FLEXOR TENDON

AND SHEATH:
ANATOMY INJURY
AND HEALING

Christian Dumontier, MD, PhD

Guadeloupe Hand Center
 FLEXOR TENDONS ANATOMY

• 2 tendons for the long

ngers : FDP, FDS

• 1 tendon for the thumb:

FPL

• Median nerve innervation,

anterior compartment of
the forearm.
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FLEXOR TENDONS ANATOMY
• Deep layer: FPL and FDP

• Intermediate layer : FDS

FLEXOR TENDONS ANATOMY
FLEXOR TENDONS ANATOMY

• Embedded in a synovial
sheath

• One for the FPL

• One for all the exors

• Communicate in 60-80% of
cases
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FLEXOR TENDONS ANATOMY

• Rich environment

• Proximal insertion of
lumbricals
• Origin: FDP (1-3,5 cm
long)
 LUMBRICALS
• Variations:
• Proximal 22%
• Distal 40% (more frequent on
the ulnar side)
• Innervation: 1-2 ☞ Median ; 3-4
☞ ulnar 60% of cases 1 ☞
Median ; 2-3-4 ☞ ulnar 20%;
1-2-3 ☞ Median ; 4 ☞ ulnar
20%
Fahrer M. Observations on the origin of the lumbrical muscles in the human hand. J. Anat. (Lond.), 1971, 110, 505
Kaplan E.B. Anatomy injuries and treatment of the extensor apparatus of the hand and the digits. Clin. Orthop., 1959, 13, 24-40.
Mehta HJ, Gardner WU. A study of lumbrical muscles in the human hand. Am J Anat. 1961;109:227–238.
Palti R, Vigler M. Anatomy and Function of Lumbrical Muscles.Hand Clin 28 (2012) 13–17
Wang K et al. A Biomechanical and Evolutionary Perspective on the Function of the Lumbrical Muscle. J Hand Surg 2014;39(1):149-155
 LUMBRICALS

• Volar to the intermetacarpal

ligament

• End on the extensor system

(radial side): 25% only on
lateral bands, 58% oblique or
traverse bers, 48% on the
phalanx or palmar plate

Wang K et al. A Biomechanical and Evolutionary Perspective on the Function of the Lumbrical Muscle. J Hand Surg
2014;39(1):149-155
Eladoumikdachi F et al. Anatomy of the intrinsic hand muscles revisited: Part II: Lumbricals. Plast. Reconstr. Surg
2002;110:1225-1231
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FLEXOR TENDONS
ANATOMY

• Tendons are within a synovial

sheath
 FLEXOR TENDONS ANATOMY
• FDS divides in two slips to insert of
the middle phalanx

• FDP goes up to the distal phalanx

 CHIASMA OF CAMPER
• Many variations

• FDS division starts at the MP level in

48,2% of cases

• FDS terminal tendon with 180°

Schmidt HS et al. Clinical Anatomy of the Chiasma Tendinum (Camper) in the Fingers. Clinical Anatomy 7:65-71(1994)
 FDP DISTAL INSERTION
• Insertion is widest proximally
and tapered distally

• Length and width were 6.2 mm

(5.1-7. mm) and 7.9 mm
(6.9-8.4 mm), w/o difference
regarding nger or sex

• Insertion distance from the

proximal joint surface is 1.2
mm (range, 0.4-2.1 mm) due to
the insertion of the volar plate 20%

Chepla KJ, Goitz RJ, Fowler JR. Anatomy of the Flexor Digitorum Profundus Insertion. J Hand Surg Am. 2015;40(2):240-244.
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 IFSSH ZONES

• Zone V = proximal to the wrist

• Zone IV: carpal tunnel

• Zone III: palm of the hand

• Zone II: digital canal up to FDS

insertion

• Zone I: distal to FDS insertion

 FLEXOR TENDON INJURY
• Rare (5 / 100,000)

• Severe injuries (associated lesions

including nerves, arteries, bones)

• A major challenge to all hand surgeons:

• Tendon ruptures (3-9%) within

10-12 post days up to 6 weeks

• At the site of the repair

 INTRA-SYNOVIAL (FLEXOR) TENDONS CAN HEAL ?

• Yes (Lundborg, late

70’s)

• Intrinsic healing

• Extrinsic healing =
Adhesion

• Extrinsic healing
starts 1st !
ANATOMY OF THE FLEXOR TENDONS

• Extra-cellular matrix
contained mainly collagen
type 1 (resists compression)

• Collagen bers arranged in

a longitudinal fashion to
form the tendon unit

• Relatively avascular
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 FLEXOR TENDON VASCULARISATION

• In zone 2, vascularisation
comes through the vincula
(sing: vinculum)

• Each tendon has 2: a brevis

and a longus

• Relative avascular zone

under A2 and A4 pulleys
 FDP VASCULARISATION

FDP insertion at the distal phalanx

(magni cation x 6.3)

• FDP bony insertion is partially

responsible for vascularization of
the tendon through two types of
vascular in ow

• Plus the vinculum brevis proximally

Leversedge FJ, Ditsios K, Goldfarb CA, Silva MJ, Gelberen RH, Boyer MI. Vascular Anatomy of the Human Flexor Digitorum Profundus Tendon
Insertion. J Hand Surg 2002;27A:806–812
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 FLEXOR TENDON SHEATH
• Annular pulleys =
mechanical role

• A2 & A4 are the most

important to lessen the
moment arm

• Cruciate pulleys: Nutrition

 PULLEYS AT THE THUMB

• 3 pulleys

• 2 annular at the joint level

(MP/IP)

• One oblique going from

proximal-ulnar to distal-
radial
 TENDON HEALING

• 3 phases

• In ammation (1 week)

• Proliferative (Weeks)

• Remodeling (Months)

Tital AL et al. Flexor Tendon: Development, Healing, Adhesion Formation, and Contributing Growth Factors. Plast Reconstr Surg. 2019 ; 144(4):
639e–647e.
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 TENDON HEALING: INFLAMMATORY PHASE =
1 WEEK

• Haematoma activates a cascade of

vasodilators and proin ammatory
mediators

• Increased vascular permeability

promotes the venue of

• In ammatory cells, platelets that

release factors stimulating
angiogenesis and tenocytes
proliferation

• Tendon repair is reliant on the

suture strength +++
Zhao C, Amadio PC, Paillard P, et al. Digital resistance and tendon strength during the rst week after exor digitorum
profundus tendon repair in a canine model in vivo. J Bone Joint Surg Am 2004;86:320–7.
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 TENDON HEALING: PROLIFERATIVE
PHASE (1-3 WEEKS)

• Fibroblasts proliferation

• Immature collagen (type III)

• Production of ECM

• Scar formation within the

tendon ➘ strength

• Risk of rupture is major at

10-12 days
 TENDON HEALING: REMODELING PHASE
(> 6 WEEKS)

• Type I collagen bers are re-

oriented in a longitudinal matter

• Collagen brils begin cross-linking

➚ strength

• Adhesions are more apparent

• Tendons never regain their

previous resistance +++
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 PATIENT INTRINSIC FACTORS
• Age

• Sex (Males > females)

• Health status

• Malnutrition

• Smoking

• Steroid use

• Poor compliance
 PATIENT EXTRINSIC FACTORS

• Wound localisation

• Type of injury

• Extent of injury

• Associated lesions (fracture,

nerves, arteries,…)

• Late presentation
 ➚ INTRINSIC
• Timing for surgery
• Limit soft-tissues trauma
during exposure
• Solid xation (purchase,
number of core sutures,
epitendinous sutures,…)

• Preserve the pulleys • Close the sheath

• Protect the tendon • Timing for rehabilitation

(retrieval, grasping,
xation…) • Active mobilisation
➘
EXTRINSIC
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 TIMING FOR SURGERY

• Equal or better results in delayed (> 1 week) repair

• Avoid immediate repair by inexperienced surgeons

Lalonde DH. An evidence-based approach to exor tendon laceration repair. Plast Reconstr Surg 2011;127:885–90
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 LIMIT SOFT-TISSUES TRAUMA
• Good exposure (concomitant
injuries)

• Incisions should allow tendon

end retrieval

• Usually Bruner type 1,5-2 cm

long

Wu YF, Tang JB. Tendon Healing, Edema, and Resistance to Flexor Tendon Gliding: Clinical Implications. Hand Clin 29 (2013) 167–178
Ann. Roy. Coll. Surg. Engl. 1973; 53: 84-88
 PRESERVE PULLEYS (1)
• Tendon repair is up to
300% larger than native
tendon

• Try to protect A2 > A4 >

A3…

Hwang MD, Pettrone S, Trumble TE. Work of exion related to different suture materials after exor digitorum profundus and exor digitorum
super cialis tendon repair in zone II: a biomechanical study. J Hand Surg Am 2009;34:700–4.
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 PRESERVE PULLEYS (2)
• If sutures cannot glide, venting
of the pulley may be a solution
(< 2/3 of A2, complete A4) -
unless other pulleys are intact

• Or decrease size of tendons

(FDS slip removal)

Kwai Ben I, Elliot D. “Venting” or partial lateral release of the A2 and A4 pulleys after repair of zone 2 exor tendon injuries. J Hand Surg Br
1998;23:649–54.
Mitsionis G, Fischer KJ, Bastidas JA, et al. Feasi- bility of partial A2 and A4 pulley excision: residual pulley strength. J Hand Surg Br 2000;25:90–4.
Savage R. The mechanical effect of partial resection of the digital brous exor sheath. J Hand Surg Br 1990;15:435–42.
Tang JB. The double sheath system and tendon gliding in zone 2C. J Hand Surg Br 1995;20:281–5.
Tomaino M, Mitsionis G, Basitidas J, et al. The effect of partial excision of the A2 and A4 pulleys on the biomechanics of nger exion. J Hand
Surg Br 1998;23:50–2.
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PROTECT THE TENDON ENDS

• Protect the vincula

• Avoid clamps on the

tendon ends (retrieval
tricks)

• Use 25G needles to hold

the stumps
 SOLID FIXATION

• Strength relies on the

sutures the 1st week

• Gapping at the suture site

increased adhesions

Tang JB. Flexor Tendon Injuries. Clin Plastic Surg 46 (2019) 295–306
 STRONG SUTURES

Lee C. Tendon physiology and Repair. Orthopaedics and Trauma 2021; 35(5):274-281
Myer C, Fowler JR. Flexor Tendon Repair Healing, Biomechanics, and Suture Con gurations. Orthop Clin N Am 47 (2016) 219–226
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 • Core placement • Locking vs grasping
(dorsal vs volar) sutures

• Core size • Type of sutures

• Tendon purchase • Knot placement

(7-12 mm)
• Epitendinous
• Asymetry sutures

Hotokezaka S, Manske PR. Differences between locking loops and grasping loops: effects on 2-strand core suture. J Hand Surg Am 1997;22: 995–1003
Taras JS, Raphael JS, Marczyk SC, et al. Evaluation of suture caliber in exor tendon repair. J Hand Surg Am 2001;26:1100–4
Soejima O, Diao E, Lotz JC, et al. Comparative mechanical analysis of dorsal versus palmar placement of core suture for exor tendon repairs. J Hand Surg
Am 1995;20:801–7.
Barrie KA, Tomak SL, Cholewicki J, et al. Effect of suture locking and suture caliber on fatigue strength of exor tendon repairs. J Hand Surg Am 2001;26:
340–6.
Cao Y, Zhu B, Xie RG, et al. In uence of core suture purchase length on strength of four-strand tendon repairs. J Hand Surg Am 2006;31(1):107–12.
Tang JB, Zhang Y, Cao Y, et al. Core suture purchase affects strength of tendon repairs. J Hand Surg Am 2005;30:1262–6.
Wu YF, Tang JB. The effect of asymmetric core suture purchase on gap resistance of tendon repair in linear cyclic loading. J Hand Surg Am 2014; 39(5):910–8
Lee SK, Goldstein RY, Zingman A, et al. The effects of core suture purchase on the biomechanical characteristics of a multistrand locking exor tendon
repair: a cadaveric study. J Hand Surg Am 2010; 35:1165–71.
Lee SK. Modern tendon repair techniques. Hand Clin 2012;28:565–70.
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 ADDITIONAL MEDICATION

• Many trials with

pharmacological agents,
growth factors,…

• Mechanical barriers

• Useless clinical evidence

Chang J. Studies in exor tendon reconstruction: biomolecular modulation of tendon repair and tissue engineering. J Hand Surg Am 2012;37:
552–61.
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 SHEATH CLOSURE
• Theoretical advantages :

• Serve as a barrier to the formation of

extrinsic adhesions,

• Provide a quicker return of synovial

nutrition,

• Act as a mold for the remodeling tendon,

• Disadvantages: technically dif cult and may

narrow and restrict tendon gliding.

• No clear-cut bene t to sheath repair has yet

been established.
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 REHABILITATION

• Usefulness ?

• When to start ?

• Active or passive ?

• Wrist immobilisation ?

Cao Y, Tang JB. Resistance to motion of exor tendons and digital edema: an in vivo study in a chicken model. J Hand Surg Am 2006;31:1645–
51.
Peters SE, Jha B, Ross M. Rehabilitation following surgery for exor tendon injuries of the hand. Cochrane Database of Systematic Reviews,
2021 (1), art. no. CD012479.
Trumble TE, Vedder NB, Seiler JG 3rd, et al. Zone-II exor tendon repair: a randomized prospective trial of active place-and-hold therapy
compared with passive motion therapy. J Bone Joint Surg Am 2010;92:1381–9.
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 CONCLUSION
• Delicate balance to avoid both tendon rupture and adhesion

• Understanding of the healing process will help the surgeon

to adapt his/her surgical technique to:

• The patient

• The injury

• The (availability) physiotherapist