For repair of a partial or complete tendon injury

 Partial laceration of the extensor tendons proximal to the metacarpophalangeal (MCP) joint may or may not require repair; those at or distal to the MCP joint level must be repaired

CONTRAINDICATIONS

 Delayed closure and/or referral to a hand specialist or orthopedic surgeon may be more appropriate in the following circumstances:

    Severe contamination or acute infection

    Injuries due to human teeth (clenched fist injury or “fight bite”)

    Delayed presentation of injury

    Extensive injury requiring prolonged use of tourniquet (longer than 20–30 minutes)

    Penetration of laceration into a joint capsule

 These cases may be taken to the operating room for surgical exploration, irrigation, and intravenous (IV) antibiotics

RISKS/CONSENT ISSUES

 Pain

 Bleeding

 Infection (theoretical risk of iatrogenic infection)

 Risk of injuring other structures—tendons, vessels, nerves

 Laceration may need to be extended to allow adequate exploration or access to the surgical field

LANDMARKS

The anatomic location of open extensor tendon injuries in the wrist or hand drives treatment decisions and emergency department (ED) management. The Verdan classification system divides the hand and wrist into eight zones (TABLE 51.1 and FIGURE 51.1), which helps determine if tendon repair should be attempted in the ED.

TECHNIQUE

 Preparation

    Remove all rings immediately!

    Radiographs, as indicated, should be employed to assess for associated fracture, foreign body, or joint space disruption

    Place the patient in a comfortable position, preferably supine, with the injury site easily accessible

    Obtain proper lighting to optimize wound exploration, which should include thorough assessment for tendon injury and foreign bodies

    Sterile technique should be employed

    Adequate anesthesia should be administered once the initial neurovascular examination is complete. Lidocaine 1% to 2% with epinephrine can be used in the hand except in areas supplied by end arteries. Local infiltration or an appropriate nerve block can be used.

    The wound should be thoroughly irrigated and free of contamination. Debridement of grossly contaminated tissue may be necessary.

    Good hemostasis is critical to wound exploration and tendon repair

       Elevate the arm for 1 minute to facilitate drainage of blood before applying a tourniquet

       Inflate a blood pressure cuff to 260 to 280 mm Hg and clamp the cuff tubes to avoid air leak, or use commercial tourniquets for arm or finger

       Apply the tourniquet for no longer than 20 minutes

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