Zone II Flexor Tendon Injuries: From No Man’s Land to No Man Left Behind!

Flexor tendons give the hand its most important function to hold and grasp objects. The tendons begin their journey from the muscles in the forearm and then travel to the fingertips. Due to their rather superficial location, they are prone to various types of injuries, from being cut by a kitchen knife or table saw, to complex occupational injuries necessitating repair. Injuries can happen in a critical area called Zone II - it is the area that spans from the base of the finger to its mid-length.

Flexor tendon repair and Kleinert Kutz share a historic relationship. For a long period in medicine it was considered taboo to repair flexor tendon injuries immediately. The results were so poor that the leading surgeons of that time advocated doing a delayed repair using a tendon graft, (i.e. a different tendon is taken from the forearm or leg). It was during this time, a young surgeon from Louisville presented his results of 80% excellent results after flexor tendon repair at the American Hand Society meeting. The result was unbelievable for the senior surgeon at that time and that they decided to visit Louisville to see the results themselves. Upon seeing the results here one of the leading surgeons remarked “If I ever get a flexor tendon injury, put me in a plane and send me to Louisville”. The rest is history and Louisville gained a permanent place in the hand surgery history.

So why exactly is a Zone II repair challenging? The tendon in the area of “Zone II'' traverses two joints coursing under tight tunnels called pulleys. In addition, the two tendons have a unique configuration, where the superficial tendon splits to allow the deep tendon to emerge through it. The two slips of superficial tendon then dive in deep, join, and then split again. This configuration is named Camper’s Chiasm. The earlier surgeons encountered a high percentage of breakdown of the repair. To mitigate the repair fails, the patients were immobilized for a prolonged period. This in turn led to the increased incidence of the tendon adhesions, where the tendon would get stuck to its surrounding tissues and barely move. These factors make a zone II flexor repair challenging. So much so that Zone II earned itself the name “No man’s land.” And it stayed so for many decades.

Dr. Kleinert’s principles in the comprehensive treatment were to provide a meticulous repair with careful tissue handling and a specialized therapy plan that avoided immobilization. Ever since Dr. Harold Kleinert’s presentation, there have been many advances in technique, anesthesia, instruments, and suture materials. However, the principles remain the same and serve as scripture for the learning hand surgeon.

Flexor tendon repairs are commonly being done under an anesthesia technique called Walant- Wide Awake Local Anesthesia and No Tourniquet. As the name suggests this procedure is done with the patient being awake, somewhat similar to a dental procedure. This allows the surgeon to assess the tendon motion and repair strength intraoperatively. The patient is discharged with a splint and instructed to keep the hand elevated and keep the fingers moving. The therapy begins within a week in most cases and the therapist encourages both active and assisted movement of the finger. The therapy continues up to 3 months, although most patients can return to duty in 6-8 weeks. Some patients need additional surgeries to improve their function.

What was once considered a no man’s land is now being routinely repaired. Kleinert Kutz surgeons continue the legacy of Dr. Kleinert to make sure no man or no flexor tendon, in this case, is left behind!

Intra-Surgery Video Script 

Dr. Bhandari instructing patient:  
“Go ahead and make a fist.” “Open up, make it straight.” “Make a fist.” “Open up.” 

For the Hearing Impaired: The above text is the words being said in the video.

Intra-Surgery Video Script 

Dr. Bhandari instructing patient:  
“Go ahead and make a fist.” “Open up, make it straight.” “Make a fist.” “Open up.” 

For the Hearing Impaired: The above text is the words being said in the video.



Dr. BhandariMeet Dr. Laxminarayan Bhandari

Kleinert Kutz hand specialists are available 24 hours a day, 7 days a week. Call (502) 561-4263 for hand emergencies or to schedule an appointment.

 

 

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