Chapter 33 Flexor Tendon Repair of the Hand



10.1055/b-0037-142204

Chapter 33 Flexor Tendon Repair of the Hand

Donald H. Lalonde

ADVANTAGES OF WALANT VERSUS SEDATION AND TOURNIQUET IN FLEXOR TENDON REPAIR OF THE HAND




  • The surgeon is less likely to have to perform secondary surgery for rupture repair if he or she tests the repair by having the patient take the fingers through a full range of motion before skin closure. If the surgeon sees gapping with the stress of full active movement, this can be repaired, with retesting of the repair to confirm that it is solid, and then the skin can be closed.1 This is like testing and ensuring good patency and blood flow through a microvascular anastomosis before skin closure.



  • See Chapter 32 for relevant videos, illustrations, and discussion of finger flexor tendon repairs.



  • A major advantage of eliminating sedation for flexor tendon repair is that you do not need to perform the procedure in the main operating room. We do all of our tendon repairs in minor procedure rooms in the clinic outside the main operating room Monday to Friday, 8 AM to 4 PM. We know that we do better surgery at 2 PM than at 2 AM. In addition, our hand therapists can teach patients during the surgery and see the repair (see Chapter 15).



  • You get to educate unsedated patients for the 90 or so minutes of the procedure without interruption. You can tell them that they can move their fingers but not use them, as the therapist will instruct. The patients will remember what you say and be even more motivated to follow hand therapy advice.



  • Patients get to see that the repaired tendon works as they watch themselves moving their fingers through a full range of motion before skin closure. They know that their fingers will function well once they get past the postoperative discomfort and stiffness if they put the necessary effort into therapy.



  • All of the general advantages listed in Chapters 2 and 32 apply to both the surgeon and the patient.



WHERE TO INJECT THE LOCAL ANESTHETIC FOR FLEXOR TENDON REPAIR OF THE HAND

The orange lines represent the laceration and the dotted red lines are the possible incisions. This operation may benefit from a median/ulnar nerve block of 10 ml of 1% lidocaine with 1:100,000 epinephrine and 1 ml of 8.4% sodium bicarbonate under the skin and under the distal forearm fascia in the proximal red injection point. Up to 20 ml of the same solution would go in the palm, starting with 10 ml over the carpal tunnel, then 10 ml in the distal palm, and 2 ml in the proximal phalanx just under the skin. If the middle phalanx also needs exposure, you can inject another 2 ml there. The flexor pollicis longus (FPL) laceration shown in the carpal tunnel in the lower illustration above may benefit from a median nerve block of 10 ml of 1% lidocaine with 1:100,000 epinephrine and 1 ml of 8.4% sodium bicarbonate under the skin and under the distal forearm fascia in the proximal red injection point. Up to 20 ml of the same solution would go in the palm, starting with 10 ml over the carpal tunnel, then 10 ml over the thenar eminence and 2 ml in the thumb proximal phalanx injection point just under the skin. (Clip 43-9 in Chapter 43 shows this case.)



  • See Chapter 1, Atlas, for more illustrations of the anatomy of diffusion of tumescent local anesthetic in the forearm, wrist, and hand.

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May 29, 2020 | Posted by in ORTHOPEDIC | Comments Off on Chapter 33 Flexor Tendon Repair of the Hand
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