Quadrigia Effect

Introduction

The quadrigia effect is characterized by an active flexion lag in fingers adjacent to a digit with a previously injured or repaired flexor digitorum profundus tendon.
Mechanism
- most commonly caused by a functional shortening of the FDP tendon due to
  - over-advancement of the FDP during tendon repair
    - >1 cm advancement associated with quadrigia
  - adhesions
  - "over-the-top" FDP repair of the distal phalanx after amputation
Pathoanatomy
- FDP tendons of long, ring, and little fingers share a common muscle belly
  - therefore excursion of the combined tendons is equal to the shortest tendon
    - improper shortening of a tendon during repair results in inability to fully flex adjacent fingers

Anatomy

Flexor digitorum profundus
Zones of the flexor tendons
- most injuries resulting in quadrigia involve Zone I

Presentation

Symptoms
- inability to fully flex the fingers of the hand adjacent to the injured finger
- patient may complain of "weak grip"
Physical exam
- upon making a fist the fingers adjacent to the injured digit will not reach full flexion
- grip strength decreased

Imaging

Radiographs
- usually not required

Treatment

Nonoperative
- observation
  - indications
    - mild symptoms not affecting quality of life
Operative
- release FDP of injured digit
  - indications
    - severe symptoms limiting function

TAG

(OBQ07.34) A butcher sustains a traumatic amputation of the ring finger through the distal interphalangeal joint. He is brought to the operating room where the flexor digitorum tendon is retrieved and advanced to the distal stump. Three months after surgery the patient notes that when he makes a fist, only his ring finger tip reaches the palm. What is this patient's clinical problem? Topic

Review Topic

1. mallet finger
2. swan neck deformity
3. boutonniere deformity
4. lumbrical plus deformity
5. quadrigia syndrome

PREFERRED RESPONSE ▶

DISCUSSION: Quadrigia syndrome occurs when a flexor digitorum profundus (FDP) tendon is shortened and advanced. Malerich et al found the tolerable degree of FDP advancement was 1 cm. The common muscle belly of the FDP prevents the tendons to the other fingers from reaching full excursion. Treatment is release of the shortened tendon. Lumbrical plus occurs when the FDP tendon retracts and causes paradoxical interphalangeal extension when trying to flex. Mallet finger is an injury to the terminal extensor tendon. Boutonniere deformity occurs from central slip injury and results in PIP flexion and DIP extension. Swan-neck deformity consists of hyperextension at the PIP joint with flexion at the DIP joint typically caused by volar plate attenuation.

REFERENCES:

1. Boyer MI: Flexor Tendon Injuries, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 5. pp 237-240.

2. Malerich MM, Baird RA, McMaster W, et al. Permissible limits of FDP tendon advancement: An anatomic study. JHS Am1987; 12:30-33. PMID:3805640 (Link to Abstract)

Question Authors:

Greg Galano MD, Derek Moore, Patrick McCulloch MD,

Please Rate Educational Value!

4.0

Average 4.0 of 14 Ratings

TAG

(OBQ04.97) A 35-year-old butcher inadvertently lacerates his ring finger FDP tendon at the level of the DIP joint which is subsequently repaired. Following the operation he notes the inability to fully flex his long and small fingers at the DIP joints with attempted fist clenching as well as a weak grip. Which of the following intraoperative maneuvers was likely responsible for this? Topic

Review Topic

1. FDP reconstruction with a long tendon graft
2. FDS to FDP transfer at level of the A2 pulley
3. Inadequate repair of the C3, A4 and A5 pulleys
4. Distal advancement of lumbricals
5. Overtensioning of the FDP tendon

PREFERRED RESPONSE ▶

DISCUSSION: The clinical presentation is most consistent with the quadrigia effect which is caused by overtensioning of the FDP tendon during surgical repair. The FDP tendons share a common muscle belly and have many interconnections. Overtensioning one tendon has a reciprocal effect on the length-tension curve of the remaining three muscle-tendon units, weakening grip strength in these digits.

Malerich et al performed a cadaveric study looking at FDP advancement on hand function. They determined advancement >1cm can lead to an imbalance of muscle function in the profundus system.

In another cadaver study, Kaufmann et al studied maximal grip strength and point of contact in the extrinsic system. They determined that FDP grip strength was optimized when the FDP point of contact was at the DIP. Thus moving the FDP insertion point distal or advancing a lacerated FDP tendon leads to a decrease in grip strength.

REFERENCES:

1. Malerich MM, Baird RA, McMaster W, et al. Permissible limits of FDP tendon advancement: An anatomic study. JHS Am1987; 12:30-33. PMID:3805640 (Link to Abstract)

2. Kaufmann RA, Kozin SH, Mirarchi A, Holland B, Porter S. Biomechanical analysis of flexor digitorum profundus and superficialis in grip-strength generation. Am J Orthop (Belle Mead NJ). 2007 Sep;36(9):E128-32. PMID:17948164 (Link to Abstract)

Question Authors:

Terrill Julien MD, John Badylak MD, Dave Marcu MD,

Please Rate Educational Value!

4.0

Average 4.0 of 12 Ratings

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Kaufmann RA, Kozin SH, Mirarchi A, Holland B, Porter S. Biomechanical analysis of flexor digitorum profundus and superficialis in grip-strength generation. Am J Orthop (Belle Mead NJ). 2007 Sep;36(9):E128-32. PMID:17948164 (Link to Abstract)
Malerich MM, Baird RA, McMaster W, et al. Permissible limits of FDP tendon advancement: An anatomic study. JHS Am1987; 12:30-33. PMID:3805640 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

Undefined

Boyer MI: Flexor Tendon Injuries, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 5. pp 237-240.

Qbank (2 Questions)

Question Comments

Question Comments

Groups

Evidence & References Show References

Topic Comments