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The Emergency Physician commonly encounters lacerations or trauma to the hand. In examining these patients, one must examine the hand and explore the wound for extensor tendon lacerations. The extensor mechanism of the hand and forearm is typically disrupted in association with penetrating trauma. Blunt trauma, such as sudden forced flexion, can also result in injury to the extensor tendons. Performing extensor tendon repair is an important skill in the Emergency Physician’s surgical armamentarium.

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Although it is important that any deficit in the extensor tendon mechanism be identified at the initial examination, the timing of tendon repair is not a critical aspect of its management. Successful repair of extensor tendons can be accomplished either acutely or within a 7 day window following injury.1 One should also be aware that at some anatomic sites, splint immobilization of the damaged tendon can produce the same optimal outcome as surgical reapproximation. This is most evident in conservative management of a mallet finger injury.

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Repair of an extensor tendon in the Emergency Department requires that the physician be familiar with the anatomy of the region and skilled in the surgical technique. Although complications of tendon repair are more frequently associated with flexor tendons, follow-up studies of extensor tendon repairs reveal similar pitfalls and problems.2 Adhesion, loss of length, and diminished flexion can all complicate the repair of an extensor tendon.3

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The anatomy of the extensor mechanism is such that following a laceration or partial disruption, the tendons seldom retract far from the site of injury.4 This is mostly due to the tethering of tendons by multiple interconnections as the tendons cross the dorsum of the hand. Additionally, the tendons over the dorsum of the hand are ensheathed in a paratenon layer of tissue. This covering is extrasynovial, thus exposing the tendons but containing them in a layer that prevents their wide separation. The physician can proceed safely with the surgical repair if both ends of a lacerated extensor tendon are identified.

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The surgical technique for repairing extensor tendons originates in studies of flexor tendon repairs. The goal of the repair is to restore tendon continuity and function while minimizing interference from the repair itself. The suture techniques of Kessler and Bunnell are two of the methods traditionally used in this repair. Modifications of these original methods have resulted in the greatest outcome measurements of tendon strength.5 Facility with these two suture techniques is essential in repairing any extensor tendon in the Emergency Department.

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The extensor tendon mechanism is an intricate system of pulleys and levers coursing along the dorsum of the forearm, wrist, and hand.6,7 The function of these tendons is to extend the fingers and wrist from a flexed position. This function is complemented in the fingers by the actions of the intrinsic muscle groups (lumbricals and interossei).

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The elegant anatomy of the hand ...

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