Injury: Tendons – Flexor

  • David ElliotEmail author


We are all guilty of complacency in our belief that all is well with flexor tendon surgery and that our knowledge of this subject is complete. Like many other parts of hand surgery, when one looks a little more closely, one discovers that much that seemed fully understood is far from understood and what we have assumed to be based on hard fact often rests on opinion. Although, currently, there is debate about many details of technique, the central tenet of modern flexor tendon surgery is to repair and move divided flexor tendons within a few days of injury.


Tendon Flexor Tendon Flexor Tendon Primary Repair Flexor Tendon Rehabilitation Flexor Tendon Rupture Flexor Tendon Adhesion 


  1. 1.
    Lexer E. Die Verwerthung der freien Sehnentransplantation. Arch Klin Chir. 1912;98:818–25.Google Scholar
  2. 2.
    Harmer TW. Tendon suture. Boston Med Surg J. 1917;177:808–10.CrossRefGoogle Scholar
  3. 3.
    Kirchmayr L. Zur Technik der Sehnennaht. ZBL Chir. 1917;40:906–7.Google Scholar
  4. 4.
    Kessler I, Nissim F. Primary repair without immobilisation of flexor tendon division within the digital sheath. Acta Orthop Scand. 1969;40:587–601.PubMedCrossRefGoogle Scholar
  5. 5.
    Lahey FH. A tendon suture which permits immediate motion. Boston Med Surg J. 1923;22:851–2.CrossRefGoogle Scholar
  6. 6.
    Bunnell S. Repair of tendons in the fingers and description of two new instruments. Surg Gynecol Obstet. 1918;126:103–10.Google Scholar
  7. 7.
    Kleinert HE, Kutz JE, Ashbell T, Martinez E. Primary repair of lacerated flexor tendons in “No Man’s Land”. Proceedings, American Society for Surgery of the Hand. J Bone Joint Surg Am. 1967;49:577.Google Scholar
  8. 8.
    Young RES, Harmon JM. Repair of tendon injuries of the hand. Ann Surg. 1960;151:562–6.PubMedCentralPubMedCrossRefGoogle Scholar
  9. 9.
    Verdan C. Réparation primaire des fléchisseurs en dehors des coulisses osteo-fibreuses des doigts. In: Chirurgie Réparatrice et Fonctionnelle des Tendons de la Main. Paris: L’Expansion Scientifique Française; 1952. p. 174–6.Google Scholar
  10. 10.
    Verdan C. La réparation immédiate des tendons fléchisseurs dans le canal digital. Acta Orthop Belg. 1958;24(Supplement III):15–23.Google Scholar
  11. 11.
    Riccio M, Battiston B, Pajardi G, Corradi M, Passaretti U, Atzei A, Altissimi M, Vaienti L, Catalano F, Del Bene M, Fasolo P, Ceruso M, Luchetti R, Landi A, Study Group on Tendon Adhesion of Italian Society of Hand Surgery. Efficiency of Hyaloglide in the prevention of the recurrence of adhesions after tenolysis of flexor tendons in zone II: a randomized, controlled, multicentre clinical trial. J Hand Surg Eur. 2010;35:130–8.CrossRefGoogle Scholar
  12. 12.
    Doyle JR, Blythe W. The finger flexor tendon sheath and pulleys: anatomy and reconstruction. In: Hunter JM, Schneider LH, editors. American Academy of Orthopaedic Surgeons symposium on tendon surgery in the hand. St. Louis: Mosby; 1975. p. 81–7.Google Scholar
  13. 13.
    Idler RS. Anatomy and biomechanics of the digital flexor tendons. Hand Clin. 1985;1:3–11.PubMedGoogle Scholar
  14. 14.
    Verdan CE, Michon J. Le traitement des plaies des tendons flechisseurs des doigts. Rev Chir Orthop. 1961;47:290–6 and 386.Google Scholar
  15. 15.
    Kleinert HE, Weiland AJ. Primary repair of flexor tendon lacerations in zone II. In: Verdan C, editor. Tendon surgery of the hand. Edinburgh: Churchill Livingstone; 1979. p. 71–5.Google Scholar
  16. 16.
    Tang JB. Flexor tendon repair in zone 2C. J Hand Surg Br. 1994;1994(19):72–5.CrossRefGoogle Scholar
  17. 17.
    Moiemen NS, Elliot D. Early active mobilization of primary flexor tendon repairs in zone 1. J Hand Surg Br. 2000;25:78–84.PubMedCrossRefGoogle Scholar
  18. 18.
    Barton NJ. Experimental study of optimal location of flexor tendon pulleys. Plast Reconstr Surg. 1969;43:125–9.PubMedCrossRefGoogle Scholar
  19. 19.
    Urbaniak JD, Cahill JD, Mortenson RA. Tendon suturing methods: analysis of tensile strengths. In: Hunter JM, Schneider LH, editors. Symposium on tendon surgery. St Louis: Mosby; 1975. p. 70–80.Google Scholar
  20. 20.
    Mason ML, Allen HS. The rate of healing of tendons. An experimental study of tensile strength. Ann Surg. 1941;113:424–59.PubMedCentralPubMedCrossRefGoogle Scholar
  21. 21.
    Strickland JW. Flexor tendon surgery. Part 1: primary flexor tendon repair. J Hand Surg Br. 1989;14:261–72.PubMedCrossRefGoogle Scholar
  22. 22.
    Savage R. In vitro studies of a new method of flexor tendon repair. J Hand Surg Br. 1985;10:135–41.PubMedCrossRefGoogle Scholar
  23. 23.
    Savage R, Risitano G. Flexor tendon repair using a “six strand” method of repair and early active mobilisation. J Hand Surg Br. 1989;14:396–9.PubMedCrossRefGoogle Scholar
  24. 24.
    Wade PJF, Wetherell RG, Amis AA. Flexor tendon repair: significant gain in strength from the Halsted peripheral suture technique. J Hand Surg Br. 1989;14:232–5.PubMedCrossRefGoogle Scholar
  25. 25.
    Lin GT, An KN, Amadio PC, Cooney WP. Biomechanical studies of running suture for flexor tendon repair in dogs. J Hand Surg Am. 1988;13:553–8.PubMedCrossRefGoogle Scholar
  26. 26.
    Kubota H, Aoki M, Pruitt DL, Manske PR. Mechanical properties of various circumferential tendon suture techniques. J Hand Surg Br. 1996;21:474–80.PubMedCrossRefGoogle Scholar
  27. 27.
    Elliot D, Moiemen NS, Flemming AFS, Harris SB, Foster AJ. The rupture rate of acute flexor tendon repairs mobilized by the controlled active motion regimen. J Hand Surg Br. 1994;19:607–12.PubMedCrossRefGoogle Scholar
  28. 28.
    Harris SB, Harris D, Foster AJ, Elliot D. The aetiology of acute rupture of flexor tendon repairs in zones 1 and 2 of the fingers during early mobilization. J Hand Surg Br. 1999;24:275–80.PubMedCrossRefGoogle Scholar
  29. 29.
    Wong JK, Alyouha S, Kadler KE, Ferguson MW, McGrouther DA. The cell biology of suturing tendons. Matrix Biol. 2010;29:525–36.PubMedCentralPubMedCrossRefGoogle Scholar
  30. 30.
    Murphy FG. Repair of laceration of flexor pollicis longus tendon. J Bone Joint Surg Am. 1937;19:1121–3.Google Scholar
  31. 31.
    Silfverskiöld KL, Andersson CH. Two new methods of tendon repair: an in vitro evaluation of tensile strength and gap formation. J Hand Surg Am. 1993;18:58–65.PubMedCrossRefGoogle Scholar
  32. 32.
    Sirotakova M, Elliot D. Early active mobilization of primary repairs of the flexor pollicis longus tendon. J Hand Surg Br. 1999;24:647–53.PubMedCrossRefGoogle Scholar
  33. 33.
    Sirotakova M, Elliot D. Early active mobilization of primary repairs of the flexor pollicis longus tendon with two Kessler two strand core sutures and a strengthened circumferential suture. J Hand Surg Br. 2004;29:531–5.PubMedCrossRefGoogle Scholar
  34. 34.
    Tsuge K, Ikuta Y, Matsuishi Y. Intra-tendinous tendon suture in the hand. Hand. 1975;7:250–5.PubMedCrossRefGoogle Scholar
  35. 35.
    Tsuge K, Ikuta Y, Matsuishi Y. Repair of flexor tendons by intratendinous suture. J Hand Surg. 1977;2:436–40.CrossRefGoogle Scholar
  36. 36.
    Tang JB, Shi D, Gu YQ, Chen JC, Zhou B. Double and multiple looped suture tendon repair. J Hand Surg Br. 1994;17:699–703.CrossRefGoogle Scholar
  37. 37.
    Tang JB, Gu YT, Rice K, Chen F, Pan CZ. Evaluation of four methods of flexor tendon repair for postoperative active mobilisation. Plast Reconstr Surg. 2001;107:742–9.PubMedCrossRefGoogle Scholar
  38. 38.
    Giesen T, Sirotakova M, Copsey AJ, Elliot D. Flexor pollicis longus primary repair: further experience with the tang technique and controlled active mobilization. J Hand Surg Eur. 2009;34:758–61.CrossRefGoogle Scholar
  39. 39.
    Savage R. The mechanical effect of partial resection of the digital fibrous flexor sheath. J Hand Surg Br. 1990;15:435–42.PubMedCrossRefGoogle Scholar
  40. 40.
    Tomaino M, Mitsionis G, Basitidas J, Grewal R, Pfaeffle J. The effect of partial excision of the A2 and A4 pulleys on the biomechanics of finger flexion. J Hand Surg Br. 1998;23:50–2.PubMedCrossRefGoogle Scholar
  41. 41.
    Mitsionis G, Bastidas JA, Grewal R, Pfaeffle HJ, Fischer KJ, Tomaino MM. Feasibility of partial A2 and A4 pulley excision: effect on finger flexor tendon biomechanics. J Hand Surg Am. 1999;24:310–4.PubMedCrossRefGoogle Scholar
  42. 42.
    Franko OI, Lee NM, Finneran JJ, Shillito MC, Meunier MJ, Abrams RA, Lieber RL. Quantification of partial or complete A4 pulley release with FDP repair in cadaveric tendons. J Hand Surg Am. 2011;36:439–45.PubMedCentralPubMedCrossRefGoogle Scholar
  43. 43.
    Kwai Ben I, Elliot D. “Venting” or partial lateral release of the A2 and A4 pulleys after repair of zone 2 flexor tendon injuries. J Hand Surg Br. 1998;23:649–54.PubMedCrossRefGoogle Scholar
  44. 44.
    Mason ML, Shearon CG. The process of tendon repair. Arch Surg. 1932;25:613–92.CrossRefGoogle Scholar
  45. 45.
    Mason ML. Primary and secondary tendon suture. A discussion of the significance of technique in tendon surgery. Surg Gynecol Obstet. 1940;70:392–402.Google Scholar
  46. 46.
    Mason ML, Allen HS. The rate of tendon healing. Ann Surg. 1941;112:424–59.CrossRefGoogle Scholar
  47. 47.
    Gelberman RH, Amilf D, Gonsalves M, Woo S, Akeson WH. The influence of protected passive mobilisation on the healing of flexor tendons: a biochemical and microangiographic study. Hand. 1981;13:120–8.PubMedCrossRefGoogle Scholar
  48. 48.
    McGrouther DA, Ahmed MR. Flexor tendon excursions in ‘No-Man’s Land’. Hand. 1981;13:129–41.PubMedCrossRefGoogle Scholar
  49. 49.
    Slattery PG, McGrouther DA. A modified Kleinert controlled mobilisation splint following flexor tendon repair. J Hand Surg Br. 1984;9:217–8.PubMedCrossRefGoogle Scholar
  50. 50.
    Silfverskiöld 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 Am. 1994;19:53–60.PubMedCrossRefGoogle Scholar
  51. 51.
    Chow JA, Thomes LJ, Dovelle S, Milnor WH, Seyfer AE, Smith AC. A combined regimen of controlled motion following flexor tendon repair in “no man’s land”. Plast Reconstr Surg. 1987;79:447–53.PubMedCrossRefGoogle Scholar
  52. 52.
    Duran RH, Houser RG. Controlled passive motion following flexor tendon repairs in zones II and III. In: Hunter JM, Schneider LH, editors. American Academy of Orthopaedic Surgeons symposium on flexor tendon surgery in the hand. St. Louis: Mosby; 1975. p. 105–14.Google Scholar
  53. 53.
    Strickland JW, Glogovac SV. Digital function following flexor tendon repair in Zone II: a comparison of immobilisation and controlled passive motion techniques. J Hand Surg. 1980;5:537–43.CrossRefGoogle Scholar
  54. 54.
    Small JO, Brennen MD, Colville J. Early active mobilisation following flexor tendon repair in zone 2. J Hand Surg Br. 1989;14:383–91.PubMedCrossRefGoogle Scholar
  55. 55.
    Cullen KW, Tolhurst P, Lang D, Page RE. Flexor tendon repair in zone 2 followed by controlled active mobilisation. J Hand Surg Br. 1989;14:392–5.PubMedCrossRefGoogle Scholar
  56. 56.
    Bainbridge LC, Robertson C, Gillies D, Elliot D. A comparison of post-operative mobilization of flexor tendon repairs with “passive flexion - active extension” and “controlled active motion” techniques. J Hand Surg Br. 1994;19:517–21.PubMedCrossRefGoogle Scholar
  57. 57.
    Baktir A, Türk CY, Kabak S, Sahin V, Kardas Y. Flexor tendon repair in zone 2 followed by early active mobilization. J Hand Surg Br. 1996;1996(21):624–8.CrossRefGoogle Scholar
  58. 58.
    Savage R. The influence of wrist position on the minimum force required for active movement of the interphalangeal joints. J Hand Surg Br. 1988;3:262–8.CrossRefGoogle Scholar
  59. 59.
    Dowd MB, Figus A, Harris SB, Southgate CM, Foster AJ, Elliot D. The results of immediate re-repair of zone 1 and 2 primary flexor tendon repairs which rupture. J Hand Surg Br. 2006;31:507–13.PubMedCrossRefGoogle Scholar
  60. 60.
    Kulkarni M, Harris SB, Elliot D. The significance of extensor tendon tethering and dorsal joint capsule tightening after injury to the hand. J Hand Surg Br. 2006;31:52–60.PubMedCrossRefGoogle Scholar
  61. 61.
    Elliot D, Harris SB. The assessment of flexor tendon function after primary tendon repair. Review. Hand Clin. 2003;19:495–503.PubMedCrossRefGoogle Scholar
  62. 62.
    Stefanich RJ, Putnam MD, Peimer CA, Sherwin FS. Flexor tendon lacerations in zone V. J Hand Surg Am. 1992;17:284–91.PubMedCrossRefGoogle Scholar
  63. 63.
    Yii NW, Urban M, Elliot D. A prospective study of flexor tendon repair in zone 5. J Hand Surg Br. 1988;23:642–8.CrossRefGoogle Scholar
  64. 64.
    Gerbino PG, Saldana MJ, Westerbeck P, Schacherer TG. Complications experienced in the rehabilitation of zone 1 flexor tendon injuries with dynamic splinting. J Hand Surg Am. 1991;16:680–6.PubMedCrossRefGoogle Scholar
  65. 65.
    Evans RB. A study of the zone 1 flexor tendon injury and implications for treatment. J Hand Ther. 1990;3:133–48.CrossRefGoogle Scholar
  66. 66.
    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 Am. 1971;53:1332–42.PubMedGoogle Scholar
  67. 67.
    Smith AM, Evans DM. Biomechanical assessment of a new type of flexor tendon repair. J Hand Surg Br. 2001;26(3):217–9.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag London 2015

Authors and Affiliations

  1. 1.St Andrews Centre for Plastic SurgeryBroomfield HospitalChelmsfordUK

Personalised recommendations