Hand and Finger Tendon Injuries in Ankara, Turkey

Hand and finger tendon lacerations usually occur as a result of sharp-object injuries and can seriously affect the hand’s range of motion. Depending on whether the flexor or extensor tendons are cut, loss of motion may occur in the fingers. Rapid and accurate intervention is of great importance.

Flexor tendon lacerations occur especially on the palm and the volar (inner) surface of the fingers. They are characterized by an inability to bend the fingers. Repairs are difficult due to complex anatomical structures. Diagnosis is made with clinical examination, and surgical intervention is required.

Extensor tendon lacerations are seen on the dorsal (outer) surface of the fingers and present with the complaint of being unable to straighten the fingers. Due to their superficial location, these injuries can be recognized more easily. If left untreated, permanent functional losses may develop.

After the tendon ends are united with microsurgery, a hand rehabilitation process is initiated. Healing is supported with splint use, controlled exercise programs, and physiotherapy. Treatment success depends on early surgery and disciplined rehabilitation.

What Are Hand and Finger Tendon Lacerations?

Hand and finger tendon lacerations are the disruption of the integrity of flexor or extensor tendons that enable movement of the fingers and wrist due to sharp objects. As a result of these injuries, loss of motion, weakness, and functional impairment may develop in the fingers. Early diagnosis and appropriate surgical repair are of great importance to prevent permanent damage and restore hand functions. The rehabilitation process is an integral part of treatment.

How does the tendon system inside our hand work, and why is it so sensitive?

The mechanism that enables hand movement can actually be likened to a highly advanced pulley-and-rope system. While the strong muscles in our forearm serve as the “motor,” the ropes that transmit the force produced by these muscles to the finger bones are the tendons. However, these tendons—the ropes—do not lie freely under the skin. There are very special tunnels and sheaths that ensure their orderly function:

Especially the flexor tendons on the palm side pass through tunnels called “pulleys” that run along the finger bones. The role of these tunnels is vital; they prevent the tendon from bowstringing away from the bone and ensure that the force created when we bend our finger turns directly into movement without creating a bowstring effect. This system is so sensitive that the space between the tendon and the tunnel is at the millimetric level.

Even the smallest bulge after an injury, a roughly placed stitch, or a firm healing tissue (scar) immediately disrupts this gliding and restricts finger motion. Therefore, the goal in hand surgery is not merely to suture the two cut ends together. The main objective is to restore the flawless function of this gliding tunnel system and make it possible for the tendon to glide through that narrow tunnel without catching. For this system to function properly, the following structures play a critical role:

• Musculus Flexor Digitorum Superficialis (FDS)
• Musculus Flexor Digitorum Profundus (FDP)
• Synovial sheaths
• Pulley system
• Vincula vascular structures

Can a cut tendon heal on its own?

I encounter this question very often. Unfortunately, the answer is no. Tendons are, by their nature, quite taut, rubber-like tissues. The moment a tendon is cut, it creates an effect like cutting a tight rubber band in the middle with scissors. Together with the pulling force of the muscles, the two ends quickly move away from each other. The severed ends can often retract far above the level of injury, sometimes into the palm or even up to the wrist. We call this “retraction” in medical terms. Because of this mechanical separation, it is biologically impossible for the tendon ends to come together and heal on their own.

In addition, tendon nourishment differs from other tissues. Tendons are nourished not so much by blood vessels but by a special fluid (synovial fluid) within their own sheaths. However, very thin capillary vascular structures called “vincula” are also critical for tendon viability. At the moment of injury, as the tendon tears, these fine vessels are also damaged. Without surgical intervention, the tendon ends cannot be nourished, lose viability, shrink, and the muscle function in that region is completely lost. Therefore, there is no such approach as “let’s wait a bit, maybe it will get better” in tendon lacerations; surgical repair is an absolute and urgent necessity.

What is “No Man’s Land,” and why do surgeons fear this region?

In the history of hand surgery, the region referred to as “Zone II”—the part from that famous line in the palm to the middle phalanx of the fingers—was for many years called “No Man’s Land.” The reason for this name is quite dramatic; because in earlier periods, treating injuries in this region was so difficult that surgeons hesitated to touch it, and the results often ended in disappointment.

So why is this region so troublesome? The problem arises entirely from anatomical crowding. In this narrow area, two different tendon systems that flex the finger (both the deep and superficial tendons) have to move stacked and intertwined within the same sheath. You can think of it like two trains trying to travel side by side in a narrow tunnel. As healing tissue forms after injury, the risk of these two tendons adhering to each other or to the surrounding sheath (adhesion) is very high. If adhesions occur, the finger locks and cannot move.

The surgeon’s task here is like walking on a tightrope: they must repair both tendons strongly enough not to rupture, but at the same time the sutures must be so delicate and smooth that they can glide without catching in that narrow tunnel. Fortunately, thanks to advances in microsurgical techniques, magnifying loupes, and specialized rehabilitation programs, we can now achieve very satisfying results even in this region that was once called “no man’s land.”

Do extensor tendon injuries on the back of the hand heal more easily?

As a common misconception, injuries on the dorsum of the hand are thought to be simpler. Yes, extensor tendons on the back of the hand differ from those on the palm; they enable us to straighten our fingers and generally do not get trapped in narrow tunnels. However, this does not mean they are “easy.”

The biggest challenge here is that the skin on the dorsum of the hand is paper-thin. The tendons lie almost immediately under the skin and very close to the bones. There is no protective fat tissue or soft tissue cushion in this area. Therefore, in simple glass cuts or blunt impacts, situations such as skin loss, bone fractures, or opening into the joint are very common in addition to tendon injury.

Also, extensor tendons are not round and rope-like like flexors; they are more like a flat band or strap. This flat structure makes suturing technically more difficult. The suture material can cut through the tendon like a “cheese wire.” Some special conditions according to the anatomical location of injuries in this region are as follows:

• Mallet Finger
• Boutonniere Deformity
• Sagittal Band Tears
• Metacarpal-Level Lacerations
• Junctura Tendinum Injuries

In particular, “Mallet Finger” at the fingertip or “Boutonniere” deformities at the middle joint can permanently distort the finger’s shape if left untreated and seriously affect daily use. Therefore, dorsal hand injuries should be approached with at least as much seriousness as palmar injuries.

Is looking at the wound alone enough to understand tendon damage?

Absolutely not. The size of the skin cut can mislead us about the magnitude of the storm inside. Sometimes a hole as small as a needle tip may have completely severed deep tendons, while sometimes a large gash may have affected only the skin. Therefore, for an experienced physician, physical examination is the backbone of the diagnosis.

Each finger and each tendon function must be tested separately. Because the mechanics of the hand are very complex; a problem in one finger’s tendon can also affect the neighboring finger. For example, to determine whether the deep flexor tendon (FDP) is functioning, we look at whether you can bend only the fingertip joint. For the superficial tendon (FDS) test, we hold the other fingers still and ask you to bend only the injured finger.

In addition to physical examination, we also benefit from technology. The methods we frequently use during the diagnostic phase are as follows:

• Detailed physical examination
• Elson test
• Ultrasonography (US)
• MRI imaging
• X-ray (in suspected fracture)

Especially ultrasonography is an excellent, fast, and painless method to see how far the tendon ends have retracted or to understand whether the tendon is completely or partially cut. In much more complex, old, or suspicious situations, we map the inside of the hand with MRI imaging and plan our surgery.

What is the best timing for surgery, and is it risky to wait?

In tendon repairs, timing is the key to success, I can say. Ideally, intervention should be performed within the first 24 hours after the injury, when tissues are fresh. We call this “Primary Repair.” If the wound is not heavily contaminated, the infection risk is under control, and the patient’s general health condition is suitable, being taken to surgery immediately yields the best result.

Sometimes patients may think the injury is “a simple cut” and do not take it seriously, or the diagnosis may be missed. Repairs performed up to the first 2 weeks (Delayed Primary) can still yield good results. However, as hours pass, things become more difficult. After 2 weeks, the tendon ends begin to shorten and shrink, the muscles they are connected to lose their elasticity, and the tunnels through which the tendon passes narrow due to disuse.

After this stage (Secondary Repair), things become much more complex. It may no longer be possible to pull the tendon ends together. In short, in a tendon laceration, we do not have the luxury of saying “it will pass tomorrow” or “let me wait a bit.” The earlier the intervention, the more magnificent the functional return.

How strong are the suture techniques used during surgery?

In the past, tendons were simply secured end-to-end with two strands. However, these repairs were weak, could not tolerate early motion, and would rupture when the patient first bent the finger. Today, in light of biomechanical and engineering studies, we use much stronger and more complex suture techniques.

Our basic philosophy in modern surgery is this: the tendon should be sutured strongly enough that the patient can begin moving the finger the day after surgery. Because motion is the enemy of adhesions. However, at the same time, the sutures must be so delicate that they glide smoothly through the tunnels without catching. To achieve this, we combine two different suture groups:

Core Sutures: These are the main ropes that carry the primary load of the tendon. Instead of 2-strand repairs, we now use special 4- or 6-strand weaving techniques (such as Modified Kessler, Tsuge) to exponentially increase the strength of the repair.

Epitendinous Sutures: These are hair-thin sutures that smooth out fraying at the cut tendon ends and create a smooth surface. These sutures facilitate tendon gliding and contribute significantly to repair strength.

As suture material, special nonabsorbable (such as polypropylene) or very slowly absorbable threads are selected. Especially in areas like the dorsum of the hand where the skin is thin, choosing materials that are not palpable and do not cause tissue reaction increases patient comfort.

What is done if the tendon ends do not reach each other or the injury is very old?

If months have passed since the injury or if a portion of the tendon tissue was torn away during the trauma, it is impossible to forcibly bring the ends together. Even if you force it, the finger will contract and cannot move. In such cases, “Tendon Grafting,” so to speak, the use of “spare parts,” comes into play.

There are tendons in our body that we can use as donors without causing functional loss. The donor tendons we most commonly use are:

• Palmaris Longus tendon (at the wrist)
• Plantaris tendon (in the leg)
• Extensor Indicis Proprius (in the index finger)
• Toe extensor tendons

The Palmaris Longus tendon, especially at the wrist, is present in the vast majority of people and removing it does not cause any deficit in hand function. The surgeon harvests this tendon and sutures it like a bridge in place of the missing tendon. In this way, the discontinuity is eliminated.

How is two-stage surgery (Hunter Rod) performed in very old injuries?

Sometimes the situation is so complex that the tunnel and bed through which the tendon should pass are completely scarred and destroyed. If we place a new tendon directly there, it will also adhere and will not function. In this case, we implement a patient, two-stage plan called the “Hunter Rod” technique.

First Stage: We completely clean the damaged area. We place a silicone rod where the tendon should be. This silicone rod stays there for a while. The body forms a smooth, tunnel-like, gliding membrane around this silicone. We wait approximately 3 months for this biological tunnel to form.

Second Stage: When the preparation is complete, we operate again. We remove the silicone rod from within that gliding tunnel that has formed. Immediately afterward, we pass the tendon graft taken from another area of the patient through this prepared tunnel and complete the repair. This method is a powerful tool that can provide mobility even in cases that appear the most hopeless.

How do tendon transfers provide a solution in patients with nerve palsy?

Sometimes the problem is not in the tendon itself but in the electrical line that gives it the “fire” command—namely, the nerves. In radial, ulnar, or median nerve palsies, muscles do not work even if tendons are intact. The hand may remain in a “wrist drop” position or lose its ability to grip. This is where the engineering side of surgery comes into play: Tendon Transfers.

In this procedure, we take the tendon of a “healthy” muscle in the arm that is functioning and can be sacrificed, and transfer it in place of another tendon that is not working but whose function is critical for the hand. You can think of it as rewiring the system. The factors that affect success in these surgeries are:

• Joint range of motion
• Strength of the muscle to be transferred
• Straight line of pull
• Brain adaptation (synergy)

For example, in a patient who cannot lift the wrist (wrist drop), we transfer one of the finger-flexing muscles or a wrist-flexing muscle to the tendon that lifts the wrist. After surgery, the brain adapts to this change. The patient realizes that their wrist lifts when they think “make a fist,” and they quickly get used to this new arrangement. In this way, a paralyzed hand becomes functional again.