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Flexor Tendon Injury Zone Classification and Management

Flexor Tendon Injury Zone Classification and Management: Flexor Tendon Injury → Clinical Examination → Injury Zone → Zone I (Distal to FDS) → Surgical R...

Pathway Overview

9 steps

Algorithm Steps

9 total

  1. 01Start

    Flexor Tendon Injury

  2. 02Action

    Clinical Examination

    Test FDP (DIP flexion) and FDS (PIP flexion with adjacent fingers extended)

  3. 03Decision

    Injury Zone

  4. 04Action

    Zone I (Distal to FDS)

    FDP only, distal to A4 pulley

    • May require tendon advancement
    • Or reinsertion to bone
  5. 05End

    Surgical Repair

    Primary repair within 2 weeks, early mobilization protocol

  6. 06Action

    Zone II (Fibro-osseous Canal)

    'No man's land' - FDP and FDS

    • Technically demanding
    • Risk of adhesions
    • Core + epitendinous suture
  7. Path rejoins step 05Shared downstream outcome
  8. 07Action

    Zone III (Lumbrical Origin)

    Palm - between A1 pulley and carpal tunnel

    • Better prognosis than Zone II
    • Associated neurovascular injury common
  9. Path rejoins step 05Shared downstream outcome
  10. 08Action

    Zone IV (Carpal Tunnel)

    Under transverse carpal ligament

    • Median nerve at risk
    • May need CTR for access
  11. Path rejoins step 05Shared downstream outcome
  12. 09Action

    Zone V (Forearm)

    Proximal to carpal tunnel

    • Muscle belly injuries
    • Associated nerve/vessel injury
  13. Path rejoins step 05Shared downstream outcome

Guideline Source

ASSH Clinical Assessment: Flexor Tendon Injuries

DOI: 10.1016/j.jhsa.2019.02.008View Guideline

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 historically 'no man's land' - technically demanding
  • Timing of repair affects outcomes
  • Rehabilitation protocol critical

Applicable Regions

USAUUKEU

UK: BSSH similar guidelines

US: ASSH zone classification standard

Version 1Next review: 2028-01-01

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Frequently Asked Questions

What is the Flexor Tendon Injury Zone Classification and Management?

The Flexor Tendon Injury Zone Classification and Management is a diagnostic clinical algorithm for Plastic Surgery. It provides a structured decision tree to guide clinical decision-making, based on ASSH Clinical Assessment: Flexor Tendon Injuries.

What guideline is the Flexor Tendon Injury Zone Classification and Management based on?

This algorithm is based on ASSH Clinical Assessment: Flexor Tendon Injuries (DOI: 10.1016/j.jhsa.2019.02.008).

What are the limitations of the Flexor Tendon Injury Zone Classification and Management?

Known limitations include: Zone II historically 'no man's land' - technically demanding; Timing of repair affects outcomes; Rehabilitation protocol critical. Individual patient factors may require deviation from these recommendations.

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