Patient Profile, Injury Pattern, and Treatment of Open Traumatic Tendon Injuries: Experience From a Tertiary Center in Addis Ababa, Ethiopia

Abstract

Background:

The incidence of hand injuries, particularly tendon lacerations, has increased following rapid industrialization in Ethiopia. Understanding patient demographics, risk factors, the nature of injuries, management options, and postoperative complications is critical for optimal prevention and care. This study aimed to assess the profile, injury pattern, and treatment of patients with open traumatic tendon injuries at the All Africa Leprosy Rehabilitation and Training Center Hospital, Addis Ababa, Ethiopia.

Methods:

This 2-year retrospective review included 239 patients with tendon injuries treated at the All Africa Leprosy Rehabilitation and Training Center Hospital between April 1, 2020, and March 29, 2022. Data on patient demographics, injury characteristics, and treatment were collected and analyzed.

Results:

Traumatic tendon injuries occurred primarily in men aged 25–65 years (61.5%). Heavy machinery was the most frequently reported cause of injury (44.4%). Factory workers were the most injured (38.9%). The flexor tendons were more commonly injured (57.3%) than the extensor tendons (34.3%). Nerve injuries were the most frequently associated injuries (49.4%), followed by vascular injuries (31%) and fractures (27.8%). Most of the patients who received treatment were treated with primary muscle and tendon repair (207 patients), followed by tendon grafting (10 patients). Infection was the most frequently identified complication (10%), followed by stiffness (8.4%) and adhesion (4.6%).

Conclusions:

Traumatic tendon injuries often affect men in the productive age group and result from machine-related accidents. However, subsequent functional limitations are devastating. Further analytic studies are necessary to demonstrate their association with other causal factors.

Takeaways

Question: What are the demographic characteristics, injury patterns, and modes of treatment of patients with open traumatic tendon injuries treated at the All Africa Leprosy Rehabilitation and Training Center Hospital?

Findings: Factory worker men aged 25–65 years, following machine-related accidents, are most affected. Flexor tendon injuries were most common, with primary muscle and tendon repair as the most frequent treatment. About 85% of patients had postoperative follow-up, and infection was the leading complication identified.

Meaning: These findings highlight the impact of such injuries on the productive workforce, underscoring the need for improved workplace safety measures and further research into contributing risk factors.

INTRODUCTION

The hands are highly vulnerable to occupational and domestic injuries. Even minor trauma to any part of the hand can result in loss of function.¹ In the era of industrialization, hand injuries are on the rise, accounting for 10%–15% of hospital admissions and 28%–29% of all injury-related emergency department visits in high-income countries (HICs).^2,3 Among these, tendon injuries constitute the largest proportion in many hospitals. Most hand injuries are preventable and often occur in working-age men.^3,4 The resulting disabilities also directly contribute to a reduction in quality of life; therefore, they are a public health concern.⁵

Despite the increase in acute traumatic tendon injuries in our setup, studies analyzing patient demographics, risk factors, management options, and postoperative complications in patients with tendon injuries remain limited, especially in low- and middle-income countries (LMICs). A study in Ethiopia reported that the majority (45%) of patients with hand trauma had isolated tendon injuries.⁴ However, this study failed to examine the postoperative complications and adverse events. To the best of our knowledge, no studies have specifically examined tendon injuries in Ethiopia or the broader East African region. Understanding patient demographics, injury patterns, treatment approaches, and associated complications is crucial to estimate the burden of traumatic tendon lacerations and to inform targeted, cost-effective prevention and management strategies in this setting.

This study aimed to analyze the patient profile, injury patterns, and treatment approaches for open traumatic tendon injuries at the All Africa Leprosy Rehabilitation and Training Center (ALERT) Hospital in Addis Ababa, Ethiopia. It also presents ALERT’s therapeutic guidelines for tendon reconstruction, offering practical insights for new hand treatment providers. By documenting these findings, we seek to lay the foundation for future research and inform policies that promote equitable care, efficient resource allocation, and improved outcomes in the treatment and rehabilitation of patients with tendon injuries.

METHODS

After ethical clearance by the institutional review board of Addis Ababa University, a retrospective study was conducted on all patients with open traumatic tendon injuries of the upper extremity who underwent surgery at the plastic surgery department of ALERT Hospital between April 1, 2020, and March 31, 2022. ALERT Hospital is a tertiary referral center in Addis Ababa, Ethiopia. Established in 1965 for leprosy care, it has since evolved into a multidisciplinary institution offering specialized services in reconstructive surgery, orthopedics, trauma, and rehabilitation. As a major referral center in the country, it handles a high volume of complex cases. ALERT also serves as a national training and research hub, supporting clinical education, surgical training, and data-driven studies in the country. The plastic, reconstructive, and hand surgery unit manages a broad spectrum of traumatic and nontraumatic conditions, making it a strategic site for studying tendon injuries in low-resource settings.

Medical record numbers were used to identify and retrieve the charts of patients who had undergone tendon repair. Data on patient profiles, injury patterns, treatment types, and postoperative complications were retrospectively reviewed from operation and clinical notes. Patients with concomitant life-threatening injuries, incomplete medical records, or no follow-up documentation (defined here as those lacking postoperative office visit documentation) were excluded from this study. Data on demographics (age, sex, location, and occupation), injury patterns (cause of injury, zones of injured tendons and digits, and associated nerve, artery, and fracture injuries), and the time from injury to presentation and treatment were collected. The zones of the hand (flexor and extensor) were classified according to the Committee of Tendon Injuries.⁶ Treatment types, postoperative follow-up patterns, and complications were recorded. A patient was considered to have no follow-up if no documentation was available after the day of surgery.

A paper-based data abstraction tool was developed and pretested on 10 randomly selected patient charts. After making necessary modifications, the tool was used to collect data from the remaining charts. Data collection was supervised by the principal investigator. Data were analyzed using Statistical Package for the Social Sciences version 23 (IBM, Armonk, NY).

Regarding the therapeutic protocol, all the patients in this cohort underwent comprehensive surgical care. Most patients received peripheral nerve blocks with or without monitored anesthesia care, or wide-awake local anesthesia with no tourniquet. General anesthesia was reserved for patients with bilateral hand injuries and for pediatric patients. Primary muscle and tendon repair are the most common procedures. Neurovascular injuries and fractures were addressed using the same anesthetic window. Vascular injuries were repaired first using either primary repair or vein grafting, followed by tendon repair. Nerve injuries were also managed with direct neurorrhaphy or nerve grafting. Similarly, fractures were fixed concurrently, except in complex or contaminated cases, in which temporary stabilization was followed by staged definitive fixation and delayed tendon reconstruction.

Tetanus toxoid injections and intravenous ceftriaxone were routinely administered preoperatively. After surgery, nonsteroidal anti-inflammatory drugs were used for pain management, and patients were instructed to take a 5- to 7-day course of oral antibiotics (eg, amoxicillin–clavulanic acid). In cases where patients had specific indications for systemic antibiotics, a tailored antibiotic regimen was determined based on clinical judgment and microbiological findings. Although studies suggest selective antibiotic use in high-resource settings,⁷ in a low-resource environment, the risks of infection, poor hygiene, and lack of follow-up outweigh the concerns of overuse.

Most patients are discharged on the same day and are directly transferred to the physiotherapy unit, where they receive appointments for the subsequent physical and occupational therapy sessions. Inpatient hospitalization is reserved for those with medical comorbidities, those who require complex surgical procedures (extended operative time or multiple surgical sites), those with anesthesia considerations (patients requiring general anesthesia with higher risks), those who require postoperative monitoring, and those with social factors that would preclude safe disposition, such as long-distance travel to hospital.

At ALERT Hospital, rehabilitation protocols following surgical repair of flexor tendons, extensor tendons, and peripheral nerves are based on evidence-based recommendations.^8–10 They were implemented according to tendon zone, nerve type, and surgical repair characteristics. Flexor tendon rehabilitation followed controlled active mobilization or modified Duran protocols (used when repairs are tight/vulnerable). A dorsal blocking splint was applied within 4–7 days. Early passive flexion and active extension were initiated, with progression to active mobilization out of the splint at 4–6 weeks. Strengthening began at 6–8 weeks and return to full function was expected by 12 weeks, depending on individual recovery. For extensor tendons, zone-specific protocols were used: static splinting for zones I–II, proximal inter phalangeal joint immobilization for zones III–IV, and early mobilization with functional splinting for zones V–VIII. Progression was guided by tendon integrity and the presence of extensor lag. Nerve repair protocols included a 3-week immobilization period, followed by scar management, sensory reeducation, and progressive mobilization. Functional splints were applied as needed.

RESULTS

Sociodemographic Characteristics

In total, 239 patients met the inclusion criteria for this study. All but 1 patient experienced unilateral hand injuries, totaling 241 upper extremity surgical sites. Of these, 221 (92.5%) were men and 18 (7.5%) were women, yielding a male-to-female ratio of 12:1. The average age of the patients was 28 years (SD, 11.03 y), with a range of 1–65 years. The most common age group was 25–65 years (61.5%), followed by 15–24 years (31.4%). Most of the patients (51.5%) resided in Addis Ababa. Factory workers constituted the largest occupational group (38.9%). The sociodemographic characteristics are summarized in Table 1.

Table 1.

Sociodemographic Characteristics

Sociodemographic Characteristics	Frequency	Percentage
Age, y
<15	17	7.1
15–24	74	31.0
25–65	148	61.9
Total	239	100.0
Sex
Male	221	92.5
Female	18	7.5
Total	239	100.0
Residence
Addis Ababa	123	51.5
Outside Addis Ababa	116	48.5
Total	239	100.0
Occupation
Factory worker	93	38.9
Daily laborer	7	2.9
Self-employed	19	7.9
Government worker	6	2.5
Unemployed	16	6.7
Unknown	98	41.0
Total	239	100.0

Injury Pattern

The left hand was injured in 56.1% (134) of patients, whereas the right hand was injured in 43.1% (103). Both hands were injured in less than 0.1% of the cases (2). Heavy machinery accounted for 44.8% of the injuries, followed by sharp metals (27.2%) and glass (20.9%) (Fig. 1). Flexor tendons were injured in 137 (57.3%) patients, whereas extensor tendons were injured in 82 (34.3%). Zone V was the most frequently injured zone for flexor tendons (62.5%), and zone VI was the most common site for extensor tendon injuries (27.7%) (Table 2).

Fig. 1.

Injury pattern.

Table 2.

The Distribution of Injured Tendons and Digits Across Zones

	Zone I	Zone II	Zone III	Zone IV	Zone V	Zone VI	Zone VII	Zone VIII	Multiple Zones	Total
Injured tendon across zones
Flexor tendon	4	33	10	1	80				9	137
Extensor tendon	3	5	2	13	10	18	4	10	17	82
Both	—	—	—	—	—	—	—	—	20	20
Total	7	38	12	14	90	21	4	10	46	239
Injured digit across zones
Thumb	2	11	2	3	—	—	—	—	1	19
Index finger	3	—	—	7	3	3	—	—	—	16
Middle finger	—	2	8	2	5	2	—	—	2	21
Ring finger	1	—	—	—	—	—	—	—	—	1
Little finger	—	8	1	0	3	2	—	—	—	14
Multiple digits	—	15	1	1	4	9	—	—	25	55
Total	6	36	12	13	15	16	—	—	28	126

Digits were injured in 52.3% (126) cases. The middle finger was the most injured single digit (21), followed by the thumb (19) and index finger (16). Zone II was the most common site of injury, involving a single digit. The distribution of injured digits across zones is summarized in Table 2.

Nerve injuries were the most frequently associated injuries (49.4%), followed by vascular injuries (31%) and fractures (27.8%). The ulnar nerve is the most frequently injured nerve (36), and the ulnar artery is the most frequently injured vessel (37). Metacarpal fractures were the most common (16), followed by proximal phalangeal fractures (13) out of the 65 total fractures identified. Nerve injuries occurred more frequently in flexor tendon injuries (90 versus 11), whereas fractures occurred more frequently in extensor tendon injuries (30 versus 21) (Table 3).

Table 3.

The Distribution of Nerve Injuries, Vascular Injuries, and Fractures Across Tendon Groups

	Tendon Group			Total
	Flexor	Extensor	Both
Nerve injuries across tendon groups
Radial nerve	1	7	0	8
Ulnar nerve	27	1	8	36
Median nerve	24	1	2	27
Ulnar and median nerve	12	0	3	15
Common digital nerve	10	1	2	13
Proper digital nerve	12	1	1	14
Median and radial nerve	4	0	1	5
Total	90	11	17	118
Vascular injuries across tendon groups
Radial artery	13	1	2	16
Ulnar artery	30	0	7	37
Digital artery (unilateral)	9	1	1	11
Digital artery (bilateral)	0	0	2	2
Ulnar and radial artery	5	0	2	7
Brachial artery	1	0	0	1
Total	58	2	14	74
Fractures across tendon groups
Radial bone	1	1	3	5
Radioulnar bone	3	3	4	10
Ulnar bone	3	2	2	7
Carpal bone	3	0	1	4
Metacarpal bone	2	12	2	16
Proximal phalanx	2	11	0	13
Middle phalanx	1	0	0	1
Distal phalanx	2	1	0	3
Multiple phalangeal	4	0	2	6
Total	21	30	14	65

Most patients (33.1%) presented within 8 hours of the injury, 15.9% of patients presented within 13–24 hours, and 14.2% presented within 25–72 hours. Twenty-eight percent of the patients received treatment within 8 hours of presentation, whereas 18% (43) received treatment within 9–12 hours. The times from injury to presentation and presentation to treatment are summarized in Table 4.

Table 4.

Time From Injury to Presentation and Presentation to Treatment

		Frequency	Percentage
Time from injury to presentation
Within 8 h	79			33.1
9–12 h	20			8.4
13–24 h	38			15.9
25–72 h	34			14.2
73 h–6 d	31			13.0
1 wk–1 mo	21			8.8
>1 mo	6			2.5
Unknown	10			4.2
Total	239			100.0
Time from presentation to treatment
Within 8 h	67			28.0
9–12 h	43			18.0
13–24 h	48			20.1
25–72 h	20			8.4
72 h–1 wk	34			14.2
>1 wk	27			11.3
Total	239			100.0

Treatment and Complications

Primary muscle and tendon repairs were the most frequent treatment (207 patients), followed by tendon grafting (10 patients). Twenty-three (9.6%) patients were managed by immobilization, as they either underwent fracture fixation and extensor tendon surgery or were pediatric patients who underwent primary extensor tendon repair only (Table 5).

Table 5.

Type of Primary Treatment Received and Follow-up Pattern of Patients

	Frequency	Percentage
Type of primary treatment received
Soft tissue and tendon reconstruction	8	3.3
Soft tissue coverage with flap	5	2.1
Primary tendon/muscle repair	207	86.6
Tendon graft	10	4.2
Tendon transfer	1	0.4
Fracture fixation	7	2.9
Splinting	1	0.4
Total	239	100.0
Follow-up pattern of patients
No follow-up	38	15.9
<1 mo	65	27.2
1–3 mo	50	20.9
3–6 mo	41	17.2
6–9 mo	13	5.4
9–12 mo	12	5.0
>12 mo	20	8.4
Total	239	100.0

Of the 239 patients, 84.9% had regular postoperative follow-ups ranging from 1 to 3 months (48.1%) to more than a year (8.4%) (Table 5). Although the specific physiotherapy regimen was not documented, most patients with regular postoperative follow-up started physiotherapy within the first week after surgery. Infection was the most common complication (10%), followed by stiffness (8.4%) and adhesion (4.6%) (Fig. 2).

Fig. 2.

Postoperative complications.

DISCUSSION

Aligning with previously published literature, the results presented herein indicate that hand tendon injuries are most common among male patients aged 25–65 years.¹¹ Although men are generally more likely to undergo hand tendon injuries worldwide, gender differences are particularly pronounced in our Ethiopian patient cohort. Unlike the male-to-female ratios reported in HICs, such as the United States,³ Germany,¹² and the Netherlands,¹³ male patients in this Ethiopian patient cohort sustained hand tendon trauma 12 times more frequently than their female counterparts. This disparity can be attributed to 2 main factors: the disproportionate reliance on manual labor in LMICs, where men are the largest cohort employed in industrial, heavy machinery, and agricultural jobs. For instance, a United Nations report on employment indicators revealed that, in contrast to 12.3% of working-age men in the United States who were employed in heavy labor, 46.2% of African men worked in the same sector.¹⁴ This leads to increased exposure to injury-causing machinery. Second, unfortunately, LMICs still lag when it concerns occupational safety and safe work legislation.¹⁵ This indicates that men in LMICs are not only more likely to be exposed to dangerous machinery but also less likely to be protected against it, potentially explaining the higher HIC–LMIC ratio.

Acute hand injuries involving tendon lacerations were the most common occupational injuries evaluated in emergency departments, often resulting from machinery use.¹⁶ In this study, machines caused 44.8% of injuries, particularly due to dislodged saws from grinders or woodworking machines. This aligns with a prospective study in Addis Ababa¹⁷ but differs from the findings of Abebe.⁴ These discrepancies highlight the challenges of industrial safety in Ethiopia, including a lack of awareness of occupational hazards, inadequate workplace safety policies, and inefficient safety management systems.¹⁸ Understanding the causes of workplace injuries is essential for prevention and improving treatment outcomes, which can significantly impact quality of life.⁵

Concerning injury pattern, flexor tendons were the most frequently injured, consistent with those reported by Abebe⁴ and Debski and Noszczyk,¹⁹ but differing from those reported by de Jong et al³ and Chang and Tay.²⁰ These differences may reflect variations in occupation and causative factors among the study populations. Zone V was the most common site of flexor tendon injuries, whereas zone VI was the most common site for extensor tendon injuries. Abebe⁴ also identified zone VI as the most common site for extensor tendon injuries, but discrepancies in flexor tendon injury zones may reflect differences in causes of injury. Zone II was the most common site of flexor tendon injuries involving a single digit, consistent with the findings reported by Chang and Tay.²⁰ This is likely due to the zone’s intrinsic anatomical architecture in which the flexor digitorum profundus and superficialis run together within a confined space.²⁰ Neurovascular injuries were the most frequently associated injuries (49.4%), higher than those reported by Abebe⁴ but lower than those reported by Chang and Tay.²⁰ Nerve injuries were more common in flexor tendon injuries, whereas fractures were more frequent in extensor tendon injuries, consistent with the findings reported by Dongsheng et al.²¹

Regarding postsurgical adverse events, despite advances in surgical repair and rehabilitation, complications such as reoperation, rupture, and adhesions persist at rates of 6%, 4%, and 4%, respectively, even in experienced settings.³ In this study, infection was the most common complication (10%), similar to that reported in a Nigerian study.²² The increased rate likely stems from inadequate wound dressing changes at suboptimal healthcare facilities and poor hygiene. This should prompt hospitals to provide wound care services in outpatient settings to reduce the infection rates. Similarly, this indicates that close follow-up is required in LMICs, with attentiveness to early signs of infection, warranting earlier antimicrobial therapy compared with patients in HICs who may have better access to safer and cleaner postoperative convalescence areas.

The adhesion rate observed in this study (4.6%) was lower than that reported in some Asian cohorts, but comparable to rates in other international series (4.8%).^3,23 However, this figure should be interpreted with caution due to several limitations. Nearly 43% of patients either did not attend follow-up or were observed for less than 1 month, which may have limited the identification of late-presenting adhesions. Additionally, some variations were noted in the clinical assessment of adhesions between providers during follow-up. These factors raise the possibility of underreporting or misclassification, making this finding questionable even within the context of a well-established physiotherapy service.

Furthermore, although it is true that delayed tendon repair poses its own set of complications, in our cohort, those presenting earlier seemed to have worsened adverse event rates, contradicting the published literature. The observed strong negative correlation between time to presentation and complications (r = −0.75, P = 0.052) may reflect treatment-seeking patterns among men, especially in LMICs. As most individuals receive hourly wages and do not have the protection from labor laws as in HICs, those with less severe injuries may choose to delay their presentation or not present whatsoever.²⁴ Similarly, health care in African countries is often out-of-pocket and not state-sponsored; only those with severe injury patterns may be willing to readily present for care.²⁵ This indicates systematic healthcare issues in LMICs where individuals are willing to neglect their health due to high costs and out-of-work wage losses.

Strengths and Limitations

The retrospective and single-center design of our study may limit its generalizability. Paper-based medical record keeping and the absence of a specific categorization for tendon injuries in the dataset make it challenging to access patient charts and accurately determine the proportion of hand injuries that are isolated tendon injuries. Furthermore, poor patient follow-up patterns and interpersonal variations in clinical judgment during the diagnosis of complications may result in undiagnosed or misdiagnosed complications.

Additionally, the study did not assess the long-term functional recovery and comorbidities of the included patients, which is essential for comprehending the true impact of tendon injuries and treatment outcomes. Future research should prioritize prospective multicenter studies that include comprehensive patient profiles and long-term outcome tracking. Finally, the limited number of studies focusing on tendon injuries necessitated our reliance on outdated articles in designing our study.

Traumatic tendon injuries in Africa, particularly East Africa, remain understudied. This study addressed a critical gap in the literature by providing comprehensive data on these injuries. Although specialized hand trauma centers are limited, ALERT Hospital, recognized as a leader in hand surgery in the country, offers valuable insights into managing hand trauma in resource-constrained settings.

Nonetheless, despite these limitations, our study, which presented comprehensive results stratified by demographics, treatment, and complications, offers robust data on various aspects of tendon injuries and is one of the largest sample sizes in East Africa. Considering the significant burden of hand trauma in low-resource settings, the findings of this study will contribute substantially to enhancing patient care and guiding future research in this region.

CONCLUSIONS

This study identified the most affected population and highlighted critical gaps in the management of these patients. To the best of our knowledge, this is the first study to focus on these aspects of tendon injury in Ethiopia and East Africa. Opportunities exist for future prospective studies to build on our design and findings, thus further expanding our understanding of this critical issue. Further analytic studies are required to explore the association between these injuries and other causal factors. This study serves as a pioneering research effort to shed light on tendon-related aspects of hand trauma in East Africa.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.