Bowed Ringer Finger Due To Pip Fracture

• The tendon must be secured through or around the distal phalanx; fixation to the distal tendon remnant or periosteum is not secure.

• The proximal tendon end must not be debrided or advanced more than 1.5 cm, to prevent tethering of the FDP and the quadrigia effect.

• For type 1 and type 2 injuries, the PIP joint level must be explored before the palm, to prevent pulling the tendon proximally and converting a type 2 injury to a type 1 injury. This will rupture the long vin-culum and its blood supply.

History and Clinical Presentation

A 43-year-old right hand dominant air transportation specialist presented with pain in his left ring finger after an injury sustained at work. The patient reported pulling on the handle of a rototiller, which suddenly stopped, causing his finger to be forcibly hyperextended. He reported hearing a snap when this occurred and experienced immediate pain in his ring finger. He reports no prior injury to this area. This patient complained of pain at the level of the distal interphalangeal (DIP) joint of the ring finger.

Physical Examination

The patient had volar swelling and tenderness, and could not actively flex his finger at the level of the DIP joint. Upon making a fist, he had a noticeable lack of flexion compared with the other digits (Fig. 36-1). The flexor digitorum profundi (FDP) to the other digits were intact as demonstrated by blocking the digits in extension at the level of the middle phalanx, and asking him to flex at the level of the DIP joints. The flexor digitorum superficialis (FDS) was intact in all fingers, as demonstrated by blocking the adjacent digits in extension at the level of the proximal interphalangeal (PIP) and DIP joints and asking the patient to actively flex at the level of the PIP joint in the examined finger. Active extension was possible at the metacarpophalangeal (MP), PIP, and DIP levels of all fingers. He had no complaints of numbness or tingling. He also had no complaints of pain in the palm, wrist, or forearm.

Dorsal Blocking Splint Finger Pip
Figure 36—1. Presentation with ring finger unable to actively flex at the distal interphalangeal (DIP) joint.
Fracture Distal Phalanx Hand
Figure 36—2. Radiographs of the distal phalanx bony avulsion.

Diagnostic Studies

Individual radiographs of the left ring finger and hand were obtained. A small bony avulsion was seen at the volar proximal aspect of the distal phalanx of the affected finger (Fig. 36-2).

Differential Diagnosis

Bony flexor digitorum profundus (FDP) avulsion Fracture/dislocation of the distal phalanx


The patient was diagnosed with bony flexor digitorum profundus avulsion. This is a classic history and presentation of an acute "jersey finger." Four types of FDP avulsions have been described, as modified from Leddy's original description:

Type 1: Distal tendinous avulsion with proximal retraction into the palm Type 2: Distal tendinous avulsion with retraction to the PIP joint level Type 3: Distal bony avulsion with retraction to the A4 pulley Type 4: Distal bony avulsion with FDP avulsion from the bony fragment

This case is an example of a type 3 or 4 avulsion injury diagnosed by radiographs and clinical examination. Surgical exploration differentiates types 3 and 4.

The ring finger is the most common profundus tendon avulsion. A typical presentation is in sports injuries when the participant grabs the opponent's jersey in a tackle, undergoing forced extension of the fingertip while the profundus is under maximal contraction. Thus the name "jersey" or "rugby" finger was coined.

Type 1 and 2 injuries are defined by proximal retraction of the FDP tendon into the palm and finger respectively, with subsequent rupture of the short and possibly long vincula. Patients with a type 1 injury often have swelling, pain, and tenderness in the palm, and patients with a type 2 injury have swelling, pain, tenderness, and decreased motion at the level of the PIP joint. Sometimes a small fleck of bone is seen volarly at the level of the PIP joint on the lateral radiograph in type 2 injuries.

Surgical Management

A comfortable ulnar gutter splint was applied to the patient with the ring and small fingers in the intrinsic-plus position. He was scheduled urgently for outpatient surgery that week. Type 1 injuries should be repaired within 7 to 10 days, as the tendon blood supply is theoretically compromised, due to rupture of the long and short vincula when the tendon retracts into the palm. Type 2, 3, and 4 injuries have a longer safety zone for repair, with successful reports greater than 2 months after injury. Earlier repair is recommended to facilitate rehabilitation, decrease morbidity, and prevent a possible conversion to a type 1 injury, with later rupture of the long vinculum and retraction into the palm.

The next day, the patient was placed supine on the operating room table after obtaining general endotracheal anesthesia. Regional axillary block anesthesia is an acceptable alternative. The arm was placed on a hand table with a well-padded proximal arm tourniquet. After prep and drape, the limb was exsanguinated with an Esmarch bandage and the tourniquet inflated to 250 mm Hg. A volar zigzag incision was made at the level of the DIP joint on the ring finger, and exploration using loupe magnification was performed down to the flexor sheath. Hemostasis was meticulously maintained using bipolar electrocautery, and both neurovascular bundles were carefully protected throughout the procedure. The sheath was opened distal to the A4 pulley, taking care to preserve this pulley throughout the procedure to prevent bow-stringing of the tendon postoperatively (Fig. 36—3). A window between the C3 and A5 pulleys was opened to expose the distal bony avulsion fragment, and it was seen that the FDP tendon was still attached to this piece of the distal phalanx, indicating a type 3 injury. Hematoma and debris were curetted from the piece and from the avulsion site. The piece was reduced and held into position with a 0.035-inch Kirschner wire, and under fluoroscopy two 1.5-mm titanium self-tapping screws

A3 pulley Flexor Flexor

Metacarpophalangeal Hemat


A3 pulley Flexor Flexor joint

Metacarpal phalangeal Figure 36-3. Anatomy of joint the flexor sheath.

Fdp Avulsion Xray
Figure 36—4. (A). Lateral radiograph and (B). a radiograph of a type 3 avulsion secured with two cortical screws.

were placed with bicortical purchase (Fig. 36—4). The fragment was seen to be stable with a range of motion. The tourniquet was deflated, hemostasis obtained, and saline irrigation performed. The skin was closed with 4—0 nylon simple sutures, a bulky dressing applied, and a dorsal blocking splint applied with the wrist in 30 degrees of flexion. The fingers were splinted in the intrinsic-plus position to relax the FDP tendon and prevent postoperative stiffness.

Type 1 and 2 injuries necessitate exploration at the level of the PIP joint, where an additional palmar zigzag incision is used to expose the flexor sheath (Fig. 36—3). A transverse incision is made into the sheath just distal to the A2 pulley or through the C1 pulley. If the FDP tendon is not found at this level, then an additional incision is made in the palm and the flexor sheath is opened proximal to the A1 pulley.

If the tendon is found at this level, it is classified a type 1 injury. The long and short vincula are ruptured, and the blood supply to the tendon is theoretically compromised. The tendon is retracted proximal to the flexor sheath, preventing this source of nutrition via intrasynovial diffusion. This necessitates earlier repair, within 7 to 10 days, to prevent possible necrosis and myostatic contracture that may develop. A 4—0 Prolene suture is placed as a core suture in the proximal tendon stump. An infant feeding gastrostomy tube or Swanson suture passer is placed in retrograde fashion from just distal to the A2 pulley (at the PIP level incision) through the flexor sheath. Care is taken to place the tube/suture passer through the flexor superficialis decussation and to exit proximal to the A1 pulley. The tube/suture passer is attached to the core suture, and the tendon is pulled distally to the level of the PIP joint. Next the tube/suture passer is fed retrograde under A4 (from the DIP level incision) and the tendon is pulled distally to the level of the avulsion at the distal phalanx. Care is taken to preserve the A2 and A4 pulleys to prevent bow-stringing postoperatively. A 25-gauge needle is used to spear the tendon at A4 to secure its position. A bone trough is created at the proximal volar aspect of the distal phalanx. Two heavy needles are drilled through the bony trough volarly, exiting dorsally and distally through the nail plate. The core suture ends are pulled through the eye of the needles and pulled through the distal phalanx and nail. They are pulled snug and tied securely over a button on top of the nail while flexing the finger. Any remaining stump of tendon at the base of the distal phalanx is sutured over this repair for additional security and healing potential. The sheath can be left open or repaired, depending on the surgeon's philosophy. The closure and postoperative care are similar to the type 3 injury described before. The suture and button are removed at 6 weeks after surgery.

If the tendon was initially found at the level of the PIP joint upon exploration, it is classified a type 2 injury. The long vinculum is assumed to be intact, providing a source of nutrition to the tendon and preventing further retraction of the tendon into the palm. The short vinculum from the distal end of the middle phalanx is ruptured. The tendon still lies within the flexor sheath and retains nutrition via in-trasynovial diffusion. Due to these factors, the repairs have been reported more than 2 months after injury. A 4—0 Prolene core suture is placed in the distal tendon end, and pulled underneath A4 as described before. The suture is pulled through and tied to a button as described for a type 1 injury.

If upon surgical exploration a type 4 injury is found, then reduction and fixation of the bony fragment would be performed with screws, as described before. The tendon avulsion from this bony fragment would then be repaired to the distal phalanx, as described for a type 1 or 2 injury.

Postoperative Management

This patient was seen the following week and started on a flexor tendon zone 1 passive range of motion protocol, as described by Evans. A dorsal blocking splint was placed to keep the wrist in 30 degrees of flexion and the MP joints in 60 degrees of flexion. A second dorsal splint was applied to the digit to maintain 45 degrees of flexion at the DIP joint. Passive flexion of the digit was allowed out of the splint several times daily. A modified passive hook fist and passive PIP extension was allowed with the MP joints flexed. Place and holds were performed for the FDS. Wrist extension to 10 degrees was allowed with the fingers flexed under therapist supervision. Sutures were removed at 10 days and radiographs obtained at follow-up visits to ensure reduction of the fragment and progression of healing.

At 21 days, active range of motion was instituted with a full fist place and hold, and the digital blocking splint was discontinued. At 28 days the patient was started with tenodesis wrist exercises, gentle isolated FDS exercises, and hook fisting. At 35 days, full DIP active motion was allowed, including extension. After bony union was confirmed radiographically and clinically, strengthening with resistance was started at 8 weeks; at 12 weeks the patient was allowed to return to full activity at work and in sports.

Alternative Methods of Management

Alternatively, Bier block or local anesthesia can be used. Care must be taken with local anesthesia, as the palm may also need to be blocked in case of a missed or converted type 1 injury. A midlateral exposure can be used in the digit rather than a volar zigzag, depending on the surgeon's preference.

The tendon end can be secured to the distal phalanx by passing the core suture ends around the bone, rather than through it. It can still be secured over a button on the nail, as described before. Another method is to anchor the suture to the distal phalanx using a bone suture anchor. This leaves the nail bed and plate intact, and obviates the need for later suture removal.

Chronic (>3 months) untreated cases can be left alone if asymptomatic. If there is bothersome instability or pain in the DIP joint, this can be treated by tenodesis or fusion. If the remaining proximal stump of the profundus tendon is tender, this can be excised from the palm. Another somewhat laborious approach would be to perform one- or two-stage tendon grafting through the superficialis, allowing active use of the DIP joint.


Rerupture of the tendon can occur early or late. This should be repaired emergently as with the initial injury. Infection, skin slough, stiffness, and irritation at the wound and button site are infrequent. A slight loss of extension at the DIP joint commonly occurs. Nonunion or malunion of a bony fragment is a rare possibility, and can be prevented with careful attention to the bony reduction and fixation.

Suggested Readings

Carroll RE, Match RM. Avulsion of the flexor profundus tendon insertion. J Trauma 1970;10:1109-1118.

Eglseder WA, Russell JM. Type IV flexor digitorum profundus avulsion. J Hand Surg [Am] 1990;15A:735-739.

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


Evans RB. A study of the zone I flexor tendon injury and implications for treatment. J Hand Ther 1990;133-148.

Leddy JP. Avulsions of the flexor digitorum profundus. Hand Clin 1985;1:77-83.

Leddy JP, Bechler J. Flexor tendon avulsion from the distal phalanx. In: Blair WF, ed. Techniques in Hand Surgery. Baltimore: Williams & Wilkins; 1996:120-128.

Leddy JP, Packer JW Avulsion of the profundus tendon insertion in athletes. J Hand Surg [Am] 1977;2A:66-69.

Schneider LH. Fractures of the distal phalanx. Hand Clin 1988;4:537-547.

Smith JH. Avulsion of a profundus tendon with simultaneous intraarticular fracture of the distal phalanx-Case report. J Hand Surg [Am] 1981;6A:600-601.

Strickland JW. Flexor tendons-acute injuries. In: Green DP, Hotchkiss RN, Peder-son WC, eds. Operative Hand Surgery, 4th ed. Philadelphia: Churchill Livingstone; 1999:1877-1883.

Trumble TE, Vedder NB, Benirschke SK. Misleading fractures after profundus tendon avulsions: A report of six cases. J Hand Surg [Am] 1992;17A:902-906.

Section VIII

Fractures and Dislocations of the Hand

A. Phalanx Fractures

Distal Phalangeal Fractures

Kevin D. Plancher

Mallet Fractures

Kevin D. Plancher

Proximal Phalangeal Shaft Fractures

Kevin D. Plancher

Proximal Phalangeal Condylar Fractures

Carrie R. Swigart

B. Metacarpal Fractures

Metacarpal Neck Fractures

Kostas J. Constantine and Thomas R. Kiefhaber

Metacarpal Shaft Fractures

Robert J. Goitz, Sokratis Varitimidis, and Dean G. Sotereanos

Metacarpophalangeal Joint Injuries: Fractures (Intraarticular) at the Base of the Proximal Phalanx, An Arthroscopic Technique

Joseph F. Slade III and John D. Mahoney

Metacarpal Head Fractures

Paul R. Greenlaw and Mark R. Belsky

C. Dislocations: Phalanx and Metacarpals

Volar Dislocations of the Proximal Interphalangeal Joint

Lisa L. Lattanza and Steven Z. Glickel

Lateral Dislocations of the Proximal Interphalangeal Joint

Christopher H. Martin and Steven Z. Glickel

Dorsal Dislocations of the Proximal Interphalangeal Joint

Rosa L. Dell'Oca and Amy Ladd

Distal Interphalangeal Joint Dislocations

John D. Wyrick

Dorsal Metacarpophalangeal Dislocations (Irreducible)

Benjamin Chang and Mark Katz

Volar Metacarpophalangeal Dislocations (Irreducible)

Benjamin Chang and Mark Katz

D. Thumb and Carpometacarpal Joint

Ulnar Collateral Ligament Injuries: "Skier's Thumb"

Kevin D. Plancher

Carpometacarpal Joint Injuries: Bennett's Fractures (Arthroscopic and Percutaneous Screw Technique)

Joseph F. Slade III and John D. Mahoney

Carpometacarpal Joint Injuries: Bennett's Fractures (Wire Technique)

Michael Jablon

Complex Fractures at the Base of the Thumb: Rolando Patterns

John A. Girotto, Shrika Sharma, Thomas J. Graham

Carpometacarpal Joint Dislocation

Andrew L. Haas and Kevin D. Plancher

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