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Vein sheathing repair of a cutaneous nerve and EPL tendon repair

    Overview

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    Learn the Vein sheathing repair of a cutaneous nerve and EPL tendon repair surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Vein sheathing repair of a cutaneous nerve and EPL tendon repair surgical procedure.
    Open hand injuries can result from a variety of mechanisms including sharp objects, commonly glass or knife or from power tools. When assessing these patients, it is important to be systematic to identify all structures which are injured. When planning the exposure allowance should be made consider the possibility that certain tendons such as EPL can retract significantly into the forearm and the exposure may need to be extended proximally. Glass injuries are common in the hand and tend to be deep and at risk of structural injury, even if the lacerations appear small.
    The patient in this case sustained lacerations to the dorsum of the hand with a broken glass which divided the extensor pollicis longus tendon and superficial radial nerve. Superficial sensory nerve repairs in the upper limb can be complicated by the development of neuromas and perineural scarring. This is particularly a problem on the dorsum of the hand where there is less subcutaneous tissue, and the sensitised nerves can cause neuropathic pain on even light pressure. I have adopted a technique of sheathing the nerves during their primary repair to reduce the risk of this painful scarring. In a comparative study of neurorrhaphy with and without vein sheathing Leuzzi and co-authors found that 70% of simple neurorrhaphy patients reported pain at the nerve repair site whereas it dropped to 25% when vein sheathing was used.
    For most cutaneous nerves, an adjacent vein can be sacrificed for wrapping around the nerve repair. For example, for the superficial radial nerve and lateral cutaneous nerves of the forearm the cephalic vein or its branches can be used. For the medial cutaneous nerve of the forearm or the dorsal branch of the ulnar nerve the basilic vein can be used. It is an anatomical fact that superficial sensory nerves accompany veins, which lends itself to this technique. There are no side effects to sacrificing a cutaneous vein as there are several superficial and deep veins which compensate for the function lost.
    There are also commercial nerve wraps available as alternatives, but these are expensive and have no real advantage over autologous veins for protecting small nerve repair. I tend to use the commercial nerve wraps for larger nerves, such as the median or ulnar nerve, when they are released from scar tissue as a secondary procedure. This is because the cutaneous veins of the upper limb are not large enough to be wrapped around larger nerves without causing constriction.
    Readers will also find the following OrthOracle techniques of interest:
    Targeted Muscle Reinnervation (TMR) of Superficial Radial Nerve using Axogen Avance processed nerve allograft
    Targeted muscle re-innervation for superficial radial neuroma
    Targeted Muscle Reinnervation (TMR) for neuroma treatment following above knee amputation
    Neurolysis digital nerve plus Vivosorb barrier wrap (Polyganics) and Z-plasties to scar contracture left little finger
    Revision carpal tunnel decompression and application of Polyganics Vivosorb membrane
    Digital nerve conduit-assisted repair with the NeurolacTM (Polyganics)
    EIP to EPL Tendon Transfer

    Leuzzi S, Armenio A, Leone L, et al. Repair of peripheral nerve with vein wrapping. G Chir. 2014;35(3-4):101-106.

    Indications

    INDICATIONS
    The indication for surgery in this case was a patient with an acute traumatic wound on the dorsum of the hand, where clinical examination has revealed likely injuries to extensor tendons and the superficial branch of radial nerve.
    The general indications for a vein-sheath technique would be as part of repair of a cutaneous nerve of the upper limb, the commonly encountered ones being:
    1. Superficial radial nerve
    2. Lateral cutaneous nerve of the forearm
    3. Medial cutaneous nerve of the forearm
    4. Palmar cutaneous nerve of the median nerve
    5. Dorsal branch of the ulnar nerve
    SYMPTOMS & EXAMINATION
    All trauma patients have to be assessed using the ATLS protocol. If it is an isolated hand injury, a detailed history has to be taken. The key questions include age, handedness, hobbies, and mechanism of injury. The exact time and mechanism of injury are important. The first aid done at the time and any treatment given at any referring hospitals have to enquired about. These are followed by questions about any symptoms experienced by the patients such as pain, inability to move wrist, thumb, or fingers and or numbness. Patients’ past medical history, drug history, allergies and social history are important.
    Examination starts with inspection of the wound. The exact location of the wound and its dimensions are noted. It is useful to describe the wound in relation to the anatomical landmarks. For example, a laceration can, be described as ‘a 5cm clean oblique incised wound over the dorsum of the right hand about 2cm proximal to the MCP joint’.
    A systematic examination of the tendons has to carried out. The extensor tendons of the hand and wrist are arranged in six compartments. It is useful to systematically examine all of them in a wrist laceration.
    1. The first compartment has the APL and EPB. These two are often difficult to test as the movements by these tendons can be produced other muscles or tendons (APB can abduct the thumb when APL is not working and EPL and extend the MCP joint when EPB is injured). Therefore, injuries to these tendons are diagnosed often based on the location of the wound over the anatomical snuff box area.
    2. The next compartments contains ECRL and ECRB. Both these tendons extend the wrist but ECRB has a more central pull and when it is injured wrist extension has a deviation to radial side.
    3. The third compartment has EPL and it can be tested by asking a patient to retropulse the thumb from a resting position on the table.
    4. The fourth compartment has EDCs and EIP. EDCs can be tested by asking the patient to extend each finger independently. EIP is tested by asking the patient to extend the index finger in isolation.
    5. The fifth compartment is EDM which is tested by asking the patient to extend the little finger independently.
    6. The sixth compartment is ECU which is tested by asking the patient to extend and ulnar deviate the wrist.
    The dorsal sensory nerves of the wrist are the superficial radial nerve and the dorsal branch of the ulnar nerve. The superficial radial nerve provides sensations to the dorsum of the thumb up to IP joint and index and middle fingers up to PIP joint. The dorsal branch of the ulnar nerve provides sensations over the dorsum of the ulnar half of the dorsum and the ring and little fingers.
    While assessing sensation it is useful to compare with the opposite hand. Patients do not usually say that the sensations are completely absent. They have diminished sensations and a ‘Tens’ test’ is a useful way to compare it with the opposite hand. This test is carried out by asking the patient to give a numerical score for an area of sensory loss with normal side being 10. Anything less than 5 is highly suspicious of a nerve injury.
    The radial artery travels into the palm through the anatomical snuffbox. It is the main supply to the thumb and index finger but even if it is divided the hand is well perfused through the ulnar artery. Whilst an Allen’s test can be carried out by blocking the ulnar artery and checking the patency of radial artery, it is difficult to carry out this test in the setting of trauma. An injury to radial artery can sometime cause pulsatile bleeding and may be alarming. The temptation to use a haemostat to control the bleeding in A&E should be resisted. In many cases the jaws of the haemostat end up catching superficial radial nerve branches as well and also make the artery unrepairable. The best way to control the bleeding is to use a rolled up gauze piece over the wound and use a crepe bandage to provide compression and elevate the arm. Pressure can be directly applied over the area of bleeding with a gloved hand. Elevation has to be carried out for five minutes by the clock. With the exception of patients who have a bleeding tendency all other bleeding should stop with this manoeuvre. One should not try to explore hand wounds in A&E as this may restart bleeding. Diagnosis of tendon injuries can be made through clinical examination and exploration in the setting of A&E adds little to the information.
    IMAGING
    X-Rays are useful to identify bony injuries and to look for foreign bodies in the wound. Plain X-Rays with AP, lateral and oblique views should be done.
    ALTERNATIVE OPERATIVE TREATMENT
    There are no alternative operative methods in the setting of trauma apart from exploration of the wounds and repair. However, there are alternative methods for repairing the tendons which relate to the type of the core suture used, a cruciate repair being one variation.
    For the repair of the superficial radial nerve one can use a variety of techniques:
    1. Simple neurorrhaphy with 9-0 Ethilon sutures
    2. Simple neurorrhaphy with vein sheathing as done in this case
    3. Simple neurorrhaphy with a sheath using a commercially available tubes such as Neurolac™ (Polyganics, USA)
    4. Conduit assisted repair using a commercially available tubes such as Neurolac™ (Polyganics, USA)
    NON-OPERATIVE MANAGEMENT
    Non-operative management is not applicable in these cases unless the patient has significant co-morbidities or other injuries when the wound may be closed under local anaesthetic and reconstructions carried out later.
    CONTRAINDICATIONS
    The only contraindications to carrying out an exploration and repair in these cases are when patients are unfit for an anaesthetic, they have other significant life threatening injuries or when the wounds are grossly contaminated when an initial debridement is carried out.

    Setup

    Explorations of hand wounds can be performed under regional or general anaesthesia. There are occasions when one can do a small wound exploration under local anaesthetic and these are usually wounds on the dorsum of the fingers where one can use a digital tourniquet. For larger wounds when an anaesthetist is not available, a Wide Awake Local Anaesthetic Technique popularly known as WALANT can be used. This technique uses local anaesthesia with Xylocaine with adrenaline 1:2,00,000. It is administered as a field block and should be administered aat least 10 minutes prior to the procedure.
    It is important to use a tourniquet while exploring hand wounds except while doing the WALANT technique and in this instance an upper arm tourniquet is used. A hand table is used as standard and surgeon uses magnification with loupes to help identify the structures.
    One dose of intravenous antibiotics is administered at induction. Most units use Flucloxacillin 1gm at the time of induction and for Penicillin allergic patients Clindamycin 500mg is used. When there is contamination with organic materials such as in bite wounds, Co-Amoxiclav 1.2gm is used and for Penicillin allergic patients, Clindamycin is administered aling with Metronidazole 500mg.
    The hand is scrubbed using a scrubbing brush prior to surgical prepping. This helps to physically clean the hands which are often dirty from industrial accidents.

    Operation – 1

    The wounds on the dorsum of the hand can be seen. There is a transverse laceration over the radial side of the wrist and there are multiple longitudinal lacerations over the dorsum of the hand. It is important to make a mental note of the injuries and plan the extensions of the wound as needed.
    In this case, clinical examination showed that the longitudinal lacerations on the hand were superficial.
    The transverse dorsal wrist incision is of concern as the EPL tendon appears divided. There is numbness along the distribution of superficial radial nerve.

    The hand is positioned on a rolled up Huck towel after prepping. For dorsal hand wounds it is important to flex the wrist to improve the exposure. It is best achieved by using a rolled up Huck towel.
    A Lead hand though used more for volar wounds, can be used for dorsal wounds. It is kept under the hand and can be used to support the wrist and fingers.

    Surgical incision is marked with a pen. Reciprocal extensions are made towards the forearm and hand hand as shown. The decision how far to extend depends on the nature of the injury. In this case EPL is divided and is likley to have retracted into the forearm. Therefore an incision extension of 5cm is done proximally and a 4cm extension distally.
    It is important to make the extensions curved as shown instead of narrow angled triangular flaps. Large rounded flaps have better vascularity and also help to advance the skin if there is a skin defect after debriding the edges.

    The arm is exsanguinated by elevating and squeezing the hand and forearm for one minute. Tourniquet is inflated to 250mm Hg.
    Incisions are made using a No.15 blade. The incision is made down to subcutaneous tissue till the dorsal veins are visible.

    The assistant applies traction on the skin edge using a Gille’s skin hook. The surgeon lifts the skin as a flap using sharp dissection. It is easier and safer to use a blade to raise the skin flaps initially. The flaps are raised including subcutaneous fat down to the plane of the superficial veins.
    It is impprtamt to recognise the various planes in the dorsum of the hand. Underneath the skin is a layer of subcutaneous fat. Below that layer is the plane where the superficial veins lie and the nerves lie beneath that. Underneath that layer is the deep fascia investing the tendons or muscles.

    Once you identify the correct plane, which is the subcutaneous layer with veins, one can use scissors to divide the fascial septae which are tethering the skin and develop the flaps.

    Nerve ends are identified
    Scissor dissection is carried out to identify the cut ends of the superficial radial nerve. Gentle spreading action of the scissors should be enough to find the nerve in the subcutaneous fat plane.
    The superficial radial nerve is the nerve supply for the dorsum of the hand on the radial side. The ulnar half of the dorsum is supplied by the dorsal branch of the ulnar nerve.
    The superficial radial nerve travels in the forearm underneath brachioradialis muscle and exits underneath the tendon to lie in the subcutaneous plane about 5-7cm proximal to the radial styloid. It divides into three to four branches and they travel over the anatomical snuff box to supply the dorsal skin.

    The cut distal end of the superficial radial nerve is identified and is shown here. The cut end looks clean with a minimal crush element.

    Scissor dissection is continued to identify the proximal end of the nerve. The proximal end of the nerve lies in the subcutaneous plane in the wrist, over the first extensor compartment. About 5-7cm from the radial styoid it can be seen emerging from underneath the brachiradialis tendon. Proximal dissection in this case is in the subcutaneous plane and there are no other structures at risk.

    The proximal end of the nerve has been identified. Unlike the distal cut end, the proximal end looks bruised suggesting a crush element to the end. This should be debrided till healthy fascicles can be seen and should be done just before the nerve repair.
    At this stage one should try and mobilise the ends and check if there is a gap between the two ends. A gap can occur if there is loss of nerve substance or because of the swelling in the wound and retraction of the nerve ends.

    The skin flaps are sutured down on the hand and forearm to allow visualisation of the deeper structures. This frees up the assistant’s hand without a retractor.

    The wound has been exposed using the sutures. A 4-0 Nylon suture has been used here.

    The wound is now washed out using normal saline. This is not only for reducing the risk of infection by removing the contamination, but to washout the blood clots and enable clear visualisation of the field.
    In general it is important to keep the surgical field moist as the dry field is at risk of bacterial colonisation. This can be achieved by intermittent irrigation or by keeping moist swabs over the wound edges.

    Following the irrigation the ends of the nerves and the distal end of EPL tendon can be seen clearly in the field.
    A dilated superficial vein is adjacent to the nerve and will be useful for the vein sheathing which will be done later after the nerve repair:
    A. Proximal end of nerve
    B. Distal end of nerve
    C. Distal end of EPL
    D. Vein

    Dissection is now carried out to mobilise the ends of EPL tendon.
    EPL travels through a sheath in an oblique manner from the wrist into the hand.
    It is important to recognise the anatomy of the dorsal extensor tendons. They are arranged in six compartments as can be seen in the next slide. EPL tendon lies in the third compartment but it crosses over the second compartment by changing its direction over Lister’s tubercle which acts as a pulley.

    The distal cut end of EPL tendon can be seen. It seems to be an oblique cut and the end appears like a clean cut. The proximal end is not seen at this point which suggests that it has retracted under the sheath.
    Though there is usually no loss of tendon in these types of injuries, retraction of the tendon can make the repair difficult.
    If the repair is carried out within the first week, both ends can be mobilised and a repair can be carried out primarily. If it is a delayed repair, this may need a tendon graft.

    The next step is to identify the proximal end of the EPL tendon.
    To do this one needs to dissect proximally into the tendon sheath. However there are some of the intact branches of the superficial radial nerve which have to be protected. At this point one should remember the anatomy of the superficial radial nerve which was described earlier. Scissor dissection is preferred which allows to pass it in to the sheath and dissect using gentle spreading action.

    Anatomical knowledge of extensor compartments is important to identify the proximal end of EPL.
    As mentioned earlier it runs in the third extensor compartment and curves around Lister’s tubercle. Dissection is carried out ulnar to Lister’s tubercle and the sheath opened.
    Dissection is first carried out over the tendon sheath separating the subcutaneous tissues using scissors. Subsequently the scissors are passed into the sheath and the sheath opened.
    Another method for retrieving the proximal end is it use a long curved instrument known as a Brand tendon passer. It can be inserted into the sheath and the end of the tendon grabbed using the teeth of the instrument.
    I have chosen to use scissors here as a tendon passer was not available in the tray.

    In this case EPL tendon has retracted proximally. The sheath is opened further and tendon end retrieved.
    The superficial radial nerve branches if intact will be lying proximally in the subcutaneous plane. One has to be careful not to injure them. Palpating the Lister’s tubercle will help to orient the compartments.
    The sheath of the EPL will be ulnar to the Lister’s tubercle proximally. Retraction of EPL is a common occurence and while consenting patients for an EPL repair it is important to explain to them about the need for a proximal extension.

    Both the ends of the tendon have been mobilised.
    The proximal end appears to be ragged with a frayed segment of the tendon. Both tendon ends can be mobilised to bring together which means a primary repair can be carried out here. If there appears to be excessive tension one can get the assistant to extend the thumb and wrist which will relieve the tension.
    Though it is a good practice to debride the ragged tendon ends prior to repair, in this case this may create excessive tension in the tendon repair and may even make a primary repair not possible. I have therefore decided not to debride the proximal end.
    One can get away with it in most cases though there is likely to be more scarring in the repair site causing adhesions.

    The proximal end of EPL is carefully passed under the intact branches of superficial radial nerve.

    There is tension between the ends of the tendon and this is common while repairing EPL. Therefore a blue hypodermic needle is used to impale the distal end of the tendon to the bone.
    The assistant has to hold the thumb in extension to facilitate the repair.

    Tendon repair is doneAt this point one needs to think about the type of repair. There are several types of repairs used for tendons. As this is a small rounded tendon, I have decided to use a modification of Kessler technique.
    The suture I have chosen in 4-0 PDS. Though it is an absorbable suture it retains tensile strength more than six weeks. It knots easily and gets absorbed after six months.
    The main advantage is that unlike monofilament non-abosrable sutures it gets absorbed and will not cause a suture irritation under the skin. This is not a problem in palmar wounds where there is more padding in the skin and therefore for flexor tendons I use Prolene sutures.
    The choice of 4-0 is because of the size of the tendon. It has a smaller needle and does not damage the already frayed tendon.

    The sutures are passed onto the distal end of the tendon. It is important to go at least 1cm distally into the stump to avoid the suture getting cut out.

    The distal part of the suture is complete. The hypodermic needle can be taken out at this stage as I have control of the distal end of the tendon by holding the sutures.

    Operation – 2

    The suture is passed proximally into the tendon. As this end is frayed one has to pass the suture proximally at least 1.5cm.

    The tendon repair looks ragged and untidy once the knot is tightened. This is due to the fact that the ends are frayed. One end of the suture is cut but it is left about 4cm long. The other end with the needle still attached is kept intact. I am planning to run a continuous suture around the tendon using the end of the suture.
    The traditional way to tidy up the ends is to use a separate epitendinous suture with 5-0 Prolene. However given the tension in the repair I have decided to continue the epitendinous sutures with the 4-0 PDS sutures.

    The epitendinous or continuous sutures are done using the same 4-0 PDS sutures which were used for the core Kessler suture. About 8 contunuous passes have been made around the tendon. The suture is now tied to the end which was left long previously.

    The completed tendon repair can be seen. The tension in the repair is evident by the hyperextension in the thumb.
    At this stage the assistant can release his hand which is maintaining the hyperextension of the thumb.

    The two ends of the nerve are mobilised using micro forceps. This allows to check the tension in the repair. It can be seen here that there is no tension in the repair.
    If there is excessive tension between the ends which makes repair not possible, there are two strategies.
    One is to cut the end of the nerve more proximally in the forearm. There is however a risk of a neuroma forming.
    The other strategy is to do a targeted muscle re-innervation which is a technique described in another section of this atlas. The proximal end of the nerve is sutured to the anterior interosseous nerve in this technique Targeted Muscle Reinnervation (TMR) of Superficial Radial Nerve using Axogen Avance processed nerve allograft
    A third option could be to use a nerve allograft if its is available. Using an autograft for a sensory nerve such as this is not advisable as this only shift the sensory deficit from one place to another.

    Vein segment is harvestedI am planning to apply a vein sheath over the nerve repair. The superficial vein adjacent to the nerve is mobilised using a tenotomy scissors. Any superficial vein can be used for this purpose.
    Choosing the vein with an appropriate sized vein is a matter of judgement. If in doubt it is better to err on the side of taking a larger vein. One should also remember that veins dilate and can have a lumen larger than one expects. In this case the cephalic vein is available but as there is a larger dorsal vein in the wound, I have chosen to use it.

    A 2cm segment of the vein is held between artery forceps.

    The vein segment is harvested using tenotomy scissors.

    The piece of vein can be seen. It is kept on a moistened gauze.

    The ends of the vein are ligated using 3-0 vicryl ties.

    The vein has blood in the lumen. The vein is flused out using normal saline. A blunt needle or a blue venflon can be used to flush the vein lumen.

    A microforceps is carefully inserted into the lumen of the vein. This is to stabilise the vein to clear the surrounding tissues from the wall of the vein.

    The fibrofatty tissue is dissected off the wall of the vein using a curved microscissors.

    The nerve ends are mobilised using micro forceps and a yellow visibilty background is placed under the nerves. The background comes in a larger sheet and you can cut it to the size you need.

    The next step is to pass the vein segment over the end of the nerve. To do this, the vein is picked up and the micro forceps passed through the lumen of the nerve.

    The jaws of the forceps are gently opened and the distal end of the nerve grabbed carefully.

    Using another micro forecps the vein sheath is pulled over the distal end of the nerve.

    The vein has been passed over the distal end of the nerve and it stays snug.

    the next step is the neurorrhaphy. This is best done under a microscope.
    The surgeon performing the nerve repair should have the hand-held controls for zoom and focus.

    It is important to trim the ends of the nerve till healthy fascicles are seen. Inadequate debridement of the nerve ends can give poor recovery of the nerve following repair.
    It is a useful step to keep moist wet gauze pieces around the repair site. This helps to the field moist and also protects the micro suture needle in case it flicks out of the needle holder.

    Nerve repair is done using 10-0 Ethilon sutures. For this nerve you only need about four or five epineural sutures.

    A close up of the nerve repair can be seen.

    The completed nerve repair is seen.

    The vein sheath is gently pulled over the repair site.

    A close up of the vein sheath over the repair can be seen.

    Operation – 3

    A single 10-0 Ethilon suture is passed from the end of the vein sheath to the nerve to secure it and stop it from sliding.

    The completed nerve repair with the vein sheath cam be seen wit the repaired tendon in the background.

    The wound is irrigated prior to closure. It is important to make sure that the veon sheath is kept moist.

    Skin closure is done using 4-0 vicryl rapide interrupted sutures. A single layer closure is sufficent.

    While closing the wound it is important that the two skin flaps are aligned accurately.

    The completed wound closure can be seen.

    The superficial wounds on the dorsum of the hand are washed out and closed with 4-0 vicryl rapide sutures.

    All the wounds have been closed.

    The wounds are dressed in layers. The first layer is jelonet, followed by dressing gauze and velband.

    It is important to protect the EPL repair using a POP backslab. A double layer of POP is cut into the shape as shown. It should extend from mid-forearm to the tip of the thumb.

    The POP backslab is applied on the volar aspect of the hand and thumb keeping the wrist and thumb extended.

    Crepe bandage is applied over the POP backslab.

    Post Operative

    Patient is discharged home the same day with advice to elevate the hand in a sling for 48 hours.
    Wound check is done between 5-7 days in the dressing clinic. The wound is redressed with a simple adhesive dressing and a thermoplastic splint applied in the same size and shape of the POP backslab.
    The hand and thumb are immobilised in the POP backslab for 6 weeks. After six weeks patient is advised to start active mobilisation exercises of the thumb and wrist. The thumb will be stiff at this stage from adhesions around the tendon.
    Patient is also advised to do scar massage and desensitisation massages around the scar. This is done to reduce the sensitivity at the site of nerve repair. The start with gentle touching over the skin followed by light massage and eventually firm massage.
    Passive mobilisation of the thumb can be attempted after 4 weeks. Patient should be able to return to normal activities at 12 weeks though the nerve recovery will continue for several months. The final review at six months is to assess the movement of the thumb and the sensory recovery of the nerve.

    Recommended Reading

    1. Leuzzi S, Armenio A, Leone L, et al. Repair of peripheral nerve with vein wrapping. G Chir. 2014;35(3-4):101-106.
    In this study authors compared 16 patients who underent peripheral nerve repair with vein sheathing with 10 patients who had simple neurorraphy. The group with vein sheathing showed better sensory and motor recovery and had less neuroma pain. The concluded that vein sheathing is beneficial in nerve repairs and is a simple adjunct which can be used.
    2. Andal Thirumalai, Rajive M Jose, Dominic Power The efficacy of vein ensheathing in protecting peripheral nerve repair sites. Journal of muscuoskeletal surgery and research. 2019;3(1): 123-127.
    This study looked at 25 patients who underwent vein sheath along with primary nerve repair or secondary neurolysis. Follow up data was available on 19 patients of which 12 patients had face to face review. None of the patients had persistent neuroma symptoms. Sensory recovery was variable and two patients had no sensory recovery. The authors concluded that vein sheathing was a useful addition to nerve repairs and neurolysis.
    3. Chinchalkar SJ, Pipicelli JG, Laxamana J, von Dehn L. Postoperative management of extensor pollicis longus repairs within close vicinity to or within the extensor retinaculum. J Hand Ther. 2010 Oct-Dec;23(4):412-9.
    This paper looks at the rehabilitation of extensor pollicis longus tebndon repairs using a new splint, trying the balance tendon glide and protection of repair. The role of tendon glide and tether in recovery of repairs is discussed.

    Reference

    • orthoracle.com

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