SCIENTIFIC ARTICLE
Delayed Reconstruction of a Flexor Digitorum Profundus Tendon Lacerated During Cesarean Delivery: Case Report Nina Lightdale-Miric, MD, Stephanie Iantorno, BA, Erin Meisel, MD We present a case of primary tendon grafting in a 14-month-old infant for an index finger flexor digitorum profundus tendon laceration sustained during cesarean section with excellent functional results at 2-year follow-up. (J Hand Surg Am. 2014;39(12):2464e2467. Copyright Ó 2014 by the American Society for Surgery of the Hand. All rights reserved.) Key words Cesarean delivery, flexor tendon laceration, pediatric hand surgery, tendon repair.
T
occurs in approximately 1 out of every 5,000 cesarean deliveries.1 Perinatal finger flexor tendon lacerations make up a small proportion of these injuries and clinical guidelines for timing and repair technique in these cases have not been established. Outside the perinatal period, immediate tendon repair has been established as the reference standard for treating pediatric tendon injuries2 and the literature describes successful early operative intervention in newborns.3 However, clinical presentation can be delayed by failure to recognize the extent of an injury, because early definitive diagnosis by clinical examination can be difficult in a newborn. There are 3 case reports of flexor tendon lacerations sustained during cesarean delivery. Kavouksorian and Noone4 reported a primary flexor tendon repair performed 10 days after cesarean birth with good to excellent results at 5 months’ follow-up. Littler3 referenced 2 cases of flexor tendons severed during cesarean delivery. Two-stage tendon grafting using silicone rods RAUMA TO THE UPPER EXTREMITY
From the Children’s Orthopaedic Center, Children’s Hospital Los Angeles, Los Angeles, CA. Received for publication February 17, 2014; accepted in revised form August 15, 2014. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Nina Lightdale-Miric, MD, Department of Orthopaedic Surgery, Children’s Hospital Los Angeles/USC Keck School of Medicine, 4650 Sunset BoulevardeMS 69, Los Angeles, CA 90027; e-mail: [email protected]. 0363-5023/14/3912-0018$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.08.018
2464
r
Ó 2014 ASSH
r
Published by Elsevier, Inc. All rights reserved.
was done in one patient at 5 months of age and in the other at 18 months. Littler noted excellent functional results in both cases despite litigious complications. Two articles describe similar injuries to extensor tendons that were both fixed without grafting.1,5 The unique anatomy of the finger flexor mechanism requires distinct considerations during repair to avoid adhesions and joint stiffness. Limits to the timing of delayed tendon repair and the use of intrasynovial or extrasynovial primary or staged grafting technique have not been established. We present a successful case of delayed primary single-stage extrasynovial tendon grafting in a 14-month-old infant for an isolated unrepaired index finger flexor digitorum profundus (FDP) tendon laceration sustained during cesarean delivery. CASE REPORT A healthy 1-month-old boy presented to an outside hand surgeon for an evaluation regarding a right index finger laceration sustained during cesarean section delivery. The patient was a twin born at full term after an uncomplicated pregnancy. No surgical interventions were made with regard to the laceration at the time of birth. The volar wound was dressed with adhesive strips and healed without complication. X-rays were unremarkable. The parents sought a hand surgery specialist consultation at one month because they noticed the child’s index finger was always resting in extension at the distal interphalangeal (DIP) joint. The specialist recommended surgery but the child did not return, for unclear reasons.
FDP TENDON LACERATED DURING CESAREAN
2465
FIGURE 1: Index finger in a 14-month-old boy. A Preoperative resting posture of the index finger in extension at the DIP joint with healed laceration (arrow). B Intraoperative graft. C Postoperative position.
The child was 5 months old when he presented to the senior author’s (N.L.-M.’s) hand surgery clinic. Initial physical examination demonstrated a wellhealed oblique scar over the volar aspect of the DIP joint of the right index finger. All fingers were pink with brisk capillary refill. The patient was able to fully actively flex and extend at the metacarpophalangeal and proximal interphalangeal joints. He demonstrated passive range of motion at the DIP joint from 0 to 10 flexion. There was no active flexion at the DIP joint and it was held in full extension (0 ) (Fig. 1). Because of the lack of passive range of motion, the patient received therapy consisting of passive range of motion exercises, stretching, and scar massage. The patient was asked to return to the surgeon’s office 6 weeks later for re-examination of both active and passive range of motion and for optimization of range of motion in anticipation of surgery. The patient was lost to follow-up and then returned to the author’s clinic at 1 year of age with persistent deficiency of the FDP tendon to the right index finger. The parents had been performing passive motion exercises, and now there was 45 of passive flexion at the DIP joint. The proximal interphalangeal joint continued to fully flex actively and without triggering. After informed consent was confirmed, the child was scheduled for surgical exploration for possible delayed primary repair, primary tendon grafting, or staged tendon grafting. At 14 months of age, the child underwent surgical intervention under general anesthesia. We made a modified Brunner incision on the volar aspect of the DIP joint. The radial and ulnar digital neurovascular bundles were intact and exhibited a normal pattern of trifurcation at the level of the DIP joint. The flexor digitorum superficialis tendon was present. There was no evidence of the FDP tendon within the finger other than the distal stump, which was approximately 3 mm in diameter and remained attached to the distal J Hand Surg Am.
r
phalanx. Using serial dilators, the A4 pulley was expanded. The initial incision was extended to the level of the carpal tunnel but there was still no evidence of the FDP tendon. The incision was again extended proximal to the wrist with a triangular flap at the wrist crease to avoid contracture. The proximal end of the FDP had retracted into the forearm and was identified by the presence of an attached lumbrical muscle. After releasing mild adhesions between it and the adjacent FDP tendons in the distal forearm, gentle traction on the tendon still allowed for its passage through the carpal tunnel to the level of the vascular palmar arch. Based on this limited excursion, as well as the availability of a palmaris longus tendon in the surgical field, it was decided to use a tendon graft. The palmaris longus tendon was identified at the wrist crease and harvested through a transverse incision approximately 6 cm proximal to the volar wrist crease and through an additional incision near its musculotendinous junction. One end of the graft was woven into the proximal stump of the FDP tendon and secured with 2 horizontal 4-0 nonabsorbable sutures. The distal aspect was passed between the chiasm of the flexor digitorum superficialis tendon and beneath the A2 and A4 pulleys (Fig. 1). The graft was then sewn into the distal stump of the profundus tendon at the distal phalanx with a 4-strand cruciate suture and an epitendinous 6-0 suture. A 20gauge needle was placed in the graft at the level of the proximal phalanx to hold the graft in place while the distal repair was performed. Once the distal repair was performed, the needle was removed and a wrist tenodesis test confirmed appropriate tension. The skin incision in the finger was closed with 5-0 chromic gut sutures (Fig. 1). The transverse incisions at the wrist and forearm were closed with inverted 4-0 and running 4-0 absorbable sutures. The patient was placed in a long arm cast past the fingertips in flexion Vol. 39, December 2014
2466
FDP TENDON LACERATED DURING CESAREAN
FIGURE 2: Postoperative hand at 2 years, demonstrating A full active extension with well-developed DIP flexion crease and B highlevel pincer function and DIP joint active flexion.
at the metacarpophalangeal, proximal interphalangeal, and DIP joints. The cast was removed after 4 weeks and the child was placed in a dorsal blocking supportive wrist orthosis to be worn full time. Hand therapy followed a passive motion pediatric flexor tendon repair protocol. At 5 weeks, the parents were instructed to begin place and hold exercises at home. The patient continued to use the wrist orthosis full time. At 7 weeks, the hand therapist began a graded strengthening program and encouraged normal use of the finger at home. Use of the wrist orthosis was discontinued at 10 weeks. By 3 months after surgery, the patient was able to pick up small objects and pinch with the right index finger. He had maintained full active range of motion at the metacarpophalangeal and proximal interphalangeal joints. Active DIP motion was from 0 to 30 . The surgeon advised continued use of an orthosis at night and provided a detailed home therapy program with strengthening exercises to advance recovery. By 2 years’ follow-up, the patient had a welldeveloped DIP joint crease (Fig. 2) and demonstrated active DIP joint flexion from 0 to 50 and strong force of DIP joint flexion to resistance. DISCUSSION Sharp flexor tendon lacerations sustained at the time of cesarean section exist along a spectrum of trauma from superficial injury to complete digit amputation. Immediate injury assessment of digit viability, need for revascularization, or wound closure is often the extent of the primary triage. Diagnosis of finger J Hand Surg Am.
r
tendon and incomplete neurovascular injury can be delayed. The current surgical consensus, with which we agree, maintains that primary, expeditious repair is the preferred operative treatment in children.8 Deferred repair of flexor tendons can lead to challenges to reconstruction such as collapse or developmental loss of the retinacular pulley system, compromising the restorative effect. Musculotendinous atrophy may also occur.3 In newborns, however, immediate repair of the flexor tendons is not always feasible or preferable. For cases in which injured children present late (outside the conventional 6-wk window for primary tendon repair), already have joint stiffness, or are not healthy enough to undergo surgical procedures, delayed surgical intervention can offer excellent outcomes and distinct advantages. In our case, the extent of flexor tendon injury sustained at birth was unrecognized until the patient presented at one month of age to a specialist. Although the specialist recommended surgery, the family sought a second opinion that resulted in an additional delay of 4 months. At this time, owing to stiffness in the DIP joint, the author surgeon primarily recommended therapy to gain passive motion. Follow-up was set for 6 weeks after weekly hand therapy appointments and home exercise. However, the next clinical visit was instead 7 months later. Although passive range of motion had been achieved, no active motion was unmasked. Surgical exploration was now more strongly indicated and the patient’s family was receptive to this recommendation. Although it presents additional reconstructive challenges, performing surgery in a child greater than 1 year of age has benefits. For example, tendons and Vol. 39, December 2014
FDP TENDON LACERATED DURING CESAREAN
neurovascular structures are larger. In addition, delaying surgery decreases the neurotoxicity risks associated with early neonatal exposure to anesthesia.6 Finally, older children can more participate actively in their postoperative therapy regimen because grasp and pinch do not develop fully until approximately 1 year of age.7 In the described case, the patient obtained preoperative passive DIP joint motion, a clear distal pulley was identified, and the injury was isolated to the FDP with an intact flexor digitorum superficialis. Primary flexor tendon grafting should be possible for patients with minimal scarring, a supple joint, no contractures or trophic changes, and intact pulleys.9 If these criteria are not met, preoperative hand therapy and/or a 2-staged operation may be required. Staged procedures with pulley reconstruction and silicone rods would also likely be needed in more proximal injuries including both superficial and deep tendons. If an inadequate distal stump had been present in our case, repair over a button would have been necessary. In addition, the graft was sewn in proximally and passed through the pulleys, and a 20-gauge needle was placed in the graft at the level of the proximal phalanx to hold the graft in place while the distal repair was performed. After the distal stitching was placed, the needle holding the graft in tension was removed. The integrity of the distal repair was tested with gentle extension and tenodesis confirmed appropriate tension. This technique was not ideal for setting the tension on the DIP joint; repairing the graft to the distal stump or button, passing the graft distally to proximally through the pulleys, and tensioning the graft in DIP flexion while performing the Pulvertaft weave proximally is the generally accepted order of repair. However, at the time of surgery, there was initial concern regarding distal stump length and integrity, and the we thought that setting tension distally to proximally might pull too hard on the distal repair. The plan was to convert to a button if the distal stump could not handle the tension; however, this was not necessary.
J Hand Surg Am.
r
2467
Described postoperative protocols in children after tendon repair include casting followed by immediate return to unrestricted range of motion,10 but pediatric hand therapists at our hospital work extensively with these children after cast removal and encourage a home program of progressive passive and active range of motion guided by a delayed start of the modified Duran protocol. It is not always possible for young children to wear orthoses and participate in therapy consistently; however, in this case, pediatric hand therapists effectively guided and monitored this child’s recovery. The child described in this case report achieved excellent functional results and surgeons consulted for delayed repair should be encouraged that successful late reconstruction is possible. Future studies are needed to determine the true incidence of newborns with finger flexor lacerations and gain more insight into limits of delayed reconstruction and indications for primary versus staged procedures. REFERENCES 1. Rinker B. Extensor tendon injury during cesarean delivery. J Hand Surg Am. 2011;36(1):125e128. 2. Amadio PC. Staged flexor tendon reconstruction in children. Ann Chir Main Memb Super. 1992;11(3):194e199. 3. Littler JW. The digital extensor-flexor system. In: Converse JM, ed. Reconstructive Plastic Surgery. 2nd ed. Philadelphia, PA: Saunders; 1977:3191e3192. 4. Kavouksorian CA, Noone RB. Flexor tendon repair in the neonate. Ann Plast Surg. 1982;9(5):415e418. 5. Fuller DA, Raphael JS. Extensor tendon lacerations in a preterm neonate. J Hand Surg Am. 1999;24(3):628e632. 6. Sanders RD, Hassell J, Davidson AJ, Robertson NJ, Ma D. Impact of anaesthetics and surgery on neurodevelopment: an update. Br J Anaesth. 2013;110(suppl 1):i53ei72. 7. Erhart RP. Sequential levels in development of prehension. Am J Occup Ther. 1974;28(10):592e596. 8. Darlis NA, Beris AE, Korompilias AV. Two-stage flexor tendon reconstruction in zone 2 of the hand in children. J Pediatr Orthop. 2005;25(3):382e386. 9. Boyes JH. Flexor tendon grafts in the fingers and thumb: an evaluation of end results. J Bone Joint Surg Am. 1950;32(3):489e499. 10. Nietosvaara YL, Lindfors NC, Palmu S, Rautakorpi S, Ristaniemi N. Flexor tendon injuries in pediatric patients. J Hand Surg Am. 2007;32(10):1549e1557.
Vol. 39, December 2014
Delayed Reconstruction of a Flexor Digitorum Profundus Tendon Lacerated During Cesarean Delivery: Case Report Nina Lightdale-Miric, MD, Stephanie Iantorno, BA, Erin Meisel, MD We present a case of primary tendon grafting in a 14-month-old infant for an index finger flexor digitorum profundus tendon laceration sustained during cesarean section with excellent functional results at 2-year follow-up. (J Hand Surg Am. 2014;39(12):2464e2467. Copyright Ó 2014 by the American Society for Surgery of the Hand. All rights reserved.) Key words Cesarean delivery, flexor tendon laceration, pediatric hand surgery, tendon repair.
T
occurs in approximately 1 out of every 5,000 cesarean deliveries.1 Perinatal finger flexor tendon lacerations make up a small proportion of these injuries and clinical guidelines for timing and repair technique in these cases have not been established. Outside the perinatal period, immediate tendon repair has been established as the reference standard for treating pediatric tendon injuries2 and the literature describes successful early operative intervention in newborns.3 However, clinical presentation can be delayed by failure to recognize the extent of an injury, because early definitive diagnosis by clinical examination can be difficult in a newborn. There are 3 case reports of flexor tendon lacerations sustained during cesarean delivery. Kavouksorian and Noone4 reported a primary flexor tendon repair performed 10 days after cesarean birth with good to excellent results at 5 months’ follow-up. Littler3 referenced 2 cases of flexor tendons severed during cesarean delivery. Two-stage tendon grafting using silicone rods RAUMA TO THE UPPER EXTREMITY
From the Children’s Orthopaedic Center, Children’s Hospital Los Angeles, Los Angeles, CA. Received for publication February 17, 2014; accepted in revised form August 15, 2014. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Nina Lightdale-Miric, MD, Department of Orthopaedic Surgery, Children’s Hospital Los Angeles/USC Keck School of Medicine, 4650 Sunset BoulevardeMS 69, Los Angeles, CA 90027; e-mail: [email protected]. 0363-5023/14/3912-0018$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.08.018
2464
r
Ó 2014 ASSH
r
Published by Elsevier, Inc. All rights reserved.
was done in one patient at 5 months of age and in the other at 18 months. Littler noted excellent functional results in both cases despite litigious complications. Two articles describe similar injuries to extensor tendons that were both fixed without grafting.1,5 The unique anatomy of the finger flexor mechanism requires distinct considerations during repair to avoid adhesions and joint stiffness. Limits to the timing of delayed tendon repair and the use of intrasynovial or extrasynovial primary or staged grafting technique have not been established. We present a successful case of delayed primary single-stage extrasynovial tendon grafting in a 14-month-old infant for an isolated unrepaired index finger flexor digitorum profundus (FDP) tendon laceration sustained during cesarean delivery. CASE REPORT A healthy 1-month-old boy presented to an outside hand surgeon for an evaluation regarding a right index finger laceration sustained during cesarean section delivery. The patient was a twin born at full term after an uncomplicated pregnancy. No surgical interventions were made with regard to the laceration at the time of birth. The volar wound was dressed with adhesive strips and healed without complication. X-rays were unremarkable. The parents sought a hand surgery specialist consultation at one month because they noticed the child’s index finger was always resting in extension at the distal interphalangeal (DIP) joint. The specialist recommended surgery but the child did not return, for unclear reasons.
FDP TENDON LACERATED DURING CESAREAN
2465
FIGURE 1: Index finger in a 14-month-old boy. A Preoperative resting posture of the index finger in extension at the DIP joint with healed laceration (arrow). B Intraoperative graft. C Postoperative position.
The child was 5 months old when he presented to the senior author’s (N.L.-M.’s) hand surgery clinic. Initial physical examination demonstrated a wellhealed oblique scar over the volar aspect of the DIP joint of the right index finger. All fingers were pink with brisk capillary refill. The patient was able to fully actively flex and extend at the metacarpophalangeal and proximal interphalangeal joints. He demonstrated passive range of motion at the DIP joint from 0 to 10 flexion. There was no active flexion at the DIP joint and it was held in full extension (0 ) (Fig. 1). Because of the lack of passive range of motion, the patient received therapy consisting of passive range of motion exercises, stretching, and scar massage. The patient was asked to return to the surgeon’s office 6 weeks later for re-examination of both active and passive range of motion and for optimization of range of motion in anticipation of surgery. The patient was lost to follow-up and then returned to the author’s clinic at 1 year of age with persistent deficiency of the FDP tendon to the right index finger. The parents had been performing passive motion exercises, and now there was 45 of passive flexion at the DIP joint. The proximal interphalangeal joint continued to fully flex actively and without triggering. After informed consent was confirmed, the child was scheduled for surgical exploration for possible delayed primary repair, primary tendon grafting, or staged tendon grafting. At 14 months of age, the child underwent surgical intervention under general anesthesia. We made a modified Brunner incision on the volar aspect of the DIP joint. The radial and ulnar digital neurovascular bundles were intact and exhibited a normal pattern of trifurcation at the level of the DIP joint. The flexor digitorum superficialis tendon was present. There was no evidence of the FDP tendon within the finger other than the distal stump, which was approximately 3 mm in diameter and remained attached to the distal J Hand Surg Am.
r
phalanx. Using serial dilators, the A4 pulley was expanded. The initial incision was extended to the level of the carpal tunnel but there was still no evidence of the FDP tendon. The incision was again extended proximal to the wrist with a triangular flap at the wrist crease to avoid contracture. The proximal end of the FDP had retracted into the forearm and was identified by the presence of an attached lumbrical muscle. After releasing mild adhesions between it and the adjacent FDP tendons in the distal forearm, gentle traction on the tendon still allowed for its passage through the carpal tunnel to the level of the vascular palmar arch. Based on this limited excursion, as well as the availability of a palmaris longus tendon in the surgical field, it was decided to use a tendon graft. The palmaris longus tendon was identified at the wrist crease and harvested through a transverse incision approximately 6 cm proximal to the volar wrist crease and through an additional incision near its musculotendinous junction. One end of the graft was woven into the proximal stump of the FDP tendon and secured with 2 horizontal 4-0 nonabsorbable sutures. The distal aspect was passed between the chiasm of the flexor digitorum superficialis tendon and beneath the A2 and A4 pulleys (Fig. 1). The graft was then sewn into the distal stump of the profundus tendon at the distal phalanx with a 4-strand cruciate suture and an epitendinous 6-0 suture. A 20gauge needle was placed in the graft at the level of the proximal phalanx to hold the graft in place while the distal repair was performed. Once the distal repair was performed, the needle was removed and a wrist tenodesis test confirmed appropriate tension. The skin incision in the finger was closed with 5-0 chromic gut sutures (Fig. 1). The transverse incisions at the wrist and forearm were closed with inverted 4-0 and running 4-0 absorbable sutures. The patient was placed in a long arm cast past the fingertips in flexion Vol. 39, December 2014
2466
FDP TENDON LACERATED DURING CESAREAN
FIGURE 2: Postoperative hand at 2 years, demonstrating A full active extension with well-developed DIP flexion crease and B highlevel pincer function and DIP joint active flexion.
at the metacarpophalangeal, proximal interphalangeal, and DIP joints. The cast was removed after 4 weeks and the child was placed in a dorsal blocking supportive wrist orthosis to be worn full time. Hand therapy followed a passive motion pediatric flexor tendon repair protocol. At 5 weeks, the parents were instructed to begin place and hold exercises at home. The patient continued to use the wrist orthosis full time. At 7 weeks, the hand therapist began a graded strengthening program and encouraged normal use of the finger at home. Use of the wrist orthosis was discontinued at 10 weeks. By 3 months after surgery, the patient was able to pick up small objects and pinch with the right index finger. He had maintained full active range of motion at the metacarpophalangeal and proximal interphalangeal joints. Active DIP motion was from 0 to 30 . The surgeon advised continued use of an orthosis at night and provided a detailed home therapy program with strengthening exercises to advance recovery. By 2 years’ follow-up, the patient had a welldeveloped DIP joint crease (Fig. 2) and demonstrated active DIP joint flexion from 0 to 50 and strong force of DIP joint flexion to resistance. DISCUSSION Sharp flexor tendon lacerations sustained at the time of cesarean section exist along a spectrum of trauma from superficial injury to complete digit amputation. Immediate injury assessment of digit viability, need for revascularization, or wound closure is often the extent of the primary triage. Diagnosis of finger J Hand Surg Am.
r
tendon and incomplete neurovascular injury can be delayed. The current surgical consensus, with which we agree, maintains that primary, expeditious repair is the preferred operative treatment in children.8 Deferred repair of flexor tendons can lead to challenges to reconstruction such as collapse or developmental loss of the retinacular pulley system, compromising the restorative effect. Musculotendinous atrophy may also occur.3 In newborns, however, immediate repair of the flexor tendons is not always feasible or preferable. For cases in which injured children present late (outside the conventional 6-wk window for primary tendon repair), already have joint stiffness, or are not healthy enough to undergo surgical procedures, delayed surgical intervention can offer excellent outcomes and distinct advantages. In our case, the extent of flexor tendon injury sustained at birth was unrecognized until the patient presented at one month of age to a specialist. Although the specialist recommended surgery, the family sought a second opinion that resulted in an additional delay of 4 months. At this time, owing to stiffness in the DIP joint, the author surgeon primarily recommended therapy to gain passive motion. Follow-up was set for 6 weeks after weekly hand therapy appointments and home exercise. However, the next clinical visit was instead 7 months later. Although passive range of motion had been achieved, no active motion was unmasked. Surgical exploration was now more strongly indicated and the patient’s family was receptive to this recommendation. Although it presents additional reconstructive challenges, performing surgery in a child greater than 1 year of age has benefits. For example, tendons and Vol. 39, December 2014
FDP TENDON LACERATED DURING CESAREAN
neurovascular structures are larger. In addition, delaying surgery decreases the neurotoxicity risks associated with early neonatal exposure to anesthesia.6 Finally, older children can more participate actively in their postoperative therapy regimen because grasp and pinch do not develop fully until approximately 1 year of age.7 In the described case, the patient obtained preoperative passive DIP joint motion, a clear distal pulley was identified, and the injury was isolated to the FDP with an intact flexor digitorum superficialis. Primary flexor tendon grafting should be possible for patients with minimal scarring, a supple joint, no contractures or trophic changes, and intact pulleys.9 If these criteria are not met, preoperative hand therapy and/or a 2-staged operation may be required. Staged procedures with pulley reconstruction and silicone rods would also likely be needed in more proximal injuries including both superficial and deep tendons. If an inadequate distal stump had been present in our case, repair over a button would have been necessary. In addition, the graft was sewn in proximally and passed through the pulleys, and a 20-gauge needle was placed in the graft at the level of the proximal phalanx to hold the graft in place while the distal repair was performed. After the distal stitching was placed, the needle holding the graft in tension was removed. The integrity of the distal repair was tested with gentle extension and tenodesis confirmed appropriate tension. This technique was not ideal for setting the tension on the DIP joint; repairing the graft to the distal stump or button, passing the graft distally to proximally through the pulleys, and tensioning the graft in DIP flexion while performing the Pulvertaft weave proximally is the generally accepted order of repair. However, at the time of surgery, there was initial concern regarding distal stump length and integrity, and the we thought that setting tension distally to proximally might pull too hard on the distal repair. The plan was to convert to a button if the distal stump could not handle the tension; however, this was not necessary.
J Hand Surg Am.
r
2467
Described postoperative protocols in children after tendon repair include casting followed by immediate return to unrestricted range of motion,10 but pediatric hand therapists at our hospital work extensively with these children after cast removal and encourage a home program of progressive passive and active range of motion guided by a delayed start of the modified Duran protocol. It is not always possible for young children to wear orthoses and participate in therapy consistently; however, in this case, pediatric hand therapists effectively guided and monitored this child’s recovery. The child described in this case report achieved excellent functional results and surgeons consulted for delayed repair should be encouraged that successful late reconstruction is possible. Future studies are needed to determine the true incidence of newborns with finger flexor lacerations and gain more insight into limits of delayed reconstruction and indications for primary versus staged procedures. REFERENCES 1. Rinker B. Extensor tendon injury during cesarean delivery. J Hand Surg Am. 2011;36(1):125e128. 2. Amadio PC. Staged flexor tendon reconstruction in children. Ann Chir Main Memb Super. 1992;11(3):194e199. 3. Littler JW. The digital extensor-flexor system. In: Converse JM, ed. Reconstructive Plastic Surgery. 2nd ed. Philadelphia, PA: Saunders; 1977:3191e3192. 4. Kavouksorian CA, Noone RB. Flexor tendon repair in the neonate. Ann Plast Surg. 1982;9(5):415e418. 5. Fuller DA, Raphael JS. Extensor tendon lacerations in a preterm neonate. J Hand Surg Am. 1999;24(3):628e632. 6. Sanders RD, Hassell J, Davidson AJ, Robertson NJ, Ma D. Impact of anaesthetics and surgery on neurodevelopment: an update. Br J Anaesth. 2013;110(suppl 1):i53ei72. 7. Erhart RP. Sequential levels in development of prehension. Am J Occup Ther. 1974;28(10):592e596. 8. Darlis NA, Beris AE, Korompilias AV. Two-stage flexor tendon reconstruction in zone 2 of the hand in children. J Pediatr Orthop. 2005;25(3):382e386. 9. Boyes JH. Flexor tendon grafts in the fingers and thumb: an evaluation of end results. J Bone Joint Surg Am. 1950;32(3):489e499. 10. Nietosvaara YL, Lindfors NC, Palmu S, Rautakorpi S, Ristaniemi N. Flexor tendon injuries in pediatric patients. J Hand Surg Am. 2007;32(10):1549e1557.
Vol. 39, December 2014
