Multi-Digit Zone II Flexor Tendon and Median Nerve Repair After Glass Laceration
Primary repair of FDS/FDP lacerations to index and middle fingers in zone II with associated median nerve neurotmesis, using modified Kessler core sutures, epitendinous repair, and microsurgical nerve coaptation.
Patient Information
- Age: 27 years
- Gender: Male
- Diagnosis: Sharp laceration left volar wrist/hand with complete FDS/FDP disruption to index and middle fingers and partial median nerve laceration
Procedure
Emergency exploration, washout, primary flexor tendon repair (FDS and FDP), median nerve neurorrhaphy, and layered wound closure with early protected mobilisation protocol.
Findings
Volar laceration extended from distal forearm to proximal palm with transaction of FDS and FDP to index and middle at the A2 pulley level (zone II). Median nerve had a 70% circumferential laceration with grouped fascicles visible; ulnar nerve and radial artery intact. No foreign body; wound time from injury to theatre under 6 hours. Radiographs excluded underlying fracture.
Surgical Technique
Brachial plexus block supplementation with loupe magnification. Flexor sheath opened with cruciate extension; tendon ends retrieved and tagged with 25G needles. Pulley preservation attempted—partial A2 release only as required for exposure. FDP and FDS to index and middle repaired with 4-strand modified Kessler using 3-0 Prolene core and 6-0 Prolene epitendinous running suture, with the FDS repair positioned 0.5 cm proximal to FDP as per standard doctrine. Median nerve repaired under operating microscope with 9-0 nylon epineurial interrupted sutures after trimming to healthy fascicles; no graft required. Skin closed with 5-0 nylon; bulky dressing and dorsal blocking splint applied with wrist in 20° flexion, MCP joints 70° flexion, IP joints free.
Outcome
At 2 weeks, wounds healed; passive mobilisation commenced per Kleinert-type protocol. At 8 weeks, total active motion index 220°, middle 210°, with protective tip-to-tip grasp. Semmes-Weinstein monofilament testing at 12 weeks showed improving two-point discrimination over median distribution (6 mm static). No rupture or tenolysis required at 6-month follow-up.
Clinical Notes
Zone II remains the most challenging flexor zone; pulley management and early controlled mobilisation were critical to outcome. Images can be added later to public/journals/zone-2-hand-repair-*.jpg.