Delayed Zone II Flexor Tendon Laceration in a Violinist
A 28-year-old violinist lacerated the volar aspect of the left index finger at the proximal phalanx 3 weeks ago with a kitchen knife. The wound healed but he cannot flex the distal interphalangeal joint; the proximal interphalangeal joint flexes weakly. There is no infection, and the finger is supple. Ultrasound shows retracted flexor digitorum profundus and flexor digitorum superficialis ends with a 3 cm gap and an intact A2 pulley. He wants to return to professional playing. He is otherwise healthy and does not smoke.
1. Compare delayed primary repair, tendon grafting, and two-stage reconstruction for this zone II injury, and recommend an approach.
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At 3 weeks, delayed primary repair is possible only if the tendon ends can be mobilized and approximated without excessive tension. A 3 cm retraction gap after 3 weeks makes direct repair likely to be under tension, which risks rupture and adhesion. A one-stage tendon graft, using palmaris longus or plantaris, is attractive because the A2 pulley is intact and the bed is supple; it allows precise tensioning and avoids a second operation. Two-stage reconstruction with a silicone rod is reserved for a scarred bed, pulley deficiency, or inability to close the sheath, because it requires a second procedure and may compromise gliding. For a violinist who needs full distal interphalangeal flexion and fine control, I would favor a one-stage graft if the bed is healthy and pulleys can be preserved; I would repair the profundus and consider superficialis repair only if it does not bulk the sheath.
2. How would you manage the pulleys and the rehabilitation program to protect the repair while restoring excursion?
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The A2 and A4 pulleys are critical for efficient finger flexion, and the A2 pulley is intact here, so I would preserve it and avoid unnecessary venting. If the graft bulges or the repair is tight, I would vent the A2 pulley only partially rather than dividing it completely. I would repair the sheath loosely to allow gliding while preventing bowstringing. Postoperatively, I would use a dorsal blocking splint and a controlled motion program. For a graft, I would begin passive flexion and active extension within a protected range after the early healing phase, then progress to active flexion and place-and-hold exercises. For a musician, I would emphasize isolated profundus gliding and avoid forceful gripping. Therapy should be supervised by a hand therapist familiar with tendon rehabilitation, and I would monitor for rupture, adhesion, and flexion contracture.
3. What outcome measures and return-to-play considerations are relevant for a violinist?
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For a violinist, the relevant outcomes are not just grip strength but distal interphalangeal joint flexion, isolated profundus excursion, speed of finger movement, coordination, and endurance during sustained playing. I would measure total active motion, fingertip-to-palm distance, and the ability to perform a slow chromatic scale and sustained bowing. Return to playing should be staged: gentle passive motion, then short practice sessions on an open string, then scales, then repertoire. Pain, swelling, and loss of flexion after practice are signs to reduce load. I would counsel him that adhesion formation and loss of fine flexion are the main risks, and that a one-stage graft may give a more predictable result than a delayed repair under tension. Protective sensation is less critical than in a manual worker, but cold intolerance and scarring over the proximal phalanx can affect instrument contact.