SURGICAL EXPOSURE OF FLEXOR

TENDONS IN THE HAND

JULIAN M. BRUNER M.D., F.A.C.S.
Des Moines, Iowa, U.S.A.

THE TERMS OF reference of this lecture are that it shall be concerned

with some subject allied to plastic surgery in which the speaker has
had experience. I have chosen to discuss the surgical exposure of flexor
tendons in the hand. My experience of this subject has been acquired
in army hand centres and in practice for 25 years in the capital city of
a mid-western American state where my father began his medical and
surgical practice in 1893. Injuries of the hand occur frequently here-
in the home, in the factory, and on the farm.
Tendon repair in general has been successful for many years. Accurate
suture of the cut tendon, with appropriate splinting to avoid dehiscence
until strong union occurs, is generally followed by good results.
On the flexor side of the hand, however, such is not the case. The
reasons are anatomical and functional. At the base of the digits anld
at the wrist tight retinacula hold the flexor tendons in their course
during flexion. A second factor militating against successful repair
is the long excursion of these tendons (2-3 in (5.1-7.6 cm)), anything
short of which means disabilty of that finger. A third factor present
in the digit (but not in the wrist) is the tenuous and vulnerable blood
supply available to the flexor tendons through the slender vincula.
These three factors have conspired to make flexor tendon surgery in
the hand difficult. Recent improvements in technique, however, have
led to better results. Among these is the use of new incisions to gain
better exposure.
Primary flexor tendon repair in the distal digit, in the proximal
palm, and in the forearm is generally successful; therefore this dis-
cussion will be limited to the two retinacular regions where success is
elusive: No Man's Land at the base of the digit and the carpal tunnel
zone at the wrist.
The late Dr. William J. Mayo, whom I assisted years ago, often
stressed the importance of wide abdominal exposure to view the path-
ological anatomy and to perform the operation. Good exposure is even
Second part of the sixth Mclndoe Lecture delivered at the Royal College of Surgeons of
England on 7th December 1972 at the meeting of the British Association of Plastic Surgeons

(Ann. Roy. Coll. Surg. Engl. 1973, vol. 53)

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 SURGICAL EXPOSURE OF FLEXOR TENDONS IN THE HAND
more pertinent in the hand, where structures are small and access
difficult.
In 1950, on the invitation of Sir Archibald Mclndoe, I attended the
meeting of the British Association of Plastic Surgeons at Hill End, St.
Albans, under the presidency of Mr. Rainsford Mowlem. After the
meeting I spent some time at East Grinstead and presented a short
paper before the house staff of the Queen Victoria Hospital on the
subject of 'Incisions for non-septic surgery of the hand'. (This paper
was later read before the house staff of the Royal Infirmary, Edinburgh,
at the invitation of Sir James Learmonth, one of my surgical chiefs
at the Mayo Clinic, and was published in the British Journal of Plastic
Surgery in 19511.) In this article I presented ideas current in 1950 re-
garding surgical exposure in the hand and described the dilemma of the
surgeon who was attempting with great frustration to expose longitudinal
structures through transverse incisions, to conform with the skin creases.
These limited crease incisions, although leaving fine scars, were a handi-
cap in obtaining necessary exposure.
As an example of how progress was retarded, let us recall the ex-
posure used for fasciectomy in Dupuytren's disease. At that time many
of us performed this operation through an incision in the distal palmar
crease supplemented by separate incisions on the finger. This meant a
difficult and obscure dissection with extensive undermining of the skin.
Today fasciectomy is done through continuous digitopalmar incisions
which give excellent exposure of the hyperplastic fascia in the region
of the joints where contracture occurs. They are often zig-zag incisions,
or longitudinal incisions, converted by Z-plasty in the finger and in
the palm as suggested by McGregor.

Exposure of flexor tendons in the digits

Primary repair. For primary repair of the flexor tendons we must
have early, clean, incised wounds, commonly seen after lacerations
caused by broken glass and sharp metal. The surgeon presented with
such a wound on the volar surface of the finger must decide how best
to obtain additional exposure for local resection of the digital theca,
tendon repair, and nerve suture.
In oblique wounds additional exposure is obtained by proximal
and distal bayonet extensions just anterior to the neurovascular bundle.
Transverse wounds on the finger pose a greater problem. These also may
be extended by bayonet incisions, but if one digital artery has been
severed or thrombosed, the distal extension must be on the same side
as the injured artery or a skin slough may occur. Transverse wounds
of the finger should not be enlarged by zig-zag extensions immediately
85
 JULIAN M. BRUNER
adjacent to the wound of injury. To do so creates skin flaps with acute
angles, and skin necrosis may occur if blood supply is compromised.
If both neurovascular bundles are severed, both nerves and one ar-
tery should be sutured if possible. In such a finger tendon repair
should then be deferred for later grafting.

Fi-. 1. Extension of wounds for primary flexor tendon repair.

Elective surgery. For elective surgery the Bunnell mid-lateral in-
cision has been standard. The volar digital skin remains intact, and the
incision heals with an acceptable scar. However, this lateral approach
leaves much to be desired, because: (1) the dorsal branches of the
digital nerve must be severed, or they remain in the way; (2) the lateral
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 SURGICAL EXPOSURE OF FLEXOR TENDONS IN THE HAND
approach to the flexor tendon may injure the collateral and retinacular
ligaments; (3) if the incision is extended into the palm it must cross the
neurovascular bundle; and (4) it is awkward to work between fingers
or on the ulnar side of the thumb.
In 1965 I departed from the traditional mid-lateral approach and
moved to the volar skin. This was prompted by an accidental zig-zag
glass cut on the finger of a young student sustained while bar-tending.
The exposure provided by this ready-made incision was so good, the
result of primary tendon repair in No Man's Land so successful, and
the subsequent scar so favourable that I decided to use this staggered
approach for other flexor tendon repairs. Such a volar approach is
direct, does not encroach on the neurovascular bundle, and may be ex-
tended into the palm as far as necessary. The digital theca is thereby
widely exposed so that it can be partially excised (for either primary
repair or tendon grafting), leaving whatever pulleys are necessary in the
finger to prevent bow-stringing of the tendon or graft.
In 1967 I reported the use of this incision at the Anglo-Scandinavian
Symposium of Hand Surgery in Lausanne and Vienna2. Three years
later at the joint meeting of the American and Scandinavian Hand So-
cieties in Finland, Sweden, and Holland I was pleased to find that this
method of exposure of the flexor tendons was frequently being used
by surgeons in those countries.
There has been some difference of opinion as to the exact delinea-
tion of the volar zig-zag incision. All agree that the hinges should be
at the skin creases of the finger and palm. However, some have
placed the hinge in the mid-lateral line of the finger. I believe that the
incision should extend only to a point directly anterior to the neuro-
vascular bundle and should not encroach upon or even expose it, thus
inviting injury. The angle at the hinge should be somewhat less than
135 degrees. Some surgeons have doubled the number of zig-zags in
each finger segment, reducing the angle to about 90 degrees, thus mak-
ing the skin serrations sharper. In the distal segment of the finger or
thumb the incision should skirt the proximal edge of the digital nerve as
it fans out to supply the pulp, thus leaving intact sensation in the finger
pad. At the end of the incision, just proximal to the vortex of the
finger print, direct access is given to the insertion of the profundus
tendon-especially important in tendon grafting. Proximally the zig-zag
course may be extended into the palm and to the thenar crease; thence
to the wrist if necessary.
Two other American surgeons were pioneers in the use of this in-
cision: Dr. J. W. Littler of New York and Dr. L. D. Howard of San
Francisco. The latter once remarked: 'The volar zig-zag incision on
the finger just had to come.'
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 JULIAN M. BRUNER
In my experience, scars resulting from this incision have been ac-
ceptable and no changes in sensation of the volar digital skin have
been noted. Flexion contractures have not resulted. If they occur, they
may be due to injury of the volar plate or to improper postoperative
splinting. The little finger especially has a strong tendency to curl up,
shrimp-like, at its interphalangeal joints. This must be prevented by
splinting these joints in extension as recommended by J. I. P. James.

Exposure of flexor tendons at the wrist

We turn now to the exposure of flexor tendons at the wrist. Their
repair in the carpal tunnel zone has often been attended with difficulty,
as it has in No Man's Land. The carpal canal, containing nine flexor
tendons and the median nerve, is normally snug, and when swelling
occurs in the synovial tissues, as it frequently does in menopausal
women, pressure is exerted on the median nerve, with resulting
paraesthesiae.
Decompression of the median nerve for 'carpal tunnel syndrome' was
first done by James Learmonth in 1930 at the Mayo Clinic on a patient
with arthritis of the wrist. He used a short transverse incision through
which he divided the transverse carpal ligament, with dramatic relief of
symptoms. It was not until about 1950, however, that this operation
came into general use. We have since learnt that wider exposure
of the carpal canal is advisable to avoid injury to the median nerve
and its motor and sensory branches. The incision commonly used is
longitudinal, with a small zig-zag at the wrist level to minimize the scar.
In my experience, section of the volar retinaculum has been without
complication. Bow-stringing of the flexor tendons does not follow as it
does on the back of the wrist when the dorsal retinaculum is severed.
If one explores this region one or two years later, he finds that the
transverse carpal ligament has been reconstituted.
Such wide exposure has not yet been exploited for the repair of ten-
dons injured within or near the carpal canal. Many surgeons still regard
the flexor retinaculum with some awe and go to great lengths not to
sever it. The transverse carpal ligament is a bridge under which the
flexor tendons ebb and flow, but like the Tower Bridge in London it
may be opened, and in due course it will close itself (Fig. 2).

Primary repair. During the past five years I have opened the carpal
canal widely for the primary repair of tendon injuries. The transverse
carpal ligament is transected, distally the palmar fascia is incised, and
proximally the antebrachial fascia is freely divided. With such wide ex-
posure, multiple tendons severed within or near the canal may be quickly
identified, matched, and repaired, also the median nerve if it is injured.
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 SURGICAL EXPOSURE OF FLEXOR TENDONS IN THE HAND
The antebrachial fascia and the transverse carpal ligament should never
be sutured. The palmar fascia should be excised locally in the region
of tendon suture to prevent adhesions (Potenza).
A word of warning! Oblique wounds on the volar surface of the
wrist may usually be connected with the standard carpal tunnel incision,

Fig. 2. Surgical exposure of flexor tendons.

but with transverse wounds of the wrist a cruciate incision must be

avoided, or sloughs may occur in the distal flaps. If there is any ques-
tion of adequate blood supply, a bridge of intact skin should be left
just distal to the transverse wrist wound under which the transverse
carpal ligament may be incised (Fig. 1).
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 JULIAN M. BRUNER
In many textbooks the surgeon is advised to suture only the pro-
fundus flexor tendons if all are cut under or near the transverse carpal
ligament. I believe the sacrifice of the sublimis tendons, so indispensable
for individual flexion of the fingers, is destructive and unnecessary. For
some time now, with wide exposure of the carpal canal, I have re-
paired all flexor tendons cut within or adjacent to it, both profundus
and sublimis. They heal well and adhesions that occur are gradually
mobilized by individual finger motions. Cross-union of profundus and
sublimis flexor tendons has not been a problem in my experience. If
such union should persist, tenolysis is available.
Elective surgery. Incisions for elective surgery at the wrist level are
often limited to short transverse or L-shaped incisions proximal to the
transverse carpal ligament. These will suffice for elective surgery on one
or two tendons. If many tendons are involved, the standard carpal tUIl-
nel incision may be necessary.
Discussion
Much experimental work has been done in recent years in regard to
the blood supply of the cut tendon and the mechanism of healing. We
know that a callus of fibroblastic tissue occurs at the site of suture and
that healing comes largely from peripheral cells in the wound and not
from the cut ends of the tendon.
After a flexor tendon is cut in the finger it is often prevented from
retracting by the vincula, in which fine blood vessels are then subjected
to strong muscle traction for hours or days, with possible thrombosis.
If this happens, a segment of the sutured tendon may actually be an
infarct. The tissue reaction to a segment of dead tendon must be in-
tense, and this may explain many a failure after primary repair. It is
in such cases that we return to the scene months later to do a tendon
graft and will find a congealed conglomerate of cicatrix.
In the Bunnell Lecture of 1971 Claude Verdans reviewed the present
re-
status of flexor tendon surgery in the hand, including both primary cut
pair and grafting. He believes that when both flexor tendons are
in No Man's Land removal of the sublimis tendon, which has been
standard practice for many years, may injure the blood supply ofsub- the
profundus tendon. He reports cases in which he has sutured both
limis and profundus tendons in No Man's Land with excellent results.
in No
My experience in the carpal tunnel zone is similar to Verdan'sretained
Man's Land-that is, the sublimis tendons may be successfully
and repaired. This suggests that a technique practised for many years of
needs to be reexamined. It may be that in the future the sacrifice ancient
the sublimis tendon in both areas will be remembered as an
pagan rite still practised by hand surgeons in 1972.
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 (a)

. :< . :~(c)
SURGICAL EXPOSURE OF FLEXOR TENDONS IN THE HAND

(b)

Fig. 3. Tendon graft, both flexors little finger (4 months post-injury).

(a) Preoperative. (b) Zigzag volar incision. (c) P.L. graft in place (d) Post
operative-hand open. (e) Postoperative-hand closed.
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 JULIAN M. BRUNER
Conclusion
During the past 25 years flexor tendon repair in the hand has made
significant advances. Flexor tendon grafting has been brought to a
highly successful level, as evidenced by the admirable series reported
by Guy Pulvertaft4 and by Joseph Boyes. Primary repair, so long in
the doldrums but so advantageous to the patient, now shows great
promise. More successful primary repairs are now being done and
the status of briefly delayed primary repair is being defined.
Improved techniques are contributing to these advances. Among these
are incisions which give better exposure. Although some surgeons may
regard the serious discussion of incisions as elementary, such is not the
case in the hand. The correct incision, indelibly inscribed on the skin,
is a plan of battle. It may portend victory or defeat from a skin slough,
or condemn the surgeon to a two-hour arduous repair which might have
been completed in one hour. Unfortunately many incorrect incisions are
depicted in textbooks and the error perpetuated through several editions.
Examples of this are misleading incisions recommended for the relief
of carpal tunnel syndrome or de Quervain's disease which expose sen-
sory nerves to injury, often with serious disability.
The volar zig-zag incision, previously proscribed but used now for
more than five years by many surgeons, is a dependable alternative
to the standard mid-lateral digital incision and greatly facilitates elective
flexor tendon surgery. The carpal tunnel incision, until recently used
only to decompress the median nerve, is now being exploited for the
rapid primary repair of multiple tendons sevefed at the wrist.
Finally, if we are to make real progress in flexor tendon surgery,
the surgeon who does primary repair and the surgeon who does ten-
don grafting must actually be one and the the same person.
The future of hand surgery. And what of hand surgery in the fu-
ture? Today in Britain and in America it is being done by plastic,
orthopaedic, and general surgeons. In this context it is a subspecialty,
but it may not remain so.
The scope of hand surgery is expanding. Surgery for rheumatoid
disease of the hand is an important branch, developed during recent
years. My colleague in Iowa City, Adrian Flatt, is one of several sur-
geons well qualified in this field who are mercifully correcting the
deformities of these crippled hands.
Microsurgery applied to the repair of small arteries and nerves is an-
other recent development, and it appears likely that hand surgeons of
the future must be skilled in the use of the operating microscope. The
accomplishments of Cobbett of East Grinstead, O'Brien of Melbourne,
and James W. Smith of New York are impressive.
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 SURGICAL EXPOSURE OF FLEXOR TENDONS IN THE HAND

(a)

gretd . (c) Finr f

2 0$ ,R 'i ~(b)

~~~ Peerte.. (b)Fin

Fig. 4. Primary repair, both flexors little~~~~~~~~~~~~~
finger..(a)

c )~ ~ ~ ~ ~ ~ ~ ~ ~ C
Fig. 4. Primary repair, both flexors little finger. (a) Preoperative. (b) Fin-
gers extended. (c) Fingers flexed.

93
 JULIAN M. BRUNER
As trauma increases in modem life, traumatic hand surgery expands,
requiring expertise in bone, nerve, and tendon repair. This suggests
that hand surgery should be a specialty in its own right. A few surgeons
located in the large cities of America confine themselves to surgery of
the hand, and a good case can be made for such limitation. If one visits
the clinics of these surgeons, he will at once appreciate the high level
of their clinical judgement and technical skill. It is likely, however,
that for some years ahead hand surgery will remain a subspecialty.
The chief problem is to develop training centres and to determine the
scope and length of such training.
The study of anatomy, now lamentably de-emphasized in some med-
ical schools and postgraduate programmes, must on the contrary, be
reinforced by repeated dissections. The Royal College of Surgeons of
England and its sister Colleges have traditionally fostered the highest
standards of anatomical knowledge. This must be maintained especially
in surgery of the hand, where the precise knowledge of normal and an-
omalous structures is of critical importance.
The desire of surgeons to avoid scars on the volar surface of the
fingers, hand, and wrist is commendable, but experience has shown
that exposure of the flexor tendons through crease incisions is in-
adequate. Poor flexor tendon surgery is often the direct result of poor
exposure. The function of grasp is by far the most important in the
hand and far outweighs cosmetic considerations. However, if rea-
sonable care is used in the closure of zig-zag incisions, they are
inconspicuous, as shown by the photos in Figures 3 and 4.
In the United States 54 centres for training in surgery of the hand
have been listed in a brochure issued by the American Society for Sur-
gery of the Hand. However, these centres have no official approval and
the training period has not been agreed upon. I believe it should include
at least one year of experience on a service where large numbers of hand
cases are seen.
At the meeting of the British Society for Surgery of the Hand ill
Windsor in May 1972 steps were taken for the development of such
centres in Great Britain. The high level of hand surgery in this country
is known throughout the world and is due in no small measure to the
work of those pioneers in this field of whom Sir Archibald Mclndoe is
an outstanding example.
REFERENCES
1. BRUNER, J. M. (1951) British Journal of Plastic Surgery, 4, 48.
2. BRUNER, J. M. (1967) Plastic and Reconstructive Surgery, 40, 571.
3. VERDAN, C. (1972) Journal of Bone and Joint Surgery, 54-A, 472.
4. PULVERTAFT, R. G., Personal communication.

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