Thumb Extensor Tendon Laceration Repair

CHAPTER 1

This is a case of a lacerationof the thumb dorsally presentingwith a likely extensor tendon lacerationrequiring surgical exploration and repair.The surgery will be performed under a local anesthesiain a wide awake hand surgery fashionwithout the use of tourniquet.The surgical site will be infiltratedwith lidocaine with epinephrine, buffered with bicarbonate.The initial injection will consistof 9 cc of 1% lidocaine with epinephrineand 1 cc of 4.2% bicarbonate.This can be readily diluted downas needed in order to anesthetize the surgical fieldfor surgical intervention.This WALANT technique is not only safer and cheaperand more convenient for the patient, but also allows usas a surgeon to be able to test our repairto make sure the repair is adequate and sound.

CHAPTER 2

With the patient awake in the operating room,the surgical site infiltrated, the laceration is openedand blunt dissection down to the level of injuryconfirms a complete extensor tendon laceration.

CHAPTER 3

Like the flexor tendons,A number of suture repair techniques are availablefor extensor tendons.In this case, a modified Kessler repair will be reinforcedwith 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 performedwith a single sutureor with two sutures as being demonstrated here.Care is taken while placing the suture,not to catch any deep structures such as the periosteumand/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 surethat there's good excursion and mobilization of the tendon,as well as to make sure that there is a good biteof our sutures within the tendon on both ends.Next, both pairs of suture ends are then sewed downin a sequential manner as demonstrated hereuntil satisfactory contactbetween the tendon edges are confirmed.Once the two core sutures and knots have been placed,the tendon repair is now reinforcedwith additional figure-of-eight sutures.

Here, a total three figure-of-eights are placedaround the core suture repair.Of note, the repair is being performed with 3-0 Ethibond.

CHAPTER 4

This is the appearance of the final tendon repair construct.Finally, and most importantly, the integrityof the repair is testedby having the patient actively extend the fingeror thumb in this case to confirm maintenance of integrityof the repair and full tendon excursion and extension.

CHAPTER 5

Once satisfied, the wound is washed and closed.In this case, the wound is being closedwith simple 4-0 chromic sutures.

CHAPTER 6

With the wound closed and the repair being protectedby an assistant, the dressing is applied.A splint is also applied.In this case, I apply what I referto 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 patientfor approximately two to four weeksin this thumb's up splintwith the repair site immobilized without tension.Thereafter the splint is applied,A removable splint is prescribed, and formal therapywith a hand therapist is also prescribedfor 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 itin full extension, and countering active thumb IP flexion.Thank you.