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Flexor Tendon Avulsion/Jersey Finger

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Ovid: 5-Minute Sports Medicine Consult, The


Flexor Tendon Avulsion/Jersey Finger
Jason E. Spring
Amy Kakimoto
Basics
3 primary injury patterns have been described based on the degree of tendon retraction, vascular disruption, and the presence of a bony fragment (1):
  • Type I: Retraction of the tendon into the palm of the hand with nearly complete disruption of the blood supply (1)
  • Type II: Retraction of the tendon to the proximal interphalangeal (PIP) joint, held in place by the intact vincula longa (1)
  • Type III: Avulsion of a large bony fragment attached to the tendon, causing retraction to stop at the distal interphalangeal (DIP) joint due to a “hang-up” at the A4 pulley, maintaining full vascular supply to the tendon (1)
  • A Type IV (also known as a type IIIb) injury has been described in the literature and refers to a condition where both an avulsion of a bony fragment at the insertion of the FDP and an avulsion of the tendon from the bony fragment exists. This condition frequently results in retraction of the tendon similar to that of a type I injury (2).
Description
  • An avulsion of the flexor digitorum profundus (FDP) tendon from its insertion at the base of the distal phalanx (3)
  • Synonym(s): Jersey finger; FDP avulsion
Epidemiology
  • A relatively uncommon injury seen primarily in sports where tackling and grasping of the jersey is probable; these sports include rugby, football, and hockey (1)
  • The classic scenario occurs when a player grabs or attempts to grab the back of another player's uniform causing forced extension to a strongly flexed distal phalanx, resulting in the avulsion of the FDP tendon at its insertion (4).
  • Although any digit can sustain this injury, the “ring” finger is by far the most commonly affected, accounting for over 75% of all cases (3).
  • Frequently misdiagnosed as a jammed or strained finger (4)
Risk Factors
Participation in any sport where tackling occurs by grabbing another player's jersey
Etiology
The FDP tendon travels along the volar side of the palm and finger. It passes distally through a split in the flexor digitorum superficialis tendon and inserts at the base of the distal phalanx. The jersey finger injury occurs when the FDP tendon is avulsed from its attachment on the distal phalanx (2).
Diagnosis
History
  • The mechanism of injury frequently involves a sudden forceful extension of the finger while grasping another player's jersey (1)[C].
  • FDP avulsions are typically seen in football, rugby, and hockey players, but rarely in other athletes (1)[C].
  • The time lapse between initial injury and presentation will dictate the urgency of surgical intervention (2)[C].
Physical Exam
  • INSPECTION: Swelling and discoloration may be present along the distal phalanx and DIP joint (1)[C].
  • PALPATION: Tenderness may be present along the length of the flexor tendon, particularly at the site of FDP tendon insertion. A palpable lump may be present at any point along the proximal digit, frequently at the PIP joint or on the palm of the hand at the A1 pulley (2)[C].
  • RANGE OF MOTION: The loss of active flexion at the DIP joint is the most reliable exam finding in an FDP avulsion injury. To assess the integrity of the FDP tendon, hold the PIP joint in full extension and ask the patient to actively flex the DIP joint (2)[C]. Alternatively, ask the patient to make a fist and look for loss of flexion at the affected DIP joint (5)[C]. Active flexion of the PIP joint and metacarpophalangeal (MCP) joint is preserved in the injured digit.
  • NEUROVASCULAR EXAM: Should always be assessed and should be normal in jersey finger injuries
Diagnostic Tests & Interpretation
Imaging
  • 3 view radiographs (anteroposterior, lateral, and oblique) are necessary to determine the presence and degree of bony avulsion and to potentially assess the level of tendon retraction (5)[C].
  • Avulsion fractures can be seen on the volar aspect of the distal phalangeal base at the FDP attachment site (3)[C].
  • Some avulsion fractures may be nothing more than a small flake of bone (common in type II injuries) (1)[C].
Differential Diagnosis
  • DIP joint dislocation
  • Distal phalanx fracture
  • Flexor digitorum superficialis avulsion
Treatment
  • All FDP avulsion injuries require surgical intervention (5)[C]; however, a few initial interventions can minimize pain and swelling while surgery is being arranged. The urgency of hand surgery referral varies depending on the classification of injury.
  • Ice
  • NSAIDs
  • The injured finger should be dorsally splinted to maintain slight flexion at the DIP and PIP joints (5)[C].
  • Patients should avoid any DIP extension (5)[C].
Additional Treatment
  • Time between injury and treatment
  • Degree of tendon retraction
  • Presence and size of bony avulsion
  • Level of blood supply to the avulsed tendon (1)[C]

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Additional Therapies
  • Several treatment options exist for athletes who present outside the window for primary repair. These include no treatment, tendon grafting, or terminal interphalangeal joint tenodesis or arthrodesis (2)[C].
  • Flexor tendon grafting may be offered if deemed necessary to the athlete's performance (1)[C].
  • Arthrodesis may be offered in cases of DIP instability or articular surface disruption (1)[C].
  • If symptoms are minimal, many athletes do not require any surgical intervention, and the loss of flexion at the DIP joint usually results in minimal functional loss. Forgoing surgery may be the optimal choice for patients with a neglected FDP avulsion (2)[C].
  • The player may deem the injury as minor and not seek care.
  • The athlete may forego treatment in favor of completing the season, accepting the loss of DIP flexion.
  • The injury may be initially misdiagnosed.
Surgery/Other Procedures
  • Type I:
    • Surgical repair should be conducted within 7–10 days of the injury (2)[C].
    • Surgery involves retrieval of the retracted tendon, feeding it back through the pulley system, and reattaching the tendon to its insertion via suture or pullout wire (1)[C].
  • Type II:
    • Early surgical repair within 7–10 days is preferred; however, due to the intact vincula longa, surgery can be delayed 6–8 wks (2)[C].
    • Surgery involves feeding the tendon under the fourth annular pulley followed by suture/pullout wire reattachment to the insertion site (1)[C].
  • Type III:
    • Early surgical intervention is preferred, but satisfactory results are possible with delayed repair of 2 wks, due to an intact blood supply to the tendon (2)[C].
    • Surgery involves open reduction and internal fixation of the avulsed bony fragment via removable wires (1)[C].
    • Wires can be removed after 3–4 wks postoperatively (1)[C].
  • Type IV or IIIb:
    • Surgical repair involves the combination of bony fragment fixation and reattachment of the retracted tendon with suture/pullout wire (2)[C].
    • The degree of tendon retraction and loss of vascular supply can be similar to a type I injury, requiring surgical intervention within 7–10 days (2)[C].
Ongoing Care
  • Following surgery, the affected hand should be placed in a dorsal blocking splint with the wrist in midflexion, the MCP joints at 75 degrees of flexion, and the PIP/DIP joints in extension or near extension (1)[C]. The hand should remain in this splint for 6 wks (2)[C].
  • Passive flexion of the PIP and DIP joints can be started within days of the surgery (1)[C].
  • Utilizing an experienced hand therapist early in the postoperative period is recommended (2)[C].
  • Strengthening activities can usually begin at 12 wks postoperatively (2)[C].
  • A mitten-type splint/cast that keeps the wrist slightly flexed with the fingers flexed into the palm may allow an athlete to return to play early, provided no grasping of the hand is required (2)[C].
  • Return to play with full grasping capabilities usually takes 4–6 mos (2)[C].
Follow-Up Recommendations
Immediate referral to an orthopedic/hand surgeon is recommended for all types of FDP avulsion injuries.
References
1. Aronowitz ER, Leddy JP. Closed tendon injuries of the hand and wrist in athletes. Clin Sports Med. 1998;17:449–467.
2. Jaworski CA, Krause M, Brown J. Rehabilitation of the wrist and hand following sports injury. Clin Sports Med. 2010;29:61–80.
3. Peterson JJ, Bancroft LW. Injuries of the fingers and thumb in the athlete. Clin Sports Med. 2006;25:527–542, vii–viii.
4. Lee SJ, Montgomery K. Athletic hand injuries. Orthop Clin North Am. 2002;33:547–554.
5. Perron AD, Brady WJ, Keats TE, et al. Orthopedic pitfalls in the emergency department: closed tendon injuries of the hand. Am J Emerg Med. 2001;19:76–80.
Codes
ICD9
  • 842.13 Sprain of interphalangeal (joint) of hand
  • 959.5 Other and unspecified injury to finger
Clinical Pearls
  • Delaying surgical treatment, particularly for type I injuries, can result in irreparable scarring of the flexor tendon and permanent loss of flexion at the DIP joint. While delayed surgical intervention may be offered in certain circumstances, favorable results are not guaranteed. Type II and III injuries frequently can be delayed several weeks without significant changes to surgical outcome, but this is not advised (1).
  • If the sport does not require grasping, it may be possible for the patient to return to play early, provided that a playing splint/cast is worn. Otherwise, return to full play usually takes 4–6 mos (2).


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