Peggers’ Super Summary of Hand Tendon Repairs

Anatomy:
FLEXOR ZONES ANAESTHETIC
 Zone 1 Distal to FDS  VOLAR - regional block
 Zone 2 Both FDS + FDP  DORSAL – local
 Zone 3 Mid palm All will depend on patients ability to tolerate the tourniquet
 Zone 4 Within carpal tunnel POSITION
 Zone 5 Proximal to carpal  Supine
tunnel  On hand board with lead hand
 Tourniquet

EXTENSOR ZONES DRAPING

 1 – DIPj (mallet)  Antiseptic solution to mid forearm
 2 – Central Slip to DIPj  Perforated drape
 3 – PIPj  Drape to mid forearm just in case tendon retracted
 4 – PIPj to MCPj down to zone 4/5
 5 – MCP
 6 – MCP to CMC Hand Incision Rules:
 7 – CMC  Hand is made up of “Functional Units”
 8 – Wrist to include forearm  Incision in one functional unit
will not compromise
PULLEYS movements of others
 Annular  Crossing into other units can
o 5 in total compromise movements
o Odd number over joints  Incisions must not cross
o Even over P1 and P2 flexion creases vertically (or
 Cruciform extensor aspects)
o 3 in total  Follow boarders of functional
o Alternative after A2 cutaneous units
 Palmar incisions to run
Associated injuries parallel to palmar creases
 Nerves  Angle between changing direction >1200
 Hand/finger perfusion
 Skin viability

Preoperative Planning:
 Zone 2 / N/V injuries / degloving or skin loss will
need plastic intevension

Equipment
 Hand set
 Lead hand
 Hand table
 Tendon retriever
 Blue needles Surgical Approach
 Tourniquet  VOLAR brunner’s incision zig-zagging from
 3/0 prolene /ethibond for core suture round bodied crease to crease mark full length of palm in case
 Round bodied 5/0 or 6/0 prolene for epidentinous incision needs to be increased to locate tendon
suture or silver schiord  DORSAL lazy s incisions around creases
 Full thickness tissue flaps to prevent necrosis
Operative Room Planning  Tack pain with Nylon 5/0 sutures to flap
INTRODUCTION  Isolated n/v bundles and tendons
 Confirm Consent / Mark / WHO form / Abx at  Tendon retriever
induction  Blue needle can be used to kebab the tendon in
place once found

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 Peggers’ Super Summary of Hand Tendon Repairs
 Sacrifice pulleys except A2 & A4 if required

Closure Complications:
 5/0 nylon mattress or vicryl rapide to skin
Early
 Join corners up 1st
 Damage to n/v structures
 Non adherent dressing
 Scarring
 Splint the hand in intrinsic plus position to mid Late
forearm
 Failure
o Wrist extended 100
 Stiffness
o MCPs flexed 800
o IPJs fully extended
 For extensor tendons apply volar splint
 For flexors tendons apply dorsal splint to avoid
over flexion or extension of repairs
 PHYSIO HAND FORM

Operative Note
Extensor tendon injury, Zone ??? , Left hand

Primary repair

GA, Supine position

TQ control, 40 mins

Sterile preparation

Dorsal wound extended in a lazy s fashion

Extensor tendon rupture identified

Collateral extensor tendon slips found intact

Primary repair with 3-0 Prolene kessler stitch + epidentinous

Stable repair

Skin edges debrided

Closure in layers

Nylon to skin

Cleaned and dressed

Back slab, Edinburgh position

TQ down

Limb elevation

Antibiotics x 3 doses

Wound check 48 hrs

Limb elevation

Suture removal 1 week

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