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Flexor digitorum profundus avulsion through enchondroma
Flexor Digitorum
Profundus
Avulsion through Enchondroma
A. I. FROIMSON and L. SHALL From the Mount Sinai Medical Center, Cleveland, Ohio 44106 A flexor digitorum profundus tendon avulsion occurring at the site of a pathological fracture through an enchondroma is reported. The avulsion appears to he the result of direct trauma crush to the distal phalanx of the little finger. The lesion was curetted and grafted using autogenous hone, the fracture was stabilized with a K-wire and the tendon was advanced and secured using Bunnell pullout wire technique. The lesion healed and function was restored.
A thirty-two year old right handed housewife was seen several hours after an injury to her right little finger which occurred while sailing. While attempting to release a rope, her little finger became wedged between the rope and the winch. Pain immediately ensued followed by numbness. Examination the same day revealed inability to flex her right little finger interphalangeal joints with pain and tenderness over the base of the proximal phalanx. The skin and neurovascular functions were intact. X-rays (Figs. 1 and 2) demonstrated a translucent lesion at the base of the distal phalanx, 7 mm. in diameter, with thinned cortex and speckled calcifications within the lesion. The cortex was interrupted on the volar side and a small fragment of bone was seen lying volar to the middle phalanx at the level of the head 5 mm. proximal to the distal interphalangeal joint. Five days after the injury, under local anaesthetic through a radial mid-axial incision on the little finger, curettage and grafting of the distal phalanx was performed using bone from the distal radius. A complete transverse fracture through the lesion was evident, although this was not clearly seen in the preoperative x-rays. Internal fixation of the fracture was obtained with a K-wire. Reattachment of the tendon was by advancement and Bunnell pullout wire technique. A compressive bandage with a splint was applied to the hand with the fingers in the functional position. The pathological diagnosis of the specimen was: ‘Enchondroma fragments, and adjacent tendon with acute inflammation’. At follow up eleven weeks post-operatively, complete healing of the distal phalanx was noted on x-ray. The interphalangeal joints each lacked ten degrees of flexion, but the range of motion was acceptable and strong. The patient returned to playing the piano, and had no further complaints concerning her finger. Received for Publication November 1983 A. I. Froimson M.D. Mount Sinai Medical Center 1800 E. 105 Ave. Cleveland. Ohio 44106 Larry Shall, M.D. Mount Sinai Medical Center 1800 E. 105 Ave. Cleveland, Ohio 44106 VOL. 9-B No. 3 OCTOBER
1984
Fig. 1 Pre-operative x-rays of the right little finger. AP showing the translucent lesion of the distal phalanx with thinned cortices and speckled calcifications within.
Discussion
A review of the literature reveals this injury to be once previously reported. Boyes (1960) reported on eighty flexor tendon ruptures, most of which occurred from indirect trauma (unexpected digital hyperextension during maximal flexion) but occasionally occurring from direct trauma, commonly a crush injury. There were no reported cases where tumour was involved. Carroll (1970) reported on thirty-five cases of flexor profundus tendon ruptures and again no cases of pathological fracture of tumour were reported. Ogunro (1983) reported the first such case of tendon avulsion as a complication of a pathological fracture through enchondroma. This is the second report of such a case, which was treated in a similar manner. 343
A. I. FROIMSON
AND
L. SHALL
Enchondromas involving the bones of the hand most commonly involve the proximal phalanges followed by the metacarpals. Lesions of the distal phalanges were relatively uncommon. The mechanism of this very uncommon injury is similar to other tendon ruptures from direct trauma, however the force required to produce the injury was probably greatly reduced. References
Fig. 2 Lateral view showing the avulsed portion volar cortex.
344
of bone from the
ALWNEH, I., GIOANINI, A., WILLMEN, H.R., PETERS, H., KljHNELT, F. and SCHUBERT, H. .I. (1977). Endochondroma of the Hand. International Surgery, 62: 218.219. BOYES, .I. H., WILSON, J. N. and SMITH, J. W. (1960). Flexor-Tendon Ruptures in the Forearm and Hand. The Journal of Bone and Joint Surgery, 42A: 637.646. CARROLL, R. E. and MATCH, R. M. (1970). Avulsion of the Flexor Profundus Tendon Insertion. The Journal of Trauma, 10: 1109-l 118. CROSBY, E. B. and LINSCHEID, R. L. (1974). Rupture of the Flexor Profundus Tendon of the Ring Finger Secondary to Ancient Fracture of the Hook of the Hamate. Review of the Literature and Report of Two Cases. The Journal of Bone and Joint Surgery, 56A: 1076-1078. FOLMAR, R. C. NELSON, C. L. and PHALEN G. S. (1972). Ruptures of the Flexor Tendons in Hands of Non-Rheumatoid Patients. The Journal of Bone and Joint Surgery, 54A: 579-584. NOBLE J. and LAMB, D. W. (1974) Enchondromata of Bones of the Hand. A Review of 40 Cases. The Hand, 6: 275-284 OGUNRO, 0. (1983). Avulsion of flexor profundus, secondary to enchondroma of the distal phalanx. The Journal of Hand Surgery, 8: 315-316. TAKIGAWA, K. (1971). Chondroma of the Bones of the Hand. A Review of 110 Cases. The Journal of Bone and Joint Surgery, 53A: 1591-1600.
THE JOURNAL
OF HAND
SURGERY
Profundus
Avulsion through Enchondroma
A. I. FROIMSON and L. SHALL From the Mount Sinai Medical Center, Cleveland, Ohio 44106 A flexor digitorum profundus tendon avulsion occurring at the site of a pathological fracture through an enchondroma is reported. The avulsion appears to he the result of direct trauma crush to the distal phalanx of the little finger. The lesion was curetted and grafted using autogenous hone, the fracture was stabilized with a K-wire and the tendon was advanced and secured using Bunnell pullout wire technique. The lesion healed and function was restored.
A thirty-two year old right handed housewife was seen several hours after an injury to her right little finger which occurred while sailing. While attempting to release a rope, her little finger became wedged between the rope and the winch. Pain immediately ensued followed by numbness. Examination the same day revealed inability to flex her right little finger interphalangeal joints with pain and tenderness over the base of the proximal phalanx. The skin and neurovascular functions were intact. X-rays (Figs. 1 and 2) demonstrated a translucent lesion at the base of the distal phalanx, 7 mm. in diameter, with thinned cortex and speckled calcifications within the lesion. The cortex was interrupted on the volar side and a small fragment of bone was seen lying volar to the middle phalanx at the level of the head 5 mm. proximal to the distal interphalangeal joint. Five days after the injury, under local anaesthetic through a radial mid-axial incision on the little finger, curettage and grafting of the distal phalanx was performed using bone from the distal radius. A complete transverse fracture through the lesion was evident, although this was not clearly seen in the preoperative x-rays. Internal fixation of the fracture was obtained with a K-wire. Reattachment of the tendon was by advancement and Bunnell pullout wire technique. A compressive bandage with a splint was applied to the hand with the fingers in the functional position. The pathological diagnosis of the specimen was: ‘Enchondroma fragments, and adjacent tendon with acute inflammation’. At follow up eleven weeks post-operatively, complete healing of the distal phalanx was noted on x-ray. The interphalangeal joints each lacked ten degrees of flexion, but the range of motion was acceptable and strong. The patient returned to playing the piano, and had no further complaints concerning her finger. Received for Publication November 1983 A. I. Froimson M.D. Mount Sinai Medical Center 1800 E. 105 Ave. Cleveland. Ohio 44106 Larry Shall, M.D. Mount Sinai Medical Center 1800 E. 105 Ave. Cleveland, Ohio 44106 VOL. 9-B No. 3 OCTOBER
1984
Fig. 1 Pre-operative x-rays of the right little finger. AP showing the translucent lesion of the distal phalanx with thinned cortices and speckled calcifications within.
Discussion
A review of the literature reveals this injury to be once previously reported. Boyes (1960) reported on eighty flexor tendon ruptures, most of which occurred from indirect trauma (unexpected digital hyperextension during maximal flexion) but occasionally occurring from direct trauma, commonly a crush injury. There were no reported cases where tumour was involved. Carroll (1970) reported on thirty-five cases of flexor profundus tendon ruptures and again no cases of pathological fracture of tumour were reported. Ogunro (1983) reported the first such case of tendon avulsion as a complication of a pathological fracture through enchondroma. This is the second report of such a case, which was treated in a similar manner. 343
A. I. FROIMSON
AND
L. SHALL
Enchondromas involving the bones of the hand most commonly involve the proximal phalanges followed by the metacarpals. Lesions of the distal phalanges were relatively uncommon. The mechanism of this very uncommon injury is similar to other tendon ruptures from direct trauma, however the force required to produce the injury was probably greatly reduced. References
Fig. 2 Lateral view showing the avulsed portion volar cortex.
344
of bone from the
ALWNEH, I., GIOANINI, A., WILLMEN, H.R., PETERS, H., KljHNELT, F. and SCHUBERT, H. .I. (1977). Endochondroma of the Hand. International Surgery, 62: 218.219. BOYES, .I. H., WILSON, J. N. and SMITH, J. W. (1960). Flexor-Tendon Ruptures in the Forearm and Hand. The Journal of Bone and Joint Surgery, 42A: 637.646. CARROLL, R. E. and MATCH, R. M. (1970). Avulsion of the Flexor Profundus Tendon Insertion. The Journal of Trauma, 10: 1109-l 118. CROSBY, E. B. and LINSCHEID, R. L. (1974). Rupture of the Flexor Profundus Tendon of the Ring Finger Secondary to Ancient Fracture of the Hook of the Hamate. Review of the Literature and Report of Two Cases. The Journal of Bone and Joint Surgery, 56A: 1076-1078. FOLMAR, R. C. NELSON, C. L. and PHALEN G. S. (1972). Ruptures of the Flexor Tendons in Hands of Non-Rheumatoid Patients. The Journal of Bone and Joint Surgery, 54A: 579-584. NOBLE J. and LAMB, D. W. (1974) Enchondromata of Bones of the Hand. A Review of 40 Cases. The Hand, 6: 275-284 OGUNRO, 0. (1983). Avulsion of flexor profundus, secondary to enchondroma of the distal phalanx. The Journal of Hand Surgery, 8: 315-316. TAKIGAWA, K. (1971). Chondroma of the Bones of the Hand. A Review of 110 Cases. The Journal of Bone and Joint Surgery, 53A: 1591-1600.
THE JOURNAL
OF HAND
SURGERY