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Flexor tendon repair

41 citationsUpdated Aug 2026

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Overview

Flexor tendon repair in Zone II is a technically demanding procedure, yet outcomes have become more predictable and satisfying [1]. Primary repair in the digital sheath area has become standard practice, characterized by a shift toward strong multistrand core sutures and modified pulley preservation [12]. Many principles of flexor tendon repair and rehabilitation can be applied to zones III–V [11]. However, no gold standard has been determined for the optimal flexor tendon repair algorithm, and repairs are usually chosen based on familiarity, popularity, and technical difficulty [2].

Despite improvements in surgical technique and rehabilitation, functional outcomes for flexor tendon injuries remain unreliable, with adhesion formation and joint contractures being the most common complications [5]. Zone I flexor tendon injuries traditionally have not yielded results as good as other flexor tendon injuries, with full motion rarely regained and good/excellent results reported in only up to 67% of cases [4]. Tendon grafting is the treatment of choice for flexor tendon injuries in zones I and II when direct repair is not possible or delayed [8]. A modified protocol for primary flexor tendon repair in zones 1 and 2 utilizes a 6-strand core suture without circumferential suturing, selective pulley division, and partial FDS resection to facilitate early active motion and improve outcomes [19].

Secondary reconstruction remains an important and useful technique for complicated flexor tendon injuries or those that have failed primary repair [6]. Consistent, successful management of flexor tendon injuries relies on understanding the anatomy, characteristics and repair of tendons in the different zones, potential complications, rehabilitation protocols, recent advances in treatment, and future directions, including tissue engineering and biologic modification of the repair site [7]. Limited evidence currently exists for zones IV and VII extensor and for flexor tendon repairs regarding relative motion orthoses for early active motion [10].

Anatomy & Pathophysiology

Flexor tendons function as cables that transmit forces to move and stabilize joints [31]. An understanding of the biomechanics of the flexor tendon system is essential to proper evaluation and treatment of disorders of the upper extremity [31]. A thorough understanding of the anatomy and mechanism of injury is critical for diagnosis, treatment, and postoperative management of flexor tendon and pulley injuries in athletes [47].

Complications: Adhesion formation is the most common complication following flexor tendon injuries [5]. Joint contractures are the most common complication following flexor tendon injuries [5]. Functional outcomes for flexor tendon injuries remain unreliable despite improvements in surgical technique and rehabilitation [5].

Rehabilitation and Management: Many principles of flexor tendon repair and rehabilitation can be applied to zones III–V [11]. Therapists must understand the implications of wrist and metacarpophalangeal (MCP) joint positioning to safely facilitate tendon gliding and prevent secondary pathomechanical changes [36]. Complex hand injuries involving flexor tendons require management of associated soft tissue and bony injuries to optimize functional outcomes [43].

Classification

Flexor tendon injuries are complex, requiring management that considers surgical timing, injury location, approach, and soft tissue handling [14]. Consistent, successful management relies on understanding the anatomy, characteristics, and repair of tendons in different zones, as well as potential complications, rehabilitation protocols, recent advances, and future directions including tissue engineering and biologic modification of the repair site [7].

Zone II: Repair in Zone II is technically demanding [1]. However, outcomes for acute repairs have become more predictable and satisfying [1]. Subdividing Zone II is a key factor to improving outcomes [40].

Zone I: Injuries traditionally have not yielded results as good as other flexor tendon injuries [4]. Full motion is rarely regained, and good or excellent results are reported in only up to 67% of cases [4].

Digital Sheath Area: Primary repair has become standard practice [12]. Techniques have shifted toward strong multistrand core sutures and modified pulley preservation [12].

Zones I and II (Grafting): Tendon grafting is the treatment of choice when direct repair is not possible or is delayed [8].

Secondary Reconstruction: This remains an important and useful technique for complicated flexor tendon injuries and those that have failed primary repair [6].

Key Factors for Outcomes: Improving outcomes in flexor tendon repair requires releasing critical pulleys (A2 and A4), using strong multi-strand repairs, and implementing early active motion [40]. Despite significant advances, the drive towards perfection in flexor tendon repair and reconstruction continues [13].

Other Considerations: No gold standard has been determined for the optimal flexor tendon repair algorithm [2]; repairs are usually chosen based on familiarity, popularity, and technical difficulty [2]. Currently, no strategies targeting growth factors are routinely used in clinical practice, though understanding their role should enable a more targeted approach to improve results [18]. Limited evidence exists for relative motion orthoses for early active motion in flexor tendon repairs [10]. The large heterogeneity in outcome domains assessed across studies highlights the need for a consistent core outcome set in future clinical research [9].

Clinical Presentation

The central tenet of modern flexor tendon surgery is to increase tendon healing and avoid adhesion formation by making a repair strong enough to move within a few days of injury [15]. Consistent, successful management of flexor tendon injuries relies on understanding the anatomy, characteristics, and repair of tendons in different zones [7]. Outcomes for flexor tendon repair in Zone II have become more predictable and satisfying [1]. However, there is large heterogeneity in the outcome domains being assessed or measured across studies on hand flexor tendon injuries [9].

Complications: Tendon adhesion and joint contracture are the most common complications after flexor tendon repair [26]. These sequelae are managed through prevention, meticulous surgical technique, and thoughtful rehabilitation protocols [26]. Repair ruptures were documented in most reports on flexor tendon repair [16]. Repair rupture rates range from 4%-10% in finger flexors [16] and range from 3%-17% in the flexor pollicis longus (FPL) of thumbs [16].

Diagnostic Considerations: Pediatric flexor tendon injuries differ from adults in diagnosis and rehabilitation [17]. Pediatric cases often require surgical exploration due to uncooperative patients [17]. Closed flexor tendon disruptions include traumatic avulsion, spontaneous midsubstance rupture, attrition rupture, infiltrative tenosynovial rupture, and iatrogenic causes [32]. Spontaneous flexor tendon ruptures of the hand occur more often than one might recognize [23]. The majority of spontaneous flexor tendon ruptures of the hand involve the profundus tendon of the small finger in the palm [23].

Management Strategy: Flexor tendon repair techniques are usually chosen based on familiarity, popularity, and technical difficulty [2]. Tendon grafting is the treatment of choice for flexor tendon injuries in zones I and II when repair is delayed [8]. Secondary reconstruction is an important and useful technique for complicated flexor tendon injuries [6] and for flexor tendon injuries that have failed primary repair [6]. Limited evidence currently exists for the use of relative motion orthoses for early active motion after finger extensor tendon repairs in zones IV and VII [10]. Limited evidence currently exists for the use of relative motion orthoses for early active motion after flexor tendon repairs [10].

Investigations

Plain radiography: Indicated to assess for associated bony injuries or avulsion fractures preceding or accompanying flexor tendon trauma.

MRI: Useful for detailed soft-tissue evaluation, particularly in complex cases where tendon integrity and surrounding soft-tissue status require precise delineation beyond clinical examination.

CT: Not routinely indicated for isolated flexor tendon injuries unless complex intra-articular fracture patterns are suspected.

Bone scan: Limited utility in the acute setting of flexor tendon repair; reserved for specific diagnostic dilemmas such as occult osteomyelitis or stress fractures if clinically indicated.

Tomosynthesis: No specific role established in the routine workup of flexor tendon injuries.

Aspiration: Not indicated for isolated flexor tendon injuries without signs of septic arthritis or tenosynovitis requiring fluid analysis.

Laboratory: Pre-operative inflammatory markers (e.g., ESR, CRP) may be obtained if infection is a differential diagnosis, though routine labs are not required for sterile repairs.

Other Considerations: Adhesion formation and joint contractures represent the most common complications following flexor tendon injuries [5]. The central tenet of modern flexor tendon surgery is to increase tendon healing and avoid adhesion formation [15]. Modern techniques aim to create repairs strong enough to permit early motion within a few days of injury [15]. Primary repair has shifted toward strong multistrand core sutures and modified pulley preservation [12]. Despite significant advances, the drive towards perfection in flexor tendon repair and reconstruction continues [13]. Rupture rates for finger flexors range from 4% to 10% [16], while rupture rates for the flexor pollicis longus (FPL) of thumbs range from 3% to 17% [16]. Tendon grafting is the treatment of choice for injuries in zones I and II when direct repair is not possible or delayed [8]. Late direct repair is possible in approximately 1 in 10 to 1 in 15 patients where tendon ends can be approximated with acceptable tension [21]. Initial clinical experience with the volar plate of the distal interphalangeal joint as a distally based flap is encouraging, and this technique may take its place in flexor tendon surgery [20]. Limited evidence currently exists for the use of relative motion orthoses after flexor tendon repairs [10]. Even otherwise healthy patients can expect some residual digital stiffness following flexor tendon sheath infection despite aggressive and prompt antibiotic therapy and surgical intervention [30]. A consistent core outcome set is needed for future clinical research on hand flexor tendon injuries [9].

Treatment

Non-Operative

Limited evidence currently exists for relative motion orthoses after flexor tendon repairs [10]. There is limited evidence informing use of relative motion flexion orthoses following zone I-III flexor tendon repair [45]. There is not sufficient evidence to support true active motion as an effective or preferable choice for flexor tendon rehabilitation at this time [38].

Operative

Indications: Secondary reconstruction is an important and useful technique for complicated flexor tendon injuries or those that have failed primary repair [6]. Patient selection, cooperation, and a rational goal are as key to success in flexor tenolysis as the operative procedure itself [24].

Surgical Approach / Technique: Flexor tendon repair in Zone II is technically demanding, but outcomes have become more predictable and satisfying [1]. Zone I flexor tendon injuries traditionally yield poorer results than other flexor tendon injuries, with full motion rarely regained and good/excellent results reported in only up to 67% of cases [4]. Consistent, successful management of flexor tendon injuries relies on understanding anatomy, characteristics, and repair of tendons in different zones [7]. Management of flexor tendon injuries relies on understanding potential complications and rehabilitation protocols [7]. Management of flexor tendon injuries relies on understanding recent advances in treatment and future directions, including tissue engineering and biologic modification of the repair site [7]. Management of flexor tendon injuries requires consideration of surgical timing, injury location, approach, and soft tissue handling [14].

A modified protocol for primary flexor tendon repair in zones 1 and 2 utilizes a 6-strand core suture without circumferential suturing to facilitate early active motion and improve outcomes [19]. The modified protocol for primary flexor tendon repair in zones 1 and 2 includes selective pulley division [19]. The modified protocol for primary flexor tendon repair in zones 1 and 2 includes partial FDS resection [19]. Increasing the number of suture strands significantly improves the mechanical strength and gap resistance of flexor tendon repairs [48]. Using locking-loop configurations significantly improves the mechanical strength and gap resistance of flexor tendon repairs [48]. Optimizing suture purchase length significantly improves the mechanical strength and gap resistance of flexor tendon repairs [48]. Understanding the role of growth factors in tendon repair should enable a more targeted approach to improve results of flexor tendon repair [18].

Adjuncts: The authors no longer perform flexor tendon repair with tourniquet, sedation, or muscle paralysis [37].

Other Considerations: Adhesion formation and joint contractures are the most common complications after flexor tendon repair [5]. Tendon adhesion and joint contracture are managed through prevention, meticulous surgical technique, and thoughtful rehabilitation protocols [26]. Flexor tenolysis requires consideration of preoperative, operative, and postoperative factors [24]. Prompt recognition of problems and treatment with hand therapy, splinting, and/or surgery may help minimize recovery time and improve function after flexor tendon injuries [22].

Complications

Tendon Rupture: Repair rupture rates for finger flexors range from 4% to 10% [16], while rates for the flexor pollicis longus (FPL) of thumbs range from 3% to 17% [16]. Zone 2 flexor tendon repairs have very low to zero incidence of rupture [50]. Conversely, Zone I flexor tendon injuries traditionally yield poorer results than other flexor tendon injuries, with full motion rarely regained [4].

Suture Technique Outcomes: Surgeons report good to excellent results in about 80% or more of tendons repaired with 4-strand or 6-strand core sutures [49]. Repair rupture rates are 2% to 5% for tendons repaired with 4-strand or 6-strand core sutures [49]. Outcomes of Zone 2 repairs are not dissimilar to those in other zones [50].

Stiffness / Arthrofibrosis: Repeated administration of sodium hyaluronate at the tendon repair site may be effective in improving postoperative active finger motion after primary hand flexor tendon repair in the mid-term [27].

Other Considerations: Late direct repair is possible in approximately 1 in 10 to 1 in 15 patients where tendon ends can be approximated with acceptable tension [21]. Prompt recognition of problems and treatment with hand therapy, splinting, and/or surgery may help minimize recovery time and improve function [22]. Patient selection, cooperation, and a rational goal are as key to success as the operative procedure itself for flexor tenolysis [24].

Recovery

Rehabilitation after surgical repair of flexor injuries remains a controversial topic, as motion at the repair site decreases the risk for adhesions but increases the risk for rupture [34]. The large heterogeneity in outcome domains assessed across studies highlights the need for a consistent core outcome set in future clinical research on hand flexor tendon injuries [9].

Rehabilitation protocol: A modified protocol for primary flexor tendon repair in zones 1 and 2 utilizes a 6-strand core suture without circumferential suturing, selective pulley division, and partial FDS resection to facilitate early active motion and improve outcomes [19]. The author recommends the partial-range active flexion protocol as a safe, efficient, and generalizable framework for rehabilitation after flexor tendon repair and other hand disorders, particularly where therapist assistance is unavailable [28].

Other Considerations: Future research is suggested to increase understanding of optimal age ranges for early active motion in children with flexor tendon injuries [29].

Key Evidence

  • [L5] Flexor tendon repair in Zone II is a technically demanding procedure, but outcomes have become more predictable and satisfying. [1] (10.1016/j.hcl.2004.11.001)
  • [L5] No gold standard has been determined for the optimal flexor tendon repair algorithm, and repairs are usually chosen based on familiarity, popularity, and technical difficulty. [2] (10.1016/j.jhsa.2014.06.025)
  • [L5] Zone I flexor tendon injuries traditionally have not yielded results as good as other flexor tendon injuries, with full motion rarely regained and good/excellent results reported in only up to 67% of cases. [4] (10.1016/j.hcl.2004.12.004)
  • [L5] Despite improvements in surgical technique and rehabilitation, functional outcomes for flexor tendon injuries remain unreliable, with adhesion formation and joint contractures being the most common complications. [5] (10.1016/j.hcl.2009.11.004)
  • [L5] Secondary reconstruction remains an important and useful technique for complicated flexor tendon injuries or those that have failed primary repair. [6] (10.1016/j.jhsa.2007.08.018)
  • [L5] Consistent, successful management of flexor tendon injuries relies on understanding the anatomy, characteristics and repair of tendons in the different zones, potential complications, rehabilitation protocols, recent advances in treatment, and future directions, including tissue engineering and biologic modification of the repair site. [7] (10.5435/jaaos-d-16-00316)
  • [L5] Tendon grafting is the treatment of choice for flexor tendon injuries in zones I and II when direct repair is not possible or delayed. [8] (10.1016/j.hcl.2004.12.003)
  • [L2] The large heterogeneity in the outcome domains being assessed/measured across studies highlights the need for a consistent core outcome set to be measured in future clinical research on hand flexor tendon injuries. [9] (10.1177/17531934251342732)
  • [L1] Limited evidence currently exists for zones IV and VII extensor and for flexor tendon repairs. [10] (10.1016/j.jht.2023.02.011)
  • [L5] Many of the principles of flexor tendon repair and rehabilitation can be applied to zones III–V. [11] (10.1016/j.hcl.2004.11.007)
  • [L5] Primary flexor tendon repair in the digital sheath area has become standard practice with a shift toward strong multistrand core sutures and modified pulley preservation. [12] (10.1016/j.hcl.2013.02.003)
  • [L5] Despite significant advances in flexor tendon repair and reconstruction, the drive towards perfection continues. [13] (10.1177/17531934251404821)
  • [L5] Flexor tendon injuries are complex, and management requires consideration of surgical timing, injury location, approach, and soft tissue handling. [14] (10.1016/j.jhsa.2024.05.013)
  • [L4] The central tenet of modern flexor tendon surgery is to increase tendon healing and avoid adhesion formation by making a repair strong enough to move within a few days of injury. [15] (10.1016/j.hcl.2013.03.001)
  • [L4] Repair ruptures were documented in most reports with rates ranging from 4%-10% in finger flexors and 3%-17% in FPL of thumbs. [16] (10.1016/j.hcl.2004.11.005)
  • [L5] Pediatric flexor tendon injuries differ from adults in diagnosis and rehabilitation, often requiring surgical exploration due to uncooperative patients. [17] (10.1016/j.hcl.2004.11.004)
  • [L5] Understanding the role that growth factors play in tendon repair should enable a more targeted approach to be developed to improve the results of flexor tendon repair, although currently no strategies are routinely used in clinical practice. [18] (10.1177/1753193413509231)
  • [L5] The authors describe a modified protocol for primary flexor tendon repair in zones 1 and 2 that utilizes a 6-strand core suture without circumferential suturing, selective pulley division, and partial FDS resection to facilitate early active motion and improve outcomes. [19] (10.1016/j.hcl.2017.03.001)
  • [L4] Initial clinical experience is encouraging and the volar plate flap technique may take its place in flexor tendon surgery. [20] (10.1016/j.jhsa.2015.11.004)
  • [L4] Late direct repair is possible in a small proportion of patients (approximately 1 in 10 to 1 in 15) where tendon ends can be approximated with acceptable tension. [21] (10.1016/j.hcl.2013.02.004)
  • [L5] Prompt recognition of problems and treatment with hand therapy, splinting, and/or surgery may help minimize recovery time and improve function. [22] (10.5435/00124635-200607000-00001)
  • [L4] Spontaneous flexor tendon ruptures of the hand occur more often than one might recognize, with the majority involving the profundus tendon of the small finger in the palm. [23] (10.1016/j.jhsa.2007.06.012)
  • [L5] The article outlines preoperative, operative, and postoperative considerations for flexor tenolysis, emphasizing that patient selection, cooperation, and a rational goal are as key to success as the operative procedure itself. [24] (10.1016/j.hcl.2004.11.008)
  • [L5] Tendon adhesion and joint contracture are the most common complications after flexor tendon repair, managed through prevention, meticulous surgical technique, and thoughtful rehabilitation protocols. [26] (10.1016/j.hcl.2014.12.004)
  • [L1] Repeated administration of sodium hyaluronate at the tendon repair site may be effective in improving postoperative active finger motion after primary hand flexor tendon repair in the mid-term. [27] (10.1016/j.jhsa.2021.07.012)
  • [L5] The author recommends the partial-range active flexion protocol as a safe, efficient, and generalizable framework for rehabilitation after flexor tendon repair and other hand disorders, particularly where therapist assistance is unavailable. [28] (10.1177/17531934211037112)
  • [L5] Future research is suggested to increase understanding of repair strength, optimal age ranges for early active motion, and cost-effectiveness. [29] (10.1016/j.jht.2014.12.002)
  • [L5] Despite aggressive and prompt antibiotic therapy and surgical intervention, even otherwise healthy patients can expect some residual digital stiffness following flexor tendon sheath infection. [30] (10.5435/jaaos-20-06-373)
  • [L5] An understanding of the biomechanics of the flexor tendon system is essential to proper evaluation and treatment of disorders of the upper extremity, as the tendons function as cables transmitting forces to move and stabilize joints. [31] (10.1016/j.hcl.2004.11.002)
  • [L5] This article reviews different causes, diagnoses, and treatment options of closed flexor tendon disruptions, including traumatic avulsion, spontaneous midsubstance rupture, attrition rupture, infiltrative tenosynovial rupture, and iatrogenic causes. [32] (10.1016/j.jhsa.2014.04.005)
  • [L5] Rehabilitation after surgical repair of flexor injuries is a controversial topic where motion at the repair site decreases risk for adhesions but increases risk for rupture. [34] (10.1016/j.jhsa.2019.02.010)
  • [L5] Therapists must understand the implications of wrist and MCP joint positioning to safely facilitate tendon gliding and prevent secondary pathomechanical changes. [36] (10.1177/17531934241265579)
  • [L5] The authors no longer perform flexor tendon repair with tourniquet, sedation, or muscle paralysis. [37] (10.1016/j.hcl.2013.02.009)
  • [L1] Based on a lack of superior benefits following true active motion regimens, there is not sufficient evidence to support true active motion as an effective or preferable choice for flexor tendon rehabilitation at this time. [38] (10.1016/j.jht.2018.06.001)
  • [L5] The article reviews a three-decade research journey demonstrating that subdividing Zone 2, releasing critical pulleys (A2 and A4), and using strong multi-strand repairs with early active motion are key to improving outcomes in flexor tendon repair. [40] (10.1177/17531934221087585)
  • [L5] Complex hand injuries involving flexor tendons require a physician-therapist team approach and management of associated soft tissue and bony injuries to optimize functional outcomes. [43] (10.1016/j.hcl.2004.12.001)
  • [L4] There is currently limited evidence informing use of relative motion flexion orthoses following flexor tendon repair. [45] (10.1016/j.jht.2022.11.004)
  • [L5] A thorough understanding of the anatomy and mechanism of injury is critical for diagnosis, treatment, and postoperative management. [47] (10.1016/j.csm.2019.12.004)
  • [L5] Increasing the number of suture strands, using locking-loop configurations, and optimizing suture purchase length significantly improve the mechanical strength and gap resistance of flexor tendon repairs. [48] (10.1016/j.jhsa.2009.12.044)
  • [L1] Over the past 10 years, surgeons have reported good to excellent results in about 80% or more of tendons repaired with 4-strand or 6-strand core sutures, with 2% to 5% repair ruptures. [49] (10.1016/j.hcl.2013.02.007)
  • [L5] Outcomes of Zone 2 repairs are not dissimilar to those in other zones with very low to zero incidence of rupture. [50] (10.1177/17531934211053757)

References

[1] Acute Flexor Tendon Repairs in Zone II. Hand Clinics. 2005. DOI: 10.1016/j.hcl.2004.11.001

[2] Flexor Tendon Repairs: Techniques, Eponyms, and Evidence. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.06.025

[4] Zone I Flexor Tendon Injuries. Hand Clinics. 2005. DOI: 10.1016/j.hcl.2004.12.004

[5] Complications After Flexor Tendon Injuries. Hand Clinics. 2010. DOI: 10.1016/j.hcl.2009.11.004

[6] Secondary Flexor Tendon Reconstruction, A Review. The Journal of Hand Surgery. 2007. DOI: 10.1016/j.jhsa.2007.08.018

[7] Flexor Tendon Injuries. Journal of the American Academy of Orthopaedic Surgeons. 2018. DOI: 10.5435/jaaos-d-16-00316

[8] Delayed Treatment of Flexor Tendon Injuries Including Grafting. Hand Clinics. 2005. DOI: 10.1016/j.hcl.2004.12.003

[9] Developing a core outcome set for hand flexor tendon injuries: a systematic review of treatment outcomes. Journal of Hand Surgery (European Volume). 2025. DOI: 10.1177/17531934251342732

[10] Relative motion orthoses for early active motion after finger extensor and flexor tendon repairs: A systematic review. Journal of Hand Therapy. 2023. DOI: 10.1016/j.jht.2023.02.011

[11] Treatment of Acute Flexor Tendon Injury: Zones III–V. Hand Clinics. 2005. DOI: 10.1016/j.hcl.2004.11.007

[12] Current Practice of Primary Flexor Tendon Repair. Hand Clinics. 2013. DOI: 10.1016/j.hcl.2013.02.003

[13] The IFSSH consensus and current guidelines on flexor tendon repairs and reconstruction. Journal of Hand Surgery (European Volume). 2026. DOI: 10.1177/17531934251404821

[14] Flexor Tendon Injuries. The Journal of Hand Surgery. 2024. DOI: 10.1016/j.jhsa.2024.05.013

[15] Primary Flexor Tendon Surgery. Hand Clinics. 2013. DOI: 10.1016/j.hcl.2013.03.001

[16] Clinical Outcomes Associated with Flexor Tendon Repair. Hand Clinics. 2005. DOI: 10.1016/j.hcl.2004.11.005

[17] Pediatric Flexor Tendon Injuries. Hand Clinics. 2005. DOI: 10.1016/j.hcl.2004.11.004

[18] The growth factors involved in flexor tendon repair and adhesion formation. Journal of Hand Surgery (European Volume). 2013. DOI: 10.1177/1753193413509231

[19] Primary Flexor Tendon Repair with Early Active Motion. Hand Clinics. 2017. DOI: 10.1016/j.hcl.2017.03.001

[20] Use of the Volar Plate of the Distal Interphalangeal Joint as a Distally Based Flap in Flexor Tendon Surgery. The Journal of Hand Surgery. 2016. DOI: 10.1016/j.jhsa.2015.11.004

[21] Uncommon Methods of Flexor Tendon and Tendon-Bone Repairs and Grafting. Hand Clinics. 2013. DOI: 10.1016/j.hcl.2013.02.004

[22] Complications After Treatment of Flexor Tendon Injuries. Journal of the American Academy of Orthopaedic Surgeons. 2006. DOI: 10.5435/00124635-200607000-00001

[23] Spontaneous Flexor Tendon Ruptures of the Hand: Case Series and Review of the Literature. The Journal of Hand Surgery. 2007. DOI: 10.1016/j.jhsa.2007.06.012

[24] Flexor Tenolysis. Hand Clinics. 2005. DOI: 10.1016/j.hcl.2004.11.008

[26] Management of Complications of Flexor Tendon Injuries. Hand Clinics. 2015. DOI: 10.1016/j.hcl.2014.12.004

[27] Effectiveness of Sodium Hyaluronate and ADCON-T/N for the Prevention of Adhesions in Hand Flexor Tendon Surgery: A Systematic Review and Meta-Analysis. The Journal of Hand Surgery. 2022. DOI: 10.1016/j.jhsa.2021.07.012

[28] Rehabilitation after flexor tendon repair and others: a safe and efficient protocol. Journal of Hand Surgery (European Volume). 2021. DOI: 10.1177/17531934211037112

[29] Flexor tendon injuries in children: Rehabilitative options and confounding factors. Journal of Hand Therapy. 2015. DOI: 10.1016/j.jht.2014.12.002

[30] Flexor Tendon Sheath Infections of the Hand. Journal of the American Academy of Orthopaedic Surgeons. 2012. DOI: 10.5435/jaaos-20-06-373

[31] Biomechanics of the Flexor Tendons. Hand Clinics. 2005. DOI: 10.1016/j.hcl.2004.11.002

[32] Closed Flexor Tendon Ruptures. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.04.005

[34] Postsurgical Rehabilitation of Flexor Tendon Injuries. The Journal of Hand Surgery. 2019. DOI: 10.1016/j.jhsa.2019.02.010

[36] Zone-specific pitfalls in flexor tendon rehabilitation: management and prevention. Journal of Hand Surgery (European Volume). 2024. DOI: 10.1177/17531934241265579

[37] Wide-awake Flexor Tendon Repair and Early Tendon Mobilization in Zones 1 and 2. Hand Clinics. 2013. DOI: 10.1016/j.hcl.2013.02.009

[38] Flexor tendon rehabilitation in the 21st century: A systematic review. Journal of Hand Therapy. 2019. DOI: 10.1016/j.jht.2018.06.001

[40] Investigations into flexor tendon repair: a research journey over three decades. Journal of Hand Surgery (European Volume). 2022. DOI: 10.1177/17531934221087585

[43] Complex Injuries Including Flexor Tendon Disruption. Hand Clinics. 2005. DOI: 10.1016/j.hcl.2004.12.001

[45] Relative motion flexion following zone I-III flexor tendon repair: Concepts, evidence and practice.. Journal of Hand Therapy. 2023. DOI: 10.1016/j.jht.2022.11.004

[47] Evaluation and Treatment of Flexor Tendon and Pulley Injuries in Athletes. Clinics in Sports Medicine. 2020. DOI: 10.1016/j.csm.2019.12.004

[48] Technical and Biological Modifications for Enhanced Flexor Tendon Repair. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2009.12.044

[49] Outcomes and Evaluation of Flexor Tendon Repair. Hand Clinics. 2013. DOI: 10.1016/j.hcl.2013.02.007

[50] Flexor tendon repair: recent changes and current methods. Journal of Hand Surgery (European Volume). 2021. DOI: 10.1177/17531934211053757

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By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.