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Proximal coiling of the profundus tendon after laceration of the finger
PROXIMAL
COILING OF THE PROFUNDUS TENDON LACERATION OF THE FINGER
AFTER
B. J. GAINOR From the Division of Orthopaedic Surgery, Universityof Missouri Health Sciences Center, Columbia, U.S.A.
Three patients who had delayed primary repair of a severed flexor digitorum profundus in the finger were found to have proximal coiling of the tendon in the palm. These patients’ hands had been inadequately immobilised during the interval between injury and surgery. The most likely pathomechanics of this unusual finding is secondary retraction and coiling of the severed tendon from unrestrained muscle contraction after division of the tendon. Precautions should be taken when retrieving the tendon stump for tenorrhaphy. Journal of Hand Surgery (British Volume, 1989) I4B: 416-418 The functional results following delayed flexor tendon repair in no man’s land are predictable and comparable to other procedures (Schneider et al., 1977). Delayed primary flexor tenorrhaphy is the method of choice for some hand surgeons (Strickland, 1982; Iselin, 1975). This technique involves immediate debridement, cleansing, and closure of the wound; the tendon is usually repaired in a few days (Milford, 1987) when the wound appears favourable and suitable expertise and time are available. The author has treated three patients with zone 2 lacerations of the flexor digitorum profundus of the little finger who were found to have proximal coiling of the profundus flexor tendon stump. These patients had been referred after wound cleansing and closure, but their injured hands had not been adequately dressed or splinted. These case histories suggest that the lack of a protective dressing and proper instruction of the patient are potential hazards in the management of flexor tendon lacerations by delayed primary repair. Case reports Case 1 A right-handed 21-year-old woman cut her left little finger on a steak knife while preparing dinner. She was seen in the emergency room very early the next morning and the 2 cm laceration on the volar aspect of the proximal phalanx was sutured. No tendon injury was appreciated and she was referred to her family physician for follow-up. The patient returned to the emergency room late that evening, reporting inability to flex her D.I.P. joint and requesting orthopaedic consultation. Next day, the wound was explored through a lazy-S type of incision. The flexor digitorum superficialis tendon was intact, but the severed flexor digitorum profundus was not within the digital sheath. A transverse incision at the distal palmar crease failed to reveal the proximal stump of the profundus tendon. Another incision was made more proximally in the palm, and the cut tendon end was found to be coiled 180” upon itself. The tendon was uncoiled and appeared healthy. It was threaded into the finger. A tenorrhaphy was done with a 416
Bunnell stitch at the level of the A3 pulley, using a nonabsorbable suture and a small-calibre absorbable running suture. The patient’s hand was placed in a dynamic rubber-band traction system. Three months later, the patient was able to extend her little finger to neutral and flex the fingertip to 1 cm from the distal palmar crease.
Case 2 An 18-month-old girl lacerated the volar aspect of her left little finger on broken glass at the level of the metacarpophalangeal joint. Her wound was closed primarily. No tendon injury was suspected. Her parents sought referral when they noticed that the child’s digit remained straight when she grasped objects. The patient came to our clinic one week after injury, when the finger had no active flexion. At operation the next day, the healed laceration was explored through a lazy-S incision. Both flexor tendons and the ulnar distal neurovascular bundle were found to be severed. The proximal ends of the tendons could not be seen in the digital sheath, so the incision was extended proximally until the tendon stumps were located near the level of the hypothenar eminence. The flexor digitorum profundus was found to be proximally coiled 180” upon itself. Both the tendon ends appeared healthy. They were threaded into the digital sheath; the superficialis slips were repaired with non-absorbable sutures and the profundus with a modified Kessler non-absorbable suture. The ulnar digital nerve was repaired using the operating microscope. The patient’s hand was closed and bandaged with a bulky dressing which was covered by a long-arm cast. Three months later, the child had a full active range of motion of the digit and could appreciate pin-prick on the ulnar aspect of the finger.
Case 3 This 13-year-old right-handed male lacerated the volar aspect of his right ring and little fingers at the level of the proximal phalanx while cleaning fish with a knife. He was seen at a nearby emergency room where the skin was THE
JOURNAL
OF HAND
SURGERY
PROXIMAL
COILING
OF THE CUT PROFUNDUS
sutured. A light gauze dressing was applied. The patient was seen in our clinic on the following day, when he had no active flexion of the distal joints of the involved fingers though he appeared to have a trace of active flexion at the PIP. joint of each digit. His hand was placed in a bulky dressing and he was instructed to elevate the hand in a sling. At operation two days later, the flexor sheaths were exposed by Bruner incisions. In the ring finger, both flexor tendons were found to be severed, but they were still retained within the digital sheath. Both tendons were also severed in the little finger; the flexor digitorum superficialis stump was delivered into the digital sheath with a tendon retriever. The proximal end of the profundus tendon could not be located until a zig-zag incision was made proximally into the palm, where it was found coiled upon itself 180”. The tendon was uncoiled and appeared healthy (Figs. 1 and 2). It was then threaded into the finger. The superficialis slips were repaired with non-absorbable sutures and the profundus with a modified Kessler non-absorbable suture. A smallcalibre absorbable running suture was used along the edge of the tenorrhaphy. The tendons in the ring finger were repaired in the same fashion. The patient’s hand was placed in a dynamic rubberband traction system. His sutures were removed about two weeks later, and he was lost to follow-up. Seven weeks later, the patient was traced to a juvenile detention centre and his care was re-established with an orthopaedic surgeon. Despite non-compliance and two fist fights, the patient was able to flex his little finger to the distal palmar crease four months after surgery. There was an extension lag of 15” at the P.I.P. joint. His ring finger had nearly the same active range of motion as his little finger.
Fig.
!
Exploration of the palm reveals the severed profundus tendon to be proximally coiled upon itself. The superficialis tendon has been delivered into the finger with a tendon retriever. Needles transfix the tendons in the digital sheaths.
VOL. 14-B No. 4 NOVEMBER
1989
Fig. 2
TENDON
Under direct visualisation, the profundus has been uncoiled distally to prepare it for threading into the finger and delayed primary repair. A paediatric feeding tube is used to pull the tendon into the digital sheath.
Discussion Severed proximal tendon ends are frequently tethered in the flexor sheath by intact vincula which prevent tendon retraction into the palm. However, it is not known how long these delicate vincula can retain flexor tendon stumps in the digital sheath if the patient’s hand is unsplinted and allowed to move freely. It is postulated that only when digits are lacerated in extension or during violent muscle contraction is a palmar incision necessary to locate proximal tendon ends (Kleinert and Smith, 1982). Beasley (1981) specifically recommends strict immobilisation of the hand after laceration to safeguard intact vincula from avulsion which would further diminish the severed tendon’s blood supply (Beasley, 1981). The unreliable patient described as Case 3 was observed to have a trace of flexion at the proximal interphalangeal joints, although his flexor digitorum superficialis tendons were found at operation to be divided. It is known that severed flexor tendons can impart a small flexion moment at the P.I.P. joint through intact vincula (Sasaki and Nomura, 1987). Unguarded flexor muscle contraction may pull the tendon out of the finger into the palm, so strict immobilisation and a protective temporary dressing are essential if delayed primary repair is chosen. The primary management of tendon lacerations is sometimes described simply as wound irrigation, cleansing and closure, if tenorrhaphy is deferred to a delayed primary procedure (Kutz et al., 1986). No attention is focused on splinting or a proper interim dressing with instructions to the patient. The three patients in this report were all inadequately splinted and wiggled their fingers freely while awaiting the delayed primary operation. In his review of the anatomy of the flexor digitorum 417
B. J. GAINOR
superficialis muscle, Kaplan (1981) describes the variations and occasional complete absence of this structure in the little finger. In this finger, the tendon is frequently extremely thin and surgeons must be aware of the almost vestigial nature of this unique tendon. The small size of the superficialis tendon in the little finger may explain, in part, why the proximal end of the severed flexor digitorum profundus can proximally coil upon itself 180” despite the presence of its adjacent superficialis tendon. The author has not observed this curious phenomenon in other digits: it may occur there, but a search of the literature revealed no appraisal or discussion of it. The flexor tendons within the digital sheath receive nutrition by both diffusion and perfusion (Manske and Lesker, 1985). It has been shown experimentally that tendons can remain viable and initiate healing when isolated in the avascular environment of the rabbit kneejoint (Lundborg et al., 1980). Although the profundus tendons in my patients were completely coiled upon themselves in the proximal palm for up to a week, the tendons all appeared viable and healed satisfactorily. When a severed tendon has withdrawn from the digital sheath into the palm, the surgeon can expect the proximal end to be at the level of the Al pulley where it has been restrained by the lumbrical origin. If milking the forearm and hand will not deliver the tendon into the finger, a simple incision near the distal palmar crease will predictably expose the tendon stump. In my three patients, an incision at the level of the Al pulley did not reveal the flexor digitorum profundus and exploration of the proximal palm was required to see the coiled tendon end. Using a tendon retriever in the finger to grasp a retracted tendon blindly must be done carefully (Leddy, 1988), but repeated “fishing” for the tendon end can be dangerous to adjacent anatomical structures (Gould and Nicholson, 1988). The use of a tendon retriever in a distal palmar incision would be unwise because of the risk of injury to the neurovascular structures in the proximal palm. Direct visualisation of tendon ends which have
418
retracted into the proximal palm, especially from the little finger, is recommended before proceeding to thread it into the finger for repair.
References BEASLEY, R. W. Hand Injuries. Philadelphia, W. B. Saunders Company, 1981: 263. GOULD, .I. S. and NICHOLSON, B. G. Flexor Tendon Injuries: Acute Repair and Late Reconstruction. In: Chapman, M. W. and Madison, M. (Eds.) Operative Orthopedics. Philadelphia, J. B. Lippincott, 1988 : 1147-l 168. ISELIN, F. Early management of fresh hand wounds with specific reference to delayed repair. In: American Academy of Orthopaedic Surgeons Symposium on Tendon Surgery in the Hand. St. Louis, C. V. Mosby Co., 1975: 88-90. KAPLAN, E. B. Anatomical variations of the forearm and hand. In: Tubiana, R. (Ed.) The Hand, Vol. 1. Philadelphia, W. B. Saunders Co., 1981: 361-374. KLEINERT, H. E. and SMITH, D. J. Primary and secondary repair of flexor and extensor tendon injuries. In: Flynn, J. E. (Ed.) Hand Surgery (3rd edn.) Baltimore, Williams and Wilkins, 1982: 220-242. KUTZ, .I. E. and BENNETT, D. L. Tendon injuries. In: Watson, N. and Smith, R. J. (Eds.) Methods and Concepts in Hand Surgery. London, Butterworths, 1986: 148-189. LEDDY, J. P. Flexor tendons-Acute injuries. In: Green, D. P. (Ed.) Operative Hand Surgery, 2nd edn. New York, Churchill Livingstone, 1988: Vol. 3: 1935-1968. LUNDBORG, G., HANSON, H.-A., RANK, F. and RYDEVIK, B. (1980). Superficial repair of severed flexor tendons in synovial environment. An experimental, ultrastructural study on cellular mechanisms. Journal of Hand Surgery, 5A: 5: 451-461. MANSKE, P. R. and LESKER, P. A. (1985). Flexor tendon nutrition. Hand Clinics of North America, 1: 1: 13-24. MILFORD, L. Tendon injuries. In: Crenshaw, A. H. (Ed.) Campbell’s Operative Orthopaedics, 7th edn. St. Louis, C. V. Mosby Company, 1987: 149-182. SASAKI, Y. and NOMURA, S. (1987). An Unusual Role of the Vinculum After Complete Laceration of the Flexor Tendons. Journal of Hand Surgery, 12B: 1: 105-108. SCHNEIDER, L. H., HUNTER, J. M., NORRIS, T. R. and MADEAU, P. 0. (1977). Delayed flexor tendon repair in no man’s land. Journal of Hand Surgery, 2: 6: 452-455. STRICKLAND, J. W. Functional recovery after flexor severance in the finger: the state of the art. In: Strickland, J. W. and Steichen, J. B. (Eds.) Dt@cult Problem in Hand Surgery. St. Louis, C. V. Mosby Co., 1982: 73-85.
Accented: IO Februarv 1989 Barry J. Gainor, M.d., Associate Professor, Missouri Health Sciences Center, Columbia,
0 1989 The British
Society
for Surgery
Division of Orthopaedic Missouri 65212, U.S.A.
Surgery,
University
of the Hand
026&7681/89/0014-0416/$10.00
THE
JOURNAL
OF HAND
SURGERY
of
COILING OF THE PROFUNDUS TENDON LACERATION OF THE FINGER
AFTER
B. J. GAINOR From the Division of Orthopaedic Surgery, Universityof Missouri Health Sciences Center, Columbia, U.S.A.
Three patients who had delayed primary repair of a severed flexor digitorum profundus in the finger were found to have proximal coiling of the tendon in the palm. These patients’ hands had been inadequately immobilised during the interval between injury and surgery. The most likely pathomechanics of this unusual finding is secondary retraction and coiling of the severed tendon from unrestrained muscle contraction after division of the tendon. Precautions should be taken when retrieving the tendon stump for tenorrhaphy. Journal of Hand Surgery (British Volume, 1989) I4B: 416-418 The functional results following delayed flexor tendon repair in no man’s land are predictable and comparable to other procedures (Schneider et al., 1977). Delayed primary flexor tenorrhaphy is the method of choice for some hand surgeons (Strickland, 1982; Iselin, 1975). This technique involves immediate debridement, cleansing, and closure of the wound; the tendon is usually repaired in a few days (Milford, 1987) when the wound appears favourable and suitable expertise and time are available. The author has treated three patients with zone 2 lacerations of the flexor digitorum profundus of the little finger who were found to have proximal coiling of the profundus flexor tendon stump. These patients had been referred after wound cleansing and closure, but their injured hands had not been adequately dressed or splinted. These case histories suggest that the lack of a protective dressing and proper instruction of the patient are potential hazards in the management of flexor tendon lacerations by delayed primary repair. Case reports Case 1 A right-handed 21-year-old woman cut her left little finger on a steak knife while preparing dinner. She was seen in the emergency room very early the next morning and the 2 cm laceration on the volar aspect of the proximal phalanx was sutured. No tendon injury was appreciated and she was referred to her family physician for follow-up. The patient returned to the emergency room late that evening, reporting inability to flex her D.I.P. joint and requesting orthopaedic consultation. Next day, the wound was explored through a lazy-S type of incision. The flexor digitorum superficialis tendon was intact, but the severed flexor digitorum profundus was not within the digital sheath. A transverse incision at the distal palmar crease failed to reveal the proximal stump of the profundus tendon. Another incision was made more proximally in the palm, and the cut tendon end was found to be coiled 180” upon itself. The tendon was uncoiled and appeared healthy. It was threaded into the finger. A tenorrhaphy was done with a 416
Bunnell stitch at the level of the A3 pulley, using a nonabsorbable suture and a small-calibre absorbable running suture. The patient’s hand was placed in a dynamic rubber-band traction system. Three months later, the patient was able to extend her little finger to neutral and flex the fingertip to 1 cm from the distal palmar crease.
Case 2 An 18-month-old girl lacerated the volar aspect of her left little finger on broken glass at the level of the metacarpophalangeal joint. Her wound was closed primarily. No tendon injury was suspected. Her parents sought referral when they noticed that the child’s digit remained straight when she grasped objects. The patient came to our clinic one week after injury, when the finger had no active flexion. At operation the next day, the healed laceration was explored through a lazy-S incision. Both flexor tendons and the ulnar distal neurovascular bundle were found to be severed. The proximal ends of the tendons could not be seen in the digital sheath, so the incision was extended proximally until the tendon stumps were located near the level of the hypothenar eminence. The flexor digitorum profundus was found to be proximally coiled 180” upon itself. Both the tendon ends appeared healthy. They were threaded into the digital sheath; the superficialis slips were repaired with non-absorbable sutures and the profundus with a modified Kessler non-absorbable suture. The ulnar digital nerve was repaired using the operating microscope. The patient’s hand was closed and bandaged with a bulky dressing which was covered by a long-arm cast. Three months later, the child had a full active range of motion of the digit and could appreciate pin-prick on the ulnar aspect of the finger.
Case 3 This 13-year-old right-handed male lacerated the volar aspect of his right ring and little fingers at the level of the proximal phalanx while cleaning fish with a knife. He was seen at a nearby emergency room where the skin was THE
JOURNAL
OF HAND
SURGERY
PROXIMAL
COILING
OF THE CUT PROFUNDUS
sutured. A light gauze dressing was applied. The patient was seen in our clinic on the following day, when he had no active flexion of the distal joints of the involved fingers though he appeared to have a trace of active flexion at the PIP. joint of each digit. His hand was placed in a bulky dressing and he was instructed to elevate the hand in a sling. At operation two days later, the flexor sheaths were exposed by Bruner incisions. In the ring finger, both flexor tendons were found to be severed, but they were still retained within the digital sheath. Both tendons were also severed in the little finger; the flexor digitorum superficialis stump was delivered into the digital sheath with a tendon retriever. The proximal end of the profundus tendon could not be located until a zig-zag incision was made proximally into the palm, where it was found coiled upon itself 180”. The tendon was uncoiled and appeared healthy (Figs. 1 and 2). It was then threaded into the finger. The superficialis slips were repaired with non-absorbable sutures and the profundus with a modified Kessler non-absorbable suture. A smallcalibre absorbable running suture was used along the edge of the tenorrhaphy. The tendons in the ring finger were repaired in the same fashion. The patient’s hand was placed in a dynamic rubberband traction system. His sutures were removed about two weeks later, and he was lost to follow-up. Seven weeks later, the patient was traced to a juvenile detention centre and his care was re-established with an orthopaedic surgeon. Despite non-compliance and two fist fights, the patient was able to flex his little finger to the distal palmar crease four months after surgery. There was an extension lag of 15” at the P.I.P. joint. His ring finger had nearly the same active range of motion as his little finger.
Fig.
!
Exploration of the palm reveals the severed profundus tendon to be proximally coiled upon itself. The superficialis tendon has been delivered into the finger with a tendon retriever. Needles transfix the tendons in the digital sheaths.
VOL. 14-B No. 4 NOVEMBER
1989
Fig. 2
TENDON
Under direct visualisation, the profundus has been uncoiled distally to prepare it for threading into the finger and delayed primary repair. A paediatric feeding tube is used to pull the tendon into the digital sheath.
Discussion Severed proximal tendon ends are frequently tethered in the flexor sheath by intact vincula which prevent tendon retraction into the palm. However, it is not known how long these delicate vincula can retain flexor tendon stumps in the digital sheath if the patient’s hand is unsplinted and allowed to move freely. It is postulated that only when digits are lacerated in extension or during violent muscle contraction is a palmar incision necessary to locate proximal tendon ends (Kleinert and Smith, 1982). Beasley (1981) specifically recommends strict immobilisation of the hand after laceration to safeguard intact vincula from avulsion which would further diminish the severed tendon’s blood supply (Beasley, 1981). The unreliable patient described as Case 3 was observed to have a trace of flexion at the proximal interphalangeal joints, although his flexor digitorum superficialis tendons were found at operation to be divided. It is known that severed flexor tendons can impart a small flexion moment at the P.I.P. joint through intact vincula (Sasaki and Nomura, 1987). Unguarded flexor muscle contraction may pull the tendon out of the finger into the palm, so strict immobilisation and a protective temporary dressing are essential if delayed primary repair is chosen. The primary management of tendon lacerations is sometimes described simply as wound irrigation, cleansing and closure, if tenorrhaphy is deferred to a delayed primary procedure (Kutz et al., 1986). No attention is focused on splinting or a proper interim dressing with instructions to the patient. The three patients in this report were all inadequately splinted and wiggled their fingers freely while awaiting the delayed primary operation. In his review of the anatomy of the flexor digitorum 417
B. J. GAINOR
superficialis muscle, Kaplan (1981) describes the variations and occasional complete absence of this structure in the little finger. In this finger, the tendon is frequently extremely thin and surgeons must be aware of the almost vestigial nature of this unique tendon. The small size of the superficialis tendon in the little finger may explain, in part, why the proximal end of the severed flexor digitorum profundus can proximally coil upon itself 180” despite the presence of its adjacent superficialis tendon. The author has not observed this curious phenomenon in other digits: it may occur there, but a search of the literature revealed no appraisal or discussion of it. The flexor tendons within the digital sheath receive nutrition by both diffusion and perfusion (Manske and Lesker, 1985). It has been shown experimentally that tendons can remain viable and initiate healing when isolated in the avascular environment of the rabbit kneejoint (Lundborg et al., 1980). Although the profundus tendons in my patients were completely coiled upon themselves in the proximal palm for up to a week, the tendons all appeared viable and healed satisfactorily. When a severed tendon has withdrawn from the digital sheath into the palm, the surgeon can expect the proximal end to be at the level of the Al pulley where it has been restrained by the lumbrical origin. If milking the forearm and hand will not deliver the tendon into the finger, a simple incision near the distal palmar crease will predictably expose the tendon stump. In my three patients, an incision at the level of the Al pulley did not reveal the flexor digitorum profundus and exploration of the proximal palm was required to see the coiled tendon end. Using a tendon retriever in the finger to grasp a retracted tendon blindly must be done carefully (Leddy, 1988), but repeated “fishing” for the tendon end can be dangerous to adjacent anatomical structures (Gould and Nicholson, 1988). The use of a tendon retriever in a distal palmar incision would be unwise because of the risk of injury to the neurovascular structures in the proximal palm. Direct visualisation of tendon ends which have
418
retracted into the proximal palm, especially from the little finger, is recommended before proceeding to thread it into the finger for repair.
References BEASLEY, R. W. Hand Injuries. Philadelphia, W. B. Saunders Company, 1981: 263. GOULD, .I. S. and NICHOLSON, B. G. Flexor Tendon Injuries: Acute Repair and Late Reconstruction. In: Chapman, M. W. and Madison, M. (Eds.) Operative Orthopedics. Philadelphia, J. B. Lippincott, 1988 : 1147-l 168. ISELIN, F. Early management of fresh hand wounds with specific reference to delayed repair. In: American Academy of Orthopaedic Surgeons Symposium on Tendon Surgery in the Hand. St. Louis, C. V. Mosby Co., 1975: 88-90. KAPLAN, E. B. Anatomical variations of the forearm and hand. In: Tubiana, R. (Ed.) The Hand, Vol. 1. Philadelphia, W. B. Saunders Co., 1981: 361-374. KLEINERT, H. E. and SMITH, D. J. Primary and secondary repair of flexor and extensor tendon injuries. In: Flynn, J. E. (Ed.) Hand Surgery (3rd edn.) Baltimore, Williams and Wilkins, 1982: 220-242. KUTZ, .I. E. and BENNETT, D. L. Tendon injuries. In: Watson, N. and Smith, R. J. (Eds.) Methods and Concepts in Hand Surgery. London, Butterworths, 1986: 148-189. LEDDY, J. P. Flexor tendons-Acute injuries. In: Green, D. P. (Ed.) Operative Hand Surgery, 2nd edn. New York, Churchill Livingstone, 1988: Vol. 3: 1935-1968. LUNDBORG, G., HANSON, H.-A., RANK, F. and RYDEVIK, B. (1980). Superficial repair of severed flexor tendons in synovial environment. An experimental, ultrastructural study on cellular mechanisms. Journal of Hand Surgery, 5A: 5: 451-461. MANSKE, P. R. and LESKER, P. A. (1985). Flexor tendon nutrition. Hand Clinics of North America, 1: 1: 13-24. MILFORD, L. Tendon injuries. In: Crenshaw, A. H. (Ed.) Campbell’s Operative Orthopaedics, 7th edn. St. Louis, C. V. Mosby Company, 1987: 149-182. SASAKI, Y. and NOMURA, S. (1987). An Unusual Role of the Vinculum After Complete Laceration of the Flexor Tendons. Journal of Hand Surgery, 12B: 1: 105-108. SCHNEIDER, L. H., HUNTER, J. M., NORRIS, T. R. and MADEAU, P. 0. (1977). Delayed flexor tendon repair in no man’s land. Journal of Hand Surgery, 2: 6: 452-455. STRICKLAND, J. W. Functional recovery after flexor severance in the finger: the state of the art. In: Strickland, J. W. and Steichen, J. B. (Eds.) Dt@cult Problem in Hand Surgery. St. Louis, C. V. Mosby Co., 1982: 73-85.
Accented: IO Februarv 1989 Barry J. Gainor, M.d., Associate Professor, Missouri Health Sciences Center, Columbia,
0 1989 The British
Society
for Surgery
Division of Orthopaedic Missouri 65212, U.S.A.
Surgery,
University
of the Hand
026&7681/89/0014-0416/$10.00
THE
JOURNAL
OF HAND
SURGERY
of