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Avulsion of the profundus tendon insertion in athletes
Avulsion of the profundus tendon insertion in athletes A review of36 avulsions of the flexor profundus tendon insertion in athletes seen during the past 5 years showed the injury to be most common in the ringjinger. The injury was classified into three types depending upon ( I ) the presence or absence of a bony fragment on roentgenograms, (2) the level to which the tendon retracted, and (3) the status of the blood supply of the avulsed tendon. If the tendon retracts into the palm at the time of injury, it should be repaired within 7 days. If the tendon retracts only to the proximal interphalangeal joint, it often can be repaired afew months after the injury. Late untreated patients who were relatively asymptomatic were left alone. Those with unstable distal interphalangeal joints were treated by fusion or tenodesis of the distal joint. A flexor tendon graft through an intact functioning superjicia/is tendon in the ringjinger seldom was indicated. Prompt diagnosis and surgical repair within the jirst week gave the best results.
Joseph P. Leddy, M.D., Piscataway, N. J., and John W. Packer, M.D., Raleigh, N. C.
Avulsion of the insertion of a profundus tendon is a relatively common injury in athletes. Several reports of ruptures of flexor tendons have been published 1 ' 9 since an early report by Von Zander10 in 1891. McMaster,!l in 1933, stated that the tendon was the strongest link in the musculotendinous chain and that rupture rarely occurred in the substance of a normal tendon. He showed experimentally that a normal tendon usually ruptured at its bony insertion and less often at the musculotendinous junction. During a recent 5 year period, we have seen 36 avulsions of the insertion of the profundus tendon in athletes. The average age of the patients was 16 years. Seventy-five percent occurred in the ring finger. In three fourths of the patients, there was a delay in treatment because the nature of the injury was not recognized immediately. , . Gunter 6 feels that the presence of a common flexor muscle belly of the profundus to the middle, ring, and little fingers makes the ring finger more susceptible to this injury. We think that the anatomic arrangement of the extensor tendons also may be a factor. When the metacarpophalangeal joints of the middle and little fingers are flexed 90°, the ring finger cannot be extended fully. The ring finger extensor tendon is pulled distally by the intertendinous connections between the extensor tendons. These act as check reins to prevent passive extension of the ring finger, making it more Received for publication Oct. 22, 1976. Reprint requests: Joseph P. Leddy, M.D., 205 Easton Ave., New Brunswick, N. J. 08901.
66
THE JOURNAL OF HAND SURGERY
January, 1977
Fig. 1. The shorter little finger slips away from the pants and continues to flex. The ring finger is forcibly extended while contracting.
susceptible to injury by hyperextension or to rupture of the tendon when the finger is flexed against a nonelastic object. The majority of these avulsions of the flexor tendon occurred in American football, when, in an effort to make a tackle, the fingers were grasping the pants or jersey of a player. As the little finger continued to flex and the tackled player pulled away, the ring finger, still caught in the pants or jersey, was extended forcibly Vol. 2, No.1, pp. 66-69
Vol. 2 No.1 January, 1977
Avulsion of profundus tendon insertion in athletes
67
Fig. 2. Necrotic, contracted tendon in the palm which cannot be reinserted .
while the profundus was contracting. This resulted in avulsion of the tendon insertion (Fig. 1). The diagnosis often is not made initially. Unless one is aware of the entity, takes an accurate history, and tests for active flexion at the distal interphalangeal joint, the injury will not be recognized. Roentgenograms are usually normal, and the patient is told he has a "jammed finger." Unfortunately, delay in diagnosis and treatment can compromise the function of the finger severely. The blood supply of the profundus tendon, though not completely understood, is derived from the insertion over the distal phalanx which supplies the distal portion of the tendon. The proximal portion receives its blood supply near the musculotendinous junction. The long and short vincula nourish the phalangeal portion of the tendon. An important contribution to the profundus tendon is made near the proximal interphalangeal joint level by the long vinculum. Factors which influence the prognosis and treatment of this injury include: (I) the level to which the tendon retracts; (2) the remaining blood supply of the avulsed tendon; (3) the length of time between injury and treatment; (4) the presence and size of a bony fragment on x-ray. Types of avulsion We have seen three basically different types of avulsion. Type I. In Type I the tendon retracts into the palm, both vincula are ruptured, and, therefore, a substantial portion of the blood supply is lost. There is no active flexion at the distal interphalangeal joint level, and
Fig. 3. Small bony fleck opposite proximal interphalangeal joint indicating level to which tendon has retracted.
there is a tender mass in the palm. The tendon should be reinserted in 7 to 10 days before the tendon becomes necrotic and contracted (Fig. 2). We use the standard pull-out wire and button technique with No. 34 monofilament stainless steel wire. Care must be taken not to injure the volar plate of the distal interplanageal joint, an injury which can result in a flexion contracture. Type II. Type II is the most common type. The tendon retracts to the level of the proximal interphalangeal joint, leaving the long vinculum intact, thereby retain-
68
The Journal of HAND SURGERY
Leddy and Packer
Fig. 4. Large bony fragment caught at the level of the distal phalanx.
ing more of its blood supply. Occasionally, a small fleck of bone is avulsed with the tendon and can be seen on roentgenograms at the proximal interphalangeal level (Fig. 3). There is no active flexion at the distal interphalangeal joint, and there is pain, swelling, tenderness, and some loss of motion at the proximal interphalangeal joint. This type is best treated by early reinsertion of the tendon into the distal phalanx. However, in contrast to Type I injuries, the tendon can be reinserted at a later date because it has retained a better blood supply and does not become necrotic and contracted. The granulation tissue which forms around the retracted tendon and at the proximal interphalangeal joint level must be excised and full passive range of motion restored prior to reinsertion of the tendon. We have repaired one of these 3 months after injury and obtained a satisfactory result. It is possible for the tendon to first retract to the proximal interphalangeal joint level and later to slip into the palm, thus becoming a Type I injury. Type III. In Type III there is a large bony fragment. The distal pulley prevents retraction beyond the middle phalanx. There is swelling, ecchymosis, tenderness over the middle phalanx, and inability to flex the distal interphalangeal joint. A large bony fragment can be seen just proximal to the distal interphalangeal joint on the lateral roentgenogram (Fig. 4). Early reinsertion of the fragment will give a satisfactory result. This is the most unusual type: Late untreated cases which are relatively asymptomatic are best left alone. We had 13 such cases. All of these patients had a full range of motion of the proximal interphalangeal joint and had no symptoms refer-
able to instability of the distal interphalangeal joint. In those late cases with instability, we favor fusion of the distal interphalangeal joint. If there is a tender lump in the palm, the necrotic tendon can be excised. Although not included in this series, we have seen four patients who, subsequent to a rupture of a profundus tendon, had two stage flexor tendon grafts performed through intact superficialis tendons. These operations were not done by us. Two had good results, but two were failures, which necessitated multiple operations subsequently. Honner7 reported success in a series of two stage tendon grafts for late untreated cases. We do not recommend this treatment because many of these patients have minimal symptoms and the potential complications are serious. We have treated 36 patients with this injury. Twelve had reinsertion of the tendon with satisfactory results. Although there was a 10° to 15° loss of extension in the distal interphalangeal joint, good flexion returned. Grip strength in those treated with early reinsertion approached normal. In nine patients the distal interphalangeal joint was fused because of instability. There were no nonunions. Six of these required excision of the tender end of the tendon in the palm. In two cases tenodesis was done with the retracted tendon. Thirteen patients seen late needed no treatment. Grip strength in those patients who had fusion or tenodesis was the same as that of the untreated group. Early diagnosis and prompt surgical treatment give the best result. Late untreated cases which are asymptomatic are best left alone. For late instability of the distal interphalangeal joint, we favor fusion. If there is
Vol. 2 No.1 January , 1977
a tender mass in the palm, the necrotic tendon end can be excised. A two stage flexor tendon graft can be utilized in late, untreated cases, but the potential risks may outweigh the possible advantages.
REFERENCES I . Blazina, M . E., and Lane, C.:Rupture of the insertion of the flexor digitorum profundus tendon in student athletes , 1. Am. Coli. Health Assoc. 14: 248 , 1966. 2. Boyes , J. H., Wilson , J. N. , and Smith, J. W.: Flexor tendon ruptures in the forearm and hand, J. Bone Joint Surg. 42A: 637, 1960. 3. Carroll, R. E., and Match, R. M.: Avulsion of the profundus tendon insertion, J. Trauma 10: 1109, 1970. 4. Chang, W. H., Thoms, O. J., and White, W. L.: Avulsion injury of the long flexor tendons, Plast. Reconstr. Surg. 50: 260, 1972. 5. Folmar, R. c. , Nelson , C. L., and Phalen , G . S.: Rup-
Avulsion of profundus tendon insertion in athletes
6.
7.
8.
9. 10. II.
69
tures of the flexor tendons in hands of non-rheumatoid patients, J. Bone Joint Surg. 54A:579, 1972. Gunter, G. S.: Traumatic avulsion of the insertion of flexor digitorum profundus , Aust. N.Z. J. Surg. 30: I, 1960. Honner, R.: The late management of the isolated lesion of the flexor digitorum profundus tendon, Hand 7: 171, 1975 . Posch, J. L., Walker, P. J., and Miller, H. :.Treatment of ruptured tendons of the hand and wrist, Am . J. Surg. 91: 669, 1956. Wenger, D. R.: Avulsion of the profundus tendon insertion in football players , Arch. Surg. 106: 145, 1973. Von Zander, Trommlerlahmung Inaug. Dissertation, Berlin, 189 \. McMaster, P. E.: Tendon and muscle ruptures. Clinical and experimental studies on the causes and location of subcutaneous ruptures, J. Bone Joint Surg. 15: 705, 1933 .
Joseph P. Leddy, M.D., Piscataway, N. J., and John W. Packer, M.D., Raleigh, N. C.
Avulsion of the insertion of a profundus tendon is a relatively common injury in athletes. Several reports of ruptures of flexor tendons have been published 1 ' 9 since an early report by Von Zander10 in 1891. McMaster,!l in 1933, stated that the tendon was the strongest link in the musculotendinous chain and that rupture rarely occurred in the substance of a normal tendon. He showed experimentally that a normal tendon usually ruptured at its bony insertion and less often at the musculotendinous junction. During a recent 5 year period, we have seen 36 avulsions of the insertion of the profundus tendon in athletes. The average age of the patients was 16 years. Seventy-five percent occurred in the ring finger. In three fourths of the patients, there was a delay in treatment because the nature of the injury was not recognized immediately. , . Gunter 6 feels that the presence of a common flexor muscle belly of the profundus to the middle, ring, and little fingers makes the ring finger more susceptible to this injury. We think that the anatomic arrangement of the extensor tendons also may be a factor. When the metacarpophalangeal joints of the middle and little fingers are flexed 90°, the ring finger cannot be extended fully. The ring finger extensor tendon is pulled distally by the intertendinous connections between the extensor tendons. These act as check reins to prevent passive extension of the ring finger, making it more Received for publication Oct. 22, 1976. Reprint requests: Joseph P. Leddy, M.D., 205 Easton Ave., New Brunswick, N. J. 08901.
66
THE JOURNAL OF HAND SURGERY
January, 1977
Fig. 1. The shorter little finger slips away from the pants and continues to flex. The ring finger is forcibly extended while contracting.
susceptible to injury by hyperextension or to rupture of the tendon when the finger is flexed against a nonelastic object. The majority of these avulsions of the flexor tendon occurred in American football, when, in an effort to make a tackle, the fingers were grasping the pants or jersey of a player. As the little finger continued to flex and the tackled player pulled away, the ring finger, still caught in the pants or jersey, was extended forcibly Vol. 2, No.1, pp. 66-69
Vol. 2 No.1 January, 1977
Avulsion of profundus tendon insertion in athletes
67
Fig. 2. Necrotic, contracted tendon in the palm which cannot be reinserted .
while the profundus was contracting. This resulted in avulsion of the tendon insertion (Fig. 1). The diagnosis often is not made initially. Unless one is aware of the entity, takes an accurate history, and tests for active flexion at the distal interphalangeal joint, the injury will not be recognized. Roentgenograms are usually normal, and the patient is told he has a "jammed finger." Unfortunately, delay in diagnosis and treatment can compromise the function of the finger severely. The blood supply of the profundus tendon, though not completely understood, is derived from the insertion over the distal phalanx which supplies the distal portion of the tendon. The proximal portion receives its blood supply near the musculotendinous junction. The long and short vincula nourish the phalangeal portion of the tendon. An important contribution to the profundus tendon is made near the proximal interphalangeal joint level by the long vinculum. Factors which influence the prognosis and treatment of this injury include: (I) the level to which the tendon retracts; (2) the remaining blood supply of the avulsed tendon; (3) the length of time between injury and treatment; (4) the presence and size of a bony fragment on x-ray. Types of avulsion We have seen three basically different types of avulsion. Type I. In Type I the tendon retracts into the palm, both vincula are ruptured, and, therefore, a substantial portion of the blood supply is lost. There is no active flexion at the distal interphalangeal joint level, and
Fig. 3. Small bony fleck opposite proximal interphalangeal joint indicating level to which tendon has retracted.
there is a tender mass in the palm. The tendon should be reinserted in 7 to 10 days before the tendon becomes necrotic and contracted (Fig. 2). We use the standard pull-out wire and button technique with No. 34 monofilament stainless steel wire. Care must be taken not to injure the volar plate of the distal interplanageal joint, an injury which can result in a flexion contracture. Type II. Type II is the most common type. The tendon retracts to the level of the proximal interphalangeal joint, leaving the long vinculum intact, thereby retain-
68
The Journal of HAND SURGERY
Leddy and Packer
Fig. 4. Large bony fragment caught at the level of the distal phalanx.
ing more of its blood supply. Occasionally, a small fleck of bone is avulsed with the tendon and can be seen on roentgenograms at the proximal interphalangeal level (Fig. 3). There is no active flexion at the distal interphalangeal joint, and there is pain, swelling, tenderness, and some loss of motion at the proximal interphalangeal joint. This type is best treated by early reinsertion of the tendon into the distal phalanx. However, in contrast to Type I injuries, the tendon can be reinserted at a later date because it has retained a better blood supply and does not become necrotic and contracted. The granulation tissue which forms around the retracted tendon and at the proximal interphalangeal joint level must be excised and full passive range of motion restored prior to reinsertion of the tendon. We have repaired one of these 3 months after injury and obtained a satisfactory result. It is possible for the tendon to first retract to the proximal interphalangeal joint level and later to slip into the palm, thus becoming a Type I injury. Type III. In Type III there is a large bony fragment. The distal pulley prevents retraction beyond the middle phalanx. There is swelling, ecchymosis, tenderness over the middle phalanx, and inability to flex the distal interphalangeal joint. A large bony fragment can be seen just proximal to the distal interphalangeal joint on the lateral roentgenogram (Fig. 4). Early reinsertion of the fragment will give a satisfactory result. This is the most unusual type: Late untreated cases which are relatively asymptomatic are best left alone. We had 13 such cases. All of these patients had a full range of motion of the proximal interphalangeal joint and had no symptoms refer-
able to instability of the distal interphalangeal joint. In those late cases with instability, we favor fusion of the distal interphalangeal joint. If there is a tender lump in the palm, the necrotic tendon can be excised. Although not included in this series, we have seen four patients who, subsequent to a rupture of a profundus tendon, had two stage flexor tendon grafts performed through intact superficialis tendons. These operations were not done by us. Two had good results, but two were failures, which necessitated multiple operations subsequently. Honner7 reported success in a series of two stage tendon grafts for late untreated cases. We do not recommend this treatment because many of these patients have minimal symptoms and the potential complications are serious. We have treated 36 patients with this injury. Twelve had reinsertion of the tendon with satisfactory results. Although there was a 10° to 15° loss of extension in the distal interphalangeal joint, good flexion returned. Grip strength in those treated with early reinsertion approached normal. In nine patients the distal interphalangeal joint was fused because of instability. There were no nonunions. Six of these required excision of the tender end of the tendon in the palm. In two cases tenodesis was done with the retracted tendon. Thirteen patients seen late needed no treatment. Grip strength in those patients who had fusion or tenodesis was the same as that of the untreated group. Early diagnosis and prompt surgical treatment give the best result. Late untreated cases which are asymptomatic are best left alone. For late instability of the distal interphalangeal joint, we favor fusion. If there is
Vol. 2 No.1 January , 1977
a tender mass in the palm, the necrotic tendon end can be excised. A two stage flexor tendon graft can be utilized in late, untreated cases, but the potential risks may outweigh the possible advantages.
REFERENCES I . Blazina, M . E., and Lane, C.:Rupture of the insertion of the flexor digitorum profundus tendon in student athletes , 1. Am. Coli. Health Assoc. 14: 248 , 1966. 2. Boyes , J. H., Wilson , J. N. , and Smith, J. W.: Flexor tendon ruptures in the forearm and hand, J. Bone Joint Surg. 42A: 637, 1960. 3. Carroll, R. E., and Match, R. M.: Avulsion of the profundus tendon insertion, J. Trauma 10: 1109, 1970. 4. Chang, W. H., Thoms, O. J., and White, W. L.: Avulsion injury of the long flexor tendons, Plast. Reconstr. Surg. 50: 260, 1972. 5. Folmar, R. c. , Nelson , C. L., and Phalen , G . S.: Rup-
Avulsion of profundus tendon insertion in athletes
6.
7.
8.
9. 10. II.
69
tures of the flexor tendons in hands of non-rheumatoid patients, J. Bone Joint Surg. 54A:579, 1972. Gunter, G. S.: Traumatic avulsion of the insertion of flexor digitorum profundus , Aust. N.Z. J. Surg. 30: I, 1960. Honner, R.: The late management of the isolated lesion of the flexor digitorum profundus tendon, Hand 7: 171, 1975 . Posch, J. L., Walker, P. J., and Miller, H. :.Treatment of ruptured tendons of the hand and wrist, Am . J. Surg. 91: 669, 1956. Wenger, D. R.: Avulsion of the profundus tendon insertion in football players , Arch. Surg. 106: 145, 1973. Von Zander, Trommlerlahmung Inaug. Dissertation, Berlin, 189 \. McMaster, P. E.: Tendon and muscle ruptures. Clinical and experimental studies on the causes and location of subcutaneous ruptures, J. Bone Joint Surg. 15: 705, 1933 .