- Email: [email protected]
Another type of profundus tendon avulsion
ANOTHER
TYPE
OF PROFUNDUS
TENDON
AVULSION
Combined with an extraarticular fracture of the terminal phalanx B. M. KATZMAN, D. A. CALIGIURI and D. M. KLEIN
From the Department of Orthopaedics, State University of New York at Brooklyn~Kings County Hospital Center, Brooklyn, New York, USA A different variant of a profundus tendon avulsion is described, in which the avulsed tendon injury (Leddy and Packer Type I, II, or III) is associated with an extraarticular fracture of the distal phalanx.
Journal of Hand Surgery (British and European Voh~me, 1997) 22B." 4:546-547 and inspected. As it was approximately 17 days old, there was some evidence of healing and thus the fracture was left undisturbed. However, to ensure stability and allow for immediate mobilization, two small K-wires were placed percutaneously across the fracture. The avulsed FDP tendon was then reinserted and tied over a button. The DIP joint was not transfixed. Postoperatively, the patient was placed in an extension-block splint and Kleinert traction. Early active mobilization was encouraged. The pins and splint were removed 5 weeks after the operation. At follow-up 4 months later, there was an almost full range of motion of the finger, and the patient had returned to his previous work.
Avulsion of the profundus tendon is not rare, and is usually associated with sport. Initially the diagnosis is often missed, particularly if the physician or trainer is not aware of the condition. The radiographs may be "negative", and the injury is diagnosed as a "sprain" or "jammed finger". The ring finger is the most commonly involved in flexor digitorum profundus avulsions (Leddy and Packer, 1977). The mechanism is typically hyperextension of a flexed finger. These injuries have been classified into three types depending on the location of the avulsed tendon (Leddy, 1985; Leddy and Packer, 1977). Subsequent to Leddy and Packer's initial description, a fourth type has been described (Buscemi and Page, 1987; Eglseder and Russell, 1990; Ehlert et al, 1992; Langa and Posner, 1986; Robins and Dobyns, 1975; Smith, 1981). This type has an intraarticular distal phalangeal fracture with avulsion of the tendon from the palmar fragment. In this report, we propose a variant that includes any type I, II or III avulsion, with a concomitant extraarticular fracture at the metaphyseal/diaphyseal junction of the distal phalanx.
DISCUSSION
One theory to explain a tendon avulsion injury with a concomitant fracture was given by Buscemi and Page (1987). They hypothesized that the tendon, with a small osseous fragment, becomes avulsed from the base of the distal phalanx. The distal phalanx is then pushed into hyperextension as a result of the continuing extension vector force, and a secondary intraarticular fracture at the base of the distal phalanx then occurs as the distal portion of the middle phalanx is forcibly driven into the base of the distal phalanx. Thus, after avulsion of the FDP and its osseous fragment, the continued hyperextension causes a "pilon-like" fracture of the distal phalanx. The mechanism of the injury we describe could be similar to that proposed by Buscemi and Page. Another hypothesis is also offered. This history was not typical of
CASE REPORT
A 45-year-old right hand dominant court officer, with no significant past medical history, presented with a 2-weekold injury of the right small finger sustained by slipping and falling in the street. He had been treated initially in a local emergency room where he was told that he had sustained a sprain. The digit was splinted and he was discharged. However, a few days later, he was recalled to the emergency room as a consultant radiologist had reviewed his radiographs and detected a distal phalangeal fracture. On examination, he was noted to be unable to flex the distal interphalangeal joint of the affected digit. Further review of the radiographs revealed a bony fragment within the flexor tendon sheath at the level of the A2 pulley, in addition to the distal phalanx fracture (Fig 1). The digit was explored via a Bruner incision and the FDP tendon, with its attached bony fragment, was found within the flexor tendon sheath at the level of the A2 pulley. It was retrieved and brought back up to its insertion. The extraarticular fracture of the distal phalanx at the junction of the metaphysis and diaphysis was exposed
Fig 1
546
Lateral X-ray of the right small finger at presentation. An oblique fracture of the distal phalanx with a bony avulsion fragment near the PIP joint within the tendon sheath can be seen.
547
P R O F U N D U S T E N D O N AVULSION
the "grasping" athletic injury. This patient may have sustained direct trauma to the distal phalanx as he fell, resulting in the short oblique fracture. If a hyperextension force was then applied, a tendon avulsion may have ensued. The mechanism of this injury is therefore uncertain. Careful physical examination and radiographic review are necessary to detect this injury. A cursory examination coupled with radiographs demonstrating an extraarticular distal phalangeal fracture could lull the surgeon into missing the all-important tendon avulsion.
Ehlert K J, Gould JS, Black KP (1992). A simultaneous distal phalanx avulsion fracture with profundus tendon avulsion. Clinical Orthopaedics and Related Research, 283: 2 6 5 2 6 9 . Langa V, Posner MA (1986). Unusual rupture of a flexor profundus tendon. Journal of Hand Surgery, 11A: 227-229. Leddy JP (1985). Avulsions of the flexor digitorum profnndus. H a n d Clinics, 1: 77-83. Eeddy JP, Packer JW (1977). Avulsion of the profundus tendon insertion in athletes. Journal of Hand Surgery, 2: 66-69. Robins PR, Dobyns JH. Avulsion of the insertion of the flexor digitorum profundus tendon associated with fracture of the distal phalanx - - a brief review. In: A A O S Symposium on tendon surgery in the hand St. Louis, C.V. Mosby, 1975: 151-156. Smith J H (1981). Avulsion of a profundus tendon with simultaneous intraarticular fracture of the distal phalanx. Journal of Hand Surgery, 6: 600-601.
References Buscemi M J, Page BJ (1987). Flexor digitorum profuudus avulsions with associated distal phalanx fl'actures. American Journal of Sports Medicine, 15: 36(~370. Eglseder WA, Russell JM (1990). Type IV flexor digitorum profundus avulsion. Journal of H a n d Surgery, 15A: 735-739.
Received: 2 October 1996 Accepted after revision: 17 February 1997 Daniel A. Caligiuri MD, SUNY Health Science Center at Brooklyn, Department of Orthopaedics, 450 Clarkson Avenue,Box 30, Brooklyn, New York 11203,USA. © 1997The British Society for Surgery of the Hand
TYPE
OF PROFUNDUS
TENDON
AVULSION
Combined with an extraarticular fracture of the terminal phalanx B. M. KATZMAN, D. A. CALIGIURI and D. M. KLEIN
From the Department of Orthopaedics, State University of New York at Brooklyn~Kings County Hospital Center, Brooklyn, New York, USA A different variant of a profundus tendon avulsion is described, in which the avulsed tendon injury (Leddy and Packer Type I, II, or III) is associated with an extraarticular fracture of the distal phalanx.
Journal of Hand Surgery (British and European Voh~me, 1997) 22B." 4:546-547 and inspected. As it was approximately 17 days old, there was some evidence of healing and thus the fracture was left undisturbed. However, to ensure stability and allow for immediate mobilization, two small K-wires were placed percutaneously across the fracture. The avulsed FDP tendon was then reinserted and tied over a button. The DIP joint was not transfixed. Postoperatively, the patient was placed in an extension-block splint and Kleinert traction. Early active mobilization was encouraged. The pins and splint were removed 5 weeks after the operation. At follow-up 4 months later, there was an almost full range of motion of the finger, and the patient had returned to his previous work.
Avulsion of the profundus tendon is not rare, and is usually associated with sport. Initially the diagnosis is often missed, particularly if the physician or trainer is not aware of the condition. The radiographs may be "negative", and the injury is diagnosed as a "sprain" or "jammed finger". The ring finger is the most commonly involved in flexor digitorum profundus avulsions (Leddy and Packer, 1977). The mechanism is typically hyperextension of a flexed finger. These injuries have been classified into three types depending on the location of the avulsed tendon (Leddy, 1985; Leddy and Packer, 1977). Subsequent to Leddy and Packer's initial description, a fourth type has been described (Buscemi and Page, 1987; Eglseder and Russell, 1990; Ehlert et al, 1992; Langa and Posner, 1986; Robins and Dobyns, 1975; Smith, 1981). This type has an intraarticular distal phalangeal fracture with avulsion of the tendon from the palmar fragment. In this report, we propose a variant that includes any type I, II or III avulsion, with a concomitant extraarticular fracture at the metaphyseal/diaphyseal junction of the distal phalanx.
DISCUSSION
One theory to explain a tendon avulsion injury with a concomitant fracture was given by Buscemi and Page (1987). They hypothesized that the tendon, with a small osseous fragment, becomes avulsed from the base of the distal phalanx. The distal phalanx is then pushed into hyperextension as a result of the continuing extension vector force, and a secondary intraarticular fracture at the base of the distal phalanx then occurs as the distal portion of the middle phalanx is forcibly driven into the base of the distal phalanx. Thus, after avulsion of the FDP and its osseous fragment, the continued hyperextension causes a "pilon-like" fracture of the distal phalanx. The mechanism of the injury we describe could be similar to that proposed by Buscemi and Page. Another hypothesis is also offered. This history was not typical of
CASE REPORT
A 45-year-old right hand dominant court officer, with no significant past medical history, presented with a 2-weekold injury of the right small finger sustained by slipping and falling in the street. He had been treated initially in a local emergency room where he was told that he had sustained a sprain. The digit was splinted and he was discharged. However, a few days later, he was recalled to the emergency room as a consultant radiologist had reviewed his radiographs and detected a distal phalangeal fracture. On examination, he was noted to be unable to flex the distal interphalangeal joint of the affected digit. Further review of the radiographs revealed a bony fragment within the flexor tendon sheath at the level of the A2 pulley, in addition to the distal phalanx fracture (Fig 1). The digit was explored via a Bruner incision and the FDP tendon, with its attached bony fragment, was found within the flexor tendon sheath at the level of the A2 pulley. It was retrieved and brought back up to its insertion. The extraarticular fracture of the distal phalanx at the junction of the metaphysis and diaphysis was exposed
Fig 1
546
Lateral X-ray of the right small finger at presentation. An oblique fracture of the distal phalanx with a bony avulsion fragment near the PIP joint within the tendon sheath can be seen.
547
P R O F U N D U S T E N D O N AVULSION
the "grasping" athletic injury. This patient may have sustained direct trauma to the distal phalanx as he fell, resulting in the short oblique fracture. If a hyperextension force was then applied, a tendon avulsion may have ensued. The mechanism of this injury is therefore uncertain. Careful physical examination and radiographic review are necessary to detect this injury. A cursory examination coupled with radiographs demonstrating an extraarticular distal phalangeal fracture could lull the surgeon into missing the all-important tendon avulsion.
Ehlert K J, Gould JS, Black KP (1992). A simultaneous distal phalanx avulsion fracture with profundus tendon avulsion. Clinical Orthopaedics and Related Research, 283: 2 6 5 2 6 9 . Langa V, Posner MA (1986). Unusual rupture of a flexor profundus tendon. Journal of Hand Surgery, 11A: 227-229. Leddy JP (1985). Avulsions of the flexor digitorum profnndus. H a n d Clinics, 1: 77-83. Eeddy JP, Packer JW (1977). Avulsion of the profundus tendon insertion in athletes. Journal of Hand Surgery, 2: 66-69. Robins PR, Dobyns JH. Avulsion of the insertion of the flexor digitorum profundus tendon associated with fracture of the distal phalanx - - a brief review. In: A A O S Symposium on tendon surgery in the hand St. Louis, C.V. Mosby, 1975: 151-156. Smith J H (1981). Avulsion of a profundus tendon with simultaneous intraarticular fracture of the distal phalanx. Journal of Hand Surgery, 6: 600-601.
References Buscemi M J, Page BJ (1987). Flexor digitorum profuudus avulsions with associated distal phalanx fl'actures. American Journal of Sports Medicine, 15: 36(~370. Eglseder WA, Russell JM (1990). Type IV flexor digitorum profundus avulsion. Journal of H a n d Surgery, 15A: 735-739.
Received: 2 October 1996 Accepted after revision: 17 February 1997 Daniel A. Caligiuri MD, SUNY Health Science Center at Brooklyn, Department of Orthopaedics, 450 Clarkson Avenue,Box 30, Brooklyn, New York 11203,USA. © 1997The British Society for Surgery of the Hand