What is the appropriate management for a patient with a lacerated wound involving tendon damage?

Management of Lacerated Wounds with Tendon Involvement

Acute tendon lacerations require immediate surgical exploration and primary repair at the time of initial wound management, as this approach yields superior functional outcomes compared to delayed reconstruction. 1

Initial Assessment and Wound Management

Immediate Priorities

• Recognize serious injury including nerve or tendon laceration during initial wound evaluation, as this determines the entire treatment pathway 2
• Perform thorough wound cleansing with gentle irrigation using sterile normal saline or dilute water povidone-iodine solution to markedly decrease bacterial infection risk 2
• Avoid damaging skin or tissues during cleansing—aggressive debridement should be performed cautiously to avoid enlarging the wound and impairing skin closure 2
• Do not close infected wounds—suturing should be avoided when possible, particularly in contaminated wounds 2

Critical Examination Findings

• Assess for pain disproportionate to injury severity near bone or joint, which suggests periosteal penetration and potential deeper involvement 2
• Recognize that hand wounds are often more serious than wounds to fleshy body parts due to complex anatomy and functional demands 2
• Evaluate for compartment syndromes, nerve severance, and fractures as noninfectious complications that require immediate intervention 2

Surgical Management of Tendon Lacerations

Timing of Repair

Primary repair should be performed at the time of initial wound exploration rather than delayed reconstruction, as acute repair leads to better functional results 1. This applies to both complete and significant partial lacerations.

Repair Technique Based on Laceration Severity

For partial tendon lacerations:

• Lacerations <25% cross-sectional area without beveling: Do not repair; use early active mobilization 3
• Lacerations 25-95% cross-sectional area without beveling: Do not suture; use early mobilization 3
• Beveled lacerations <25% cross-sectional area: Either excise or repair with simple interrupted suture 3
• Beveled lacerations >25% cross-sectional area: Repair with a few simple sutures 3

For complete tendon lacerations:

• Use modified Kessler sutures with appropriate suture material (e.g., PDS 4.0) for primary repair 4
• Consider acellular tissue graft augmentation in high-demand patients to enhance tensile strength and promote vascular ingrowth 5
• Perform concomitant nerve repair if nerve injury is identified, as primary nerve repair minimizes painful neuroma formation 1

Post-Repair Protection

• Apply dorsal splint immediately to protect the tendon repair 4
• Elevate the injured extremity during the first few days after injury, especially if swollen, to accelerate healing 2
• Initiate progressive rehabilitation program with early protected mobilization based on repair strength 4

Antimicrobial Management

Prophylactic Antibiotics

Administer amoxicillin-clavulanate as first-line oral therapy for contaminated wounds with tendon involvement 2. This provides coverage against common wound pathogens including anaerobes.

Alternative regimens:

• Doxycycline as monotherapy 2
• Penicillin VK plus dicloxacillin 2
• Fluoroquinolones (ciprofloxacin, levofloxacin, moxifloxacin) plus metronidazole or clindamycin for anaerobic coverage 2

Avoid first-generation cephalosporins, penicillinase-resistant penicillins, macrolides, and clindamycin monotherapy as these have poor activity against common wound pathogens 2.

Intravenous Options for Severe Infections

Use β-lactam/β-lactamase combinations (ampicillin-sulbactam, piperacillin-tazobactam), second-generation cephalosporins (cefoxitin), or carbapenems (ertapenem, imipenem, meropenem) for hospitalized patients 2.

Adjunctive Measures

• Update tetanus prophylaxis (0.5 mL intramuscularly) if status is outdated or unknown 2
• Consider rabies prophylaxis for animal bites in high-prevalence areas after consulting local health department 2
• Follow up within 24 hours either by phone or office visit for outpatients 2
• Hospitalize if infection progresses despite appropriate antimicrobial and ancillary therapy 2

Monitoring for Complications

Infectious Complications Requiring Prolonged Therapy

• Septic arthritis and osteomyelitis: Require 4-6 week antibiotic courses 2
• Tendonitis and synovitis: Require 3-4 week courses 2
• Subcutaneous abscess formation: May require surgical drainage 2

Functional Complications

• Tendon rupture: Risk with inadequate repair or premature mobilization 3
• Trigger finger: Can occur but may resolve spontaneously 3
• Residual functional deficit: More likely with delayed repair 1

Expected Recovery Timeline

Most patients achieve excellent functional outcomes with appropriate primary repair and early mobilization 3. Elite athletes can return to original activity levels within 7 weeks with optimal repair technique and dedicated physical therapy 5.