Extensor tendon repair in zone 4 (hand)
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Extensor tendon injuries in the hand are commonly encountered by hand surgeons and have a peak incidence in working males between 20-29 years of age. Historically static splinting of these injuries was often advocated, but with plentiful evidence that surgical repair improves outcomes an understanding of the complex anatomy of the extensor tendon system is essential for their appropriate management.
From the perspective of extensor tendon injury and repair eight distinct zones are recognised, running from distal phalanx to the forearm. Repairing an extensor tendon injury without a good understanding of the the nuances of each individual zone of injury can result in an extensor lag, stiffness, or failure of the repair, all of which can have significant implications in a working population.
In contrast to flexor tendon injuries, the surgical management of extensor tendon injuries is not limited by the restrictions imposed by the fibro-osseous tunnel of the flexor system.
As with flexor tendon injuries though, the mechanism tends to be sharp lacerations for the most part. Attritional rupture secondary to degenerative and inflammatory conditions are a different category of injury whose management is not considered in this section. Least commonly avulsion type injuries can occur and may require repair also.
Surgical repair of extensor injuries are marked by certain unique challenges such as the thin flat nature of the distal extensor tendons which require alternatives to standard core suture techniques. In this section repair of a simple partial extensor tendon injury over the proximal phalanx (zone 4) will be demonstrated. Alongside this the important considerations of other extensor zones will be discussed.
As with all tendon injuries, the post-operative rehabilitation regime is of critical importance to ensure the best possible result is obtained.
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Author:Tahseen Chaudhry FRCS (Tr & Orth)
Institution: The Queen Elizabeth Hospital, Birmingham, UK