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Chronic painful subluxation of the metacarpal halangeal joint extensor tendons
Chronic painful subluxation of the metacarpal phalangeal joint extensor tendons Chronic subluxation of the extensor tendons of the metacarpal phalangeal joint has been documented in six patients on active duty in the United States Navy. These patients had painful full flexion and gripping in the knuckle, especially when they were performing their jobs. No extension lag was noted. Three patients had a -severed junctura tendinum between the long and index fingers, which was believed to be a contributing factor to extensor tendon subluxation. Local anesthesia was administered to these patients, and the lesions were surgically corrected by reefing of the extensor hood and the sagittal band and repair of the junctura tendinum. (J HAND SURG llA:420-3, 1986.)
M. J. Saldana, M.D., Me, USN, and R. A. McGuire, M.D., Me, USN, Portsmouth, Va.
Chronic subluxation of the extensor tendons of the fingers is an unusual problem in patients who have nonrheumatoid arthritis. It usually occurs in either the third or fourth digit and is usually the result of trauma. If untreated, it can result in a painful grip as the tendon "snaps" off the metacarpal head. We are reporting six cases and discuss Our philosophy of treatment.
Case reports Case 1. A 22-year-old, right-handed male sailor was treated in the hospital for nonsuppurative flexor sheath tenosynovitis 2 months after he sustained a 220 volt injury to the dorsum of the hand. Immediately after the injury he had surgical decompression of the interosseous compartments through two dorsal incisions . While he was recovering from his nonsuppurative tenosynovitis, the patient noticed a painful "snapping" over the knuckle of the long finger with obvious ulnar subluxation of the extensor digitorum communis (EDC) Jo that finger (Fig. 1). With the patient under local anesthesia, an ,operation was performed. The junctura between the long and index fingers had been previously severed during an operation for decompression of the second interosseous comFrom the Orthopedic Department, Portsmouth Naval Hospital, Portsmouth, VA 23780. Received for publication June 6, 1985; accepted in revised form Sept. 9, 1985. The views herein are those of the authors and do not necessarily reflect the views of'the United States Navy or the Department of Defense. Reprint requests: M. J. Saldana, Captain, MC, USN, Division of Hand Surgery, Orthopedic Department, Portsmouth Naval Hospital, Portsmouth, VA 23780.
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Fig. 1. Extensor digitorum communis tendon subluxed on knuckle of long finger.
Fig. 2. Attenuated radial sagittal band and extensor hood.
Vol. llA , No.3 May 1986
Chronic subluxation of extensor tendons
421
Fig. 3. A, Attenuated hood and sagittal band plus severed junctura. B, Surgical reefing of hood and sagittal band and repair of junctura. partment. There was laxity of the sagittal band and the extensor hood on the radial side of the long finger, but no tear was evident (Fig. 2). The junctura was repaired and the extensor hood and sagittal band were reefed with No. 4-0 PDS (Polydioxanone sutures) . The index and long metacarpal phalangeal joints were kept extended for 6 weeks. Measurement of the patients' Jamar grip was 80% of that of his dominant uninjured hand 6 months after the injury. Case 2. A 22-year-old left-handed machinist' s mate had a 6-month history of painful subluxation of the EDC tendon to the ulnar side of the long finger. Two years previously, he had a distal radius comminuted intra-articular fracture, which was treated with pins and plaster. A fracture of the second metacarpal developed as a complication of the pins"and-plaster treatment; this was treated with open reduction internal fixation (O.R.LF.) with cross Kirschner wires . Three months later he noticed the painful ulnar subluxation of the long finger extensor tendon when gripping an object and making a fist. The~e was no extensor lag of the long finger. Findings and treatment were identical to those of the first case. Case 3. A 26-year-old marine experienced painful ulnar subluxation of the right dominant long finger 8 months after he sustained a laceration to the dorsum of the hand. He had no extension lag. Findings at surgery were identical to those of the first two cases. Six months postoperatively the patient returned to duty with equal strength in both hands. Case 4. A 27-year-old boiler technician had a 2-year history of painful subluxation of the EDC to the radial side of the ring finger when he made a fist. He had punched a fellow shipmate in the mouth and sustained a laceration to the ulnar side of the knuckle of the ring finger. No treatment was sought when the injury occurred. There was no extension lag. At operation a 1 cm rent in the extensor hood on the ulnar side
was repaired. The junctura between the long and ring fingers was intact. One year later the grip measurements were equal to those of the uninjured side. Case 5. A 19-year-old right-handed boatswain's mate had painful subluxation of the EDC to the ulnar side of the long finger when he made a fist. Three years earlier, while pulling on a line, he experienced a snap with pain and swelling over the long finger knuckle . He could not recall having extension lag . Surgical exploration revealed an attenuated sagittal band and extensor hood without a rent. Repair was accomplished with simple reefing. Jamar grip measurements taken at 24 months were equal to those of his nondominant hand. Case 6. A 28-year-old right-handed medical repair technician had bilateral painful long finger ulnar subluxation of the EDC at the metacarpal phalangeal joint. There was no history of trauma. The tendon remained in its centralized location until about 80° of flexion was achieved, and then the tendon "snapped" into an ulnarly subluxed position. The patient did not demonstrate hypermobility of any other joints. There was laxity of the hood and sagittal band on the radial side, without evidence of a previous tear. The method of repair used was identical to that of the previous case.
Operation
With the patient under local anesthesia, the operation is perfonned through a longitudinal incision exposing the hood and proximal tendon until the junctura tendinum is visualized. With No. 4-0 PDS sutures, the attenuated radial side of the hood and sagittal band is reefed. The junctura, if previously torn, is repaired at the same time (Fig. 3). The tendon should remain centralized when the patient makes a fist. The wound is
422
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Fig. 4. A. Extensor tendons to long and index fingers seen with fingers in extension. B. Extensors to long and index fingers coming together as the index finger is gently flexed .
closed with simple sutures. A plaster splint that holds the metacarpal phalangeal joints in extension, with the wrist at 30° of extension, is applied. The proximal interphalangeal joints are left free to move. The plaster splint is changed to an Orthoplast splint on the second or third postoperative day, and the latter is kept on for 6 weeks . Gentle active motion is started at 6 weeks. , Resistive motion and tight-grip holding are allowed at l~ weeks. Our patients resume light work wearing the splints by the end of the second postoperative week.
Discussion Kettlekamp et al. l describe the anatomic characteristics that lead to ulnar dislocation of the extensor tendon. They also describe the forces acting across the metacarpal phalangeal joint with normal motion and show how these affect the extensor tendons and predispose them to dislocation. They believe that surgical anatomic repair is indicated for acute extensor tendon dislocation associated with a tear of the extensor hood. Ulnar deviation of the fingers with dislocation of the
The Journal of HAND SURGERY
extensor tendons is a well-known sequela in patients with rheumatoid arthritis.2-4 Tendon dislocation was also reported in elderly women who did not have rheumatoid arthritis when pathologic findings were thought to indicate excessive joint laxity.s Seronegative polyarthritis is associated with habitual dislocation of extensor tendons. All of the patients had documented extensor lag associated with the tendon dislocation.6 Our last case is similar to two cases reported by McCoy and Winsky, 7 in which there appeared to be a congenital weakness of the periarticular structures of the metacarpal phalangeal joint. In the normal hand the structure of the articular surfaces of the metacarpal heads allows for ulnar deviation of the fingers. Hakstian and Tubiana's8 studies showed that the index and long finger articular surfaces had a 10° to 15° ulnar inclination, while the ring and small fingers had less inclination. ZancolW described the forces that contribute to keeping the extensor tendons centralized on the metacarpal phalangeal joints. The fibers on the radial side of the extensor hood and sagittal band act as a restraining force. He also stated that the radial interosseous muscles contributed as they contract and pull on the radial side of the extensor hood. If the fingers are held in extension and the index finger is gently allowed to flex, the extensor tendons of the index and long fingers initially approximate each other. As the EDC to the index finger is passively moved from an extended position to a flexed position while the long finger is held extended, the junctura tendinum between the two fingers acts as a restraining structure and brings the two tendons together (Fig. 4). If the fingers are brought into full flexion, the restraining forces that prevent ulnar dislocation of the tendons are the radial interosseous muscles and the radial side of the sagittal band and hood. As a tight fist is made, then the first dorsal interosseous exerts a radially deviating force on the extensor tendon to the index finger. The junctura between the index and long fingers helps prevent ulnar dislocation of the long-finger extensor tendon. Several loop procedures for correction of extensor tendon dislocation have been described. 7 • 10-12 Our patients with chronic subluxation of the central tendons had no extensor lag. There was a painful grip associated with a snap as the tendon suddenly went from a centralized position to a subluxed position with finger flexion. The discomfort interfered with the patients' work. None of our patients had tears in the sagittal bands or extensor hoods, but laxity was noted on the radial side
Vol. l1A, No.3 May 1986
of the hood. Three of our patients had a tom junctura tendinum between the index and long EDC tendons, which was believed to be a contributing factor to subluxation. REFERENCES 1. Kettelkamp DB, Flatt AE, Moulds R: Traumatic dislocation of the long finger extensor tendon. J Bone Joint Surg [Am] 53:229-40, 1971 2. Fowler SB, Riordan DC: Surgical treatment of rheumatoid deformities of the hand. J Bone Joint Surg [Am] 40:1431, 1958 3. Smith RJ, Kaplan EB: Rheumatoid deformities at the metacarpophalangeal joints of the fingers. J Bone Joint Surg [Am] 49:31-47, 1967 4. Flatt AE: The care of the rheumatoid hand. St. Louis, 1963, The CV Mosby Co 5. Harvey FJ, Hume KF: Spontaneous recurrent ulnar dislocation of the long extensor tendons of the fingers. J HANO SURG 5:492-4, 1980
Chronic subluxation of extensor tendons
6. Bracey DJ, Jeffreys TE: Habitual extensor tendon dislocation. Hand 11:284-94, 1979 7. McCoy FJ, Winsky AJ: Lumbrical loop operation for luxation of the extensor tendons of the hand. Plast Reconstr Surg 44:142-6, 1969 8. Hakstian RW, Tubiana R: Ulnar deviation of the fingers. The role of joint structure and function. J Bone Joint Surg [Am] 49:299-316, 1967 9. Zancolli EA: Structural and dynamic bases of hand surgery. Philadelphia, 1972, JB Lippincott Co 10. Elson RA: Dislocation of the extensor tendons of the hand. J Bone Joint Surg [Br] 49:324-6, 1967 11. Michon J, Vichard P: Luxations laterales des tendons estenseurs en regard de l'articulation metacarpo-phalangienne. Rev Med de Nancy 86:595-601, 1961 12. Kilgore EE, Graham WP, Newmeyer WL, Brown LG: Correction of ulnar subluxation of the extensor communis. Hand 7:272-4, 1975
Duplication of the extensor carpi ulnaris tendon Three cases are presented, in which an anomalous tendon slip between the extensor carpi ulnaris tendon and the extensor apparatus of the fifth finger was found. One of the patients was a violinist, who had serious impairment of the left wrist joint and the small finger due to the anomaly. The symptoms disappeared after excision. (J HAND SURG llA:423-S, 1986.)
Troels Barfred, M.D., Ph.D., and Sven Adamsen, M.D., Odense, Denmark
Anomalies related to the muscles and of the hand may occur on the palmar l -3 and the dorsal. aspects of the hand_ Examples of extensor anomalies are absence or variations of the insertion of one or more tendons from the extensor digitorum communis,4 anomalies of the conexus intertendinei, 2 and presence of an extensor digten~ons
From the Department of Orthopaedic Surgery, Odense University Hospital, Odense, Denmark. Received for publication May 6, 1985; accepted in revised form Aug. 14, 1985. Reprint requests: Troels Barfred, M.D., Ph.D, Department of Orthopaedic Surgery, Odense University Hospital, DK-5000 Odense C., Denmark
Fig. 1. The supposed course of the tendon slip arising from the ECU tendon inserting in the extensor apparatus of the small finger. Inside the frame is the course seen at operation.
THE JOURNAL OF HAND SURGERY
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M. J. Saldana, M.D., Me, USN, and R. A. McGuire, M.D., Me, USN, Portsmouth, Va.
Chronic subluxation of the extensor tendons of the fingers is an unusual problem in patients who have nonrheumatoid arthritis. It usually occurs in either the third or fourth digit and is usually the result of trauma. If untreated, it can result in a painful grip as the tendon "snaps" off the metacarpal head. We are reporting six cases and discuss Our philosophy of treatment.
Case reports Case 1. A 22-year-old, right-handed male sailor was treated in the hospital for nonsuppurative flexor sheath tenosynovitis 2 months after he sustained a 220 volt injury to the dorsum of the hand. Immediately after the injury he had surgical decompression of the interosseous compartments through two dorsal incisions . While he was recovering from his nonsuppurative tenosynovitis, the patient noticed a painful "snapping" over the knuckle of the long finger with obvious ulnar subluxation of the extensor digitorum communis (EDC) Jo that finger (Fig. 1). With the patient under local anesthesia, an ,operation was performed. The junctura between the long and index fingers had been previously severed during an operation for decompression of the second interosseous comFrom the Orthopedic Department, Portsmouth Naval Hospital, Portsmouth, VA 23780. Received for publication June 6, 1985; accepted in revised form Sept. 9, 1985. The views herein are those of the authors and do not necessarily reflect the views of'the United States Navy or the Department of Defense. Reprint requests: M. J. Saldana, Captain, MC, USN, Division of Hand Surgery, Orthopedic Department, Portsmouth Naval Hospital, Portsmouth, VA 23780.
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THE JOURNAL OF HAND
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Fig. 1. Extensor digitorum communis tendon subluxed on knuckle of long finger.
Fig. 2. Attenuated radial sagittal band and extensor hood.
Vol. llA , No.3 May 1986
Chronic subluxation of extensor tendons
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Fig. 3. A, Attenuated hood and sagittal band plus severed junctura. B, Surgical reefing of hood and sagittal band and repair of junctura. partment. There was laxity of the sagittal band and the extensor hood on the radial side of the long finger, but no tear was evident (Fig. 2). The junctura was repaired and the extensor hood and sagittal band were reefed with No. 4-0 PDS (Polydioxanone sutures) . The index and long metacarpal phalangeal joints were kept extended for 6 weeks. Measurement of the patients' Jamar grip was 80% of that of his dominant uninjured hand 6 months after the injury. Case 2. A 22-year-old left-handed machinist' s mate had a 6-month history of painful subluxation of the EDC tendon to the ulnar side of the long finger. Two years previously, he had a distal radius comminuted intra-articular fracture, which was treated with pins and plaster. A fracture of the second metacarpal developed as a complication of the pins"and-plaster treatment; this was treated with open reduction internal fixation (O.R.LF.) with cross Kirschner wires . Three months later he noticed the painful ulnar subluxation of the long finger extensor tendon when gripping an object and making a fist. The~e was no extensor lag of the long finger. Findings and treatment were identical to those of the first case. Case 3. A 26-year-old marine experienced painful ulnar subluxation of the right dominant long finger 8 months after he sustained a laceration to the dorsum of the hand. He had no extension lag. Findings at surgery were identical to those of the first two cases. Six months postoperatively the patient returned to duty with equal strength in both hands. Case 4. A 27-year-old boiler technician had a 2-year history of painful subluxation of the EDC to the radial side of the ring finger when he made a fist. He had punched a fellow shipmate in the mouth and sustained a laceration to the ulnar side of the knuckle of the ring finger. No treatment was sought when the injury occurred. There was no extension lag. At operation a 1 cm rent in the extensor hood on the ulnar side
was repaired. The junctura between the long and ring fingers was intact. One year later the grip measurements were equal to those of the uninjured side. Case 5. A 19-year-old right-handed boatswain's mate had painful subluxation of the EDC to the ulnar side of the long finger when he made a fist. Three years earlier, while pulling on a line, he experienced a snap with pain and swelling over the long finger knuckle . He could not recall having extension lag . Surgical exploration revealed an attenuated sagittal band and extensor hood without a rent. Repair was accomplished with simple reefing. Jamar grip measurements taken at 24 months were equal to those of his nondominant hand. Case 6. A 28-year-old right-handed medical repair technician had bilateral painful long finger ulnar subluxation of the EDC at the metacarpal phalangeal joint. There was no history of trauma. The tendon remained in its centralized location until about 80° of flexion was achieved, and then the tendon "snapped" into an ulnarly subluxed position. The patient did not demonstrate hypermobility of any other joints. There was laxity of the hood and sagittal band on the radial side, without evidence of a previous tear. The method of repair used was identical to that of the previous case.
Operation
With the patient under local anesthesia, the operation is perfonned through a longitudinal incision exposing the hood and proximal tendon until the junctura tendinum is visualized. With No. 4-0 PDS sutures, the attenuated radial side of the hood and sagittal band is reefed. The junctura, if previously torn, is repaired at the same time (Fig. 3). The tendon should remain centralized when the patient makes a fist. The wound is
422
Saldana and McGuire
Fig. 4. A. Extensor tendons to long and index fingers seen with fingers in extension. B. Extensors to long and index fingers coming together as the index finger is gently flexed .
closed with simple sutures. A plaster splint that holds the metacarpal phalangeal joints in extension, with the wrist at 30° of extension, is applied. The proximal interphalangeal joints are left free to move. The plaster splint is changed to an Orthoplast splint on the second or third postoperative day, and the latter is kept on for 6 weeks . Gentle active motion is started at 6 weeks. , Resistive motion and tight-grip holding are allowed at l~ weeks. Our patients resume light work wearing the splints by the end of the second postoperative week.
Discussion Kettlekamp et al. l describe the anatomic characteristics that lead to ulnar dislocation of the extensor tendon. They also describe the forces acting across the metacarpal phalangeal joint with normal motion and show how these affect the extensor tendons and predispose them to dislocation. They believe that surgical anatomic repair is indicated for acute extensor tendon dislocation associated with a tear of the extensor hood. Ulnar deviation of the fingers with dislocation of the
The Journal of HAND SURGERY
extensor tendons is a well-known sequela in patients with rheumatoid arthritis.2-4 Tendon dislocation was also reported in elderly women who did not have rheumatoid arthritis when pathologic findings were thought to indicate excessive joint laxity.s Seronegative polyarthritis is associated with habitual dislocation of extensor tendons. All of the patients had documented extensor lag associated with the tendon dislocation.6 Our last case is similar to two cases reported by McCoy and Winsky, 7 in which there appeared to be a congenital weakness of the periarticular structures of the metacarpal phalangeal joint. In the normal hand the structure of the articular surfaces of the metacarpal heads allows for ulnar deviation of the fingers. Hakstian and Tubiana's8 studies showed that the index and long finger articular surfaces had a 10° to 15° ulnar inclination, while the ring and small fingers had less inclination. ZancolW described the forces that contribute to keeping the extensor tendons centralized on the metacarpal phalangeal joints. The fibers on the radial side of the extensor hood and sagittal band act as a restraining force. He also stated that the radial interosseous muscles contributed as they contract and pull on the radial side of the extensor hood. If the fingers are held in extension and the index finger is gently allowed to flex, the extensor tendons of the index and long fingers initially approximate each other. As the EDC to the index finger is passively moved from an extended position to a flexed position while the long finger is held extended, the junctura tendinum between the two fingers acts as a restraining structure and brings the two tendons together (Fig. 4). If the fingers are brought into full flexion, the restraining forces that prevent ulnar dislocation of the tendons are the radial interosseous muscles and the radial side of the sagittal band and hood. As a tight fist is made, then the first dorsal interosseous exerts a radially deviating force on the extensor tendon to the index finger. The junctura between the index and long fingers helps prevent ulnar dislocation of the long-finger extensor tendon. Several loop procedures for correction of extensor tendon dislocation have been described. 7 • 10-12 Our patients with chronic subluxation of the central tendons had no extensor lag. There was a painful grip associated with a snap as the tendon suddenly went from a centralized position to a subluxed position with finger flexion. The discomfort interfered with the patients' work. None of our patients had tears in the sagittal bands or extensor hoods, but laxity was noted on the radial side
Vol. l1A, No.3 May 1986
of the hood. Three of our patients had a tom junctura tendinum between the index and long EDC tendons, which was believed to be a contributing factor to subluxation. REFERENCES 1. Kettelkamp DB, Flatt AE, Moulds R: Traumatic dislocation of the long finger extensor tendon. J Bone Joint Surg [Am] 53:229-40, 1971 2. Fowler SB, Riordan DC: Surgical treatment of rheumatoid deformities of the hand. J Bone Joint Surg [Am] 40:1431, 1958 3. Smith RJ, Kaplan EB: Rheumatoid deformities at the metacarpophalangeal joints of the fingers. J Bone Joint Surg [Am] 49:31-47, 1967 4. Flatt AE: The care of the rheumatoid hand. St. Louis, 1963, The CV Mosby Co 5. Harvey FJ, Hume KF: Spontaneous recurrent ulnar dislocation of the long extensor tendons of the fingers. J HANO SURG 5:492-4, 1980
Chronic subluxation of extensor tendons
6. Bracey DJ, Jeffreys TE: Habitual extensor tendon dislocation. Hand 11:284-94, 1979 7. McCoy FJ, Winsky AJ: Lumbrical loop operation for luxation of the extensor tendons of the hand. Plast Reconstr Surg 44:142-6, 1969 8. Hakstian RW, Tubiana R: Ulnar deviation of the fingers. The role of joint structure and function. J Bone Joint Surg [Am] 49:299-316, 1967 9. Zancolli EA: Structural and dynamic bases of hand surgery. Philadelphia, 1972, JB Lippincott Co 10. Elson RA: Dislocation of the extensor tendons of the hand. J Bone Joint Surg [Br] 49:324-6, 1967 11. Michon J, Vichard P: Luxations laterales des tendons estenseurs en regard de l'articulation metacarpo-phalangienne. Rev Med de Nancy 86:595-601, 1961 12. Kilgore EE, Graham WP, Newmeyer WL, Brown LG: Correction of ulnar subluxation of the extensor communis. Hand 7:272-4, 1975
Duplication of the extensor carpi ulnaris tendon Three cases are presented, in which an anomalous tendon slip between the extensor carpi ulnaris tendon and the extensor apparatus of the fifth finger was found. One of the patients was a violinist, who had serious impairment of the left wrist joint and the small finger due to the anomaly. The symptoms disappeared after excision. (J HAND SURG llA:423-S, 1986.)
Troels Barfred, M.D., Ph.D., and Sven Adamsen, M.D., Odense, Denmark
Anomalies related to the muscles and of the hand may occur on the palmar l -3 and the dorsal. aspects of the hand_ Examples of extensor anomalies are absence or variations of the insertion of one or more tendons from the extensor digitorum communis,4 anomalies of the conexus intertendinei, 2 and presence of an extensor digten~ons
From the Department of Orthopaedic Surgery, Odense University Hospital, Odense, Denmark. Received for publication May 6, 1985; accepted in revised form Aug. 14, 1985. Reprint requests: Troels Barfred, M.D., Ph.D, Department of Orthopaedic Surgery, Odense University Hospital, DK-5000 Odense C., Denmark
Fig. 1. The supposed course of the tendon slip arising from the ECU tendon inserting in the extensor apparatus of the small finger. Inside the frame is the course seen at operation.
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