Hand Injury / Tendon and Nerve Repair | Repair and reconstructive options

Flexor tendons bend the fingers and thumb, while extensor tendons straighten them. In fingers, flexor tendons pass through a tight sheath and pulley system, so repair must balance strength with smooth gliding and avoid adhesions. At the wrist, flexor repairs may be theoretically easier in some respects because tendons are not confined within a sheath, yet multiple structures and associated nerve or arterial injuries can make these operations demanding. Primary flexor repair is generally preferred when possible; secondary flexor surgery, such as grafting or tenolysis, usually has worse reported results. Extensor repairs have fewer clinical investigations, and many postoperative principles were derived or modified from flexor care.

Direct end-to-end repair uses core and peripheral sutures and suits acute clean cuts with little tendon loss. If more than about 1 cm must be removed, or the muscle has shortened, direct repair can leave the finger too flexed, so a graft may bridge the gap. When ends have retracted and cannot be brought together without tension, a graft may also be needed. Early single-stage grafting may be possible when pulleys are intact; otherwise a two-stage graft with a silicone spacer may be used. Clean cuts are more suitable for direct repair, while crushing injuries may cause more swelling and adhesions. The choice depends on injury mechanism, tissue condition and your priorities.

In a two-stage repair, the first operation usually places a silicone rod to create a smooth tunnel and address scar, contracture or pulley problems; the tendon graft is placed about three months later. This staged approach protects the graft from poor bed conditions. If the injury is more than two weeks old, the proximal tendon may have retracted, making staged repair more likely. It is not suitable with active infection, major soft-tissue or skin loss, neurovascular compromise, or an unwillingness to follow rehabilitation. Some patients later need a procedure to free the tendon from scar, sometimes called a third stage, and in some cases joint fusion or amputation may be a better alternative.

Hand injuries often involve several structures at once, including tendons, nerves, vessels, bone or skin. Vascular repair is performed after skeletal and tendon repair unless critical ischemia is present, when a temporary shunt may be used. Nerve repair usually follows skeletal, tendon and vascular reconstruction because it is less urgent and its delicate techniques can be affected by more aggressive steps. Nerve repairs are often done at the same time as tendon repair, and all divided structures may be repaired when possible and safe. Extensive contamination requires careful cleaning before repair, and the repair bed should be well nourished. Microsurgical facilities may be needed for small vessel and nerve repair, and the exact plan varies with injury mechanism and contamination.

The wide-awake approach lets the surgeon check tendon tension and active motion before closing, which can make tendon repair more reliable. It also avoids systemic anesthetic effects and tourniquet discomfort. Many tendon and nerve conditions can be approached this way, but the exact plan depends on the injury, anatomy and surgeon experience. The surgeon can adjust repair tension immediately if movement is too tight or too loose. However, it requires comfort with some bleeding and familiarity with anatomy, so it is easier for experienced surgeons. It is contraindicated when perfusion is compromised, such as Buerger disease, connective tissue disease or severe vascular problems with chronic renal failure.

A skin laceration is not always a reliable guide to underlying damage. If the finger was flexed when cut, the tendon end can lie more distally than the skin wound, and wrist tendons may retract significantly. Clean, simple cuts usually need less exposure, while ragged, crushing or multi-structure injuries need more. Nerve repair also needs wide exposure from healthy to injured tissue to align ends accurately. Multiple divided structures can make the operation longer, and partial retinaculum release may be needed at the wrist to reach retracted tendons. The surgeon must also protect nearby vessels and nerves while creating enough room for a strong, gliding repair. This is why the final incision can exceed the original cut.

When skin loss is extensive and tendon or nerve repair is needed, providing skin cover often takes priority because tendon and nerve healing need both skin and underlying soft tissue. A graft may suit a well-vascularized bed, while a flap may be preferred when deeper structures are exposed or more durable cover is needed. Options range from direct closure to grafts or flaps, and the plan should protect movement and sensation while limiting scarring and repeated operations. The approach can be staged or combined, depending on tissue damage, contamination and surgical judgment. A cautious staged plan may provide primary flap cover first, then tendon or nerve reconstruction later, especially when contamination or tissue damage is significant.

Clean cuts usually allow easier retrieval and repair with less tissue disturbance, while ragged or crushing injuries can cause marked swelling and adhesion formation. In nerve injuries, greater severity means more scarring and less functional recovery; sensory or pure motor nerves generally do better than mixed nerves, distal injuries better than proximal ones, and children better than adults. Delayed repair can also reduce results. In severe crush injuries, nerves may be avulsed and reconstruction may be deferred, while tendons are repaired primarily when possible. Surgical skill, repair tension and coordination with therapy also influence outcomes, and complications are expected in major crush injuries. Recovery also depends on tissue damage, repair quality and rehabilitation.