Flexor Tendon Lesions in Children

Nikolaos A Darlis, MD, PhD

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Primary Flexor Tendon Repair

Secondary Reconstruction

Infantile Trigger Digits

Flexor Tendon Lacerations

Incidence• 3.6 per 100,000 children

per year• falling on broken glass• zones II or V most

common

Children are different…

• Diagnosis more difficult

• Late presentation more common

• Sensory examination not feasible

Approach

• midlateral incisions not advised in infants and very young children.

•absorbable sutures for skin closure

Strands...

• less than 2 years old: 2-strand– FDP is 2–3 mm wide and 0.5–1 mm thick

•over 5 years old : 4-strand feasible

FDP only repair

• acceptable option in children• without FDS excision

Zone I injuries

• pull-out suture with a button tie-over; proximal to nail bed

Rehabilitation

Immobilization up to 4 weeks tolerated in

young children

Rehabilitation

• Teenagers: as for adult injuries

• Between 5 and 10 years: modified early mobilization under hand therapist supervision, but immobilized between PT sessions

• Pre-schoolers (0–5 years):(above elbow) cast for max of 4 weeks

Inadvertent Grasping• Cast

– Elbow 120° of flexion, forearm in supination, wrist and fingers in flexion

• ‘pulp to palm’ suture before applying the cast

• Toddlers and infants who have just started to walk splint additional 2 weeks

• botulinum toxin type A (50–100 units) to muscle bellies ofinjured tendons+ passive ROM

Tuzuner et al. (2004)

But still…

Primary or Delayed Primary flexor tendon repair in children produces satisfactory results in 72 to 89% of the patients

Vahvanev 1981, Hollwarth 1985, Grobbelaar 1994, O’Connell 1994, Berndtsson 1995,

Fittussi 1999, Kato 2002

Complications

• Compared with adults, adhesions less likely in children

…but not uncommon

• Joint contractures: uncommon

Complications

• Atrophy of the injured finger may affect unrepaired / repaired/ delayed repaired/ reconstructed flexor tendons

• Growth arrest of the distal phalanx in zone 1 injuries

Failed Repair

• Tendon adhesions • Rerupture• Joint contracture (rare)

Flexor tenolysis

• Better if age > 10 yrs• Compliance!

One-stage tendon grafting

• prerequisites: Full passive motion, minimal scarring, intact annular pulleys…

Two-stage flexor tendon grafting (Modified Paneva Technique)

FDPFDS

STAG E II

FDPFDS

S.RRe c o nstruc te d p ulle ys

STAG E I

FDPFDS

Sc a r tissuePre -o p

Stage I

FDPMN

FDS

Stage II

0

1

2

3

4

5

Άριστο Καλό Ικανοποιητικό Πτωχό

Results Buck Gramco scale

Excellent Good Satisfactory Poor

Flexor Tendon Reconstruction in Children

Amadio et al 1988 N=10 80% failure

Αmadio 1992 N=14 50% failure

Valenti & Gilbert 2000

N=22 73% good & excellent13% poor

Darlis & Beris, 2003

N=9 88% good & excellent12% poor

Pediatric Trigger Thumb

• 0.3-2.2% of all congenital upper extremity anomalies• 3.3/1000 live births @ 1 year of age

• either with a fixed contracture of interphalangeal (IP) joint or clicking or snapping of the thumb IP joint

Congenital(?) Trigger Thumb

• No trigger thumb in 1116 newborns5 developed later (8-30 mo)

Kikuchi & Ogino JHS(A), 2007

• No trigger thumb in 7700 newbornsMoon et al, JHS (B), 2001

Spontaneous Resolution

Risks of Surgery

General anesthesia before the age of 3?

Late Surgery May Cause Deformity?

• Not until well above the 3 year limit

–23 thumbs after the age of 3, no residual flexion deformity. Skov et al 1990

–61 children above 3 years of age no residual contracture. Dunsmuir & Sherlock, 2000

–Tan et al, 2002–31 trigger thumbs > 5 years of age no deformity. Hanet al 2010

When to Operate:

• 1. The natural history – 7/10 spontaneous resolution at median time of 4 years after diagnosis– explained to the parents, and they do not want to wait for such a long duration.

• 2. Failure of previous operation

• 3. Frequent annoying pain

Pediatric Trigger Finger Different

• Spontaneous resolution rare

• A1 pulley release may not be adequate (A2/ slip of superficialis removal)

Baek GH © ASSH 2014

Pediatric Trigger Finger Different

• Prolonged PIP flexion may cause hypoplasia of the proximal phalangeal head

Baek GH © ASSH 2014

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