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Closed rupture of both flexor tendons in the same digit
CLOSED
RUPTURE
OF BOTH FLEXOR SAME DIGIT
TENDONS
IN THE
M. LANZETTA and W. B. CONOLLY From the Sydney Hospital Hand Unit, Australia
Closed ruptures of both normal flexor tendons in the same finger are extremely rare, only nine cases having been reported in the literature. We describe the case of a patient who sustained a closed rupture of both flexor digitorum profundns and flexor digitorum superficialis of the ring finger, following a forced hyperextension injury. The patient was treated by a two stage reconstruction of the flexor digitorum profundus. He regained full flexion and extension of the finger. Journal of Hand Surgery (British Volume, 1992) 17B : 479-480 of the ring finger joints. Examination revealed a tender mass in the palm over the axis of the fourth metacarpal (Fig. 1). X-rays did not show any flecks of bone avulsed from the distal or middle phalanges. No previous injury had occured. Three days after the injury the finger was explored. The operative findings were avulsion of the flexor digitorum profundus from the distal phalanx and avulsion of the flexor digitorum superficialis from its insertion at the middle phalanx. The vincula longa and brevia were completely ruptured, as was the lumbrical attachment of the flexor digitorum profundus, allowing the avulsed ends to retract to the mid-palm. The A2 pulley was found to be stretched and partially ruptured, indicating the severe grade of trauma sustained. The A2 pulley was reconstructed, the tendons resected to the carpal tunnel area and a silastic rod was placed in the flexor tendon sheath. Nine weeks after the operation the patient underwent the second stage of the flexor tendon grafting procedure, and the left plantaris tendon was placed in the ring finger. Full extension and flexion of the ring finger were gradually regained and the patient resumed heavy work as a mechanic four months after the second operation (Figs. 2 and 3).
Although there have been many cases of closed rupture of flexor digitorum profundus alone, only nine cases of simultaneous closed rupture of both flexors tendons in the same finger have been reported, by Boyes et al in 1960 (eight cases) and Flomar et al in 1972 (one case). In Boyes' series, five cases were due to hyperextension of the finger and three to forced flexion, whereas Folmar reported his case as an "atraumatic rupture".
Case report A 28-year-old mechanic presented with a history of trauma to his dominant right hand. At the time of the injury, the patient was working on a car engine suspended over his head. His right hand was placed in a very narrow space, with the dorsum lying on a flat surface and the palmar aspect in contact with part of the engine. The wrist was held supported in a neutral position and could neither flex nor extend. The fingers were grasping a part of the engine with the metacarpophalangeal joints fully flexed. The engine suddenly slipped away extending the ring finger, and causing the injury to the flexor tendons of that finger. He complained of light pain and inability to flex any
Fig. 1 Patient with avulsion of flexor digitorum profundus and superficialis of the right ring finger. The patient was unable to flex the ring finger at any of its joints. In the mid-palm along the axis of the fourth metacarpal is a tender mass.
Fig. 2
479
Intra-operative appearance of rupture of both flexor tendons. FDS is shown with its decussation, and F D P is held in a loop.
480
T H E J O U R N A L O F H A N D S U R G E R Y VOL. 17B No. 4 A U G U S T 1992
Fig. 3 Four months after the second stage of the tendon grafting procedure, the patient has regained (a) full extension and (b) full flexion of the ring finger.
References BOYES, J. H., WILSON, 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 P H A L E N , G. S. (1972). Ruptures of the flexor tendons in hands of non-rheumatoid patients. Journal of Bone and Joint Surgery, 54A :3:579-584.
Accepted: 27 February 1992 W. B. Conolly, Sydney Hospital Hand Unit, Macquarie Street, Sydney 2000, Australia. 9 1992The British Society for Surgery of the Hand
RUPTURE
OF BOTH FLEXOR SAME DIGIT
TENDONS
IN THE
M. LANZETTA and W. B. CONOLLY From the Sydney Hospital Hand Unit, Australia
Closed ruptures of both normal flexor tendons in the same finger are extremely rare, only nine cases having been reported in the literature. We describe the case of a patient who sustained a closed rupture of both flexor digitorum profundns and flexor digitorum superficialis of the ring finger, following a forced hyperextension injury. The patient was treated by a two stage reconstruction of the flexor digitorum profundus. He regained full flexion and extension of the finger. Journal of Hand Surgery (British Volume, 1992) 17B : 479-480 of the ring finger joints. Examination revealed a tender mass in the palm over the axis of the fourth metacarpal (Fig. 1). X-rays did not show any flecks of bone avulsed from the distal or middle phalanges. No previous injury had occured. Three days after the injury the finger was explored. The operative findings were avulsion of the flexor digitorum profundus from the distal phalanx and avulsion of the flexor digitorum superficialis from its insertion at the middle phalanx. The vincula longa and brevia were completely ruptured, as was the lumbrical attachment of the flexor digitorum profundus, allowing the avulsed ends to retract to the mid-palm. The A2 pulley was found to be stretched and partially ruptured, indicating the severe grade of trauma sustained. The A2 pulley was reconstructed, the tendons resected to the carpal tunnel area and a silastic rod was placed in the flexor tendon sheath. Nine weeks after the operation the patient underwent the second stage of the flexor tendon grafting procedure, and the left plantaris tendon was placed in the ring finger. Full extension and flexion of the ring finger were gradually regained and the patient resumed heavy work as a mechanic four months after the second operation (Figs. 2 and 3).
Although there have been many cases of closed rupture of flexor digitorum profundus alone, only nine cases of simultaneous closed rupture of both flexors tendons in the same finger have been reported, by Boyes et al in 1960 (eight cases) and Flomar et al in 1972 (one case). In Boyes' series, five cases were due to hyperextension of the finger and three to forced flexion, whereas Folmar reported his case as an "atraumatic rupture".
Case report A 28-year-old mechanic presented with a history of trauma to his dominant right hand. At the time of the injury, the patient was working on a car engine suspended over his head. His right hand was placed in a very narrow space, with the dorsum lying on a flat surface and the palmar aspect in contact with part of the engine. The wrist was held supported in a neutral position and could neither flex nor extend. The fingers were grasping a part of the engine with the metacarpophalangeal joints fully flexed. The engine suddenly slipped away extending the ring finger, and causing the injury to the flexor tendons of that finger. He complained of light pain and inability to flex any
Fig. 1 Patient with avulsion of flexor digitorum profundus and superficialis of the right ring finger. The patient was unable to flex the ring finger at any of its joints. In the mid-palm along the axis of the fourth metacarpal is a tender mass.
Fig. 2
479
Intra-operative appearance of rupture of both flexor tendons. FDS is shown with its decussation, and F D P is held in a loop.
480
T H E J O U R N A L O F H A N D S U R G E R Y VOL. 17B No. 4 A U G U S T 1992
Fig. 3 Four months after the second stage of the tendon grafting procedure, the patient has regained (a) full extension and (b) full flexion of the ring finger.
References BOYES, J. H., WILSON, 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 P H A L E N , G. S. (1972). Ruptures of the flexor tendons in hands of non-rheumatoid patients. Journal of Bone and Joint Surgery, 54A :3:579-584.
Accepted: 27 February 1992 W. B. Conolly, Sydney Hospital Hand Unit, Macquarie Street, Sydney 2000, Australia. 9 1992The British Society for Surgery of the Hand