Flexor Tendon Injury

Dec 30, 2021 3 min read

The aim of this section is to help you convey your ability to treat a Plastic Surgery trauma. A solid candidate is competent in diagnosis, surgical technique, and post-operative rehabilitation.

In this section, you'll find a clinical scenario, consent, call the boss,

Clinical Scenario

Review the clinical information before answering the following questions.

A 27-year-old presents to the family doctor with a cut on her ring finger. The injury occurred when cutting an avocado with a knife. She is concerned because she can "no longer make a fist". She is not sure if part of the knife broke as well. You ask the patient to present to your trauma clinic.

On examination, there is a 2cm oblique laceration along zone 2 of the right ring finger. There is no neurovascular disturbance. She cannot flex her DIPJ. She can flex her PIPJ but it's painful. In your medical notes, you draw your findings as illustrated below.

1. What would you ask in your history?

History of Presenting Complaint

  1. Date and Time of Injury
  2. Mechanism of Injury: cutting or puncturing, force
  3. Blade: clean, serrated, width

Social and Medical History

  1. Social History: dexterity, occupation
  2. Medical History: conditions, medications, smoking status, allergies
  3. Surgery: previous general or regional anesthetic
  4. Patient Expectations

Current Management

  1. Medical: Antibiotics, Tetanus
  2. Radiological: X-Rays
  3. Surgical: Dressings

2. What is your clinical diagnosis? 

This patient has a zone 2 FDP injury (loss of DIPJ flexion) with a ?partial FDS injury (suggested pain on flexion of FDP). Digital nerves and arteries are intact.

3. What investigations would you order? 

  • Routine pre-operative blood (unlikely a laceration results in low hemoglobin or platelet)
  • b-HCG as may require a general anaesthetic
  • Xray: assess any foreign body, a fracture is unlikely

4. What are the zones of the hand?

In the fingers:

  1. Distal to FDS
  2. FDS to Proximal aspect of A1 Pulley
  3. Proximal Aspect of A1 Pulley to Distal Aspect of the Carpal Tunnel
  4. Carpal Tunnel
  5. Proximal to Carpal Tunnel

In the thumb:

  1. Distal to the A2 pulley
  2. A2 Pulley to A1 Pulley
  3. Proximal to A1 Pulley

You can read more about zones of the hand

Please consent a patient on the information provided below. 
Following the history and clinical examination, you decide the patient will require surgery for a zone 2 FDP and partial FDS tendon injury. Please consent her. She is very anxious due to a previous negative experience when receiving a local anesthetic.

Key Points

An example answer

Good evening, my name is P'Fella and I am here to consent you for this operation. To start with, can you please confirm your personal details and what you understand of the operation today?

Ok, I am going to explain what will happen before, during, and after the surgery. At any stage feel free to ask questions. But first, I just need to confirm your name and understanding of the procedure.

Before the operation, you will be meeting different health care staff. They are all here for your treatment and will be involved in performing your surgery or the anesthetic. To start off, there will be a surgical checklist to confirm your details. Then you will receive the anesthetic. This will involve a mask being gently placed over your face as you fall asleep.

During the operation, our goal is to repair your tendon and skin. I will be using a tourniquet and will need to extend your scar to allow good visualization of all the structures. You will be given IV antibiotics. Once I have identified the divided tendon, I will suture it together. Sometimes, I need to place a synthetic rod into the flexor sheath but I don't this is will be the case today. If other structures are divided, such as the shorter FDP tendon or a nerve or artery, I will also repair that too. There is the option for a local anesthetic but I do feel putting you to sleep is the better option.

After the operation, I will see you and make sure you are suitable to go home. You will have a cast on the arm and an antibiotic prescription. We will ask you to elevate the arm in a sling. Ideally, we will like to see you back in our clinic between days 3-5 post-op. The stitches are dissolving so won't need to be taken out. At this stage, you will meet our hand therapists and a custom splint is made for you. The rehabilitation process does take time and patience. The end goal is to restore function back to your ring finger. I cannot guarantee that it will be the same standard as pre-injury. You will be off work, sport, and driving for several weeks to months.

With any operation, there are risks and complications you need to be aware of. These may be related to the surgery or the anesthetic.

• Skin: infection, wound breakdown, scar sensitivity
• Tendon: re-rupture, adhesions, tenolysis
• Nerve/Artery: iatrogenic injury, grafts.
• Bone: Joint stiffness
• Two-stage reconstruction
• Anaesthetic complications
• Multiple operations

Without this operation, you will not be able to regain full function in the ring finger.

I understand this is a lot of information to take on. Before I get you to sign the consent form and mark your finger, do you have any questions for me?

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