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A 22-year-old rugby player presents with a mass at the base of his ring finger 5 months after sustaining an injury while making a tackle. Physical examination demonstrates a lack of active distal interphalangeal joint flexion, but full passive range of motion of all joints of the ring finger. Radiographs are normal. What is the most appropriate treatment to regain normal finger function?
excision of the palmar mass and 2-stage tendon grafting
excision of the palmar mass and single stage tendon grafting
excision of the palmar mass and distal interphalangeal joint fusion
active silicone rod implantation
flexor digitorum profundis repair
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This patient has a chronic jersey finger (flexor digitorum profundis avulsion). With the chronicity of the injury, it would be more amenable to grafting rather than direct repair given retraction of the FDP tendon that occurs with time that makes direct repair impossible. According to Green’s text, active silicone tendon rod implants have not proven to be effective. A 2-stage tendon grafting is the treatment of choice in cases of neglected or chronic (>3mo) tendon injuries or when previous surgery has failed. Two-stage flexor tendon grafting involves implanting a silicone rod (flexible silicone–Dacron-reinforced gliding implant) in the first stage and a free tendon graft (usually palmaris longus or plantaris) through the pseudosheath formed around the silicone in the second stage as intitially described by Hunter and Salisbury in 1971. In single-stage flexor tendon grafting, the tendon graft notoriously adheres to the surrounding fibro-osseous tunnel significantly limiting range of motion, but in 2-staged tendon grafting the pseudosheath that is formed around the silicone implant in the first stage greatly reduces the formation of post-operative adhessions to the tendon graft in the second stage.
Amadio et al showed at 6 month follow-up of staged flexor tendon reconstruction, patients expressed 54% good to excellent results, but 16% of patients required tenolysis following the second stage of the procedure. LaSalle et al followed 43 flexor tendon 2 stage reconstructions by comparing passive ROM after stage 1 to postop active ROM after stage 2. They reported 16% excellent results, 23% good, 26% fair, and 35% poor. They stated that tenolysis following the second stage improved results on the patients reporting poor outcomes. A distal interphalangeal fusion would be reserved for failed reconstruction or a patient that does not desire/will not be compliant with likely lengthy postoperative therapy needed for a staged tendon grafting.
Amadio PC, Wood MB, Cooney WP 3rd, Bogard SD.
J Hand Surg Am. 1988 Jul;13(4):559-62. PMID: 3418059 (Link to Abstract)
Amadio, JHS 1988
LaSalle WB, Strickland JW.
J Hand Surg Am. 1983 May;8(3):263-7. PMID: 6875225 (Link to Abstract)
LaSalle, JHS 1983
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A 16-year-old football player sustains an injury to his ring finger after making a tackle. A clinical photograph is shown in Figure A. What is the most likely diagnosis?
Flexor digitorum superficialis avulsion
Central slip rupture
Sagittal band rupture
Distal extensor tendon rupture
Flexor digitorum profundus avulsion
The photograph demonstrates the inability to flex the ring finger DIP. Based on the mechanism and clinical findings this injury represents a "rugby jersey finger", which is an avulsion of the flexor digitorum profundus (FDP) tendon.
Tuttle et al reviewed these injuries and concluded treatment for an acute injury is FDP tendon reinsertion. For chronic injuries, a 2-staged tendon grafting is required.
Tuttle HG, Olvey SP, Stern PJ
Clin. Orthop. Relat. Res.. 2006 Apr;445:157-68. PMID: 16601414 (Link to Abstract)
Tuttle, CORR 2006
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An overview of a scanning technique for a hand exam including probe type, probe...