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Profiling Zone 2: A Risk-Based View of Flexor Tendon Injuries
Angela V Atkinson, BS, Jacqueline R Fuentes, BA, Ashlynn B LaFlamme, BA, Jared A Hilton, MD, Kevin M Klifto, DO, PharmD; Stephen H Colbert, MD
University of Missouri, Columbia, MO
Introduction: Zone 2 flexor tendon injuries present a unique surgical challenge due to their complex anatomy and limited tendon gliding space. While the anatomical difficulties of this zone are well established, less is known about the patient-level risk factors that predispose individuals to these injuries. This study compares the comorbidity profiles and injury patterns of Zone 2 injuries to those in all other flexor tendon zones, with the aim of guiding early identification and informing treatment strategies.
Materials & Methods: This IRB-approved, retrospective study included patients who underwent flexor tendon repair between 2009 and 2023 at a single institution. Patients were grouped by injury zone, with Zone 2 injuries compared to all others. Demographics, comorbidities, injury characteristics, and complication outcomes were extracted from the medical record. Group comparisons were performed using chi-square tests for categorical variables and independent t-tests for continuous variables, including follow-up duration. Unadjusted odds ratios with 95% confidence intervals were calculated to estimate the association between injury zone and binary outcomes. Statistical significance was defined as ? = 0.05.
Results: Among 494 patients, 180 (36%) sustained Zone 2 injuries. Zone 2 injuries were significantly more likely to involve the small finger radial digital nerve (OR 3.13, 95% CI 1.34-7.35, p=0.009), and more likely to result in contractures at last follow-up (OR 3.05, 95% CI 1.57-5.94, p=0.001). Stiffness at last follow-up was also more common (OR 1.53, 95% CI 1.08-2.19, p=0.018). Conversely, Zone 2 injuries had significantly lower odds of ulnar artery injury (OR 0.07, 95% CI 0.02-0.22, p<0.001) and arterial repair (OR 0.28, 95% CI 0.13-0.56, p=0.0004). There was no significant difference in 90-day return to the emergency department or in average follow-up duration (24.2 vs. 30.0 weeks, p=0.161).
Conclusion: Zone 2 flexor tendon injuries are associated with distinct complication profiles, including higher rates of nerve involvement, stiffness, and contracture, yet fewer vascular repairs. These findings emphasize the need for zone-specific intraoperative vigilance and tailored rehabilitation protocols to mitigate long-term morbidity following Zone 2 injury.
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