Finger

Deformities
Yusuf Bharmal
Finger extensor mechanism anatomy

Lateral view Dorsal view

DIP = distal interphalangeal
joint  MCP =
metacarpophalangeal joint  ORL
= oblique retinacular ligament 
PIP = proximal interphalangeal
joint
TRL = transverse retinacular
ligament.
Anatomy
• The extrinsic extensor tendon:
– Originates in the forearm.
– Courses over the MCP joint.
– Has an indirect attachment
to  the proximal phalanx.
• The primary extensor force
across  the MCP joint is
transmitted  through the
sagittal band  connections
to the volar plate.
– The tendon trifurcates over
the  proximal phalanx.
Anatomy
• Central slip:
– The central continuation of 
the extensor tendon.
– Attaches to the dorsal base 
of middle phalanx.
– Exerts an extensor force 
across the PIP joint.
Anatomy
Interossei and lumbricals:
– Provide the intrinsic
contribution  to extensor
mechanism.
– Form a lateral band on each
side  of the digit, passing
volar to the  MCP joint.
– The lateral bands join
with the  lateral slips of
the extrinsic  extensor
tendon at the level of  PIP
joint to form the
conjoined  lateral bands.
– The two conjoined lateral
bands  then converge
dorsally and insert  at the
base of the distal phalanx 
as the terminal extensor
tendon.
Anatomy
• Triangular Ligament:
– A thin tissue connecting the 
conjoined lateral bands over the 
middle phalanx.
– Stabilises CLB, Prevents separation
and volar  migration of the conjoined
lateral bands when  the PIP joint is
flexed.
Anatomy
• Transverse Retinacular Ligaments:
– Originate from each side of the PIP joint volar 
plate.
– Insert dorsally into the adjacent conjoined 
lateral band.
– Stabilize CLB and limit dorsal migration of
the conjoined  lateral bands during PIP
joint extension.
Anatomy
• Oblique Retinacular Ligaments:
– Arise from the flexor tendon sheath and volar 
aspect of the proximal phalanx.
– Course distally to insert onto the dorsal base  of
the distal phalanx with the terminal  extensor
tendon, thus linking and coordinating  PIP and
DIP joint motion.
Pathoanatomy
• A well-balanced system exists  between intrinsic and extrinsic 
tendons, and between flexion and  extension forces across each
finger  interphalangeal (IP) joint.

• Any injury causing a flexion or extension  deformity in one

IP joint can lead to tendon  imbalance, creating an opposite deformity in
the  adjacent IP joint.
• At DIP joint: FDP flexion force
is counterbalanced by  the terminal extensor tendon.
• At PIP joint: flexion forces of the FDP and FDS  tendons are
counterbalanced by the extension forces  of the conjoined
lateral bands and the central slip of  extensor apparatus.
Balance between flexion and extension  forces
at the finger joints

The single dots represent the axis of flexion-

extension  at each joint.
The double dots represent the areas of action
of the  corresponding tendons at each joint.
 • Systemic e.g.
RA, Gout, Genetic
conditions
What are
• Traumatic
the
• Degenerative(OA)
causes..?
• Congenital
 • INTRINSIC PLUS DEFORMITY
• SWAN NECK DEFORMITY
• BUTTON HOLE DEFORMITY
Systemic • ULNAR DRIFT OF
disease FINGERS & RADIAL DEVIATION 
OF WRIST
 • Mallet fi nger(ED)

• Jersey Finger(FDP)

• Rotational deformity/
Traumatic Bony deformity post
fi nger fracture.

• Nerve injury - Claw hand

Degenerative • Small joint OA

Osteoarthritis •  Heberden or Bouchard

node 
 
 - Problems in formation of the par ts

• Radial clubhand

• Ulnar clubhand

- Failure of parts of the hand to separate

• Simple syndactyly

Congenital • Complex syndactyly

- Duplications of fi ngers

• Polydactyly

- Undergrowth of fi ngers

• Underdeveloped fi ngers or thumbs  

- Overgrowth of fi ngers

• Macrodactyly

- Congenital constriction band syndrome

Swan Neck
deformity
• Swan-neck deformity  is described as
a fl exion  posture of the DIP 
and hyperextension  posture of the
PIP, at times with fl exion of  the
MCP.
• It is caused by muscle
imbalance and may be  passively correc
table, depending on the  fi xation of the
 original and secondary  deformities.

• Although usually associated with rheu
matoid  arthritis, swan-
neck deformity may occur in  patients 
with lax joints and in patients with  co
nditions such as Ehlers-
Danlos syndrome
This  deformity  may begin as
a mallet  deformity  associated  with a disr
uption  of the   extensor tendon
at the distal  joint
with  secondar y  overpull  of
the central  tendon,  causing  hyperextensi
on of the lax proximal   interphalangeal
joint. The proximal   interphalangeal
joint may actively  fl ex normally.

Or the deformity  may begin at the  proxi

mal   interphalangeal  joint because  synovi
tis causes  herniation of the  capsule, tigh
tening  of the  lateral  bands and  central  t
endon, and  eventual  adherence  of the  la
teral bands in a  fi xed  dorsal  position,  so
 they can no longer   slide over the  condyl
es when the proximal   interphalangeal  joi
nt is fl exed
Management

Figure of eight ring splint

FDS tenodesis

Lateral band mobilization

Arthrodesis / arthroplasty
Boutonniere 
deformity
(Buttonhole)
• Fixed flexion of the PIP
& hyperextension  of the DIP joint

• Due to interruption or
stretching of the central  slip of the
extensor tendon,
forcing the lateral Bands to begin sublux
ating volarward.
Boutonnière deformity. A, Primary synovitis of proximal interphalangeal (PIP) joint can lead to
attenuation of  overlying central slip and dorsal capsule and increased flexion at PIP joint. Lateral band subluxation volar
to  axis of rotation of PIP joint can lead in time to hyperextension. Contraction of oblique retinacular ligament,  which
originates from flexor sheath and inserts into dorsal base of distal phalanx, can lead to extension  contracture of distal
interphalangeal joint. B, Clinical photograph illustrates flexion posture of PIP
joint and  hyperextension posture of distal interphalangeal joint in boutonnière deformity.​
 Treatment Goals
• Prevent extensor tendon complete rupture.

• Reduce swelling and pain.

• Prevent PIP joint flexion contracture.

• Prevent lateral band subluxation.

• Prevent oblique retinacular ligament contracture.

• Restore AROM/PROM of MCP, PIP, and DIP joints.

• Maintain ROM of uninvolved joints of the upper extremity.

• Return to previous level of function
 •An injury that involves disruption of
Mallet the extensor mechanism at the
level of the distal interphalangeal
Finger (DIP) joint.
Alternative Names

•Baseball fi nger

•Drop fi nger
Mechanism of Injury
• Most common 
mechanism:
– Sudden forced flexion of  the
extended fingertip.
– This results in either:
• stretching or tearing of 
extensor tendon substance  or
• avulsion of tendon insertion 
from the dorsum of distal 
phalanx, with or without a 
fragment of bone.
 Depending upon whether the thin extensor tendon is torn in its substance or pulls off a 
small piece of bone at its insertion, two types are recognized:

 Mallet finger of tendon origin.

 Mallet finger of bony origin.
Mechanism of Injury

• Less frequent mechanism:

– Forced hyperextension of the DIP joint.
– This causes fracture at the dorsal base of the distal phalanx.
• Open injuries are caused by a laceration, crush, or deep
abrasion.

• With a mallet injury, the delicate balance  between flexion

and extension forces is  disrupted.
• The following sequence of events occurs:
– Discontinuity of the terminal extensor tendon
– Migration of extensor apparatus proximally
– Increased extensor tone at PIP relative to DIP joint.
– Early or late swan neck deformity (hyperextension  of PIP joint
with concomitant flexion of DIP joint) can  occur.
Classification  Acute vs. Chronic
• Acute mallet deformities = those  occurring within 4
weeks of injury.
• Chronic deformities = those presenting  later than 4 weeks
from injury.
Classification  Doyle Classification
• Type I: Closed injury, with or
without a small avulsion fracture
at the dorsal base of distal phalanx.
• Type II: open tendon injuries
caused by laceration at or around
the DIP joint.
• Type III: also open injuries; they
occur from a deep soft-tissue
abrasion with loss of skin and
tendon substance.
• Type IV: mallet fractures
Clinical Evaluation
• Recognition and diagnosis of a mallet  finger are
relatively straightforward.
• Patients present with pain, deformity,  and/or difficulty
using the affected finger.
Clinical Evaluation
• Inspection:
– Soft tissues
– Deformity:
• Most patients develop an extensor lag at
the DIP joint immediately after injury.
• The deformity may be delayed by a few
hours or even days.
• Concurrent hyperextension of the PIP
joint (ie, swan neck posture) may be
noted with active finger extension.
Clinical Evaluation
• Palpation:
– Tenderness can be elicited in acute injuries  with
palpation over the dorsal margin of DIP  joint.
• ROM:
– Measure finger MCP and PIP joint motion.
Radiographic Evaluation
• Posteroanterior, oblique, and  lateral
radiographs of the digit  are recommended
to assess  for bone injury and joint 
alignment.
Treatment Options
• Non-surgical:
– Successful in most
mallet injuries.
• Surgical:
– Treatment of either
an acute or a 
chronic mallet
finger
– Salvage of failed
prior treatment
 •It is due to avulsion of flexor digitorum profundus
from its  insertion on distal phalanx.

•This is the opposite of ‘mallet finger’ and the patient

is unable  to flex the distal interphalangeal joint.

• It is seen in football and rugby players .

Jersey
finger