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The "button over the nail" is the most commonly used technique in order to re-insert the flexor digitorum profundus tendon into the distal phalanx in the management of Zone 1 injuries. Recent evidence in the literature has highlighted an associated morbidity with the technique. In this study, 37 patients were identified that had been treated using the "button technique", for which outcome data is collected by hand therapists as part of a prospective flexor tendon injury audit. Retrospective case note review was performed to determine incidence of post-operative surgical complications.

There were limited complications with the use of the "button technique" overall. However, functional outcome when compared to other studies are relatively poor with mean range of motion at the distal interphalangeal joint being 37.5 degrees. The authors would recommend any decision to change technique for the management of these injuries should consider functional outcome in the presence of a low surgical complication rate.

Eighty-two patients who were treated by suture repair for Zone I flexor tendon injuries over a ten-year period were identified, to determine the incidence of post-operative surgical complications and subsequent re-operations.

Eighty-five percent of patients completed 12 weeks follow-up post-surgery. Of these patients almost all had good to excellent outcome in terms of total active movement (TAM). However when assessing the range of motion at the distal interphalangeal joint (DIPJ), only 23% could be classified as having good or excellent results at final follow-up. A total of six patients (7.32%) required surgery for tendon repair complications.

This study illustrates that DIPJ ROM is more indicative of functional recovery after tendon repair in flexor Zone I. Given the DIPJ is important in providing a fine pinch and a span pinch grip movements, patients should be counselled for inability to perform these functions post-tendon repair.

Due to its mostly motor content, repair of the radial nerve is considered to yield favourable results. This is despite the fact that there are limited studies looking at the outcomes of end-to-end repair secondary to sharp penetrating trauma. We retrospectively reviewed the outcome of a series of repaired level 2 and level 3 radial nerves following penetrating stab injuries. Twenty-seven cases with adequate follow-up were included. All the patients underwent direct end-to-end repair. We evaluated the motor recovery of the target muscles using the British Medical Research Council (MRC) grading system. Wrist extension recovered in 93% of cases at a mean of six months. Finger extension recovered in 74% and thumb extension in 52% of cases within the follow-up period. We conclude that end-to-end repair is possible in the majority of level 2 and level 3 radial nerve lacerations secondary to penetrating stab injuries. Acceptable results can be expected.

Background: Surgical repair is advocated for flexor tendon lacerations deeper than 70%. Repair can be undertaken with different suturing techniques and using different materials. Different materials used for tendon repair will have a different gliding resistance (GR) at the joint. Previous studies have compared strength of repair and gliding resistance for various braided suture materials and for 100% laceration of flexor tendons. We directly compare the GR of two monofilament sutures when used for a peripheral running suture repair of partially lacerated tendons.

Methods: Sixteen flexor tendons and A2 pulleys were harvested from Turkey feet. They were prepared, partially lacerated to 50% depth, and then repaired with a core suture (modified Kessler technique with 4-0 Ethibond) as well as an additional superficial running suture of either 6-0 Prolene or Nylon (half randomised to each). Gliding resistance was measured for all tendons before and after repair, at different flexion angles (40 and 60 degrees) and for different loads (2N and 4N).

Results: After surgical repair, gliding resistance was increased for all tendons (P < 0.01). The tendons repaired with Prolene had a higher mean gliding resistance than those repaired with Nylon (P = 0.02). Increased flexion angle and load amplified the gliding resistance (both P < 0.01).

Conclusions: 6-0 Nylon was associated with a lower gliding resistance than 6-0 Prolene but the minor differences bare unknown clinical significance.

Background: The objective was to study the hypotheses that an advanced zone II flexor tendon rehabilitation protocol would avoid rupture, achieve a high range of excursion, and minimize interphalangeal contracture during both the early phases and at the conclusion of healing. We also proposed the null hypothesis of no difference between any two of the zone II subdivisions.

Methods: Fifty-one consecutive adult patients with zone II flexor tendon repairs of a single finger were retrospectively evaluated on an active contraction rehabilitation protocol with no splint, no tenodesis protection, and immediate full composite extension. There were 38 males and 13 females with a mean age of 39 years (range 18–69) involving 15 index, 7 long, 6 ring, and 23 small fingers. Repairs were located in flexor subzone IIA for 8 fingers; subzone IIB, 14; subzone IIC, 19; and subzone IID, 10. Differences in outcome between any two subzones were compared by T-test with p < 0.05.

Results: Mean active arcs of motion in degrees at 3 weeks post repair were PIP 1-93; DIP 0-44; and total active motion (TAM) 221. At 6 weeks PIP 2–98; DIP 1–51; and TAM 236. At 10–12 weeks PIP 1–101; DIP 1–56; and TAM 246. Final TAM by flexor subzone IIA was 243; IIB, 251; IIC, 246; and IID, 246. There were no significant differences between any two subzones. Mean final DASH score was 5. There were no ruptures.

Conclusions: The results support the hypotheses. Outcomes of the therapy protocol demonstrated the lack of interphalangeal joint flexion contractures, high range of total active motion achieved early and sustained, and no ruptures. No differences were identified between and two of the flexor subzones.

We report a case of complete laceration of both flexor tendons in the dominant ring finger of a young male caused by a closed volar fracture fragment of the proximal phalanx. Careful clinical examination, reasonable index of suspicion and ultrasound confirmation play a pivotal role in the diagnosis and surgical planning of this rare yet consequential injury. Good outcomes can be achieved from the surgical management and rehabilitation of both soft tissue and bony injuries when planning of surgical approaches and fixation techniques are facilitated by an accurate pre-operative diagnosis.

Background: Finger injuries caused by green onion cutting machines in Korean kitchens have unique characteristics of an incomplete amputation in which multiple parallel soft tissues and blood vessels are injured in the same form. In this study, we aimed to describe unique finger injuries and to report the treatment outcomes and experiences of performing possible soft tissue reconstructions.

Methods: This case series study included 65 patients (82 fingers) from December 2011 to December 2015. The mean age was 50.5 years. We retrospectively classified the presence of fractures and the degree of damage in patients. The injured area involvement level was categorised as distal, middle or proximal. The direction was categorised as sagittal, coronal, oblique or transverse. The treatment results were compared according to the amputation direction and injury area.

Results: Of the 65 patients, 35 had a partial finger necrosis and needed additional surgeries. Finger reconstructions were performed through stump revision or local or free flap use. The survival rate was significantly lower in patients with fractures. As for the injury area, distal involvement led to 17 out of 57 patients displaying necrosis and all 5 patients showing the same in proximal involvement.

Conclusions: Unique finger injuries caused by green onion cutting machines can easily be treated with simple sutures. Then prognosis is affected by the extent of injury and the presence of fractures. Reconstruction is necessary for finger necrosis owing to extensive blood vessel damage and limitations when making this selection.

Level of Evidence: Level IV (Therapeutic)

Background: Treatment of muscle belly lacerations remains a problem for surgeons. Inadequate repair of lacerations can cause functional disability. To date, there is no consensus on the method of repair for these injuries. We have previously described a technique of repairing mid-substance muscle belly lacerations. The aim of this study was to determine the ultimate strength of an intact muscle belly and to compare the anchor suture (AS) technique with the modified Kessler (MK) technique.

Methods: Fifteen fresh frozen hind-legs from adolescent pigs were divided into three groups and used for the testing. Each group consisted of five specimens. Group one was the intact control group, group two was repaired with the MK technique and group three was repaired with the AS technique. Following repair, the muscles were secured in a custom-made fixation apparatus and underwent linear tensioning at a rate of 25 mm/min, generating a load-displacement curve for each specimen. The data regarding ultimate strength, modes of failure and number of intact suture/anchor constructs (for groups 2 and 3) was calculated.

Results: The ultimate strength of the intact muscle group of was found to be 608.1 ± 107.9  N. This was significantly (p < 0.05) higher than the pull-out strength of the MK and AS groups. The pull-out strength of the AS group was 143.1 ± 36.7 N, nearly twice that of the MK group 69.8 ± 16.4 N (p = 0.11). Suture pull-out was the most common mode of failure.

Conclusions: The AS technique was found to have both higher strain and nearly twice the ultimate pull-out strength compared to the MK repair group. We suggest the AS technique as a viable technique for mid-substance muscle belly repairs.