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A Novel Technique for the Treatment of Jersey Fingers

Publish date: May 9, 2018

TAKE-HOME POINTS

Transosseous repair of FDP has been long utilized, tying the sutures over a polyethylene button at the nail plate, which is associated with significant complications.
Avoiding use of a button decreases these complications, eliminating damage to the nailbed and eliminating external sutures, thus decreasing infection risk.
Keith needles can be utilized to pass the sutures from volar to dorsal, and can be inserted using a wire drive; their position can be checked fluoroscopically prior to suture passage.
This technique can be used in conjunction with skeletal fixation of associated fractures.
This technique can be utilized in pediatric patients, placing the sutures distal to the physis.

References

1. Leddy JP, Packer JW. Avulsion of the profundus tendon insertion in athletes. J Hand Surg Am. 1977;2(1):66-69. doi:https://doi.org/10.1016/S0363-5023(77)80012-9.

2. Langa V, Posner MA. Unusual rupture of a flexor profundus tendon. J Hand Surg Am. 1986;11(2):227-229. doi:https://doi.org/10.1016/S0363-5023(86)80056-9.

3. Ehlert KJ, Gould JS, Black KP. A simultaneous distal phalanx avulsion fracture with profundus tendon avulsion: A case report and review of the literature. Clin Orthop Relat Res. 1992;(283):265-269.

4. Smith JH. Avulsion of a profundus tendon with simultaneous intraarticular fracture of the distal phalanx–case report. J Hand Surg Am. 1981;6(6):600-601. doi:10.1097/00006534-198305000-00081.

5. Al-Qattan MM. Type 5 avulsion of the insertion of the flexor digitorum profundus tendon. J Hand Surg Br. 2001;26(5):427-431. doi:10.1054/jhsb.2001.0619.

6. Bunnell S. Surgery of the hand, 2nd edition. Philadelphia, PA: JB Lippincott; 1948:381-466.

7. Hallock GG. The Mitek Mini GII anchor introduced for tendon reinsertion in the hand. Ann Plast Surg. 1994;33(2):211-213.

8. Sood MK, Elliot D. A new technique of attachment of flexor tendons to the distal phalanx without a button tie-over. J Hand Surg Br. 1996;21(5):629-632. doi:https://doi.org/10.1016/S0266-7681(96)80146-X.

9. Schultz RO, Drake DB, Morgan RF. A new technique for the treatment of flexor digitorum profundus tendon avulsion. Ann Plast Surg. 1999;42(1):46-48. doi:10.1097/00000637-199901000-00008.

10. Manske PR, Lesker PA. Avulsion of the ring finger flexor digitorum profundus tendon: An experimental study. Hand 1978;10(1):52-55. doi:https://doi.org/10.1016/S0072-968X(78)80025-4.

11. Gerbino PG, Saldana MJ, Westerbeck P, Schacherer TG. Complications experienced in the rehabilitation of zone I flexor tendon injuries with dynamic traction splinting. J Hand Surg Am. 1991;16(4):680-686. doi:https://doi.org/10.1016/0363-5023(91)90194-G

12. Evans RB. Zone I flexor tendon rehabilitation with limited extension and active flexion. J Hand Ther. 2005;18(2):128-140. doi:10.1197/j.jht.2005.02.001

13. Kang N, Marsh D, Dewar D. The morbidity of the button-over-nail technique for zone 1 flexor tendon repairs. Should we still be using this technique? J Hand Surg Eur Vol. 2008;33(5):566-570. doi:10.1177/1753193408090118

14. Taras JS. Flexor tendon reconstruction: Single stage flexor tendon grafting: FDP, FDS disrupted. In: Green DP, Hotchkiss RN, Pederson WL, Wolfe SW, eds. Green’s Operative Hand Surgery. 5th ed. Philadelphia, PA: Elsevier Health Sciences; 2005:248-249.

15. McCallister WV, Ambrose HC, Katolik LI, Trumble TE. Comparison of pullout button versus suture anchor for zone I flexor tendon repair. J Hand Surg Am. 2006;31:246-251. doi:10.1016/j.jhsa.2005.10.020

16. Matzsuzaki H, Zaegel MA, Gelberman RH, Silva MJ. Effect of suture material and bone quality on the mechanical properties of zone 1 flexor tendon-bone reattachment with bone anchors. J Hand Surg Am. 2008;33(5):709-717. doi:10.1016/j.jhsa.2008.01.025

17. Singh R, Kakarala G, Persaud I, Roberts M, Strandring S, Compson J. The optimal length of tissue anchors for distal phalanges. A study in 395 cadaver digits. J Bone Joint Surg Br. 2006;88-B(SUPP I):37.

18. Giannikas D, Athanaselis E, Matzaroglou C, Saridis A, Tyllianakis M. An unusual complication of Mitek suture anchor use in primary treatment of flexor digitorum profundus tendon laceration: a case report. Cases J. 2009;2:9319. doi:10.1186/1757-1626-2-9319

19. Tiong WH, O'Sullivan ST. Extrusion of bone anchor suture following flexor digitorum profundus tendon avulsion injury repair. J Plast Reconstr Aesthet Surg. 2011;64(9):1242-1244. doi:10.1016/j.bjps.2011.01.016

20. Silva MJ, Hollstien SB, Brodt MD, Boyer MI, Tetro AM, Gelberman RH. Flexor digitorum profundus tendon-to-bone repair: An ex vivo biomechanical analysis of 3 pullout suture techniques. J Hand Surg Am. 1998;23(1):120-126. doi:10.1016/S0363-5023(98)80099-3

21. Latendresse K, Dona E, Scougall PJ, Schreuder FB, Puchert E, Walsh WR. Cyclic testing of pullout sutures and micro-mitek suture anchors in flexor digitorum profundus tendon distal fixation. J Hand Surg Am. 2005;30(3):471-478. doi:10.1016/j.jhsa.2004.10.014

22. Lee SK, Fajardo M, Kardashian G, Klein J, Tsai P, Christoforou D. Repair of flexor digitorum profundus to distal phalanx: a biomechanical evaluation of four techniques. J Hand Surg Am. 2011;36(10):1604-1609. doi:10.1016/j.jhsa.2011.07.017

ABSTRACT

The avulsion of the flexor digitorum profundus from its insertion, or “jersey finger,” is a relatively common injury. Numerous modifications have been made to the classification and treatment of this injury since its initial description. We describe a novel variation of the surgical management of jersey finger.

The avulsion-type injury of the flexor digitorum profundus (FDP) from its insertion on the distal phalanx is relatively common. FDP avulsions are seen in athletes and nonathletes, and are the result of the sudden hyperextension of the distal interphalangeal joint during active flexion. These injuries usually occur while grasping the jersey of an opposing player and are thus commonly referred to as “jersey finger.” Initially described in 1977 by Leddy and Packer¹, FDP avulsions are classified on the basis of the proximal extent of the retraction of the FDP and the presence or absence of a bony avulsion fracture fragment. Type I injuries are defined by tendon retraction to the level of the palm, where it is tethered by the lumbricals. At this level, the vinculum longus profundus (VLP) and vinculum brevis profundus (VBP) are ruptured, resulting in the substantial loss of intrinsic and extrinsic vascular supply to the tendon. In type II injuries, which are the most common type of FDP avulsions, the FDP tendon retracts to the level of the proximal interphalangeal (PIP) joint. Although the VBP is disrupted in this scenario, the VLP remains preserved because it arises at the level of the volar plate of the PIP joint. Type III lesions involve tendon avulsions with an associated bony fragment that is typically sufficiently large to not pass through the flexor sheath, thus limiting retraction to the level of the A4 pulley. Both vincula remain intact, given that the VBP originates at the distal portion of the middle phalanx. The Leddy and Packer classification was later expanded to include type IV and V injury patterns, which are less common than other injury patterns. Similar to type III injuries, type IV injuries involve a bony avulsion; however, the FDP subsequently ruptures from this fragment and the tendon subsequently retracts into the finger or palm.^2,3 Type V injuries are more complex than other injury types because they involve a concomitant distal phalanx fracture with the FDP avulsion.⁴ Al-Qattan⁵ subclassified type V injuries into extra-articular (type Va) and intra-articular (type Vb) distal phalanx fractures on the basis of the distinct management of these 2 entities.

Numerous techniques have been proposed and described for the repair of FDP avulsion injuries. The pullout suture-dorsal button combination is the most widely described technique and was initially described by Bunnell.⁶ Unfortunately, this technique is accompanied by numerous potential postoperative complications.⁶ Nail plate deformity is the most commonly described complication. Other complications include local wound irritation, pain, button snagging, and repair failure. Additionally, the presence of external sutures creates a potential route of ingress for bacterial infection.

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