Flexor Digitorum Profundus Avulsion Research Articles

Management of Distal Phalanx Intraarticular Comminuted Fracture of Small Finger with Zone I Flexor Tendon Avulsion: A Case Report

Distal phalanx fractures are a common injury in both athletes and civilians. These fractures can differ greatly in severity and treatment indications depending on the size, location, and stability of the fracture in addition to appreciation of any bony comminution. Tendon avulsion in conjugation with a fracture complicates treatment and outcomes further. The classification system for these fractures have been well classified to include Type I, II, II, and IV with IV having subtypes. More recently, Type V has been added to the classification system. Designated as a comminuted distal phalanx fracture with flexor digitorum profundus avulsion, this Leddy-Packer type has two subgroups: namely, comminution without intra-articular involvement (Va) and comminution that includes the articular surface. We report the case of a 42-year-old female presenting with injury to the distal phalanx of the right small finger sustained after her dog ran away from her as she held the collar, exerting significant force in opposition to her flexed fingers. Upon exam and following appropriate imaging, her injury was defined as a Leddy and Packer Type Vb jersey finger injury. This was effectively treated with open reduction, internal fixation of the comminuted distal phalanx base and avulsion fragment. A notably rare injury, Leddy-Packer Type Vb distal phalanx avulsion injuries must be treated in a case-by-case basis, but open reduction internal fixation with plating proves an appropriate and effective means of repair in the correct patient.

The Evaluation of a Flexor Digitorum Profundus-to-Volar Plate Zone I Repair Versus Button Repair: An In Vitro Biomechanics Study

The purpose of the study was to evaluate joint kinematics and tendon work of flexion (WOF) following a flexor digitorum profundus (FDP)-to-volar plate (VP) repair technique relative to a pullout button for zone I flexor tendon injuries. Fourteen digits were tested using an invitro active finger motion simulator under 3 repaired conditions following a simulated zone I avulsion: button, FDP-VP, and "no slack" FDP-VP (corrected for additional VP length). Outcome metrics included active joint range of motion (ROM), fingertip strength, FDP and flexor digitorum superficialis tensile loads, and WOF. The button and FDP-VP techniques restored WOF to the intact condition for FDP and flexor digitorum superficialis. All repairs restored distal interphalangeal joint ROM and kinematics to the intact condition. Similarly, all repairs restored WOF; however, the "no slack" FDP-VP significantly increased WOF by 10% to 12% over the simple FDP-VP repair. The button technique had similar fingertip strength to the intact condition, whereas the FDP-VP repairs significantly reduced peak fingertip strength from intact, albeit only 1-2 N compared with the button repair. In this invitro cadaveric model, the button and FDP-VP techniques restored WOF and ROM to within intact levels, with no difference between these repairs in all measured outcome metrics. Based on its initial strength and its equal biomechanical performance compared with the button repair, the FDP-VP technique may be a viable option for treating FDP avulsions.

A Meta-Analysis of Biomechanical Studies for Suture Button Pullout Versus Suture Anchor Repair of Flexor Digitorum Profundus Avulsions.

There is no current consensus on which of the two most common flexor digitorum profundus (FDP) avulsion repair constructs, via suture button pullout (SBP) or suture anchor (SA), is biomechanically superior. Our purpose was to compare these repair methods via systematic review and meta-analysis of available literature. We performed a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-guided systematic review of PubMed, the Cochrane library, and Embase. We only included studies with direct comparison data for both techniques. We performed a meta-analysis comparing the reported biomechanical results using pooled data for initial repair stiffness (N/mm), gap formation (mm), and ultimate load to failure (N). Seven studies met inclusion criteria, including a total of 201 cadaveric specimens. Four studies reported initial construct stiffness, with pooled analysis showing superiority for SA repairs (P < .05). Four studies evaluated gap formation, with pooled analysis demonstrating less gapping with SA repair (P < .05). Mean gap formation was 2.4 (±1.4) mm and 3.9 (±2.0) mm for the SA and SBP groups, respectively. All 7 studies assessed load to failure, with pooled analysis revealing no significant difference between groups (P > .05). We lacked statistical power to determine equivalence between techniques for load to failure. Both groups had failure values significantly lower than the native FDP. Via meta-analysis, there was increased initial construct stiffness and less gap formation for SA compared to SBP for FDP reinsertion, with no significant differences for ultimate failure load.

Complications and Clinical Outcomes Following Zone I Flexor Tendon Repair Using All-Inside Suture Fixation

The purpose of this study was to evaluate complications and outcomes of an all-inside repair technique for flexor digitorum profundus (FDP) avulsions. A retrospective review of a single institution database identified all FDP avulsions that were repaired using an all-inside technique by a single surgeon. In this method, 2 Keith needles are drilled from the volar to dorsal aspect, exiting proximal to the nail matrix and within the extensor tendon. Nonabsorbable sutures were placed in the flexor tendon and passed through the bone tunnels, tying dorsally over the distal phalanx. The demographics characteristics, injury characteristics, the surgical procedure, postoperative complications, and outcomes were reviewed. Seventeen patients were included in the study. The average age was 40 years (range, 21-68 years), and 2 patients were women. Seventeen fingers were included: 14 ring fingers, 1 index finger, and 2 little fingers. Six patients had an associated distal phalanx fracture and one had an associated distal interphalangeal joint dislocation. The average time between injury and surgery was 9 days (range, 2-18 days). Four patients had complications: 3 with erythema related to infection, which appeared to be a reaction to the suture prompting removal, and 1 with a subungual mass related to the suture at removal. One patient had persistent pain. Postoperative range of motion, assessed using the Strickland criteria, was excellent or good in 5 (33%) of 15 patients, but this was predominantly due to motion at the proximal joints as overall DIP motion was limited. Patients had a mean distal interphalangeal joint range of motion of 24° (range, 0° to 55°). In our series, repair of FDP avulsions via all-inside suture fixation is associated with limited distal interphalangeal joint motion and an incidence of infection (24%) at final follow-up. Therapeutic V.

Cyclic Testing of a Modified Pull-Out Suture Repair Technique for Flexor Digitorum Profundus Avulsion in a Turkey Foot Model.

Background: Numerous repair techniques have been described for closed flexor digitorum profundus (FDP) avulsion. One option is a pull-out suture tied over the nail plate (Bunnell repair). We modified the Bunnell repair by incorporating a portion of the distal interphalangeal (DIP) joint volar plate into the repair to improve strength and reduce gapping. The aim of this study is to compare gap formation and load to failure between the Bunnell repair and our modification in a turkey foot model. Methods: Twenty-four fresh-frozen cadaveric turkey feet were divided into two repair groups namely the conventional Bunnell pull-out suture technique and the modified Bunnell pull-out suture technique, incorporating the middle-third of the DIP joint volar plate into the repair. Both repairs were carried out with 3-0 prolene suture and underwent ex-vivo cyclic loading at 2-12 n in a sinusoidal wave for 100 cycles to simulate a passive range of motion (ROM) protocol. Subsequently, specimens were loaded to failure at 12 mm/minute. Gap formation and load to failure were measured. Results: No repair ruptures occurred during cyclical testing. Mean gap formation was 9.2 mm (±1.49) in the Bunnell repair, and 3.5 mm (±1.19) in the modified Bunnell repair (p < 0.0001). The mean load to failure for the Bunnell repair was 35.4 n compared to 45 n for the modified repair (p = 0.0017). Conclusions: Gap formation was reduced and load to failure increased by augmenting the Bunnell pull-out suture repair with the central portion of the DIP joint volar plate.

Closed Traumatic Avulsion of Both Flexor Digitorum Tendons: An Addition to the Leddy and Packer Classification and Review of the Literature

ObjectiveWe encountered the case of a patient who presented with an avulsion of both flexor digitorum profundus (FDP) and flexor digitorum superficialis (FDS) tendons from their respective insertion in the ring finger. We aim to discuss the novel treatment of this injury pattern in the context of all previously encountered cases in the literature. Materials and MethodsWe examined the case of our patient with avulsion of both flexor tendons in the same finger and discuss the novel method of treatment in our case. Additionally, we performed a literature review of all previous reported cases and discuss the treatment modalities and outcomes associated with each. ResultsWe have shown a novel and successful treatment technique for avulsion of both the FDP and FDS tendons. We identified twelve other cases of this injury pattern and have compared all outcomes documented. ConclusionClosed tendon avulsion of both flexor tendons in the same finger is rare. We described a case and additionally propose a modification to the flexor tendon avulsion classification to incorporate this injury pattern and aid its management.

Repair of flexor digitorum profundus avulsions including the palmar plate: a retrospective comparative study of 56 cases.

We retrospectively reviewed 56 fingers with a type 1 flexor digitorum profundus avulsion (jersey finger) injury. Nineteen fingers were treated with a four-strand pull-out suture technique that did not include the distal palmar plate, and 37 were treated with a six-strand pull-out suture technique that included the distal palmar plate. An early active mobilization regimen was used. At follow-up (mean 13 and 14months, respectively), total active interphalangeal joint motion was significantly better in the six-strand/palmar plate group, as were the results assessed with the Strickland-Glogovac grading system and patient satisfaction according to the Stark criteria. No repair ruptures occurred in this group versus two ruptures in the four-strand/no-palmar-plate group. We consider that the better results can be attributed to a stronger repair, which facilitated early active mobilization.Level of evidence: III.

Hook Plate as a Treatment for Flexor Digitorum Profundus Avulsion Types II and III

Avulsion fracture types II and III of flexor digitorum profundus (FPD), also called Jersey Finger, in flexor zone 1 are an uncommon pathology requiring surgical treatment. The aim of this study was to assess whether hook miniplates were an accessible and reliable option to repair FDP avulsion types II and III. Between July and August 2018, we treated 2 consecutive patients' zone 1 Leddy-Packer type II and III FDP injuries with hook plates and 1.2 × 7 mm screws included in Medartis Aptus Hand fixation system set. Patients were aged 37 and 39 years, a man and a woman, respectively. At the end of the follow-up, we evaluated the Visual Analog Scale, range of motion, grip strength, and Quick Disabilities of the Arm, Shoulder, and Hand. Both patients completed 12 months of follow-up with excellent functional and radiological results. Neither presented complications or residual disability. This injury has been treated with a wide range of surgical techniques, including anchor suture, pullout button sutures, screws, and plates. However, due to the difficulty in surgical fixation of fragments around finger joints, limited access to ligaments and tendons, and the lack of cases, none of the techniques have turned out as a clear option above others. Hook plates placed in distal phalanx emerge as surgical treatment for FDP avulsion types II and III in flexor zone 1, with excellent clinical outcomes.

Mini-Plate and Screw Fixation Technique for Comminuted Flexor Digitorum Profundus Avulsion Fracture

Avulsion fracture of flexor digitorum profundus (FDP) tendon is relatively rare fracture at the distal phalangeal base than avulsion fracture of terminal extensor tendon. Terminal extensor avulsion fracture, known as bony mallet finger, could be successfully treated by closed reduction and pinning, such as extension block technique. However, most of FDP avulsion fracture, known as Jersey’s finger, needed open reduction, because of the proximal migration of fracture fragment and difficulty of pin fixation. Up to date, most of FDP avulsion fractures were treated by open reduction and fixation by pull-out suture or suture anchor technique. We report a case of comminuted FDP avulsion fracture, successfully treated by open reduction and mini-plate and screw fixation technique.

The Accommodation of Bone Anchors Within the Distal Phalanx for Repair of Flexor Digitorum Profundus Avulsions

Avulsion injury of the flexor digitorum profundus (FDP) tendon has been traditionally repaired with a pull-out suture over the nail plate. Complication rates with this method and improvements in anchor design have led to the increased use of bone anchors to give a rigid all-inside repair. However, the dimensions of the distal phalanx may limit their use. The primary hypothesis was that 2 micro bone anchors could fit in either perpendicular or 45° proximally angled positions within each distal phalanx. A further hypothesis was that 1 mini bone anchor could fit in similar positions in the distal phalanx. Thirty-two fresh frozen fingers were dissected, and the FDP tendon was removed from the distal phalanx footprint. Two bone anchor types were used, mini and micro sizes, and inserted at 2 angles, perpendicular and 45° proximally angled. Observations of dorsal cortex and joint space penetration were recorded. Distal phalanx dimensions were measured for each finger. The micro anchors penetrated the dorsal cortex in perpendicular tests in little fingers only. The micro anchor did not penetrate the joint in any angled tests. The mini bone anchor penetrated the dorsal cortex in 100% of perpendicular tests and the joint in 63% of angled tests, although none of these included the middle finger. Two micro bone anchors fit within the distal phalanx in all fingers tested, except the little finger, when placed in the perpendicular position. At a 45° angle, the distal phalanx of the little finger can also accommodate micro bone anchors without any evidence of complication when placed 4 mm from the joint. The mini anchors were too large to fit in a perpendicular position within the distal phalanx. In the 45° angled position, the joint was not penetrated by the mini anchor in only middle fingers. The study provides anatomical evidence of the accommodation of micro bone anchors within the distal phalanx in perpendicular or 45° angled positions for the repair of FDP tendon avulsion injury.

Evaluation of the Acquisition of Ultrasound Proficiency in Hand Surgery Fellows.

To evaluate hand surgery fellow ultrasound (US) evaluations and performance of clinically relevant tasks after brief instruction. Six hand surgery fellows completed an US assessment and a survey on US use before and 1 month after a 30-minute US course. The time to obtain an adequate image decreased from 4 minutes 42 seconds (4:42; range, 3:57-7:55) to 0:52 (range, 0:30-1:14; P < .001). Participants' performance for structure identification improved from 9.7 (range, 8-13) to 12 (range, 10-13) of 14 structures (P < .05). The average time to completion decreased from 14:6 (range, 12:08-18:30) to 9:34 (range, 4:40-15:54; P < .01). After instruction, all 6 participants identified and measured the cross-sectional area of the median nerve, identified and measured a zone 3 flexor tendon gap, and identified a simulated flexor digitorum profundus avulsion and its level of retraction (P < .05). Five of 6 successfully administered an US-guided injection to the extensor carpi ulnaris subsheath. After a 30-minute instructional session, hand surgery fellows can achieve a basic level of US competency.

A Novel Technique for the Treatment of Jersey Fingers.

The avulsion of the flexor digitorum profundus from its insertion, or "jersey finger," is a relatively common injury. Numerous modifications have been made to the classification and treatment of this injury since its initial description. We describe a novel variation of the surgical management of jersey finger.

The Versatile Hook Plate in Avulsion Fractures of the Hand.

In a retrospective review of our use of hook plates in hand fractures from 2008 to 2014, a total of 63 cases were identified from the hospital data base. There were 35 cases of Mallet fractures, 16 cases of proximal interphalangeal joint fracture dislocations, 5 cases of flexor digitorum profundus avulsion fractures, 5 cases of Central slip avulsions, and 2 collateral ligament avulsions. All fractures healed well with this technique with no biomechanical failures and good functional outcome. Plates needed removal in a total of 25 cases, of which 14 were in mallet fractures. Thirteen (21%) cases suffered complications, of which the majority were again related to mallet fractures. The hook plate is a simple device that can be created quite easily with readily available materials. We have extended the use of these plates to avulsion fracture fixation in the hand and found this to be a versatile technique. The risk of fragmenting the small fracture fragment is reduced because the hooks secure it and the plate is fixed in the bone. If done meticulously, joint congruence can be achieved. It has a biomechanical advantage over current methods of fracture fixation of small but important bone fragments in the hand.

Traumatic avulsion of the flexor digitorum profundus tendon. Jersey finger, a 29 cases report

Traumatic avulsion of flexor digitorum profundus (jersey finger) is an uncommon injury. Our study aimed to describe functional outcomes of jersey fingers after surgical treatment. From January 2004 to 2014, we performed surgery on 32 patients who had jersey finger. Twenty-six of these patients were male and 6 were female with a mean age of 37.2years (range 16–68). Of the 32 cases, 11 were sports injuries, 16 presented on the ring finger and 13 on the little finger. Using the Leddy and Packer and Smith classifications, 16 of the injuries were type I, 4 were type II, 5 were type III, 7 were type IV. The mean time between injury and surgery was 6.8days (range: 0–32). The surgical techniques used were anchor, pull-out, or an association of both these techniques. Prior to the patient discharge, functional outcomes were evaluated. Twenty-nine patients were evaluated in total and three patients were lost. Of the 29, the average time between surgery and discharge was 36.6months ranging from 4.5 to 118months. According to the Buck-Gramcko classification, six patients had an excellent result, six had a good result, seven had a satisfactory result and ten a poor result. The mean Quick DASH score immediately to prior discharge was 5.66 (range: 0–56.82). Twelve complications were reported on nine patients. No infections were reported. Rapid diagnosis and rapid surgical treatment led to restoration of full range motion.

Diagnosis, Treatment, and Return to Play for Four Common Sports Injuries of the Hand and Wrist.

Hand and wrist injuries in the high-level athlete are challenging because they may be underestimated by the patient, family, and team, and return to play may be longer than desired. The needs of the player and the team must be balanced with the long-term functional ramifications of the injury. Four common soft-tissue sports injuries are flexor digitorum profundus avulsion, flexor pulley rupture, extensor carpi ulnaris dislocation, and thumb metacarpophalangeal joint ulnar collateral ligament injury. For each of these injuries, the assessment, treatment, and considerations for return to play should be individualized on the basis of the patient, the sport, and the timing of the injury.

Commentary on “Reattachment of Flexor Digitorum Profundus Avulsion: Biomechanical Performance of 3 Techniques”. Zone I Flexor Tendon Repairs: More Strength Not Worth Altered Joint Kinematics

Commentary on “Reattachment of Flexor Digitorum Profundus Avulsion: Biomechanical Performance of 3 Techniques”. Zone I Flexor Tendon Repairs: More Strength Not Worth Altered Joint Kinematics

Reattachment of Flexor Digitorum Profundus Avulsion: Biomechanical Performance of 3 Techniques

To investigate whether inclusion of the volar plate in repair of flexor digitorum profundus avulsions increases the strength of the repair and resists gapping. Cadaveric fingers (n = 18) were divided into 3 equal groups. The first technique involved 2 micro-suture anchors only (A). The second used only volar plate repair (VP). The third group was a hybrid, combining a micro-suture anchor with volar plate augmentation (AVP). Specimens were loaded cyclically to simulate passive motion rehabilitation before being loaded to failure. Clinical failure was defined as 3 mm of gapping, and physical failure as the highest load associated with hardware failure, suture breakage, anchor pullout, or volar plate avulsion. Gapping throughout cycling was significantly greater for the A group than VP and AVP with no difference detected between VP and AVP groups. Gapping exceeded 3 mm during cycling of 3 A specimens, but in none of the VP or AVP specimens. Load at clinical and physical failure for A was significantly lower than for VP and AVP, whereas no difference was detected between VP and AVP. In this cadaveric model, incorporating the volar plate conferred a significant advantage in strength, increasing the mean load to physical failure by approximately 100 N. According to previous biomechanical studies, current reconstructive strategies for flexor digitorum profundus zone I avulsions are not strong enough to withstand active motion rehabilitation. We demonstrated the potential use of volar plate augmentation and the prospective advantageous increase in strength in this cadaveric model. In vivo performance and effects on digital motion are not known.

Distal Phalanx Osteomyelitis Complicating Zone I Flexor Tendon Repair with a Non-Pullout Suture Tied Over a Dorsal Button: A Report of Two Cases.

Traditional methods for flexor tendon-to-bone repair, such as zone I flexor tendon injuries or distal graft fixation in flexor tendon reconstruction, include a pullout suture tied over a dorsal button as described by Bunnell1-8. However, locking suture techniques have a higher load to failure than nonlocking configurations9-13; a non-pullout locking suture configuration previously has been described14,15. With use of this technique, the non-pullout suture is cut flush with the nail at the time of button removal, leaving suture material within the distal phalanx and tendon. Complications of a tie-over button method include nail deformity5,6,16-18, perionychial irritation or necrosis6,16,19, and infection5,6,16-22. We present two cases of delayed presentation of distal phalanx osteomyelitis after zone I flexor tendon repair with a non-pullout suture configuration that was tied over a dorsal button. Both patients were informed that data concerning their cases would be submitted for publication, and they provided consent. Case 1. A healthy twenty-eight-year-old man with a closed distal flexor digitorum profundus (FDP) avulsion injury of the left ring finger underwent surgical repair ten days after injury. We performed an eight-strand modified Becker technique with use of 3-0 looped Supramid suture (S. Jackson, Alexandria, Virginia) tied over a well-padded polypropylene suture button. Sutures were placed 3 mm apart through the distal phalanx with straight Keith needles; the needles were drilled from the midpoint of the FDP insertion, exiting the midportion of the sterile nail matrix. Preoperative antibiotics were administered intravenously within one hour of surgery. There were no perioperative complications. Rehabilitation emphasizing early motion and tenodesis as a low force/high excursion protocol was initiated under the supervision …

Biomechanical Characteristics of Suture Anchor Implants for Flexor Digitorum Profundus Repair

To determine strength and failure characteristics of 2 suture anchors used to repair simulated flexor digitorum profundus avulsions during passive mobilization protocol simulation. We simulated avulsion of the flexor digitorum profundus tendon in 30 distal phalanges from fresh-frozen human cadavers. Repair was performed with a 1.3× 3.7 mm Micro-Mitek suture anchor (3-0 Orthocord suture) and a 2.2× 4.0-mm Corkscrew suture anchor (2-0 FiberWire suture). All specimens were loaded cyclically from 2 to 15 N at 5 N/s for a total of 500 cycles. Samples were tested to failure at the completion of 500 cycles. Load at failure, load at first noteworthy displacement (> 2 mm), elongation of the system, gap formation at the tendon-bone interface, and the mechanism of failure were assessed. Suture failure at maximum load was the prevalent failure mechanism in both groups. No statistically significant difference in elongation of the tendon-suture complex was observed. The Corkscrew suture anchor showed a significantly superior performance in load to failure, load at first significant displacement, and gap formation at the tendon-bone interface. The significantly higher load capacity at first displacement (> 2 mm) and the significance of a lower gap formation at the repair site seem to be the most relevant clinical parameters. Based on this concept, the Corkscrew anchor may be superior biomechanically to the Micro-Mitek when considering an early passive mobilization protocol. The choice of an appropriate implant may influence the postoperative mobilization protocol and thereby improve currently reported success rates. Defining a biomechanically superior implant will provide an essential basis for further studies in flexor tendon repair research.

Flexor digitorum profundus avulsion injuries in Oztag players

Flexor digitorum profundus avulsion injuries in Oztag players