1. Fewer complications were noted for two-tendon repairs
2. Topic
3. zone 5 =flexor Mu. insertion to carpal tunnel
4. zone 4 is the carpal tunnel and its contents.
5. Zone 3 from the distal edge of the carpal ligament to the proximal edge of the A1 pulley.
   1. anatomy
      1. Lumbrical-origi. & Inset FDP--1&2 median, 3&4 ulnar n.
         1. Fun.
            1. When MCP
            2. flexed fully
            3. changes position proximally because the FDP tendon slides proximally
            4. extended
            5. extend PIP & DIP
            6. flex MCP
      2. palmer interossei
         1. when MCP
            1. fully extended
            2. Subtopic 2
            3. Subtopic 3
6. zone 2, or “no man's land.: start from proximal aspect of the A1 pulley to FDS insertion,The distal palmar crease superficially marks the termination of zone 3 and the beginning of zone 2.
   1. areas of zone 2- defined by the position of the distal tendon stump with the finger in the resting position
      1. A=under the A4
      2. B=under the C1
      3. C= under A2
         1. Tang recommends repair of one tendon repair of FDP with excision of the FDS , due to high rate of adhesions in this area if both the FDS and FDP were repaired
      4. D=under A1
      5. Subtopic 5
         1. anatomy
            1. Subtopic 1
            2. Subtopic 2
   2. Subtopic 2
      1. http://www.wheelessonline.com/ortho/zone_ii_flexor_injuries
7. Zone 1 is distal to the insertion of the FDS tendon. A laceration in zone 1, by definition, injures only the tendon of the FDP
   1. S/S
      1. no
      2. Subtopic 2
   2. Dx. X ray
      1. classification TYPES (Leddy and Packer) according to the site of the proximal Avulsed FDS stump, MRI maybe used to find the stump
         1. I - palm
         2. II - chiasm of the FDS in P2
         3. intra articular is (A) Extra Articular is (B)
            1. III - A4
            2. IV- palm
            3. V-A4 & P3 shaft #
8. Rx. pre OP grading depend on scaring extent (BoYES): 1-minimal scar 2-Heavy scar 3-ristricted ROM 4-n. damage=atrophic skin, 5-Multi scar or atrophy
   1. Elderly, complex injury more than 1 year old, pt. not motivated, no access to hand OT post-op, nerve injury
      1. I. nothing, Arthrodesis(=joint fusion), Amputation
   2. motivated pt., Pre-OP OT (to improve PROM & test pt. motivation)
      1. boyes grade 1, intact tendon, sheath & Mu., good PROM, pt. older than 11y.
         1. II.Tenolysis
   3. Definitive repair delayed more than 3 weeks, making it impossible to do an end-to-end repair
      1. tendon grafting
         1. Where to graft from
            1. extrasynovial
            2. Palmaris longus-for palm to finfertip recon. found in up to 85% of ppl. no sculpting needed
            3. Plantaris tendon - for forearm to fingertip or multi-palm to fingertips found by U/S or MRI on medial aspect of the Achilles tendon-may need sculpting before using
            4. long toe extensors can provide excellent grafts. Their presence is never in doubt, and their diameter is adequate for most needs. Three long tendon grafts can be acquired when the tendons to the second, third, and fourth toes are harvested- at dorsal of the foot's metatarso-phalangeal joint
            5. intra-synovial (proven less adhesions in animals only)
            6. Toe Flexors limited use
         2. Single stage tendon grafting surgery indicated for
            1. boyes 1 or 2 with injury to zone I, need DIP flex, and grip power by fixing RF&LF
            2. Boyes 3 w/ injury to FDS & FDP
         3. Two Stage tendon grafting using silicon for 3 months
            1. boyes 3,4,5, malfunctioning pulley(recon. a tunnel w/sillicon then graft 3 months later)