9-34 Hand III

HAND III: FLEXOR TENDONS
James A Masson FRACS

ANATOMY AND PHYSIOLOGY
Extrinsic flexion of the fingers and thumb is provided by the flexor digitorum profundus (FDP), flexor
digitorum superficialis (FDS), and flexor pollicis longus (FPL) muscles. In the distal third of the forearm,
the superficialis tendons lie anterior to the profundus group, with the middle and ring finger superficialis
tendons volar to those of the index and little fingers.
As they exit from the carpal tunnel, the
superficialis and profundus tendons pair off to their
respective digits, with the superficialis tendons still
volar. At the level of the metacarpophalangeal joints,
the flexor tendons begin their course through the
synovium-lined fibroosseous tunnel, known as the
digital flexor sheath.
There are subtle anatomic relationships between
the superficialis and profundus tendons within the
sheath. As the superficialis tendon enters the flexor
sheath, it lies volar to the profundus. It flattens out,
and splits into two slips near the end of the A1
pulley. These slips of the superficialis diverge, pass
around the profundus, and rejoin dorsal to it. This
reconstitution of the superficialis is known as
Campers chiasm (Fig 1). Finally, the superficialis
tendon again splits into radial and ulnar slips that
proceed to insert onto the middle phalanx, from
the base to its mid-portion.1
Fig 1. Decussation of the FDS within the flexor sheath. (Reprinted

with permission from Idler RS: Anatomy and biomechanics of the
digital flexor tendons. Hand Clin 1: 4, 1985.)
The course of the flexor digitorum profundus

is predictable. As it enters the flexor sheath, the
tendon lies dorsal to the superficialis and travels
through Campers chiasm to lie volar and superficial, finally inserting into the proximal portion of
the distal phalanx. The shapes of both the profun-
dus and superficialis tendons alter as they pass

distally within the fibro-osseous sheath, due to
changes in the intratendinous arrangement of their
collagen fibers.2-5
The FDS to the little finger is the most variable of
all the musculotendinous units in the hand.6-9
Approximately 34% to 42% of normal hands have
some deficiency of the little finger FDS. The tendon is absent in 16% to 23% of cases, and 18% to
21% of patients with deficient little finger FDS get
some power transmitted from the ring finger FDS.
Finally, the right and left hands are asymmetrical
with respect to the FDS 26% of the time.
The flexor pollicis longus is the most radial structure within the carpal tunnel. It passes deep to the
tendon of flexor carpi radialis, then enters its own
fibrous sheath. It inserts into the base of the distal
phalanx of the thumb.
The lumbricals are responsible for flexion of the
metacarpophalangeal joints. However, as they are
also extensors of the interphalangeal joints of the
fingers, they will be discussed in the Extensor Tendons volume of Selected Readings.
Tendon Sheath and Pulleys
Each finger and the thumb has a synovial-lined
fibroosseous tunnel called the flexor tendon
sheath. In the fingers, the flexor tendon sheath
begins at the level of the distal palmar crease (metacarpal neck) and ends at or just distal to the distal
interphalangeal joint.10 It is an uninterrupted synovial membrane, reinforced at intervals by the pulley system, and creates a synovium-lined space.
Any structure which enters that space, be it tendon, artery, vein, or nerve, is invested by a layer of
visceral synovium.11 The sheath serves three important functions: (1) it allows smooth tendon gliding; (2) through its retinacular reinforcing pulleys, it
maintains the flexor tendons close to the volar surface of the phalanges, maximizing mechanical efficiency and preventing bowstringing; and (3) it provides an enclosed synovial fluid environment for
tendon nutrition.12
SRPS Volume 9, Number 34
Doyle and Blythe13 initially described four annular bands and three cruciform bands that make up
the retinacular pulley system. Kleinert and Broudy14
subsequently added a fifth annular pulley, and
Manske and Lesker15 identified the importance of
the palmar aponeurosis pulley, the anatomy of
which was further elucidated by Doyle.16
The palmar aponeurosis (PA) pulley (sometimes
referred to as the A0 pulley) is made up of transverse fibers and paratendinous bands of the palmar aponeurosis near the proximal end of the flexor
tendon sheath. The PA pulley forms a tunnel around
the flexor tendon and appears to act in conjunction with the first and second annular pulleys of the
digital flexor mechanism. The palmar aponeurosis
pulley should be considered part of the finger pulley system, since it overlaps the flexor synovial
sheath.16 Loss of motion associated with transection of the A1 or A2 pulley is insignificant as long as
the PA pulley remains intact.15,17
It is generally agreed, therefore, that the
retinacular portion of the flexor tendon sheath consists of the palmar aponeurosis pulley, five annular
pulleys, and three cruciform pulleys18 (Fig 2).
Fig 2. The components of the digital flexor sheath. (Reprinted

with permission from Idler RS: Anatomy and biomechanics of the
digital flexor tendons. Hand Clin 1:6, 1985.)
The flexor sheath does not buckle nor impinge

on the flexor tendons during flexion because: (1)
the broader, stronger A2 and A4 pulleys are located
over the proximal and middle phalanges, respectively, and are away from the joints, whereas the
narrower A1, A3, and A5 pulleys are over the joints;
(2) the pulleys are segmental in nature, with thin
synovial pouches between them which bulge out
between the pulleys; (3) the thin, narrow, cruci-
form pulleys are obliquely oriented and also located

close to the joints.18 The thin parts of the sheath do
not load-bear during flexion, because the series of
pulleys becomes approximated to form a continuous surface composed of strong fibrous bands (Fig
3). The pulley system shortens in flexion by 38% in
the fingers and by 30% in the thumb.19
Fig 3. Sheath bulging and flattening during flexion-extension.

Insert: synovial pocket formation. (Reprinted with permission
from Mester S et al: Biomechanics of the human flexor tendon
sheath investigated by tenography. J Hand Surg 20B: 502, 1995.)
The A2 and A4 pulleys are usually considered the

most important in terms of mechanical efficiency
and prevention of bowstringing.20-26 Manske and
Lester,,27 surprisingly, found the A2 pulley to be the
weakest, despite being the longest, with the A1 and
A4 pulleys being most important.28 This is borne
out in cases of closed traumatic ruptures of the
pulleys where the sequence of ruptures is usually
A2 first, then A3, A4, and rarely, A1.29 Both ultrasound and MRI are very sensitive in diagnosing
annular pulley ruptures.30 Savage31 showed in a
cadaver model that division of up to four contiguous pulleys did not affect profundus tendon excursion or flexion force, tendon bowstringing, nor distance from nail to distal palmar crease. He also
claimed that the A2 and A4 pulleys were no more
important mechanically than the other pulleys, provided that the majority of the sheath was intact.
Tomaino et al32, in a cadaveric biomechanical study,
suggested that 25% of the A2 pulley, up to 75% of
the A4 and 25% of the A2 and A4 pulleys together
can be excised without significant effects on angular rotation of the finger. Likewise, Tang33 suggested
that partial incision or enlargement of the A2 pulley
can be performed for tendon repairs in zone II
without mechanical detriment. A diametrically

opposed view was taken by Delattre et al,34 who
claimed that even minor resection of the proximal
pulley mechanism causes severe mechanical
imbalance by enhancing flexion of the MP joint at
the expense of the PIP joint. In a study looking
specifically at FDS biomechanics, Hamman et al35
concluded that the A2 and A3 pulleys were the
most important for maintenance of normal FDS
function.
Flake and colleagues36 studied the number, type,
position, and size of the pulleys of the flexor tendon sheath in children ranging in age from newborn to 15 years, and found the pulley system of
children to be remarkably similar to that of adults.
The pulleys of the flexor pollicis longus are
arranged differently to conform with the greater
mobility and unique architecture of the thumb.37
The thumb has two annular pulleys, located over
the MP and IP joints respectively. The oblique pulley, lying over the proximal phalanx between the
two, is the most important, and should be preserved
or reconstructed (Fig 4).38
Fig 4. The pulley system of the flexor pollicis longus. (Reprinted

with permission from Schneider LH, Hunter JM: Flexor Tendons
Late reconstruction. In Green DP (ed): Operative Hand Surgery,
3rd ed. Churchill Livingstone, 1993. Chapter 51, p 1895.)
The interior of the flexor tendon sheath is not a

perfectly smooth cylinder, as often depicted.
Lundborg and Myrhage39 found that the inside of
the sheath contained pockets. Further work by Amis
and Jones40 elucidated the cause of these pockets.

The thin parts of the sheath do not attach directly
to the proximal and distal borders of the pulleys.
Instead, they often overlap proximally and distally,
so that the pulleys sit proud of the surrounding
sheath. These edges may be of significance in postoperative triggering following tendon surgery.
HISTOLOGY
A tendon consists of metabolically active connective tissue (86% collagen) in a ground substance
that contains a small number of fibroblasts. Tendon
bundles within each tendon are composed of collagen fibers and tenocytes bound together by a
fine layer of connective tissue, the endotenon,
through which blood vessels and lymphatics run.41
In cross-section, a tendon shows histologic differences, with tenocytes in the area of maximal friction adjacent to the pulley system differentiating
into more chondrocytic-type cells.
The endotenon is a continuation of the perimysium proximally, and in turn becomes continuous
with the periosteum distally. The collagen fibers in
the bone become the perforating fibers of Sharpey.42
The paratenon is a loose areolar vascular tissue
that surrounds nonsheathed tendons and contains
long elastic fibers and redundant vessels to maintain circulation to the tendon during excursion.
Cohen and Kaplan11 studied the histologic and
ultrastructural morphology of the flexor tendon
sheath. The sheath is in two layers, an outer one of
parietal synovium forming the walls of the sheath,
and an epitenon or visceral synovium layer covering the tendons within the sheath. Between the
two layers on the phalangeal side is the mesotenon
through which the vincula run (Fig 5). Other than
at the vincular origins, the parietal and visceral synovial layers are continuous proximally at the cul-desac and distally at the tendon insertions.
Ellis et al43 studied the A2 pulley and found that it
had three distinct layers. The outer layer is continuous with the membranous sheath. It is richly vascularized and serves as a source of nutrition. The
middle layer maintains the structural integrity of the
pulley through its radially oriented collagen fibrils
and resists tendon bowstringing. The inner layer
has a smooth, gliding surface with modified fibroblasts which secrete hyaluronic acid, and this layer
facilitates efficient tendon excursion.
Fig 5. Cross section of the digital flexor tendon mechanism at the

level of the A4 pulley. (After Cohen MJ, Kaplan L: Histology and
ultrastructure of the human flexor tendon sheath. J Hand Surg
12A:25, 1987.)
TENDON NUTRITION AND HEALING

Tendons have an intrinsic ability to heal. The
healing process depends on the processes of vascular perfusion and synovial diffusion, but the relative importance of each mechanism still remains
contentious (Fig 6). Many different animal models
have been used to study tendon healing and this
has produced considerable confusion. The chicken,
rabbit, dog, and nonhuman primate have been the
most extensively studied, both in vivo and in vitro.
Although each animal model has inherent similarities to the human, it must be kept in mind that there
are still differences which may be important, and
that results of in vitro models in animals should be
extrapolated to the in vivo human situation with
caution. Even in the studies of human flexor tendons, earlier papers often did not distinguish
between intrasynovial and extrasynovial tendons.
In recent years, human tendons have been studied
in vitro.
Tendon Blood Supply
Mayer44 is credited with the first description in
the English literature of the vascularity of flexor
tendons (1916). He pointed out that tendons may
receive blood supply from three sources: (1) the
musculotendinous junction; (2) the bony insertion;
and (3) through the mesenteric vincular vessels.
He also noted the avascular zone on the volar
(frictional) surface of the tendon. Edwards41 and
Brockis45 described a longitudinal intratendinous
vascular network with frequent cross-anastomoses.
Peacock46 demonstrated that the blood supply from
the muscular origin or bony insertion of a tendon
Fig 6. Tendon nutrition in the digital sheath. (Reprinted with

permission from Messina A: The double armed suture: Tendon
repair with immediate mobilization of the fingers. J Hand Surg
17A:140, 1992.)
supplied only a short segment at either end, and

that the blood supply to tendons is segmental,
through a mesotenon. Other authors validated the
importance of the vincular vessels.47-49
All of the early anatomical studies were performed on non-viable tissue - fetus, cadavers, or
amputation specimens. The first intravital study of
tendon circulation was performed in 1969 by
Schatzker and Brnemark.50 They confirmed that
the blood supply to tendons is segmental, regardless of whether it is extrasynovial or intrasynovial.
Furthermore, any surgical maneuver which separated the tendon from its paratenon or mesotenon
was found to devitalize that segment of tendon. A
subsequent intravital study by Lundborg51 disagreed
with these findings. He was able to demonstrate
that complete mobilization of an extrasynovial tendon in the rabbit resulted in minimal disturbance in
microvascular flow. He further defined the volar

avascular zone of intrasynovial flexor tendons, and
proposed that synovial diffusion may be important
in this region.52 Both tendons have an area of relative avascularity between their respective vincula.
In the FDP, this is over the PIP joint, whereas in the
FDS, it is over the MP joint.53
Leffert54 better defined the vincula, which arise
from the proximal and distal transverse digital arteries at the level of both interphalangeal joints. On
the surface of the tendon, vessels are longitudinally oriented and dorsal, so that they are not compromised by the sheath during flexion. At the level
of the IP joints, both profundus and superficialis
tendons demonstrated transverse vessels, which
are branches of the vincula and are thought to
allow continued blood flow even during maximal
flexion. The actual tendon fiber arrangement is also
thought to protect the vascularity during tendon
compression in flexion.2
Several authors55-57 describe in detail the long
and short vincula to the FDP and FDS tendons and
their origins from four transverse branches of the
digital arteries (Fig 7). The short vinculum is fairly
constant, whereas the long vinculum displays more
variability. In flexor tendon lacerations, an intact
vinculum may prevent retraction of the tendon.
Splinting the wrist in flexion after flexor tendon
injury decreases the flexion power of the finger
flexors and decreases the likelihood of vincular
rupture.58-60
The thumb is similarly supplied by two vincula,
one each at the metacarpophalangeal (MP) and
interphalangeal (IP) joints.61-65 The long vinculum
at the level of the MP joint is absent in 50% of
cases; when absent, the tendon is less vascular
and is free to retract when severed. The short
vinculum is a strong structure, and is able to transmit some flexion force even after division of the
FPL at the level of the IP joint. The short vinculum
is present in about 90% of cases.64 The median
nerve artery supplies the tendon in the area
between the musculotendinous junction and the
digital sheath.62
Synovial Diffusion
In 1963, Potenza proposed that the process of
synovial diffusion might satisfy all of the metabolic
needs of the intrasynovial flexor tendon.66 Matthews
Fig 7. Vincula and flexor tendons. VLS, vinculum longum

superficialis, VLP, vinculum longum profundus, VBS, vinculum
breve superficialis, VBP, vinculum breve profundus. (Reprinted
with permission from Kleinert HE, Lubahn JD: The current state
of flexor tendon surgery. Ann Chir Main 3:10, 1984.)
noted that devascularized segments of tendon survived within the intact synovial sheath.67 McDowell
and Snyder thought that vascular loops, seen at
the junction of the tendon with vincula and sheath
reflections, acted like dialyzing membranes and
allowed the fluid that emerged to diffuse into the
tendons.68 Through a series of studies using tracer
materials, in a variety of experimental animals,
Manske and colleagues concluded that diffusion
appeared to be more important than vascular perfusion as a nutrient pathway to the flexor tendons.69-73 Even where all vascular connections were
divided, diffusion was effective in maintaining the
viability of the tendon. Radioisotope studies, performed by other authors in other animal models,
confirmed these findings.74-78 It appears that the
milking action of the tendon as it passes underneath the pulleys is important in enhancing the
diffusion process. Katsumi showed that it was not
only synovial fluid that was capable of nourishing
flexor tendons, but also extracellular tissue fluid.78
The nutrient capability of synovial diffusion challenges many traditional concepts in flexor tendon
surgery. If synovial diffusion is able to support a
tendon in its entirety, then the placement of sutures
in the volar, avascular segment might not be so
critical. The dorsal placement of core sutures has
been shown to be stronger than volar placement.79,80 Dorsal placement has certain mechanical
advantages which can be attributed to decreased

sheath friction and the biomechanics of the joint
and the pulley system which create compression
of the volar side of the tendon. Tendon grafts,
which had been thought to have required the
ingrowth of blood vessels via adhesions to survive,
can survive on diffusion,74 and may be mobilized
immediately.81,82 Theoretically, it would also seem
appropriate to repair or reconstruct the synovial
sheath at the time of repair.83-91 However, the benefit of sheath reconstruction has been challenged
in several experimental and clinical studies.92-97
In the clinical situation, where the metabolic
requirements of the healing tendon are likely
greater than in controlled experimental situations,
vascular perfusion and synovial diffusion probably
have complementary functions.
Tendon Healing
There have been many studies over recent years
which show that tendons have an intrinsic repair
capability. Historically, the works of Skoog and
Persson,98 Potenza,99,100 Peacock,102,103 and others
claimed that tendon healing required the ingrowth
of cells and vessels from surrounding connective
tissues in the form of adhesions. It now seems that
adhesions may constitute an inflammatory process
at the site of injury, or may represent an extension
of the intrinsic tendon healing process to the surrounding tissues.
Lindsay and Birch104 concluded that the only
fibroblasts that could proliferate were those that
invaded from the periphery, and that the tendon
cells could only produce ground substance. They
showed that the epitenon generated new fibroblasts by mitosis, and that these fibroblasts subsequently migrated into the tendon junctures and
began their healing process. They stated that all
connective tissue cells in the tendon were capable
of producing immature cells.105,106 Matthews and
Richards 107 demonstrated that an incompletely
divided flexor tendon, without suture material, and
lying free within an otherwise uninjured digital
sheath, healed normally, without the appearance
of adhesions. Furlow 108 concluded that intrasynovial tendons have an intrinsic repair capability, that adhesions are not necessary for the process, and moreover, that early motion will prevent or disrupt adhesions.
In vitro tissue culture studies by Lundborg109 and

others110 demonstrated healing of lacerated rabbit
tendons when placed within the knee joint and
subcutaneous pockets. These results were contested by many who considered that this represented seeding from exogenous cells. When nonviable tendons were placed in a similar environment, they also healed.111-113 Lundborg subsequently
modified his model, preventing cell seeding, and
the tendons still healed.114 Both epitenon and
endotenon cells had repair capabilities in a synovial
environment.
Cell-free culture media were first used to study
flexor tendon healing by Becker.115 He confirmed
the capacity of tendon explants to provide viable
collagen-synthesizing fibroblasts. Manske116-118 and
Gelberman 119,120 were able to show that the
phagocytosis of injured tendon collagen occurred
by differentiation of epitenon fibroblasts, and that
endotenon cells were primarily responsible for collagen synthesis. Even in the absence of epitenon
cells, tendon gaps can be bridged by endotenon
cells.121 Mass and Tuel122 demonstrated that segments of human flexor tendons have the same
capacity to survive culturing and to mobilize an
intrinsic healing response to include cell division,
cell migration, phagocytosis, and synthesis of new
collagen.
Several authors have demonstrated greater cellular, biochemical, and vascular activity in the
epitenon, rather than the endotenon. Garner et
al123 used a monoclonal antibody to procollagen I
to show that the onset and location of collagen in
the healing tendon may be the epitenon. The
endotenon does not begin to synthesize collagen
for 2 to 3 weeks. Birdsell had noted the delay in
endotenon collagen synthesis several years
before. 124 Gelberman and coworkers 125 found
high levels of expression for procollagen type I
mRNA in the surface layer of healing tendons,
confirming that cells intrinsic to epitenon contribute the greatest quantity of native tendon collagen to the repair site during the early stages of
flexor tendon healing. Expression of TGF beta-1
by mRNA suggests a role for both intrinsic
(tenocyte) and extrinsic (tendon sheath fibroblast)
healing in flexor tendons.126
Fibroblast chemotaxis and adherence appear to
be related to the secretion of fibronectin.127,128
Fibronectin concentrations are elevated in injured
tendons, and are also elevated in repaired tendons

subjected to early motion regimens.128 Duffy et al
suggest that mitogenic or growth-promoting factors may be released following flexor tendon injury
and may modulate the intrinsic repair mechanism.129,130
Gelberman,131,132 Woo,133 and others134 have
shown that early controlled passive motion after
tendon repair augments the intrinsic repair process
(Fig 8).
healing tendon, where metabolic demands are

higher than synovial diffusion alone may be able
to support.1137 Pennington85 found that the vincular
blood supply did not affect the healing of the
profundus tendon in chickens, but Amadio and
colleagues came to the opposite conclusion in a
human clinical study.138
Mobilized tendons also display higher tensile
strengths, improved gliding function and tendon
excursion, increased repair site total DNA, and
decreased adhesion formation.120,139 Other animal
models have also shown a decrease in adhesion
formation with motion140-142 and improved early
tensile properties.143,144 Not only does controlled
motion appear to be beneficial, but the frequency
and duration of the therapy may also be important.132,144
INJURIES
Flexor Tendon Zones
The level of injury to a flexor tendon determines
the treatment and has prognostic implications. In
1980, an International Committee defined a universal nomenclature for flexor tendon zones145 (Fig
9). In the fingers, there are 5 zones:
Fig 8. Flexor tendon healing. (A) A mobilized tendon that is

healing by cellular ingrowth from the epitenon. (B) An immobilized tendon healing by adhesion and endotenon cellular ingrowth. (Reprinted with permission from Gelberman RH, et al:
Flexor tendon healing and restoration of the gliding surface. An
ultrastructural study in dogs. J Bone Joint Surg 65A:78,79 1983.)
The first event seen is revascularization of the

repair site, despite the absence of adhesions. Local
vascular endothelial growth factor (VEGF) mRNA
accumulation at the repair site is the probable
mediator and is produced by cells at the repair
site.135 Vessels were seen to extend through normally avascular regions, and intratendinous vessels about the site of repair originated from surface vessels.125 Increasing mobility is associated
with a longitudinal orientation of delicate vessels.131
Conversely, immobilization has been shown to
produce a marked decrease in the vascularity of
the tendon bed.136 These findings suggest that
vascular perfusion may still be important in the
Fig 9. Zones of tendon injury within the hand. (Reprinted with

permission from Strickland JW: Flexor tendon repair. Hand
Clin 1:56, 1985.)
Zone I.
Zone II.
Zone III.
Zone IV.
Zone V.
Distal to the FDS insertion

From the A1 pulley to the FDS insertion
From the distal end of the carpal
tunnel to the A1 pulley
Carpal tunnel
Proximal to the carpal tunnel
In the thumb, there are also 5 zones, the latter

two of which correspond to those of the fingers:
Zone
Zone
Zone
Zone
Zone
I.
II.
III.
IV.
V.
Distal to the IP joint

From the A1 pulley to the IP joint
Thenar eminence
Carpal tunnel
Proximal to the carpal tunnel
through the muscle belly, or at its insertion.

Intratendinous rupture is unusual in patients who
do not have rheumatoid arthritis. It may occur as a
result of pathology within the tendon (eg, infection, gout, or following steroid injection).165-167
Chronic attrition ruptures may follow fractures of
the distal radius or carpal bones.168-175 Occasionally
no underlying pathology is found, and these ruptures may be appropriately termed spontaneous.176-178
The surgical management depends on the level
of the rupture, the time interval between injury and
treatment, and the status of the superficialis tendon.178 Primary repair may be feasible in early cases,
but the surgeon may need to resort to tendon
transfers, grafts, or DIP joint stabilization procedures.
With isolated superficialis rupture, no treatment may
be the best option. The treatment should also
address the underlying cause, if one exists.
Partially Severed Tendons

Assessing the cross-sectional area of a partial tendon laceration using loupes or even calipers is notoriously inaccurate.146 Triggering, secondary to partial
laceration or rupture of the superficialis tendon, has
been documented.147-152 Schlenker and others recommend surgical repair of partial lacerations on the
basis that entrapment and rupture might also ensue.153
Wray and Weeks recommend early active
motion of partial flexor tendon lacerations instead
of surgical repair.154 Suturing partially divided tendons has been shown to decrease their tensile
strength.155 Beveled lacerations involving less than
25% of the diameter of a tendon can be either
excised or repaired with a single stitch, while larger
beveled lacerations, which might catch on a pulley,
should be repaired with a few simple sutures.
Patients with transverse tendon lacerations ranging
from 25% to 95% of the cross-sectional area were
managed nonoperatively, with early mobilization,
and obtained excellent function.156 Other authors
confirm the validity of nonoperative treatment.157162
Early mobilization is also advocated in partial
tendon lacerations in children.163
Tendon Ruptures
McMaster showed that a tendon will not normally rupture in its mid-substance.2164 It will preferentially dehisce at the musculotendinous junction,
Tendon Avulsions
Traumatic avulsion of the insertion of the flexor
digitorum profundus tendon is typically, although
not exclusively, an injury of young fit males engaged
in contact sports. Originally described in Australian
Rules football players,179 it is seen in all codes of
football, where the finger of a player is caught on
the shorts or jersey of another player during a tackle,
ie, when the finger is forcibly extended during maximal profundus contraction.180-182
The ring finger is most commonly involved, and
various explanations have been offered for this.
The common flexor profundus muscle belly to the
middle, ring, and little fingers,179 when combined
with the relative lack of independence of extension of the ring finger imposed by the juncturae of
the extensor tendons,181 makes it susceptible to a
hyperextension force. The breaking strength of the
FDP insertion of the ring finger is usually significantly less than for the middle finger.183 The ring
finger becomes the most prominent fingertip during flexion, due to flexion of the mobile fourth
carpometacarpal joint, rendering it more palmar
than the middle finger. Furthermore, as the MP
joint of the ring finger is more proximal than the
middle, the fingertip is also more proximal, and will
engage objects first and release them last.184
Leddy181 proposed a classification for avulsion
injuries, which has been supplemented by Smith.185
Tendon retracts into the palm with rupture of both vincula

Type II Tendon retracts to the level of the PIP
joint, leaving long vinculum intact
Type III A large bony fragment avulsed with the
tendon is prevented from retraction
beyond the middle phalanx by the A4 pulley
Type IV Avulsion fracture of the distal phalanx and
an associated tendon avulsion from the
fragment with subsequent retraction of the
tendon.
Type I
Fig 10. Leddys classification of FDP avulsion injuries. (Reprinted with permission from Strickland JW: Development of
flexor tendon surgery: twenty-five years of progress. J Hand Surg
25A:214, 2000.)
The ideal surgical management of these injuries

involves reinsertion of the tendon into the base of
the distal phalanx. Avulsion or distal tendon laceration of the FDP tendon is classically repaired to the
base of the distal phalanx via a pullout suture which
may be tied over a button. However, biomechanical studies have suggested that none of the 3 commonly used suture techniques (Bunnell, Kessler,
and Kleinert) is strong enough to withstand the
higher forces associated with active mobilization
protocols.186,187 Bone anchors have recently been
described for this purpose and may offer advantages in terms of strength and morbidity.188-190 The
divided, edematous FDP tendon can be difficult to
pass back beneath the intact A4 pulley. Elliot has

suggested venting the A4 pulley to allow passage
of the tendon.191 There is biomechanical evidence
to support the validity of this technique in both the
A2 and A4 pulleys.192,193 Where there is concern
about partially releasing the A4 pulley, Elliot has
also suggested excising half of the distal end of the
FDP tendon longitudinally, which allows the remaining demi-tendon to be passed beneath the pulley.194 The type I injury should be reattached within
7 to 10 days, before devascularization and muscle
contracture make this impossible. There is less
urgency with the type II injury, as the vascularity of
the tendon is maintained, as is most of the length.
Type III injuries necessitate open reduction and
internal fixation of the avulsed bone fragment. Type
IV injuries require both fixation of the bone fragment and reinsertion of the tendon.185,195
The management of old, untreated cases must
be tailored to the individual. If there is no special
requirement for active flexion of the DIP joint, and
the joint is stable, no treatment is required. Instability necessitates DIP fusion. Tendon grafting must
be undertaken with caution, as a previously normal
FDS may be impeded.
Isolated rupture of the superficialis insertion is a
rare entity.196,197 Surgery may be indicated for the
subsequent PIP flexion contracture or to release
tethering of the profundus. Simultaneous rupture
of both superficialis and profundus tendons in the
same digit is a very rare injury which is usually
managed by FDP tendon grafting,176,198,199 although
primary repair has been reported.200
Children
Physical evaluation and diagnosis of a tendon
injury in a young child are more difficult than in
adults because of a childs inability to cooperate
with the examiner. Detection of any associated
nerve injuries may be suggested by the location of
the skin wound, but is often only accurately defined
at the time of surgical exploration.
Early authors have shown that results for primary repair of flexor tendons in the digital sheath
are generally better than for adults, although the
same does not hold for tendon grafts.201-203 In children, wounds heal more rapidly, and have a greater
capacity for remodeling.204 Children are also less
likely to develop joint stiffness. However, this should
not be misconstrued as carte blanche to universally good results in flexor tendon surgery in children. This surgery should only be performed by
the experienced.
As was the trend with adults, FDS excision and
tendon grafting were once used liberally.205-208 However, repair of both tendons within zone II is the
usual practice now, and affords good results.208
Age is no barrier to flexor tendon surgery, with
successful repair reported in a neonate.209
Immobilization for 4 weeks in an above-elbow
cast, followed by unrestricted motion, produces
comparable results to early motion protocols, so
there is no real place for the latter in young children.210,211 Flexor tenolysis is not often required in
children, but when it is, should probably be deferred
until after the first decade of life.212
SURGICAL MANAGEMENT
A number of techniques, each applicable to specific circumstances, is available for the repair of
most tendon lacerations. These options are as follows:
primary tendon repair
delayed primary tendon repair

secondary tendon repair
profundus advancement
tendon graft
tendon transfer
arthrodesis
capsulodesis
tenodesis
There are many excellent review articles on the

primary repair of divided flexor tendons, from the
Louisville213-215 and Indiana216-220 groups, and others,21-223 to which the reader is referred.
Primary tendon repair is performed within 24
hours of injury and is probably the preferred option
in most cases, as long as there is no evidence of
wound sepsis.224 Delayed primary repair, performed between 24 hours and 2 weeks, ie, before
the wound has securely healed, is indicated in
grossly contaminated wounds. The benefits of early
tendon repair still apply, and the functional results
are comparable to primary tenorrhaphy.225-227 Early
10
secondary repair takes place between 2 to 5

weeks after the injury,228,229 whereas late secondary repair occurs after 5 weeks. Primary repair
and early secondary repair all yield similarly good
function, but the earlier the surgery, the less likely
are wound edema and infection. The results of late
secondary repair tend to be poor because of tendon swelling, muscle retraction, and extension deficit.230,231
Lacerations of the profundus tendon distal to
the FDS insertion can be treated by profundus
advancement of up to 1 cm.232 This technique must
be used with great caution, as excessive shortening will cause a flexion deformity of the repaired
digit, and hyperextension in adjacent digitsthe
quadriga effect.233,234
Delayed tendon grafting with or without sheath
induction by a silastic rod remains appropriate in
cases not amenable to early repair, and will be
discussed later. It is reserved for late cases in which
scarring of the bed, loss of pulleys, permanent
retraction of the tendon ends, or joint contracture
prevents direct repair. Immediate tendon grafting
for acute tendon loss is controversial, but may be
indicated in the presence of an adequately debrided
wound, and an appropriate soft tissue bed, even if
that necessitates free tissue transfer.235
The indications for and technique of tendon
transfer have been reviewed in the previous issue
of Selected Readings, Peripheral Nerves and Tendon Transfers. The indications for tendon transfer
in flexor tendon surgery are fairly limited, and documented results have been variable. The FDS to the
ring finger is the usual donor tendon, and has been
transferred to the little finger FDP in the digital
sheath236,237 and the FDP tendon in late zone III
lacerations.238 It is most commonly indicated for
motoring the FPL tendon, usually in delayed or late
cases of tendon division,239-241 or where there has
been loss of function of the FPL muscle belly
through denervation, devascularization, or direct
muscle damage.242
The treatment of isolated lacerations of the FDP,
especially in zone I, must be individualized, as for
tendon avulsions. Arthrodesis and capsulodesis
are salvage procedures which sacrifice active motion
of the distal interphalangeal joint for stability. As
DIP motion only accounts for 15% of the total arc
of motion of the finger,243 these are not unreasonable procedures in patients in whom active
motion of the joint is not essential. A capsulodesis

may stretch with time, but does allow passive flexion of the distal joint.244 Arthrodesis produces a
strong, stable tip.
A tenodesis can be static,245,246 in which case
there will be no DIP motion, or dynamic,247,248 in
which case FDS contraction will produce some
active flexion of the DIP joint (Fig 11).
sion of the PIP joint may occur if the superficialis is

not addressed. The therapy protocol must maintain PIP extension, as the intrinsics may be weak in
the presence of associated median and/or ulnar
nerve injuries. Tendon function in this zone is usually good,250,251 although not universally so.252,253
Associated injuries to the median and ulnar nerves
at the level of the wrist result in more disability and
poorer hand function than do the tendon injuries
themselves. Because return of function in the hand
is much more dependent on adequate reinnervation, no compromise in nerve repair should be
made. Tenolysis is required in about 15% of cases.254
Zone IV: Because of the smaller tolerances
within the carpal tunnel, repair of tendon lacerations at this level is more controversial, as adhesion
formation may be considerable. Ideally all structures should be repaired, with a limited synovectomy. Kleinert recommends leaving all or part of
the deep volar carpal ligament to prevent
bowstringing, and reconstructing it with tendon
grafts if divided.215 However, one must also be aware
of the possibility of acute median nerve compression from swelling if this is done.
Zone III: Tendon lacerations across the palm in
the region where the lumbricals branch off the
profundus tendons may be repaired primarily as in
the forearm, and the prognosis is nearly as good.
Common digital nerves and arteries and both tendons should be repaired. Eventual functional results
are again dictated by the quality of reinnervation
after repair of associated nerve injuries.
Fig 11. (Above) Dynamic tenodesis of the DIP joint. (Below)

Alternative technique when the distal stump is too short for the
standard tenodesis. (Reprinted with permission from Kahn S: A
dynamic tenodesis of the distal interphalangeal joint, for use after
severance of the profundus alone. Plast Reconstr Surg 51:536,
1973.)
Repair by Zone
Zone V: Primary repair of all tendons is preferred, as delayed repair beyond 4 weeks causes
shortening of the muscle that requires interposition tendon grafts for correction. Both superficialis
and profundus tendons should be repaired, and
this should not preclude the possibility of independent flexor function.249 Furthermore, hyperexten-
Zone II: Poor functional results after primary

tendon repair in the region between the distal palmar crease and the insertion of the superficialis
tendon led to the popularization of tendon grafting
as the preferred treatment of these injuries until
the mid-20th century. Verdan once again legitimized
primary repair of zone II flexor tendon injuries in
the 1960s,255,256 and many authors since have reaffirmed its feasibility.213-223,257-263
Primary repair of both tendons is widely accepted
unless the injury is massive or there is marked contamination. FDS excision, once popular as it was
thought to create more space for the FDP repair,
still has its advocates.264 Strickland advocates FDS
repair because of the advantages of maintaining
11
vincular blood supply to the FDP, preserving independent finger motion,265 improved strength of
power grip, providing a bed for smooth gliding of
the FDP, less potential for PIP joint hyperextension,
and a possibly reduced rupture rate through loadsharing.219 Absolute contraindications to primary
repair of zone II tendon injuries are human bite
lacerations and suspected cellulitis. Relative
contraindications include associated trauma to other
structures (eg, complicated phalangeal fractures)
and skin loss.266
In a multivariate prospective analysis of zone II
repairs, Silfverskild and May267,268 found that the
controlled range of motion of the finger at 3 weeks
was the single most influential factor with regard to
final DIP and PIP joint range of motion. Other
important variables were age (most influential on
DIP joint ROM), number of tendons injured (most
influential on PIP joint ROM), swelling, and the
number of digits involved.
Zone I: Injuries to the profundus tendon distal
to the insertion of the superficialis have already
been discussed under Tendon Avulsions. Techniques for this injury run the whole gamut of the
reconstructive ladder and include primary repair,
tendon advancement (<1 cm), tendon graft, and
tenodesis, capsulodesis, or arthrodesis of the DIP
joint.
In short, primary repair of both tendons is the
accepted norm in all zones of the fingers and hand.
Associated neurovascular injuries can be repaired
primarily with the tendons. However, if there are
complex fractures which cannot be anatomically
reduced and rigidly fixed to allow early motion, or
if there is an extensive skin or soft tissue deficit,
these problems should be addressed first and tendon reconstruction delayed accordingly. These
associated injuries may have adverse effects on
final tendon function and must be dealt with before
tendon repair.
The Thumb
The first surgical option in the repair of FPL tendon lacerations at all levels should be primary tendon suture.269,270 Great caution should be exercised in dealing with FPL lacerations in zone III, as a
number of very important anatomical structures
12
pass in close proximity to the FPL sheath (Fig 12).242

Associated neurovascular injuries are very common. It is often safer to retrieve the tendon proximally through a separate wrist incision, and feed it
back down the sheath with the aid of a small bore
catheter, rather than dissect extensively in this area.
Urbaniak242 and Bruner271 describe the approach
to expose the FPL tendon (Fig 13).
Fig 12. Anatomy of the flexor pollicis longus. (Reprinted with

permission from Urbaniak JR: Repair of the flexor pollicis longus.
Hand Clin 1:70, 1985.)
Fig 13. Surgical exposure of the FPL. 1 - Bruner incision. 2 & 3

- More proximal incisions in the palm and wrist may be extended
(dotted lines) to join the thumb incision when necessary. Insert
- Alternative midlateral incision and possible extension. (Reprinted with permission from Urbaniak JR: Repair of the flexor
pollicis longus. Hand Clin 1:72, 1985.)
Most authors recommend tendon advancement for lacerations within 1 cm of the insertion.241,242,272 This technique can also be used in
more proximal FPL lacerations if the tendon is
concomitantly lengthened at the wrist242,272 or fractionally lengthened at the musculotendinous junction to avoid distal suturing within the tendon sheath.
An anomalous tendon slip, from the FPL to the
index finger FDP, has been reported in as many as
31% of individuals,273 and may complicate this procedure if not detected and excised.
In general, the results of flexor tendon repair in
the thumb are better than in the fingers because of
the simpler anatomy (two phalanges, one tendon).
In late cases, or salvage of failed primary repairs,
treatment alternatives are tendon grafts,242,272,274,275
tendon transfers,237-241 and arthrodesis or tenodesis
of the IP joint.276,277 The results of secondary surgery
may not be as favorable as primary surgery.272
Operative Techniques
Skin and Tendon Sheath Incisions
An accurate history of the mechanism of injury
will help to plan the incisions. If the injury occurred
with the finger in extension, the tendon division will
be at the same level as the skin wound. Conversely,
if the finger was flexed at the time of injury, the
flexor tendon division will be distal to the skin wound.
The proximal tendons will retract to a level commensurate with vincular integrity. Distal extension of
the wound will be necessary. A separate incision
may be necessary at the level of the distal palmar
crease to retrieve the proximal tendon end, rather
than opening the digito-palmar fat pad.
Access to the flexor tendon sheath is via midlateral278 or Bruner volar zigzag incisions279 or combinations of the two which best incorporate the
initial skin laceration (Fig 14). Acute angles at the
tips of the flaps should be avoided. On the pulp of
the finger, the incision should be on the side opposite that which is used for tactile functionie, the
ulnar side of the index, middle, and ring fingers and
the radial side of the little finger and thumb.
Lister has described the window method of
flexor tendon exposure.280 The tendons should
be kept moist at all times, as excessive exposure
to air and drying has been shown to inhibit cellular activity in flexor tendons.281 The integrity of
the annular pulleys is maintained, and it allows
for sheath closure at the end of the procedure.
The sheath is opened through the cruciate pulleys on either side of the A4 pulley, making a
Fig 14. Surgical exposure of the flexor tendon sheath. (Reprinted

with permission from Leddy JP: Flexor Tendons Acute injuries.
In Green DP (ed): Operative Hand Surgery, 3rd ed., Churchill
Livingstone, 1993 Chapter 50, p. 1829.)
longitudinal incision 2 to 3 mm from its lateral

margin. An L-shaped cut is completed with a transverse limb, adjacent to the annular pulley from
which the tendon end will be retrieved, but away
from the end into which it will be passed (Fig
15). This creates a funnel into which the tendon
can be drawn and will avoid snagging. The reader
is referred to Listers article for a detailed
description of proximal, proximal combined, and
distal combined repairs.280
Fig 15. Flexor tendon access through the cruciate pulleys.

(Reprinted with permission from Lister GD: Incision and
closure of the flexor sheath during primary tendon repair.
Hand 15:127, 1983.)
13
Callan and Morrison describe an even simpler

technique.282 A transverse incision is made in the
sheath 1 cm distal to the proximal cut end of the
distal tendon segment. With full flexion of the wrist
and MP joints, both tendon ends can be delivered
through this incision. Following tendon repair, the
tendon and sheath repairs are at different levels.
Furthermore, closure of the transverse sheath incision does not narrow the internal diameter of the
sheath.
Tendon Retrieval
After the sheath has been exposed, the tendon
ends must be retrieved atraumatically into the
retinacular window. Tendon-retrieval forceps should
be passed down the sheath with great caution, and
probably only when the tendon end is visible. The
delicate lining of the sheath is easily damaged, and
a rent will promote adhesion formation. If tendonretrieval forceps must be used, flexible ones are
less traumatic than hemostats or other rigid instruments.283
Physical maneuvers, such as milking the forearm with the wrist and MP joints maximally flexed,
may deliver the ends. This can also be supplemented
by wrapping an Esmarch bandage from the elbow
to the wrist.284 Suction, using a small silastic catheter introduced retrogradely down the sheath, may
be beneficial.285 If these techniques are unsuccessful, then the sheath must be opened more proximally, usually through a separate distal palmar crease
incision, and the proximal tendon ends retrieved.
The lumbrical origin prevents retraction of the FDP
proximal to this. The most common techniques
involve the passage of fine infant-feeding catheters
down the sheath. To these catheters are attached
core sutures which have already been placed
through the proximal tendon end.286-288 Endoscopic
retrieval has also been described.289 The exact relationship of the superficialis and profundus tendons
must be maintained through Campers chiasm.
Suture Materials and Techniques
The use of controlled motion after flexor tendon repair increases tendon strength by augmenting the intrinsic repair process131-134 and decreases
adhesion formation.140-144 Active motion protocols
might be expected to produce even better results.
14
However, conventional two-strand suture techniques are not strong enough to resist gapping
and may rupture under such conditions. Immediately after a tendon repair, the strength of the repair
is entirely dependent upon the suture material and
the technique with which it is inserted.290 Therefore, the quest continues for the ideal suture and
suture technique.
The ideal suture should knot securely, be strong,
nonreactive, easy to handle, and inelastic.291 There
is no significant difference between the two most
commonly used suture materials, monofilament
polypropylene and braided polyester.291 Likewise,
the suture technique employed should be easy to
use, minimize interference with the tendon vascularity,292 resist gapping, be sufficiently strong to
allow motion, and result in a smooth external juncture without increasing the bulk of the tendon.293,294
Locating the knots outside rather than within the
repair site may result in higher ultimate tensile
strength,295 although it may also increase the risk of
adhesions. The epitenon-first technique allows the
knot to be placed remote from the repair site.296
Some authors think that locking loops do not
increase the strength of tendon repairs, and that
they may actually lower the threshold for gap formation.297,298 The evidence to date has been equivocal. Manske, however, found that locking loops
had advantages over grasping loops in reducing
gap formation.299
Most tendon suture methods employ a core
suture and an epitendinous suture. The latter was
originally thought to be primarily of esthetic importance in tidying up the ends. However, many
studies have shown that it both increases the overall strength of the repair and is most important in
resisting gap formation.300-306 Gap formation results
in a greater extrinsic repair response, with increased
adhesions and a poorer clinical outcome,137,307-309
although early motion may decrease its clinical significance.310,311 The simple continuous running
epitendinous suture is considerably weaker than
several recent innovations, all of which incorporate a transverse grasp within the tendon substance
at an intermediate distance between the tendon
end and the core suture (Fig 16).300,301,304,305
It is difficult to compare the many biomechanical
studies that have been performed on tendon
suture techniques, as there is great variation in the
animal model, type of tendon used, in vivo (mobili-
Fig 16. Epitendinous suture techniques. (Reprinted with permission from Strickland JW: Development of flexor tendon surgery: twentyfive years of progress. J Hand Surg 25A:214, 2000.)
zation versus immobilization) versus in vitro

(method of preservation), static versus cyclic loading,312 and end-point of the study. However, most
agree that there is not a great difference between
the many popular two-strand methods,313-316 and
when repairs rupture, they tend to do so at the
suture knots.314 The initial strength of these repairs
is proportional to the number of suture strands that
cross the repair site as well as the caliber of the
suture material. Core sutures of 3-0 are significantly
stronger than the more conventional 4-0 suture.317,318 Therefore, it is not surprising that more
recent trends have looked at doubling,319-322 tripling323-328, and even quadrupling the number of
strands crossing the repair site,329 as well as using
more powerful tissue grasps (Fig 17). The Savage
six-strand technique (Fig 18) has been shown to be
3X stronger than the most popular method in clinical usethe Kleinert/Pennington modification of
the Kirchmayr/Kessler suture (Fig 19).323,330
Becker331,332 and Ketchum333 used a different
principle in their techniques, which incorporate lateral rows of crisscrossing continuous sutures that
compress the tendon ends. In the Becker technique, the beveling of the ends means that longitu-
dinal pull on the tendon compresses the repair site,

resisting gapping (Fig 17).331,332,334,335 A modification of the Becker technique was found to provide
adequate strength for early active motion when
the FDS was repaired at Campers chiasm when
compared with a modified Kessler or horizontal
mattress suture.336
Recent experimental innovations have incorporated an external nylon mesh,337 or an internal
Dacron splint within the repair,338 both of which
have strengths comparable to the Savage repair.
The aim of all these new techniques is an attempt
to develop a repair commensurate with early gentle
active motion. Several clinical studies have actually
done this, with promising results.321,324,332,339,340
Pulley and Sheath Reconstruction
Although reconstruction of the retinacular part
of the sheath is not necessary for tendon nutrition
or mechanical efficiency,92-97 the same cannot be
said for the annular pulley system. Reconstruction
of the A2 and A4 pulleys is considered the minimum,20-26 but four and five pulley reconstructions
have been shown to perform better than two pul-
15
Fig 17. Techniques of end-to-end flexor tendon repair. (Reprinted with permission from Strickland JW: Development of flexor tendon
surgery: twenty-five years of progress. J Hand Surg 25A:214, 2000).
leys. 341,342 In a mathematical cadaver model,

Hunter343 and Hume344 have suggested that there
should be a pair of pulleys created either side of
each joint, placed symmetrically at the metaphyseal
flare. Ideally, the reconstructed pulley should be
strong enough to allow immediate motion.
The quest for the ideal pulley reconstruction
addresses two main issuesthe material (autogenous, xenograft,345 alloplastic), and the optimal
16
method of fixation. To date, most reconstructions

have utilized autogenous tissuefascia lata, tendon,
extensor retinaculum from the hand and foot, and
volar plateand have secured these by passing the
material through drill holes, circumferentially around
the digit, or by using what remains of the original
pulley for purchase (Fig 20).280,346-351 The Karev
belt loop352 was found to be mechanically effective and strong in three biomechanical cadaver stud-
ies,352-354 whereas the Okutsu triple loop351 was

thought better, and strong enough to permit early
active motion, in another study.355 In a human in
vitro biomechanical study, Listers technique using
extensor retinaculum produced the least resistance
to tendon gliding.356 Intrasynovial sources of pulley
material may make better pulleys in terms of resistance to glide than extrasynovial sources.357
Fig 18. Six-strand repair (Savage). (A) Insertion of one of the

grasping stitches. (B) Six sequential stitches are passed in this
way. (C) They are distributed around the circumference of the
tendon, avoiding the vincular area. (Reprinted with permission
from Savage R, Risitano G: Flexor tendon repair using a six strand
method of repair and early active mobilisation. J Hand Surg
14B:397, 1989.)
Fig 20. Autogenous pulley reconstructions (A) Using the

always present fibrous rim (Weilby). (B) Volar plate belt
loop (Karev). (C) Triple loop (Okutsu). (After Lin G-T et al:
Biomechanical analysis of finger flexor pulley reconstruction. J
Hand Surg 14B:278, 1989.)
Fig 19. A strength-versus-force graph showing 2-, 4-, and 6strand repairs plotted against passive, light active flexion and
strong grip. The data are adjusted for friction, edema, and stress.
(Reprinted with permission from Strickland JW: Development of
flexor tendon surgery: twenty-five years of progress. J Hand Surg
25A:214, 2000).
All autogenous reconstructions have a tendency

to stretch out with time, leading to recurrence of
bowstringing and loss of mechanical efficiency. For
this reason, alloplastic alternatives have been
looked at with great interest.358-368 Both Nitex361,362
(a woven monofilament nylon fabric) and, more
17
recently, PTFE363-368 have shown great promise in

animal studies. These materials are well tolerated,
eliciting no foreign body reaction and causing no
adhesions, permit excellent tendon gliding with no
trauma to the tendons, and are mechanically efficient and strong enough to permit immediate
motion. They have yet to be tested in a human
clinical situation.
REHABILITATION
Early controlled mobilization protocols are
now accepted practice following flexor tendon
repair. Experimental work has shown their
value, 120,131-134,141-144 and numerous clinical studies attest to their benefits. Immobilization, once
the accepted standard, is now reserved for
young children. 210 The mobilization protocols are
either based on the passive regimens,369-374 after
Duran and Houser,375,376 or active-extension and
passive rubber-band flexion,267,268,495,377-394 as popularized by Kleinert213 and Lister.214 Some protocols incorporate components of each.395-400 The
extremes of motionearly active flexion401-410 and
continuous passive motion411,412 have also been
described, with promising results.
The premise upon which all these protocols
are based is that early motion will produce differential gliding between both the superficialis and
profundus tendons, and equally importantly,
between the flexor tendons and the tendon
sheath, to minimize adhesion formation. Numerous clinical and cadaver studies have tried to
determine how much differential motion does
occur in an attempt to define an optimal motion
regimen. 413-427
Differential Excursions
McGrouther and Ahmed413 studied the excursions of the flexor digitorum superficialis and flexor
digitorum profundus tendons relative to each
other and to the synovial sheath in zone II in a
cadaver model. They found that for each 10
degrees of isolated DIP motion, the FDP moves
only 1 mm in relation to the FDS. For each 10
degrees of PIP joint motion, the FDP and FDS
move 1.3 mm relative to the sheath. Passive MP
joint motion produces no relative motion. The
authors noted that the traditional Kleinert splint
18
produced relatively small amounts of DIP motion,

and suggested incorporating a palmar pulley, which
now forms the basis of most active extension protocols.267,268,381-394
Wehb and Hunter414-416 studied the gliding
excursions of flexor tendons in the hand by measuring motion of the profundus and superficialis
tendons in vivo during carpal tunnel releases. Three
finger positions were found to provide maximal
differential gliding for both flexor tendons. In the
straight fist position, the superficialis tendon achieves
maximum gliding with respect to flexor sheath and
bone. The profundus achieves maximum gliding in
the fist position, while in the hook position, maximum gliding is achieved between the two flexor
tendons. Horibe417 found that the PIP joint was the
most effective in producing tendon excursion relative to the sheath and in minimizing adhesions.
Greenwald et al418 demonstrated that FDP excursion increases as the number and size of joints
flexed increases.
Wehb found that maximal gliding of the FPL is
obtained by flexing the MP and IP joints.415 In
contrast, Brown and McGrouther419 found that
thumb MP motion produced no tendon excursion of the FPL over the proximal phalanx in a
cadaver study. They recommend immobilizing the
MP joint in the dynamic mobilization of FPL repairs,
claiming a 70% increase in excursion over mobilization of both joints. As in the fingers, controlled
motion produces better results than immobilization.420
Wehb416 also studied the effect of wrist motion
on tendon excursion. Wrist motion increases
superficialis tendon excursion to a greater degree
than profundus excursion. FPL excursion is affected
to a lesser degree by wrist motion. These findings,
supported by other authors,428-431 led to the development of the dynamic wrist tenodesis splint (Figs
21 & 22).389
The aforementioned studies were performed
either in cadaver tendons or normal patients. The
effect of flexor tendon repair has demonstrable
effects on the theoretical ideal. Postoperative
edema greatly increases the work of flexion.421
Phillips et al showed that using a Kleinert regime,
the fingers moved much less than expected.422
Silfverskild et al423 showed that compared to active
motion, controlled motion was relatively less efficient at producing tendon excursion at the DIP
Fig 21. Splint mobilization after flexor tendon injuries. (A)

Kleinert splint. Wrist in flexion with rubber band traction about
the wrist. (B) Brooke Army Hospital splint. Wrist in flexion,
palmar pulley to traction above the wrist. (C) Dynamic tenodesis effect; wrist flexion produces finger extension and wrist
extension produces finger flexion. (Reprinted with permission
from Horii E, Lin GT, Cooney WP et al: Comparative flexor tendon
excursion after passive mobilization: An in vitro study , J Hand Surg
17A:559, 1992.)
joint than at the PIP joint, and that the latter was
primarily responsible for most of the total ROM of
the finger. In a subsequent study, utilizing a more
aggressive four finger protocol, they showed that
the magnitude of excursion at both joints was
important.424 Hagberg and Selvik425 found that adding an active component to the protocol improved
excursion at the A4 level.
Strickland assessed zone II repairs treated with a
passive regimen, and was able to obtain 5 to 8 mm
of tendon excursion.426 Passive flexion of the DIP
joint produced proximal excursion of the FDP only.
Flexion of the PIP joint, with the DIP joint extended,
produced proximal excursion of both tendons.
Composite flexion of both joints produced proximal motion and separation of both tendons.
Fig 22. Estimated tendon excursion (measured in mm) with 3

types of mobilization splints: the Kleinert splint (no palmar bar),
the Brooke Army splint (with a palmar bar pulley, and the Mayo
Clinic synergistic dynamic tenodesis splint, which permits wrist
extension. (Reprinted with permission from Horii E, Lin GT,
Cooney WP et al: Comparative flexor tendon excursion after
passive mobilization: An in vitro study , J Hand Surg 17A:559,
1992.)
Despite a preference among surgeons for the

active extension/passive rubber band flexion programs over controlled passive techniques, full passive digital flexion and extension of the PIP and DIP
joints probably produces the same excursion as
the various modifications of the Kleinert splint in
current use.426
Most authors would advocate restricting full use
of the hand until 12 weeks from the time of tendon
repair. However, Adolfsson et al432 permitted full
activity after 8 weeks, following a two-strand repair
with Maxon and a passive flexion-active extension
protocol, without significantly increasing the risk of
dehiscence. Although there was a 5.7% rupture
rate, the ruptures all occurred early, in the second
and third weeks.
19
EVALUATION OF RESULTS
COMPLICATIONS
It is difficult to determine the relative advantages

of one therapy protocol over another. As with so
many other aspects of flexor tendon surgery, there
is no universal agreement as to what constitutes an
ideal evaluation system. Even when the same system is used to compare studies, it is difficult to
control for the many patient and injury variables.
The widely accepted and simple Boyes method
measures the distance from the fingertip pulp to
the distal palmar crease during maximal active finger flexion.433,434 The Louisville system combines
the pulp-to-palm distance with a measurement of
the total extension deficit of all three joints.214 The
ASSH method adds the active or passive flexion
angles of the MP, PIP, and DIP joints and subtracts
any extension deficit. Total active and passive ROM
can thus be determined.435 Buck-Gramckos system allocates points for each of 3 parameters
composite digital joint flexion, pulp-to-palm distance,
and extension deficit.436 Strickland claims that as
motion of the MP joint is rarely affected to a significant degree after flexor tendon surgery, and is
dependent on intrinsic function, its inclusion in an
assessment system unfairly biases results. His formula gives a percentage of expected normal function.426,437,438 Several studies have compared the
commonly used systems (Table 1).439-441
Probably the best results to date have come
from Chows group, employing the Washington
regimen.395,396 Using a protocol that incorporated
both controlled active extension against passive
flexion by rubber band and the use of controlled
passive flexion and extension, they were able to
achieve 82% excellent and 16% good results in 44
patients with zone II injuries by the Strickland formula. However, this patient population was unique
in that it consisted of young, fit military personnel
who followed a regimented timetable of therapy,
and were seen daily by the therapist or treating
surgeon for the duration of their treatment. A report
of the same technique used in a civilian population
produced results that were in marked contrast to
Chows.442
Ejeskr443 and Gault444 assessed variables other
than range of motion of the joints. They found a
decrease in functional parameters (finger flexion
force and pressure, finger pinch pressure, key pinch,
and hand grip strength) following flexor tendon
repair.
The two major complications of flexor tendon

surgery are rupture of the tendon repair, and the
formation of adhesions.445-450 Adhesions will be discussed under tenolysis.
Most clinical studies report a small but definite
incidence of tendon repair rupture, averaging about
5%, regardless of the suture technique or therapy
protocol.447 One recent study by Peck et al451 comparing a passive and active regimen found an alarming 46% rupture rate in the active group. The rupture rate is higher with FPL tendon repairs than
with repairs in the fingers, especially with active
motion protocols.452 Few, however, have looked
at the management of such ruptures. Allen et al448
concluded that prompt repair of ruptured flexor
tenorrhaphies and rehabilitation with active motion
exercises is effective treatment. The advantages
offered are: (1) not having to wait for the inflammation to recede, (2) avoiding the longer and more
involved grafting procedures, and (3) preventing
the stiffness that can occur when the patient loses
interest in rehabilitation. Clinical suspicion may be
confirmed by ultrasound or MRI.449
Small et al404 found re-repair technically more
difficult than the original procedure, but concurred
that it is the treatment of choice.
20
SECONDARY SURGERY
Tendon Grafts
Despite advances in primary suture and rehabilitation of tendon injuries, there is still a place for
tendon grafts in hand surgery, primarily for the more
severely injured fingers. Extensive use of tendon
autografts in the past for the repair of simple lacerations within the digital sheath has generated a great
deal of clinical and experimental data.255,256,453-471
The reader is referred to the many excellent
review articles on one and two-stage tendon grafting. 350,472-478
The decision whether to perform a one-stage or
two-stage graft is made primarily on the basis of
the soft tissue status of the finger. If the tendon
laceration is accompanied by minimal scarring,
supple joints, and an adequate pulley system, then
a one-stage palm-to-pulp graft would be appropriate.479 In contrast, staged flexor tendon reconstruction is a salvage procedure that is used where the
(Reprinted with permission from: A, C, and D - Jansen CWS,

Watson MG: Measurement of range of motion of the finger after
flexor tendon repair in zone II of the hand. J Hand Surg 18A:411,
1993; B - So YC et al: Evaluation of results in flexor tendon repair:
A critical analysis of five methods in ninety-five digits. J Hand Surg
15A:258, 1990.)
initial injury is too severe to allow primary repair or

one-stage grafting. Factors to consider are the severity of the initial injury (crush, associated fractures, skin loss, nerve and artery damage), scarring
of the tendon bed, loss of retinacular pulley system, and scarred profundus bed with intact
superficialis. Patients with severe neurovascular
impairment are poor candidates for this surgery. In
some patients arthrodesis or amputation might be
the most appropriate treatment. Finally, the patient

must understand the complexity of the problem
and be able to comply with the lengthy and involved
therapy following two operations.
Boyes developed a classification for the preoperative status of fingers that has some prognostic
significance for the choice of procedure433,434 (Table
2). In general, one-stage grafting is appropriate in
grade I fingers while two-stage grafting is reserved
21
for grades II to V. The true condition of the sheath

cannot be determined until the time of surgery, so
whenever a surgeon embarks upon a one-stage
graft, he/she should be prepared to convert this to
a two-stage procedure if the conditions so dictate.
Although there is no hard-and-fast rule with regards
to age, the best results have been obtained in young
people between 10 and 30 years of age.
TABLE 2
Boyes Preoperative Classification
for Tendon Grafting
(Reprinted with permission from Imbriglia JE et al: Secondary

flexor tendon reconstruction. Hand Clin 5:395, 1989.)
Both procedures should be preceded by a

period of therapy which aims to optimize the condition of the finger through scar management, correction of joint contractures, etc.480-482 Likewise, the
initial stages of both procedures are similar. The
sheath is approached through Bruner or mid-lateral
incisions, which will usually extend from the pulp to
the distal end of the carpal tunnel. Scarred sheath is
dissected and excised, leaving each with as much
normal pulley system as possible. The scarred flexor
tendons are removed from the sheath, leaving a
tail of 1 cm, and are divided proximally at the level
of the lumbricals. Scarred or shortened lumbrical
muscles should be excised to prevent the development of a lumbrical-plus finger. If the PIP joint
tends towards hyperextension, then an FDS tenodesis can be performed. Joint contractures may
require release by capsulotomy and volar plate and/
or collateral ligament release.
At this stage, the suitability for proceeding to a
primary graft can be determined. Heavy scarring of
the tendon bed and the need for reconstruction of
the pulley system will be the main determinants.
Should the decision be made to insert a silicone
rod at this stage, then all other reconstruction should
be performed at this first stage, ie, pulley recon-
22
struction, nerve repair or graft, skin graft or flap

coverage for skin replacement, and joint release.
The first stage of a two-stage tendon reconstruction involves implantation of a silastic rod for induction of a pseudosheath.483-496 Examination of the
pseudosheath reveals it to be composed of three
layers: an intima, a media, and an adventitia.493 The
intima cells contain a glycosaminoglycan substance
and have a secretory capacity. The media cells are
rich in collagen for structural support, while the
adventitia is a highly vascular layer made up of
loose fibrous tissue. 497,498 The pseudosynovial
sheath stabilizes by 8 weeks, and provides lubrication, diffusible nutrients, and an organized vascular
system, and is not susceptible to longitudinal contracture.493,494 Chamay and Gabbiani,499 in a single
case report, showed myofibroblastic contracture
of the pseudosheath that necessitated eventual
amputation of the digit.
The tendon implant is passed from the fingertip
proximally within the pulley system, and through
the intact carpal tunnel to lie in the distal forearm in
a plane between the tendons of FDS and FDP,
identified through a distal volar ulnar forearm incision. With the fingers flat on the table, 1 to 2 cm of
implant should lie free proximal to the wrist crease.
The largest implant is selected that will glide freely
in the sheath (usually 3 to 4 mm for women and 4
to 5 mm for men). The rod is secured distally, either
by suture to the FDP stump for the standard Hunter
rod or by a screw into the distal phalanx through
the metal bracket of the Holter-Housner rod, taking care not to damage the germinal matrix of the
nail (Fig 23). Gliding should be demonstrated on
the table, with 3 to 4 cm of excursion from finger
extension to maximal passive flexion with the wrist
neutral. Active tendon implants, which are connected to the muscle unit proximally, have also
been investigated.500-506 They have the theoretical
advantage of tuning the muscle and allowing the
pulley reconstruction to be tested.
The first stage is followed by a period of therapy,
once again aimed at optimizing the status of the
finger for the second stage. This involves scar management, reduction of edema, correction of
contractures, and maintaining the maximum passive range obtained at the time of the initial surgery.480-482 Complications that might be encountered during this time are synovitis, infection, and
loosening of the distal juncture with proximal
Fig 23. Distal tendon-silastic rod juncture. (Reprinted with

permission from Hunter JM: Staged flexor tendon reconstruction.
J Hand Surg 8:790, 1983.)
migration of the implant.507,508 Synovitis may result

from overzealous therapy or inhibition of gliding
within a sheath that is too tight. A period of immobilization will usually allow its resolution. If the implant
becomes dislodged, the hand should be immobilized, and the second stage can usually be undertaken as planned. Infection, which is rare, will require
implant removal, debridement and irrigation,
immobilization, and antibiotics. Once the soft tissues have settled, the first stage may be repeated, if
desired.
There is no set time for the second stage. It can
be performed when the soft tissue condition of the
finger permitsie, soft scars, supple joints, and good
passive range of motion.509-515 This will usually be at
about 2 to 3 months after the first stage. One-stage
grafts have been performed many years after injury
with success, as the second stage of a tendon
reconstruction provided that joint mobility is maintained.516-518 In the second stage, the rod is replaced
by an autologous tendon graft. The distal part of
the finger wound is opened, as is the forearm
wound, to expose both ends of the rod. A suitable
donor graft is harvested.519-522 The palmaris longus
tendon (avg. 13 cm) is most commonly used, as it
is present in 75% to 85% of people,520-523 but is not
usually long enough for a pulp-to-forearm graft of
the central digits. It may be used for the thumb or
little finger, or for a superficialis finger, and in
pulp-to-palm grafts. For the central digits, the plantaris tendon (avg. 31 cm), present in 81-93% of
patients, should be considered.524-528 Other donor
tendons include the long extensors to the central
three toes (avg. 30 cm),529 the extensor indicis pro-
prius (avg. 10 cm), and extensor digiti minimi tendons530 (avg. 11 cm). The paratenon is usually
excised,531 though some espouse its virtues.532,533
The graft is attached to the proximal end of the rod
and is drawn distally through the pseudosheath as
the rod is withdrawn.
Recent experimental work in dogs has shown
marked differences in behavior between grafts of
extrasynovial and intrasynovial origin. 534-539
Intrasynovial tendons would appear to be the ideal
choice for a donor tendon.540 Compared with their
extrasynovial counterpart, they heal intrinsically by
a proliferation of epitenon cells with minimal adhesion formation;534,536 intrinsic neovascularization
takes place from the proximal suture site;538,541 and
they synthesize less matrix components and DNA,
suggesting that they remain viable through synovial diffusion.536-541 In contrast, extrasynovial tendons appear to act as scaffolds, undergoing extensive cellular death followed by a rapid repair process. 542
The final part of the procedure is identical for
both one and two-stage procedures. The graft is
secured proximally and distally outside the fibroosseous canal, but the actual sequence of steps
varies between authors. The distal juncture usually
employs a pull-out suture through a drill hole or
osteoperiosteal flap (Fig 24),453-458,543-548 and can be
reinforced with sutures to the profundus stump. A
biomechanical study suggests that none of the pullout suture techniques is sufficiently strong to withstand active mobilization without significant gapping at the tendon-bone interface.549
The possibility of a composite bone-tendon graft
for bone-to-bone healing has been investigated.551
An appropriate donor muscle is identified, and the
proximal juncture is performed with a weave, with
as many passes as possible (Fig 25).314,552,553 For a
one-stage graft, the juncture can usually be performed in the palm to the native FDP, as it will be
held out to length by the lumbrical. For a two-stage
graft, the juncture will usually be in the forearm,
bypassing the scarring in the palm, to the common
FDP muscle mass. The appropriate tension is established by examining the cascade of the normal fingers and making the graft slightly tighter than its
normal position would dictate.554 This can be confirmed on the table with the tenodesis effect of
wrist motion. Occasionally a bridge graft may be
indicated for division of the flexor tendons between
23
the musculotendinous junction and the distal palmar crease (ie, with normal tendon-sheath relations
distally).555,556
Fig 24. Distal tendon graft juncture demonstrating the Bunnell

pull-out technique. (Reprinted with permission from Schneider
LH: Staged flexor tendon reconstruction. Hand Clin 1:115, 1985.)
Fig 25. Proximal juncture with a Pulvertaft weave. (Reprinted

with permission from Kleinert HE, Lubahn JD: The current state
of flexor tendon surgery. Ann Chir Main 3:15, 1984.)
A modification of the two-stage procedure has

been described by Paneva-Holevich.557,558 At the
initial injury, the severed proximal ends of the
superficialis and profundus are sutured to one
another in the palm. At the second operation, the
superficialis is cut at its musculotendinous junction
and passed distally down the sheath, pedicled on
the original tendon juncture.559,560 The first stage
may also be combined with a silicone rod.561-565
The treatment of an isolated division or rupture
of a profundus tendon with an intact superficialis
remains contentious, and must be tailored to the
patients needs.566-576 Many of the issues have been
addressed in Tendon Avulsions. The problem
really comes down to whether it is worth risking
compromise of a normally functioning FDS to obtain
some flexion of the DIP joint. Most consider it
24
worthwhile in the index and middle fingers of young

people, and sometimes the little finger for restoration of power grip. Approximately 80% of patients
undergoing one-stage grafting for isolated profundus loss achieve satisfactory results. In a finger with
good skin, supple joints, and an intact FDS there
appears to be no advantage to two-stage tendon
reconstruction over a conventional graft.577
Controlled motion programs have begun to win
favor in the postoperative management of flexor
tendon grafts,81,82,578 although an initial period of
immobilization of 3 weeks is still preferred by
many.457,579 The protocols are very similar to those
used for primary tendon repairs, with particular
attention to preventing recurrence of flexion
contractures. Tonkin et al compared a Kleinert regimen with immobilization following tendon grafting.580 Although there was no difference in final
motion, the rate of graft rupture and need for
tenolysis was higher in the immobilized group.
Complications that can develop after tendon grafting include infection, adhesions, graft rupture581
(proximal or distal juncture, and rarely, mid-substance582), bowstringing (secondary to pulley inadequacy), swan neck deformity, flexion contractures
of the PIP and DIP joints, and either a quadriga
effect234 (too tight a graft) or lumbrical plus finger583 (too long a graft). As with rupture after primary tendon repair, prompt reexploration offers
the best chance for recovery. It may be possible to
reattach a distal juncture rupture, but consideration
should be given to inserting another rod in the
absence of a functioning FDS, or stabilizing the DIP
joint with a functioning FDS.581
The place of tendon grafting in children is still
debated, as reported numbers are small. Many
advocate not grafting children under the age of 5,
as they cannot comply with the therapy456-458,584,585
and have poorer results than adults who have the
same surgery.201-203 Others claim similar results in
young children as in adults.586-588 Providing that joint
mobility can be maintained, there is no reason why
grafting cannot be deferred until the child is of a
more compliant age.589 Nishijima590 has shown that
a tendon graft grows with its host, so flexion contracture from relative graft shortening should not
be a problem. Postoperative therapy, as with primary repair in children, should be immobilization
for 3 to 4 weeks, followed by unrestricted motion.
The assessment of results after tendon grafting

is perhaps more difficult than after primary tendon
repair, as there is even greater variability in the preoperative condition of the finger.591-593 Different
grading systems are required, as the percentage of
TAM obtained, compared to the preoperative TPM,
is probably a more realistic indicator of results (Table
3). For conventional one-stage grafts, Boyes and
Stark assessed 1000 consecutive grafts and found
that the most important prognostic factors to be
scarring, joint involvement, age, bilateral nerve injury,
and the joint involved.433,434,594 Weeks and Wray
looked at the rate of recovery following tendon
grafting.595 Although there was an initial rapid
increase in recovery, improvement continued for
many months. By 22 weeks after grafting, 90% of
final motion had been achieved.
TABLE 3
Classification of Results Following
Flexor Tendon Grafts and Tenolysis
(Reprinted with permission from LaSalle WB, Strickland JW: An

evaluation of the two-stage flexor tendon reconstruction technique. J Hand Surg 8:264, 1983.)
Most studies concur that two-stage grafting can

restore reasonable flexion in salvage situations while
accepting a significant complication rate.509,510,513,596
Adjunctive tenolysis can improve results further,
and may be indicated in a significant percentage of
cases.597
Tenolysis
The most important factors in the production of
tendon adhesions are tendon suture, immobilization, and sheath excision.598 Immediate postoperative controlled motion protocols negate the effects
of sheath excision, yet the adverse effect of tendon suture remains. Surgical glove powder pro-
duces irritation of the sheath, but not adhesion

formation.599
Attempts at reducing adhesions have been both
mechanical and pharmacological. The interposition
of flaps or grafts of sheath between the injured
tendons and between the tendons and bone, has
been successful in a chicken model,600,601 whereas
the effect of a continuous load to the tendon has
not.602 Silastic sheeting has been used clinically.603
-Aminoproprionitrile604-607 and cis-hydroxyproline608 showed experimental promise, but their use
is limited clinically because of toxicity or impairment of wound healing. Neither polyvinylpyrrolidone609 nor ADCON-T/N610,611 showed any benefit. Agents affecting early fibrinous adhesions such
as ibuprofen,612-614 indomethacin,615 aprotonin616
and sodium hyaluronate show promise.617-621 However, not all reports of the use of hyaluronate have
been favorable.622,623 Hagberg found no benefit
from topically applied sodium hyaluronate after tenorrhaphy or tendon grafting in a clinical trial.624 In
early animal models, a single intraoperative dose
of 5-fluorouracil reduced postoperative tendon
adhesions, but this has not yet been tested in
humans.625,626 Cortisone and its various derivatives
have been used topically and systemically with good
effect, and are probably the most commonly used
adjuncts to tenolyis.627-632
Tenolysis may be indicated following flexor tendon repair or grafting when the passive range of
joint motion exceeds the active joint motion despite
aggressive physical therapy.438,633-635 One must consider the extent of limitation of active motion as it
relates to a particular patients age, occupational
needs, and desires, as well as the sensory and circulatory status of the tissues. The possibility that
tenolysis may bring no improvement or even
worsen the deficiency should be kept in mind. In
addition, there is a tendency for recurrence of
adhesions or rupture of the tendon during surgical
mobilization.
Successful tenolysis requires careful patient
selection and a well-motivated patient. The patient
must understand that if the operative findings so
dictate, it may be necessary to proceed to a silicone rod insertion as the first stage of a two-stage
tendon reconstruction. As with all tendon surgery,
the soft tissues should be in good condition, with
soft scars, supple joints, and normal or near-normal
passive range of motion.
25
Tenolysis may be considered 3 months or more

after repair, provided there is no appreciable
improvement in active range of motion for 1 to 2
months.438,636,637 This surgery is ideally performed
under local anesthesia supplemented by intravenous sedation.638 If a wrist tourniquet is also used
to minimize ischemic forearm pain, patients can
actively cooperate in the procedure, demonstrating to both the surgeon and themselves the extent
of adhesion release.
Wide surgical exposure via Bruner or mid-lateral
incisions is required. Meticulous division of all adhesions between the superficialis and profundus
tendons and between the tendons and sheath is
undertaken, leaving as much of the normal sheath
and pulleys as possible.639,640 Poor quality of the
residual flexor tendon or inadequacy of pulleys
may dictate insertion of a silicone rod, although
pulley reconstruction can be performed at the time
of tenolysis.438,634 As with other types of tendon
surgery, the post-operative therapy is vital in maintaining what has been achieved intraoperatively,
and should commence the same day as surgery.372,399,641 Reconstructed pulleys need to be protected, as do thin tendons, which may be at risk of
rupture.
Improved function can be expected in more than
50% of patients regardless of the cause of the
adhesions, in what is considered a salvage operation.632,642,643
26
SALVAGE SURGERY
Superficialis Finger
In flexor tendon surgery, the ideal goal is restoration of active flexion at both interphalangeal joints.
However, when active motion at the distal interphalangeal joint is not possible or advisable more
limited goals must be set. The superficialis finger
represents such a salvage operation, where motion is restored at the MP and PIP joints and the
DIP joint is stabilized by arthrodesis or tenodesis.644
About 85% of the total arc of motion of the finger
is provided by the MP and PIP joints, so a useful
finger can still be obtained.243
The Osborne redemption operation was
described to restore PIP joint flexion after
bowstringing of a tendon graft from pulley failure
or after failure of primary tendon repair.645 The
single-stage procedure involves tenotomy of the
tendon graft or repaired tendon at the distal phalanx and reinsertion of the shortened tendon to
the proximal one-third of the middle phalanx. Tenodesis or arthrodesis of the DIP joint and tenolysis
are usually required. When associated scarring prevents this, a two-stage procedure can be employed,
but with the end of the silicone rod fixed to the
middle phalanx instead of the distal phalanx.645
Along similar lines, a modification of the PanevaHolevich operation has been described, with a preliminary silicone rod prior to a pedicled superficialis
graft to the base of the middle phalanx.646,647
BIBLIOGRAPHY
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
Idler RS: Anatomy and biomechanics of the digital flexor

tendons. Hand Clin 1:3, 1985.
Field PL: Tendon fiber arrangement and blood supply. Aust N
Z J Surg 40:298, 1971.
Wilson WF, Hueston JT: The intratendinous architecture of the
tendons of flexor digitorum profundus and flexor pollicis longus.
Hand 5:33, 1973.
Enna CD, Ruby JR: Scanning electron microscopic study of long
flexors in human fingers. J Hand Surg 6A:329, 1981.
Walbeehm ET, McGrouther DA: An anatomical study of the
mechanical interactions of flexor digitorum superficialis and
profundus and the flexor tendon sheath in zone 2. J Hand Surg
20B:269, 1995.
Kaplan EB: Muscle and tendinous variation of the flexor digitorum
superficialis of the small finger of the hand. Bull Hosp Joint Dis
30:59, 1969.
Shrewsbury MM, Kuczynski K: Flexor digitorum superficialis
tendon in the fingers of the human hand. Hand 6:121, 1974.
Baker DS et al: The little finger superficialis - Clinical investigation of its anatomic and functional shortcomings. J Hand Surg
6:374, 1981.
Austin GJ et al: Variations of the flexor digitorum superficialis
of the small finger. J Hand Surg 14A:262, 1989.
Robb JE: The termination of flexor tendon sheaths. Hand 11:17,
1979.
Cohen MJ, Kaplan L: Histology and ultrastructure of the human
flexor tendon sheath. J Hand Surg 12A:25, 1987.
Strauch B, De Moura W: Digital flexor tendon sheath: An
anatomic study. J Hand Surg 10A:785, 1985.
Doyle JR, Blythe W: Macroscopic and functional anatomy of the
flexor tendon sheath. J Bone Joint Surg 56A:1094, 1974.
Kleinert HE, Broudy AS: Direct repair and dynamic splinting of
flexor tendon lacerations. In: Clinical Biomechanics. A Case
History Approach. ed. J Black, JH Numbleton, New York,
Churchill Livingstone, 1981, pp 1-23.
Manske PR, Lesker PA: Palmar aponeurosis pulley. J Hand Surg
8A:259, 1983.
Doyle JR: Anatomy and function of the palmar aponeurosis
pulley. J Hand Surg 15A:78, 1990.
Phillips C, Mass D: Mechanical analysis of the palmar aponeurosis pulley in human cadavers. J Hand Surg 21A:240, 1996.
Doyle JR: Anatomy of the finger flexor tendon sheath and pulley
system. J Hand Surg 13A:473, 1988.
Azar C et al: Dynamic anatomy of the flexor pulley system of the
fingers and thumb. J Hand Surg 9:595, 1984.
Barton NJ: Experimental study of optimal location of flexor
tendon pulleys. Plast Reconstr Surg 43:125, 1969.
Brand PW et al: Tendon and pulleys at the metacarpophalangeal
joint of a finger. J Bone Joint Surg 57A:779, 1975.
Goldstein SA et al: A biomechanical evaluation of the function
of the digital pulleys. Orthop Trans 8:354, 1984.
Peterson WW et al: Effect of pulley excision on flexor tendon
biomechanics. J Orthop Res 4:96, 1986.
Lin G-T et al: Functional anatomy of the human digital flexor
pulley system. J Hand Surg 14A:949, 1989.
Lin G-T et al: Mechanical properties of human pulleys. J Hand
Surg 15B:429, 1990.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
Idler RS, Strickland JW: The effects of pulley resection on the

biomechanics of the PIP joint. J Hand Surg 9:595, 1984.
Manske PR, Lesker PA: Strength of human pulleys. Hand 9:147,
1977.
Rispler D et al: Efficiency of the flexor tendon pulley system in
human cadaver hands. J Hand Surg 21A:444, 1996.
Bowers WH et al: Closed traumatic rupture of finger flexor
pulleys. J Hand Surg 19A:782, 1994.
Bodner G et al: Diagnosis of digital flexor tendon annular pulley
disruption: comparison of high frequency ultrasound and MRI.
Ultraschall Med 20:131, 1999.
Savage R: The mechanical effect of partial resection of the digital
fibrous flexor sheath. J Hand Surg 15B:435, 1990.
Tomaino M et al: The effect of partial excision of the A2 and A4
pulleys on the biomechanics of finger flexion. J Hand Surg 23B:
50, 1998.
Tang JB: The double sheath system and tendon gliding in zone
2C. J Hand Surg 20B:281, 1995.
Delattre JF et al: The mechanical role of the digital fibrous sheath:
Application to reconstructive surgery of the flexor tendons. Anat
Clin 5:187, 1983.
Hamman J et al: A biomechanical study of the flexor digitorum
superficialis: effects of digital pulley excision and loss of the
flexor digitorum profundus. J Hand Surg 22A:328, 1997.
Flake J et al: Postnatal growth and development of the flexor
tendon pulley system. J Pediatr Orthop 10:612, 1990.
Doyle JR, Blythe W: Gross and macroscopic anatomy of the
flexor tendon sheath and pulleys of the thumb. J Hand Surg 1:79,
1976.
Lissimos AG et al: Biomechanics of the thumb flexor pulley
system. J Hand Surg 19A:475, 1994.
Lundborg G, Myrhage R: The vascularization and structure of
the human digital tendon sheath as related to flexor tendon
function: An angiographic and histological study. Scand J Plast
Reconstr Surg 11:195, 1977.
Amis AA, Jones MM: The interior of the flexor tendon sheath
of the finger. The functional significance of its structure. J Bone
Joint Surg 70B:583, 1988.
Edwards DAW: The blood supply and lymphatic drainage of
tendons. J Anat 80:147, 1946.
Van der Meulen JC: Tendon healing. Clin Plast Surg 4:439,
1977.
Ellis FD et al: The second annular pulley: a histologic examination.
J Hand Surg 20A:632, 1995.
Mayer L: The physiological method of tendon transplantation.
Surg Gynecol Obstet 22:183, 1916.
Brockis JG: The blood supply of the flexor and extensor tendons
of the fingers in man. J Bone Joint Surg 35B:131, 1953.
Peacock EE Jr: A study of the circulation in normal tendons and
healing grafts. Ann Surg 149:415, 1959.
Nichols HM et al: Alteration of the blood supply of flexor tendons
following injury. Am J Surg 87:379, 1954.
Smith JW: Blood supply of tendons. Am J Surg 109:272, 1965.
Colville J et al: Role of mesotenon in tendon blood supply. Plast
Schatzker J, Brnemark P: Intravital observation on the microvascular anatomy and microcirculation of the tendon. Acta Orthop
Scand (Suppl). 126:3, 1969.
27

51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.
75.
76.
77.
78.
79.
28
Lundborg G: The microcirculation in rabbit tendon. In vivo

studies after mobilisation and transection. Hand 7:1, 1975.
Lundborg G et al: The vascularization of human flexor tendons
within the digital synovial sheath region - structural and functional aspects. J Hand Surg 2A:417, 1977.
Zhang ZZ et al: Blood supply of the flexor digital tendon in the
hand and its clinical significance. Surg Radiol Anat 12:113, 1990.
Leffert RD et al: The vincula with particular reference to their
vessels and nerves. J Bone Joint Surg 56A:1191, 1974.
Ochiai N et al: Vascular anatomy of flexor tendons. I. Vincular
system and blood supply of the profundus tendon in the digital
sheath. J Hand Surg 4:321, 1979.
Armenta E, Lehrman A: The vincula to the flexor tendons of the
hand. J Hand Surg 5A:127, 1980.
Zbrodowski A et al: Mesotendons of digital flexor muscles and
their vasculature. Hand 13:231, 1981.
McCash CR: The immediate repair of flexor tendons. Br J Plast
Surg 14:53, 1961.
Richards HJ: Digital flexor tendon repair and return of function.
Ann R Coll Surg Engl 59:25, 1977.
Gainor BJ: Proximal coiling of the profundus tendon after
laceration of the finger. J Hand Surg 14B:416, 1989.
Lundborg G: The vascularization of the human flexor pollicis
longus tendon. Hand 1:28, 1979.
Hergenroeder PT et al: The vascularity of the flexor pollicis
longus tendon. Clin Orthop 162:298, 1982.
Azar CA et al: Blood supply of the flexor pollicis longus tendon.
J Hand Surg 8:471, 1983.
Armenta E, Fisher J: Anatomy of flexor pollicis longus vinculum
system. J Hand Surg 9:210, 1984.
Zbrodowski A et al: Mesotendons of the flexor pollicis longus
muscle. Acta Anat 151:131, 1994.
Potenza AD: Critical evaluation of flexor tendon healing and
adhesion formation within artificial digital sheaths. J Bone Joint
Surg 45A:1217, 1963.
Matthews P: The fate of isolated segments of flexor tendons
within the digital sheath - A study in synovial nutrition. Br J Plast
Surg 29:216, 1976.
McDowell CL, Snyder DM: Tendon healing: An experimental
model in the dog. J Hand Surg 2:122, 1977.
Manske PR et al: Nutrient pathways to flexor tendons using
hydrogen washout technique. J Hand Surg 3:32, 1978.
Manske PR et al: Nutrient pathways to flexor tendons of chickens
using tritiated proline. J Hand Surg 3:352, 1978.
Manske PR, Lesker PA: Nutrient pathways of flexor tendons in
primates. J Hand Surg 7:436, 1982.
Manske PR, Lesker PA: Comparative nutrient pathways to the
flexor profundus tendons in zone II of various experimental
animals. J Surg Res 34:83, 1983.
Manske PR, Lesker PA: Flexor tendon nutrition. Hand Clin 1:13,
1985.
Lundborg G et al: The role of the synovial fluid and tendon sheath
for flexor tendon nutrition. An experimental tracer study on
diffusional pathways in dogs. Scand J Plast Reconstr Surg 14:99,
1980.
Landi A et al: The blood flow of rabbits tendons. Acta Orthop
Scand 54:832, 1983.
Hooper G et al: Blood flow and clearance in tendons. J Bone Joint
Surg 66B:441, 1984.
Kain CC et al: The effect of vascularization on avian flexor tendon
repair. A biochemical study. Clin Orthop 233:295, 1988.
Katsumi M et al: Experimental investigation of healing process
of tendons with or without synovial coverage in or outside of
synovial cavity. J Niigata Med Assoc 95:532, 1981.
Soejima O et al: Comparative mechanical analysis of dorsal
versus palmar placement of core suture for flexor tendon
repairs. J Hand Surg 20A:801, 1995.
80.
81.
82.
83.
84.
85.
86.
87.
88.
89.
90.
91.
92.
93.
94.
95.
96.
97.
98.
99.
100.
101.
102.
103.
104.
105.
106.
Komanduri M et al: Tensile strength of flexor tendon repairs in

a dynamic cadaver model. J Hand Surg 21A:605, 1996.
Khan K et al: Early active mobilization after second stage flexor
tendon grafts. J Hand Surg 22B:372, 1997.
Silfverskild KL, May EJ: Early active mobilization of tendon
grafting using mesh reinforced suture techniques. J Hand Surg
20B:301, 1995.
Eiken O, Rank F: Experimental restoration of the digital synovial
sheath. Scand J Plast Reconstr Surg 11:213, 1977.
Forgon M, Biro V: Reconstruction of the digital tendon-sheath
in no mans land with autologous transplanted vein-graft.
Hand 10:28, 1978.
Pennington DG: The influence of tendon sheath integrity and
vincular blood supply on adhesion formation following tendon
repair in hens. Br J Plast Surg 32:302, 1979.
Strauch B et al: The fate of tendon healing after restoration of
the integrity of the tendon sheath with autogenous vein grafts.
J Hand Surg 10A:790, 1985.
Kessler FB et al: Fascia patch graft for a digital flexor sheath defect
over primary tendon repair in the chicken. J Hand Surg 11A:241,
1986.
Peterson WW et al: Effect of various methods of restoring flexor
sheath integrity on the formation of adhesions after tendon
injury. J Hand Surg 15A:48, 1990.
Tonkin M, Lister G: Results of primary tendon repair with
closure of the tendon sheath. Aust N Z J Surg 60:947, 1990.
Liu A-M, Lu S-B: Reconstruction of sheath with fascial graft in
flexor tendon repair. J Hand Surg 16B:179, 1991.
Tang JB et al: Autogenous free sheath grafts in reconstruction
of injured digital flexor tendon sheath at the delayed primary
stage. J Hand Surg 18B:31, 1993.
Peterson WW et al: The effect of flexor sheath integrity on
tendon nutrition and gliding. J Hand Surg 11A:762, 1986.
Lister GD, Tonkin M: The results of primary flexor tendon repair
with closure of the tendon sheath. J Hand Surg 11A:767, 1986.
Saldana MJ et al: Flexor tendon repair and rehabilitation in zone
II open sheath technique versus closed sheath technique. J
Hand Surg 12A:1110, 1987.
Seyfer AE, Bolger WE: Effects of unrestricted motion on healing:
A study of posttraumatic adhesions in primate tendons. Plast
Gelberman RH et al: Influences of flexor sheath continuity and early
motion on tendon healing in dogs. J Hand Surg 15A:69, 1990.
Tang J-b et al: Flexor sheath closure during delayed primary
tendon repair. J Hand Surg 19A:636, 1994.
Skoog T, Persson BH: An experimental study of the early healing
of tendons. Plast Reconstr Surg 13:384, 1954.
Potenza AD: Tendon healing within the flexor digital sheath in
the dog. J Bone Joint Surg 44A:49, 1962.
Potenza AD: The healing of autogenous tendon grafts within the
flexor digital sheath in dogs. J Bone Joint Surg 46A:1462, 1964.
Peacock EE Jr: Tendon repair: Some aspects of wound healing
affecting restoration of gliding function. J Bone Joint Surg
46A:909, 1964.
Peacock EE: Some technical aspects and results of flexor tendon
repair. Surg 58:330, 1965.
Peacock EE: Biology of tendon repair. N Engl J Med 276:680,
1967.
Lindsay WK, Birch JR: The fibroblast in flexor tendon healing.
Plast Reconstr Surg 34:223, 1964.
Lindsay WK, Thomson HG: Digital flexor tendons: An experimental study. Part I. The significance of each component of the
flexor mechanism in tendon healing. Br J Plast Surg 12:289,
1959.
Lindsay WK, McDougall EP: Digital flexor tendons: An experimental study. Part III. The fate of autogenous digital flexor
tendon grafts. Br J Plast Surg 13:293, 1961.

107. Matthews P, Richards H: The repair potential of digital flexor
tendons. An experimental study. J Bone Joint Surg 56B:618,
1974.
108. Furlow LT: The role of tendon tissues in tendon healing. Plast
109. Lundborg G, Rank F: Experimental intrinsic healing of flexor
tendons based upon synovial fluid nutrition. J Hand Surg 3:21,
1978.
110. Hansson H-A et al: Restoration of superficially damaged flexor
tendons in synovial environment. An experimental ultrastructural study in rabbits. Scand J Plast Reconstr Surg 14:109, 1980.
111. Potenza AD, Herte MC: The synovial cavity as a tissue culture
in situ - Science or nonsense? J Hand Surg 7:196, 1982.
112. Chow SP et al: The healing of freeze-dried rabbit flexor tendon
in a synovial fluid environment. Hand 15:136, 1983.
113. Menon J et al: Role of synovial fluid cells in the healing of flexor
tendons. Clin Orthop 199:300, 1985.
114. Lundborg G et al: Intrinsic tendon healing. A new experimental
model. Scand J Plast Reconstr Surg 19:113, 1985.
115. Becker H et al: Intrinsic tendon cell proliferation in tissue culture.
J Hand Surg 6:616, 1981.
116. Manske PR, Lesker PA: Histological evidence of flexor tendon
repair in various experimental animals. An in vitro study. Clin
Orthop 182:297, 1984.
117. Manske PR, Lesker PA: Biochemical evidence of flexor tendon
participation in the repair process - An in vitro study. J Hand Surg
9B:117, 1984.
118. Manske PR et al: Intrinsic restoration of the flexor tendon surface
in the nonhuman primate. J Hand Surg 10A:632, 1985.
119. Gelberman RH et al: Flexor tendon repair in vitro: A comparative histologic study of the rabbit, chicken, dog and monkey. J
Orthop Res 2:39, 1984.
120. Gelberman RH et al: Flexor tendon repair. J Orthop Res 4:119,
1986.
121. Abrahamsson S-O et al: Restoration of the injured flexor tendon
surface: A possible role for endotenon cells. A morphological
study of the rabbit tendon in vivo. J Hand Surg 17B:553, 1992.
122. Mass DP, Tuel R: Intrinsic healing of the laceration site in human
superficialis flexor tendons in vitro. J Hand Surg 16A:24, 1991.
123. Garner WL et al: Autonomous healing of chicken flexor tendons
in vitro. J Hand Surg 13A:697, 1988.
124. Birdsell DC et al: Collagen production in regenerating tendon.
Plast Reconstr Surg 37;504, 1966.
125. Gelberman RH et al: Genetic expression for type I procollagen
in the early stages of flexor tendon healing. J Hand Surg 17A:551,
1992.
126. Chang J et al: Gene expression of transforming growth factor
beta-1 in zone II flexor tendon wound healing: evidence for dual
mechanisms of repair. Plast Reconstr Surg 100937, 1997.
127. Gelberman RH et al: Fibroblast chemotaxis after tendon repair.
J Hand Surg 16A:686, 1991.
128. Amiel D et al: Fibronectin in healing flexor tendons subjected
to immobilization on early controlled passive motion. Matrix
11:184, 1991.
129. Duffy FJ et al: Intrinsic mitogenic potential of canine flexor
tendons. J Hand Surg 17B:275, 1992.
130. Duffy FJ et al: Growth factors and canine flexor tendon healing:
initial studies in uninjured and repair models. J Hand Surg
20A:645, 1995.
131. Gelberman RH et al: The influence of protected passive
mobilization on the healing of flexor tendons: A biochemical
and microangiographic study. Hand 13:120, 1981.
132. Gelberman RH et al: Influences of the protected passive mobilization interval on flexor tendon healing. A prospective randomized clinical study. Clin Orthop 264:189, 1991.
133. Woo SL-Y et al: The importance of controlled passive mobilization on flexor tendon healing. Acta Orthop Scand 52:615, 1981.
134. Kubota H et al: Effect of motion and tension on injured flexor

tendons in chickens. J Hand Surg 21A:456, 1996.
135. Boyer MI et al: Quantitative variation in vascular endothelial
growth factor mRNA expression during early flexor tendon
healing: an investigation in a canine model. J Orthop Res
19(5):869, 2001.
136. Rothman RH, Slogoff S: The effect of immobilization on the
vascular bed of tendon. Surg Gynecol Obstet 124:1064, 1967.
137. Ketchum LD: Primary tendon healing: A review. J Hand Surg
2:428, 1977.
138. Amadio PC et al: The effect of vincular injury on the results of
flexor tendon surgery in no-mans-land. J Hand Surg 9:597,
1984.
139. MacMillan M et al: An experimental flexor tendon repair in zone
II that allows immediate post-operative mobilization. J Hand Surg
12A:582, 1987.
140. Farkas LG et al: Peritendinous healing after early movement of
repaired flexor tendon: Anatomical study. Ann Plast Surg 5:298,
1980.
141. Nelson DL et al: The effects of intermittent passive motion on
flexor tendon repair. Orthop Trans 10:270, 1986.
142. Hitchcock TF et al: The effect of immediate constrained digital
motion on the strength of flexor tendon repairs in chickens. J
Hand Surg 12A:590, 1987.
143. Feehan LM, Beauchene JG: Early tensile properties of healing
chicken flexor tendons: Early controlled passive motion versus
postoperative immobilization. J Hand Surg 15A:63, 1990.
144. Takai S et al: The effects of frequency and duration of controlled
passive mobilization on tendon healing. J Orthop Res 9:705,
1991.
145. Kleinert HE, Verdan C: Report of the Committee on Tendon
Injuries. J Hand Surg 8:794, 1983.
146. Grewal R et al: Bundle pattern of the flexor digitorum profundus
tendon in zone II of the hand: a quantitative assessment of the
size of a laceration. J Hand Surg 21A:978, 1996.
147. Janecki CJ Jr: Triggering of the finger caused by flexor-tendon
laceration. J Bone Joint Surg 58A:1174, 1976.
148. Bilos ZJ et al: Trigger finger following partial flexor tendon
laceration. Hand 9:232, 1977.
149. Rayan GM, Elias L: Trigger finger secondary to partial rupture
of the superficial flexor tendon. Orthopedics 3:1090, 1980.
150. Gordon SL: Late rupture of one slip of the flexor digitorum
superficialis: An unusual cause of triggering. Clin Orthop
158:142, 1981.
151. Elias LS et al: Partial flexor tendon laceration: A cause of trigger
finger. Orthopedics 5:441, 1982.
152. Frewin PR, Scheker LR: Triggering secondary to an untreated
partially-cut flexor tendon. J Hand Surg 14B:419, 1989.
153. Schlenker JD et al: Three complications of untreated partial
lacerations of flexor tendon - Entrapment, rupture, and triggering. J Hand Surg 6:392, 1981.
154. Wray RC Jr et al: Effects of mobilization on tensile strength of
partial tendon lacerations. Surg Forum 26:557, 1975.
155. Ollinger H et al: Effects of suture on tensile strength gain of
partially and completely severed tendons. Surg Forum 26:63,
1975.
156. Wray RC Jr et al: Clinical treatment of partial tendon lacerations
without suturing and with early motion. Plast Reconstr Surg
59:231, 1977.
157. Reynolds B et al: Should an incompletely severed tendon be
sutured? Plast Reconstr Surg 57:36, 1976.
158. Bishop AT et al: Treatment of partial flexor tendon lacerations:
The effect of tenorrhaphy and early protected mobilization. J
Trauma 26:301, 1986.
159. McGeorge DD, Stilwell JH: Partial flexor tendon injuries: To
repair or not. J Hand Surg 17B:176, 1992.
29

160. McCarthy DM et al: Effect of partial laceration on the structural
properties of the canine FDP tendon: an in vitro study. J Hand
Surg 20A:795, 1995.
161. Hariharan JS et al: Partial lacerations of human digital flexor
tendons: a biomechanical analysis. J Hand Surg 22A:1011, 1997.
162. Al-Qattan MM: Conservative management of zone II partial
flexor tendon lacerations greater than half the width of the
tendon. J Hand Surg 25A(6):1118, 2000.
163. Stahl S et al: Partial lacerations of flexor tendons in children. J
Hand Surg 22B:377, 1997.
164. McMaster PE: Tendon and muscle ruptures: Clinical and experimental studies on the cause of spontaneous ruptures. J Bone
Joint Surg 15:705, 1933.
165. Posch JL et al: Treatment of ruptured tendons of the hand and
wrist. Am J Surg 91:669, 1956.
166. Boyes JH et al: Flexor tendon ruptures in the forearm and hand.
J Bone Joint Surg 42A:637, 1960.
167. Hoffman S et al: Unusual flexor tendon ruptures in the hand. Arch
Surg 96:259, 1968.
168. McMaster PE: Late ruptures of extensor and flexor pollicis longus
tendons following Colles fractures. J Bone Joint Surg 14:93,
1932.
169. Folmar RC et al: Ruptures of the flexor tendons in the hands of
non-rheumatoid patients. J Bone Joint Surg 54A:579, 1972.
170. Southmayd WW et al: Rupture of the flexor tendons of the
index finger after Colles fracture. J Bone Joint Surg 57A: 562,
1975.
171. Crosby EB, Linscheid RL: Rupture of the flexor profundus
tendon of ring finger secondary to ancient fracture of the hook
of the hamate. J Bone Joint Surg 56A:1976, 1974.
172. Rae PS, Finlayson D: Closed rupture of flexor pollicis longus
tendon associated with treatment of Bennetts fracture. J Bone
Joint Surg 57A:562, 1975.
173. Stern PJ: Multiple flexor tendon ruptures following old anterior
dislocation of the lunate. J Bone Joint Surg 63A:489, 1981.
174. Hallett JP, Motta GR: Tendon ruptures in the hand with particular
reference to attrition ruptures in the carpal tunnel. Hand
14:283, 1982.
175. Mahring M et al: Attrition flexor tendon rupture due to
scaphoid non-union initiating an anterior interosseous nerve
syndrome: a case report. J Hand Surg 10B:62, 1985.
176. Matthews RN, Walton JN: Spontaneous rupture of both flexor
tendons in a single digit. J Hand Surg 9B:134, 1984.
177. Kumar S, James R: Closed rupture of flexor profundus tendon
in the palm. J Hand Surg 10B:193, 1985.
178. Imbriglia JE, Goldstein SA: Intratendinous ruptures of the flexor
digitorum profundus tendon of the small finger. J Hand Surg
12A: 985, 1987.
179. Gunter GS: Traumatic avulsion of the insertion of flexor
digitorum profundus. Aust N Z J Surg 30:1, 1960.
180. Wenger DR: Avulsion of the profundus tendon in footballers.
Arch Surg 106:145, 1973.
181. Leddy JP, Packer JW: Avulsion of the profundus tendon insertion
in athletes. J Hand Surg 2:66, 1977.
182. Lunn PG, Lamb DW: Rugby finger - Avulsion of profundus of
ring finger. J Hand Surg 9B:69, 1984.
183. Manske PR, Lesker PA: Avulsion of the ring finger digitorum
profundus tendon: An experimental study. Hand 10:52, 1978.
184. Bynum DK Jr, Gilbert JA: Avulsion of the flexor digitorum
profundus: Anatomic and biomechanical considerations. J Hand
Surg 13A:222, 1988.
185. Smith JH: Avulsion of a profundus tendon with simultaneous
intraarticular fracture of the distal phalanx. J Hand Surg 6:600,
1981.
186. Silva MJ et al: Flexor digitorum profundus tendon-to-bone
repair: an ex vivo biomechanical analysis of 3 pullout suture
techniques. J Hand Surg 23A:120, 1998.
30
187. Silva MJ et al: The effects of multiple-strand suture techniques

on the tensile properties of repair of the flexor digitorum
profundus tendon to bone. J Bone Joint Surg 80:1507, 1998.
188. Skoff HD et al: Bone suture anchors in hand surgery. J Hand Surg
20B:245, 1995.
189. Buch BD et al: The Mitek Mini G2 suture anchor: biomechanical
analysis of use in the hand. J Hand Surg 20A:877, 1995.
190. Brustein M et al: Bone suture anchors versus the pullout button
for repair of distal profundus tendon injuries: a comparison of
strength in human cadaveric hands. J Hand Surg 26A:489, 2001.
191. Kwai BI, Elliot D: venting or partial lateral release of the A2 and
A4 pulleys after repair of zone 2 flexor tendon injuries. J Hand
Surg 23B:649, 1998.
192. Mitsionis G et al: Feasibility of partial A2 and A4 pulley excision:
effect on finger flexor tendon biomechanics. J Hand Surg
24A:310, 1999.
193. Mitsionis G et al: Feasibility of partial A2 and A4 pulley excision:
residual pulley strength. J Hand Surg 25B:90, 2000.
194. Elliot D et al: The flexor digitorum profundus demi-tendon
a new technique for passage of the flexor profundus tendon
through the A4 pulley. J Hand Surg 26B:422, 2001.
195. Eglseder WA, Russell JM: Type IV flexor digitorum profundus
avulsion. J Hand Surg 15A:735, 1990.
196. Gibson CT, Manske PR: Isolated avulsion of a flexor digitorum
superficialis tendon insertion. J Hand Surg 12A:601, 1987.
197. Schnebel BE et al: Isolated traumatic avulsion of the flexor
digitorum sublimis: A case report. Am J Sports Med 17:692, 1989.
198. Lanzetta M, Conolly WB: Closed rupture of both flexor tendons
in the same digit. J Hand Surg 17B:479-480, 1992.
199. Backe H, Posner MA: Simultaneous rupture of both flexor
tendons in a finger. J Hand Surg 19A:246, 1994.
200. Cheung KMC, Chow SP: Closed avulsion of both flexor tendons
of the ring finger. J Hand Surg 20B:78, 1995.
201. Bell JL et al: Injuries to flexor tendons of the hand in children.
202. Wakefield AR: Hand injuries in children. J Bone Joint Surg
46A:1226, 1964.
203. Entin MA: Flexor tendon repair and grafting in children. Am J
Surg 109:287, 1965.
204. Grobbelaar AO, Hudson DA: Flexor tendon injuries in children.
J Hand Surg 19B:696: 1994.
205. Entin MA: Philosophy of tendon repair. Orthop Clin North Am
4:859, 1973.
206. Arons MS: Purposeful delay of the primary repair of cut flexor
tendons in some-mans-land in children. Plast Reconstr Surg
53:638, 1974.
207. Herndon JH: Treatment of tendon injuries in children. Orthop
Clin North Am 7:717, 1976.
208. Vahvanen V et al: Flexor tendon injury of the hand in children.
A long-term follow-up study of 84 patients. Scand J Plast Reconstr
Surg 15:43, 1981.
209. Kavouksorian CA, Noone RB: Flexor tendon repair in the
neonate. Ann Plast Surg 9:415, 1982.
210. OConnell SJ et al: Results of zone I and zone II flexor tendon
repairs in children. J Hand Surg 19A:48, 1994.
211. Fitoussi F et al: Flexor tendon injuries in children: factors
influencing prognosis. J Pediatr Orthop 19(6):818, 1999.
212. Birnie RH, Idler RS: Flexor tenolysis in children. J Hand Surg
20A:254, 1995.
213. Kleinert HE et al: Primary repair of lacerated flexor tendons in
no-mans land. J Bone Joint Surg 49A:577, 1967.
214. Lister G et al: Primary flexor tendon repair followed by immediate controlled mobilization. J Hand Surg 2:441, 1977.
215. Kleinert HE, Cash SL: Management of acute flexor tendon
injuries in the hand. Instr Course Lect 34:361, 1985.
216. Strickland JW: Management of acute flexor tendon injuries.
Orthop Clin North Am 14:827, 1983.

217. Strickland JW: Flexor tendon repair. Hand Clin 1:55, 1985.
218. Strickland JW: Flexor tendon injuries: Part 2: Flexor tendon
repair. Orthop Rev 15:701, 1986.
219. Strickland JW: Flexor tendon surgery. Part 1: Primary flexor
tendon repair. J Hand Surg 14B:261, 1989.
220. Strickland JW: Development of flexor tendon surgery: twentyfive years of progress. J Hand Surg 25A:214, 2000.
221. Schneider LH, Bush DC: Primary care of flexor tendon injuries.
Hand Clin 5:383, 1989.
222. Tonkin MA: Primary flexor tendon repair: Surgical techniques
based on the anatomy and biology of the flexor tendon system.
World J Surg 15:452, 1991.
223. Steinberg DR: Acute flexor tendon injuries. Orthop Clin North
Am 23:125, 1992.
224. Gelberman RH et al: Healing of digital flexor tendons: Importance of the interval from injury to repair. A biomechanical,
biochemical, and morphological study in dogs. J Bone Joint Surg
73A:66, 1991.
225. Salvi V: Delayed primary suture in flexor tendon division. Hand
3:181, 1971.
226. Schneider LH et al: Delayed flexor tendon repair in no mans
land. J Hand Surg 2:452, 1977.
227. Matev I et al: Delayed primary suture of flexor tendons cut in the
digital theca. Hand 12:158, 1980.
228. Brown PW: Lacerations of the flexor tendons of the hand. Surg
Clin North Am 49:1255, 1969.
229. Reef TC, Forshew FC: Delayed primary tendon surgery in the
hand. J Hand Surg 3:287, 1978.
230. Green WL, Niebauer JJ: Results of primary and secondary flexortendon repairs in no mans land. J Bone Joint Surg 56A:1216,
1974.
231. Ejeskr A: Flexor tendon repair in no mans land. II. Early versus
late secondary tendon repair ad modum Kleinert. Scand J Plast
232. Malerich MM et al: Permissible limits of flexor digitorum
profundus tendon advancement: An anatomic study. J Hand
Surg 12A:30, 1987.
233. Wagner CJ: Delayed advancement in the repair of lacerated
flexor profundus tendons. J Bone Joint Surg 40:1241, 1958.
234. Verdan CE: Syndrome of the quadriga. Surg Clin North Am
40:425, 1960.
235. Ninkovic M et al: Emergency free tissue transfer for severe
upper extremity injuries. J Hand Surg 20B:53, 1995.
236. Boswick JA Jr: Tendon transfers for tendon injuries in the upper
extremities. Orthop Clin North Am 5:253, 1974.
237. Schneider LH: Tendon transfers in muscle and tendon loss.
Hand Clin 4:267, 1988.
238. Schneider LH, Wehb MA: Delayed repair of flexor profundus
tendon in the palm (zone 3) with superficialis transfer. J Hand
Surg 13A:227, 1988.
239. Posner MA: Flexor superficialis tendon transfers to the thumb
- An alternative to the free tendon graft for treatment of chronic
injuries within the digital sheath. J Hand Surg 8:876, 1983.
240. Schneider LH, Wiltshire D: Restoration of flexor pollicis longus
function by flexor digitorum superficialis transfer. J Hand Surg
8:98, 1983.
241. Ebelin M et al: Secondary surgery of the flexor pollicis longus
tendon. A comparative study of forty-three cases. Ann Chir Main
4:111, 1985.
242. Urbaniak JR: Repair of the flexor pollicis longus. Hand Clin 1:69,
1985.
243. Littler JW: The physiological and dynamic function of the hand.
Surg Clin North Am 40:259, 1960.
244. Kleinert HE, Meares A: In quest of the solution to severed flexor
tendons. Clin Orthop 104:23, 1974.
245. Spak I: Tenodesis of the distal finger joint - A method of repair
by loss of the flexor profundus function. Acta Chir Scand
110:338, 1955-56.
246. Potenza AD: Flexor tendon injuries. Orthop Clin North Am

1:355, 1970.
247. Kahn S: A dynamic tenodesis of the distal interphalangeal joint,
for use after severance of the profundus alone. Plast Reconstr
Surg 51:536, 1973.
248. Rigg BM: A simple transfer for the isolated division of the flexor
digitorum profundus. Hand 7:246, 1975.
249. Yii NW et al: A prospective study of flexor tendon repair in zone
5. J Hand Surg 23B:642, 1998.
250. Winston ME: The results of treatment of injuries to the flexor
tendons. Hand 4:45, 1972.
251. Puckett CL, Meyer VH: Results of treatment of extensive volar
wrist lacerations: The spaghetti wrist. Plast Reconstr Surg 75:714,
1985.
252. Strzyzewski H: Multiple injuries to flexor tendons and nerves
above the wrist. Hand 4:183, 1972.
253. Carroll RE, Match RM: Common errors in the management of
wrist lacerations. J Trauma 14:553, 1974.
254. Stefanich RJ et al: Flexor tendon lacerations in zone V. J Hand
Surg 17A:284, 1992.
255. Verdan CE: Primary repair of flexor tendons. J Bone Joint Surg
42A:647, 1960.
256. Verdan CE: Half a century of flexor-tendon surgery. Current status
and changing philosophies. J Bone Joint Surg 54A:472, 1972.
257. Pho RW et al: Primary repair of flexor tendons within the digital
theca of the hand. Hand 10:154, 1978.
258. Ejeskr A: Flexor tendon repair in no mans land. I. A follow-up
study on primary tendon repair ad modum Verdan. Scand J Plast
259. Earley MJ, Milward TM: The primary repair of digital flexor
tendons. Br J Plast Surg 35:133, 1982.
260. Nielsen AB, Jensen PO: Primary flexor tendon repair in no
mans land. J Hand Surg 9B:279, 1984.
261. Langlais F et al: Primary repair of flexor tendon in zone II (103
digits): Results and limitations of Kleinerts method. Ann Chir
Main 5:301, 1986.
262. Singer M, Maloon S: Flexor tendon injuries: The results of
primary repair. J Hand Surg 13B:269, 1988.
263. Tropet Y et al: Recent simple flexor tendon injuries in zone I,
II, III of Verdan. Results of tendon repairs concerning 115
fingers in 99 patients. Ann Chir Main 7:109, 1988.
264. Tang JB: Flexor tendon repair in zone 2C. J Hand Surg 19B:72,
1994.
265. Boulas HJ, Strickland JW: Strength and functional recovery
following repair of flexor digitorum superficialis in zone 2. J
Hand Surg 18B:22, 1993.
266. Gault DT, Quaba AA: The role of cross-finger flaps in the primary
management of untidy flexor tendon injuries. J Hand Surg
13B:62, 1988.
267. May EJ et al: The correlation between controlled range of motion
with dynamic traction and results after flexor tendon repair in
zone II. J Hand Surg 17A:1133, 1992.
268. Silfverskild KL et al: Factors affecting results after flexor tendon
repair in zone II: A multivariate prospective analysis. J Hand Surg
18A:654, 1993.
269. Noonan KJ, Blair WF: Long-term follow-up of primary flexor
pollicis longus tenorraphies. J Hand Surg 16A:651, 1991.
270. Nunley JA et al: Direct end-to-end repair of flexor pollicis longus
tendon lacerations. J Hand Surg 17A:118, 1992.
271. Bruner JM: Surgical exposure of the flexor pollicis longus
tendon. Hand 7:241, 1975.
272. Urbaniak JR, Goldner JL: Laceration of the flexor pollicis longus
tendon: Delayed repair by advancement, free graft or direct
suture. A clinical and experimental study. J Bone Joint Surg
55A:1123, 1973.
273. Linburg RM, Comstock BE: Anomalous tendon slips from the
flexor pollicis longus to the flexor digitorum profundus. J Hand
Surg 3:287, 1978.
31

274. Araico Laguillo J, Ortiz Monasterio JM: Subcutaneous flexor
pollicis longus tendon graft technique Plast Reconstr Surg
45:578, 1970.
275. Pulvertaft RG: Tendon grafts for flexor tendon injuries in the
fingers and thumb. A study of technique and results. J Bone Joint
Surg 38B:175, 1956.
276. Kyle JB, Eyre-Brook AL: The surgical treatment of flexor tendon
injuries in the hand. Results obtained in a consecutive series of
57 cases. Br J Surg 41:502, 1954.
277. Kilgore ES Jr et al: The dubiousness of grafting the dispensable
flexor pollicis longus. Am J Surg 132:292, 1976.
278. Rank BK, Wakefield AR, Hueston JT: Surgery of Repair as
Applied to Hand Surgery, 4th Ed. Baltimore, Williams & Wilkins,
1973.
279. Bruner JM: The zig-zag volar-digital incision for flexor-tendon
surgery. Plast Reconstr Surg 40:571, 1967.
280. Lister GD: Incision and closure of the flexor sheath during
primary tendon repair. Hand 15:123, 1983.
281. Abrahamsson S-O: Exposure to air during surgery inhibits
cellular activity in flexor tendons. J Hand Surg 21:299, 1996.
282. Callan PP, Morrison WA: A new approach to flexor tendon
repair. J Hand Surg 19B:513, 1994.
283. Ersek RA, Gadaria U: The flexible tendon retriever. J Hand Surg
10A:415, 1985.
284. Goshgarian G: Retrieving the proximal end of a severed flexor
tendon. Plast Reconstr Surg 62:108, 1978.
285. Pennington DG: Atraumatic retrieval of the proximal end of the
severed digital flexor tendon. Plast Reconstr Surg 60:468, 1977.
286. Kilgore ES Jr et al: Atraumatic flexor tendon retrieval. Am J Surg
122;430, 1971.
287. Sourmelis SG, McGrouther DA: Retrieval of the retracted flexor
tendon. J Hand Surg 12B:109, 1987.
288. Titley OG: A modification of the catheter method for retrieval
of divided flexor tendons. J Hand Surg 21B:391, 1996.
289. Li K et al: Endoscopic retrieval of severed flexor tendons. J Hand
Surg 20A:278, 1995.
290. Ketchum LD: Suture materials and suture techniques used in
tendon repair. Hand Clin 1:43, 1985.
291. Trail IA et al: An evaluation of suture materials used in tendon
surgery. J Hand Surg 14B:422, 1989.
292. Bergljung L: Vascular reactions after tendon suture and tendon
transplantation; a stereomicro-angiographic study on the calcaneal tendon of the rabbit. Scand J Plast Reconstr Surg (Suppl) 4:7,
1968.
293. Coert JH et al: Flexor tendon-pulley interaction after tendon
294. Momose T et al: The effect of knot location, suture material, and
suture size on the gliding resistance of flexor tendons. J Biomed
Mater Res 53:806, 2000.
295. Aoki M et al: Effect of suture knots on tensile strength of
repaired canine flexor tendons. J Hand Surg 20B:72, 1995.
296. Papandrea R et al: Biomechanical and clinical evaluation of the
epitenon-first technique of flexor tendon repair. J Hand Surg
20A:261, 1995.
297. Mashadi ZB, Amis AA: The effect of locking loops on the strength
of tendon repair. J Hand Surg 16B:35, 1991.
298. Wagner WF et al: A biomechanical comparison of techniques
of flexor tendon repair. J Hand Surg 19A:979, 1994.
299. Hotokezaka S, Manske PR: Differences between locking loops
and grasping loops: effect on 2-strand core suture. J Hand Surg
22A:995, 1997.
300. Lin G-T: Biomechanical studies of running suture for flexor
tendon repair in dogs. J Hand Surg 13A:553, 1988.
301. Wade PJF et al: Flexor tendon repair: Significant gain in strength
from the Halsted peripheral suture technique. J Hand Surg
14B:232, 1989.
302. Bhatia D et al: Factors affecting the strength of flexor tendon
32
303. Trail IA: The mechanical strength of various suture techniques.

J Hand Surg 17B:89, 1992.
304. Mashadi ZB, Amis AA: Strength of the suture in the epitenon
and within the tendon fibers: Development of stronger peripheral suture technique. J Hand Surg 17B:172, 1992.
305. Silfverskild KL, May EJ: Flexor tendon repair in zone II with a
new suture technique and an early mobilization program
combining passive and active flexion. J Hand Surg 19A:53, 1994.
306. Diao E et al: Effect of peripheral suture depth on strength of
tendon repairs. J Hand Surg 21A:234, 1996.
307. Lindsay WK et al: Digital flexor tendons: An experimental study.
Part II. The significance of a gap occurring at the line of suture.
Br J Plast Surg 13:1, 1960.
308. Ejeskr A, Irstam L: Elongation in profundus tendon repair. A
clinical and radiological study. Scand J Plast Reconstr Surg 15:61,
1981.
309. Seradge H: Elongation of the repair configuration following
flexor tendon repair. J Hand Surg 8A:182, 1983.
310. Silfverskild KL et al: Gap formation during controlled motion
after flexor tendon repair in zone II: A prospective clinical study.
J Hand Surg 17A:539, 1992.
311. Silfverskild KL, May EJ: Gap formation after flexor tendon
repair in zone II. Results with a new controlled motion
programme. Scand J Plast Reconstr Surg Hand Surg 27:263,
1993.
312. Choucka J et al: Cyclical testing of zone II flexor tendon repairs.
J Hand Surg 25A:1127, 2000.
313. Kessler I, Nissim F: Primary repair without immobilization of
flexor tendon division within the digital sheath. An experimental and clinical study. Acta Orthop Scand 40:587, 1969.
314. Urbaniak JR et al: Tendon suturing methods: Analysis of tensile
strengths. In: AAOS Symposium on Tendon Surgery in the
Hand. St. Louis, Mosby, 1975, Ch 8, pp 70-80.
315. Wray RC, Weeks PM: Experimental comparison of techniques
of tendon repair. J Hand Surg 5:144, 1980.
316. Defino HLA et al: Studies on tendon healing. A comparison
between suturing techniques. J Hand Surg 11B:444, 1986.
317. Taras JS et al: Evaluation of suture caliber in flexor tendon repair.
J Hand Surg 26A:1100, 2001.
318. Barrie KA et al: Effect of suture locking and suture caliber on
fatigue strength of flexor tendon repairs. J Hand Surg 26A:340,
2001.
319. Haddad RJ Jr et al: Comparative mechanical analysis of a loopedsuture tendon repair. J Hand Surg 13A:709, 1988.
320. Lee H: Double loop locking suture: A technique of tendon repair
for early active mobilization. Part I: Evolution of technique and
experimental study. J Hand Surg 15A:945, 1990.
321. Lee H: Double loop locking suture: A technique of tendon repair
for early active mobilization. Part II: Clinical experience. J Hand
Surg 15A:953, 1990.
322. Robertson GA, Al-Qattan MM: A biomechanical analysis of a
new interlock suture technique for flexor tendon repair. J Hand
Surg 17B:92, 1992.
323. Savage R: In vitro studies of a new method of flexor tendon
324. Savage R, Risitano G: Flexor tendon repair using a six strand
method of repair and early active mobilisation. J Hand Surg
14B:396, 1989.
325. Noguchi M et al: In vitro biomechanical analysis of suture
methods for flexor tendon repair. J Orthop Res 11:603, 1993.
326. Wagner WF Jr et al: A biomechanical comparison of techniques
of flexor tendon repair. J Hand Surg 19A:979, 1994.
327. Tang JB et al: Double and multiple looped suture tendon repair.
J Hand Surg 19B:699, 1994.
328. Thurman RT et al: Two-, four-, and six-strand zone II flexor tendon
repairs: an in situ biomechanical comparison using a cadaver
model. J Hand Surg 23A:261, 1998.

329. Winters SC et al: The effects of multiple-strand suture methods
on the strength and excursion of repaired intrasynovial flexor
tendons: a biomechanical study in dogs. J Hand Surg 23A:97,
1998.
330. Sanders DW et al: Cyclic testing of flexor tendon repairs: an in
vitro biomechanical study. J Hand Surg 22A:1004, 1997.
331. Becker H, Davidoff M: Eliminating the gap in flexor tendon
surgery. A new method of suture. Hand 9:306, 1977.
332. Becker H et al: Early active motion following a beveled technique
of flexor tendon repair: Report on fifty cases. J Hand Surg 4:454,
1979.
333. Ketchum LD et al: Experimental evaluation of factors affecting
the strength of tendon repairs. Plast Reconstr Surg 59:708,
1977.
334. Pribaz JJ et al: Primary repair of flexor tendons in no-mans land
using the Becker repair. J Hand Surg 14B:400, 1989.
335. Greenwald D et al: Mechanical analysis of tendon suture
techniques. J Hand Surg 19A:641, 1994.
336. Miller L, Mass DP: A comparison of four repair techniques for
Campers chiasma flexor digitorum superficialis lacerations: tested
in an in vitro model. J Hand Surg 25A:1122, 2000.
337. Silfverskild KL, Andersson CH: Two new methods of tendon
repair: An in vitro evaluation of tensile strength and gap
formation. J Hand Surg 18A:58, 1993.
338. Aoki M et al: Tendon repair using flexor tendon splints: An
experimental study. J Hand Surg 19A:984, 1994.
339. Brunelli G et al: Slip-knot flexor tendon suture in zone II allowing
immediate mobilisation. Hand 3:352, 1983.
340. Messina A: The double armed suture: Tendon repair with
immediate mobilization of the fingers. J Hand Surg 17A:137,
1992.
341. Hunter JM et al: The pulley system. J Hand Surg 5:283, 1980.
342. Hunter JM, Cook JF: The pulley system. Rationale for reconstruction. In: Difficult Problems in Hand Surgery. Ed by J. W.
Strickland and J. B. Steichen, St. Louis, CV Mosby pp 94-102,
1982.
343. Hunter JM et al: The reconstructed flexor retinacular pulley
system: A cadaver and mathematical biomechanical study. J
Hand Surg 9:595, 1984.
344. Hume EL et al: Biomechanics of pulley reconstruction. J Hand
Surg 16A:722, 1991.
345. Cheng JCY et al: Use of bioprosthetic tendon in digital pulley
reconstruction - An experimental study. J Hand Surg 11B:225,
1986.
346. Wray RC Jr, Weeks PM: Reconstruction of digital pulleys. Plast
347. Kleinert HE, Bennett JB: Digital pulley reconstruction employing
the always present rim of the previous pulley. J Hand Surg 3:297,
1978.
348. Lister GD: Reconstruction of pulleys employing extensor retinaculum. J Hand Surg 4:461, 1979.
349. Karev A: The belt loop technique for the reconstruction of
pulleys in the first stage of flexor tendon grafting. J Hand Surg
9A:923, 1984.
350. Strickland JW: Flexor tendon injuries: Part 4: Staged flexor
tendon reconstruction and restoration of the flexor pulley.
Orthop Rev 16:78, 1987.
351. Okutsu I et al: Three-loop technique for A2 pulley reconstruction. J Hand Surg 12A:790, 1987.
352. Karev A et al: The mechanical efficiency of the pulley system in
normal digits compared with a reconstructed system using the
belt loop technique. J Hand Surg 12A:596, 1987.
353. Widstrom CJ et al: A mechanical study of six digital pulley
reconstruction techniques: Part I. Mechanical effectiveness. J
Hand Surg 14A:821, 1989.
354. Widstrom CJ et al: A mechanical study of six digital pulley
reconstruction techniques: Part II. Strength of individual reconstructions. J Hand Surg 14A:826, 1989.
355. Lin G-T et al: Biomechanical analysis of finger flexor pulley

reconstruction. J Hand Surg 14B:278, 1989.
356. Nishida J et al: Flexor tendon-pulley interaction after pulley
reconstruction: a biomechanical study in a human model in
vitro. J Hand Surg 23A:665, 1998.
357. Seiler JG et al: Reconstruction of the flexor pulley. The effect of
the tension and source of the graft in an in vitro dog model. J
Bone Joint Surg 80:699, 1998.
358. Gonzales RI: Experimental use of teflon in tendon surgery. Plast
359. Bader K, Curtin JW: Clinical survey of silicone underlays and
pulleys in tendon surgery in hands. Plast Reconstr Surg 47:576,
1971.
360. Duncan KH, Lewis RC: Flexor tendon pulley reconstruction
using velour backed silicone sheeting. Orthop Trans 9:35,
1985.
361. Peterson WW et al: Development of a synthetic replacement for
the flexor tendon pulleys - An experimental study. J Hand Surg
11A:403, 1986.
362. Kain CC et al: Reconstruction of the digital pulley in the monkey
using biologic and nonbiologic materials. J Orthop Res 6:871,
1988.
363. Dunlap J et al: Flexor tendon pulley reconstruction - A histological
and ultrastructural study in non-human primates. J Hand Surg
14B:273, 1989.
364. Dunlap J et al: Biomechanical and histologic evaluations of pulley
reconstructions in nonhuman primates. J Hand Surg 15A:57,
1990.
365. Hanff G et al: Reconstruction of the flexor tendon pulley with
expanded polytetrafluoroethylene (E-PTFE). An experimental
study in rabbits. Scand J Plast Reconstr Surg Hand Surg 25:25,
1991.
366. Semer NB et al: Digital pulley reconstruction with expanded
polytetrafluoroethylene (PTFE) membrane at the time of
tenorraphy in an experimental animal model. J Hand Surg
17A:547, 1992.
367. Hanff G, Abrahamsson S-O: Cellular activity in E-PTFE reconstructed pulleys and adjacent regions of deep flexor tendons.
J Hand Surg 21B:419, 1996.
368. Hanff G, Abrahamsson S-O: Matrix synthesis and cell proliferation in repaired flexor tendons within E-PTFE reconstructed
flexor tendon sheaths. J Hand Surg 21B:642, 1996.
369. Hernandez A et al: Preliminary report on early mobilization for
the rehabilitation of flexor tendons. Plast Reconstr Surg 40:354,
1967.
370. Strickland JW, Glogovac SV: Digital function following flexor
tendon repair in zone II: A comparison of immobilization and
controlled passive motion techniques. J Hand Surg 5:537,
1980.
371. Creekmore H et al: Comparison of early passive motion and
immobilization after flexor tendon repairs. Plast Reconstr Surg
75:75, 1985.
372. Cannon NM, Strickland JW: Therapy following flexor tendon
surgery. Hand Clin 1:147, 1985.
373. Stone RG et al: An evaluation of early motion management
following primary flexor tendon repair: Zones 1 - 3. J Hand Ther
2:223, 1989.
374. Evans R: A study of the zone I flexor tendon injury and
implications for treatment. J Hand Ther 3:133, 1990.
375. Duran RJ, Houser RG: Controlled passive motion following
flexor tendon repair in zones two and three. In: A.A.O.S.
Symposium on Tendon Surgery in the Hand, pp. 105-111. St.
Louis, C.V. Mosby, 1975.
376. Duran RJ et al: A preliminary report in the use of controlled
passive motion following flexor tendon repair in zones II and III.
J Hand Surg 1:79, 1976.
377. Young RES, Harmon JM: Repair of tendon injuries of the hand.
Ann Surg 151:562, 1960.
33

378. Ejeskr A: Flexor tendon repair in no-mans land: Results of
primary repair with controlled mobilization. J Hand Surg 9A:171,
1984.
379. Citron ND, Forster A: Dynamic splinting following flexor tendon
380. Knight SL: A modification of the Kleinert splint for mobilisation
of digital flexor tendons. J Hand Surg 12B:179, 1987.
381. Becker H, Hardy M: A constant tension dynamic splint. Plast
382. Slattery PG, McGrouther DA: A modified Kleinert controlled
mobilization splint following flexor tendon repair. J Hand Surg
9B:217,1984.
383. Lopez MS, Hanley KF: Splint modification for flexor tendon
repairs. Am J Occup Ther 38:398, 1984.
384. McLean NR: Some observations on controlled mobilisation
following flexor tendon injury. J Hand Surg 12B:101, 1987.
385. Edinburg M et al: Early postoperative mobilization of flexor
tendon injuries using a modification of the Kleinert technique.
J Hand Surg 12A:34, 1987.
386. Slattery PG: The modified Kleinert splint in zone II flexor tendon
injuries. J Hand Surg 13B:273, 1988.
387. May EJ, Silfverskild KL: A new power source in dynamic
splinting: Clinical experience and results. J Hand Ther 2:169,
1989.
388. Werntz JR et al: A new dynamic splint for postoperative
treatment of flexor tendon injury. J Hand Surg 14A:559, 1989.
389. Cooney WP et al: Improved tendon excursion following flexor
tendon repair. J Hand Ther 2:102, 1989.
390. Burge PD, Brown M: Elastic band mobilization after flexor
tendon repair; splint design and risk of flexion contracture. J
Hand Surg 15B:443, 1990.
391. Chow SP et al: A splint for controlled active motion after flexor
tendon repair. Design, mechanical testing, and preliminary
clinical results. J Hand Surg 15A:645, 1990.
392. Jansen CWS, Minerbo G: A comparison between early dynamically controlled mobilization and immobilization after flexor
tendon repair in zone 2 of the hand: Preliminary results. J Hand
Ther 1:20, 1990.
393. May EJ et al: Controlled mobilization after flexor tendon repair
in zone II: A prospective comparison of three methods. J Hand
Surg 17A:942, 1992.
394. May EJ, Silfverskild KL: Rate of recovery after flexor tendon
repair in zone II. A prospective longitudinal study of 145 digits.
Scand J Plast Reconstr Surg Hand Surg 27:89, 1993.
395. Chow JA et al: A combined regimen of controlled motion
following flexor tendon repair in no mans land. Plast Reconstr
Surg 79:447, 1987.
396. Chow JA et al: Controlled motion rehabilitation after flexor
tendon repair and grafting. A multi-centre study. J Bone Joint
Surg 70B:591, 1988.
397. Dovelle S, Heeter PK: The Washington Regimen: Rehabilitation of the hand following flexor tendon injuries. Phys Ther
69:1034, 1989.
398. Gerbino PG II et al: Complications experienced in the rehabilitation of zone I flexor tendon injuries with dynamic traction
splinting. J Hand Surg 16A:680, 1991.
399. Stewart KM: Review and comparison of current trends in the
postoperative management of tendon repair. Hand Clin 7:447,
1991.
400. Saldana MJ et al: Further experience in rehabilitation of zone
II flexor tendon repair with dynamic traction splinting. Plast
401. Emery F: Immediate mobilization following flexor tendon repair. A preliminary report. J Trauma 17:1, 1977.
402. Hester TR Jr et al: Early mobilization of repaired flexor tendons
within digital sheath using an internal profundus splint: Experimental and clinical data. Ann Plast Surg 12:187, 1984.
34
403. Cullen KW et al: Flexor tendon repair in zone 2 followed by

controlled active mobilisation. J Hand Surg 14B:392, 1989.
404. Small JO et al: Early active mobilisation following flexor tendon
repair in zone 2. J Hand Surg 14B:383, 1989.
405. Gratton P: Early active mobilization after flexor tendon repairs.
J Hand Ther 6:285, 1993.
406. Bainbridge LC et al: A comparison of post-operative mobilization of flexor tendon repairs with passive flexion-active extension and controlled active motion techniques. J Hand Surg
4:517, 1994.
407. Elliot D et al: The rupture rate of acute flexor tendon repairs
mobilized by the controlled active motion regimen. J Hand Surg
19B:607, 1994.
408. Baktir A et al: Flexor tendon repair in zone 2 followed by early
active mobilization. J Hand Surg 21B:624, 1996.
409. Riaz M et al: Long term outcome of early active mobilization
following flexor tendon repair in zone 2. J Hand Surg 24B:157,
1999.
410. Kitsis CK et al: Controlled active motion following primary flexor
tendon repair: a prospective study over 9 years. J Hand Surg
23B:344, 1998.
411. Chow J, Schenck RR: Early continuous passive movement in
hand surgery. Curr Surg 46:97, 1989.
412. Bunker TD et al: Continuous passive motion following flexor
tendon repair. J Hand Surg 14B:406, 1989.
413. McGrouther DA, Ahmed MR: Flexor tendon excursions in nomans land. Hand 13:129, 1981.
414. Wehb MA: Differential tendon gliding in the hand. J Hand Surg
9:596, 1984.
415. Wehb MA, Hunter JM: Flexor tendon gliding in the hand. Part
1. In vivo excursions. J Hand Surg 10A:570, 1985.
416. Wehb MA, Hunter JM: Flexor tendon gliding in the hand. Part
2. Differential gliding. J Hand Surg 10A:575, 1985.
417. Horibe S et al: Excursion of the flexor digitorum profundus
tendon: A kinematic study of the human and canine digits. J
Orthop Res8:167, 1990.
418. Greenwald D et al: Dynamic analysis of profundus tendon
function. J Hand Surg 19A:626, 1994.
419. Brown CP, McGrouther DA: The excursion of the tendon of
flexor pollicis longus and its relation to dynamic splintage. J Hand
Surg 9A:787, 1984.
420. Percival NJ, Sykes PJ: Flexor pollicis longus tendon repair: A
comparison between dynamic and static splintage. J Hand Surg
14B:412, 1989.
421. Lane JM et al: Gliding function following flexor-tendon injury.
422. Phillips GF et al: Finger mobility following flexor tendon repair.
J Bone Joint Surg 10B:337, 1985.
423. Silfverskild KL et al: Flexor digitorum profundus tendon
excursions during controlled motion after flexor tendon repair
in zone II: A prospective clinical study. J Hand Surg 17A:122,
1992.
424. Silfverskild KL et al: Tendon excursions after flexor tendon
repair in zone II: Results with a new controlled-motion program.
J Hand Surg 18A:403, 1993.
425. Hagberg L, Selvik G: Tendon excursion and dehiscence during
early controlled mobilization after flexor tendon repair in zone
II: an x-ray stereophotogrammetric analysis. J Hand Surg 16A:669,
1991.
426. Strickland JW: Biologic rationale, clinical application, and results
of early motion following flexor tendon repair. J Hand Ther 2:71,
1989.
427. Horii E et al: Comparative flexor tendon excursion after passive
mobilization: An in vitro study. J Hand Surg 17A: 559, 1992.
428. Armstrong TJ, Chaffin DB: An investigation of the relationship
between displacements of the finger and wrist joints and the
extrinsic finger flexor tendons. J Biomech 11:119, 1977.

429. Savage R: The influence of wrist position on the minimum force
required for active movement of the interphalangeal joints. J
Hand Surg 13B:262, 1988.
430. Zhao C et al: Effect of synergistic wrist motion on flexor
digitorum profundus tendon excursion. Clin Orthop 396:223,
2002.
431. Zhao C et al: Effect of synergistic wrist motion on adhesion
formation after repair of partial flexor digitorum profundus
tendon lacerations in a canine model in vivo. J Bone Joint Surg
84A:78, 2002.
432. Adolfsson L et al: The effects of a shortened postoperative
mobilization programme after flexor tendon repair in zone 2.
J Hand Surg 21B:67, 1996.
433. Boyes JH: Flexor-tendon grafts in the fingers and thumb. An
evaluation of end results. J Bone Joint Surg 32A:489, 1950.
434. Boyes JH: Evaluation of results of digital flexor tendon grafts. Am
J Surg 89:1116, 1955.
435. American Society for Surgery of the Hand: Clinical assessment
committee report. Aurora, CO, ASSH, 1976.
436. Buck-Gramcko D et al: Bewertungskriterien bei nachuntersuchungen von beugesehnenwiederherstellungen. Handchir
8:65, 1976.
437. Strickland JW: Results of flexor tendon surgery in zone II. Hand
Clin 1:167, 1985.
438. Strickland JW: Flexor tendon injuries: Part 5: Flexor tenolysis,
rehabilitation and results. Orthop Rev 16:137, 1987.
439. Nielsen AB, Jensen PO: Methods of evaluation of the functional
results of flexor tendon repair of the fingers. J Hand Surg 10B:60,
1985.
440. So YC et al: Evaluation of results in flexor tendon repair: A critical
analysis of five methods in ninety-five digits. J Hand Surg
15A:258, 1990.
441. Jansen CWS, Watson MG: Measurement of range of motion of
the finger after flexor tendon repair in zone II of the hand. J Hand
Surg 18A:411, 1993.
442. Schenck RR, Lenhart DE: Results of zone II flexor tendon
lacerations in civilians treated by the Washington regimen. J
Hand Surg 21A:984, 1996.
443. Ejeskr A: Finger flexion force and hand grip strength after
tendon repair. J Hand Surg 7A:61, 1982.
444. Gault DT: Reduction of grip strength, finger flexion pressure,
finger pinch pressure and key pinch following flexor tendon
445. Lister G: Pitfalls and complications of flexor tendon surgery.
Hand Clin 1:133, 1985.
446. Schneider LH: Complications in tendon injury and surgery.
Hand Clin 2:361, 1986.
447. Elliot D et al: The rupture rate of acute flexor tendon repairs
mobilized by the controlled active motion regimen. J Hand Surg
19B:607, 1994.
448. Allen BN et al: Ruptured flexor tenorrhaphies in zone II: Repair
and rehabilitation. J Hand Surg 12:18, 1987.
449. Matloub HS et al: Magnetic resonance imaging scanning in the
diagnosis of zone II flexor tendon rupture. J Hand Surg 21A:451,
1996.
450. Taras JS et al: Complications of flexor tendon injuries. Hand Clin
10:93, 1994.
451. Peck FH et al: A comparative study of two methods of controlled
mobilization of flexor tendon repairs in zone 2. J Hand Surg
23B:41, 1998.
452. Sirotakova M, Elliot D: Early active mobilization of primary
repairs of the flexor pollicis longus tendon. J Hand Surg 25B:409,
2000.
453. Bunnell S: Repair of tendons in the fingers and description of
two new instruments. Surg Gynecol Obstet 26:103, 1918.
454. Bunnell S: Repair of tendons in the fingers. Surg Gynecol Obstet
35:88, 1922.
455. Graham WC: Flexor-tendon grafts to the finger and thumb. J

Bone Joint Surg 29:553, 1947.
456. Littler JW: Free tendon grafts in secondary flexor tendon repair.
Am J Surg 74:315, 1947.
457. Pulvertaft RG: Tendon grafts for flexor tendon injuries in the
fingers and thumb. J Bone Joint Surg 38B:175, 1956.
458. Pulvertaft RG: Experiences in flexor tendon grafting in the hand.
J Bone Joint Surg 41B:629, 1959.
459. Wakefield AR: The management of flexor tendon injuries. Surg
Clin North Am 40:267, 1960.
460. Wakefield AR: Late flexor tendon grafts. Surg Clin North Am
40:399, 1960.
461. Brand PW: Tendon grafting. Illustrated by a new operation for
intrinsic paralysis of the fingers. J Bone Joint Surg 43B:444, 1961.
462. Adamson JE, Wilson JN: The history of flexor tendon grafting.
463. McCormack RM et al: Flexor-tendon grafts in the less-thanoptimum situation. J Bone Joint Surg 44A:1360, 1962.
464. Pulvertaft RG: Problems of flexor-tendon surgery of the hand.
465. Williams SB: New dynamic concepts in the grafting of flexor
tendons. Plast Reconstr Surg 36:377, 1965.
466. Tubiana R: Incisions and techniques in tendon grafting. Am J
Surg 109:339, 1965.
467. Thompson RV: An evaluation of flexor tendon grafting. Br J Plast
Surg 20:21, 1967.
468. Butler B Jr et al: Flexor-tendon grafts in the severely scarred digit.
An experimental study in dogs. J Bone Joint Surg 50A:452, 1968.
469. McFarlane RM: Flexor tendon injuries within the finger: A study
of the results of tendon suture and tendon graft. J Trauma 8:987,
1968.
470. Tubiana R: Technique of flexor tendon grafts. Hand 1:108,
1969.
471. Harrison SH: Delayed primary flexor tendon grafts. Hand 1:106,
1969.
472. Hunter JM: Staged flexor tendon reconstruction. J Hand Surg
8:789, 1983.
473. Wilson RL: Flexor tendon grafting. Hand Clin 1:97, 1985.
474. Schneider LH: Staged tendon reconstruction. Hand Clin 1:109,
1985.
475. Wehb MA: Flexor tendon injury. Late solution. Hand Clin
2:133, 1986.
476. Strickland JW: Flexor tendon injuries: Part 3: Free tendon grafts.
Orthop Rev 16:18, 1987.
477. Strickland JW: Flexor tendon surgery. Part 2: Free tendon grafts
and tenolysis. J Hand Surg 14B:368, 1989.
478. Imbriglia JE et al: Secondary flexor tendon reconstruction. Hand
Clin 5:395, 1989.
479. Sakellarides HT, Papadopoulos G: Surgical treatment of the
divided flexor digitorum profundus tendon in zone 2, delayed
more than 6 weeks, by tendon grafting in 50 cases. J Hand Surg
21B:63, 1996.
480. Fetrow KO: Diagnosis and management of the severed flexor
tendon of the hand. Surg Clin North Am 54:923, 1974.
481. Stanley BG: Flexor tendon injuries: Late solution. Therapists
management. Hand Clin 2:139, 1986.
482. Mackin EJ: Prevention of complications in hand therapy. Hand
Clin 2:429, 1986.
483. Bassett CAL, Carroll RE: Formation of tendon sheath by siliconerod implants. J Bone Joint Surg 45A:884, 1963.
484. Nicolle FV: A silastic tendon prosthesis as an adjunct to flexor
tendon grafting: An experimental and clinical evaluation. Br J
Plast Surg 22:224, 1969.
485. Van der Meulen JC: Silastic spacers in tendon grafting. Br J Plast
Surg 24:166, 1971.
486. Helal B: The use of silicone rubber spacers in flexor tendon
surgery. Hand 5:85, 1973.
35

487. Farkas LG et al: An experimental study of the changes following
silastic rod preparation of a new tendon sheath and subsequent
tendon grafting. J Bone Joint Surg 55A:1149, 1973.
488. Hunter JM et al: Study of early sheath development using static
nongliding implants. J Biomed Mater Res 8:155, 1974.
489. Hunter JM et al: Sheath formation in response to limited active
gliding implants (Animals). J Biomed Mater Res 8:163, 1974.
490. Hunter JM et al: The characteristics and long-term fate of the
pseudosynovial sheath formed in response to passive and active
gliding tendon prostheses in primates. J Hand Surg 2:233, 1977.
491. Hunter JM, Jaeger SH: Tendon implants: Primary and secondary
usage. Orthop Clin North Am 8:473, 1977.
492. Eskeland G et al: The ultrastructure of normal digital flexor
tendon sheath and of the tissue formed around silicone and
polyethylene implants in man. J Bone Joint Surg 59B:206, 1977.
493. Hunter JM et al: The pseudosynovial sheath - its characteristics
in a primate model. J Hand Surg 8:461, 1983.
494. Rayner CRW: The origin and nature of pseudo-synovium
appearing around implanted silastic rods. An experimental
study. Hand 8:101, 1976.
495. Leonard AG, Dickie WR: Observations on the use of silicone
rubber spacers in tendon graft surgery. Hand 8:66, 1976.
496. Marshall KA et al: Immediate insertion of silicone rubber rods
in fingers with cut flexor tendons. Plast Reconstr Surg 61:77,
1978.
497. Conway H et al: Studies on the revascularization of tendons
grafted by the silicone rod technique. Plast Reconstr Surg
46:582, 1970.
498. Urbaniak JR et al: Vascularization and the gliding mechanism of
free-flexor tendon grafts inserted by the silicone-rod method.
499. Chamay A, Gabbiani G: Digital contracture deformity after
implantation of a silicone prosthesis: Light and electron microscopic study. J Hand Surg 3:266, 1978.
500. Hunter JM: Artificial tendons. Early development and application. Am J Surg 109:325, 1965.
501. Bader KF, Curtin JW: A successful silicone tendon prosthesis.
Arch Surg 97:406, 1968.
502. Hunter JM et al: The use of gliding artificial tendon implants to
form new tendon beds. J Bone Joint Surg 51A:790, 1969.
503. Kessler FB et al: An active tendon prosthesis: Development and
present status. J Hand Surg 2:233, 1977.
504. Hunter JM: Tendon salvage and the active tendon implant: A
perspective. Hand Clin 1:181, 1985.
505. Singer D et al: The actively gliding tendon implant (prosthesis)
evaluated in flexor tendon reconstruction. J Hand Surg 11A:762,
1986.
506. Hunter JM et al: Active tendon implants in flexor tendon
reconstruction. J Hand Surg 13A:849, 1988.
507. Dziewulski P: The migrating tendon spacer. Br J Plast Surg
44:393, 1991.
508. Soucacos PN et al: Two-stage treatment of flexor tendon
ruptures. Silicon rod complications analyzed in 109 digits. Acta
Orthop Scand Suppl 275:48, 1997.
509. Hunter JM, Salisbury RE: Flexor-tendon reconstruction in severely damaged hands. A two-stage procedure using a siliconedacron reinforced gliding prosthesis prior to tendon grafting.
510. Honner R, Meares A: A review of 100 flexor tendon reconstructions with prosthesis. Hand 9:226, 1977.
511. Sakellarides HT: Severe injuries of the flexor tendons in no
mans land and with excess scarring and flexion contracture
treated with silicone rod and tendon grafting. Orthop Rev 6:51,
1977.
512. Schmitz PW, Stromberg WB Jr: Two-stage flexor tendon
reconstruction in the hand. Clin Orthop 131:185, 1978.
36
513. Schneider LH: Staged tendon reconstruction using the method

of Hunter. A personal series involving 57 flexor tendons. J Hand
Surg 3:287, 1978.
514. Wehb MA et al: Two-stage flexor-tendon reconstruction: Tenyear experience. J Bone Joint Surg 68A:752, 1986.
515. Amadio PC et al: Staged flexor tendon reconstruction in the
fingers and hand. J Hand Surg 13A:559, 1988.
516. Millar R et al: The results of long-delayed flexor tendon grafting.
Hand 4:261, 1972.
517. Jones MW, Matthews JP: Flexor tendon grafting 48 years after
injury. J Hand Surg 13B:284, 1988.
518. Wurtz LD, Hanington KR: A second-stage flexor tendon reconstruction after 18 years. J Hand Surg 16A:711, 1991.
519. White WL: Tendon grafts: A consideration of their source,
procurement and suitability. Surg Clin North Am 40:403,
1960.
520. Wehb MA: Tendon graft donor sites. J Hand Surg 17A:1130,
1992.
521. Wehb MA: Tendon graft anatomy and harvesting. Orthop Rev
23:253, 1994.
522. Carlson GD et al: Morphologic and biomechanical comparison
of tendons used as free grafts. J Hand Surg 18A:76, 1993.
523. Reimann AF et al: The palmaris longus muscle and tendon. A
study of 1600 extremities. Anat Rec 89:495, 1944.
524. Daseler EH, Anson BJ: The plantaris muscle. An anatomical study
of 750 specimens. J Bone Joint Surg 25:822, 1943.
525. White WL: The unique, accessible and useful plantaris tendon.
526. Harvey FJ et al: Surgical availability of the plantaris tendon. J Hand
Surg 8A:243, 1983.
527. Mackay IR, McCulloch AS: Imaging the plantaris tendon with
ultrasound. Br J Plast Surg 43:689, 1990.
528. Simpson SL et al: The plantaris tendon graft: An ultrasound study.
J Hand Surg 16A:708, 1991.
529. Aulicino PL et al: The independent long extensor tendon of the
fifth toe as a source of tendon grafts for the hand. J Hand Surg
14B:236, 1989.
530. Snow JW: Ulnar half of extensor digiti quinti proprius tendon
for flexor grafts. Plast Reconstr Surg 42:603, 1968.
531. Viegas SF: Tips of the trade: 17. A simple technique to facilitate
paratenon and muscle fiber stripping of free tendon grafts.
Orthop Rev 18:1101, 1989.
532. Schneewind JH, Kline IK: The role of paratenon in healing of
experimental tendon transplants. J Bone Joint Surg 46A:910,
1964.
533. Momose T et al: Effect of paratenon and repetitive motion on
the gliding resistance of tendon of extrasynovial origin. Clin
Anat 15:199, 2002.
534. Gelberman RH et al: Intercalary flexor tendon grafts. A morphological study of intrasynovial and extrasynovial donor tendons.
Scand J Plast Reconstr Surg 26:257, 1992.
535. Gelberman RH et al: Angiogenesis in healing autogenous
flexor-tendon grafts. J Bone Joint Surg 74A:1207, 1992.
536. Seiler JG III et al: Autogenous flexor-tendon grafts. A biochemical and morphological study in dogs. J Bone Joint Surg 75A:1004,
1993.
537. Ark JW et al: Cellular survival and proliferation in autogenous
flexor tendon grafts. J Hand Surg 19A:249, 1994.
538. Abrahamsson S-O et al: Variations in cellular proliferation and
matrix synthesis in intrasynovial and extrasynovial tendons: An
in vitro study in dogs. J Hand Surg 19A:259, 1994.
539. Abrahamsson S-O et al: Autogenous flexor tendon grafts:
Fibroblast activity and matrix remodeling in dogs. J Orthop Res
13:58, 1995.
540. Seiler JG III et al: The flexor digitorum longus: an anatomic and
microscopic study for use as a tendon graft. J Hand Surg 20A:492,
1995.

541. Chaplin DM: The vascular anatomy within normal tendons,
divided tendons, free tendon grafts and pedicle tendon grafts
in rabbits. A microradioangiographic study. J Bone Joint Surg
55B:369, 1973.
542. Abrahamsson S-O, Gelberman R: Maintenance of the gliding
surface of tendon autografts in dogs. Acta Orthop Scand 65:548,
1994.
543. Whiston TB, Walmsely R: The reaction of bone and tendon after
tunnelling of bone and insertion of tendon. J Bone Joint Surg
42B:377, 1960.
544. Stenstrom SJ: A contribution to the technique of the distal
anastomosis in secondary flexor tendon grafting. Plast Reconstr
Surg 33:172, 1963.
545. Stenstrom S: A new method for the distal anastomosis in flexor
tendon grafting. Scand J Plast Reconstr Surg 1:64, 1964.
546. Weiner DL et al: Improved method for distal attachment of flexor
tendon grafts. Modification of Stenstrom technique. Plast
547. Mangus DJ et al: Tendon repairs with nylon and a modified
pullout technique. Plast Reconstr Surg 48:32, 1971.
548. Sood MK, Elliot D: A new technique of attachment of flexor
tendons to the distal phalanx without a button tie-over. J Hand
Surg 21B:629, 1996.
549. Silva MJ et al: Flexor digitorum profundus tendon-to-bone
repair: an ex vivo biomechanical analysis of 3 pullout suture
techniques. J Hand Surg 23:120, 1998.
550. Hallock GG: The Mitek Mini GII anchor introduced for tendon
reinsertion in the hand. Ann Plast Surg 33:211, 1994.
551. Singer D et al: Comparative study of the use of prefabricated
bone tendon grafts and conventional tendon grafts in flexor
tendon reconstruction. J Hand Surg 14A:830, 1989.
552. Pulvertaft RG: Suture materials and tendon junctures. Am J Surg
109:346, 1965.
553. Gabuzda GM et al: Tensile strength of the end-weave flexor
tendon repair. An in vitro biomechanical study. J Hand Surg
19B:397, 1994.
554. Colville J and Dickie WR: Tendon graft length. Br J Plast Surg
22:37, 1969.
555. McCormack RM, Bales HW: The use of mini-tendon grafts to
restore functional balance in the hand. J Bone Joint Surg
56A:1094, 1974.
556. Stark HH et al: Bridge grafts of flexor tendons. J Hand Surg 8:618,
1983.
557. Paneva-Holevich E: Two-stage plasty in flexor tendon injuries of
the fingers within the digital synovial sheath. Acta Chir Plast
7:112, 1965.
558. Paneva-Holevich E: Two-stage tenoplasty in injury of the flexor
tendons of the hand. J Bone Joint Surg 51A:21, 1969.
559. Demichew NP: Reconstructive operations on tendons and a
tendo-ligamentous apparatus. Acta Chir Plast 21:154, 1979.
560. Naam NH: Staged flexor tendon reconstruction using pedicled
tendon graft from the flexor digitorum superficialis. J Hand Surg
22A:323, 1997.
561. Alms A: Pedicle tendon graft for flexor tendon injuries of the
fingers. J Bone Joint Surg 55B:881, 1973.
562. Chong JK et al: Combined two-stage tenoplasty with silicone
rods for multiple flexor tendon injuries in No-Mans Land. J
Trauma 12:104, 1972.
563. Kessler FB: Use of a pedicled tendon transfer with a silicone rod
in complicated secondary flexor tendon repairs. Plast Reconstr
Surg 49:439, 1972.
564. Winspur I et al: Staged reconstruction of flexor tendons with a
silicone rod and a pedicled sublimis transfer. Plast Reconstr
Surg 61:756, 1978.
565. Brug E, Stedtfeld HW: Experience with a two-staged pedicled
flexor tendon graft. Hand 11:198, 1979.
566. Jaffe S, Weckesser E: Profundus tendon grafting with the

sublimis intact. An end-result study of thirty patients. J Bone Joint
Surg 49A:1298, 1967.
567. Goldner JL, Coonrad RW: Tendon grafting of the flexor
profundus in the presence of a completely or partially intact
flexor sublimis. J Bone Joint Surg 51A:527, 1969.
568. Versaci AD: Secondary tendon grafting for isolated flexor
digitorum profundus injury. Plast Reconstr Surg 46:57, 1970.
569. Stark HH et al: Flexor tendon graft through intact superficialis
tendon. J Hand Surg 2:456, 1977.
570. Pulvertaft RG: The treatment of profundus division by free
tendon graft. J Bone Joint Surg 42A:1363, 1960.
571. Honner R: The late management of the isolated lesion of the
flexor digitorum profundus tendon. Hand 7:171, 1975.
572. Nichols HM: The dilemma of the intact superficialis tendon.
Hand 7: 85, 1975.
573. Wilson RL et al: Flexor profundus injuries treated with delayed
two-staged tendon grafting. J Hand Surg 5:74, 1980.
574. McClinton MA et al: One hundred tendon grafts for isolated
flexor digitorum profundus injuries. J Hand Surg 7A:224, 1982.
575. Schneider LH: One hundred tendon grafts for isolated flexor
digitorum profundus injuries. J Hand Surg 8A:225, 1983.
576. Pulvertaft RG: Tendon grafting for the isolated injury of flexor
digitorum profundus. Bull Hosp Jt Dis 44:424, 1984.
577. Sullivan DJ: Disappointing outcomes in staged flexor tendon
grafting for isolated profundus loss. J Hand Surg 11B:231, 1986.
578. Bakalim G: Primary mobilization after secondary flexor tendon
surgery. Scand J Plast Reconstr Surg 9:240, 1975.
579. Tubiana R: Post operative care following flexor tendon grafts.
Hand 6:152, 1974.
580. Tonkin M et al: Post-operative management of flexor tendon
grafting. J Hand Surg 13B:277, 1988.
581. Kraemer BA et al: Characteristics and management of flexor
tendon graft disruption. Br J Plast Surg 40:258, 1987.
582. Eshman SJ et al: Intratendinous rupture of a flexor tendon graft
many years after staged reconstruction: a report of three cases.
J Hand Surg 25A:1135, 2000.
583. Parkes AR: The lumbrical plus finger. J Bone Joint Surg
53B:236, 1971.
584. Amadio PC: Staged flexor tendon reconstruction in children.
Ann Chir Main Memb Super 11:194, 1992.
585. Hartrampf CR Jr: Purposeful delay of cut flexor tendons in some
mans land in children. Plast Reconstr Surg 54:95, 1974.
586. Hage J, Dupuis CC: The intriguing fate of tendon grafts in small
childrens hands and their results. Br J Plast Surg 18:341, 1965.
587. Hunter JM, Salisbury RE: Use of gliding artificial implants to
produce tendon sheaths. Techniques and results in children.
588. Bora FW Jr: Profundus tendon grafting with unimpaired sublimis
function in children. Clin Orthop 71:118, 1970.
589. Valenti P, Gilbert A: Two-stage flexor tendon grafting in
children. Hand Clin 16:573, 2000.
590. Nishijima N et al: Growth of autografted tendons: An experimental study in vivo. J Hand Surg 13A:234, 1988.
591. White WL: Secondary restoration of finger flexion by digital
tendon grafts. An evaluation of seventy-six cases. Am J Surg
91:662, 1956.
592. Harrison S: Delayed primary flexor tendon grafts of the fingers.
A comparison of results with primary and secondary tendon
grafts. Plast Reconstr Surg 43:366, 1969.
593. Tubiana R: Results and complications of flexor tendon grafting.
Orthop Clin North Am 4:877, 1973.
594. Boyes JH, Stark HH: Flexor tendon grafts in the fingers and
thumb. A study of factors influencing results in 1000 cases. J
Bone Joint Surg 53A:1332, 1971.
595. Weeks PM, Wray RC: Rate and extent of functional recovery
after flexor tendon grafting with and without silicone rod
preparation. J Hand Surg 1:174, 1976.
37

596. Weinstein SL et al: Evaluation of the two-stage flexor-tendon
reconstruction in severely damaged digits. J Bone Joint Surg
58A:786, 1976.
597. LaSalle WB, Strickland JW: An evaluation of the two-stage flexor
tendon reconstruction technique. J Hand Surg 8:263, 1983.
598. Matthews P, Richards H: Factors in the adherence of flexor
tendons after repair: An experimental study in the rabbit. J Bone
Joint Surg 58B:230, 1976.
599. Jaffray D et al: Does surgical glove powder increase adhesions
in flexor tendon surgery? J Hand Surg 10B:65, 1985.
600. Farkas LG: Use of interposed flap of tendon sheath to prevent
adhesions after the repair of a cut flexor profundus tendon.
Experimental study in chickens. Plast Reconstr Surg 62:404,
1978.
601. Tang J-b et al: Dorsal and circumferential sheath reconstructions
for flexor sheath defect with concomitant bony injury. J Hand
Surg 19A:61, 1994.
602. Wray RC Jr et al: Effect of continuous load on the mechanical
properties of tendon adhesions. Hand 13:92, 1981.
603. Stark HH et al: The use of paratenon, polyethylene film, or silastic
sheeting to prevent restricting adhesions to tendons in the
hand. J Bone Joint Surg 59A:908, 1977.
604. Herzog M et al: Effect of beta-aminioproprionitrile on adhesions
following digital flexor tendon repair in chickens. Surg Forum
21:509, 1971.
605. Bora FW et al: Inhibitors of collagen biosynthesis as a means of
controlling scar formation in tendon injury. J Bone Joint Surg
54A:1501, 1972.
606. Porat S et al: Improvement of gliding function of flexor tendons
by topically applied enriched collagen solutions. J Bone Joint Surg
62B:208, 1980.
607. Speer DP et al: The control of peritendinous adhesions using
topical b-aminopropionitrile base. J Surg Res 38:252, 1985.
608. Lane JM et al: cis-Hydroxyproline limits work necessary to flex
a digit after tendon injury. Clin Orthop 109:193, 1975.
609. Hurwitz PJ et al: Experimental coating of flexor tendons with
polyvinylpyrrolidone to reduce postoperative adhesions. Plast
610. Mentzel M et al: The effectiveness of ADCON-T/N, a new antiadhesion barrier gel, in fresh divisions of the flexor tendons in
Zone II. J Hand Surg 25B:590, 2000.
611. Liew SH, Potokar T, Bantick GL et al: The use of ADCON-T/N
after repair of zone II flexor tendons .Chir Main 20:384, 2001
612. Kulick MJ, Hentz VR: Preliminary evaluation of the ability of
injectable ibuprofen to decrease peritendinous adhesions in a
primate model J Hand Surg 8:618, 1983.
613. Kulick MI et al: Oral ibuprofen: Evaluation of its effect on
peritendinous adhesions and the breaking strength of a tenorrhaphy. J Hand Surg 11A:110, 1986.
614. Kulick MI et al: Injectable ibuprofen: Preliminary evaluation of
its ability to decrease peritendinous adhesions. Ann Plast Surg
13:459, 1984.
615. Szabo RM, Younger E: Effects of indomethacin on adhesion
formation after repair of zone II tendon lacerations in the rabbit.
J Hand Surg 15A:480, 1990.
616. Komurcu M et al: Reduction of restrictive adhesions by local
aprotonin application and primary sheath repair in surgically
traumatized flexor tendons of the rabbit. J Hand Surg 22A:826,
1997.
617. St. Onge R et al: A preliminary assessment of Na-hyaluronate
injection into No mans land for primary flexor tendon repair.
Clin Orthop 146:269, 1980.
618. Weiss C et al: The role of Na-hylan in reducing postsurgical
tendon adhesions. Bull Hosp Jt Dis 46:9, 1986.
619. Thomas SC et al: Hyaluronic acid and its effect on postoperative
adhesions in the rabbit flexor tendon. A preliminary look. Clin
Orthop 206:281, 1986.
38
620. Amiel D et al: Hyaluronan in flexor tendon repair. J Hand Surg

14A:837, 1989.
621. Wiig M et al: Effects of hyaluronan on cell proliferation and
collagen synthesis: a study of rabbit flexor tendons in vitro. J Hand
Surg 21A:599, 1996.
622. Green S et al: The inhibition of flexor tendon adhesions. Bull
Hosp Jt Dis 46:16, 1986.
623. Meyers SA et al: Effect of hyaluronic acid/chondroitin sulfate on
healing of full-thickness tendon lacerations in rabbits. J Orthop
Res 7:683, 1989.
624. Hagberg L: Exogenous hyaluronate as an adjunct in the prevention of adhesions after flexor tendon surgery: A controlled
clinical trial. J Hand Surg 17A:132, 1992.
625. Khan U et al: Modulation of the formation of adhesions during
the healing of injured tendons. J Bone Joint Surg 82:1054, 2000.
626. Moran SL et al: Effects of 5-fluorouracil on flexor tendon repair.
J Hand Surg 25A:242, 2000.
627. Carstam N: The effect of cortisone on the formation of tendon
adhesions and on tendon healing. Acta Chir Scand Suppl 82:1,
1953.
628. Wrenn RH et al: An experimental study of the effect of cortisone
on the healing process and tensile strength of tendons. J Bone
629. James JIP: The use of cortisone in tenolysis. J Bone Joint Surg
41B:209, 1959.
630. Douglas LG et al: The effects of dexamethasone, norethandrolone,
promethazine and a tension-relieving procedure on collagen
synthesis in healing flexor tendons as estimated by tritiated
proline uptake studies. Can J Surg 10:36, 1967.
631. Ketchum LD: Effects of triamcinolone on tendon healing and
function. A laboratory study. Plast Reconstr Surg 47:471, 1971.
632. Kapetanos G: The effect of a local corticosteroids on the healing
and biomechanical properties of the partially injured tendon.
Clin Orthop 163:170, 1982.
633. Fetrow KO: Tenolysis in the hand and wrist. A clinical evaluation
of two hundred and twenty flexor and extensor tenolyses. J Bone
634. Strickland JW: Flexor tenolysis. Hand Clin 1:121, 1985.
635. Whitaker JH et al: The role of flexor tenolysis in the palm and
digits. J Hand Surg 2:462, 1977.
636. Wray RC Jr et al: Experimental study of the optimal time for
tenolysis. Plast Reconstr Surg 61:184, 1978.
637. Hurst LN et al: Results of tenolysis. A controlled evaluation in
chickens. Plast Reconstr Surg 52:171, 1973.
638. Hunter JM et al: A dynamic approach to problems of hand
function using local anesthesia supplemented by intravenous
fentanyl-droperidol. Clin Orthop 104:112, 1974.
639. McDonough JJ, Stern PJ: Modified 69 blade for tenolysis. J Hand
Surg 8:610, 1983.
640. Schreiber DR: Arthroscopic blades in flexor tenolysis of the
hand. J Hand Surg 11A:144, 1986.
641. McCarthy JA et al: Continuous passive motion as an adjunct
therapy for tenolysis. J Hand Surg 11B:88, 1986.
642. James JIP: The value of tenolysis. Hand 1:118, 1969.
643. Jupiter JB et al: Results of flexor tendon tenolysis after replantation in the hand. J Hand Surg 14A:35, 1989.
644. Hunter JM et al: Reconstruction of the sublimis finger. Orthop
Trans 3:321, 1979.
645. Blackmore SM et al: Superficialis finger reconstruction: A new
look at a last-resort procedure. Hand Clin 7:461, 1991.
646. Chuinard RG and Dabezies EJ: Two-stage superficialis flexor
tenoplasty utilizing silicone rods and superficialis-profundus
tenorrhaphy. Orthop Trans 3:322, 1979.
647. Chuinard RG et al: Two-stage superficialis tendon reconstruction in severely damaged fingers. J Hand Surg 5:135,
1980.
RECOMMENDED READING
Idler RS: Anatomy and biomechanics of the digital flexor tendons. Hand Clin 1:3, 1985.
Doyle JR: Anatomy of the finger flexor tendon sheath and pulley system. J Hand Surg 13A:473, 1988.
Doyle JR, Blythe WF: Anatomy of the flexor tendon sheath and pulleys of the thumb. J Hand Surg 2:149,
1977.
Ochiai N, Matsui T, Miyaji N, Merklin RJ, Hunter JM: Vascular anatomy of the flexor tendons. I. Vincular
system and blood supply of the profundus tendon in the digital sheath. J Hand Surg 4:321, 1979.
Manske PR: The flexor tendon. Orthopedics 10:1733, 1987.
Gelberman RH: Flexor tendon physiology: tendon nutrition and cellular activity in injury and repair.
Instr Course Lect 34:351, 1985.
Gelberman RH, Woo S L-Y: The physiological basis for application of controlled stress in the rehabilitation
of flexor tendon injuries. J Hand Ther 2:66, 1989.
Hariharan JS, Diao E, Soejima O, Lotz JC: Partial lacerations of human digital flexor tendons:
a biomechanical analysis. J Hand Surg 22A:1011, 1997.
Wray RC Jr, Holtman B, Weeks PM: Clinical treatment of partial tendon lacerations without suturing and
with early motion. Plast Reconstr Surg 59:231, 1977.
OConnell SJ, Moore MM, Strickland JW, Frazier GT, Dell PC: Results of zone I and zone II flexor tendon
repairs in children. J Hand Surg 19A:48, 1994.
Kleinert HE, Cash SL: Management of acute flexor tendon injuries in the hand. Instr Course Lect 34:361,
1985.
Strickland JW: Development of flexor tendon surgery: twenty-five years of progress. J Hand Surg
25A:214, 2000.
Strickland JW: Flexor tendon injuries: I. Foundations of treatment. J Am Acad Orthop Surg 3:44, 1995.
Strickland JW: Flexor tendon injuries: II. Operative technique. J Am Acad Orthop Surg 3:55, 1995.
Diao E, Hariharan JS, Soejima O, Lotz JC: Effect of peripheral suture depth on strength of tendon repairs.
J Hand Surg 21A:234, 1996.
Miller M, Mass DP: A comparison of four repair techniques for Campers chiasma flexor digitorum
superficialis lacerations: tested in an in vitro model. J Hand Surg 25A:1122, 2000.
Nunley JA, Levin LS, Devito D, Goldner RD, Urbaniak JR: Direct end-to-end repair of flexor pollicis longus
tendon lacerations. J Hand Surg 17A:118, 1992.
Wehb MA, Hunter JM: Flexor tendon gliding in the hand. Part II. Differential gliding. J Hand Surg 10A:575,
1985.
Strickland JW: Biologic rationale, clinical application, and results of early motion following flexor tendon
repair. J Hand Ther 2:71, 1989.
Dovelle S, Heeter PK: The Washington regimen: Rehabilitation of the hand following flexor tendon
injuries. Phys Ther 69:1034, 1989.
Peck FH, Bucher CA, Watson JS, Roe A: A comparative study of two methods of controlled mobilization of
flexor tendon repairs in zone 2. J Hand Surg 23B:41, 1998.
Kitsis CK, Wade PJ, Krikler SJ, Parson NK, Nicholls LK: Controlled active motion following primary flexor
tendon repair: a prospective study over 9 years. J Hand Surg 23B:344, 1998.
Cooney WP, Lin GT, An K-N: Improved tendon excursion following flexor tendon repair. J Hand Ther
2:102, 1989.
Imbriglia JE, Hunter J, Rennie W: Secondary flexor tendon reconstruction. Hand Clin 5:395, 1989.
Hunter JM, Jaeger SH, Matsui T, Miyaji N: The pseudosynovial sheath - its characteristics in a primate
model. J Hand Surg 8:461, 1983.
Wehb MA: Tendon graft anatomy and harvesting. Orthop Rev 23:253, 1994.
Strickland JW: Flexor tendon injuries. Part 5. Flexor tenolysis, rehabilitation and results. Orthop Rev 16:137,
1987.
39

9-34 Hand III

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

9-34 Hand III

Uploaded by

Copyright:

Available Formats

HAND III: FLEXOR TENDONS

James A Masson FRACS

Fig 1. Decussation of the FDS within the flexor sheath. (Reprinted

The course of the flexor digitorum profundus

dus and superficialis tendons alter as they pass

SRPS Volume 9, Number 34

Fig 2. The components of the digital flexor sheath. (Reprinted

The flexor sheath does not buckle nor impinge

form pulleys are obliquely oriented and also located

Fig 3. Sheath bulging and flattening during flexion-extension.

The A2 and A4 pulleys are usually considered the

SRPS Volume 9, Number 34

without mechanical detriment. A diametrically

Fig 4. The pulley system of the flexor pollicis longus. (Reprinted

The interior of the flexor tendon sheath is not a

and Jones40 elucidated the cause of these pockets.

SRPS Volume 9, Number 34

Fig 5. Cross section of the digital flexor tendon mechanism at the

TENDON NUTRITION AND HEALING

Fig 6. Tendon nutrition in the digital sheath. (Reprinted with

supplied only a short segment at either end, and

SRPS Volume 9, Number 34

microvascular flow. He further defined the volar

Fig 7. Vincula and flexor tendons. VLS, vinculum longum

SRPS Volume 9, Number 34

advantages which can be attributed to decreased

In vitro tissue culture studies by Lundborg109 and

SRPS Volume 9, Number 34

tendons, and are also elevated in repaired tendons

healing tendon, where metabolic demands are

Fig 8. Flexor tendon healing. (A) A mobilized tendon that is

The first event seen is revascularization of the

Fig 9. Zones of tendon injury within the hand. (Reprinted with

SRPS Volume 9, Number 34

Distal to the FDS insertion

In the thumb, there are also 5 zones, the latter

Distal to the IP joint

through the muscle belly, or at its insertion.

Partially Severed Tendons

SRPS Volume 9, Number 34

Tendon retracts into the palm with rupture of both vincula

The ideal surgical management of these injuries

pass back beneath the intact A4 pulley. Elliot has

SRPS Volume 9, Number 34

delayed primary tendon repair

There are many excellent review articles on the

secondary repair takes place between 2 to 5

SRPS Volume 9, Number 34

motion of the joint is not essential. A capsulodesis

sion of the PIP joint may occur if the superficialis is

Fig 11. (Above) Dynamic tenodesis of the DIP joint. (Below)

Zone II: Poor functional results after primary

SRPS Volume 9, Number 34

pass in close proximity to the FPL sheath (Fig 12).242

Fig 12. Anatomy of the flexor pollicis longus. (Reprinted with

Fig 13. Surgical exposure of the FPL. 1 - Bruner incision. 2 & 3

SRPS Volume 9, Number 34

Fig 14. Surgical exposure of the flexor tendon sheath. (Reprinted

longitudinal incision 2 to 3 mm from its lateral

Fig 15. Flexor tendon access through the cruciate pulleys.

SRPS Volume 9, Number 34

Callan and Morrison describe an even simpler