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Outcomes After Primary Repair and Staged Reconstruction of Zone I and II Flexor Tendon Injuries in Children

Piper, Samantha L., MD*,†; Wheeler, Lesley C., BA*; Mills, Janith K., MPAS*; Ezaki, Marybeth, MD*; Oishi, Scott N., MD*

Journal of Pediatric Orthopaedics: May/June 2019 - Volume 39 - Issue 5 - p 263–267
doi: 10.1097/BPO.0000000000000912
Hand & Upper Extremity

Background: Delayed diagnosis of flexor tendon injury in children is common, and consequent flexor sheath scarring may necessitate a 2-stage reconstruction. Previous studies show variable outcomes after 2-stage flexor reconstruction in children, especially those below 6 years old. We evaluated functional and subjective outcomes of primary repair and staged reconstruction of zone I and II tendon injuries in children under 6 years of age.

Methods: A retrospective chart review identified 12 digits in 10 patients who had undergone surgical treatment of a zone I or II flexor tendon injury. Seven digits had a primary repair and 5 had a 2-stage reconstruction. Time delay from injury to surgery for primary repairs averaged 18 weeks and for 2-stage reconstruction averaged 24 weeks. Outcomes included total active motion, tip pinch and grip strength, sensation, and the Pediatric Outcomes Data Collection Instrument (PODCI).

Results: Average follow-up was 8 years. At final follow-up, mean total active and passive motion of the involved digit was similar between the primary reconstruction and staged groups, and 58% had a “good” or “excellent” American Society for Surgery of the Hand; total active motion (ASSH TAM) result (71% in the primary repair group, 40% in the 2-stage reconstruction group). All regained grip and pinch strength equal to the contralateral hand. The average PODCI Upper Extremity score was 99 (99 in the primary repair group, 98 in the 2-stage reconstruction group) and PODCI Global Function score was 94 (97 in the primary repair group, 91 in the 2-stage reconstruction group). No complications occurred.

Conclusions: Our small study demonstrates that both primary repair and 2-stage flexor tendon reconstruction have acceptable long-term functional and subjective outcomes in children below 6 years old, although staged reconstruction had a lower overall ASSH TAM score and subcategorical PODCI scores. Although staged reconstruction has acceptable outcomes in this population, prompt primary repair of flexor tendon injuries in children should always be attempted.

Level of Evidence: Level 4—therapeutic.

*Department of Hand and Upper Extremity Surgery, Texas Scottish Rite Hospital for Children, Dallas, TX

Department of Orthopaedic Surgery, University of California, San Francisco, CA

No funding was received from National Institutes of Health (NIH); Wellcome Trust; Howard Hughes Medical Institute (HHMI); or other(s) for this work.

The authors declare no conflicts of interest.

Reprints: Scott N. Oishi, MD, Department of Hand and Upper Extremity Surgery, Texas Scottish Rite Hospital for Children, 2222 Welborn St., Dallas, TX 75219. E-mail:

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