Tendon injuries are often associated with hand or wrist lacerations. Accurate assessment requires documentation of both motor function and strength. Partial tendon ruptures, including near complete, may still result in normal function.
Management and Disposition
Prior to wound exploration, a thorough exam is performed to assess neurovascular and motor function. All individual flexor and extensor tendons are assessed, including deep and superficial. Abnormal resting posture of the involved extremity can also indicate tendon injury. Tendons are taken through a full range of motion, including re-creation of limb position at the time of insult, to detect injuries along the tendon length. Adequate exploration requires excellent hemostasis achieved through direct pressure or use of a blood pressure cuff or other tourniquet. Initial wound care should include irrigation, exploration for foreign bodies, debridement, antibiotics, and tetanus prophylaxis if indicated.
Partial tendon lacerations are treated conservatively, with splinting in neutral position and follow-up. Isolated extensor tendon lacerations may be repaired in the ED with subsequent specialist follow-up. Flexor tendon lacerations generally require consultation with a hand surgeon or orthopedic surgeon.
While extensor tendon repair may be accomplished by an emergency care physician with appropriate training and experience, flexor tendon lacerations are a challenging orthopedic problem and require referral.
Flexor tendons are weakest approximately 3 weeks after repair.
Inability to flex the distal phalanx with intact proximal phalanx extension suggests a flexor digitorum profundus disruption.
Flexor Tendon Laceration. This patient presented after sustaining a laceration to his third and fourth digits (A). The injury was associated with an inability to flex these two digits. Wound exploration revealed the distal segment of the transected flexor tendon apparatus (B). (Photo contributor: Matthew D. Sztajnkrycer, MD, PhD.)
Video 18-01: Flexor Digitorum Profundus Injury Examination
Extensor Tendon Lacerations. Note the laceration over the third and fourth metacarpals (A). Inability to extend the long fingers is evidence of complete extensor tendon disruption. Another extensor tendon laceration associated with inability to extend the fifth digit. (B). (Photo contributors: Selim Suner, MD, MS [A]; David Effron, MD [B].)
Flexor Tendon Laceration. Wrist laceration and associated complete tendon rupture. (Photo contributor: David Effron, MD.)