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TYPE 5 AVULSION OF THE INSERTION OF THE FLEXOR DIGITORUM PROFUNDUS TENDON
TYPE 5 AVULSION OF THE INSERTION OF THE FLEXOR DIGITORUM PROFUNDUS TENDON M. M. AL-QATTAN From the Division of Plastic Surgery, King Saud University, Riyadh, Saudi Arabia
Four cases of avulsion of the insertion of the flexor digitorum profundus tendon with an osseous fragment are presented. In each case, there was another significant fracture of the distal phalanx. The current classification system for flexor profundus avulsions is reviewed and an extended classification is offered which considers such avulsions. Journal of Hand Surgery (British and European Volume, 2001) 26B: 5: 427–431
Avulsion of the insertion of flexor digitorum profundus tendon occurs most commonly in young men involved in athletic activities. The injury occurs in all fingers, but it has been reported to occur in the ring finger in more than 75% of cases (Boyes et al., 1960; Chang et al., 1972;
Cheung and Chow, 1995; Kevu et al., 1996; Lanzetta and Conolly, 1992; Le and Hentz, 2000; Leddy, 1985; McMaster, 1933; Smith, 1981; Wenger, 1973). Stamos and Leddy (2000) have described four types of avulsion (Fig 1). Type 1 is an avulsion without fracture, with the
Fig 1 The extended classification of avulsion of the insertion of the flexor digitorum profundus tendon. The comminuted distal phalangeal fracture is extraarticular in type 5A and is intraarticular in type 5B injury. 427
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THE JOURNAL OF HAND SURGERY VOL. 26B NO. 5 OCTOBER 2001
Fig 2 Type 5a injury. a, b) Preoperative radiographs. c) A radiograph immediately after surgery. d) The healed fracture.
FLEXOR TENDON AVULSION INJURIES
Fig 3 Type 5b injury. a,b) Preoperative radiographs. c,d) The healed fracture.
429
tendon retracting into the palm and rupture of both vincula. In Type 2 avulsions, a small fleck of bone is avulsed with the tendon which retracts to the level of the proximal interphalangeal joint leaving the long vinculum intact. Type 3 injuries have a large bony fragment which prevents retraction beyond A4 pulley. Type 4 avulsions have a bony fragment, but there is a simultaneous avulsion of the tendon from this which allows tendon retraction into the palm. The main reason for classifying flexor profundus avulsion injuries is its impact on management and determining the timing of surgical reconstruction (Table 1). Type 1 and 4 injuries result in severe damage to the extrinsic tendon blood supply and should be repaired within 10 days, before muscle retraction occurs. The author has treated four cases of profundus avulsion with an osseous fragment in which there was a significant extension of the fracture into the distal phalanx. The resulting comminuted distal phalangeal fracture has an impact on both management and timing of surgery. The author thus considers that these injuries should be classified separately as type 5 injuries (Fig 1).
PATIENTS AND METHODS
PIP = Proximal interphalangeal joint. DIP = Distal interphalangeal joint.
Management of cases with undisplaced extraarticular fractures can be delayed. All other cases should be treated within two weeks to avoid malunion and/or joint incongruity Stability of the distal phalanx/DIP joint should be obtained prior to fixation of the avulsed osseous fragment Avulsion with an osseous fragment and concomitant fracture of the distal phalanx 5
No later than 7–10 days Fixation of the fracture and reinsertion of the tendon Avulsion with an osseous fragment and simultaneous avulsion of the tendon from the fracture fragment, tendon in the palm 4
Repair is still possible even after a delay of few months Fixation of the osseous fragment gives an excellent result Avulsion with a large osseous fragment, tendon near the DIP joint
Repair is still possible within the first few weeks
3
Not later than 7–10 days
Avulsion with a small chip fracture, tendon at the PIP joint 2
In delayed primary repair, scarring of PIP joint should be resected prior to tendon reinsertion
Avulsions without fracture, tendon in the palm 1
Specific management considerations Description Type
Table 1—Management considerations and timing of surgery in different types of flexor profundus avulsions
Simple pull-out suture
THE JOURNAL OF HAND SURGERY VOL. 26B NO. 5 OCTOBER 2001
Timing of surgery
430
In a 7 year period (1994–2000), four cases of avulsion of the insertion of the profundus tendon with significant extension of the fracture into the distal phalanx were diagnosed and treated. The ring finger was the involved finger in each case. All the injuries were related to sports and occurred in young (26–35 years) men. The comminuted distal phalangeal fracture was extraarticular (Type 5a) in two cases and intraarticular (Type 5b) in the other two. All these injuries were treated within 72 hours of injury through a palmar zigzag incision. In patients with type 5a extraarticular fractures (Fig 2), anatomical reduction of the flexor tendon and its osseous fragment was done using a 3–0 polypropylene pull-out suture which was tied over a button on the dorsum of the finger. Care was given to pass one limb of the pull-out suture through the proximal phalangeal fragment and the other limb through the distal fragment. This prevents fracture displacement. In type 5b injuries (Fig 3), the distal interphalangeal joint was first stabilized with a K-wire. The fragment with its attached tendon was then reduced with a pullout suture tied over a button on the dorsum of the finger. Postoperative protected mobilization was done using a dorsal ‘‘blocking’’ splint with the wrist in 208 flexion and the metacarpo-phalangeal joints in 208 flexion. The splint and K-wires were removed at 4 weeks when exercises against resistance were started. The pull-out sutures were removed at 6 weeks when normal unrestricted use of the hand was permitted.
FLEXOR TENDON AVULSION INJURIES
RESULTS There were no immediate postoperative complications such as infection or rupture. One patient developed a nail bed deformity from the pull-out suture. Final functional results were assessed after a minimum followup period of 6 months and were graded by the method of Strickland and Glogovac (1980). The total active motion of the interphalangeal joints was excellent in all cases and ranged between 1608 and 1758 (normal=1758). DISCUSSION All four cases of profundus avulsion described in this report had a significant extension of the fracture into the distal phalanx. This comminution has an impact on both the management and timing of surgery (Table 1). Buscemi and Page (1987) have suggested that profundus tendon avulsions with concomitant intraarticular fractures should be considered as a separate group and I consider that concomitant extraarticular fractures should also be included in this group (Type 5).
431 Buscemi MJ, Page BJ (1987). Flexor digitorum profundus avulsions with associated distal phalanx fractures. A report of four cases and review of the literature. American Journal of Sports Medicine, 15: 366–370. Chang WHJ, Thomas OJ, White WL (1972). Avulsion injury of the long flexor tendons. Plastic and Reconstructive Surgery, 50: 260–266. Cheung KMC, Chow SP (1995). Closed avulsion of both flexor tendons of the ring finger. Journal of Hand Surgery, 20B: 78–79. Kevu JE, Calder SJ, Clearly JE (1996). Complete avulsion of the palmar cortex of the distal phalanx. Journal of Hand Surgery, 21B: 758–759. Lanzetta M, Conolly WB (1992). Closed rupture of both flexor tendons in the same digit. Journal of Hand Surgery, 17B: 479–480. Le TB, Hentz VR (2000). Hand and wrist injuries in young athletes. Hand Clinics, 16: 597–607. Leddy JP. Avulsions of the flexor digitorum profundus (1985). Hand Clinics, 1: 77–83. McMaster PE (1933). Tendon and muscle ruptures. Clinical and experimental studies on the causes and location of subcutaneous ruptures. Journal of Bone and Joint Surgery, 15: 705–722. Smith JH (1981). Avulsion of a profundus tendon with simultaneous intraarticular fracture of the distal phalanx-case report. Journal of Hand Surgery, 6: 600–601. Stamos BD, Leddy JP (2000). Closed flexor tendon disruption in athletes. Hand Clinics, 16: 359–365. Strickland JW, Glogovac SV (1980). Digital function following flexor tendon repair in zone II: A comparison of immobilization and controlled passive motion techniques. Journal of Hand Surgery, 5: 537–543. Wenger DR (1973). Avulsion of the profundus tendon insertion in football players. Archives of Surgery, 106: 145–149.
References
Received: 12 January 2001 Accepted after revision: 20 April 2001 M. M. Al-Qattan, Division of Plastic Surgery, P.O. Box 18097, Riyadh 11415, Saudi Arabia
Boyes JH, Wilson JN, Smith JW (1960). Flexor tendon ruptures in the forearm and hand. Journal of Bone and Joint Injury, 42A: 637–646.
# 2001 The British Society for Surgery of the Hand doi: 10.1054/jhsb.2001.0619, available online at http://www.idealibrary.com on
Four cases of avulsion of the insertion of the flexor digitorum profundus tendon with an osseous fragment are presented. In each case, there was another significant fracture of the distal phalanx. The current classification system for flexor profundus avulsions is reviewed and an extended classification is offered which considers such avulsions. Journal of Hand Surgery (British and European Volume, 2001) 26B: 5: 427–431
Avulsion of the insertion of flexor digitorum profundus tendon occurs most commonly in young men involved in athletic activities. The injury occurs in all fingers, but it has been reported to occur in the ring finger in more than 75% of cases (Boyes et al., 1960; Chang et al., 1972;
Cheung and Chow, 1995; Kevu et al., 1996; Lanzetta and Conolly, 1992; Le and Hentz, 2000; Leddy, 1985; McMaster, 1933; Smith, 1981; Wenger, 1973). Stamos and Leddy (2000) have described four types of avulsion (Fig 1). Type 1 is an avulsion without fracture, with the
Fig 1 The extended classification of avulsion of the insertion of the flexor digitorum profundus tendon. The comminuted distal phalangeal fracture is extraarticular in type 5A and is intraarticular in type 5B injury. 427
428
THE JOURNAL OF HAND SURGERY VOL. 26B NO. 5 OCTOBER 2001
Fig 2 Type 5a injury. a, b) Preoperative radiographs. c) A radiograph immediately after surgery. d) The healed fracture.
FLEXOR TENDON AVULSION INJURIES
Fig 3 Type 5b injury. a,b) Preoperative radiographs. c,d) The healed fracture.
429
tendon retracting into the palm and rupture of both vincula. In Type 2 avulsions, a small fleck of bone is avulsed with the tendon which retracts to the level of the proximal interphalangeal joint leaving the long vinculum intact. Type 3 injuries have a large bony fragment which prevents retraction beyond A4 pulley. Type 4 avulsions have a bony fragment, but there is a simultaneous avulsion of the tendon from this which allows tendon retraction into the palm. The main reason for classifying flexor profundus avulsion injuries is its impact on management and determining the timing of surgical reconstruction (Table 1). Type 1 and 4 injuries result in severe damage to the extrinsic tendon blood supply and should be repaired within 10 days, before muscle retraction occurs. The author has treated four cases of profundus avulsion with an osseous fragment in which there was a significant extension of the fracture into the distal phalanx. The resulting comminuted distal phalangeal fracture has an impact on both management and timing of surgery. The author thus considers that these injuries should be classified separately as type 5 injuries (Fig 1).
PATIENTS AND METHODS
PIP = Proximal interphalangeal joint. DIP = Distal interphalangeal joint.
Management of cases with undisplaced extraarticular fractures can be delayed. All other cases should be treated within two weeks to avoid malunion and/or joint incongruity Stability of the distal phalanx/DIP joint should be obtained prior to fixation of the avulsed osseous fragment Avulsion with an osseous fragment and concomitant fracture of the distal phalanx 5
No later than 7–10 days Fixation of the fracture and reinsertion of the tendon Avulsion with an osseous fragment and simultaneous avulsion of the tendon from the fracture fragment, tendon in the palm 4
Repair is still possible even after a delay of few months Fixation of the osseous fragment gives an excellent result Avulsion with a large osseous fragment, tendon near the DIP joint
Repair is still possible within the first few weeks
3
Not later than 7–10 days
Avulsion with a small chip fracture, tendon at the PIP joint 2
In delayed primary repair, scarring of PIP joint should be resected prior to tendon reinsertion
Avulsions without fracture, tendon in the palm 1
Specific management considerations Description Type
Table 1—Management considerations and timing of surgery in different types of flexor profundus avulsions
Simple pull-out suture
THE JOURNAL OF HAND SURGERY VOL. 26B NO. 5 OCTOBER 2001
Timing of surgery
430
In a 7 year period (1994–2000), four cases of avulsion of the insertion of the profundus tendon with significant extension of the fracture into the distal phalanx were diagnosed and treated. The ring finger was the involved finger in each case. All the injuries were related to sports and occurred in young (26–35 years) men. The comminuted distal phalangeal fracture was extraarticular (Type 5a) in two cases and intraarticular (Type 5b) in the other two. All these injuries were treated within 72 hours of injury through a palmar zigzag incision. In patients with type 5a extraarticular fractures (Fig 2), anatomical reduction of the flexor tendon and its osseous fragment was done using a 3–0 polypropylene pull-out suture which was tied over a button on the dorsum of the finger. Care was given to pass one limb of the pull-out suture through the proximal phalangeal fragment and the other limb through the distal fragment. This prevents fracture displacement. In type 5b injuries (Fig 3), the distal interphalangeal joint was first stabilized with a K-wire. The fragment with its attached tendon was then reduced with a pullout suture tied over a button on the dorsum of the finger. Postoperative protected mobilization was done using a dorsal ‘‘blocking’’ splint with the wrist in 208 flexion and the metacarpo-phalangeal joints in 208 flexion. The splint and K-wires were removed at 4 weeks when exercises against resistance were started. The pull-out sutures were removed at 6 weeks when normal unrestricted use of the hand was permitted.
FLEXOR TENDON AVULSION INJURIES
RESULTS There were no immediate postoperative complications such as infection or rupture. One patient developed a nail bed deformity from the pull-out suture. Final functional results were assessed after a minimum followup period of 6 months and were graded by the method of Strickland and Glogovac (1980). The total active motion of the interphalangeal joints was excellent in all cases and ranged between 1608 and 1758 (normal=1758). DISCUSSION All four cases of profundus avulsion described in this report had a significant extension of the fracture into the distal phalanx. This comminution has an impact on both the management and timing of surgery (Table 1). Buscemi and Page (1987) have suggested that profundus tendon avulsions with concomitant intraarticular fractures should be considered as a separate group and I consider that concomitant extraarticular fractures should also be included in this group (Type 5).
431 Buscemi MJ, Page BJ (1987). Flexor digitorum profundus avulsions with associated distal phalanx fractures. A report of four cases and review of the literature. American Journal of Sports Medicine, 15: 366–370. Chang WHJ, Thomas OJ, White WL (1972). Avulsion injury of the long flexor tendons. Plastic and Reconstructive Surgery, 50: 260–266. Cheung KMC, Chow SP (1995). Closed avulsion of both flexor tendons of the ring finger. Journal of Hand Surgery, 20B: 78–79. Kevu JE, Calder SJ, Clearly JE (1996). Complete avulsion of the palmar cortex of the distal phalanx. Journal of Hand Surgery, 21B: 758–759. Lanzetta M, Conolly WB (1992). Closed rupture of both flexor tendons in the same digit. Journal of Hand Surgery, 17B: 479–480. Le TB, Hentz VR (2000). Hand and wrist injuries in young athletes. Hand Clinics, 16: 597–607. Leddy JP. Avulsions of the flexor digitorum profundus (1985). Hand Clinics, 1: 77–83. McMaster PE (1933). Tendon and muscle ruptures. Clinical and experimental studies on the causes and location of subcutaneous ruptures. Journal of Bone and Joint Surgery, 15: 705–722. Smith JH (1981). Avulsion of a profundus tendon with simultaneous intraarticular fracture of the distal phalanx-case report. Journal of Hand Surgery, 6: 600–601. Stamos BD, Leddy JP (2000). Closed flexor tendon disruption in athletes. Hand Clinics, 16: 359–365. Strickland JW, Glogovac SV (1980). Digital function following flexor tendon repair in zone II: A comparison of immobilization and controlled passive motion techniques. Journal of Hand Surgery, 5: 537–543. Wenger DR (1973). Avulsion of the profundus tendon insertion in football players. Archives of Surgery, 106: 145–149.
References
Received: 12 January 2001 Accepted after revision: 20 April 2001 M. M. Al-Qattan, Division of Plastic Surgery, P.O. Box 18097, Riyadh 11415, Saudi Arabia
Boyes JH, Wilson JN, Smith JW (1960). Flexor tendon ruptures in the forearm and hand. Journal of Bone and Joint Injury, 42A: 637–646.
# 2001 The British Society for Surgery of the Hand doi: 10.1054/jhsb.2001.0619, available online at http://www.idealibrary.com on