Flexor tendon zone 2 extends from the A1 pulley at the MCP joint to the insertion of FDS on the middle phalanx. This zone, historically called "no man's land" by Bunnell, contains both FDS and FDP within the fibrous flexor sheath between the A1, A2, C1, A3 pulleys — the most technically demanding area for flexor tendon repair.
Zone 2 flexor tendon repair is one of the most technically demanding procedures in hand surgery. Both FDS and FDP are repaired within the intact flexor sheath, preserving A2 and A4 pulleys while the tendon ends are coapted. Core suture (Kessler, modified Kessler, or Tajima technique) plus running epitenon suture is the standard repair. Early controlled mobilisation (Kleinert or Duran protocol) prevents adhesion formation in zone 2 where adhesions are most problematic.
Dense adhesion formation between the repaired tendon and the A2 pulley sheath in zone 2 following flexor tendon repair, producing a tenolysis-requiring result in 15-30% of zone 2 repairs despite optimal technique and early mobilisation.
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