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The results of treatment of injuries to the flexor tendons
The Results of Treatment of ln]uries to the Flexor Tendons--M. E. Winston
THE
RESULTS
OF TREATMENT OF INJURIES TO THE FLEXOR TENDONS
M. E. WINSTON, Bolton The object of this paper is to present the results of treatment in 131 patients who sustained injuries to the flexor tendons of the fingers. METHOD OF TREATMENT
The method of treatment depends on the nature of the wound, the interval of time since the injury, and the site of the injury. In a clean cut tidy wound, of the type caused by a knife or glass, where surgery could be carried out within eight hours from the time of injury, it has been the author's practice since 1952 to carry out primary repair of a divided flexor tendon. If these conditions were not fulfilled, tendon repair was deferred until the wounds were healed. OPERATIVE TREATMENT
Operation is carried out under a general anaesthetic. A sphygmomanometer cuff is applied to the upper arm but not inflated. Preliminary cleansing of the part by soap and water followed by saline is performed. The wound is then cleansed with saline although Cetavlon is used if oil or grease is present. After sterile towels are in place, a sterile Esmarch bandage is applied and the cuff inflated to 300 m m o f mercury. Adequate exposure is obtained by extending the wounds according to accepted principles. The cuff is released at the end of a dissection and heamostasis secured. The tendon is sutured with fine silk using a Bunnell stitch. The tendon sheath, if present, is removed in the neighbourhood of the tendon repair. After would closure, a compression dressing of fluffed out gauze and crepe bandage is applied. The wrist and fingers are immobilised in slight flexion with a posterior plaster splint. The hand is elevated for forty-eight hours on a pillow and prophylactic antibiotics are given. Immobilisation is continued for three weeks, then a plaster slab is applied with the wrist in neutral position and the fingers free, for a further week. DIVISION OF THE FLEXOR TENDONS BETWEEN THE DISTAL PALMAR CREASE A N D THE INSERTION OF THE FLEXOR DIGITORUM SUPERFICIALIS
When both the flexor digitorum profundus and the flexor digitorum superficialis were injured, between the distal palmar crease and the insertion of flexor digitorum superficialis in the middle phalanx, repair of the flexor digitorum profundus only was carried out and the flexor digitorum superficialis was excised, leaving a slip of the tendon to prevent hyperextension of the proximal interphalangeal joint. Where the flexor digitorum superficialis was found, at operation, to be intact the flexor digitorum profundus was not repaired. An intact superficialis was never Sacrificed. In twenty-eight patients both the flexor digitorum profundus and the flexor digitorum superficialis were divided. Thirty-two fingers were injured of which twenty-nine were available for analysis (Table 1). Vol. 4
No. 1
1972
45
The Results of Treatment of Injuries to the Flexor Tendons--M. E. Winston TABLE 1 F L E X O R T E N D O N INJURIES I N THE F I N G E R S 69 P A T I E N T S
F.D.S. and P.--28 patients--32 fingers injured. F.D.P. --4t patients--45 fingers injured. Treatment
Primary repair of the flexor digitorum profundus was carried out in twenty-one fingers with injury to both tendons in the finger of which eighteen were available for analysis. Secondary suture of the flexor digitorum profundus was carried out in five patients with injury to both tendons in the finger. Tendon grafting was carried out in four patients in whom both tendons had been divided in the finger. No operation was performed in two patients with injury to both tendons in the finger (Table 2). TABLE 2 T R E A T M E N T OF F L E X O R T E N D O N INJURIES IN THE F I N G E R
F.D.P. and S . . . . . . . . . . . . . . . . F.D.P . . . . . . . . . . . . . . . . . . .
No operation Primary Secondary suture suture 2 21 5 8 35 2
Graft 4 -
R E S U L T S OF T R E A T M E N T
Where both tendons were divided in the finger between the distal palmar crease and the insertion of the flexor digitorum superficialis, full movement was obtained in six patients where primary suture of the flexor digitorum profundus was carried out, and in one patient who had a tendon graft. One patient in whom secondary suture was performed had full flexion but had 45 degrees limitation of extension. The finger cou,ld be brought to the palm in four patients who had primary suture performed. There were nine poor results including two who had no operation, and in the remaining seven patients, the finger could be brought to within -~in., lin. and 1½in. from the palm (Table 3). (Figs 1A and lB.)
Fig. 1A & lB. Divided flexor digitorum profundus and superficialis in the little finger of the right hand. Result eleven years after primary suture. 45
Vol. 4
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1972
The Results o/ Treatment of Injuries to the Flexor Tendons--M. E. Winston TABLE 3 RESULTS O F T R E A T M E N T OF DIVISION OF T H E F L E X O R T E N D O N S B E T W E E N THE D I S T A L P A L M A R C R E A S E A N D T H E I N S E R T I O N OF F L E X O R D I G I T O R U M SUPERFICIALIS
No operation Primary Secondary Tendon suture suture graft Full movement
...............
Finger to the palm .., ......... Finger to within ½in. of palm . . . . . . . . . Finger to within tin. of palm . . . . . . . . . Finger to within 1½in. of palm . . . . . . . . . Poor result .,. ............... No operation ...............
-
6
2
4 1 2 1 4 -
1 -(FuA1flexion) 1 2 1 -
1 1 2 -
DIVISION OF T H E F L E X O R D I G I T O R U M P R O F U N D U S D I S T A L TO THE I N S E R T I O N OF THE F L E X O R D I G I T O R U M SUPERFICIALIS
W h e n the flexor digitorum profundus was divided distal to the insertion of the flexor digitorum superficialis, primary suture of the flexor digitorum profundus was carried out if the conditions were satisfactory, otherwise secondary suture was performed. Some patients were seen some time after primary suture of the skin had been performed and, in a certain number of patients, the function was acceptable, and no further operation was carried out at this stage. In this type of case a tenodesis or fusion of the distal interphalangeal joint could be carried out at a later date, if necessary, rather than secondary suture or tendon graft which might jeopardise the function of an intact flexor digitorum superficialis. No tendon grafts were carried out for repair of the flexor digitorum profundus alone. I n forty-one patients the flexor digitorum profundus alone was divided in forty-five fingers (Table 1). Treatment
Primary repair was carried out in thirty-five fingers with injury digitorum profundus alone. Secondary suture was carried out in two patients with injury digitorum profundus alone. T e n d o n grafting. No tendon grafting was carried out in division digitoru,m profundus alone in the finger. N o operation was performed in eight patients who had sustained flexor digitorum profundus alone in the finger (Table 2).
to the flexor to the flexor of the flexor injury to the
Results o~ T r e a t m e m
Full movement was obtained in seven patients who had primary suture performed. In twenty-six patients the finger could be brought to the palm, of whom eight had no operation performed, There were five poor results. In the remaining seven patients the finger could be brought to within ½in. to lin. from the palm (Table 4). (Figs. 2 and 3.) Vol. 4
No. 1
1972
47
The Results of Treatment of Injuries to the Flexor Tendons--M. E. Winston
Fig. 2A & 2B.
Divided flexor digitorum profundus in the ring and little fingers, right hand. Result sixteen years after primary suture.
Fig. 3A & 3B.
Division of flexor digitorum profundus in the index finger, right hand. Result thirteen years after primary suture.
TABLE 4 RESULTS OF S U T U R E OF F L E X O R DIG1TORUM P R O F U N D U S ~DISTAL TO T H E I N S E R T I O N O F F L E X O R D I G I T O R U M SUPERFICIALIS No operation Full movement . . . . . . . . . . . . Finger to the palm Finger to within ½in. of the palm ..... Finger to within ~in. of the palm ... Finger to within 1½in. of the palm ... Poor result . . . . . . . . . . . . ... . .
8 -
Primary suture
Secondary suture
7 1Z 3 3 1 4
Tendon graft
1 1
DIVISION OF THE F L E X O R POLL!C!S L O N G U S T h e m e t h o d s o f t r e a t m e n t o f s i x t e e n p a t i e n t s w i t h d i v i s i o n o f the f l e x o r pollicis l o n g u s a r e s h o w n i n T a b l e 5, TABLE 5 DIVISION O F F L E X O R POLLICIS L O N G U S 16 PATIENTS No:operation 1
48
Primary suture 9
Secondary suture 4
Tendon graft 2
VOil 4
NO. 1
' 1972
The Results ol Treatment of ln]uries to the Flexor T e n d o n s - - M . E. Winston
Following suture of flexor pollicis longus, there was limitation of movement in the interphalangeal joint in all of the repairs in this review, but the function was adequate. Movement in the metacarpophalangeal joint of the thumb was satisfactory in all the patients (Fig. 4).
Fig. 4A & 4B. Primary suture flexor pollicis longus. Result sixteen years after primary suture. F L E X O R T E N D O N DIVISION IN THE P A L M
Where both the flexor digitorum profundus and the flexor digitorum superficialis were divided, both tendons were repaired provided the conditions for primary suture were present. At this level it was possible to interpose soft tissue or lumbrical muscle between the suture lines of the flexor digitorum profundus and superficialis and retain independent action of these tendons. m this series there were twenty-one patients with injuries to the flexor digim r u m profundus and the superficialis in the palm, the tendons to twenty-five fingers being injured. Two patients had divided the flexor digitorum superficialis alone in the palm. Thus there were twenty-seven fingers injured in twenty-three paticnt.~ Treatment
Primary suture was carried out in twenty-two fingers, and secondary suture in five fingers. Results
Full movement was obtained in thirteen fingers where primary suture was performed, and in one finger with secondary suture. The finger could be brought to the palm in four fingers which had primary suture, and three with secondary suture. In four cases the finger can be brought to within lin. to llin. of the palm. Three of these had primary suture, and one secondary suture. Two fingers which had primary suture had a poor result (Table 6. Figs. 5 and 6). TABLE 6 RESULTS OF S U T U R E OF DIVISION OF TENDONS, IN THE P A L M
No operation Full movement ............... Finger to palm ............... Finger to within kin. from palm Finger to within lin. from palm Finger to within 1½in. from palm Poor result . . . . . . . . . . . . . . . . . . Vol. 4
No. 1
1972
...... ...... ......
Primary Secondary Tendon suture suture graft 13 1 4 3 m
1 2 2
1
49
The Results of Treatment of Injuries to the Flexor Tendons--M. E. Winston
Fig. 5. Division in the palm of the flexor digitorum profundus and superficialis of the index finger, right hand. Result sixteen years after secondary suture. Note how the index finger can be curled into the palm when both tendons are repaired. Fig. 6. Division in the palm of the flexor digitorum profundus and superficialis to the index, middle and ring finger. Result thirteen years after primary suture of flexor digitorum profundus only. Note how the finger cannot be curled into the palm when only the flexor digitorum profundus is repaired. FLEXOR
TENDON
D!VIS!ON
AT THE WRIST
Twenty-three patients had injury to the flexor tendons at the wrist. If the conditions were satisfactory, p r i m a r y suture was carried out where the tendons had been divided at the level of the wrist. I n all b u t one, p r i m a r y repair of both tendons was performed. T w o patients had secondary suture carried out. If the point of division was in the carpal tunnel, the flexor digitorum p r o f u n d u s only was repaired and the carpal tunnel was left unsutured. Treatment
P r i m a r y suture was carried out in twenty-one patients. Secondary suture was carried out in two patients. Results
Full m o v e m e n t was obtained in eighteen patients, sixteen of w h o m had primary suture and two of whom had secondary suture performed. The finger could bc brought to the palm in four patients who had p r i m a r y suture performed. There was one poor result in one patient who had p r i m a r y suture performed (Table 7).
RESULTS
OF SUTURE
TABLE 7 OF FLEXOR TENDON
INJURIES
AT THE WRIST
No operation Primary Secondary Tendon suture suture graft Full movement ............... Finger to the palm ... Finger to within ½in. of tlae" palm" ... Finger to within lin. of palm . . . . . . . . . Finger to within 1½in. of palm . . . . . . . . . Poor result . . . . . . . . . . . . . . . . . .
iii
-
16
2
-
. -
4
-
-
.
. 1
.
. .
.
-
.
-
-
CONCLUSIONS
I n this series, 131 patients sustained injuries to the flexor tendons. P r i m a r y suture was carried out in 105 patients, secondary suture in eighteen patients. No operation was carried out in eleven patients a n d in six patients a t e n d o n graft was carried out (Table 8). 50
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The Results of Treatment of Injuries to the Flexor Tendons--M. E. Winston
Analysis of the results show that the results in the small series in whom tendon grafts were carried out were not satisfactory in four out of the six patients. The results of secondary suture were satisfactory in twelve out of eighteen patients. Primary suture gave good results in eighty-three out of 105 patients. A further analysis showed that where both tendons had been divided in "no man's land" thirteen out of the eighteen patients had satisfactory results. It is known that primary suture in the palm, wrist and fingers distal to the insertion of flexor digitorum superficialis gives satisfactory results and this is supported in this series. Where the flexor digitorum profundus alone had been injured, good results were obtained in thirty out of the thirty-five patients. Primary suture in the pahn resulted in good results in eighteen patients out of the twenty-two and primary suture at the level of the wrist gave good results in twenty out of tweny-one patients (Table 9). From this series it can be seen that the results of tendon grafting are uncertain. Primary and secondary suture are easier procedures to carry out than tendon grafting, and a review of the results of treatment show that primary and secondary suture carried out in satisfactory conditions can give sufficiently good results to justify this method of treatment. It may be that the preliminary use of silastic rods followed by secondary tendon grafting will improve the results. TABLE 8 F L E X O R T E N D O N D I V I S I O N . A N A L Y S I S OF P R O C E D U R E S Site of flexor t e n d o n d i v i s i o n
No operation
F l e x o r d i g i t o r u m p r o f u r t d u s a n d flexor d i g i t o r u m superficialis in t h e finger ... F l e x o r d i g i t o r u m p r o f u n d u s in tt~e'finger' ... F l e x o r pollicis l o n g u s in the t h u m b ...... T e n d o n d i v i s i o n in t h e p a l m ......... T e n d o n d i v i s i o n at t h e wrist .........
FLEXOR TENDON Site of flexor t e n d o n division
Flexor digitorum profundus a n d flexor d i g i t o r u m superficialis in t h e finger Flexor digitorum profundus in t h e finger F l e x o r pollicis longu's in ti~e thumb T e n d o n d i v i s i o n in ii~e pal'm T e n d o n d i v i s o n at t h e wrist
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1972
Secondary suture
Tendon graft
2 8 1 -
18 35 9 22 21
5 2 4 5 2
4 2 -
11
105
18
6
TABLE 9 D I V I S I O N . A N A L Y S I S OF ]RESULTS
Primary suture Excellent Fair and and Good Poor
Secondary suture Excellent Fair and and Good Poor
Tendon graft Excellent Fair and and Good Poor
13
5
4
1
2
4
30
5
1
1
-
-
2 18 20
7 4 1
5 2
4 . .
83
22
12
6
2
6
16.8%
9.2%
4.6%
1.5%
4.6%
63.3% E x c e l l e n t - - l e s s t h a n ½in. 1 G o o d - - ½ i n . to lin. [ F a i r - - l i n . to 1½in. 1 P o o r - - M o r e t h a n 1½in. I
Primary suture
. .
. .
2 . .
T h e distance of t h e finger tips f r o m t h e distal p a h n a r crease w i t h full flexion of t h e finger.
51
The Results of Treatment of Injuries to the Flexor Tendons--M. E. Winston
SUMMARY
The results of treatment of flexor tendon injuries in 131 patients arc reviewed. The results show that good results can be obtained with primary suture carried out in tidy wounds within eight hours of injury and it is justified to carry out primary suture in these conditions. Secondary suture can also give some satisfactory results. In the finger, suture of flexor digitorum profundus only is advised if both tendons are injured between the distal palmar crease and the insertion of flexor digitorum superficialis. Distal to the insertion of flexor digitorum superficialis, primary suture of flexor digitorum profundus is indicated. In the palm both tendons can be sutured. In the wrist both tendons can be sutured unless the point of division is in the carpal tunnel where flexor digitorum profundus only should be repaired and the carpal tunnel left unsutured. At tile wrist repair of the flexor digitorum profundus only might be carried out if the suture lines of all the tendons would be so close as to be likely to adhere to one another and prevent independent action of the tendons.
I wish to thank Mr. Singh of the Department of Medical Photography at Bolton Royal Infirmary and Mrs. Joan Stafford for their help in the preparation of this paper.
52
Vol. 4
No. 1
1972
THE
RESULTS
OF TREATMENT OF INJURIES TO THE FLEXOR TENDONS
M. E. WINSTON, Bolton The object of this paper is to present the results of treatment in 131 patients who sustained injuries to the flexor tendons of the fingers. METHOD OF TREATMENT
The method of treatment depends on the nature of the wound, the interval of time since the injury, and the site of the injury. In a clean cut tidy wound, of the type caused by a knife or glass, where surgery could be carried out within eight hours from the time of injury, it has been the author's practice since 1952 to carry out primary repair of a divided flexor tendon. If these conditions were not fulfilled, tendon repair was deferred until the wounds were healed. OPERATIVE TREATMENT
Operation is carried out under a general anaesthetic. A sphygmomanometer cuff is applied to the upper arm but not inflated. Preliminary cleansing of the part by soap and water followed by saline is performed. The wound is then cleansed with saline although Cetavlon is used if oil or grease is present. After sterile towels are in place, a sterile Esmarch bandage is applied and the cuff inflated to 300 m m o f mercury. Adequate exposure is obtained by extending the wounds according to accepted principles. The cuff is released at the end of a dissection and heamostasis secured. The tendon is sutured with fine silk using a Bunnell stitch. The tendon sheath, if present, is removed in the neighbourhood of the tendon repair. After would closure, a compression dressing of fluffed out gauze and crepe bandage is applied. The wrist and fingers are immobilised in slight flexion with a posterior plaster splint. The hand is elevated for forty-eight hours on a pillow and prophylactic antibiotics are given. Immobilisation is continued for three weeks, then a plaster slab is applied with the wrist in neutral position and the fingers free, for a further week. DIVISION OF THE FLEXOR TENDONS BETWEEN THE DISTAL PALMAR CREASE A N D THE INSERTION OF THE FLEXOR DIGITORUM SUPERFICIALIS
When both the flexor digitorum profundus and the flexor digitorum superficialis were injured, between the distal palmar crease and the insertion of flexor digitorum superficialis in the middle phalanx, repair of the flexor digitorum profundus only was carried out and the flexor digitorum superficialis was excised, leaving a slip of the tendon to prevent hyperextension of the proximal interphalangeal joint. Where the flexor digitorum superficialis was found, at operation, to be intact the flexor digitorum profundus was not repaired. An intact superficialis was never Sacrificed. In twenty-eight patients both the flexor digitorum profundus and the flexor digitorum superficialis were divided. Thirty-two fingers were injured of which twenty-nine were available for analysis (Table 1). Vol. 4
No. 1
1972
45
The Results of Treatment of Injuries to the Flexor Tendons--M. E. Winston TABLE 1 F L E X O R T E N D O N INJURIES I N THE F I N G E R S 69 P A T I E N T S
F.D.S. and P.--28 patients--32 fingers injured. F.D.P. --4t patients--45 fingers injured. Treatment
Primary repair of the flexor digitorum profundus was carried out in twenty-one fingers with injury to both tendons in the finger of which eighteen were available for analysis. Secondary suture of the flexor digitorum profundus was carried out in five patients with injury to both tendons in the finger. Tendon grafting was carried out in four patients in whom both tendons had been divided in the finger. No operation was performed in two patients with injury to both tendons in the finger (Table 2). TABLE 2 T R E A T M E N T OF F L E X O R T E N D O N INJURIES IN THE F I N G E R
F.D.P. and S . . . . . . . . . . . . . . . . F.D.P . . . . . . . . . . . . . . . . . . .
No operation Primary Secondary suture suture 2 21 5 8 35 2
Graft 4 -
R E S U L T S OF T R E A T M E N T
Where both tendons were divided in the finger between the distal palmar crease and the insertion of the flexor digitorum superficialis, full movement was obtained in six patients where primary suture of the flexor digitorum profundus was carried out, and in one patient who had a tendon graft. One patient in whom secondary suture was performed had full flexion but had 45 degrees limitation of extension. The finger cou,ld be brought to the palm in four patients who had primary suture performed. There were nine poor results including two who had no operation, and in the remaining seven patients, the finger could be brought to within -~in., lin. and 1½in. from the palm (Table 3). (Figs 1A and lB.)
Fig. 1A & lB. Divided flexor digitorum profundus and superficialis in the little finger of the right hand. Result eleven years after primary suture. 45
Vol. 4
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The Results o/ Treatment of Injuries to the Flexor Tendons--M. E. Winston TABLE 3 RESULTS O F T R E A T M E N T OF DIVISION OF T H E F L E X O R T E N D O N S B E T W E E N THE D I S T A L P A L M A R C R E A S E A N D T H E I N S E R T I O N OF F L E X O R D I G I T O R U M SUPERFICIALIS
No operation Primary Secondary Tendon suture suture graft Full movement
...............
Finger to the palm .., ......... Finger to within ½in. of palm . . . . . . . . . Finger to within tin. of palm . . . . . . . . . Finger to within 1½in. of palm . . . . . . . . . Poor result .,. ............... No operation ...............
-
6
2
4 1 2 1 4 -
1 -(FuA1flexion) 1 2 1 -
1 1 2 -
DIVISION OF T H E F L E X O R D I G I T O R U M P R O F U N D U S D I S T A L TO THE I N S E R T I O N OF THE F L E X O R D I G I T O R U M SUPERFICIALIS
W h e n the flexor digitorum profundus was divided distal to the insertion of the flexor digitorum superficialis, primary suture of the flexor digitorum profundus was carried out if the conditions were satisfactory, otherwise secondary suture was performed. Some patients were seen some time after primary suture of the skin had been performed and, in a certain number of patients, the function was acceptable, and no further operation was carried out at this stage. In this type of case a tenodesis or fusion of the distal interphalangeal joint could be carried out at a later date, if necessary, rather than secondary suture or tendon graft which might jeopardise the function of an intact flexor digitorum superficialis. No tendon grafts were carried out for repair of the flexor digitorum profundus alone. I n forty-one patients the flexor digitorum profundus alone was divided in forty-five fingers (Table 1). Treatment
Primary repair was carried out in thirty-five fingers with injury digitorum profundus alone. Secondary suture was carried out in two patients with injury digitorum profundus alone. T e n d o n grafting. No tendon grafting was carried out in division digitoru,m profundus alone in the finger. N o operation was performed in eight patients who had sustained flexor digitorum profundus alone in the finger (Table 2).
to the flexor to the flexor of the flexor injury to the
Results o~ T r e a t m e m
Full movement was obtained in seven patients who had primary suture performed. In twenty-six patients the finger could be brought to the palm, of whom eight had no operation performed, There were five poor results. In the remaining seven patients the finger could be brought to within ½in. to lin. from the palm (Table 4). (Figs. 2 and 3.) Vol. 4
No. 1
1972
47
The Results of Treatment of Injuries to the Flexor Tendons--M. E. Winston
Fig. 2A & 2B.
Divided flexor digitorum profundus in the ring and little fingers, right hand. Result sixteen years after primary suture.
Fig. 3A & 3B.
Division of flexor digitorum profundus in the index finger, right hand. Result thirteen years after primary suture.
TABLE 4 RESULTS OF S U T U R E OF F L E X O R DIG1TORUM P R O F U N D U S ~DISTAL TO T H E I N S E R T I O N O F F L E X O R D I G I T O R U M SUPERFICIALIS No operation Full movement . . . . . . . . . . . . Finger to the palm Finger to within ½in. of the palm ..... Finger to within ~in. of the palm ... Finger to within 1½in. of the palm ... Poor result . . . . . . . . . . . . ... . .
8 -
Primary suture
Secondary suture
7 1Z 3 3 1 4
Tendon graft
1 1
DIVISION OF THE F L E X O R POLL!C!S L O N G U S T h e m e t h o d s o f t r e a t m e n t o f s i x t e e n p a t i e n t s w i t h d i v i s i o n o f the f l e x o r pollicis l o n g u s a r e s h o w n i n T a b l e 5, TABLE 5 DIVISION O F F L E X O R POLLICIS L O N G U S 16 PATIENTS No:operation 1
48
Primary suture 9
Secondary suture 4
Tendon graft 2
VOil 4
NO. 1
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The Results ol Treatment of ln]uries to the Flexor T e n d o n s - - M . E. Winston
Following suture of flexor pollicis longus, there was limitation of movement in the interphalangeal joint in all of the repairs in this review, but the function was adequate. Movement in the metacarpophalangeal joint of the thumb was satisfactory in all the patients (Fig. 4).
Fig. 4A & 4B. Primary suture flexor pollicis longus. Result sixteen years after primary suture. F L E X O R T E N D O N DIVISION IN THE P A L M
Where both the flexor digitorum profundus and the flexor digitorum superficialis were divided, both tendons were repaired provided the conditions for primary suture were present. At this level it was possible to interpose soft tissue or lumbrical muscle between the suture lines of the flexor digitorum profundus and superficialis and retain independent action of these tendons. m this series there were twenty-one patients with injuries to the flexor digim r u m profundus and the superficialis in the palm, the tendons to twenty-five fingers being injured. Two patients had divided the flexor digitorum superficialis alone in the palm. Thus there were twenty-seven fingers injured in twenty-three paticnt.~ Treatment
Primary suture was carried out in twenty-two fingers, and secondary suture in five fingers. Results
Full movement was obtained in thirteen fingers where primary suture was performed, and in one finger with secondary suture. The finger could be brought to the palm in four fingers which had primary suture, and three with secondary suture. In four cases the finger can be brought to within lin. to llin. of the palm. Three of these had primary suture, and one secondary suture. Two fingers which had primary suture had a poor result (Table 6. Figs. 5 and 6). TABLE 6 RESULTS OF S U T U R E OF DIVISION OF TENDONS, IN THE P A L M
No operation Full movement ............... Finger to palm ............... Finger to within kin. from palm Finger to within lin. from palm Finger to within 1½in. from palm Poor result . . . . . . . . . . . . . . . . . . Vol. 4
No. 1
1972
...... ...... ......
Primary Secondary Tendon suture suture graft 13 1 4 3 m
1 2 2
1
49
The Results of Treatment of Injuries to the Flexor Tendons--M. E. Winston
Fig. 5. Division in the palm of the flexor digitorum profundus and superficialis of the index finger, right hand. Result sixteen years after secondary suture. Note how the index finger can be curled into the palm when both tendons are repaired. Fig. 6. Division in the palm of the flexor digitorum profundus and superficialis to the index, middle and ring finger. Result thirteen years after primary suture of flexor digitorum profundus only. Note how the finger cannot be curled into the palm when only the flexor digitorum profundus is repaired. FLEXOR
TENDON
D!VIS!ON
AT THE WRIST
Twenty-three patients had injury to the flexor tendons at the wrist. If the conditions were satisfactory, p r i m a r y suture was carried out where the tendons had been divided at the level of the wrist. I n all b u t one, p r i m a r y repair of both tendons was performed. T w o patients had secondary suture carried out. If the point of division was in the carpal tunnel, the flexor digitorum p r o f u n d u s only was repaired and the carpal tunnel was left unsutured. Treatment
P r i m a r y suture was carried out in twenty-one patients. Secondary suture was carried out in two patients. Results
Full m o v e m e n t was obtained in eighteen patients, sixteen of w h o m had primary suture and two of whom had secondary suture performed. The finger could bc brought to the palm in four patients who had p r i m a r y suture performed. There was one poor result in one patient who had p r i m a r y suture performed (Table 7).
RESULTS
OF SUTURE
TABLE 7 OF FLEXOR TENDON
INJURIES
AT THE WRIST
No operation Primary Secondary Tendon suture suture graft Full movement ............... Finger to the palm ... Finger to within ½in. of tlae" palm" ... Finger to within lin. of palm . . . . . . . . . Finger to within 1½in. of palm . . . . . . . . . Poor result . . . . . . . . . . . . . . . . . .
iii
-
16
2
-
. -
4
-
-
.
. 1
.
. .
.
-
.
-
-
CONCLUSIONS
I n this series, 131 patients sustained injuries to the flexor tendons. P r i m a r y suture was carried out in 105 patients, secondary suture in eighteen patients. No operation was carried out in eleven patients a n d in six patients a t e n d o n graft was carried out (Table 8). 50
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The Results of Treatment of Injuries to the Flexor Tendons--M. E. Winston
Analysis of the results show that the results in the small series in whom tendon grafts were carried out were not satisfactory in four out of the six patients. The results of secondary suture were satisfactory in twelve out of eighteen patients. Primary suture gave good results in eighty-three out of 105 patients. A further analysis showed that where both tendons had been divided in "no man's land" thirteen out of the eighteen patients had satisfactory results. It is known that primary suture in the palm, wrist and fingers distal to the insertion of flexor digitorum superficialis gives satisfactory results and this is supported in this series. Where the flexor digitorum profundus alone had been injured, good results were obtained in thirty out of the thirty-five patients. Primary suture in the pahn resulted in good results in eighteen patients out of the twenty-two and primary suture at the level of the wrist gave good results in twenty out of tweny-one patients (Table 9). From this series it can be seen that the results of tendon grafting are uncertain. Primary and secondary suture are easier procedures to carry out than tendon grafting, and a review of the results of treatment show that primary and secondary suture carried out in satisfactory conditions can give sufficiently good results to justify this method of treatment. It may be that the preliminary use of silastic rods followed by secondary tendon grafting will improve the results. TABLE 8 F L E X O R T E N D O N D I V I S I O N . A N A L Y S I S OF P R O C E D U R E S Site of flexor t e n d o n d i v i s i o n
No operation
F l e x o r d i g i t o r u m p r o f u r t d u s a n d flexor d i g i t o r u m superficialis in t h e finger ... F l e x o r d i g i t o r u m p r o f u n d u s in tt~e'finger' ... F l e x o r pollicis l o n g u s in the t h u m b ...... T e n d o n d i v i s i o n in t h e p a l m ......... T e n d o n d i v i s i o n at t h e wrist .........
FLEXOR TENDON Site of flexor t e n d o n division
Flexor digitorum profundus a n d flexor d i g i t o r u m superficialis in t h e finger Flexor digitorum profundus in t h e finger F l e x o r pollicis longu's in ti~e thumb T e n d o n d i v i s i o n in ii~e pal'm T e n d o n d i v i s o n at t h e wrist
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1972
Secondary suture
Tendon graft
2 8 1 -
18 35 9 22 21
5 2 4 5 2
4 2 -
11
105
18
6
TABLE 9 D I V I S I O N . A N A L Y S I S OF ]RESULTS
Primary suture Excellent Fair and and Good Poor
Secondary suture Excellent Fair and and Good Poor
Tendon graft Excellent Fair and and Good Poor
13
5
4
1
2
4
30
5
1
1
-
-
2 18 20
7 4 1
5 2
4 . .
83
22
12
6
2
6
16.8%
9.2%
4.6%
1.5%
4.6%
63.3% E x c e l l e n t - - l e s s t h a n ½in. 1 G o o d - - ½ i n . to lin. [ F a i r - - l i n . to 1½in. 1 P o o r - - M o r e t h a n 1½in. I
Primary suture
. .
. .
2 . .
T h e distance of t h e finger tips f r o m t h e distal p a h n a r crease w i t h full flexion of t h e finger.
51
The Results of Treatment of Injuries to the Flexor Tendons--M. E. Winston
SUMMARY
The results of treatment of flexor tendon injuries in 131 patients arc reviewed. The results show that good results can be obtained with primary suture carried out in tidy wounds within eight hours of injury and it is justified to carry out primary suture in these conditions. Secondary suture can also give some satisfactory results. In the finger, suture of flexor digitorum profundus only is advised if both tendons are injured between the distal palmar crease and the insertion of flexor digitorum superficialis. Distal to the insertion of flexor digitorum superficialis, primary suture of flexor digitorum profundus is indicated. In the palm both tendons can be sutured. In the wrist both tendons can be sutured unless the point of division is in the carpal tunnel where flexor digitorum profundus only should be repaired and the carpal tunnel left unsutured. At tile wrist repair of the flexor digitorum profundus only might be carried out if the suture lines of all the tendons would be so close as to be likely to adhere to one another and prevent independent action of the tendons.
I wish to thank Mr. Singh of the Department of Medical Photography at Bolton Royal Infirmary and Mrs. Joan Stafford for their help in the preparation of this paper.
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