Table of Contents
This case consists of repairing an extensor tendon laceration of a thumb. Extensor tendon lacerations are one of the most common soft tissue injuries of the hand. Surgical repair of the tendon was offered, and the operation was performed using wide-awake local anesthesia no tourniquet (WALANT) technique. Intraoperatively, a complete laceration of the extensor tendon was confirmed repaired using a modified Kessler technique and reinforced with an epitendinous repair. Before closure, the patient tested competency of the repair with confirmation of restoration with the active extension to ensure proper function. The patient was placed in a reverse thumb spica splint following wound closure. Postoperatively, the patient was immobilized in full thumb extension for approximately two weeks and then converted to a removable splint and prescribed supervised hand therapy for a total recovery of 8–12 weeks.
Extensor tendon; laceration; tendon repair; walant.
Extensor tendon lacerations are relatively common injuries to the hand. In the United States, they are estimated to cause over 25% of all soft tissue injuries.4 Without intervention, these injuries can lead to impairment of hand function.2 Patients are often men with laboring occupations.3 The dominant hand of patients is more commonly injured, with the thumb being the most likely digit, followed by the index and middle fingers, while the small finger is the least affected.2, 19
Anatomically, extensor tendons are divided into six compartments at the wrist level, typically numbered from radial to ulnar as follows.3 The memo code is: 2 2 1 5 1 1.
- Compartment 1 has two tendons: the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons.
- Compartment 2 has two tendons: the extensor carpi radialis longus (ECRL) and extensor carpi radialis brevis (ECRB) tendons.
- Compartment 3 has one tendon: the extensor pollicis longus (EPL) tendon.
- Compartment 4 has five tendons: four tendons of the extensor digitorum communis (EDC) and one tendon of extensor indicis proprius (EIP).
- Compartment 5 has one tendon: the extensor digiti minimi (EDM) tendon.
- Compartment 6 has one tendon: the extensor carpi ulnaris (ECU) tendon.
- Fibro-osseous sheaths separate these compartments with the extensor retinaculum over the top of the compartments to prevent bowstringing of the tendons.
Kleinert and Verdan's system classifies the extensor tendons into eight zones.7 The odd zones cover the joints, and the even zones are between the joints. The tendon excursion and thickness increase from distal to proximal, requiring stronger repair. Moreover, more distal tendon injury results in inferior outcomes than more proximal injuries. Zone I refers to the area over the DIP joint leading to mallet finger deformity; zone II encompasses the middle phalanx; zone III refers to the site over the PIP joint leading to boutonniere deformity; zone IV is over the proximal phalanx; zone V refers to the site over the MP joint and is mainly injured with clenched fist bite; zone VI encompasses the metacarpal; zone VII is over the wrist joint; and zone VIII involves the extensor tendons between the musculotendinous junction and the wrist joint.7
The patient presented in this case incurred a complete zone IV extensor tendon laceration over the dorsal thumb with inability to actively extend the thumb, which necessitated exploration and surgical repair. The injury occurred within one week before surgery.
Any open wound to the dorsal hand should prompt evaluation for an extensor tendon injury. The laceration site over the dorsum of the hand with altered cascade of the resting posture of the hand as well as inability to actively extend a joint distal to a laceration indicates potential damage to an extensor tendon. It is also essential to perform an exam against resistance as partial lacerations can still extend without resistance but are painful or weak with resistance. These tendons are commonly examined by having the patient place their hand flat on a surface and being told to extend each digit.2 Occasionally, full extension of a finger can still occur even with an extensor tendon laceration as some joints have multiple extensors (as seen with the EDM and EIP). Additionally, if the laceration is proximal to the junctura tendinea, which are interconnections of the extensor tendons in zone VI, the patient may still be able to extend the finger even if the extensor tendon proximally is lacerated.
Radiographs can be taken to identify potential fractures or foreign bodies.5 Advanced imaging is generally not required. In equivocal cases where the diagnosis is uncertain, then advanced imaging with an ultrasound or MRI can be considered.
From a surgical perspective, Miller’s criteria are typically used to evaluate the extent of injuries. These criteria state that surgery is indicated if:4
- More than 25% of the tendon has been cut
- The patient is unable to extend the digit.
- There is associated contamination requiring a formal washout and debridement.
- The joint is unstable.
- The patient can comply with the postoperative protocol.
As discussed above, extensor tendon injuries are commonly grouped into eight zones, with each having a different recommendation for treatment. Type II mallet injury, an open laceration in zone I, requires surgical intervention, while closed mallet injuries can usually be treated nonoperatively.
Zone II injuries are often due to lacerations or crush injuries. Treatment options are based on the presence of extensor lag. Without extensor lag, splinting can be recommended; however, extensor lag is an indication for surgical intervention.2
Zone III injuries can lead to boutonniere deformities. The lateral bands can maintain active extension, so the deformity may not present until 10–14 days after the injury.8 Closed injuries can be treated with splinting. Surgery is recommended with open lacerations, displaced avulsion fractures of the central slip insertion, and failed non-operative management.2
Complete lacerations should be treated surgically in Zone IV followed by 4–6 weeks of volar splinting to allow passive extension.
Zone V injuries are unique in that they are typically open and are commonly seen as fist bite trauma. The primary treatment recommendations include irrigation and debridement (if a human bite). The tendon is repaired if the wound is clean; otherwise, the wound is left open for delayed repair.2
Stronger sutures are required in zone VI-VIII lacerations because of larger tendon diameter and greater excursion and tension. To avoid overstretching the repair, it is recommended to splint all fingers even if only one tendon is repaired.10 Results of surgical repair in these zones are generally better than the more distal zones. Repair is followed by immobilization of the wrist in 30 degrees of extension for 4–6 weeks, followed by another 4–6 weeks of therapy.
Thumb extensor injuries are common; however, due to the width of the MCP joint, complete lacerations of all components, including EPL and EPB, are rare.12 EPB repair does not have clear recommendations as an intact EPL can still extend the MCP joint. When the EPL is lacerated, surgical repair is indicated. Open injuries typically consist of primary repair followed by 4–6 weeks of splinting the thumb in extension, followed by another 4–6 weeks of therapy. A primary repair as described here can readily be performed within 2–4 weeks of the injury.
Tetanus prophylaxis and antibiotics should be considered based on the recommendations for tetanus and the cleanliness of the open wound. It is recommended to repair these injuries within two weeks to achieve better results.2
The procedure in our patient was done using wide-awake local anesthesia no tourniquet (WALANT) technique. This WALANT technique is safer and less expensive, but more importantly, allows us to test our repair while still in the operating room.
As with any lacerations, the following reconstructive principles should always be followed: restoring vascular supply, stabilizing the wound bed, and reestablishing skeletal stability.6 It is also vital to have early movement of the joints. This has been shown to decrease adhesions and contractures.13 Passive range of motion (ROM) in the splint is usually started early after surgery, active assisted exercise in the splint after two weeks, and active ROM out of the splint can be allowed after 4–6 weeks.13
Superior outcomes are expected in the more proximal zones. Time to repair is another determining factor for better results. When repair is done within five days of the injury, patients gain 98% of their original ROM, while repairs done after five days have a 90% chance of gaining full ROM.15 The distal zones are more prone to stiffness, adhesions, rerupture, or extensor lag.
Complications consist of tendon rerupture, decrease in ROM, adhesions, extension lag, loss of flexion, and finger deformities.2 Swan neck and boutonniere deformities might also occur in zone I-II and zone III injuries, respectively. Adhesions can be potentially reduced by early mobilization of the joints when possible.16
Children under six years of age usually heal more rapidly and regain full ROM even with prolonged immobilization. They also have lower complication rates than adult populations.1
We demonstrated a successful repair of a complete extensor tendon laceration in zone III of the thumb. The degree of injury can be challenging to determine preoperatively as some joints have multiple tendons working together to extend a digit. However, a thorough physical exam is essential. The time from injury to repair is important for better outcomes. However, tendon retraction is much less than that seen with flexor tendons allowing for delayed direct repair. Laceration over the thumb MCP can involve EPL, EPB, or both. Various extensor repair techniques include modified Kessler, modified Brunelli, four-strand cruciate, and mattress sutures. Our preferred repair consists of a core 4-0 suture using locked modified Kessler to avoid bunching the repair. It is then reinforced with 1–3 cross-stitch sutures (figure-of-eight) based on the surgeon’s preference. Care is taken to avoid capturing surrounding tissue with the repair, including: capsular tissue, periosteum, or subcutaneous tissue, to allow for optimal tendon excursion.
Extensor tendon repair surgery can be performed under any type of anesthesia, but repair using local anesthesia is recommended, often now referred to as WALANT technique. It allows the surgeon to test the repair, assess and adjust repair tension, confirm adequate tendon excursion, and observe joint motion intraoperatively. Moreover, the repair strength can be tested to communicate better with the physical therapist regarding the permitted ROM, and the patient can witness their repair to deliver confidence in their postoperative recovery and therapy. The WALANT technique continues to gain popularity because of its safety profile, decreased expense, and intraoperative advantages listed above.
Our patient had an uncomplicated repair and demonstrated full thumb extension and tendon excursion before wound closure. The patient was placed in a reverse thumb spica splint on the volar thumb to immobilize the IP, MCP, and CMC joints in extension and counteract active flexion.
Early mobilization is widely accepted after tendon repair to avoid adhesions; however, we tend to move slower with extensor tendons. The patient is placed in the reverse thumb spica splint for 2–4 weeks to avoid tension on the repair, followed by a removable splint and hand therapy for 6–8 weeks. Alternatively, dynamic splinting in MCP lacerations can be started after three days to allow MP joint flexion to about 30 degrees, keeping the wrist in 45 degrees of extension.20 About 3–5-mm extensor tendon glide by a controlled arc of motion limits adhesion formation. It is shown that 60 degrees of thumb IP motion creates a 5-mm tendon glide at Lister’s tubercle. Overall recovery may take 8–12 weeks, which should be discussed with patients to set goals and expectations.
Nothing to disclose.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
- Hart RG, Uehara DT, Wagner MJ. Emergency and Primary Care of the Hand. Irving, TX: American College of Emergency and debride Physicians; 2001. 175-88.
- Griffin M, Hindocha S, Jordan D, Saleh M, Khan W. Management of extensor tendon injuries. Open Orthop J. 2012;6:36-42. doi:10.2174/1874325001206010036.
- Amirtharajah M, Lattanza L. Open extensor tendon injuries. J Hand Surg Am. 2015 Feb;40(2):391-7; quiz 398. doi:10.1016/j.jhsa.2014.06.136.
- Dy CJ, Rosenblatt L, Lee SK. Current methods and biomechanics of extensor tendon repairs. Hand Clin. 2013 May;29(2):261-8. doi:10.1016/j.hcl.2013.02.008.
- Miranda BH, Spilsbury ZP, Rosala-Hallas A, Cerovac S. Hand trauma: a prospective observational study reporting diagnostic concordance in emergency hand trauma which supports centralised service improvements. J Plast Reconstr Aesthet Surg. 2016 Oct;69(10):1397-402. doi:10.1016/j.bjps.2016.06.030.
- Carty MJ, Blazar PE. Complex flexor and extensor tendon injuries. Hand Clin. 2013 May;29(2):283-93. doi:10.1016/j.hcl.2013.02.010.
- Kleinert HE, Verdan C. Report of the Committee on Tendon Injuries (International Federation of Societies for Surgery of the Hand). J Hand Surg Am. 1983 Sep;8(5 Pt 2):794-8. doi:10.1016/s0363-5023(83)80275-5.
- Hart RG, Uehara DT, Kutz JE. Extensor tendon injuries of the hand. Emerg Med Clin North Am.1993 Aug;11(3):637-49.
- Blair WF, Steyers CM. Extensor tendon injuries. Orthop Clin North Am. 1992 Jan;23(1):141-8.
- Thompson, J. S., & Peimer, C. A. (1998). Extensor Tendon Injuries: acute repair and late reconstruction. Operative Orthopaedics. Philadelphia: Lippincott.
- Newport ML, Blair WF, Steyers CM Jr. Long-term results of extensor tendon repair. J Hand Surg Am. 1990 Nov; 15(6):961-6. doi:10.1016/0363-5023(90)90024-l.
- Din KM, Meggitt BF. Mallet thumb. J Bone Joint Surg Br. 1983 Nov; 65(5):606-7. doi:10.1302/0301-620X.65B5.6643565.
- Newport ML, Tucker RL. New perspectives on extensor tendon repair and implications for rehabilitation. J Hand Ther. 2005 Apr-Jun;18(2):175-81. doi:10.1197/j.jht.2005.01.006.
- Bulstrode NW, Burr N, Pratt AL, Grobbelaar AO. Extensor tendon rehabilitation a prospective trial comparing three rehabilitation regimes. J Hand Surg Br. 2005 May; 30(2):175-9. doi:10.1016/j.jhsb.2004.10.016.
- Merritt WH. Relative motion splint: active motion after extensor tendon injury and repair. J Hand Surg Am. 2014 Jun;39(6):1187-94. doi:10.1016/j.jhsa.2014.03.015.
- Neuhaus V, Wong G, Russo KE, Mudgal CS. Dynamic splinting with early motion following zone IV/V and TI to TIII extensor tendon repairs. J Hand Surg Am. 2012 May;37(5):933-7. doi:10.1016/j.jhsa.2012.01.039.
- Shaikh, SA, Bawa A, Shahzad N, Yasmeen S, Beg MSA. Comparison of modified Kessler technique versus four strand cruciate technique for repair of long flexor tendons of fingers: a randomized controlled trial. Surg Med Open Access J. 2018;1:1-4. doi:10.31031/SMOAJ.2018.01.000518.
- Wongsiri S, Liawrungrueang W. Biomechanical study of a newly developed continuous double knots technique compared with the 4-strand double-modified Kessler technique for flexor tendon repair. J Exp Orthop. 2021 Sep 24;8(1):79. doi:10.1186/s40634-021-00404-4.
- Patillo D, Rayan GM. Open extensor tendon injuries: an epidemiologic study. Hand Surg. 2012;17(1):37-42. doi:10.1142/S0218810412500062.
- Evans RB, Burkhalter WE. A study of the dynamic anatomy of extensor tendons and implications for treatment. J Hand Surg Am. 1986 Sep;11(5):774-9. doi:10.1016/s0363-5023(86)80039-9. Erratum in: J Hand Surg [Am]. 1086 Nov;11(6):914.
Cite this article
Bloom E, Kachooei AR, Ilyas AM. Thumb extensor tendon laceration repair. J Med Insight. 2023;2023(334). doi:10.24296/jomi/334.
Table of Contents
- Reinforce Repair with Figure-of-Eight Sutures
This is a case of a laceration of the thumb dorsally presenting with a likely extensor tendon laceration requiring surgical exploration and repair. The surgery will be performed under a local anesthesia in a wide awake hand surgery fashion without the use of tourniquet. The surgical site will be infiltrated with lidocaine with epinephrine, buffered with bicarbonate. The initial injection will consist of 9 cc of 1% lidocaine with epinephrine and 1 cc of 4.2% bicarbonate. This can be readily diluted down as needed in order to anesthetize the surgical field for surgical intervention. This WALANT technique is not only safer and cheaper and more convenient for the patient, but also allows us as a surgeon to be able to test our repair to make sure the repair is adequate and sound.
With the patient awake in the operating room, the surgical site infiltrated, the laceration is opened and blunt dissection down to the level of injury confirms a complete extensor tendon laceration.
Like the flexor tendons, A number of suture repair techniques are available for extensor tendons. In this case, a modified Kessler repair will be reinforced with figure-of-eight sutures. Here you can see the tendon edges exposed. The proximal Kessler suture has already been placed, and now the distal Kessler is being placed. A modified Kessler stitch can be performed with a single suture or with two sutures as being demonstrated here. Care is taken while placing the suture, not to catch any deep structures such as the periosteum and/or the joint capsule, so there's good excursion of the tendon upon repair. With both ends tagged with a modified Kessler suture, both tendon edges are stressed, first to make sure that there's good excursion and mobilization of the tendon, as well as to make sure that there is a good bite of our sutures within the tendon on both ends. Next, both pairs of suture ends are then sewed down in a sequential manner as demonstrated here until satisfactory contact between the tendon edges are confirmed. Once the two core sutures and knots have been placed, the tendon repair is now reinforced with additional figure-of-eight sutures.
Here, a total three figure-of-eights are placed around the core suture repair. Of note, the repair is being performed with 3-0 Ethibond.
This is the appearance of the final tendon repair construct. Finally, and most importantly, the integrity of the repair is tested by having the patient actively extend the finger or thumb in this case to confirm maintenance of integrity of the repair and full tendon excursion and extension.
Once satisfied, the wound is washed and closed. In this case, the wound is being closed with simple 4-0 chromic sutures.
With the wound closed and the repair being protected by an assistant, the dressing is applied. A splint is also applied. In this case, I apply what I refer to as a "thumb's up" splint, or also known as a reverse thumb spica splint. The postoperative course consists of early immobilization. Unlike flexor tendons, which we move quickly, extension tendons, we can move slower. In this case, I'll immobilize the patient for approximately two to four weeks in this thumb's up splint with the repair site immobilized without tension. Thereafter the splint is applied, A removable splint is prescribed, and formal therapy with a hand therapist is also prescribed for the next six to eight weeks. Total recovery time is typically, for these injuries and repairs, about 8-12 weeks. Here you can see application of the thumb's up splint, or the reverse thumb spica splint, which captures the volar pulp of the thumb, maintaining it in full extension, and countering active thumb IP flexion. Thank you.