Phẫu Thuật Tạo Hình (Tập 6): Bàn Tay Và Chi Trên – Neligan (Ấn bản 4)

223
Secondary procedures
Anesthesia
Active involvement of the patient in assessing tendon mobil­
ity and adequacy of release is a key step of surgery. This is
achieved by using sedative anesthesia, combined with local
anesthesia at the operation area,234,288 or only local anesthesia
(no sedation) with the patient awake during the entire surgi­
cal period.123,124 The author uses 2% lidocaine infiltrated locally
in the subcutaneous tissues or as a digital nerve block at the
metacarpal level if the patient does not want to be awake. To
perform wide-awake tenolysis, the author injects 10 ml of 1%
lidocaine with 1 : 100 000 epinephrine to the surgical field in
each digit and the palm. Axillary block or general anesthesia
are used if the surgeon expects an extensive operation, such
as tenolysis in more than 2–3 digits, a staged reconstruction
procedure, or if the patient is unlikely to tolerate surgery with
local anesthesia.
Operative techniques
Through either a Bruner or midlateral incision, dissection
proceeds from the unaffected area to the affected area. Tenoly­
sis requires wider surgical exposure. All limiting adhesions
are meticulously divided and care is taken to define the
borders of the flexor tendons. During dissection, some sur­
geons advise preservation of the sheath as much as possible,
but others prefer to excise the synovial sheath. Regardless, the
major pulleys should be maintained, and the synovial sheath
imbedded within the scar is removed. It is necessary to main­
tain the A2 and A4 pulleys at a minimum. If possible, the A3
pulley and its adjacent sheath are also preserved. A variety of
instruments may aid in dissection of the scarred tendons from
inner surfaces of the major pulleys.289–291 Whenever possible,
the FDS and FDP tendons are separated from one another. In
some cases with severe adhesions, the FDS tendon has to be
resected locally. Dissection is continued until normal tissues
are revealed and no scar around the tendon is visible. Ade­
quacy of the release is then checked by active digital flexion
if the patient is wide-awake, or by a gentle proximal traction
on the proximal part of the tendon. A separate proximal inci­
sion in the palm can be created to pull the tendon. The quality
of the tendon and integrity of the pulleys are checked. If
tendon continuity is maintained only by scar or greater than
one-third of the tendon width is lost, the tendon is unlikely
to function properly and the case should proceed to staged
tendon reconstruction. If the critical pulleys are destroyed, it
is appropriate to proceed to pulley reconstruction (Box 9.11).
Over the years, many attempts have been made to develop
strategies to block or limit adhesion formation.292–302 Thus
far, few of these attempts have reliably reduced adhesions
clinically and are used routinely. Some surgeons favor use
of steroids.286 One multicenter clinical trial indicated ben­
efits of using a hyaluronan gel in reducing adhesions after
tenolysis.303
Fig. 9.53  Methods of flexor pulley reconstruction.
(A) Reconstruction of the A4 and A2 pulleys using flexor
tendon grafts passed circumferentially around proximal and
middle phalanges. The tendon graft passes deeper to the
extensor apparatus at the proximal phalangeal level and
superficial to the extensors at the middle phalangeal level.
(B) A tendon graft is woven through remnant of the A2
pulley to reconstruct the A2 pulley. (C) Use of a slip of
flexor digitorum superficialis (FDS) tendon for middle
digital pulley reconstruction. (D) An operative picture
showing the FDS tendon slip as a source of graft for
reconstructing multiple pulleys. The FDS was sutures to
the remnants of the pulleys and periosteum.
A
B
C
Grafts
Graft
Button
Button
FDS tendon
slip
FDS tendon slip
A2 pulley
D

224
SECTION II
CHAPTER 9 • Flexor tendon injuries and reconstruction
Postoperative tendon movement is critical to the success of
tenolysis and remains the most effective method to prevent
recurrence of adhesions.305–309 The amplitude, frequency, and
forces of motion should be decided based on intraoperative
findings. The surgeons should directly discuss with the thera­
pists to consolidate a therapy program. A tendon appearing
nearly normal in a minimally scarred bed with a strong pulley
system is appropriate for a more vigorous motion protocol.
When a tendon is of poor quality – with a dense scar, a lysed
segment, or a decrease in tendon caliber – or if pulleys have
been reconstructed, gentle active motion or delayed initiation
of the finger motion are indicated.234 In this instance, a “place
and hold” maneuver after passive digital motion into full
flexion is useful to reduce tension and the likelihood of tendon
disruption. Passive motion of the fingers is helpful in prevent­
ing finger joint contractures and in decreasing the resistance
to active finger movement. The motion program usually is
continued for 4–6 weeks.
Future directions
Though most hand surgeons are performing a stronger
primary flexor tendon repair than previously, postoperative
motion regimes have not been updated and active flexion
exercises have yet to be used in some regions or units. The
most efficient rehabilitation protocols for the hand with
various injury conditions remain to be determined. Some
surgeons or therapists advocate early hand and wrist mobili­
zation with short splints from fingertip to the wrist. Though
this appears to have merits and is reasonable, we are awaiting
for validation with the scope of its application being defined.
Currently, traditional tendon-to-bone junction repairs have
been questioned and alternatives are sought, but it remains to
be determined mechanically and clinically what methods can
reliably replace traditional pullout repairs. Wide-awake flexor
tendon repair has become a favorite practice of some surgeons
(including the author); we anticipate greater popularity.
Reducing adhesion formation in severely jeopardized tendons,
a long tendon defect, or loss of multiple tendons (which are
often seen in complex or extensive hand or forearm injuries)
continue to present major clinical challenges and are unsolved
problems. We expect that advancements in basic science – in
biological modulation of tendon healing and adhesion forma­
tion, development of engineered tendon grafts or tendon
allografts – will help provide solutions to these very difficult
conditions associated with tendon injuries.
Fig. 9.54  Distal junction of the tendon implant in stage 1. (A) The distal junction
wire method. A figure-of-eight suture of a monofilament wire (no. 32) is placed in
the implant and sutured to the FDP stump. Additional sutures are supplemented on
each side of the implant. (B) Screw-plate fixation method. A self-taping Woodruff
screw (2-mm) is used, which is inserted into a drill hole in the phalanx using a
K-wire (0.035-inch).
A
B
Distal tendon stump
Tendon implant
Tendon implant
15˚–20˚
0.035 wire
Postoperative treatment
Oral analgesics usually alleviate pain during the postopera­
tive period. Transcutaneous placement of local anesthetic
catheters may be considered for patients with low pain
thresholds or those undergoing extensive operations. Repeated
digital nerve block can also be used.304 Active motion of the
fingers can begin on the first day after surgery. Some surgeons
advocate waiting for several days or until soft-tissue inflam­
mation and pain subside to start motion.
BOX 9.11  Tenolysis
1. Local anesthesia is advised, to allow active finger flexion when
needed during surgery.
2. Adequate surgical exposure is required to expose all adhesions.
3. Preserve the critically located annular pulleys (A2 and A4 as a
minimal).
4. Check mobility of the released tendon to confirm adequacy of
surgery.
5. Postoperative motion is paramount to the success of this
procedure.
6. Rigor of motion regimes is decided according to intraoperative
findings of the released tendons. Motion exercise should always
be applied and continued for 4–6 weeks.

225
Future directions
19. Tang JB. Indications, methods, postoperative motion and outcome
evaluation of primary flexor tendon repairs in Zone 2. J Hand Surg
(Eur). 2007;32:118–129. This article provides a comprehensive and
updated review of the current indications for primary tendon repairs in
zone 2. The author’s techniques of multistrand repairs and rehabilitation
are detailed. Most importantly, the author defines the needs, mechanical
basis, and areas of releasing the critical parts of the major digital annular
pulleys to facilitate tendon repairs. The author highlights the importance
of releasing the critical pulley parts and strong surgical repairs in
achieving predictable primary flexor tendon repairs in this most difficult
area. Subdivision of zone 2 and novel criteria for outcome evaluation are
also presented in this article.
25. Giesen T, Sirotakova M, Copsey AJ, Elliot D. Flexor pollicis
longus primary repair: further experience with the Tang
technique and controlled active mobilisation. J Hand Surg (Eur).
2009;34:758–761. This clinical study reported the most up-to-date
clinical outcomes of repairs of lacerated flexor pollicis longus (FPL)
tendons from a renowned center dealing with flexor tendon injuries.
These authors have made a series of reports of their results in treating
FPL injuries over the past two decades; this most recent report
documents their outcomes in 50 FPL injuries. With a six-strand core
tendon repair alone (without peripheral repairs), they achieved good or
excellent functional recovery in 80% of thumbs, with zero tendon
rupture with an active motion regime. These are the best clinical
results of FPL tendon repairs reported thus far. It is worth noting that
the authors did not elaborate peripheral sutures in these FPL tendon
repairs, and the oblique pulley in the thumb was vented to
accommodate tendon repairs.
42. Boyes JH, Stark HH. Flexor-tendon grafts in the fingers and
thumb. A study of factors influencing results in 1000 cases. J Bone
Joint Surg Am. 1971;53:1332–1342. This classic article reported perhaps
the largest case series of free tendon grafting in the fingers and thumbs.
The authors analyzed the factors influencing the prognosis for free
tendon grafting and showed that the tendon grafting procedure used can
produce clinically acceptable function. However, hand conditions are
extremely important. Prognostic factors include conditions of the soft
tissues and joints. Extensively scarred tendon bed and joint damage led
to the worst prognosis after tendon graft surgeries.
46. Hunter JM, Salisbury RE. Flexor-tendon reconstruction in severely
damaged hands. A two-stage procedure using a silicone Dacron
reinforced gliding prosthesis prior to tendon grafting. J Bone Joint
Surg Am. 1971;53:829–858.
123. Lalonde DH, Martin AL. Wide-awake flexor tendon repair and
early tendon mobilization in zones 1 and 2. Hand Clin.
2013;29:207–213. This article provides details on how surgeons can
repair flexor tendon under local anesthesia with tourniquet control and
how the patient can actively move the repaired digit during surgery to
ascertain the repair is strong and appropriate for early active motion.
Early active motion protocols used by the authors are also illustrated in
details.
Access the complete reference list online at

Fig. 9.55  In stage 2, the tendon implant is replaced by a tendon graft. (A) The implant is exposed through a small incision at the distal part of the finger. After being
disconnected from the flexor digitorum profundus tendon stump, the implant is sutured to the tendon graft. The implant is pulled proximally through the newly formed
sheath to lead the grafted tendon. (B) The graft has been tunneled in the hand. The distal tendon junction is completed in a way similar to tendon grafting either through a
pullout suture or a robust direct suture repair. The proximal junction of the graft is made at either the distal forearm or the palm as shown. (C) An intraoperative view of
pulling the implant out of the finger. Note the proximal end of the implant was sutured to the grafted tendon. Therefore, after the implant was pulled out, the grafted tendon
was inside the sheath. (D) The distal end of the graft was securely sutured directly to the distal stump of the FDP tendon, which is my preferred method in recent years.
Autogenous tendon graft
Tendon graft
Tendon implant
A
B
C
D

226
SECTION II
CHAPTER 9 • Flexor tendon injuries and reconstruction
149. Elliot D, Giesen T. Primary flexor tendon surgery: the search for a
perfect result. Hand Clin. 2013;29:191–206.
150. Tang JB, Chang J, Elliot D, et al. IFSSH Flexor Tendon Committee
report 2014: from the IFSSH Flexor Tendon Committee. J Hand
Surg (Eur). 2014;39:107–115.
173. Tang JB. Release of the A4 pulley to facilitate zone II flexor tendon
repair. J Hand Surg Am. 2014;39:2300–2307.
213. Tang JB, Amadio PC, Boyer MI, et al. Current practice of primary
flexor tendon repair: a global view. Hand Clin. 2013;29:179–189.
233. Strickland JW. Delayed treatment of flexor tendon injuries
including grafting. Hand Clin. 2005;21:219–243. This is an extensive
review of secondary tendon surgeries, covering indications, techniques,
and postoperative care of free tendon grafting, staged tendon
reconstruction, and tenolysis. This article is the most recent in an array
of reviews about techniques for flexor tendon surgeries written by an
experienced hand surgeon. This article provides an update on historical
developments of surgical techniques, the author’s personal approaches,
and current practice of these secondary repair procedures, which are
generally considered classic operations, little changed over recent decades.

226.e1
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clinical outcomes of repairs of lacerated flexor pollicis longus (FPL)
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active mobilization following flexor tendon repair using the
six-strand technique: short- and long-term evaluations. J Hand
Surg (Eur). 2015;40:250–258.
233. Strickland JW. Delayed treatment of flexor tendon injuries
including grafting. Hand Clin. 2005;21:219–243. This is an extensive
review of secondary tendon surgeries, covering indications, techniques,
and postoperative care of free tendon grafting, staged tendon
reconstruction, and tenolysis. This article is the most recent in an array
of reviews about techniques for flexor tendon surgeries written by an
experienced hand surgeon.
234. Azari KK, Meals RA. Flexor tenolysis. Hand Clin. 2005;21:211–217.
235. Adamson JE, Wilson JN. The history of flexor tendon grafting. J
Bone Joint Surg Am. 1961;43:709–716.
236. Pulvertaft RG. Tendon grafts for flexor tendon injuries in the
fingers and thumb. A study of technique and results. J Bone Joint
Surg Br. 1954;38:175–194.
237. Pulvertaft RG. Indications for tendon grafting. In: AAOS
Symposium on Tendon Surgery in the Hand. Philadelphia: CV Mosby
Co; 1975:123–131.
238. White WL. Secondary restoration of finger flexion by digital
tendon grafts: an evaluation of seventy-six cases. Am J Surg.
1956;91:662–668.
239. White WL. Tendon grafts: a consideration of their source,
procurement and suitability. Surg Clin North Am. 1960;40:403–413.
240. Tubiana R. Technique of flexor tendon grafts. Hand. 1969;1:108–114.
241. McClinton MA, Curtis RM, Wilgis EF. One hundred tendon grafts
for isolated flexor digitorum profundus injuries. J Hand Surg Am.
1982;7:224–229.
242. Moberg E. Experiences with Bunnell’s pull-out wire sutures.
Br J Plast Surg. 1951;3:249–251.
243. Skoff HD, Hecker AT, Hayes WC, et al. Bone suture anchors in
hand surgery. J Hand Surg [Br]. 1995;20:245–248.
244. Beris AE, Darlis NA, Korompilias AV, et al. Two-stage flexor
tendon reconstruction in zone II using a silicone rod and a
pedicled intrasynovial graft. J Hand Surg Am. 2003;28:652–660.
245. Ipsen T, Barfred T. Early mobilization after flexor tendon grafting
for isolated profundus tendon lesions. Scand J Plast Reconstr Surg
Hand Surg. 1988;22:163–167.
246. Tanaka T, Zhao C, Ettema AM, et al. Tensile strength of a new
suture for fixation of tendon grafts when using a weave technique.
J Hand Surg Am. 2006;31:982–986.
247. Matsuzaki H, Zaegel MA, Gelberman RH, Silva MJ. Effect of
suture material and bone quality on the mechanical properties of
zone I flexor tendon-bone reattachment with bone anchors. J Hand
Surg Am. 2008;33:709–717.
248. Khan K, Riaz M, Murison MS, Brennen MD. Early active
mobilization after second stage flexor tendon grafts. J Hand Surg
[Br]. 1997;22:32–34.
249. Dowdy P, Richard RS, McFarlane RM. Palmar cutaneous branch of
the median nerve passing through the Palmaris longus tendon:
cadaveric study. J Hand Surg Am. 1994;19:199–202.
250. Reimann AF, Daseler E, Anson BJ, Beaton LE. The palmaris longus
muscle and tendon: a study of 1,600 extremities. Anat Rec.
1944;89:495–505.
251. Daseler MS, Anson BJ. The plantaris muscle. J Bone Joint Surg.
1943;25:822–827.
252. Harvey FJ, Chu G, Morrison WA. The plantaris tendon as a
tendoosseous graft. Part I. An anatomic study. J Hand Surg [Br].
1992;17:467–470.
253. Wilson RL. Flexor tendon grafting. Hand Clin. 1985;1:97–107.
254. Bruner JM. The zig-zag volar-digital incision for flexor tendon
surgery. Plast Reconstr Surg. 1967;40:571–574.
255. Bunnell S. Repair of tendons in the fingers. Surg Gynecol Obstet.
1922;35:88–97.
256. Bunnell S. Surgery of the Hand. 2nd ed. Philadelphia: JB Lippincott;
1948:381–466.
257. Peacock EE. Some technical aspects and results of flexor tendon
repair. Surgery. 1965;58:330–342.
258. Pulvertaft RG. Suture materials and tendon junctures. Am J Surg.
1965;109:346–352.
259. Tubiana R. Incisions and techniques in tendon grafting. Am J Surg.
1965;109:339–345.
260. Nichols HM. The dilemma of the intact superficialis tendon. Hand.
1975;7:85–86.
261. Reid DAC. The isolated flexor digitorum profundus lesion. Hand.
1969;1:115–117.
262. Wakefield AR. The management of flexor tendon injuries. Surg
Clin N Am. 1960;40:267–273.
263. Bora FW. Profundus tendon grafting with unimpaired sublimis
function in children. Clin Orthop Relat Res. 1970;71:118–123.
264. Chan W, Thomas OJ, White WL. Avulsion injury of the long flexor
tendons. Plast Reconstr Surg. 1972;50:260–264.
265. Goldner JL, Coonrad RW. Tendon grafting of flexor profundus in
the presence of a completely or partially intact flexor sublimis. J
Bone Joint Surg Am. 1969;51:527–532.
266. Jaffe S, Weckesser E. Profundus tendon grafting with the sublimis
intact. An end result of thirty patients. J Bone Joint Surg Am.
1967;49:1298–1308.
267. Paneva-Holevich E. Two-stage tenoplasty in injury of the flexor
tendons of the hand. J Bone Joint Surg Am. 1969;51:21–32.
268. Kesler FB. Use of a pedicled tendon transfer with a silicone rod in
complicated secondary flexor tendon repairs. Plast Reconstr Surg.
1972;49:439–443.
269. Hunter JM. Artificial tendons. Early development and application.
Am J Surg. 1965;109:325–338.
270. Hunter JM. Staged flexor tendon reconstruction. J Hand Surg Am.
1983;8:789–793.
271. Schneider LH. Treatment of isolated flexor digitorum profundus
injuries by tendon grafting. In: Hunter JM, Schneider LH, Mackin
EJ, eds. Tendon Surgery in the Hand. St. Louis: CV Mosby;
1987:303–311.
272. Chuinard RG, Dabezies EJ, Matthews RE. Two stage superficialis
reconstruction in severely damaged fingers. J Hand Surg Am.
1980;5:135–143.
273. Hunter JM, Singer DI, Jaeger SH, Mackin EJ. Active tendon
implants in flexor tendon reconstruction. J Hand Surg Am.
1988;13:849–859.
274. Schneider LH. Staged tendon reconstruction. Hand Clin.
1985;1:109–120.
275. LaSalle WB, Strickland JW. An evaluation of the two-stage
tendon reconstruction technique. J Hand Surg Am. 1983;8:
263–267.
276. Hunter JM, Jaeger SH. Flexor tendon reconstruction and
rehabilitation using active tendon implants. In: Green DP, ed.
Operative Hand Surgery. 3rd ed. New York: Churchill Livingstone;
1993:1900–1914.
277. Hunter JM, Singer DI, Mackin EJ. Staged flexor tendon
reconstruction using passive and active tendon implants. In:
Hunter JM, Schneider LH, Mackin EJ, Callahan AD, eds.
Rehabilitation of the Hand: Surgery and Therapy. 3rd ed. St. Louis: CV
Mosby; 1990:427–457.
278. Amadio PC, Wood MB, Cooney WP, Bogard SD. Staged flexor
tendon reconstruction in the fingers and hand. J Hand Surg Am.
1988;13:559–562.
279. O’Shea K, Wolfe SW. Two-stage reconstruction with the modified
Paneva-Holevich technique. Hand Clin. 2013;29:223–233.
280. Fetrow KO. Tenolysis in the hand and wrist: a clinical evaluation
of 220 flexor and extensor tenolyses. J Bone Joint Surg Am.
1967;49:667–685.
281. James JIP. The value of tenolysis. Hand. 1969;1:118–119.

226.e7
References
282. Jupiter JB, Pess GM, Bour CJ. Results of flexor tendon tenolysis
after replantation in the hand. J Hand Surg Am. 1989;14:35–44.
283. Birnie RH, Idler RS. Flexor tenolysis in children. J Hand Surg Am.
1995;20:254–257.
284. Strickland JW. Flexor tendon surgery. Part 2. Free tendon grafts
and tenolysis. J Hand Surg [Br]. 1989;14:368–382.
285. Strickland JW. Flexor tenolysis. Hand Clin. 1985;1:121–132.
286. Whitaker JH, Strickland JW, Ellis RG. The role of tenolysis in the
palm and digit. J Hand Surg Am. 1977;2:462–470.
287. Wray RC, Moucharafieh B, Weeks PM. Experimental study of the
optimal time for tenolysis. Plast Reconstr Surg. 1978;61:184–189.
288. Hunter JM, Schneider LH, Dumont J, Erickson JC. A dynamic
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289. McDonough JJ, Stern PJ. Modified 69 blade for tenolysis. J Hand
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290. Schreiber DR. Arthroscopic blades in flexor tenolysis of the hand. J
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291. Constantinescu MA, Greenwald DP, Amarante MT, et al. Effects of
laser versus scalpel tenolysis in the rabbit flexor tendon. Plast
Reconstr Surg. 1996;97:595–601.
292. Bora F, Lane JM, Prockop DJ. Inhibitors of collagen biosynthesis as
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293. Wrenn RL, Goldner JL, Markee JL. An experimental study of the
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294. Carstam N. The effects of cortisone on the formation of tendon
adhesions and on tendon healing: an experimental investigation in
the rabbit. Acta Chir Scand. 1953;182:1–111.
295. James JIP. The use of cortisone in tenolysis. J Bone Joint Surg Br.
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296. Pinkerton M. Amnioplastin for adherent digital flexor tendons.
Lancet. 1942;1:70–72.
297. Nichols H. Discussion of tendon repair with clinical and
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1949;129:223–234.
298. Ketchum LD. The effects of triamcinolone on tendon healing and
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299. Stark HH, Boyes JH, Johnson L, Ashworth CR. The use of
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300. Karakurum G, Buyukbebeci O, Kalender M, Gulec A. Seprafilm
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301. Ferguson RE, Rinker B. The use of a hydrogel sealant on flexor
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303. Riccio M, Battiston B, Pajardi G, et al. Efficiency of hyaloglide(R)
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clinical trial. J Hand Surg (Eur). 2010;35:130–138.
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305. Cannon NM, Strickland JW. Therapy following flexor tendon
surgery. Hand Clin. 1985;1:147–165.
306. Foucher G, Lenoble E, Ben Youssef K, Sammut D. A postoperative
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307. Ketchum LD, Martin NL, Kappel DA. Experimental evaluation of
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passive motion as an adjunct therapy for tenolysis. J Hand Surg
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309. Goloborod’ko SA. Postoperative management of flexor tenolysis. J
Hand Ther. 1999;12:330–332.

SECTION II • Acquired Traumatic Disorders
10 
Extensor tendon injuries
Kai Megerle and Karl-Josef Prommersberger
SYNOPSIS
■ A thorough understanding of the complex anatomy is crucial for
successful treatment of extensor tendon injuries.
■ Injuries are classified into nine anatomic zones. Treatment strategies
vary considerably according to the location of the lesion, ranging from
splinting to tendon grafting.
■ Minimal variations in tendon length may result in considerable
alteration in range of motion.
■ As in flexor tendon injuries, postoperative care is an essential part of
the treatment concept.
■ Closed ruptures of the extensor tendon at the level of the distal
interphalangeal (DIP) and proximal interphalangeal (PIP) joints are
typically treated conservatively.
■ Lacerations at the level of the metacarpophalangeal (MP) joint (zone V)
are not infrequently caused by human bites and are prone to infection
unless thoroughly debrided.
■ Ruptures of the sagittal bands may result in subluxation of the extensor
tendon at the level of the MP joint.
■ The swan-neck deformity is characterized by DIP joint flexion and PIP
joint hyperextension. It can be caused by an untreated mallet injury or
palmar plate laxity.
■ The boutonnière deformity is characterized by hyperextension of the
DIP joint and PIP joint flexion. It can be caused by rupture of the
central slip of the extensor tendon or palmar subluxation of the lateral
bands.
■ Complex injuries to the dorsum of the hand can involve skin, tendon,
and bone. Adequate debridement is of paramount importance. Before
reconstructing tendons, fractures must be stabilized and soft-tissue
coverage must be provided.
Introduction
Injuries to the extensor tendons are frequently underestimated.
Several reasons might contribute to this phenomenon, includ­
ing easy access to the tendons due to the thin soft-tissue
envelope, their extrasynovial nature, and limited retraction.
However, in contrast to common belief, injuries to the exten­
sor tendon apparatus are often more difficult to treat than
those of flexor tendons. First of all, a thorough understanding
of the complex interactions between the long extensor tendons
and the intrinsic muscles of the hand is necessary to achieve
good postoperative results. Second, the extensor apparatus
consists of superficial, thin structures that are very close to the
underlying bones, which makes them prone to develop severe
adhesions. Moreover, their excursion amplitude is limited, so
that even subtle lengthening or shortening will result in severe
restrictions of range of motion. Postoperative regimes vary
considerably in respect to the exact location of the lesion and
have to be selected carefully.
However, not only the tendon itself but also the surrounding
soft tissues have to be taken into consideration when establish­
ing a treatment concept. Extensor tendons are easily exposed
on the dorsum of the fingers and hand even after minor trauma
due to the thin tissue envelope. Additional procedures are
frequently necessary. Shortcomings in adequate soft-tissue
coverage will inevitably result in poor overall results, even if
the tendons themselves were addressed properly.
Access the Historical perspective section online at

Basic science/disease process
The anatomy of the extensor mechanism is complex and some
functional details are still subject to discussion. However, in
order to be able to provide the best possible treatment in a
given pathologic situation, fundamental knowledge about the
functional anatomy of this complex system is paramount.
Anatomy of the extensor tendons
The extensor mechanism consists of extrinsic muscles, which
are located on the forearm (extensor digitorum, extensor
  Access video content for this chapter online at expertconsult.com

227.e1
Historical perspective
Historical perspective
The history of tendon surgery reaches back to about AD 200.
Galen (130–201) mistook the tendons for nerves and suggested
in his Ars Parva that no sutures should be placed within the
tendons in order not to cause pain and convulsion. The error
was not corrected until the 10th century, when Avicenna of
Boukhara (980–1037), in Persia, advocated surgical suturing
of tendons. However, this new concept did not reach the west
until much later – Galen’s dogma was not refuted until the
18th century. The basic structure of the extensor tendon
mechanism was illustrated by Albinus in 1734. The next step
forward was the concept of tendon transplantation, which
was introduced in the late 19th century. In the beginning of
the 20th century extensive clinical and experimental research
was conducted, especially in Germany. Lexer published the
results of 10 flexor tendon grafts in 1912. During the first half
of the 20th century, Bunnell developed basic principles of
flexor tendon surgery which were published in his masterly
book Surgery of the Hand in 1944.1 Fowler and Landsmeer
advanced the concept of the balanced forces and dynamics
between the flexor and extensor apparatus in the 1940s.
During the 1960s operating techniques were introduced that
are still in use today.

228
SECTION II
CHAPTER 10 • Extensor tendon injuries
carpi ulnaris (ECU) tendons run through the fifth and sixth
extensor compartments, respectively. The ECU not only func­
tions as an extensor for the wrist, but is also part of the
triangular fibrocartilage complex (TFCC) and thus a major
stabilizer for the distal radioulnar joint.
The two extensor proprii tendons of the index and the little
finger are located on the ulnar sides of the corresponding
communis tendons and allow for individual movements of
the peripheral fingers. On the dorsum of the hand, the ED
tendons are interconnected by the juncturae tendinum which
facilitate combined extension of the fingers. Lacerations of the
extensor tendons which are located proximal to the juncturae
may be masked by the function of these bands. The patterns
of the intertendinous connections are highly variable and
have been classified into three types: filamentous, fibrous, and
tendinous bands.3 At the level of the proximal phalanges, the
extensor tendons split up into three parts: the central band
and two lateral bands (Fig. 10.2). These merge with the intrin­
sic extensor system to form the complex extensor apparatus
of the digits.
The extrinsic extensor tendons themselves have three inser­
tion sites on the phalanges. Proximally, the tendon is fixed at
the level of the metacarpal heads to the palmar plate by the
sagittal bands. This attachment centers the tendon of the MP
joint and prevents hyperextension. The most important inser­
tion is located at the base of the middle phalanx. Distally, the
terminal tendon is attached to the distal phalanx. In addition
to these three sites, there is a variable degree of attachment of
the tendon to the proximal phalanx.
Intrinsic muscles
The intrinsic muscular system of the hand consists of seven
interosseous and four lumbrical muscles. The three palmar
interosseous muscles arise from the medial sides of the second,
fourth, and fifth metacarpal bones and join the extensor
Fig. 10.1  Extensor compartments: I, APL and EPB; II, ECRL and ECRB; III, EPL; IV,
ED and EI; V, EDM; VI, ECU. APL, Abductor pollicis longus; ECU, extensor carpi
ulnaris; ECRB, extensor carpi radialis brevis; ECRL, extensor carpi radialis longus;
ED, extensor digitorum; EDM, extensor digiti minimi; EI, extensor indicis; EPB,
extensor pollicis brevis; EPL, extensor pollicis longus.
EIP
EPL
EPB
APL
ECRL
ECRB
Lister’s tubercle
Synovial sheaths
Retinaculum
ED
ECU
EDM
Juncturae
tendinum
I
II III IV
V VI
Fig. 10.2  Extensor apparatus.
Triangular ligament
Central slip of common extensor
Lateral slip of common extensor
Lumbrical muscle
Interosseous muscles
Terminal tendon
Lateral band
Oblique fibers of interossei
Sagittal band
Common extensor tendon
indicis, extensor digiti minimi (EDM)), intrinsic muscles,
which are located at the level of the metacarpals (interosseous
and lumbrical muscles), and fibrous structures.
Extrinsic muscles
All extrinsic tendons pass through the six compartments of
the extensor retinaculum on the back of the wrist (Fig. 10.1).
The first compartment is attached to the outer rim of the
radius and contains the tendons of the abductor pollicis
longus (APL) and extensor pollicis brevis (EPB) muscles. In
34% of patients the compartment is further divided by an
additional septum, which has implications for the etiology
and treatment of de Quervain’s disease.2 The extensor carpi
radialis longus (ECRL) and extensor carpi radialis brevis
(ECRB) tendons run through the second compartment, which
is bordered by Lister’s tubercle on the ulnar side. The third
compartment crosses the wrist in a diagonal fashion above the
second compartment, while Lister’s tubercle acts as a pivot
point for the extensor pollicis longus (EPL) tendon. While
passing through the compartment, the tendon is quite vulner­
able to ruptures, e.g., in fractures of the distal radius. The
fourth compartment contains both the extensor digitorum
(ED) and extensor indicis (EI) tendons. The EDM and extensor

229
Basic science/disease process
Landsmeer was able to show that at least three muscles are
necessary to control two joints in such a multiarticular chain.4
For the proximal phalanx, these are the extrinsic extensor and
flexor muscles and the diagonal intrinsic system (lumbrical
and interosseous muscles). In the middle phalanx there is no
diagonal muscle system; instead the third component is made
up of the oblique retinacular ligament (Landsmeer’s ligament)
which has its origin at the flexor pulley and inserts distally
into the extensor apparatus. Both of these diagonal systems
run palmar to the joint axis proximally and dorsal to the joint
axis distally. They play a crucial role in the coordination of
extension and flexion movements of the fingers by linking the
extrinsic flexor and extensor muscles.
Functions of the intrinsic muscles
It is generally believed that the intrinsic muscles of the hand
act as flexors at the MP joints and extensors at the interpha­
langeal joints. However, this is not always true for the interos­
seous muscles. They approach the extensor apparatus at a
much smaller angle (less steep) than the lumbrical muscles.
Due to this little anatomical difference, the function of the
interosseous muscles is highly dependent on the position of
the interosseous hood and therefore as well of the position of
the MP joint. When the MP joints are in extension, the interos­
seous muscles cover the articular space and the oblique fibers
of the interossei are put into tension, which translates into
extension of the interphalangeal joints. However, when the
MP joints are in flexion, the interosseous muscles slide distally
on the proximal phalanx. During contraction of the muscles,
the interosseous hood is pulled towards the hand and the
flexion movement of the MP joint is enforced. In this position,
the interossei lose the extensor function on the distal joints.
apparatus of the digits at the level of the proximal phalanx
after crossing palmar to the axis of the MP joint. The four
dorsal interosseous muscles originate with two heads each
from the adjacent sides of the five metacarpal bones. The first
two interosseous muscles approach the index and middle
finger from the radial side; the third and fourth approach the
middle and ring finger from the ulnar side. They have inser­
tions at the proximal phalanges and the interosseous hood of
the extensor apparatus before joining the lateral bands.
The lumbrical muscles are considered some of the most
variable muscles of the human body, while the degree of
variation increases from the radial to ulnar muscles. In general,
they arise from the radial sides of the flexor digitorum pro­
fundus tendons at the level of the metacarpals and join the
extensor apparatus from the radial side.
With this arrangement, all four digits have three intrinsic
muscles contributing to the extensor apparatus, with the
missing ulnar interosseous muscle for the little finger being
equivalent to the abductor digiti minimi muscle (Fig. 10.3).
The thumb also has three short muscles that join the extensor
apparatus: the flexor pollicis brevis (FPB) and abductor pol­
licis brevis (APB) muscles on the radial side and the adductor
pollicis (ADP) muscle on the ulnar side.
Functional anatomy
Linked chains
The movement of the fingers is a highly complex mechanism.
It is dependent upon a delicate equilibrium between the
extrinsic extensor and flexor muscles and the intrinsic muscles.
Biomechanically, the finger can be compared to a multiarticu­
lar chain comprised of the three phalangeal bones (Fig. 10.4).
Fig. 10.3  The distribution of intrinsic muscles in
the fingers. Roman numbers indicate finger
numbers. ADM, Abductor digiti minimi; DA, dorsal
aponeurosis; ED, extensor digitorum; EDM, extensor
digiti minimi; EI, extensor indicis; ID, dorsal
interosseous muscles; IP, palmar interosseous
muscles, numbered from radial to ulnar; L, lumbrical
muscles, numbered from radial to ulnar; La,
accessory lumbrical muscle (variation).
A
B
C
D
II
III
IV
V
DA
L1
ID 1
IP 1
EIP
ED
L2
ID 2
ID 3
La
IP 2
ID 4
L3
ED
EDM
ADM
IP 3
L4
Fig. 10.4  Linked chains. ED & EI, Extensor digitorum and extensor indicis;
FCR, flexor carpi radialis; L, lumbrical muscle; Obliq. R. lig., oblique retinacular
ligament (Landsmeer’s ligament).
ED & EI
Radius
FCR
L
Oblique R. lig

230
SECTION II
CHAPTER 10 • Extensor tendon injuries
Clinical tips
Always obtain a focused history, including the exact
mechanism of injury. Expect concomitant osseous involvement
in crush injuries. Long-term outcomes should be kept in mind
and communicated with the patient when formulating a
treatment plan.
Clinical tips
Intrinsic muscle function may obscure complete lacerations of
the ED tendons by extension of the PIP and DIP joints. Always
check extension of the MP joints to rule out ED injuries.
Fig. 10.5  Test of the extensor pollicis longus tendon.
The lumbricals join the extrinsic tendon at a much greater
angle than the interossei and are therefore not depending in
their function on MP joint position. They act as extensors at
the proximal and DIP joint in both extension and flexion of
the MP joint.
Extrinsic muscle function
It has been shown biomechanically that both the extrinsic
flexor and extensor muscles have a component that acts as an
extensor on the proximal phalanx. Under physiologic condi­
tions this force is counteracted by the intrinsic muscles.
Paralysis of these muscles (as in ulnar nerve palsy) therefore
results in hyperextension of the MP joints. Without intrinsic
muscle function the long extensors exhaust their potential at
the level of the proximal phalanx. Anatomical studies have
demonstrated that isolated contraction of the extrinsic exten­
sors results in hyperextended, clawlike position of the MP
joints, but not complete finger extension.3 For complete exten­
sion of the interphalangeal joints intrinsic muscle function is
therefore mandatory.
Mechanisms of joint extension
The MP joint is extended by the extrinsic extensor tendon.
However, there have been debates about how tendon force is
transmitted to the joint. The variable direct attachment of the
tendon to the proximal phalanx has been shown to have no
significant contribution to MP joint extension.5 It has been
postulated that instead the fibrous connections of the extensor
tendon to the flexor sheath are the primary transmitters for
extension of the joint.
Extension of the PIP joint is mediated by the central slip of
the extensor tendon. However, as stated above, intrinsic
muscle function is necessary in order to enable the extrinsic
extensor tendon to act on the PIP joint. At the level of the PIP
joint, the extensor tendon is centered by the transverse reti­
nacular ligaments. Harris and Rutledge have stressed the
importance of the correct position and balance between the
central slip and the lateral bands in order to maintain normal
PIP extension.5
Until the late 1940s, extension of the DIP joint was thought
only to be mediated by the terminal part of the extensor
mechanism. In 1949 Landsmeer defined the function of the
oblique retinacular ligament, which had been unclear since
its identification in the 1800s.6 He described the extension
of the DIP joint as a combination of the terminal lateral
bands and a tenodesis effect mediated by these ligaments.
Later these findings were questioned.5 However, dis­
section of the ligament results in lack of extension of the
DIP joint.
Diagnosis/patient presentation
The diagnosis of extensor tendon injuries is often evident.
However, partial lesions can be missed if the remaining
tendon is strong enough to create some extension force. As a
general rule, open lesions should therefore be surgically
explored to identify the extent of the injury and prevent sec­
ondary ruptures. The function of the ED tendon should be
assessed by extension of the MP joint of the affected digit
against resistance.
The EPB tendon inserts into the extensor tendon apparatus of
the thumb at varying levels and may be able to extend the IP
joint of the thumb. If there is a questionable rupture of the
EPL tendon, it should therefore not be tested by extension of
the IP joint. Instead, the patient should be asked to lift the
thumb off the table, which will be impossible without an
intact EPL tendon (Fig. 10.5).
Kleinert and Verdan proposed a system to classify lesions
of the extensor tendon apparatus into eight zones according
to the level of the lesion.7 Doyle has added a ninth zone by
dividing the forearm into the distal (zone 8) and proximal
forearm (zone 9).8 This classification is presented in Fig. 10.6.
Patient selection
The repair of simple lacerations of the extensor tendon can be
safely performed in the emergency room. However, as the
lesions are generally underestimated and require sufficient
exposure of the tendon, a thorough knowledge of the surgical
anatomy and treatment regimes is mandatory. Lesions proxi­
mal to zone VI should be treated in the operating room. The
use of loupe magnification should be considered. The patient
should be aware that, despite the often short duration of

231
Treatment/surgical technique
zones VI and proximally, the extensor tendon resembles a
flexor tendon and as such can be repaired with a core suture
and an epitendinous running suture. Commonly used suture
strengths include 3-0 and 4-0 for core sutures and 5-0 for
epitendinous sutures. For neither flexor nor extensor tendons
is there any scientific evidence for an advantage of using
resorbable or nonresorbable suture materials. Fig. 10.7 gives
an overview of common types of core suture. In order to
achieve maximum core suture strength, locking stitches
should be preferred over grasping stitches in order to prevent
suture pull-out and reduce gapping.16 However, grasping
suture techniques have a higher tensile strength and less gap
formation in extensor tendon repair than mattress or figure-
of-eight stitches.17 For flexor tendons, it has been shown that
at least four core strands should be applied in order to enable
early active motion18 and the same is probably true for exten­
sor tendon repair.
In the more distal zones of injury, locking or grasping core
stitches become increasingly difficult due to flattening of the
tendon. Newport et al. report that grasping stitches in zone IV
injuries are strong enough to enable postoperative early active
motion.19 More recently, Chung et al. have demonstrated that
a single cross-stitch may even be superior to multiple cross-
stitches in a modified Becker repair of the extensor tendon in
zone IV.20 Simple running stitches should be avoided due to
the low pull-out strength in favor of more complex locking
suture techniques.
operations, postoperative treatment protocols can be compli­
cated and may last for several months.
Wide-awake surgery is a concept that is becoming increas­
ingly accepted. In this approach, procedures are performed
with no sedation and no tourniquet with the use of tumescent
lidocaine and epinephrine. This technique has been proven to
be safe and cost-effective.9–12 Most importantly, however, with
the patient able to move the fingers during the operation, the
surgeon can verify the success of tenolysis or tendon repair
procedures immediately.13 Not only tendon repairs and
tenolysis, but also tendon transfers can be most effectively
performed in this approach.14
Treatment/surgical technique
Suturing techniques
The size of the extensor tendon varies considerably during its
course from the distal forearm to its terminal insertion at the
distal phalanx. While the tendon is round and thick proxi­
mally, it becomes thin and flat more distally. Suturing tech­
niques therefore have to be adapted specifically to the location
of the lesion. Whatever technique is chosen, it should provide
the best stability with the least shortening possible.
In zones II to IV, extensor tendons are thin and flat and,
thus, less amenable to suture techniques involving multiple
core sutures. For lacerations in theses areas, epitendinous
suture techniques have demonstrated favorable results.15 In
Fig. 10.6  The zones of extensor tendon injuries.
I
II
III
IV
V
VI
VII
VIII
IX
TI
TII
TIII
TIV
TV
Fig. 10.7  Different types of core sutures.
Mattress
Figure-of-eight
Modified Bunnell
Modified Kessler
Clinical tips
Always check the stability of the sutured tendon
intraoperatively by gentle movements of the finger. If possible,
use locking core stitches in preference to other techniques.
Soft-tissue coverage can be very thin in fingers, so patients
may be able to make out dyed suture material through the
skin.
Zone I
The mallet finger
The mallet finger is characterized by persistent flexion of the
distal phalanx due to a lesion of the extensor apparatus at the
level of the DIP joint. It represents a classic closed injury that

232
SECTION II
CHAPTER 10 • Extensor tendon injuries
is usually treated conservatively, although open injuries may
occur as well.
The flat terminal extensor tendon inserts at the base of the
distal phalanx where it blends with the joint capsule. Since its
excursion is only about 4 mm, even small gaps may result in
a considerable lack of extension. It should be kept in mind
that the full extension of the distal phalanx is also dependent
on an intact oblique retinacular ligament.
Mallet fingers can be classified by the degree of osseous
involvement. Isolated tendinous ruptures are differentiated
from injuries that involve bony avulsions. The latter have
been classified into avulsions of small triangular fragments,
large fragments that result in palmar subluxation of the
phalanx, and epiphyseal detachments in children.
Most surgeons prefer conservative treatment with splints
over operative therapy for uncomplicated injuries, although
the scientific evidence is limited.21,22
Niechajev reviewed 135 patients who had been treated for
various types of mallet finger with a minimal follow-up of 12
months.23 The author concludes that operative treatment
should only be performed in cases with subluxation of the
distal phalanx or avulsed fragments that are more than one-
third of the joint surface and with a diastasis of more than
3 mm. Stern and Kastrup reviewed 123 mallet injuries retro­
spectively.24 Thirty-nine patients were treated surgically,
resulting in a complication rate of 53%, including infection,
nail deformities, joint incongruities, fixation failure, and bony
prominence. The authors conclude that splinting is the pre­
ferred treatment option in nearly all mallet fingers. Handoll
and Vaghela included four trials in a systematic review.25–29
They concluded that there is insufficient evidence from ran­
domized trials to establish the effectiveness of custom-made
or off-the-shelf finger splints, the advantage of surgical treat­
ment over splinting, or even the advantage of splinting over
no treatment at all.
The best available evidence therefore supports conserva­
tive treatment by splinting for the majority of cases. Conserva­
tive treatment usually implies immobilization of the DIP joint
in extension while sparing the PIP joint. By extension or slight
hyperextension of the joint the two ruptured ends of the
tendon are approximated (Figs. 10.8 & 10.9). The fibrous tissue
of the resulting scar is thought to be strong enough to restore
extension of the joint. The type of splint is not nearly as
important as patient compliance. Prefabricated stack splints
have been shown to be equally effective as simple aluminum
splints or custom sandwich splints (Figs. 10.10 & 10.11). Most
authors recommend full-time splinting for at least 6–8 weeks
followed by a period of 2–6 weeks of splinting at night to
enable further shrinking of the immature scar. All patients
should be thoroughly instructed to avoid ineffective use of the
splints. The splints should only be removed when flexion of
the DIP joint by the strong pull of the FDP tendon is counter­
acted, e.g., through resting the finger flat on a table. By thor­
ough splinting, a residual lack of extension of 10° or less can
be expected.30
Surgical treatment for closed injuries should only be con­
sidered in fragment sizes greater than one-third of the joint
surface. Transfixation of the DIP joint with a Kirschner wire
has been suggested for sole treatment of the mallet injury in
addition to other surgical interventions.31,32 To avoid scarring
of the finger pulp, Tubiana has suggested an oblique angle
when crossing the DIP joint.33
Fig. 10.8  Acute mallet injury, reduced by stack splint: posteroanterior view.
Fig. 10.9  Acute mallet injury, reduced by stack splint: lateral view.
Fig. 10.10  Aluminum splint.

233
Treatment/surgical technique
preferable. Alternatively, a pull-out suture may be applied, as
described by Doyle.8
Open injuries
Most authors agree to operative treatment for open injuries.
In some cases, suturing of the skin alone and supporting the
joint in extension or slight hyperextension is enough to
Fig. 10.11  Stack splint.
When surgical intervention is indicated, the size of the
avulsed fragment should be carefully evaluated for direct
fixation. This can be very difficult to achieve and may result
in further fragmentation of the avulsed bone. In case of a
rather small fragment, indirect reduction by extension block
pin fixation should be preferred (“doorstop osteosynthesis”).
In this technique the distal phalanx is maximally flexed and
a 1.0-mm Kirschner wire is advanced into the middle phalanx
dorsal to the avulsed fragment at a 45° angle, creating the
extension block against which the fragment is reduced. The
joint is then extended, reducing the fragment. This position is
secured by a second Kirschner wire inserted longitudinally
across the DIP joint for transfixation. The wires are cut and a
splint is applied for at least 6 weeks (Figs. 10.12–10.15).
If the avulsed fragment seems large enough, it may either
be pinned directly percutaneously or reduced in an open
fashion through a zigzag incision of the distal and middle
phalanges. In case of open reduction, screw fixation seems
Fig. 10.12  Mallet injury: posteroanterior view.
Fig. 10.13  Mallet injury: lateral view. Despite the stack splint, the fragment is not
properly reduced.
Fig. 10.14  Postoperative doorstop: posteroanterior view.

234
SECTION II
CHAPTER 10 • Extensor tendon injuries
this level can give rise to the characteristic boutonnière defor­
mity when the proximal phalanx herniates through the central
slip defect. However, the deformity will not develop immedi­
ately after the injury. Disruption of the tendon first leads to
an inability to extend the PIP joint actively while passive
extension is possible. Only after the lateral bands migrate
palmarly and retraction of the central slip occurs will hyper­
extension of the DIP joint develop.
Closed injuries
A closed avulsion injury of the central slip may not be imme­
diately evident and extension may be retained by means of
the lateral bands. If in doubt, extension of the PIP joint should
therefore always be tested against resistance.
The central slip may be restored without surgical interven­
tion by extension splinting. As flexion of the DIP joint stretches
the extensor mechanism and facilitates dorsal relocation of the
lateral bands, the DIP joint should not be included in immo­
bilization. Instead patients should be encouraged to move the
DIP joint actively and passively while wearing the PIP splint
(Fig. 10.17). Several authors have proposed pinning the PIP
joint in extension by a Kirschner wire.34–36 Most authors
suggest keeping the joint in extension for 5–6 weeks.35–37
Surgical treatment has been suggested for avulsion injuries
with large bony fragments or unstable transarticular frac­
tures.33 If the fragment is too small to be pinned directly, it
may be excised and the tendon reinserted into the middle
fragment with a bone anchor.
Open lacerations
Open injuries should always be thoroughly explored. Care
should be taken specifically to include the lateral bands and
the triangular ligament in the inspection.
approximate the ends of the ruptured tendon and allow direct
healing. When sutures are needed to approximate the tendon
ends, a suture that incorporates both skin and tendon may be
superior to individual suturing of the tendon, because further
tendon dissection may decrease the blood supply and com­
promise healing.
Chronic injuries
If tendinous ruptures over the DIP joint are not or insuffi­
ciently treated, gapping of the tendon ends will result in the
incorporation of fibrous tissue and lack of extension. A swan-
neck deformity may occur. The approach to these conditions
is described below (under secondary procedures).
Zone II
Injuries to the extensor tendon over the middle phalanx
usually result from sharp, direct lacerations or crush injuries.
Acute lacerations should be explored to determine the extent
of the tendon injury. If less than 50% of the tendon substance
are injured, the tendon is considered stable and no further
treatment is necessary. If more than half of the tendon is
involved, additional suturing is necessary. When evaluating
these injuries, phalangeal extension should always be tested
against resistance. Doyle recommended a running stitch
combined with a Silfverskiöld cross-stitch8 (Fig. 10.16). Care
should be taken to avoid considerable shortening of the
tendon which will result in lack of flexion of the DIP joint.
Zone III
Injuries to the extensor tendon at the level of the PIP joint
(zone III) occur as both closed and open injuries, ranging from
minor strains to complete ruptures or lacerations. Injuries at
Fig. 10.15  Postoperative doorstop: lateral view 6 weeks after doorstop
osteosynthesis.
Fig. 10.16  (A,B) Silfverskiöld cross-stitch for sutures in zone II injuries.
A
B
Clinical tips
Because of the excursion of the tendon at the time of injury,
the full extent of tendon involvement may not be visible at first
sight. It is therefore mandatory to carefully inspect the tendon
proximally and distally to the skin lesion.

235
Treatment/surgical technique
relationship between tendon and bone, adhesions frequently
occur and tenolysis is often necessary. Some form of a post­
operative early active motion regimen is therefore advisable
to reduce loss of range of motion. Maintenance of the wrist in
an extended position will “unload” the tendon and allow
early range of motion of the finger.
The mechanism of injury is of special importance in open
zone III injuries with regard to the extent of injury to both the
tendinous structures and the surrounding soft tissues. In clean
and sharp lacerations, the wound can be easily enlarged and
the injured tendon should be sutured directly or reinserted
into the middle phalanx. A Silfverskiöld cross-stitch may be
used where appropriate to enforce the suture. In contrast,
contaminated defect wounds, e.g., after saw injuries, are a lot
more difficult to deal with. If there is considerable loss of
tendon, an immediate reconstruction should be attempted.
Snow described a retrograde tendinous flap created from the
proximal tendon that is flipped over to bridge the defect over
the joint (Fig. 10.18).38 Aiache et al. proposed a longitudinal
split of the two lateral bands that are joined in the midline to
reconstruct the tendinous insertion and to cover the joint (Fig.
10.19).39 Any loss of covering skin should be replaced imme­
diately as well; options include local random pattern flaps,
reversed cross-finger flaps, or flaps from the dorsal metacarpal
artery system.
Postoperatively, a Kirschner wire may be used to reinforce
splinting of the PIP joint, which should be kept for 4–6 weeks.
Tenolyses or joint releases are frequently necessary, but should
be delayed until 3–6 months after the injury.
Zone IV
As the extensor becomes very broad over the proximal
phalanx, partial lacerations are more commonly observed
than complete injuries of the tendons. Therefore extension
should be examined against resistance. Surgical inspection is
necessary to assess the exact extent of the injury. Newport
et al. have demonstrated that modified Kessler sutures do not
result in significant shortening of the tendon and allow 30° of
flexion in the PIP joint without gapping.19
Extensor tendon injuries in zone IV are often associated
with fractures of the proximal phalanx.40 Due to the close
Fig. 10.17  (A,B) Splinting for closed extensor tendon ruptures in zone III.
A
B
Fig. 10.18  (A,B) Snow’s technique of reconstructing the central slip. MP,
Metacarpophalangeal; PIP, proximal interphalangeal.
A
B
PIP
MP
Lateral band
Central slip
Fig. 10.19  (A,B) Reconstruction of the central slip involving splitting of the lateral
bands (Aiache’s technique).
A
B

236
SECTION II
CHAPTER 10 • Extensor tendon injuries
for 3 weeks. In case of an unstable tendon, the laceration
should be sutured.
Closed ruptures of the sagittal bands are much more
common than open injuries and usually occur in the course
of a primary disease of the joints such as rheumatoid arthritis.
Ishizuki describes two layers of the sagittal bands, a superfi­
cial and a deep layer.44 He postulated that degenerative rup­
tures affect only the superficial layer, while traumatic ruptures
affect both layers. Traumatic and spontaneous ruptures of the
sagittal bands may be treated by splinting within 10–14
days.45,46 In older injuries, direct suturing of the bands should
be attempted. Reconstruction of the sagittal bands in chronic
subluxation is discussed in the section on secondary surgery,
below.
Zone VI
Extensor tendon lesions at the level of the metacarpal bones
have a better prognosis than in more distal zones.40 This is due
to several reasons. First, the tendons are very broad and can
usually be sutured by a 3-0 core stitch and an epitendinous
running suture. Moreover, they are extrasynovial and are not
associated with any joints. At the same time, tendon excursion
is greater than in more distal locations and imbalances
between extensor and flexor systems are less likely to occur.
Soft-tissue coverage is better than in distal zones, but still
quite thin compared to flexor tendons.
At this level, the function of the extrinsic extensor tendon
is to extend the MP joint. Therefore MP joint extension should
be tested against resistance. However, the extrinsic tendons
are linked by the juncturae tendinum and patients may still
be able to extend the joints by means of the adjacent tendons.
Postoperatively, early mobilization with a dynamic splint­
ing regime is indicated to reduce tendon adhesions. Loss of
flexion has been reported to be more common than loss of
extension.40
Zone VII
Injuries to the extensor tendons at the level of the extensor
retinaculum are due to either open lacerations that often affect
multiple tendons or closed ruptures, most often after distal
radius fractures.
In order to repair open lacerations at this level, at least a
part of the retinaculum has to be opened. There has been an
ongoing debate whether or not to reconstruct the retinaculum
over the affected tendon. Some surgeons advocate excising
the retinaculum in order to avoid postoperative adhesions.
Others suggest reconstructing at least parts of the retinaculum
to prevent subluxation or bowstringing of the tendons.
Although adhesions between the tendons and the retinaculum
seem more likely, Newport et al. found no differences between
the outcomes of zone VII lesions in comparison to lesions in
adjacent zones.40 The tendon repair itself should be performed
with a stable core suture and an epitendinous running stitch.
Special attention should also be paid to concomitant injuries
of sensory branches of the radial and ulnar nerves. Primary
coaptation of the nerve ends should be performed in order to
prevent the development of painful and difficult-to-manage
neuromas.
As the tendons are arranged very close to each other,
injuries of multiple tendons through one laceration occur
Zone V
At the level of the MP joints, the extensor tendon consists of
the central extensor tendon and the sagittal bands. Due to the
broad width of the extensor apparatus complete lacerations
are uncommon. On the other hand, partial lacerations can be
easily missed because the remaining tendon may be sufficient
to maintain extension function. Surgical exploration is there­
fore warranted. It should be taken into account that the injury
to the tendon may be located more proximally than the skin
laceration if the tendon was injured in flexion and the explora­
tion is performed with the digit in extension. If possible, a core
suture with an epitendinous running stitch should be per­
formed. In the rare cases of complete lacerations, the tendon
will not significantly retract proximally, as it is restrained by
the sagittal bands and the juncturae.
Human bite injuries
A common mechanism of injuries to the extensor tendon in
zone V is a human bite injury caused by a punch to the
opponent’s face (fight bites; Fig. 10.20). Bite wounds are
heavily contaminated and prone to serious infection. As skin
damage is often minimal, these injuries are frequently under­
estimated by the patient and treatment is delayed until infec­
tion has developed. Primary inspection is mandatory in fresh
injuries, as are X-ray studies to detect avulsed bony fragments
or teeth. During exploration, the tendon should be split lon­
gitudinally and the MCP joint irrigated with antibiotic solu­
tion.41 Partial lacerations of the tendon often do not require
suturing; a number of authors suggest delayed primary treat­
ment after the occurrence of infection has been ruled out.42
Sagittal band injuries
The central tendon is centered over the MP joint by the lateral
bands which attach to the palmar plate of the joint. Open or
closed injuries to the sagittal bands may result in subluxation
of the tendon to the unaffected side during flexion. Partial
lacerations will not result in subluxation unless two-thirds of
the sagittal band is affected.43 Stable lacerations can be treated
by buddy-taping of the affected finger to an adjacent finger
Fig. 10.20  Fight bite in the ring-finger metacarpal. The extensor tendon is split
longitudinally.

237
Postoperative care
however, while prolonged immobilization allows healing of
the tendon without disturbances, it still promotes loss of
motion due to the formation of adhesions. The problem can
be addressed by early active or passive motion which in turn
increases the risk of gap formation and ruptures of the sutured
tendons. As for flexor tendon injuries, in recent years, dynamic
postoperative treatment protocols have been developed that
reduce postoperative adhesion formation without jeopardiz­
ing the stability of the sutured tendon.
Nevertheless, strict immobilization is the treatment of
choice for some indications. Mallet injuries should be treated
by full-time static splinting for 8 weeks. The same is true for
closed ruptures of the central slip (zone III injuries). Immobi­
lization should also be considered for injuries proximal to the
extensor retinaculum (zones VIII and IX) because it may not
be possible to achieve adequate tensile strength by suturing
fascial layers around the muscle.
Postoperative immobilization of open injuries in zones
III–V will inevitably result in severe adhesions, because the
tendon is very broad and in close relationship to the adjacent
bone in this area. To overcome this problem, Evans described
a postoperative treatment protocol that reduces adhesions by
limited early active motion (“short arc motion”).49 The regime
is based on biomechanical studies that examined the extensor
tendon excursions necessary to prevent adhesion formation.
Duran et al.50 found that 3–5 mm of passive tendon glide is
sufficient to achieve this goal. Evans51 compared intraoperative
measurements of tendon excursions in zone IV and V with
previous measurements of Brand and Hollister,52 and esti­
mated that 60° of PIP joint flexion translates into 5 mm of
tendon glide at Lister’s tubercle.
For the protocol, three finger splints are required. The
affected digit is immobilized between training sessions in an
extension split in 0° extension of the DIP and PIP joints. At
every waking hour, the splint is removed and a controlled
active motion protocol is followed. First a splint is put on to
block flexion of the PIP joint at 30° and flexion of the DIP at
20–25°. After 20 repetitions of active and passive motion
within the defined limits, a third splint is put on that stabilizes
the PIP joint in 0° extension while sparing the DIP joint. The
patient then actively extends and flexes the DIP joint 20 times.
During the second and third week of the protocol, flexion of
the PIP joint is increased to 40° and 50°. In a retrospective
study, Evans reported on significant improvement of clinical
results with the dynamic protocol when compared to a group
of patients who were immobilized postoperatively.50
Dynamic mobilization for injuries in zones V–VII can be
achieved by passive extension with a rubber band system
combined with active flexion of the affected digit (Fig. 10.21).
This protocol has also been termed the “reversed Washington”
or “reversed Kleinert” regimen. The patient is encouraged to
perform active flexion and passive extension exercises 10
times every hour for 3 weeks, starting on the second postop­
erative day. The range of motion for flexion of the MP joint is
restricted at 30° in the beginning and gradually increased to
60° until the end of the third week. Active motion is initiated
after 3 weeks and the splint is removed after 6 weeks. The
load of the tendon is gradually increased over 6 weeks. In a
prospective, randomized study, better total active motion was
achieved in zone V and VI lesions after 4, 6, and 8 weeks
after a dynamic splinting protocol when compared to static
splinting.53
frequently. Identification of the tendons can be quite difficult,
because they tend to retract into the forearm. A thorough
knowledge of the surgical anatomy is therefore mandatory.
Botte et al. described a useful technique of labeling the
retrieved tendons by placing sterile labels on hemostats that
are clamped to sutures placed in the proximal ends of the
tendon.47
Ruptures of the EPL tendon are most often associated with
fractures of the distal radius or rheumatoid arthritis. Two
main causes for EPL ruptures after distal radius fractures have
been hypothesized.48 On the one hand, the tendon may be
injured while drilling the holes for palmar plate fixation or by
choosing screws that are too long and protrude into the exten­
sor compartments. On the other hand, dislocated dorsal
fragments of the fracture may harm the tendon. Because of
the degenerative nature of the process, an end-to-end repair
of the tendon is usually not possible without unacceptable
shortening of the tendon. Instead, reconstruction of the tendon
can be performed by EI to EPL tendon transfers or interposing
tendon grafts. Both techniques are discussed in the section on
secondary surgery, below.
Zones VIII/IX
Lesions of the extensor tendons at levels VIII and IX include
injuries of the musculotendinous junctions and muscle bellies.
As in zone VII injuries, the recovery and identification of
retracted tendons can be quite challenging. Combined injuries
to muscles and/or nerves are possible. Knowledge of the
sequence of motor innervation helps to distinguish a motor
nerve injury from a tendon injury. The motor branches of the
wrist and fingers have been divided into two groups, a proxi­
mal superficial group and a distal deep group.42 The proximal
superficial group consists of the ECRL, ECRB, ED, EDM, and
ECU muscles. The entry of nerve fibers into the muscles is
near the lateral epicondyle. When exposing the posterior
interosseous nerve, the interval between the wrist ECRB and
ECRL tendon (proximal to the supinator muscle) and the ED,
EDM, and ECU (distal to the supinator) should be chosen to
avoid injury to motor branches. The distal deep group consists
of the APL, EPB, EPL, and EI. They originate in the distal half
of the forearm, close to the skeletal plane.
Adequate repair of muscles and tendons can be very dif­
ficult in this area. Sutures of muscle fibers alone have virtually
no tensile strength. Therefore an effort should be made to
suture tendons or fascial layers instead of muscle fibers alone.
Nevertheless, these sutures are usually not strong enough for
dynamic postoperative treatment protocols and immobiliza­
tion for 3–4 weeks should be initiated postoperatively.
Postoperative care
As with flexor tendon injuries, the importance of an adequate
postoperative treatment cannot be overestimated. Extensor
tendon healing itself does not differ very much from flexor
tendon healing. However, it has to be considered that the
treatment protocol needs to address the powerful antagonist
force of the opposing flexor tendons. Initially, static postop­
erative treatment regimes were considered sufficient for all
injuries, as in theory tendon adhesion is limited due to the
mostly extrasynovial nature of extensor tendons. In reality,

238
SECTION II
CHAPTER 10 • Extensor tendon injuries
Hung et al. reported on 38 patients with an average of 229°
of total active motion after postoperative dynamic splinting.60
Patients with lesions in zones II–IV showed the worst results,
with an average of 188° total active motion. For lesions at the
level of the MP joint, several studies reported superior results
after postoperative dynamic splinting protocols when com­
pared with immobilization, ranging from 237° to 254° of total
active motion.60,63,64
Complications
The most common complication after extensor tendon injuries
is the formation of adhesions between the tendon and sur­
rounding tissues. Under these circumstances, a tenodesis
restraint may occur, limiting PIP joint flexion when the MP
joint is also flexed. Adhesion formation should be addressed
first by hand therapy and splinting of the affected joints in
order to improve tendon gliding. If there is not adequate
improvement in range of motion after 4–6 months, extensor
tendon tenolysis can be considered. A stable skin envelope is
a prerequisite before performing any additional procedures.
Tenolysis can be elegantly performed utilizing the wide-
awake technique with no sedation and no tourniquet with the
use of tumescent lidocaine and epinephrine (see patient selec­
tion, above).
Tenolysis alone may not be sufficient to achieve an improve­
ment in range of motion. An additional capsulotomy, collateral
ligament release, or even flexor tendon tenolysis may be
necessary.65 Creighton and Steichen reported the results of
extensor tenolysis after phalangeal and metacarpal fracture
repair.66 Total active range of motion was improved by 31%
on average, but only 21% when an additional capsulotomy
was necessary.
Secondary procedures
Early dynamic motion is also superior to immobilization
after transfer of the EI tendon for EPL reconstruction.54 After
performing a Pulvertaft weave, the tendon is more stable and
splinting can be discontinued after 3 weeks. However, active
extension of the thumb has no advantage over dynamic
splinting after transfer of the EI tendon.55
A different concept for lacerations in zones IV to VII is the
immediate controlled active motion (ICAM) splinting proto­
col.56 This protocol, also referred to as relative motion splint­
ing, encourages active motion of the affected digit which is
kept in 15° to 20° less relative motion than the adjacent joints
by a simple splint for 6 weeks. The rationale for this concept
is that placing the finger in a slightly more extended position
than the neighboring digits results in a reduction of force,
regardless of the position of the MP joint.57 Recently, ICAM
has also been applied for postoperative care after correction
of boutonnière deformities, sagittal band ruptures and side-
to-side tendon-transfers in caput ulnae syndrome.58
Outcomes, prognosis, and
complications
Outcomes
Outcomes vary considerably with the location of the lesion,
the extent of concomitant injuries to the bone or surrounding
soft tissues, timing of the repair, and adequate postoperative
care. Clinical results are most often assessed by total active
motion.59 Hung et al. established 270° of total active motion in
a digit as a normal value.60 Some authors have adapted evalu­
ation systems for flexor tendon injuries.7,61 Alternatively,
results can be compared by total lag of extension or flexion,
as proposed by Miller in 1942.62
Lesions distal to the MP joints lead to less favorable results
than more proximal lesions. Newport et al. report the results
of a retrospective analysis of 101 patients, most of whom were
treated with static splinting.40 Good or excellent results with
an average total active motion of 230° were achieved in 64%
of patients without an associated injury. However, lesions in
zones I through IV resulted in good or excellent results in only
50% of patients. Evans found a total active motion of 147° 6
weeks after repair of lacerations in zone III and an early active
motion regimen.49
Fig. 10.21  Dynamic extension splint.
Clinical tips
Secondary correction of established finger deformities is
exceedingly difficult. Patients should be aware that restoration
of “normal” finger movement is rare.
The hanging fingertip
Even a minimal increase in tendon length will result in an
extensor lag after a mallet injury. In many patients, therefore,
some residual deformity will occur. However, this deformity
is rarely of any relevance in terms of long-term prognosis.67
With the extension lag exceeding 40–50°, however, a consider­
able number of patients will desire correction. In this case,
additional immobilization should be considered for up to 6
months after the injury, especially if there is any doubt about
the adequacy of the primary treatment.
If conservative treatment fails, surgical treatment should be
discussed with the patient. Due to the delicate equilibrium
between the extensor and the flexor tendon system, results are
not always satisfactory after secondary surgery. None of the
procedures available will invariably provide reliable results.
Correction of the deformity may be incomplete, there may be
some loss of flexion in the DIP joint, and pain reduction cannot

239
Secondary procedures
mallet injury. A thorough history-taking and physical exami­
nation will distinguish the mallet etiology from other causes.
In this case, the disrupted extensor tendon results in a con­
centration of extensor force at the PIP joint (Fig. 10.25). If the
palmar plate of the joint is lax, the swan-neck deformity will
occur immediately. However, even if it is not lax to begin with,
it will stretch over time due to increased extensor pull. If
hyperextension of the PIP joint exceeds a critical point, snap­
ping of the joint will occur. This may be often more disconcert­
ing to the patient than the postural deformity.
A tenotomy of the central slip has been used to address the
swan-neck deformity in patients with a chronic mallet defor­
mity in which the terminal extensor tendon cannot be
repaired.68 This procedure has also been referred to as the
Fowler release. By transection of the central slip, rebalancing
of the extensor mechanism should occur in order to increase
the extension force on the DIP joint. Grundberg and Reagan
reported on a series of 20 patients with an average reduction
of PIP joint extension of 10° to less than 2°.69 A biomechanic
study demonstrated the ability to correct an extensor lag of
be reliably predicted. Any accompanying arthritis of the joint
should be ruled out; in case of cartilaginous deterioration, DIP
joint fusion should be considered.
If surgical correction is indicated, a simple combined exci­
sion of callus and skin may be the procedure of choice. This
dermatotenodesis has also been referred to as the Brooks–
Garner procedure. In this procedure, an elliptical wedge of
skin and underlying soft tissues, including the scarred exten­
sor tendon, is excised from the dorsum of the involved DIP
joint (Figs. 10.22–24). The wound edges are closed by en bloc
sutures, resulting in a slight hyperextension of the joint. The
DIP joint is then transfixed with a Kirschner wire to keep the
joint in the desired position for 6 weeks.
Alternatively, a Fowler release (central slip tenotomy) or
even a reconstruction of the spiral oblique retinacular liga­
ment may be performed. Both procedures are primarily used
to correct swan-neck deformities and require a supple PIP
joint. They are therefore discussed in the following section.
The swan-neck deformity
The swan-neck deformity is a classic finger deformity that can
be caused by many reasons, including congenital PIP palmar
plate laxity and intrinsic tightness. Often it is associated with
some form of arthritis; however, it can also result from a
Fig. 10.22  Hanging fingertip.
Fig. 10.23  Resection of skin and tendon.
Fig. 10.24  Transfixation of the distal interphalangeal joint.
Fig. 10.25  (A,B) Pathophysiology of the swan-neck deformity. The deformity
persists when the tendon heals with lengthening.
A
B

240
SECTION II
CHAPTER 10 • Extensor tendon injuries
hyperlax palmar plates at the level of the PIP joint. In these
cases, correction of the laxity can be indicated, e.g., by a
tenodesis of the flexor digitorum superficialis tendon.
The boutonnière deformity
Acute injury to the central band of the extensor tendon will
result in an acute boutonnière deformity as both lateral bands
shift palmarly due to the accompanied disruption of the tri­
angular ligament. In the acute phase, the deformity should
be easily reducible and may be treated as described above.
However, if left untreated, a chronic contracture results from
shortening of the oblique retinacular ligament (Fig. 10.27).
This condition has long been recognized as one of the most
challenging problems in hand surgery.74
Preoperative considerations
Any surgical correction of the deformity should only be per­
formed if the PIP joint can be extended passively. This can
sometimes be achieved conservatively by a physical therapy
program in combination with static and dynamic splinting. In
severe cases, an additional operative tenoarthrolysis may be
necessary. This procedure can sometimes be combined with
revision of the extensor tendon from a dorsal approach.
However, in severe cases a first-stage palmar approach to
release the joint contracture is combined with a staged sec­
ondary procedure from dorsally. If combined with a splinting
regimen, the tenoarthrolysis may be sufficient to achieve
functional improvement, so that further operations can be
avoided.
Burton and Melchior have listed several more aspects that
should be considered before attempting a surgical correction
of the deformity.75 Patients should be aware that postoperative
splinting is an essential part of the treatment strategy and may
up to 46°.70 The authors noted that extensor lags greater than
36° may not achieve full correction of the deformity. Increas­
ing the extent of the release will potentially increase the risk
of a secondary extensor lag of the PIP joint, but there was no
clear relationship between the occurrence of a lag and the
amount of release in a recent biomechanical study.71 It should
be noted that there is some confusion in the literature about
the operation that is referred to as a “Fowler release”. Fowler
also described a procedure to address the boutonnière defor­
mity by rebalancing the extensor tendon (see below). However,
in this operation the extensor tendon is divided distal to the
insertion of the central slip and thus even increasing extension
forces at the level of the PIP joint.
Alternatively, the extensor tendon may be reconstructed by
a tendon graft (spiral oblique retinacular ligament or SORL
reconstruction: Fig. 10.26). Thompson et al. described a proce­
dure using a palmaris tendon to restrain PIP extension and to
extend the DIP.72 In this technically demanding operation, the
tendon graft is fixed to the distal phalanx by a pull-out suture.
It is then passed between the flexor tendon and the palmar
plate of the PIP joint into an osseous tunnel in the proximal
phalanx (see Fig. 10.26). Although Girot et al. reported a 95%
success rate to correct PIP hyperextension, experience with
this procedure seems to be limited.73
Swan-neck deformities which are not primarily related to
injuries of the distal extensor tendon should be approached
differently. Frequently, these deformities are caused by
Fig. 10.26  (A–C) Spiral oblique retinacular ligament. A palmaris longus tendon
graft is passed between the flexor tendon and the palmar plate and fixed to the
distal phalanx by a pull-out suture.
A
B
C
Lateral band
Volar plate
Primary insertion of central tendon
Fig. 10.27  (A,B) Pathophysiology of the boutonnière deformity. Subluxation of the
lateral bands results in redistribution of forces and an extensor lag in the proximal
interphalangeal joint. Retraction of the oblique retinacular ligament prohibits
reduction in chronic deformities.
A
B
Central tendon
Oblique retinacular ligament
Lateral band

241
Secondary procedures
combining a tenotomy and tendon relocation (Fig. 10.29).78 In
Matev’s technique, the lateral bands are incised at different
levels (Fig. 10.30). The distal end of the longer slip is sutured
to the proximal end of the other slip, resulting in an increase
in length of the terminal tendon in order to reduce tension on
the DIP joint. The free slip is then relocated medially to restore
the central slip.79
In extensive defects of the central slip, the lateral bands
may be insufficient for reconstruction. In these cases, free
tendon grafts may be indicated. Littler described a figure-of-
eight weave through the base of the middle phalanx and the
lateral bands.80 Several other variations of fixation of the graft
have been proposed.32,77,81
Delayed sagittal band reconstruction
(Video 10.1 )
The function of the sagittal bands is to align the tendon cen­
trally on the MP joint. If the sagittal band is ruptured, the
tendon may subluxate to the unaffected side. The lesion most
often involves a longitudinal or oblique tear on the radial side
of the tendon which leads to an ulnar dislocation at the level
of the MP joint.82 Tendon dislocation rarely occurs in patients
not suffering from rheumatoid arthritis. If conservative treat­
ment fails, surgical reconstruction of the sagittal band is
indicated. In addition to the reconstruction, a release of the
contracted contralateral sagittal band may be necessary in
long-standing cases.43 Several techniques have been described
for reconstruction, if direct repair is not possible because of
missing soft tissue or severe scarring82–85 (Fig. 10.31).
be necessary for months after surgery. Any attempt to recon­
struct the soft tissues around the PIP joint should be avoided
if the joint shows any signs of arthritis. In this case, joint
fusion or arthroplasty should be considered. The boutonnière
deformity does not necessarily compromise the extent of
flexion in the PIP joint or grip strength. An increase in exten­
sion of the joint should not be traded for a stiff finger or loss
of grip strength.
There are two main categories of procedure to address the
boutonnière deformity: tenotomy or reconstruction of the
extensor tendon by tendon relocation or tendon grafting.
Tenotomy
Tenotomy of the extensor tendon on the middle phalanx is
referred as the Dolphin or Fowler procedure.76,77 It may be the
procedure of choice when patients mainly complain about
hyperextension of the DIP joint. The incision should be per­
formed just distally to the insertion of the central slip. In
Dolphin’s description, the tendon is divided more proximally
in order to preserve the distal insertions of the oblique reti­
nacular ligament (Fig. 10.28). The lateral bands should be able
to slide proximally in order to increase the tone on the PIP
joint to allow improved extension and reduce tension on the
DIP joint. Postoperatively, the PIP joint should be splinted in
extension, allowing free range of motion of the DIP joint. It
has been recommended to apply splinting for 6–8 weeks.75
Secondary reconstruction of the extensor tendon
If the main patient complaint is the lack of extensor function,
secondary reconstruction of the extensor should be consid­
ered. This goal can be achieved by either tendon relocation or
tendon grafting. Intraoperative transfixation of the PIP joint
with a Kirschner wire has been subject to controversial discus­
sion for any type of reconstruction. In severe flexion contrac­
tures of the joint, it may be beneficial.
The central slip can be reconstructed as described by Snow
(see Fig. 10.18). The end of the reconstructed tendon is either
sutured to the remaining insertion on the middle phalanx or
reinserted directly into the phalanx.
A large number of techniques have been described to
reconstruct the central slip using the lateral bands. By reloca­
tion of the lateral bands the tension of the terminal tendon on
the DIP joint is reduced while increasing the extension force
on the PIP joint. Littler and Eaton described the resection of
both lateral bands in order to relocate them dorsally and
suture them on to the insertion of the central slip, thus
Fig. 10.28  Treatment of the boutonnière deformity by tenotomy as described by
Dolphin and Fowler. Dolphin’s tenotomy preserves the insertions of the oblique
retinacular ligament.
Dolphin
Fowler
Fig. 10.29  Littler operation. The lateral bands are resected and relocated to the
central tendon.
Oblique retinacular ligament
Fig. 10.30  (A,B) Matev’s technique for reconstruction of the central slip.
Both lateral bands are cut at different heights and relocated to reconstruct the
central slip.
A
B

242
SECTION II
CHAPTER 10 • Extensor tendon injuries
Carroll et al. reported the results of three patients who were
operated on with their technique in five fingers.81 No recur­
rent subluxation was noted. Watson et al. found no recurrent
subluxation in 21 sagittal band reconstructions in 16 patients
after a mean of 16 months.82
The missing tendon: tendon transfers versus
tendon grafting (Video 10.2 )
In cases of degenerative rupture of an extensor tendon, direct
suturing is not usually possible because of an existing gap or
extensive degeneration of the tendon ends. In the absence of
rheumatoid arthritis, the EPL tendon is most often affected.
To reconstruct extensor function two options exist. First, the
tendon can be reconstructed with the use of a tendon graft,
e.g., derived from the palmaris longus tendon (Fig. 10.32A–D).
Second, reconstruction is possible by transfer of another
tendon. In case of an EPL rupture, the EI tendon is most fre­
quently used (Fig. 10.33A–D).
Good results have been reported for both techniques.88–91
In general, both show similar results.92 However, each
technique has specific advantages and disadvantages. For
reconstructions with tendon grafts two weaving sutures are
performed, which increases the risk of insufficiencies and
ruptures. Harvesting of a tendon graft is necessary, but donor
site morbidity should be minimal with the use of a palmaris
longus graft. In contrast to tendon transfers no cortical
rearrangement and adaption are needed. However, clinical
results after tendon grafting are worse in long-standing
ruptures because of atrophy and contracture of the affected
muscles.93
Cortical adaptation is necessary after tendon transfers, but
this is usually not a problem even in older patients. The opera­
tive technique is usually easier and faster. Because only one
weaving suture is performed, the risk of tendon ruptures may
be lower than in tendon transfers. After transfer of the EI
tendon isolated extension of the index finger is maintained in
most patients.94 However, it has to be considered that the
strength of isolated index finger extension is weakened.95,96
This is not a problem for daily life activities, but may be a
problem in specific patients, such as musicians.
Soft-tissue management and staged
reconstruction in combined injuries
Wheeldon described an anchoring of the ulnar-sided junc­
tura tendinum to the radial side of the extensor hood.85 Elson
passed a retrograde tendon slip beneath the deep transverse
metacarpal ligament and sutured it to the joint capsule.86
McCoy and Winsky described another reconstructive proce­
dure that used a proximally based tendon slip.84 In their
“lumbrical loop operation” the tendon was wrapped around
the lumbrical muscle and then sutured to itself. Kilgore et al.87
and Carroll et al.83 both described techniques that utilized
distally or ulnarly based tendon slips that were passed around
the radial collateral ligament and then sutured to themselves.
In Watson’s technique, a distally based central tendon slip is
looped through the deep transverse metacarpal ligament.82
Fig. 10.31  Different techniques for reconstruction of the sagittal band.
(A) Disruption of the radial sagittal band results in ulnar subluxation of the
extensor tendon. (B) Primary suturing. (C) Wheeldon’s technique: the ulnar
junctura tendinum is relocated to the deep intercarpal ligament. (D) McCoy’s
technique: the tendon is split distally and wrapped around the lumbricalis
muscle. (E) Carroll’s technique: an ulnarly distal-based slip of the extensor
digitorum tendon is wrapped around the radial collateral ligament (RCL).
A
B
C
D
E
Ulnar
subluxation
Ulnar
Radial
Primary
suture
Juncturae tendinum
(Wheeldon)
Tendon slip
(McCoy)
Tendon slip
(McCoy)
Tendon slip
(Carroll)
Lumbrical
Ulnar sagittal
fibers released
Scarred radial
sagittal band
RCL
Clinical tips
Regardless of the preferred technique for sagittal band
reconstruction, make sure the tendon is stabilized while
maintaining full finger flexion. A dynamic postoperative
protocol is advisable.
Clinical tips
Soft tissue coverage of the fingers must allow for full flexion of
the finger joints. After debridement of skin on the dorsum of
the fingers, local flaps are often necessary to avoid exposure
of the extensor tendon postoperatively.

243
Secondary procedures
Fig. 10.32  Reconstruction of a ruptured extensor pollicis longus (EPL) tendon with the use of a palmaris longus tendon graft. (A) Degenerative rupture of the extensor
pollicis longus tendon. Direct suture is not possible. (B) Harvest of the ipsilateral palmaris longus tendon as a graft. (C) Weaving suture of the graft to the proximal stump
of the tendon. (D) Weaving suture of the graft to the distal stump. Notice full extension of the thumb in wrist flexion.
A
B
C
D
Lesions of the extensor tendons are often complicated by
lesions of the bones and joints and by loss of skin. The treat­
ment of these combined defects poses a difficult problem for
the treating surgeon. Extensive scarring can be expected and
must be taken into consideration when formulating a treat­
ment plan. As in other mutilating injuries, basic reconstructive
principles apply. Before attempting reconstruction of the
tendons, several requirements must be fulfilled. First of all,
radical debridement of all devitalized tissue is mandatory.
Before closure, the wound should not contain any contamina­
tion or tissue of compromised blood supply in order to prevent
infection. Primary radical debridement has been shown to be
superior to several serial debridement steps, because of the
formation of edema and infected granulation tissue, which is
only poorly penetrated by antibiotic treatment.97–100
Second, osseous structures must be stabilized before turning
to soft tissues. This can be achieved by internal or external
fixation as appropriate. Third, a stable soft-tissue coverage for
tendons and bony structures must be provided. In case of
combined lesions of the dorsum of the hand, often pedicled or
free tissue transfer is necessary. While the dorsal side of the
hand is frequently used as a donor side to harvest soft-tissue
flaps for coverage of palmar defects, the opposite is not true.
Instead, flaps are usually harvested from adjacent proximal or
distal regions on the hand and forearm. The pedicled radial
forearm flap is a classic pedicled workhorse flap for coverage
of the dorsum of the hand. However, due to sacrifice of the
radial artery and the conspicuous donor site, variations of the
original technique such as perforator-based flaps or fascial
flaps should be considered.101 Another classic pedicled flap is
the posterior interosseous artery flap (Figs. 10.34–10.38). With
the advancement of microsurgical techniques, free tissue
transfers are now more frequently performed.102
The timing of combined reconstructive procedures has
been subject to discussions. Traditionally, these injuries have
been addressed by multistage procedures.103 However, since
Godina’s classic work on the value of early debridement and
Clinical tips
Extensive undermining of the skin should be avoided at the
back of the hand. Soft tissue coverage is thin and breaks
down easily, leading to complex defects.

244
SECTION II
CHAPTER 10 • Extensor tendon injuries
A
B
Fig. 10.33  Reconstruction of a ruptured extensor pollicis longus (EPL) tendon by transfer of the extensor indicis (EI) tendon. (A) Distal stump of the ruptured extensor
pollicis longus tendon. (B) Harvest of the extensor indicis tendon at the base of the index finger. (C) The EI tendon is reflected to the level of the wrist and a subcutaneous
tunnel is created. (D) Weaving suture of the tendons.
C
D
Fig. 10.34  Postinfectious defect of the dorsum of the hand with exposed extensor
tendons.
Fig. 10.35  Defect after debridement of the extensor tendons. The metacarpal
bones are exposed.

245
Future directions
with complex defects in zones VI and VII who received soft-
tissue coverage only without reconstruction of tendon
defects.111
Conclusion
Extensor tendon injuries are frequently underestimated.
However, even slight disturbances in the delicate balance
between the flexor and the extensor tendon systems will result
in significant loss of finger function. Therefore, a clear under­
standing of the pertinent anatomy is essential to achieve good
treatment results. Acute injuries require early diagnosis and
treatment, which should always take the surrounding soft-
tissue structures into consideration. Chronic injuries and
subsequent finger deformities such as swan-neck and bouton­
nière deformities are very difficult to correct and require a
thorough analysis of the underlying tendon imbalance. As is
true for other tendon injuries, good results cannot be achieved
without the choice of the right postoperative treatment
protocol.
Future directions
The functional anatomy of the extensor mechanism is complex
and certain aspects less clear than some publications might
suggest. Therefore, biomechanical research will hopefully
improve the treatment of injuries to the extensor apparatus
and especially their sequelae. However, most research today
is probably directed towards other aspects, namely suture
techniques and postoperative treatment protocols. These two
are connected, as stronger suture techniques allow earlier and
more extensive motion exercises. These developments are
reflected in the latest revision of this chapter and will hope­
fully continue to improve clinical results for our patients.
Fig. 10.36  Soft-tissue reconstruction by a posterior interosseus artery flap. The
missing tendons have been reconstructed by transfer of the extensor indicis tendon.
Fig. 10.37  Recovery of extensor function.
Fig. 10.38  Flexor function 12 weeks after reconstruction.
free tissue transfer for lower-extremity defects, today probably
most surgeons apply the same principles in upper-extremity
reconstruction with the aim of achieving soft-tissue coverage
within 72 hours.104 Several authors have reported excellent
results after one-stage procedures for defects involving the
dorsum of the hand with the use of emergency free flaps.105–107
Reconstruction of missing tendons is usually performed at the
time of soft-tissue coverage by primary grafting or tendon
transfers. Because the creation of a secondary tendon sheath
is not necessary, staged reconstruction of extensor tendons
utilizing silicone rods is rare.108–110 Adams reported on six
patients who were treated by two-staged reconstructions of
complex defects of the extensor tendon at the level of the PIP
joint.110 Active extension of the PIP joint could be achieved in
all patients with an average extensor lag of 15°. In contrast,
Quaba et al. presented good clinical results in nine patients
5. Harris CJ, Rutledge GLJ. The functional anatomy of the extensor
mechanism of the finger. J Bone Joint Surg Am. 1972;54:713–726.
6. Landsmeer JM. The anatomy of the dorsal aponeurosis of the
human finger and its functional significance. Anat Rec. 1949;104:31–
44. Classic description of the function of the oblique retinacular ligaments
which is the anatomical foundation for numerous reconstructive
procedures of the distal extensor tendon.
17. Newport ML, Williams CD. Biomechanical characteristics of
extensor tendon suture techniques. J Hand Surg Am.
1992;17:1117–1123.
Access the complete reference list online at

246
SECTION II
CHAPTER 10 • Extensor tendon injuries
25. Handoll HH, Vaghela MV. Interventions for treating mallet finger
injuries. Cochrane Database Syst Rev. 2004;(3):CD004574.
38. Snow JW. Use of a retrograde tendon flap in repairing a severed
extensor in the pip joint area. Plast Reconstr Surg. 1973;51:555–558.
Although only 6 cases in 3 years are reported, this is the classic
description of one of the most commonly used techniques to reconstruct
defects of the central slip.
49. Evans RB. Early active short arc motion for the repaired central slip.
J Hand Surg Am. 1994;19:991–997. Based on several anatomical studies,
Evans introduces a new early active motion protocol for extensor tendon
injuries in zones III and IV. Sixty-four digits in 55 patients were
investigated. Patients who were treated by early active motion
demonstrated better functional results than those who were treated by
immobilization.
50. Duran RJ, Houser RG, Stover MG. Management of flexor tendon
lacerations in Zone 2 using controlled passive motion
postoperatively. In: Hunter JM, Schneider LH, Mackin EJ, et al., eds.
Rehabilitation of the Hand. St. Louis: CV Mosby; 1978:217–224.
53. Mowlavi A, Burns M, Brown RE. Dynamic versus static splinting of
simple zone V and zone VI extensor tendon repairs: a prospective,
randomized, controlled study. Plast Reconstr Surg. 2005;115:482–487.
68. Bowers WH, Hurst LC. Chronic mallet finger: The use of Fowler’s
central slip release. J Hand Surg Am. 1978;3:373–376.
76. Dolphin JA. Extensor tenotomy for chronic boutonnière deformity
of the finger; report of two cases. J Bone Joint Surg Am. 1965;47:161–
164. Description of the classic technique to address the problem of the
boutonnière deformity.
78. Littler JW, Eaton RG. Redistribution of forces in the correction of
boutonnière deformity. J Bone Joint Surg Am. 1967;49:1267–1274.
Littler and Eaton describe the pathophysiology of the boutonnière
deformity and the results of 8 patients who were treated by detachment
and proximal reinsertion of the lateral bands.

246.e1
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22. Leinberry C. Mallet finger injuries. J Hand Surg Am. 2009;34:
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23. Niechajev IA. Conservative and operative treatment of mallet
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24. Stern PJ, Kastrup JJ. Complications and prognosis of treatment of
mallet finger. J Hand Surg Am. 1988;13:329–334.
25. Handoll HH, Vaghela MV. Interventions for treating mallet finger
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26. Auchincloss JM. Mallet-finger injuries: a prospective, controlled
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27. Kinninmonth AW, Holburn F. A comparative controlled trial of a
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28. Maitra A, Dorani B. The conservative treatment of mallet finger
with a simple splint: a case report. Arch Emerg Med. 1993;10:
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29. Warren RA, Norris SH, Ferguson DG. Mallet finger: a trial of two
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30. Abouna JM, Brown H. The treatment of mallet finger. The results
in a series of 148 consecutive cases and a review of the literature.
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31. Casscells SW, Strange TB. Intramedullary wire fixation of
mallet-finger. J Bone Joint Surg Am. 1957;39-A:521–526.
32. Weeks PM. The chronic boutonnière deformity: a method of repair.
Plast Reconstr Surg. 1967;40:248–251.
33. Tubiana R. Surgical repair of the extensor apparatus of the fingers.
Surg Clin North Am. 1968;48:1015–1031.
34. McFarlane RM, Hampole MK. Treatment of extensor tendon
injuries of the hand. Can J Surg. 1973;16:366–375.
35. Elliott RAJ. Injuries to the extensor mechanism of the hand. Orthop
Clin North Am. 1970;1:335–354.
36. Sakellarides HT. The extensor tendon injuries and the treatment.
R I Med J. 1978;61:307–313.
37. Stewart IM. Boutonnière finger. Clin Orthop. 1962;23:220–226.
38. Snow JW. Use of a retrograde tendon flap in repairing a severed
extensor in the pip joint area. Plast Reconstr Surg. 1973;51:555–558.
Although only 6 cases in 3 years are reported, this is the classic
description of one of the most commonly used techniques to reconstruct
defects of the central slip.
39. Aiache A, Barsky AJ, Weiner DL. Prevention of the boutonnière
deformity. Plast Reconstr Surg. 1970;46:164–167.
40. Newport ML, Blair WF, Steyers CMJ. Long-term results of extensor
tendon repair. J Hand Surg Am. 1990;15:961–966.
41. Dreyfuss UY, Singer M. Human bites of the hand: a study of one
hundred six patients. J Hand Surg Am. 1985;10:884–889.
42. Nolan WB. Extensor tendon injuries and reconstruction. In:
Mathes SJ, Hentz V, eds. Plastic Surgery. Philadelphia: Saunders;
2005:401–421.
43. Koniuch MP, Peimer CA, VanGorder T, et al. Closed crush injury of
the metacarpophalangeal joint. J Hand Surg Am. 1987;12:750–757.
44. Ishizuki M. Traumatic and spontaneous dislocation of extensor
tendon of the long finger. J Hand Surg Am. 1990;15:967–972.
45. Araki S, Ohtani T, Tanaka T. Acute dislocation of the extensor
digitorum communis tendon at the metacarpophalangeal joint. A
report of five cases. J Bone Joint Surg Am. 1987;69:616–619.
46. Inoue G, Tamura Y. Dislocation of the extensor tendons over the
metacarpophalangeal joints. J Hand Surg Am. 1996;21:464–469.
47. Botte MJ, Cohen MS, von Schroeder HP. Method of tendon
labeling in forearm injuries. J Hand Surg Am. 1991;16:763–764.
48. Benson EC, DeCarvalho A, Mikola EA, et al. Two potential causes
of EPL rupture after distal radius volar plate fixation. Clin Orthop
Relat Res. 2006;451:218–222.
49. Evans RB. Early active short arc motion for the repaired central
slip. J Hand Surg Am. 1994;19:991–997. Based on several anatomical
studies, Evans introduces a new early active motion protocol for extensor
tendon injuries in zones III and IV. Sixty-four digits in 55 patients were
investigated. Patients who were treated by early active motion
demonstrated better functional results than those who were treated by
immobilization.
50. Duran RJ, Houser RG, Stover MG. Management of flexor tendon
lacerations in Zone 2 using controlled passive motion
postoperatively. In: Hunter JM, Schneider LH, Mackin EJ, et al.,
eds. Rehabilitation of the Hand. St. Louis: CV Mosby; 1978:217–224.

246.e2
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CHAPTER 10 • Extensor tendon injuries
51. Evans RB. Therapeutic management of extensor tendon injuries.
Hand Clin. 1986;2:157–169.
52. Brand PW, Hollister AM. Clinical Mechanics of the Hand. St. Louis:
CV Mosby; 1999.
53. Mowlavi A, Burns M, Brown RE. Dynamic versus static splinting
of simple zone V and zone VI extensor tendon repairs: a
prospective, randomized, controlled study. Plast Reconstr Surg.
2005;115:482–487.
54. Germann G, Wagner H, Blome-Eberwein S, et al. Early dynamic
motion versus postoperative immobilization in patients with
extensor indicis proprius transfer to restore thumb extension: a
prospective randomized study. J Hand Surg Am. 2001;26:1111–1115.
55. Giessler GA, Przybilski M, Germann G, et al. Early free active
versus dynamic extension splinting after extensor indicis proprius
tendon transfer to restore thumb extension: a prospective
randomized study. J Hand Surg Am. 2008;33:864–868.
56. Howell JW, Merritt WH, Robinson SJ. Immediate controlled active
motion following zone 4-7 extensor tendon repair. J Hand Ther.
2005;18:182–190.
57. Sharma JV, Liang NJ, Owen JR, et al. Analysis of relative motion
splint in the treatment of zone VI extensor tendon injuries. J Hand
Surg Am. 2006;31:1118–1122.
58. Merritt WH. Relative motion splint: active motion after extensor
tendon injury and repair. J Hand Surg Am. 2014;39:1187–1194.
59. Soni P, Stern CA, Foreman KB, et al. Advances in extensor tendon
diagnosis and therapy. Plast Reconstr Surg. 2009;123:52e–57e.
60. Hung LK, Chan A, Chang J, et al. Early controlled active
mobilization with dynamic splintage for treatment of extensor
tendon injuries. J Hand Surg Am. 1990;15:251–257.
61. Khandwala AR, Blair J, Harris SB, et al. Immediate repair and
early mobilization of the extensor pollicis longus tendon in zones
1 to 4. J Hand Surg [Br]. 2004;29:250–258.
62. Miller H. Repair of severed tendons of the hand and wrist. Surg
Gynecol Obstet. 1942;75:693–698.
63. Ip WY, Chow SP. Results of dynamic splintage following extensor
tendon repair. J Hand Surg [Br]. 1997;22:283–287.
64. Kerr CD, Burczak JR. Dynamic traction after extensor tendon
repair in zones 6, 7, and 8: a retrospective study. J Hand Surg [Br].
1989;14:21–22.
65. Uhl RL. Salvage of extensor tendon function with tenolysis and
joint release. Hand Clin. 1995;11:461–470.
66. Creighton JJJ, Steichen JB. Complications in phalangeal and
metacarpal fracture management. Results of extensor tenolysis.
Hand Clin. 1994;10:111–116.
67. Moss JG, Steingold RF. The long term results of mallet finger
injury. A retrospective study of one hundred cases. Hand. 1983;15:
151–154.
68. Bowers WH, Hurst LC. Chronic mallet finger: The use of Fowler’s
central slip release. J Hand Surg Am. 1978;3:373–376.
69. Grundberg AB, Reagan DS. Central slip tenotomy for chronic
mallet finger deformity. J Hand Surg Am. 1987;12:545–547.
70. Chao JD, Sarwahi V, Da Silva YS, et al. Central slip tenotomy for
the treatment of chronic mallet finger: an anatomic study. J Hand
Surg Am. 2004;29:216–219.
71. Hiwatari R, Kuniyoshi K, Aoki M, et al. Fractional Fowler
tenotomy for chronic mallet finger: a cadaveric biomechanical
study. J Hand Surg Am. 2012;37:2263–2268.
72. Thompson JS, Littler JW, Upton J. The spiral oblique retinacular
ligament (SORL). J Hand Surg Am. 1978;3:482–487.
73. Girot J, Marin-Braun F, Amend P, et al. [Littler’s operation (SORL
= spiral oblique retinacular ligament) in the treatment of swan
neck]. Ann Chir Main. 1988;7:85–89.
74. Massengill JB. The boutonnière deformity. Hand Clin. 1992;8:
787–801.
75. Burton RI, Melchior JA. Extensor tendons – late reconstruction. In:
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Surgery. New York: Churchill Livingstone; 1999:1988–2021.
76. Dolphin JA. Extensor tenotomy for chronic boutonnière deformity
of the finger; report of two cases. J Bone Joint Surg Am.
1965;47:161–164. Description of the classic technique to address the
problem of the boutonnière deformity.
77. Fowler SB. The management of tendon injuries. J Bone Joint Surg
Am. 1959;41-A:579–580.
78. Littler JW, Eaton RG. Redistribution of forces in the correction of
boutonnière deformity. J Bone Joint Surg Am. 1967;49:1267–1274.
Littler and Eaton describe the pathophysiology of the boutonnière
deformity and the results of 8 patients who were treated by detachment
and proximal reinsertion of the lateral bands.
79. Matev I. Transposition of the lateral slips of the aponeurosis in
treatment of long-standing boutonnière deformity of the fingers.
Br J Plast Surg. 1964;17:281–286.
80. Littler RW. The digital extensor-flexor system. In: Converse JM, ed.
Reconstructive Plastic Surgery. Philadelphia: WB Saunders;
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81. Suzuki K. Reconstruction of post-traumatic boutonnière deformity.
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82. Watson HK, Weinzweig J, Guidera PM. Sagittal band
reconstruction. J Hand Surg Am. 1997;22:452–456.
83. Carroll CT, Moore JR, Weiland AJ. Posttraumatic ulnar subluxation
of the extensor tendons: a reconstructive technique. J Hand Surg
Am. 1987;12:227–231.
84. McCoy FJ, Winsky AJ. Lumbrical loop operation for luxation of the
extensor tendons of the hand. Plast Reconstr Surg. 1969;44:142–146.
85. Wheeldon FT. Recurrent dislocation of extensor tendons in the
hand. J Bone Joint Surg Br. 1954;36-B:612–617.
86. Elson RA. Dislocation of the extensor tendons of the hand. Report
of a case. J Bone Joint Surg Br. 1967;49:324–326.
87. Kilgore ES, Graham WP, Newmeyer WL, et al. Correction of ulnar
subluxation of the extensor communis. Hand. 1975;7:272–274.
88. Bora FWJ, Osterman AL, Thomas VJ, et al. The treatment of
ruptures of multiple extensor tendons at wrist level by a free
tendon graft in the rheumatoid patient. J Hand Surg Am.
1987;12:1038–1040.
89. Moore JR, Weiland AJ, Valdata L. Tendon ruptures in the
rheumatoid hand: analysis of treatment and functional results in
60 patients. J Hand Surg Am. 1987;12:9–14.
90. Williamson SC, Feldon P. Extensor tendon ruptures in rheumatoid
arthritis. Hand Clin. 1995;11:449–459.
91. Wilson RL, DeVito MC. Extensor tendon problems in rheumatoid
arthritis. Hand Clin. 1996;12:551–559.
92. Chung US, Kim JH, Seo WS, et al. Tendon transfer or tendon graft
for ruptured finger extensor tendons in rheumatoid hands. J Hand
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93. Nakamura S, Katsuki M. Tendon grafting for multiple extensor
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94. Moore JR, Weiland AJ, Valdata L. Independent index extension after
extensor indicis proprius transfer. J Hand Surg Am. 1987;12:232–236.
95. Magnussen PA, Harvey FJ, Tonkin MA. Extensor indicis proprius
transfer for rupture of the extensor pollicis longus tendon. J Bone
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96. Noorda RJ, Hage JJ, de Groot PJ, et al. Index finger extension and
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97. Haury B, Rodeheaver G, Vensko J, et al. Debridement: an essential
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98. Burke JF. Effects of inflammation on wound repair. J Dent Res.
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100. Lister G, Scheker L. Emergency free flaps to the upper extremity. J
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Pedicled Radial Forearm Flap. Hand (N Y). 2010;5:37–42.

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1988;13:66–71.

SECTION II • Acquired Traumatic Disorders
11 
Replantation and revascularization
William W. Dzwierzynski
SYNOPSIS
■ Replantation should be considered for all amputated parts; the only
absolute contraindication to replantation is a patient too sick to tolerate
surgery.
■ A “string sign” or “ribbon sign” in the amputated part suggests the
digital vessels are not suitable for replantation.
■ Skeletal shortening should be considered. Bone shortening also
facilitates a primary nerve and vessel repair.
■ Rigid bone fixation is desired for early mobilization. Interosseous wires
offer an excellent option for rigid fixation.
■ Revascularization of amputations proximal to the wrist
should be performed before 12 hours of cold ischemia
(6 hours of warm ischemia). If ischemia time is over 4 hours,
consideration should be given to temporary arterial shunting prior to
bone fixation.
■ Pharmacological management of replantation and revascularization
remains controversial. Our current protocol includes heparin
irrigation at a dilution of 100 units/mL during surgery and a
heparin bolus of 50–100 units/kg before release of microvascular
clamps.
■ The psychological implications of amputation and replantation must be
considered. The hand plays a significant role in a patient’s identity and
psyche.
Introduction
Restoring life has always been a dream. From the mythologi­
cal resurrection of the phoenix to the rising of Lazarus from
the dead, returning life to the dead remains a miracle. Replan­
tation restores life to the lifeless extremity: a miracle of modern
surgery.
Access the Historical Perspective section online at

Basic science/disease process
Pathophysiology of ischemia and reperfusion
Tissue tolerance to ischemia varies significantly. In normal
ambient temperature, irreversible changes can occur in muscle
with only 2 hours of ischemia; skin properly cooled and stored
in a nutrient media can be viable for over a month.4 Ischemia
causes tissue hypoxia and the conversion from aerobic to
anaerobic metabolism. Adenosine triphosphate (ATP) is pro­
duced by glycolysis which leads to the buildup of lactic acid
in the tissue and the resultant reduction of intercellular pH.5
As the supply of ATP is diminished, intracellular Na+ and
Ca2+ concentrations are increased. Chemical mediators and
enzymes are triggered by ischemia, resulting in the produc­
tion of phospholipase A2 and lysozymes. If continued beyond
the critical point, these processes lead to eventual cell
necrosis.
Revascularization is essential before these processes
become irreversible, but revascularization can lead to its own
problems. Reperfusion injury can cause problems as severe as
the initial ischemic insult. When ischemic tissue is suddenly
reperfused, reactive oxygen species (ROS) are produced.
These include superoxide (O−
2), hydrogen peroxide (H2O2),
and hydroxyl radical (OH−).6 The ROS react with the cell
membranes, especially in the endothelial cells. They cause
direct cell damage and produce inflammatory mediators,
complement activation, and leukocyte adhesion. This cascade
increases vascular permeability and can cause cell death
despite revascularization. Reperfusion-generated mediators
may have systemic effects when vessels are unclamped and
the inflammatory mediators are released to the circulation.
This can lead to a decreased level of consciousness, jaundice,
cardiac arrhythmia, metabolic acidosis, myoglobinuria, and
multisystem organ failure.7 Methods to prevent or reduce
ischemia–reperfusion injury include hypothermia, interarte­
rial flushing, ischemic preconditioning, antithrombotic agents,
  Access video content for this chapter online at expertconsult.com

247.e1
Historical perspective
Historical perspective
Malt performed the first replantation on May 23, 1962 at the
Massachusetts General Hospital on a 12-year-old boy who
had his arm amputated in a train accident.1 The first digital
replantation was performed in Japan on January 7, 1965 by
Komatsu and Tamai.2 Subsequent to these historical events,
replantation surgery took off with a flourish. China was the
epicenter of early replantation surgery. The American Replan­
tation Mission to China report in 1974 highlighted the replan­
tation efforts in China to an astonished American surgical
audience.3 The boundaries of replantation surgery continue
to expand, now reaching into the realm of extremity
transplantation.2

248
SECTION II
CHAPTER 11 • Replantation and revascularization
irreversible damage with ischemia times greater than 6–9
hours. Digits can tolerate longer periods of ischemia. Success­
ful replantation can be achieved even after prolonged ische­
mia. VanderWilde et al. reported a successful hand replantation
after 54 hours of cold ischemia.8 Wei et al. reported a series of
three successful digital replants with 84, 86, and 94 hours of
cold ischemia.9 All patients had satisfactory functional results
and no vascular compromise. Lin et al. reviewed their experi­
ence with 31 replantations (two thumb, 21 finger, and two
hand amputations), all with over 24 hours of either cold or
warm ischemia. The overall success rate was 64%. Only one
of the hands was successfully replanted; 15 of the 23 digits
were salvaged.10
Replantation center
A replantation center, usually a trauma center, with a dedi­
cated team is optimal for success of replantations. The replan­
tation center should include an emergency room and
paramedic system familiar with the transportation of the
injured patient and the amputated part (Table 11.1). This often
includes a medical air transportation system to facilitate rapid
transportation from the accident scene. At the replantation
center, the operating room should be large enough to allow
two independent surgical teams to operate, one on the patient
and the second on the amputated part (Fig. 11.2). Chung et al.
reviewed the database from the Agency for Healthcare Policy
and Research, evaluating 304 cases of finger replantation.
Over 906 hospitals were represented in the database but only
15% performed a finger replantation in the year reviewed;
60% of these hospitals performed only one replant. Only 2%
of the hospitals in the database performed 10 or more cases.
He postulated that replantations should be best performed at
high-volume centers.11 Chen and Narayan reviewed the eco­
nomic trends of upper extremity replantations over a 10-year
period and found an increasing tendency for these surgeries
to be performed at large teaching institutions.12 A survey of
members of the American Society of Surgery of the Hand
found that only 56% of its members perform replantation
surgery, despite 94% of the responders describing their micro­
surgical training as good or excellent.13
free-radical scavengers, and leukocyte inhibitors.4,5 While
many of these techniques show promise experimentally or in
elective free flap surgery, pretreatment is not an option in
traumatic replantation and revascularization. In major limb
replantation, once arterial flow is established, the vein should
be allowed to bleed to eliminate ROS, prior to establishing
flow to the systemic circulation.
Diagnosis/patient presentation
Transportation
The most critical factors in replantation and revascularization
surgery are management of the patient and the amputated
part. Proper handling of the amputation is essential to revas­
cularization and replantation success. The part is wrapped in
moist saline gauze and placed in a waterproof plastic bag. The
plastic bag is placed in a container of ice (Fig. 11.1). The part
should not come into direct contact with the ice. Freezing the
severed extremity can cause direct irreversible damage to
the microvascular system. Timely, efficient transportation of
the patient and the amputated part to the replantation center
is critical for survival and function. Muscle undergoes
Fig. 11.1  The amputated part should be wrapped in moist gauze placed in a
plastic bag which is chilled in an ice–water mixture. Direct contact of the part with
the ice must be avoided.
Early care of amputated part
Amputated
part
Saline
moistened
gauze
Within
Sealed
plastic bag
Into
Saline ice slurry
Table 11.1  Replantation center criteria
1. An efficient ground and air transportation system to transfer the
patient from the injury site or referring hospital to the replant
center
2. Experienced microsurgical teams, able to work in shifts
3. A well-prepared emergency room staff to stabilize and quickly
evaluate the patient with physical examination, X-rays, and
laboratory tests
4. Experienced anesthetists, operating room, and microsurgical
staff available 24 hours/day, 7 days/week
5. Proper microscopes, instruments, and sutures
6. A carefully trained nursing staff for postoperative care and
monitoring
7. Physical and occupational therapists trained in post
replantation rehabilitation
8. Psychologists and social workers to help the patient cope with
his or her injuries and continue an active and useful life

249
Patient selection
Thumb amputations also deserve special emphasis. While
thumb reconstruction can be achieved with methods such as
pollicization or toe transfer, these reconstructions have a sig­
nificant donor site cost. Thumb replantation should be con­
sidered even if shortening or arthrodesis is necessary. The
thumb primarily functions as a post for opposition. Decreased
motion in a thumb is generally well accepted, and even a stiff
thumb contributes to the overall function of the hand.
Patients who have lost multiple digits also deserve an extra
consideration in replantation. Where a single digit loss may
be well tolerated, patients who have lost multiple digits have
a significantly greater disability. Salvaging one or two fingers
in a mutilated hand may preserve essential function of the
hand. In multiple-digit amputations consideration should
also be made for “spare-parts surgery”. If an amputation is
through the metacarpophalangeal (MCP) joint of the long
finger and more proximal on the index finger, replantation of
the index finger to the long finger ray, preserving the joint,
may increase the patient’s overall function. Replantation
above the elbow is advocated for preservation of elbow func­
tion but generally distal function in the hand is poor.16 Finger­
tip replantations, once considered not indicated, are now seen
as an excellent level of replantation. Replantation of a digit
distal to the flexor digitorum superficialis (FDS) insertion
generally has excellent function because only one flexor
tendon requires repair, and should be strongly considered.
The only absolute contraindication to replantation is pre­
serving life over limb. A patient with life-threatening injuries
or multiple medical problems who cannot withstand pro­
longed surgery should not undergo replantation. An uncoop­
erative patient is also a contraindication for replantation.14 In
a patient with acute major life-threatening injuries, an ampu­
tated hand or digit may be kept in cold storage and the patient
reassessed in 24 hours. If the patient is stable enough to
undergo surgery, delayed replantation may be considered.
There are several relative contraindications to digital
replantation17 (Table 11.3). These contraindications are related
both to the microvascular success rate and ultimate hand
function compared to an amputation revision. All patients
must be evaluated individually to determine if they are a
candidate for digital replantation. While age is not an absolute
contraindication for replantation, older patients carry a greater
risk of arteriosclerosis of the vessel, joint stiffness, and gener­
ally decreased function secondary to less recovery of sensa­
tion. Okada et al. reviewed eight replantations in patients over
Patient selection
Indications and contraindications
Needless to say, the critical patient selection criterion for
replantation is a patient with an amputation. The amputated
part must be both available and in satisfactory condition for
the replantation (Table 11.2). Digits recovered from the
stomach of an attacking animal or extracted from industrial
grinders generally do not meet this criterion. Outside these
obvious examples, replantation should at least be considered
for all amputated parts. Generally accepted indications for
replantations in the upper extremities are thumb amputa­
tions, multidigit amputations and any amputation in a child.14
Often adult patients with single-digit amputations, especially
the index finger, are generally not considered candidates for
replantation.15 Replantation of a single digit is generally
indicated in children. This is partly due to improved healing
in children but also because of the future potential of the child.
Lower-extremity and upper arm replantations also are indi­
cated in a child.
Fig. 11.2  Replantation operation room set-up. The pressure pump is situated at the
patient’s head. The fluid cooler/warmer (far right) is used for icing the amputated
part.
Table 11.2  Indications for replantation
Strong indications
• Multiple digital amputations
• Thumb amputations
• Whole hand
• Transmetacarpal and partial hand amputations
• Any amputated part in a child
• Single digit amputation distal to flexor digitorum superficialis
insertion
Relative indications
• Sharp injuries at elbow or proximal forearm
• Humeral-level amputations
Table 11.3  Relative contraindications to replantation
• Concomitant life-threatening injury
• Systemic illness (e.g., small-vessel disease)
• Poor anesthesia risk
• Mentally unstable patients
• Single finger proximal to flexor digitorum superficialis insertion
in adults
• Multiple segmental injuries in the amputated part
• Severe crushing or avulsion of the tissues
• Extreme contamination
• Prior surgery or trauma to the amputated part
• Prolonged warm ischemia time
• Ribbon sign, red line sign
• Most index finger amputations

250
SECTION II
CHAPTER 11 • Replantation and revascularization
Fig. 11.3  (A,B) A midlateral exposure of the amputated part offers greater access
to the neurovascular structures.
A
B
Cross-section of digit
Dorsal veins
Bone
Digital
nerve (volar)
Digital nerve
Digital artery
Extensor tendon
Flexor tendon
Extensor tendon:
Central slip
Lateral band
Digital artery
(volar)
65 years old. Function of these digits was generally classified
as poor, although all patients were satisfied with their results.
Expectations in the elderly patient may be less than those of
a younger patient.18
Treatment/surgical technique
(Video 11.1 )
Operative sequence
Replantation surgery is an exacting and strenuous operation.
It should proceed in an organized and deliberate fashion.
When replantation is considered feasible, the amputated part
is brought to the operating room and explored to identify the
neurovascular structures. This may even be performed while
the patient is still in the emergency room being evaluated and
stabilized.
If two surgical teams are available, both the amputated part
and the patient can undergo simultaneous surgery. The ampu­
tated part is brought to the operating room first. Using loupe
magnification, all structures are examined. The blood vessels
and nerves are usually examined at high magnification with
the operating microscope before committing to perform a
replantation. Under the operating microscope, the part is
examined for suitability of replantation. Tissue loss is evalu­
ated, along with the level of amputation. Multiple levels of
injury may be found which were not apparent during the
emergency room examination. The neurovascular structures
should be evaluated for evidence of avulsion injuries. A string
sign or ribbon sign means the digit is not suitable for replanta­
tion. These signs are indicated by a red streaking of blood
along the path of the artery, usually implying an avulsion
injury. The artery and nerves should be identified and tagged
with a 7-0 polypropylene suture or microclips. If the digital
vessels cannot be readily identified through the wound, the
digital vessels can be exposed through a midaxial incision
(Fig. 11.3). Dorsal veins are identified and tagged in a similar
fashion. The location of the veins is more variable, and they
may not be readily visible. Two or three veins should be
identified. Preliminary bone fixation and methods of tendon
repair are considered at this time. The digital tendon suture
may be placed while the amputated digit is on the back table.
The distal aspect of the bony fixation can also be secured,
whether this is with K-wires, interosseous wires, or a mini
fixation plate.
Once the patient is under anesthesia, the proximal level of
the injury is explored. Replantation surgery is usually per­
formed under general anesthesia. Regional anesthesia may
be considered for a cooperative patient. Regional anesthesia
offers the added benefit of decreased postoperative pain
and possible vasodilatation. A Foley catheter is inserted and
proper body warming is assured by utilizing a warming
blanket and warming the operating room. All pressure points
should be well padded to avoid pressure injuries; this includes
the occiput to avoid scalp alopecia.
The sequence of the repair in digital replantation varies
among surgeons, with some advocating arterial repair after
bony fixation and flexor tendon repair while others advocate
repair of the dorsal structures, including the extensor tendon,
dorsal veins, and skin prior to repairing any volar structures.17
The author favors repairing the volar structures first, and then
proceeding to the dorsal structures. Repair of the extensor
tendons is performed prior to releasing the tourniquet. Dorsal
veins are repaired either before or after tourniquet release,
depending on their visualization.
Bone fixation
The time spent in achieving rigid digital fixation is well worth
the additional effort required (Fig. 11.4). Adequate fixation of
the replanted digit is essential not only for short-term healing
but also for long-term function. Rigid fixation of the bony
fracture can reduce pain, allow early mobilization of the hand,
and improve long-term function. The final outcome of the
replantation lies in the ultimate function of the hand. Function
is linked to motion, and motion is optimized by early mobi­
lization. Rigid bone fixation is desired for early mobilization.
Skeletal shortening should be considered in all replantations;
this can allow more secure bone fixation and lessen the need
for vessel and nerve grafting14 (Fig. 11.5). In a thumb, shorten­
ing of the digit should be performed judiciously.19
A variety of methods are available for bone fixation. The
simplest method is K-wire fixation. K-wires are universally
available and can be easily and rapidly inserted. The simplest
fixation is a longitudinally placed K-wire. While easily per­
formed, longitudinal K-wires have many disadvantages.

Fig. 11.4  Techniques of bony fixation include: (A) crossed K-wires;
(B) single longitudinal K-wire; (C) I-O wire and K-wire; (D) 90-90 I-O wires;
(E) intermedullary fixation; (F) compression plate; (G) H-plate;
and (H) lag screw.
A
B
C
D
E
F
G
H
Fig. 11.5  (A) 46-year-old with distal forearm amputation. (B) Bone shortening and
dynamic compression plating allowed primary repair of the neurovascular structures.
(C) Hand after replantation and fasciotomies.
A
B
C

252
SECTION II
CHAPTER 11 • Replantation and revascularization
application is technically demanding and angulation and
malunions can occur.19
Tendon repair
Secure tendon repair is necessary for early-motion protocols.
Inexperienced surgeons may desire to fix the tendons quickly
in order to move on to the revascularization of the fingers. In
properly cooled digital amputations, ischemia time can be
safely prolonged without any deleterious effects on success
rates and overall function. The extra 20–30 minutes required
to obtain a good tendon repair is time well spent. We prefer
to use a modified Kessler repair along with an epitendinous
suture. The Kessler repair is easy and quick to perform. The
use of a looped 4-0 braided polyethylene fiber suture allows
a strong four-strand repair without significant bulk. The
epitendinous suture supplies increased strength, facilitates
tendon gliding, and allows proper tendon tensioning of the
core suture. The pulleys should always be preserved. The
distal core suture may be first performed and then the tendon
is glided under the pulley for the final repair.
The distal core tendon suture is usually performed on the
back table. The proximal tendon is identified and secured
with a 25-gauge needle to the underlying tissue to prevent
retraction. Utilizing a 6-0 polypropylene suture, the epitendi­
nous repair is started on the dorsal aspect of the tendon, with
a locked, running suture. After completion of the dorsal epi­
tendinous repair, the core suture repair is woven through the
proximal portion of the tendon. The knot is tied in the sub­
stance of the tendon. Finally the volar epitendinous repair is
performed with a running locking stitch, utilizing the remain­
ing portion of the 6-0 polypropylene suture. This four-strand
repair is strong enough to initiate early active motion
protocols.
K-wires do not offer rigid fixation, longitudinal K-wires do
not control against rotation and, almost by necessity, must go
through the joint. Longitudinal K-wires are best utilized in
distal replants and revascularizations where other fixation
methods may not be technically feasible.
Cross K-wires offer more advantages than longitudinal
K-wire fixation, most notably the control of rotation. Cross
K-wires can be difficult for the novice to perform in simple
fracture fixation and devascularization injuries, but complete
amputation simplifies the process of cross K-wire place­
ment. While the amputated digit is on the back table, the
K-wires can be inserted in a retrograde fashion. The neuro­
vascular structures need to be meticulously protected and
the amputated part securely held to avoid spinning the part
uncontrollably.
Kirschner wires offer control of rotational deformity but
greater care must be taken with early digital motion. Cross
K-wires give an acceptable result although rigid fixation is not
achieved. Late digital stiffness and fracture malunion may
occur. Kirschner wires should be reserved for cases where
rapid fixation is necessary and in children.19
Interosseous (I-O) wires offer an excellent option for rigid
fixation in amputations. I-O wires can be technically demand­
ing to perform, but offer the advantage of rigid fixation and
the ability to correct for any rotational deformity prior to final
tightening of the wires. Three sets of wires, two longitudinal
and one radial ulnar, give as much rigidity as a fixation plate.
The exposure granted by the amputation allows easier access
to the bone for I-O wire placement. The ends of the wires
should be turned in to the fracture site to add additional
strength to the configuration and to avoid impingement on
the tendons.20 Ninety-ninety-wire bone fixation has a low
nonunion rate and provides secure compression of the frac­
tures.17,19,21,22 Bioabsorbable poly-DL lactic acid rods have been
introduced for rapid intermedullary fixation of phalangeal
replantations . A series of 9 replanted digits show initial
strength to tolerated early motion protocols and good to excel­
lent results in all cases.23
Clinical tips
Interosseous wire fixation is a quick and secure method of
bony fixation for digital replantations. While the amputated part
is on the back table, two tunnels – one radial to ulnar and one
dorsal to volar – are made with a 21-gauge hollow needle or
K-wire. The 21-gauge needle allows a 26-gauge wire to pass
through the tunnel easily.
Clinical tips
In tendon repair, performing the back wall of the epitendinous
suture first allows better approximation of the core suture. The
tendon is held securely with a 25-gauge needle to the soft
tissue, and then a running locking 6-0 polypropylene suture is
used for the back wall. The core suture is placed without any
tendon “bunching”. The running polypropylene suture is then
continued on the volar aspect of the tendon.
Plate fixation offers secure fixation for fractures. Standard
miniplates, while offering secure fixation and compression,
have the disadvantage of requiring significant periosteal
stripping and more extensive soft-tissue exposure. Small “H”
plates offer similar fixation strength with less exposure and
periosteal stripping. One disadvantage of plates is the lack of
adjustability. If distinct registration points are not present on
the bone, improper fixation can lead to rotational deformities.
The increased dissection and periosteal stripping may lead to
increased scarring and tendon adhesions. Generally plate fixa­
tion is more time-consuming than other methods of fixation.
A low-profile H-plate may allow less dissection; however, this
Controversy exists among surgeons as to whether both the
FDS and FDP tendons should be repaired in zone 2 replanta­
tions.24 Waikakul et al., in their series of 1018 replantations,
found patients who had a sharp guillotine zone 2 amputation
had good to acceptable results in terms of range of motion
with repair of both tendons. In crush, degloving, or avulsion
injuries, repairing only the FDP tendon or both tendons gave
poor results. Repairing the FDP stump to the proximal super­
ficialis tendon gave the best result, which was statistically
significant.25 Ross et al. prospected and evaluated tendon
function after replantation using a modified Kessler repair
with 4-0 polyester suture. The average total active motion was
129°. Patients with zone 1 and 5 injuries had a significantly
better active range of motion. Replantation after avulsion
injury resulted in lower range of motion compared to sharp
injuries. When they evaluated patients who had one tendon

253
Treatment/surgical technique
not have a strong pulsatile flow, the vessel is cut back and
irrigated until pulsatile flow is obtained. It is preferable to
repair both digital arteries, if possible. Zumiotti et al. found
that when two arteries and more than one vein were anasto­
mosed, the success rate was highest.28 In the index finger, long
finger, and thumb, the ulnar digital artery is usually larger
and should be preferentially repaired. In the small finger, the
radial digital artery is usually of larger diameter. Adequate
exposure to the blood vessels is essential. Skin hooks attached
to rubber bands may facilitate artery exposure. If this is not
adequate, additional incisions should be made to aid expo­
sure. In the proximal and middle phalanx, zigzag incisions are
preferable, while in distal replantations a midaxial incision is
preferred.14
If after proper debridement the gap precludes primary
repair, a vein graft should be used. Theoretically an increased
potential of thrombosis exists when vein grafts are used since
there are two microvascular anastomoses. However, clinical
studies do not support an increased incidence of thrombosis.
When vein grafts are utilized, venous discrepancies may be
managed by a variety of techniques, including fish mouth
incisions, sleeve anastomosis, or end-to-side coupling or step-
down vein grafts.29 Vein grafts can be harvested from the
palmar side of the thenar eminence of the hand, the distal
volar forearm, or the dorsal foot (Fig. 11.7). For arterial recon­
struction in the finger, the author prefers the dorsal foot veins
because they are thicker-walled and better match the digital
artery. For more proximal amputations the greater or lesser
saphenous veins can be harvested. When there is a large
discrepancy between the distal and proximal vessels, an
repaired versus those with a repair of both tendons, the
average motion for fingers with both tendons repaired was
136° compared to 111° for fingers with only the FDP tendon
repaired. This was statistically significant. Of all factors in the
surgeon’s control, the most important was initiating early
therapy. Early therapy increased both active and passive
range of motion and did not significantly increase the inci­
dence of tendon rupture.24
Artery repair
A patent arterial repair is essential to successful replantation.
The red line sign, or ribbon sign, is an indication of torsion or
stretch of the vessel and suggests a relative contraindication
to replantation.26 Arteries should be debrided to beyond the
zone of injury. The lumen of the artery should be explored
to make certain there are no intimal flaps which can cause
thrombosis. The arteries should be examined and cut back,
as necessary, prior to inflation of the tourniquet. The vessel
is flushed with a dilute heparin solution at a concentration of
100 units/mL. The heparinized saline solution can be placed
in a pressure bag to assure a constant, accurate irrigation
pressure (Fig. 11.6). Manual irrigation with a standard 3-cc
syringe may produce excessive irrigation pressure. Yan et al.
found that irrigation pressures under 80 mmHg are as effec­
tive as higher pressures at removing clots and did not damage
the vessel endothelium.27 After irrigation, the vascular clamp
is released to visualize the arterial flow. If the artery does
Fig. 11.6  (A) Pressure bag irrigation with pharmacy-prepared heparin irrigation
solution. (B) Irrigation hand control.
A
B
Fig. 11.7  The dorsum of the foot provides a source of potential vein grafts. The
branching pattern allows revascularization of several vessels.
Dorsal venous arch of foot

254
SECTION II
CHAPTER 11 • Replantation and revascularization
exploration of the amputated part, release of the arterial
clamp will allow visualization of the dorsal veins as they fill
with blood; but the resulting bleeding may obscure the clean
microvascular field.
A functional venous anastomoses is important to overall
success rate in replantation; however, the more distal the
amputation, the less this factor comes into play. Distal ampu­
tations can be successfully replanted even without a venous
anastomosis as long as some method of venous egress is
assured.34–37 In a series of 120 replantations distal to the FDS
insertion, a 91.7% success rate was achieved when two veins
were repaired. This success rate dropped to 84.4% when only
one vein was repaired, but with no vein anastomosis, a 40%
success rate was still achieved.38 The Chang Gung hospital
group from Taiwan reviewed 30 fingertip amputations per­
formed without a venous anastomosis. 90% of the digits
survived, however the average transfusion rate was 4.0 units
of blood; and the average length of time needed to maintain
external bleeding was 6.8 days.39 Various methods of venous
outflow other than direct vein coaptation have been described.
These include use of leeches (Hirudo medicinal), arterial
venous anastomoses, nail plate removal, heparin rubs,
subcutaneous heparin instillation, nail ablation, and dermal
implantation.34,35,39–41
Nerve repair
Sensibility is even more important than range of motion.14
Primary repair of the nerve can be performed in most clean
guillotine-type injuries. Bone shortening facilitates a primary
nerve repair.42 Patient factors influencing nerve recovery are
age, level of injury, and mechanism of injury. Surgeon-
controllable factors include digital blood flow and postopera­
tive sensory re-education. Repair of more than one artery
improves nerve recovery.43 If there is any question of the
quality of the nerve it should be debrided to identify a good
fascicular pattern. Nerve grafts or conduits can be used for
small nerve defects. Conduits are constructed utilizing a
variety of materials, including segments of vein, collagen,
silicone, Gore-Tex, polyester, and polyglycolide.44 Conduits
are best limited to defects of less than 2 cm in length.45 Some
conduits are extremely rigid and may impede motion if placed
over a joint or are at risk for erosion of overlying skin. Con­
duits are best used for sensory nerve defects; for motor nerves
standard nerve autografts are preferred. Nerve grafts can be
harvested from a variety of donor sites. In the upper extremity
these include the posterior interosseous or median ante­
brachial cutaneous nerves. The sural nerve is the standard
donor graft in the lower extremity. The fascicles of the sural
nerve match the digital nerve topology well. After successful
nerve repair, replanted fingers typically achieve protective
sensation with a two-point discrimination under 15 mm, and
the majority will achieve static two-point discrimination less
than 12 mm.46
Skin closure
Skin closure should be performed with special precautions
not to constrict arterial inflow or venous outflow. If there is
any concern a skin graft should be utilized. A small graft over
the midlateral incision covering the vascular pedicle is far
safer than a tight closure. If there is a deficit of skin and an
Fig. 11.8  Ligation of branches of the dorsal subcutaneous veins can provide
additional length for primary venous repair.
arterial graft should be considered. Sources of grafts include
the superficial or deep inferior epigastric arteries, the descend­
ing branch of the lateral femoral circumflex artery and the
subscapular artery system. Shuck and Masden reviewed the
use of arterial grafts; no long term outcome studies have been
published but intermediate outcome studies show patencies
up to 100%.30
Lee et al. prospectively followed 75 finger replantations
with Doppler examinations for 60 days postoperatively. In
37% of successful replantations Doppler signals, which were
initially present, were not heard on postoperative day 15. This
rate was five times greater for crush injuries than for guillotine
amputation. Their replantation center now routinely admin­
isters anticoagulants for 2 weeks in all replantations, regard­
less of the degree of tissue damage. They postulate that by
continuing anticoagulation, reduced morbidity such as cold
intolerance and sensory abnormalities may be achieved.31
Vein repair
Repair of the veins is one of the most crucial steps in replanta­
tion. The number of veins repaired correlates well with success
in digital replantation.32,33 In a devascularized extremity or
digit, a small skin bridge of only a few millimeters can allow
adequate venous outflow. Dorsal veins can be found by
identifying bruising or small hematomas just under the skin
(Fig. 11.8). The veins are usually repaired after repair of one
or both of the digital arteries. If ischemia time is prolonged,
the vein can be repaired after the first digital artery and then
the hand supinated to repair a second digital artery. Vein
grafts to bridge segments of venous loss are used as required.
Additional length on dorsal veins may be achieved by divid­
ing the interconnecting branches between the veins. At least
one vein should be repaired prior to release of the arterial
clamp. If a vein could not be identified on the initial

255
Treatment/surgical technique
the patient often avoids use of this finger.19 Replantation of
the distal amputation of the ring and little finger is strongly
advocated because of their need for full length in order to get
optimal hand closure and good grip function, especially when
torque needs to be applied.14
A functional hand can be achieved with an opposable
thumb, a satisfactory first webspace, a stable wrist, and at
least two fingers. Heterotrophic replantation can maximize
hand function. If the thumb and index finger are amputated
and the distal thumb is not replantable, replantation of the
index finger to the thumb position, a microvascular polliciza­
tion, should be performed.50 Forty to 50% of hand function is
accounted for by the thumb. Restoration of at least two fingers
is most important in achieving hook grasp, power grasp, and
precision handling.51 The value of the ulnar digits to hand
function, especially power grip, is underappreciated. Priority
should be given to restoration of the ulnar digits after salvage
of the thumb.
A functional MCP joint is a significant priority for deter­
mining digital reconstruction. Digits with injuries through the
MCP joint should be considered for heterotrophic transfer to
another ray with a functional MCP joint. “Spare-parts surgery”
should be considered in any multidigit amputation. If a digit
is non-replantable, skin can be harvested for use as a skin
graft. Tendon, nerves, and vessels can also be used for grafts.
Proximal amputations
Amputations at the level of the palm and proximal forearm
offer unique challenges and opportunities. The functional
deficit of amputations at this level is devastating and replanta­
tion and revascularization offer the opportunity for meaning­
ful function of the hand. At this level, the vessels are larger
and the procedure is technically easier. Because of the pres­
ence of muscle in the amputated part, timing of revasculariza­
tion is critical. Revascularization of wrist and more proximal
amputations should be performed before 12 hours of cold
ischemia or 6 hours of warm ischemia.3 Rapid revasculariza­
tion is necessary to preserve muscle viability and prevent
myoglobinuria. For injuries at the level of the distal forearm
and hand, preservation of the intrinsic muscles is important
to hand function but unlikely to result in myoglobinuria if
critical ischemia time is exceeded. The risk of reperfusion
injury is low due to their small mass; if function of the muscle
is to be preserved, revascularization should be expediently
performed (Fig. 11.12). If the injury is at the level of the palmar
arch or distal, an arterial graft or reversed “Y” vein graft,
usually from the dorsal foot, can be harvested to revascularize
multiple common digital arteries (Fig. 11.13).
Injuries in the distal forearm and wrist have excellent
functional results after replantation and every effort should
be made to salvage these injuries.52 Bone fixation should be
performed first, shortening of the bones at this level provides
quicker fixation and decreased need for vein and nerve grafts,
and yields almost no functional loss. If ischemia time is over
4 hours, consideration should be given to temporary arterial
shunting prior to bone fixation. A carotid shunt or an inter­
vascular catheter is used (Fig. 11.14). Only one artery and one
vein is required to revascularize the extremity successfully.
After opening the arterial clamp, bleeding from multiple
distal veins will require ligation or clamping with microvas­
cular clamps. The risk of exsanguination with arterial and
arterial defect requiring a vein graft, consideration should be
given to using a venous flow-through flap (vascularized by
the digital artery).47 The flap is harvested from the distal
ipsilateral volar wrist or forearm. A vein of sufficient size is
identified and a skin flap slightly larger than the skin defect
is designed, centered over the vein. The flap should not extend
more than 1.5 cm from the vein. The vein is reversed and used
to bridge the arterial defect and the skin island covers the skin
defect.
Special circumstances
Thumb replantation
Thumb replantation and revascularization deserve special
consideration (Fig. 11.9). The ulnar digital artery of the thumb
is usually of larger caliber and is preferentially repaired. The
ulnar digital artery of the thumb, however, is difficult to
access under the microscope. Even with the use of a lead
hand, exposure is a challenge. It is the rare revascularization
where a direct arterial repair is possible. The use of an inter­
positional vein graft from the radial artery to the snuff box
simplifies revascularization in thumb replantation17,19 (Fig.
11.10). An 8–10-cm vein graft is harvested, usually from the
dorsal foot or saphenous vein. The graft is reversed and irri­
gated. The distal anastomosis of the vein graft is performed
on the back table before bone and tendon fixation. Performing
the anastomosis on the back table allows easy positioning of
the amputated thumb. The distal aspect of bone fixation
should be performed prior to the distal revascularization.
Care should be taken when doing the proximal bone fixation,
as the vein graft can easily become wrapped up in the power
equipment. In the thumb pulp sizable palmar veins can
usually be identified superficial to the arteries and these
should be identified.48
Rosson et al. compared the functional outcome of thumb
replantation versus great toe transplantation. In 384 thumb
amputations over a 20-year period, an 85% success rate was
obtained in thumb replantations. Complications occurred in
29% of cases. The average replant patient underwent four
additional operations. Patients achieved 30% diminished
protective sensation and light touch as compared to the
normal contralateral thumb. In great toe to thumb transplan­
tations the surgical success rate was 93%, but 43% of patients
had complications. The motion in the interphalangeal joint
was better in toe transplants than in the replanted thumb;
sensation was comparable in both groups.49
Multiple digits
Multiple digit replantations are a significant surgical chal­
lenge and should be performed in a replantation center with
significant experience in this type of surgery (Fig. 11.11). The
time commitment is considerable: 3–4 hours should be allowed
for each amputated finger. There may be a time-saving benefit
from performing all the bony and tendon work first, then
bringing in the microscope to do the microvascular repairs.
Although total surgical time may be reduced, the warm
ischemia time for each digit is increased. As many digits as
possible are replanted. The finger with the best chance of
function is repaired first. An exception to this rule is the index
finger. If the index finger is stiff or has decreased sensation,

256
SECTION II
CHAPTER 11 • Replantation and revascularization
Fig. 11.9  (A) A 22-year-old college student with a thumb
avulsion amputation. The arteries were avulsed at the level
of the interphalangeal joint. The digital nerves were avulsed
in the carpal tunnel. (B) The amputated thumb with
avulsion of the flexors and extensor tendons from the
muscle origin. (C) Radiograph of hand. (D) The
subscapular arterial tree provides an accessible source for
a stepdown arterial graft. (E) Early postoperative photo of
successful revascularization. The patient developed
protective sensation and useful opposition function of the
thumb.
A
B
C
D
Axillary artery
Subscapular artery
Circumflex scapular artery
Thoracodorsal artery (latissimus branch)
Thoracodorsal artery (serratus branch)
E

257
Treatment/surgical technique
venous shunts is significant. Considerable bleeding can occur
and the patient should have matched blood available. If
shunting is utilized, the vein should be allowed to drain prior
to connecting it to the proximal circulation.53
In patients with a multiple-level mangled extremity, the
goal of treatment is to restore prehension and sensibility. A
sensate partial hand is quite often better than a prosthesis16
(Fig. 11.15). However patients with crush or avulsion injuries
may be poor candidates for replantation. Adequate debride­
ment is the critical first step in reconstruction.54 Vein grafts
should be liberally used to avoid injured segments of artery
and vein.29 With major limb replantation, fasciotomies are
usually required. Godina emphasized that, upon completion
of aggressive debridement, the wound should resemble a
tumor resection.55 Nonviable tissue with bacterial contamina­
tion is associated with loss of salvaged limb. The sequence of
repairs for forearm replantation is bony fixation followed by
arterial and venous repair. The vena comitantes should be
repaired primarily; if this is not successful, then dorsal or
antecubital veins are utilized. Nerves should be repaired after
the arteries with the possible exception of the ulnar nerve,
which lies deep to the ulnar artery.54
Amputations at the proximal forearm present a difficult
clinical decision process. Functional results are generally
worse at this level than in more distal amputations. Because
of the loss of muscle tissue, poor motor nerve recovery, loss
of intrinsic function and postoperative scarring, results after
replantation at this level are disappointing.
Amputations proximal to the elbow should be considered,
if only to salvage a functional elbow joint. Recovery of distal
function is poor. The greater muscle mass in a proximal limb
Fig. 11.10  If a primary anastomosis cannot be performed, the gap can be bridged
with a reversed vein graft or transposition from an adjacent proper digital artery.
Vein graft
Vein graft
Vessel graft
(same finger)
Radial artery
Fig. 11.11  (A) Four-finger amputation in a 26-year-old smoker. (B) Radiographs demonstrate amputation distal to the flexor digitorum superficialis insertion.
(C) Radiographs of the amputated digits. (D) Immediately postoperative, after four-finger replantation. Small skin grafts were harvested to cover dorsal veins.
(E) Radiographs demonstrate secure fixation with 90-90 I-O wire technique. (F) Six months postoperatively. The replantation was lost on the small finger despite salvage
attempts. (G) Excellent function of the hand was achieved despite minimum motion at the distal interphalangeal joints.
A
B
C
D
E
F
G

258
SECTION II
CHAPTER 11 • Replantation and revascularization
success and functional and aesthetic results with replanta­
tions (Fig. 11.16). These distal anastomoses can challenge the
surgeon’s microvascular skills (Fig. 11.17). In distal crush
injuries it is often difficult to get the proper size match of the
distal artery. Transfer of a digital artery from an adjacent digit
may be utilized, especially in children where the size match
is critical.57 A step-down arterial graft should be utilized if a
vein graft is required and the reversed vein segment has too
great of a size mismatch. A method of temporary intravascular
stenting using 4-0 to 6-0 (0.199–0.07 mm) nylon monofilament
stents for very-small-vessel anastomoses has been advocated
for distal fingertip amputations; 11-0 or 12-0 sutures are placed
in the vessel around the stent, which is removed prior to the
last two sutures being placed. Vessels as small as 0.15 mm
have been anastomosed using this technique. Microvascular
survival of 85% has been reported.58
amputation is more susceptible to ischemia time. Metabolic
breakdown products from the muscles entering the systemic
circulation after revascularization can result in reperfusion
syndrome. Death may occur in patients with above-elbow
replants who develop reperfusion syndrome.56 A functional
elbow and below-elbow prosthesis may offer the patient the
best result, but many patients are reluctant to undergo a revi­
sion amputation after a successful replantation despite having
poor function.
Distal amputations
Replantation distal to the distal interphalangeal (DIP) joint
was once considered as folly. Patients with amputation revi­
sions at this level generally did very well functionally. Recent
experience with distal replantations now shows both excellent
Fig. 11.12  (A) Miter saw injury in a 26-year-old carpenter; all fingers were
avascular. (B) Preoperative radiograph. (C) Radiograph demonstrating fixation with
I-O wires and crossed K-wires. (D) Postoperative extension. (E) Postoperative flexion.
A
B
C
D
E

259
Treatment/surgical technique
outflow is medicinal leeches. Leeches effectively remove
congested blood and detach when engorged. Additionally,
they inject hirudin, a potent anticoagulant which results in
bleeding long after the leech detaches.
The leech is applied to the congested part and allowed to
attach. If the arterial blood supply is poor, the leech may
detach prematurely and attempt to wander to another site,
this usually implies that the initial diagnosis of venous con­
gestion was wrong. The patient’s dressing should be fabricated
to allow the leech to attach only to the congested part. Leeches
While arteries in very distal replants can be difficult to
repair, veins may be a nightmare. The surgeon should be
familiar with the venous anatomy of the digits and the thumb.
Repairing volar veins may be preferable in these distal inju­
ries, since they are easier to dissect than the dorsal veins,
which lie in a dense fibrous tissue.59 Occasionally suitable
veins for repair are not available; a successful outcome can
still be obtained in these cases if there is an effective means of
ensuring temporary venous outflow while the collateral cir­
culation develops. The primary method of temporary venous
Fig. 11.13  Branches of the subscapular artery are utilized
for revascularization of multiple distal vessels.
Subscapular artery
Circumflex scapular artery
Thoracodorsal artery
(latissimus dorsi branch)
Thoracodorsal artery
(serratus branch)
Fig. 11.14  Silicone temporary vascular stent is used in
major limb replantation prior to bone fixation if ischemia
time is prolonged.
“Vascular keeper”
Shunt
Median nerve