Tendon Repair & Hand Reconstruction | Dr. Fang Yousheng (Hand Surgery) | CMCS Shanghai

About Dr. Fang Yousheng

Dr. Fang Yousheng is a senior hand surgeon at Huashan Hospital, Fudan University — one of China's foremost centres for hand surgery, microsurgical reconstruction, and tendon surgery, and a national reference institution for the management of complex hand trauma and functional reconstruction. He specialises in tendon repair, tendon transfer, and functional hand reconstruction following trauma and degenerative conditions, combining advanced surgical technique with individualised rehabilitation planning to optimise long-term hand function outcomes. Dr. Fang's clinical philosophy holds that flexor tendon repair — particularly in Zone II, the anatomically demanding region within the fibro-osseous flexor sheath — requires not only precise surgical technique at the time of repair but also a carefully designed postoperative rehabilitation programme that balances the competing demands of tendon healing and the prevention of adhesion formation. His department at Huashan Hospital has established one of Shanghai's most comprehensive hand surgery and tendon reconstruction programmes, integrating primary repair, staged tendon grafting, tendon transfer, and structured early mobilisation rehabilitation into a unified care pathway for patients with complex flexor tendon injuries.

Case Overview

Mr. Wang (pseudonym), a young Chinese man, sustained multiple flexor tendon lacerations of the right hand with severe skin and soft tissue contusion in a traumatic injury — presenting with complete loss of active finger flexion and significant functional impairment affecting daily activities and work. Following emergency transfer to Huashan Hospital, Dr. Fang Yousheng conducted a detailed clinical assessment, confirming multiple flexor tendon lacerations and evaluating the extent of associated soft tissue injury. The surgical team performed tendon exploration, primary repair of the lacerated tendons, and functional reconstruction — including tendon transfer or grafting where required. A detailed postoperative rehabilitation programme was designed and implemented under Dr. Fang's supervision. Over the course of rehabilitation, active finger flexion recovered progressively, and the patient regained near-complete hand function — returning to daily activities and work. This case demonstrates Dr. Fang's expertise in the surgical and rehabilitative management of complex flexor tendon injuries and the capacity of Huashan Hospital's hand surgery programme to achieve excellent functional outcomes in challenging multi-tendon trauma cases.

Patient Background

• Name / Nationality: Mr. Wang (pseudonym) — Chinese male, young adult
• Mechanism of injury: Traumatic laceration of the right hand with severe skin and soft tissue contusion — multiple flexor tendon divisions
• Chief Complaint: Complete loss of active finger flexion of the right hand following traumatic injury; severe soft tissue contusion; inability to perform daily activities or work
• History of present illness: Mr. Wang sustained a traumatic laceration of the right hand resulting in multiple flexor tendon divisions with associated severe skin and soft tissue contusion. On presentation, active finger flexion was completely absent in the affected fingers — the patient was unable to make a fist or perform any grip function with the right hand. The injury significantly impaired his ability to perform activities of daily living and rendered him unable to work. He was transferred to Huashan Hospital for specialist hand surgery assessment and management.
• Functional assessment at presentation: Active finger flexion: absent in affected fingers; grip strength: severely reduced; pinch function: impaired; activities of daily living: significantly dependent; work capacity: nil

Diagnostic Workup

Clinical Examination

• Systematic assessment of flexor tendon integrity: flexor digitorum profundus (FDP) tested by isolated distal interphalangeal (DIP) joint flexion with proximal interphalangeal (PIP) joint held extended; flexor digitorum superficialis (FDS) tested by isolated PIP joint flexion with adjacent fingers held in full extension; flexor pollicis longus (FPL) tested by isolated interphalangeal (IP) joint flexion of the thumb
• Findings: complete loss of active FDP and FDS function in multiple fingers consistent with complete tendon division; zone of injury identified by wound location and tendon function assessment
• Assessment of associated injuries: skin and soft tissue contusion extent mapped; neurovascular status of the fingers assessed — digital nerve and vessel integrity evaluated by two-point discrimination testing and capillary refill

Imaging

• Plain radiographs of the right hand: Bony injury excluded; foreign body assessment; joint integrity confirmed
• Wound assessment: Wound contamination level, skin and soft tissue viability, and the feasibility of primary closure assessed in the emergency department and confirmed intraoperatively

Dr. Fang's pre-operative assessment: The clinical examination tells us everything we need to know about the tendon injury — the systematic testing of FDP and FDS function in each finger maps the tendon divisions precisely before we open the wound. In this patient, the pattern of tendon loss is clear, and the zone of injury is the critical variable. Zone II — the region within the fibro-osseous flexor sheath between the A1 pulley and the FDS insertion — is the most technically demanding zone for flexor tendon repair because both FDP and FDS run in close proximity within the sheath, and the repair must be strong enough to allow early active mobilisation while being smooth enough to glide within the sheath without adhesion. The soft tissue contusion adds complexity — contused tissue heals with more scar than clean-cut tissue, and the inflammatory response from the contusion will increase the risk of adhesion formation around the repair. The rehabilitation programme must be designed from the outset to counteract that tendency: early controlled active mobilisation, commenced within days of surgery, is the most effective strategy for preventing adhesion formation and achieving a functional range of motion. The surgery and the rehabilitation are a single integrated treatment — neither is sufficient without the other.

Diagnosis and Surgical Treatment Strategy

The diagnosis established by Dr. Fang Yousheng was Multiple Flexor Tendon Lacerations of the Right Hand with severe skin and soft tissue contusion.

The surgical principle was: tendon exploration, primary repair of all divided tendons with a strong multi-strand core suture technique, pulley preservation or reconstruction to maintain the mechanical advantage of the flexor system, and wound closure with skin grafting or flap coverage where required — followed immediately by a structured early active mobilisation rehabilitation programme.

Operative procedure — Flexor Tendon Exploration, Repair, and Functional Reconstruction:

• Wound extension and exploration: Bruner zigzag incisions used to extend the traumatic wound and expose the flexor tendon system within the fibro-osseous sheath; systematic exploration of all flexor tendons in the zone of injury; retrieval of retracted proximal tendon stumps
• Tendon repair: Primary repair of divided FDP and FDS tendons using a multi-strand core suture technique (four- or six-strand repair) to achieve sufficient repair strength for early active mobilisation; circumferential epitendinous suture to smooth the repair site and reduce surface friction within the sheath
• Pulley management: Preservation of the A2 and A4 pulleys — the critical pulleys that prevent bowstringing of the flexor tendons; partial pulley venting performed where required to accommodate the bulk of the repair without creating a mechanical block to tendon gliding
• Tendon transfer or grafting: Where primary repair was not achievable due to tendon loss or retraction beyond the length of direct repair, tendon grafting or transfer performed to restore continuity of the flexor system
• Associated injury repair: Digital nerve repair performed where nerve division was identified; skin and soft tissue coverage achieved by primary closure, skin grafting, or local flap as required by the extent of the soft tissue defect
• Wound closure and dressing: Layered closure; dorsal blocking splint applied in the position of safe immobilisation — wrist in slight flexion, MCP joints in flexion, IP joints in extension — to protect the repair while allowing early controlled mobilisation

Postoperative rehabilitation protocol — Early Active Mobilisation:

• Days 1–5: Dorsal blocking splint maintained; wound care; oedema management; passive finger flexion exercises within the splint to maintain joint mobility
• Days 5–21 (Early Active Mobilisation Phase): Controlled active finger flexion exercises commenced within the dorsal blocking splint — place-and-hold technique: passive positioning of the fingers in full flexion followed by active muscle contraction to hold the position; this generates sufficient tendon excursion to prevent adhesion formation while keeping the repair force within safe limits
• Weeks 3–6: Progressive active flexion exercises; composite fist exercises; blocking exercises to isolate FDP and FDS function; splint wear progressively reduced
• Weeks 6–12: Progressive strengthening; grip and pinch strengthening; return to light daily activities; splint discontinued
• Months 3–6: Full functional rehabilitation; work hardening; return to unrestricted activities and work

Treatment Course and Outcomes

Intraoperative

• Tendon exploration, primary repair, and functional reconstruction completed under Dr. Fang's guidance; all divided tendons repaired with multi-strand core suture technique; pulley integrity maintained; associated nerve and soft tissue injuries addressed; wound closed; dorsal blocking splint applied

Postoperative Recovery

• Early active mobilisation programme commenced within the first week of surgery; patient compliant with rehabilitation protocol under physiotherapy supervision
• Progressive improvement in active finger flexion range of motion over the course of rehabilitation; no tendon rupture; no significant adhesion formation requiring tenolysis
• At three months: active finger flexion substantially restored; grip strength improving; patient able to perform activities of daily living independently
• At six months: finger function near-complete; patient returned to work; grip strength approaching normal for age and hand dominance
• Patient highly satisfied with functional outcome

Dr. Fang's clinical reflection: Flexor tendon repair in Zone II is one of the most technically demanding procedures in hand surgery — not because the surgery itself is complex, but because the margin for error is so small. The repair must be strong enough to withstand the forces of early active mobilisation — if it ruptures, the outcome is catastrophic and a second operation is required. But the repair must also be smooth enough to glide within the sheath without forming adhesions — if it adheres, the patient loses the range of motion that the surgery was designed to restore, and a tenolysis is required. The multi-strand core suture technique and the circumferential epitendinous suture give us the strength and the surface smoothness we need. The early active mobilisation programme — commenced within days of surgery — is what prevents the adhesions. In this patient, the combination of a technically sound repair and a well-executed early mobilisation programme produced a near-complete functional recovery. That is the standard we aim for in every flexor tendon repair.

Expert Commentary — Dr. Fang Yousheng

1. Flexor Tendon Anatomy and Zone II Injury: Why the Fibro-Osseous Sheath Makes Tendon Repair So Demanding

The flexor tendon system of the hand is an anatomical masterpiece of mechanical efficiency — and Zone II, the region within the fibro-osseous flexor sheath between the A1 pulley at the base of the finger and the FDS insertion at the middle phalanx, is the zone where that efficiency is most precisely engineered and most vulnerable to disruption by injury. Within Zone II, both the FDP and FDS tendons run in close proximity within the sheath, lubricated by synovial fluid and constrained by the annular and cruciate pulleys that prevent bowstringing and maintain the mechanical advantage of the flexor system. The sheath is a closed, low-friction environment that is essential for normal tendon function — and it is precisely this environment that makes Zone II tendon repair so demanding. A repair performed within the sheath must be strong enough to withstand the forces of early active mobilisation — forces that are necessary to prevent adhesion formation — while being smooth enough to glide within the sheath without creating a mechanical block. The bulk of the repair site, the surface irregularity of the suture knots, and the inflammatory response to the suture material all contribute to the risk of adhesion formation between the repair site and the sheath wall. The technical evolution of flexor tendon repair over the past three decades — from two-strand to four-strand to six-strand core suture techniques, combined with circumferential epitendinous sutures — has been driven by the need to achieve sufficient repair strength for early active mobilisation while minimising the bulk and surface irregularity of the repair site. The current generation of multi-strand repair techniques, combined with structured early active mobilisation protocols, has transformed the outcomes of Zone II flexor tendon repair — achieving functional results that were not possible with the immobilisation-based protocols of earlier decades.

2. Early Active Mobilisation After Flexor Tendon Repair: The Biological Rationale and the Clinical Protocol

The shift from postoperative immobilisation to early active mobilisation as the standard rehabilitation protocol after flexor tendon repair represents one of the most important advances in hand surgery rehabilitation of the past four decades — and it is grounded in a clear biological rationale. Tendon healing occurs through two concurrent processes: extrinsic healing, driven by fibroblast ingrowth from the surrounding sheath and peritendinous tissues, which produces the adhesions that restrict tendon gliding; and intrinsic healing, driven by tenocytes within the tendon substance itself, which produces the collagen that restores tensile strength without adhesion formation. Early controlled mobilisation — by generating tendon excursion within the sheath — stimulates intrinsic healing, reduces extrinsic adhesion formation, and maintains the gliding surface between the tendon and the sheath wall. The clinical protocol for early active mobilisation after flexor tendon repair is built around the place-and-hold technique: the fingers are passively positioned in full flexion — bringing the repair site to its maximum excursion within the sheath — and the patient then actively contracts the flexor muscles to hold that position. This generates the tendon excursion necessary to prevent adhesion formation while keeping the repair force within the safe range for the multi-strand repair. The protocol is commenced within the first week of surgery and progressed systematically over the following weeks as repair strength increases with healing. The critical requirement for early active mobilisation is a repair of sufficient strength to withstand the mobilisation forces without rupture — which is why the technical quality of the repair is the prerequisite for the rehabilitation programme. Surgery and rehabilitation are not sequential events in flexor tendon management — they are a single integrated treatment strategy, and the rehabilitation programme must be planned at the time of surgery.

3. Managing Soft Tissue Injury in Flexor Tendon Trauma: Skin Coverage, Wound Healing, and the Risk of Adhesion

Flexor tendon injuries rarely occur in isolation — the mechanism of injury that divides the tendon typically also damages the overlying skin and soft tissues, the digital nerves and vessels, and the fibro-osseous sheath. The management of the associated soft tissue injury is as important as the tendon repair itself in determining the functional outcome, because the quality of the soft tissue envelope around the repair site directly influences the risk of adhesion formation and the feasibility of early active mobilisation. Skin and soft tissue contusion — as in this patient — produces an inflammatory response that increases fibroblast activity in the peritendinous tissues and raises the risk of extrinsic adhesion formation around the repair site. Achieving tension-free skin closure over the tendon repair is essential: a wound that is closed under tension will dehisce, exposing the tendon repair to desiccation and infection, and the resulting scar will adhere to the underlying tendon and prevent gliding. Where primary closure is not achievable without tension — because of skin loss or soft tissue contusion — skin grafting or local flap coverage must be performed at the time of tendon repair to provide a tension-free, well-vascularised soft tissue envelope. The choice between skin graft and flap coverage depends on the size and location of the defect, the vascularity of the wound bed, and the surgeon's assessment of the coverage that will best support the early active mobilisation programme. In this patient, the extent of the soft tissue contusion required careful assessment and individualised coverage planning — ensuring that the soft tissue envelope over the tendon repair was optimised for the early mobilisation programme that was the key to the functional outcome.

How CMCS Shanghai Coordinated This Case

CMCS Shanghai supported Mr. Wang and his family throughout the emergency transfer, surgical, and rehabilitation pathway at Huashan Hospital, Fudan University, including: urgent coordination of emergency transfer to Huashan Hospital's hand surgery department with advance notification to Dr. Fang Yousheng's team; bilingual interpretation throughout the clinical examination, diagnostic discussion, surgical planning consultation, and all postoperative review appointments; bilingual explanation of the tendon repair procedure, the postoperative rehabilitation protocol, and the expected timeline and goals of functional recovery; coordination of postoperative physiotherapy and occupational therapy with bilingual liaison with the rehabilitation team, written early active mobilisation protocol provided in the patient's preferred language, and structured follow-up appointment coordination; monitoring of rehabilitation progress with bilingual communication of functional recovery milestones to the patient and family; and assessment coordination for secondary reconstructive procedures — including tenolysis planning — where indicated at follow-up.

For international patients with flexor tendon injuries, complex hand trauma, or other hand and wrist conditions requiring specialist surgical management and rehabilitation in Shanghai, Dr. Fang Yousheng's team at Huashan Hospital offers a clinically rigorous, technically advanced approach — combining precise tendon repair technique, individualised rehabilitation planning, and long-term functional follow-up to achieve the best possible hand function outcomes. CMCS ensures that expertise is accessible: in the patient's language, with every step of the surgical and rehabilitation pathway coordinated and communicated clearly, from emergency transfer through full functional recovery and return to work.

This case report is de-identified and published for educational purposes. All clinical details have been anonymized in accordance with patient privacy standards. CMCS Shanghai is a medical concierge service and does not provide direct medical care.