1. Flexor Tendon Injuries Tricks of the Trade Mr Andrew Mahon Consultant Orthopaedic and Hand Surgeon University Hospital North Durham

2. History Demographics –Age, Hand Dominance, Occupation, Hobbies Mechanism –Blade, Glass, Power Tools, Closed Avulsion Time of Injury Tetanus Fitness for theatre

4. Examination Look at the Hand!! –Posture, Colour Wounds –Tidy, Untidy, Contaminated Test Sensation Know how to examine tendons

7. Question 1 Linburg – Comstock anomaly

8. Question 2 How do you assess the injured hand in a young child?

9. Examination - Children Look Sweating – pen test Wrinkling test Tenodesis Direct pressure over tendons / muscles

10. Don’t Under-estimate the Injury!

12. Question 3 What is the injury?

13. Leddy and Packer

14. Take an X-Ray

15. Surgery Skin Associated structures Flexor sheaths FDS FDP

16. Skin - Incisions Need adequate exposure Avoid scar contracture

18. Associated Structures Inspect Nerves and Vessels

19. Question 4 Which are the most important pulleys in the flexor sheath?

20. Question 4 Which are the most important pulleys in the flexor sheath? A2 A4

21. Flexor Sheath Lister’s Windows A4 Pulley

23. Deliver the Tendon

25. Zone 1 Repair < 1cm reattach to bone –Button –Suture anchor > 1cm tenorraphy

26. Tendon Repair Techniques Core suture –2, 4, 6, 8 strands Circumferential (epitendinous) suture –Running –Halsted –Silfverskiold

27. Core Sutures

28. Kessler

29. Core Sutures 4 strand cruciate Strickland

30. Question 5 What is the most important factor affecting core suture strength?

31. Question 5 What is the most important factor affecting core suture strength? The number of suture strands crossing the repair site

32. Question 6 What is the optimum suture bite length for a core suture?

33. Question 6 What is the optimum suture bite length for a core suture? 7mm to 1 cm Aim for 1cm

34. Circumferential Sutures Adds to repair strength Reduces bulk at repair site

35. Sequence of Repair In finger repair FDS first

36. Goals of Repair (Zone 2) Strong enough for active motion No gapping Free glide through pulleys Minimal handling to reduce adhesions Untidy Repair

37. Rehabilitation Controlled active movement (Belfast)

38. Rehabilitation Kleinert –Active extension –Passive flexion

39. Rehabilitation

40. Question 6 What is the optimum wrist position for immobilisation following flexor tendon repair?

41. Question 6 What is the optimum wrist position for immobilisation following flexor tendon repair? Slight extension –(Savage)

42. Rehabilitation Dorsal splint –MCPs 70 - 90° –Full extension allowed at PIPs Full time 6 weeks At night / in crowds until 12 weeks No resisted exercises until 8 weeks Driving 10 weeks