Tendon Repair

Introduction

Tendon repair of the hand is surgery to repair damaged or divided tendons. Most tendon damage is caused by cuts to the hands from glass or knives.

What are 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.

There are two groups of tendons in the hand:

Extensor tendons – which run from the forearm, across the back of your hand to your fingers and thumb, allowing you to straighten your fingers and thumb
Flexor tendons – which also run from your forearm, through your wrist and across the palm of your hand, allowing you to bend your fingers

Why do I need tendon repair surgery?

Tendon repair of the hand is necessary when one or more tendons in your hand are divided or ruptured (split), 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. Some common causes of tendon injuries are described below.

Cuts – Cutting your hand can result in an injury to your tendons.
Sports injuries – Tendons can be overstretched and rupture when you take part in sport. This is more common in contact sports such as football and rugby, or activities that involve a lot of gripping, such as rock climbing.
Bites – Animal bites can cause tendon damage. However, human bites are a more common cause and most often occur when a person punches another person in the teeth, cutting their hand in the process.
Crushing injuries – Jamming your finger in a door or having your hand crushed in a car accident can divide or rupture a tendon.
Rheumatoid arthritis – Rheumatoid arthritiscan cause your tendons to become inflamed. In the most severe cases, this can lead to tendons rupturing.

Tendon repair surgery

Tendon repair involves making an incision in your hand to locate the ends of the divided tendon, and then stitching the tendon ends together.

Extensor tendons are easy to reach, so repairing them is relatively straightforward. Depending on the type of injury, it may be possible to repair extensor tendons using a local anaesthetic to numb the affected area.

Repairing flexor tendons is more complex because they can be difficult to get to and, in many cases, are located near important nerves. Flexor tendon repair usually needs to be carried out under general anaesthetic in an operating theatre.

Recovering from surgery

Both types of tendon surgery require a lengthy period of recovery (rehabilitation) because the repaired tendons will be very weak until the ends heal together. Depending on the location of the injury, recovery can take between one and three months.

Rehabilitation involves protecting your tendons from overuse using hand splints. A hand splint is a rigid support worn around the hand, which is designed to hold your hand securely in position to prevent excessive movements that could cause the tendon to rupture while it is healing. You will also need to do hand exercises regularly to prevent the repaired tendons from sticking to nearby tissue.

When you can return to work will depend on your job. Light activities can often be resumed after 6–8 weeks and heavy activities and sport after 10–12 weeks. Read more about recovering from tendon repair of the hand.

Outlook

After an extensor tendon repair you should have a working finger, but may not regain full movement. The outcome is often better when the injury is a clean cut to the tendon rather than one that involves crushing or damage to the bones and joints.

A flexor tendon injury is generally more serious as they are responsible for carrying more force than an extensor tendon. After a flexor tendon repair it is quite common for some fingers not to regain full movement, although the tendon repair will still give a better result than no surgery.

In some cases there are complications after surgery, such as infection or the repaired tendon snapping or sticking to nearby tissue.

How tendon repair is performed

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

Tendon repair is not usually regarded as emergency surgery, but is generally carried out as quickly as possible after the injury (usually within 24 to 48 hours).

This is because the longer the tendons remain ruptured, 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.

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 anaesthetic (also known as a regional anaesthetic). A regional anaesthetic is when medication is used to make part of your body totally numb.

If your tendon was damaged due to a wound, the wound will be thoroughly cleaned out with water. An incision 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 stop you moving your hand and damaging the repaired tendons. The wound 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.

Dr. B C Shah will then extend the wound (or make an incision if there is no wound) to locate the damaged tendons.He will use forceps to bring the two ends of the damaged tendon together. The tendons are then stitched back together and the wound in the hand 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.

Recovery after tendon repair

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.

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 or local 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 painkillers, such as ibuprofen, for up to two weeks.

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 hand therapy in hospital before you go home.

Rehabilitation after extensor tendon repair

Before you leave hospital, a hand 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.

You will be taught a number of different hand exercises. These 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
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
Resume sporting activities after 10-12 weeks

Dr. B C Shah 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 recovery 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, 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
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 10 weeks
Resume medium activities after 10 weeks
Drive an HGV vehicle after 10 weeks
Resume sporting activities after 10-12 weeks
Resume heavy activities after 12 weeks

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

Complications of tendon repair

Some common complications of tendon repair include infection, a failed repair (which can cause the tendon to snap) and the repaired tendon sticking to nearby tissue.

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 where there are a lot of 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
A high temperature (fever) of 38°C (100.4°F) or above

Contact Dr. B C Shah 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 notice a sudden snapping or ‘pinging’ sensation in your hand. However, you may not notice that the tendon has snapped until you discover that you cannot move your finger or fingers in the same way as before.

If you think that your tendon has snapped, contact Dr. B C Shah. 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 movement 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.