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A 28-year-old NFL running back complains of continued hand pain three days following an injury sustained while being tackled. He was splinted on the field. He has tenderness over the long finger metacarpal head, with subluxation of the extensor tendon into the intermetacarpal area during active metacarpophalangeal joint flexion. A representative MRI is shown in Figure A. What is the next best step in management of this patient?
Continued splinting in flexion
Continued splinting in extension
Open repair of the disrupted junctura tendinae
Open repair of the disrupted sagittal band
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Based on the history and physical exam findings this patient has sustained a traumatic rupture of the sagittal band. In this professional athlete, the next best step would be to perform an open repair of the sagittal band. This will allow for earlier aggressive rehabilitation and a quicker return to sport.
Sagittal band ruptures may be traumatic (as in this case) or attritional in nature (as in rheumatoid arthritis). A direct blow to the MCP leads to forced flexion of the digit and subsequent stretching/rupture of the affected structure. On physical exam the tendons are most unstable with the wrist flexed; MCP flexion will lead to dislocation of the tendon into the intermetacarpal gutter. Acute injuries may be treated with extension bracing for 4-6 weeks, but in professional athletes, direct open repair of the sagittal band is indicated.
Catalano et al. review sagittal band injuries treated with a thermally molded plastic splint that held the MCP in ~25-35 degrees of hyperextension. Patients were evaluated over 14 months; out of 11 sagittal band injuries, splinting was successful in eight of them. They recommend initial nonsurgical management with custom splinting.
Hame et al. review the results of the management of sagittal band injuries in the professional athlete. The lesion commonly found was the disruption of the extensor mechanism with predictable sagittal band tears. In their series, all patients regained full range of motion and returned to their respective sports. They recommend surgical intervention in elite athletes in the form of extensor tendon centralization and sagittal band repair.
Figure A shows a T1 weighted axial cut of the affected hand; subluxation of the tendon (arrow) can be identified with disruption of the sagittal band (arrowhead).
The video provided briefly reviews injury to the sagittal band.
Answer 1: Observation is not indicated in this patient
Answer 2, 3: Splinting in extension would be an acceptable option in the non-athlete, but direct repair is indicated in a professional athlete
Answer 4: The junctura tendinae are not injured in this patient
Catalano LW, Gupta S, Ragland R, Glickel SZ, Johnson C, Barron OA
J Hand Surg Am. 2006 Feb;31(2):242-5. PMID: 16473685 (Link to Abstract)
Catalano, JHS 2006
Hame SL, Melone CP
Am J Sports Med. 2000 Nov-Dec;28(6):879-82. PMID: 11101112 (Link to Abstract)
Hame, AJSM 2000
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A 20-year-old man has pain, swelling, and popping over his index metacarpophalangeal joint after striking a wall 3 days ago. Radiographs are normal, but physical exam reveals a palpable defect over the dorsum of the joint with clenching of the fist, and this defect is resolved with extension of the metacarpophalangeal joint. What is the next most appropriate step in treatment?
Trigger finger steroid injection
Extension splinting of the metacarpophalangeal joint
Extensor hood reconstruction
Metacarpophalangeal joint arthrodesis
“Boxer’s knuckle” refers to injury to the extensor hood mechanism that results following resisted extension ("flicking") of the finger or direct trauma to the MP joint, usually involving the radial sagittal band of the middle or ring finger. Often, both the sagittal band and the dorsal capsule are torn. The hallmark of the physical examination is pain over the MCP with a palpable defect in the dorsal capsule, and it is important to examine for EDC subluxation with MP flexion. Sagittal band injuries seen within 3 weeks of injury may be treated nonoperatively with an MP joint flexion blocking splint. Patients presenting later than 2 to 3 weeks after the injury or patients who failed a trial of splinting are candidates for surgical repair.
Hame et al reviewed 27 patients who were treated for Boxer’s Knuckle. The authors concluded that in cases in which conservative treatment has failed, these injuries should be treated with sagittal band repair with centralization of the extensor tendon without repair of the capsule. In the acute period however (less than 3 weeks), as is the scenario for this patient, conservative management with extension splinting should be attempted first.
Araki et al performed a study of 16 cases of rupture of the extensor hood initially treated conservatively with splinting. While 8/16 responded successfully to nonoperative management, the remaining 8 did not improve with conservative treatment and were eventually treated with surgical repair and closure of the joint capsule when injured.
Illustration A shows a clinical image of a boxer's knuckle and Illustration B displays an axial T2 MRI with a sagittal band rupture. Video V demonstrates a sagittal band reconstruction.
Hame SL, Melone CP
Hand Clin. 2000 Aug;16(3):375-80, viii. PMID: 10955211 (Link to Abstract)
Hame, HANDC 2000
Araki S, Ohtani T, Tanaka T.
J Bone Joint Surg Am. 1987 Apr;69(4):616-9. PMID: 3571321 (Link to Abstract)
Araki, JBJS 1987
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Watson technique of sagittal band reconstruction. Distally based EDC tendon slip...
Repair of the sagittal band centralizing the extensor tendon
Physical exam findings of a patient with a sagittal band rupture
HPI - patient noticed it when sound became more audible more 4 ms