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Flexor tendon repair
Why are we operating?
Rejoining a cut flexor tendon inside its tight fibrous tunnel, then the paradox: a repair that must be strong enough to move on day one, because stillness is what ruins it.
Indication: Flexor tendon division in the hand or wrist; classically a knife or glass across the flexor surface.
The operation in 4 steps
01Exploration
The wound is extended along Bruner zigzag lines under tourniquet, and both tendon ends retrieved, the proximal end often having recoiled up the palm.
Why: The skin wound understates the injury: the tendon divides wherever the finger was flexed at impact. Zigzag extensions cross flexion creases obliquely because a straight scar down a finger becomes a contracture.
02Assessing the zone
The level of division is named by zone; zone II, where both flexor tendons share one sheath in the finger, changes the stakes.
Why: Zone II was once called no man's land because repairs there stuck to everything around them. Modern technique repairs it, but the zone still names the difficulty: two tendons, one unforgiving tunnel, pulleys that cannot be sacrificed.
03The repair
A multi-strand core suture joins the ends, tidied with a running epitendinous stitch.
Why: The strand count is the strength budget for early motion: enough strands to survive rehabilitation, tied without bunching, gliding smooth through the pulleys the repair must pass under.
04Closure and early protected motion
Skin closed, a dorsal blocking splint fitted, and a hand-therapy protocol of early protected movement started within days.
Why: The paradox that defines this surgery: an immobilised repair heals stuck to its tunnel and the finger never moves again; a moving repair glides while it heals. The therapist is half the operation.
Anatomy you need
The forearm flexors and their tendons; in the finger both flexors share one sheath, which is why zone II is famous.
What can go wrong
Watch it done
Flexor tendon repair techniques
Core suture configurations and the epitendinous stitch, drawn and compared.
Source: Hand, Plastic, Reconstructive and Nerve Surgery · Watch on YouTubeFlexor tendon rehabilitation
The hand therapy that decides the result: early active motion protocol.
Source: University Hospitals Birmingham · Watch on YouTube
Conceptual teaching for learners preparing to observe and assist under supervision, not operative instructions. Five minutes from now you should know why this operation exists, what its shape is, and which structures it is designed not to injure.