Thumb Extensor Tendon Laceration Repair

CHAPTER 1

This is a case of a laceration of the thumb dorsally presenting with a likely extensor tendon laceration requiring surgical exploration and repair. The surgery will be performed under a local anesthesia in a wide awake hand surgery fashion without the use of tourniquet. The surgical site will be infiltrated with lidocaine with epinephrine, buffered with bicarbonate. The initial injection will consist of 9 cc of 1% lidocaine with epinephrine and 1 cc of 4.2% bicarbonate. This can be readily diluted down as needed in order to anesthetize the surgical field for surgical intervention. This WALANT technique is not only safer and cheaper and more convenient for the patient, but also allows us as a surgeon to be able to test our repair to make sure the repair is adequate and sound.

CHAPTER 2

With the patient awake in the operating room, the surgical site infiltrated, the laceration is opened and blunt dissection down to the level of injury confirms a complete extensor tendon laceration.

CHAPTER 3

Like the flexor tendons, A number of suture repair techniques are available for extensor tendons. In this case, a modified Kessler repair will be reinforced with figure-of-eight sutures. Here you can see the tendon edges exposed. The proximal Kessler suture has already been placed, and now the distal Kessler is being placed. A modified Kessler stitch can be performed with a single suture or with two sutures as being demonstrated here. Care is taken while placing the suture, not to catch any deep structures such as the periosteum and/or the joint capsule, so there's good excursion of the tendon upon repair. With both ends tagged with a modified Kessler suture, both tendon edges are stressed, first to make sure that there's good excursion and mobilization of the tendon, as well as to make sure that there is a good bite of our sutures within the tendon on both ends. Next, both pairs of suture ends are then sewed down in a sequential manner as demonstrated here until satisfactory contact between the tendon edges are confirmed. Once the two core sutures and knots have been placed, the tendon repair is now reinforced with additional figure-of-eight sutures.

Here, a total three figure-of-eights are placed around the core suture repair. Of note, the repair is being performed with 3-0 Ethibond.

CHAPTER 4

This is the appearance of the final tendon repair construct. Finally, and most importantly, the integrity of the repair is tested by having the patient actively extend the finger or thumb in this case to confirm maintenance of integrity of the repair and full tendon excursion and extension.

CHAPTER 5

Once satisfied, the wound is washed and closed. In this case, the wound is being closed with simple 4-0 chromic sutures.

CHAPTER 6

With the wound closed and the repair being protected by an assistant, the dressing is applied. A splint is also applied. In this case, I apply what I refer to as a "thumb's up" splint, or also known as a reverse thumb spica splint. The postoperative course consists of early immobilization. Unlike flexor tendons, which we move quickly, extension tendons, we can move slower. In this case, I'll immobilize the patient for approximately two to four weeks in this thumb's up splint with the repair site immobilized without tension. Thereafter the splint is applied, A removable splint is prescribed, and formal therapy with a hand therapist is also prescribed for the next six to eight weeks. Total recovery time is typically, for these injuries and repairs, about 8-12 weeks. Here you can see application of the thumb's up splint, or the reverse thumb spica splint, which captures the volar pulp of the thumb, maintaining it in full extension, and countering active thumb IP flexion. Thank you.