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CME

Extensor Tendon: Anatomy, Injury, and
Reconstruction
W. Bradford Rockwell, M.D., Peter N. Butler, M.D., and Bruce A. Byrne, M.D.
Salt Lake City, Utah

Learning Objectives: After studying this article, the participant should be able to: 1. Describe the anatomy of the extensor
tendons at the wrist, hand, and fingers. 2. Describe acute and chronic pathologic conditions affecting the extensor
mechanism. 3. Understand physiology and techniques for repair of traumatic injuries. 4. Understand reconstructive
options for chronic disorders.
Although seemingly simple in its anatomy and function, the extensor mechanism of the hand is actually a
complex set of interlinked muscles, tendons, and ligaments. A thorough understanding of the extensor anatomy is required to understand the consequences of injury
at various levels. Reconstructive options must restore normal function. Whereas primary repair of anatomic structures is frequently possible in acute injury, it is rarely
possible in chronic situations. Technically exacting procedures may be necessary to restore function. (Plast. Reconstr. Surg. 106: 1592, 2000.)

proprius and extensor digiti minimi are usually
ulnar and deep to the extensor digitorum communis at the metacarpophalangeal joints. The
extensor digitorum communis to the little finger is present less than 50 percent of the time.3
When absent, it is almost always replaced by a
junctura tendinum from the ring finger to the
extensor apparatus of the little finger.4 The
juncturae tendinum join the extensor digitorum communis tendons proximal to the metacarpophalangeal joint. Lacerations proximal to
the juncturae may still allow extension of the
involved digit by pull from an adjacent finger
passing through the juncturae. The four extensor digitorum communis tendons originate
from a common muscle belly and have limited
independent action. The extensor indicis proprius and extensor digiti minimi have independent muscle bellies and are common donor
tendons for transfer.
At the wrist, the extensor tendons are more
round and have sufficient bulk to hold a suture. Over the hand, they are thin and flat with
longitudinal fibers that do not hold suture
well.5 The extrinsic extensor tendons have four
insertions—the metacarpophalangeal joint
palmar plate through the sagittal bands, a tenuous insertion on the proximal phalanx, and
stout insertions on the middle and distal phalanges.6 At the metacarpophalangeal joint
level, the extensor tendons are held in place by
the intrinsic tendons and the sagittal band that

The anatomy and function of the extensor
mechanism of the hand are more intricate and
complex than those of the flexor system. The
extensor apparatus is a linkage system created
by the radial nerve innervated extrinsic system
and the ulnar nerve and median nerve innervated intrinsic system.1 These interconnecting
components can compensate for certain deficits in function.
The muscle bellies of the extrinsic extensors
arise in the forearm and enter the hand
through six compartments formed by the extensor retinaculum, a fibrous band that prevents bowstringing of the tendons (Fig. 1). At
the wrist, tendons are covered by a synovial
sheath, but not over the dorsal hand or fingers.
The extensor pollicis brevis, abductor pollicis
longus, extensor pollicis longus, extensor digitorum communis, extensor indicis proprius,
and extensor digiti minimi have independent
origins and functions.2 The extensor indicis

From the Division of Plastic Surgery, University of Utah Health Sciences Center. Received for publication November 3, 1999; revised June
13, 2000.

1592

the extensor pollicis brevis extends the metacarpophalangeal joint. However. At the proximal interphalangeal joint. The lateral bands join the extrinsic extensor mechanism proximal to the midportion of the proximal phalanx and continue to the distal finger dorsal to the axis of the proximal interphalangeal and distal interphalangeal joints. The boutonnie`re and swanneck deformities are examples.8 Distal to this level. On the radial side. maintaining them in close proximity. it helps stabilize the lateral bands.11 The triangular ligament connects the lateral bands over the dorsum of the middle phalanx. and the oblique retinacular ligaments function at the proximal and distal interphalangeal joints. and the abductor pollicis longus extends the carpometacarpal joint. Once the balance is disturbed. a deformity at one joint may cause a reciprocal deformity at an adjacent joint.6 The intrinsic tendons are composed of four dorsal interossei (abductors). Excursion of the extensor tendons over the finger is less when compared with the flexor tendons. Preservation of relative tendon length between the central slip and lateral bands is important. and four lumbrical muscles. 106. whereas the extensor pollicis brevis usually has one.8. the central slip of the extensor mechanism trifurcates. fibers of the adductor pollicis also insert on the extensor pollicis longus. When evaluating a deformity at a particular joint. When coursing palmar to the proximal interphalangeal joint. At the midportion of the proximal phalanx. The interossei tendons enter the finger dorsal to the intermetacarpal ligament. The extensor mechanism of the thumb is different from that of the fingers in that each joint has an independent tendon for extension. the transverse retinacular ligament maintains the position of the extensor mechanism and creates limits on its dorsal-palmar excursion. The extrinsic extensor tendons extend the metacarpophalangeal joint primarily and the interphalangeal joints secondarily. Because of this interrelationship of joints. The intrinsic tendons create the linkage at the metacarpophalangeal and proximal interphalangeal joints.8 Its previously described role of mechanically linking simultaneous proximal and distal interphalangeal extension10 has been discounted. The abductor pollicis longus almost always has multiple tendon slips.7 The intrinsic muscles flex the metacarpophalangeal joint and extend the proximal and distal interphalangeal joints.14 This small excursion contributes to a system with a delicate balance among its various components.15 The intrinsic muscles of the thumb primarily provide rotational control. but both components are capable of proximal and distal interphalangeal extension. and restoration of normal balance may be very difficult. excursion may vary from 212. 7 / 1593 EXTENSOR TENDON arises from the palmar plate and the deep intermetacarpal ligament. ACUTE INJURY Extensor tendon injuries are encountered much more frequently than flexor tendon injuries because of their less protected anatomic location. The extensor pollicis longus extends the interphalangeal joint. At the proximal interphalangeal joint.9 The oblique retinacular ligament arises proximally from the middle third of the proximal phalanx and the A2 pulley and inserts into the lateral portion of the extensor tendon along the middle phalanx. 2). These two muscles can extend the interphalangeal joint to neutral. No. the deformities are progressive.Vol. three palmar interossei (adductors). but also contribute to metacarpophalangeal flexion and interphalangeal extension. The interossei originate from the lateral sides of the metacarpals and run distally on both sides of the fingers except the ulnar side of the little finger. On the ulnar side. the abductor pollicis brevis tendon continues to insert on the extensor pollicis longus. all passing palmar to the axis of the metacarpophalangeal joint (Fig.6 The components of the linkage system pass palmar to one joint and dorsal to the next. because of the misconception that they are comparatively simple to treat. The tendons of these intrinsic muscles join to form the lateral bands. there is an exchange of fibers from the central slip to the lateral bands and from the lateral bands to the central slip. The lumbricals arise from the radial side of the flexor digitorum profundus tendon and pass palmar to the intermetacarpal ligament. The central slip primarily attaches to the base of the middle phalanx. significantly masking an extensor pollicis longus laceration. be mindful of the tendon pathways and their relationship to the flexion-extension axis of that joint and adjacent joints. they are often treated in the emergency room by uninitiated physicians who underestimate .13 to 8 mm. Overlapping linkage systems also contribute to this balance.

because good outcomes are not always as easily obtained as once assumed.16 The management of extensor injuries demands the same degree of skill and knowledge required for the care of flexor tendon injuries. extensor pollicis longus. Juncturae tendinum provide interconnections between the extensor digitorum communis (EDC) tendons in the distal portion of the dorsal palm. APL. whereas the lateral band component continues to insert on the base of the distal phalanx. The tendon then inserts on the base of the proximal. and surgical outcome are varied because structural and functional systems are different from fingertip to forearm. 2. the injury. extensor pollicis brevis. The extrinsic extensor tendons contribute the central slip to the extensor mechanism in the finger.12–14. deformity. The intermetacarpal ligament separates the lumbrical tendon that is palmar from the interossei tendons that are dorsal. Recent clinical reports advocate the importance of initial treatment and postoperative rehabilitation of extensor tendon injuries. EPB. The intrinsic system contributes the lateral bands that pass palmar to the axis of the metacarpophalangeal (MP) joint and dorsal to the axis at the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints. Over the distal portion of the proximal phalanx. and distal phalanges. The type of injury. the central slip trifurcates as the central slip and lateral bands share fibers. The oblique retinacular ligament is a component of the linkage system. The sagittal band centralizes the extensor tendon over the metacarpal head at the metacarpophalangeal joint. preservation of length is far more critical to restore normal tendon balance. extensor carpi ulnaris. passing palmar to the rotational axis of the proximal interphalangeal joint and dorsal to the joint axis at the distal interphalangeal joint.1594 PLASTIC AND RECONSTRUCTIVE SURGERY. The triangular ligament helps maintain close proximity of the lateral bands over the middle phalanx. This led to the categorization of tendon injuries into anatomical zones. The transverse retinacular ligament stabilizes the extensor tendon at the proximal interphalangeal joint. abductor pollicis longus. ECRB. . ECU. The extensor tendons enter the hand through six fibrous tunnels that are made by the extensor retinaculum at the wrist. The extensor tendon has four insertions. middle. extensor carpi radialis brevis. Verdan’s12 zone system is the most widely accepted and allows for a more logical discussion of treatment plans and outcomes associated with each area. Verdan defined eight zones—four odd-numbered zones overlying each of the joints and four FIG. EPL. December 2000 jury and outcome is an important concept. The extensor indicis proprius (EIP) and the extensor digiti minimi (EDM) are typically ulnar and deep to the communis tendons at the metacarpophalangeal joint. 1.18 The relationship between the location of in- FIG. The central slip inserts on the base of the middle phalanx. extensor carpi radialis longus. but not in the hand or fingers. with one being on the metacarpophalangeal palmar plate through the sagittal band. ECRL. A small sheath is present around each individual tendon at the wrist.17 Because excursion of the extensor tendon over the finger is less than with the flexors.

Zone 2 Injury (Middle Phalanx) In contrast to zone 1 injuries. In type IV-B. and tendon substance. splinting alone is sufficient. forceful flexion of the distal interphalangeal joint in an extended digit.. with the wire cut off beneath the skin to allow the patient to continue working. followed by splinting for 3 to 4 weeks. No. where there is no palmar subluxation.Vol. after which the Kirschner wire is removed and motion started.19 Mallet finger injuries are classified into four types: • Type I: Closed.21 A proximally displaced fragment not in continuity with the distal phalanx may also require open reduction and internal fixation. so closed reduction results in correction of the deformity. An Alumafoam splint (Millpledge Healthcare. followed by active motion.20 The extensor mechanism is attached to the basal epiphysis. and only in rare circumstances. U. The fracture fragment size is a less important consideration than the fragment’s location. 7 / 1595 EXTENSOR TENDON even-numbered zones overlying the intervening tendon segments and increasing in number from distal to proximal. hyperextension of the proximal interphalangeal joint (swan-neck deformity) may develop because of proximal retraction of the central band. the treatment involves routine wound care and splinting for 7 to 10 days. This should also be protected with a splint for 6 weeks. Type II injures may be repaired with a simple figure-of-eight suture through the tendon alone or a roll-type suture (dermatotenodesis) incorporating the tendon and skin in the same suture. using the thumb to apply extension force to the distal phalanx of the injured finger when showering). but is more often closed. including dorsal skin necrosis. The mechanism for the closed injury is most commonly a sudden. . followed by 2 weeks of night splinting. If less than 50 percent of the tendon width is cut. with a bony fragment from its insertion in the distal phalanx. The management of mallet finger is still a topic for debate. followed by 2 weeks of night splinting. Excellent remodeling of the articular surface occurs in most mallet fractures. Alternatively. • Type II: Laceration at or proximal to the distal interphalangeal joint with loss of tendon continuity. Kirschner wire fixation of the distal interphalangeal joint in extension. When left untreated for a prolonged time. Type III injuries with loss of tendon substance require immediate soft-tissue coverage and primary grafting or late reconstruction using a free tendon graft.K. Mallet finger deformity in a child is usually a transepiphyseal fracture of the phalanx. • Type IV: (A) Transepiphyseal plate fracture in children. splinting for 6 weeks with 2 weeks of night splinting yields good results. (B) hyperflexion injury with fracture of the articular surface of 20 to 50 percent. zone 2 injuries are usually secondary to a laceration or crush injury rather than an avulsion. 106. Type IV-C with palmar subluxation of the distal phalanx is usually best managed operatively with open reduction and internal fixation using a Kirschner wire and possibly a pull-out wire or suture (Fig. subcutaneous cover. The physician should be aware that there are complications with splinting. and (C) hyperextension injury with fracture of the articular surface usually greater than 50 percent and with early or late palmar subluxation of the distal phalanx. Type IV-A is best managed by closed reduction. the recommended treatment is continuous splinting of the distal interphalangeal in extension for 6 weeks. with or without avulsion fracture. followed by 2 weeks of night splinting. 3). In the vast majority of cases. Injuries involving more than 50 percent of the tendon should be repaired primarily. For type I injuries. will achieve the same results. followed by 6 weeks of splinting.) is used to keep the distal interphalangeal joint at 0 degrees. A mallet finger may be open. Kirschner wire should be left in place for 6 weeks. Zone 1 Injury (Mallet Finger) Disruption of continuity of the extensor tendon over the distal interphalangeal joint produces the characteristic flexion deformity of the distal interphalangeal joint. The patient must understand that splinting must be continuous (e. Nottinghamshire. especially with acute swelling. This results in rupture of the extensor tendon or avulsion of the tendon often.9 The distal interphalangeal joint is splinted in extension for 6 weeks. • Type III: Deep abrasion with loss of skin.g.

both central slip and lateral band injuries should be expected. If primary repair of the central slip is not possible. A closed mallet injury without a fracture or with a nondisplaced fracture can be treated with closed splintage. portions of the lateral bands can be sutured together in the dorsal midline of the finger to reconstruct the central slip (Fig.1596 FIG. The usual method of repair is to pass a suture through the central tendon and secure it to the middle phalanx with or without the bony fragment. 3. It usually appears 10 to 14 days after the initial injury. The injury can be closed or open. December 2000 passive extension of the joint23. centered over the proximal interphalangeal joint. In the elderly. (2) axial and lateral instability of the proximal interphalangeal joint associated with loss of active or FIG. However. Reduction is then completed and the Kirschner wire is passed retrograde through the fragment (if possible) and into the middle phalanx. Acute disruption of the extensor tendon over the proximal interphalangeal joint may not be amenable to primary repair of the central slip. surgical repair might be avoided by splinting. 4. Through a dorsal approach over the distal interphalangeal joint. A flap may be raised from the proximal portion of the central slip to restore active extension (Fig. in a true boutonnie`re deformity. and wrist joints are left free. Intraoperative radiographs confirm appropriate reduction. The middle segments are sutured in the midline to reconstruct the function of the central slip. the fragments are isolated. metacarpophalangeal. because the tendon ends do not retract in this area. but no deformity. This technique will help prevent formation of a boutonnie`re deformity. and (3) failed nonoperative treatment. 4). Results are still fairly good. The boutonnie`re deformity then develops gradually. A Kirschner wire is passed antegrade through the bulk of the distal phalanx. This results in the classic deformity with loss of extension at the proximal interphalangeal joint and hyperextension at the distal interphalangeal joint. 5). For open injuries. . especially in closed trauma. PLASTIC AND RECONSTRUCTIVE SURGERY. Length of time for splinting ranges from 4 to 6 weeks. A mallet fracture with joint subluxation requires reduction and internal fixation. followed by an extension splint until there is radiographic evidence of bony union. Surgical indications for closed boutonnie`re deformity are: (1) displaced avulsion fracture at the base of the middle phalanx13.22 Initial treatment for closed injury should be splinting of the proximal interphalangeal joint in extension. The Kirschner wire is removed in 6 weeks. Kirschner wire fixation of the proximal interphalangeal joint is maintained for 10 to 14 days. with reapplication of the splint if the deformity recurs. the period of absolute immobilization can be reduced to 2 weeks to help them regain full flexion.16 Diagnosis is best made after splinting the finger straight for a few days and reexamining it after swelling subsides.24 Zone 3 Injury (Boutonnie`re Deformity) The boutonnie`re deformity is caused by disruption of the central slip at the proximal interphalangeal joint. The distal interphalangeal. and the central slip may avulse with or without a bony fragment. Absent or weak active extension of the proximal interphalangeal joint is a positive finding. The lateral bands can be divided longitudinally over a distance of 2 cm. The early injury may be associated with localized swelling.

Zone 4 Injury (Proximal Phalanx) Zone 4 injuries usually involve the broad extensor mechanism.16 However. partial release of the retinaculum is required in most cases to gain exposure to the lacerated tendons. If just a proprius tendon is involved. irrigated.17 For partial injuries. all fingers should be splinted. Wound cultures should be taken before irrigation and the patient started on broad-spectrum antibiotics.16. only the affected finger need be splinted with the wrist. 7 / 1597 EXTENSOR TENDON FIG. and usually spare the lateral bands.17 Immobilization of the wrist in 30 to 45 degrees of extension and the metacarpophalangeal joint in 20 to 30 degrees of flexion is performed with the proximal interphalangeal joint free. repair is rarely required.11 Zone 5 Injury (Metacarpophalangeal Joint) Injuries over the metacarpophalangeal joint are almost always open and should be treated as a human bite until proven otherwise. early motion should be considered. When associated with a human bite. use of early dynamic splinting has been shown to improve results. therefore.9. If the extensor digitorum communis is involved.26 If early dynamic splinting is used. .18 Again. and secondary repair is rarely needed.12 However.Vol. a distally based central slip flap may be created from the proximal portion of the extensor tendon. Zone 7 Injuries (Wrist) Controversy exists whether excision of part of the retinaculum over the injury site is necessary to prevent postoperative adhesions.16 Zone 6 Injuries (Dorsal Hand) Single or partial tendon lacerations in zone 6 may not result in loss of extension at the metacarpophalangeal joint because extensor forces are still transmitted from adjacent extensor tendons through the juncturae tendinum. primary repair should be performed. 5. is best made by direct inspection. All involved structures should be repaired separately. 106. repair should be performed with stronger. The injury more often occurs with the joint in flexion. The flap remains attached to its local portion of tendon. The more proximal portion of the flap is then folded distally and sutured to the distal portion of the central slip. followed by 6 weeks of splinting in extension. when there is no loss of extension in the interphalangeal joints. The wound is extended for thorough inspection and debrided.9 Arthrotomy of the metacarpophalangeal joint should be considered in cases of bite injury or suspected pyarthrosis. so the tendon injury will actually be proximal to the dermal injury. For complete lacerations. including partial injuries. No. If primary repair of a central slip laceration is not possible. Because the tendons are thicker and more oval. Diagnosis. the incidence of complications is directly related to the time from injury to treatment. Conventional splinting places the wrist and fingers in extension for 4 to 6 weeks. The wound usually heals within 5 to 10 days. In any case. The hand is splinted with the wrist in 45 degrees of extension and the metacarpophalangeal joint in 15 to 20 degrees of flexion. The resulting defect in the proximal portion of the central slip is primarily repaired. The sagittal bands should be repaired to prevent lateral migration of the extensor digitorum communis tendon and subsequent metacarpophalangeal extension loss. adhesions are less likely. are usually partial.25. and left open. Splinting the proximal interphalangeal joint in extension for 3 to 4 weeks without repair is equivalent to repair of the tendon with 5-0 nonabsorbable suture. core-type sutures. Primary tendon repair is indicated after thorough irrigation. Diagnosis can only be made by direct inspection. at least some portion of the retinaculum should be preserved to prevent extensor bowstringing. Early dynamic splinting has also improved outcome. which retract significantly in this area.

All tendons and the capsule should be repaired separately using coretype sutures. Dynamic Splinting for Extensor Injuries Since its introduction by Kleinert et al. with the wrist in 40 degrees of extension and slight radial deviation and the thumb metacarpophalangeal joint in full extension. wrist flexors are excellent tendon transfer donors for finger extension. because bad outcomes are likely for patients who cannot understand or partic- . Evaluation of established extensor disorders must include all three joints as they are interrelated. several key points should be reemphasized.29 Because of the broad extensor expansion at the metacarpophalangeal joint of the thumb. mallet thumbs are rare. ensuring patient education is paramount.” Early controlled motion with a dynamic extensor splint has been found to decrease adhesions and subsequent contractures. multiple figure-eight sutures are used with a slowly absorbing material.31 It has been most effective when used for injuries in zones 5 to 8. Treatment of the thumb extensors at the forearm level is identical to that of the fingers.27 Difficulty also may be encountered with injuries at the musculotendinous junction because the fibrous septa retract into the substance of the muscles. although some would still opt for surgical repair. and it should be repaired. although several studies are promising.30 early controlled motion has been used after flexor repair to overcome the adhesions associated with repair in “no man’s land. restoration of independent wrist and thumb extension should be given priority. For closed injuries.9 Its usefulness in the more distal zones is less apparent. full active extension is initiated. Therefore. The splint allows incomplete active flexion and passive extension. December 2000 gus retracts significantly when divided and usually requires that the first compartment be released for successful repair.28 especially as closed injuries. lying palmar to the axis of rotation at a proximal joint and dorsal at the next distal joint.12 Splinting is for 4 to 5 weeks.g. There is an extension lag in both metacarpophalangeal and interphalangeal joints with extensor pollicis longus injury. For open injuries. and controlled wrist function is essential to normal finger extensor mechanics. making it difficult to identify individual tendons. because the extensors originate from the lateral epicondyle. most would recommend primary repair..32 Preoperatively. CHRONIC INJURY To understand better extensor tendon reconstruction. There is little data comparing operative and nonoperative treatments.1598 A four-strand nonabsorbable core suture is used. In zones 6 and 7. proximal interphalangeal flexion is associated with distal interphalangeal extension in the boutonnie`re deformity). splinting for 6 weeks without surgical repair is appropriate. The technique should only be used in the cooperative patient. When repairing the muscle bellies. The delicate balance of the extensor complex is partially based on a series of overlapping linkage systems. Splinting should be for 3 to 4 weeks. The extensor mechanism has much less tolerance for changes in tendon length than the flexor mechanism. Thus. and treatment is usually directed at the most proximal involved joint. followed by splinting for 6 weeks. splinting the elbow in flexion may also be beneficial. Dynamic motion of the metacarpophalangeal joints may be started at 2 weeks and has improved results. with the wrist in radial deviation and the thumb in maximal abduction. the terminal extensor tendon is much thicker on the thumb. and is most advantageous when a skilled hand therapist is available to fabricate the splint and monitor the patient. late extensor disorders are reciprocal at adjacent joints (e.6 Finger extension is synergistic with wrist flexion. Static immobilization of the wrist in 45 degrees of extension and metacarpophalangeal joints in 15 to 20 degrees of flexion is maintained for 4 to 5 weeks.. Isolated laceration of the extensor pollicis brevis at this level is also rare and its repair is optional but recommended. In this situation. Therefore.26.11 Also.4. Zone 8 Injuries (Dorsal Forearm) Multiple tendons may be injured in this area. because extension of the metacarpophalangeal joint is possible with an intact extensor pollicis longus. traumatic division of all components of thumb extension is rare. After 4 weeks.6 The precise tension in this system changes with joint flexion and contraction.2. the abductor pollicis lon- PLASTIC AND RECONSTRUCTIVE SURGERY. Thumb Injuries Although anatomically the thumb interphalangeal and finger distal interphalangeal joints are similar.

31 although dynamic splinting may be used in motivated. Complications after repair of lesions proximal to the metacarpophalangeal joint include adhesions of the tendons (most common). or a sling procedure. this condition generally should be surgically corrected by delayed primary repair that is technically difficult. 106. The metacarpophalangeal joints must remain in extension for several weeks while the other joints are ranged.35. donor deficits. Operative treatment of this condition includes tenolysis or extrinsic extensor release. usually associated with distal radius fractures and rheumatoid arthritis. The hand surgeon must remember that many established imbalances will respond to nonoperative treatment.” extensor lag. and the patient can hold this position. Inability to extend the finger metacarpophalangeal joint or radially abduct the thumb despite intact radial nerve function indicates a problem proximal to the metacarpophalangeal joint. For wrist extensors. or side-to-side extensor digitorum communis transfers are used for extensor digitorum communis ruptures.36 and around the wrist rather than through the interosseous membrane to lessen scarring. The procedure concludes with the wrist splinted in moderate extension and the metacarpophalangeal joints splinted at 70 degrees flexion. This should be continued for 3 to 4 weeks. especially if this is begun early. the extensor retinaculum is expendable in this procedure.33 Unless held to length by the juncturae. Joint contractures are contraindications to reconstruction of extensors. congenital. No. the pronator teres is the common choice. When diagnosed during the first 2 weeks. The extensor pollicis longus tendon is a commonly ruptured tendon. and pain and swelling. the tendon reduces. but the other finger extensors also have a significant propensity to rupture. The extensor indicis proprius or palmaris longus is frequently used for extensor pollicis longus functional transfer.38 After 2 weeks. but also with traumatic. ulnar deviation of the digit. The central portion of the extensor assembly is excised over the proximal phalanx. these procedures should not be considered until a 6-month trial of hand therapy has been completed. epileptic. However. if passively extended. preserving the sagittal bands and the central slip distally at its insertion on the base of the middle phalanx. Physical findings include “catching.1. If the extrinsic extensor becomes adherent or foreshortened. Although the sagittal bands must be preserved.Vol. Setting tension properly with the wrist maximally extended and the fingers flexed is essential. 7 / EXTENSOR TENDON ipate in postoperative therapy and those who have unrealistic goals.6 Clinically. flexion at the metacarpophalangeal causes an extension force at the proximal interphalangeal by dorsal tenodesis restraint.37. These patients with extrinsic extensor tendon tightness are not able to fully flex the involved fingers. followed by active range of motion for 1 to 2 weeks and later passive ranging. reliable patients. and degenerative states.1.39 The latter two procedures take a sling of extensor digitorum communis to recentralize the tendon. usually on the radial side. this subluxation can be effectively treated with metacarpophalangeal extension splinting and encouraged proximal interphalangeal motion. whereas the extensor indicis proprius. Most patients respond well to exercises that emphasize extensor excursion and splinting.34 Tendon transfers are the most reliable technique for reconstruction of chronic extensor tendon deficits at this location. the motor unit undergoes myostatic contraction. the extensor slips off the metacarpal head fulcrum and loses 1599 its mechanical advantage for extension. rupture or attenuation. The patient cannot extend from flexion. and joint stiffness.6 This procedure separates the extrinsic and intrinsic extensors. precluding secondary tendon repair.1.37 This can be an acute or chronic finding. This situation occurs most commonly with not only rheumatoid arthritis. flexor carpi ulnaris. It is recommended that both of these procedures be performed while allowing the patient to move the fingers actively on . the patient can flex the proximal interphalangeal only with the metacarpophalangeal extended. dorsal tenodesis.35 Technical points in this procedure include passing the transfer subcutaneously rather than beneath the retinaculum because wrist flexion is synergistic with finger extension. Tenolysis is best for fingers with scarring but adequate tendon length. The sagittal bands wrap around the metacarpophalangeal joint. stabilizing the extrinsic extensors centrally with attachment to the palmar plate. Littler’s technique of extrinsic extensor tendon release is indicated for short tendons or long lengths of scarring. but.6.6 With rupture or attenuation of these bands.

46 The superficialis tenodesis technique uses one slip of the flexor digitorum superficialis attached distally and affixed proximally to the proximal phalanx. surgical resection of the lateral bands over the proximal phalanx will relieve intrinsic tightness.47 This method does not rebalance the extensor mechanism at the distal joint. When compliance with postoperative splinting and exercises is difficult. In rheumatoid patients. This creates laxity in the distal tendon because of the fixed attachment of the central tendon at the proximal interphalan- FIG.44 When intrinsic tightness is present. one must correct the metacarpophalangeal joint deformity first. and mallet deformity with coexistent palmar plate laxity. In contrast. 7) with Kirschner wire fixation of the proximal interphalangeal joint in 20 degrees of flexion. putting maximum tension on the intrinsics. intrinsic release must also be performed. If the condition will not resolve with therapy. Correction of the malunited middle phalanx is the appropriate treatment of this cause. uses a free tendon graft to spiral palmarly to reconstruct the oblique retinacular ligament (Fig. while remaining palmar to the proximal interphalangeal joint axis and dorsal to the distal interphalangeal joint axis. For those cases where rebalancing of the extensor mechanism with correction of the proximal interphalangeal palmar plate incompetence is necessary. the Kirschner wire is removed at 4 weeks and replaced by a dorsal blocking splint. Swan-neck deformity describes a finger with proximal interphalangeal joint hyperextension and distal interphalangeal flexion. 6) is diagnosed by the inability to flex the proximal interphalangeal joint when the metacarpophalangeal joint is brought into full extension. This posture can result from various causes. as with spastic patients. Although it is a dynamic imbalance initially. December 2000 geal joint. The original method described by Littler45 uses the lateral band either ipsilaterally or spiraling palmarly attached at the base of the proximal phalanx for oblique retinacular ligament reconstruction.40 This condition usually responds well to exercise and splinting. making passive proximal interphalangeal flexion difficult. A realistic goal is 5 to 10 degrees flexion at the proximal interphalangeal joint rather than complete extension.6 Be aware that this does not address the palmar plate laxity in the swan-neck deformity.6 Conservative splinting and exercises are not helpful in the treatment of swan-neck deformity. excessive proximal interphalangeal joint flexion deformity from too . 6. spastic conditions such as cerebral palsy and stroke. fixed or dynamic. rheumatoid arthritis. the incompetent palmar plate allows hyperextension at the proximal interphalangeal joint. spiral oblique retinacular ligament technique.1600 the table.43 Surgical correction must recognize the underlying cause: only the mallet deformity need be corrected if this is the cause. surgical treatment includes eliminating the dual control of proximal interphalangeal joint extension by excision of the oblique fibers and lateral band of the extensor hood over the middle of the proximal phalanx. causing the lateral bands to migrate dorsally. two general techniques are commonly used: oblique retinacular ligament reconstruction or superficialis tenodesis. Complications include recurrence of the deformity caused by attenuation. PLASTIC AND RECONSTRUCTIVE SURGERY. Oblique retinacular ligament reconstruction involves creating a tenodesis that passively tightens and extends the distal interphalangeal joint as the proximal interphalangeal joint actively extends.41 For patients in whom nonoperative treatment fails. arthrodesis of the proximal interphalangeal joint is appropriate.42 Pathomechanically. A modification of this. including palmar plate laxity at the proximal interphalangeal joint. The unopposed flexor digitorum profundus deforms the distal phalanx into flexion. malunion of middle phalanx fractures. This will create tension on the more distal extensor apparatus. Postoperatively. it may progress to a fixed deformity. Intrinsic tightness is caused by shortening of the intrinsic musculotendinous apparatus. Testing for intrinsic tightness is performed by passively extending the metacarpophalangeal joint. intrinsic tendon tightness (Fig. Range of motion is begun almost immediately.

48 It is primarily caused by disruption of the cental slip and transverse retinacular fibers at the proximal FIG. This cannot be stressed enough because surgical repair is fraught with complications.35 Similar to many other extensor imbalances. the central tendon deficit is so large that it requires a tendon graft passed through a bone tunnel at the dorsal base of the middle phalanx and criss-crossed to be sutured . creating a fixedflexion deformity. Curtis et al. Oblique retinacular ligament reconstruction can be conducted with existing local tissue or with a tendon graft. Perhaps a systematic approach to the management of chronic boutonnie`re deformity is best. and fixed-joint changes. 7. active-forced flexion of the distal interphalangeal joint with the proximal interphalangeal in extension will cause stretching of the oblique retinacular ligament.Vol. One technique to repair late boutonnie`re deformity uses the central slip primary repair with reattachment of the lateral bands dorsal to the proximal interphalangeal joint axis. The oblique retinacular ligament shortens along with the lateral bands.48 Three stages have been described. allowing the lateral bands to migrate palmar to the axis of the proximal interphalangeal joints. and results with conservative therapy may be as good or better than with surgery. including dynamic imbalance. Tension in the tendon graft is adjusted to correct the original deformity. 7 / EXTENSOR TENDON FIG. the lateral bands move palmar to the axis of the proximal interphalangeal joint. probably the most reliable procedure is that advocated by Littler and Eaton50 This involves lengthening of the lateral band by incomplete transection of the extensor mechanism over the middle of the middle phalanx. it begins as a dynamic process that can lead to a fixed deformity.49 described a four-stage approach progressing from tenolysis to transverse retinacular ligament sectioning to lengthening of lateral bands over the middle phalanx to repair of the central slip. 106. Extensor tone at that joint is decreased but the force of the extensor mechanism is passed through the lateral bands to the distal interphalangeal joint where hyperextension occurs. established tendon contracture with supple joints. Swan-neck deformities are characterized by proximal interphalangeal hyperextension and distal interphalangeal flexion. Occasionally. (Above) The boutonnie`re deformity is usually the result of the central slip rupturing at the proximal interphalangeal joint. a supple proximal interphalangeal joint with satisfactory passive motion is a prerequisite. They may adhere in this position. If the condition is left untreated. For any reconstruction. boutonnie`re deformity is best treated with splinting and exercises. especially after superficialis tenodesis. with or without division of the terminal extensor insertion on the distal phalanx to restore distal interphalangeal function. 1601 interphalangeal joint. the distal interphalangeal hyperextends. and flexor adhesions. Littler originally described this technique with suturing of the lateral bands dorsally. Boutonnie`re deformity refers to a finger posture with the proximal interphalangeal joint flexed and the distal interphalangeal joint hyperextended (Fig. tight of a tenodesis. No. Splinting supports the proximal interphalangeal joint and the two proximal phalanges only. especially before the deformity occurs. 8. However. Secondly. The grafted tendon is placed dorsal to the distal interphalangeal joint and palmar to the axis of rotation of the proximal interphalangeal joint. The exercises include active-assisted proximal interphalangeal joint extension that will cause worsening of the distal interphalangeal extension. 8). (Below) In the chronic condition. Like swan-neck deformity. but leaving the oblique retinacular ligament intact. and become flexors of this joint.

E. H.53 The hyperextension deformity at the distal interphalangeal joint may cause greater difficulty for the patient than the lack of proximal interphalangeal joint extension. P. M. H. C.. M. S.. R. 31.. C. H. R. Willson. A. Extensor tendon injuries of the hand.. 1992. E. Blair. A. J. Y. and Sherwin. Louis: Mosby. 13: 24. Longterm results of extensor tendon repair.. Clin. Elson. Patel.. Hand Clin. 1984. De Quervain’s syndrome: Surgical and anatomical studies of the fibroosseous canal. E. Bone Joint Surg. In J. J. 4: 865.). Conservative treatment of mallet thumb. Atasoy. J. Boyes (Ed. (Am. J. Bone Joint Surg. Urbaniak. D. 1984.).) 15: 595. A. and Weightman. 1990. (Am. B. C. M. J. A. (Am.. 48: 1015. R. H. St.) 17: 268.. G. Tubiana. 24. M. V. and Stommo. et al. Tendons. Mackin. Detailed anatomy of the extensor mechanism at the proximal aspect of the finger. J. R. D. W. and E. L. New York: Churchill Livingstone.. Orthop.. J. 2. New York: McGraw-Hill.) 6: 493. and Hayes. 1989..1602 PLASTIC AND RECONSTRUCTIVE SURGERY. J. 8. (Am. 1973. Wrist position and extensor tendon amplitude following repair. Z. H. M. T. J. and A. D. Jr. Philadelphia: Lippincott. Schneider. Rupture of the central slip of the extensor hood of the finger: A test for diagnosis. Peimer. Newport. 29. J. G. T. 11. Mackin (Eds. W. Furlong. Bone Joint Surg. 1981. 1975. Synovitis of the extensors of the fingers associated with extensor digitorum brevis manus muscle: A case report. Philadelphia: Lippincott. M Hunter. M. 16: 366. M. 30... M. J. (Br. North Am.) 68: 229. Callahan (Eds. A. S.. In J. and Kutz. Edmonson. J. Hotchkiss. 1996. Hand Surg. 5. (Am. 1991. A. J. Primary and Secondary Repair of Flexor and Extensor Tendon Injuries. J. 12. G. 6th Ed.) 13: 156. Rupture of the extensor pollicis longus tendon after Colles fracture and by rheumatoid arthritis. The functional anatomy of the extensor mechanism of the finger. L. 3B205 Salt Lake City. Clin. J. I. Campbell’s Operative Orthopedics. Littler. Joint Dis. injuries and treatment of the extensor apparatus of the hand and fingers. In D. 1992. In D. Bull. C. Kutz.. Boyes.D. 5th Ed. S.. Extensor Tendons: Acute Injuries. Hosp.). L. Wehbe.. R. Orthop. H. St. Tendon Surgery in the Hand. E. 33. 32. Burton. Med. M.. C. In C. W. 27. J. 16. 1993.. H. 1995. L. R. to the lateral bands. Operative Orthopaedics. 2nd Ed. Kleinert. and Elbert. Aulicino.. Schultz. McFarlane. K. In M. M. and Desai..). B.) 65: 606.. Operative Hand Surgery.54 The complexity of the extensor mechanism is created by a delicately balanced musculotendinous system controlled by two linkage systems. 25. M. Peimer (Ed. F. F. J. J. W. S. Bradford Rockwell. Clin. and Schneider.) 14: 72. Clin. Y. H. Hand Surgery. and Melchior. R. 47: 415. 1990. Peimer. E. 21. Extensor tendon injuries. A. El-Gammal. J. L. Cox. 1963. L. Browne. E. both acute and chronic. R. Surg. Yamaguchi. J. Minamikawa. 2nd Ed. North Am. P. H. Minamikawa. 1972. December 2000 14. J. (Br. J.. Hunter.) 66: 658. Management of Acute Extensor Tendon Injuries. Mallet thumb. North Am. Oetker. J. P. 1987. D. and Steyers. H. 34. 30: 39. 95: 278. L. M. 1993. and Ribik. Division of Plastic Surgery University of Utah Health Sciences Center 50 North Medical Drive.) 45: 1654. Din. 1969. 11: 403. M.51 Lateral band tendon transfers have also been described by Littler52 and Matev. 1968. Anatomy. Steyers. Hand Surg. Surg. C. 22. 1986.edu REFERENCES 1. M.) 54: 713.) 15: 49. K.. 3rd Ed. 1970. Minamikawa. Landsmeer. Blair. C. W. Anatomy of the oblique retinacular ligament of the index finger. and Peimer. 1981.. C. E. St. Early dynamic splinting for extensor tendon injuries. Can. J.. 11: 637. (Am. Rehabilitation of Extensor Tendon Injuries. Bone Joint Surg. 1959. M. Surgery of the Hand and Upper Extremity. 1983. Doyle. F.). Hand Surg. 1993. Hart. Clin. F. Mallet fractures. Lipson. (Am. Hand Surg. 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M. 1981. R. W. and Eaton. 1983.) 53: 1313. Converse (Ed. J. Bone Joint Surg. Philadelphia: Saunders. 43. 40.) 12: 227.. G. Y.. Palmer. C. W. J. Schneider. W. No. Littler. Vol. New York: Churchill Livingstone. R. 1987. Redistribution of forces in correction of boutonnie`re deformity.) 33: 836. Hand Surg. L. van der Meulen.) 8: 167. Philadelphia: Saunders. Hand 4: 154. Inoue. A. (Am. Smith. J. The lumbrical plus finger. R. 39. 6: 733. E. J. and Brown.). S. J. J. 53.) 10: 11. (Am. Non-ischemic contractures of the intrinsic muscles of the hand. J. H. 37. 41. The spiral oblique retinacular ligament (SORL). 1964. In J. S. . The treatment of prolapse and collapse of the proximal interphalangeal joint. Correction of ulnar subluxation of the extensor communis. J. Orthop. R. C. G. 1975. J. Hand Clin. E. 1603 EXTENSOR TENDON W. Operative Hand Surgery. Newmeyer. W. J. J. and Bevin. L. 49. and Weiland. J. Br. 11: 441. Reconstructive Plastic Surgery.. J. (Am.. Converse (Ed. K. Hand Surg.. North Am. Causes of prolapse and collapse of the proximal interphalangeal joint. Nalebuff. Repair of extensor tendon insertions in the fingers. M. A. Transportation of the lateral slips of the aponeurosis in treatment of long-standing “boutonnie`re deformity” of the fingers. Philadelphia: Saunders. Meadows. W. Thompson. H. J. A staged technique for the repair of the traumatic boutonnie`re deformity. and Millender.. 50. Clin. Littler. Hand Surg. 1977. 1967. Littler. R.. A Textbook of Orthopedics. C. 17: 281. Plast. J. Salisbury. A. and Tamura.) 49: 1267. 38. Bone Joint Surg. 45. Hand Surg. 106. Reconstructive Plastic Surgery. J.. M.. A. 1971. S. R... Kilgore. G. (Br. J. W. J. M.). and Provost. R. 51. Principles of Reconstructive Surgery of the Hand. (Am. Graham. J. P. Littler. 1999. W. E. In M. 1951. Moore. 1952.Vol. 54. The Hand and Wrist. 1996. 6. W. J. 48. In Atlas of Reconstructive Surgery. Surg.. and Glisson. H. (Am. 47. Jr. (Am. Dislocation of the extensor tendons over the metacarpophalangeal joints.) 3: 482. Surgical treatment of the swan-neck deformity in rheumatoid arthritis. and Sherwyn.. Bone Joint Surg.. F. 1972.) 21: 464. Treatment of the chronic boutonnie`re deformity by extensor tenotomy. Boutonnie`re Deformity.). J. Matev. Self-Assessment Examination follows on page 1604. 1970. 42. 7 / 36. (Am. Reid. The Digital Extensor-Flexor System. The extensor retinaculum of the wrist: An anatomical and biomechanical study. R. C. 1978. 1995... J. van der Meulen. H. Philadelphia: Saunders.. B. Littler. Skahen. Posttraumatic ulnar subluxation of the extensor tendons: A reconstructive technique. Petersen (Eds. J. L. Carroll. Hand 7: 272. 44. Parkes. I. 1975.). and Upton.. 1972. 1964. L. E. Hand 4: 147. J. Werner. M. Curtis. J. R. Nichols. Hand Surg. 1985. Hand 2: 164. A. Howorth (Ed. 4th Ed. G. 52. In 46. L..

. . E) Controlled early motion of distal interphalangeal joint.) Failure of conservative.D. and Reconstruction.Self-Assessment Examination Extensor Tendon: Anatomy. 6. B) Percutaneous Kirschner wire fixation of distal interphalangeal joint in extension. WHICH OF THE FOLLOWING STATEMENTS IS TRUE? A) Intrinsic tightness refers to resistance of proximal interphalangeal joint flexion while the metacarpophalangeal joint is flexed. C) Splinting of only distal interphalangeal joint in extension.D. Butler. Byrne. ZONE 6 (DORSAL HAND) INJURIES ARE BEST DIAGNOSED BY: A) Loss of active extension of distal interphalangeal joint. Bradford Rockwell. E) Intrinsic tightness plus posture of finger. M. C) Swan-neck deformity. Injury.. by W. THE RECOMMENDED TREATMENT FOR CLOSED MALLET FINGER IS: A) Surgical repair of tendon. M. To complete the examination for CME credit. INDICATIONS FOR OPERATIVE MANAGEMENT FOR CLOSED BOUTONNIE OF THE FOLLOWING EXCEPT: A. B) Loss of active extension of proximal interphalangeal joint. M. 4. B) Palmar migration of the lateral bands 7 to 10 days after injury. B) Joint contractures are contraindications to extensor reconstruction. turn to page 1673 for instructions and the response form. B) Intrinsic extensor tightness. D) Direct inspection. WHAT PERCENTAGE OF PEOPLE HAVE AN EXTENSOR DIGITORUM COMMUNIS TENDON TO THE LITTLE FINGER? A) 100 percent B) 98 percent C) 90 percent D) 80 percent E) Less than 50 percent ` RE DEFORMITY INCLUDE ALL 2. proximal interphalangeal extension and distal interphalangeal extension. D) When the extrinsic extensor subluxates off the metacarpal head. 3.D. C) Swan-neck deformity refers to a finger posture of proximal interphalangeal joint flexion and distal interphalangeal joint hyperextension. E) Mallet finger. D) Axial and lateral instability of the proximal interphalangeal joint associated with loss of active or passive proximal interphalangeal joint extension. nonoperative management. E) Extrinsic tightness causes a posture of metacarpophalangeal flexion. C) Displaced avulsion fracture of the base of the middle phalanx. C) Loss of active extension of metacarpophalangeal joint. ALL OF THE FOLLOWING CONDITIONS USUALLY RESPOND WELL TO SPLINTING AND EXERCISE PROGRAMS EXCEPT: A) Extrinsic extensor tightness. it usually falls to the radial side. and Bruce A. D) Splinting of proximal interphalangeal and distal interphalangeal joint in extension. Peter N. 5. 1. D) Boutonnie`re deformity.