Evaluation of the Results of Repair of Flexor Digitorum Superficialis and Flexor Digitorum Profundus Tendon Injury of the Hand at Zone-V

Research Article

Chronic Dis Int. 2016; 3(1): 1020.

Evaluation of the Results of Repair of Flexor Digitorum Superficialis and Flexor Digitorum Profundus Tendon Injury of the Hand at Zone-V

Rahman MT¹*, Alim MA², Datta NK³, Uddin MJ4, Hossain MA5, Sharmin R6, Faisal MA7, Tarik MM8 and Nabi SG9

1Adhunic Sadar Hospital, Bangladesh

2Institute of Public Health Nutrition, Bangladesh

3Department of Orthopaedic Surgery, Bangabondhu Sheikh Mujib Medical University, Bangladesh

4Department of Orthopaedic Surgery, Cox’s Bazar Medical College Hospital, Bangladesh

5Department of Orthopaedic Surgery, Bangladesh

6Forensic Medicine, Dhaka Medical College, Bangladesh

7Department of Orthopaedic Surgery BSMMU, Bangladesh

8Tanor Upazila Health Complex, Bangladesh

9Mugda Medical College, Bangladesh

*Corresponding author: Rahman MT, Junior Consultant, Adhunic Sadar Hospital, Natore, Bangladesh

Received: April 16, 2016; Accepted: July 12, 2016; Published: July 13, 2016


Hand is the most important organ of a man. For proper functioning of hand intactness of tendons (both flexor and extensor) are essential. Injury to the tendons in hand produces nonfunctioning or deforming hand. Deformity becomes worse when tendon injury occurs in zone- v (especially when injury occurs in flexor digitorum superficialis and flexor digitorum profundus). Flexor tendon injury is one of the most common hand injuries. Zone-v flexor tendon injuries may involve major nerves and arteries as well as the wrist and finger flexors. Total 17 patient’s repaired zone-v flexor tendons injuries were followed up for 2.5 to 12 months. The postoperative rehabilitation program consisted of a regime of modified kleinert technique was applied. Outcome parameters of the hand functions were measured according to the Buck-Gramco (1983) assessment system, grip and key pinch strength values, and return to work status. Out of 17 patients functional results were excellent in 4 (23.5%) patients, good in 10 (64.7%), fair in 2 (11.8%), and poor in 1 (5.9%) patient. No tendon ruptures or tenolysis occurred in our series of 17 patients who were employed at the time of injury, 14 patients returned to their original occupations. Satisfactory functional results can be obtained when proper surgical technique was coupled with careful postoperative management in patients with zone-v flexor tendon injuries.

Keywords: Flexor digitorum superficialis; Flexor digitorum profundus; Repair; Zone-v; Bangladesh


Hand is the medium of introduction to the outside world. Its unique repertoire of pre-hensive movements and tactile activity sets us apart from all other species. The hand is the sophisticated and highly specialized organ, as it has grasping, pinching, and hooking functions, carried out by musculotendinous units. It can give information about the position, size, and shape of an object by its highly developed sensory mechanism and described as third eye. Flexor tendon injury is one of the most common hand injuries. Surgical repair of flexor tendon requires an exact knowledge of anatomy, careful adherence to some basic surgical principles, sound clinical judgment, strict atraumatic surgical technique and a well planned post operative programme. Hand function will be grossly impaired if flexor tendon is injured as muscle activity is finally carried out by intact tendon attached to the bone. For injured flexor tendon in the hand, the goal of treatment is recovery of functionally acceptable digital motion with intact tendon. Repair of all divided flexor tendons in zone-v has been encouraged because of the contributions of the Flexor Digitorum Superficialis (FDS) tendons to grip strength, their action in making pinch and flexion of the Proximal Interphalangeal (PIP) joint more stable and their effect in providing superior individual finger flexion.

Repair of flexor tendon in zone-v is easier than zone-II because presence of pulleys, which maintain gliding and prevent of bowstring effect of tendon during flexion and extension of fingers. If pulleys are injured, first reconstruct the pulleys then tendon by tendon graft. In zone-v tendon excursion is more than zone-II that’s why tendon repair is easier by positioning of hand.

Hand is the most important organ of a man. For proper functioning of hand intactness of tendons (both flexor and extensor) are essential. Injury to the tendons in hand produces nonfunctioning or deforming hand. Deformity is more when tendon injury occurred in zone-v (especially when injury occurs in FDS and Flexor Digitorum Profundus (FDP)). Deformed or nonfunctioning hand of a man produces burden not only to the family but also to the society. With the development of human civilization or the development of medical science day by day injured hand can be repaired. After repair of tendons in hand by proper technique hand function can be normal or near to normal and patient can able to re-back his/her normal job. Although there are several retrospective series of zone-v flexor tendon injuries [1-4], they have concentrated largely on the injuries to the median and ulnar nerves and not on injuries of the finger flexors. To the best of our knowledge no such work has been done in Bangladesh.

Therefore, the present work was carried out to evaluate the beneficial effect of repair of FDS and FDP tendon injury of the hand at zone-v.

Methods and Materials

A prospective study was carried out between January 2008 and December 2009 at Bangabandhu Sheik Mujib Medical University, Dhaka, Bangladesh. Within the study period 31 patients were treated with lacerations (sharp weapon) involving the flexor aspect of the wrist and /or distal third of the forearm. Of them 23 patients were selected for this study. Out of 23 patients 21 were included in the study had complete division of at least one digital flexor tendon. But two patients were below 12 years with a glass laceration of the wrist were excluded as they were not expected to comply with post operative physiotherapy regimen. Finally 19 patients were eligible for the study however, among them two failed to return for follow up for a minimum period of 2.5 months. Therefore, 17 patients (77% follow up rate) with lacerations of the flexor aspect of the wrist or distal forearm who had a total of 61 FDS and 51 FDP divisions were reviewed. The patients were followed up for 2.5 to 12 months. The deformity was determined by Buck-Gramco (1983) evaluation criteria [5].

Details of tendon repaired procedure

All patients were operated as the routine cases by general anesthesia. Patient was supine in position on the table with injured limb on side trolley at right-angle to body. Tourniquet was applied and continued for 75 minutes and released for 5-10 minutes and reapplied when needed. Painting of the limb was done by povidone iodine after soap water washing. The cut tendons were exposed by Lazy-s incision. Skin and palmar fascia were dissected in a single layer, and tendon sheath and neurovascular bundles were carefully identified and protected. Proximal and distal end were identified. If needed proximal cut ends were exposed through extending the incision proximally to the forearm. All tendons except palmaris longus were repaired by 4 ‘0’ atraumatic prolene for core suturing and 6 ‘0’ prolene for epitendinous suturing. After exposing both the cut ends were repaired by modified Kessler’s method with epitendinous suture by prolene. Finally skin was closed by interrupted sutures with a drain in situ.

Tension measurement: Full traction was applied to FDP musculotendinous unit and then released 20 percent tension, and attached. If tension would adequate, the fingers were extended when wrist was passively flexed.

Postoperative management

The patients were examined at the evening for vital signs, such as pulse, blood pressure, respiration, swelling of the hand, circulation of the fingers and collection in the drain. On the 2nd Post Operative Day (POD) drain was removed, on 3rd or 4th POD bulky dressing was replaced by light one and advised for passive flexion and active extension of the fingers in the plaster slab for 2 weeks. On the 12th POD stitches were removed and active contraction of flexor muscles of forearm were advised with wrist and fingers in fist position along with passive flexion and active extension of fingers and were advised to attend after 3 weeks outpatient department. At the end of 3 weeks, the patients were advised for controlled active flexion of the fingers to reduce the distance between fingers tip and palm by measuring the breadth of the fingers of other hand. During this period, patients were advised to remove the cast intermittently for 3 times a day and warm water and wax bath were advised at home or at physiotherapy department. They were also instructed to do gradual extension of the wrist with the fingers in passive flexion to improve the gliding of tendons and to maintain tendon length. After exercise, re-application of the cast was advised. At one month the patients were advised to remove the cast at day time and controlled active flexion exercise to continue. Passive hyperextension was strictly forbidden. Patients were also advised for deep friction massage, controlled passive extension of the fingers and to apply cast at bed time. After 6 weeks the cast was totally discarded and patients were instructed to start light activity like to hold glass, tea cup etc. At the end of 8 weeks the grip strengthening of the fingers along with controlled hyperextension of the fingers was emphasized. Grip strengthening was included squeezing of sponge roll and table pulley activity. Heavy resistance exercise was advised after 3 months and emphasis was on return to work.

In this series, total 17 patients were included and operated. The man age of the patients was 18 years. Among them, 2 (11.8%) patients were within 11-20 years of age group, 8 (47.1%) in between 21-30 years and 4 (23.5%) above 31 to 40 years, 2 (11.8%) patients were within 41-50 years, only 1 patient was within 51-60 years. Male patients were predominant (70.6%). More than half (52.9%) of the patients were businessmen and service holders. Right hand was involved over three-fourths (76.5%) cases. More than half (58.8%) injury was occurred due to broken glasses followed by machinery injury (17.7%). In this series, none of the patients were treated before the first 2 weeks of injury, 7 (41.2%) patient was operated within 5-8 weeks interval, 3 (17.7%) was operated within 9-12 weeks interval, 2 (11.8%) between 13-16 weeks, 1 (5.9%) between 17-20 weeks, 4 (23.5%) between 21-24 weeks. In case of 12 (70.6%) patients injury was associated with nerve involvement. Twenty nine percent of the patients were treated between 17-24 weeks interval since injury. Nearly half (47.1%) of the patients were followed up for the lowest duration 2.5 - 6 months after operations. However, 29.4% of the patients were followed up after operations for the highest duration 11 - 12 months. Socio-demographic with other characteristics is shown in the Table 1.