| 03.07.

21 - 14:53

44 Extensor Tendon Injuries and Repair

24
James Nolan Winters and Brian Mailey

Abstract time elapsed to presentation (acute vs. chronic). Important var-

20
This chapter highlights the dorsal hand anatomy and complex iables to obtain from the history include: handedness, occupa-
extensor tendon biomechanics. tion, prior hand injuries, mechanism, and position of hand
Provocative physical examination maneuvers, common during injury. Flexion of the hand during laceration injury
mechanisms of injury, and extensor tendon zones are reviewed results in a tendon laceration located more proximally, in rela-

/
in detail. Conservative and operative treatment options are tion to the skin laceration site.

01
listed for each zone of injury including: technical pearls, splint- Recognition and treatment of injuries should be performed
ing, and rehabilitation protocols. as soon as possible following initial injury. Acute, clean transec-
tion injuries can be repaired primarily within the first 2 to
Keywords: anatomy, extensor tendon, injury, repair, zones 3 weeks. Chronic injuries, contaminated wound beds, or trau-

/
matic degloving with significant skin and soft tissue loss

04
require additional reconstructive considerations: tendon grafts,
tendon transfers, additional soft tissue coverage, etc. This chap-
44.1 Introduction ter will focus on the acute management and repair of extensor
tendon injuries.
An intricate balance exists between the soft tissue and bony
elements of the hand. The extensor tendons, flexor tendons,

s,
and intrinsic muscles create a normal resting cascade for the 44.2.1 Anatomy and Biomechanics
bony skeleton. The extensor tendons are superficial, visible
under the skin, and easily exposed to injury in the setting of Finger extension occurs through an intricate mechanism involv-

ie
dorsal hand trauma. Variable anatomy, inter-tendon connec- ing the extrinsic and intrinsic musculature. The radial nerve
tions, and lack of suspicion by the examiner can mask injury to and posterior interosseous branch innervate the extensor mus-
the extensor mechanism. During the evaluation, it is important culature. The extensors are subdivided into superficial and deep
ar groups, at the forearm level. The superficial group contains the
to have a high index of suspicion for injury based on any differ-
ences between the injured and noninjured hands. This chapter following muscles: extensor carpi radialis longus and brevis
will highlight conservative and operative treatment options in (ECRL and ECRB), extensor digitorum communis (EDC), exten-
r
extensor tendon repair. sor digiti minimi (EDM), and extensor carpi ulnaris (ECU). The
Lib

deep group contains the following muscles: abductor pollicis

longus (APL), extensor pollicis brevis (EPB), extensor pollicis
44.2 Indications longus (EPL), and extensor indicis proprius (EIP).
The extensor tendons traverse six dorsal compartments at
Extensor tendon injuries occur from two primary mechanisms: wrist level, numbered radial to ulnar (▶ Fig. 44.2). The first dor-
closed ruptures (e.g., mallet finger, ▶ Fig. 44.1a) or open sharp sal compartment contains APL and EPB tendons. ECRL and ECRB
lacerations (▶ Fig. 44.1b). Appropriate repair and reconstruction
ine

compromise the second compartment. Palpation of Lister’s

are dictated by location of the injury (e.g., zone 1, 2, 3, etc.), and tubercle over the distal radius allows identification of the third
Irv
C
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er

Fig. 44.1 (a) Closed mallet finger of the small finger. Extensor lag is noted at the distal interphalangeal (DIP) joint, with inability to extend actively.
Us

There are no lacerations or soft tissue defect noted. (b) Dorsal view of a type 2 mallet finger of the long finger with sharp laceration in extensor tendon
zone 1. (c) Lateral view demonstrating extensor lag and inability to perform active extension at DIP joint. (d) Lateral radiograph of soft tissue mallet
finger.

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44.3 Operative Technique

volar plate and create a sling for the extensor tendon. This pre-

24
vents subluxation of the extensor tendon and aids in MCP ex-
tension. The extensor tendon trifurcates over the proximal
phalanx into a central slip and two lateral slips. The central slip
inserts onto the base of the middle phalanx, creating proximal

20
interphalangeal (PIP) extension. Interossei and lumbricals also
provide contributions to the extensor mechanism allowing for
MCP flexion with PIP extension (▶ Table 44.1). The lateral com-
ponents join the lumbricals on the radial side and interossei on

/
both sides to form the conjoined lateral bands. The lateral bands

01
coalesce dorsally to form the terminal tendon inserting on the
base of the distal phalanx and creating DIP extension. The
extensor mechanism and lateral bands receive additional stabi-
lization from two important retinacular ligaments. The triangu-

/
lar ligament arises at the middle phalanx, preventing volar

04
subluxation of the lateral bands during PIP flexion. The trans-
verse retinacular ligament arises from the PIP volar plate and
attaches to the lateral bands to prevent dorsal subluxation with
extension. Comprehensive knowledge of this detailed system is
advantageous in evaluating and treating extensor tendon

s,
injuries.

44.2.2 Extensor Tendon Injuries

ie
Injuries to the extensor tendons are classified by location into
nine separate zones, starting distally (▶ Fig. 44.2). Odd number
ar
zones are mainly joints (e.g., zones 1 and 3 are over the DIP and
PIP joints, respectively) and even number zones are mainly
bones (e.g., zones 2 and 4 lie over the middle and proximal pha-
r
langes, respectively). The thumb is classified into five zones.
Lib

Fig. 44.2 Extensor tendon zones are numbered 1 to 9 (white text):

44.3 Operative Technique
zone 1: distal interphalangeal (DIP) joint of digits, interphalangeal (IP)
joint of thumb; zone 2: middle phalanx of digits, proximal phalanx of
44.3.1 Zone 1
thumb; zone 3: proximal interphalangeal (PIP) joint of digits, Injury to the terminal tendon, overlying the DIP joint, is com-
metacarpophalangeal (MCP) joint of thumb; zone 4: proximal phalanx
monly termed a mallet finger. This injury pattern manifests fol-
ine

of digits, metacarpal of thumb; zone 5: MCP joint of digits,

lowing forced flexion during times of active extension. Doyle
carpometacarpal (CMC) joint of thumb; zone 6; metacarpals; zone 7:
wrist level; zone 8: distal forearm; zone 9: extensor muscle belly. The classification system describes four types of mallet fingers
dorsal extensor compartments are numbered 1 to 6 (black text): 1. (▶ Table 44.2).2 Type 1 represents closed injury with loss of ten-
APL = abductor pollicis longus and EPB = extensor pollicis brevis. 2. don continuity (with or without small avulsion fracture). Type
ECRL = extensor carpi radialis longus and ECRB = extensor carpi radialis 2 injuries are open lacerations with loss of tendon continuity
Irv

brevis. 3. EPL = extensor pollicis longus. 4. EDC = extensor digitorum at/or proximal to DIP. Type 3 injuries are open with loss of over-
communis and EIP = extensor indicis proprius. 5. EDM = extensor digiti
lying skin, subcutaneous tissue, and tendon substance. Type 4
minimi. 6. ECU = extensor carpi ulnaris. JT, junctura tendinae.
injuries have large mallet fractures (▶ Fig. 44.4a).
Closed mallet fingers are generally treated nonoperatively
with DIP splinting in full extension for 6 to 8 weeks
C

compartment, EPL, which lies immediately ulnar. The fourth (▶ Fig. 44.4b).3,4 PIP joint should be left free. Additional splint-
compartment houses EDC and EIP. The fifth and sixth compart- ing and night-time splinting may be required for up to 12
:U

ments contain EDM and ECU, respectively. In general, the weeks. If the patients’ occupation prevents them from splinting
extensor tendons have consistent anatomy with some degree of (e.g., surgeon, dentist) or incapable of compliance (e.g., child),
variability. They become thin, flat, and superficial at the meta- then percutaneous pinning may be considered. DIP joint is
carpal level. Interconnections exist amongst EDC tendons, pinned in full extension for 6 to 8 weeks with K-wire tips
known as juncturae tendinae (JT), disguising injuries as distal buried under skin (▶ Fig. 44.4c).
er

pull from the neighboring EDC tendons creating movement, if Open mallet fingers require surgical repair to approximate
the injury is proximal to the JT. EPL and EPB power extension of the tendon ends or fixate the tendon to the base of the distal
the thumb. phalanx. Clean type 2 mallets may be repaired in the emer-
Us

The biomechanical complexity increases distal to the meta- gency department. The terminal tendon is quite thin and differ-
carpophalangeal (MCP) joint (▶ Fig. 44.3) with involvement of ential suturing of the skin and tendon may not be possible.
the intrinsic musculature.1 The sagittal bands attach to the MCP Tenodermodesis may be performed with running of horizontal

249
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| 03.07.21 - 14:53

Extensor Tendon Injuries and Repair

24
Fig. 44.3 (a, b) Dorsal and lateral views of the
distal extensor mechanism composed of the
extensor tendon, stabilizing ligaments, and
intrinsic musculature. Note the common extensor
tendon trifurcation into central slip and two

20
lateral bands, which join to form the terminal
tendon. Stabilizing ligaments include: sagittal
band, transverse retinacular ligament, oblique
retinacular ligament, and triangular ligament.
Intrinsic musculature includes: lumbricals, dorsal

/
interossei, and palmar interossei. The lumbricals

01
insert onto the oblique fibers of the radial side of
the extensor expansion. The dorsal interossei
insert onto transverse fibers of the extensor
expansion and base of the proximal phalanx. The
palmar interossei insert onto the lateral band on

/
the adductor side of digit.

04
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Lib
ine
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mattress sutures to incorporate skin, tendon, and periosteum in easily reduced. Open reduction may be required for difficult
C

one bite for reapproximation.5 This should be followed by DIP fracture fragments. This is performed by first slightly flexing
placement in full extension with splinting or pinning for 6 to 8 the DIP joint. A dorsal blocking K-wire is inserted to prevent
weeks. proximal migration of the fracture fragment. The finger is the
:U

Grossly contaminated, unstable DIP joint, type 3 and type 4 then extended completely reducing the distal phalanx to the
injuries require a greater degree of operative attention and in fracture fragment and an additional K-wire is passed across
most cases should be repaired in the operating room. Type 3 the DIP joint to immobilize the fracture and tendon injury for
injuries with loss of tendon and overlying tissue may require 6 weeks.
er

flap coverage for reconstruction (e.g., cross finger, homodigital, Closed mallet thumbs may be treated the same as fingers
hatchet, etc.). Secondary reconstruction of the terminal tendon with full-extension splinting for 6 to 8 weeks (▶ Table 44.3).
can then be performed with tendon graft or oblique retinacular Open injuries should be treated surgically with direct repair
ligament. Reconstruction of a type 4 mallet finger may be followed by full-extension splinting for 6 to 8 weeks. The EPL
Us

treated in a number of different ways.6 Closed reduction and tendon is more substantial and can tolerate a core locking
percutaneous K-wire fixation may be performed if fragment is suture.

250
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| 03.07.21 - 14:53

44.3 Operative Technique

Table 44.1 Insertions of intrinsic muscles

24
Short intrinsic Origin Insertion Innervation Action
muscles
Lumbricals

20
● 1st and 2nd Radial two FDP tendons Oblique fibers on radial side of extensor Median nerve Extend IP joint of IF and LF
(unipennate muscles) expansion (dorsal prox. phalanx) IF and LF
● 3rd and 4th Ulnar three FDP tendons, cleft Oblique fibers on radial side of extensor Deep branch of Extend IP joint of RF and SF
between tendons (bipennate expansion (dorsal prox. phalanx) RF and SF ulnar nerve
muscles)

/
Dorsal Adjacent metacarpals as Transverse fibers of extensor expansion Deep branch of Abduct IF, LF, RF, and SF

01
interossei bipennate muscle (lateral tendon of deep belly) and base of ulnar nerve from axial line of LF; flexion
(1–4) 1 (MC 1 & 2) proximal phalanx (superficial belly of medial of MCP
2 (MC 2 & 3) tendon) Percentage insertion into bone/EM:
3 (MC 3 & 4) 1st DIO: 100/0; 2nd: 60/40; 3rd: 6/94; 4th:
4 (MC 4 & 5) 40/60

/
04
Palmar Palmar surface of metacarpals Lateral band on adductor side of IF, RF, and Deep branch of Adduct IF, RF, and SF
interossei 2, 4, and 5 as unipennate SF Approximate insertion into bone/EM: 1st ulnar nerve toward axial line of LF;
(1–3) muscles PIO: 0/100; 2nd: 0/100; 3rd: 10/90 MCP flexion
Abbreviations: DOI, dorsal interossei; EM, extensor mechanism/expansion; IF, index finger; IP, interphalangeal; LF, long finger; MC, metacarpal; MCP,
metacarpophalangeal; PIO, palmar interossei; RF, ring finger; SF, small finger.

s,
Table 44.2 Doyle classification of mallet fingers
misdiagnosed on presentation as a jammed finger with PIP
swelling, tenderness, and weak PIP extension against resistance.
Injury Description
Clinical suspicion requires performance of Elson test, which is

ie
Type 1 Closed injury (with or without small dorsal avulsion fracture) performed by holding the PIP joint of affected finger in flexion
Type 2 Open laceration and asking the patient to extend DIP.8 Normal patients cannot
Type 3 Open injury (deep abrasion resulting in loss of skin, extend DIP due to slack in lateral bands. Disruption of central
subcutaneous tissue, and tendon substance)
ar
slip results in DIP hyperextension on testing and no force felt by
Type 4 Mallet fractures the patient in attempting to extend the PIP joint.
a) Transphyseal injury of distal phalanx (pediatric population) Closed injuries should be treated with PIP extension splinting
r
b) Avulsion fracture involving 20–50% of articular surface for 6 to 8 weeks, followed by night-time splinting. The DIP joint
c) Avulsion fracture involving > 50% of articular surface
Lib

should be left free and actively flexed to help pull the lateral
bands dorsally.
Open injuries should be explored operatively due to potential
44.3.2 Zone 2 for PIP joint violation. Surgical treatment options depend upon
Typically, tendon injuries over the middle phalanx result from laceration site of central slip and bony fracture fragment size.
sharp transection. Partial lacerations involving less than 50% of Proximal lacerations with adequate distal tendon stock should
ine

the tendon and no extension lag do not require repair. In this be repaired with a core suture. Avulsions and distal central slip
instance, the wound should be irrigated, skin closed, and exten- injury with adequate tendon quality can be repaired using a
sion splint placed for 2 weeks, followed by restricted strength bony suture anchor driven into the middle phalanx. Avulsions
use for the following month. Lacerations greater than 50% may with larger fracture fragments may require K-wire or screw
be repaired with figure of eight suture or horizontal mattress fixation.
Irv

sutures. Epitendinous sutures are time consuming and not nec- Three surgical procedures have been described for central slip
essary. Repair should be followed by DIP extension splinting for injuries not amenable to primary repair. If adequate proximal
6 weeks. If significant tendon and soft tissue loss is present, central slip tendon persists, then it can be reattached to the
then flap coverage and secondary tendon repair will be middle phalanx via suture anchor. The base of the middle pha-
required to span the defect. Tendon graft (e.g., palmaris longus) lanx is prepared and the bone roughened up to promote tendon
C

or tendon sharing techniques have been described. healing. The 2-mm suture anchor is inserted and then reat-
Laceration to EPL in zone 2 should be repaired with core-type tached to the proximal extensor tendon via a turndown proce-
suture (e.g., modified Kessler), if possible. Splinting with thumb dure, popularized by Snow (▶ Fig. 44.6a).9 This is performed by
:U

IP extension and MCP free for 6 weeks is necessary. Short-arm exposing the intact extensor tendon over the proximal phalanx
thumb spica with thumb in extension may also be used postop- and designing a distally based extensor tendon flap in a rectan-
eratively. gular or triangular fashion. A few millimeters of distal tendon is
left attached to the lateral bands, and one or two sutures are
placed in the corners of each base to prevent the flap from pull-
44.3.3 Zone 3
er

ing through. It is then turned over onto itself and attached to

Injury to the central slip can result in a boutonniere deformity the base of the middle phalanx via a suture anchor or pull-out
presenting as DIP hyperextension and PIP flexion (▶ Fig. 44.5).7 button. If inadequate remaining central slip exists, then central-
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This results from lateral band volar migration. Patients are often ization of the lateral bands described by Aiache et al is an

251
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| 03.07.21 - 14:53

Extensor Tendon Injuries and Repair

24
Fig. 44.4 (a) Bony mallet. The lateral radiograph
demonstrates the proximally retracted fracture
fragment of distal phalanx base due to terminal
tendon pull proximally. Fractures at this location
involve varying degrees of articular surface. (b)

20
Stack splint for mallet finger injuries. The splint
keeps the distal interphalangeal (DIP) joint held in
extension, while allowing proximal interphalan-
geal (PIP) joint flexion. This splint is kept in place
for 6 to 8 weeks without removing. (c) Closed

/
reduction and percutaneous fixation of bony

01
mallet. The lateral radiograph shows a dorsal
blocking K-wire placed within the head of the
middle phalanx to prevent proximal migration of
fracture fragment from terminal tendon pull. A
longitudinal K-wire is placed through the distal

/
and middle phalanx to pin the DIP joint in

04
hyperextension. (d) Right index finger mallet
following removal of K-wires. Clinically, the
patient has loss of hyperextension at DIP, but
without flexion deformity. This is considered an
acceptable outcome.

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Table 44.3 Extensor tendon rehab protocols

Week Immobilization Dynamic splinting and Early active motion
(zones 1–3: 6 weeks; early passive motion
zones 4–6: 4 weeks)
1–2 ● Volar-based resting splint ● Dynamic splint with cable dorsally ● Volar-based splint
ine

● Wrist: 40 degrees extension placed ● Wrist immobilized in 30 degrees extension

● MCP: 0–20 degrees flexion ● Wrist immobilized in 40 degrees ● MCP blocked in 45 degrees flexion
● Ips: 0 degree extended extension ● IP joints free
● MCP: 0 degree ● Active MCP flexion and extension, with IPs
● Palmar block allowing 30–40 degrees extended in week 1
MCP active flexion ● Active MCP flexion and extension, with IP
Irv

● Early active MCP flexion and passive flexion and extension in splint in week 2
extension with IP extended ● 10x/hour in splint
● 20x/hour in splint
3–4 ● Splint continued ● Splint modified removing palmar block ● Splint modified with MCP blocked in 70
● Graded joint mobilization in hand and allowing for full MP active flexion degrees
therapy ● Active EDC glide
C

5 ● No change ● Discontinue splint ● Discontinue splint

● Graded joint mobilization in hand ● Graded joint mobilization in hand therapy
therapy
:U

6–12 ● Discontinue splint ● Completion of graded joint ● Completion of graded joint mobilization
● Continue graded joint mobilization mobilization ● Start light ADLs
with increase in resistance ● Start light ADLs ● Gradually increase resistance in ADLs
● Further night-time splinting ● Gradually increase resistance in ADLs
dependent on zone of injury
er

> 12 ● Return to normal activities without ● Return to normal activities without ● Return to normal activities without
restrictions restrictions restrictions
This chart is to serve as a general overview to each rehabilitation plan. Variations exist based on extensor tendon zone of injury, duration of splinting,
Us

and between individual surgeon preferences.

Abbreviations: ADLs, activities of daily living; EDC, extensor digitorum communis; IP, interphalangeal joint; MCP, metacarpophalangeal joint.

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44.3 Operative Technique

option.10 This is performed by releasing the transverse retinac- superficialis (FDS) tunneled through a volar-dorsal hole at

24
ular ligaments, which are pulling the lateral bands volar. The middle phalanx base and reattachment to the extensor
lateral bands are then relocated dorsally over the digit and proximally.11
sutured to each other over the PIP joint with braided nonab-
sorbable sutures (▶ Fig. 44.6b). Ahmad and Pickford described a 44.3.4 Zone 4

20
third reconstructive option by using a slip of flexor digitorum
Injury to the extensor tendon overlying the proximal phalanx
most commonly results from sharp laceration. The tendon is
broad and flat here (▶ Fig. 44.7), with partial lacerations being

/
quite common. Focused physical examination testing with iso-

01
lation of fingers will show reduced strength with extension.
Exploration and repair may be performed in the emergency
department for clean lacerations. Relaxing incisions and recre-
ating the position of the hand at time of injury will help iden-

/
tify the lacerated edges. Lacerations less than 50% do not
require repair; however, a figure of eight suture or horizontal

04
mattress can be used for repair.12 Safety position splinting for
2 weeks followed by early motion is recommended. Total trans-
ection of the extensor tendon requires repair. Multiple suture
techniques have been shown to provide adequate strength for
early range of motion protocols including: Kleinert modifica-

s,
tion of Bunnell, modified Kessler, modified Becker, and running,
Fig. 44.5 Boutonniere deformity of the right small finger showing interlocking horizontal mattress.13,14,15 Generally, two or three
horizontal mattress sutures are placed. The broad flat extensor

ie
classic hyperextension at distal interphalangeal (DIP) joint and flexion
at proximal interphalangeal (PIP) joint. Elson test can be performed to tendon has progressively less excursion over the digit and can
diagnose central slip injury: PIP flexed to 90 degrees over the edge of therefore tolerate less changes in length. Care is taken to avoid
table. Patient asked to extend middle phalanx against resistance. If
central slip injury is present, the patient will be able to extend the DIP
ar
bunching and over-shortening of the tendon. The amount of
tendon excursion is approximately 11 mm at the MP joint,
joint with the PIP joint in flexion. This is caused by the pull of the lateral
bands. 6 mm at the PIP joint, and 3 mm at the DIP joint.16 Slight
changes in length can affect tendon function.
r
Lib
ine
Irv
C
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er

Fig. 44.6 (a, b) Central slip reinsertion with extensor tendon turnover (black box = extensor defect). Distally based rectangular flap denoted by dashed
lines. Sutures at base of flap connected to lateral bands to prevent pull-through. Note suture anchor placed through tendon to secure to middle
phalanx. (c, d) Relocation of lateral bands (black box = extensor defect). Release of transverse retinacular ligament (TRL) on radial and ulnar side to free
Us

lateral bands denoted by dashed lines. Lateral bands then brought dorsally and sutured in midline overlying proximal interphalangeal (PIP) joint.

253
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| 03.07.21 - 14:53

Extensor Tendon Injuries and Repair

24
Fig. 44.7 A cadaver extensor tendon zone 4 is
shown here. (a) Dorsal view with a broad, flat
tendon. (b) The thin and flat tendon from a
lateral view. The extensor tendon has minimal
excursion in this zone and does not tolerate

20
changes in length. Care should be taken to
approximate tendon edges, avoiding over-
tightening or bunching.

/
/ 01
04
ie s,
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Lib
ine

Fig. 44.8 (a, b) Fight bite injury occurs in a flexed position while the
hand is clenched in a fist. When examined in extension, these injuries
may be missed as the tendon and joint capsule have moved more
proximally. To appropriately determine if the violation of the joint Fig. 44.9 Sagittal band rupture. Preoperative photo of left hand
capsule has occurred, the examiner should have the patients flex their showing sagittal band injury of the long finger resulting in ulnar
Irv

digits to recreate the position of the hand during the injury. Green: subluxation of extensor digitorum communis (EDC) tendon into
extensor tendon. Blue: joint capsule. Yellow: sagittal band. Red arrow webspace with flexion at metacarpophalangeal (MCP) joint. Sagittal
denotes path of injury. Note the different alignment of injured band rupture is usually due to radial sided involvement of sagittal band,
structures with finger extended. commonly referred to as boxer’s knuckle. Sagittal band injury can be
clinically confused with Vaughan-Jackson syndrome, rupture of
extensor tendons. Note index finger extensor tendon remains
C

centralized over MCP joint.

44.3.5 Zone 5
Injuries overlying the MCP joint can result from altercations
:U

and the joint inoculation may be missed if the finger is only

(fight bite, ▶ Fig. 44.8), sharp laceration, or closed sagittal band examined in extension.
rupture. In fight bites, tendon lacerations are of secondary con- Sharp lacerations and closed trauma can injure the sagittal
cern in the initial evaluation. Violation of the MCP joint and band. This will result in extensor tendon subluxation in the
infection from oral flora is the primary concern and should be ulnar direction (▶ Fig. 44.9a). Sharp laceration should be thor-
er

managed first.4 These injuries should be washed out and surgi- oughly irrigated and repaired with interrupted figure out eight
cally debrided. Wounds may be left open for dressing changes, sutures. Patients should be splinted with MP joints in full ex-
intravenous (IV) antibiotics, and splinting. Repair of extensor tension for roughly 1 week followed by flexion and extension
lacerations can be done as in zone 4 acutely or at a later date. It
Us

exercises. Buddy taping should be applied following splint

is important to evaluate the MP joint capsule through a range of removal to limit abduction and adduction. Closed ruptures pre-
motion, as the injury typically occurs with the finger in flexion senting within 2 weeks should be treated with MCP extension

254
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| 03.07.21 - 14:53

44.3 Operative Technique

24
Fig. 44.10 These photos represent a patient
undergoing sagittal band reconstruction. (a)
Intraoperative photo of left long finger with ulnar
subluxation of extensor digitorum communis
(EDC) tendon following radial sided sagittal band

20
rupture. Freer elevator demonstrates the defect
in the radial sided sagittal band. (b) Demonstra-
tion of utilization of a sagittal band step cut for
repair. This is performed by lengthening the ulnar
side of the sagittal band, in combination with

/
radial sided sagittal band imbrication shown here.

01
(c) Centralization of the extensor tendon over the
metacarpophalangeal (MCP) joint is shown. This
can be done using a proximally based slip of EDC
(McCoy repair) or junctura tendinae (Wheeldon
repair). (d) Postoperative photos of the same

/
patient’s right hand status post reconstruction of

04
long, ring, and small finger sagittal bands
showing extension at proximal interphalangeal
(PIP) and distal interphalangeal (DIP) joints with-
out subluxation of EDC tendons during MCP
flexion.

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splinting for 6 weeks. Chronic ruptures or failed conservative tendons can be adequately explored and repaired in the
treatment should be taken back to the operating room for sur- emergency department in this location. They have adequate
gical repair. Primary repair of the native sagittal band is the bulk for core sutures and develop fewer adhesions.1 Extend-
preferred method.6 A C-shaped incision is made on the MCP ing the laceration may help identify the proximal and distal
joint with proximal and distal extensions. The skin is then ends. A 25-gauge hypodermic needle can be used to hold the
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retracted to identify the edges of the sagittal bands. A 4–0 transected ends in close proximity without tension during
suture is then used in an interrupted figure of eight fashion for repair. Multistrand core locking sutures are appropriate if
repair. The contralateral side may need to be released in a step- feasible, otherwise horizontal mattresses will suffice. The
cut method, if the injury is chronic and the tissues shortened hand is splinted in 20 degrees of wrist extension with
(▶ Fig. 44.10). The skin is closed and patient splinted in MCP ex- 20 degrees of MP flexion, and neutral PIPs.17,18,19
C

tension as above. A yolk splint can be used to allow the other

digits to move while off-loading the injured digit.
44.3.7 Zone 7
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Injury to extensor tendons at the wrist innately involves the exten-

44.3.6 Zone 6 sor retinaculum. Knowledge of the six dorsal compartments is crit-
Extensor tendon injuries overlying the metacarpals are often ical when identifying and realigning multiple transected tendons.
difficult to recognize on examination due to interconnections The extensor retinaculum can be opened in a stair-step fashion to
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through junctura tendinae. A high index of suspicion should assist in later repair. Additional proximal and distal exposure may
be present with any dorsal hand laceration given the superfi- be required for correct identification of tendons. Core sutures are
cial location. Asking the patients to recreate the position of used to repair tendons, as above. The retinaculum is then closed
their hand during the time of injury may help identify lacer- with figure of eight sutures to prevent bow-stringing of the exten-
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ated tendon edges prior to surgical exploration. Extensor sor tendons. Splinting ensues for 4 weeks, as in zone 6.

255
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| 03.07.21 - 14:53

Extensor Tendon Injuries and Repair

24
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04
Fig. 44.11 Vaughan-Jackson syndrome. Inability to extend fingers due to rupture of digital extensor tendons from ulnar to radial sided fashion. Results
from distal radioulnar joint (DRUJ) instability with dorsal ulnar head creating friction point for extensor tendon glide, eventually causing rupture. (a)
Radiograph of rheumatoid arthritis patient showing erosions, carpal space narrowing, ankylosis, and DRUJ involvement. (b) This patient had inability to
extend small, ring, and long fingers. Scheduled to undergo extensor reconstruction and Darrach’s procedure (ulnar head resection). (c) Intraoperative
photo of same the patient demonstrating all extensor tendons ruptured except extensor indicis proprius (EIP) and extensor digitorum communis (EDC)

s,
to index finger. These tendons were used to reconstruct the other extensor defects.

ie
Patients may also undergo rupture of extensor tendons in this extensor tendon injuries tolerate less shortening or bunching in
zone from thumb spica splints, distal radius hardware, or rheu- the repairs. Postoperative splinting and motion protocols are
matoid arthritis deformities (e.g., von Jackson, ▶ Fig. 44.11). imperative to regain function and prevent adhesions.17,18,19,20
These injuries frequently require tendon transfers or tendon
ar Chronic ruptures or large degloving injuries may require secon-
grafting, along with tendon transfers. dary repair with tendon grafts or transfers.
r
44.3.8 Zone 8/9 References
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Damage in these regions usually involve the musculotendinous

[1] Wolfe SWHR, Pederson WE, Kozin S. Green’s Operative Hand Surgery. 6th ed.
junction and the muscle belly itself. The superficial radial sen- Philadelphia: Churchill Livingstone; 2010
sory nerve, posterior interosseous nerve (PIN), and radial nerve [2] Bendre AAHB, Hartigan BJ, Kalainov DM. Mallet finger. J Am Acad Orthop
can also be damaged in this region depending on the depth of Surg. 2005; 13(5):336–344
laceration. The strength of repairs is limited by lack of tendon [3] Pike J, Mulpuri K, Metzger M, Ng G, Wells N, Goetz T. Blinded, prospective,
randomized clinical trial comparing volar, dorsal, and custom thermoplastic
or fibrous septa to reapproximate. When tendons are present in
ine

splinting in treatment of acute mallet finger. J Hand Surg Am. 2010; 35

adequate stock proximally and distally, core sutures should be (4):580–588
placed. Multiple figure of eight sutures should be used to reap- [4] Lin JD, Sr, Strauch RJ. Closed soft tissue extensor mechanism injuries (mallet,
proximate the muscle belly itself. Tendon transfers may be used boutonniere, and sagittal band). J Hand Surg Am. 2014; 39(5):1005–1011
[5] Amirtharajah M, Lattanza L. Open extensor tendon injuries. J Hand Surg Am.
as salvage procedures, if the tendon repairs rupture. Postsurgi-
2015; 40(2):391–397, quiz 398
cal splint should be placed with wrist in 40 degrees of exten-
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[6] Matzon JLBD, Bozentka DJ. Extensor tendon injuries. J Hand Surg Am. 2010;
sion, MCP joint in 20 degrees of flexion, and IP joints free for 4 35(5):854–861
to 6 weeks.17 [7] Coons MS, Green SM. Boutonniere deformity. Hand Clin. 1995; 11(3):387–402
[8] Elson RA. Rupture of the central slip of the extensor hood of the finger. A test
for early diagnosis. J Bone Joint Surg Br. 1986; 68(2):229–231

44.4 Conclusion [9] Snow JW. A method for reconstruction of the central slip of the extensor ten-
C

don of a finger. Plast Reconstr Surg. 1976; 57(4):455–459

[10] Aiache A, Barsky AJ, Weiner DL. Prevention of the boutonniere deformity.
The extensor mechanism is a complex interrelation between
Plast Reconstr Surg. 1970; 46(2):164–167
the extrinsic and intrinsic musculatures. Astute knowledge of [11] Ahmad F, Pickford M. Reconstruction of the extensor central slip using a dis-
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anatomy and high clinical suspicion help in identifying injury. tally based flexor digitorum superficialis slip. J Hand Surg Am. 2009; 34
Appropriate splinting should be utilized in closed injuries to (5):930–932
prevent mallet finger, boutonniere deformity, and ulnar sublux- [12] Newport ML, ML. Zone I-V extensor tendon repair. Tech Hand Up Extrem
Surg. 1998; 2(1):50–55
ation at the MCP joint from sagittal band rupture. Partial lacera-
[13] Newport MLPG, Pollack GR, Williams CD. Biomechanical characteristics of
tions less than 50% do not require repair. Total transection
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suture techniques in extensor zone IV. J Hand Surg Am. 1995; 20(4):650–656
injuries should be repaired according to zone of injury. The [14] Lee SKDA, Dubey A, Kim BH, Zingman A, Landa J, Paksima N. A biomechanical
more proximal tendons are amenable to core sutures. Distal study of extensor tendon repair methods: introduction to the running-
Us

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Murphy et al., Reconstructive Plastic Surgery: An Atlas of Essential Procedures, First Edition (ISBN 978-1-62623-517-5), © 2022. Thieme. All rights reserved.
This document is intended for personal use only and may not be passed on to third parties in any form! Usage subject to terms and conditions of license.
| 03.07.21 - 14:53

44.4 Conclusion

interlocking horizontal mattress extensor tendon repair technique. J Hand [18] Khandwala ARWJ, Webb J, Harris SB, Foster AJ, Elliot D. A comparison of dynamic

24
Surg Am. 2010; 35(1):19–23 extension splinting and controlled active mobilization of complete divisions of
[15] Woo SHTT, Tsai TM, Kleinert HE, Chew WY, Voor MJ. A biomechanical com- extensor tendons in zones 5 and 6. J Hand Surg [Br]. 2000; 25(2):140–146
parison of four extensor tendon repair techniques in zone IV. Plast Reconstr [19] Kitis A, Ozcan RH, Bagdatli D, Buker N, Kara IG. Comparison of static and
Surg. 2005; 115(6):1674–1681, discussion 1682–1683 dynamic splinting regimens for extensor tendon repairs in zones V to VII. J
[16] Boyes JH. Bunnell’s Surgery of the Hand. 4th ed. Philadelphia: JB Lippincott Plast Surg Hand Surg. 2012; 46(3–4):267–271

20
Co; 1964 [20] Ng CY, Chalmer J, Macdonald DJM, Mehta SS, Nuttall D, Watts AC. Rehabilita-
[17] Sameem M, Wood T, Ignacy T, Thoma A, Strumas N. A systematic review of tion regimens following surgical repair of extensor tendon injuries of the
rehabilitation protocols after surgical repair of the extensor tendons in zones hand—a systematic review of controlled trials. J Hand Microsurg. 2012; 4
V-VIII of the hand. J Hand Ther. 2011; 24(4):365–372, quiz 373 (2):65–73

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257
Murphy et al., Reconstructive Plastic Surgery: An Atlas of Essential Procedures, First Edition (ISBN 978-1-62623-517-5), © 2022. Thieme. All rights reserved.
This document is intended for personal use only and may not be passed on to third parties in any form! Usage subject to terms and conditions of license.