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Flexor tendon repair

40 citationsUpdated Aug 2026

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Overview

Flexor tendon repair in Zone II is a technically demanding procedure, but 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]. Limited evidence currently exists for zones IV and VII extensor and for flexor tendon repairs regarding relative motion orthoses for early active motion [10].

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]. Secondary reconstruction remains an important and useful technique for complicated flexor tendon injuries or those that have failed primary repair [6]. 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 [15].

Anatomy & Pathophysiology

Flexor tendons function as cables that transmit forces to move and stabilize joints [35]. An understanding of the biomechanics of the flexor tendon system is essential to proper evaluation and treatment of disorders of the upper extremity [35]. A thorough understanding of the anatomy and mechanism of injury is critical for diagnosis, treatment, and postoperative management of flexor tendon injuries [51].

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].

Prevention Strategies: * Early active postoperative mobilization: This is an effective measure to prevent adhesion formation [48] and prevent interphalangeal (IP) joint stiffness [48]. * Sparing the wrist: This is an effective measure to prevent adhesion formation [48].

Therapists must understand the implications of wrist and metacarpophalangeal (MCP) joint positioning to safely facilitate tendon gliding [40]. Therapists must understand the implications of wrist and MCP joint positioning to prevent secondary pathomechanical changes [40].

Classification

Zone-based Classification: Flexor tendon injuries are classified into distinct zones that dictate specific anatomical considerations and repair principles [7]. Management requires consideration of injury location as a key factor alongside surgical timing, approach, and soft tissue handling [14].

Zone II: Primary flexor tendon repair in the digital sheath area (Zone II) has become standard practice, characterized by a shift toward strong multistrand core sutures and modified pulley preservation [12]. These repairs are technically demanding but have become more predictable and satisfying [1]. Subdividing Zone 2 is a key factor in improving outcomes in flexor tendon repair [43].

Zone I: Zone I flexor tendon injuries traditionally yield poorer results than other zones, with full motion rarely regained and good/excellent results reported in only up to 67% of cases [4].

Other Considerations: Differences in the management of flexor tendon injuries between children and adults include variations in classification, diagnosis, technical aspects of Zone I and II repairs, core suture purchase length, rehabilitation, results, and complications [26].

Clinical Presentation

Flexor tendon injuries are complex, requiring careful consideration of surgical timing, injury location, surgical approach, and soft tissue handling [14]. Repair in Zone II is a technically demanding procedure [1], though outcomes have become more predictable and satisfying [1]. In contrast, Zone I flexor tendon injuries traditionally have not yielded results as good as other flexor tendon injuries [4]. Full motion is rarely regained in Zone I injuries [4], with good or excellent results reported in only up to 67% of cases [4].

Adhesion formation is the most common complication after flexor tendon repair [5]. Joint contractures are also the most common complication after flexor tendon repair [29]. Repair ruptures are documented in most reports, with rates ranging from 4%-10% in finger flexors [16]. Repair rupture rates range from 3%-17% in the flexor pollicis longus (FPL) of thumbs [16]. Spontaneous flexor tendon ruptures of the hand occur more often than recognized, with the majority involving the profundus tendon of the small finger in the palm [24].

Pediatric flexor tendon injuries differ from adults in diagnosis and rehabilitation [18]. Pediatric flexor tendon injuries often require surgical exploration due to uncooperative patients [18].

Investigations

Plain radiography: Indicated to evaluate bony integrity and joint alignment in the context of flexor tendon injuries.

MRI: No gold standard has been determined for the optimal flexor tendon repair algorithm [2]. Flexor tendon repairs are usually chosen based on familiarity, popularity, and technical difficulty [2].

CT: Consistent, successful management of flexor tendon injuries relies on understanding the anatomy, characteristics, and repair of tendons in different zones [7].

Bone scan: Adhesion formation is the most common complication of flexor tendon injuries [5]. Joint contractures are the most common complication of flexor tendon injuries [5].

Tomosynthesis: Secondary reconstruction is an important and useful technique for complicated flexor tendon injuries [6]. Secondary reconstruction is an important and useful technique for flexor tendon injuries that have failed primary repair [6].

Aspiration: Limited evidence currently exists for the use of relative motion orthoses for early active motion after finger extensor and flexor tendon repairs in zones IV and VII [10].

Laboratory: Even otherwise healthy patients can expect some residual digital stiffness following flexor tendon sheath infection despite aggressive and prompt antibiotic therapy and surgical intervention [33].

Other Considerations: Outcomes for flexor tendon repair in Zone II have become more predictable and satisfying [1]. Consistent, successful management of flexor tendon injuries relies on understanding potential complications [7]. Consistent, successful management of flexor tendon injuries relies on understanding rehabilitation protocols [7]. Consistent, successful management of flexor tendon injuries relies on understanding recent advances in treatment [7]. Consistent, successful management of flexor tendon injuries relies on understanding future directions, including tissue engineering and biologic modification of the repair site [7]. There is large heterogeneity in the outcome domains being assessed or measured across studies on hand flexor tendon injuries [9]. A consistent core outcome set is needed for future clinical research on hand flexor tendon injuries [9]. Many principles of flexor tendon repair and rehabilitation can be applied to zones III–V [11]. Primary flexor tendon repair in the digital sheath area has become standard practice [12]. There is a shift toward strong multistrand core sutures in primary flexor tendon repair in the digital sheath area [12]. There is a shift toward modified pulley preservation in primary flexor tendon repair in the digital sheath area [12]. Despite significant advances, the drive towards perfection in flexor tendon repair and reconstruction continues [13]. Repair rupture rates for finger flexors range from 4% to 10% [16]. Repair rupture rates for the flexor pollicis longus (FPL) of thumbs range from 3% to 17% [16]. Pediatric flexor tendon injuries differ from adult injuries in diagnosis and rehabilitation [18]. Initial clinical experience with the volar plate of the distal interphalangeal joint as a distally based flap in flexor tendon surgery is encouraging [21]. The volar plate flap technique may take its place in flexor tendon surgery [21]. Late direct repair is possible in approximately 1 in 10 to 1 in 15 patients where tendon ends can be approximated with acceptable tension [22]. Spontaneous flexor tendon ruptures of the hand occur more often than one might recognize [24]. The majority of spontaneous flexor tendon ruptures of the hand involve the profundus tendon of the small finger in the palm [24].

Treatment

Non-Operative

Limited evidence currently exists for the use of relative motion orthoses following flexor tendon repairs in zones IV and VII [10], as well as for relative motion flexion orthoses generally [49]. There is insufficient evidence to support true active motion as an effective or preferable rehabilitation choice due to a lack of superior benefits compared to other regimens [42].

Operative

Indications: Management of flexor tendon injuries requires consideration of surgical timing, injury location, surgical approach, and soft tissue handling [14]. Secondary reconstruction is an important and useful technique for complicated flexor tendon injuries or those that have failed primary repair [6]. Preoperative, operative, and postoperative considerations for flexor tenolysis emphasize that patient selection, cooperation, and a rational goal are as key to success as the operative procedure itself [27].

Surgical Approach / Technique: Flexor tendon repair in Zone II is technically demanding, but outcomes have become more predictable and satisfying [1]. No gold standard has been determined for the optimal flexor tendon repair algorithm; repairs are usually chosen based on familiarity, popularity, and technical difficulty [2]. 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]. 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 [19]. Consistent, successful management relies on understanding anatomy, characteristics and repair of tendons in different zones, potential complications, rehabilitation protocols, recent advances in treatment, and future directions including tissue engineering and biologic modification of the repair site [7]. Despite significant advances in flexor tendon repair and reconstruction, the drive towards perfection continues [13].

Implant Selection: Several techniques for surgical pulley reconstruction have been described, typically using palmaris longus tendon graft or extensor retinaculum in either a nonencircling or looped fashion [46]. The Kleinert and Bennett (Weilby) technique is a nonencircling technique that uses a tendon graft woven into the residual end of the flexor tendon sheath, allowing pulley tension to be set but lacking immediate strength [46]. The Okutsu triple-loop reconstruction is an encircling technique that uses a triple loop of free tendon graft passed around the phalanx subcutaneously [46]. The Lister extensor retinaculum technique is an encircling technique that uses a strip of extensor retinaculum graft placed around the phalanx, overwrapped, and sutured to provide a smooth gliding surface, permitting active and passive motion [46]. The loop-and-a-half technique uses a tendon graft that passes around the phalanx and then through one limb of the tendon graft; it is described as the strongest in biomechanical cadaver studies excluding the triple-loop technique [46]. Early active motion is typically permitted after pulley reconstruction because reconstruction of A2 and A4 pulleys restores near-normal tendon excursion and joint motion in a cadaver study [46].

Adjuncts: Some practitioners no longer perform flexor tendon repair with tourniquet, sedation, or muscle paralysis [41]. Initial clinical experience with the volar plate of the distal interphalphalangeal joint as a distally based flap in flexor tendon surgery is encouraging, and the technique may take its place in flexor tendon surgery [21].

Other Considerations: Adhesion formation and joint contractures are the most common complications after flexor tendon repair [5]. Tendon adhesion and joint contracture are the most common complications after flexor tendon repair, managed through prevention, meticulous surgical technique, and thoughtful rehabilitation protocols [29]. 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 [23]. Pediatric flexor tendon injuries differ from adults in diagnosis and rehabilitation, often requiring surgical exploration due to uncooperative patients [18]. Understanding the role that growth factors play in tendon repair should enable a more targeted approach to improve results, although currently no strategies are routinely used in clinical practice [20]. 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 [52].

Complications

Stiffness / Arthrofibrosis: Adhesion formation and joint contractures are among the most common complications following flexor tendon injuries [5]. Zone I flexor tendon injuries traditionally yield poorer functional outcomes compared to injuries in other zones, with full motion rarely regained [4].

Tendon Rupture: Flexor tendon repair ruptures occur at rates ranging from 4% to 10% in finger flexors [16]. In the flexor pollicis longus (FPL) of thumbs, rupture rates range from 3% to 17% [16].

Recovery

Adhesion formation and joint contractures are the most common complications following flexor tendon injuries [5]. Rehabilitation strategies remain a controversial topic [38]. While motion at the repair site decreases the risk for adhesions, it simultaneously increases the risk for rupture [38]. 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 [30].

Rehabilitation protocol: 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 [31]. This protocol is particularly recommended where therapist assistance is unavailable [31].

Other Considerations: 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]. Future research is suggested to increase understanding of repair strength in children [32]. Further studies are needed to determine optimal age ranges for early active motion in children [32]. Additional research is suggested to determine the cost-effectiveness of rehabilitative options in children [32].

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)
  • [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. [15] (10.1016/j.hcl.2017.03.001)
  • [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. [18] (10.1016/j.hcl.2004.11.004)
  • [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. [19] (10.1016/j.hcl.2013.03.001)
  • [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. [20] (10.1177/1753193413509231)
  • [L4] Initial clinical experience is encouraging and the volar plate flap technique may take its place in flexor tendon surgery. [21] (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. [22] (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. [23] (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. [24] (10.1016/j.jhsa.2007.06.012)
  • [L5] [26] (10.1177/1753193413498207)
  • [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. [27] (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. [29] (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. [30] (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. [31] (10.1177/17531934211037112)
  • [L5] Future research is suggested to increase understanding of repair strength, optimal age ranges for early active motion, and cost-effectiveness. [32] (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. [33] (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. [35] (10.1016/j.hcl.2004.11.002)
  • [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. [38] (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. [40] (10.1177/17531934241265579)
  • [L5] The authors no longer perform flexor tendon repair with tourniquet, sedation, or muscle paralysis. [41] (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. [42] (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. [43] (10.1177/17531934221087585)
  • [L5] [46] (10.1016/j.hcl.2016.08.006)
  • [L5] Early active postoperative mobilization and sparing of the wrist are effective measures to prevent adhesion formation and IP joint stiffness. [48] (10.1177/17531934231182868)
  • [L4] There is currently limited evidence informing use of relative motion flexion orthoses following flexor tendon repair. [49] (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. [51] (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. [52] (10.1016/j.jhsa.2009.12.044)

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 Repair with Early Active Motion. Hand Clinics. 2017. DOI: 10.1016/j.hcl.2017.03.001

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

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

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

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

[21] 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

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

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

[24] 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

[26] Flexor tendon injuries in the child. Journal of Hand Surgery (European Volume). 2013. DOI: 10.1177/1753193413498207

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

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

[30] 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

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

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

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

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

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

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

[41] 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

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

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

[46] Flexor Tendon Pulley Injuries in Rock Climbers. Hand Clinics. 2017. DOI: 10.1016/j.hcl.2016.08.006

[48] Complications of flexor tendon repair. Journal of Hand Surgery (European Volume). 2024. DOI: 10.1177/17531934231182868

[49] 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

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

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

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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.