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Extensor Tendon Injuries in The Hand JAAOS
Extensor Tendon Injuries in The Hand JAAOS
Abstract
Until recently, extensor tendon injuries were often discounted as an important zones, the extensor tendons are
hand problem. However, studies have shown that not all extensor lacerations covered by paratenon, and nutri-
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fare well and that loss of flexion can be problematic. Newer postoperative proto- tion is supplied primarily by perfu-
cols emphasizing tendon gliding have improved results, and better repair tech- sion. The intratendinous vascular
niques and postoperative rehabilitation regimens are under investigation. This architecture outside the retinacu-
article reviews the evaluation of acute open and closed extensor tendon injuries, lum is similar throughout the ten-
their conservative and surgical treatment, and postoperative rehabilitation don, with small branches to the
options. tendon from the surrounding fas-
J Am Acad Orthop Surg 1997;5:59-66 cia.15
In zone VI, the tendons of the
long, ring, and small fingers are
connected by juncturae tendinum
The extensor mechanism of the through VIII, as well as recent that course distally and obliquely.
hand and digits has received con- advances in treatment and rehabili- These interconnections must be
siderable attention in the recon- tation. considered when evaluating exten-
struction of chronic deformities, sor tendon injuries. The extensor
but acute injuries have received far indicis proprius and extensor digiti
less attention. Although the exten- Anatomy quinti, which run ulnar to their
sor mechanism is relatively superfi- respective extensor digitorum com-
cial and therefore easy to expose, The extensor mechanism of the munis (EDC) tendons and allow
operative repair can be technically hand can be divided into eight independent extension of the index
challenging because the extensor zones (Fig. 1) to aid in the evalua- and small fingers, must also be
tendons are thin and flat, are weak- tion and treatment of acute in- considered in an evaluation.
er than flexor tendons, have less juries.13 The even-numbered zones In zone V, the extensor tendons
gliding amplitude, and are difficult are over bones, and the odd-num- are centrally located over the
to suture well. bered zones are over joints. The dif- metacarpal head, held in place by
There has been a resurgence of ferent numbering for the extensor sagittal bands that run on each side
interest concerning acute extensor mechanism of the thumb reflects its
tendon repairs because outcomes smaller number of phalanges.
after traditional static splinting Zone VIII, the most proximal
have been shown to be less than zone, contains the musculotendi-
Dr. Newport is Associate Professor,
acceptable by contemporary stan- nous junction. In zone VII, the ten- Department of Orthopaedic Surgery,
dards. 1-5 Investigations have dons lie within an enveloping University of Connecticut Health Center,
shown that dynamic postoperative tenosynovium and the sheath of Farmington.
protocols can improve the out- the extensor retinaculum over the
come. 6-10 Stronger suture repair wrist joint. Under normal circum- Reprint requests: Dr. Newport, Department of
Orthopaedic Surgery, University of
techniques and postoperative pro- stances, diffusion is responsible for
Connecticut Health Center, 10 Talcott Notch
tocols with active motion are cur- most of the tendon nutrition in this Road, Farmington, CT 06034-4037.
rently being developed. 11,12 This region. 14 The vascular supply is
article will review the diagnosis derived from the mesotendon, Copyright 1997 by the American Academy of
and treatment of acute open and which runs the entire length of the Orthopaedic Surgeons.
closed extensor injuries in zones I retinaculum. In the remaining
A B
Fig. 2 A, Traditional dynamic extension splint. B, Dynamic extension splint modified with dorsal hood to minimize extensor muscle
activity.
principles developed for flexor ten- activity has not been shown to best repair in zone VI, providing
don rehabilitation whereby protect- cause extensor repair rupture with the optimal combination of tendon
ed gliding of tendons decreases standard dynamic splinting, it does shortening, resultant MCP and PIP
adhesion formation without caus- point to a peril peculiar to extensor range of motion, and repair
ing undue stress at the repair site. tendon repair. 6-8 Many assump- strength.23 The modified Bunnell
Although Duran estimated that 3 to tions based on flexor tendon repair, and modified Kessler techniques
5 mm of excursion is required to but without substantiation for are equally effective in zone IV.24
prevent adhesion formation after extensor tendon repair, have been However, a newly modified
flexor tendon repair, no such crite- made in the past. These are now Bunnell technique and a whipstitch
rion exists for extensor tendons. being consistently challenged with technique have recently been
Indeed, there is disagreement laboratory and outcomes analysis. shown to be stronger and more
about how much extensor tendon The clinical success of the new advantageous in a cadaveric
excursion occurs in the noninjured rehabilitation protocols has stimu- model.12 These techniques are sim-
hand. 8,18-21 Dynamic extensor lated studies on repair tech- ple to use and add approximately
splinting has also been used in niques. 11,18,23,24 Common suture one third greater strength, as
more distal zones, including zones techniques (Fig. 3) used for repair judged by 2-mm gap formation
III and IV, with improved results in zones IV and VI have been eval- and load to failure, than the usual
compared with injuries treated by uated for their strength, tendency modified Bunnell technique.
static splinting.9,10 to shorten the tendon, and poten- Clinical testing currently under
The relatively poor results with tial effect on digital range of way shows promising early results.
static splinting and the enthusiasm motion.23,24 It has been shown that Other studies have investigated
directed toward dynamic splinting there may be an important iatro- the effect of wrist position on
led to electrophysiologic investiga- genic component to fair and poor extensor tendon excursion; howev-
tion of the dynamic splinting tech- results, at least in zone VI, where er, there continues to be disagree-
nique. Unexpected and inappro- common suture techniques typical- ment about the amount of extensor
priate extensor musculature activity ly shorten the tendon approximate- excursion that occurs, varying from
occurred during both active flexion ly 6 mm. In a cadaveric model, this 2 mm to as much as 8 mm. 8,18-20
and passive extension and at rest.22 amount of shortening produces an Additional research has analyzed
The addition of a dorsal block 18-degree loss of motion at both the mathematically the forces across
hood, which holds the MCP joints MCP and PIP joints. the extensor system that occur with
in 15 degrees of flexion (Fig. 2, B), These biomechanical studies short-arc active motion (0 to 30
halted this inappropriate activity. have shown that the modified degrees), as is seen during postop-
While inappropriate muscular Bunnell technique produces the erative rehabilitation.11
Treatment
Severely contaminated wounds,
open fractures, and joint capsule
lacerations require emergent and
thorough irrigation and debride-
ment. Fractures and skin loss
should be treated in the initial pro-
cedure when feasible. Fractures
should be fixed rigidly enough to
allow early dynamic splinting or
active motion.
For lacerations without associat-
ed injury, the extensor tendon can
be repaired emergently or in a
delayed primary fashion after irri-
Mattress Figure-of-eight Modified Bunnell Modified Kessler gation, debridement, and loose clo-
sure of the wound. If the repair is
Fig. 3 Four commonly used repair techniques for extensor tendon lacerations. delayed, it should be performed
within 7 days, before the tendon
ends retract or soften.
All repairs are best performed
Tendon Lacerations tance. A complete laceration of the with adequate anesthesia, lighting,
extensor tendon will prevent full and exposure. Repair should be
Evaluation MCP extension. done with 3-0 or 4-0 nonabsorbable
A careful evaluation of the A partial extensor laceration suture material. For repairs in
injured hand, including a thorough may be painful or may demon- zones V through VIII, the modified
neurovascular examination, is strate incomplete MCP extension. Kessler or Bunnell technique with
essential in the treatment of exten- Partial lacerations should be direct- 4-0 nonabsorbable suture is effec-
sor tendon lacerations. Flexor ten- ly visualized to determine whether tive.
don function should be assessed, repair is necessary. Although no Injuries to the extensor retinacu-
and appropriate radiographs studies have been performed to lum in zone VII should be repaired
obtained. The wound should be determine the amount of partial with suture, taking care to avoid
thoroughly inspected, with adjunc- laceration that requires repair, I impingement of the repair on the
tive use of local or regional block believe that a tendon lacerated over retinaculum. If impingement
anesthesia as necessary. Injuries 50% of its width should be repaired would occur, a portion of the reti-
near a joint must be carefully to ensure adequate balance and to naculum can be resected to allow
inspected for violation of the cap- prevent further disruption. unhindered tendon excursion.
sule; sterile saline or methylene Injuries proximal to the junc- For injuries in zones III and IV,
blue should be injected into the turae tendinum in zone VI require emergent care should proceed as
joint for verification if any doubt special attention. A finger may necessary for open joints, fractures,
exists. fully extend by way of a junctura or contaminated wounds. A modi-
For lacerations in zones V even though its extensor tendon is fied Kessler or Bunnell technique
through VIII, careful testing of completely lacerated. This can be with 4-0 nonabsorbable suture is
MCP extension should be per- evaluated by asking the patient to effective if sufficient tendon thick-
formed with the wrist held in neu- extend each finger individually ness is present. These techniques
tral and the interphalangeal joints while holding all others flexed at are significantly better (P<0.05)
extended. Extension of the inter- the MCP joints, thereby blocking than a mattress or figure-of-eight
phalangeal joints, produced by the the pull of the juncturae. If the repair (Fig. 3).24 The lateral bands,
intrinsics, should not be interpret- extensor tendon is intact, the if injured, should be repaired sepa-
ed as representing extrinsic exten- patient will be capable of at least rately with 5-0 or 6-0 suture. Ex-
sor integrity. The patient should be some extension, which should be tensor lacerations in these zones
asked to fully extend each finger at comparable to that of the contralat- occur with a high rate of associated
the MCP joint against gentle resis- eral finger of the noninjured hand. injuries (80%) and have the poorest
outcome.11 Some advocate the use are obvious. The tendon becomes and wrist are splinted and the MCP
of percutaneous pinning of the PIP adherent to underlying periosteum joint is left free. Evans and
joint in full extension to keep ten- and overlying skin, producing a Thompson11 recommend that only
sion off the repair. I perform this potential loss of flexion. Evans and the interphalangeal joints be
only when mandated by the bone Thompson11 have shown that the included. If a static rehabilitation
injury or when the patient is non- force of efforts to overcome adhe- protocol is chosen, an aluminum-
compliant. sions can attenuate the repair and and-foam or molded-plastic splint
The surgical techniques used for result in increasing extensor lag is positioned on the dorsal or volar
repair in zones I and II are less well during the course of rehabilitation. aspect of the digit, depending on
defined than for the more proximal Immobilized tendons also lose the soft-tissue injury and the sur-
zones. Most often used are a run- strength over time.11,26 Controlled geon’s preference. Both the DIP
ning or mattress technique or the stress has been shown to combat and PIP joints are held in full
tenodermodesis technique of this by improving tensile strength, extension. If the wrist is included,
McFarlane and Hampole, 25 in improving gliding properties, it should be splinted in 30 degrees
which the skin and tendon are increasing repair-site DNA, and of extension. Static splinting
sutured as one layer. Because the accelerating changes in peritendi- should be maintained for 4 to 6
DIP joint is extremely difficult to nous vessel density and configura- weeks, after which gentle active
maintain in full extension by tion.26 motion is begun. Passive motion is
splints, pinning the joint in exten- Dynamic extension splinting delayed another 2 to 4 weeks.
sion best protects the repair and offers an alternative for minimizing Others have advocated dynamic
allows monitoring of the skin. The adhesion problems by allowing extension splinting for these distal
PIP joint should remain free for full several millimeters of extensor ten- injuries.9,10 The splint is similar to
activity after the skin and nail bed don gliding without placing undue that used for more proximal
have healed. stress across the repair site. Al- injuries, but does not include the
though the optimal amount of ex- wrist and need include only the
Rehabilitation tensor excursion that is required to affected digit. The MCP joint is
In recent years, research has limit adhesion is not known, held in slight flexion, and the out-
been directed toward postoperative dynamic splinting has been useful rigger mechanism and sling hold
rehabilitation for extensor injuries in improving outcomes in proximal the interphalangeal joints in full
in an effort to improve results. zones. The splint is applied dorsal- extension. Hung et al9 modify this
Static splinting has a long history, ly 3 to 5 days after injury and holds apparatus slightly to place the
and the results are well docu- the wrist in 30 degrees of extension MCP joints in approximately 70
mented. and the MCP joints in 10 to 15 degrees of flexion. In theory, this
For injuries in zones V through degrees of flexion (Fig. 2). The position rotates the sagittal bands
VIII, a static splint can be made of interphalangeal joints are held in 0 distally, thus decreasing tension
plaster or molded plastic that is fit- degrees of extension by rubber within the distal segments of the
ted to the volar aspect of the hand bands attached to slings. While extensor mechanism and limiting
and wrist. The fingers next to the most reports have dealt with sim- the pull of the EDC tendon on the
injured digit are also included to ple injuries, this postoperative pro- repair site. These techniques pro-
protect against the pull of adjacent tocol can also be beneficial in the duced improved outcomes com-
tendons through the juncturae. treatment of injuries that involve pared with static splinting.
The wrist is placed in approximate- well-stabilized fractures or other Another rehabilitation option
ly 30 degrees of extension, the MCP soft-tissue damage. for injuries in zones III and IV is
joints in approximately 15 degrees Postoperative treatment is still early controlled active motion as
of flexion, and the interphalangeal evolving for injuries in zones III advocated by Evans and Thomp-
joints in full extension. Splinting is and IV. Static splinting of only the son,11 who demonstrated excellent
maintained for 4 to 6 weeks, after affected finger can be used. clinical results. With this method,
which active range of motion is Although some would advocate the finger is splinted in full exten-
begun. Passive range-of-motion splinting of the wrist and MCP sion between exercise sessions.
exercises are begun approximately joints for distal injuries, Dagum The MCP joint is not included in
2 weeks later. and Mahoney 19 have shown that the splint. During exercise, per-
The inherent disadvantages of little or no stress occurs at a zone formed four to six times a day, the
immobilizing a lacerated tendon III or IV repair site if the PIP joint static splint is replaced by a splint
that allows 30 degrees of flexion. active motion for another 6 weeks degrees of flexion. The PIP joints
Active flexion to the block and after the pin is removed. are left free, and range of motion is
active extension to neutral are encouraged to promote gliding of
performed several times during the lateral bands. Incomplete
each session. After 2 weeks, the Closed Injuries injuries can be treated with static
splint is modified to allow ap- splinting or with buddy-taping.
proximately 40 degrees of flexion. Closed injuries to the extensor Rayan and Murray28 recommend
Splinting is discontinued after 6 mechanism in zones III through conservative splinting after sagittal
weeks, and full active range-of- VIII are relatively rare, especially band injury for up to 6 weeks after
motion exercises are begun. The when compared with open injuries injury, even with complete dislo-
authors have calculated that this and mallet injuries. Closed injuries cation of the extensor tendon.
short arc of motion produces in zones VI through VIII are almost However, because the balance of
approximately 290 g of force nonexistent except when associated the extensor mechanism over the
across the extensor repair and that with a systemic disorder, such as MCP joint is delicate, open repair
limiting flexion to 30 degrees pro- rheumatoid arthritis. of complete injuries is generally
vides a safety factor. Corrobo- While the central tendon is sel- recommended to ensure that the
ration of these calculated forces in dom injured in closed injuries to ruptured sagittal fibers are appro-
zone IV was shown in a laborato- the extensor mechanism in zone V, priately reapproximated and the
ry study in which the force across the sagittal bands that hold the tendon is well centered over the
the repaired tendon produced by EDC tendon centrally over the MCP joint. Repair can usually be
full flexion was approximately metacarpal head can rupture. This accomplished by simple reapproxi-
400 g.24 This compares favorably can occur from a direct blow to the mation of the sagittal fibers with
with the initial repair strength dorsal aspect of the metacarpal 4-0 or 5-0 absorbable suture in a
with the modified Bunnell and head or from forced extension or mattress fashion. If some delay has
Kessler techniques, which was ap- flexion of the MCP joint. Swelling occurred or the extensor tendon
proximately 2,150 g in a cadaver and ecchymosis are minimal. The has a tendency to subluxate after
study.24 patient usually notes modest pain reapproximation of the sagittal
Static splinting of the DIP joint and is unable to initiate MCP fibers, the opposite (usually ulnar)
alone after repair of lacerations in extension from a flexed position, sagittal fibers should be partially
zones I and II is generally recom- but will be able to maintain exten- released to allow accurate central-
mended for 4 to 6 weeks, after sion after the finger has been pas- ization of the tendon.
which active range-of-motion exer- sively extended. Closed ruptures of the central
cises can be begun. A pin transfix- The differential diagnosis slip overlying the PIP joint can
ing the DIP joint is particularly should include extensor tendon occur with volar dislocation of the
helpful in dealing with any soft- rupture, tendon laceration, and PIP joint, with forced flexion of the
tissue component of these injuries. radial nerve dysfunction. The long PIP joint, or with a severe contu-
Gliding is my preferred method finger is most often affected, sion to the dorsum of the PIP. The
of postoperative rehabilitation because its radial sagittal fibers are joint dislocation itself is generally
whenever the clinical situation weaker and its joint is the most recognized from a careful history
allows. For extensor tendon lacer- exposed to blunt trauma; however, and radiographs. A central slip
ations in zones V through VIII, I any finger may be affected. The rupture may not be recognized in
have used a dynamic splint with a extensor tendon usually dislocates the immediate postinjury period
dorsal block hood in the past. ulnarly into the intermetacarpal because of the pain and swelling
With the use of stronger suture valley because of the ulnar pull of associated with the dislocation.17
techniques, active motion exercises the flexor and extensor tendons, Deformity may take 2 to 3 weeks to
have been incorporated into the re- but ulnar sagittal fiber rupture occur as the untethered lateral
habilitation program with promis- with radial dislocation has also bands slide volarly, producing a
ing early results. For injuries in been described.27 typical boutonniere posture. Be-
zones III and IV, I recommend If the injury is detected immedi- cause patients frequently present
short-arc active-motion exercises. ately, a static splint or short-arm with a presumed dislocation that
In zones I and II, I typically keep cast can be applied with the MCP they themselves have reduced, a
the DIP joint pinned for 6 weeks joints of the affected finger and high index of suspicion should be
after tendon repair and allow only each adjacent finger held in 0 maintained to identify a concomi-
tant injury to the central slip when swelling, ecchymosis, and finger Treatment of type IVC injuries is
there is dorsal tenderness and droop are the usual presenting still controversial. Many are re-
swelling about the PIP joint. Early signs and symptoms. Radiographs ducible and can be treated conserv-
simple treatment can prevent late are used to assess the presence of a atively. Wehbé and Schneider 30
disabling deformity. fracture and the degree of joint have shown that these injuries,
Detection of a central slip rup- subluxation. even if associated with volar sub-
ture is relatively straightforward. Doyle29 has described four types luxation, can be treated with splint-
After the PIP joint has been relo- of mallet injury. Type I is a typical ing alone, with results at least com-
cated, extension of the joint is care- extensor tendon avulsion from the parable to those for injuries treated
fully evaluated. Extension lag, distal phalanx. Type II is a lacera- with open reduction and internal
pain with extension, or pain with tion of the tendon. Type III is a fixation. The difficulty of ap-
resisted extension should raise the deep avulsion that injures tendon proaching this area surgically is
suspicion of a central slip rup- and skin. Type IV is a fracture of evident, as the skin has a tenuous
ture.17 Full extension may still be the distal phalanx; this type is fur- blood supply, and the fracture frag-
possible if the lateral bands have ther divided into three categories. ment is quite small. Anatomic
not yet moved volarly, but it will Type IVA is a transepiphyseal frac- restoration is often difficult, and
be painful and weak. If the diag- ture in a child. Type IVB involves complications are frequent.30
nosis remains unclear, a dilute less than half the articular surface For type IVC injuries in which
solution of arthrographic dye can of the joint without joint subluxa- the volar subluxation of the joint is
be injected into the joint. Extru- tion; the mechanism of injury is unacceptable after attempted re-
sion of dye dorsally into the soft usually hyperflexion. Type IVC duction and appropriate splinting,
tissues indicates a central slip rup- involves more than one half the a more conservative option is to
ture along with rupture of the dor- articular surface of the joint and reduce the joint and pin it percuta-
sal capsule. can involve volar subluxation of neously without direct exposure of
Central slip rupture is treated the joint; this injury may be caused the fracture. A Kirschner wire in
with immobilization of the PIP by hyperextension of the joint. the distal fragment can serve as a
joint in 0 degrees of extension with Type I mallet finger is treated by joystick to maneuver the fragment
a dorsal or volar splint for 6 weeks; splinting the DIP joint, holding it in into position. The wire is then ad-
this encourages DIP joint motion to 0 degrees of extension with a dor- vanced through the proximal frag-
keep the lateral bands mobile and sal or volar splint. Care must be ment (if it is large enough) and
gliding. These injuries can be treat- taken not to hyperextend the joint across the DIP joint. This allows
ed successfully up to 6 weeks after as this can compromise the blood near-anatomic restoration of joint
rupture, although serial casting or supply to the dorsal skin. I prefer to and fracture and avoids the poten-
dynamic splinting may be neces- use a dorsally applied aluminum- tial complications of internal fixa-
sary to regain full passive exten- and-foam splint, as this leaves the tion. Nevertheless, complications,
sion before continuous splinting in patient’s touch pad free. Half the such as articular incongruence,
full extension. If the PIP joint can- thickness of the foam is removed so wire breakage, and infection, can
not be passively brought into 0 that the digit is not pulled into still occur.31
degrees of extension initially or hyperextension. Splinting is con-
after serial splinting, capsular and tinuous for 6 weeks. If there is
volar plate release may be neces- active extension and little or no Summary
sary before performing a difficult droop at reevaluation, the splint is
extensor tendon reconstruction. applied at bedtime only for another While extensor injuries often result
Closed rupture of the extensor 6 weeks. in loss of extension, this is seldom
mechanism is quite common in Type II injuries should be re- disabling. However, these injuries
zone I. The well-known mallet fin- paired as discussed previously. frequently result in loss of flexion,
ger is usually evident immediately Type III injuries may require skin which is greater in severity and fre-
after injury, with an obvious droop grafting and other reconstruction. quency than loss of extension. As a
of the finger at the DIP joint and a Type IVA fractures should be consequence, extensor tendon
lack of active extension. The mech- reduced if necessary and splinted injuries deserve careful attention in
anism of injury is usually forced for 6 weeks. Type IVB fractures diagnosis, treatment, and rehabili-
flexion of the fingertip, often from should also be reduced if necessary tation to offset potential loss of
the impact of a thrown ball. Pain, and splinted. function.
References
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