Introduction
All lacerations to the hands or feet
must be carefully examined for underlying tendon injury. To find such
injuries, examine the patient for a functional deficit of the anatomic
part. Flexor tendon injuries of the hand require complex specialized
repairs and should be promptly referred to a surgical hand specialist.
Although many extensor tendon injuries may also require specialized
repair, extensor injuries to the dorsum of the hand (Verdan
classification zone VI) may often be treated in the office or emergency
department.
Even with normal function on finger
examination, a tendon may be partially lacerated. Unrepaired partial
tendon lacerations can result in delayed rupture 1 to 2 days after the
initial injury. Repair any tendon that is >50% transected.
If only a minimal laceration is discovered, apply a splint for 3 weeks,
followed by passive motion exercises for 2 to 3 weeks.
A tendon that angles around curves,
pulleys, or joints is surrounded by a thin tendon sheath. A lacerated
tendon within an intact sheath often will not heal. If the sheath is
absent or severed, the proximal part of the tendon will grow in an
attempt to reattach to the distal portion, often resulting in adherence
to surrounding structures. Adhesions are part of the repair process, and
they may occasionally interfere with function. Patients who are
compliant with instructions and motivated toward rehabilitation usually
have a greater chance of a good outcome after tendon repair.
View OriginalView Original
When the tendon is cut completely
through, the ends may retract a significant distance from the site of
trauma. Careful examination and extension of the incision may be
necessary to identify both ends. However, extensor tendons on the dorsum
of the hand are crosslinked and usually do not retract to the same
degree as flexor tendons. During the first 2 weeks of healing, a
repaired tendon develops a fibroblastic bulbous connection. Organized
tendon collagen usually does not begin to form until the third week. By
the end of the fourth week, swelling and vascularity markedly decrease.
After the swelling has abated and the junction becomes strong, the
tendon can fully perform its gliding motion. For tendon repairs to be
successful, the tendons must be covered with healthy skin. Skin grafting
should be performed when there is a significant area of skin avulsion or
necrosis. Tendon injuries that are complicated by tissue maceration,
contamination, or passage of more than 8 hours should be treated in the
operating room.
Uncontrolled motion of the hand during
the first 3 weeks after repair often results in rupture or attenuation
of the repair. Classically, the repaired tendons are immobilized for 1
week to prevent rupture and to promote healing. Place a plaster splint
on the palmar surface from the forearm to the fingertips. Place the
wrist in 30 degrees of extension, the metacarpophalangeal joints in 20
degrees of flexion, and the fingers in slight flexion. Keep the fingers
from flexing during splint changes. Active motion is started after 5 to
14 days to improve the final strength of the repair. Physical and
occupational therapy consultation is usually helpful.
Strong healing can be observed as
early as 6 weeks after the tendon repair. Some centers have shown that
early, limited, controlled motion using specialized orthotics may
improve outcomes (see 01412520).
Extensor tendon injuries over fingers
(Verdan classification zones I through IV) involve complex structures
and often result in poor healing with office repair. Because these
tendons lie close to the joint capsule, any complete tendon laceration
over a joint should raise the suspicion of joint capsule injury and
should be treated in the operating room. Lacerations directly over the
metacarpophalangeal joints (zone V) may be successfully repaired in the
office by skilled surgeons. Zone VI repairs are the most commonly
performed repairs by primary care physicians. Possible complications of
tendon repair include local infection, finger contracture, delayed
tendon rupture, or local adhesions. Patients with associated digital
fractures or with ragged lacerations tend to have poorer results.
Equipment
- Sterile field
- Suture material (4-0
Ethibond or 4-0 Ticron) - Lidocaine 1% plain
Indications
- Partially lacerated
extensor tendon in the dorsum of the hand - Transected extensor
tendon in the dorsum of the hand
Contraindications
- Tendon injuries
associated with tissue maceration - Tendon injuries
associated with contamination - Tendon injuries more
than 8 hours old - Extensor tendon
injuries over the dorsum of the fingers, flexor tendon injuries,
or joint involvement should be referred to hand surgeon.
The Procedure
Step 1
Examine the hand laceration
and identify the ends of the tendon. If the ends of the tendon have
retracted from the skin incision, extend the fingers to push the
tendon ends back to the incision site. Extensor tendon injuries may
be repaired by direct end to end approximation using the Kessler or
modified Bunnell technique.
Step 1 View Original Step 1 View Original
The Kessler Technique
Step 2
Begin by passing
suture in the proximal portion of the tendon and exiting through
the cut end.
Step 2 View Original Step 2 View Original
Step 3
Then, pass the
suture into the distal piece of tendon through the cut end and
exit on the same side distally.
Step 3 View Original Step 3 View Original
Step 4
Leaving an
external suture loop, a pass is then made through the substance
of the tendon.
Step 4 View Original Step 4 View Original
Step 5
Leaving another
external loop on the other side of the tendon, the suture is
then passed from the outside portion of the distal tendon and
out the cut end.
Step 5 View Original Step 5 View Original
Step 6
The suture then
enters the proximal cut end of the tendon through the cut end
and tension applied to bring the ends of the tendon
together.
Step 6 View Original Step 6 View Original
Step 7
The suture ends
can then be tied. (Note: The suture loop may also be tied to
have the knot placed between the injured portion of the
tendon).
- PITFALL: Do not over tighten. If the
tendon repair is under to much tension it will limit
flexion after it heals. - PEARL: Knot location placed dorsally
allows for easier removal if the permanent suture knot
becomes symptomatic.
Step 7 View Original Step 7 View Original
Step 8
Finish the repair
by placing a running suture connecting the tendon ends (see Running Cutaneous Suture).
Step 8 View Original Step 8 View Original
End-to-end Repair with Simple Interrupted or Horizontal Mattress
Sutures
Step 1
Begin by placing a
simple interrupted suture at one edge of the tendon so as to
close the defect (see Simple Interrupted
Suture).
- CLINICAL PEARL: Make sure to match the
ends of tendons as anatomically as possible to ease
repair and promote healing.
Step 1 View Original Step 1 View Original
Step 2
Tie the simple
interrupted suture snugly but not so tight as to cause the ends
to bulge.
- CLINICAL PEARL: Try to handle the
tendon as little as possible and with as little
compression from the forceps to minimize iatrogenic
injury.
Step 2 View Original Step 2 View Original
Step 3
Continue placing
interrupted sutures across the tendon to the opposite side.
- PEARL: This technique may also be
accomplished using interrupted sutures (see Horizontal Mattress Suture).
Step 3 View Original Step 3 View Original
Step 4
Continue placing
interrupted sutures until the laceration is completely closed
and tie off.
Step 4 View Original Step 4 View Original
Complications
- Loss of flexion and
stiffness from over tightening repair - Infection
- Rerupture of tendon
repair - Adhesions
- Stiffness
Pediatric Considerations
Pediatric patients often require
sedation until the patient is splinted to reduce noncompliance with the
procedure. Excessive motion during or immediately after the repair will
weaken or place the repair at risk of re-rupture.
Postprocedure Instructions
Splint the extremity in extension
for 3 weeks. Begin active flexion and passive extension from 3 weeks to
6 weeks after injury. Instruct the patient to avoid aggressive use of
hand and fingers for 10 to 12 weeks postinjury.
Coding Information and Supply Sources
View Large CPT Code Description 2008 Average 50th Percentile Fee Global Period 26410 Extensor tendon repair, dorsum of hand, single; primary or
secondary, each tendon $1,559.00 90 CPT is a registered trademark of the American
Medical Association.2008 average 50th Percentile Fees are provided courtesy of 2008
MMH-SI 's copyrighted Physicians ' Fees and
Coding Guide.
For suture supply sources, see Appendix
G.
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