Suspected Flexor Tendon Laceration
Hand/finger laceration with weakness
All Pathways
Plastic SurgeryEmergency
Flexor Tendon Laceration Assessment and Repair
Flexor Tendon Laceration Assessment and Repair: Suspected Flexor Tendon Laceration → History and Examination → Test FDS Function → Flexor Tendon Zones →...
Pathway Overview
12 steps
Algorithm Steps
12 total
01Start 02Action History and Examination
Assess mechanism and function
- HISTORY:
- - Mechanism (sharp vs crush)
- - Time since injury
- - Hand dominance
- - Occupation/hobbies
- EXAMINATION:
- - Wound location (predict zone)
- - Active finger flexion
- - Cascade (resting posture)
- - Neurovascular status
03Action Test FDS Function
Flexor digitorum superficialis
- Hold adjacent fingers in extension
- Ask patient to flex PIP joint
- FDS intact: Can flex PIP independently
- FDS cut: Cannot flex PIP alone
- Note: Little finger FDS often absent/weak
04Action Flexor Tendon Zones
Verdan classification
- ZONE I: Distal to FDS insertion
- - Only FDP present
- ZONE II: 'No Man's Land' (A1 pulley to FDS insertion)
- - FDP + FDS in tight sheath
- - Historically worst outcomes
- ZONE III: Palm (lumbrical origin to A1)
- - FDP + FDS, more space
- ZONE IV: Carpal tunnel
- - Tendons + median nerve
- ZONE V: Wrist to forearm
- - Muscle-tendon junction
05Decision Partial vs Complete Laceration?
Affects management
- <50% transected: May not need repair
- >50-60% transected: Repair recommended
06Action Partial Laceration (<50%)
Conservative vs repair
- Options:
- - Trim frayed edges, no repair
- - Epitendinous repair only
- - Splint and early motion
- Watch for triggering
- Repair if >50-60% involved
07Action Postoperative Protocol
Rehabilitation critical
- SPLINTING:
- - Dorsal blocking splint
- - Wrist 20° flexion, MCP 70° flexion
- - IP joints extended
- EARLY MOTION PROTOCOLS:
- - Passive flexion, active extension
- - Place and hold (Duran/Kleinert)
- - True active motion (selected cases)
- PROGRESSION:
- - 4-6 weeks: Begin active flexion
- - 8-12 weeks: Resistance
- - 3-4 months: Return to activities
08Action Complications
Watch for
- RUPTURE: 2-5%
- - Usually 10-21 days postop
- - Need revision repair/graft
- ADHESIONS: Most common
- - Limits tendon gliding
- - May need tenolysis
- STIFFNESS:
- - PIP contracture common
- - Therapy essential
- SWAN NECK (Zone I):
- - From FDP scarring
09Outcome Outcomes
Expected results
- Zone II: 75-90% good/excellent
- Modern multi-strand repairs improved outcomes
- Early active motion protocols help
- Measure: Total active motion (TAM)
- Excellent: >75% normal TAM
- Good: 50-75% normal TAM
10Action Timing of Repair
When to operate
- PRIMARY (<24h): Ideal if clean
- DELAYED PRIMARY (1-14 days): Acceptable
- SECONDARY (>3-4 weeks): More difficult
- LATE (>6 weeks): May need graft/staged
- FACTORS:
- - Wound contamination
- - Associated injuries
- - OR availability
11Action Surgical Repair Principles
Modern technique
- APPROACH:
- - Bruner incisions for exposure
- - Preserve pulleys (especially A2, A4)
- CORE SUTURE:
- - Multi-strand technique (4-6 strand)
- - Stronger = earlier motion
- - Kessler, Cruciate, Tang techniques
- EPITENDINOUS SUTURE:
- - 5-0 or 6-0 running/simple
- - Smooths repair, adds strength
- FDS REPAIR:
- - Zone II: Repair one slip if tight
- - May excise both slips if needed
- Path rejoins step 07Shared downstream outcome
12Action Test FDP Function
Flexor digitorum profundus
- Stabilize PIP joint in extension
- Ask patient to flex DIP joint
- FDP intact: Can flex DIP
- FDP cut: Cannot flex DIP
- Always test thumb FPL separately
- Path rejoins step 04Shared downstream outcome
Guideline Source
ASSH Flexor Tendon Repair Guidelines
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Zone II ('no man's land') historically difficult
- Pediatric tendons more challenging
- FDP vs FDS injury affects strategy
- Therapy protocol crucial for outcome
Applicable Regions
USEU
Version 1Next review: 2027-01-11
Next steps
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Related Resources
Frequently Asked Questions
What is the Flexor Tendon Laceration Assessment and Repair?
The Flexor Tendon Laceration Assessment and Repair is a emergency clinical algorithm for Plastic Surgery. It provides a structured decision tree to guide clinical decision-making, based on ASSH Flexor Tendon Repair Guidelines.
What guideline is the Flexor Tendon Laceration Assessment and Repair based on?
This algorithm is based on ASSH Flexor Tendon Repair Guidelines (DOI: N/A).
What are the limitations of the Flexor Tendon Laceration Assessment and Repair?
Known limitations include: Zone II ('no man's land') historically difficult; Pediatric tendons more challenging; FDP vs FDS injury affects strategy; Therapy protocol crucial for outcome. Individual patient factors may require deviation from these recommendations.
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