HAND (2009) 4:357–361
DOI 10.1007/s11552-009-9199-2
REVIEW ARTICLES OF TOPICS
Type IV FDP Avulsion: Lessons Learned Clinically
and Through Review of the Literature
Steven L. Henry & Mark A. Katz & David P. Green
Received: 9 November 2008 / Accepted: 3 April 2009 / Published online: 28 April 2009
# American Association for Hand Surgery 2009
Abstract The type IV flexor digitorum profundus avulsion
is a rare injury involving fracture of the volar base of the
distal phalanx and separation of the tendon from the
fracture fragment. Recommendations for management are
sparse and are substantiated only by a few isolated case
reports. We recently encountered two of these injuries, both
of which proved challenging, particularly with regard to
joint incongruity and tendon adhesions. In reviewing the
literature, it is apparent that no consensus exists regarding
surgical strategies. However, based on our experience and
that of other authors, we can suggest the following: (1) high
index of suspicion of this potentially deceptive injury, with
use of magnetic resonance imaging or ultrasound if
preoperative confirmation is needed; (2) rigid bony fixation
that prevents dorsal subluxation of the distal phalanx; (3)
tendon repair that is independent of the bony fixation; and
(4) early range of motion therapy.
Keywords Avulsion . FDP . Flexor digitorum profundus .
Jersey finger . Type IV
Financial disclosure No financial conflict of interest exists on the
part of any of the authors with any commercial entity whose products
are described, reviewed, evaluated, or compared in this manuscript.
No external funding was utilized.
S. L. Henry (*)
Institute for Reconstructive Plastic Surgery of Central Texas,
University Medical Center at Brackenridge,
1400 N IH 35, Ste 320,
Austin, TX 78701, USA
e-mail: steve7973@gmail.com
M. A. Katz : D. P. Green
The Hand Center of San Antonio,
21 Spurs Lane, Suite 310,
San Antonio, TX 78240, USA
Introduction
Flexor digitorum profundus (FDP) avulsions or jersey
fingers are injuries with which most hand surgeons are
familiar, whether they involve separation of the tendon
from the distal phalanx or fracture of the distal phalanx at
the tendon’s insertion. Relatively few, however, have
encountered the injury involving both a fracture and a
separation of the tendon from the fracture fragment, the so-
called type IV FDP avulsion. Because of its rarity, there is
little evidence to guide treatment and to warn against
potential complications. Our group recently encountered
two such injuries, both of which proved challenging. In
discussing these cases we will review the literature and
provide suggestions for the management of these injuries.
Case 1
A 21-year-old collegiate defensive tackle sustained an
injury to his left ring finger while rushing the passer. His
trainer diagnosed an FDP avulsion and placed him in a
splint. When seen in our clinic 3 days later, the digit was
extensively ecchymotic, especially at the pulp and distal
interphalangeal (DIP) level. There was no active flexion at
the DIP, and there was moderate edema and tenderness at
the volar P1 area. Plain films revealed an avulsion fracture
involving the volar 50% of the base of P3, volarly rotated
90°, with dorsal subluxation of the remainder of P3 (Fig. 1).
On operative exploration, a type IV FDP avulsion was
discovered, with the tendon retracting to the level of P1.
The fragment and the tendon stump were secured simulta-
neously, using a 2-0 prolene suture woven through the
tendon, passed through both the fragment and the remain-
der of P3 via two Keith needles, and tied over a button.
Intraoperative fluoroscopy demonstrated acceptable reduc-
358 HAND (2009) 4:357–361

Figure 1 Above, left FDP avul-

sion fracture with dorsal sub-
luxation of P3. Above, right
Type IV avulsion repaired with
simultaneous fixation of bone
and tendon using pullout suture.
Below, left Early postoperative
appearance. Wire marker volar
to P2 indicates that tendon re-
pair is intact, but fracture has
shifted and subluxation has re-
curred. Below, center Repair
revised with closed reduction
and percutaneous pinning.
Below, right Long-term follow-
up shows joint incongruity and
persistent subluxation.

tion of the fracture and correction of the subluxation. On
postoperative day3, he was referred to our therapist for
initiation of a Duran-type rehabilitation protocol. On his
return to clinic on postoperative day11, plain films showed
displacement of the fragment and recurrent subluxation. He
was returned to the operating room the following day, when
closed reduction and percutaneous longitudinal pin fixation
were performed. Therapy was resumed at postoperative day
3. The K-wire was removed at 1 month. Plain films taken at
3 months showed significant joint incongruity and persis-
tence of subluxation. The digit was pain-free but the range of
motion of the DIP joint was only 0–30° passive and 10–20°
active. At 1 year, his motion was unchanged, but because the
digit caused no functional limitations, he declined further
treatment.
showed a comminuted fracture of the base of P3 with
moderate displacement of the volar fragment and no
subluxation (Fig. 2). A magnetic resonance imaging
(MRI) was obtained, demonstrating retraction of the tendon
to the proximal P2 level. In the OR, the fractures were
reduced and fixed with a longitudinal K-wire and a 1.0-mm
cortical screw. The tendon was then repaired with 2-0
prolene passed through the main portion of P3 and tied over
a button. Duran-type rehabilitation protocol was begun on
postoperative day3. Plain films demonstrated anatomic
alignment of the fracture, articular congruency, and good
positioning of the screw. At 5 months, he had 55° passive
and 15° active range of motion at the DIP joint. The
potential need for tenolysis was discussed, but the patient
was subsequently lost to follow-up.

Case 2
A 52-year-old male injured his right ring finger while
pulling on the starter cord of a power washer. He was seen
in the ER the next day, diagnosed with a distal phalanx
fracture, and his finger was placed in a splint. In our clinic
the following day, the ring finger was ecchymotic distally,
with severe tenderness over the DIP and in the region of the
A1 pulley. There was no active DIP flexion. Plain films
Discussion
In 1977, Leddy and Packer [11] published their classic
article describing their series of 36 FDP avulsions.
Although the injury had been recognized and described
much earlier in numerous case reports and small series [1,
3, 4, 7, 8, 13, 14, 20], they were the first to classify the
injury into three types (Table 1). In type I, the tendon is
HAND (2009) 4:357–361
Figure 2 Above, left FDP avulsion fracture. Above, right MRI
demonstrating avulsion of tendon to P2 level. Below, left Fixation
with K-wire and cortical screw. Below, right Long-term follow-up
shows solid union and excellent joint congruity.
avulsed at the insertion and retracts into the palm, tethered
only by the lumbricals. As the vincula are ruptured, the
tendon stump is potentially devascularized, and repair
should theoretically be performed promptly (7–10 days)
or ischemic degeneration might ensue. In type II, which is
the most common type, the long vinculum remains intact,
tethering the tendon stump at the proximal interphalangeal
(PIP) level and maintaining its blood supply. These injuries
can be reconstructed weeks or even months later. In type
III, the tendon is avulsed along with a large bony fragment
that catches on the distal tendon sheath, preventing
retraction beyond the head of the middle phalanx.
Table 1 Classification of FDP
avulsion. Type Description
I Tendon retracts to palm; vincula ruptured, necessitating early repair
II Tendon retracts to PIP; vincula intact, permitting delayed repair
III Tendon attached to large bony fragment that catches on distal sheath (minimal retraction)
IV Tendon separates from bony fragment, retracts to palm (subtype I) or PIP (subtype II)
359
Absent from Leddy and Packer’s original classification
was what we now call type IV, which is similar to type III
except that the tendon separates from the bony fragment
and retracts proximally into the finger or palm, as in type II
or I injuries, respectively. This unusual variant was first
mentioned in the literature by Böhler in discussing Carroll
and Match’s 1969 presentation; in his experience, he
claimed a 50% incidence of this yet-unnamed type of
avulsion [3]. The first formal report came in 1974 by
Robins and Dobyns [15], followed in 1981 by Smith [17],
who was the first to suggest that it be classified as a type IV
injury. Several case reports followed [2, 5, 6, 9, 10, 16, 18,
19], and counting the cases of Robins and Dobyns and
Smith, there have been a total of 19 reported cases in the
literature (preceding ours).
The details of these 19 cases are collated in Table 2. The
mean patient age was 35 years (range, 16–53), and the most
common mechanism was pulling on a jersey (53% of cases
for which the mechanism was specified) or a starter cord
(24%). The ring finger was affected in 94% of specified
cases, consistent with most series of FDP avulsions (the
ring finger’s susceptibility probably has a multifactorial
basis, including a relatively longer length in the grasping
hand, a weaker tendon insertion [12], and less independent
movement owing to the common flexor muscle belly [8]
and juncturae tendiniae [11]).
In 53% of cases, the tendon retracted to the level of P2 or
the PIP joint, as with a type II avulsion, and in the remaining
47%, it retracted to the level of P1 or the palm, as with a type I
avulsion. In theory, in the latter situation, which we have
called subtype I, the vincula are ruptured, while in the former,
subtype II, the vincula remain intact and tether the tendon in
the middle of the finger. By this definition, our first case was
subtype I and the second subtype II, although we did not
observe the status of the vincula in our cases nor was it
mentioned in any of the reviewed case reports. The
implication, of course, is that subtype I injuries would require
early repair from the standpoint of tendon vascularity.
Importantly, in only 35% of reviewed cases—and in
neither of ours—was the level of tendon retraction signaled
by a small fleck of bone on plain film. MRI and ultrasound
are therefore valuable diagnostic tools in this situation. If
such a test is not obtained, the vigilant course would be to
360 HAND (2009) 4:357–361

Table 2 Previously reported type IV FDP avulsion.

Age Mechanism Digit Retraction Bone Surgical approach Outcome

subtypea fleckb

Robins and NS Starter cord Ring II No Fragment held with 2 transverse K-wires; tendon “FDP tendon was
Dobyns sutured to periosteum functioning”
NS NS NS I Yes Fragment excised (by another surgeon); tendon DIP: 35° arc of motion
sutured to periosteum
Smith 36 Fall Ring I No P3 stablilized with dorsal blocking K-wire; fragment NS
held with 2 transverse K-wires; tendon secured
with pullout wire
Langa and 53 Fall Ring I No Pullout wire passed thru tendon and fragment, PIP: loss of 10°
Posner holding both simultaneously extension; DIP: 10–35°
Buscemi and 35 Jersey Ring II Yes P3 stabilized with axial K-wire; fragment held with DIP: −5–60°; TAM: 255°
Page 32 Jersey Ring NS NS pullout wire; tendon secured with separate pullout DIP: −5–50°; TAM: 245°
wire
36 Jersey Ring NS NS DIP: 0–45°; TAM: 245°
45 Bowling Ring II Yes DIP: 0–45°; TAM: 245°
Schwartz 45 Starter cord Ring I No P3 stabilized with axial K-wire; fragment (commi- PIP: “normal ROM”;
nuted) excised as part of volar plate arthroplasty; DIP: 5–45°
tendon secured with pullout wire
Eglseder and 31 Jersey Ring I No Fragment held with 2.0mm cortical screw and MP: 0–85°; PIP: −10–
Russell counter-rotation wire; tendon secured with pullout 98°; DIP: 5–62°
wire
Ehlert 24 Jersey Ring II No Fragment held with pullout wire; tendon secured PIP: 0–95° active, 0–
with pullout suture 105° passive; DIP: 0–
45° active, 0–65°
passive
Trumble, 31 Starter cord Ring I No Arthrodesis (surgery delayed 6–8weeks) TAM: 200°
Vedder and 16 Jersey Ring I Yes TAM: 195°
Benirschke
33 Machinery Middle I No TAM: 190°
operation
24 Jersey Ring II No Fragment held with 1.5mm cortical screw; tendon TAM: 225°
51 Starter cord Ring II No secured with pullout suture TAM: 230°
29 Jersey Ring II No TAM: 225°
Takami, et al 33 Jersey Ring II Yes Fragment held with K-wires (orientation not speci- “Normal ROM of the
fied); tendon secured with pullout suture finger”
Kang, Pratt NS NS NS II Yes Fragment held with 1.5mm miniplate; tendon sutures DIP: 10–80°
and Burr anchored to plate
a
In subtype I, tendon retracts to level of P1 or palm, as in type I avulsions, and in subtype II, tendon retracts to level of P2 or PIP, as in type II
avulsions
b
Refers to small piece of bone sometimes seen on lateral radiograph, indicating level to which tendon retracted (not to be confused with main
fracture fragments)
NS not specified

approach all suspected type IV injuries as subtype I injuries
with early intervention.
As can be seen in Table 2, surgical approaches were
widely variable. Unfortunately, it is difficult to compare
these approaches, as postoperative protocols were largely
omitted and outcomes inconsistently reported. However, a
few inferences can be drawn.
First and foremost, most authors fixed the fragment
and attached the tendon separately, and in general, their
reported outcomes were very good. Of the various means
of bony fixation, cortical screws [5, 19] seemed to result
in the best range of motion at the DIP joint, although K-
wires [15, 17, 18] and pullout wires [2, 5, 6, 16] also
yielded good outcomes. Three authors added a K-wire
oriented axially [2, 16] or as a dorsal blocking pin [17] to
prevent dorsal subluxation of P3; this wire did not seem
to diminish results substantially.
In contrast, only one author attempted to hold the
fragment and tendon simultaneously with a single pullout
wire [10]. Although the patient healed strongly and had a
pain-free joint, her range of motion was relatively poor.
One author used a miniplate from a craniofacial set for
the fracture and sutured the tendon to the miniplate [9]. The
patient’s range of motion was outstanding—the best in our
HAND (2009) 4:357–361
review. The plate and screws were said to be palpable but
not problematic.
In two reports, the fragment was excised; in one case
[15], this was performed by another surgeon and, in the
other [16], as part of a planned volar plate arthroplasty. A
stable joint with good range of motion was achieved in both
patients.
DIP arthrodesis was performed for three patients, all
seen late and all with subtype I injuries [19]. In this
situation, tendon advancement and direct repair is impos-
sible. If the joint is stable and painless, no treatment is
necessary, but if not, arthrodesis is the most predictable
option. In rare circumstances, a tendon graft may be
attempted but only in highly motivated and understanding
patients [3].
As for our cases, results have thus far been disappoint-
ing. Both patients have achieved bony union (albeit with
suboptimal joint congruity in the first case) but have
minimal active range of motion at the DIP joint, despite
early range of motion therapy. At presentation, both digits
were notable for substantial ecchymosis, and blood within
the tendon sheath undoubtedly contributed to the adhesions
that restrict them today. While generally good outcomes
were reported in the literature, we believe that such
difficulties are not atypical and suspect that many surgeons
have encountered similar problems with adhesions in
previous (unreported) instances of type IV injuries.
Nonetheless, from our experience, we would recommend
independent repairs of the bone and tendon, as rigid
fixation of the fracture is of paramount importance if an
early motion rehabilitation protocol is to be successful.
Cortical screws appear to be preferable, assuming the bone
stock is sufficient. We would not hesitate to add an anti-
subluxation K-wire if fixation were uncertain, even if this
delays the onset of therapy.
Summary
Our cases of type IV FDP avulsion demonstrate the
difficulties that can be encountered in the surgical treatment
of this rare injury. Pitfalls include missed or delayed
diagnosis, joint subluxation or incongruity, and flexor
tendon adhesions. From our experience and review of the
literature, we recommend (1) MRI or ultrasound if the
diagnosis is suspected and preoperative confirmation is
required, (2) rigid bony fixation including stable correction
of subluxation, (3) independent tendon repair, and (4) early
range of motion therapy.
361
References
1. Boyes JH, Wilson JN, Smith JW. Flexor tendon ruptures in the
forearm and hand. J Bone Joint Surg. 1960;42A:637–46.
2. Buscemi MJ Jr, Page BJ 2nd. Flexor digitorum profundus
avulsions with associated distal phalanx fractures: a report of four
cases and review of the literature. Am J Sports Med.
1987;15:366–70. doi:10.1177/036354658701500413.
3. Carroll RE, Match RM. Avulsion of the profundus tendon
insertion. J Trauma. 1970;10A:1109–18.
4. Chang WH, Thomas OJ, White WL. Avulsion injury of the long
flexor tendons. Plast Reconstr Surg. 1972;50:260–4. doi:10.1097/
00006534-197209000-00011.
5. Eglseder WA, Russell JM. Type IV flexor digitorum profundus
avulsion. J Hand Surg. 1990;15A:735–9.
6. Ehlert KJ, Gould JS, Black KP. A simultaneous distal phalanx
avulsion fracture with profundus tendon avulsion: a case report
and review of the literature. Clin Orthop Relat Res.
1992;283:265–9.
7. Folmar RC, Nelson CL, Phalen GS. Ruptures of the flexor
tendons in hands of non-rheumatoid patients. J Bone Joint Surg.
1972;54A:579–84.
8. Gunter GS. Traumatic avulsion of the insertion of flexor
digitorum profundus. Aust N Z J Surg. 1960;30:1–8.
doi:10.1111/j.1445-2197.1960.tb03078.x.
9. Kang N, Pratt A, Burr N. Miniplate fixation for avulsion injuries
of the flexor digitorum profundus insertion. J Hand Surg.
2003;28B:363–8.
10. Langa V, Posner MA. Unusual rupture of a flexor profundus
tendon. J Hand Surg. 1986;11A:227–9.
11. Leddy JP, Packer JW. Avulsion of the profundus tendon insertion
in athletes. J Hand Surg. 1977;2:66–9.
12. Manske PR, Lesker PA. Avulsion of the ring finger flexor
digitorum profundus tendon: an experimental study. Hand.
1978;10:52–5. doi:10.1016/S0072-968X(78)80025-4.
13. McMaster LE. Tendon and muscle ruptures: clinical and experi-
mental studies on the causes and location of subcutaneous
ruptures. J Bone Joint Surg. 1933;15A:705–22.
14. Posch JL, Walker PJ, Miller H. Treatment of ruptured tendons of
the hand and wrist. Am J Surg. 1956;91:669–81. doi:10.1016/
0002-9610(56)90302-6.
15. Robins PR, Dobyns JH. Avulsion of the insertion of the flexor
digitorum profundus tendon associated with fracture of the distal
phalanx: a brief review. In AAOS Symposium on Tendon Surgery
in the Hand. St. Louis: Mosby; 1975. p. 151–6.
16. Schwartz GB. Flexor digitorum profundus avulsion: a unique
presentation. Orthop Rev. 1989;18:793–5.
17. Smith JH Jr. Avulsion of a profundus tendon with simultaneous
intra-articular fracture of the distal phalanx—case report. J Hand
Surg. 1981;6:600–1.
18. Takami H, Takahashi S, Ando M, et al. Flexor digitorum
profundus avulsion with associated fracture of the distal phalanx.
Arch Orthop Trauma Surg. 1997;116:504–6. doi:10.1007/
BF00387588.
19. Trumble TE, Vedder NB, Benirschke SK. Misleading fractures
after profundus tendon avulsions: a report of six cases. J Hand
Surg. 1992;17A:902–6.
20. Wenger DR. Avulsion of the profundus tendon insertion in
football players. Arch Surg. 1973;106:145–9.