Closed treatment of nonrheumatoid extensor tendon dislocations at the metacarpophalangeal joint

PURPOSE: Acute sagittal band injuries at the metacarpophalangeal (MCP) joint resulting in subluxation or dislocation of the extensor tendons may cause pain and swelling at the MCP joint and limit active extension of the MCP joint. These injuries often are treated with surgical repair or reconstruction. This article outlines a nonsurgical treatment protocol that uses a customized splint for acute, nonrheumatoid extensor tendon dislocations caused by injury to the sagittal bands. METHODS: We retrospectively reviewed 10 patients with 11 acute sagittal band injuries who were treated with a splint of thermally molded plastic that differentially holds the injured MCP joint in 25 degrees to 35 degrees of hyperextension relative to the adjacent MCP joints. All the sagittal band ruptures resulted in complete dislocation of the extensor digitorum communis (EDC) tendon-Rayan and Murray type III injuries. Active proximal interphalangeal and distal interphalangeal motion was begun immediately at the time of initial splinting. The average follow-up period was 14 months. RESULTS: At the time of final evaluation all patients had full range of motion in flexion and extension. Eight patients had no pain and 3 had moderate pain. Four patients (5 digits) had no extensor tendon subluxations and 3 had barely discernable subluxations. Three patients had moderate subluxation of the EDC tendon and their treatments were considered failures. One of these patients had subsequent sagittal band reconstruction. CONCLUSIONS: Our results show acute sagittal band injuries in nonrheumatoid patients resulting in dislocation of the EDC tendon can be managed nonsurgically in many patients with a customized splint called the sagittal band bridge. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.     

指伸肌腱滑脱的原因分析与手术要点

目的　探讨指伸肌腱滑脱的损伤机制、手术方法和术后复发的关系。方法　 1987年至 1999年 ,在 17例指伸肌腱滑脱手术中 ,在修复矢状束、腱帽和关节囊损伤的同时 ,重视了腱间筋膜的修复。通过模拟实验 ,分析腱间筋膜、矢状束和腱帽在指伸肌腱滑脱中的作用。结果　术后随访 3个月～ 10年 ,17例伸指功能均恢复正常 ,未见复发者。实验结果证实 ,切断指伸肌腱桡侧矢状束和腱帽 ,仅引起指伸肌腱的部分滑脱 ,此时切断腱间筋膜则引起其向尺侧的完全滑脱。结论　矢状束和腱帽损伤的同时 ,伴有腱间筋膜损伤是该症关键的病理机制。手术修复腱间筋膜是防止复发的根本     

Subluxation of the Extensor Carpi Ulnaris Tendon Associated with the Extensor Digitorum Tendon Subluxation of the Long Finger

A twenty-year-old male visited our clinic with wrist and long finger metacarpophalangeal (MP) joint pain. Dynamic ultrasonography revealed sagittal band (SB) ulnar subluxation and extensor carpi ulnaris (ECU) volar subluxation. Magnetic resonance imaging showed longitudinal splitting and dislocation of the volar half slip of the ECU tendon. The redundant radial SB was augmented and ECU sheath was advanced to the periosteum using suture anchors. He was able to perform his previous activities at the last follow-up. We encountered a case of "simulateous" ECU dislocation with extensor tendon subluxation of the long finger at the MP joint. Therefore, we report this case with a review of the relevant literature.     

Dynamic lumbrical muscle transfer for correction of posttraumatic extensor tendon subluxation

Posttraumatic ulnar subluxation of the extensor tendon over the metacarpal head results from rupture of the radial sagittal fibers. The patient will complain of limited digital extension and pain. Various techniques have been described to correct the disorder by either reefing the sagittal fibers or using a slip of extensor tendon around the radial collateral ligament. Unfortunately, these techniques are either technically not feasible, reefing of the sagittal fibers, or result in significant stiffness, using a strip of extensor tendon. The author describes an extraarticular technique which uses a dynamic muscle transfer that is synergistic with metacarpophalangeal flexion.     

Chronic painful subluxation of the metacarpal phalangeal joint extensor tendons

Chronic subluxation of the extensor tendons of the metacarpal phalangeal joint has been documented in six patients on active duty in the United States Navy. These patients had painful full flexion and gripping in the knuckle, especially when they were performing their jobs. No extension lag was noted. Three patients had a severed junctura tendinum between the long and index fingers, which was believed to be a contributing factor to extensor tendon subluxation. Local anesthesia was administered to these patients, and the lesions were surgically corrected by reefing of the extensor hood and the sagittal band and repair of the junctura tendinum.     

The sagittal band: anatomic and biomechanical study

Forty-eight digits from 12 human adult fresh-frozen and formalin-preserved cadaveric hands were used to study the anatomy and biomechanics of the sagittal band (SB) and to investigate the mechanism of its injury. The SB was observed to be part of a complex retinacular system in proximity to the metacarpophalangeal (MCP) joint collateral ligaments and the palmar plate. Dynamic changes in SB fiber orientation were observed with different positions of the MCP and wrist joints. The fibers were perpendicular (0 degrees ) to the extensor tendon in neutral position, distally angulated 25 degrees at 45 degrees of MCP flexion, and 55 degrees with full flexion. Swan-Ganz catheter measurements were obtained deep to the SB in varying positions of the MCP joint. The average pressure generation was greatest (50 mm Hg) during full MCP joint flexion and least (30 mm Hg) during 45 degrees flexion. When MCP joint radial or ulnar deviation was added the average measurement was greatest (57) in neutral MCP position and least (35 mm Hg) in 45 degrees flexion. Serial sectioning of the ulnar SB produced no extensor tendon instability. Partial proximal but not distal sectioning of the radial SB produced tendon subluxation. Complete sectioning of the radial SB produced tendon dislocation. Wrist flexion increased tendon instability after radial SB sectioning. We conclude that (1) extensor tendon instability following SB disruption is most common in the long finger and least common in the small finger; (2) ulnar instability of the extensor tendon is due to partial or complete radial SB disruption, (3) the degree of extensor tendon instability is determined by the extent of SB disruption, (4) proximal rather than distal SB compromise contributes to extensor tendon instability, (5) great forces are inflicted on the SB while the MCP joint is in full extension or less frequently in full flexion, which may be the mechanism of its injury, and (6) wrist flexion contributes to extensor tendon instability after SB disruption and may exacerbate the severity of its injury.     

Relationship Between Juncturae Tendinum and Sagittal Bands

The juncturae tendinum and sagittal bands transmit precise forces through the dorsum of the hand. Both structures are integral in the mechanics of normal digital extension and in stabilization of the metacarpophalangeal (MCP) joints. Extensor tendon injury, or rupture/attenuation of sagittal bands and/or juncturae tendinum, may disrupt the kinematic chain and lead to a number of abnormal hand postures and motions. Early treatment of extensor tendon and/or sagittal band injury is dependent upon proper recognition of primary pathology. Proper evaluation and the use of special clinical tests should be implemented to rule out other pathologies. Once diagnosed, treatment may consist of relative motion splinting and standard pain/edema control measures to increase joint motion, tendon excursion, and functional use of the hand.     

Extensor tendon dislocation in cerebral palsy.

An 18-year-old man with cerebral palsy presented with a flexion deformity of the middle finger particularly at the metacarpophalangeal joint and ulnar dislocation of the extensor tendon. Releasing the tight ulnar sagittal band and imbricating the attenuated radial sagittal band allowed centralization of the extensor tendon. For complete correction of other deformities intrinsic release and extrinsic flexor muscle lengthening were done. Extensor tendon instability in this case was due to the combined forces of the extrinsic and intrinsic muscles on the retinacular system of the extensor mechanism.     

Extension limitation and deviation of fingers by the scarred junctura tendinum: a case report

The juncturae tendinum (inter-extensor connections) are structures connecting each of the extensor digitorum communis (EDC) tendons. Nine months before the presentation to us, this 21-year-old man had painful swelling on the dorsum of the right hand after punching. At present, the patient showed an ulnar deviation of the long finger and a limited extension of the ring finger. The scarred junctura tendinum between long and ring fingers inhibited proximal sliding of the EDC tendon of ring finger, and affect the functions of adjacent metacarpophalangeal joint. The scarred junctura tendinum was resected, while the sagittal band was preserved to prevent subluxation of the EDC tendon of long finger. One year after operation, the range of motion of fingers was full.     

Anomalous tendon to the middle finger for sagittal band reconstruction: report of 2 cases

Multiple techniques with good outcomes have been described for sagittal band reconstruction. We describe 2 cases of sagittal band reconstruction using an anomalous slip of the extensor tendon to the middle finger. This anomalous slip can be a resource for surgical reconstruction that can add stability to primary sagittal band repair.     

The Skier's Thumb: Ulnar Displacement of the Extensor Pollicis Longus Tendon - a New Type?

The incidence of disruption of the ulnar collateral ligament of the thumb's metacarpophalangeal joint (skier's thumb, gamekeeper's thumb) has increased over the past 20 years. Six different types of injury could be defined. Soft tissue interposition in the joint as well as radial dislocation of the extensor pollicis tendon have been described. We present the case of a skier's thumb with ulnar dislocation of the extensor pollicis longus tendon and tendon interposition in the joint provoking subluxation. The question arises if it possibly constitutes a new, seventh type of this injury.     

Chronic ulnar wrist pain secondary to partial rupture of the extensor carpi ulnaris tendon

An unusual case of symptomatic partial rupture of the extensor carpi ulnaris (ECU) tendon after trauma is described. The patient was successfully treated by surgical removal of a prominent ulnar ridge, debridement of the ECU tendon, and ECU subsheath reconstruction. Extensor carpi ulnaris subluxation and partial rupture should be considered in the differential diagnosis of a patient with chronic ulnar wrist pain.     

Congenital flexion deformity of the middle finger and sagittal band hypoplasia

PURPOSE: To report a congenital anomaly of the middle finger. METHOD: Nine patients (16 digits) are reported with congenital flexion deformity of the metacarpophalangeal (MCP) joint of the middle finger. Three patients (4 digits) had isolated deformities to the middle finger and in 6 the deformity was part of congenital ulnar drift (CUD) of the hand. Three patients had Freeman-Sheldon syndrome, 2 had nonsyndromic CUD, and 1 had arthrogryposis multiplex congenita. In CUD patients the middle finger had substantially greater flexion deformity of the MCP joint in comparison with other digits. Seven patients were treated surgically and 2 were treated nonsurgically. Five of the surgical patients had bilateral middle finger involvement. RESULTS: During surgery on 12 digits sagittal band hypoplasia of varying degrees was encountered in all patients and in all patients the extensor tendon of the middle finger was underdeveloped and often ulnarly displaced. Longitudinal imbrication of the remnants of the extensor tendon and centralizing the tendon if necessary by radial sagittal band reefing improved MCP joint flexion deformity. CONCLUSIONS: Congenital middle finger-in-palm deformity in our patients was caused by sagittal band and extensor tendon hypoplasia.     

Dynamic assist splinting for attenuated sagittal bands in the rheumatoid hand

The extensor mechanism of the hand is complex, requiring effective functioning of all involved structures, including the sagittal bands. The sagittal bands function to maintain the extensor tendons in midline and to limit their distal excursion. Injury to the sagittal bands or sagittal band attenuation can cause instability and ulnar displacement/subluxation of the extensor tendons into the valleys between the digits and lead to a subsequent loss of active finger extension at the metacarpophalangeal joints. Secondary conditions may also develop, such as swan-neck deformity, as is frequently observed in the rheumatoid arthritis population. To prevent or reduce an extension lag and secondary changes and to maintain the functional use of the hand, a dynamic metacarpophalangeal extension assist splint is necessary. This splint enables extension at the metacarpophalangeal joints, thus enabling the functional use of the hand. This article reviews the biomechanics of the sagittal bands and the corrections that enable finger extension at the metacarpophalangeal joints, thus preventing secondary conditions.     

The Skier's Thumb: Ulnar Displacement of the Extensor Pollicis Longus Tendon – a New Type?

The incidence of disruption of the ulnar collateral ligament of the thumb's metacarpophalangeal joint (skier's thumb, gamekeeper's thumb) has increased over the past 20 years. Six different types of injury could be defined. Soft tissue interposition in the joint as well as radial dislocation of the extensor pollicis tendon have been described. We present the case of a skier's thumb with ulnar dislocation of the extensor pollicis longus tendon and tendon interposition in the joint provoking subluxation. The question arises if it possibly constitutes a new, seventh type of this injury.     

Late spontaneous rupture of extensor pollicis longus tendon after blunt trauma with no residual fracture

Spontaneous rupture of extensor pollicis longus tendon was first reported by Dupley in 1876. This rupture has been reported after distal radius fracture (Colles fracture), rheumatoid arthritis, steroid injections or systemic steroid treatment, and occupational tenosynovitis. The main etiologies of this rupture are the fracture of the tendon over the irregular bone surface following the fracture or inflammatory processes as in rheumatoid arthritis. Most ruptures are usually found at Lister’s tubercle. Some authors suggested ischemic etiology in the cases following wrist trauma with no residual fracture. We describe a case of rupture of the extensor pollicis longus tendon 1 month after a blunt wrist trauma with no residual fracture. The rupture was at the myotendinous junction (MTJ). To highlight on this rupture, we believed it was caused from both vascular and mechanical factors. The mechanical factor was the position of the myotendinous junction under the extensor retinaculum. The vascular factor was the nature of the myotendinous junction being the most sensitive to ischemia.Level of Evidence: Level V, diagnostic study.     

Results of primary extensor tendon repair in relation to the zone of injury and pre-operative outcome estimation

Introduction The outcome of primary extensor repair in hand surgery has been widely explored, but little systematic effort has been made to investigate the influence of the anatomical zone of tendon injury. Therefore, the aim of our study was to assess the outcome of primary extensor tendon repair with a special focus on the pre-operative state and Verdan’s anatomical zones. Our hypothesis being tested was that the outcome after primary extensor repair depends on the complexity of trauma and the site of lesion. Materials and methods One hundred and seventy seven patients with 203 extensor tendon repairs were studied. After tendon repair and a 6-week protective immobilization, physiotherapy was carried out. A score proposed by Geldmacher and Schwarzbach was applied to estimate the outcome pre-operatively and to assess the results in a follow-up after a mean of 13 months. Correlations were tested between the anatomical zone of tendon injury, the pre-operative expectation and the results as considered both by the patient and the physician. Results In Verdan’s zones 1, 2, 4 and 5, excellent or good results were obtained in the vast majority of patients. Due to a higher frequency of complex injuries with concomitant soft tissue and bony injuries, the outcome was significantly worse after tendon repair in zones 3 and 6, as expected after the pre-operative estimation. In addition, a strong correlation was found for all anatomical zones between the pre-operative estimation and the outcome as judged both by the physician and the patient. Conclusion Recovery of finger function after primary extensor tendon repair depends on the complexity of trauma and the anatomical zone of tendon injury. Static splinting is an appropriate tool after primary extensor tendon repair in Verdan’s zone 1, 2, 4 and 5, whereas injuries in zones 3 and 6 may demand for a different treatment regimen.     

Nonoperative treatment of traumatic dislocations of the extensor digitorum tendons in patients without rheumatoid disorders

Traumatic subluxation and dislocation of the extensor digitorum tendons are uncommon in patients without rheumatoid disorders. Management of the acute injury is not well defined in the orthopedic literature. Two cases of traumatic dislocations of the extensor digitorum tendon were seen acutely in young persons without rheumatoid disease. These patients were successfully managed by early closed reduction and immobilization. This treatment had yielded good hand function to date, without recurrence of the dislocation. One of these cases was particularly unusual in that the direction of the tendon dislocation was radial. This particular injury has not been previously described.     

Traumatic boutonniere deformity of the thumb

We report three patients who presented 3 to 8 months after sustaining a closed injury to the dorsoradial aspect of the metacarpophalangeal joint of the thumb. All three patients had an extensor lag of the metacarpophalangeal joint and paradoxical hyperextension of the interphalangeal joint. There were no collateral ligament injuries. The patients required surgical treatment which included advancement and reattachment of the extensor pollicis brevis insertion and imbrication of the dorsoradial capsule to restore the anatomical alignment of the extensor pollicis longus. Surgical treatment of dorsoradial injuries to the thumb metacarpophalangeal joint may be required for injuries that result in subluxation of the extensor pollicis longus tendon and a boutonnière deformity of the thumb.     

Excision of aberrant abductor pollicis longus tendon slips for decompression of de Quervain's disease

Release or excision of the first extensor compartment is a commonly performed surgical procedure to treat de Quervain's disease. This technique can potentially cause palmar subluxation of the extensor tendons. The abductor pollicis longus (APL) tendon has multiple slips which can be used as a resource for tendon transfer without loss of function. The technique described in this paper is decompression of the first extensor compartment by excision of an aberrant APL tendon slip without releasing the first extensor compartment. This technique was used in 24 wrists in 21 patients, and outcome assessed. All our patients had relief from pain and tenderness. No patients needed immobilization and none had subluxation of the extensor tendons. Patients without workers' compensation returned to work 15 days after surgery.