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Introduction
  • The quadriga 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 quadriga
      • adhesions
      • retraction of the tendon
      • "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
 

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Questions (3)
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(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? Review Topic

QID: 1202
1

FDP reconstruction with a long tendon graft

4%

(156/4072)

2

FDS to FDP transfer at level of the A2 pulley

3%

(103/4072)

3

Inadequate repair of the C3, A4 and A5 pulleys

2%

(81/4072)

4

Distal advancement of lumbricals

3%

(128/4072)

5

Overtensioning of the FDP tendon

88%

(3582/4072)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(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? Review Topic

QID: 695
1

mallet finger

2%

(48/2243)

2

swan neck deformity

1%

(22/2243)

3

boutonniere deformity

1%

(32/2243)

4

lumbrical plus deformity

6%

(143/2243)

5

quadrigia syndrome

88%

(1984/2243)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5
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GROUPS (1)
Topic COMMENTS (5)
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