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.     

Extensor mechanism slide for the treatment of proximal interphalangeal joint extension lag: an anatomic study

PURPOSE: We describe a technique for correction of proximal interphalangeal joint (PIP) extensor lag secondary to angulation and/or shortening of proximal phalanx fractures. METHODS: Proximal phalanx fracture malunions with 2.5 mm of shortening, 5.0 mm of shortening, and apex volar angulation of 40 degrees were simulated in 15 cadaver fingers, creating PIP extensor lags. The metacarpophalangeal (MCP) joint was pinned in neutral. Transection of the ulnar and radial sagittal bands, the extensor digitorum communis (EDC) insertion on the MCP joint capsule, and the juncturae tendinae then was performed. The PIP extensor lag before and after each of the earlier-noted releases was recorded. The MCP joint then was freed and MCP hyperextension was recorded. With the MCP joint in neutral position the sagittal bands then were reapproximated with sutures and MCP extension was measured. RESULTS: The 2.5 mm of axial shortening, 5.0 mm of axial shortening, and 40 degrees of apex volar angulation fracture models produced an average extensor lag of 6.2 degrees , 25.8 degrees , and 42.5 degrees , respectively. Maximal correction of PIP extensor lag required transection of both sagittal bands, EDC insertion on the MCP capsule, and the juncturae tendinae with an average residual extensor lag of -0.8 degrees for the 2.5-mm shortening model, 0.7 degrees for the 5.0-mm shortening model, and 3.2 degrees for the 40 degrees -angulation model. The MCP joint hyperextension increased by 20 degrees to 30 degrees after the releases but decreased to only 1.8 degrees if the sagittal bands were reapproximated to the EDC tendon at their new resting position with the MCP joint in neutral position. CONCLUSIONS: In the cadaver model the PIP extensor lag can be improved substantially by transection of the sagittal bands, release of the EDC insertion on the MCP capsule, transection of the juncturae tendinae, and reapproximation of the sagittal bands to the EDC tendon.     

Anatomy of the juncturae tendinum of the hand

Three distinct morphologic types of juncturae tendinum of the extensor tendons were identified in the dissection of 40 cadaver hands. Type 1 juncturae consists of filamentous regions within the intertendinous fascia that attached to the extensor tendons on either side of the intermetacarpal space in a transverse or oblique direction. The second type, consists of much thicker and well-defined connecting bands. Type 3 juncturae consist of tendon slips from the extensor tendons and were subclassified into "y" or "r" subtypes depending on shape. Type 1 juncturae were present in 88% of the second intermetacarpal spaces and in 28% of the third intermetacarpal spaces. Type 2 juncturae were present in 40% of the third intermetacarpal spaces and in 23% of the fourth intermetacarpal spaces. Type 3 juncturae were present in 33% of the third intermetacarpal spaces and in 80% of the fourth intermetacarpal spaces. Juncturae were absent in all of the first intermetacarpal spaces and in 12% of the second intermetacarpal spaces; they were present in all other spaces. The extensor indicis proprius did not receive a junctural connection, whereas extensor digiti quinti tendons did receive junctural connections. Intertendinous fascia was present between all extensor digitorum communis tendons regardless of presence of juncturae.     

Extensor quadriga: Pathomechanics and treatment

The extensor tendons to the index, long, ring and small fingers are motored by the common extensor digitorum communis muscle body. Effective function of this muscle can only occur if the gliding amplitude of each of its four extensor tendons is normal. As a corollary, limitation of the excursion of any of the individual tendons by adhesions at a fracture or tendon repair site, a fixed flexion contracture at the metacarpophalangeal joint, or by rupture, attenuation or laceration of a saggital band or juncturae tendinum, will result in reduction of the excursion of the adjacent extensor tendons. This pathological state has been termed the extensor quadriga because of its similarities to the analogous pathology affecting the flexor digitorum profundus system. Improper management of this clinical entity may lead to an abnormal pathomechanical kinematic chain imbalance. Early identification and treatment is critical to address this entity appropriately.     

Relative motion extension management of zones V and VI extensor tendon repairs: Does international practice align with the current evidence?

Study DesignElectronic Web-based survey.IntroductionTherapists participating in an international survey selected relative motion extension (RME) as the “most used” approach for the postoperative management of zones V and VI extensor tendon repairs. A subgroup of respondents identified RME as their preferred approach and were asked about their routine RME practices.Purpose of the StudyThe purpose of this study was to capture data from routine RME users about their practices and compare this with the RME evidence.MethodsAn English-language survey was distributed to 36 International Federation of Societies for Hand Therapy full-member countries. Participation required therapists to have postsurgically managed at least one extensor tendon repair within the previous year. Those who selected RME as their “most used” approach were asked to identify which variation of the RME approach they favored: RME plus (with wrist orthosis), RME only, or “both” RME plus and RME only, and then were directed to additional questions related to their choice.ResultsRespondents from 28 International Federation of Societies for Hand Therapy full-member countries completed the survey. RME users (N = 368; 41.5% of sample) contributed to this secondary data. Respondents favored the RME variation “RME plus” (47%), followed by “both” (44%), then “RME only” (9%) with most managing single digit/simple injuries (n = 287, 81%) versus multiple digit/complex injuries (n = 96, 27%), and partial repairs (n = 278, 79%).DiscussionPractices not aligning with limited level II-IV evidence includes half of RME only users not adding/substituting an overnight orthosis; use of RME plus versus RME only for both repairs of independent extensor tendons and repairs proximal to the juncturae tendinum; fabrication of three not four-finger orthotic design; and restricting use to only repairs of one or two fingers.ConclusionsRME plus and RME only are used interchangeably depending on surgeon preferences and patient/tendon factors. Compared with RME plus, from this survey, it appears that the RME only approach yields similar uncomplicated, early return of motion and hand function.     

Junctura anatomy.

Detailed dissection of 240 cadaver hands was undertaken, with particular attention to the connections between the extensor tendons. Three types of junctura were clearly identified: fascia, ligament, and tendon. Each hand had three juncturae. The most frequent presentation was for the three juncturae to be fascia-ligament-tendon, from radial to ulnar. A few aberrations of extensor tendon anatomy were also discovered, which might affect their use in tendon transfers.     

Anatomy and functional significance of the long extensors to the fingers and thumb

Intrinsic and extrinsic hand muscles power finger extension. These two muscle groups have different anatomy that allows complimentary function at the interphalangeal joints and opposing function at the metacarpophalangeal joints. Independent extension of each finger is not possible because of anatomic constraints including the juncturae tendinum and intertendinous fascia between the extrinsic extensor tendons on the dorsum of the hand. Anatomic variations of the extrinsic extensor tendons are frequent and knowledge is important when assessing the traumatized or diseased hand.     

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.     

Independent index extension after extensor indicis proprius transfer

The extensor indicis proprius was used to restore mobility to a variety of hand movements in 27 patients. Retained independent index finger extension was obtained in a majority of patients postoperatively. Potential postoperative complications of index extension lag and deviation may be avoided if the extensor indicis proprius is sectioned immediately proximal to the dorsal hood. A corresponding laboratory study was undertaken to better define the anatomic constraints limiting independent finger extension. Distinct differences between juncturae tendinum and extensor compartment musculature help explain why the index finger may function as a relatively independent unit.     

Concomitant injuries affect prognosis in patients with central slip tear

Central slip tears often occur with concomitant hand injuries. However, the outcome of a central slip tear and the effect of concomitant injuries are rarely reported. We evaluated 67 fingers in 63 patients with central slip tears who underwent primary surgery in our hospital between April 2009 and June 2017. We performed multivariate analyses, with proximal interphalangeal (PIP) joint active range of motion (AROM) and existing extension lag greater than 10° as dependent variables and age, existence of concomitant fractures, skin defects, collateral ligament injuries, ruptured lateral bands, ruptured flexor tendons or vascular injury in the injured finger as independent variables. Concomitant injuries of tendons in the adjacent fingers were also independent variables. The average AROM of the PIP joint was 62°, and extension lag occurred in 34 fingers (51%). Patients aged?>?40 years with fractures of the injured finger or flexor tendon injuries in an adjacent finger had low decreases in AROM (partial regression coefficient [95% confidence interval, CI]: ?13.7 [43–66], ?31.6 [30–57], ?34.5 [32–60] and ?33.5 [10–43]). Extensor tendon injuries in an adjacent finger caused significantly more extension lag in the PIP joint (odds ratio [95% CI]: 3.2 [1.0–9.6]). The present study indicated the negative impact of a tendon injury on adjacent fingers, a circumstance widely known as the quadriga phenomenon. Ultimately, we can use these prognostic factors in surgical repair planning, particularly when comparing treatments such as central slip reconstruction and primary arthrodesis.     

Tendon injuries across the world: treatment

This article outlines current status of primary and secondary surgical treatment of flexor and extensor tendon injuries in the hand and rehabilitation regimens worldwide. Unsolved problems associated with tendon repairs in the hand are tendon adhesions, rupture of the repairs, finger stiffness, power of hand motion, and surgical skills. Future development may include improvement of tendon healing through biological approaches, repair techniques, and, in particular, establishment of adequate rehabilitation systems and training of surgeons in some regions of the world.     

Treatment of a zone III extensor tendon injury using a single relative motion with dorsal hood orthosis and a modified short arc motion protocol—A case report

Study DesignCase report.IntroductionZone III extensor tendon injuries are typically treated with early mobilization or by a period of immobilization followed by gradual motion. In both scenarios, the use of multiple orthoses is required.Purpose of the studyThis case report examines the effective use of a single, modified relative motion orthosis throughout the protected rehabilitation phase after a zone III extensor tendon repair.MethodsA patient with extensor tendon zone III laceration to his index finger (10th revision of the International Statistical Classification of Diseases and Related Health Problems s66.328) was treated using a single, relative motion with dorsal hood orthosis. The exercise protocol followed a modified immediate short arc motion program.ResultsFollowing laceration and complete rupture of the central slip, the patient regained full range of motion, strength, and function.DiscussionIt is becoming more common to use a relative motion flexion (RMF) orthosis to correct or improve extensor lag due to boutonniere deformity or stiffness after finger fractures. There is very little literature to support the use of the RMF orthosis after zone III extensor tendon repair. To produce a single orthosis that is useful through the entire protected phase of rehabilitation, the RMF orthosis is easily modified by addding a dorsal hood to create the relative motion dorsal hood orthosis (RMDH).ConclusionOur case report shows the successful treatment of a zone III extensor tendon repair using a single relative motion with dorsal hood orthosis and early active motion throughout the entire protected phase of rehabilitation.     

A brief review of extensor tendon injuries specific to the pediatric patient

Extensor tendon injuries in the pediatric population require careful evaluation and treatment. This article focuses on the differences in injury type and treatment of pediatric versus adult extensor tendon injuries. A detailed history and physical examination is crucial in the management of extensor tendon injuries of the young patient. Treatment of pediatric extensor tendon injuries depends largely on the site of injury. A majority of these injuries may be treated with splinting or primary repair. Treatment methods that require high compliance must be adjusted for the young child.     

改良Mason-Allen缝合技术修复Ⅰ、Ⅱ区指伸肌腱损伤

目的 报道改良Mason-Allen缝合技术修复Ⅰ和Ⅱ区指伸肌腱损伤的临床效果.方法 采用改良的Mason-Allen缝合技术修复Ⅰ和Ⅱ区指伸肌腱150例230指.结果 术后观察,伤指均未发生肌腱再断裂;大部分伤指屈伸运动功能恢复近乎完全,无需行肌腱松解术.少数伤指合并骨折,固定时间较长,因此,肌腱粘连较重,进行了肌腱松解术.结论 改良Mason-Allen缝合技术修复Ⅰ和Ⅱ区指伸肌腱损伤效果满意,可应用于临床.     

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.     

Transfer of either index finger extensor tendon to the extensor pollicis longus tendon

BACKGROUND:

Extensor pollicis longus (EPL) tendon ruptures have been treated succesfully with the transfer of the extensor indicis proprius (EIP) tendon. Situations exist in which, due to intraoperative observations, another tendon transfer may be considered preferable to the standard EIP transfer method.

OBJECTIVES:

To determine whether transfer of the extensor digitorum communis II (EDC II) tendon from the index finger to the EPL tendon, leaving the EIP tendon to the index finger intact, would serve as an equally efficient transfer and not adversely affect the function of the hand.

METHODS:

Two patients who had the EDC II tendon transferred to the ruptured EPL tendon, and two patients who had the EIP tendon transferred, were retrospectively reviewed. In each transfer type, one patient had suffered an EPL tendon rupture after a Colles’ fracture, and the other had rheumatoid arthritis. The rupture occurred on the non-dominant side in one patient in each transfer type. Each patient was examined and subjected to range of motion and power testing at least one year following surgery.

RESULTS:

All four patients showed a minimal extension lag with the lift off test, but there was no noticeable difference in range of motion, pinch grip and hand grip strength between the transfer types. Both EDC II transfer patients demonstrated an 8° to 15° loss of thumb interphalangeal joint flexion compared with the unoperated side; EIP transfer patients demonstrated less than a 5° loss. Three patients demonstrated a minor extension lag in the index finger and middle finger. Extension power of the thumb and index finger in all patients varied with wrist flexion and extension and ranged from 50% to 150% of the unoperated side.

CONCLUSIONS:

These case reports suggest that either index finger tendon may be successfully transferred in EPL tendon ruptures.     

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.     

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.     

A survey of extensor pollicis longus tendon injury at the time of distal radius fractures

BackgroundThe purpose of this study is to investigate the presence or absence, incidence, and degree of extensor pollicis longus (EPL) tendon injury by visual confirmation of the EPL at the time of osteosynthesis for distal radius fractures.MethodsThe subjects were 25 patients (5 males and 20 females; mean age: 56 years) with distal radius fracture that had a dorsal roof fragment. During osteosynthesis using a volar locking plate, the third compartment was exposed in order to determine the EPL injury. The survey items in this study were: incidences of the forms of EPL injury (1: absent, 2: tendon floor fibrillation, and 3: laceration), and the presence or absence of periosteal rupture on the EPL tendon floor. In addition, on the final follow-up, the presence or absence of EPL rupture, the range of wrist motion, grip strength, Visual Analog Scale (VAS) score, Quick Disabilities of the Arm, Shoulder and Hand (Q-DASH) score, and the Mayo wrist score were investigated.ResultsDuring the operation, EPL injury was classified as: 1) absent (12%), 2) tendon floor fibrillation (52%), or 3) laceration (36%). In the EPL tendon floor, periosteal rupture was observed in all patients. The mean postoperative follow-up period was 8 months (6–12 months) and no EPL rupture was observed in any patient. The wrist range of motion was 71° for flexion, 75° for extension, 84° for pronation, and 85° for supination, and the grip (% compared with the unaffected side) was 79%. The VAS, Q-DASH and Mayo scores were 1, 10 and 93 respectively.ConclusionThis study showed a high incidence of EPL tendon injury at the time of distal radius fractures (88%). To improve the ambient environment of the damaged tendon may be useful in terms of the prevention of tendon injury.     

Postoperative hand therapy management of zones V and VI extensor tendon repairs of the fingers: An international inquiry of current practice

Study DesignElectronic Web-based survey.IntroductionEvidence supports early motion over immobilization for postoperative extensor tendon repair management. Various early motion programs and orthoses are used, with no single approach recognized as superior. It remains unknown if and how early motion is used by hand therapists worldwide.Purpose of the StudyThe purpose of this study was to determine if there is a preferred approach and identify practice patterns for constituents of International Federation of Societies for Hand Therapy full-member countries.MethodsParticipation in this English-language survey required respondents to have postoperatively managed at least one extensor tendon repair within the previous year. Approaches surveyed included programs of immobilization, early passive (EPM), and early active (EAM) with motion delivered by resting hand, dynamic, palmar/interphalangeal joints (IPJs) free, or relative motion extension (RME) orthoses. Survey flow depended on the respondent's answer to their “most used” approach in the previous year.ResultsThere were 992 individual responses from 28 International Federation of Societies for Hand Therapy member countries including 887 eligible responses with an 81% completion rate. The order of most used program was EAM (83%), EPM (8%), and immobilization (7%). The two most used orthoses for delivery of EAM were RME (43%) and palmar/IPJs free (25%). The RME orthosis was preferred for earlier recovery of hand function and motion. Barriers to therapists wanting to use the RME/EAM approach related to preference of surgeon (70%) and clinic (24%).DiscussionIn practice, many therapists select from multiple approaches to manage zone V and VI extensor tendon repairs. Therapists believed TAM achieved with the RME/EAM approach was superior to the other approaches. Contrary to the literature, in practice, many therapists modify forearm-based palmar/IPJs free orthosis to exclude the wrist to manage this diagnosis.ConclusionsThe RME/EAM approach was identified as the favored approach. Practice patterns and evidence did not always align.