How to perform a extensor tendon repair in the hand area
Source
Surgeon:
Matti Mustaniemi (hand surgeon)
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Summary
Focus: Durable repair of a lacerated or severed extensor tendon in the hand area.
Key elements: Adequate exposure, peripheral and core suturing, testing tendon function through range of motion, wound closure, immobilization, and awareness of pitfalls and complications.
Indications and Clinical Context
General
Medical expert: Matti Mustaniemi, hand surgeon
Name of Procedure: Extensor tendon repair in the hand area
Goal of Operation
Durable extensor tendon repair
Problem
Laceration or severing of an extensor tendon
Diagnosis
Injury of extensor muscles and tendons of other finger at wrist and hand level (ICD-10: S66.3)
Short Pathophysiological Description
Injury to tendons of the dorsal hand or finger causes significant impairment of finger extension. Tendon injuries may cause permanent stiffness and articular malposition. There may also be avulsions of tendons from bone, including terminal band avulsions and central slip avulsions. However, avulsions will not be discussed here.
Key Anatomical Structures
Extensor tendon structure in different parts of the hand
Tendon and paratenon
Periosteum
Step-by-Step Technique
Preparations and Anesthesia
Nerve block anesthesia or, for example, brachial plexus blockade can be used.
Tourniquet if possible, using a rubber band or antebrachial/humeral tourniquet.
Use the original wound from the injury itself to create more visibility to the injured tendon area.
Expose the injured tendon area adequately and separate the tendon from the paratenon.
The Peripheral Suture
Use 6-0 non-absorbable sutures, taking approximately 2 mm bites from opposite ends of the lacerated tendon.
Continuous suture is generally used.
The objective is to bring the ends of the lacerated tendon neatly together; bunching up the tendon ends gently is advised.
Try to avoid “manipulating” the tendon with instruments, as it is easily friable. Also make sure not to catch paratenon or periosteum together with the tendon suture.
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The Core Suture
This suture should be stronger, for example 3-0 TiCron or a similar braided suture.
Stronger core suture should be used proximally to the MCP level. Distally, a more superficial technique is sufficient.
Take the bites approximately 10 mm from the tendon laceration. Use continuous or simple interrupted sutures.
Tighten the suture carefully: gentle compression and slight bunching up are allowed.
Use enough knots. More than 4 terminal knots is advised to prevent the suture from unravelling. The knots can be within or outside the tendon.
Ensuring the Outcome
Check that the tendon is not sutured onto underlying structures.
Test the suturing and ensure the tendon function. The suture must hold during the whole range of motion. In a wide-awake situation, you can ask the patient to gently move the affected finger/wrist.
If you see gapping or failure of the suturing, re-do the suturing.
Wound Closure
Skin closure alone is enough.
To prevent wound fistula, make sure no suture ends or knots remain in the wound.
Make sure the skin sutures do not adhere to the underlying structures.
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Piftalls and Complications
Pitfalls
Suturing to the Surrounding Tissues
If the tendon is accidentally sutured to the surrounding tissues, troublesome adhesions may form, preventing tendon glide and finger movement.
Excessive Tension
Suturing the tendon ends together too tightly may disrupt the flexor-extensor tissue balance and result in severe mobility problems. For example, in injuries caused by a circular saw blade with major loss of tendon, the ends cannot be joined directly and instead a tendon graft should be used.
Incorrect Immobilization
The hand should be immobilized in the SAFE position, as dorsiflexion of the wrist will help to avoid tightness proximal to the MCP joint. Extension of the IP joint helps to avoid tightness distal to the MCP joints. The MCP joint should only be extended for a very limited time, a maximum of 2–3 weeks, and avoided whenever possible.
Too early mobilization may prevent healing; see postoperative care instructions.
Disregard of Associated Injuries
Be aware there may be associated injuries caused by the trauma. Take care not to disregard injuries of the smaller sensory nerves of the dorsum of the hand.
Complications
Suture-Induced Fistulas
Non-absorbable sutures ending up in the wound may cause infection and necrosis at the tendon suture site.
Adhesions
Adhesions are fibrous tissue formations between the repaired tendon and the adjacent tissues, potentially leading to considerable functional impairment. Functional impairment may also result from accidental suturing of the tendon to the surrounding tissues; this can be avoided by careful suturing.
Rupture
The most common cause of rupture is suture failure. Make enough durable knots and ensure the end result before closing the wound.
Aftercare
General Instructions
Immobilization for 6 weeks in the SAFE position: a volar splint with the adjacent digits included. Depending on the severed site, even more than the adjacent joints may need to be immobilized.
Skin sutures are removed at 2 weeks. At this point, an individual splint may be applied in order to facilitate washing.
Guidance at 6 weeks includes instructions for step-by-step rehabilitation and scar care.
Full weight-bearing not until after 3 months.
FAQ
What is the goal of extensor tendon repair in the hand area?
The goal of the operation is durable extensor tendon repair.
What anesthesia can be used?
Nerve block anesthesia or, for example, brachial plexus blockade can be used.
How should the tendon repair be checked before wound closure?
Check that the tendon is not sutured onto underlying structures, test the suturing, and ensure tendon function. The suture must hold during the whole range of motion.
What should be done if gapping or failure of the suturing is seen?
If gapping or failure of the suturing is seen, the suturing should be re-done.
How long is immobilization used after the procedure?
Immobilization is used for 6 weeks in the SAFE position with a volar splint and the adjacent digits included.
When is full weight-bearing allowed?
Full weight-bearing is not allowed until after 3 months.
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