1. Introduction

2. Surgical Approach

a. Reinforce Repair with Figure-of-Eight Sutures

3. Extensor Tendon Repair with Modified Kessler Technique

4. Assessment of Repair

5. Closure

6. Thumb's Up / Reverse Thumb Spica Splint and Post-op Remarks

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.

<h4>CHAPTER 1</h4>

<p>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.</p>

<h4>CHAPTER 2</h4>

<p>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.</p>

<h4>CHAPTER 3</h4>

<p>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.</p>

<p>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.</p>

<h4>CHAPTER 4</h4>

<p>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.</p>

<h4>CHAPTER 5</h4>

<p>Once satisfied, the wound is washed and closed.
In this case, the wound is being closed
with simple 4-0 chromic sutures.</p>

<h4>CHAPTER 6</h4>

<p>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.</p>


Watch this narrated surgical video of a thumb extensor tendon laceration repair performed by Dr. Asif Ilyas at the Rothman Institute.

DOI
Publication Date	2023/08/17
Article ID	334
Production ID	0334
Volume	2023
Issue	334
https://doi.org/10.24296/jomi/334

Thumb Extensor Tendon Laceration Repair

Procedure Outline

Table of Contents