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Laceration Injuries at the Wrist

- Discussion: Zone IV:
    - extends from distal end of transverse retinacular ligament to proximal margin;
    - combined nerve - tendon procedure may be delayed for 21 days if wound is contaminated, if crushing trauma has occurred;
    - median nerve management: (nerve repair)
           - lacerations of flexor tendons within the carpal canal are typically assoc w/ partial or complete laceration of median nerve;
           - nerves should be repaired first and the tendons last;
           - median nerve may be repaired primarily in a clean wound;
           - median nerve is aligned by noting the proximal and distal central arteries, and by  proximal and distal electric stimulation (< 48 hrs);
           - delayed electrical stimulation is possible with the patient awake;
                   - distal nerve, however, may not show motor & sensory fibers stimulation;
           - tension is removed from nerve suture line by flexing wrist 30 deg and MP joints 60 deg;
    - post op:
           - digit can be manipulated toward extension, provided wrist in maintained in 30 deg of flexion;
           - main complication formation of adhesions between the flexor tendons and the carpal walls;

- Discussion: Zone V:
    - extends from the proximal transverse carpal ligament at the wrist to musculocotinous junction of flexor tendons in forearm;
    - in this area there may be concomitant ulnar nerve & artery damage as well as radial artery & median nerve damage;
           - primary repair of the arteries is usually indicated;
           - if wound is contaminated, arteries are repaired and delayed repair of tendons and nerves is planned;
    - post op:
         - wrist is maintained in volar flexion for 21 days and gradually brought into dorsiflexion during the subsequent 6 weeks

- references:
    - Optimizing independent finger flexion with zone V flexor repairs using the Massachusetts General Hospital flexor tenorrhaphy and early protected active motion.
    - Dynamic Splinting With Early Motion Following Zone IV/V and TI to TIII Extensor Tendon Repairs