Missed tendon injuries.

The timing of the repair of divided tendons may be debated but in most cases a clearly divided tendon should be repaired primarily and, whether or not primary repair is indicated, 'the ideal treatment programme is immediate surgery performed by an experienced surgeon' (McGrouther et al., 1990). If a tendon injury is missed, deformity may occur, the patient may need further surgical procedures, the period of disability between injury and normal use will be longer and the long term result may be less good. Unfortunately it is well recognized that such injuries can be missed. There is very little written about the incidence of missed tendon injuries but two series of flexor tendon repairs describe late diagnosis occurring in 15% (Early & Mlward, 1982) and 20% (Morgan & Palmer, 1989) of cases. Honner in 1975 described his treatment of 44 patients with late diagnosed flexor digitorum profundus injuries. There is even less written on the incidence of missed extensor tendon injuries but the numerous procedures available for the management of the chronic boutonniere deformity (Froelich et al., 1988) indicates how commonly this injury is missed. The problem is therefore a significant one and although numerous review articles on tendon injury recognize the problem of late diagnosis and the difficulties of diagnosis, the question of why and how these injuries are missed which is so important if the problem is to be avoided, has not been addressed. Over several years and in more than one hospital, I have seen 25 patients with 26 open tendon injuries missed at a first attendance to the Accident & Emergency (A&E) department. These I investigated and in this report I seek to show how and why these occurred. The injuries missed are shown in Table 1 and the mechanisms of injury are shown in Table 2. One patient has an associated nerve injury missed and on five occasions the tendon injury was missed at two visits to the A&E Department.