Extensor Tendon Injury Repair

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.

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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

Bibliography

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J Hand Ther.

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