الفهرس 
AnatomyOnly 14 pages are availabe for public view
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Abstract
Human hand is a miraculous tool of the body that serves us extremely well in a multitude of ways, we successfully use our hands to identify objects , communication and extracting a wealth of information about the surrounding objects. A complex system of interconnected joints with a Distinctive groups of muscles and tendons mechanisms and numerous other aiding structures, form a sophisticated biomechanical system that gave humans the ability to perform complicated tasks and develop dexterous professions that require sophisticated hand and finger movement.
Tendon surgery is one of the most important topics in hand surgery; its importance to hand function and its rising gain of interest to hand surgeons are well-reflected in the vast number of investigations and publications devoted to this topic. Surprisingly, despite revolutionary changes in the treatment of tendon injuries and disorders. This field still needs more and more effort to raise awareness for the importance of the presence of well-trained hand surgeons teams integrated in different trauma centers.
With close knowledge to the basic science, a wealth of research and participation has been accumulated. Our knowledge of tendon biology and biomechanics has increased greatly, technology introduced a number of new research fields such as gene therapy, tissue engineering, stem cell delivery, and gene therapy.
In the early half of the last century, Bunnell used the term No man’s Land to describe the region where the flexor tendon passes through the digital sheath (zone 2 for the flexor system). Bunnell advised surgeons to be cautious when repairing the flexor tendon in zone 2 and outlined rigid conditions
Since the mid-1980s, the clinical practice of tendon surgery has evolved considerably, and a great number of innovative techniques have emerged. They include a myriad of novel repair techniques, use of new suture materials, novel tendon sheath and pulley treatments, vascularized tendon grafts, and the development of various postoperative rehabilitation.
Injuries to the flexor tendons occur in the digits, palm, wrist, or distal and mid-forearm. Repairs of flexor tendons in the digital sheath area are technically demanding.
In the tenth century, Avicenna, an Arabian surgeon, was credited with performing the first tendon repair surgery. In Europe, however, Galen teachings resulted in infrequent tendon repair such that teaching at that time (circa 150 AD) involved an intimate relationship between tendons and nerves, so much so that physicians feared severe consequences from damaging or even touching a nerve or a tendon. In England around 1850, Syme reported success with several cases of tendon repair paving the way for modern tendon repair and reconstruction.
Functional results after flexor tendon repair in zone 2 have markedly improved over the past three decades. However, a big dilemma of flexor tendon repair in zone 2 remains the challenge between scar formation and risks of rupturing the repairs. Not only repair techniques but also postoperative mobilization require a balance between these two extremes.
Primary and delayed primary flexor tendon repairs are indicated in clean-cut tendon injuries with limited damage to the peri-tendinous tissues or a wound that can be converted to a clean-cut wound. Neurovascular injury is not a contraindication to primary repairs. Loss of soft tissue coverage over the tendon or the presence of fractures is a borderline contraindication.
partial tendon laceration are common they present usually in the clinic several weeks after the injury due to persistence of symptoms, by which time the cutaneous wound may be healed and closed. Evidence of triggering or entrapment is adequate indication for exploration of the wound. Partial tendon lacerations can also be seen in a large wound together with complete lacerations of other tendons, which are easy to diagnose. However, the topic of treating partial tendon laceration remains a subject of debate in hand surgery. Opinions are divided on whether management of partial tendon laceration is best achieved through surgical or nonsurgical approach.
Tendon adhesions form frequently after tendon repairs and reconstructions, phalangeal fractures, and deep tissue (e.g., flexor sheath) infections. Multiple postoperative modalities including early active range of motion protocols have been developed to optimize tendon gliding. Aggressive therapy may be sufficient to restore full range of motion for mild adhesions. Alternatively, tenolysis can be a beneficial procedure for patients who have provided sufficient effort during vigorous therapy and have plateaued in their range of motion progress.
Between roughly 1920 and 1960, secondary repair was the preferred choice when dealing with flexor tendon injuries in zone 2. Subsequent advances in primary repair, especially with newer suture designs and rehabilitation techniques, have made primary repair the preferred option for the vast majority of zone 2 injuries. Nonetheless, secondary repair options remain viable in many circumstances. Newer research may also expand the role of secondary reconstruction.
Flexor tendon reconstruction is a spectrum of challenging treatment options ranging from non-operative treatment to tenolysis to single-stage and multistage reconstructive surgical procedures. Secondary tendon reconstruction is indicated in the patients whose tendon injuries are not treated at the primary or delayed primary stages, whose injuries to the tendon are too serious, or where destruction of the flexor pulleys are too extensive, which prevents primary repair of the tendon. In the presence of severe scar in the tendon gliding bed or extensive pulley damages, both patient and surgeon are to be prepared for multiple surgical procedures.
Over the course of the past 100 years, we have come full circle in our approach: For a long period, injured flexor tendons in the hand were immobilized or resected, with later grafting. In the 1960s, passive mobilization programs were in vogue, and today sophisticated active mobilization programs are the preferred approach. Nonetheless, there is limited high-quality evidence supporting one form of early mobilization over another.
Tendon surgery has certainly advanced over the past century. repairs are stronger and more reproducible; most surgeons who deal with these injuries have had some sort of training in the management of tendon injuries, and within the past 60 years hand surgery has developed as a specialty, while within the past 30 years hand therapy has joined it as a recognized field of specialization. There are hand surgeons in nearly every country on the planet; in the larger and more developed countries, there are literally thousands of trained hand surgeons and therapists and we shall experience every day more and more advancement in this rapidly flourishing field of surgery.