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Traumatic rupture of the profundus tendon proximal to the lumbrical origin
Traumatic rupture of the profundus tendon proximal to the Iumbrical origin Traumatic flexor tendon ruptures are rare in patients without rheumatoid arthritis. A case of closed flexor digitorum profundus tendon rupture in the palm, proximal to the lumhrical origin, is presented. Thorough patient evaluation revealed no associated tendinous or bony pathology. (J HAND Smc 1!390;15A:484-6.)
Lorenzo G. Walker, MD, and Malcolm A. Lesavoy,
I
n 189 1, von Zander’ reported the first case of spontaneous flexor tendon rupture in the hand. Kersley,’ in 1948 was the first to publish a case of profundus rupture associated with rheumatoid arthritis. Although flexor tendon ruptures occur infrequently in patients with rheumatoid arthritis,3 this injury is extremely rare in patients without rheumatoid arthritis. In 1960, Boyes and co-authors4 presented a series of 80 flexor tendon ruptures that occurred in 78 patients over a 13-year period. Only three had no identifiable cause, prompting them to restrict the use of the term “spontaneous” rupture to those occurring within the tendon substance without underlying or associated pathologic changes. All three patients in Boyes’ series experienced “minor trauma” one while “pinching a battery clamp,” one “pulling a small cart,” and the other as he “pushed open a light overhead cockpit door.” Adhering to this definition, we report a case of “spontaneous” flexor digitorum profundus rupture in the palm proximal to the lumbrical origin. Case report A 53-year-old right-handed white man experienced the sudden onset of pain in his left hand while lifting a steel ramp at work. He was seen in the emergency department of a local
From the Hand Surgery Service, University of California at Los Angeles, Los Angeles, Calif. Received for publication
Feb. 2, 1989; accepted in revised form July
14, 1989. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Malcolm Lesavoy, MD, Associate Professor, Division of Plastic Surgery, U.C.L.A. Medical Center, Los Angeles, CA 90024.
MD, Los Angeles,
C&f.
hospital where no swelling or tenderness was noted in the palm or affected digit. Routine radiographs revealed no evidence of bony abnormality. The hand was placed in an anterior wrist splint, which he discarded 3 days later, without seeking further care. Seven weeks later, after noting the loss of power grip, he returned to the emergency room where the diagnosis was injury to the flexor digitorum profundus. He was then referred to our care. On physical examination, no skin wound was present. The patient was unable to actively flex the distal interphalangeal joint of his left long finger (Fig. 1) but had full passive motion at this joint. The working diagnosis was avulsion of the flexor digitorum profundus tendon at its insertion; radiographic studies of the carpal canal were therefore not obtained. Results of routine laboratory studies were unremarkable. At operation, the distal insertion of the profundus tendon was found to be intact. Further exploration revealed the site of rupture in the palm, proximal to the lumbrical origin; the carpal canal was thus not explored. The fibrosed lumbrical was avulsed from the profundus tendon during exploration (Fig. 2). No intrinsic tendon pathology was noted in the ruptured tendon or adjacent tendons and no associated bony abnormalities were evident. Delayed primary tendon repair was not possible and tendon grafting was not elected in an attempt to minimize adhesions to the intact superticialis. Therefore, the distal profundus tendon was tenodesed to the intact superficialis tendon in the palm (Fig. 3). Six months after operation, the patient was pleased with the function of the long finger and his grip strength has returned to normal. Distal interphalangeal flexion equaled 10 degrees, proximal interphalangeal flexion equaled 110 degrees, and metacarphalangeal flexion equaled 90 degrees. No further tendon ruptures have been noted.
Discussion
Reprint requests:
3/l/15915
484
THE JOURNAL OF HAND SURGERY
Flexor tendon ruptures in the patient without rheumatoid arthritis are extremely uncommon. Approximately 150 cases have been reported in the English-
Vol. 15A, No. 3 May 1990
Traumatic rupture of profundus tendon proximal to lumbrical origin
485
Fig. 1. Obvious injury to the flexor digitorum profundus tendon of the long finger.
Fig. 2. Flexor digitorum profundus rupture in the palm, prox-
Fig. 3. Tenodesis to the intact superticialis tendon in tbe palm.
imal to tbe lumbrical origin. language literature. When underlying disease or infection within the tendon cannot be documented, direct or indirect trauma, (such as hyperextension of the finger during forceful flexion) is responsible for most of these injuries.4 Rupture of the profundus at its insertion on
the distal phalanx commonly occurs in the ring finger, often during athletics. Attritional flexor tendon ruptures have been associ-’ ated with multiple underlying bony abnormalities such as congenital abnormalities of the carpal bones,4 Kien-
486
The Journal of HAND SURGERY
Walker and Lesavoy
bock’s disease,’ pisotriquetral arthrosis.6 Posttraumatic bony changes resulting from previous Colles’ fracture,‘, 8 scaphoid nonunion ,9 old hook of the hamate fracture,4. lo and neglected lunate”, l2 and perilunate13 dislocations have also been implemented as etiologic agents. These bony causes were excluded in this patient. The studies of Lundborg and associates pinpoint14 avascular areas within the substance of the profundus tendon but fail to denote an avascular region within the palm. In 1985 Kumar and JamesI reported a case of an isolated spontaneous profundus rupture occurring at the level of the lumbrical origin. Because the intact lumbrical origin facilitated reapproximation, a modified Kessler repair produced a good result. In our patient, primary tendon repair would have necessitated a more extensive exposure because of the absence of an intact lumbrical or vinculum. To expedite the patient’s return to his previous employment, tenodesis was thought to be the procedure of choice and no lumbrical minus function resulted. Since Boyes published his extensive review, many authors have shared his skepticism regarding the concept of “spontaneous” flexor tendon ruptures. Many cite the work of McMaster,16 published in 1933, which states that normal, healthy tendons do not rupture within their substance but rupture elsewhere in the musculotendinous unit. He also demonstrated that a given tendon would have to be weakened by 50% before rupture could take place. These classic studies cannot be ignored and we agree that thorough evaluation of patients wtih closed flexor tendon ruptures is necessary to exclude intrinsic pathologic conditions of the tendon substance and underlying bony abnormalities. Nevertheless, the pathogenesis of spontaneous tendon rupture without associated tendinous or bony pathology remains obscure and deserves further investigation, REFERENCES 1. von Zander W. Trommlerlahmug.
Inaug dissertation. Berlin: G. Schade, 1891. 2. Kersley GD. Spontaneous rupture of muscle as a complication of rheumatoid
arthritis. Br Med J 1948;2:942.
3. Ertel AN, Millender LH, Nalebuff E, McKay D, Leslie B. Flexor tendon ruptures in patients with rheumatoid arthritis. J HAND SURG 1988;13A:860-6. 4. Boyes JH, Wilson JN, Smith JW. Flexor tendon ruptures in the forearm and hand. J Bone Joint Surg 1960; 42A:637-46. 5. James JIP. A case of rupture of flexor tendons secondary to Kienbiick’s disease. J Bone Joint Surg 1949;31B: 521-3. 6. Lutz RA, Monsivais JJ. Piso-triquetral arthrosis as a cause of rupture of the profundus tendon of the little finger. J HAND SURG 1988;13B:102-3. 7. McMaster PE. Late ruptures of extensor and flexor pollicis longus tendons following Colles’ fracture. J Bone Joint Surg 1932;14A:93-101. 8. Rymaszewski LA, Walker AP. Rupture of flexor digitorum profundus tendon to the index finger after a distal radial fracture. J HAND SURG 1987;12B:11.5-16. 9. Mahring M, Semple C, Gray IC. Attritional flexor tendon rupture due to scaphoid nonunion imitating an anterior interosseous nerve syndrome: a case report. J HAND SURG 1985;10B:62-4. 10. Crosby EB, Linscheid RL. Rupture of the flexor profundus tendon of the ring finger secondary to ancient fracture of the hook of the hamate. J Bone Joint Surg 1949;31B:521-3. 11. Stem PJ. Multiple flexor tendon ruptures following an old anterior dislocation of the lunate. J Bone Joint Surg 1981;63A:489-90. 12. Johnston GHF, Bowen CVA. Attritional flexor tendon ruptures by an old lunate dislocation. J HAND SURG 1988;13A:701-3. 13. Speigel H. Spontanruptur der beugesehnen bei alter perilunarer dorsalluxation der hand. Montasschr f Unfallheilk u Versicherungsmed 1949;52:314-16. 14. Lundborg G, Myrhage R, Rydevik B. The vascularization of human flexor tendons within the digital synovial sheath region-structural and functional aspects. J HAND SURG 1977;2A:417-22. 1.5. Kumar S, James R. Closed rupture of flexor profundus tendon in the palm. J HAND SURG 1985;10B:193-4. 16. McMaster PE. Tendon and muscle ruptures. Clinical and experimental studies on the causes and location of subcutaneous ruptures. J Bone Joint Surg 1933;15A:705-22.
Lorenzo G. Walker, MD, and Malcolm A. Lesavoy,
I
n 189 1, von Zander’ reported the first case of spontaneous flexor tendon rupture in the hand. Kersley,’ in 1948 was the first to publish a case of profundus rupture associated with rheumatoid arthritis. Although flexor tendon ruptures occur infrequently in patients with rheumatoid arthritis,3 this injury is extremely rare in patients without rheumatoid arthritis. In 1960, Boyes and co-authors4 presented a series of 80 flexor tendon ruptures that occurred in 78 patients over a 13-year period. Only three had no identifiable cause, prompting them to restrict the use of the term “spontaneous” rupture to those occurring within the tendon substance without underlying or associated pathologic changes. All three patients in Boyes’ series experienced “minor trauma” one while “pinching a battery clamp,” one “pulling a small cart,” and the other as he “pushed open a light overhead cockpit door.” Adhering to this definition, we report a case of “spontaneous” flexor digitorum profundus rupture in the palm proximal to the lumbrical origin. Case report A 53-year-old right-handed white man experienced the sudden onset of pain in his left hand while lifting a steel ramp at work. He was seen in the emergency department of a local
From the Hand Surgery Service, University of California at Los Angeles, Los Angeles, Calif. Received for publication
Feb. 2, 1989; accepted in revised form July
14, 1989. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Malcolm Lesavoy, MD, Associate Professor, Division of Plastic Surgery, U.C.L.A. Medical Center, Los Angeles, CA 90024.
MD, Los Angeles,
C&f.
hospital where no swelling or tenderness was noted in the palm or affected digit. Routine radiographs revealed no evidence of bony abnormality. The hand was placed in an anterior wrist splint, which he discarded 3 days later, without seeking further care. Seven weeks later, after noting the loss of power grip, he returned to the emergency room where the diagnosis was injury to the flexor digitorum profundus. He was then referred to our care. On physical examination, no skin wound was present. The patient was unable to actively flex the distal interphalangeal joint of his left long finger (Fig. 1) but had full passive motion at this joint. The working diagnosis was avulsion of the flexor digitorum profundus tendon at its insertion; radiographic studies of the carpal canal were therefore not obtained. Results of routine laboratory studies were unremarkable. At operation, the distal insertion of the profundus tendon was found to be intact. Further exploration revealed the site of rupture in the palm, proximal to the lumbrical origin; the carpal canal was thus not explored. The fibrosed lumbrical was avulsed from the profundus tendon during exploration (Fig. 2). No intrinsic tendon pathology was noted in the ruptured tendon or adjacent tendons and no associated bony abnormalities were evident. Delayed primary tendon repair was not possible and tendon grafting was not elected in an attempt to minimize adhesions to the intact superticialis. Therefore, the distal profundus tendon was tenodesed to the intact superficialis tendon in the palm (Fig. 3). Six months after operation, the patient was pleased with the function of the long finger and his grip strength has returned to normal. Distal interphalangeal flexion equaled 10 degrees, proximal interphalangeal flexion equaled 110 degrees, and metacarphalangeal flexion equaled 90 degrees. No further tendon ruptures have been noted.
Discussion
Reprint requests:
3/l/15915
484
THE JOURNAL OF HAND SURGERY
Flexor tendon ruptures in the patient without rheumatoid arthritis are extremely uncommon. Approximately 150 cases have been reported in the English-
Vol. 15A, No. 3 May 1990
Traumatic rupture of profundus tendon proximal to lumbrical origin
485
Fig. 1. Obvious injury to the flexor digitorum profundus tendon of the long finger.
Fig. 2. Flexor digitorum profundus rupture in the palm, prox-
Fig. 3. Tenodesis to the intact superticialis tendon in tbe palm.
imal to tbe lumbrical origin. language literature. When underlying disease or infection within the tendon cannot be documented, direct or indirect trauma, (such as hyperextension of the finger during forceful flexion) is responsible for most of these injuries.4 Rupture of the profundus at its insertion on
the distal phalanx commonly occurs in the ring finger, often during athletics. Attritional flexor tendon ruptures have been associ-’ ated with multiple underlying bony abnormalities such as congenital abnormalities of the carpal bones,4 Kien-
486
The Journal of HAND SURGERY
Walker and Lesavoy
bock’s disease,’ pisotriquetral arthrosis.6 Posttraumatic bony changes resulting from previous Colles’ fracture,‘, 8 scaphoid nonunion ,9 old hook of the hamate fracture,4. lo and neglected lunate”, l2 and perilunate13 dislocations have also been implemented as etiologic agents. These bony causes were excluded in this patient. The studies of Lundborg and associates pinpoint14 avascular areas within the substance of the profundus tendon but fail to denote an avascular region within the palm. In 1985 Kumar and JamesI reported a case of an isolated spontaneous profundus rupture occurring at the level of the lumbrical origin. Because the intact lumbrical origin facilitated reapproximation, a modified Kessler repair produced a good result. In our patient, primary tendon repair would have necessitated a more extensive exposure because of the absence of an intact lumbrical or vinculum. To expedite the patient’s return to his previous employment, tenodesis was thought to be the procedure of choice and no lumbrical minus function resulted. Since Boyes published his extensive review, many authors have shared his skepticism regarding the concept of “spontaneous” flexor tendon ruptures. Many cite the work of McMaster,16 published in 1933, which states that normal, healthy tendons do not rupture within their substance but rupture elsewhere in the musculotendinous unit. He also demonstrated that a given tendon would have to be weakened by 50% before rupture could take place. These classic studies cannot be ignored and we agree that thorough evaluation of patients wtih closed flexor tendon ruptures is necessary to exclude intrinsic pathologic conditions of the tendon substance and underlying bony abnormalities. Nevertheless, the pathogenesis of spontaneous tendon rupture without associated tendinous or bony pathology remains obscure and deserves further investigation, REFERENCES 1. von Zander W. Trommlerlahmug.
Inaug dissertation. Berlin: G. Schade, 1891. 2. Kersley GD. Spontaneous rupture of muscle as a complication of rheumatoid
arthritis. Br Med J 1948;2:942.
3. Ertel AN, Millender LH, Nalebuff E, McKay D, Leslie B. Flexor tendon ruptures in patients with rheumatoid arthritis. J HAND SURG 1988;13A:860-6. 4. Boyes JH, Wilson JN, Smith JW. Flexor tendon ruptures in the forearm and hand. J Bone Joint Surg 1960; 42A:637-46. 5. James JIP. A case of rupture of flexor tendons secondary to Kienbiick’s disease. J Bone Joint Surg 1949;31B: 521-3. 6. Lutz RA, Monsivais JJ. Piso-triquetral arthrosis as a cause of rupture of the profundus tendon of the little finger. J HAND SURG 1988;13B:102-3. 7. McMaster PE. Late ruptures of extensor and flexor pollicis longus tendons following Colles’ fracture. J Bone Joint Surg 1932;14A:93-101. 8. Rymaszewski LA, Walker AP. Rupture of flexor digitorum profundus tendon to the index finger after a distal radial fracture. J HAND SURG 1987;12B:11.5-16. 9. Mahring M, Semple C, Gray IC. Attritional flexor tendon rupture due to scaphoid nonunion imitating an anterior interosseous nerve syndrome: a case report. J HAND SURG 1985;10B:62-4. 10. Crosby EB, Linscheid RL. Rupture of the flexor profundus tendon of the ring finger secondary to ancient fracture of the hook of the hamate. J Bone Joint Surg 1949;31B:521-3. 11. Stem PJ. Multiple flexor tendon ruptures following an old anterior dislocation of the lunate. J Bone Joint Surg 1981;63A:489-90. 12. Johnston GHF, Bowen CVA. Attritional flexor tendon ruptures by an old lunate dislocation. J HAND SURG 1988;13A:701-3. 13. Speigel H. Spontanruptur der beugesehnen bei alter perilunarer dorsalluxation der hand. Montasschr f Unfallheilk u Versicherungsmed 1949;52:314-16. 14. Lundborg G, Myrhage R, Rydevik B. The vascularization of human flexor tendons within the digital synovial sheath region-structural and functional aspects. J HAND SURG 1977;2A:417-22. 1.5. Kumar S, James R. Closed rupture of flexor profundus tendon in the palm. J HAND SURG 1985;10B:193-4. 16. McMaster PE. Tendon and muscle ruptures. Clinical and experimental studies on the causes and location of subcutaneous ruptures. J Bone Joint Surg 1933;15A:705-22.