Flexor tendon injuries of the hand

Adapting sutures on tendon ends

The primary requirement for surgical intervention is the precise apposition of the damaged fragments. A classic example of the adapting technique is the Rozov suture.

The technique for its placement is as follows: the surgical thread is passed through the tendon tissue in a strictly transverse direction. Then, from additional puncture sites, both ends of the thread are directed parallel to the course of the tendon fibers directly to the cut site. The second damaged segment is sutured in a similar manner, after which the threads are tied together.

The main advantage of this method is that it well adapts the tendon ends without disrupting its local blood supply. However, the construct has a critical flaw—it is unable to withstand significant load and easily cuts through soft tissues. For this reason, it is advisable to use the Rozov suture exclusively in combination with proximal locking sutures.

Proximal locking sutures and transfixation

To temporarily compensate for muscle traction and unload the injury site during the healing period, locking sutures are used. They are placed outside the rupture zone on the proximal segment (the one connected to the muscle) and removed after healing.

• Bunnell suture: Passed with several stitches through the proximal end. Fixed with an additional thread, the ends of which are brought out to the skin proximally (it will be needed for extraction). The ends of the suture itself are brought out distally and fixed on a button to create tension. Upon removal, the suture is cut off from the button and pulled out by the additional thread.
• Pugachev suture: Stitches are placed in a transverse direction through the proximal section. The ends of the thread are brought out in opposite directions onto the skin and secured on buttons.
• Kausch suture: A removable suture made of synthetic material or thin wire. Its feature is that the loop of each stitch through the central end is fixed by placing an additional thread (n-n). When extracting the first one, it is precisely the n-n thread that is pulled out.

An alternative is transfixation — temporary fixation of the tendon through tissues to the bone. According to the Bsteh method, the proximal section is attached to the bone with a percutaneously inserted injection needle. In the Vreden method, tension is eliminated by two needles inserted through the skin and tendon on both sides of the injury.

Ruptures of the knee joint tendon-ligament apparatus

The principles of tendon suturing are actively used in injuries of the knee extensor apparatus (quadriceps femoris, its tendinous expansion, patella, and patellar ligament). Open injuries are easily diagnosed and sutured during primary surgical debridement (PSD). Closed injuries are more common.

There are three main mechanisms of rupture:

1. Direct (most frequent): a blow to the patella area with an extended joint.
2. Indirect: a sharp, uncoordinated muscle contraction during forced flexion under body weight (stopping while running, jumping).
3. Fall on a flexed knee: usually leads to rupture of the muscle's tendinous expansion.

Clinical presentation and diagnostics

In a rupture of the tendinous expansion, there is a "stick blow to the knee" sign, a crunch, and pronounced edema along the anterior surface of the thigh. Palpation reveals a painful depression above the patella (intensified when the muscle is contracted), and the torn end of the rectus muscle is palpated higher up. The patella is not taut and easily displaced. In complete rupture, active extension of the lower leg is completely absent (passive extension is preserved).

In a rupture of the patellar ligament, maximum edema and depression are localized below the patella. The patella itself shifts upward (normally its lower pole is at the level of the joint line). The muscle contraction test shows that the ligament does not tense, and the patella shifts even more.

For accurate diagnosis, ultrasound, MRI, and radiography are used. On lateral functional (stress) radiographs during muscle contraction, ligament rupture results in upward displacement of the patella, while expansion injury shows no such displacement.

Prehospital care and treatment principles

At the first aid stage, the extremity is fixed with transport splints in an extended position with mandatory foot fixation. Adequate immobilization provides a sufficient analgesic effect. Administering local anesthetics in non-sterile conditions is strictly contraindicated.

Treatment is exclusively surgical (end-to-end suturing or reattachment to the bone). It is optimal to perform the intervention in the first 24 hours. In the early stages (up to 7 days), the use of a closed percutaneous suture is possible.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Features of performing primary surgical debridement (PSD) in open tendon ruptures.
• Technique of performing percutaneous (closed) suture in the first 7 days after injury.
• Comparison of the informative value of ultrasound and MRI in partial tendon ruptures.
• Choice of suture material: advantages of synthetic threads and wire.

Other topics in the "Specialized Adult Traumatology" section

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.