Principles

Penetrating trauma to the dorsum of the hand needs to be examined carefully for any loss of the neurovascular status or motor/tendon function. The wound should be anesthetized and explored to visualize the potentially involved tendon; the wound should be extended, if necessary, to understand the personality of the specific injury (Fig. 189-3). When a tendon is completely transected, the cut ends can retract a considerable distance. Because a partial tendon laceration might appear to have full function on examination, the wound must be evaluated judiciously. Unrepaired partial tendon lacerations can result in delayed rupture 1 to several days after the initial injury. The entire tendon complex must be observed throughout the entire arc of motion at the injury location and function compared with that of the unaffected same finger on the opposite hand. Most practitioners believe a repair is warranted if 50% or more cross-sectional damage has occurred. After closure, a tendon repair must have healthy padded skin above it for viability, or tissue grafting will be necessary. Wounds older than 6 to 8 hours need aggressive cleansing with strong consideration toward leaving the wound open for a later staged irrigation or débridement with subsequent closure. During this interval, exposed bone, joint, and tendon tissue should be loosely covered with native tissue or a damp sterile gauze followed by a bulky dressing and an anterior-posterior splint, extending from fingertip to forearm. Tendon repair may be delayed up to 7 days.

Figure 189-3 Exploration of an extensor tendon injury over the metacarpophalangeal joint with wound extension for appropriate visualization.

(Courtesy of John Lubahn, MD.)

A repaired tendon develops a fibroblastic bulbous connection during the first 2 weeks. Tendon collagen usually does not begin to form until the third week. At the end of the fourth week, swelling and vascularity will decrease. Once the junction becomes strong, the tendon can tolerate active gliding; therefore, physical therapy and rehabilitation can be initiated. Knowledge of appropriate splinting and necessary therapy is essential when caring for these injuries. Repaired tendons usually are immobilized to promote healing and to prevent tendon rupture. After hand extensor tendon repair, the splint typically can be placed on the dorsal surface from the forearm to the fingertips to protect and prevent active extension. The digits and wrist may be slightly flexed within the tolerances of the splint. These joints must be protected against flexion when changing dressings or splints. After a 3-week period of immobilization, depending on the particular circumstances, passive motion can generally be initiated under the guidance of a skilled hand therapist. Reasonable strength may return to this repaired tendon as early as 6 weeks after the injury, again depending on the patient’s reliability and health status (e.g., neurologic status, tobacco use, metabolic and rheumatologic issues). Protected, nonloaded motion with a dynamic splint under the supervision of a hand therapist is increasingly chosen for postoperative care.

The vast majority of flexor tendon injuries should be treated by a clinician trained to repair these injuries in an appropriate surgical suite. In particular, flexor tendon injuries located in “no-man’s land” (between the proximal palmar crease and the proximal interphalangeal joint) are significantly challenging. Results of tendon repair are consistently better when fixed primarily (within 7 days) rather than secondarily (after 7 days or delayed). Familiarity with the sources referenced is encouraged if managing tendon injuries (Baratz and colleagues, 2005; Hutson and Rovinsky, 2004; Thompson and Peimer, 2001; Wright, 2003).

Contraindications

Equipment

• 27-gauge, -inch needle (small-gauge needles are preferred to administer anesthesia)

• Additional 27-gauge, -inch needles (useful to pierce and stabilize tendon end; optional)

• Sterile pack containing -inch needle holder; curved dissecting scissors; one or more mosquito hemostats; suture scissors; Adson forceps with and without teeth; skin hooks; small self-retaining retractor (e.g., Alm, Holzheimer, Weitlaner)

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