1
38 (24–59)
7 Middle, 3 ring
A2 in 8, A2 + A3 in 4
were kept in full extension. Physiotherapy was started
after splint removal. Manual work, full load-bearing,
and sport activities were not permitted for 3 months.
The time from injury to surgery was 9 (range, 6 to 13)
weeks for patients treated with extensor retinaculum
graft and 7 (range, 5 to 9) weeks for patients treated with
palmaris longus tendon graft.
Evaluations
The mean follow-up was 48 (range, 18 to 43) months
after extensor retinaculum graft and 57 (range, 16 to 48)
months after palmaris longus tendon graft. Evaluations
included measurement of the ranges of motion of all
joints of involved fingers using a goniometer. Pinch
strength and the power grip strength were measured.
The circumference of the finger was measured at the
distal end of the A2 pulley. The outcome was also
assessed using the Buck-Gramcko score.19 Patients were
asked if they would undergo the treatment again in the
event of the same injury occurring to another finger.
Results
The MCP and the DIP joints of all patients had almost
normal active movement at preoperative and postopera­
tive examination. The PIP joint extension was also unre­
stricted at preoperative and postoperative examination.
Before surgery, grip strength of the injured hand was
reduced to 42 kg (range, 29 to 57 kg) and pinch grip
reduced to 6 kg (range, 3 to 9 kg), due to pain in all
patients.
In the patients with extensor retinaculum graft, pre­
operative PIP joint flexion was 82° (70° to 90°). After
surgery, the PIP joint flexion improved to 91° (85° to
100°) (i.e., 97% of the uninjured side). Postoperative
power grip strength was 48 kg (34 to 60 kg) (96% unin­
jured side). Postoperative pinch grip strength was 8 kg
(4 to 11 kg), which was equal to that of the uninjured
side. The circumference of the finger was 76 mm (60 to
90 mm) before surgery and 70 mm (58 to 88 mm) after
surgery (94% uninjured side).
In the patients with palmaris longus graft, preopera­
tive PIP joint flexion was 80° (75° to 90°). After surgery,
PIP joint flexion was 91° (80° to 100°) (94% uninjured
side). Postoperative power grip strength was 48 kg (32
to 68 kg) (98% uninjured side); the pinch grip was 7 kg
(3 to 10 kg), equal to that of the uninjured side. The
circumference of the finger was 66 mm (58 to 80 mm)
before surgery and 62 mm (54 to 82 mm) after surgery
(94% uninjured side).

236
Section 2:  Primary Flexor Tendon Surgery
Using the Buck-Gramcko score, 10 had excellent
result, 2 had good results, and 1 had fair results after
extensor retinaculum grafting, and there were 7 excel­
lent, 2 good, and 1 fair after palmaris longus tendon
grafting. All 15 climbers returned to their previous stan­
dard of climbing. In 13 of these climbers, the pulleys
were reconstructed using extensor retinaculum. All non­
climbers returned to their previous work and described
no restrictions of finger dexterity. All patients said that
they would want similar surgery if they had the same
injury. No significant difference was noted in active
range of digital motion, finger circumference, power,
and pinch grip strength between the two methods of
reconstruction.
Figure 20(C)-5  A, Preoperative MRI
demonstrating bowstringing as increased
distance between bone and tendon
(arrow) after rupture of A2, C1, and A3
pulleys. B, Postoperative MRI after pulley
reconstruction (A2) using an extensor
retinaculum graft showing decreased
distance (arrow) between phalanx and
tendon.
A
B
Figure 20(C)-6  Fixation of the extensor retinaculum graft to
the fibro-osseous floor. P, Periosteum; FDP, flexor digitorum
profundus tendon; R, remnants of the normal pulley.
FDP
Graft
P
R
Figure 20(C)-7  Graft of extensor retinaculum 10 mm in
width, together with the periosteum from the floor of the
extensor tunnel. G, Extensor retinaculum graft; EPL, extensor
pollicis longus tendon.
ET
G
DISCUSSION
Partial ruptures and isolated single pulley ruptures can
be treated conservatively by immobilization of all finger
motion in the acute phase and taping the injured finger
above the pulley after pain had been reduced.5 In