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DO ASSOCIATED LESIONS (SAGITTAL BAND

,
JUNCTURAE TENDINUM, CAPSULAR DISRUPTION,…) ON

THE DORSUM OF THE HAND HAVE
ANY CONSEQUENCES IN EXTRINSIC
EXTENSOR TENDONS REPAIR ?
Christian Dumontier, Jean-Claude Rouzaud
Centre de la Main, Guadeloupe, FWI et Institut Montpelliérain
de la Main, Montpellier

Remerciements: Dr Carmès, Pr Uzel et le laboratoire d’anatomie de Guadeloupe

www.diuchirurgiemain.org
SHOULD WE REPAIR AN ISOLATED
LESION OF THE EIP ?

• Loss of extension strength
of the index after EIP
transfer is around 50-65%

• Some authors reported
extension lag

• ➽ Should be repair

Noorda RJP et al. Index Finger Extension and Strength After Extensor Indicis Proprius Transfer. JHS 1984;19A:844-849.
Kerr CD, Gittins ME. Analysis of donor deficit after extensor indicis proprius tendon transfer. J Am Osteopath Assoc 1991;91:245-6,249.
Moore JR, et al. Independent index extension after extensor indicis proprius transfer. J Hand Surg 1987;12A:232-6.
Magnussen PA, et al. Extensor indicis proprius transfer for rupture of the extensor pollicis longus tendon. J Bone Joint Surg 1990;72B: 881-3.
DO WE NEED TO REPAIR THE EXTENSOR DIGITI MINIMI ?

• Has been used for tendon transfer

• EDC 5 is absent in up to 67% of
cases

• In up to 17% of cases, EDM is the
only extensor of the little finger

• ➽ Should be repair

Zilber S, Oberlin C. Anatomical Variations of the Extensor Tendons to the Fingers over the Dorsum of the Hand: A Study of 50
Hands and a Review of the Literature. Plast. Reconstr. Surg. 2014;113: 214-221
Gonzalez MH et al. The Extensor Tendons to the Little Finger: An Anatomic Study.J Hand Surg 1995;20A:844-847.
SHOULD WE REPAIR THE CAPSULE ?
• No idea and no clear sentence in
literature

• By analogy: Open joint injuries should
be closed

• By analogy: Capsular tear in Boxer’s
knuckle are poorly tolerated and
should be closed

Patzakis MJ, Dorr LD, Ivler D, Moore TM, Harvey JP Jr. The early management of open joint injuries. A prospective study of one hundred and forty patients. J Bone
Joint Surg Am. 1975;57(8):1065-70.
Melone CP Jr, Polatsch DB, Beldner S. Disabling Hand Injuries in Boxing: Boxer’s Knuckle and Traumatic Carpal Boss. Clin Sports Med 28 (2009) 609–621
Gladden JR (1957). Boxer’s knuckle. A preliminary report. American Journal of Surgery, 93: 388–397.
Posner MA, Ambrose L. Boxer’s knuckle-dorsal capsular rupture of the metacarpophalangeal joint of a finger. J Hand Sur 1989;14A:229-236.
Arai A et al. Treatment of soft tissue injuries to the dorm of the metacarpophalangeal joint (Boxer’s knuckle) . J Hand Surg 2002;27B(1)90-95.
CAPSULAR REPAIR ?

• Persistent flow of joint fluid
lead to chronic swelling

• However reparable
longitudinal capsular tear in
bower’s knuckle may be
different from transverse
tears ?
OPEN JOINT INJURIES
• Mostly sharp wounds over MP
joints ➜ capsular suture if
possible

• OR fight bite injuries +++ (60 to
95% capsular injuries) ➜ Middle
> Ring > Index ➜ Do not extent
the rent in the sagittal band and
go through the extensor
Shewring DJ, Trickett RW, Subramanian KN, Hnyda R. The management of clenched fist
‘fight bite’ injuries of the hand. J Hand Surg 2015;40E(8):819-824.
Patillo D, Rayan GM. Open extensor tendon injuries: an epidemiologic study. Hand Surg.
2012;17(1):37e42.
WHAT IS THE ROLE OF SAGITTAL BANDS ?

• They avoid bowstringing effect in
hyperextension

• They are (partly ≈ 8%)
responsible for MP joint
extension

Zancolli EA. Structural and dynamic bases of hand surgery. 2nd Ed. Philadelphia: JB Lippincott, 1979:3–36.
Marshall TG et al. Mechanics of Metacarpophalangeal Joint Extension. J Hand Surg 2018; 43(7):681.e1-e5
WHAT IS THE ROLE OF SAGITTAL BANDS ?

• They stabilize the extensor
over the MP joint

• Only the radial band

• In its proximal part (50%)

• If the wrist is in flexion

Young CM, Rayan GM. The Sagittal Band: Anatomic and Biomechanical Study. J Hand Surg 2000;25A:1107–1113.
CLINICAL CONSEQUENCES

• Should repair
radial sagittal
bands

• Should protect
repair with limited
MP flexion
WHAT ARE JUNCTURAE TENDINUM USEFUL FOR ?

• They limit finger
independence ?

• They stabilise the extensors
during MP flexion ?

• They can compensate for
extension of adjacent
fingers ?
RadioGraphics
FINGER INDEPENDENCE DOES NOT DEPEND
OF JUNCTURAE
596 May-June 2003

RadioGraphics
• There is no finger
independence during extension
Figure 8. Axial anatomic slice (a) and corresponding T1-weighted MR image (b) obtained a
hand show the extensor digitorum tendons (arrowheads) and extensor digiti minimi tendons (a

due to the frequent fibrous
ranged on the same level. Note the difficulty of identifying the tendon for each finger owing to t
and variability.

bands in the muscles
Dorsum of the Hand (Zone VI)
The dorsum of the hand features greater ana-
• At wrist level there are 3 to 7 tomic variability because of tendinous multiplicity
and the presence of connections between the dif-
tendon bands ferent tendons. In most cases, Figure
there is3.more
one tendon for each finger between
forearm the
Axialthan
wrist
show
anatomic slice (a) and axial T1-weighted MR i
the and
extensor muscles. 1 ! extensor carpi radialis lo
sor digiti
the MCP joints (15). Furthermore, minimi,
this 4 ! extensor carpi ulnaris, 5 ! abductor pollici
multiplic-
pollicis longus, 8 ! extensor indicis, 9 ! brachioradialis.
ity increases near the ulnar zone (16,17). The
• Orientation of juncturae (from most frequent distribution pattern is as follows: a

EDC4 to EDC 3 or 5) single extensor indicis tendon brevis,
extensor digitorum tendon of the
locatedextensor
nimi,index
ulnar todigitorum,
and finger
extensor
the extensor digiti mi-
in carpi ulnaris. These mus-
firs
ser
the MCP joint; a single extensorclesdigitorum
mainly originate
ten- from the posterior side of the thu
lateral
don for the index finger; a single thick epicondyle
extensor and in a portion of the inter- do
digitorum tendon for the middle muscular
finger;septum.
a doubleThe extensor carpi radialis lon- an
Kaplan EB. Anatomy, injuries and treatment of the
extensor extensor
digitorum apparatus
tendon of inserts
forgus
the the
ringhand on and
theno
finger; fingers. Clin
dorsum Orthop
of the base of1959;13:24-41
the sec- of
extensor digitorum tendon forond the metacarpal,
little finger;the extensor carpi9.
Figure radialis brevis (a) an
Conventional
THEY DO NOT STABILIZE THE EXTENSORS
DURING MP FLEXION

• Role for sagittal bands

• Extensors of the little finger
rarely dislocate (due to
juncturae ?)

• Few case report (congenital
absence of junctura or
division) of tendon subluxation

Kang N, Smith P. Congenital Absence of the Juncturae Tendini Contributing to Dislocation of the Extensor Tendons. J Hand Surg 2001;26A:501–505.
Farrar NG, Kundra A. Role of the juncturae tendinum in preventing radial subluxation of the extensor communis tendons after ulnar sagittal band
rupture: a cadaveric study. Orthopedics, doi:10.5402/2012/597681
Young CM, Rayan GM. The Sagittal Band: Anatomic and Biomechanical Study. J Hand Surg 2000;25A:1107–1113.
ROLE IN ADJACENT FINGER EXTENSION

• Lacerations proximal to the
juncturae may still allow
extension of the involved digit
by pull from an adjacent finger
passing through the juncturae.

• Proximal traction on the index finger extensors provides 32% of maximal extension
of the long finger MCP joint ☞ reduced by 10% to 22% by cutting the junctura

• Traction on EDC4 provides 67% of long finger extension = 38° ☞ After cutting
the junctura, the long finger MCP joint is only able to extend to 20°.

Von Schroeder HP, Botte MJ. The functional significance of the long extensors and juncturae tendinum in finger extension. J Hand
Surg 1993;18A:641-7.)
JUNCTURAE SHOULD (PROBABLY) NOT BE
REPAIRED

• Division of juncturae is
mandatory in reverse
intermetacarpal flaps w/o
consequences

• Radial juncturae are fascial
structures that are
sometimes absent

• Ulnar juncturae may be
used for tendon grafting
SURGICAL CONSEQUENCES

• A extensor tendon repair distal
to the junctura need
immobilization of all fingers in
extension to protect the repair

• If proximal to junctura, only the
repaired finger should be
immobilized
AS A CONCLUSION
• Capsular injury: closure if possible

• EDM: Repair

• EIP: Repair

• Sagittal bands: radial should be repaired, ulnar ?

• Juncturae: Probably not
THANKS FOR ATTENTION