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Profundus tendon blockage: Quadriga in finger amputations
The Journal of HAND SURGERY
Carr and Davis
of dorsal wrist ganglion pain. J HAND SURG 3:326-32,
1978 4. Lister GD, Belsole RB, Kleinert HE: The radial tunnel syndrome. J HAND SURG 4:52-9, 1979 5. Spinner M: Injuries to the major branches of peripheral nerves of the forearm. Philadelphia, 1978, WB Saunders Co 6. Daniell W: Fusiform swellings on the terminal portions of peripheral nerves. J Neuropathol Exp Neurol 13:46775, 1954
7. Sunderland S, Bradley KC: The perineurium of peripheral nerves. Anat Rec 113:125,1952 8. Buck-Gramcko D: Denervation of the wrist joint. J HAND SURG 2:54-61, 1977 9. Wilhelm A: Zur Innervation der Gelenke der Oberen Extremitat. Z Anat Entwicklungsgesch 120:331-71, 1958 10. Wilhelm A: Die Gelenkdenervation und ihre anatomischen Grundlagen, Ein neves Behandlungsprinzip in der Handchirurgie. Heft Unfallheilkd 86:1-109, 1966
Profundus tendon blockage: Quadriga in finger amputations After finger amputations, spontaneous adhesions of the resected profundus tendon may occur in the finger stump or palm. Because of the normal interconnections of the profundus tendons, such adhesions can block the excursion of the profundus tendons to intact fingers, resulting in the quadriga syndrome, or profundus tendon blockage. This causes a decrease in the power and range of movement of the terminal joints of the uninjured fingers when they are fully flexed. Three degrees of severity of this weakness are described. The findings and results of surgery in 20 patients demonstrate that the condition is surgically correctable by release of the adherent profundus tendon of the amputated digit. Full active flexion and extension of the intact fingers in the early postoperative period after primary amputation should prevent them from developing profundus tendon blockage. (J HAND SURG 10A:878-83, 1985.)
B. R. Neu, M.D., F.R.C.S.(C), J. F. Murray, M.D., F.R.C.S.(C), and J. K. MacKenzie, M.D., Toronto, Ont., Canada
Claude Verdan I has coined the term "syndrome of quadriga" to describe the profundus tendon imbalance that occurs when this tendon is advanced and sewn to the extensor over the end of an amputation stump. He drew an analogy of the condition to that of a Roman charioteer guiding four horses with interconnected reins. Restrictive excursion through one rein (or profundus tendon) limits the excursion of the other three. Verdan later noted that spontaneous adhesions or From the Sunnybrook Medical Centre, Toronto, Ont., Canada. Presented at the Annual Meeting of the American Society for Surgery of the Hand, Atlanta, Ga., February 1984. Received for publication May 2, 1984; accepted in revised form Jan. 31, 1985. Reprint requests: James F. Murray. M.D .. Sunnybrook Medical Centre. 2075 Bayview Ave., Toronto, Ont.. Canada M4N 3M5.
878
THE JOURNAL OF HAND SURGERY
"blocage" of the resected profundus tendon of an amputated finger could result in a quadriga syndrome or "pseudoblocage" of the profundi in adjacent intact fingers.2 We have taken the liberty of using the English term "blockage" to describe the effect on the adjacent digits. The literature and most hand surgery texts advise against sewing the deep flexor and extensor tendons together over the end of a finger amputation ,3 8 but only Verdan 2 and Stack9 note the imbalance in function that can occur from spontaneous adhesions of the profundus in finger amputations (Fig. I). In this article, the relevant anatomy of the profundus muscle and its tendons are reviewed, the clinical manifestations of profundus tendon blockage (PTB) are described, and the severity of blockage is graded. The operative findings and the results of surgery to correct the condition in 20 consecutive patients are reported. 0
Vol. lOA, No.6. Part 1 November 1985
Profundus tendon blockage
879
=:==t;t-
-=-_--:----1.,(1'--1
I;
Fig. 1. Diagram of the quadriga syndrome or profundus tendon blockage from spontaneous adhesions of the resected profundus tendon of the amputated ring finger. The tethering effect is transmitted to the profundi of the intact fingers.
Anatomy The basis for PTB lies in the anatomy of the muscle and its tendons. The common origin arises from the flexor aspect of the ulna and the interosseous membrane, separating into two muscle bellies. The larger ulnar mass moves the ulnar three digits and the smaller radial part the index finger. This separation continues in the distal forearm and carpal tunnel where an ulnar sheet of tendons is distinct from that to the index finger. The sheet consists of seven to 12 tendon units, clearly linked together before forming the three definitive tendons (Fig. 2, A). The ulnar tendons are also joined at the base of the palm by the origins of the third and fourth lumbrical muscles (Fig. 2, B). Independence of the profundus tendon to the index finger is lost through the tenacious synovium at the level of the carpal tunnel, called by Fahrer lO the' 'fibromembranous retinaculum," which envelopes all the profundi and attaches them to the sides and floor of the carpal tunnel (Fig. 2, C). Clinical manifestations of blockage The interconnections of the profundi are easily found in the normal hand when the ring finger is held extended, and full flexion of the other fingers (including the index) is impaired (Fig. 3). The tethered profundus tendon of the ring finger blocks the excursion of the profundus tendons to the other digits. The finger amputee with PTB complains of decreased strength in the intact fingers when gripping or holding small-handled objects such as a hammer, screwdriver, or knife handle. Strong and repetitive flexion of these fingers may cause a cramping type of pain over the front of the wrist and forearm. An examination reveals that there is full flexion and good power to the distal interphalangeal joints of the intact fingers when the
Fig. 2. A, The profundus tendons in the lower forearm and carpal tunnel region, and the proximal origin of the lumbrical muscles. The profundus to the index finger is separate from the sheet of tendons to the ulnar three fingers. Note the interconnections between the ulnar three tendons. B, The origin of the lumbrical muscles of the profundus tendons at the base of the palm. The third and fourth lumbricals unite the ulnar three profundi. C, The fibromembranous synovium uniting all four profundi tendons to the floor and side walls of the carpal tunnel. Traction on the ulnar three profundi is transmitted to the profundus tendon of the index finger.
proximal two joints are held in extension (Fig. 4, A). However, when the proximal joints are flexed, the power in the terminal joint is reduced, and flexion is often decreased (Fig. 4, B). Three grades of severity
880
Neu. Murray. alld MacKellZie
The Journal of HAND SURGERY
Fig. 3. The ring finger is held in extension. Blockage occurs in the remaining fingers, including the index finger, resulting in little or no flexion of the terminal phalanges. Forced or repeated flexion of these fingers causes pain in the wrist and forearm.
Fig. 5. Grades I and II PTB. A, Patient with amputation of the proximal interphalangeal joint of the small finger has full flexion of the terminal phalanx of the long finger (grade I) and partial flexion of the ring finger (grade II) . B, There is decreased power in both .
Fig. 4. The clinical test for PTB . A, Excellent power and full flexion of the terminal phalanx of the intact finger when the proximal two joints are held in full extension. B, Blockage when the finger is flexed .
of blockage are recognized (Table I) (Figs. 5 and 6). It is more pronounced in those fingers next to the amputation stump. In the small finger, a grade III blockage may restrict flexion of the proximal interphalangeal joint, as well as the distal joint, because of an absent or weak superficialis tendon .
Treatment The aim of surgical treatment is to obtain full excursion of the profundus tendons to the intact normal
fingers. Most patients with grade I blockage do not require treatment, whereas many with grades II and III are candidates for an operation. The profundus tendon of the amputated finger is usually tethered in the amputation stump distal to the metacarpophalangeal (MCP) joint. It is exposed proximal to the flexor tendon sheath through a curved mid palmar incision and separated from the overlying superficial is tendon that is preserved. It is not necessary to identify the actual site of distal fixation, but it is very important to be sure that there is free play of the tendon through the carpal tunnel. If there is a restriction, the incision must be extended proximally and further adhesions completely released . The profundus tendon is transec ted near the origin of the lumbrical muscle and a segment is excised. If the amputated finger has a functioning proximal interphalangeal joint, the lumbrical to this finger is divided to avoid a lumbrical plus problem in the stump . When the profundus has retracted into the palm proximal to the MCP joint, it may be adherent on its deep surface to the fascia covering the palmar
Vol. lOA . No . 6. Part I November 1985
Profundus tendon blockage
881
Fig. 6. Grade III PTB . A, A patient with marked blockage of profundi to the intact fingers after amputation of the small finger through the base of the proximal phalanx. B, The profundus and superficialis tendons are adherent just distal to the MCP joint. C, Both tendons have been divided and separated from one another. and the profundus is being tested for normal excursion through the carpal tunnel. It is resected near the origin of the lumbrical muscle . D, Full flexion and full power restored to the terminal phalanges.
interossei. If more than one finger is amputated, the incision may have to be extended well into the proximal palm to completely free all the involved profundi. The tendons of the intact fingers showing blockage are also examined. Traction with a tendon hook is sufficient to free adhesions that may have formed between the profundus and superficialis tendons . A padded dressing must permit the fingers early and full active movement. Most patients will promptly notice the improved pull on the terminal phalanges.
Clinical material Clinical manifestations , operative findings, and the results of surgery in 20 consecutive patients are summarized in Table II. All suffered their injuries at work and were initially managed by other surgeons . Four elective amputations had been performed after failed tendon surgery. Fourteen patients had single amputations and six had multiple amputations . Fourteen had
Table I. Profundus blockage grading Grade
Dip flexion
Dip power
Full II III
Reduced
Reduced Reduced
Absent
Absent
Legend: DIP. distal interphalangeal.
grade III blockage in at least one of the intact fingers, and six had grade II; none had been recognized before attending the Hand Clinic . It was most common in the ulnar three fingers , but the index finger was involved in four cases . Surgical release of the PTB was done 3 months to 9 years after the amputation . In aU but three patients, the resected profundus tendon of the amputated finger was adherent distal to the MCP joint. Follow-up examinations were done 3 to 34 months after surgery. Blockage was completely eliminated in 17 patients . One required a second operation to release
882
The Journal of HAND SURGERY
Neu, Murray, and MacKenzie
Table II.
Patient
Sex
Injury
Amputation
Par S
Time from amputation to blockage release (mo)
Age at time of blockage release (yr)
Finger(s) blocked, grade ( )
Site of adhesions (relative to MCP joint)
Follow-up (mo)
A. I.
M
Crush
Long PIP
P
107
41
Ring (II)
Distal
9
R. M.
M
Crush
Long mid PP
P
10
57
Proximal
8
A. P.
M
Crush
Ring mid PP
P
II
69
E. D.
F
Crush
35
M
Crush
P P P P
24
H. P.
Index MCP Long MCP Small MCP Ring mid PP
Ring (III); small (III) Index (III); long (III); small (III) Ring (III)
70
30
D. D.
M
Saw cut
Index mid PP
P
11
H. B.
M
Saw cut
P
A. C.
M
Crush
Index mid PP Long mid PP Ring mid PP Long PIP
D. H.
M
Saw cut
D.M.
M
Saw cut
M.R.
M
Crush
D. C.
M
Paint injection
Comment/ results Complete release Complete release Complete release
Distal
34
Distal
12
No improvement Complete release Complete release Complete release
Proximal
6
22
Long (III); small (II) Ring (II)
Distal
8
7
30
Small (III)
Distal
7
P
19
51
Distal
8
Small DIP
P
3
45
Index (I); ring (II) Ring (II)
Distal
3
Long mid PP Ring mid PP Small MCP
P P P
7
20
Small (III)
Distal
6
18
38
Distal
8
Ring MCP
P
24
24
Long (III); ring (III) Index (III); long (III); small (III)
Proximal
30
Complete release Partial release; blockage (I) Complete release Complete release Complete release
Legend: P, primary; S, secondary; PIP. proximal interphalangeal. PP, proximal phalanx; Mep, metacarpal phalangeal joint; DIP. distal interphalangeal; MP, middle phalanx.
adhesions in the carpal tunnel that had been missed. Two patients were improved, but still had grade I blockage, and one patient had no improvement and declined further surgery. Discussion Amputation of one or more fingers is a common cause of permanent disability in people with work-related hand injuries. The patient's complaint of decreased grip strength is expected and is reasonably attributed to the anatomic loss. Frequently overlooked, however, is the loss of strength in the intact fingers due to PTB. The relationship of a cramping forearm or wrist pain to PTB is also not appreciated. We feel this pain is due to stretching of the carpal tunnel synovium or a shearing stress between the fixed and moving components of the muscle origin.
Patients with failed tendon surgery or an old injury that results in a stiff, extended finger should be carefully checked for PTB before elective amputation. Adhesions of the profundus tendon in the damaged fingers will usually extend throughout most of the fibroosseus tunnel. This blockage must be released at the time of the elective amputation. After a primary finger amputation, the resected profundus tendon retracts and tends to develop adhesions. Early active, full flexion of the intact fingers immediately after surgery will prevent the tendon from becoming adherent where it can cause blockage. Both the patient and the surgeon may contribute to a delay in early finger movement. Many of these injuries are anatomically mutilating and psychologically upsetting, and some patients are reluctant to look at the injured hand, let alone move the fingers. An overly sympathetic
Vol. lOA. No.6, Part 1 November 1985
Profundus tendon blockage
883
Table II-coot'd ..
P or
S
Amputation
Time from amputation to blockage release (mo)
Age at time of blockage release (yr)
Patient
Sex
Injury
O. H.
M
Failed tendon
Small DIP
S
13
57
C. A.
M
Crush
Ring MCP
P
14
A . T.
M
Crush
Small PIP
P
W.H.
M
Crush
Ring mid MP
M. B.
M
Failed tendon repair
T. L.
M
A. R.
M
Failed tendon repair Crush
W. F.
F
Failed tendon repair
Site of adhesions (relative to MCP joint)
Finger(s) blocked, grade ( )
Follow-up (mo)
Distal
4
24
Long (II) ; ring (II) Small (III)
Distal
23
15
55
Ring (III)
Distal
3
P
9
21
Long (III)
Distal
12
Small PIP
S
3 41
20 23
Long (II); ring (II)
Distal
12
Ring PIP
S
18
37
Distal
21
Index mid MP Long mid PP Ring MCP
P
9
43
Long (III); small (III) Ring (II)
Distal
7
S
15
48
Index (II)
Distal
18
Comment/ results Complete release Complete release Complete release Complete release Two operations, complete release Complete release Complete release Partial release blockage (I)
Summary Crush 11 Saw cut 4 Failed Tendon 4 repair Paint injection
Index Long Ring Small
4 8 9 7
P 16
S
Average 21
4
surgeon may also try to keep them physically and emotionally comfortable in a splinted, bulky dressing. The support and supervision of exercises by the hand therapist during the early rehabilitation phase of treatment is invaluable.
REFERENCES I. Verdan C: Syndrome of the quadriga. Surg Clin North Am 40:425-6, 1960 2. Verdan C: In Flynn JE, editor: Hand surgery, ed 1. Baltimore. 1966, The Williams & Wilkins Co, p 225 3. Beasley RW: Hand injuries. Philadelphia, 1981, WB Saunders Co, p 351 4. Flatt AE: The care of minor hand injuries. St. Louis, 1979, The CV Mosby Co, p 166
Average 38
Index Long Ring
4 9 II
Distal 17 Proximal 3
Average II
Complete 17 release Partial 2 release No improvement
5. Lister G: The hand-diagnosis and indications. Edinburgh, 1977, Churchill Livingstone, p 55 6. Littler, JW: In Converse JD, editor: Reconstructive plastic surgery, ed 2, vol6 . Philadelphia, 1977, WB Saunders Co , p 3145 7. Rank BK, Wakefield AR, Hueston 11: Surgery of repair as applied to hand injuries. Edinburgh, 1973, Churchill Livingston, p 38 8. Weckesser EC: Treatment of hand injuries. Chicago, 1974, Year Book Medical Publishers, p 118 9. Stack HG: In Rob C, Smith R: Operative surgery, ed 3. London, 1970, Butterworth Publishers, p 354 10. Fahrer M: In Verdan C, editor: Tendon surgery of the hand. Edinburgh, 1979, Churchill Livingstone, pp 1724
Carr and Davis
of dorsal wrist ganglion pain. J HAND SURG 3:326-32,
1978 4. Lister GD, Belsole RB, Kleinert HE: The radial tunnel syndrome. J HAND SURG 4:52-9, 1979 5. Spinner M: Injuries to the major branches of peripheral nerves of the forearm. Philadelphia, 1978, WB Saunders Co 6. Daniell W: Fusiform swellings on the terminal portions of peripheral nerves. J Neuropathol Exp Neurol 13:46775, 1954
7. Sunderland S, Bradley KC: The perineurium of peripheral nerves. Anat Rec 113:125,1952 8. Buck-Gramcko D: Denervation of the wrist joint. J HAND SURG 2:54-61, 1977 9. Wilhelm A: Zur Innervation der Gelenke der Oberen Extremitat. Z Anat Entwicklungsgesch 120:331-71, 1958 10. Wilhelm A: Die Gelenkdenervation und ihre anatomischen Grundlagen, Ein neves Behandlungsprinzip in der Handchirurgie. Heft Unfallheilkd 86:1-109, 1966
Profundus tendon blockage: Quadriga in finger amputations After finger amputations, spontaneous adhesions of the resected profundus tendon may occur in the finger stump or palm. Because of the normal interconnections of the profundus tendons, such adhesions can block the excursion of the profundus tendons to intact fingers, resulting in the quadriga syndrome, or profundus tendon blockage. This causes a decrease in the power and range of movement of the terminal joints of the uninjured fingers when they are fully flexed. Three degrees of severity of this weakness are described. The findings and results of surgery in 20 patients demonstrate that the condition is surgically correctable by release of the adherent profundus tendon of the amputated digit. Full active flexion and extension of the intact fingers in the early postoperative period after primary amputation should prevent them from developing profundus tendon blockage. (J HAND SURG 10A:878-83, 1985.)
B. R. Neu, M.D., F.R.C.S.(C), J. F. Murray, M.D., F.R.C.S.(C), and J. K. MacKenzie, M.D., Toronto, Ont., Canada
Claude Verdan I has coined the term "syndrome of quadriga" to describe the profundus tendon imbalance that occurs when this tendon is advanced and sewn to the extensor over the end of an amputation stump. He drew an analogy of the condition to that of a Roman charioteer guiding four horses with interconnected reins. Restrictive excursion through one rein (or profundus tendon) limits the excursion of the other three. Verdan later noted that spontaneous adhesions or From the Sunnybrook Medical Centre, Toronto, Ont., Canada. Presented at the Annual Meeting of the American Society for Surgery of the Hand, Atlanta, Ga., February 1984. Received for publication May 2, 1984; accepted in revised form Jan. 31, 1985. Reprint requests: James F. Murray. M.D .. Sunnybrook Medical Centre. 2075 Bayview Ave., Toronto, Ont.. Canada M4N 3M5.
878
THE JOURNAL OF HAND SURGERY
"blocage" of the resected profundus tendon of an amputated finger could result in a quadriga syndrome or "pseudoblocage" of the profundi in adjacent intact fingers.2 We have taken the liberty of using the English term "blockage" to describe the effect on the adjacent digits. The literature and most hand surgery texts advise against sewing the deep flexor and extensor tendons together over the end of a finger amputation ,3 8 but only Verdan 2 and Stack9 note the imbalance in function that can occur from spontaneous adhesions of the profundus in finger amputations (Fig. I). In this article, the relevant anatomy of the profundus muscle and its tendons are reviewed, the clinical manifestations of profundus tendon blockage (PTB) are described, and the severity of blockage is graded. The operative findings and the results of surgery to correct the condition in 20 consecutive patients are reported. 0
Vol. lOA, No.6. Part 1 November 1985
Profundus tendon blockage
879
=:==t;t-
-=-_--:----1.,(1'--1
I;
Fig. 1. Diagram of the quadriga syndrome or profundus tendon blockage from spontaneous adhesions of the resected profundus tendon of the amputated ring finger. The tethering effect is transmitted to the profundi of the intact fingers.
Anatomy The basis for PTB lies in the anatomy of the muscle and its tendons. The common origin arises from the flexor aspect of the ulna and the interosseous membrane, separating into two muscle bellies. The larger ulnar mass moves the ulnar three digits and the smaller radial part the index finger. This separation continues in the distal forearm and carpal tunnel where an ulnar sheet of tendons is distinct from that to the index finger. The sheet consists of seven to 12 tendon units, clearly linked together before forming the three definitive tendons (Fig. 2, A). The ulnar tendons are also joined at the base of the palm by the origins of the third and fourth lumbrical muscles (Fig. 2, B). Independence of the profundus tendon to the index finger is lost through the tenacious synovium at the level of the carpal tunnel, called by Fahrer lO the' 'fibromembranous retinaculum," which envelopes all the profundi and attaches them to the sides and floor of the carpal tunnel (Fig. 2, C). Clinical manifestations of blockage The interconnections of the profundi are easily found in the normal hand when the ring finger is held extended, and full flexion of the other fingers (including the index) is impaired (Fig. 3). The tethered profundus tendon of the ring finger blocks the excursion of the profundus tendons to the other digits. The finger amputee with PTB complains of decreased strength in the intact fingers when gripping or holding small-handled objects such as a hammer, screwdriver, or knife handle. Strong and repetitive flexion of these fingers may cause a cramping type of pain over the front of the wrist and forearm. An examination reveals that there is full flexion and good power to the distal interphalangeal joints of the intact fingers when the
Fig. 2. A, The profundus tendons in the lower forearm and carpal tunnel region, and the proximal origin of the lumbrical muscles. The profundus to the index finger is separate from the sheet of tendons to the ulnar three fingers. Note the interconnections between the ulnar three tendons. B, The origin of the lumbrical muscles of the profundus tendons at the base of the palm. The third and fourth lumbricals unite the ulnar three profundi. C, The fibromembranous synovium uniting all four profundi tendons to the floor and side walls of the carpal tunnel. Traction on the ulnar three profundi is transmitted to the profundus tendon of the index finger.
proximal two joints are held in extension (Fig. 4, A). However, when the proximal joints are flexed, the power in the terminal joint is reduced, and flexion is often decreased (Fig. 4, B). Three grades of severity
880
Neu. Murray. alld MacKellZie
The Journal of HAND SURGERY
Fig. 3. The ring finger is held in extension. Blockage occurs in the remaining fingers, including the index finger, resulting in little or no flexion of the terminal phalanges. Forced or repeated flexion of these fingers causes pain in the wrist and forearm.
Fig. 5. Grades I and II PTB. A, Patient with amputation of the proximal interphalangeal joint of the small finger has full flexion of the terminal phalanx of the long finger (grade I) and partial flexion of the ring finger (grade II) . B, There is decreased power in both .
Fig. 4. The clinical test for PTB . A, Excellent power and full flexion of the terminal phalanx of the intact finger when the proximal two joints are held in full extension. B, Blockage when the finger is flexed .
of blockage are recognized (Table I) (Figs. 5 and 6). It is more pronounced in those fingers next to the amputation stump. In the small finger, a grade III blockage may restrict flexion of the proximal interphalangeal joint, as well as the distal joint, because of an absent or weak superficialis tendon .
Treatment The aim of surgical treatment is to obtain full excursion of the profundus tendons to the intact normal
fingers. Most patients with grade I blockage do not require treatment, whereas many with grades II and III are candidates for an operation. The profundus tendon of the amputated finger is usually tethered in the amputation stump distal to the metacarpophalangeal (MCP) joint. It is exposed proximal to the flexor tendon sheath through a curved mid palmar incision and separated from the overlying superficial is tendon that is preserved. It is not necessary to identify the actual site of distal fixation, but it is very important to be sure that there is free play of the tendon through the carpal tunnel. If there is a restriction, the incision must be extended proximally and further adhesions completely released . The profundus tendon is transec ted near the origin of the lumbrical muscle and a segment is excised. If the amputated finger has a functioning proximal interphalangeal joint, the lumbrical to this finger is divided to avoid a lumbrical plus problem in the stump . When the profundus has retracted into the palm proximal to the MCP joint, it may be adherent on its deep surface to the fascia covering the palmar
Vol. lOA . No . 6. Part I November 1985
Profundus tendon blockage
881
Fig. 6. Grade III PTB . A, A patient with marked blockage of profundi to the intact fingers after amputation of the small finger through the base of the proximal phalanx. B, The profundus and superficialis tendons are adherent just distal to the MCP joint. C, Both tendons have been divided and separated from one another. and the profundus is being tested for normal excursion through the carpal tunnel. It is resected near the origin of the lumbrical muscle . D, Full flexion and full power restored to the terminal phalanges.
interossei. If more than one finger is amputated, the incision may have to be extended well into the proximal palm to completely free all the involved profundi. The tendons of the intact fingers showing blockage are also examined. Traction with a tendon hook is sufficient to free adhesions that may have formed between the profundus and superficialis tendons . A padded dressing must permit the fingers early and full active movement. Most patients will promptly notice the improved pull on the terminal phalanges.
Clinical material Clinical manifestations , operative findings, and the results of surgery in 20 consecutive patients are summarized in Table II. All suffered their injuries at work and were initially managed by other surgeons . Four elective amputations had been performed after failed tendon surgery. Fourteen patients had single amputations and six had multiple amputations . Fourteen had
Table I. Profundus blockage grading Grade
Dip flexion
Dip power
Full II III
Reduced
Reduced Reduced
Absent
Absent
Legend: DIP. distal interphalangeal.
grade III blockage in at least one of the intact fingers, and six had grade II; none had been recognized before attending the Hand Clinic . It was most common in the ulnar three fingers , but the index finger was involved in four cases . Surgical release of the PTB was done 3 months to 9 years after the amputation . In aU but three patients, the resected profundus tendon of the amputated finger was adherent distal to the MCP joint. Follow-up examinations were done 3 to 34 months after surgery. Blockage was completely eliminated in 17 patients . One required a second operation to release
882
The Journal of HAND SURGERY
Neu, Murray, and MacKenzie
Table II.
Patient
Sex
Injury
Amputation
Par S
Time from amputation to blockage release (mo)
Age at time of blockage release (yr)
Finger(s) blocked, grade ( )
Site of adhesions (relative to MCP joint)
Follow-up (mo)
A. I.
M
Crush
Long PIP
P
107
41
Ring (II)
Distal
9
R. M.
M
Crush
Long mid PP
P
10
57
Proximal
8
A. P.
M
Crush
Ring mid PP
P
II
69
E. D.
F
Crush
35
M
Crush
P P P P
24
H. P.
Index MCP Long MCP Small MCP Ring mid PP
Ring (III); small (III) Index (III); long (III); small (III) Ring (III)
70
30
D. D.
M
Saw cut
Index mid PP
P
11
H. B.
M
Saw cut
P
A. C.
M
Crush
Index mid PP Long mid PP Ring mid PP Long PIP
D. H.
M
Saw cut
D.M.
M
Saw cut
M.R.
M
Crush
D. C.
M
Paint injection
Comment/ results Complete release Complete release Complete release
Distal
34
Distal
12
No improvement Complete release Complete release Complete release
Proximal
6
22
Long (III); small (II) Ring (II)
Distal
8
7
30
Small (III)
Distal
7
P
19
51
Distal
8
Small DIP
P
3
45
Index (I); ring (II) Ring (II)
Distal
3
Long mid PP Ring mid PP Small MCP
P P P
7
20
Small (III)
Distal
6
18
38
Distal
8
Ring MCP
P
24
24
Long (III); ring (III) Index (III); long (III); small (III)
Proximal
30
Complete release Partial release; blockage (I) Complete release Complete release Complete release
Legend: P, primary; S, secondary; PIP. proximal interphalangeal. PP, proximal phalanx; Mep, metacarpal phalangeal joint; DIP. distal interphalangeal; MP, middle phalanx.
adhesions in the carpal tunnel that had been missed. Two patients were improved, but still had grade I blockage, and one patient had no improvement and declined further surgery. Discussion Amputation of one or more fingers is a common cause of permanent disability in people with work-related hand injuries. The patient's complaint of decreased grip strength is expected and is reasonably attributed to the anatomic loss. Frequently overlooked, however, is the loss of strength in the intact fingers due to PTB. The relationship of a cramping forearm or wrist pain to PTB is also not appreciated. We feel this pain is due to stretching of the carpal tunnel synovium or a shearing stress between the fixed and moving components of the muscle origin.
Patients with failed tendon surgery or an old injury that results in a stiff, extended finger should be carefully checked for PTB before elective amputation. Adhesions of the profundus tendon in the damaged fingers will usually extend throughout most of the fibroosseus tunnel. This blockage must be released at the time of the elective amputation. After a primary finger amputation, the resected profundus tendon retracts and tends to develop adhesions. Early active, full flexion of the intact fingers immediately after surgery will prevent the tendon from becoming adherent where it can cause blockage. Both the patient and the surgeon may contribute to a delay in early finger movement. Many of these injuries are anatomically mutilating and psychologically upsetting, and some patients are reluctant to look at the injured hand, let alone move the fingers. An overly sympathetic
Vol. lOA. No.6, Part 1 November 1985
Profundus tendon blockage
883
Table II-coot'd ..
P or
S
Amputation
Time from amputation to blockage release (mo)
Age at time of blockage release (yr)
Patient
Sex
Injury
O. H.
M
Failed tendon
Small DIP
S
13
57
C. A.
M
Crush
Ring MCP
P
14
A . T.
M
Crush
Small PIP
P
W.H.
M
Crush
Ring mid MP
M. B.
M
Failed tendon repair
T. L.
M
A. R.
M
Failed tendon repair Crush
W. F.
F
Failed tendon repair
Site of adhesions (relative to MCP joint)
Finger(s) blocked, grade ( )
Follow-up (mo)
Distal
4
24
Long (II) ; ring (II) Small (III)
Distal
23
15
55
Ring (III)
Distal
3
P
9
21
Long (III)
Distal
12
Small PIP
S
3 41
20 23
Long (II); ring (II)
Distal
12
Ring PIP
S
18
37
Distal
21
Index mid MP Long mid PP Ring MCP
P
9
43
Long (III); small (III) Ring (II)
Distal
7
S
15
48
Index (II)
Distal
18
Comment/ results Complete release Complete release Complete release Complete release Two operations, complete release Complete release Complete release Partial release blockage (I)
Summary Crush 11 Saw cut 4 Failed Tendon 4 repair Paint injection
Index Long Ring Small
4 8 9 7
P 16
S
Average 21
4
surgeon may also try to keep them physically and emotionally comfortable in a splinted, bulky dressing. The support and supervision of exercises by the hand therapist during the early rehabilitation phase of treatment is invaluable.
REFERENCES I. Verdan C: Syndrome of the quadriga. Surg Clin North Am 40:425-6, 1960 2. Verdan C: In Flynn JE, editor: Hand surgery, ed 1. Baltimore. 1966, The Williams & Wilkins Co, p 225 3. Beasley RW: Hand injuries. Philadelphia, 1981, WB Saunders Co, p 351 4. Flatt AE: The care of minor hand injuries. St. Louis, 1979, The CV Mosby Co, p 166
Average 38
Index Long Ring
4 9 II
Distal 17 Proximal 3
Average II
Complete 17 release Partial 2 release No improvement
5. Lister G: The hand-diagnosis and indications. Edinburgh, 1977, Churchill Livingstone, p 55 6. Littler, JW: In Converse JD, editor: Reconstructive plastic surgery, ed 2, vol6 . Philadelphia, 1977, WB Saunders Co , p 3145 7. Rank BK, Wakefield AR, Hueston 11: Surgery of repair as applied to hand injuries. Edinburgh, 1973, Churchill Livingston, p 38 8. Weckesser EC: Treatment of hand injuries. Chicago, 1974, Year Book Medical Publishers, p 118 9. Stack HG: In Rob C, Smith R: Operative surgery, ed 3. London, 1970, Butterworth Publishers, p 354 10. Fahrer M: In Verdan C, editor: Tendon surgery of the hand. Edinburgh, 1979, Churchill Livingstone, pp 1724