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Repair of digital flexor tendon injuries in the hand
REPAIR OF DIGITAL FLEXOR TENDON INJURIES IN THE HAND
By STEWARTH. HARRISON, F.R.C.S., L.D.S.R.C.S.(Edin.) From the Mount Vernon Centre of Plastic Surgery and the Windsor Group of Hospitals
THIS paper presents ioo cases of flexor tendon injuries in the hand, of which twenty-four affected the thumb and seventy-six the finger within the area described by Bunnell as " n o man's land." Eighty-six cases were repaired by tendon grafting. The cases are subdivided into the following groups : ThumbsFlexor tendon grafts I8 Tendon suture 4 Tendon transplant I Tendon lengthening I TOTAL
Fingers-Primary tendon suture Primary tendon graft . . Tendon graft with half sublimis Tendon graft with excision of sublimis
2j 8 II
i8 39 TOTAL
72
Previous publications on flexor tendon grafting have given rise to discussion on the following points : m I. The relative merits of primary repair as compared with secondary. 2. If primary repair is preferred, then should the repair be by suture or by grafting ? 3. The choice of the tendon graft. 4. The problem of the divided flexor profundus in the presence of an intact sublimis. 5. The choice of suture material. 6. The method of fixation at the proximal and distal junctions of the graft. In evaluating the results of this series these points will be considered and discussed. Assessment of the end results following tendon repairs in the finger is determined by the ability of the patient to touch the palm with the tip of the injured finger. Perfection, by measuring the distance from the point at which the finger tip touches the palm to the flexor crease of the metacarpo-phalangeal joint and deducting from this a similar distance on the normal hand (Figs. I and 2). Graphs are included relating the measurement to the percentage of cases in the 2II
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three groups of finger grafts. All cases having limked extension o f 3o degrees or over are classified separately. Other methods of assessment have been published, as for example, taking 27o degrees as the normal range of a finger, or measuring the distance o f the finger
FIG, I
FIG. :2
Figs. I and 2.--Estimation of finger flexion by deducting the distance between the point at which the normal finger tip touches the palm and the metacarpo-phalangeal joint crease, from a similar measurement on the affected hand. tip from the distal palmar crease ; but no m e t h o d other than a photographic record can give a clear visual picture of an end result, and even that does not necessarily interpret a functional end result, which relates only to a patient's ability to adapt himself to his specific job. T o show the end results of tendon grafts for the t h u m b a table is included which shows the total range of movement o f the terminal interphalangeal joint. THUMB REPAIRS In this series there are twenty-four repairs for the divided flexor pollicis grouped as follows : T e n d o n grafts 18 T e n d o n suture . 4 T e n d o n transplant I T e n d o n lengthening I
REPAIR
OF
DIGITAL
FLEXOR
TENDON
INJURIES
IN
THE
HAND
2I 3
The results of the tendon sutures were :-(a) One tendon re-attached as a primary procedure--result poor. (b) Two primary sutures--result poor. (c) One secondary suture--result full range. One primary transplant using flexor sublimis from the ring finger--result: range at terminal joint i8o/ii 5 compared with the normal thumb which was i8o/9o. FLEXOR TENDON GRAFTS OF THE THUMB The span was limited by I½- in. 100 One tendon lengthening in which the advancement was made above the wrist 8O --result poor. Eighteen tendon grafts of which I t . fifteen were palmaris grafts and three 6o were toe extensors. One primary graft using palmaris resulted in a range of o I8O/iO 3 compared with i8o/9o on the 4o normal side. The total range of move- tO ment of eighteen grafts is shown in 2o Table I, and the percentage of joint motion in Fig. 3. (Boyes' graph.) In all cases some limitation of the 0 I I I I 100 80 60 40 20 total span was present; but no patient failed to adapt himself to this disability PERCENTAGE OF JOINT MOTION although some complained of slight VOL. FLEXION PASS. FLEXION × 100 disability in gripping. It will be seen in Table I that six FiG. 13 cases extended beyond I8o degrees, and Percentage of joint m o t i o n in flexor t e n d o n only two flexed to 9o degrees. The average grafts of the t h u m b . range of motion was I82"9/I35. TABLE I Range of Movement in Flexor Tendon Grafts of the Thumb Extension.
1215
I95 I95 I8OI I80 I80
i4o i65 i55
I80 I80 I 8 0 ' I 8 0
9 ° io 5 ioo i i 5 i4o
laver]age. I80 I75 I65
i25J i40 i55 Flexion.
I50 I90 I95 I80 1901 I82"9 ,
9 ° IO 5 I3 o I8o I65 I6O I7O J i35.o I
Operation.--The incision (seen in Fig. 5) allows the proximal end of the divided flexor pollicis, which retracts into the thenar muscles, to be found without difficulty using this approach, The theca is excised, leaving a wide pulley over the base of the proximal phalanx. The distal segment of the
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tendon is removed as far distal as possible, leaving only a small part for junction with the graft. An incision is made in a longitudinal direction on the forearm, and the flexor pollicis and palmaris are identified. A long silk suture is passed through the proximal end of the divided tendon and withdrawn with the tendon into the wound of the forearm. The tendon graft--using either palmaris or a toe extensor--is then sutured to the silk and withdrawn distally through the tunnel, using the silk as a guide and a tractor. The graft is passed under the pulley and
FIG. 4
FIG. 5
FIG. 6
Figs. 4 to 6.--Pre-operative and post-operative terminal joint range of the right thumb. Incision outlined.
sutured with silk (3/0) to the distal attachment of the pollicis tendon. The method of suturing is a figure-of-eight through the graft and a single loop on both needles through the distal part of the tendon. The thumb incision is then closed and the pulp of the thumb anchored to the palm by a silk suture with the terminal joint flexed. The proximal junction of the graft is made at the musculo-tendinous junction of the flexor pollicis. Approximation is side to side, and the junction is covered with muscle. Absolute immobilisation is provided by plaster of Paris, with the wrist and terminal joint in flexion, maintained for three weeks. Fig. 4 shows the right thumb before operation. Fig. 5 is a post-operative view, with the skin incision outlined, showing limited span but full extension. Fig. 6 shows the post-operative range of flexion compared with the normal. The operation is performed under general anaesthesia, using a tourniquet which is not released until the plaster of Paris is applied and set. In order to assess function it is necessary to analyse the optimal positions which the terminal joint should adopt in basic movement.
REPAIR
OF
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FLEXOR
TENDON
INJURIES
IN
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HAND
215
There are four basic functional positions (see Figs. 7, 8, 9, and IO) : q I. Pinch, in which contact between the pulps of the thumb and index finger create a circle. 2. Pinch grip, in which the maximal apposable surfaces of the pulps of the index finger and thumb come into contact. 3. Tripod pinch, in which the pulp of the thumb opposes both the index and middle finger pulps. 4. Grip, in which the terminal phalanx of the thumb locks the index and middle fingers in the position of a fist.
FIG. 7
FIG. 8
FIG. 9
FIG. IO
Figs. 7 to I O . - - T h c functional positions o f t h e t h u m b .
In pinch, the terminal joint of the thumb is in a position of approximately I45 degrees of flexion. In pinch grip and tripod pinch the terminal interphalangeal ioint is hyperextended. In grip, the terminal ioint is in a position of approximately 14o degrees of flexion. It will be seen, therefore, that a poor result following tendon repair, i.e., inability to hyperextend or inability to flex to 90 degrees, will not seriously interfere with fine movement ; but limitation of hyperextension will interfere with power pinch and limitation of flexion will affect grip. Lifting, carrying, and holding are not seriously affected in the poor result cases except in those with acute flexion deformity of the terminal joint--a rare complication. It should be noted, however, that the span of the hand is limited in all cases which fall short of full extension and this gives rise to disability only in certain specific occupations, e.g., bricklayers. In this series of eighteen tendon grafts no patient complained of any serious disability or was unable to return to his pre-accident occupation although the average range of movement was only 47"9 degrees compared with a normal of approximately ioo degrees.
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Primary suture of the divided distal end of the flexor pollicis should be accepted as the treatment of choice provided the state of the wound warrants further exposure ; if not, the skin should be closed and the tendon repaired by grafting later. Kelly (1959) claims good results in ten out of fifteen cases of primary repairs. In this series either primary or secondary tendon grafting has been given preference where the tendon has been divided more proximally. Admittedly, the number of cases of suture recorded here are too few to substantiate this claim, but the results of suture were so poor that this method was discarded in favour of grafting i n which a uniformly satisfactory functional end result could be confidently expected. Furthermore, it would appear that the same factors which influence the decision either to suture or to graft in division of the flexor tendons within the digital sheaths of the fingers to a large extent also apply to the thumb. One case of primary tendon transplant of the sublimis of the ring finger to replace the divided flexor pollicis is included. The end result of this procedure was a good range of terminal joint movement ; but the span was limited by I½ in. It was decided that this method of treatment should be reserved for exceptional cases. FLEXOR TENDON REPAIRS OF THE FINGERS
These cases are divided into the following groups : Primary tendon suture Primary tendon graft . . Tendon graft with half sublimis Tendon graft with excision of sublimis TOTAL
8 II
18 39
72
Primary Tendon S u t u r e . - - I n this group of eight cases all the tendons were divided within the flexor sheath distal to the level of the metacarpo-phalangeal joint. The patients were carefully selected, the suture material was 3/o silk, and the end results were as follows : Two primary sutures failed and were later successfully grafted. Three cases were successfully sutured. One failed and the finger was amputated. One failed and was left with severe limitation of movement. One was not followed up. The small number of cases presented is an indication that this method of repair has not proved generally acceptable. It has now been discarded in favour of grafting except for two classes of patient. Firstly, patients in the late age groups who have sustained a distal division in whom it is desired to create a tenodesis, and secondly for selected patients in the early age groups, particularly those with long, slender hands and fingers. Two of the three successfully treated patients in this group were under 5 years of age. In each case the sublimis was removed and the profundus sutured. P r i m a r y T e n d o n Grafts.--Harrison (1956) records fourteen cases of primary flexor grafts and a comparable series of thirteen secondary grafts. No significant
REPAIR
OF
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TENDON
INJURIES
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HAND
217
difference exists between these two series ; but there are obvious advantages in primary grafting, summarised as follows :-I. Reduced time off work and period of incapacity. 2. Reduced incidence of disuse atrophy. 3. The gliding mechanism is intact and the withdrawal of the divided tendon is atraumatic in the absence of fibrous adhesions. 4. The exact length of tendon replacement can be measured accurately. There is some difference of opinion on the advisability of this procedure, largely based on the assumption that there is an increased risk of infection ; but provided the criterion of selection is rigidly applied the risk is insignificant. No case of infection occurred in this or in the previously reported series. The criterion of selection is a clean incised wound of short duration. Of the sixty-eight flexor tendon grafts reported in this paper there were eleven primary grafts in ten patients. Table II shows a summary of the results. TABLE II Primary Flexor Tendon Grafts of the Finger Decades. Result.
Touched palm Limited flexion No movement, Amputation .
No.
.
2
8
Middle
Ring Little
.
5
~Cent.
Palmaris Grafts.
Toe Extensor Grafts.
I
...
r 72'7
4
4
I
I
[ I8'I
I
I
5
.,°
G--
Digit. .
4
......
Total
Index
3
Per
No.
Failed.
.
o
" ,
-I
I 2
:
6
2
Percent.
5 -
2 7"2
I
2 7-2 I8'I
]
2 7 .2
Limited extension Hyperextension . Crush Incised
2 2 I IO
In this group one case involving the ring finger was disabled from limited extension. There were two cases which subsequently developed a hyperextension deformity at the proximal interphalangeal joint. This complication is regarded as being due to removal of the sublimis and consequent loss of support for the anterior capsule and will be discussed later, There were two failures, and of these, one came to amputation. This was a case of crush injury and the tendon graft had been passed through the two slips of the sublimis. The other patient was the only one in the fifth decade. In eight of the eleven grafts the finger tip touched the palm, giving a successful end result in 72"7 per cent., and of these 25 per cent. recovered a full range of movement. Fig. I I relates the percentage of grafts to the palmar measurement after deduction of the normal in eight cases that touched the palm. The grafts were either palmaris or toe extensor, and there was no significant difference in the results from the choice of graft. Fig. 14 shows the post-operative
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views, immediately after the removal of the plaster of Paris, of a patient who had divided both flexor tendons of the ring and little fingers with a penknife, transversely, at the level of the middle joint crease. Both sublimis tendons were removed. The profundus to the ring finger was repaired by suture, and the little finger by a palmaris graft, as a primary procedure. EIGHT PRIMARY FINGER T E N D O N GRAFTS T O U C H E D THE PALM
100
80 u3 LL (_9 b_ 0 hi (..9
60
~ 4o Z l.t.I
J
J
X
a_ 20
0. ~/4
t/2
3/4
1
194
lJ/2 "
THE DIFFERENCE IN MEASUREMENT BETWEEN THE T W O HANDS FROM THE POINT THE FINGER TIP TOUCHES THE PALM TO THE METACARPO-PHALANGEAL JOINT CREASE FI~.
ii
Primary finger tendon grafts.
Figs. 12 and 13 show the final results five months after operation. The range in the tendon-grafted little finger was -~ in. better than the ring. The rate of recovery in the fingers was equal. Flexor T e n d o n Grafting with Preservation of H a l f the S u b l i m i s . m This modification in the technique of flexor tendon grafting was described previously (Harrison, 1959) and is used for those cases in which the flexor profundus has been divided and the sublimis is undamaged. Attempts to thread a graft through the two slips of the sublimis as a method of repair were followed by such poor results that they were abandoned and it became accepted practice to remove the intact sublimis when inserting a tendon graft ; however, when the latter series came to be reviewed, it was found that a percentage had developed a hyperextension deformity at the proximal interphalangeal joint. This deformity progresses to a subluxation, and so far has proved impossible to correct. The object of this modification is to prevent a hyperextension deformity, to conserve a flexing mechanism within the digit, and to provide adequate space within the digital pulleys to accommodate a graft.
REPAIR
OF
DIGITAL
FLEXOR
FIG. I2
TENDON
INJURIES
FIG. Z3
IN
THE
HAND
219
FIG. I4
Fig. i 2 . - - I n c i s i o n s used for primary repair of the profundus of the ring finger and primary t e n d o n graft of the little finger. Figs. I3 and z 4 . - - S h o w i n g the final range of movement.
The operation is performed either as a primary or a secondary procedure. The steps of the operation are similar to primary and secondary grafting except that one slip of the sublimis is removed, leaving the vincula attached to the remaining slip. A clear plane of cleavage is found in the tendon and half the sublimis is removed well up into the palm. There are eighteen cases in this series and the results are shown in Table III. Four cases were classed as failures and fourteen were successful (77"8 per cent.). A full range occurred in 28 per cent. There were TABLE III Flexor Tendon Grafts with Preservation of Half the Sublimis f
Decades. Result.
/ No.
2
I
Touched palm • " ! ~ 4 L i m i t e d flexion No movement Amputation
/4
Total Digit. Index Middle Ring . Little
18
No.
8 4
4
! 4
5
5
I
I
...
3
Z
5
Palmaris
77"8[
...
--13 I-3--
i
C_C
. . . . . .
Per
Toe Extensor i iqantarls Grafts. i Grafts.
3
Cent__ °jets 22 '2
I
I I
. . . . . .
4
;]
2
Failed.
Per Cent.
z o I I
44 '4 z6.4 I6"4 22 "2
3
I 0 0 "O I
/
I
L i m i t e d extension . Hyperextension Crush . Incised Burn Avulsion
""
I
""
z4
I I
3
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two cases in which primary skin loss was dealt with by a cross-finger flap and tendon grafts were inserted later. Both recovered a full range of movement. Fig. 15 shows skin loss with division of the flexor profundus affecting the middle finger, and areas of skin loss on the index and ring fingers without tendon involvement. Fig. 16 shows a primary repair of the skin by cross-finger flap for the middle finger and free grafts for the index and ring fingers.
FIG. 15
FIG. 16
FIG. 17
FIG. 18
Fig. IS.--Skin loss on the middle finger w k h division of the flexor profundus. Fig. I6.--Cross-finger flap. Fig. I 7 . - - D o n o r site of cross-finger flap. Fig. i 8 . - - H e a l e d donor area. Figs. 19 to 21 .--Final range after tendon grafting, with preservation of half the sublimis.
FIG. 19
FIG. 20
FIG. 21
Fig. 17 shows the donor site on the dorsum of the ring finger, and Fig. 18 the healed donor site. Figs. I9, 2o, and 2I show the final range of movement after flexor tendon grafting with preservation of half the sublimis. No case of hyperextension deformity of the proximal interphalangeal joint occurred in either this or the original series. In all cases recovering a functional range of movement independent profundus and sublimis action can be demonstrated. Fig. 22 relates the percentage of grafts to the palmar measurement after deduction of the normal in fourteen cases that were able to touch the palm.
REPAIR
OF DIGITAL
FLEXOR
TENDON
INJURIES
IN
THE
HAND
FOURTEEN TENDON GRAFTS PRESERVING HALF SUBLIMIS TOUCHED THE PALM
100
80
f
t/3 I--LL
=<
60
(.D It_ 0 ILl F-Z
40
0
20
0
I
I
~
I
I
¼
'/2
3/4
1
lJ/4
'/2"
THE DIFFERENCE IN MEASUREMENT BETWEEN THE TWO HANDS FROM THE POINT THE FINGER TIP TOUCHES THE PALM TO THE METACARPO-PHALANGEAL JOINT CREASE FIG. 22 Flexor tendon grafts with preservation of half the sublimis.
Fm. 23
FIG, 24
FIG. 25
FIG. 26
FIG. 27
Figs. 23 and 24.--Pre-operative range following division of the flexor profundus of the little finger. The sublimis was undamaged. Fig. 2 5 . u S h o w i n g the incision used for exposure of the little finger. Figs. 2.6 and 27.--Final range after tendon grafting with preservation of half the sublimis.
22I
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Figs. 23 and 24 show the pre-operative range of motion in the little finger following division of the flexor profundus with intact sublimis function. Fig. 25 shows the incision after repair by tendon graft with preservation of half the sublimis. Figs. 26 and 27 show the final range five months after operation. TWENTY-NINE FINGER T E N D O N GRAFTS WITH EXCISION OF SUBLIMIS T O U C H E D THE PALM 100
80 uo LL < rY 60 o LL 0 O3 0
J
40
Z w o PeW
20
0
1
I
i
I
¼
½
¾
1
i
1¼
~½"
THE DIFFERENCE IN M E A S U R E M E N T BETWEEN THE T W O H A N D S FROM THE P O I N T THE FINGER TIP T O U C H E S THE PALM T O THE M E T A C A R P O - P H A L A N G E A L J O I N T CREASE FIG. 28 Flexor tendon
grafts with excision of sublimis.
Secondary Tendon Grafts with Removal o f Sublimis.--There were thirty-nine cases in this group (see Table IV). The sublimis was removed in all cases whether damaged or not. It will be seen from the table that the number of hyperextension deformities occurring were four, an incidence of lO-2 per cent. It is possible that this figure may ultimately prove to be higher as the deformity may appear several years after tendon grafting following a relatively minor extension injury. Three cases had limited extension and all were in the group of limited flexion. Twenty-nine cases, 74"3 per cent., touched the palm and the functional end result was good in all cases. Fig. 28 shows the final assessment in which, 3o- 7 per cent., the distance from the point the finger tip touched the palm to the metacarpo-phalangeal joint crease was equal onboth sides and, 74"3 per cent., the difference was I½ in. or less. It may be of interest to note that the results of tendon grafting in the middle finger are better than in any other finger. The ring and little fingers are comparable, but the index finger gives less good results than any of the others.
REPAIR OF DIGITAL
FLEXOR
TENDON INJURIES
IN THE H A N D
223
TABLE I V Secondary Tendon
Grafts w i t h E x c i s i o n o f S u b l i m i s Decades.
Result.
I
Touched p a l m Limited flexion . N o movement Amputation Total
Middle Ring . Little
29
2
9 3
No.
I2
3
9 2
2
39
Digit. Index
•
No.
II
Failed.
IO
5
2
, L.
I
I
...
9
4
3
,
.
.
74'3 I I7.9f
19 2
8 5
!
2 ...
2"51
...
I
...
I00"O ]
22
15
2
...
Per Cent. 23 .o 33 "3 17.6 25 .6
•
4
Toe
P e r I P a l m a m s I t~xten~or ' S u b h m l s C e n .t . G . r a. f t s. . . . G .r a f t s i G r a f t s .
Limited extension Hyperextension Crush Incised Attrition Tendon sheath infection
4 9 27 I I
Crush injuries are frequently followed by a poor end result and in this series five out of nine were failures. Two primary sutures failed and were later grafted with a successful end result. Two grafts were passed through the slips of the sublimis and failed; one was later regrafted with removal of sublimis and a successful result ensued, but the other came to amputation. One patient aged 4 2 was deaf and dumb and, despite two consecutive tendon grafts on the same finger, failed to obtain useful movement. One patient lost both tendons following a suppurative tenosynovifis, but regained a full passive range of movement. A tendon graft was inserted and 6o degrees of active movement was regained in the proximal interphalangeal joint• The patient developed a hyperextension deformity and the attempt to correct this by the insertion of a new pulley merely served to reduce still further the final range of movement. OPERATION
FOR T E N D O N
GRAFTING
Apart from minor variations the surgical technique was the same for the three groups. Indicafions.--In primary grafting a clean incised wound of short duration is essential. In secondary grafting operation is performed when the wound is soundly healed provided that there is no limitation of joint movement. Contraindications.--Crush injuries are a contraindication to primary grafting, and secondary grafting should be deferred until a passive range of movement has been recovered• Grafting when the tendon injury is associated with a fracture should be deferred until the fracture has united and a passive range of movement has been recovered.
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The operation for tendon grafting is based on the principles outlined by Rank and Wakefield (1952) in which the theca is excised, leaving pulleys over the proximal and middle phalanges. The incisions used for the fingers can be seen in Figs. I4, 29, and 3o. The skin flap on the fingers is elevated superficial to the nerve and artery ill order to avoid any interference with the blood supply. If the theca is fibrotic where a pulley is required then a new pulley is made by passing a tendon graft circumferentially around the phalanx.
FIG. 2 9 Incision for exposure of t h e i n d e x finger.
FIG. 30 Incision for exposure of t h e m i d d l e finger.
The distal end of the tendon graft is sutured with a figure-of-eight stitch, using 3/o silk carrying two needles. The needles are passed through the deep aspect of the distal end of the profundus, then back from superficial to deep. Thus the end of the profundus is made to overlap the junction on the superficial aspect. The incision in the finger is then closed. A traction suture on the pulp is passed through the palm and tied over the distal pu!p after measuring the distance from the tip of the finger to the palm and comparing this with the normal hand (see Fig. 31 which shows the measurement of tension in the normal finger). The wrist is held in the same position as the opposite hand. Fig. 32 shows the finger tip being anchored to the palm with silk after measuring off the same degree of flexion as seen in Fig. 31. By this means the length of graft required is estimated and any surplus is removed at the site of the proximal junction. In primary grafting the graft is laid alongside the two parts of the profundus removed, and is cut to the exact size. The proximal end of the graft is again sutured with 3/o silk carrying two needles inserted as a figure-of-eight and the two ends are made to emerge at the cut end. The four ends are then tied, leaving a buried knot between the junction ;
REPAIR
OF DIGITAL
FLEXOR
TENDON
INJURIES
IN
TItE
HAND
225
the latter is then covered with lumbrical muscle, leaving the knot of the suture buried. Plaster of Paris is applied with the wrist and fingers flexed. When the plaster is set the tourniquet is released. Absolute immobilisation is maintained for three to four weeks. At the end of this period active movements are begun. Two points are worthy of emphasis :-I. The prevention of muscle pull is determined by the immobilisation provided by the plaster of Paris and not by the suture material which is designed only for approximation and not to resist tension ; as a result no tendon junction has parted in this series. 2. Silk is not considered to be a cause of limiting adhesions if it is properly placed.
FIG. 31
FIG. 32
Figs. 3I and 32.--Method of estimating the length of the tendon graft by measurement of the tension in the normal hand.
Post-operative Care.--After removal of the plaster of Paris the patient is persuaded to exercise each individual joint of the affected finger and then all the fingers and hand for a period each hour systematically throughout the day. The best results are obtained in young co-operative patients by encouragement and a close doctor-patient relationship. In no other branch of surgery is the need for complete confidence between doctor and patient greater than in hand surgery. Only in those patients who do not respond to this treatment are physiotherapy and live splints employed. In cases which develop inco-ordination occupational therapy is valuable. The splint most commonly used is seen in Figs. 33, 34, and 35 and was made by the Vauxhall Rehabilitation Centre. It consists of piano wire looped to provide springs, and slings made of chamois leather. Physiotherapy should be confined to supervision of active movements and constant encouragement to persevere. Specialised services such as the Vauxhall Rehabilitation Centre and the Farnham Park Rehabilitation Centre are ideally designed for the rehabilitation of hand injuries and provide the means to work the hand to the best possible advantage by using designed grips to work machines. This has the advantage of exercising the hand and fingers and at the same time distracts the patient's attention from the injured part. The work provides continuous resisted active movement over the relatively short period of time which elapses between the time of operation and the establishment of mature fibrous tissue responsible for permanent limitation 3D
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of movement. The average time for full recovery of movement is five months. Further improvement after this period is progressively slower and the end results progressively less satisfactory.
FIG. 33
FIG. 34
FIG. 35
Figs. 33 to 35.--Spring splint for correcting flexion deformity.
After one year the question of tenolysis should be considered in those cases with limited movement due to adhesion of the graft. An occasional good result can be obtained, especially in the rare case where the adhesions are confined to the junction in the palm ; but the usual finding is dense adhesion of the graft along the entire length of the digit and into the hand. The results of tenolysis in such cases have proved to be poor. More recently the results have seemed to be better and it is assumed that the instillation of a combined solution of hydrocortisone and chloromycetin daily for seven days, by means of an indwelling polythene tube, following tenolysis, may have been a factor in this improvement. The tube extends from the palm, along the finger, and emerges through the distal pulp. The wounds are exposed and movements commenced immediately. James (1959) uses 15o mg. of cortisone daily for fourteen days and has reviewed twenty-two cases. CONCLUSIONS
The end resuks of the repair of a flexor tendon, whether k is the thumb or the finger, are dependent on the patient's abilky to adapt himself to whatever disabilky persists. The basic functional requirements of the thumb have been briefly analysed and k is apparent that a limited range of movement and a reduction of the span of the hand can be compensated for in the majority of occupations. It is not surprising, therefore, that good results can be claimed for different methods of treatment. In the fingers, the patient's abilky to adapt himself to a permanent deformity is to some extent governed by the finger involved. A flexion deformity
REPAIR
OF
DIGITAL
FLEXOR
TENDON
INJURIES
IN
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HAND
227
of the middle or ring fingers is more disabling than the index and little fingers because the finger tip will transgress the transverse plane of the hand when a flat hand is required. The index and little fingers can compensate by hyperextension at the metacarpo-phalangeal joints. It is important to realise that in many industrial occupations, e.g., sheet metal workers, carpenters, and draughtsmen, a flat hand is an essential functional requirement. The same disability causes the patient to catch the finger tips on various objects, making him clumsy at work and the hand awkward to use. The index and little fingers can compensate for a limited range of movement not acceptable for the middle and ring fingers by their capacity for greater independent movement and compensatory metacarpo-phalangeal joint range. On page 2II of this paper certain points were tabulated for discussion, and the following conclusions are drawn :-I. There is no contraindication to primary grafting of a divided flexor tendon in the presence of a clean incised wound of short duration. On the contrary it is easier, quicker, less traumatising, and reduces the period of disablement as compared with secondary grafting. No case of infection has occurred in this or in a previous series published. 2. It is suggested that the results of primary graftings are preferable to primary suture, except in avulsions and distal divisions, or when a tenodesis is an acceptable end result. 3. In this series the choice of graft lay between the palmaris and the toe extensors. There were twenty-eight palmaris grafts and thirty-five toe extensors. In the palmaris group there were 17-9 per cent. failures and in the toe extensor group 34"3 per cent. failures. Two sublimis grafts and three plantaris grafts were all successful. It would appear from this series that the results were better using palmaris. Boyes (195o) made a similar observation. Pulvertaft (1956) does not consider that the choice of graft materially influences the result. The toe extensor has had preference in this series for the following reasons :-(a) The assistant procures the graft and there is a saving of time. (b) The graft is thinner than the palmaris. (c) The forearm scar when using palmaris is often unsightly, whereas the dorsum of the foot rarely is. Against (a) (b) (c) (d)
the toe extensor : m The patient is confined to bed longer. Residual cedema persists in patients in the older age groups. Delayed healing is more commonly seen in the foot than in the forearm. One patient developed a phlebothrombosis and a pulmonary embolus from which he fortunately recovered ; but the vital period for rehabilitation was lost and the finger remains stiff.
The figures in this paper show a significant difference between palmaris and toe extensor grafts and further consideration should be given to the choice of graft. 4. The problem of the divided flexor profundus in the presence of an intact sublimis cannot be answered by any one method of treatment. The half sublimis modification shows good results in 77"8 per cent. of cases. Independent action of the tendons can be demonstrated and the capsule of the joint is adequately
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protected against minor extension injuries. In the younger age groups this method is the treatment of choice. In the middle age groups it is used for the index and little fingers whereas tenodesis may be considered for the middle and ring fingers. In the later age groups tenodesis is probably the treatment of choice. In cases in which both tendons have been divided and have to be removed, .one slip of the sublimis must be preserved whenever possible to reinforce the capsule of the joint. This applies not only to tendon grafting but also when sublimis is used as a transplant, otherwise a hyperextension deformity will occur as an insidious process of capsular stretching or as the result of a minor extension injury. This deformity may not appear for several years after grafting for obvious reasons. 5- The choice of suture material has been much discussed, but it is felt that this does not influence the result so much as the following :-(a) The distal junction should be well beyond the terminal joint. (b) The proximal junction should be accurately made and any inequalities at the junction covered by lumbrical muscle. (c) The suture should be considered a method of approximation and not fixation. The latter is provided by absolute immobilisation in plaster of Paris wkh reduction of muscle pull to the minimum by flexion of the wrist and fingers. Lindsay et al. (I96O) report an experimental study on the use of silk and stainless steel and note that both are adequate. They state that proximal muscle pull is a major cause of gap. It is assumed, therefore, that a safe junction can be established only by immobilisation in plaster. In this series there has been no evidence to show that any tendon junction, proximal or distal, has parted. 6. The method of joining the proximal and distal ends of the graft has been discussed. The distal junction should be well beyond the terminal joint. The proximal junction should be accurate and covered by lumbrical muscle. SUMMARY This paper reviews IOO tendon repairs, of which sixty-eight were flexor tendon grafts of the fingers and eighteen were grafts of the thumb. The end results are tabulated and graphed. It is evident that good function can be obtained in the presence of a limited range of movement in some cases. Of the eighteen thumb grafts the average range was 182"9/135. No functional disability was claimed although the majority had both a reduced range of movement and a reduced span. Primary tendon grafting of the fingers is advocated in the presence of an incised wound of short duration. There were eleven patients in this series with a 72 per cent. successful end result. The half sublimis modification of tendon grafting is described and the indications for the use of this method. There were eighteen patients in this group with a successful end result in 77"8 per cent. There were thirty-nine secondary tendon grafts with a successful end result in 74"3 per cent. The total of successful end results in the three groups of finger grafts was 75 per cent.
REPAIR
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HAND
229
The fingers involved were : ~ Digit. Index . Middle Ring Little
Number.
Failures.
20 19 I2 17
5 2 3 6
TOUCHED E X C I S I O N SUBLIMIS HALF SUBLIMIS P R I M A R Y FINGER GRAFTS .
Successes.
75.o 89"0 75.o 64.8
per per per per
cent. cent. cent. cent.
PALM 74.3 per cent. 77.8 per cent. - . . . . . . . . . . . . 72.7 per cent. • . . . . .
100
80
js U") I-la_
60
o"
,£9 Ix. 0
/"
J ~-I~ sI
40
./"
i~.~.~-o
-~'~
Z bJ n," 20
0
I I/4
I 112
I 3//4
I ]
I ] ?4
THE DIFFERENCE IN M E A S U R E M E N T BETWEEN THE T W O H A N D S FROM THE P O I N T THE FINGER TIP T O U C H E S THE PALM T O THE M E T A C A R P O - P H A L A N G E A L J O I N T CREASE FIG. 36
Composite graph. There were seventeen crush injuries of the fingers treated by grafting, of which nine were failures--an incidence of 52"9 per cent. The choice of grafts for the fingers was as follows : Graft. Palmaris . Toe extensor Sublimis Plantaris .
Total.
Successes.
Failures.
Successful.
28 35 2
23 23 2
5 12 o
82.I per cent. 65"7 per cent. IOO.O per cent.
2
2
o
IOO.O per cent.
Hyperextension deformity of the proximal interphalangeal joint appeared in two cases in the primary grafting group and four in the secondary group. No case occurred in the half sublimis group. Attention is drawn to the serious nature of this complication of tendon grafting and the means to avoid its occurrence. Fig. 36 is a composite graph to show the comparison between the three groups
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of finger grafts that touched the palm and the difference in measurement between the normal and the affected finger. Seventy-five per cent. of all cases that touched the palm had a difference in measurement between the two hands of I½ in. or less. Of all grafts that touched the palm, 27"9 per cent. had a full range of flexion and maximal recovery occurred within five months of operation. Flexion contracture of 3o degrees or more occurred in I 1.7 per cent. In Boyes' series, 5o per cent. came to within I½ in. of the distal crease and 25 per cent. had complete flexion. In Pulvertaft's series, quoting the profundus and sublimis group, 7 ° per cent. came to within I in. of the distal palmar crease and 9 per cent. had perfect flexion. Twelve cases had flexion contracture of 30 degrees or more. I would like to express my thanks to Mr Rainsford Mowlem for his interest and advice during the period in which this study has been in progress. I would also like to express my thanks to Miss Nora Walker of the Photographic Department, Mount Vernon Hospital, and to Mr Fisk of the Photographic Department, Canadian Red Cross Memorial Hospital, Taplow.
REFERENCES BOYES, J. H. (I95O). J. Bone J t Surg., 32A, 589. HARRISON, S. H. (1956). Brit. reed. ft., 2, 746. --(1958). Brit. ff. plast. Surg., i i , lO6. --(196o). "Transactions of the International Society of Plastic Surgeons," 2nd Congress, London, 1959, P. 217. JAMES, J. I. P. (1959). J. Bone Jr Surg., 4rA, 2o 9. KELLY, A. P. (1959). ft. Bone Jr Surg., 4IA, 581. LINDSAY, W. K., THOMSON, H. G., and WALKER, F. G. (196o). Brit. J. plast. Surg., I3, I. PULVERTAFT,R. G. (1956). J. Bone Jr Surg., 38B, 175. RANK, B. K., and W~EFIELD, A. R. (1952). Brit. J. plast. Surg., 4, 244.
By STEWARTH. HARRISON, F.R.C.S., L.D.S.R.C.S.(Edin.) From the Mount Vernon Centre of Plastic Surgery and the Windsor Group of Hospitals
THIS paper presents ioo cases of flexor tendon injuries in the hand, of which twenty-four affected the thumb and seventy-six the finger within the area described by Bunnell as " n o man's land." Eighty-six cases were repaired by tendon grafting. The cases are subdivided into the following groups : ThumbsFlexor tendon grafts I8 Tendon suture 4 Tendon transplant I Tendon lengthening I TOTAL
Fingers-Primary tendon suture Primary tendon graft . . Tendon graft with half sublimis Tendon graft with excision of sublimis
2j 8 II
i8 39 TOTAL
72
Previous publications on flexor tendon grafting have given rise to discussion on the following points : m I. The relative merits of primary repair as compared with secondary. 2. If primary repair is preferred, then should the repair be by suture or by grafting ? 3. The choice of the tendon graft. 4. The problem of the divided flexor profundus in the presence of an intact sublimis. 5. The choice of suture material. 6. The method of fixation at the proximal and distal junctions of the graft. In evaluating the results of this series these points will be considered and discussed. Assessment of the end results following tendon repairs in the finger is determined by the ability of the patient to touch the palm with the tip of the injured finger. Perfection, by measuring the distance from the point at which the finger tip touches the palm to the flexor crease of the metacarpo-phalangeal joint and deducting from this a similar distance on the normal hand (Figs. I and 2). Graphs are included relating the measurement to the percentage of cases in the 2II
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three groups of finger grafts. All cases having limked extension o f 3o degrees or over are classified separately. Other methods of assessment have been published, as for example, taking 27o degrees as the normal range of a finger, or measuring the distance o f the finger
FIG, I
FIG. :2
Figs. I and 2.--Estimation of finger flexion by deducting the distance between the point at which the normal finger tip touches the palm and the metacarpo-phalangeal joint crease, from a similar measurement on the affected hand. tip from the distal palmar crease ; but no m e t h o d other than a photographic record can give a clear visual picture of an end result, and even that does not necessarily interpret a functional end result, which relates only to a patient's ability to adapt himself to his specific job. T o show the end results of tendon grafts for the t h u m b a table is included which shows the total range of movement o f the terminal interphalangeal joint. THUMB REPAIRS In this series there are twenty-four repairs for the divided flexor pollicis grouped as follows : T e n d o n grafts 18 T e n d o n suture . 4 T e n d o n transplant I T e n d o n lengthening I
REPAIR
OF
DIGITAL
FLEXOR
TENDON
INJURIES
IN
THE
HAND
2I 3
The results of the tendon sutures were :-(a) One tendon re-attached as a primary procedure--result poor. (b) Two primary sutures--result poor. (c) One secondary suture--result full range. One primary transplant using flexor sublimis from the ring finger--result: range at terminal joint i8o/ii 5 compared with the normal thumb which was i8o/9o. FLEXOR TENDON GRAFTS OF THE THUMB The span was limited by I½- in. 100 One tendon lengthening in which the advancement was made above the wrist 8O --result poor. Eighteen tendon grafts of which I t . fifteen were palmaris grafts and three 6o were toe extensors. One primary graft using palmaris resulted in a range of o I8O/iO 3 compared with i8o/9o on the 4o normal side. The total range of move- tO ment of eighteen grafts is shown in 2o Table I, and the percentage of joint motion in Fig. 3. (Boyes' graph.) In all cases some limitation of the 0 I I I I 100 80 60 40 20 total span was present; but no patient failed to adapt himself to this disability PERCENTAGE OF JOINT MOTION although some complained of slight VOL. FLEXION PASS. FLEXION × 100 disability in gripping. It will be seen in Table I that six FiG. 13 cases extended beyond I8o degrees, and Percentage of joint m o t i o n in flexor t e n d o n only two flexed to 9o degrees. The average grafts of the t h u m b . range of motion was I82"9/I35. TABLE I Range of Movement in Flexor Tendon Grafts of the Thumb Extension.
1215
I95 I95 I8OI I80 I80
i4o i65 i55
I80 I80 I 8 0 ' I 8 0
9 ° io 5 ioo i i 5 i4o
laver]age. I80 I75 I65
i25J i40 i55 Flexion.
I50 I90 I95 I80 1901 I82"9 ,
9 ° IO 5 I3 o I8o I65 I6O I7O J i35.o I
Operation.--The incision (seen in Fig. 5) allows the proximal end of the divided flexor pollicis, which retracts into the thenar muscles, to be found without difficulty using this approach, The theca is excised, leaving a wide pulley over the base of the proximal phalanx. The distal segment of the
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tendon is removed as far distal as possible, leaving only a small part for junction with the graft. An incision is made in a longitudinal direction on the forearm, and the flexor pollicis and palmaris are identified. A long silk suture is passed through the proximal end of the divided tendon and withdrawn with the tendon into the wound of the forearm. The tendon graft--using either palmaris or a toe extensor--is then sutured to the silk and withdrawn distally through the tunnel, using the silk as a guide and a tractor. The graft is passed under the pulley and
FIG. 4
FIG. 5
FIG. 6
Figs. 4 to 6.--Pre-operative and post-operative terminal joint range of the right thumb. Incision outlined.
sutured with silk (3/0) to the distal attachment of the pollicis tendon. The method of suturing is a figure-of-eight through the graft and a single loop on both needles through the distal part of the tendon. The thumb incision is then closed and the pulp of the thumb anchored to the palm by a silk suture with the terminal joint flexed. The proximal junction of the graft is made at the musculo-tendinous junction of the flexor pollicis. Approximation is side to side, and the junction is covered with muscle. Absolute immobilisation is provided by plaster of Paris, with the wrist and terminal joint in flexion, maintained for three weeks. Fig. 4 shows the right thumb before operation. Fig. 5 is a post-operative view, with the skin incision outlined, showing limited span but full extension. Fig. 6 shows the post-operative range of flexion compared with the normal. The operation is performed under general anaesthesia, using a tourniquet which is not released until the plaster of Paris is applied and set. In order to assess function it is necessary to analyse the optimal positions which the terminal joint should adopt in basic movement.
REPAIR
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FLEXOR
TENDON
INJURIES
IN
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HAND
215
There are four basic functional positions (see Figs. 7, 8, 9, and IO) : q I. Pinch, in which contact between the pulps of the thumb and index finger create a circle. 2. Pinch grip, in which the maximal apposable surfaces of the pulps of the index finger and thumb come into contact. 3. Tripod pinch, in which the pulp of the thumb opposes both the index and middle finger pulps. 4. Grip, in which the terminal phalanx of the thumb locks the index and middle fingers in the position of a fist.
FIG. 7
FIG. 8
FIG. 9
FIG. IO
Figs. 7 to I O . - - T h c functional positions o f t h e t h u m b .
In pinch, the terminal joint of the thumb is in a position of approximately I45 degrees of flexion. In pinch grip and tripod pinch the terminal interphalangeal ioint is hyperextended. In grip, the terminal ioint is in a position of approximately 14o degrees of flexion. It will be seen, therefore, that a poor result following tendon repair, i.e., inability to hyperextend or inability to flex to 90 degrees, will not seriously interfere with fine movement ; but limitation of hyperextension will interfere with power pinch and limitation of flexion will affect grip. Lifting, carrying, and holding are not seriously affected in the poor result cases except in those with acute flexion deformity of the terminal joint--a rare complication. It should be noted, however, that the span of the hand is limited in all cases which fall short of full extension and this gives rise to disability only in certain specific occupations, e.g., bricklayers. In this series of eighteen tendon grafts no patient complained of any serious disability or was unable to return to his pre-accident occupation although the average range of movement was only 47"9 degrees compared with a normal of approximately ioo degrees.
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Primary suture of the divided distal end of the flexor pollicis should be accepted as the treatment of choice provided the state of the wound warrants further exposure ; if not, the skin should be closed and the tendon repaired by grafting later. Kelly (1959) claims good results in ten out of fifteen cases of primary repairs. In this series either primary or secondary tendon grafting has been given preference where the tendon has been divided more proximally. Admittedly, the number of cases of suture recorded here are too few to substantiate this claim, but the results of suture were so poor that this method was discarded in favour of grafting i n which a uniformly satisfactory functional end result could be confidently expected. Furthermore, it would appear that the same factors which influence the decision either to suture or to graft in division of the flexor tendons within the digital sheaths of the fingers to a large extent also apply to the thumb. One case of primary tendon transplant of the sublimis of the ring finger to replace the divided flexor pollicis is included. The end result of this procedure was a good range of terminal joint movement ; but the span was limited by I½ in. It was decided that this method of treatment should be reserved for exceptional cases. FLEXOR TENDON REPAIRS OF THE FINGERS
These cases are divided into the following groups : Primary tendon suture Primary tendon graft . . Tendon graft with half sublimis Tendon graft with excision of sublimis TOTAL
8 II
18 39
72
Primary Tendon S u t u r e . - - I n this group of eight cases all the tendons were divided within the flexor sheath distal to the level of the metacarpo-phalangeal joint. The patients were carefully selected, the suture material was 3/o silk, and the end results were as follows : Two primary sutures failed and were later successfully grafted. Three cases were successfully sutured. One failed and the finger was amputated. One failed and was left with severe limitation of movement. One was not followed up. The small number of cases presented is an indication that this method of repair has not proved generally acceptable. It has now been discarded in favour of grafting except for two classes of patient. Firstly, patients in the late age groups who have sustained a distal division in whom it is desired to create a tenodesis, and secondly for selected patients in the early age groups, particularly those with long, slender hands and fingers. Two of the three successfully treated patients in this group were under 5 years of age. In each case the sublimis was removed and the profundus sutured. P r i m a r y T e n d o n Grafts.--Harrison (1956) records fourteen cases of primary flexor grafts and a comparable series of thirteen secondary grafts. No significant
REPAIR
OF
DIGITAL
FLEXOR
TENDON
INJURIES
IN
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HAND
217
difference exists between these two series ; but there are obvious advantages in primary grafting, summarised as follows :-I. Reduced time off work and period of incapacity. 2. Reduced incidence of disuse atrophy. 3. The gliding mechanism is intact and the withdrawal of the divided tendon is atraumatic in the absence of fibrous adhesions. 4. The exact length of tendon replacement can be measured accurately. There is some difference of opinion on the advisability of this procedure, largely based on the assumption that there is an increased risk of infection ; but provided the criterion of selection is rigidly applied the risk is insignificant. No case of infection occurred in this or in the previously reported series. The criterion of selection is a clean incised wound of short duration. Of the sixty-eight flexor tendon grafts reported in this paper there were eleven primary grafts in ten patients. Table II shows a summary of the results. TABLE II Primary Flexor Tendon Grafts of the Finger Decades. Result.
Touched palm Limited flexion No movement, Amputation .
No.
.
2
8
Middle
Ring Little
.
5
~Cent.
Palmaris Grafts.
Toe Extensor Grafts.
I
...
r 72'7
4
4
I
I
[ I8'I
I
I
5
.,°
G--
Digit. .
4
......
Total
Index
3
Per
No.
Failed.
.
o
" ,
-I
I 2
:
6
2
Percent.
5 -
2 7"2
I
2 7-2 I8'I
]
2 7 .2
Limited extension Hyperextension . Crush Incised
2 2 I IO
In this group one case involving the ring finger was disabled from limited extension. There were two cases which subsequently developed a hyperextension deformity at the proximal interphalangeal joint. This complication is regarded as being due to removal of the sublimis and consequent loss of support for the anterior capsule and will be discussed later, There were two failures, and of these, one came to amputation. This was a case of crush injury and the tendon graft had been passed through the two slips of the sublimis. The other patient was the only one in the fifth decade. In eight of the eleven grafts the finger tip touched the palm, giving a successful end result in 72"7 per cent., and of these 25 per cent. recovered a full range of movement. Fig. I I relates the percentage of grafts to the palmar measurement after deduction of the normal in eight cases that touched the palm. The grafts were either palmaris or toe extensor, and there was no significant difference in the results from the choice of graft. Fig. 14 shows the post-operative
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views, immediately after the removal of the plaster of Paris, of a patient who had divided both flexor tendons of the ring and little fingers with a penknife, transversely, at the level of the middle joint crease. Both sublimis tendons were removed. The profundus to the ring finger was repaired by suture, and the little finger by a palmaris graft, as a primary procedure. EIGHT PRIMARY FINGER T E N D O N GRAFTS T O U C H E D THE PALM
100
80 u3 LL (_9 b_ 0 hi (..9
60
~ 4o Z l.t.I
J
J
X
a_ 20
0. ~/4
t/2
3/4
1
194
lJ/2 "
THE DIFFERENCE IN MEASUREMENT BETWEEN THE T W O HANDS FROM THE POINT THE FINGER TIP TOUCHES THE PALM TO THE METACARPO-PHALANGEAL JOINT CREASE FI~.
ii
Primary finger tendon grafts.
Figs. 12 and 13 show the final results five months after operation. The range in the tendon-grafted little finger was -~ in. better than the ring. The rate of recovery in the fingers was equal. Flexor T e n d o n Grafting with Preservation of H a l f the S u b l i m i s . m This modification in the technique of flexor tendon grafting was described previously (Harrison, 1959) and is used for those cases in which the flexor profundus has been divided and the sublimis is undamaged. Attempts to thread a graft through the two slips of the sublimis as a method of repair were followed by such poor results that they were abandoned and it became accepted practice to remove the intact sublimis when inserting a tendon graft ; however, when the latter series came to be reviewed, it was found that a percentage had developed a hyperextension deformity at the proximal interphalangeal joint. This deformity progresses to a subluxation, and so far has proved impossible to correct. The object of this modification is to prevent a hyperextension deformity, to conserve a flexing mechanism within the digit, and to provide adequate space within the digital pulleys to accommodate a graft.
REPAIR
OF
DIGITAL
FLEXOR
FIG. I2
TENDON
INJURIES
FIG. Z3
IN
THE
HAND
219
FIG. I4
Fig. i 2 . - - I n c i s i o n s used for primary repair of the profundus of the ring finger and primary t e n d o n graft of the little finger. Figs. I3 and z 4 . - - S h o w i n g the final range of movement.
The operation is performed either as a primary or a secondary procedure. The steps of the operation are similar to primary and secondary grafting except that one slip of the sublimis is removed, leaving the vincula attached to the remaining slip. A clear plane of cleavage is found in the tendon and half the sublimis is removed well up into the palm. There are eighteen cases in this series and the results are shown in Table III. Four cases were classed as failures and fourteen were successful (77"8 per cent.). A full range occurred in 28 per cent. There were TABLE III Flexor Tendon Grafts with Preservation of Half the Sublimis f
Decades. Result.
/ No.
2
I
Touched palm • " ! ~ 4 L i m i t e d flexion No movement Amputation
/4
Total Digit. Index Middle Ring . Little
18
No.
8 4
4
! 4
5
5
I
I
...
3
Z
5
Palmaris
77"8[
...
--13 I-3--
i
C_C
. . . . . .
Per
Toe Extensor i iqantarls Grafts. i Grafts.
3
Cent__ °jets 22 '2
I
I I
. . . . . .
4
;]
2
Failed.
Per Cent.
z o I I
44 '4 z6.4 I6"4 22 "2
3
I 0 0 "O I
/
I
L i m i t e d extension . Hyperextension Crush . Incised Burn Avulsion
""
I
""
z4
I I
3
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two cases in which primary skin loss was dealt with by a cross-finger flap and tendon grafts were inserted later. Both recovered a full range of movement. Fig. 15 shows skin loss with division of the flexor profundus affecting the middle finger, and areas of skin loss on the index and ring fingers without tendon involvement. Fig. 16 shows a primary repair of the skin by cross-finger flap for the middle finger and free grafts for the index and ring fingers.
FIG. 15
FIG. 16
FIG. 17
FIG. 18
Fig. IS.--Skin loss on the middle finger w k h division of the flexor profundus. Fig. I6.--Cross-finger flap. Fig. I 7 . - - D o n o r site of cross-finger flap. Fig. i 8 . - - H e a l e d donor area. Figs. 19 to 21 .--Final range after tendon grafting, with preservation of half the sublimis.
FIG. 19
FIG. 20
FIG. 21
Fig. 17 shows the donor site on the dorsum of the ring finger, and Fig. 18 the healed donor site. Figs. I9, 2o, and 2I show the final range of movement after flexor tendon grafting with preservation of half the sublimis. No case of hyperextension deformity of the proximal interphalangeal joint occurred in either this or the original series. In all cases recovering a functional range of movement independent profundus and sublimis action can be demonstrated. Fig. 22 relates the percentage of grafts to the palmar measurement after deduction of the normal in fourteen cases that were able to touch the palm.
REPAIR
OF DIGITAL
FLEXOR
TENDON
INJURIES
IN
THE
HAND
FOURTEEN TENDON GRAFTS PRESERVING HALF SUBLIMIS TOUCHED THE PALM
100
80
f
t/3 I--LL
=<
60
(.D It_ 0 ILl F-Z
40
0
20
0
I
I
~
I
I
¼
'/2
3/4
1
lJ/4
'/2"
THE DIFFERENCE IN MEASUREMENT BETWEEN THE TWO HANDS FROM THE POINT THE FINGER TIP TOUCHES THE PALM TO THE METACARPO-PHALANGEAL JOINT CREASE FIG. 22 Flexor tendon grafts with preservation of half the sublimis.
Fm. 23
FIG, 24
FIG. 25
FIG. 26
FIG. 27
Figs. 23 and 24.--Pre-operative range following division of the flexor profundus of the little finger. The sublimis was undamaged. Fig. 2 5 . u S h o w i n g the incision used for exposure of the little finger. Figs. 2.6 and 27.--Final range after tendon grafting with preservation of half the sublimis.
22I
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BRITISH JOURNAL OF PLASTIC SURGERY
Figs. 23 and 24 show the pre-operative range of motion in the little finger following division of the flexor profundus with intact sublimis function. Fig. 25 shows the incision after repair by tendon graft with preservation of half the sublimis. Figs. 26 and 27 show the final range five months after operation. TWENTY-NINE FINGER T E N D O N GRAFTS WITH EXCISION OF SUBLIMIS T O U C H E D THE PALM 100
80 uo LL < rY 60 o LL 0 O3 0
J
40
Z w o PeW
20
0
1
I
i
I
¼
½
¾
1
i
1¼
~½"
THE DIFFERENCE IN M E A S U R E M E N T BETWEEN THE T W O H A N D S FROM THE P O I N T THE FINGER TIP T O U C H E S THE PALM T O THE M E T A C A R P O - P H A L A N G E A L J O I N T CREASE FIG. 28 Flexor tendon
grafts with excision of sublimis.
Secondary Tendon Grafts with Removal o f Sublimis.--There were thirty-nine cases in this group (see Table IV). The sublimis was removed in all cases whether damaged or not. It will be seen from the table that the number of hyperextension deformities occurring were four, an incidence of lO-2 per cent. It is possible that this figure may ultimately prove to be higher as the deformity may appear several years after tendon grafting following a relatively minor extension injury. Three cases had limited extension and all were in the group of limited flexion. Twenty-nine cases, 74"3 per cent., touched the palm and the functional end result was good in all cases. Fig. 28 shows the final assessment in which, 3o- 7 per cent., the distance from the point the finger tip touched the palm to the metacarpo-phalangeal joint crease was equal onboth sides and, 74"3 per cent., the difference was I½ in. or less. It may be of interest to note that the results of tendon grafting in the middle finger are better than in any other finger. The ring and little fingers are comparable, but the index finger gives less good results than any of the others.
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TABLE I V Secondary Tendon
Grafts w i t h E x c i s i o n o f S u b l i m i s Decades.
Result.
I
Touched p a l m Limited flexion . N o movement Amputation Total
Middle Ring . Little
29
2
9 3
No.
I2
3
9 2
2
39
Digit. Index
•
No.
II
Failed.
IO
5
2
, L.
I
I
...
9
4
3
,
.
.
74'3 I I7.9f
19 2
8 5
!
2 ...
2"51
...
I
...
I00"O ]
22
15
2
...
Per Cent. 23 .o 33 "3 17.6 25 .6
•
4
Toe
P e r I P a l m a m s I t~xten~or ' S u b h m l s C e n .t . G . r a. f t s. . . . G .r a f t s i G r a f t s .
Limited extension Hyperextension Crush Incised Attrition Tendon sheath infection
4 9 27 I I
Crush injuries are frequently followed by a poor end result and in this series five out of nine were failures. Two primary sutures failed and were later grafted with a successful end result. Two grafts were passed through the slips of the sublimis and failed; one was later regrafted with removal of sublimis and a successful result ensued, but the other came to amputation. One patient aged 4 2 was deaf and dumb and, despite two consecutive tendon grafts on the same finger, failed to obtain useful movement. One patient lost both tendons following a suppurative tenosynovifis, but regained a full passive range of movement. A tendon graft was inserted and 6o degrees of active movement was regained in the proximal interphalangeal joint• The patient developed a hyperextension deformity and the attempt to correct this by the insertion of a new pulley merely served to reduce still further the final range of movement. OPERATION
FOR T E N D O N
GRAFTING
Apart from minor variations the surgical technique was the same for the three groups. Indicafions.--In primary grafting a clean incised wound of short duration is essential. In secondary grafting operation is performed when the wound is soundly healed provided that there is no limitation of joint movement. Contraindications.--Crush injuries are a contraindication to primary grafting, and secondary grafting should be deferred until a passive range of movement has been recovered• Grafting when the tendon injury is associated with a fracture should be deferred until the fracture has united and a passive range of movement has been recovered.
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The operation for tendon grafting is based on the principles outlined by Rank and Wakefield (1952) in which the theca is excised, leaving pulleys over the proximal and middle phalanges. The incisions used for the fingers can be seen in Figs. I4, 29, and 3o. The skin flap on the fingers is elevated superficial to the nerve and artery ill order to avoid any interference with the blood supply. If the theca is fibrotic where a pulley is required then a new pulley is made by passing a tendon graft circumferentially around the phalanx.
FIG. 2 9 Incision for exposure of t h e i n d e x finger.
FIG. 30 Incision for exposure of t h e m i d d l e finger.
The distal end of the tendon graft is sutured with a figure-of-eight stitch, using 3/o silk carrying two needles. The needles are passed through the deep aspect of the distal end of the profundus, then back from superficial to deep. Thus the end of the profundus is made to overlap the junction on the superficial aspect. The incision in the finger is then closed. A traction suture on the pulp is passed through the palm and tied over the distal pu!p after measuring the distance from the tip of the finger to the palm and comparing this with the normal hand (see Fig. 31 which shows the measurement of tension in the normal finger). The wrist is held in the same position as the opposite hand. Fig. 32 shows the finger tip being anchored to the palm with silk after measuring off the same degree of flexion as seen in Fig. 31. By this means the length of graft required is estimated and any surplus is removed at the site of the proximal junction. In primary grafting the graft is laid alongside the two parts of the profundus removed, and is cut to the exact size. The proximal end of the graft is again sutured with 3/o silk carrying two needles inserted as a figure-of-eight and the two ends are made to emerge at the cut end. The four ends are then tied, leaving a buried knot between the junction ;
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225
the latter is then covered with lumbrical muscle, leaving the knot of the suture buried. Plaster of Paris is applied with the wrist and fingers flexed. When the plaster is set the tourniquet is released. Absolute immobilisation is maintained for three to four weeks. At the end of this period active movements are begun. Two points are worthy of emphasis :-I. The prevention of muscle pull is determined by the immobilisation provided by the plaster of Paris and not by the suture material which is designed only for approximation and not to resist tension ; as a result no tendon junction has parted in this series. 2. Silk is not considered to be a cause of limiting adhesions if it is properly placed.
FIG. 31
FIG. 32
Figs. 3I and 32.--Method of estimating the length of the tendon graft by measurement of the tension in the normal hand.
Post-operative Care.--After removal of the plaster of Paris the patient is persuaded to exercise each individual joint of the affected finger and then all the fingers and hand for a period each hour systematically throughout the day. The best results are obtained in young co-operative patients by encouragement and a close doctor-patient relationship. In no other branch of surgery is the need for complete confidence between doctor and patient greater than in hand surgery. Only in those patients who do not respond to this treatment are physiotherapy and live splints employed. In cases which develop inco-ordination occupational therapy is valuable. The splint most commonly used is seen in Figs. 33, 34, and 35 and was made by the Vauxhall Rehabilitation Centre. It consists of piano wire looped to provide springs, and slings made of chamois leather. Physiotherapy should be confined to supervision of active movements and constant encouragement to persevere. Specialised services such as the Vauxhall Rehabilitation Centre and the Farnham Park Rehabilitation Centre are ideally designed for the rehabilitation of hand injuries and provide the means to work the hand to the best possible advantage by using designed grips to work machines. This has the advantage of exercising the hand and fingers and at the same time distracts the patient's attention from the injured part. The work provides continuous resisted active movement over the relatively short period of time which elapses between the time of operation and the establishment of mature fibrous tissue responsible for permanent limitation 3D
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of movement. The average time for full recovery of movement is five months. Further improvement after this period is progressively slower and the end results progressively less satisfactory.
FIG. 33
FIG. 34
FIG. 35
Figs. 33 to 35.--Spring splint for correcting flexion deformity.
After one year the question of tenolysis should be considered in those cases with limited movement due to adhesion of the graft. An occasional good result can be obtained, especially in the rare case where the adhesions are confined to the junction in the palm ; but the usual finding is dense adhesion of the graft along the entire length of the digit and into the hand. The results of tenolysis in such cases have proved to be poor. More recently the results have seemed to be better and it is assumed that the instillation of a combined solution of hydrocortisone and chloromycetin daily for seven days, by means of an indwelling polythene tube, following tenolysis, may have been a factor in this improvement. The tube extends from the palm, along the finger, and emerges through the distal pulp. The wounds are exposed and movements commenced immediately. James (1959) uses 15o mg. of cortisone daily for fourteen days and has reviewed twenty-two cases. CONCLUSIONS
The end resuks of the repair of a flexor tendon, whether k is the thumb or the finger, are dependent on the patient's abilky to adapt himself to whatever disabilky persists. The basic functional requirements of the thumb have been briefly analysed and k is apparent that a limited range of movement and a reduction of the span of the hand can be compensated for in the majority of occupations. It is not surprising, therefore, that good results can be claimed for different methods of treatment. In the fingers, the patient's abilky to adapt himself to a permanent deformity is to some extent governed by the finger involved. A flexion deformity
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TENDON
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227
of the middle or ring fingers is more disabling than the index and little fingers because the finger tip will transgress the transverse plane of the hand when a flat hand is required. The index and little fingers can compensate by hyperextension at the metacarpo-phalangeal joints. It is important to realise that in many industrial occupations, e.g., sheet metal workers, carpenters, and draughtsmen, a flat hand is an essential functional requirement. The same disability causes the patient to catch the finger tips on various objects, making him clumsy at work and the hand awkward to use. The index and little fingers can compensate for a limited range of movement not acceptable for the middle and ring fingers by their capacity for greater independent movement and compensatory metacarpo-phalangeal joint range. On page 2II of this paper certain points were tabulated for discussion, and the following conclusions are drawn :-I. There is no contraindication to primary grafting of a divided flexor tendon in the presence of a clean incised wound of short duration. On the contrary it is easier, quicker, less traumatising, and reduces the period of disablement as compared with secondary grafting. No case of infection has occurred in this or in a previous series published. 2. It is suggested that the results of primary graftings are preferable to primary suture, except in avulsions and distal divisions, or when a tenodesis is an acceptable end result. 3. In this series the choice of graft lay between the palmaris and the toe extensors. There were twenty-eight palmaris grafts and thirty-five toe extensors. In the palmaris group there were 17-9 per cent. failures and in the toe extensor group 34"3 per cent. failures. Two sublimis grafts and three plantaris grafts were all successful. It would appear from this series that the results were better using palmaris. Boyes (195o) made a similar observation. Pulvertaft (1956) does not consider that the choice of graft materially influences the result. The toe extensor has had preference in this series for the following reasons :-(a) The assistant procures the graft and there is a saving of time. (b) The graft is thinner than the palmaris. (c) The forearm scar when using palmaris is often unsightly, whereas the dorsum of the foot rarely is. Against (a) (b) (c) (d)
the toe extensor : m The patient is confined to bed longer. Residual cedema persists in patients in the older age groups. Delayed healing is more commonly seen in the foot than in the forearm. One patient developed a phlebothrombosis and a pulmonary embolus from which he fortunately recovered ; but the vital period for rehabilitation was lost and the finger remains stiff.
The figures in this paper show a significant difference between palmaris and toe extensor grafts and further consideration should be given to the choice of graft. 4. The problem of the divided flexor profundus in the presence of an intact sublimis cannot be answered by any one method of treatment. The half sublimis modification shows good results in 77"8 per cent. of cases. Independent action of the tendons can be demonstrated and the capsule of the joint is adequately
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protected against minor extension injuries. In the younger age groups this method is the treatment of choice. In the middle age groups it is used for the index and little fingers whereas tenodesis may be considered for the middle and ring fingers. In the later age groups tenodesis is probably the treatment of choice. In cases in which both tendons have been divided and have to be removed, .one slip of the sublimis must be preserved whenever possible to reinforce the capsule of the joint. This applies not only to tendon grafting but also when sublimis is used as a transplant, otherwise a hyperextension deformity will occur as an insidious process of capsular stretching or as the result of a minor extension injury. This deformity may not appear for several years after grafting for obvious reasons. 5- The choice of suture material has been much discussed, but it is felt that this does not influence the result so much as the following :-(a) The distal junction should be well beyond the terminal joint. (b) The proximal junction should be accurately made and any inequalities at the junction covered by lumbrical muscle. (c) The suture should be considered a method of approximation and not fixation. The latter is provided by absolute immobilisation in plaster of Paris wkh reduction of muscle pull to the minimum by flexion of the wrist and fingers. Lindsay et al. (I96O) report an experimental study on the use of silk and stainless steel and note that both are adequate. They state that proximal muscle pull is a major cause of gap. It is assumed, therefore, that a safe junction can be established only by immobilisation in plaster. In this series there has been no evidence to show that any tendon junction, proximal or distal, has parted. 6. The method of joining the proximal and distal ends of the graft has been discussed. The distal junction should be well beyond the terminal joint. The proximal junction should be accurate and covered by lumbrical muscle. SUMMARY This paper reviews IOO tendon repairs, of which sixty-eight were flexor tendon grafts of the fingers and eighteen were grafts of the thumb. The end results are tabulated and graphed. It is evident that good function can be obtained in the presence of a limited range of movement in some cases. Of the eighteen thumb grafts the average range was 182"9/135. No functional disability was claimed although the majority had both a reduced range of movement and a reduced span. Primary tendon grafting of the fingers is advocated in the presence of an incised wound of short duration. There were eleven patients in this series with a 72 per cent. successful end result. The half sublimis modification of tendon grafting is described and the indications for the use of this method. There were eighteen patients in this group with a successful end result in 77"8 per cent. There were thirty-nine secondary tendon grafts with a successful end result in 74"3 per cent. The total of successful end results in the three groups of finger grafts was 75 per cent.
REPAIR
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FLEXOR
TENDON
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229
The fingers involved were : ~ Digit. Index . Middle Ring Little
Number.
Failures.
20 19 I2 17
5 2 3 6
TOUCHED E X C I S I O N SUBLIMIS HALF SUBLIMIS P R I M A R Y FINGER GRAFTS .
Successes.
75.o 89"0 75.o 64.8
per per per per
cent. cent. cent. cent.
PALM 74.3 per cent. 77.8 per cent. - . . . . . . . . . . . . 72.7 per cent. • . . . . .
100
80
js U") I-la_
60
o"
,£9 Ix. 0
/"
J ~-I~ sI
40
./"
i~.~.~-o
-~'~
Z bJ n," 20
0
I I/4
I 112
I 3//4
I ]
I ] ?4
THE DIFFERENCE IN M E A S U R E M E N T BETWEEN THE T W O H A N D S FROM THE P O I N T THE FINGER TIP T O U C H E S THE PALM T O THE M E T A C A R P O - P H A L A N G E A L J O I N T CREASE FIG. 36
Composite graph. There were seventeen crush injuries of the fingers treated by grafting, of which nine were failures--an incidence of 52"9 per cent. The choice of grafts for the fingers was as follows : Graft. Palmaris . Toe extensor Sublimis Plantaris .
Total.
Successes.
Failures.
Successful.
28 35 2
23 23 2
5 12 o
82.I per cent. 65"7 per cent. IOO.O per cent.
2
2
o
IOO.O per cent.
Hyperextension deformity of the proximal interphalangeal joint appeared in two cases in the primary grafting group and four in the secondary group. No case occurred in the half sublimis group. Attention is drawn to the serious nature of this complication of tendon grafting and the means to avoid its occurrence. Fig. 36 is a composite graph to show the comparison between the three groups
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of finger grafts that touched the palm and the difference in measurement between the normal and the affected finger. Seventy-five per cent. of all cases that touched the palm had a difference in measurement between the two hands of I½ in. or less. Of all grafts that touched the palm, 27"9 per cent. had a full range of flexion and maximal recovery occurred within five months of operation. Flexion contracture of 3o degrees or more occurred in I 1.7 per cent. In Boyes' series, 5o per cent. came to within I½ in. of the distal crease and 25 per cent. had complete flexion. In Pulvertaft's series, quoting the profundus and sublimis group, 7 ° per cent. came to within I in. of the distal palmar crease and 9 per cent. had perfect flexion. Twelve cases had flexion contracture of 30 degrees or more. I would like to express my thanks to Mr Rainsford Mowlem for his interest and advice during the period in which this study has been in progress. I would also like to express my thanks to Miss Nora Walker of the Photographic Department, Mount Vernon Hospital, and to Mr Fisk of the Photographic Department, Canadian Red Cross Memorial Hospital, Taplow.
REFERENCES BOYES, J. H. (I95O). J. Bone J t Surg., 32A, 589. HARRISON, S. H. (1956). Brit. reed. ft., 2, 746. --(1958). Brit. ff. plast. Surg., i i , lO6. --(196o). "Transactions of the International Society of Plastic Surgeons," 2nd Congress, London, 1959, P. 217. JAMES, J. I. P. (1959). J. Bone Jr Surg., 4rA, 2o 9. KELLY, A. P. (1959). ft. Bone Jr Surg., 4IA, 581. LINDSAY, W. K., THOMSON, H. G., and WALKER, F. G. (196o). Brit. J. plast. Surg., I3, I. PULVERTAFT,R. G. (1956). J. Bone Jr Surg., 38B, 175. RANK, B. K., and W~EFIELD, A. R. (1952). Brit. J. plast. Surg., 4, 244.