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Tendon repair, hand

Introduction

Tendon repair of the hand is a surgical procedure to repair tendons that have been damaged and split. Most cases of tendon damage occur as a result of cuts to the hands.

Tendons

Tendons are tough cords of tissue that connect muscles to bones. When you contract (tighten) a group of muscles, the attached tendons will pull on certain bones, allowing you to make a wide range of physical movements.

Tendons in the hand

There are two groups of tendons in the hand:

  • extensor tendons, and
  • flexor tendons.

Extensor tendons

Extensor tendons run from the muscles in your forearm across the back of your hand to each of your fingers and thumbs. Your extensor tendons allow you to straighten your fingers and thumbs.

Flexor tendons

Flexor tendons also run from the muscles in your forearm, passing through a number of channels in your wrist and across the palm of your hand to each of your fingers and thumbs. Your flexor tendons allow you to bend your fingers, make a fist and grip objects.

Tendon repair

Tendon repair involves locating the split tendons, making an incision in your hand, then stitching the tendons together.

Extensor tendons are easily accessible, so repairing them is relatively straightforward. Depending on the type of injury, it may be possible to repair extensor tendons in an accident and emergency (A&E) department using a local anaesthetic to numb the affected area.

Repairing flexor tendons is more complex because they can be difficult to access and are often located near important nerves. Flexor tendon repair usually needs to be carried out by an experienced orthopaedic surgeon (a surgeon who specialises in joint and bone surgery) in an operating theatre.

Rehabilitation

Both types of tendon surgery require a lengthy period of rehabilitation because the repaired tendons will still be very weak. Depending on the location of the injury, rehabilitation can take between one and three months.

Rehabilitation involves protecting your tendons from overuse with hand splints. A hand splint is a rigid support, in the form of a glove, which is designed to hold your hand securely in position so that it can heal properly. Rehabilitation also involves preventing the repaired tendons from becoming stuck on nearby tissue through regular hand exercises.

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Why is it necessary?

Tendon repair of the hand is necessary when one or more tendons in your hand become ruptured (split) or strained, leading to loss of normal hand movements.

If your extensor tendons are damaged, you will be unable to straighten one or more of your fingers. If your flexor tendons are damaged, you will be unable to bend one or more of your fingers.

Tendon damage can cause pain and inflammation (swelling) in your hand.

Common causes of tendon injuries

Some common causes of tendon injuries are described below.

Cuts

An accidental cut to your hand, such as cutting your hand on glass at home or when using a tool at work, can result in an injury to your tendons.

Sports injuries

Tendons can be overstretched and rupture when you take part in sporting activities, particularly contact sports such as football and rugby.

A common type of sports injury is known as ‘jersey finger’. Jersey finger occurs when a rugby player tries to grab another player’s jersey and a finger (most commonly the ring finger) is caught and pulled, snapping the tendon or pulling it away from the bone.

Activities that involve a lot of gripping, such as rock climbing, may also overstretch and rupture your tendons.

Bites

Animal bites, such as a dog bite, can cause tendon damage. However, human bites are a more common cause. Most human bites are due to what doctors call ‘fight bites’, which occur when where a person punches another person in the teeth, cutting their hand in the process.

Jamming or crushing injuries

Jamming your finger in a door or having your hand crushed in a car accident can strain and rupture a tendon.

Rheumatoid arthritis

Rheumatoid arthritis can cause your tendons to become inflamed. In the most severe cases, this can lead to tendons becoming ruptured.

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How is it performed?

Tendon repair is not usually regarded as emergency surgery, but is generally carried out as quickly as possible after the injury (usually within 24 hours).

This is because the longer the tendons remain ruptured (split), the more scarring will develop on the end of the tendons. This could lead to a reduction in the range of your normal hand movement.

Before surgery is carried out, X-rays may be taken of your hand, wrist and forearm. This is to check whether there is any additional damage, such as a fracture, that may also need to be repaired.

Depending on the nature of your injury, you may be given antibiotics and a tetanus jab to prevent your hand from becoming infected.

Extensor tendon repair

Extensor tendon repair is usually performed under a local or regional anaesthetic. A regional anaesthetic is when medication is used to block nerve sections from certain parts of your body, so that your hand will be totally numb.

If your tendon was damaged due to a wound, the wound will be thoroughly cleaned out with water. An incision (cut) will be made in your hand (or, in the case of a wound, the wound may be made larger) and the two ends of the ruptured tendon will be stitched together.

A splint (a rigid support to protect the hand) is usually applied to your hand to stop you damaging the repaired tendon(s). The wound in the hand is then closed.
If nothing else has been damaged, extensor tendon repair surgery will take around 30 minutes to complete.

Flexor tendon repair

Flexor tendon repair is usually performed under a regional or general anaesthetic.
A tourniquet will be applied to your upper arm to stop the blood circulating and to make it easier to perform the operation safely. A tourniquet is a type of cuff that is used to constrict (squeeze) the blood supply.

The surgeon will then extend the wound (or make an incision if there is no wound) to locate the damaged tendons. They will use forceps to bring the two ends of the damaged tendon together. The tendons are then stitched back together and the wound in your hand will be closed. A splint will be applied to protect the newly repaired tendons.

A simple flexor tendon repair takes 45-60 minutes. Complex surgery for more severe injuries could take much longer.

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Recovery

After the operation

If you have had a general anaesthetic, you will wake up in the recovery room after your operation. To help you breathe, you may have an oxygen mask on your face. You may feel a bit drowsy.

If you had a regional anaesthetic, you will be able to go back to the ward sooner, but your arm will be numb and floppy for several hours. It is normal for your hand to be elevated in a sling (a large bandage designed to support a body part) to control inflammation (swelling) of the hand.

Following the operation, your hand is likely to be bruised and swollen and, when the anaesthetic wears off, it will be painful. You will need to take moderate painkillers, such as ibuprofen, for up to two weeks.

Going home

When you will be able to return home will depend on how badly your hand was damaged. You may be able to go home on the same day, once you have recovered from any anaesthetic and arrangements have been made for your aftercare.

You will not usually be able to drive, so you may need someone to take you home. If you live on your own and you have had a general anaesthetic, you may be advised to stay in hospital overnight. You may also need to stay overnight if you need to have some hand therapy in hospital before you go home.

Rehabilitation after extensor tendon repair

Before you leave hospital, you will be introduced to a hand therapist. The therapist will place your hand in a protective splint (a rigid support that is designed to protect the hand) to prevent the repaired tendons from being overstretched.

You will usually be advised to wear the splint at all times for at least four weeks, then during the night for the following two weeks.

The hand therapist will teach you a number of different hand exercises. The exercises are designed to prevent the repaired tendons from getting stuck to surrounding tissue, which would reduce your range of hand movements.

Examples of hand exercises used in rehabilitation include:
 

  • gently lifting a finger away from the splint with your other hand, and
  • gently bending your finger joints while sliding your nails along the splint towards your palm.
     

If you smoke, it is highly recommended that you quit because smoking can impair circulation in your hand and delay your recovery time.

Returning to work after extensor tendon repair

How quickly you can return to work and resume normal daily activities will depend on the nature of your job, as well as the type and location of your injury. Most people are able to:
 

  • resume light activities, such as using a keyboard or writing with a pen, after six weeks,
  • drive a car or motorcycle after eight weeks,
  • resume medium activities, such as light lifting or shelf stacking, after eight weeks,
  • drive a heavy goods vehicle (HGV) after eight weeks,
  • resume heavy activities, such as heavy lifting or building work, after 10 weeks, and
  • resume sporting activities after 10-12 weeks.
     

Your hand therapist or surgeon can give you a more detailed estimate of your likely recovery time.

It is very important that you follow all the instructions and advice given to you regarding the use of your hands during your recover period. If you attempt to use the repaired tendons before they have fully healed, it could cause them to split apart.

Rehabilitation after flexor tendon repair

As with extensor tendon repair, you will be introduced to a hand therapist before leaving hospital and a protective splint will be fitted to your hand.

You will usually be advised to wear the splint at all times for at least four to five weeks, then during the night for a further two weeks.

As with extensor tendon repair, you will be taught a range of hand exercises to prevent the repaired tendons from becoming stuck to surrounding tissue. These will include:
 

  • gently bending your fingers into your palm with your other hand, and
  • gently straightening your fingers so that your fingernails touch the splint.
     

If you smoke, it is strongly recommended that you quit because smoking can impair circulation in your hand and delay your recovery time.

Returning to work after flexor tendon repair

After flexor tendon repair, most people are able to:
 

  • resume light activities after eight weeks,
  • drive a car after eight weeks,
  • drive a motorcycle after nine weeks,
  • resume medium activities after ten weeks,
  • drive an HGV vehicle after 10 weeks,
  • resume sporting activities after 10-12 weeks, and
  • resume heavy activities after 12 weeks.
     

Attempting to make use of repaired tendons before they are fully healed could cause them to split apart.

Hand splints

You will need to wear a hand splint after surgery to protect the repaired tendons from damage. In cases of extensor tendon repair, you will need to wear the splint all the time for at least four weeks, then at night for a further two weeks.
In cases of flexor tendon repair, you will need to wear the splint all the time for at least four to five weeks, then at night for a further two weeks.

Beware of everyday activities such as:
 

  • squeezing toothpaste tubes or shampoo bottles,
  • getting out of the bath,
  • opening doors,
  • taking your hand out of a sleeve (it can catch).
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Complications

Some common complications of tendon repair are outlined below.

Infection

A post-operative infection develops in around 5% of cases of tendon repair. The risk of infection is highest if you damage your hand in an environment that is more likely to be contaminated with germs, such as a farm. Crushing injuries are also more likely to cause an infection.

Symptoms that may indicate that your hand has developed an infection include:

  • redness and swelling in your hand,
  • a feeling of tenderness or pain, and
  • a high temperature (fever) of 38°C (100.4°F) or above.

Contact your GP if you think you have developed an infection. Most infections can be successfully treated with antibiotics.

Tendon snap

In an estimated 5% of cases of tendon repair, the repair fails. This results in the snapping of the repaired tendon.

Most tendon snaps occur soon after the operation when the tendon is weakest. Tendon snaps often happen in people who do not follow the advice about resting the affected tendon. Accidental trips, falls or suddenly catching your splint on an object can also snap the tendon.

Sometimes, it is obvious that you have snapped the tendon because you will notice a sudden snapping or ‘pinging’ sensation in your hands. However, you may not notice that the tendon has snapped until you discover that you cannot move your finger(s) in the same way as before.

If you think that your tendon has snapped, contact your surgical team. Further surgery is usually required to repair the tendon.

Tendon adhesion

Tendon adhesion is a medical term which means that the tendons have become stuck to nearby tissue and have lost some of their range of movement, specifically the ability to move around bones. This is known as tendon glide.

This can cause some loss of movement which, in most cases, is minor. More serious cases of tendon adhesion require surgery to free the stuck tendon.

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Alternatives

In most cases of tendon injury, surgery is the only available treatment option. The exception is a type of extensor tendon injury known as ‘mallet finger’.

Mallet finger

Mallet finger occurs when the tendon at the very tip of one of your fingers becomes damaged and ruptured. This leads to:

  • inflammation (swelling),
  • redness, and
  • an inability to properly extend the affected finger.

Most cases of mallet finger occur as a result of a sports injury, when a person catches their finger suddenly against another object, such as a cricket ball.

As the damage to the tendon is usually minimal, it is often possible to repair it using a splint (a rigid support that is designed to protect the hand and hold it in place). Over time, this allows the tendon to heal back together. Most people need to wear a finger splint for six to eight weeks.

Surgery will be required if splinting does not lead to the repair of the tendon.

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