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Introduction
  • Refers to an avulsion injury of FDP from insertion at base of distal phalanx
    • a Zone I flexor tendon injury
  • Epidemiology
    • ring finger involved in 75% of cases
      • during grip ring fingertip is 5 mm more prominent than other digits in ~90% of patients
        • therefore ring finger exposed to greater average force than other fingers during pull-away
  • Pathophysiology
    • FDP muscle belly in maximal contraction during forceful DIP extension
Anatomy
  • Muscles
    • Flexor Digitorum Profundus (ulnar n. and AIN n.) 
  • Flexor zones
    • zone I extends from insertion of FDS distally
Classification
 
 Leddy and Packer classification
(based on level of tendon retraction and presence of fracture)
Type
Description
Treatment
Images
Type I FDP tendon retracted to palm. Leads to disruption of the vascular supply   Prompt surgical treatment within 7 to 10 days   
Type II FDP retracts to level of PIP joint Attempt to repair within several weeks for opitmal outcome  
Type III Large avulsion fracture limits retraction to the level of the DIP joint Attempt to repair within several weeks for opitmal outcome
Type IV Osseous fragment and simultaneous avulsion of the tendon from the fracture fragment  ("Double avulsion” with subsequent retraction of the tendon usually into palm) If tendon separated from fracture fragment, first fix fracture via ORIF then reattach tendon as for Type I/II injuries       
Type V Ruptured tendon with bone avulsion with bony comminution of the remaining distal phalanx (Va, extraarticular; Vb, intra-articular)    

Presentation
  • Physical exam
    • pain and tenderness over volar distal finger
    • finger lies in slight extension relative to other fingers in resting position   
    • no active flexion of DIP
    • may be able to palpate flexor tendon retracted proximally along flexor sheath
Imaging
  • Radiograhs
    • may see avulsion fragement 
Treatment
  • Operative
    • direct tendon repair or tendon reinsertion with dorsal button
      • indications
        •  acute injury (< 3 weeks)
      • technique
        • advancement of > 1 cm carries risk of a DIP flexion contracture or quadrigia 
      • postoperative rehab should include either
        • early patient assisted passive ROM (Duran) or
        • dynamic splint-assisted passive ROM (Kleinert)
    • ORIF fracture fragment
      • indications
        • types III and IV (for type IV then repair as for Type I/II injuries)
      • techniques
        • with K-wire, mini frag screw or pull out wire
        •  examine for symmetric cascade once fixation completed
    • two stage flexor tendon grafting 
      • indications
        • chronic injury (> 3 months) in patient with full PROM of the DIP joint
    • DIP arthrodesis
      • indicated as salvage procedure in chronic injury (> 3 months) with chronic stiffness
Complications
  • Quadrigia
    • advancement of > 1 cm carries risk of a DIP flexion contracture or quadrigia
 

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