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Home / Hand Soft Tissue / Flexor tendon repair and safe immobilisation
Hand Soft Tissue

Flexor tendon repair and safe immobilisation

Flexor tendon laceration repair, protected mobilisation, safe hand position and orthosis design

34 questions 7 source pages 1 fact-check flags

Images appear with the first question taken from each source page — tap a question to open it.

34 questions
Q1Which hand soft-tissue conditions are covered in this lecture?▸
  • Contractures and masses: Dupuytren contracture (palmar fascial cord causing progressive finger flexion deformity), De Quervain, wrist ganglion
  • Tendon problems: flexor tendon injury, Quadriga effect
  • Pain syndrome: CRPS
Q2Which nerve injuries are covered under hand soft tissue?▸
  • Median, ulnar and radial nerve injuries
  • Brachial plexus injuries
Q3Which infection, emergency and reconstructive topics are covered?▸
  • Hand infection; finger tip injury
  • Compartment release
  • Replantation
  • Reconstruction ladder
  • Hand splint for rehabilitation
Q4How would you describe this clinical photo and what is your differential?▸
  • Red and swollen right hand after 6 weeks of casting for a distal radius fracture
  • Ddx: complex regional pain syndrome (CRPS)
  • Also consider infection and DVT
Q5What is complex regional pain syndrome (CRPS)?▸
  • Sustained sympathetic activity in a perpetuated reflex arc, characterised by pain out of proportion to physical findings
  • Previously known as RSD (reflex sympathetic dystrophy)
Q6What are the Budapest criteria for diagnosing CRPS?▸
  • Exclude other diagnoses
  • Continuing pain disproportionate to any inciting event
  • >=1 symptom in >=3 categories, or >=1 sign in >=2 categories
  • Categories: sensory (hyperaesthesia/allodynia), vasomotor (temperature/colour asymmetry), oedema/sweating (asymmetry, hyperhidrosis), motor/trophic (weakness, tremor, trophic hair/skin/nail changes)
Q7What is the differential diagnosis of CRPS?▸
  • Neuropathic: post-injury neuralgia
  • Inflammatory: RA/SLE, soft tissue inflammation
  • Vascular: PVD
  • Psychiatric: malingering, somatization
Q8How is CRPS classified and staged?▸
  • International association for the study of pain classification - type 1: without demonstrable nerve lesion; type 2: identifiable nerve damage
  • Lankford stage: acute (<3 months) - inflammation (pain, red, sweaty, swollen), XR normal
  • Dystrophic (3-12 months): worse pain, cyanosis, dry skin
  • Atrophic (>12 months): decreased pain, stiffness
Q9What investigations are used in CRPS?▸
  • Bone scan has high negative predictive value
  • Positive scan phase pattern: 2 min arteriogram, 5-10 min blood pool (cellulitis, synovitis), 2-3 hr bone phase
Q10How do you prevent CRPS after a distal radius fracture?▸
  • Vitamin C 500mg daily x 50 days in distal radius fractures treated conservatively
  • Avoid prolonged immobilisation
Q11What is the treatment of CRPS?▸
  • Prevention: vitamin C 500mg daily x 50 days in distal radius fractures treated conservatively; avoid prolonged immobilisation
  • Refer pain specialist; aim symptom control and improve ROM
  • Conservative: physiotherapy (tactile discrimination training, contrast bath, stress loading exercise, TENS), medication (NSAID, alpha blocker, CCB, antidepressant, GABA agonist)
  • Operative: surgical sympathectomy (type 1), surgical decompression (type 2)
Q12What is the presentation and differential diagnosis after a neglected flexor tendon laceration?▸
  • Failed flexion over DIPJ/PIPJ, wound over volar side of MCPJ; suspected neglected FDP and FDS injury
  • Ddx for decreased ROM: adhesion, re-rupture, joint contracture, bowstringing, triggering, quadriga effect
Q13What history is important in a neglected flexor tendon injury?▸
  • Mechanism of injury
  • Timing
  • Occupation
  • PMHx
  • Smoking
Q14How do you assess a neglected flexor tendon injury?▸
  • Supple skin; full passive ROM and stable joint; Sensate digit. Adequate vascularity
  • Check for palmaris longus; test individual FDS and FDP function
  • XR for fracture; USG for degree of retraction - >1cm gap cannot go for primary repair
Q15How is an isolated FDS or FDP injury managed?▸
  • Isolated FDS: conservative
  • Isolated FDP options: DIPJ fusion, flexor reconstruction, FDP stump tenodesis to FDS (or MP neck), tendon transfer for non-functioning motor unit
  • If both involved, choose one as donor: FDS better independent motion but weaker (60% of FDP strength); FDP less independent motion but stronger
Q16How do you decide between one-stage and two-stage flexor reconstruction?▸
  • Intraop decision after debriding scarred ends: assess gap, tendon quality, proximal stump excursion
  • One stage if good pulley, good skin, good joint, good patient
  • If staged, graft PL; Hunter-Salisbury (suture stump and distal to rod to induce sheath; anastomosis at DP base and zone 3 or 5 - zone 3 preferred to preserve lumbrical, zone 5 fewer adhesions)
  • Paneva-Hollovich: suture FDP and FDS, rod induces pseudosheath, only one anastomosis in second stage; pulley with belt loop (PL) or FDS tail
Q17How do you choose between graft and tendon transfer?▸
  • How to compare and contrast graft vs tendon transfer? Decision based on a few factors, has to be individualized
  • Individualise by number of tendons involved and chronicity
  • Graft has 2 healing sites but uses native muscle; transfer has 1 healing site but donor muscle downgrades one motor grade
  • Graft uses native muscle; transfer uses a donor motor unit
Q18How does proximal stump excursion guide graft versus transfer?▸
  • >2cm: graft
  • <1cm: transfer
  • 1-2cm: controversial
Q19When is the timing for tendon transfer?▸
  • When tissue equilibrium has been achieved: bone stability, joint supple, soft tissue envelope satisfactory
Q20What are the prerequisites of tendon transfer?▸
  • Patient: compliance, disease non-progressive
  • Donor muscle: expendable, adequate strength (proportional to cross-section), expect one grade loss, synergistic
  • Donor tendon: adequate excursion (Smith 357 rule: 3cm wrist, 5cm finger extensor, 7cm finger flexor), normal tension (actually want more), same line of pull, one tendon one function
  • Recipient: tissue equilibrium
Q21What term is associated with the quadriga effect on this section?▸
  • Lumbrical plus
Q22Explain the quadriga effect and lumbrical plus.▸
  • Not covered in the speaker notes beyond the term lumbrical plus
Q23What is this splint and how does it work?▸
  • Dynamic controlled passive movement splint for flexor tendon repair rehab - Kleinert splint
  • Blocks MCPJ extension; string and pulley system attached to rubber band and injured finger allows passive flexion and active extension
  • Wrist 30deg flexion, MCPJ 30deg flexion; low excursion low force program
  • Kept 4-6 weeks postop; at night rubber band released and IPJ kept in extension to prevent flexion contracture
Q24What other flexor tendon rehab protocols do you know?▸
  • Controlled passive: Kleinert / Duran / Strickland
  • Early active: Belfast
Q25What is the rationale of a dynamic splint?▸
  • Prevent extrinsic healing which causes scar formation
  • Encourage intrinsic tendon healing which aligns collagen fibres -> stronger tendon, more excursion, fewer adhesions
Q26How do you choose the flexor rehab protocol?▸
  • Patient factor: compliance (non-cooperative/children -> static splint)
  • Injury factor: zone of injury (zone 2 needs dynamic splint to prevent adhesion); multiple/bilateral finger injury -> Kleinert instead of Duran
  • Surgery factor: repair strength
Q27What are the practical points about the Kleinert splint used in the centre?▸
  • Difficult to instruct patient for active movement, but low re-rupture rate + good range
  • During active extension there is reciprocal flexor relaxation (no co-contraction/active tension)
  • 3-4mm motion is adequate to prevent adhesions
Q28What is the position of safe immobilisation of the hand?▸
  • Wrist 30deg extension, MCPJ 70-90deg flexion, IPJ extended
Q29Why are the MCPJ flexed but IPJ extended in the safe position?▸
  • MC head is cam shaped (ellipsoid joint) with collaterals tight in flexion - maintains the collateral (proper) ligament at maximal length
  • IPJ hinged like, collaterals tight in extension, flexor stronger than extensor - maintains the volar plate at maximal length
  • Goal: tighten collaterals in MCPJ/PIPJ and maintain volar plate length
Q30Why is the wrist held in 30deg extension in the safe position?▸
  • Wrist 30deg extension is functional as flexors are stronger than extensors
Q31What is the purpose of an upper limb orthosis / outrigger splint?▸
  • Promote function
  • Immobilise to promote healing and prevent deformity
  • Position the hand weakened by weakness
  • Correct an existing deformity
Q32How do you approach a patient with wrist drop?▸
  • Confirm wrist drop (not joint/bony problem)
  • Rule out systemic problem (CVA, MND)
  • Localise the pathology
Q33What history and examination findings are relevant in wrist drop?▸
  • Hx: onset/progression, sensory deficit, closed/open injury, previous OT, rule out other nerve root involvement
  • Inspect: posture, wasting, scar, radial deviation of wrist
  • Palpate along radial nerve and sensation; passive wrist range and all radial-innervated muscles; Tinel
  • Examine shoulder and C spine
Q34What is the management of radial nerve palsy / wrist drop?▸
  • Dynamic splint, NCT (nerve conduction test)
  • Jones tendon transfer: PT to ECRB, PL to EPL, FCU to EDC
  • Brand's transfer (modification of Jones): PL, PT, FCR (not FCU, to maintain dart-throwing motion of wrist)

Fact check

Prevention: vitamin C 500mg daily for 50 days in distal radius fractures treated conservatively — contested — The Zollinger RCT and a 2017 meta-analysis support 500mg x 50 days, but a 2015 meta-analysis found no significant reduction in CRPS (RR 0.45, 95% CI 0.18-1.13) and graded the evidence low quality — (medium confidence) — source
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