- Published on
Emergency and Acute Medicine - Tendon Laceration
Tendon laceration is an important traumatic injury that can significantly impair function if not properly identified and treated. Any laceration near a tendon must be carefully explored through a full range of motion to exclude injury, as even partial disruptions can lead to long-term disability. These injuries may result from external trauma such as penetrating injuries from knives, glass, gunshot wounds, or foreign bodies, as well as blunt trauma causing crushing or avulsion forces. Less commonly, tendon damage may occur internally due to entrapment or laceration from fractures. Upper-extremity injuries are more commonly associated with workplace accidents, home injuries, assaults, or self-harm, while lower-extremity injuries are often related to occupational incidents or motor vehicle accidents.
Pain is the most consistent presenting symptom, often accompanied by functional deficits such as weakness or inability to move a joint. Associated soft tissue findings may include swelling, bruising, visible lacerations, and bleeding. Abnormal resting posture of a limb or joint instability should raise suspicion for tendon injury. A detailed history is essential, including mechanism of injury, timing, hand dominance, and tetanus immunization status.
Physical examination plays a critical role in diagnosis. The resting position of the hand should be assessed, noting the natural cascade of finger flexion. Each tendon must be evaluated individually, with testing against resistance to detect subtle injuries. Flexor tendon injuries may present with inability to flex specific joints, such as loss of distal interphalangeal flexion in flexor digitorum profundus injuries or proximal interphalangeal flexion in flexor digitorum superficialis injuries. Extensor tendon injuries are suggested by weakness or inability to extend the digits. Direct visualization of the tendon through the wound, ideally in a well-lit and bloodless field after local anesthesia, is essential, and the tendon should be examined throughout its full range of motion.
Investigations are guided by clinical suspicion. Radiographs are commonly used to detect fractures or radiopaque foreign bodies. Ultrasound can help identify complete tendon lacerations, although partial injuries are more difficult to visualize. MRI may be used in selected cases. Wounds presenting late or showing signs of infection should be cultured. Differential diagnoses include associated fractures, foreign bodies, and specific tendon-related deformities such as boutonnière deformity, mallet finger, and jersey finger.
Initial management focuses on hemorrhage control, immobilization, and preservation of neurovascular function. In the emergency setting, treatment includes adequate analgesia, tetanus prophylaxis, and thorough irrigation of the wound. Antibiotics, typically a first-generation cephalosporin such as cefazolin, are administered, with broader coverage required for contaminated wounds such as human bites. Devitalized tissue should be debrided, and foreign bodies removed.
Partial tendon lacerations involving more than 20% of the tendon cross-sectional area require repair. Simple extensor tendon injuries may be repaired in the emergency department using nonabsorbable sutures, while flexor tendon injuries and those involving the wrist or forearm require prompt consultation with a hand surgeon, ideally within 12 hours. If surgical repair is not immediately available, the wound should be irrigated, the skin loosely closed, and the limb immobilized in a functional position using a splint.
Disposition depends on the severity and type of injury. Infected tendon lacerations or those caused by human bites require hospital admission and operative management. Significant flexor tendon injuries often require admission or transfer for surgical repair. Selected uncomplicated extensor tendon injuries that are repaired and properly splinted may be discharged with close surgical follow-up.
A key clinical point is that partial tendon lacerations are frequently missed because patients may retain near-normal range of motion. Strength testing is therefore essential, as significant injuries can still demonstrate preserved motion. Any laceration over the metacarpophalangeal joint should be considered a potential human bite until proven otherwise. Early recognition, careful examination, and appropriate referral are critical to prevent long-term functional impairment.
Tendon laceration is an important traumatic injury that can significantly impair function if not properly identified and treated. Any laceration near a tendon must be carefully explored through a full range of motion to exclude injury, as even partial disruptions can lead to long-term disability. These injuries may result from external trauma such as penetrating injuries from knives, glass, gunshot wounds, or foreign bodies, as well as blunt trauma causing crushing or avulsion forces. Less commonly, tendon damage may occur internally due to entrapment or laceration from fractures. Upper-extremity injuries are more commonly associated with workplace accidents, home injuries, assaults, or self-harm, while lower-extremity injuries are often related to occupational incidents or motor vehicle accidents.
Pain is the most consistent presenting symptom, often accompanied by functional deficits such as weakness or inability to move a joint. Associated soft tissue findings may include swelling, bruising, visible lacerations, and bleeding. Abnormal resting posture of a limb or joint instability should raise suspicion for tendon injury. A detailed history is essential, including mechanism of injury, timing, hand dominance, and tetanus immunization status.
Physical examination plays a critical role in diagnosis. The resting position of the hand should be assessed, noting the natural cascade of finger flexion. Each tendon must be evaluated individually, with testing against resistance to detect subtle injuries. Flexor tendon injuries may present with inability to flex specific joints, such as loss of distal interphalangeal flexion in flexor digitorum profundus injuries or proximal interphalangeal flexion in flexor digitorum superficialis injuries. Extensor tendon injuries are suggested by weakness or inability to extend the digits. Direct visualization of the tendon through the wound, ideally in a well-lit and bloodless field after local anesthesia, is essential, and the tendon should be examined throughout its full range of motion.
Investigations are guided by clinical suspicion. Radiographs are commonly used to detect fractures or radiopaque foreign bodies. Ultrasound can help identify complete tendon lacerations, although partial injuries are more difficult to visualize. MRI may be used in selected cases. Wounds presenting late or showing signs of infection should be cultured. Differential diagnoses include associated fractures, foreign bodies, and specific tendon-related deformities such as boutonnière deformity, mallet finger, and jersey finger.
Initial management focuses on hemorrhage control, immobilization, and preservation of neurovascular function. In the emergency setting, treatment includes adequate analgesia, tetanus prophylaxis, and thorough irrigation of the wound. Antibiotics, typically a first-generation cephalosporin such as cefazolin, are administered, with broader coverage required for contaminated wounds such as human bites. Devitalized tissue should be debrided, and foreign bodies removed.
Partial tendon lacerations involving more than 20% of the tendon cross-sectional area require repair. Simple extensor tendon injuries may be repaired in the emergency department using nonabsorbable sutures, while flexor tendon injuries and those involving the wrist or forearm require prompt consultation with a hand surgeon, ideally within 12 hours. If surgical repair is not immediately available, the wound should be irrigated, the skin loosely closed, and the limb immobilized in a functional position using a splint.
Disposition depends on the severity and type of injury. Infected tendon lacerations or those caused by human bites require hospital admission and operative management. Significant flexor tendon injuries often require admission or transfer for surgical repair. Selected uncomplicated extensor tendon injuries that are repaired and properly splinted may be discharged with close surgical follow-up.
A key clinical point is that partial tendon lacerations are frequently missed because patients may retain near-normal range of motion. Strength testing is therefore essential, as significant injuries can still demonstrate preserved motion. Any laceration over the metacarpophalangeal joint should be considered a potential human bite until proven otherwise. Early recognition, careful examination, and appropriate referral are critical to prevent long-term functional impairment.
0 Comments
