Flexor Injury Rehabilitation Splint Trial (FIRST): protocol for a pragmatic randomised controlled trial comparing three splints for finger flexor tendon repairs.

BACKGROUND: Without surgical repair, flexor tendon injuries do not heal and patients' ability to bend fingers and grip objects is impaired. However, flexor tendon repair surgery also requires optimal rehabilitation. There are currently three custom-made splints used in the rehabilitation of zone I/II flexor tendon repairs, each with different assumed harm/benefit profiles: the dorsal forearm and hand-based splint (long), the Manchester short splint (short), and the relative motion flexion splint (mini). There is, however, no robust evidence as to which splint, if any, is most clinical or cost effective. The Flexor Injury Rehabilitation Splint Trial (FIRST) was designed to address this evidence gap. METHODS: FIRST is a parallel group, superiority, analyst-blind, multi-centre, individual participant-randomised controlled trial. Participants will be assigned 1:1:1 to receive either the long, short, or mini splint. We aim to recruit 429 participants undergoing rehabilitation following zone I/II flexor tendon repair surgery. Potential participants will initially be identified prior to surgery, in NHS hand clinics across the UK, and consented and randomised at their splint fitting appointment post-surgery. The primary outcome will be the mean post-randomisation score on the patient-reported wrist and hand evaluation measure (PRWHE), assessed at 6, 12, 26, and 52 weeks post randomisation. Secondary outcome measures include blinded grip strength and active range of movement (AROM) assessments, adverse events, adherence to the splinting protocol (measured via temperature sensors inserted into the splints), quality of life assessment, and further patient-reported outcomes. An economic evaluation will assess the cost-effectiveness of each splint, and a qualitative sub-study will evaluate participants' preferences for, and experiences of wearing, the splints. Furthermore, a mediation analysis will determine the relationship between patient preferences, splint adherence, and splint effectiveness. DISCUSSION: FIRST will compare the three splints with respect to clinical efficacy, complications, quality of life and cost-effectiveness. FIRST is a pragmatic trial which will recruit from 26 NHS sites to allow findings to be generalisable to current clinical practice in the UK. It will also provide significant insights into patient experiences of splint wear and how adherence to splinting may impact outcomes. TRIAL REGISTRATION: ISRCTN: 10236011.

Flexor Tendon Rupture Secondary to Gout.

Extra-articular deposition of monosodium urate crystals is a widely recognized manifestation of gout. However, gouty infiltration of flexor tendons in the hand resulting in tendon rupture is exceedingly rare. This case report highlights a patient with gouty infiltration of flexor tendons in the right middle finger resulting in rupture of both the flexor digitorum profundus and flexor digitorum superficialis. Given the extent of gouty infiltration and need for pulley reconstruction, the patient was treated with two-stage flexor tendon reconstruction. Febuxostat was prescribed preoperatively to limit further deposition of monosodium urate crystals and continued postoperatively to maximize the potential for long-lasting results. Prednisone was prescribed between the first- and second-stage operations to prevent a gout flare while the silicone rod was in place. In summary, tendon rupture secondary to gouty infiltration is the most likely diagnosis in patients with a history of gout presenting with tendon insufficiency.

Validation of the Efficacy of Ultrasound Speckle Tracking in Measuring Tendon Gliding After Finger Flexor Tendon Repair.

OBJECTIVE: Restricted tendon gliding is commonly observed in patients after finger flexor tendon (FFT) repair. The study described here was aimed at quantifying the amount of FFT gliding to evaluate the recovery of post-operative tendons using a 2-D radiofrequency (RF)-based ultrasound speckle tracking algorithm (UST). METHODS: Ex vivo uniaxial tensile testing of porcine flexor tendons and in vivo isometric testing of human FFT were implemented to verify the efficacy of UST beforehand. The verified UST was then applied to the patients after FFT repair to compare tendon gliding between affected and healthy sides and to investigate its correlation with the joint range of motion (ROM). RESULTS: Excellent validity was confirmed with the average R2 value of 0.98, mean absolute error of 0.15 ± 0.08 mm and mean absolute percentage error of 5.19 ± 2.43% between results from UST and ex vivo testing. The test-retest reliability was verified with good agreement of ICC (0.90). The affected side exhibited less gliding (p = 0.001) and smaller active ROM (p = 0.002) than the healthy side. Meanwhile, a significant correlation between tendon gliding and passive ROM was found only on the healthy side (ρ = 0.711, p = 0.009). CONCLUSION: The present study provides a promising protocol to evaluate post-operative tendon recovery by quantifying the amount of FFT gliding with a validated UST. FFT gliding in patients with different levels of ROM restriction should be further explored for categorizing the severity of tendon adhesion.

An isolated rupture of the flexor digitorum tendon of the index finger following volar locking plate fixation of a distal radius fracture: A case report.

Volar locking plates (VLP) have been widely used recently to treat distal radius fractures and are considered the gold standard. One of the most common complications of distal radius fracture surgery is flexor pollicis longus rupture, which may also occur in other tendons. Here, we report a case of isolated rupture of the flexor digitorum profundus to the index finger after VLP fixation of a distal radial fracture. Only a few cases of this have been reported in the literature. In previously reported cases, the cause of tendon rupture was repetitive mechanical stress due to implant protrusion. In our case, the plate was placed too distally; however, soft tissue completely covered the distal part of the plate. There was obvious synovitis within the carpal tunnel; therefore, pressure within the carpal tunnel may have increased. The cause of rupture in our case was thought to be a combination of direct mechanical stress and poor circulation due to inadequate VLP fixation.

Closed Traumatic Zone 2 Flexor Tendon Injury of the Long Finger - A Case Report.

Closed rupture of the flexor digitorum profundus (FDP) tendon causes loss of flexion at the distal interphalangeal joint. Following trauma, these are known to present as avulsion fractures (Jersey finger) commonly in ring fingers. Traumatic tendon ruptures at the other flexor zones are seldom noted and are often missed. In this report, we present a rare case of closed traumatic tendon rupture of the long finger FDP at zone 2. Though it was missed initially, was confirmed with Magnetic Resonance Imaging and underwent successful reconstruction using an ipsilateral palmaris longus graft. Level of Evidence: Level V (Therapeutic).

The Outcomes of Flexor Tendon Injury Repair of the Hand: A Clinico-Epidemiological Study.

Background and objective The incidence of flexor tendon injury is estimated to be 7-14 per 100,000 population. In India, such injuries are common and about 5% of these injuries require repair of the flexor tendon. In the present study, we share our experience of hand flexor tendon repair at a tertiary care center in western India. Material and methods Over a period of three years, 45 patients were admitted for tendon repair. After performing a proper evaluation, patients were taken for tendon repair. Primary outcome and secondary outcome parameters were assessed at the end of three months. Physiotherapy was continued for a longer duration in patients with movement restrictions. Data were compiled at each stage. Results The mean age of the patients was 28.84 years (range: 13-68 years) with a majority of the cases belonging to the age group 15-60 years. The majority of hand injuries were accidental (caused by work-related accidents, machine injuries, or animal bites) amounting to 80% (n=36), followed by assault cases (11%, n=5) and self-inflicted injuries, i.e., attempted suicides (around 9%, n=4). Among all injuries, the majority were in zone V (60%, n=27) followed by 24.4% (n=11) of cases in zone II. A few cases were in zone I, III, and IV (2.2%, 11.2%, and 2.2% respectively). The Buck-Gramcko scoring for primary injury was excellent with a recovery rate of 57.78%. Conclusion Flexor tendon injuries should be repaired with the aim of recovering strength as well as mobility. For optimal outcomes, total active motion protocol should be commenced immediately after the surgical repair. However, long-term physiotherapy may be required for attaining desired benefits.

Flexor Tendon Attritional Ruptures Following Distal Radius Volar Plate Fixation.

PURPOSE: To investigate patient and radiographic factors that may correlate with the time to flexor tendon rupture following volar plate fixation of distal radius fractures. METHODS: A total of 31 patients who underwent volar plate removal because of flexor tendon rupture were analyzed. Patient demographics and the interval from operative fixation until rupture were determined retrospectively. Volar tilt and lateral carpal alignment were measured radiographically. The Soong classification was used to grade volar plate prominence. The correlation between the duration to tendon rupture and volar tilt, carpal alignment, and age was evaluated. RESULTS: There were 7 men and 24 women. Mean age at the time of hardware removal and flexor tendon management was 66 years (n = 31). Radiographs were classified as Soong 1 (n = 24) and Soong 2 (n = 3). The mean measured volar tilt was -4° (range, -20°-+7°). The mean interval from operative fixation until complete tendon rupture was 4.9 years, (range, 0.3-13.1 years; n = 30). There was no correlation between the time interval to rupture and the magnitude of tilt, carpal alignment, or age at the time of operative fixation. CONCLUSIONS: Although volar plate prominence was present in all patients with flexor tendon ruptures, radiographic parameters including the degree of dorsal tilt, lateral carpal alignment, and patient age did not correlate with the time interval from fixation to tendon rupture. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Comparison of Clinical Outcomes of Endoscope-Assisted Technique and Conventional Surgery in Zone 2 Flexor Tendon Repair.

PURPOSE: The purpose of the study was to compare clinical outcomes between patients who underwent endoscope-assisted flexor tendon repair and those who underwent conventional surgery. METHODS: Patients were divided into 2 groups. Group 1 (endoscope-assisted surgery) included 21 patients (27 fingers) and group 2 (conventional surgery) included 19 patients (25 fingers). Outcomes assessed included the mean total active motion, Strickland classification, prevalence of rerupture, tenolysis requirement, and infection rate. RESULTS: The mean total active motion was 152.3° in group 1 and 134.7° in group 2, which was significantly higher in group 1 compared to group 2. An excellent or good outcome was achieved in 25 (92.5%) of the fingers in group 1 as opposed to 17 (68%) fingers in group 2. CONCLUSIONS: We conclude that endoscope-assisted surgery is an alternative method for tendon surgery, enables a minimally invasive approach, and provides a favorable range of motion. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Revision of Flexor Tendon Repair: Factors Associated With Flexor Tenolysis.

BACKGROUND: Tenolysis restores mobility to the flexor tendon through the lysis of adhesions that inhibit and negatively impact functional outcomes following flexor tendon repair. Despite extensive literature on operative techniques and therapy protocols used to minimize adhesion formation, there are limited data examining the association of patient, injury, and postoperative factors with tenolysis. This study aims to: (1) quantify tenolysis rates following flexor tendon repair or reconstruction; and (2) identify patient demographic factors, medical comorbidities, injury characteristics, postoperative diagnoses, and complications associated with tenolysis. METHODS: PearlDiver was used to identify patients who underwent a flexor tendon repair or reconstruction from 2010 to 2020. Patients were stratified by whether or not flexor tenolysis was performed. Patient demographics, comorbidities, injury characteristics, postoperative diagnoses, and complications were recorded. Logistic regression analysis was used to identify independent risk factors associated with tenolysis. RESULTS: Database review identified 10 264 patients who underwent either flexor tendon repair or reconstruction, with 612 patients (6.0%) subsequently undergoing tenolysis. Logistic regression analysis determined that vascular injury preceding flexor tendon repair, surgical wound disruption, nerve injury diagnosed postoperatively, postoperative tendon rupture, and need for repeat flexor tendon repair were associated with an increased odds of tenolysis. Patient age, sex, and comorbidities were not associated with performance of tenolysis. CONCLUSIONS: Although tenolysis rates may differ according to physician and patient preferences, identification of factors associated with tenolysis following flexor tendon repair allows surgeons to risk-stratify patients prior to surgery and help guide postoperative expectations if complications arise.

Incidence of Flexor Tendon Injuries in Complex Intra-Articular Distal Radius Fractures Fixed With Volar Rim Plate Osteosynthesis.

AIM: The volar rim plate is anatomically contoured to provide buttressing of distal radius fragments including the lunate fossa. The low-profile design of the plate minimizes flexor tendon irritation. This study aims to determine the Disabilities of the Arm, Shoulder, and Hand (DASH) score and the presence of flexor tendon irritation at around one-year post operation. METHOD: Between June 2020 and May 2021, all patients with AO-23B3 and AO-23C (1-3) distal radius fractures who were treated with a volar rim plate fixation were included in this study. At 12 months after surgery, the patients were evaluated utilizing DASH score as a routine as well as evidence of flexor tendon rupture or irritation. RESULTS: Twenty-five patients were finally included in this study. Of these, three required additional dorsal plating for dorsal subluxation, four required fixation of ulna styloid with tension band wiring, and the rest (18) had volar rim plate fixation in isolation. The mean DASH score was 16.3. Two of the patients had flexor tendon irritations; one in the middle finger and another in the ring and little finger. None had flexor tendon rupture. CONCLUSION: The volar rim plate is designed to tackle complex intra-articular distal fractures which are near the watershed line. There was no evidence of flexor tendon irritation on routine follow-up. The outcome was satisfactory in this small series despite the complexity of the fractures. Evidence of flexor tendon irritation requires prompt attention to enable early implant removal.

Comparison of Modified Kessler and McLarney Techniques in Zone II Flexor Tendon Repair.

Introduction Hand injuries are common in the routine practice of any upper limb surgeon. The laceration of the flexor tendons can engage the functional prognosis of the hand. Hence, there exist a multitude pf suturing techniques whose goal is to have a solid repair, allowing an early rehabilitation. Our study aims at comparing the functional results after flexor tendon repairs in zone II using two different techniques, modified Kessler technique and McLarney technique. Methods Our study included 42 patients, divided into two groups, one having benefited from the modified Kessler technique and the other from the McLarney technique. The modified Strickland classification was used to compare the functional results at six months after surgery of the two techniques. Results Our study showed a better post-operative functional outcome with a lower risk of post-operative rupture in patients operated with the McLarney four-strand technique compared to patients operated with the modified Kessler two-strand technique. Conclusion Hand wounds in zone II remain a therapeutic challenge for any orthopedic surgeon due to the multiplicity of factors involved in the prognosis, in particular the type of suture. The suture with more than two strands has proven its effectiveness and its reproducibility, making it possible to find the balance sought by the surgeon, namely a suture that is not cumbersome, easy and quick to perform, and strong enough to start early rehabilitation.

Spontaneous Midsubstance Rupture of the Flexor Digitorum Profundus Tendon of the Long Finger.

Closed flexor tendon injuries can often result from trauma that causes sudden forceful extension of an actively flexed digit. These closed tendon injuries commonly occur as avulsions in flexor zone I. Spontaneous midsubstance flexor tendon ruptures are rare, especially in the absence of an underlying pathology. Diagnosing such injuries accurately is challenging and critical. We present a case of a zone III spontaneous flexor tendon rupture of the long finger after forceful eccentric loading. Surgical exploration was performed, and the level of the rupture was identified during surgery. A side-to-side tendon repair technique was performed using a palmaris longus tendon graft. No underlying pathology to explain the rupture was found in this case. This report emphasizes the importance of considering spontaneous midsubstance ruptures, identifying the level of ruptures, and preoperative planning for such cases. It reviews the possible causes and treatment of spontaneous flexor tendon rupture.

Purulent Flexor Tendon Rupture of the Hand due to Mycobacterium abscessus Infection: A Case Report and Review of the Literature.

Mycobacterium abscessus infection of the upper extremities is uncommon. However, M abscessus can cause severe chronic tenosynovitis, and delayed diagnosis may result in poor outcomes. We describe an unusual clinical case of purulent flexor tendon synovitis followed by subcutaneous tendon rupture due to M abscessus infection in a patient with diabetes mellitus. A 76-year-old man presented to our hospital with painful, erythematous swelling over his left fourth finger. On physical examination, the left fourth finger was swollen and reddish, with persistent exudate from the surgical scar. The left elbow was also swollen and reddish with persistent discharge, which was consistent with olecranon bursitis. The patient was unable to flex his left fourth finger, and the passive range of motion of the finger was also restricted. The physical examination findings and patient history suggested purulent flexor tendinitis. His infection healed after radical debridement of necrotic tissue and administration of antibiotics effective against M abscessus. Third-stage flexor reconstruction restored the function of the fourth finger. The combination of surgical debridement and chemotherapy was the most effective treatment for mycobacterial tenosynovitis. This case shows that M abscessus can cause chronic severe purulent tenosynovitis and flexor tendon rupture after tendon surgery. Although early diagnosis and combination treatment with debridement and chemotherapy might improve outcomes by limiting the severity and duration of damage to the flexor synovial system, late-presenting patients require combined radical debridement of necrotic tissue and aggressive chemotherapy followed by staged flexor tendon reconstruction.

Flexor tendon rupture after volar plating of distal radius fracture: A systematic review of the literature.

Flexor tendon rupture after volar plate fixation of distal radius fracture (DRF) is rare. There is no consensus as to how to prevent them. The aim of our study was to identify the pathological mechanisms, and to establish the clinical and epidemiological profile of patients suffering from this complication. We carried out a systematic review using the PubMed, Scopus and Cochrane databases. Studies were included if they described complete or partial flexor tendon rupture following volar plate fixation of DRF. Forty-six 46 were included, for a total of 145 patients were reported: 138 from the literature, and 7 from our personal experience. Etiology was usually mechanical, by impingement with either the plate or protruding screws. Plate impingement was due to positioning beyond the watershed line, consolidation with posterior tilt, plate thickness, or low palmar cortical angle. Mean patient age was 62.4 years (range, 23-89 years). Median postoperative interval was 8 months (range, 3-120 months). Flexor pollicis longus was the most frequently injured tendon. The plate should be positioned proximally to the watershed line if possible, to ensure good initial reduction. Hardware should be removed 4 months after surgery if the plate is causing impingement according to the Soong criteria or if signs of tenosynovitis appear.

Proximal row carpectomy combined with primary flexor pollicis longus tenorrhaphy: An effective treatment alternative for a rare case of flexor pollicis longus rupture due to scaphoid nonunion advanced collapse.

This study describes a case of flexor pollicis longus rupture resulting from long-term scaphoid nonunion advanced collapse. The tendon rupture mechanism was attrition due to sharp bone protuberances from the scaphoid in the carpal tunnel. Although this extremely rare complication has already been reported in the literature, our study is original in showing that proximal row carpectomy with consequent wrist shortening allowed primary tendon repair without transferring the flexor digitorum superficialis tendon of the ring finger or grafting the palmaris longus tendon, which besides using two-level suturing, interposes a non-vascularized tissue.

The sole rupture of flexor digitorum tendons to the index finger following volar locking plate fixation of distal radius fracture: A case report.

Distal radius fracture is a common injury, especially in elderly people, and internal fixation with volar locking plate (VLP) is becoming an increasingly popular technique for the management of displaced and/or unstable distal radius fractures. One of the most common complications of this treatment is the flexor tendon rupture, mostly of the flexor pollicis longus (FPL). While the rupture of flexor digitorum tendons to the index (FDI) mostly occurs concomitantly with the rupture of FPL after the treatment using volar plating for distal radial fracture, sole rupture of the FDI without FPL rupture is very rare. Here, we report a case of the sole rupture of FDI after volar locking plating and analyze its pathogenesis indicating that the lift-up of the distal ulnar edge of the plate related to the malcorrection of the fracture site is the culprit for this specific complication.

Changes in the Rate of Postoperative Flexor Tendon Rupture in Patients with Distal Radius Fractures.

Background: Flexor tendon rupture is a major complication after volar locking plating for distal radius fracture (DRF). Few studies have investigated changes in the rate of postoperative flexor tendon rupture in patients with DRFs. The present study aimed to investigate the changes in the rate of postoperative flexor tendon rupture and to assess plate placement and reduction positions. Methods: We retrospectively reviewed patients in whom more than 24 months had passed since DRF surgery. The patients were interviewed by telephone. Forty-nine patients (50 fractures; 2007-2009) from institution A were included in group 1 and 81 patients (84 fractures; 2013-2016) from institution B were included in group 2. The DRF surgery method was similar between the two groups. The rate of flexor tendon rupture, Soong classification grade, and radiological index (i.e., volar tilt [VT], radial inclination [RI], and ulnar variance [UV]) were statistically investigated in both groups. Results: Patient epidemiology was not significantly different between the two groups. The flexor tendon rupture rates were 2% and 0% in groups 1 and 2, respectively, without a significant difference. With regard to the Soong grade, 44 fractures were grade 2 and 6 were grade 1 in group 1, whereas 18 were grade 2, 38 were grade 1, and 28 were grade 0 in group 2, with a significant difference (p < 0.05). With regard to the radiological index, the mean VT values were 5° and 11° in groups 1 and 2, respectively, with a significant difference (p < 0.05). However, RI and UV showed no significant difference. Conclusions: Plate placement and reduction positions, which are risk factors for flexor tendon ruptures after DRFs, have improved recently when compared with previous findings. With these changes, the rate of flexor tendon rupture is presumed to have decreased.

Delayed rupture of the flexor tendons as a complication of malunited distal radius fracture after nonoperative management: A report of two cases.

Rupture of the flexor tendons is a rare complication following distal radius malunion after nonoperative management. This article presents 2 cases of delayed flexor tendon ruptures following malunited distal radius fracture and discusses the characteristics, operative management, and outcomes of this rare complication by reviewing the previous literature. Our analysis demonstrate that surgical reconstruction of ruptured tendons provides good outcomes when the number of tendon ruptures is small. If multiple tendon ruptures are present, surgical outcomes may be poor despite surgical reconstruction. Osseous surgery would be necessary to prevent additional tendon ruptures; however, less invasive and simple surgeries arrowing early rehabilitation would be preferable.

Sliding Position of the Flexor Tendons Relative to the Hook of Hamate in CT Scans.

BACKGROUND: The aim of this study was to assess the height of nonunion formation injuring the ulnar-side finger flexor tendon, the positional relationship between the hook of the hamate and little finger flexor tendon was evaluated on CT scans. METHODS: The subjects were 20 healthy patients (40 hands) (14 males and 6 females, mean age: 28 years old). Their hands were imaged in extension and flexion of the fingers on CT. The position of the little finger flexor tendon was determined regarding the height of the hook of the hamate as 100%. RESULTS: The heights of the flexor digitorum profundus tendons were 46 ± 6% in extension and 44 ± 9% in flexion, and those of the flexor digitorum superficialis tendons were 87 ± 8% in extension and 91 ± 9% in flexion. CONCLUSIONS: Our study suggested that 40% of the base of the hook of the hamate does not contact with the flexor tendon, suggesting that flexor tendon injury is unlikely to occur in that region.

Five-decade-delayed closed flexor tendon rupture due to Galeazzi dislocation fracture associated with Behçet syndrome: A case report.

INTRODUCTION: Closed flexor tendon rupture after a malunited distal radius fracture is rare and usually becomes apparent early after the fracture. Most cases are accompanied by a severe distal radio-ulnar joint capsule injury, wherein bone protrusion (as a spur) directly stresses the tendons. We experienced a nonspecific flexor tendon rupture associated with an old fracture and the presence of collagen disease. PRESENTATION OF CASE: A 63-year-old woman presented with delayed complete rupture of the flexor digitorum profundus (FDP) of the fifth digit. Her history included closed fracture on the left wrist at age 13 years. At 27 years, she was diagnosed with Behçet syndrome and commenced oral prednisolone 10 mg/day. At the current admission, physical examination revealed that she was incapable of fifth finger flexion after minor passive extension. The fifth digit FDP rupture appeared to be due to damage at the wrist-level fracture site. A tiny capsule rupture was seen on the volar side of the distal radio-ulnar joint. We resected ulnar head osteophytes protruding from the capsule hole and transferred tendon from the fifth FDP to the fourth FDP. CONCLUSION: Reportedly, metalloproteases weaken tendon structure by acting as a collagenase in patients with Behçet syndrome. Also, vasculitis next to a tendon and steroid intake are considered to impede the tendon repair process. Hence, even minor trauma may lead to complete tendon rupture. Although an injury seems slight, we should take into account the possible history of bone and joint trauma.