Tendon laceration (hand:wrist)MANAGEMENT

TRAUMA PRESENTATIONS · 12 SECTIONS

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453 items

☷ Legend

01Approach to the Critical Patient/attcp57

Triage priorities

›High risk states

›Uncontrolled hemorrhage

›If brisk bleeding, direct pressure and hemostatic dressing

›If persistent bleeding, tourniquet proximal to injury and time stamp

›Neurovascular compromise

›Absent distal pulses

›Cool pale digit

›Capillary refill delay

›Compartment syndrome concern

›Disproportionate pain

›Pain with passive stretch

›Open fracture concern

›Deformity

›Crepitus

›Deep infection concern

›Fever

›Rapidly progressive swelling

Immediate actions

›Limb protection and analgesia

›Elevation

›Hand above heart level

›Remove rings and constrictors

›Analgesia plan

›Acetaminophen oral

›NSAID oral if no contraindication

›Opioid oral if severe pain

›Regional anesthesia options

›Digital nerve block for finger injury

›Wrist block for hand injury

Early consultations

›Hand surgery activation triggers

›Suspected complete tendon transection

›Loss of active motion against gravity

›Loss of motion against resistance

›Any flexor tendon laceration suspicion

›Volar wound at finger, palm, or wrist with weakness

›Pain with attempted flexion

›Complex extensor tendon injury

›Zone III over PIP joint

›Central slip concern

›Neurovascular injury suspicion

›Sensory loss in nerve distribution

›Weak intrinsic muscles

›Fight bite concern

›Dorsal MCP wound after punch

›Contamination

›Farm injury

›Bite

›Salt water exposure

Stabilization targets

›Monitoring and documentation

›Baseline neurovascular status

›Two point discrimination

›Light touch by nerve distribution

›Capillary refill

›Pulse oximetry on digit if concern

›Functional baseline

›Isolated joint motion testing

›Pain limited exam noted

›Photo documentation policy compliant

02History/hx48

Injury context

›Mechanism and timing

›Time since injury

›Minutes to hours

›Greater than 24 hours

›Mechanism

›Clean sharp laceration

›Crush laceration

›Saw injury

›Glass injury

›Environment

›Clean indoor

›Soil or farm

›Water exposure

›Contamination clues

›Bite history

›Fight bite

›Grease or metal debris

Symptoms and function

›Tendon specific complaints

›Loss of finger flexion

›DIP flexion loss

›PIP flexion loss

›Loss of finger extension

›DIP extension lag

›PIP extension lag

›MCP extension weakness

›Wrist motion loss

›Wrist extension weakness

›Thumb extension loss

›Pain pattern

›Pain with active motion attempt

›Pain with passive stretch

Risk modifiers

›Patient factors

›Diabetes

›Wound healing risk

›Immunosuppression

›Steroids

›Biologics

›Smoking or vaping nicotine

›Tendon healing risk

›Anticoagulant use

›Bleeding risk

›Hand dominance and occupation

›Work restrictions impact

›Immunization status

›Tetanus vaccine timing

›Unknown status

›More than 10 years

›More than 5 years with dirty wound

03Physical Exam/exam43

Wound and tendon exam

›Inspection and functional testing

›Wound assessment

›Location and length

›Depth estimate

›Visible tendon or muscle

›Foreign body suspicion

›Extensor mechanism testing

›Isolated DIP extension

›Terminal extensor tendon integrity

›Isolated PIP extension

›Central slip integrity

›MCP extension against resistance

›EDC integrity

›Sagittal band injury consideration

›Flexor mechanism testing

›FDP testing

›PIP held in extension, DIP flexion

›FDS testing

›Adjacent fingers held in extension, PIP flexion

›Tenodesis effect

›Wrist extension, passive finger flexion

›Wrist flexion, passive finger extension

Neurovascular exam

›Neurovascular status

›Sensory testing

›Median nerve distribution

›Ulnar nerve distribution

›Radial nerve distribution

›Motor testing

›Thumb opposition

›Finger abduction and adduction

›Thumb IP extension

›Perfusion

›Capillary refill

›Radial and ulnar pulses

›Allen test if arterial injury concern

Pitfalls

›Missed injury patterns

›Partial tendon laceration

›Preserved motion with pain

›Weakness only against resistance

›Extensor tendon redundancy

›Near normal extension despite significant laceration

›Pain limited exam

›Re exam after anesthesia

04Differential Diagnosis/ddx36

Traumatic causes of motion loss

›Tendon and related injuries

›Flexor tendon laceration

›ICD-10-CM S66.1XXA

›SNOMED CT flexor tendon laceration of hand

›Extensor tendon laceration

›ICD-10-CM S66.3XXA

›SNOMED CT extensor tendon laceration of hand

›Sagittal band rupture

›MCP extensor subluxation

›Central slip injury

›Boutonniere risk

›Jersey finger

›FDP avulsion

›Mallet finger

›Terminal extensor injury

›Volar plate injury

›PIP hyperextension trauma

Associated injuries

›Non tendon injuries

›Digital nerve laceration

›Sensory deficit

›Digital artery laceration

›Ischemia

›Fracture

›Phalanx

›Metacarpal

›Distal radius with tendon involvement

›Joint capsule violation

›Traumatic arthrotomy

›Foreign body

›Glass

›Metal

Infection mimics

›Infection and inflammation

›Flexor tenosynovitis

›Kanavel signs

›Cellulitis

›Septic arthritis of MCP or PIP

05Laboratory Tests/lt15

Infection and bleeding context

›Selective labs

›Infection concern

›CBC for systemic infection concern

›CRP for deep infection concern

›Blood cultures if sepsis concern

›Bleeding concern

›INR for warfarin use

›Platelets if thrombocytopenia concern

Procedural and operative planning

›Pre op context labs

›Planned urgent operative repair

›Type and screen if significant bleeding risk

›Serum glucose mmol/l if diabetes concern

Point of care tests

›Bedside tests

›Capillary glucose mmol/l for altered mental status or diabetes concern

›Hypoglycemia mimic of weakness considered

06Diagnostic Tests/dt51

Scoring Systems

›Classification systems used clinically

›Extensor tendon zones

›Zone I DIP joint

›Zone II middle phalanx

›Zone III PIP joint

›Zone IV proximal phalanx

›Zone V MCP joint

›Zone VI dorsum of hand

›Zone VII wrist

›Zone VIII distal forearm

›Flexor tendon zones

›Zone I distal to FDS insertion

›Zone II from FDS insertion to distal palmar crease

›Zone III palm

›Zone IV carpal tunnel

›Zone V proximal to carpal tunnel

MRI

›Advanced imaging considerations

›Indications

›Occult partial tendon laceration with persistent dysfunction

›Chronic injury with unclear anatomy

›Limitations

›Poor ED practicality

›Delays definitive management

›Cross sectional imaging role

›Indications

›Radiolucent foreign body concern with negative X ray

›Complex fractures with tendon involvement

›Limitations

›Radiation

›Lower soft tissue contrast than MRI

Ultrasound

›Point of care and radiology ultrasound

›Indications

›Suspected tendon discontinuity with equivocal exam

›Partial laceration concern

›Retraction localization for surgical planning

›Technique pearls

›High frequency linear probe

›Longitudinal and transverse views

›Dynamic assessment with gentle active motion

›Interpretation pitfalls

›Overestimation of small gaps

›Anisotropy artifact

Plain radiography

›X ray role

›Indications

›Glass or metal foreign body concern

›Suspected fracture or avulsion

›Fight bite with possible tooth fragment

›Views

›AP

›Lateral

›Oblique

07Disposition/dispo27

Level of care

›Disposition pathways

›Immediate hand surgery evaluation in ED

›Flexor tendon laceration suspicion

›Complete extensor tendon laceration suspicion in high complexity zones

›Nerve or artery injury suspicion

›Open fracture

›Joint capsule violation concern

›Fight bite

›Gross contamination

›Urgent hand surgery follow up within 24 to 72 hours

›Simple extensor tendon laceration repaired or splinted per local protocol

›Partial tendon laceration with preserved function

›Transfer to hand surgery capable center

›No local hand coverage and high risk features

›Ischemic digit

Discharge criteria

›Safe outpatient management

›Hemostasis achieved

›No expanding hematoma

›Neurovascularly intact

›Normal capillary refill

›No new sensory deficit after block resolution anticipated

›Immobilization plan in place

›Appropriate splint

›Elevation instructions

›Follow up arranged

›Hand surgery or plastics

›Primary care for tetanus follow up if needed

08Treatment/t82

Wound care

›Local wound management

›Irrigation and debridement principles

›High volume irrigation for contaminated wounds

›Avoid tendon desiccation

›Skin closure strategy

›If tendon repair deferred, loose approximation as needed

›If fight bite concern, avoid primary closure of dorsal MCP wounds

›Dressings

›Nonadherent dressing over tendon exposure

›Bulky protective dressing

Immobilization

›Splinting by suspected tendon group

›Extensor tendon injury splints

›Distal finger zones

›DIP extension splint for terminal extensor injury patterns

›PIP joint zone

›PIP extension splint if central slip concern

›Dorsum of hand and wrist zones

›Wrist extension splint

›MCP slight flexion as tolerated

›Flexor tendon injury splints

›Dorsal blocking splint concept

›Wrist flexion

›MCP flexion

›IP joints relative extension

Antibiotics

›Antibiotic decision framework

›Uncomplicated clean laceration

›No routine prophylaxis supported by evidence summaries

›Shared decision making for high risk hosts

›Tendon exposed or deep structure involvement

›Oral prophylaxis commonly used by practice patterns

›Escalate to IV for gross contamination or open fracture

›Bite wounds and fight bite

›Antibiotics recommended due to high risk location

›Rabies assessment for mammalian bites per local public health

›Oral regimens

›Cephalexin oral

›Adult typical dosing per local formulary

›Penicillin allergy alternative selection

›Amoxicillin clavulanate oral

›Bite wounds

›Duration 3 to 5 days typical

›Clindamycin plus trimethoprim sulfamethoxazole oral

›Bite wounds with penicillin allergy

›Duration 3 to 5 days typical

›IV regimens

›Cefazolin IV

›Open fracture coverage

›Add gram negative and anaerobe coverage for heavy contamination per protocol

›Ampicillin sulbactam IV

›Severe bite infection concern

Tetanus prophylaxis

›Tetanus vaccination

›Clean minor wound

›Booster if more than 10 years since last dose

›Dirty or contaminated wound

›Booster if more than 5 years since last dose

›Unknown or incomplete immunization

›Tetanus vaccine

›Tetanus immune globulin for high risk wounds per immunization guidance

Tendon repair considerations

›Repair strategy overview

›Flexor tendon laceration

›Definitive repair typically in OR by hand specialist

›Early evaluation prioritized

›Repair timing often within 7 to 10 days when feasible

›Extensor tendon laceration

›Selected zones suitable for ED repair by trained clinicians

›Complex zones managed by specialist

›Partial lacerations

›Nonoperative management consideration if less than 50% and full strength present

›Specialist input preferred

Pain control

›Analgesia plan

›Nonopioid first line

›Acetaminophen oral

›NSAID oral if no contraindication

›Opioid short course if severe pain

›Lowest effective dose

›Avoid driving guidance

Evidence notes

›Evidence grading statements

›Extensor tendon laceration ED management guidance described in emergency medicine consensus resources

›Evidence level commonly expert consensus

›ACEP Level C style recommendations applicable when based on consensus and lower quality data

›Bite wound antibiotic prophylaxis supported by consensus for high risk locations

›Class IIa style recommendation based on guideline consensus

09Special Populations/sp29

Pregnancy

›Pregnancy specific considerations

›Imaging selection

›X ray with shielding when indicated

›Ultrasound favored when feasible

›Analgesia

›Acetaminophen preferred

›NSAID avoidance in later pregnancy

›Antibiotics

›Beta lactams generally preferred when appropriate

›Avoid teratogenic agents when alternatives exist

Geriatric

›Older adult considerations

›Skin fragility

›Higher dehiscence risk

›Anticoagulation

›Hematoma risk

›Baseline arthritis

›Masking of functional deficits

›Cognition and adherence

›Splint compliance risk

Pediatrics

›Pediatric considerations

›Exam limitations

›Limited cooperation

›Need for analgesia and anxiolysis strategies per policy

›Growth plate injuries

›Lower threshold for X ray

›Splint sizing and fit

›Frequent re checks for swelling

›Nonaccidental injury consideration

›Inconsistent history

10Background/b27

Epidemiology

›Frequency and context

›Common mechanisms

›Kitchen knife

›Glass

›Power tools

›Commonly missed injuries

›Partial tendon lacerations

›Associated nerve lacerations

Pathophysiology

›Injury mechanics

›Complete transection

›Loss of continuity

›Retraction depending on zone

›Partial laceration

›Preserved continuity with weakness

›Delayed rupture risk with continued use

›Tendon sheath involvement

›Adhesion risk

›Tenosynovitis risk in contaminated wounds

Therapeutic Considerations

›Time sensitivity and outcomes

›Flexor tendon repair timing

›Early specialist evaluation improves planning

›Delays increase stiffness and adhesion risk

›Immobilization tradeoffs

›Protection of repair or injury

›Stiffness risk with prolonged immobilization

›Early motion protocols

›Typically specialist supervised after repair

11Patient Discharge Instructions/pdi25

copy discharge instructions

›Discharge instructions

›Wound care

›Keep dressing clean and dry for 24 to 48 hours

›After 24 to 48 hours, gentle soap and water if allowed by clinician

›No soaking in bath, pool, or hot tub until cleared

›Splint care

›Keep splint on at all times unless instructed otherwise

›Elevation above heart level as much as possible for 48 hours

›Activity restrictions

›No lifting or gripping with injured hand

›No sports until cleared

›Medications

›Pain control as prescribed

›If antibiotics prescribed, complete full course

›Follow up

›Hand surgery appointment within recommended timeframe

›If appointment not scheduled within 24 hours, contact clinic or return for assistance

›Return to ED now

›Increasing pain not controlled with medication

›New numbness or tingling

›Fingers turning pale, blue, or cold

›Increasing swelling with tight splint symptoms

›Fever

›Pus, spreading redness, or red streaks

›Splint breakage or inability to keep hand immobilized

12References/r13

Key sources

›Evidence based and specialty sources

›AAOS OrthoInfo Flexor tendon injuries

›Repair timing and early evaluation statements

›NCBI Bookshelf StatPearls Flexor tendon lacerations

›ED temporizing measures and repair timing discussion

›NCBI Bookshelf StatPearls Hand extensor tendon lacerations

›Zone based management overview

›ACEP Now review of extensor tendon lacerations

›ED management considerations and splinting concepts

›Systematic reviews of prophylactic antibiotics for uncomplicated hand lacerations

›Limited benefit signal in uncomplicated cases

›Peer reviewed reviews on ultrasound accuracy in hand tendon trauma

›Dynamic ultrasound performance and limitations

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

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