Extensor Tendon Repair Info Evidence Consent
Reviewed by Dr Kieran Hirpara, Specialist Orthopaedic Surgeon Last reviewed
Why this operation has been suggested
Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your hand, and arrange imaging if it is needed to work out what has happened.
Extensor tendons are the cords on the back of your hand and fingers that straighten them. They can be cut by a laceration, torn by a crush or sporting injury, or rupture after a fracture. Many of these injuries, such as mallet finger, are treated without surgery using a splint. Others need repair, especially open cuts, long-standing tears, or injuries where the tendon has been badly damaged. We consider surgery when splinting has not given enough improvement, or straight away when the injury is acute and the tendon will not heal on its own. The aim is to restore the tendon's length and strength so your finger or thumb can straighten again, giving you a working, pain-free hand.
Before the operation
Once your operation is booked, we will give you clear instructions to follow in the days before you come in. You will need to stop eating and drinking seven hours before surgery. We ask for seven hours so you can be brought forward if the theatre list runs early. Your surgeon will tell you which of your usual medicines to stop and which to keep taking, so bring a written list of everything you take, including any blood thinners. Arrange for someone to drive you home afterwards, as you will not be able to drive yourself. Wear loose, comfortable clothing with sleeves that are easy to remove. Most people need no other preparation. If you have other medical conditions, you may need blood tests or a review with the anaesthetist, the doctor who gives the anaesthetic.
On the day
You will come to the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will meet the anaesthetist there. This operation is done under general anaesthetic. A regional nerve block is sometimes added for post-operative pain relief; the anaesthetist will discuss this with you on the day. You are then taken into the operating theatre, where the operation is performed. Afterwards you will wake up in the recovery area, where nurses monitor you while the anaesthetic wears off. Once you are stable, you will either go to the ward or go home, depending on the procedure and your recovery.
What the operation involves
The exact steps depend on where the tendon is torn and how badly. Extensor tendons run just under the skin on the back of the hand and fingers, so your surgeon can usually reach the injury through a cut over the back of the affected finger or hand. If the skin itself was injured, damaged tissue is cleaned away first, and healthy skin cover may be brought over the area.
Once the tendon ends are found, your surgeon sews them back together. The repair is made strong enough to cope with the early movements your hand will do afterwards. If a length of tendon is missing or too damaged to sew, the gap can be bridged instead. This may be done with a piece of tendon taken from a finger that cannot be saved, with a graft, or by moving a nearby tendon to take over the job of the torn one. Your surgeon aims to restore the tendon's natural length, because a tendon left too loose or too tight will not straighten the finger properly.
The cut is closed with stitches and covered with a dressing. You will go home with written instructions on caring for your hand.
What happens next matters as much as the repair itself. Some repairs need a splint that holds the finger still, while others are started on early, protected movement within the first weeks. One approach allows 30 degrees of active movement in the first two weeks, increasing to 40 degrees in the third week and 50 degrees in the fourth week. Your surgeon will match the plan to your injury and tell you exactly what you can and cannot do.
After the operation
You will wake up in the recovery area, where nurses watch you as the anaesthetic wears off. Your hand will be dressed and may be resting in a splint, depending on your injury. Pain relief is planned before you leave theatre, and you can tell the nurses if you are sore at any point. Someone should stay with you for the first 24 hours. Most people move around normally soon after waking; the operation is on your hand, not your legs. Your team will tell you whether you go home the same day or stay one night in hospital. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you.
Recovery
Your hand will be sore and swollen for the first days and weeks. This is normal. Keeping your hand raised on pillows, even while you sleep, helps the swelling settle. Simple pain relief as directed by your team usually eases the discomfort.
Your dressing stays on for about 10 days. Depending on your injury, you may wear a splint that holds the finger still, or you may be started on early protected movement. If early movement is part of your plan, you will be shown exactly how far to bend and straighten the finger and how often. The movements are small at first and increase as the repair strengthens. Rehabilitation is with Ruby Doolan, a hand therapist at Extend Rehabilitation. She will guide your exercises and make any splint you need.
At home you can do most everyday things that do not strain the hand. You will need to avoid lifting, gripping and anything that could knock the repair until your therapist clears you. Keep the hand clean and dry until we review the wound. As the swelling settles and movement returns, the exercises become easier and the finger starts to straighten more smoothly.
Recovery varies from person to person. Your timeline may differ, and your surgeon and hand therapist will guide you at each review.
What can go wrong
Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early.
The most common problem after this surgery is stiffness. The finger may not straighten fully or bend into a full fist, and grip strength can stay weaker than before. This happens when the tendon scars down to the tissue around it while the hand is held still. Your therapist will watch for this at each visit and adjust your exercises. If movement stalls or the finger feels increasingly tight, bring it up at your next review rather than waiting.
Sometimes a small amount of straightening power is lost even when everything else goes well. You may notice the finger sits slightly lower than its neighbours when you try to straighten it, or that it will not bend all the way into your palm. This is called an extensor lag. It is worth knowing this can happen, especially if the injury was old before it was treated. Mention it at review so your therapist can work on it.
The repair itself can fail. If you feel a sudden pop or the finger that was straightening well suddenly droops again, contact the clinic straight away. Do not wait for the next appointment.
Infection is uncommon but needs quick attention. Watch for pain that keeps getting worse instead of easing, redness spreading out from the wound, swelling that builds rather than settles, or any fluid leaking from the stitches. A fever with a sore hand is also a warning sign. If you see any of these, call the clinic the same day or go to the emergency department if it is after hours.
If surgery is needed to free a scarred tendon later, this is called tenolysis. It is not part of the original plan, but it is an option if stiffness does not respond to therapy. Your surgeon will discuss it with you only if your movement plateaus.
The complications table on this page lists typical rates if you want the specifics.
When to call us
Problems are easier to fix when they are caught early. Call us if your pain keeps getting worse instead of easing, or if the skin around the wound becomes redder, hotter or starts leaking fluid. Call us if you feel feverish, if your fingers or hand go numb, or if you cannot move the finger at all. If you notice sudden swelling and pain in your calf, or you become short of breath, go to emergency. If the finger that was straightening well suddenly droops, or you feel a pop, call us straight away.
Evidence & references
This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.
Anatomy & Pathophysiology
General Hand Architecture
- The hand is composed of 19 bones, 17 articulations, and 19 muscles situated entirely within the hand [2].
- Approximately the same number of tendons activated by forearm muscles are present in the hand [2].
- The hand functions efficiently only if the proximal joints of the limb are stable and yet mobile [2].
- The dorsal aspect of the hand is convex, while the anterior, palmar, or volar aspect is concave [2].
- The palmar surface is the functional surface of the hand, while the dorsal surface is usually visible and aesthetically important [2].
- The thumb has a more proximal and lateral position than the four fingers, allowing movement inward and outward from the palm [2].
- When fingers are extended and separated, their tips lie on the circumference of a circle whose center is the head of the third metacarpal [2].
Metacarpal and Longitudinal Arch Anatomy
- The metacarpal arch possesses adaptability due to the mobility of the peripheral metacarpals [7].
- The index metacarpal is the most firmly fixed of the metacarpals [7].
- The ring metacarpal has approximately 10 degrees of mobility in flexion and extension [7].
- The fifth metacarpal has a range of flexion–extension of approximately 20 degrees [7].
- The second to fifth metacarpals are bound together by the deep transverse intermetacarpal ligament, also known as the interglenoid ligament [7].
- The interglenoid ligament ties together the anterior glenoid ligaments of the metacarpophalangeal articulations, known as volar plates [7].
- The metacarpophalangeal joints serve as the keystones of the longitudinal arches of the hand [7].
- The volar plates prevent hyperextension at the metacarpophalangeal joints [7].
- The sagittal bands of the extensor apparatus insert onto the volar plate [7].
- The first annular segment of the pulley of the flexor tendons inserts onto the volar plate [7].
Extensor Tendon and Intrinsic Muscle Anatomy
- There are seven interosseous muscles in the hand, consisting of four dorsal and three volar muscles [4].
- The dorsal interossei are abductors, while the volar interossei are adductors [4].
- The middle finger has two dorsal interossei and no volar interossei because the central axis of the hand lies within it [4].
- Each dorsal interosseous muscle, with the exception of the third, has two muscle heads: a superficial head and a deep head [4].
- The superficial head of the dorsal interosseous muscles abducts and weakly flexes the proximal phalanx [4].
- The deep head of the dorsal interosseous muscles forms the lateral band at the level of the metacarpophalangeal joint [4].
- The deep head of the dorsal interosseous muscles flexes and weakly abducts the proximal phalanx while extending the middle and distal phalanges [4].
- Transverse fibers arch dorsally from each lateral band to join over the dorsum of the finger, flexing the proximal phalanx [4].
- Oblique or spiral fibers from the lateral bands insert onto the lateral tubercles at the base of the middle phalanx to extend the middle phalanx [4].
- The lateral bands are joined by the lateral slips of the extensor tendon to form the conjoined lateral band [4].
- The two conjoined lateral bands unite at the distal third of the middle phalanx to form the terminal tendon [4].
- The terminal tendon inserts at the base of the distal phalanx to extend it [4].
- The volar interossei have only one muscle head and do not insert onto the proximal phalanx [4].
- The flexor digiti quinti brevis forms the ulnar lateral band of the little finger [4].
Cutaneous and Vascular Anatomy
- The dorsal cutaneous unit extends from the wrist to the proximal interphalangeal joints of the fingers and the interphalangeal joint of the thumb [3].
- The dorsal covering of the interphalangeal articulations forms a unique cutaneous unit characterized by considerable excess of skin when digits are in extension [3].
- The palmar integument is subdivided into two zones by the oppositional crease of the thumb [3].
- The skin of the radial portion of the palm covers the thenar eminence and is relatively well vascularized and mobile [3].
- The skin of the ulnar and distal portion of the palm covers the hypothenar eminence and has poor mobility [3].
- The central triangular part of the palm has fixed, poorly vascularized skin that covers the superficial palmar aponeurosis [3].
- Incisions made along the sides of the diamond-shaped cutaneous contact zones in flexed digits present a minimal chance of retraction [3].
- The princeps pollicis artery is the terminal branch of the radial artery that crosses the first intermetacarpal space [8].
- The princeps pollicis artery runs along the ulnar side of the first metacarpal bone and along the volar surface of the adductor muscle [8].
- The princeps pollicis artery divides into two terminal rami, the collateral palmar arteries of the thumb, at the level of the metacarpophalangeal joint flexion crease [8].
- Only 15% of anatomical dissections of the palmar arteries of the thumb fall into the classical "typical" category [8].
- In the second segment of the thumb, the ulnar collateral artery is often easier to dissect than the radial collateral artery [8].
- A subtendinous anastomosis at the level of the neck of the first phalanx acts as a moderator between the two collateral arteries [8].
- The dorsal arteries of the thumb originate from palmar arteries at the level of the first metacarpal and head distally on the side of the two distal phalanges [8].
Investigations
- Clinical evaluation of the injured or dysfunctional hand and wrist requires combining patient history with a careful physical examination to pinpoint or narrow the scope of possible pathologic processes [1].
- Diagnostic tests such as imaging and serum laboratory studies are useful in determining pathology but can be expensive, time consuming, and often nonspecific [1].
- A careful physical examination is essential to direct care and future testing if indicated [1].
- A systematic method to approaching the physical examination of the hand and wrist is essential due to the number of structures in a small space [1].
- An 8-MHz Doppler tone assessment may be used to identify superficially displaced neurovascular bundles when Dupuytren cords lie beneath soft fleshy prominences [11].
- False-negatives are possible with 8-MHz Doppler tone assessment for identifying neurovascular bundles [11].
- Doppler imaging is a promising improvement for identifying structures, but higher resolution imaging technology is needed [11].
- MR assessment of Dupuytren’s disease is hindered by the resolution of current equipment, orientation issues due to multiplanar deformities of the fingers, and lack of intraoperative availability [11].
- MRI is probably most useful in identifying additional pathology such as flexor tendon bowstringing [11].
- MRI may be helpful in providing a quantitative noninvasive measure of cellularity of affected areas, which is an index of biologic activity [11].
- The potential staging tool of MRI for measuring cellularity has not been investigated yet on a large scale [11].
References
[1] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy, Evaluation, Clinical Examination, and Imaging > Evaluation and Clinical Examination: Current Concepts.
[2] Exam Of The Hand Wrist 2Ed. INTRODUCTION.
[3] Exam Of The Hand Wrist 2Ed. Functional cutaneous units.
[4] Green S Operative Hand Surgery. Interosseous and Hypothenar Muscles.
[7] Exam Of The Hand Wrist 2Ed. The arches of the hand > The metacarpal arch.
[8] Exam Of The Hand Wrist 2Ed. Techniques of investigation of the arterial supply by J P Melki > Vascularization of the thumb > Palmar aspect.
[11] Dupuytren S Disease And Related Hyperproliferative Disorders. 54. The Future of Dupuytren’s Research and Treatment > 54.4 Mechanical Measurements and Procedures > 54.4.4 Imaging.
