OT notes · Orthopaedics

Repair of open hand injury and flexor / extensor tendon repair

Usual anaesthesia
Brachial plexus block or general anaesthesia; digital or wrist block for small distal injuries
Position
Supine with the arm on a hand table, pneumatic tourniquet on the upper arm
Setting
emergency

Operative note template for exploration and debridement of an open hand injury with primary flexor or extensor tendon repair, with a filled example for a zone II flexor tendon repair of the middle finger after a knife cut.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • wound infection
  • adhesions and stiff finger, may need tenolysis later
  • rupture of the repair, may need re-repair or tendon graft
  • flexion contracture of the finger
  • bowstringing if pulleys are damaged
  • numbness if digital nerves are injured or cannot be repaired
  • scar tenderness
  • long hand therapy programme and splint for 6 to 8 weeks
  • second operation if the wound is too dirty for primary repair

Pre-operative details for this operation

  1. Time and mechanism of injuryexact time, sharp or crush, glass / knife / machine / bite; contamination
  2. Interval from injury to surgeryprimary repair is usually within 12 hours; delayed primary up to about 10 days
  3. Hand dominance and occupation
  4. Side, digit(s) and zoneflexor zones I to V, extensor zones I to IX, thumb zones
  5. Pre-op tendon examinationFDP: DIP flexion with PIP held; FDS: PIP flexion with other fingers held straight; extensors: MCP / PIP / DIP extension
  6. Pre-op nerve and vascular examinationtwo-point or light-touch sensation on each side of the digit, capillary refill, Allen test if wrist wound
  7. X-ray of the handNo fracture or foreign bodyFractureRadio-opaque foreign body
  8. Tetanus prophylaxisstatus and what was given in casualty
  9. Antibiotic givendrug, dose, time; or 'not indicated, clean sharp wound'

Anaesthesia and position

  1. AnaesthesiaSupraclavicular / infraclavicular / axillary brachial plexus blockGeneralDigital blockWALANT (local with adrenaline, no tourniquet)
  2. PositionSupine, arm on hand table
  3. Tourniquetsite, pressure (mmHg), time up, time down; exsanguination by Esmarch or by elevation for 2 min if crush / fracture
  4. Loupe magnificationYesNo

Operative findings

  1. Woundsite, length, direction, clean / contaminated / crushed, skin loss, flaps and their viability
  2. Foreign bodyNoneGlassWoodOther
  3. Tendons cutname each: FDP / FDS / FPL / EDC etc., complete or partial (% of width), level of cut ends, how far the proximal end retracted
  4. PulleysA2 and A4 intact / damaged; which part of the sheath was opened
  5. Digital nerves and arteriesradial and ulnar sides: intact / cut / contused
  6. Bone and jointfracture, joint opened, volar plate

Procedure (steps)

  1. Wound irrigation and debridementnormal saline volume; devitalised tissue excised; nerve ends not debrided; foreign bodies removed; re-drape and change gloves after cleaning
  2. Wound extensionBruner zigzagMidlateralExtension into palm / forearmdo not cross flexion creases at a right angle
  3. Neurovascular bundles identified and protected
  4. Sheath openedwhich cruciate window (C1, A3, C2, C3); length opened (1.5 to 2 cm); A2 and A4 preserved or vented
  5. Retrieval of proximal stumpMilking forearm and flexing wristCatheter / feeding tube methodSeparate incision at distal palmar creaseSkin hook
  6. Temporary holding of stumps25 or 26 G needle across the sheath and tendon
  7. Orientation checkedFDP through the FDS hiatus; FDS slips not rotated (Camper chiasm)
  8. Core suturetechnique (modified Kessler / Adelaide / cruciate / Lee), number of strands (4, 6, 8), suture material and size, knots buried
  9. Epitendinous suturerunning circumferential, 5-0 or 6-0 monofilament (polypropylene or nylon)
  10. Zone I only: tendon-to-bone fixationDirect repair to distal stumpSuture anchor in distal phalanxPull-out suture over padded button
  11. Gliding checkedpassive flexion / extension, no gap, no catching on pulley edge
  12. Extensor tendon repair (if any)zone, technique (core suture with cross-stitch / roll stitch / figure-eight in muscle), suture material and size
  13. Nerve and artery repair (if any)done after tendon repair; epineural suture size; ends tagged if repair deferred
  14. SheathLeft openRepaired with 5-0 or 6-0 nylon
  15. Tourniquet released, haemostasis securedtime released; digit perfusion after release

Closure, drains and dressing

  1. Skininterrupted 4-0 or 5-0 nylon; left open / loosely closed if contaminated
  2. Dressingpadded, bulky, not tight
  3. SplintDorsal blocking splint (flexor repair)Volar splint, wrist in extension (extensor repair)Relative-motion splintwrite the wrist, MCP and IP joint angles

Specimens and implants

  1. Wound swab for cultureSentNot sent
  2. Suture anchor / K-wiretype, size, make, batch number and sticker; or 'none'

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Limb elevationhand above heart level on a pillow or sling
  2. Neurovascular check of the digitscolour, capillary refill, sensation; loosen dressing if tight
  3. Splintdo not remove; angles as written in the note
  4. Analgesiadrug, dose, frequency
  5. Antibioticsonly if the wound was contaminated or a bite; drug and duration
  6. Hand therapy protocolname it (Kleinert / Duran / early active motion) and the start day; referral to physiotherapy
  7. Wound reviewfirst dressing day; sutures out at 10 to 14 days
  8. Warning to patientno gripping or lifting with the hand; report sudden loss of finger bending (rupture)
  9. Follow-upweekly with therapist; splint off at 6 to 8 weeks; strengthening from 8 to 10 weeks

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mr. S.K., 28 years, right-handed cook, cut the palmar side of his left middle finger with a kitchen knife while cutting raw meat 4 hours before surgery. He could not bend the DIP or PIP joint of that finger. Sensation on both sides of the finger was normal.

Case details

Date: 14/05/2026. Emergency. OT 3.

Time of injury 17:00. In OT 20:40. Block given 20:50. Tourniquet up 21:10. Tourniquet down 22:25. Out of OT 22:45.

Surgeon: Dr A. (2nd-year resident, Orthopaedics). Assistant: Dr B. (1st-year resident). Consultant: Dr C., scrubbed for the tendon repair.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Diagnosis: open injury left middle finger, flexor zone II, with loss of active DIP and PIP flexion. Suspected FDP and FDS cut.

Wound 1.5 cm transverse over the proximal phalanx, clean, sharp knife injury. No skin loss.

X-ray left hand AP and oblique: no fracture, no foreign body.

Tetanus prophylaxis given in casualty at 18:30 as per immunisation status (write the status and what was given). Wound contaminated by the knife used on raw meat: inj cefazolin 2 g IV at 20:55, before tourniquet inflation.

Consent: general, procedure-specific and anaesthesia consent taken in Hindi. Risks explained: infection, adhesions, stiffness, rupture of repair, need for later tenolysis or graft, long splint and therapy programme.

WHO checklist sign in and time out done. Side and digit marked.

Anaesthesia and position

Left supraclavicular brachial plexus block. Supine, left arm on hand table. Pneumatic tourniquet on left upper arm over padding, limb exsanguinated with Esmarch, inflated to 250 mmHg at 21:10. Parts painted with povidone-iodine and draped. Loupes 2.5x.

Findings

Clean transverse cut over the middle of the proximal phalanx. No foreign body.

FDP and FDS of the left middle finger completely cut in zone II. Proximal stumps retracted to the level of the A1 pulley. Distal stumps seen on flexing the DIP and PIP joints.

A2 pulley cut in its distal one-third. A4 intact.

Radial and ulnar digital nerves and arteries intact. No bone or joint injury.

Procedure

Wound irrigated with 1 litre of normal saline. Skin edges trimmed minimally. Gloves changed and field re-draped.

Wound extended proximally and distally in a Bruner zigzag. Skin flaps raised, both neurovascular bundles identified and protected.

Sheath opened through the C1 and C2 windows, about 2 cm in total. Distal one-third of A2 vented. A4 preserved.

Proximal stumps delivered by milking the forearm with the wrist flexed. Held with a transverse 26 G needle through sheath and tendons. Distal stumps delivered by flexing the finger and held the same way.

FDP checked to lie in the FDS hiatus. FDS slips checked for rotation at the Camper chiasm.

FDS slips repaired first with a locked core suture of 4-0 braided polyester (Ethibond). FDP repaired with a 4-strand cruciate core suture of 4-0 braided polyester, knots buried within the repair.

Running circumferential epitendinous suture of 6-0 polypropylene (Prolene) to FDP.

Passive flexion and extension checked: no gap, smooth gliding under A2 and A4. Holding needles removed. Sheath left open.

Tourniquet released at 22:25 (tourniquet time 75 min). Finger pink with brisk capillary refill. Haemostasis with bipolar cautery.

Closure

Skin closed with interrupted 5-0 nylon. Padded bulky dressing.

Dorsal blocking plaster splint from below the elbow to the fingertips: wrist 20 degrees flexion, MCP joints 60 degrees flexion, IP joints straight.

End of procedure

Blood loss minimal, about 20 ml. No transfusion.

Mop, needle and instrument count correct.

No intra-operative complications. No implants. No specimen.

Shifted to ward in stable condition. Pulse 80/min, BP 124/78 mmHg. Fingertip pink.

Post-op orders

Left hand elevated in a sling above heart level.

Check colour, capillary refill and sensation of the left middle finger hourly for 4 hours, then 4-hourly.

Do not remove the splint. No active gripping.

Analgesia as per the anaesthesia chart.

Physiotherapy referral: controlled passive motion (Duran) within the splint from POD 1.

Review in fracture clinic at 1 week. Sutures out at 10 to 14 days. Splint for 6 weeks.

Signature

Dr A., JR-2, Orthopaedics. Reg. no. ________. 14/05/2026, 23:00.

Must document for this operation

  • Time of injury and time of repair. Timing decides whether the repair is primary, delayed primary or secondary, and explains the result if it fails.
  • Each tendon, nerve and artery by name, with its zone and whether it was cut completely or partly. The next surgeon planning a tenolysis or tendon graft needs to know exactly what was repaired and what was left.
  • Which pulleys were opened or vented, and whether A2 and A4 were kept. Pulley loss causes bowstringing, and the record shows whether reconstruction may be needed later.
  • Core suture technique, number of strands and suture size. The therapist decides how early active motion can start based on the strength of the repair.
  • Tourniquet pressure and total tourniquet time. Tourniquet time is often left out of orthopaedic notes in audits, and it matters if nerve palsy follows.
  • Splint position with joint angles and the therapy protocol chosen. A wrong splint position or unclear protocol is a common cause of rupture or stiffness.
  • Whether the wound was closed primarily or left open, and why. Contaminated, crushed and bite wounds should not be closed primarily, and the note must show this was judged.

Common mistakes in these notes

  • Writing 'tendon repaired' without naming the tendon, digit, side and zone.
  • Not recording the pre-operative nerve examination, so a later numbness cannot be dated.
  • Leaving out the suture material, size and number of core strands.
  • Not writing the tourniquet time.
  • Writing 'splint applied' without joint angles or the rehabilitation plan.
  • Not recording tetanus prophylaxis for an open wound.

Indian practice and paperwork

  • The public-hospital OT checklist (NQAS) expects tetanus prophylaxis to be given when indicated and the antibiotic to be given before incision. Write the tetanus status and the time the antibiotic was given. (NHSRC NQAS Assessor's Guidebook for District Hospitals 2020, Vol I, ME E15.2)
  • Consent must explain the procedure, risks, benefits, alternatives and who will do the operation, in a language the patient understands. In a teaching unit, say that a resident may do the repair under supervision. (NABH 5th ed. (2020), PRE.4(c))
  • NABH expects the operative note to be written before the patient leaves recovery. (NABH 5th ed. (2020), COP.14(e))

Sources

  • Azar FM, Sawyer JR, et al., eds. Campbell's Operative Orthopaedics. 15th ed. Elsevier, Ch 70, Acute hand injuries (initial management, antibiotics, skin closure); Ch 71, Flexor and extensor tendon injuries; Ch 2, Tourniquets, pp. 3117-3123; 3145-3164; 3180-3190; 137-138.
  • Azar FM, Beaty JH, eds. Campbell's Core Orthopaedic Procedures. 2nd ed. Elsevier; 2024, Technique 36, Flexor tendon repair (Thompson NB), pp. 165-171.
  • Saghieh S, Weinstein SL, Hoballah JJ, eds. Operative Dictations in Orthopedic Surgery. Springer; 2013, Ch 97, Flexor tendon repair (Dibo S, Bakhach J); Ch 98, Extensor repair (Kawtharani F), pp. 343-348.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Table 1: cefazolin 2 g IV (3 g if 120 kg or more), within 60 min before incision, redose at 4 h. academic.oup.com/ajhp/article/70/3/195/5112717
  • Campbell's Operative Orthopaedics 15e, Ch 70, Tables 70.1 and 70.2 (pdf 4000-4002): no antibiotic for clean low-risk wounds; cefazolin once for contaminated stab wounds; bites need ampicillin-sulbactam and are left open.
  • Campbell's Operative Orthopaedics 15e, Ch 2, Tourniquets, pp. 137-138: tourniquet time 2 hours or less in healthy adults under 50; 135-255 mmHg satisfactory for the upper limb.

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

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