Hand and Wrist Tendinopathies

Fig. 23.1
Classification of jersey fingers Type 1 – 5 (copyright Dr. Margaret Fok)

Patient with jersey finger usually presents with a stiff and swollen finger with a classic description of the injury mechanism. A loss of DIPJ flexion is observed. Tenderness may be felt along the flexor tendon sheath, and a mass suggesting the location of the FDP stump can sometimes be palpated. Radiographs of the affected finger are taken to assess bone integrity of the distal phalanx. Dynamic ultrasound and MRI can also be used to confirm the diagnosis and to assess the extent of stump retraction. Management

Surgical treatment is advocated for all types of jersey fingers in the acute settings. The classification system bears prognostic value. As there is a loss of nutrient supply of the tendon with the rupture of both short and long vinculum in type 1 injury, early surgery of tendon to bone repair within 10 days is advised to prevent necrosis of the tendon (Leddy and Parker 1977). Meanwhile, a less significant loss in nutrient supply is noted for type 2 injury due to the preservation of long vinculum. Though early repair is recommended, successful outcomes have been reported for as late as 3 months after surgery (Leddy and Parker 1977).

For type 3 injury, as the FDP is avulsed together with a bony fragment of the distal phalanx, retraction is not a concern and treatment can be done by fixing the bone fragment to the distal phalanx with screw(s) or Kirschner wires. Type 4 injury involves both bone avulsion and FDP rupture. Thus, both bone fixation and tendon repair are advocated. Meanwhile, for type 5 injury, the treatment plan depends on the severity of the distal phalanx fractures. Fixation of fracture can be performed in some cases. In severe comminuted fracture cases, direct tendon to bone repair may be chosen instead. The DIPJ may need to be stabilized based on the involvement of the articular surface and the stability of the joint (Tuttle et al. 2006).

Tendon to bone repair can be achieved by bringing the stump of the tendon to the bone by either using suture anchor(s) or using osseous tunnels with pullout button on the finger nail. The technique of using pullout button has enjoyed a long history of successful outcome (Bunnell 1948; Leddy 1985; Skoff et al. 1995). However, due to the irritation of the button, people are now shifting to the use of suture anchor(s). While it has proven to have a comparable load to failure strength with the pullout button, its fatigue to failure of the anchor bone interface has yet to be confirmed (Brustein et al. 2001). The adjustment of tendon tension in tendon to bone repair is important. A normal resting cascade of the fingers needs to be achieved after the repair. An excessive tension of the FDP repaired tendon may give rise to quadriga phenomenon (Schreuders 2012).

Regardless of the treatment methods, rehabilitation after the repair of the tendon is long, as protection to prevent forced extension and gripping activities is needed for around 12 weeks. Some athletes opt to treat this condition either in a delayed manner, i.e. to wait for the completion of a season or nonoperatively. This may be feasible if the patient has a full range of movement of the proximal interphalangeal joint (PIPJ) of the finger and a stable DIPJ (Goldfarb et al. 2016). The stump of the retracted FDP may be excised if discomfort is noted.

23.1.2 Mallet Finger

Mallet finger is the failure of the terminal extensor digitorum tendon, instead of the FDP tendon as of the jersey finger. It occurs when the DIPJ is forcefully flexed in an actively extended position or in axial loading. It is commonly seen in sport injuries like football, basketball or volleyball games (Wehbe and Schneider 1984). Like the jersey finger, it can be a result of either a detachment of the tendon from the bone or a bone avulsion of the dorsal base of the distal phalanx.

Mallet finger can be presented with a swelling of the DIPJ and a flexion deformity of the DIPJ of the affected finger. When tested, a failure to actively extend the DIPJ can be observed. Radiograph is often needed to assess whether there is a bony component to the injury (Fig. 23.2a) and whether there is an associated DIPJ palmar subluxation.


Fig. 23.2
(a) Mallet finger x-ray, (b) mallet splint and (c) Ishiguro technique, which involves an extension block wire to hold the fragment and a longitudinal wire across the DIP joint. Note there is still some dorsal subluxation in this image. (d) Internal tension band suture technique for mallet finger fracture. The suture captures the septae of the finger and secures the extensor mechanism to it. A neutralization K wire is also required (copyright Dr. Gregory Bain). (e) Small dorsal plate and neutralization of K wire Management

Unlike jersey finger, most mallet fingers can be satisfactorily treated with splint only (Fig. 23.2b) (Okafor et al. 1997; Stern and Kastrup 1988). This is even applicable for patients with delayed presentation. A short mallet splint to keep the DIPJ in extension for 6–8 weeks is often advocated (Crawford 1984; Kinninmonth and Holburn 1986). Garberman et al. showed that satisfactory outcome can be achieved with splint in mallet fingers of an average of 53 days from injury (Garberman et al. 1994). In the presence of a fracture, a lateral radiograph of the affected finger, together with the splint, is needed to ensure that no joint subluxation is created post application of the splint. It is well known that they can subluxate up to 3 weeks, so repeat imaging is required (Crawford 1984).

Surgical treatment has previously been recommended for fractures which involve more than 30% of the articular surface and palmar subluxation of DIPJ (Hamas et al. 1978). Kirschner wires and screws may be used (Damron et al. 1993; Hofmeister et al. 2003; Tuttle et al. 2006). This can restore the articular surface and prevent secondary degenerative changes. Moreover, early mobilization of the joint and prevention of skin complications, created by splint, have been proposed (Nakamura and Nanjyo 1994). Nevertheless, despite the presence of a large articular fragment and even joint subluxation, studies have shown satisfactory results with splint alone (Okafor et al. 1997; Wehbe and Schneider 1984). If there is marked subluxation, we would often use the Ishiguro technique, which involves an extension block wire to hold the fragment and a longitudinal wire across the DIP joint (Ishiguro et al. 1997) (Fig. 23.2c). If it is a delayed presentation, then it may not be possible to reduce the fracture with this percutaneous technique, in which case we use an internal tension band suture technique (Bauze and Bain 1999) (Fig. 23.2d) or a small hooked plate protected by neutralization k-wire (Fig. 23.2e).

Both conservative and operative treatments for mallet finger have been associated with a high complication rates (Stern and Kastrup 1988; Wehbe and Schneider 1984). While the complications of conservative therapy are often transient like skin ulceration from the splint, the complications of surgical intervention are often more long term, e.g. joint incongruity, infection, nail deformity and implant failure. It is known that a residual extension lag of an average of 80 is observed with the treatment of splint (Okafor et al. 1997). While this will not lead to any functional deficit, patient may regard this as a poor cosmetic outcome. Thus, we recommend reserving surgery for a specific group of patients who desire to have early mobilization and better cosmetic outcome.

23.1.3 Extensor Tendon Subluxation

Traumatic subluxation of the extensor tendon at the metacarpophalangeal joint (MCPJ) is a relatively less common sport injury when compare to mallet finger and jersey finger. It is caused by the rupture of sagittal band, the primary stabilizer of the extensor tendon at the MCPJ level (Fig. 23.3a). The mechanisms of injury are usually direct trauma, forced flexion or resisted extension of the MCPJ (Inoue and Tamura 1996; Lin and Strauch 2014).


Fig. 23.3
(a) Radial sagittal band rupture causing extensor tendon subluxation to the ulnar side (copyright Dr. Margaret Fok). (b) Intraoperative view, with the rent in the sagittal band identified (white arrow). As the finger is straight, the central tendon is in the midline. (c) With finger flexion the rent opens and allows the tendon to subluxate to the ulnar side. (d) The granulation tissue is debrided, including any synovium. (e) The sagittal band is sutured to the central tendon. (f) With finger flexion the central tendon remains stable. (g) A dynamic splint is required for 6 weeks until the tendon heals. This splint keeps the MCP joint extended but allows the PIP to mobilize (Fig. 23.3b–g: copyright Dr. Gregory Bain)

Patient often presents with a snapping pain in the MCPJ of the affected finger. They may either observe the subluxation of the tendon on active finger flexion or complain of a loss in active extension of the affected finger. Passive finger extending position can be maintained. As the radial sagittal band is longer and thinner than the ulnar counterpart, the rupture usually occurs on the radial side, resulting in an ulnar subluxation of the tendon (Young and Rayan 2000). The middle finger is most commonly affected (Inoue and Tamura 1996). There is also a related condition that occurs commonly in boxers and karate practitioners named boxer’s knuckle (Nagaoka et al. 2006). It is a chronic condition which occurs due to repeated punching motion and involves a tear of the MCPJ and sagittal band rupture. Management

Treatment for extensor tendon subluxation can be conservative in the acute stage, i.e. within 3 weeks from injury (Rayan and Murray 1994). After the reduction of the extensor tendon into its designated route with MCPJ in extension, splint is applied to block MCPJ from flexion while freeing PIPJ. Buddy splint may also be added. The splint is applied for 6–8 weeks. Catalano et al. (2006) reported 8 of 11 injuries had no pain and either minimal or no subluxation at an average of a 14-month follow-up, while Rayan and Murry (1994) reported 12 of 18 injuries had no pain and tendon subluxation at an average of a 13-month follow-up.

In the subacute group, it is possible to still repair the sagittal band, without the need for a full reconstruction. This does give a better insight into the pathoanatomy and the true clinical problem (Fig. 23.3b). The sagittal band requires to be surgically repaired to the central tendon (Fig. 23.3 c–f). Post-operatively it is placed into a splint to prevent MCP flexion, but allows active PIP motion for 6 weeks (Fig. 23.3g).

For chronic sagittal band injuries or failed conservative therapy, surgical treatment is indicated. Many different procedures including repair of the sagittal band (Kettelkamp et al. 1971) and tendon stabilization using grafts like juncturae tendinum (Wheeldon 1954) and local proximal- or distal-based partial extensor digitorum communis slips (Carroll et al. 1987; Watson et al. 1997) have been described. One author (MF) prefers to reconstruct the sagittal band with a distally based partial extensor digitorum to create the radial sling for tendon stabilization (Fig. 23.4a) (Carroll et al. 1987).


Fig. 23.4
(a) Reconstruction of the sagittal band with half of the central tendon, passed around the collateral ligament (copyright Dr. Margaret Fok). (b) Sagittal band reconstruction with a half strip of the common extensor tendon. The half strip passes through the central tendon, at the proximal edge of the sagittal band. It then passes deep to the DIML and back through the central tendon at the level of the distal margin of the sagittal band (copyright Dr. Gregory Bain)

Only gold members can continue reading. Log In or Register to continue

Stay updated, free articles. Join our Telegram channel

Sep 6, 2017 | Posted by in ORTHOPEDIC | Comments Off on Hand and Wrist Tendinopathies

Full access? Get Clinical Tree

Get Clinical Tree app for offline access