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Closed avulsion of both flexor tendons of the ring finger
C L O S E D A V U L S I O N OF B O T H F L E X O R T E N D O N S OF T H E RING FINGER K. M. C. CHEUNG and S. P. CHOW
From the Department of Orthopaedic Surgery, Universityof Hong Kong, Queen Mary Hospital, Hong Kong Closed avulsion of both flexor digitorum profundus and superficialis from the same finger is rare. Only ten cases have been described in the literature. The majority were treated with a two stage reconstruction of the flexor digitorum profundus. We describe a case in which primary repair of both tendons was performed.
Journal of Hand Surgery (British and European Volume, 1995) 20B: 1:78-79 were seen on X-ray. A diagnosis of closed rupture of both flexor tendons was made, and exploration was performed 4 days after the initial injury. The flexor tendons were explored through a zig-zag incision. Both flexor tendons had been avulsed from their insertions. The stump of FDP was found within the A2 pulley while FDS was found at the entrance to the A1 pulley (Fig 2). The vinculum longum to FDP was preserved. A primary repair was performed. FDS was repaired to its bony insertion by suture to a raised periosteal flap.
Case report
A 24-year-old right-handed policeman presented with a painful right ring finger which he could not flex. This occurred during a fight when he was assaulted. He recalled that he sustained this injury while he held onto one attacker's belt as the attacker was trying to pull away forcefully. Clinical examination revealed a swollen and bruised right ring finger and total inability to flex the affected PIP and DIP joints actively (Fig 1). Tenderness was elicited in the distal part of the proximal phalanx and over the head of the fourth metacarpal. No fractures
Fig 1
No active flexion of the proximal and distal interphalangeal joint of the ring finger was possible.
Fig 2
78
Operative photograph showing the level of retraction of the two tendons a=FDP; b=FDS.
AVULSION OF BOTH FLEXOR TENDONS
79
Fig 4
Fig 3
6 m o n t h s after surgery, s h o w i n g n e a r n o r m a l extension of all fingers.
FDP was repaired in a similar manner but also additionally reinforced with a pull-out wire suture. Post-operatively he was treated in our flexor tendon programme. This consisted of 6 weeks of protected active mobilization in a rubber band splint together with passive joint mobilization, followed by graded active flexion of the involved finger. 10 weeks after surgery he was able to return to work. Assessment at 14 weeks showed that he had-a full range of movement in the MP and PIP joints. He has a mild flexion contracture of 4 ° of the DIP joint. His grip strength was 65% of the left hand. He was discharged from physiotherapy at that stage. Assessment 6 months after surgery showed that he has returned to full time active duty and has no functional problems (Figs 3 and 4). Objectively, however, the 4 ° flexion contracture persisted, and his grip strength was 51% of the other side. DISCUSSION Closed traumatic avulsion of both flexor tendons from their insertions is rare. Only ten cases have been
6 m o n t h s after surgery, s h o w i n g full flexion of all finger joints.
described in the literature (Boyes et al, 1960; Folmar et al, 1972; Lanzetta and Conolly, 1992). The aetiological factors involved are thought to be sudden hyperextension, forced flexion and crushing, while intra-tendinous pathology, congenital abnormalities, fractures, and chronic synovitis may result in atraumatic ruptures (Boyes et al, 1960). From the history, the cause of rupture in the above case would appear to be strong flexion against a force trying to extend the finger. Nine of the reported cases were treated by excision of the tendon and secondary reconstruction by tendon grafting (Boyes et al, 1960; Folmar et al, 1972; Lanzetta and Conolly, 1992). One case was treated by amputation because of persistent joint stiffness (Boyes et al, 1960). In our patient, we felt that primary repair of the avulsions was justified because of early detection and preservation of the vinculum longum, and hence the nutritional supply to the tendon. This has the advantage of a single operation, leading to earlier return to work. We are uncertain of the cause of the reduction in grip strength between the 3- and 6-month assessment. However, as the patient has no functional deficit at 3 months after surgery, he was discharged from physiotherapy and may have discontinued his own strengthening excercises, resulting in this reduction. Although more cases treated in the same manner with a longer follow-up would be needed before any conclusions can be drawn, primary repair of the avulsed tendons is an alternative to excision and delayed tendon grafting. References BOYES, J. H., V([LSON, J. N. and SMITH, J. W. (1960). Flexor-tendon ruptures in the forearm and hand. Journal of Bone and Joint Surgery, 42A: 4: 637-646. FOLMAR, R. C., NELSON, C. L. and PHALEN, G. S. (1972). Ruptures of the flexor tendons in hands of non-rheumatoid patients. Journal of Bone and Joint Surgery, 54A: 3: 579-584. LANZETTA, M. and CONOLLY, W. B., (1992). Closed rupture of both flexor tendons in the same digit. Journal of Hand Surgery, 17B: 4: 479-480. Accepted: 17 August 1994 Dr K. M. C. Cheung, FRCS. Department of Orthopaedic Surgery, Queen Mary Hospital, Pokfulam Road, Hong Kong. © 1995 The British Societyfor Surgery of the Hand
From the Department of Orthopaedic Surgery, Universityof Hong Kong, Queen Mary Hospital, Hong Kong Closed avulsion of both flexor digitorum profundus and superficialis from the same finger is rare. Only ten cases have been described in the literature. The majority were treated with a two stage reconstruction of the flexor digitorum profundus. We describe a case in which primary repair of both tendons was performed.
Journal of Hand Surgery (British and European Volume, 1995) 20B: 1:78-79 were seen on X-ray. A diagnosis of closed rupture of both flexor tendons was made, and exploration was performed 4 days after the initial injury. The flexor tendons were explored through a zig-zag incision. Both flexor tendons had been avulsed from their insertions. The stump of FDP was found within the A2 pulley while FDS was found at the entrance to the A1 pulley (Fig 2). The vinculum longum to FDP was preserved. A primary repair was performed. FDS was repaired to its bony insertion by suture to a raised periosteal flap.
Case report
A 24-year-old right-handed policeman presented with a painful right ring finger which he could not flex. This occurred during a fight when he was assaulted. He recalled that he sustained this injury while he held onto one attacker's belt as the attacker was trying to pull away forcefully. Clinical examination revealed a swollen and bruised right ring finger and total inability to flex the affected PIP and DIP joints actively (Fig 1). Tenderness was elicited in the distal part of the proximal phalanx and over the head of the fourth metacarpal. No fractures
Fig 1
No active flexion of the proximal and distal interphalangeal joint of the ring finger was possible.
Fig 2
78
Operative photograph showing the level of retraction of the two tendons a=FDP; b=FDS.
AVULSION OF BOTH FLEXOR TENDONS
79
Fig 4
Fig 3
6 m o n t h s after surgery, s h o w i n g n e a r n o r m a l extension of all fingers.
FDP was repaired in a similar manner but also additionally reinforced with a pull-out wire suture. Post-operatively he was treated in our flexor tendon programme. This consisted of 6 weeks of protected active mobilization in a rubber band splint together with passive joint mobilization, followed by graded active flexion of the involved finger. 10 weeks after surgery he was able to return to work. Assessment at 14 weeks showed that he had-a full range of movement in the MP and PIP joints. He has a mild flexion contracture of 4 ° of the DIP joint. His grip strength was 65% of the left hand. He was discharged from physiotherapy at that stage. Assessment 6 months after surgery showed that he has returned to full time active duty and has no functional problems (Figs 3 and 4). Objectively, however, the 4 ° flexion contracture persisted, and his grip strength was 51% of the other side. DISCUSSION Closed traumatic avulsion of both flexor tendons from their insertions is rare. Only ten cases have been
6 m o n t h s after surgery, s h o w i n g full flexion of all finger joints.
described in the literature (Boyes et al, 1960; Folmar et al, 1972; Lanzetta and Conolly, 1992). The aetiological factors involved are thought to be sudden hyperextension, forced flexion and crushing, while intra-tendinous pathology, congenital abnormalities, fractures, and chronic synovitis may result in atraumatic ruptures (Boyes et al, 1960). From the history, the cause of rupture in the above case would appear to be strong flexion against a force trying to extend the finger. Nine of the reported cases were treated by excision of the tendon and secondary reconstruction by tendon grafting (Boyes et al, 1960; Folmar et al, 1972; Lanzetta and Conolly, 1992). One case was treated by amputation because of persistent joint stiffness (Boyes et al, 1960). In our patient, we felt that primary repair of the avulsions was justified because of early detection and preservation of the vinculum longum, and hence the nutritional supply to the tendon. This has the advantage of a single operation, leading to earlier return to work. We are uncertain of the cause of the reduction in grip strength between the 3- and 6-month assessment. However, as the patient has no functional deficit at 3 months after surgery, he was discharged from physiotherapy and may have discontinued his own strengthening excercises, resulting in this reduction. Although more cases treated in the same manner with a longer follow-up would be needed before any conclusions can be drawn, primary repair of the avulsed tendons is an alternative to excision and delayed tendon grafting. References BOYES, J. H., V([LSON, J. N. and SMITH, J. W. (1960). Flexor-tendon ruptures in the forearm and hand. Journal of Bone and Joint Surgery, 42A: 4: 637-646. FOLMAR, R. C., NELSON, C. L. and PHALEN, G. S. (1972). Ruptures of the flexor tendons in hands of non-rheumatoid patients. Journal of Bone and Joint Surgery, 54A: 3: 579-584. LANZETTA, M. and CONOLLY, W. B., (1992). Closed rupture of both flexor tendons in the same digit. Journal of Hand Surgery, 17B: 4: 479-480. Accepted: 17 August 1994 Dr K. M. C. Cheung, FRCS. Department of Orthopaedic Surgery, Queen Mary Hospital, Pokfulam Road, Hong Kong. © 1995 The British Societyfor Surgery of the Hand