Tendon repair of the hand is a surgical procedure to repair tendons that have been damaged and split.

Most cases of tendon damage occur as a result of cuts to the hands.

Tendons Tendons are tough cords of tissue that connect muscles to bones. When you contract (tighten) a group of muscles, the attached tendons will pull on certain bones, allowing you to make a wide range of physical movements. Tendons in the hand There are two groups of tendons in the hand: 1. Extensor tendons Extensor tendons run from the muscles in your forearm across the back of your hand to each of your fingers and thumbs. Your extensor tendons allow you to straighten your fingers and thumbs. 2. Flexor tendons Flexor tendons also run from the muscles in your forearm, passing through a number of channels in your wrist and across the palm of your hand to each of your fingers and thumbs. Your flexor tendons allow you to bend your fingers, make a fist and grip objects.

Tendon repair Tendon repair involves locating the split tendons, making an incision in your hand, then stitching the tendons together. Extensor tendons are easily accessible, so repairing them is relatively straightforward. Depending on the type of injury, it may be possible to repair extensor tendons in an accident and emergency (A&E) department using a local anesthetic to numb the affected area. Repairing flexor tendons is more complex because they can be difficult to access and are often located near important nerves. Flexor tendon repair usually needs to be carried out by an experienced orthopedic surgeon (a surgeon who specializes in joint and bone surgery) in an operating theatre.

The flexor tendons are smooth, flexible, thick strings which bend your fingers - they look a bit like clothesline rope. They work like a bicycle brake cable to bend your fingers, sliding in and out of the finger as it straightens and bends. If a flexor tendon is cut in half, the end connected to the muscle is often pulled back into the palm - no way to heal on its own. This is a very precision mechanism, and it doesn't take much to gum up the works. Even a cut only part way into the tendon can be a big problem. The most common and difficult problem that people have after a tendon injury is stiffness - losing the ability to either fully bend or straighten the finger - which can be permanent. This is a possible problem for anyone who has had a flexor tendon injury. Surgery and other special treatment are usually needed to make this as little a problem as possible.

What caused it?



Most often, flexor tendons are damaged from a cut. Fingers have special creases which let the skin fold when you make a fist - at these points, the tendons are just beneath the skin, and are easily injured by even a small cut in the skin. Less often, flexor tendons may tear or be torn off the bone by a sudden pull against a strong grip, without tearing the skin. What can you do to help? Ice, elevation, and have it checked out by a doctor. If the injury involved a cut, medical evaluation is particularly important - to check whether or not tetanus shot, antibiotics or other treatment is required, even if stitches aren't needed. After injury, if surgery is needed, there is a limited amount of time to operate and get the best possible result. Surgery delayed for more than two weeks has less of a chance of having a satisfactory outcome.

What can a therapist do to help?

 Surgery is only half the battle for this problem. Therapy is a necessary and essential treatment for most people recovering from a flexor tendon injury.  Special hand therapy usually involves making one or more custom splints, performing and supervising special exercises, and making the hand feel better in general.

What can a doctor do to help?

 Confirm that this is the problem, and check for nerve injury or other problems which can occur at the same time.  Treatment really depends on the type of injury. Your doctor may recommend: Moving the fingers and doing exercises right away. Hand therapy. A splint or a cast, along with special exercises. Performing surgery to repair the damage.

Sewing a cut flexor tendon together is something like sewing two small ropes together, end to end. Special stitches are used on both the inside and the outside - but even with the best stitches, the repair can still be pulled apart if it is not protected by a special splint. It can take as long as two months before healing has made the repair strong.

Sometimes the end of the tendon is cut or pulled off the bone. This may require stitches through the bone or a special implant to anchor the tendon back to the bone.

How successful is treatment? It depends on many things - getting full motion back is less likely if there is a nerve injury or a broken bone next to the tendon injury there is a long healing period before surgery the person is prone to thick scars the damage was caused by a crush injury there are problems participating in hand therapy after surgery

The location of the injury also has a big influence on how well people recover after surgery - cuts in the fingers don't do as well as those in the forearm. These locations are referred to as "zones, as shown in this diagram. The areas shown in red are referred to as "no man's land" - because stiffness is such a common problem after injuries in this area. In addition, there are many other factors which can also affect the odds of having a good result versus a stiff hand. After a flexor tendon injury, most people lose some movement in the finger, despite all efforts. It really takes everything going in your favor, including luck, to have a full recovery. However, if all goes well, the hand will work better after surgery than if surgery were not done, and that's the reason for doing it.

How are Extensor Tendons Injured? Extensor tendons are just under the skin, directly on the bone, on the back of the hands and fingers. Because of their location, even a minor cut can easily injure them. Jamming a finger may cause these thin tendons to rip apart from their attachment to the bone. After this type of injury, you may have a hard time straightening one or more joints. Treatment is necessary to return use to the tendon and finger. How are Extensor Tendon Injuries Treated? Cuts that split the tendon may need stitches, but tears caused by jamming injuries are usually treated with splints. Splints stop the healing ends of the tendons from pulling apart and should be worn at all times until the tendon is fully healed. Your doctor will apply the splint in the correct place and give you directions on how long to wear it. Sometimes a pin is placed through the bone across the joint as an internal splint in addition to the external splint.

What are the Common Extensor Tendon Injuries? Mallet finger refers to the droop of the end joint where an extensor tendon has been cut or separated from the bone. Sometimes a piece of bone is pulled off with the tendon, but the result is the same: a fingertip that cannot actively straighten. Whether the tendon injury is caused by a cut or jammed finger, splinting is necessary. Often the cut tendon requires stitches. A splint is used to keep the fingertip straight until the tendon is healed. The size of the splint and length of time you will have to wear it is determined by the type and location of your injury. The splint should remain in place constantly during this time. The tendon may take four to eight weeks or longer in some patients, to heal completely. Removing the splint early may result in drooping of the fingertip, which may then require additional splinting. Your physician will instruct you to remove the splint at the proper time. Sometimes there is a mild permanent droop, despite proper splint wear.

Boutonniere deformity describes the bent-down (flexed) position of the middle joint of the finger from a cut or tear of the extensor tendon at the middle joint. Treatment involves splinting the middle joint in a straight position until the injured tendon is fully healed. Sometimes, stitches are necessary when the tendon has been cut and even if the tendon is torn. If the injury is not treated, or if the splint is not worn properly, the finger can quickly become even more bent and finally stiffen in this position. Be sure to follow your doctors instructions and wear your splint for a minimum of four to eight weeks. Your doctor will tell you when you may stop wearing the splint. Lacerations or cuts on the back of the hand that go through the extensor tendons cause difficulty in straightening the finger at the large joint where the fingers join the hand. Stitching the tendon ends together is the usual way of treating these injuries, followed by splinting to protect the repair. The splint for a tendon injury in this area may include the wrist and part of the finger. Dynamic splinting, which is a splint with slings that allows some finger motion, may be used for injuries of this kind. The dynamic splint allows early movement and protects the healing tendon.

Figure 1: Extensor tendons, located on the back of the hand and fingers, allow you to straighten your fingers and thumb.

Figure 2: The mallet finger deformity causes a droop of the fingertip. This is caused by injury to the extensor tendon at the last finger joint.

Figure 3: The boutonnire deformity with progressive flexion, or bending, of the middle joint may result in a stiff finger in this position if not treated. The end joint also hyperextend (bends backward) from the altered force across the finger.

What Can I Expect as a Result of my Extensor Tendon Injury? Extensor tendon injuries may form scar that causes the tendon to adhere to nearby bone and scar tissue, limiting the movement of the tendon. The scar tissue that forms may prevent full finger bending and straightening even with the best of treatment. Many factors can affect the seriousness of the injury, including fracture, infection, medical illnesses, and individual differences. To improve motion, hand therapy may be necessary. Surgery to free scar tissue may sometimes by helpful in serious cases of motion loss. Your physician will explain the risks and benefits of the various treatments of extensor tendon injuries.