Extensor Tendons
Injuries
Surgeons who treat hand injuries have devel-
oped a great respect for inj urie s of the fl exor ten-
dons .22 The re is w idespread knowle dge about the
pitfalls and compl ications e ncounte red in the man-
age me nt of these inj uries. Injuries of the extensor
mechanism , b y contras t , may see m re lati vely sim-
ple to treat , but this is not so .28 Extensor injuri es
have not bee n given the same degree of atte ntion,
despite the advice of man y authors.22 •27 •28 •4 1 , 49 -90
Repair of the comp lex exte nsor mechani sm is oft e n
performed b y the you ngest or least skille d surgeon ,
with anticipation of success by sim pl e approx ima-
tion of the tendon ends . 1 · 41 T he manage me nt of
injurie s to th e e xte nso r mechanism demands th e
same amount of skill and knowl edge requ ired for
the care of fl e xor tendon injurie s. The extensor
mechanism in the finger , in comparison to that of
the fl exors , is thinne r ' le ss substantial. and less
likely to hold suture s w e I1_ 3 1. 43 At the wrist and
forearm , however , the exte nsors· substance and
cross-sectional are a are much more like th e fl exor
tendons .43 Injuri e s to the exte nsor tendons are
common du e to th e ir re latively exposed and sup e r-
ficial location . The dorsal asp ect of the hand and
wri st is cove re d with a thin laye r of suppl e skin with
l
Acute
51
James R. Doyle
minimal subcutan eous tissue. In many ar eas , such
as th e distal fi nger j oint , the te ndon is very thin and
subject to rupture with sufficie nt force. Injury may
be second,u-y to lace ration, deep abrasion , crush ,
or av ulsion, and the majority of extensor tendon
injuries are at joint levels. Pe netrat ing wounds that
disrupt the te ndon are also prone to enter the joint;
this is tru e not onl y at the inte rphalange aljoints but
also at the MP joint .28 The degree of joint contami-
nati on must be evaluate d and considered in th e
treatment plan .
Simple loss of continuity due to laceration or
avulsion of the extensor mechanism in the hand and
finge rs is usually not associated with imme diate r e-
traction of the tendon ends b ecause of th e multiple
soft tissue attachments and inte rconnections at
various levels .39 ·5 7 Furthermore , the extensor
mechani sm in the hand is extrnsynovial , exce pt at
the ,.,,ri st whe re the tendons are covered w ith a
syno vial she ath .39 · 40 Parate non surrounds the ex-
te nsor te ndo ns ove r the dorsurn of the hand , and
te ndo ns cove re d with parnte non do not separate
w idely wh e n lacerate d. 57 The refore. divide d e x-
te nso r tendons ,lre usuall y fr e e to re tract only on
th e d orsurn of the wrist . Because of this. many te n-
2045
2046 Operative Hand Surgery / 5 1
don injuri es, esp ecially in th e fingers, may be
treated successfully b y splinting alone . In the hand
and finge rs , any gap in the te ndon following lacera-
tion or avulsion is usuall y du e to unopposed Hexion
of the joints rather tha11 to retraction of the te n-
don. 57
When seen and treated early and properly, an
extensor tendon injury usually responds we ll. Be-
cause of th e complex and delicate balance of th e
extensor mechanism in the fing er , delayed or late
treatment of injuries does not carry the same favor-
able prognosis since it is often impossible to restore
the delicate balance of the various components of
th e ext e nsor mechanism .34 ,39,51 ,90
ANATOMY
Exte nsion of the fin ger is a comp lex act and is
considered to b e more intricate than finger flexion .
This mechanism is composed of two separate and
neurologically indepe nde nt systems - namely,
the radial nerve-innervated extrinsic extensors
and the intrinsic systems supplied by the ulnar and
me dian nerves. 19 Considerable d ifferences of opin-
ion exist regarding the mechanics of finger exten-
sion. 34 The re have been many contributions to the
understanding of this complex mechanism, and the
reader is referred to these reports for a detailed
review of the subject .19,27,34,39,40,45,46,49,58 - 60,83,91
However, a brief description of the anatomy of the
exte nsor mechanism is important in understanding
the prope r treatment , and the following discussion
is use ful in this regard.
The e xte nsor mechanism arises from multipl e
muscle b e lli es in the for earm. The exte nsor pollicis
longus , exte nsor pollicis brevis, exte nsor indicis
proprius , and ex tensor digiti quinti proprius have a
comparatively indepe nde nt origin and action. 39
Th e proprius te ndon s at the MP joint level are al-
most always to th e ulnar side of the communis te n-
dons. Th e littl e fin ge r proprius tendon over the
me tacarpal and wrist level may b e represented by
two distinct t e ndinous structures. Kaplan , how-
eve r , note d th at the variations in the disposition
and th e m,mbe r of tendon s are numerous .39 In con-
tras t to the proprius t e ndons, the extensor digi-
torum communis is c haracterized b y limited inde-
p e nde nt action and u suall ~ has four .distinct
te ndons .39 Th ese te ndons gam e ntrance mto the
hand throu gh a series of fibroo sseous tunnels at the
wrist level. At this level, th e te ndon s are covered
with a synovial sheath. Th e extensor retinaculum is
a wide fibrous band that prevents bowstringing of
th e te ndons across the joint (Fig. 51-1). It consists
of two laye rs : the supratendinous and the infraten-
di nous. The infrate ndinous layer is limited to an
are a deep to the u lnar three compartmen ts. The six
dorsal compartments are separated b y septa that
arise from the suprate ndinous r etinacu lurn and in-
sert on to the radius .89 Just proximal to the MP joint
leve l, the communis te ndons a.re joine d together by
obliqu e interconne ctions called jimctura(' ten-
dinum, (Fig. 51 -1) . These connecting bands usually
run in a d istal dire ct ion from the ring fin ger corn-
munis to the little and middle fingers and from th e
middle to the index finge r. 39 Because of these in-
terconnections , laceration of the mi ddle finger
communis te ndon just proximal to this junctura
may result in only incomple te extension loss of the
middle finger. 62
The extensor tendon at the MP joint level is j,_,]d
in p lace over the dorsum of the joint b y the
joined te ndons of the intrinsic muscles a1
transverse lamina or sagittal band, which to'.
tether and kee p the ext e nsor tendons cent1
ove r the joint. 39 The sagittal band ,u-ises fr ,
volar plate and the inte nne tac,up al li ganH
the neck of the metacarpals . 19,39 Any inju n
extensor hood or expansion may r esult in sul
tion or dislocation of the ext e nsor t endon . HJ
The exte nsor mechanism at the leve l of the
mal aspect of the fing e r is composed of a l
criss-crossed fibe r patte rn , which changes i,
me tric arrange me nt as the finger flex es ,1
te nds. This arrange me nt allows the lateral lu
b e displaced volarly in fl exion and to retu rn
dorsum of the fin ge r in exte nsion .75 The in t 1
te ndons from the lumbricals and interosseou:-. ·
cl es join the exte nsor me chanism at about th e L
of the proximal and midportion of tlw pnn. .
phalanx and continu e di stally to the DIP joint ()I ·
fin ger .39,75 .
1
At th e MP joint level, the intrinsic muscles .i '
 Doyle / E.xlt: n'>or Tendons Acute ln1unes 2047

v\

j
J
JUNCTURA
TENDINUM
EPL
EOYP

EC
ED
RHIN

SYN.SHEAT
A

Fig. 51 -1. (A) T he exl<·11sor l<'11do11 s gai n e 11tra11c.;e to th e ha11d from I ht' forC'arm by a series
of six fibroosst'ous canals . T hese canals are cov(• re d b y a substantial reti11acul11m . which
p re \·t•11ts bowstringing of the ex tensor ten dons . T he firs t compartment nrntains tht' ab-
duc:tor pollicis longus and extenso r poll icis b revis ; th e second tht> radial wris t extt>nsors .
tht> third tht' e xtensor pollicis longus; the four th the extensor digitorum communis to tht>
four fingers . as wt'll as the ex tensor inc.licis proprius; th<• fifth the extensor c.ligi ti quinti
proprius ; and the sixth the t>xtensor carpi ulnaris . Th<' comrnunis tendon s are joint>d
distally near the MP joints by fibrous intt>rconnections callec.ljuncturae te11<li111m1 Thest•
juncturae attach only to the communis tendon s and aid in surgical recognition of tht•
proprius tendons of the index and little fingers . resp ecti vely . The proprius lt•ndons an·
always positioned to the ulnar side of the adjacent comrnunis tt>ndons . Beneath t ht• n · ti
nacu lum . the extensor tendons are covered with a sy novial sheath (B) Tlw proprius
tendons to the index and little finge rs are capable of independent action . and tht'ir func
tion may be t>v aluated as depict e d . With the middl e and ring fingns !lt·wd into tilt' palm ,
the proprius tc11do11s ca11 extend tht' index and little fingt•rs .
2048 Operative Hand Surgery / 51
tendons are volar to the joint axis of rotation. At the
PIP joint, however, they are dorsal to the joint axis.
The extensor mechanism at the PIP joint is best
described as a trifurcation of the extensor tendon
into the central slip, which attaches to the dorsal
base of the middle phalanx and the two lateral
bands 34 (Fig. 51-2) . The lateral bands pass on either
side of the PIP joint and continue distally to insert
at the dorsal base of the distal phalanx. The exten-
sor mechanism is maintained in place over the PIP
joint by the transverse retinacular ligaments. The
extensor tendon achieves simultaneous extension
of the two finger joints by a mechanism in which
the central slip extends the middle phalanx and the
lateral bands bypass the PIP joint to extend the
distal phalanx. The fibers overlying the PIP joint
are differentially loaded as the finger moves. In the
flexed position, the most central fibers are tensed,
CENT. S
OBL. . .
B and the intermetacarpal lig·aments at the neck
DI ULAR LIG.
p about the level of the.,: proximal and mi d po· ·
CENT. SU
EXT
T. BAND
AGITTAL
BAND
CENTRAL
SLIP
whereas in extension the lateral fibers are
tensed .45,59 The most important feature of this
mechanism is that the three elements are in bal-
ance. 34,90 Specifically, the lengths of the central
slip and two lateral bands must be such that exten-
sion of the PIP and DIP joints takes place together
so that when the middle phalanx is brought up int~
alignment with the proximal phalanx, the distal
phalanx reaches alignment at the same time. 34 This
mechanism depends on the relative length of the
central slip and two lateral bands. This precise and
consistent length relationship is what is so difficult
to restore when the mechanism has been dam-
aged. 34 •57 . 9 o Loss of this critical relationship at the
PIP joint level with relative lengthening of the cen-
tral slip results in the characteristic boutonniere
deformity.34
Although the extensor mechanism may be in-
Fig. 51-2. The extensor tendon at th e MP
joint level is held in place by the transverse
lamina or sagittal band, which , teth ers and
centers the extensor tendons ove r the joint.
This sagittal band arises from the vol ar plate
of the metacarpals . Any i~ ury to thi s extensor
hood or expansion may result in subl uxat.011 or
dislocation of the extensor tendon . The intr 11 -
sic tendons from the lumbrical and in te cs
seous muscles join the extensor mechanisr, , t
of the proximal phalanx an d continue cl <
to the DIP joint of the finger. The ext~
mechanism at the PIP joint is best d escr- 1,
a trifurcation of the extensor tendon intr,
central slip, which attaches to th e dorsa
of the middle phalanx, and the two I..
bands. These lateral bands continue dist·,
insert at the dorsal base of th e distal plw
The extensor mechanism is main tai nt-
~Iace over the PIP joint by the transve1.
tmacular ligaments .
d
 Doyle / Extensor Tendons-Acute Inj uries 2049

jured at an y level from the distal joint of the finger multiple sutures of a synthetic nonabsorable mate-
to the forearm , certain injury levels are character- rial. Experimental data on repaired muscle lacera-
istic and will b e di scussed here relative to their tions in laboratory animals (rabbits) implies that
most likely injured areas . useful but not complete function can be restored
with adequate repair. A muscle segment totally
isolated from its motor point may not contribute to
the contractile function of the innervated muscle .30
If there is evidence of nerve involvement, the ap-
propriate branches are identified and traced out to
EXTENSOR MECHANISM INJURIES
AT SPECIFIC LEVELS their insertions. Penetrating wounds may often in-
jure the nerve at or near its entrance into the mus-
cle belly. Retraction of the distal nerve stump into
Proximal Forearm Level the muscle belly may occur and defy location and
subsequent repair. Many times it is impossible to
The wrist and common finger extensors , as well determine nerve damage at the time of surgery in
as the little finger proprius, arise from the region of the immediate postinjury period . However, after 7
the lateral epicondyle at the elbow. The th umb to 10 days of de nervation, a muscle will spontane-
extensors and abductors, along with the proprius ously contract fo r several minutes in response to
tendon of the index fing er , arise from the forearm succinylcholine used during induction of general
below the elbow. Inj uries at this level are usually anesthesia. 17 (This response may last for months
due to a penetrating wound with a knife or piece of fo llowing denervation; the exact end point is not
broken glass . The size of the skin wound may give known.) Additional information may be gained by
little indication of the magnitude of the inj ury. Sin- electrodiagnostic studies 3 to 4 weeks following
gle or multiple functional units may be inj ured. inj ury. The decision fo r secondary nerve rep air or
The demonstrated loss of function may be due to reconstruction versus tendon transfer will depend
muscle transec tion , nerve inj ury, or both . Such loss on the judgment and experience of the surgeon .
of function in a penetrating injury in the proximal If the lesion is confined to the muscle belly, de-
forearm may defy accurate preoperative diagnosis. finit ive repair is carried out . The muscle is usually
The radial nerve at the level of the distal arm gives quite hemorrhagic and muscle planes are difficult
off branches to the brachialis, brachioradialis, and to identify. Identification is aided by irrigation and
extensor carpi radialis longus. A major division of gentle sponging of the cut muscle ends. The wound
this nerve then occurs as it divides into the sensory is evacuated of all hematoma, and then multiple
branch and the posterior interosseous nerve sutures are placed to reapproximate the muscle
(motor branch) . The superficial (sensory) branch belly.95 The identification of intramuscular fibrou s
continues distally under cover of the brachiora- septa and fascia for placement of sutures will aid in
dialis into the forearm , wrist, and hand areas. The preventi ng the sutures from pulling out of the mus-
posterior interosseous ne rve gives branches to the cle. Coaptation of the cut ends of those muscles
extensor carpi radialis b revis and supinator, which that arise at or distal to the elbow is facilit ated by
it penetrates and supplies, and then innervates the wrist extension.
remainder of the extensor muscle group .
A penetrating wound in the proximal one-third POSTOPERATI V E MANAG EM ENT
of the forearm with functional loss must be care-
fully explored to determine the exact etiology of Postoperatively, the extremity is supported in a
the loss. Under tourniquet control and appropriate plaster splint or cast that maintains the wrist in 45
anesthesia, the wound margins are debrided and degrees extension (dorsifl exion) and the MP joints
then extended proximally and distally and the ex- in 15 to 20 degr ees flexion. T he elbow joint is im-
tent of damage is noted . If it can b e determined that mobilized in 90 degrees flexion if the muscles in-
the wounds extend only into the muscle belly, a volved ari se at or ab ove the lateral epicondyle . Im-
careful repair of the muscle belly is p erform ed with mobilization is continued for 4 weeks postinjury,

<hr
20 50 Operative Hand Surgery / 51
and then protected range of motion is permitted,
but a night splint is used to maintain t he wrist in
extension for another 2 weeks.
Distal Forearm Level
Injuries at t he muscle tendon j unct ion requ ire
careful reapproximation of the sep arated p arts. Al-
though t he dist al tendon accepts and holds sutures
well , the p roximal m u scle b e lly does not, and r e ap-
proxi m atio n of the se p arate d p arts is faci litated b y
m ulti p le n onabsorbable suture s that coapt the ten-
don and muscle toge the r . T e ndons characteristi-
cally o riginat e from a fibrou s tissue raphe in the
substance of the muscle belly several ce ntime ters
p roximal to the ar ea whe r e the te ndon is grossly
identi fi able as a distinct structure . To obtain a sig-
nificant purchase on the muscle b elly with the su-
tures , these se pta should b e identified and the su-
tures placed in this fibrou s ti ssue area as much as
possible in order to ke ep the sutures from pulling
out . The knots are bur ie d b e tween the tendon and
the m uscle. Care is take n to avoid strangulation of
the m u scle w ith the sutures , which may cause ne-
crosis of the muscle . Small ab sorb able sutures may
be u sed t o r e p air the fascial margins of the muscle.
P ostoperative splinting is important and should in-
clude the w rist and m e tacarpals, as previously de -
scribed fo r proximal muscle injurie s. Immobili za-
tion is maintaine d for 4 weeks, followed by an
additional 2 weeks of night splinting.
Wrist Level
Injuries to the ext e nsor mech anism at the w rist
level are associate d w ith injuries to the r e tinacu-
lum. 4 •22 •74 T his r e tinaculu m prevents b owstringing
of the extensor tendons, but any lacer ations of the
extensors at this level are usu ally associated with
subsequent adhesions to the overlying retinacu-
lum. For this reason , portions of the extensor reti-
naculum located over the site of tendon repair
3 22
should be excised to prevent adhesions . , ,52,74
The tendon (tendons) is repaired using a standard
core -type suture of appropriate nonabsorbable ma-
terial. T he retinaculum is then excised so that the
suture line does not impinge on any part of the
retinaculum with passive flexion and extension of
the fingers and wrist . Multiple tendon injuries at
t his level mu st be dealt wit h by appropriate exci-
sion of the retinaculum. P ortions of the re tinacu-
lum should be preserved either proximal or distal
to the sut ur e line to prevent bowstringing, and this
is usually technically feasible to do. However, if
this cannot b e done because of the multiple levels
in injuries, the retinaculum should be completely
excised. There w ill be some postoperative bow-
stringing, but this d oes not interfere significantly
with function .22
The anatomy of the ar ea must be well under-
stood, and F igure 5 1-1 de monst rates the appropri-
ate anatomic r e lationships in th is area. Retraction
of tendons lacerated at this level occurs, and trau-
matic wounds must be ext e nded proximally and
distally to find the te ndon e nds. L acerations on the
radial side of the w r ist m ay inj ure t he short thumb
extensor and the abductor p ollicis longus tendons ,
as well as the radial w r ist ext ensors. T he abductor
pollicis longus m ay b e r e presented by two to four
slips or te ndon segm e nts, and all portions of the
te ndon should b e identified and repaired . If signifi
cant distal stump length is present , a buried core
suture is sufficie nt for r e p air (see Chapter 49 fo r
techniques of te ndon sutures) . If, however , the
level of injury is at or near t he osseous insertion
the tendon (tendo ns) must be fi r mly reattached to
bone using a 4- 0 nonabsorbable su ture for small"
te ndons or 3 - 0 fo r larger tendons such as the \\ r· s
exte nsors . A pull-ou t wire technique may also ',
used to reattach these tendons to their osseous
sertions. T he tendon must be firmly anchorec
b one, but car e must be taken to prevent exces•·
shortening of the tendon.
In addition to injury by laceration, the exte n
tendons may rupture following a closed fracturt
dislocate fo llowing injury to the retinacul um. '
extensor pollicis longus and extensor digi tor
communis tendons may rupture followin g a Col
fracture and the extensor carpi ulnaris tendon 11 '
dislocate ulnarward with forceful supination. P
mar flexion and ulnar deviation .20.26 ,53,72 Im pen
ing rupture of the extensor pollicis longus has be~
treated by subcutaneous transposition from it
11'1

c.:anal. 8 T reatme nt of ac.:ute rupt ures of tl1< ~ex t c nsor
po lli c.:is longus te11<lo11 is b y transfer of th e cxt<\nsor
in<lic.:is p rop r iu s te11do11 (o r in tcrcalary graft ) and
th e rup tured c.:o mmuni s te ndon s by i11tcrcalary
graft or sutu ri ng of th e di stal te ndo n stump to aclja-
c.: ent extensor te ndo ns (sec C hapt e r 52). Di sloca-
tion of the extensor carp i ulnari s te ndon is trc ~atcd
by re pair of the fi b roosseo us sheatlt w ith a fr ee
tendo n graft or a porti on of the ex te nsor rdi nac.: u-
lu m. 20
POSTOP ERATIVE MANAGEMENT
Re p air of th e abdueto r te ndons is protec.:t ed by
application of a splint or pl as te r east w ith th e wri st
in 40 degrees dorsifl ex ion and sli ght radi al <lcv ia-
tion , along with exte nsion of th e thumb metacar-
pal, for 4 weeks. Thi s is foll owed b y 2 weeks of
p rote cti ve ni ght splintin g. Th e exte nsor pollicis
b revis re p air is p ro tected b y immobili zation with
the wrist in 40 degrees exte nsion and th e thumb in
a moderate amount of ex te nsion. Re pair of th e ex -
tensor pollicis long us is protected by wri st and
thum b exte nsion at the MP joint and e levation of
the thumb in the plane of the palm (radial abdu c.: -
ti on). Re p air of the radi al wri st ex te nsors is pro-
te cted by p las te r immobili zati on wi th th e wri st in
45 degrees exte nsion for 4 weeks. Re pair of th e
fin ger exte nsors requires a p ro tecti ve splint or cas t
with the wrist in 45 degrees ex te nsion with immo-
bili zation of the MP joints in 1.5 degrees fl exion .
The interphalangeal joints need not b e immobi -
li zed fo ll owing re pairs of the fin ger or thumb ex-
tensors at the wrist leve l.
F ollowing rep air of any exte nsor te ndon , it is
advisable fo r the surgeon to observe te nsion on th e
suture lin e un de r direct vision , with the wound
open as th e w rist and hand are p ositi one d as no ted
above. This ass ures that ther e will b e ap propriate
relaxation at th e suture line .
Metacarpal Level
The extensor tendons over the me tacarpal region
are covered on ly with parate non . Significant adh e-
sions are unlikely. Howe ve r , injuri e s of th e ten-
.....__
Doyl<' / Extensor Tendons - Ac ute lnj uri(•s 20 51
dons at thi s l<-\vcl may be associated wi th some te m-
po rary adh es ions of th e skin to th t~ underlyi ng
med1 anis m. Th ese are us uall y co rrected in tim e b y
ap propri ate exe rcise , and te no lys is is se ldo m indi -
cated f'or sim p le lace rati ons at thi s level.
Th e te ndon is re paire d w ith a buried core su tu re
(sc<! C hapt e r 49).
POSTOPERATIVE MANAG EMENT
Th e wri st is immobili zed in 4,5 degrees ex te nsio n
and th e MP joints are in 15 degrees Hex io n. Thi s is
continu e d for 4 weeks foll owed by 2 weeks of p ro-
lcet ivc night splint ing . If any of the commu ni s te n-
don s are injured , all fin gers mu st b e imm obili zed
because of th e conjoin e d action and in terco nnec-
tion s of th e co mmuni s te ndo ns. H oweve r , if onl y
the propriu s te ndon s are inju red , b ecause of the ir
inde pe nde nt action , onl y th e in volved di git needs
to be immobili zed . Th e positi o n and durati on of
irnm obili zation used are th e same as th ose fo r th e
c.: ommuni s te ndons.
C ru sh or avul sion injuri es of th e exte nsor mecha-
ni sm ove r the me tacarpal leve l w ith or without
fraet ure may be assoc.:iated w ith signi fican t postop-
e rati ve adhesion s. F or thi s reaso n, it is important to
obtain care ful re appro xim ati o n of the te ndon e nds
and to provide adequate so ft t issu e coverage ove r
the site of te ndo n re pair. In cru sh injuri es , pro-
tected range of moti on may be starte d as early as 3
wee ks followin g re pair, but anot he r 3 w ee ks of
ni ght splintin g is required to preve nt st retching o r
le ngth e ni ng of the re p air.
Secretan 's Di sease
(Peritendinous Fibros is)
In 1901 , H e nri Secre tan ,76 describe d 11 cases of
p e rsiste nt hard e de ma on the dorsum of th e h and
associate d w ith work-relate d injuri es. All patie nts
we re cove red by workers compe nsation insurance,
su stain ed trauma not suffici e nt to prod uce frac.:-
ture, and had prolonged sy mptoms and findi ngs .
Thi s condition has al so been call ed dorsal hard
ede ma of th e hand , pe rite nd inous fi b rosis of tlw
dorsum of the hand, and facti tious lymphe d t>ma of
th e hand .6 7 ·6 8 · 78 Typi cally, a worker, us ually male ,
2052 Operative Ha nd Surgery / 5 1
d t>scribes a blow to the dorsum of the hand without
frncture or laceration and th en develops firm , per-
sistent swelling over the back of the hand with s_ub-
sequ ent loss of fin ger flexion and prolonged tun e
out of wo rk. Since Secretan's 1901 report, contro-
ve rsy has developed regarding the etiology and
treatme nt of thi s condition.
Etiology
A numbe r of factors have been reported in asso-
ciati on with this condition including: (l) prove n or
suspecte d self- inflicted traum a such as repeated
blows to th e bac k of th e hand or appli cation of
tourniqu ets; (2) compensable work-related inju-
ries; and (3) ne urosis, p sychosis, or suicidal tend-
ency.51·78 Boyes surmised that this condition is an
e xampl e of re fl ex dystrophy in which edema is the
major sign, just as pain is th e principal finding in
causalgia. 6 Bu reau e t al1° stated that this condition
is a fo rm of re fl ex vasomotor edema. In 1969, Omer
e t al63 re ported th eir e xperimental efforts to pro-
du ce this condition in monkeys b y blunt trauma,
inj ection of autologous blood, and a tight wrist-to-
elbow cast to cause venous and lymphatic obstruc-
tion. No one single modality produced th e condi-
ti on, but an y two in combination did produce th e
lesion.
Treatment
Most authors advi se nonoperative management
of this condition. Boyes advised studious neglect,
avoiding all passi ve manipulation , heat, and mas-
sage but encouraging patient exercise by voluntary
means. 6 Saferin and Posch noted poor results in 3
pati ents operated on to excise this lesion. They ob-
se rved p rolonged di sability of 2 to 5 years and ad-
vised splinting and active exercise as treatment.73
Bureau et al1° reported that two patients who had
excisioi;i of th e mass fail ed to improve, and they
advocated gentle therapy and relaxation tech-
niques. Encouraging results with steroid injections
were noted in 2 cases. Reading described 4 cases of
hard edema of the dorsum of th e hand who had
resection of th e lesions by other surgeons. Each
de monstrated prolonged difficulti es in healing and
none was improved by surgery. All hands improved
67
. t ·ted by a plaste r dressing. Re d fe rn e t
w h en pro ec . h I. d' .
68 d ·'b d their experi e nce wit t 11s con 1hon
a1 esc11 e . . f cl
. t' nts in whi ch 13 had e xc1swn o a orsal
111 15 pa ,e ' I l'f
fibroma (dense fibrou s tissue with vase~ ar pro 1 -
eration, thickened vessel walls, an occasw~al orga-
nized intravascular thrombus, and pe nvascul ~r
lymphocytic infiltration) with e xte nso'.· te nolys1s
whe n necessary. Eleve n of fift een pati e nts we re
abl e to return to work. The average tim e from in-
jury to return to work was 14 months. Most authors
have noted a prolonged re covery tim e and a hi gh
recurrence rate with or without surge ry. Louis51
and s·mith 78 agree that direct confrontation of the
pati ent with factitious disease is dange rou s for th e
patient and the doctor.
Author's Preferred Treatment
This condition must be recognized as a factitious
illness. Patients with factitious illnesses are not
feigning illness; they are causing it. 51 ·78 Confronta-
tion in th e form of accusation can be pote nti all y
harmful to both the patient and doctor, and should
be avoided. 51 ·78 The physical proble m o r lesion
may resolve when compensation is terminate d. In
spite of th e report by Redfern e t al ,68 this is not a
surgical lesion. Best results have bee n achi eved b y
psychotherapy.67 Protective casting, although it
may result in immediate improvement and confirm
a diagnostic impression, may not be e ffec ti ve as
definitive treatment. Howe ver, this techniqu e may
demonstrate to the therapist or patient on some
level (conscious or unconscious) th e se lf-inflicte d
nature of the problem .67 Active physical th e rap y
may be useful in many cases in conjunction with
psychotherapy.
MP Joint Level
HUMAN BITE WOUNDS
Injuries at this le vel are most ofte n associated
with open wounds. A small pe ne t rating wound
o~er the MP joint may be associate d with a hu man
bite or striking someone in the mouth with a
clenc~ed fist, and a careful history must be take n .
Mo st , if not all , patie nts will deny this mechanism of
injury. This is a contamin ated wound , and the orga-
nisms in vo lved are capable of producing a signifi -
cant wound infection . Gram-positive bacteri a
(usually streptococci and staphyl ococci) are most
fre qu ently culture d. The incide nce of gram-nega-
tive organisms is lowe r and th ey are usually found
in associati on with gram -positive organisms. The
incide nce of complications is directl y related to th e
tim e span from injury to trea tm e nt. 18 A radi ograph
should be obtaine d to note th e presence or abse nce
of fracture or fore ign body. The wound must be
ext e nded proximally and di stally to permit inspec-
tion of th e joint, and aernbi c and anaerobi c cul t ures
should be tak en. The wound is debrided , irrigated ,
and left open. Appropriate antibi oti cs should be
started immediate ly (prefe rabl y preope rative ly).
Und er no circumstances should a human bite
wo und be closed.5·54 Most te ndon injuri es asso-
ciated with this type of wound are parti al and need
no t be re paired imm ed iate ly. The hand is splinte d
with the wrist in 4,5 deg rees extension and th e MP
joints in 15 to 20 degre es fl ex ion . The soft tissues,
including th e capsul e and exte nsor hood , are al-
lowed to see k th eir ow n positi on ove r t he joint .
Parti al or e ve n comp lete lace rations are seldom if
eve r associated with signifi cant re trac ti on at thi s
level. The te ndon laceration may be repaired sec-
ondaril y in 5 to 7 days or even late r, dependin g on
the nature of th e wound at th e tim e of inspectio n.
SIMPLE LACERATIONS
Simple lacerati ons of the ex te nsor te ndon or
hood at th e MP joint le ve l should be repaired using
simpl e sutures of nonabsorbabl e mate ri al. Inju ri es
of the e xt e nso r te ndon at t his level are not asso-
ciate d wi t h ret racti on of th e e nds , and simple su-
t ure fo llowed b y 3 to 4 wee ks of splin tin g is appro-
priate treatm ent. The wri st is splin ted in 45
d egree s ext e nsion and t he M P joi nts are he ld in 15
to 20 d eg rees Hexion fo r 3 to 4 weeks, and the n
protected range of moti on is started . Lace rati ons of
th e h ood or sagittal bands at this level must be re-
paired so th at the ext e nsor te ndo n will re main ce n-
trali zed over th e dorsu m of the joint . Failure to
re pai r thi s type of inj ury may resu lt in subluxati on
of th e ex te nso r te ndon and associat ed loss of ex te n-
sion.
Doyle / Ex tenso r Te ndons - Acute Injuries 2053
TRAUMATIC DISLOCATION OF
EXTENSOR TENDON
Subluxati on or di slocation of t he exte nsor te ndon
may occur at th e MP joint foll owing lace ration of
th e hood , or it may occur followin g force ful fl ex ion
or exte nsion injury of the finge r.24·42 In traum ati c
di slocation with laceration, th e middle fin ge r is
most co mmonly in volved. The lesion is seco ndary
to a tear of th e sagittal band and obliq ue fibers of
th e hood, usuall y on th e radial side, although ru p-
ture of th e uln ar sagittal band and radi al disloca-
ti on has been reporte d.42·69 Uln ar dislocatio n is th e
usual findin g and is assoc iate d with incomplete
fi nger exte nsio n and uln ar de viati on of th e in-
vol ved di git 42·98 (F ig. 5 1-3). The middle fin ger is
most commonl y in vol ved , and this may be due to an
inhe re nt anatomi c weakn ess since the exte nsor
tend on of the long fin ger is si tuated on top of th e
transve rse fi be rs and has a comparati ve ly loose at-
tachm ent at this level. 42 Acu te tears are satisfa cto-
ril y treated by pri mary suture of the de fect. 35.4 2
Two cases of ac ute traumat ic di slocati on of the
middl e fin ge r ex te nsor , one with uln ar subl uxati on
and one wit h radial sublu xation were sucessfu ll y
t reated by plas te r cast imm obilization with the M P
joints in fu ll ex te nsion for 4 wee ks. These two cases
were uniqu e in th at d iagnos is was made and treat-
me nt begun within hou rs of the injury. 69 This is in
di stin ct co nt rast to t he usual situat ion that is diag-
nosed and treated days or wee ks after injury, in
which case surgery in the form of primary suture of
the defect or secondary reconstru ction is indi-
cated. If primary suture is not possible , the tran s-
verse fibers of th e ho od are anchored to the MP
join t capsule. Reefin g of the radial fibers over the
hood, along with rel ease of thE' ulnar sidE' of the
hood, also provides an accE'plable rPpair. 12 Th"
ten don must be accurately cent<'rl'd o, er lh <' MP
join t, and the repair must be strong E'nough to n·s1,t
rec urrence of th e sublu xation during fl,•,1011 of th,·
fin ger. If the radial portion of the hood is ,1bse nl o,
not suitable for repair. some t,-pe oi tctlH ·r 11111,l 1,,
mad e to ce ntrali ze the lc11do11. A po l"linn nfi111·c-
turae tendinum may bE' used l'or tlii, purpo". II is
lappe d ove r th e extensor and s11 l11n•d lo tlw _ininl _
capsule on th e radial sicle. 98 A rl'lrogrcHk slip ,,f
extensor may also be usC'd and is anclton·d to tlw
2054 Operative Hand Surgery / 51

f
ULNA( , . ADIAL
Bt~
I
'/
[~
1, i,
ULNA ,,

SUB Y,f
I ,,-.
,,r /
I
I

. \
' . ' . -~
7 I I 1/ I I ..

IPRIMARY
SUTURE
(KETTLEKAMP)
JUNCTURAE
TENDINU
.I. D nr~~~oWP
(WHEELD
·· ,.t ~-~

Fig. 5 1-3. Subluxation or dislocation of the exten-

sor tendon at the MP joint may occur fo llow ing
laceration of the hood or following force ful fle x on
or exte nsion of the finger. T he lesion is seconclar,
to a tear of the radial portion of the sagi ttal bane
(A), which allows ulnar subluxation of the exte , ,
tendon. Acute or fresh injuries are satisfacto · .
treated by primary suture of the defect in the h J
and sagittal band (B). Late cases may require ac,
tional reconstruction . Wheeldon 98 has descri b<
method using a portion of the juncturae tend '
to stabilize the tendon over the dorsum .9f the ,
(C). T he junctura is lapped over the extensor
don and sutured to the joint capsule on the L
side. McCoy and Winsky 56 have also devist'
technique (D) for stabilizing the exte nsor b~
moving a portion of the extensor tendon on
radial side of the finger , passing it arou nd the lt
brical tendon , and suturing it b ack to itself (E
The clinical picture of ulnar subluxation of the
tensor tendon in the long fing er.

deep transverse intermetacarpal ligament 24 or
passed around the lumbrical tendon and sutured
back to itself 56 (Fig. 51-3) . (See Chapter 52 for
furth er discussion of the late management of this
proble m.)
Proximal Phalanx Level
Injuri es at this level are usually characterized by
partial laceration of the extensor mechanism be-
cause of the broad configuration of the tendon over
the curved shape of the underlying phalanx and
consequent protection of the lateral bands. 62 ,93
These injuries can be diagnosed only by direct in-
spection .61 ·62 Laceration of an isolated lateral band
may b e repaired with fin e nonabsorbable suture
and early protected motion started. Complete lac-
erations of the central slip should be repaired with
fin e nonabsorbable suture since relative lengthen-
ing of the central slip may occur with resultant im-
balance between the central slip and the lateral
bands. The repair should be protected for 2 to 3
wee ks by immobilizing the MP and PIP joints of the
injured digit in 15 to 20 degrees fl exion.
PIP Joint Level (Boutonniere
Lesion)
Disruption of the central slip of the extensor ten-
don at the PIP joint level along with volar migration
of the lateral bands will result in the so-called bou-
tonniere deform ity, with subsequent loss of exten-
sion at the middle joint and compensatory hyper-
extension at the distal joint. This lesion may be
secondary to closed b lunt trauma with acute for ce-
ful fl exion of the PIP joint, producing avulsion of
the central slip from its insertion on the dorsal base
of the middle phalanx with or without frac ture and
laceration of the extensor tendon at or near its in-
sertion. 8 0 Volar dislocation of the PIP joint may also
result in avul sion of the central slip and subsequent
boutonniere deformity.80 · 82 · 87
In closed injuri es, the characteristic b outonni ere
deformit y may not be present at the tim e of injury
and usually develops over a 10- to 2 1-day p eriod
follo wing injury. This condition is often missed
even in an open wound. A painful, tender, and
swollen PIP joint that has been recently injured
Doyle / Extensor Tendons - Acute Injuries 20 55
should arouse suspicion . Active motion is de-
creased and the finger is held semiflexed. Car-
ducci 11 reviewed 43 of _71 patients treated in an
emergency room with the diagnosis of jammed or
sprained finger over a 14-month p eriod, and noted
that 2 of the 43 patients developed a boutonniere
deformity. He described 2 diagnostic tests that are
useful in early recognition of this lesion: (1) a 15 to
20 degree or greater loss of active extension of the
PIP joint when the wrist and MP joint are full y
flexed; and (2) extravasation of intraarticular radio-
opaque dye dorsal and distal to the PIP joint. Lo-
vett and McCalla52 also noted that weak extension
against resistance is an excellent diagnostic fi nding
and is suggestive if not diagnostic of central slip
injury. Boyes5 noted that early diagnosis may b e
facilitated by holding the PIP joint in full extensi on
and testing the amount of passive fl exion of the
distal joint. With disruption of the central slip and
volar migration of the lateral band, flexion of the
distal joint is markedly decreased.5 In fresh ca-
davers, Harris and Rutledge 34 and Micks and
Hager 58 observed that section of the central slip
alone did not result in the boutonniere defo rmity.
However , the boutonniere deformit y did develop
if the PIP joint was repetitively fl exed while ten-
sion was applied to the extrinsic extensor. The lat-
eral bands tore away from the other fib ers, produc-
ing a boutonniere defo rmity. The boutonniere
deformit y illustrates the problem of balance in the
fin ger , which is a chain of joints with multiple ten-
don attachments. This chain collapses into an ab-
normal posture or deformit y when there is an im-
balance of the critical forc es maintaining
equilibrium .84 Zancolli has divided thi s sequence
into three stages . At fi rst, there is fl exion of the PIP
joint du e to loss of the central slip and the unop-
posed fo rce of the fl exor digitorum superficialis .
Later, with stretching of the expansion (transverse
reti nacular ligament and triangular ligament) be-
tween the central and lateral slips, the lateral bands
migrate volarward to a position volar to the axis of
joint rotation. Finally, in this p osition of the lateral
bands, the pull of the intrinsic muscles is directed
exclusively to the distal joint, which progressively
hyperextends. The MP joint is also hyperextended
b y action of the long extensor tendon. 100 In the
discussions that fo llow, treatment of the early acute
boutonniere deformity is arbitrarily divided into
 Operative' Hand Surgery / 51
e dosed or avulsion injuries and open injuries
ith lace ration of the extensor tendons at or near
.e PIP joint.
IETHODS OF TREATMENT OF
LOSED ACUTE BOUTONNIERE
,EFO RMITY
Correction of this deformity is dependent on
storation of the normal tendon balance and the
ecise le ngth relationship of the central slip and
:eral bands. In acute cases, before fixed contrac-
rns have occurred, this may be achieved by two
sic means : (l) splinting of the PIP joint into pro-
essively full exte nsion or (2) insertion of a trans-
Licu lar K-wire to maintain the PIP joint in full
tension . At the same time, active and passive
xion exercises of the distal joint are performed as
..:om mended by Boyes. 5 Splinting of the PIP joint
d active Aexion of th e DIP joint have been said to
.tw the lateral bands distally and dorsally and to
Juce the separation of the torn ends of the ce n-
,1 slip of the exte nsor te ndon. This allows repair
contracture of the disrupted tendon ends at
dr anatomic length and migration of th e lateral
nds to their normal anatomic position above th e
nt axis of rotation at the PIP joint. 7-14
Stewart 87 ·88 has achi eved the same good results
• a plaster cylinde r finger cast with the distal joint
·xed (the mallet finger posture) and the PIP joint
extension. The plaster is maintained for 6 weeks ,
J th e MP joint is free to move during that time.
ter re moval of the plaster, the DIP joint is mobi-
c,d first before unrestricted motion of the PIP
nt is allowed, since, according to Stewart, the
eral bands made tight by DIP joint flexion would
,erwise exert more than normal traction on the
1led central slip during PIP joint flex ion. 87
1g 44 and Stewart 88 have emphasized the impor-
1ce of earl y recognition and closed treatme nt of
· boutonniere deformity because of the fact that
gical correction of this late or established defor-
t y is unpredictable .
,fetal , plastic, plaster, and dyn amic splints have
·n used for the maintenance of the PIP joint in
ension . Most authors agree that only the PIP
,t ne eds to be splinted , although McFarl ane and
,npol e 57 advised immobilization of th e wrist and
joint because of difficulties encountered in
;ntaining th e PIP joint in full exte nsion . They
ta K-wire placed obliquely across the
also note d th a .. . d· 1·
. . rr d firm immob1hzat10n an 1s a more re 1-
JOlllt anor s . . . . Ae xion exe rcises. 22 The K-wire is left in place for 5
able way of holding the PIP JOlllt m e xtens10n . A
shorter splint that immobilizes only th e MP and PIP
• · t s can the,1 be use d . Mcfarl ane and Hampole
J0lll
continued the splint for 4 weeks and re moved the
K-wire in 3 weeks. In olde r patients, they reduce d
the time of absolute immobility to 2 wee ks.57 T u-
biana also advises splinting the wrist in e xtension,
along with immobilizati?~ o~ the MP _j o int in 10
degrees flexion, the PIP JOlll t m ex te nsion , and th e
DIP joint in 45 degrees fl exion fo r 4 weeks. At th e
e nd of that time, only the PIP j oint is kept immobi-
lized in extension for another week.90 Both Boyes 5
and King 44 have used the Bunne ll-typ e safety-pin
splint with good success. Boyes 4 has used thi s
me thod since 1957 and has note d satisfacti o n with
the method in early bouton nie re cases. The splint is
worn for 5 weeks. If the middle j oin t cann ot be
fully extended passively, it is b ro ught into e xte n-
sion by dynamic splinti ng with the safe ty-pin splint
and strap. The distal j oint must be le ft free . The
patient is advised to use th e splint constan tl y and to
perform strong acti ve fl exion of th e d istal joint . If
the distal joint can be fu lly fl exe d with the PIP j oi nt
extended, all compone nts of the ex te nsor me cha-
nism have been restored to their normal re lat io n-
ships and balance, and the splint may b e disco nt in-
ued4·5(Fig. 5 1-4) .
In closed bou tonnie re deform ity, Boye s5 advo-
cated operative treatme nt unde r two circ um-
stances: (l) the central sli p has been avu lse d w ith a
bone fragment and is lying free over th e PIP j oint; it
should be replaced or excised and the te nd on re at-
tach ed with a pull-ou t wire ; and (2) a long-standi ng
boutonniere deformity in a you ng p e rson. Tu-
biana00 also favors surge ry in recent close d ru p-
tures with avulsion of a bone fr agment . D e pe nd ing
on its size, th e fragme nt is e xcised or reattac he d . If
th e fragment is excised , th e central sli p sho uld be
'.e~tta~hed to th e base of th e middle p ha lanx. T he
Jomt rs transfix ed with a K-wire for 1 O days fo l-
lowed by a splint. Spinner and Choi have not e d that
closed anterior or volar dislocations of the PIP j o in t
I,
us_ually result in rupture of th e ce ntral sli p along
with rupture of a collateral ligamen t and volar plate
a nd subsequent boutonniere de formity .82 The y
h_ave observed that these potentially disablin g soft
tissu
. e inJ'uries must b e recog111•zed and re pa1re<. · 1
Spurner and Cho·1
recommend prompt re du ction
1
Fig. 5 1-4. The Bunnell-type safety-pi n spl in t is th e au-
thor 's preferred method for the management of a closed
bouton niere deformi ty (A). The spli nt is worn constantly
and the strap on the splint is tightened on a dail y basis
unt il fu ll extension of the PIP joint is achieved. The ter-
minal cross bar does not go beyond the distal joint fl ex ion
crease (B), and the patient is inst ru cted to actively and
passively fl ex th e distal joint whi le the proximal joint is
held in max imum extension . The spli nt is used on a con-
tin uous basis for several weeks un til fu ll passive exten-
sion of the PIP joint can be achi eved along wi th full or
nearly fu ll fl ex ion of the DIP join t. When this occurs, the
length relationships and balance between the central slip
and the lateral bands have been achieved and th e splin t
can be disco ntinu ed.
and primary repair of all rupture d structures (ce n-
tral sli p , coll ateral ligament , and volar plate) , co m-
b ine d with stabili zation of the PIP joint in exte n-
sio n wi th a K-wire for 3 weeks, fo ll owe d by gradual
mobi li zation over the nex t 3 to 4 weeks while th e
PIP joint is prote cte d. Motion of the d istal joint is
enco urage d in the earl y postoperative period . It
can be anti cipate d th at this me thod wi ll produce
satisfactory resu lts, althoug h j oint stiffn ess can be a
problem be cause of th e e xte nsive soft ti ssu e injury.
Transarticular K-wire fixation of th e PIP joint in
full e xte nsion is pre ferred by Ell iott 22 and Sakell ar-
ides.74 Elliott uses a light volar splin t as additi onal
Doyle / Extensor Tendons - Acute Injuries 2057
protection and leaves th e distal joint free for active
weeks, and an e xternal splint is worn for anoth e r
week, followed by a night splint for a second wee k.
Afte r re moval of the splint, active e xte nsion exer-
cises are e ncou raged and distal joint flexion is con-
tinu ed with manual support of the middle phalanx
in exte nsion . Max imum recovery may take 9
months. 22 Sake llar ides noted that exte rnal splint-
ing of th e PIP joint is often not satisfactory in main -
taining full PIP joint extensio n, and it is hi s practice
to insert an oblique transarticular 0.035-inch K-
wire to maintain this joint in extension. The wi re is
removed aft e r 6 weeks and active exercises are
begu n.74
A difference of opinion exists in the definition of
earl y and late boutonniere d eformity. Th e defini-
tion is important in terms of splinting versus surgi-
cal repair of the boutonnie re deformity. Boyes7
noted th at splinting is effe ctive as late as 3 0 days
after injury . King 44 stated that if th e joints are
loose , particularly in a young patie nt , a trial of
spli nt ing was worthwhile even after 6 we eks and up
to 12 wee ks. Sake llarides74 categorizes th e lesion
as a late case if th e rupture is se ve ral weeks old and
advocates e xcision of scar tissu e and repair of te n-
don e nds in late cases . According to Mcfarlane and
H ampole 57 and Chase, 14 th e tim e inte rval be twee n
date of injury and treatm e nt see ms to be less im -
portant than th e prese nce or abse nce o f a fi xe d
fl e xion contrac ture at th e PIP joint. McF arl ane and
Hampole not ed that if th e PIP joint can be ex-
te nd e d passively , th e late ral bands are probabl y
not fix e d vol ar to th e ax is of move ment and splin t-
ing alo ne is like ly to yie ld a good res ult. T hey note d
th at th e fin ge r shoul d be spli nt e d fo r 6 weeks con-
tinously and th e n fo r anothe r 3 wee ks at ni ght to
all ow th e scar ti ssue that has re-es tablished th e co n-
tinuity of th e exte nso r me chani sm to shorten
e nou gh to co rre ct the defo rm ity.57 Chase ex-
pressed a simi lar viewpoint th at scar ti ssue in the
boutonni e re de formit y will cont rac t whf'n giH"ll
th e opportunity. In hi s opi ni on , splin ting is usPful
e xcept in a fi xe d defo rmi ty.' "
Author's Preferred M eth od
My pe rsonal pre fe re nce fo r management of th e
ac ut e closed bout onnie re is th e safe ty-pin splint ,
wh ic h is used to achi eve ex te nsion in th e PIP joint.
2058 Operative Hand Surgery / 5 1
The term inal cross b a r does not go beyond the dis-
tal joint He xion crease. and th e pati e nt is instructe d
to ac t ively fl ex the di stal joint while the PIP j oint is
h e ld in maximum exte nsion (Fig . 5 J-4) . The we b
st rap o n the splint is tighte ne d on a dail y basi s until
full ex te nsio n of th e PIP j o int is ac hieved . This ma y
require several days or eve n weeks. The spli nt is
u sed in this manne r on a continuous basis for st-'v-
eral weeks until full passive exte nsion of t he PIP
j o int can b e ac hieved , along with fu ll or ne,u·ly foll
flexi o n of the DIP joint. Whe n this occurs , t he
le n gth re lationships and balance b e tween the ce n-
tral slip and th e late ral bands have bee n ac hieve d
and the splint can b e discontinued . Some te mpo-
rary loss of fl e xion at the PIP joint may be note d ,
but this w ill reso lve w ith addi t ional e xercise of t he
fin ger. If p artial re curre nce of the defo rmity is
noted , the splint is reapplie d and the same exe rc ise
plan carrie d out. This method has b een use d w ith
su ccess in closed boutonniere deformity of great e r
th an 6 months ' duration , as w e ll as the rece nt
closed acute boutonniere d e form ity . O ne advan-
tage of this method ove r a transart icular K-wire is
that an y p assive motion lost at the PIP joi nt (fix ed
fl exion contracture) can b e gradually con ected by
the splint. Altho ug h this technique can cone ct pas-
sive loss of joint motion at the PIP joint in an estab-
lishe d boutonnie re de formit y, it of course cannot
restore t e ndon substance lost as a result of a deep
abrasion or burn to the dorsum of the PIP j oi nt .
Reconstructi ve procedures are require d in these
insta nces; these are discussed in C hap te r 52 .
METHODS OF TREATMENT OF
LACERATIO N S O VE R TH E PIP JOIN T
L ace rations ove r the PIP joint are likely to e nte r
the joint sp ace. The first aim of tre atme nt should b e
to pre ve nt infection. 90 This require s cleansing, de-
bridem e nt , and appropriate antibiotics as indi-
cate d . Most authors agr ee that a lace ration of the
ce ntral slip and/ or lateral b ands at the PIP joint
levels shou Id b e pnman . ·1y r e paire
· d .3 ,2 2, s1 .14 Th e
skin and te ndon may b e brought togethe r with a
fi g ure-of-e ight or roll-typ e stitc h , or the lacerate d
t e ndon e nds m ay b e re approximate d with burie d
inte rrupte d suture s. Afte r re p air, the PIP joint
must b e maintaine d in ex te nsion and thi s may b e
d o ne w ith a splint o r K-wi rc .57 lfin st~Hi ci(' nt di sta l
stump of th e ce ntral slip is avail abl e for r<' pair , th<'
ce ntral slip 111ust b e n \al't adwd to hon e .311 ·'i 2 Th is
ma y be don f' with a pull -out w ire techn iqu e• o r hy
an choring the tendon lo th e dorsal h asc of til t> rnid-
cll e phalan x b y a nouabsorhahl (-' suture passed
through a small transve rse drill hole ove r the base
of the phalanx. If th e late ral ba nds arc also injured
al o ng with th e ce ntral slip , th ey shou ld al so be r e-
paired w ith inte rrupte d buried sutures. In au ac ut e
lace ration ove r t he PIP joint w ith laceration of th e
ce ntral slip and late ral bauds, McFarlan e and H arn -
p ole firs t place a K-wire ac ross th e joint with th<)
joint in fu ll exte usion. T he various compon e uts of
th e exte nso r me c han ism ne e d not be idc ntiftt)d , in
the ir opini on , but are simply clustere d toge th e r
wi th figu re -of-e ig ht su tu res and th e hand and wrist
are imm obil ize d as done for a close d boutonni c rc
de fo rmi ty . The K-w ire is re move d in 3 wee ks, and
o nl y the PIP j o nt is immobi lized for a noth e r
week.57 Ell iott also notes th at acute lace ration s at
thi s leve l re qui re K-w ire fi xation of th e PIP joint in
exte nsion along with re pair o f the te ndon with a
pu ll-out wire su ture or wit h inte rru p te d buri ed su-
ture s. T he K-w ire is re move d afte r 5 we e ks, an d
the n a continuo us e xte r nal splint is worn fo r an-
ot he r week. 2 2 Sake lla rides 74 tre ats ope n lacera-
tions ove r the PIP joint by capsu lar and ten don
re pair wi th 4 - 0 Me rsile ne a nd a t ransarti cu lar K
wire for 5 to 6 w eeks .
Although simple lace ration of the e xte11so
mechani sm at this le ve l can b e tre ate d b y re lati v<'I
simple suture s, Snow 7 9 and Aiche , Barsky, a11
W e iner 2 note d difficu lti es in r e pair of pri rn a,
ac ute bouton nie r e de fo r miti e s associate d wi th lo
of subst ance of the e xte nsor mechani sm at ti,,
le vel. In an atte mpt to resolve this probl e m, Snow
describe d a r e trograde (distal -based ) fl ap take
from the central slip and ap pli e d as a re in forci 11 .•
batte n ove r the ce ntral slip re pair (Fig . 5 1-5). Al'tc
th e lacerate d exte nsor h as been suture d in the ro 11
tine e nd-to-e nd manne r , this re trog rade fl ap 1
brought ove r th e e ntire area proxim al and distal !(
the re p air. The donor site of the te ndo n fl ap i~
close d primarily . The hand is dressed in the posi
tion of function for 3 w eeks, a nd the n g uarded 111_0
tion is starte d . The me thod is also fo und to b e usefu l
in cases whe re a gap is prese nt in the ex tenso r
mechani sm , as in grinding wheel injuries . Aid1< ·.
 Doyle / Extensor Te ndons- Acute Injuries 2059

:;•,· . the ir mi<l<ll e segme nts are reapproximate<l in the

: :::;-w:~~
mi<llin e ove r th e base of th e mi<l<ll e phalanx wi th
,5 - 0 silk (Fi g. 51 -6). Th e lateral segme nts are left in
,}~):~ ,11·
position an<l re present th e lumbrical in sertions an<l
retinacu lar ligame nts. The wri st is splinted in ex-
,\;
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SLIP
F ig. 5 1-5 . Acute bo utonni ere defo rm iti es associated
with loss of substance of the exte nsor mechanism at th e
PIP joint are diffic ult to treat . In an atte mpt to solve th is
problem , Snow 79 describe d a retrograde fl ap taken fro m
the central slip of the extensor (A) and applied it as a
reinforcing batten over the central sli p re pai r. The retro-
grade flap is carefully sutured into place over th e repair
site to act as a reinforcement in the area of repair. The
defect in the central slip is then closed with interrupted Fig. 5 1-6. Aiche , Barsky, and Weiner 2 have described
sutures (B). cases of acute disru ption of the extensor te ndon over th e
PIP joint wi th shredded tendon and loss of tendon sub-
stance. In their technique , primary reconstruct ion of the
central slip is pe rform ed by identifying and dissecting
free the two lateral bands from the oblique and trans-
Barsky, and Weiner2 similarly have no ted cases of
verse retinacular ligam ents . These bands are th en split
acute disruption of the exte nsor mechanism over longitudinally for about 2 cm (A) and their middle seg-
the PIP joint with badly shredde d tendon and loss ments reapproximated in the midli ne over the base of the
of te ndon substance . Primary reconstruction of the middl e phalanx using 5 - 0 nonabsorbable suture (B).
central slip is p e rforme d by ide ntifying and dis- The lateral segments are left in positi on and represent
secting fr ee the two late ral bands from the oblique th e lumbrical inserti ons and retinacul ar ligaments. The
and transverse r etinacular ligame nts . These bands authors state that this procedure will aid in prevention of
are then split longitudinally for ab out 2 cm, and th e bout onniere deformity.
2062 Operative Ha nd Surgery / 51
The most common t ype of mallet finger is Type I,
which is due to loss of conti nuity either from tear-
ing of th e substance of th e tendon just pr~xi~al to
th e joint or avu lsion of the te ndon from its mser-
tion , with or without a small flak e of bone. One-
fo urth of Stark, Boyes, and Wilson 's cases were as-
sociated with a small bone flak e or chip . In their
se ries, the presence of a bone chip did not alter th e
end result of treatm ent in any way. 86 McFarlane
an d Hampole, 57 however, noted that in their seri es
of 50 cases of mallet fin ge r, injuries with fracture
did not obtai n results as good as those injuries
without fracture, but th ey included all fractures of
varyin g sizes in this nine -patie nt group. Abouna
an d Brown 1 noted no significant difference in th e
res ults with th e presence of a small flake of bone on
x-ray examination .
The degree of de formity in this injury may vary
from a few degrees ofloss of exte nsion to a 75 to 80
degree drop fin ger de formit y. Although th e fin ger
deformity is usually immediate in its onset, in some
cases it may be delayed b y a few hours or days. 1
This is especiall y true of those closed injuries with a
crushing eleme nt to th e dorsum of the distal joint.
In parti al or inco mpl ete tears of th e tendon , th e
lesion may be represented by a small amount of
exte nsion loss that becomes progressively worse
following additional traum a or repeated active
fl exion of the joint.
A lace ration over or near th e DIP joint that tran-
sects th e te ndon also produces a characteristic mal -
le t deformit y. Lacerations directly over the joint
more often than not e nt er the joint, and thi s must
be considered in treatme nt because of th e pote ntial
for joint contamination . Deep abrasion-type inju-
ri es over the distal joint may result in significant
loss of soft tissue cover and a portion or all of th e
underl yi ng tendon mechanism. The joint is almost
always exposed . The manage ment of this injury is
far differe nt than that for a simple closed mallet
deformity , and staged surgical reconstruction is re-
quire d.
A blow on the end of a finger with a hype rexten-
sion forc e may be associated with a fracture of th e
dorsal base of the distal phal anx. There is often a
resultant malle t de formity and earl y or late volar
sublu xation of th e distal phalanx. 47 ·96 This injury
must be distinguish ed from th e usual closed mall et
finger, since its treatme nt is based on th e manage-
Doyle / Extensor Tendons - Acu te Injuries 2063
me nt of th e lesion as a fracture and not as a te ndon
injury as such. The same applies to~ fract ~re of th e
basal epiph ysis of the distal phalanx ma child. Man-
agement of these fractures is discussed on page
2066 . These comments do serve to em phas ize th e
need for radiographi c evaluation in all patie nts
with mallet finger deformity .
METHODS OF TREATMENT OF
CLOSED (TYPE I) MALLET
FINGER INJURIES
The primary goal in all me thods of treatm e nt is
res toration of th e con tinuity of th e injured te nd on
with maximum recovery of fun ction . Both conse rv- A
ative (noninvasive) and operative (invas ive) treat-
men ts have bee n advocated to achi eve thi s goal.
Conservative treatment includes th e use of plaste r
cas t immobilization and various types of fin ge r
splints . Surgical treatment includes K-wire fixa-
tion , external te ndon suture, and direc t repai r of
the te ndon with or without K-wire fix ati on.
Plaster Cast
In I 937 Smillie 77 described his p las te r techn ique
for correction an d immobili zati on of th e mall et
finger deformity . Othe rs have used thi s me thod
with certain modifications, including Watso n-
Jones (1940),94 Howie (1947) ,37 Williams
(1947),99 and, more recently, Stark, Boyes, and
Wilson (1962),86 and Green (1975). 31 These plas-
Fig. 51 -7. Plaster cast immobili zation for mallet fin ge r is sometimes a useful procedure in pat ients who are unrPli-
ter casts are applied so that th e DIP join t is in sligh t able or unabl e to und erstan d or co nsistent ly apply a splint. This techniqu e has bee n described by Smill ie77 and
hyperexte nsion and th e PIP joint is in approx i- Green .3 1 (A) An J 8-inch strip of 3- or 4-inch dry plaster is ro lled into a tube and slipped over the end of th e injured
mately 60 degrees flexion . Bunne ll 9 exp lain e d the flng er. No padding is used. (B) The patien t <l ips his han d in to a bucket of water, holdi ng the tube of plaster in place
rationale for this p osition by stating that fl exion of over th e fin ger. (C) The pati ent himself ho lds the finger in the correct position of im mob ili zation whi le th e physician
th e PIP joint resulted in advanceme nt of th e late ral smooths out the plaster. (D) The co mpl eted cast. Removal is facilitated by soaking the plaster in water. (Green DP.
bands for a distance of 3 mm , which , alon g with Rowland SA: Fract ures and di slocation s in the hand. p. 273 . In Rockwood CA , Gree n DP (eds) Fractures. JB
hyperextension of th e DIP joint, promoted app rox - Lippi ncott , Philadelphia, J975.)
imation of th e torn exte nsor te ndon at th e DIP
joint. In 1959 Kaplan ,39 however, note d th at thi s
position should not be used for treatment of malle t Smi ll ie's me thod (Fig . 51 -7) , how ever, is very use- plaster splint th at avo ids press ure over the PIP and
finger. Specifi call y, he obse rved that th e ex te nso r ful in p at ie nts who are unre li ab le or who are unable DIP joints. It avo ids hyperex tension at the distal
mechani sm was moderately relaxe d ove r all thre e to unde rstand or consiste nt ly appl y a spli nt cor- joint and do es not exceed 60 degrees llexion at the
finger joints wh en th e fin ge r was held in mod e rate rectl y.31 If th e re is doubt abo ut a patient 's re liabil - PIP joint. 86 Alth ough it may he argued that PIP
extension . In recent years, Kap lan's vi e wpoint has ity or ab ilit y to follow inst ru ctio ns, a pl aste r cas t joint immobi lization is not required in the manage-
bee n affirme d by clinical expe ri e nce . That is, most may be advantageo us . Stark , Boyes , and Wi lson me nt of thi s lesio n, fr om a practical , it·wpoint it i,
authors have not found it necessary to imm obili ze note d th at a plaste r cas t prope rl y appl ied gives sat- highly unl ikely th at a finger cast appli<'d without
isfactory res ul ts ; t his te chn ique includes a prec ut fl ex io n at th e PIP joint wou ld remain ll1 place for a
th e PIP joint in the treatm e nt of mall e t fin ger. 1
2064 Operative Hand Surgery / 51
significant pe riod of time . Flexi on of the PIP joint.
and its subsequent incorporation in plaster, seems
to be a practical solution to keeping a finger cas t in
place . Hallberg and Lindholm 32 in 1960 reported
on 76 patients with mallet finger treate d by plaster
immobilization and noted a 5-degree extension loss
in :28 patit>nts. a 5 to 20 degree loss in 11 , and a
greater than 20 degree loss in 37.
Splints
Lewin 48 in 1925 described a tubular metal splint
that maintained the DIP and PIP joints in full ex-
tension . Numerous splints of metal, wood, and
plastic have been described and used since that
time .23 -31,38 ,81 Most authors agree that splinting
should be continuou s for a 6-week pe riod. Night
splinting for an additional 2 weeks has been advo-
cate d by some authors. The majority of splints are
placed on the volar side of th e digit, although New-
meyer61 has applied his padded aluminum splint
dorsall y. These splints are shaped to fit the individ-
ual fing er and are usu all y held in place by tape;
they are designed to hold th e terminal joint in full
exte nsion or slight hype rexte nsion. A great variety
of splints have bee n designed and used . McFarlane
and Ham pole 57 in 1973 reviewed SO cases of mallet
finger personally treated by them with splinting of
the di stal joint for 6 weeks. The series included
closed injuries, open injuries, and avulsions,
whe ther seen at th e time of injury or some months
late r. Eighty percent of their cases obtained an ex-
cell ent to good result with splinting alone. The re-
sults were sati sfactory even wh en the p ati ent was
seen late . Kaplan39 also noted th at even cases that
are several months old may yield a good result. In
his series, both early and late cases were treated
with 6 weeks of continuous splinting, followed by 2
weeks of night splinting. Mcfarlane and Hampo le
noted that even 3 months after injury, splinting
alone will probably yield a satisfactory result. They
note d that fair and poor results we re not du e to
treatm ent but to poor patient cooperation or inade-
quate immobilization. Even mallet fing ers due to
laceration of th e extensor mechanism at or near the
distal joint that were treated by splint alone dem-
onstrated res ults comparable to close d injuries
treated by splinting. McFarlane and Hampole fur-
th er noted that wh en so me com pone nt of th e ex-
tensor mechanism within the digit was torn or di-
vided th e tendon e nds did not re tract very far , and,
eve n in untreated injuries, scar tissu e will bridge
the gap. If this scar tissue rea~tion is minimi ze~ by
splinting th e joint in extens10n , normal relat10n -
ships can be restored. Engelbrecht25 ex_presse? a
similar opinion when he observed that m p lacm g
th e distal joint in full extension, a perfect opposi-
tion of the tendon ends was obtained and that after
careful suturing, there was often a small gap be-
tween the tendon e nds, causing unsatisfactory
postoperative results. Abouna and Brown 1in 1968,
in a series of 110 cases fo llowed for 6 months to 3
years and treated by continuous splinting of the
distal joint for 6 weeks , noted that 72 perce nt of the
cases had an extension defect ofless than 5 degrees,
13.4 percent had an extension loss of 5 to 15 de-
grees, and 14.6 percent had an extension loss
greater than 15 degrees. Crawford 15 in 1984 re-
ported on his experie nce with 151 cases of malle t
finger using a polythene (Stack) splint. The spli nt
was found to be highly effective, and open reduc-
tion of even major fracture fragmen ts with out sub-
luxation of the distal phalanx was not necessary.
Splinting was maintained for 8 weeks con tinuousl y,
followed by 2 weeks of night splinting.
K-Wi re Fixation
Pratt 65 in 1952 described a technique for inter-
nal immobilization of the mallet fing er de formity in
which a longitudinal K-wire was placed across the
DIP joint and into the neck of the proximal phalanx
with the PIP joint flexed . This meth od was de-
signed to provide constant and rigid fi xation of the
mallet finger deformity an d, at th e same time , pro-
vide Hexion of the PIP joint. Watson-Jones
(1956) 94 spoke against this method, as d id ot hers
who noted technical d ifficulti es with prope r inser-
tion of the K-wire, as well as residual joint stiffness
at th e PIP joint level. Pratt's method has been
abandoned because of these problems.
Casscells and Strange 12 in 1957 adv ised immobi -
li zation of only the DIP joint with a K-wire . The y
reaffirm ed their recommendation for this me thod
13
in 1969. Longitudinal K-wire immobilization has
also bee n recommended b y Fli nchum (1959) ,29
Engelbrecht (1966), 25 and Ell iott (1979 ).22 Tu -
biana (1968) 90 abandoned use of th e longitudinal
K-wire in favor of an oblique transarticular wire
after he observed a few cases of fibrou s scarring of
the pulp. Weinberg, Stein , and Wesler 97 in 1976
described another me th od of fixation of the distal
joint b y means oft:wo K-wires placed from dorsal to
volar into the di stal and middle phalanges respec-
tively, with the two wires diverging at a 15- to 2O-
degree angl e. A rubb er band is th en wrapped
around th e protruding wires on th e dorsum of the
finger to bring th e joint into ex tension . A light plas-
ter dressing is the n applied . Some of th eir patients
developed loss of flexion of th e terminal joint. This
method was discussed b y Littler,50 who expressed
concern th at only 6 ofl5 cases in th e author's series
regained full DIP joint fl exion . Littler believed this
was du e to damage within the flexor sheath or fixa-
tion of th e extensor mechanism over th e middle
phalanx caus ed by inse rtion of th e K-wires. I ag ree
with Little r's opinion and advise that other simpler
and safer methods are available and should be used.
Extern al Tendon Sutu re
Hillman 36 in 1956 described a techniqu e for
treatment of the malle t fing er and associat ed frac-
tures of the distal phalanx by insertion of a #2 silk
suture beginning at th e pulp and continuing dis-
tall y along th e dorsal aspect of th e di stal joint. The
silk suture was ti ed over small vin yl tubes app lied
to the pulp of the fin ger and to th e dorsum of th e
PIP joint. Hillman described nin e cases with satis-
facto ry results following this meth od . The author
does not re comme nd H illman ·s meth od because of
pote ntial proble ms with scar fo rm ati on in the soft
tissues.
Di rect Repa ir
Mason 55 in 1930 recommended imm ed iate opt'r-
ative repair of closed mallet fin ger inj urit's . How-
ever , Rose nzwei g 71 subsequ entlv no ted that the
res ults of operative rep air are not alwavs sati_sfac -
tory since the ex tensor tendon at the dist al Joint is
extremely thin and sutures almost always t!,u- out.
Robb ,70 as we ll as Stark , Boyes . an d Wilso n found
that ope rative repair was not net: essan· in t:lose cl
mallet fin ger defo rm ity . Nit: hols. 62 Stark . Boyes .
and Wilson 86 and Ellio tt 22 did , howcYer, recom-
mend sutur~ of acute lacerations of th c extensor
mechani sm over th e DIP joi nt wi th niall et Anger
Doyle / Extensor Tendons Acute Injuries 2065
de formity, followed by internal or extern al splint-
ing. Nichols 62 advised interrupt ed mattress su tures
of 6- 0 silk or a fin e pull-out wire anchored to the
nai l. Elliott 22 advised repair of this lesion with a
contin uous -1-0 monofilament wire suture. the
ends of which were left protruding from the skin on
either side of th e phalanx for ease of remoYal after
the tendon had healed.
Author's Preferred Method (Type I)
My personal preference for treatm ent of Type I
mall e t fin ger injuries is a comm erci ally a,·ai lable
volar splint made of plastic (Stack finger splint )
(Fig. 51-8). The splint is available in eigh t sizes,
and, with appropriate selection and padding. can
be used to fit almost all fin ge rs with mallet finger
deforn1ity. The splint is taped in place an d used
continuously for a minimum of 6 weeks. The pa-
ti ent is advised to remove the splint only for cleans-
ing of th e finger and is cautioned to maintain th e
distal joint in ext ension at all tim es during removal
of the splint. The splint is then reapplied by the
patient and carefull y retaped to main tain th e distal
joint in ex tension. This method is found to be quite
satisfactory in a cooperative patient who under-
stand s the nature of th e inj ury and th e recom-
mend ed treatme nt. The method has been found to
be quite successful in the majority of patie nts with
early as well as late mallet finger deformity -e, en
in patients seen as late as 6 months followin g injun·
At th e encl of6 weeks. th e splint is rt> mo,·ed and tht'
finge r inspected. The pati ent is allowed to begin
guard ed fl exion exercises at that time. The patient
; hould carry th e splint with him . and ifan e,tension
loss is noted at any tim e foll O\,ing rem mal of the
splint. th e splint is immediatelv reapplied and left
in place for anoth er 2 wee ks. The s,1me proce,s 1,
th en repeat ed . The pati ents who are uncooperat i, e
or who , for one reason or anothe1 ..ire unabl,· to
wear a splint as just clesnibed. the Smillie-, pL1stc1
cast is applied as desc rib ed b" Gr e,·nJ 1 \fig 51- ~
In rare circumstances, such ,Ls with a health pro-
fessiona l (den ti st, surgeo n, t'tc \. an ,•,lt'nl:ll ,plint
may be diffi cult if not imposs1bl,· to" c,ir. In tlwse
un;1stial circumstan ces. a O.O~-~ -111c h K-\1 ire 1,
placed obli que ly acro ss the distal 1O1nt to m,iintain
it in full exte nsion .31The wire i, cut of! l)('neath th,·
skin , and the patient is warned to prot<'d t he joint
2066 Operat ive Hand Surgery / 5 1
Fig. 51-8. The author 's personal preference for treat-
ment of mallet fin ger is with a comme rcially available
volar splint made of plastic (Stack finger splint) . This
sp lint is available in e ight sizes and , with appropriate
selectio n and p adding, can be used to fit almost all fin gers
with th e malle t fin ger de formit y. The splint is taped in
place and is used continuously for a minimum of 6 weeks .
T he p atient is advise d to re move the splint only for
cleansing of the fin ger and is caution ed to maintain the
distal j oi nt in exte nsion at all times during re moval of the
splint . T h is me thod is found to b e quite satisfactory in a
cooperative p atie nt who unde rstands the nature of the
injury and t he reco mme nded treatme nt.
against st re nuous fle xion since the wire can be b ent
or b roken. T he K-wire is le ft in place for 6 weeks,
fo llowed b y 2 weeks of night splinting .
METHODS OF TREATMENT OF OPEN
MALLET FINGER INJURIES (TYPES II
A N D Ill)
Fresh lacerations of the extensor mechanism
ove r the distal joint with malle t finger deformity
ar e rep aired b y a simple figure-of-eight or roll-type
sutu re, which r eapproximates the ski n and tendon
. lt eously (Fig. 51-9). A small d r essing is ap-
s1mu an . h' h . . h
p lied incorporati ng a sp1mt , w 1c ma~ntams t e
. t I · int in full extension. The suture 1s removed
d is a JO d h d' I . . .
at about Io to I 2 d ays, an t e 1sta Jomt 1s main-
tained in the extend ed position by the_ pn~viously
descr ibed Stack plastic splint . T he sp~•~t 1s main-
tained in p osition continuously for a mmu~um of 6
wee ks , followed b y prote cted range . ofl motion
. . The
splint is r eapplie d if any extens10n oss 1s noted
following removal of the splint. Type III mallet de-
formities with loss of tendon su bst_a nce and soft
tissue cove rage require r e co nstruch ve surgery to
provide skin coverage with late reconst ruction by
free tendon graft to restore tendon conti nuity or
arthrodesis of the joint (see Chapter 52).
METHODS OF TREATMENT OF
MALLET FINGER WITH FRACTURE
(TYPE IV)
Mallet finger deformity resulting fro m a fracture
of the distal phalanx in a child is usually a trans-
epiphyseal fracture of the phalanx. 21 T he extensor
mechanism is attached to the basal epiphysis, and
closed reduction of the fracture resul ts in correc-
tion of the deformity . Continuous external splint-
ing of the distal joint in full extension fo r 3 to 4
weeks results in union of the fracture and correc-
tion of the deformity .
In an adult, Type IV malle t fin ger injuries are
associated with significant fractu re fragm ents.
Type IV-Bis a h yperflexion injury and the fr actu T
fragment is usually 20 to 50 p ercent of the do
articular surface of the distal phalanx .47 Type I
mallet fracture is a h yperextension inj ury a1 ·
ge nerally associate d with a fracture fragmen t
is gre ater than 50 p e rcent of the articular surfa c
the distal phalanx and is accompanied b y volar s
luxation of the distal phalanx. 47 Loss of the nor
balance of forc es between t he extensor and fi e
mechanisms and signifi cant disruption of the do
joint capsule results in volar subluxation of th e c
tal p halanx on t he middle phalanx. This type
fract ure wi th an associated mallet fin ger defo rm
is said to be a relative ly uncommon injury. Stai
Boyes, and W ilson 86 d escribe d only five such cast
in a series of 168 malle t fin ger d eformities treatt' ,
over a 13-year p eriod . Abou na and Brown 1 not ed
only eight T yp e IV lesions in 148 mall et inju ries
 Doyle / Extensor Te ndons Acute Injuries 2067

FIGURE 8SUTURE

ROLL SUTURE

Fig. ~1-9. Fresh lacerations of the e xte nsor mechanism over the distal joint with mallet finger deformity (A) are
repa~red b y a roll -ty p e suture , which simultane ously approximates th e skin and tendon (B,C). A small dressing is
applied along w ith a splint , whi ch maintains th e joint in full exte nsion . The sutures are removed at 1 Oto 12 days bu t
the splint is con tin ued for a total of 6 w eeks. A figure-of-eight vertical suture (D) may also be used , which simulta-
neously closes the d e fe ct in th e tendon and skin . Splinting is mandatory for 6 weeks .

Wehbe and Schne ide r ,96 however , reporte d 44
mallet fractures in 160 mall e t injuri es , 13 of which
demonstrate d volar subluxation of the distal pha-
lanx . This f racture is not to be confused with the
more comm on small bone chip associated w ith a ten-
don avulsion and m allet finger deformit y. The mal-
let fi nger wit h a tiny avul sion frac ture sh ould b e
managed the sam e as a closed malle t fi nger inj ur y
(see p age 206 2).
Operative treat m e nt has been recomme nded for
fracture fragm e n ts involving greate r than one t hird
of the articul ar su rface. An accurate re duction is
advocate d to preven t joint d e formit y with second-
85
ary arthriti s and stiffness.3 1 ·3 3 ·8 5 Stark advised a
dorsal appro ach w it h di vision of th e uln ar collate ral
ligament as an aid in re duction . One or two small
(0 .028 or 0 .035 inch) K-wires or a pull -out wire
suture is use d for fix ation of the fracture . Th e col-
lateral ligame nt is repaire d prior to closure . Post-
ope rati ve manage me nt includes a me tal splint that
holds the PIP joint in moderate fl exion and the
di stal j oi nt in extension (but not hyperextensi on).
PIP joint splinting is discontinued after 3 weeks,
bu t continuous spl inti ng of the dis tal joint is done
u ntil the fr acture has h ealed radiographi cally, at
which ti me t he K-wires are r emoved. Stark notes
that , in his exper ience, this technique h as p re-
vente d painful and limite d motio n in the d istal
joint .
Hamas , H orre ll , and Pierre t 33 de scribe d an alte r-
 2068 Operative Hand Surgery / 51

corrected after which the longitudinal K-wire is

native surgical technique in which a midlateral in-
cision is extended to the corner of the nail. The
dorsal skin flap of cuticle and subcutaneous tissue is
raised from the nail and paratenon. The extensor
tendon is divided 5 mm proximal to its insertion.
The distal phalanx is flexed and the joint distracted
to expose the articular surface. A 0 .035 K-wire is
drilled into the articular surface of the distal pha-
lanx volar to the fracture line and withdrawn dis-
tally. The fracture is then reduced under direct
vision and held with an Allis clamp while one or two
0.028 K-wires are drilled across the fracture site in
a volar- lateral direction . The distal phalanx is then
brought up into neutral and any volar subluxation
driven across the joint into the middle phalanx .
Radiographs are used to confirm the reduction , and
the extensor tendon is repaired with fin e inter-
rupted nylon. Care is taken to align the cuticle dur-
ing skin closure . The K-wires are left in place for 6
to 8 weeks until union is demonstrated b y radio-
graph . This time coincides with the duration re-
quired for tendon healing . Hamas , Horrell , and
Pierret describe consistently good results with this
method.
In contrast to these recommendations for open
reduction Wehbe and Schneider 96 recommended
nonoperative treatment by extension splinting of

Fig. 51-10.. Author 's bl recommended

. f technique
. for reduction and fixat·ion o f t h e mallet
fracture with volar su uxation o the distal phalanx. (A) The joint is ex d h
dorsal zigzag incision . (B) A 0 .035 double-ended K-wire is drilled long·t1 pdo_se lit rhough a
. 1 p h a1anx . (C) Th e JOmt
t h e d 1sta · · 1s· d d ·u ma Y t rough
11 Y across
· re d uce , the K-wire is driven pro xima the
joint, and the fracture f ragment 1s re uced. If the fracture fragment ca tb . .
· · · I f 4 O · · d h h h
m position , a oop o - wire 1s passe t roug t e fragment and distal h 1
nno e mamtamed
nd .
ove r a padded button . Intraope rative radiographs are made to de term. p a anx_ a tied
. . I K . . cl . me anatomic reduc
tion . The transarti cu ar -wire 1s protecte with a splint for 6 weeks . The ull O . -
may b e removed in 3 or 4 weeks . P - ut wire

'i
!I

all mallet fractures including the hyperextension
type with subluxation of the distal phalanx. They
believe that restoration of joint congruity does not
influence the end result since remodeling of the
articular surface is reported to lead to a near nor-
mal painless joint in spite of persistent joint sublux-
ation . Lange and Engber47 suggested that hyperex-
tension mallet fractures with volar subluxation
require accurate reduction . They observed that
application of standard extension splint manage-
ment to hyperextension injuries results in unac-
ceptable volar subluxation and has been associated
with quite unsatisfactory results . Crawford 15 has
obtained encouraging results with conservative
treatment of fractures by the use of the molded
polythene (Stack) splint even with relatively large
fracture fragments. He has abandoned open reduc-
tion and internal fixation except for those occa-
sional cases where volar subluxation of the distal
phalanx is present. Eighty-nine of his 151 cases had
fracture fragments comprising 20 to 50 percent of
the joint surface. Eleven of these 8 9 fracture mallet
cases had volar subluxation . Seven of these 11 cases
required operative treatment due to inability to
reduce or maintain the reduction of the volar sub-
luxation in a splint. Surgery was in the form of open
reduction and K-wire fixation of the distal joint in
extension. Crawford further advised that in some
cases with large fracture fragments (35 to 50 per-
cent of the joint surface) the distal joint should not
be hyperextended in the splint since this may en-
15
courage palmar subluxation of the distal phalanx .
Author's Comment and Preferred
Method for Treatment of Type IV
(B-C) Mallet Fractures
Operative repair of mallet fractures is a tec~ni -
cally difficult and potentially hazardous operatwn .
A~tempted fixation of the fr~cture fr~gm~nt by ~~
wires or wire loop may result m commmutwn oft
fragment and loss of attachme nt of the extensor
mechanism . I agre e with Crawford 15 that ope n re-
duction of mallet fractures should be rese rv~d fo~
those fractures with associate d volar subluxatwn °
the distal phalanx. E xcelle nt re modeling of th e ar-
ticular surface often occurs. In those cases of malle t
fracture with volar subluxation of the di st al pha-
Ianx, the j oint is expose d t h roug h a z igzag dorsa1
Doyle / Extensor Te ndo ns - Acute Injuries 2069
incision, a 0 .035 K-wire is passed longitudinally
through the distal phalanx, the joint reduced, the
fracture fragment manipulated into place and the
K-wire passed across the joint, holding it in full
extension (Fig. 51-10). X-rays in two planes are
taken in the operating room to verify reduction. If
the fracture fragment cannot be maintained in
close apposition to the major fragment , a pull-out
wire is used to hold it in position. The transarticular
K-wire is protected by a splint for 6 weeks, after
which the K-wire is removed and motion started.
REFERENCES
1. Abouna JM , Brown H : The treatment of mallet
finger , the results in a series of 148 consecutive
cases and a review of the literature . Br J Surg
55:653 - 667 , 1968
2. Aiche A, Barsky AJ , Weiner DL: Prevention of
boutonniere deformity . Plast Reconstr Surg
46 :164 - 167 , 1979
3. Blue Al, Spira M, Hardy SB: Repair of extensor
tendon injuries of the hand. Am J Surg 132: 128-
132 , 1976
4. Boyes JH : Bunnell 's Surgery of the Hand . 4th Ed.
pp . 469 - 4 70 . JB Lippincott , Philadelphia, 1964
5 . Boyes , JH : Bunnell's Surgery of the Hand. 5th Ed.
pp . 439 - 442 . 616 - 618 . JB Lippincott, Philadel-
phia, 1970
6. Boyes JH : Bunnell 's Surgery of the Hand. 5th Ed .
p . 653 . JB Lippincott, Philadelphia, 1970
7. Boyes JH : Boutonniere deformit y (discussion). p .
56 . In Cramer LM , Chase RA (eds): Symposium on
the Hand . Vol 3 . CV Mosby , St Louis, 197 1
8 . Bunata RE: Impending rupture of the extensor p ol-
licis longus te ndon after a minimally displaced
Colles' fractur e . A case report . J Bone Join t Surg
65A:401 - 402 , 1983
9 . Bunnell SB: Surgery of the Hand. 1st Ed . pp . 490 -
493 . JB Lippincott, Philadelphia, 1944
10 . Bureau H , Decaillet J, Magalon G: Le syndrome de
Secretan existe- t-il. Sem Hop Pari s 55:449 , 1979
11. Carducci AT: Potenti al boutonniere deform ity. Its
recogniti on and treatme nt . Orthop Rev 10 : 121 -
123 , 198 1
12. Casscells SW, Strange TB: Intramedullary wire fix-
ation of mallet fi nger . J Bone Joint Surg 39A: 52 1 -
526 , 1957
 - , II allet fractures including the hyperextension
a mwith subluxation of the distal phalanx . They
type . f. .
believe that restorat10n o ~omt congruity does not
. fl u ence the end result smce remodeling of the
tll
ticular surface is report e d to lead to a near nor-
ar I painless joint in spite of persistent joint sublux-
47
~~on . Lange and Engber su_ggested that hype rex-
t nsion mallet fractures with volar subluxation
equire accurate reduction . They observed that
re d d
application of stan ar extension splint manage -
ment to hyperextension injuries results in unac-
ceptable volar subluxation and has been associated
with quite unsatisfactory results . Crawford 15 has
obtained encouraging results with conservative
treatment of fractures by the use of the molded
polythene (Stack) splint even with r e latively large
fracture fragments . He has abandoned open reduc-
tion and internal fixation except for those occa-
sional cases where volar subluxation of the distal
phalanx is present. Eighty-nine of his 151 cases had
fracture fragments comprising 20 to 50 percent of
the joint surface . Eleven of these 8 9 fracture malle t
cases had volar subluxation. Seve n of these 11 case s
required operative treatment due to inability to
reduce or maintain the reduction of the volar sub-
luxation in a splint . Surgery was in the form of ope n
reduction and K-wire fixation of the distal joint in
extension. Crawford further advised that in some
cases with large fracture fragments (35 to 50 per-
cent of the joint surface) the distal joint should not
be hyperextended in the splint since this may en-
courage palmar subluxation of the distal phalanx . 15
Author's Comment and Preferred
Method for Treatment of Type IV
(B-C) Mallet Fractures
Operative repair of mallet fractures is a tec~ni-
cal!y difficult and potentially hazardous operatwn .
Attempted fixation of the fracture fragment by K-
Wires or wire loop may result in comminution of th e
fragment and loss of attachment of the e xte nsor
rnechanism . I agree with Crawford 15 that open r e -
duction of mallet fractures should be r eserved for
th0 se fractures with associate d volar subluxation of
t~e distal phalanx . Exce llent r emodeling of the ar-
ticular surface ofte n occurs. In those cases of malle t
fracture with volar subluxation of the d ist al pha-
lanx, the joint is e xpose d through a zigzag d orsal
Doyle / Extensor Tendons - Acute Injuries
incision, a 0 .03.5 K-wire is passed longitudinally
2069
through the distal phalanx, the joint reduced , the
fracture fragment manipulated into place and the
K-wire passed across the joint , holding it in full
extension (Fig. ,51 -10). X-rays in two planes are
taken in the ope rating room to verify reduction. If
the fracture fragment cannot be maintained in
close apposition to the major fragment , a pull -out
wire is used to hold it in position. The transarticular
K-wire is protected by a splint for 6 weeks, after
which the K-wire is removed and motion started.
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fing e r, th e results in a se ries of 148 consecutive
case s and a revi e w of the literature . Br J Surg
55 :65 3 - 667 , 1968
2 . Aich e A, Barsky AJ, Weiner DL: Prevention of
boutonnie re de formity . Plast Rec onstr Surg
46 :164 - 167, 1979
3 . Blue AI , Spira M , Hardy SB: Repair of extensor
tendon injuries of the hand. Am J Surg 132 : 128 -
132 , 1976
4 . Boyes JH : Bunnell 's Surgery of the H and. 4th Ed.
pp . 469 - 4 70 . JB Lippincott , Philadelphia, 1964
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pp . 439 - 442 . 616 - 61 8 . JB Lippincott , Philade l-
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123 , 1981 .
Casscells SW, Strange TB: Intrame d ullary w ire fix -
12 · ati o n of malle t finge r . J Bone Joint Surg 3 9 A:,5 2 l -
.526 , 1957
2070 O perative Ha nd Surgery / 51
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and extensor tendon injuries . p. 149. In Flynn JE
(ed) : Hand Surgery. 2nd Ed. Williams & Wilkins,
Baltimore, 1975
94 . Watson-Jones R: Fractures and Joint Injuries . 4th
Ed. Vol. 2. p . 645. ES Livingstone, Edinburgh,
1956
95 . Weeks PM , Wray RC: Management of Acute Hand
Injuries. A Biologic Approach . 2nd Ed. p. 3 14. CV
Mosby, St Louis, 1978
96 . Wehbe MA, Schneider LH: Mallet fractures. J
Bone Joint Surg 66A:658-669, 1984
97 . Weinberg H, Stein HC, Wexler MR: A new method
for treatment of mallet finger. Plast Reconstr Surg
58 :347 - 349, 1976
98 . Wheeldon FT: Recurrent dislocation of extensor
tendons . JBone Joint Surg 36B:612-617 , 1954
99 . Williams EG: Treatment of mallet finger. Can Med
Assoc J .57:582, 1947
100. Zancolli E: Structural and Dynamic Bases of Hand
Surgery. pp. 105-106. JB Lippincott, Philadel-
phia, 1968
Extensor Ten dons -
Reconstruction
ANATOMY AND FUNCTION
T h e funct ion of the e xtensor tendo n asse mbly
has been described b y Littler 76 as a " fu gue of
movement. " T he extensor mechanism is a system
of subtlety, complex in its interrelati onships, yet
simple in that this tendon system exte nds th ree
. . ts an d fl exes one JOin
. . t .62 - 61 ,1 6 .1s.1 9
JOm
Simply cataloge d , the fi nger extrins~c ex~e nsor
syste m originates in the fo rearm , is radiall y m_n~r-
vated , and has four inserti ons (into the MP Jomt
volar plate and into the do rsal b ase of each phalan x)
(Fig. 52-1). T he fin ger intrinsic syste m is co mposed
of the seven interosseo us and fo ur lumbrical mus-
cles, all passing volar to the axis of moveme nt at th e
MP joints and the n dorsal to th~ interph~lang~al
joints (Fig. 52-2), arborizing and mte rrelat mg with
the components of the extrinsi c exte nso r te ndons
(Fig. 52-3) . The e xtrinsic exte nsors exte nd the
finger MP joints, and the intrinsics fl ~x- the ~p
joints and extend the inte rphalangeal JOrnts (Fig.
52-4). b "l"
Th e thumb with its pre requisite for mo I ity
with stability,' has an inde pe nde nt exte nsor mo~or
for each joint - exte nsor p ollicis longus fo r th em-
Late
52
Richard I. Burton
terphalangeal joint , exte nsor poll icis b revis for the
MP joint, and abductor pollicis longus fo r th e car-
pometacarpal joint. The thumb intri nsic musculo-
tendinous units prim aril y p rovide rotati onal con -
trol of the thumb axis, although the se muscles do
also fl ex the MP joint and exte nd the inte rphalan-
geal joint . Because of this relati vely inde pe nde nt
control of each thumb joint, fun ctional de fi cits are
more straightforward to correct than most of the
late di sorde rs of the fin ge r exte nsor syste m.
Certain gene ral conce pts abou t th e fun ction of
the fin ge r exte nsor tendon system merit e mphasis .
An understanding of these concepts will cl arify the
alte red dynamics of established exte nsor mech a-
ni sm di sorders and pe rmi t rational treat me nt se-
lecti on fro m th e several options av ailable .
1. The m ovem ent of fi nger ntensio11 is synergistic
with wrist fiexion , and the e ffecti ve excursion of
th e extrinsic exte nso r tendo ns is increased by
wri st fl ex ion 22 •76 ·78 ·79 (F ig. 52-5A and B). Th us,
(1) active wrist cont rol is important for normal
fin ger extensor mec hanics ; (2) wrist fl exors are
exce lle nt donor musculotendinous units fo r
transfer to re pl ace abse nt extrinsic extensors of
2073
2074 O perative Ha nd Surge ry / 52

/ ----------
/ ~ ' ~o,.

&Yb ¢ --
~ ( ~".-w. Refinocular

_J)/

Fig. 52-1. The extrinsic extensor tendon system passes dorsal to the axis of motion at all
thre e finger joints and has four insertions . Those into the dorsal base of the middle and
distal phalanges are functionall y the most important in a normal digit, although the inser-
tio n throu gh the shroud fib e rs at the MP joint assumes prime importance in the pathome-
chanics of the claw hand. The prime functional insertion is into the dorsal base of the
middle phalanx (see text and Fig. 52-11 ). (Eaton RC: The extensor mechanism of the
fi ngers. Bull Hosp Joint Dis 30 :39 - 4 7, 1969.)

the MP joints; and (3) such transfers will be
more functional in the presence of active wrist
motion w ith greater effective transfer excur-
sio n .
2 . Distal to the MP joint the extensor mechanism
(including extrinsic and intrinsic components) is
a single fascial-tendon expansion w ith four firm
attach ments to fi xed points -one insertion at
th e d orsal b ase of each phalanx (the distal and
mi ddle being stout and the proximal more tenu-
ou s) and the fo urth into the MP joint volar plate
via t he sagittal (shro u d) fib e rs.76 · 79 Thus, this
single ap oneuro tic te ndon exp ansion , which
must e xtend thre e joints, is secured to bone at
all t hree j oints w ith fi xe d tendon le ngths b e -
tween these points of fixation w ithout any intc
posed muscular units (Fig . 5 2-6). This is vc
different from the fle xor sys te m , which has
independent flexor for each j oint , each wi t
different excursion .
3 . This extensor tendon com plex is based on a se,
of overlapping linkage system s 22 · 16 •1 9 (F
5 2-5B). The compone nts normally p ass vol ar
the axis of rotation at one j oint and d orsal to t
next most distal joint- the intri nsic muscu
te ndinous units at the MP and PIP joints and t
oblique re tinacular ligament at t he PIP and D
joints.63 - 67 ,7 6 ,79
4 . Tension in the normal extensor tendon meclu
nism at any given joint is dependent on the pos
 Burton / Exte nsor Tendons Late Reconstruction 2075

,· '.~·, .

_./::>~ '<[l~:1.:.t~~ - •' 7r>:r_;;.i

Fig. 5 2-2 . T he intrinsic muscul ote ndinous syste ms are comprised of the inte rossei and
lumbricals. The inte rossei abduct and adduct the fin gers, as well as fl ex the MP joints and
extend ~h ~ inte rp halangeal j oi nts. The lumbricals fun cti on as exte nsors of th e inte rpha-
lan geal JOmts . T hey p ass volar to th e ax is of the MP j oint and are thus fl exors, as is attested
to b y the absence of the claw posture for the index and long fin gers in the ulnar nerve
deficient hand . (Little r JW, Burton RI , Eaton RC : The dynami cs of digital exte nsion .
AAOS Soun d Slide Program : #467 , #468 , 1976 .)

tion of that j oint and the adjacent joints . The
dorsovolar location of th e exte nsor syste m
change s with joint flexio n and exte n sion. F or
example , the dorsal to volar d isplace m e nt of the
late ral b ands with P IP joint fl e xio n relaxes distal
exte n sor system tension e nough to allow simul-
tane ous DIP joint fl e xion 47 ·76 ·79 (F ig. 52-7) . Al-
te rnation of this in the p athologic state impose s
a rest raint to distal joint motion .
5 . Th e d efor,nities of late extensor 11iechanism dis-
orders am reciprocal at adj acent joints because
of th e factors d e scribe d above in points 2 , 3 , and
4 _22, 6 3- 6 7, 7 6 ,7 9 The r e are m any e xample s: (1) in
the m alle t fin ger , secondar y PIP j o int h yp e r ex-
te nsion m ay occur in m aximum atte mpte d di gi-
tal exte nsio n (see Fi g . 52-27 ); (2) in the bouton-
ni er e d eformit y , PIP j oint fl ex ion is associate d
w ith DIP j oint h y p erext e n sio n (see Figs. 52-19 ,
52-20 , and 52-2 1); (3) in the sw an-neck fin ge r ,
PIP j oint h y p e r ext e n sion cau ses DIP j oint
droop (see Fi gs . 52- 15 , 52- 16 , and 52- 17) ; (4) in
intrinsic tightness , MP exte nsion limits PIP joint
fl exion (see Fi g . 52-13) ; and (5) in the rheuma-
toid h and, the deformity of MP joint extensor
lag and ulnar drift is commonl y associated with
PIP j oint h yp e rexte nsion , i.e. , swan-neck de for-
mity .
6. The extensor mechanism has far less tolerance
than the fi exor system to changes in tendinous
lengths. 70 •76 ·79 ·8 1 Th e e fficienc y and power of the
extensor system can b e lost and deformity im-
posed b y only a few millimeters of tendon dis-
placemen t in relation to joint axes or by only a
few millime te r s of sh ortenin g or lengthe ning of
the criti cal tendon lengths, which pass b etween
th e fi xed points of the exten sor mech anism at
each of the three fin ger joints (see F ig. 5 2-1 ).
7. The linkage syste m and critical tolerances re sult
in fo ur d ynami c con cepts that should b e e mpha-
sized if establishe d exte nsor mechanism de for -
miti es ar e to b e unde rstood and proper treat-
m ent se lecte d .79 ( 1) The component parts ofthis
2076 Operative H,md Surgery / 52

Fig. 52-3. The intrinsic and extrin sic exte nsor te ndon syste ms arbori ze and interdigitate
to form a complex of interconnected te ndons spanning the three fi nger joints. As the re is
no longitudinal elasti city or motor un it distal to the MP joint, synchronous joi nt move-
me nts are continge nt upon the shiftin g of this tendon complex relative to the axis of j oint
motion (see text) . (E aton RG : T he exte nsor mechanism of the fi ngers. Bull Hosp Joint Dis
30 :39- 47 , 1969 .)

-- - - -
----~---
•
.
-----
_::--,
, '. .
.:....__ , ,

J
I JtSlor jNnf c-- 1
Fig. 52-4. The extrinsic system and intrinsic extensor system (represented he re b y the
lumbrical) serve as antagonists at the -~p joint ,_t~ere by " balancing" the joint . T hey
combine to act as an exte nsor of the PIP JOmt . The ll" site of inse rtion into the dorsal b f
th e middle phalanx is the prime functional insertion of the extensor mechan · adseho
. . . ism , an t e
integrity of its nor mal fun ction depe
. nds. on the mtact PIP volar plate mech amsm · . D e fi -
ciency of this volar plate mechamsm will alter th e extensor mechani cs at th· . . d
· l JOll1t
secondaril y at the d1sta • Ier JW, Burton RI Eaton RG · Th d1s Jomt. an f
· · (see text ) . (Litt
di gital exte nsion . AAOS Soun d SII'd e Program: # 46 7, #468, '197 6 .) · e ynam1 cs o
 Burton / Extensor Tendons - Late Reconstruction 2077

8
Fig. 52-5. (A) The motion of digital ex tension is potentiated by and synergistic with wrist
flexion . (B) As the wrist is fl exed by the flexor carpi radialis (FCR) and the flexor carpi
ulnaris, tone is increased in the exte nsor digitorum communi s and proprius systems (EDC
& P) , thu s passive ly bringing th e MP joint into extension . Exte nsion of this joint increases
th e ton e in th e intrinsic sys te m (re prese nt ed here by the lumbrical [L ]) b y te nodesis
action, th e reb y extending th e PIP joint. T he obliqu e re tinacul ar ligam ent (Obliq.R. lig.)
by a simi lar mechanism will tenodese th e distal joint into exte nsion . (A from Little r JW ,
Burton RI , Eaton RC: Th e dynamics of digital extension . AAOS Sound Slide Program :
#467 , #46 8, 1976. B redrawn from Little r JW: The fin ger ext e nsor mech anism. Surg Clin
North Am 47 :415 - 432 , 1967. Re drawn with permission from WB Saunde rs Co, Phi ladel-
phia.)
 2078 Operative Hand Su rgery / 52

Fig. 52 _6 _ The extensor mechanism distal to the MP

. . t IS
JOIO . a truncated cone of a single tendon . . system
controlling three joints. Note the relat~o~sh1p of _the
·
vanous components to the axis of JO.mt. motion.
(Flexor digitorum profundus, P; flexor d1g1to'.um su-
perficialis, S; lumbrical, L; volar ~late, V: P.; mter~s-
seous, io; central tendon , C. T.; oblique retmacular lig-
ament, O.R.lig.) (Littler JW, Burton RI, Eaton ~G:
The dynamics of digital extension . AAOS Sound Slide
Program: #467 , #468 , 1976.)

dynamic system of tenodeses are interrelated .
This system is a se ries of fixed tendinous and
11
retinacular lengths , whose distal function is
normally dete rmined by the more proximal
joint position . In established pathologic states,
joint deformity may b e imposed b y the dynamic
imbalance at the adjacent more proximal joint.
Thus, any evaluation of a late estab lished exten-
sor mechanism disorder must include a very
careful assessment of extensor mechanism func-
a particular effect on the others. This ac
for the complicate d nature of normal ,
finger extension and causes th e predicta
ciprocal joint de formiti es. For example.
MP joint goes into hype re xtension in th
devoid of median and ulnar nerve funct i<'
PIP joint fl exes , producing the so-call e
h and . In the boutonniere deformity with
sor lag of the PIP j oint , hyperextension
mity is induced in the distal joint . Thus, 1

tion at all three joints . (2) An imbalance at one rect the PIP joint extensor lag of the claw
joint will cause a predictable deformity in the the treatment is not directed to the tendon
next adjacent joint. The fixed lengths of these PIP joint, b ut is to rebalance the MP joint
tendinous structures dic tate that the position of larly, to correct the DIP joint hyperexte 11 51
any one joint in this triarticular system will exert --
b ou t onmere, •
pnmary treatment mu st be

\
 insertion
C.T.

Lat. band
Obl iq. ret. lig.

.· .... .-::.-, -,
:_ : :·.- -::. _'._.. . .; ,
__ _

· . .- ·.

C
Fig. 52-7. (A,B) An understanding of the relationship of the lateral band and oblique
retinacular ligamen t (O.R.lig.) to the axis of motion at the PIP joint is essential. Note that
the lateral band is dorsal to the joint axis when the finger is extended. (C) With PIP joint
fl e xion , the lateral bands move distally and volar to the axis of motion at the PIP joint, thus
r e laxing tension on the lateral bands and allowing simultaneous flexi on of the distal j oint .
Loss of this normal lateral band mobility at the PIP joint will impose restraint to di stal joint
fl e xion . When the lateral bands are adherent dorsally, PIP joint flexion is limited ; if
combined with PIP joint hyperextension , distal joint droop occurs and the swan-neck
de formit y is prese nt . When the late ral bands at the PIP joint adhere and fo reshorte n
volarl y, di stal joint hypere xtension results, with a boutonniere de form ity (see text). (A
and B re drawn from Little r JW, Burton RI, Eaton RC : The dynamics of digital ex te nsion .
AAOS Sound Slide Program : #467 , #46 8 , 1976 .)
 2080 Operative Hand Surgery / 52
rected not to the DIP joint, b ut instead to the
PIP joint (F igs. 52-7 and see 5 2-1 9). (3) The
importance of tendon pathway in relation to the
fiexion-extension axis must be emphasized . As
mentioned , the intrinsic system originates volar
to the axis of motion at the MP joint and passes
dorsal to it at the PIP joint (Figs. 52-2, 52-4, and
52-5). Thus , in the normal state, active MP joint
extension will potentiate PIP joint extension.
The oblique retinacular ligament has an analo-
gous course (one joint distally) volar to the PIP
joint and dorsal to the DIP joint.63 ,76 •79 Thus,
deformity at one joint invariably induces a re-
ciprocal deformity at the next joint- a collapse
of the linkage system . In planning the correc-
tion of any established extensor mechanism im-
balance, tendon pathways must be precisely
evaluated. This assessment must consider not
onl y the accepted traditional concepts of direc-
tion of pull to the point of insertion, but also the
relationship of the transfer line of pull to the axis
of motion for each joint position of each joint it
passes, and whether it will properly shift its po-
sition to the axes of each of the joints as they flex
and e xtend . ( 4) As mentioned, the extensor sys-
tem has a critical amplitude in three dimensions.
An y incre ase or decrease in length of the se ten-
dons may induce major disability, whether from
th e original pathology or from a well-inten-
tioned surgeon .
;1
I
I TREATMENT OPTIONS
I be obtained with a careful , co nscientio us sp
This fun ctional complexity of the extensor mech-
anism , whe n altere d in certain pathologic state s,
11
I
can result in late te ndo n imbalance with or without
fi xed j o int contractures. The physician must be ac-
cu rate in the assessme nt of the deformity, and
treat ment mus t b e p recise. Be fore making final de-
cisions regarding tr eatm ent , the surgeon must con-
sider t he fo llowing fo u r factors.
l . Patient education is essential. T he patient should
be informed oft he complexity of the established
deform ity and the d etails and chronicity of
treatme nt. The patient may initially be incredu-
lous when learning what is involved to treat
these proble ms , such as an established bouton-
nie re, which is the late r e sult of " j ust a jammed
fin ger. " There must be a commitme nt of time
and effort b y physician, therapist , and patient.
If the patient is unwilling or unable to follow
very specific long-range exercise and spli nting
instructions, surgical reconstruction of the ex-
tensor mechanism is best avoided.
2. The potential functional gain or risk must be real-
istically assessed . Many of these p atients will
present with a concern about the appearance of
a " crooked finger ," rather than with a fu nc-
tional deficit . For example, most patie nts with a
boutonniere deformity have normal grasp. To
lose full PIP joint flexion in order to regain full
extension may be very helpful in certain situa-
tions , but very detrimental in others. This will
depend on the digit involved, the p atient's oc-
cupation, and the amount of discomfort present .
3. A surgical rebalancing or reconstruction of the
extensor mechanism should never be attempted if
fi xed joint deformity is present. This is tru e at the
MP, PIP, and DIP joint levels (an example of
each is given below) . A tendon transfe r (e .g., the
extensor indicis propius to exte nsor di gi ti
quinti) to reestablish active MP joint exten sion
of the little finger following rupture will fa il if ;1
fi xed flexion deformity of that joint ex ,h
Littler's boutonniere reconstruction will nc
successful unless full p assive PIP j oi nt e ,
sion-flexion is first present . T e ndon recon s
tion for mallet deformity cannot b e do ne
out full passive DIP joint exte nsion.
prerequisite of passive joint mob ilit y can c
ing and e xercise p rogram . O ccasionally, pa
mobility will not be regaine d wi th the ex e
and splinting program and a two-stage su r
program will be need ed. F irst the joint rele
done. T his m ust be followed by th e rn a
nance of fu ll passive motion of all three j
with a compulsive exer cise and splinting
gram. The n, the extensor tendon reconstru c
is p~rformed as a second stage. After appro
ate immobilization for tendon healing , th e
tie~t ~gain must follow a compulsive lon~-t\
splmtmg and exercise program to sustain 1
 Burton / Extensor Tendons - Late Reco nstruction 208 1

gains from the surgery and to prevent both stiff- the reader is referred as follows:
ness and/ or recurrence of deformity.
4 . Many established extensor mechanism imbal- 1. Extrinsic exte nsor musculotendinous deficit
ances will respond to nonoperative treatment. secondary to radi al ne rve injury (Chapter 37) or
Very few chronic e xtensor mechanism di sorders rheu matoid arthritis (Chapter 44) ;
distal to the metacarpals should have surgery 2. Claw hand with loss of intrinsic extensor muscu-
done as the initial treatment . Those patie nts lote ndinous PIP joint exte nsion secondary to
without fi xed deformity oft e n resp ond to a con- median and/or uln ar nerve dysfuncti on (Chap-
sci e ntious exercise and splinti ng program . In te rs 38 , 39, and 40) ;
those with fixed contractures , as these joints re- 3 . Swan-neck de formit y secondary to the spastic-
spond to the exercise and splinting program , the ity of ce reb ral palsy or stroke (Chapters 8 and 9)
dynamic extensor mechanism imbalance may or rhe umatoid arthritis (Chapter 4 4) ;
also correct. W ith or without joint contractures, 4. Boutonnie re deformit y secondary to Dupuy-
the e xte nsor assembly pathology involves onl y a tre n's contracture (Chapte r 12) , burns (Chapter
few mi llimeters of abnormal le ngth or abe rrant 54), or rhe umatoid arthritis (Chapte r 44) ;
path way . The exte nsor syste m may " self-ad- 5 . Congenital exte nsor mechanism de ficits at the
just " wi th the d iscipl ine of hand the rap y. The wri st, as in arthrogryposis, or in the digits, as in
foreshortened structures are actively stre tched camptodactyly (Chapte r 10);
out to normal le ngth b y the pati e nt , and the 6 . De tails of intrinsic tightn ess (Chapte r 14);
atte nuated co mponents contrac t the necessary 7. Exte nsor mechanism disruptions secondary to
1 or 2 mm in response to control of joint position infection , such as in septic boutonnie re at the
b y sp linting. PIP joint in the drug addict or in the human bite
at the MP joint (Chapte r 23) ; and
8. Techniques for the essential adjunctive p roce-
Specific Operative Procedures dures of small joint fu sion (Chapte r 4) , arthro-
plas ty (Chapte r 7) , and surgical release of stiff or
T he operative procedures pe rtine nt to exte nsor contracted joints (Chapte r 11 ).
mechanism reconstr ucti on are presented sequ e n-
tiall y in this chapter, starting wi th the reestabli sh- LATE EXTRINSIC EXTENSOR TENDON
ment of more proximal j oint exte nsion and consid- RECONSTRUCTION IN THE
ering, in turn , the next most di stal joint. Because of FOREARM, WRIST, AND DORSUM
the above-described co ncept of collapse reciprocal OF THE HAND
deformities with the mo re proximal joint influenc-
ing the adjacen t d istal j oi nt, the surgeon must start The extrinsic exte nsor te ndon system powers ex-
proximally and work dis tally. te nsion in the wrist and the finger MP joints, ab-
The established chronic extensor mechanism ducti on in the thumb metacarpal, and exte nsion in
disorders to be discussed in this chapte r are : (I ) loss the thumb MP and interphalangeal joints .
of extrinsic extensor fu nction secondary to old If the patient is unable to e xte nd actively the
musculote ndinous injury proximal to the MP joint; fi nger MP joint or radially abduct the thumb met a-
(2) subluxation of extrinsic extensor at the MP joint carpal in the p resence of intact radial ne rve func -
level ; (3) extrinsic extensor tendon tightness; (4) tion , the tendon deficit may be an ywhe re proxi mal
intrinsic tightness ; (5) swan-neck deformity; (6) to the MP joint. These injuries are the most
boutonnie re deformity; (7) late extensor hood straightforward of the extensor mechanism prob-
proble ms ; and (8) mallet fin ger, with and without lems to reconstruct. Unless the injury is distal to the
fracture . juncturae tendinum , th e motor unit contracts with
Many of the surgical proce dures e sse nti al for the te ndon re traction . The myostatic muscle contrac-
adequ at e treatme nt of establi shed exte nsor mecha- ture that develops imposes a gap between the
ni sm disorde rs are d esc ribed in d e tail in othe r disrupte d te ndon e nds. Th is p recludes the second-
chapte rs in this b ook. For these sp ecific e ntities, ary te ndon re pair in all but th e most unusual cases .
2082 Operat ive Hant! Surg(•ry / 5:l
It is rare th at repair b y d in 'ct s11t11 rt· is t' ith cr possi-
b le o r advisabl e . To tr y d in •ct n ·pair of the irr<' vcr-
sibl y contracte d moto r unit to th t• d istal tt•mlon w ill
commit the p atie nt to sc vt'rt' t!xtri11sic cxte 11sor
t ight ness and li rn it act ive Hex ion st•<·o11dary to th<·
d orsal te nodes is (see page 2088) .
T he re aso11ahl e alte rnati ves for smgi cal trnat -
rnent are te nd o11 t ransfe rs or int e rcalat e d lcll(lon
" mini -grafts. " 44
T e ndon transfe r is t he most reliablt' trcatmt•11t.
The reader is refe rre d to C hapters 37 , 38 , 39, ,10 ,
and 44 for the principl e s of tc 11do11 transfers i11 re -
gard to sy ne rgism , excursion , motor pow e r , di rnc-
ti on o f p ull , and c hoice of i11 sertio11 ; to Chapte rs 37
and 44 for o p e rat ive technique ; and to Chapte r 4U
for techniqu e o f te ndon re p air. 111 lat e reco11stru c-
t ion of the extrin sic e xte nsor afte r trauma, the re
are ce rtain sp ecifi c conside ration s that should be
emph asized .
1. If th e te nd on re pair sit e w ill pass b e ne ath the
e xtensor re t inac ulum at the wrist with acti ve
di gital fl e xion and exte nsion , the path of the
t ransfer sh o uld b e pl aced in the subc ut ane ous
fat rather th an b e neath the re tinaculum . This
e nsures a straight line of pull and minimi zes the
risk of adhe re nce and scarring of the transfer
into its b e d . The amount of bowstring at the
w rist is not a funct ional proble m , b ecause wrist
fl exio n is sy ne rgistic w ith fin ger and thumb ex-
tension and thus the carpus itse lf will function as
a pulley with the wri st in the fl e xe d posit ion .
The inse rtio ns of the wri st exte nsors and thumb
abductor are close to the cente r of rotatio n for
th e wrist , and thus the amount of te ndon p ro-
lapse imp oses much less functi o nal limit atio n
than wo uld scar ring and adhe re nce to the re ti-
nacu lum if th e te ndon repair we re to p ass b e -
neath it .
2 . If th e transfer is that of a fl exor into an extensor
(e .g., fl exor carpi u lnaris or , less commonly
flexor digitorum supe rficialis) , the path aro uncl
th e subc utaneous borde r of the for e arm is b e t-
te r than through the int e rosseo us me mbran
The re is le ss chance of scarring of the transfer~
the b e d in the path of the transfer.
3 . A normal wri st j oint shou ld rarely b e fu sed i
orde r to provide wrist ext e nsor motors a~
transfe rs for fin ge r and/or thumb func t ion .
-1 . In so nw pa ti e n ts, th e origi 11al i11j ur y ma y have
in vol ved loss o f o vc rl yi11~ ski11 a 11<l su bcut a1H:-
c>1t s ti ss ue suc h th at th e p a th of th e proposed
t ra11 sfc r is throu g h au area of heavy scar or b<:-
tlt'at h a ski11 graft adh e r c 11t to scar and/or bmw.
In t hcsc situatio11 s th e area m ay have to lw re-
surfaced with a flap first. A t th e tim e of fl ap
attac hme nt , th e proposed path of t he transfer
can he prepare d with a sili<.;on e te ndo n rod
placed b e nc at h th e flap a11d flap m a rgi ns to facil -
it ate the suhscqu e 11t t rau sfe rs.
Author' s Preferred Methods for
Chronic Exten sor Tendon Deficit
Proximal to the MP Joint
Late r reco11 struction b y te ndon tran sfe r , if it i11 -
vol vcs loss of all ex trin sic e xte n sor mu sc ul olt'n -
<linou s fun ctio n , pre se nts an alm ost ide nti cal situ a-
tion to that of a r adi al p a lsy d istal to th e tri ceps
inne rvation . Th e ide al tran sfer s for th is d e ficit arr
pronato r te res to exte n sor carp i radi ali s b revi~ to
regain wrist exte n sion , fl e xor c a rpi ulnari s to l'X -
te nsor di gitorum communis fo r fin ger exte m · 11,
and palm ari s longus to reesta bli sh th e thu ml 11
~ucti o n-exte nsion a rc (see Ch a pt e r 37 fo r alt <
live trans fe rs) . Obviously , if th e act ive moto r
are not suffi cie ntly long to reach th e <li stal r<
e nt te ndon , the proximal unit c a n b e p rol on g<
th e use of an inte rcalate d te ndon graft .
In le ss severe injuri es invol vin g loss of on h
or two exte nsor units, some co mmo nl y
t .ransfers
. n 0 t r e qumng
· · gra f t prol o ngat ion arc
lme d m T able 52 -1.
The tec hnique of min i-grafts h as b een used ,
a Ite rn a t'tve to te ndon t ran sfer s.44 The gap h e h ·
th e re t racte d tend on ends is b r idge d w ith a
Table 5 ~-1. Commonly Used Transfers
m Less Severe Injuries
Funct ion Lost
Transfer Possibilities
Extensor pollicis longus
Exte nsor indicis proprius or
Abductor p o (J·ic1s• Iongu s p almaris longus
E Brachiora<lialis
xt e nsor <ligitorum
comm uni s Ex te nsor indicis propriu s or
side -to-side to adjace nt e xte 11>01
. .
<l 1g1toru m co mmuni.s (F'1g. ·5'2 h )
Exte nsor carpi radialis fl exor carpi ulnaris
Pronator te res
longus, brevis

me nt of te ndon graft . The au thor pre fers the use of
te ndon transfers unless the un us ual situation o ut-
line d b elow is fo und at surgery. Success of t he
min i-graft technique is pre d icate d on two assump-
tions: (I ) the myostatic muscle contracture has not
become irrever sible ; and (2) the muscle bell y or
contractilit y can still im part ade quate excursion to
the distal tendo n for full range of motion . The re is
one situ ation in wh ich these assumptions are ofte n
valid. If the original injury is distal to the wrist and
th e proxi mal te ndo n re tractio n is lim ite d b y adhe r-
e nce, the distal e nd of the proximal tendon has
so me e ffecti ve attachme nt distal to the wrist . Thus,
(1) som e motor un it le ngth is re tai ned ; and (2) ac-
ti ve wrist motio n will impart some passive excur-
sion to the muscl e . Th ese preclude a myostati c
cont ractu re .
Operat ive Techniques
Except as di scussed above , the operati ve tech-
niq ue for tendon tran sfe r is the same as that fo r
te ndon transfe r to reestabl ish ac tive exte nsion of
the thumb , fin gers, and/o r wri st in radial nerve
p alsy (Chapte r 37) , and in rhe umatoid arthritis
(Chapte r 44) (Fig. 52-8).
In the transfer re pair for wrist exte nsion , the te n-
sion should be snug wi th the wrist in 30 to 40 de-
grees exte nsion . In transfer or minigraft for MP
exte nsion , th e te nsion should be as tight as reason-
able te ndon traction wi ll allow whi le th e wrist is in
max imum e xtension and the digi ts in a fi st. In the
ope rating room afte r these latter repairs are co m-
ple ted , passive wrist e xte nsion shou ld allow fu ll
passive fist formation and passi ve wrist fl exion
should tenode se the involve d digits into exte nsio n.
Postoperative Care
The immobili zation is speci fic . The small joi nts
of the hand should be in the " safe p osition " with
the MP joints fl exed 60 to 70 degrees, interphalan-
geal joints extended, and thu mb in the fis t projec-
tion . Th e wrist is held in 10 degrees less t han maxi -
mum exte nsion . If the transfers involve units that
originate p roximal to the elbow , the elbow should
be immobi lized in 90 degree fl exion with the fore-
arm rotation positioned according to that which
will minimi ze static te nsion on the repairs; for ex-
ample, in supination for fl exor carpi ulnaris aro und
Bu rto n / Ex tensor Tendons - La te Reconstruction 2083
the ul nar border of fo rearm into extensor digi-
torum co mmun is, in pro nation for pronato r te res
into exte nsor carpi radialis brevis, and in ne ut ral if
both transfe rs have b een done .
D urati on of con tinuous immobilization is 4 to 6
weeks. Exercises are started aft er that interval. If
begun at 4 weeks , the exe rcises must be done very
carefu lly wi th acti ve assisted ex te nsion and limite d
active fl exion to avo id ru pture . Splinting is contin-
ue d, except du ring therapy exe rcises, for a to tal of
2 months afte r surge ry, and the n the patient is
graduall y weane d from the splint during the third
mont h.
Complications
Four pote ntial compli cati ons are noteworth y.
1. Scarring of the tendons, especially at the repair
sites , is th e most common compli cati on. Th is
risk can be mi ni mi zed by careful atte ntion to the
p reoperative assessment and the p ostoperative
hand th erapy as de tailed ab ove . Thi s complica-
tio n may present as (I ) simple failure of the
transfer to fu nction or (2) extrinsic extensor te n-
don tightness (see page 20 88) . The treat ment
of this complication should start with a specifi c
the rap y program of exercises and splinting in an
atte mpt to improve muscle cont rol and ampli-
tude of th e musculotendinous unit . Should this
fa il afte r se veral months, consideratio n should
be give n to tenolysis. If the soft tissue cove rage
is poor (i.e ., secondary to previous inj ury) , a
local or distant fl ap may be indi cate d as we ll.
2. Rup ture and/ or attenuation doe s occur, even
unde r favorabl e conditions. T his proble m can
be best avo ided by p reci se secure te ndon re -
pairs , b y p roper (not excessive) tensi on in the
musculotendi nous unit at the initial repair, by
continuing the immobi lizatio n for an adequate
interval aft e r surgery , and by co mpulsive fol -
lowing of the subseq uent exerci se p rogram and
gradual weaning from a splint with the gradu -
ated resumption of hand activities .
If the muscu lotendinous unit is in continu ity
b ut at tenuated, it is occasionally possible to sal-
vage the situation nonoperative ly with a dy-
namic assist splint accompanied by static splint -
in g at night . Otherwise, it is necessary to re do
the tendon repair.
2084 Ope ra tive Hand Surgery / 52

Extensor d igitorum
communis to index

\ Extensor ;nd;c;s ~ropr;us

,.,\ I . t .,
J
V. t. .

Fig. 52-8. The technique of tendon transfer for long-standing disruption of the extrinsic
extensor tendons varies with the situation encountered at surgery. Principles and tech-
niques are similar to those for transfers in radial nerve palsy. The choice of motor units and
the type of repair used must be adapted to the individual situation. A typical finding is loss
of the extensor digitorum communis to the ring and little fingers and loss of the extensor
digiti quinti. An example of the type of transfers that can be used is shown here . The distal
stump of the extensor indicis proprius is sutured side to side to the extensor digitorum
com mun is . The proprius is then divided just proximal to this repair site and transferred to
the extensor digiti quinti . The repair site , if possible, should be well distal to the retinacu -
lum and should be away from areas of previous scar, as these are points of potential tendon
adherence. The extensor digitorum communis tendon to the ring finger can be repaired
side to side to that of the long finger . The tendon repair done may be one of several types ,
depending on the size of the tendons involved. The repair of the ring communis to that of
the long is frequently of an interweaving type, secured by multiple horizontal mattress
sutures . The proprius transfer may b~ sutured wit~ a modified Kessler or interweaving
technique . (See Chapter 49 for techniques of specific types of tendon junctures.)

If the musculotendinous repair has ruptured,
it should be repaired immediately before the
motor unit contracts. If not , another transfer
may be needed. . r
3 . Donor deficits may comphchate the resultk. Defi-
cits may be secondary to eit er a too-wea mus-
cle use d for transfer, or weak or absent function
originally performed by the muscle used fo i
transfer. The former is usually from fai l~ rt 0
appreciate weakness in the donor prior . ,
t ransier, t h e I atter from fa1·1ure to re cogn /t
stJ 1
weakness in muscles that will b e needed to J
stitut e for the transfer donor funct ion. An exain~
11 50 1
pie of this latter situation is u se of an exte
 Burton / Extensor Tendons - Late Recon struction 2085

indicis proprius transfer for extensor pollicis

longus deficit , not recognizing coexistent ab-
sent extensor digitorum communis index func-
tion .
4. Joint stiffness can be a proble m especially in the
fing er MP or PIP joints. Contributing factors
may be the sequ e lae of old injury, immobiliza-
tion in other than " safe position ," or failure to
follow the sp eci fic exercise and splinting pro- ?,l<•
I
gram . Treatmen t must be prompt (see Chapter
1 J).

SUBLUXA TION OF EXTRINSIC

EXTENSOR AT THE MP
JOINT LEVEL

As the ex te11sor te ndons (the communi and pro-

prii) pass ove r th e me tacarpal head , a modification
of th e re tinacular system , in the form of sagittal (or
shroud) fib e rs, stabilizes th e ex tensor te n-
dons . 22 · 76 · 79 Th ese fibers arise from th e ex trinsic
ex te nsor , e mbrace th e metacarpal head , and insert
Fig. 52-9. The metacarpal head (II) serves as a pulley for
into th e volar plate (Fig . .52-9) . With MP joint mo-
the extrinsic extensor tendon , which passes over the
tion , th ese sagittal (coronal) fib e rs p ass to and fro in apex of the metacarpal head. The extrinsic extensor is
a sagittal plane, not unlike a buck e t handle or he l- stabilized in this position by the sagittal bands (shroud
me t visor, as th e central te ndon moves distal to fibers), which embrace the metacarpal head and attach
76 79
proximal with MP joint fl exion and ex te nsion · to the volar plate mechanism . Suspended from this volar
(Fig . .52-10) . plate mechanism is the A I pulley of the flexor mecha-
On e essential function of these shroud fib e rs is nism . Rupture of a sagittal band from trauma or attenua-
the mai11te nance of th e ce ntral position of the ex - tion from arthritis will cause the extrinsic extensor ten-
te nsor te ndon over the apex of th e me tacarpal head don to subluxate from the apex of the metacarpal head
during MP joint fl exion and exte nsion . This is abso- pulley, thus losing its mechanical advantage for exten-
sion (see tex t) . (Littler JW, Burton RI , Eaton RG : The
lutely necessary for th e me chanics of MP joint fl ex-
dynamics of digital extension . AAOS Sound Slide Pro-
ion and ex tensio n because , to e xte nd active ly the gram : # 467, #468, 1976.)
flexed MP joint , th e functional pulley of th e extrin -
sic extensor is th e me tacarpal head 79 (Fig. ,52-9) .
Th e sagittal fib ers have several other functions , th e are overwhelmed. A secondary and disabling PIP
most important being re lat e d to th e pathome - joint recurvatum deformity can then develop . The
chanics of th e claw hand an d not p e rtin e nt to this abnormal p at h of the central tendon is then acting
chapter. to cause not onl y PIP j oin t recurvature but also
With rupture or attenuation of th ese sagit tal uln ar d eviation , as well as the obvious extensor def-
fibers (more common on the radial asp ect) th e ex- icit at the MP joint.79
trinsic extensor tendon slip s off th e ape x of th e
me tacarpal head . Th e powe r dissipated by abnor- Diagnosis
rnal late ral -volar or downward displaceme nt of the
ce ntral exte nsor te ndon is diverte d excessively to This condi tion is simple to diagnose in the n o n-
the PIP join I le ve l. 79 With time (e specially if PIP rheumatoid patie nt . Usually the re is a history of
joi11t disease is pre se nt as in rheumatoid arth r itis), blunt trauma to the metacarpal head . The patie nt
th e structures res training PIP joint hype rext e nsion will have exce ll e nt acti ve MP joint fl e xion , b ut will
2086 Operative Hand Surgery / 52

joint motion is encouraged. At 3 to 4 weeks th

splint is removed three times a day for gentle active
MP joint flexion with passive MP joint extensio n.e
Except for these exercises, sp Iinting is continuous
for 2 months .

Operative Techniques
There are three types of surgical repair fo r this
clinical problem . All are best exposed as would be
done for MP joint arthroplasty (see Chapter 7).
These procedures are for isolated digital imbalance
secondary to trauma and are not adequate for the
rheumatoid patient unless combined with multiple
other procedures, such as intrinsic releases, collat-
eral ligament releases, and, frequentl y, joint
arthroplasties (see Chapter 44) .
Delayed Primary Repair. If the disruption is diag-
nosed and referred for treatment in the subacute
situation (usually after laceration or closed crush
injury) , delayed primary repair of the ru ptured
Fig. 52-10. The sagittal fibers move to and fro with ex- sagittal fibers is possible. This may be technically
trinsic extensor tendon excursion, thus maintaining the difficult for two reasons : (I) the shroud fib ers are
extrinsic extensor over the apex of the metacarpal head normally quite thin , and the fiber orient at wn is
throughout the arc of active MP joint motion . (Littler such that sutures do not hold well . Small hor-- 1nnL1l
JW, Burton RI , Eaton RG : The dynamics of digital exten- mattress sutures are the most effective · and Lie
sion. AAOS Sound Slide Program : #467 , #468 , 1976.) cause the metacarpal head is rounded ~nd t
considerable tension on the extr insic extem ,
be unable to extend the MP joint from the flexed the joint flexed , the tendon will snap off the ,
position . If the joint is passively extended to Ode- the metacarpal head into the " valley" un lc
grees, the tendon reduces to the apex of the meta- sagittal fiber repair is stout and of the r
carpal head and the patient will then be able to hold length . If the sagittal fibers are too friabl e o
the MP joint in full extension against resistance . surgery is done late after the fibers ha,
This is the critical point in differentiating extensor tracted, either of the following two p roced
tendon subluxation at the MP joint from a more effective . Of these two operations, I pre f
proximal extrinsic extensor tendon rupture or lac- dorsal_ tenodesis to the sling procedure becau
eration . techmcally easier.
Dorsal Tenodesis. A dorsal tenode sis is creat e
Nonoperative Treatment ca~efully adjusted new distal juncturae te nd
(Littler JW: Pe rsonal communication , 197 0'
If the diagnosis is made early, the shroud fibers exposure is the same as that used for arthropla~
on the side toward which the tendon subluxat es the MP joint of the involved ray and the adja
will not have contracted . These patients often do finge r to the side of the rupture d sagittal fibe i .,
ve r y we ll with splint treatment . The splint must
pre fer a gently curved longitudinal incision. 1
hold the involved MP joint at O degrees to allow
exte nsor digito rum communis te ndon of this 01 Z1
healing of the ruptured or attenuated shroud fib e rs cent digit is split lo ngitudinally for its distal 3 L'I
without tension while the extrinsic extensor rests over the m e tacarpal , and one limb is tnwsected ,ii
over the apex of the metacarpal head . Acti ve PIP th e proximal exte nt of th e split . A horizontal ni.it -
 Burton / Extensor Tendons - Late Reconstruction 2087

tress suture is placed at the distal margin to prevent
propagation of this split distally. This distally based
tendon slip is then passed through or around the
extensor digitorum communis of the involved digit
and sutured back to itself. The tension is carefully
adjusted before the tenodesis is sutured, to ensure
that the recipient extensor digitorum communis
remains centralized with MP flexion and extension.
The procedure can be done under wrist block anes-
thesia to permit active motion when the tenodesis
repair is being adjusted.
Sling Procedure. A sling is constructed to the in-
trinsic tendon of the involved digit . In a fashion
similar to the dorsal tenodesis , a distally based strip
of extensor digitorum communis is raised , with one
critical difference . In the dorsal tenodesis , the ten-
don strip is raised from the tendon of the adjacent
finger . In the sling procedure, the tendon strip is
raised from the subluxating tendon itself. 76 •78 This
strip is then sutured to the intervolar plate (deep
transverse metacarpal) ligament. As an alternative,
this strip is passed volarly around the leading mar-
gin of the intrinsic wing tendon on the side of the
digit with the deficient shroud fibers . The tension
is similarly adjusted and the teno<lesis sutured back
to itself.
Postoperative Care
The hand is immobilized with the MP joint in 0
degrees and the PIP joints free . At 5 to 7 days the
patient is started on active PIP joint exercises (simi-
lar to the acute non-operative treatment , these ac-
tive PIP flexion -extension exercises must be done
with the MP joint passively supported either at

Fig. 52-11. In the normal digit,

the prime functional insertion of
the extrinsic extensor tendon is
through the central tendon into the
dorsal base of the middle phalanx .
Traction on the extrinsic extensor
will lift the finger as a beam if the
volar plate at this PIP joint is com-
petent . Thus, normal extrinsic ex-
tensor tone may impose PIP joint
recurvature if the volar plate (V.P.)
is lax . However, once the MP joint y
starts to hyperextend, the prime in-
sertion of the extrinsic extensor
shifts to the sagittal fibers into the ~ ----
.I, l-
volar plate at the MP joint, and ex-
trinsic extensor tone is lost at the ('\__ _~ --- ; ~f,11
PIP joint. In the absence of normal
intrinsic MP joint flexor power, the
extrinsic extensor tendon is unable
to extend the PIP joint as the MP
joint comes into the hyperextended
position (claw hand) . (Littler JW,
Burton RI , Eaton RC : The dynamics
of digital exte nsion . AAOS Sound
Slide Program: #467 , #468 , 1976 .)
\
 2088 Operat ive Han d Surgery / 52
n eut ral or sligh t hypere xte nsion). The purpose of
these e xercise s is to gain some excursion of the
involved re construction . At 2 weeks , ge ntle active
MP joint fle xion is started with a dorsal exte nsion
assi st spli n t . Unprote cted use of the hand is not
II , p e rm itted for 10 weeks .
I I EXTRINSIC EXTENSOR TENDON
TIGHTNESS (DORSAL TENODESIS)
The extrinsic exte nsor tendon passes dorsal to
bot h the MP and PIP joints on the way to its prime
function al insertion into the tube rcle at the dorsal
b ase of the m iddl e phalanx (Fig. 5 2-11 ). In some
situ ations the muscle b elly is contracted in the fore-
ar m . Mo re co mmonly, the te ndon is scarred to the
b one or ret inaculum at the wrist or adhe re nt to a
metacarpal on the dorsu m of the hand . Whe n this
occ urs , the te ndon lacks the necessary excursion to
I I
lJ
\ I
11:
I joint is fl e xe d , t he PIP J
A ~ L.
Extrinsic extensor
I
I B
I;
pe rmit simultane ous fl exio11 of the MP and PIP
joints.73,78,79
Thus, if th e e xtrinsic e xte nsor becomes adherent
ove r the me tacarpal or fores horte ned , active or
passive MP joint fl e xion imposes, b y dorsal teno-
<lesis restraint , an un yie lding e xtension forc e at the
PIP joint (Fig. 5 2-12) . As seen clinicall y, PIP joint
fl e xion imposes MP joint hype re xtensi on and MP
joint fl exion imposes PIP joint e xten si on .22 This
condition is known as " extrinsic extensor tendon
tightness ." These p atients compl ain of in abil ity to
fl e x fully the involve d finger(s).
On e xamination , the patie nt can act ively fl ex the
PIP joint with the MP joint e xte nded or fl e x the MP
joint with the PIP joint e xte nde d . Simultaneous fu ll
fl exion of both joints, howeve r , is not poss ibl t> ei-
the r actively or passive ly . Whe n the MP joi nt is
passively brought i11to full He xion b y th e exami ner,
the PIP joint is te nodese<l into exte nsio11 ; both pas-
Fig. 52-12 . T he te st fo r 1
sic tightn e ss. If the <'X I
ex t e nso r t e ndo n is ad hc1
th e m e t acar pal, the li rn
of e xcursion di stal to I ha t
w ill limit o r p re clu de si
ne o us Hexi o n o f the M
PIP j o ints . (A,B ) As tl
pulle d into ex te nsi on. (C
versely , as th e PIP joint
th e MP joi nt is te nodcst
h yp e re xte nsio11 . T he ( I
test for th is co11ditio11 1"
onstrate <l in A. W ith P
MP j oi nt Hexion (I) , th ,
tendon jo int is fe lt to te nod es<' i 11 1
te nsion (2) .

sive and acti ve fl exion of the PIP joint are limited . If
the MP joint is placed in neutral or extension by the
examiner, the PIP joint can be fl exed (Fig . 52- 12) .
This condition is seen in a variety of clinical situa-
tions: ( 1) after metacarpal fractures , particularly
open injuries or those requiring open reduction
and internal fi xation , (2) following extensive soft
tiss ue injuries over the dorsum of the hand or wrist ,
especially if grafts are required for closure , (3) sub-
seque nt to an y extrinsic extensor tendon repair
after laceration , transfer, or graft if there is scarring
of the tendon to adjace nt fasci a or bone, (4) conse-
quent to crush injuri es of the dorsum of the hand,
and (5) after extensor tendon repairs or transfers
that are sutured under excessive tension .
Nonoperative Treatment
In a high percentage of patie nts, the condition
responds well to a program of exe rcises and static
or dynamic splinting. This is particularly true if the
diagnosis is made early and the therapy program is
instituted before the dorsal scarring becomes ma-
ture and/ or joint contractures develop . In this con-
text, it should be noted that the problem can ofte n
be preve nted if it is anticipated and exercises
started 2 to 8 weeks afte r injury or surgery. The
specific exercises commence as soon as they can be
done safely (very carefull y under close supervision
and in combination with protective splinting) wi th-
out jeopardizing soft tissue , te ndon , or osseous
healing. These exercises are designed to emphasize
acti ve extrinsic exte nsor te ndon excursion .
If tendon and bony unions are secure by 8 weeks,
the exercises can include active assisted fl exion of
the MP and PIP joints simultaneousl y and active
assisted exte nsion. Freque ntl y the use of a fl e xion
glove or fl exion assist splint is he lpful , especially at
night. Care must be take n to e nsure that the in-
creasing fl exion is fro m improved te ndon excursion
and no t from stre tching or atte nuati on of the te n-
don . For this reason the splinting p rogram may also
need to include exte nsion assist splints and exer-
cises.
Operat ive Techniqu es
Two types of p rocedures , each e ntire ly d iffe re nt
in concept , may be helpful : te nolysis or extrinsic
exte nsor release . Ne ithe r should be considered
Burto n / Extenso r Tend ons - Late Reconstructio n 2089
until 6 months of hand therapy have fail ed to
achieve the desired mobility . If MP and/or PIP
joint fixed contractures are present, simultaneous
joint release is essential (see Chapter 11 fo r tech-
nique) .
Author's Preferred Method for
Extrinsic Extensor Tendon Tightness
The author prefers tenolysis if the condition and
length of the tendon are reasonable , and the prob-
le m is one of adhe rence and scarring of the tendon.
Obviously the shorter the le ngth of te ndon involve-
me nt the easier the procedure and the more favor -
able the result. If the proble m is one of inadequate
tendon le ngth (i .e ., the tendon is too short), or
scarring for a long le ngth of te ndon proximal to the
junctura te ndinum (to re tain active MP e xtension
from adjacent normal digits) , I prefe r the Little r
extrinsic tendon release .
Extensor Tendon Tenolysis. Te nolysis is discussed
in detail in Chapte r 50 as it is applied to the fl exor
syste m. The principles and techniques are the same
for the extrinsic exte nsors, except the re is no criti-
cal annular restraint (pulley) syste m that has to b e
preserved, although the sagittal bands at the MP
joint must be protected . The exte nsor re tinaculum
at the wrist is expe ndable , for digit al extension nor-
mally occurs simultaneously with wrist fl exion .
Thus , extensor te ndon bowstring at the wrist does
not occur significantly with normal hand use .
Extrinsic Extensor Tendon Release. Extrinsic ex-
te nsor te ndon re lease is a concept developed b y
Little r. 22 ·73 ·76 lt is p redicated on a separation of the
intrinsic and extrinsic extensor te ndon syste ms and
a se parati on of the du al e xtrinsic-int rinsic exte nsor
control of the PIP joint (F ig. 52-14). T he e xtrinsic
ex te nsor te ndon release is contraindicated in the
hand with weak or absent int rinsic musculote n-
dinou s fu nction .
The cent ral portion of the e xt e nsor assembl y is
e xcised over the p roximal p halangeal shaft. 73 Both
the sagi ttal bands at the MP joi nt and the ce ntral
te ndon insertion at the dorsal b ase of the mid d le
phalanx must be carefully protected and pre -
served . This leaves the e xtrinsic e xtenso r to exte nd
the MP j oint only and rel ies on the int rinsic syste m
to exte nd the PIP joint . T hus, the distal ext e nt of
2090 Operative H and Surgery / 52
te ndon rese ction must be 5 to 8 mm proximal to the
PIP j oint so as not to disturb the conflue nce of the
late ral b ands and the exte nsor mechanism insertion
into the dorsal base of the middle phalanx. If the
tendon excision is carried too far di stally a bouton-
niere may result . ' joint extensor lag is developing . Should this start to
This procedure is best done with digital block
anesthesia. The patient can thus actively flex and
extend the fingers after the re lease, pe rmitting the
surgeon to be certain as to the adequacy of tendon
resection. A wrist block should not be used as this
will also block intrinsic muscle innervation.
Postoperative Care
The postoperative program is very similar for the
two procedures and is identical to that outlined
under the section on nonoperative treatment . Gen-
tle active assisted range of motion , both Hexion and
extension, within the limits of discomfort , is begun
on the first day. These exercises are done several
times daily . Sutures are removed at 2 weeks , but
exercise s and splinting may be necessary for many
months.
ntrinsic extensor
B mechanism
If the ex trinsic exte nsor tendon re lease has been
done, the window in the te ndon apone urosis over
the proximal phalanx fill s with a " pseudotendon "
scar within 8 weeks . Duri ng this time the patient
must be carefully che cked to b e certain that no PIP
occur, the PIP joint should be splinted in Odegrees
between the exercise periods.
INTRINSIC EXTENSOR TENDON
TIGHTNESS
The topic of intrinsic extensor tendon tightness is
covered in detail in Chapter 14 . To avoid confusion
with extrinsic tendon tightness , one must contrast
and emphasize the differences on physical exami-
nation , because both entities can follow crush in-
jury with or without metacarpal fracture and both
are associated with limitation of PIP joint fl exion .
In intrinsic tightness, when the MP joint is pas-
sively brought into full extension by the examiner,
active or passive PIP joint Hexion is limited 22 (Fig.
52-13). The finger with intrinsic tightness fre-
Fig. 52-13 . The te st for intrinsic
tightness . If th e intrinsic muscu-
lotendinous syste m is fores ho1 1-
ened, exte nsion of the MP i ·1 l
either active ly or passive!:
increase the tone in th is S)
and thus impose a restrai
flexion of the PIP joint. (
This is teste d b y the exam
( I) b y passively ex te nding
MP joint and (2) by testin1--
p assive fl exion of the pro.x
joint. If fl exion of the PIP jo
greater whe n the MP joi
flexed than when it is exten
an element of intrinsic tigh t
is present. (C) As the MP jo 1
allowe d to fl ex tone decreas
the intrinsic s;stem and th e
joint is able to flex furth er.

quently responds to an appropriate exercise pro-
gram .
If the exercises provide incomplete correction,
thi s condition is similarly treated with a procedure
that eliminates the dual control of PIP joint exten-
sion by excision of the wing tendons30,3I ,33,7I ,76,79
(Fig. 52-14). This procedure eliminates intrinsic
PIP joint extension, leaving the extrinsic tendon to
extend the PIP joint (this latter is possible because
interosseous muscle MP joint Hexion remains in-
tact). Note that this is not an operation for correc-
tion of the swan-neck deformity, because it does
not address the major problem of PIP joint volar
plate laxity .75 ·79
Resected
Resected central tendon
oblique fibers
and lateral band
of extensor
hood
Fig. 52-14. Extrinsic or int rinsic extensor tendon re-
lease. Partial resection of the appropriate portion of the
extensor mechanism in carefully selected cases is very
helpful in the treatment of intri nsic tightness or extrinsic
extensor te ndon tight ness . In patients with extrinsic ex-
tensor tendon tightness, the central tendon portion is
resect ed . In those wi th intrinsic tightness, only the lat-
eral bands are resected as indicated. (See text fo r de-
tails. )
Burton / Extensor Tendons - Late Recon struct ion 209 1
SWAN -NECK DEFORMITY
Swan-neck deformity describes a posture of the
finger in which the PIP joint is hyperexte nded and
the DIP joint is flexed . Initially this is a dynamic
imbalance that occurs when the patient attempts
maximal active digital extension . This dynamic
finger imbalance can progress to a fixed deformity
with joint changes.
There are many etiologies for this pathologic
state. Swan-neck deformity is seen consequent to :
( 1) injuries resulting in volar plate laxity at the PIP
joint; (2) spastic conditions-both stroke and ce-
rebral palsy (Chapters 8 and 9) ; (3) rheumatoid
arthritis (Chapter 44) ; (4) fractures of the middle
phalanx healed in hyperextension; (5) mallet defor-
mity at the distal joint when there is coexiste nt
volar plate laxity at the PIP joint (see page 2109) ;
and (6) generalized systemic ligamentous laxity.
An understanding of the altered functional dy-
namics is essential. The prime functional insertion
of the conjoined extensor mechanism is into the
tubercl e at the dorsal base of the middle pha-
lanx.76·79 ·82 Thus, normal digital extension is predi-
cated upon a competent PIP joint volar plate mech-
anism that will not permit PIP joint hyperextension
as the exensor mechanism lifts the fin ger into full
extension (Figs. 52-4 and 52-11) . In the abnormal
state of PIP joint hyperextension , there is a dorsal
displacement of the lateral bands at the PIP joint .
This dorsal prolapse of the lat eral bands slackens
the distal tension because of the fi xed attachme nt
of the central te ndon at the PIP joint level (F ig.
52- l 5A and B) . Thus, a droop of the distal joint is
imposed as the flexor digitorum profundus be-
comes an unopposed, deform ing force .76 ,79,82
The re are definit e similarities in the pat home-
chanics and surgical treatment of the claw and
swan-neck deformities .79 Both have the important
pathology of a hype rextended proxi mal joint and
fl exed distal joint. Both have fi xed points for the
exte nsor tendon assembly at the proximal joint that
limit active exte nsion at the distal joint . These fixed
points are the sagittal fib ers at the MP joint fo r the
claw and the central tendon inse rtion at the PIP
joint for the swan-neck. Both have a fle xor tendon
acting as a deforming forc e at the distally involved
joint - the flexor digitorum superfi cial is at the PIP
joint in the claw and the fl exor digito ru m pro-
2092 Operative Hand Surgery / 52

r-- D

E
F

Fig. 52-15. (A- D) Li ttle r oblique retinacular ligament reconstruction (see text). (E- K) Littler superficialis t f'
desis (see tex t). (A- D redrawn from Li ttler JW: The finger extensor mechanism. Surg Clin North Am 47:41 5 - ➔
1967. By permission ofWB Saunde rs Co ., Philadelphia. E- K reproduced with permission from Burton RI : The h;i
pp . 137 _ I 90 . In Goldstein LA, Dickerson RC (eds.): Atlas of Orthopaedic Surgery. 2nd Ed. CV Mosby , St Lo
1981.) (Figure continues.)

fundus at the DIP joint for the swan-neck. Both
have a yoke tendon restraint at the proximally in-
volved hyperextended joint - the sagittal fibers at
the PIP joint in the claw and the transverse retina-
cular fibers at the PIP joint in the swan-neck. With
these similar pathomechanics , it is not surpris i
that both deformities are rebalanced by the ret
tablishment of flexion (or limitation ofhyperexte
sion) at the proximal joint imbalance (Table 52-:2
Patients with swan-neck deformity can be subd

t H
t with atte mpted acti ve maximu m e xtension , and
J :~1, .J
Fig. 52-15 (Continued) .
Table 52-2. Dynamic Similarities of Two Common Collapse Deformities
D ynamic Factor
Hyperextension proximal joint
Loss of proximal joint restraint
Fixed point at proximal joint
Fl exor tendon as deforming force at
distal joint
Surgical correction
Bu rton / Exte nsor Tendo ns - Late Reconstruct ion 2093
vide d into those with fu ll active PIP j oint fl exion
who simply have a dynamic imbalance of the fi nger
those who have developed fi xed de formit y with
secondarv contractu res and joint changes. As al-
ready me-n tioned, no swan-neck dynamic rebalanc-
ing is possible in the presence of joint d e formity
(see Chapte r 1 1 fo r treatment of stiff joints).
Nonoperative Treatment
Swan-neck de formity is one of the few extensor
mechanism imbalances that does not respond to a
conservative splinting and exercise progr am . Such
a program may relieve fi xed contractures and/ or
intrinsic tightness , b ut the volar plate laxity will
persist, as will the dynamic imbalance at the inter-
ph alangeal joints.
Operative Techniques
In deciding the most appropriate surgical proce -
dure for swan-neck de formit y, the e ntire h and
must be considered . Four examples are give n : (1 ) if
the imbalance is secondar y to a mallet deformity,
onl y the mall et need be correcte d because restora-
tion of p roper distal joint balan ce will correct the
excess PIP joint extensor tone : (2) if the condi tion is
fr om a fr acture of the middle phalanx healed in
hyperexte nsion, corre ct ion of this bony malalign-
ment is the best treatment for the deformity (see
Chapte r 17) since reestablishing the alignment and
length of the skeleton will reb alance the extensor
system ; (3) in swan-neck associated with severe
K spas ticity or in a patie nt whose postoperative ad-
he re nce to splinting and exerci ses is doubtfu l, ar-
throdesis of the PIP joint is an excellent choice of
procedure (se e Chapte r -i for technique) ; (4) in the
pati ent with rhe umatoid art hritis , it is absolutely
Claw Deformity Swan-neck Deform it y
MP PIP
Intrinsics Volar plate
Sagittal fibers at MP Ce ntral te ndon insertio n .it PIP
Flexor digitorum super6cialis at PIP Flexor digitorum pro fo ndus at DIP
MP capsulodesis (Zancolli): or tendon PIP tenodesis (Swanson or Lit tler)
transfer for MP flexion
2094 Operative Hand Surgery / 52
e ssential to cor rect any te ndon imb alance or fl e x-
ion cont ract ure at the MP joint before treating a
swan-n eck defo r mity. Failure to corre ct this more
proximal MP fl exion de formit y or imbalance will
prede te rmine failu r e of the attempt at swan-neck
r econstruc tio n in the rheumatoid h and.
Furthe rmore , it must b e re peate dly e mphasized
that co rrection of intrinsic tightness will not corre ct
swan-neck defor mit y unless the PIP joint volar
plate laxit y is also correcte d .
If the swan-neck deformity is associated with se-
ve re joint c hange s, such as those se en with ad-
vanced rheumatoid arthritis , old fracture disloca-
ti ons, e tc. , the PIP joint itself may require
arthroplast y (see Chapters 7 and 44) or arthrodesis
(see Chapter 4) .
In the supple swan -neck deformity , the altered
e xtensor m e chanism d ynamics at the PIP joint
disrupt the linkage of the e xtensor me chanism . The
posture of the DIP joint is totally de pendent on the
e xte nsor balance and joint position at the PIP joint
(and secondarily , and in turn , at the MP joint) .
If the swan-neck deformity is a matter of exten-
sor m echanism rebalancing with corre ction of PIP
joint volar plate incompetence, there are two com-
monly used methods of reconstruction : the oblique
re tinacular ligament reconstruction and the super-
fici alis te nodesis at the PIP joint.
Oblique Retinacular Ligament Reconstruction
(Littler) . There are two techniques for this
proc edure - the original one as described by
Little r75,76,so.s2 and the improved modification as
m ore rece ntly reported by Thompson , Littler, and
Upton as the " spiral oblique " ligament reconstruc-
tion _1 39 Both techniques must be done in the digit
w ithout fi xed d e formity and without joint destruc-
tion . The principle is the same in e ach technique ,
i.e., a tenodesis that ( 1) passively tightens as the
PIP joint acti vely exte nds , thus serving as a check-
r ein to p reve nt PIP hyperexte nsio n; (2) is h e ld
volar to the PIP j oin t axis; and (3) passively teno-
d eses the DIP j oint into exte n sion as the PIP ac-
t ively extends. Thus, the oblique and spiral r eti na-
cular ligament reco nstruction directl y corrects
both inte rphalangeal joints. The original p roce-
dure uses the lateral b and , and the modi fication
uses a free tendon graft (palmaris longus or other
su itabl e do nor) .
Lateral Band Techn ique (Littler) . T he exposure
is throug h a long hockey stick incision on the ulnar
dorsolateral asp ect (F ig. ,5 2-15A - D ). The ulnar
late ral band is le ft attach e d d ist ally and is divided at
the musculotendinous j u nc tion proximally near the
le vel of the MP joint. The lateral band should be
handle d minimally , with onl y skin h oo ks or fin e
forceps , as it is sharpl y inc ised from t he transverse
re tinacular fib e rs of the exte nsor assembly. This
freed and distall y base d late ral b and is rerouted
volar to Cleland's ligaments. Thus, the ne w path of
the lateral band is dorsal to the DIP joint and volar
to the PIP joint. Proximally, at the b ase of the prox-
imal phalanx, the re route d late ral b and is secured
with sufficient tension to restrain the PIP j oint at a
position 20 degrees short of full extension, at which
point the tenodesis tension should be such to lift
the DIP joint to O degrees . The proximal attach-
ment may be done by passing the late ral band
through a window in the proximal flexor tendon
sheath (A2 level) and then suturing it b ack to itself.
As a more secure alternative , the proximal late ral
band is placed through a hole in the b o ne of the
proximal phalangeal base with a pull-o ut suture
over a button at the opposite side of the d igit . For
an eve n more secure repair, the lateral band may
be routed volarly across the digit and the n through
the bone of the proximal phalanx (Fig . 52-16) .
Tendon Graft Technique (SORL O Reconstruc
tion) (Thompson and Littler). 139 The exp osure <•
the digit is similar to that of the lateral band tee!
nique . Two through-and-through holes ar e mad
with gouges (Fig. 52- 1 7) - the fi rst being in th
anteroposterior direction at the b ase of the dist ,
phalanx , with care take n to protect the germiM
nail matrix and flexor digitorum p rofu ndus inse1
tion , and the se cond going transversely t hrough th .
base of the p roximal phalanx. The path of the graf
(palmaris longus , if available) starts distally at tht
dorsum of the distal phalanx and passes volarly ant
proximally alo ng the side of the middle phalanx arn 1
an te rio rly and oblique ly across the front of the PIP
joint to t he opposite sid e of t he digi t at the proximal
me taphysis of the p roximal phalanx. Thus , the free
tend on graft is spiraled aro und the digit in a subcu-
• SO RL = Spiral Oblique Re tinacular Ligament.
 A

:.. :- _- _-

1.J. /
- '4.-.

/. B
I
-~
/.L .
Y.
~ ' R. [)
. ~-. ~
'
C -.;
.. ~ t
D

z_t-:~t'.•
._. · ; ·: I

Fig. 52-16 . Oblique re tinacular ligame nt re construction fo r swan-neck deformity as mod-

ified by Little r from hi s original p rocedure to provide more secure repair. The oblique
re tinacular ligament is route d oblique ly across th e volar asp ect of the di git volar to the
fl exo r sh eath b ut d eep to th e ne urovascul ar bundles. Th is precludes any chance of the
tenodesis migrating dorsal to the axis of motion at the PIP j oint. In addit ion , the proxi mal
e nd of the obliq ue re tinacular li gament is passed through the bone and secured to a
b utton, th us providing a far more secure proximal fixat ion than that origi nally descri b ed
by Li ttl e r , in which th e tenodesis is secured b y su tu res into the flexor sheath as illust rat e d
in F igure 5 2-1 SA - D . (Little r JW : T he digital e xtenso r-flexor syste m . pp . 3166 - 32 14 . In
Converse JM (ed) : Reconstructive Plastic Surge ry . Vol. 6 . WB Sau nders, Philadelphia,
1977 .)
 2096 Operati ve Hand Su rgery / 52

Fig. 52-l 7. Pal maris longus teno-

Lateral band . desis for oblique reti nacular li ga-
ment reconstructi on for swan-
neck deformity , called the spiral
Pri mary insert ion of oblique retinacular ligament
central tendon
(SORL) . The pathology of the
swan-neck deformity involves hy-
A lar plate perexte nsion of the PIP joint with
e xtensor lag at the distal joint,
combined with a laxity of the volar
plate (A). The palmaris longus can
be used to provide a tenodesis to
correct the imb alance at both
joints in a fashion analogous to
that illustrated in Figure 52-16.
I
The essential differe nces are ( 1)
I I the use of the palmaris longus ten-
B don as a graft rather than the
oblique retinacular ligament, thus
making a simpler dissection; and
(2) it is easier to adjust the tension
of this tenodesis . (See text for op-
erative details .) (Redrawn from
Thompson JS, Littler JW, UptonJ :
The spiral oblique retinacular
ligament . SORL. J Hand Surg
C 3:482 - 487 , 1978.)

hand. However, it does not rebalance the extensor

taneous plane , but deep to the neurovascular bun- mechanism at the distal joint and may or may not
dles . The path of this tendon graft tenodesis is correct the distal joint extensor lag completely, de-
ide ntical to that of the oblique retinacular ligament pending upon the severity of the distal joint droop
reconstruction as illustrated in Figure 52-16, the and the condition of the tendon at that location .
essential diffe rence being that the former utilizes a Exposure is via the volar zigzag incision as de
free te ndon graft and the latter a lateral band from
scribed by Littler74 and later by Bruner,7 an
that digit . The proximal e nd of the tenodesis graft is
usually requires only the limbs of the incision ovr
passed through the hole in the proximal phalanx
the proximal and middle phalanges. The flexor te11
and secured either to the periosteum or over a but-
don sheath is resected between the A2 and A4 pu
ton with a pull-out suture . The distal end of the
leys. One slip of the flexor digitoru m super6cialis
graft is slid through its distal insertion in a dorsal to
transected as proximally as can be safely and gent
volar di rection . The tenodesis tension is adjusted
reached and is left attached distally. The pro ~
by slowly pulling more of the graft through the
mally divided and distally based slip is then passP
terminal phalanx until the proximal joint rests in 20
through a drill hole in a volar to dorsal directio
degrees flex ion with the distal joint at O degrees. 1
through the proximal phalanx and sutured to a bu
ton over the dorsum . The PIP joint is then stab
Superficialis Tenodesis (Littler). This tenodesis
lized in 20 degrees flexio n with a pe rcutaneou
utilizes one slip of the fle xor digitorum superficial is
as described by Littler 70 (Fig. 5 2-15E - K). This K-wire .
Other operations have been described to pro
forms a very stout tenodesis at the PIP joint , recon-
vide a passive volar restraint to excessive PIP joint
stituting a check-rein restraint to prevent hypere~-
extension. These include suturing the superfi cial
tension that is secure enough even fo r the spastic

e

Rexor into the neck of the proximal phalanx with-
out tendon transection (Swanson) 136 ; fascia} or ten-
don graft, bridging the joint anteriorly (Adams)1 ;
tightening of the volar capsule (Bate)3; and reat-
tachment of the ruptured volar plate (Portis)_ 107
Author's Preferred Method for
Swan-neck Deformity
There is no single preferred method for all situa-
tions. The author favors the spiral oblique recon-
struction with the pathway illustrated in Figures
52-16 and 52-1 7 to that of the procedure as first
described by Littler (Fig. 52-15A-D) . The spiral
pathway is more secure, as it does preclude the
chance of the tenodesis migrating dorsal to the axis
of motion at the PIP joint.
The spiral technique using the lateral band is
preferable if intrinsic tendon tightness is present ,
as the harvesting of the lateral band will simulta-
neously effect an intrinsic release on one side of the
digit. If the opposite lateral band is also tight , it
should be released as shown in Figure 52-14.
If the droop of the terminal joint is severe, or if
the quality of the extensor tendon complex is poor
distal to the PIP joint, the tendon graft technique is
definitely preferred by the author.
There are two circumstances in which the author
favors the superficialis tenodesis. The first is that
where a particularly stout repair is advisable- for
example, the spastic hand of cerebral palsy. The
second is the situation of correcting three or four
fingers at the same operative procedure, as this
tenodesis is somewhat easier and can be done more
quickly.
If the PIP joint itself is involved with collateral
ligament adherence , volar plate scarring, fibrous
ankylosis, or joint arthritic changes, the surgeon
will need to consider arthrodesis or arthroplasty
(see Chapters 4 , 7, and 44) , as the soft tissue proce-
dures described in this section alone will not suf-
fice .
Postoperative Care
For all of the above techniqu es, the prot ective
dressing and K-wire are removed at 4 weeks.
Thereafter, the involved digit is protected with a
dorsal spli nt that holds th e PIP joint in 20 degrees
Burton / Extensor Tendons - Late Recon struction 2097
flexion and the DIP joint in O degrees. The patient
is started on active assisted PIP flexion exercises
with active extension, using the splint as a " back
stop" to block active PIP extension at a position of
20 degrees flexion . This protective splint is gradu-
ally straightened to 5 to IO degrees from 6 to I 0
weeks after surgery.
It should be noted that the intended goal of these
surgical procedures for swan-neck deformity is to
prevent hyperextension of the PIP joint. Ideally,
the joint should be limited at O degrees, but, prac-
tically and realistically speaking, the best long-
term results without recurrence will be obtained
when the proximal joint is check reined at 5 to I 0
degrees flexion . This is the desirable goal, and at-
tempts should not be made to stretch out the con-
tracture with dynamic splinting and exercises to 0
degrees extension .
Complications
The major postoperative difficulties are (I)
stretching out or rupture of these tenodeses with
recurrence of deformity , (2) placing the tenodesis
too tight , resulting in excessive PIP joint flexion
deformity and potentially a boutonniere (espe-
cially with the oblique retinacular ligament proce-
dure) , and (3) loss of joint flexion mobility from
flexon tendon scarring (especially after superfi-
cialis tenodesis) .
The attenuation or rupture of the tenodesis is
best prevented by careful adherence to the postop-
erative program . Should such complications occur
from overenthusiastic and premature use of the
unprotected digit by the patient , the situation can
often be salvaged by resumption of extension block
splinting for several months to allow rehealing
and/or contracture of the tenodesis .
Excessive fixed flexion contracture of the PIP
joint , with or without the distal joint recurvature of
boutonniere, is a ve ry difficult problem to correct.
Fortunatel y, it does not occur often, especially
with careful attention to surgical technique and
postoperative care.
If th e repair is done with excess tension or if the
exercise program is not carefull y foll owed , an un-
acceptable amount of fl exion de fo rmity of the PIP
joint may result . This is best treated with a very
closely superv ised exercise and splinting hand
2098 Ope rative Hand Surgery / 51
I
/~;
/ II
therapy program as would be used for a bouton-
niere deformity (see page 210 I) .
Scarring of the flexor tendons will not happen
often , but when it does occur, the digital function is
seriously compromise d . It may respo_n d well to _a
hand therapy program or may require tenol ys1s
(see Chapter 50) .
Fig. 52-18. The proximity of tlw extrin-
sic extensor mechanism to the bone of
the proximal phalanx combined with its
anatomic distribution on three sides of
the proximal phalanx imposes a high risk
of extensor mechanism scarring to thr
proximal phalanx after tendon injuries
at this level and in fractures of the proxi-
mal phalanx (see text) . (Li ttler JW. Bur-
ton RI. E aton RC : The dyn:un ics of
digital extension . AAOS Sound Slide
Program : #467 , #468 . 1976 .)
LATE EXTENSOR HOOD ADHEREN CE
Following lacerations of the exte nsor mech;i
over the proximal phalanx, expeci ally if fracl
are present_ the extensor hood may adhere I()
hone or periosteum of the proximal ph:Janx . Th
d
m·e two anatomic reasons for this : ( 1) the tc!l
e
 Burton / Extensor Tendons - Late Reco nstruct ion 2099

normally is in direct proximity to the periosteum, have an obvious limitation of active PIP joint e x-
separated only b y a very thin layer of areolar tissue; tension . More importantly, they have a loss of ac-
and (2) this extensor tendon assembly surrounds tive and passive PIP joint flexion because of the
the proximal phalanx on three sides (Fig. 52-18). exte nsor tenodesis tethering restraint .
Should this pathologic state exist, it may be of
two types: ( 1) following tangential lacerations, the
Treatment
scar is limited in its extent, involving only a portion
of the extensor mechanism , such as only the central Usually these injuries prese nt as a limitation of
tendon or only a lateral band; and (2) following a PIP joint motion and are best treated by an exercise
comminuted fracture , crush injury, or old shred- and splinting program that emphasizes active as-
ding-type extensor tendon injuries, the scarring is sisted PIP joint flexion and extension .
extensive with broad areas of tendon adherence to Occasionally a patient will not respond to this
two or three sides of the proximal phalanx . conservative program . In the patient with scarring
Regardless of which of the two types of adher- of just the central tendon or one lateral band, the
ence is present , on examination, these patients offending portion of the extensor assembly is best

Central tendon

A Oblique retinacular
ligament

B
Fig. 52-19. Pathomechani cs of the boutonnie re deformit y. (A) As the central ten-
don eithe r ruptures or att e nuat es, ext ensor tone is decreased at the dorsal base of
the middle phalanx, allowing the PIP joint to drop into fl exion . (B) As the joint
fl exes, the late ral bands move volar to the axis of motion. They will adhere in that
p osition, and the cent ral tendon heals in the atte nuated position . The pathome-
chanics of the established boutonniere involve not only the atte nuation of the cen-
tral tendon , but the displaced , adhe rent , and foreshortened lateral bands resting
volar to the axis of moti on at the PIP joint. Excess extensor pull th us seco ndarily
b ypasses the PIP joint and is imposed dorsally at the DIP joint , causi ng a recurvatur~
at this distal joint (see text and Fig. 52-20) . (Redraw n from Burton RI , Eaton RC :
Commo n hand injuries in the athle te. O rthop Clin North Am 4:809 - 828 , 1973 .
Re print ed wit h permission from WB Saunders Co., Philadelphia .)
 2100 Operative Han d Surgery / 52

not synonymous with a PIP joint flexion defo r-

resected , as would be done for extrinsic or intrinsic
release as described on page 2091 (Fig. 52-14) .
I l
i I
Should the area of adherence be of the broad ,
latter type , conservative treatment is difficult and
resu lts are limited. The effort is well justified, how-
ever, for the results from extensive surgical exten-
sor tenolysis over the proximal phalanx are poor.
BOUTONN IERE DEFORM ITY
If the extensor mechanism linkage system dy-
namics is primaril y disrupted at the PIP joint, a
boutonniere deformity develops. A boutonniere is
mity.79 ,8 1 Simply stated, a boutonniere deformity
refers to a finger posture with the PIP joint flexed
and the DIP joint hyperextended. It occurs second-
ary to dorsal disruption of the extensor assembly at
the PIP joint and initially is a d ynamic imbalance of
the extensor linkage system (Fig. 52- 19). When left
untreated, the cond ition will progress to a fix ed
deformity, in which case there are fixed contrac-
tu res in th is posture that will not passively correct
(Fig . .52-20).
The basic initial p athomechanics are attenua-
tion, attrition , or rupture of the central tendon over

E. . ... --?.~
- -·······"'1"°
---.'------_;y ,•.

l
,..~ t
L. .
B C
Fig. 52-20. (A) Established bouton niere deformity (see text) . (B) In th I t .
PIP joint serves to flex the joint. The extrinsic and intrinsic e t e ate eS abhshed boutonniere , all power at 1t
. All f h . . d. . . x ensor tone at the PIP . . . b d t
attenuation . o t e extnns1c an mtrms1c extensor ton e passes thr h h Jom t 1s a se nt ue o
at the PIP joint. Obviously, the flexor tendons impart only flex or t oug ~. e.I~teral bands volar to the axis of mot •
only flexor power at the proximal j oint. All of the extensor tone is . odn: at t disto
iverte JOmt.
th dThus,
· I .there
. . is no e xte nsor po,\ '
sion . At this stage , the contracted lateral bands limit even passive e t . f th e ista Jomt imposing hyperextl
the p atient with late established boutonniere de formity. The de n; tnsitn ~ ethPIP j~int. (C) Ope rative find inl!~1
bands are see n well volar to this axis of motion . The attenuation of~.;r~ e is at e axis of joint mo tio n. The latf' •
JW, Eaton RG, Redistdbution of fo,ces in coffection of boo tonnie,e de tnt'.al tendon is i mpmsi ve . (B from Lit~•·1
1967 .) eo rmity. JBo neJointSurg49A . lZ6 7 - l:2 ·

4
 Burton / Extensor Tendons - Late Reco nstruc tion 2101

the PIP joint or off the dorsal base of the middle plate scarring and contracture, collater~l liga-
phalanx, and prolapse of the lateral bands volar to ment scarring, and intraarticular fibrosis.
the PIP joint axis 10 · II •79 •81 (Fig. 52- 19). This central
tendon change may be secondary to laceration, Nonoperative Treatment
closed avulsion, crush injury, or the synovitis of
The best treatment is to recognize the potential
rheumatoid arthritis or osteoarthritis . By whatever
problem before it occurs and by doing so prevent
etiology, there is damage to the central tendon and
the problem (Chapter 51 ). Surgical correction of
the dorsal transverse retinacular fibers . It is critical
the established boutonniere deformity is fraught
to realize that the boutonniere does not merely
involve damage to the central tendon , but also al-
terations of the transverse retinacular fibers , which
permit the volar subluxation of the lateral bands. In
the acute situation , the patient will have full active
Hexion and full passive extension of both interpha-
langeal joints. In fact , some patients with the PIP
joint placed at O degrees are able to maintain full
active PIP extension . Once the joint flexes enough
for volar lateral band displacement , however, ac-
tive extension arc is lost , as the lateral bands do not
pass dorsal to the axis of PIP motion .
If the condition is left untreated , the dorsal cen- A
tral tendon and dorsal transverse retinacular fibers
continue to lengthen , the volar transverse retinac-
ular fibers tighten , and the lateral bands are re-
strained anterior to the PIP joint axis . The fix e d or
rigid boutonniere is thus established as the lateral
bands shorten, the oblique retinacular ligaments
thicken and shorten, and secondary joint changes
occur 79 ·81 (Fig. 52-20) .
In this imbalance of the late boutonniere de for -
mity, all flexor and extensor power is conce ntrated
for PIP joint flexion . Not only the flexor digitorum
profundus and superficialis, but all of the extensor
mechanism via the dislocated lateral bands , act as Fig. 52-21. Exercise program for boutonniere defor-
PIP joint flexors (Fig . 52-20) . Therefore , the defor- mity . Many patient s with boutonniere deformity re-
mity is " self-accelerating" from this unopposed spond very well to a carefully structured exercise and
PIP joint flexion force .79 splinting program. The exercise is done in three steps.
Thus , there are three types (or stages) of the (A) The patient is instructed to place the index finger of
the opposite hand on the dorsum of the PIP joint of the
boutonniere deformity :
involved finger. The thumb of the uninvolved hand is
placed on the Oexor aspect of the DIP joint . (B) The PIP
Stage 1. The dynamic imbalance , passively sup- joint is then passively extended by the patient as far as
ple , in which the late ral bands are subluxated can be tolerated. This will passively correct the defor-
but not adherent ante riorly ; mity at the proximal joint, but will increase the to ne in
Stage 2 . Establishe d exte nsor tendon contrac- the lateral bands and oblique retinacular ligament, in-
ture in whi ch the de formit y cannot b e pas- creasing the hyperextension at the DIP joint . As a third
sively correcte d as the late ral b ands are s_hort- step to the exe rcise (C), the patient then actively fl exes
e ned and thicke ne d , but the joint itself is not the DIP joint over the thumb of the opposite hand, thus
involved ; and stretching the oblique retinacular ligaments and lateral
Stage 3 . Secondary joint ch anges, such as volar bands (see text).
:_2~10~2:_~0~p~e~ra~ti~ve~H~a~n~d~S_'.:u~rg'.:e~ry'._!_/~5~2~---------------------------
with difficulties and pitfalls, although it is techn!-
call y possible . Fortunately , many of these deformi-
ties will respond to a specific and conscientious
splinting and exerci se program. Certain general-
ities merit e mphasis: ( 1) the earlier the splints and
exercises are begun the better, for the dynamic
imbalance of Stage I will almost always respond
extremely well to conservative management; (2)
attention must be paid to regaining DIP joint flex -
ion as well as PIP joint extension ; (3) almost all
those fingers in Stage 1 and many of those in Stage 2
are best treated without surgery; (4) unless bone or
joint changes have occurred, surgery should not be
considered without first trying the therapy pro-
gram for several weeks and, if early objective mea-
sure able improvement is noted, continuing the
conservative program; and (5) surgery cannot take
the place of any exercise and splinting program,
but is used in addition to such a program. Thus
surgery is not a shortcut in either time or patient
effort. Finally, in those fingers that respond con-
servatively , the result equals or exceeds that possi-
ble from surgery.
The critical exercise involves two sequential ma-
ne uvers (Fig. 52-21) . The.first is active assisted PIP
joint extension. This will stretch the tight volar
structures, such as the volar plate, flexor sheath,
and volar transverse retinacular fibers . This initial
part of the exercise will cause the lateral bands to
ride dorsal to the PIP joint axis and will put longitu-
dinal tension on the lateral bands and oblique reti-
nacular ligaments. This in turn will increase the
tenodesis of the DIP joint into hyperextension . In
other words, passive correction of the proximal de-
formity will increase the distal deformity .
The second maneuver is maximal active forced
flexion of the DIP joint while the PIP joint is held at
0 degrees (or as close to that position as the PIP joint
will allow) . This will gradually stretch the lateral
bands and oblique retinacular ligaments to their
physiologic length.
The splinting program involves a combination of
active and static splints worn during the day and
static splints worn at night (Fig. 52-22A-D). The
splint supports only the PIP joint and the proximal
two phalanges, leaving the MP and DIP joints free.
This exercise and splinting program must be
maintain ed for a minimum of 2 to 3 months and
often much longer , to gain the maximum possible
correction and prevent recurrence .
Operative Techniques
There are many surgical proce dures for bouton-
niere deformity . Seve n considerations must be
strongly emphasized.
1. These operations must be precisely done . They
are deceptively difficult and should not be at-
tempted by the surgeon who only occasionally
operates on the hand .
2. Operative treatment should rarely be necessary
in the supple boutonniere, as this condition
usually responds to conservative management.
3 . The procedure should be done within the con-
text of a pre- and postoperative exercise and
splinting program . The exercises and splints are
needed for several months after surgery.
4 . The tendon procedure is best done after the
joint has full passive mobility . In some difficult
problems with a very stiff joint, the surgical cor-
rection must be done in two stages. The first
stage is the release of the joint (see Chapter 11),
and the second is the tendon reconstruction. In
many patients, after the joint release is com-
pleted and the exercise program resumed, the
extensor mechanism rebalances with the consci-
entious performance of the two-stage exercisE'
program and the splinting/cast support of tht>
PIP joint. In these patients the second sur ll
stage is not required.
5 . If the radiograph shows significant art
changes, extensor mechanism rebalancing
be combined with implant arthroplast)
Chapter 7) or with PIP joint fusion (see Ch
4).
6. Most patients with a boutonniere deform1
t~in full flexion and, therefore , full grip
hon ; thus, most patients even with this (
mity , have good function '. As surgery is plat
the surgeon must be constantly aware 0
need not to jeopardize flex or function in a
tempt to gain extension
· All procedures involve ~ rebalancing of the
7
~e~sor system, decreasing the tone at the di~
Jomt and diverting it to the proximal joint .
Extensor Tendon Division. Many different typt
ohf operations have been described for treatment 0 1
t e. .establish e d b outonmere
., c ·
de1orm1ty. I r1 111'·
opinion, the most reliable procedure is that ach 0
cated b y Eaton and Littler.23 This is sim ilar in prin
 Burton / Extensor Tendons - Late Reconstruction 2103

Fig. 52-22. Many types of

splints are helpful in the
nonoperative treatment of
boutonniere deformity . (A)
These splints may be one of
a number of types of dy-
namic splin ts, or may in-
volve the use of static splint-
ing, such as small cylinde r
casts, etc . (B) In the patie nt
with some fixed flexion con-
tracture o f the PIP j oint, a
cylinder cast can b e made
that the patient can re move
for skin care and b athi ng,
but wear at all other times .
This splint holds the proxi -
mal joint in its maximally
corrected position . The di s-
tal joint is le ft free to fl ex.
Thus, throughout the day
the patient is flex ing the di s-
tal joint and gradually
stretching th e contracte d
oblique retinacular liga-
ments and late ral bands .
(Figure continues.)

ciple to the essential first p art of their initial proce-
dure81 and not unlike th at described by Dolphin, 21
Fowler,31- 33 and Nalebuff 98 (Fig. 52-23) . A favor-
able surgical result is much more predictable in the
patie nt who has full passive extension preopera-
tively . This operation is b e st done via a dorsal
bayonnet incision centered over the PIP joint. The
extensor mechani sm is divided transversely over
the junction of the mid and proximal thirds of the
middle phalanx, distal to the dorsal tran sverse reti -
nacular fibers . This thus separates th e fixed point of
the extensor mechanism at the dorsal base of the
middle phalanx from the fixed point at the di stal
phalanx. This allows the mechanism to slide proxi -
 :2~10~4~-~
0 ~p~e~ra~t~iv~e~H~a~n~d~S~u:'.:rg~e:r~
y ..!./~5:_
2 _ _ _ _ _ _ _ _ _ _ __ __ _ _ _ _ __ __ _ _ _ ___

i'

Fig. 52-22 (Continued). (C)

As passive correction of the
proximal joint is obtained
with the exercise program
illustrated in Figure 5 2-21,
increasingly straighter cyl-
inder casts are made for the
patient. By continuing the
exercise program and the
i: serial cylinder cast, the bou-
tonniere defo rmity can fre-
quently be gradually cor-
rected. (D ) The correction
of the j oint contracture at
the proximal level is fre-
quently aided by the use of
dynamic splints (see text).

I
II
I'
'I/

lly at the proximal metaphyseal level of the mid-
~: phalanx. The lateral_band ten_d~n he~ls in this
leng thened position . This release 1s identical to the
critical first step of the proce ure d escn"b e d m
d ·
I I
I 967 s1 except that any redundancy oflateral band
is all~wed to slide proximally (rather than be su-
tured dorsally) . The results are increased to'
the central tendon insertion at the base of the l'
imal phalanx, decrease of the excessive tone 0 1
extensor tendon at the DIP joint level, and d(l
shift of the lateral bands relative to the PIP J'. .
axis as the converging bands slide proximally . J'li t'

J
 Burton / Extensor Tendons Latt~ Rf>const ru r tion 2105

Fig. 52-23. Although most cases

of boutonniere deformit)' re- ., ✓
= Cent,al tendoo
spond well to the exercise pro-
gram , surgical reconstruction . B . . . .~ Extrin sic extensor tendon
. II lS
occas10na y necessary. The
procedure for the supple bou- . .. ,,, " .
Intrinsic system
tonniere described by Eaton
and Littler,23 Dolphin 21 Obl ique Lateral
Fowler,31 -33 and Naleb uff98 us,es retinacular band
ligament
the surgical principle of decreas-
ing the extensor tone at the distal
joint by incomplete tra.nsection
~f the extensor mechanism (leav- Tip
mg th_e oblique retinacular liga- Tip
Central
ment mtact) , allowing the lateral Latera l b tendon
bands of the extensor mecha- C
I
nism to slide proximally and in-
crease the tone at the PIP joint
(see text). (Reproduced with
permission from Burton RI : The
hand. pp. 13 7 - I 90 . In Gold-
stein LA, Dickerson RC (eds) :
Atlas of Orthopaedic Surgery.
2nd Ed. CV Mosby, St Lou is ,
1981.)

D
. •

-
~ - . -
l -
-~ ~-
} - -

•-T '-
I I .
that the oblique retinacular ligament is not divided ;
its preservation is necessary or the distal joint wi ll
droop .
Postoperative Care. The digit is covered wi th a
small sterile dressing, and active assisted rang~ of
motion exercises are resumed . Be tween exercises
the PIP joint is splinted in full extension . Usually
the DIP joint is left free , but if a slight droop is
no ted , the distal joint is spli nted in full exte nsion
between exercises. This splinting is continued for 6
to 8 wee ks , and then the pati e nt is weaned fr om the
splint .
 2106 Operative Hand Surgery / 52
23
pie to the more recent operation . The lateral
82
Littler' s Boutonniere Reconstruction. 81 , The tra- bands and central tendon act only to extend the PIP
ditional Littler procedure is recommended if the joint and have no ~£feet on the D~P joint. A very
lateral bands are so foreshort ened and heavily important concept 1s that the previously displaced
scarred that they contribute significantly to the lateral bands no longer restrain PIP joint extension
fixed flexion deformity at the PIP joint (Fig. th e volar restraint having been transfe rred to a~
52-20). In this procedure , the lateral bands (except active extensor. The oblique retinacular ligament
for the lumbrical and the oblique retinacular liga- and lumbrical (on the radial side) are left to control
ments) are di vided at the middle phalanx , identical the extensor tone at the DIP joint. As the PIP joint
to the operation described above . The lateral bands is actively extended, the tone increases in the
are then rolled dorsally and sutured to the central oblique retinacular ligament, passively lifting the
tendon insertion (Fig. 52-24). Thus, the extensor
DIP joint into extension .
mechanism is simplified , and the component parts The PIP joint is stabilized in full extension with
of the extensor mechanism to the PIP and DIP an oblique K-wire (0 .045 inch) .
joints are separated. Note the similarity in princi-

I I

I
.
Fig. 52-24. In patients with the severely contracted boutonniere defor m1·t y, 1•t may be
ds•an d d1vert
necessary to transect •t h e lat eraIhb anbl . all of their power to the do rsalb ase of t h e
middle phalanx' relymg · upon
I t ed o 1que
( retmacular. ligament to control the d'is t al JOmt
. .
This is known as the Litt er proce ure see text). (Littler JW: The digital e xt ensor-fl exor·
system. pp. 3 166 - 32! 4. In Converse JM (e d ): Reconstructive Plastic Surgery. Vol . 6 _WB
Saunders, Philadelphia, 1977 .)
 Burt o n / Extensor Te ndon s- Late Reconstruction 2107

Note that this reconstruction cannot be done if

the boutonniere is acute or if the chronic state is
such that the central te ndon is too thinned to ac-
cept the sutures from the lateral bands.
Postoperative Care. The finger and hand are
supported in a hand dressing with an external plas-
ter shell or splint for 3 weeks. At 3 weeks the K-
wire and sutures are removed, and the PIP joint is
splinted dorsally in full extension , with the MP and
DIP joints left free . If the distal joint tends to
droop, it is also included in the splint in full exten-
sion . At 4 weeks gentle active range of motion ex-
ercises fo r both interphalangeal joints are begun
but the dorsal splint is continued between exer-
cises for a total of 2 to 4 months after surgery ,
depending on the clinical progress.

Te ndon Graft Procedure. O n occasion, the central

tendon deficit will b e so large or atte nuated as to
p reclude the use of these procedures, and a te ndon
graft w ill be required , as described by Fowler,33
Nichols,99 and, more recently, Littler 8 2 (Fig.
5 2-25) . This procedure should be done only if full
p assive e xte nsion of the joint is prese nt preopera-
tively. A long slender strip of the palmari s longus or
extensor digiti quinti is passed through two adja-
cent holes in the dorsal base of the middl e phalanx. L -

Each e nd of the te ndon slip is passed th rough and

sutured to the contralateral lateral band . The holes
in the middle phalanx must b e carefull y placed :
they must be as dorsal as possible to obt ain me-
chanical advantage for the graft insert ion , and
great care must be exercised not to fr act ure the
bone b ridge be tween th e hol es . Th e joint is stabi -
lized in full extension with an oblique 0 .0 45 -inch
K-wire . T he postoperati ve care is identical to that
described above for the traditional Littler proce-
dure .
Lateral Band Tendon Transfer Procedures. A lat-
eral band transfer ,73 as an alte rnative to this type of
tendon graft , has also been described by Littl er .
This procedure utili zes the uln ar lateral band as a
tendon transfer. The lateral band is transected over
the distal end of the middle phalanx and left at-
tached to its proximal muscl es. Both radial and
ulnar lateral bands are released from the volar
transverse retinacular fibers . The ulnar lateral
band is then passed (as a tendo n transfer) th rough
Fig. 52-25. In those patie nts with marked extensor lag at
the PIP joint wi th abse nce of the ce nt ral te ndon insertion
an<l defi cient late ral bands, te ndon graft may be neces-
sary . The procedure , as described by Fowle r and illus-
trated b y Little r, involves a te ndo n graft using the pal-
mari s longus, as shown he re . (Li ttle r JW: The digital
exte nsor-fl exor system . pp . 3 166 - 32 14. In Con ve rse
JM (ed): Reconstructive Plasti c Surgery . Vol. 6 . WB
Saund e rs, Philadelphia, 1977 .)
the radi al late ral band at the PIP joint level and
then through two holes in the dorsal base of the
middle phalanx (placed as for the tendon graft de-
scribed above) . T he postoperative care is similar to
that for the graft .
Anoth er lateral band transfer p rocedure has
been described by Matev.88 ·8 9 The ulnar lateral
 - - - --

2108 Op<>rative Hand Su rge ry / .52

band is trans<:>d ed at th e level of the DIP joint , th <:>

result from a care full ~ ~esigned and close! 01
lowe d exercise and splmtmg program may e y ; ·
---
radial band at the midshaft level of the> middle pha- exceed that obtained with surgery. qua or
lanx. Both late ral bands are transferred , the longer Should .surgery . be necessary as a fi nal re sort in
.
d'
proxim al ulnar one ac ross the dorsum of the middl e those patients not re spon mg to the conscie t·
. h n ious
ph alanx to the distal radial stump , and the shorte r splinting an d e xerci se program t e summary of th
proximal radi al one through the central tendon and author's prefere nces is as follows. e
into the perioste um at the dorsal base of the middl e
phalanx. Matev recomme nds 3 weeks of immobili- 1. Initiall y all establish ed boutonniere fing
zation with th e MP joi11t fl exed 45 degrees and the should be tre ated with the splinting and ex:~~
intc rphalangeal joints in full e xtensio11 , followed cise program as outlined in the text and in Fig-
b y a graduat f' d active exe rcise and splinting pro-
ures 52 -21 and 52-22.
gram . 2 . In the occasional Stage 1 and Stage 2 (see page
Secondary Direct Central Tendon Repair. 2101) boutonniere that does not respond, the
Mason 86 described primary surgical repair of the Eaton-Littler procedure (Fig. 52-23), the
ce ntral te ndon in the acute injury. This concept has Little r-Eaton procedure (Fig. 52-24), or the
b een applied to the chronic state by Kilgore and Matev procedure are recommended. The
Graham 5 6 and later by Elliott .24 Kilgore and Gra- Eaton-Little r is the simplest to do technically,
ham do a Y-V type advance ment , whereas Elliott but does require some compete nce of the ex-
simply resects the redundant attenuated central tensor insertion into the dorsal base of the mid-
te ndon and the n pe rforms a direct repair. Note that dle phalanx . Ifl find this exte nsor insertion inad-
both th ese procedures are successful only if there is equate once the E aton-Littler release is
no restraint to full passive PIP joint extension. As completed, I then prefer to add the repair of the
these are th e patie nts with supple deformities Littler-Eaton .
man y will respond ve ry well to the exercise ancl 3. If at surgery it is obvious that the central tendon
spli11ting program without surgery . This conserva- insertion is deficient and the late ral bands inad-
tive program should be attempted first. equate , the Little r -Fowler tendon graft (Fig.
52-25) can b e use d .
Author' s Preferred Method 4 . If the joint is involve d with fibrou s anhlosis or
The difficulty of surgical reconstruction for late arthritis , then fusion (Chapte r 4) or art h,roplasty
boutonnie re de formit y is indicated by the numbe r (Chapters 7 and 44 ) is re comme nded .
of these and many othe r procedures described in
th e past. The results from some are less predictable DIP JOINT EXTENSOR DISORDERS
th an from those described above . Other proce- (MALLET FINGER DEFORMITY)
dures for the less severe boutonniere deformity
have been re placed by the much more reliable re- The te r mma· l JOmt
· · o f the fi nger has no
sults obtain ed from the careful e xercise and splint- function
. · n den t o f t h e position
indepe . . of t
ing program d escribed on page 21 O1. prox1maljoint79,s2
t . (Fi·g ) Tl
. 52 - 26 . 1e range
F or the boutonnie re deformity , the enthusiastic ex e ~sion of the DIP joint fr om a flexed pl
surgeon must be e ve r mindful that : (1) e ven the predicate d on active exte nsion of the PIP j
most care ful ope rati ve techniques may not over- cause of th e 61xe d te ndon and re ti nacu lar
come the fibrobl asti c response of th e exte nsor a lfready de sen . ·b e d on page 2075 active f' '
mechanism parate non ~ith its destruction of glid- o these. two , ·ph aIangeaI JOmts
ir1te1 . . ' 1s. 111
. t er
ing surfaces and loss of a fe w millimeters of e xcur- C .e ithe r DIP Jomt
d With · · h yper exten sion or
sio11 ; (2) th e most e ncouraging early surgical res ult e or~ity, the PIP joint mechanics mu st ,th
may be d estro yed by a fe w millime te rs of att e nua- examm ed ' fo r th e pnme . pathology may lw
tion as a re pair site stre tches out from poor atteu- morkt:• dpro xim al level in the bou tonni ere or
~i on to th_e ~x~rcise and splinting prog~·am; and (3)
.I
neeb 'l· e formit y. Ab sence of normal Iatcr,1 I
m JI
1f a good J0111t 1s p rese nt , as see n on ra<l1ograph , the 0 1 ity at the PIP j o int , if associated with ,1 1 1

- --
 Burton / Extt•nsor Tendons Late Reconstruction 2109

noted that this increase' in PIP joint extt>nsor ten -

don te11sio11 h y di stal disruption is the principle of
tht' Littl<'r-Eaton , Fowler , Dolphin , and Nal ebuff
release procedures for early boutonni e re .
Init ially , the acu te mall et deformi ty can be on e of
three types : tendon disruptio n, tendon avu lsion
wi th small fl eck of bont'. and te ndon av ulsion with
an in t raarticular bone fragment comprisin g a sig-
"
) nificant portion of the joint surface and with volar

F ig. 52-26 . T he DIP join t has little imlqw11dc11t actiu·

extension . When th e PIP joi11t is in maximu m flc, io 11 . the
tone in t he lateral ban ds is maxi m ally rc hx cd to pern ut
si mu ltaneous active fl e xion of t he dis ta l joi11t. Th is !ax il) . Ext--:mo_ _ __
howe\'er , predudes act i, e exte11sio11 of the distal Joint 111
this position . (L itt ler J\.V . B11rt o11 HI. Eat on RC : The lh -
namics of di gi t al ex 1<•11sion . AAOS S01111d Slide P ro~r.1111
= 467 , i.e-168 . 1976.) B V.P lax ,ty

<lisp la ce nwn t and sho rt en ing . wi ll impos t> D IP join t
h y perex te11sio 11 . If t ht> lat e ral hands lHl\\·st ring d or-
sally at tlie PIP joint. DIP j o int 1•xtenso r bi,! m a~
oc.cur (see pn·, io u s discus'.'>io11s 011 bo11to1111ii•re ,md
s1,1. an rwc:k deformi ti es) .
T lw most comn1011 exl<'nsor 11 wdu11is111 disorde r
at ti,<.· DI P joint is an ex t e nsor b g. t lw_ so -called
mallc-t Jeforr11il\ secomlan· to lo~ s of t•xtensor
pov.(•r to tlw !(:rmi11al s1•g 1;wn t This c.wse~ th e
ex t e11sor 11wd1..1111'>111 to shift pro.\i1n;1 l l~ , i11 crt>a ..,i11 g
F ig. 52 -27 . (_\ ) \\' ith d1,ruptio11 of tht· t·"<ll-mor 11wd1a-
111s m ,it the d1st..1.l JOllll an t' .\ lt•11,or la); u1.x:1ir, . 111 thi-;
s1 tu.1t io11 tone of tlw t'"<lt'mo r 1m·clia11i<;m .it tht· proximal
Joint 1~ i11crt•~f'<l T iu'> p.1t1t•11t ,, 1th c1 la"< volar platt• at th t·
PIP J0 111t then <lt· \ e lopt•<l , 1 )\\ a11 nec k <lt·fun111 t y ,1.·<:011d -
,tr) t o tht' ol d t· \t t·mor tl"ndon l,H·<·ratio11 a t th t· Ji ,t al
JO i11I ( B) Tl 1t- ,1lll'rt·d ex t t'mor 111t'd1c1.11 i \ 111 1mpo~e, th1·
~\Llll 1w1..k defor1111ty ,i-., tl, t· lt·11Jo11 <1~~t·111bl} -.lid1 ·, pro ,
11 11,dl) 111 tht" p rt- ,t· 11u• of a l.i., PIP \'OLlr pl,ltt' ( \ ' P ) Bot It
tlw 111tn11Si(' ( /,,t J ,rnd t· xtr im ic ( Ext ) e.xlt'mor, nmtrib -
11t f" t o tlt i~ 1no ,1111 c1l 1111bala11ct' (_ \ from L ittlt·r J\V . Bu r

t lit' <:>.l1·11..,or to , w al tl w P IP Jo111l n ·bti , e to tl w t o11 HI E.1to11 HG Tlt e d) 11.11nic:, of di~1tal 1· \ k11,t011

D I P j n i1tl If tli<· pat w11t h;L\ a la, PIP J0 11 1t ' ola r AAOS Sound Sl iJt· Pro~r.1111 R- lti7 R- l( i ", I 'l76 B re·
plat e tlti~ J<,i11I will liyp1 ·1t·xt<-1,d .1, a Wlo11d.1r~ d raw11 fro111 L1 t tl n JW H11rto11 1U. Eatu11 H.C T l,1· dy -
11.11 111n of d igi tal , · xlt · 11,1011 AA OS Sound Slide Pro ~r.1111
J,,fonrnt ,· 7 ll .1t't A -,1·< ,11,d,1ry ,wan 1wck will I lt11, dt ·
\,(• lop (Fig '5:2 Z,, P ..trt ·11tli1-t u ally 11 ..,1io11ld lw
R- lh 7 R- l( i~ ] ()-;'ti l
 2110 Operative H and Surgery / 52
~
joint subluxation (Fig. 52-28) . The initial treat- P resent ' the distal joint
11
).
is best treated with
arth rod.
ment of these is detailed in Chapter 51. These can esis (see Chapter 4
be treated as fresh injuries up to 4 weeks.
92 If th~ droop is passive_ly co~rectable With ..
Should the patient be seen later with a chronic congrmty, the extensor mserhon is exp d101 nt
. . ose d
mallet deformity, one of several situations may sally as for an acute InJury. Three types oft nd0or.
I
exist, each condition with or without a secondary reconstruction by shortening are feasibl e b e n
swan-neck deformity: (1) supple or fixed following of the pseudotendon (scar tissue), which fi~~a~e
I old injury of the type seen in Figure 52-28A or B gap from the old rupture . e
I I (no fracture) ; these joints usually have congruous First, a tuck may be taken in the tendon . Second
surfaces. (2) supple or fixed following old injury of a seg_ment of tendon is resec~ed and an end-to-end
the type seen in Figure 52-28C or D (with frac- repair done under appropnate tension.24 Third
ture); these joints usually have incongruity , and (3) the insertion of the pseudotendon is divided, and
established secondary osteoarthritis. the tendon is advanced into the bone of the dorsal
There are several situations that may justify the base of distal phalanx . All three techniques simply
patient's seeking late treatment for mallet defor- involve a shortening of the tendon length between
mity: pain in the joint, concern about appearance, the fixed points at the dorsal bases of the distal and
secondary swan-neck deformity, or the complaint, middle phalanges.
" the finger is hooked and gets in my way ." It must be emphasized that only 2 to 3 mm of
tendon usually needs to be resected, so critical and
Operative Techniques small is the amplitude of the extensor at this level.
Excess shortening will impose distal joint hyperex-
If the deformity is fixed and does not respond to tension deformity.
exercises and splinting, if the joint surfaces are in- Regardless of the technique used for the tendou
congruous , or if significant degenerative arthritis is shortening, a K-wire is used to stabilize the termi-

Long extensor

, .... -,
----. ....;;
_,· . -- \

~ 1 1

Obl;q" e '...-r~-;::t~in=--a-cu_ l_a _r -lig_a_m--..,•":, ~ , / Fig. 52-28. Mallet deformit y c

ondary to tendon rupture (A), te
cur sec·
: ulsion
A Lateral band with a small fleck of attached l
i). or a
1jnt in·
significant intraarticular fractu n Thi,
congruity and anterior subluxa
~]osed
latter type usually cannot be re ithat·
because of fracture displacement JCture
tempted closed r eduction of a I I phJ·
fragment , the r ealignment of tl gn1ent
lanx on the middle may extrude C 1J1ill'

1 I I
dorsally. When seen late, Type i ithotil
I
b e a supple or fixed deformity, w i suit in
swan-neck. T ypes A and B usu ~ , 11 joi11I
congruous joint surfaces, but Ty!_ .G
on B
incongruity (see text). (Burton Rl o rthoP
Common hand injuries in the ath l -,er111is·
Clin North Am 4 :809-838 , 197 3

D
, sion of WB Sa unders Co ., Philadel_

n:tl j t)il\t i\t tl d q ,? rt"'S fo r -• I\) (, W t't' h . ,md the Dll'
lit
j oin t is im nh)bili 7t'd wi th :\ dt)rsal spliut at all tin 1t'S
for ti to ~ " l''t'ks. Wlwn t lw DU' tln i,)11 t'\'.('rdst'S
:ni.' 1..·on11nt'lll'<'tl. tht'\ 11111st ht' l':\rt'fo lh n·c:nlatt-d
and tlw splint ~rad\;:\lh Wt':uwd sn t hi,t ·t ht' r<'-
h' l){lirt.~! h'ndnu will " slidt' :md ),l:hdc .. :1nd not slrl'kh
out .
i If !ht· d,:h)nuit~ is supp It' fo llowin)!; :rn llltl injury
,d nt tlw t ~ P'(' St't' n in Fi~m' t ' 5~-:.!SC. sur~k:\l l'll lTt't'-
l tit.mis possihk hut m :n lw, t'n· ditHt·ult ht'l':\11se of
d tlw fi.wl'sht,rh'nt' d :m~l l'l' Htr~~l·h'd volhteral lic::1-
d and Yl)br pbk . if t ht' :mtl'ritH' joint snhlu~:1-
llh't1t s
\ titm is such t h :\t st,mt' pro:dmi,1 miimt io n of t hc
n h •n nin :tl phabm: has lll'l'Urt't'd as wl'll. Tht' jnint is
d t'XPO...'-t'tl dtll~ tlly . Tlw ~t'n n inal n ail m:\tri, 1~n1st he
t':U't'fully prott'l'h'd . T lw frac hm' is fn,cd from ad-
if h ~sions. P:u-t t'f tlw l't) ll:tlt'r:tl li~anwn ts may re-
qnirt' st>dion in n rdt' r tn ~:tin su tlt l'it•nt h,'H~th h)
J
t'l)rrt'\.'t tlw n,hr su blu:x~tt in n . The fr:ldun' is th en
rt>dth.'t>tL stabili z t' ti. :md fi.lllcn,·t,d postnpt' ratin--ly
:\S focm <\ t'Uh-' inj u r y l St't' Ch:tp t er.') l ). Tht' St'l'Ond-
:try b te t'Pt'n n :•dudin n nf tlwst' chron ic fradun-·s
rnn bt" diffin1lt. ~md the.> rt·'su lts dis:tppointin~. Ac-
curak n ~duditltl nuy lw elus iH'. bnn y unio11 slow .
:md fin:tl itlin t n ll,t ilm li m it e tL
Fnwle ~·s L'e ntr:tl slip rt-'lt>:\St' is another kchnique
th at t \m Yi t:'l d good resu lts in e:m...full y seleeted pa-
tien ts with d;ronic m :\ll l"' t fi ngl"' r inj uri t's. Hnw-
t>Ye r . tlw opc> rnti on :tnd the postoperati,·t> mana~e -
nwn t must ht" nwt icul n us ly 1wrfornwd :1ccnrd i11g to
thl"' pre<.'ise gu idt> li,ws d c.>serilwd h~· Bciwers and
H u rst. 6
Postoperative Ca re
Followin\! bte rt>p ,tir. the trt>atm e nt is simil:tr tn
that for acute injury . TlH" jllint m u st lw protected in
0 dt"\!ree s fo r S w eeks :md is tlwn gr:tduall y " ·e:uH' d
fro n; t he immob ili zatio n .
Author 's Preferred Method for Late
Ma llet Deformity
If o n h- the tendo n ,\t t lw tt"rmin:tl join t 1s Ill -
Yoh ed (i.e .. no fr:.ctu r<.> . no dege n t:'ratiH' :u·thritis .
and 1w st:'condan PIP hypert:> xtension ). a w ell se-
cure-cl tuck in t h-e tend on is t~fieetiYt:' if ca re full y
r e-h abilitatt>d :ls o utl ined abcn e .
If hoth the P IP and DIP join ts :tre w ithou t old
fracturl"' and "ithout :u·th ritk changes . bu t the
Burh)fl / I xlt'mor TC' ndons - Lalt' ~~constru ction 2111
malkt has l't'sultt•d in a seco1Hfar y swa11-11cck pos-
hl l'('(Fi~. !}:!-27 ). tht' spiral oblique ligame nt re -
t'1H1strnctio11 with a tendon graft (Fig . ,52- 17) is n~c -
om111t' nd<'cl . This has th<' great advantage of
din·~·tl y addressing th<' problem at both of the
joints .
· If then' is an old displaced fracture present (th e
type ill ustrat ed in F ig. 52-28C) that is sympto-
nmtk . or if then' are traumatic arthritic change s
prest' nt . arthrodesis of th is DIP join t is recom -
nwndt'd if the patient's symptoms are sufficien t to
warrant thl' surgical inte rve ntion .
SUMMARY
The extt-'nsor mechan ism is complex , ye t elegant
- :\ si ng It' tendon system of interre late d compo-
nt' nls c~mtrolling thre e joints. The concepts of
fiwd poin ts and le ngths and re c iprocal deformiti es
arc nitical for unde rstanding the pathomechanics
and trt' atnwnt of establish e d d efo rmiti es of the ex -
knsnr mechanism . D e formiti es ;u-e common sec-
ond:u·~· to disruption by trauma or arthritis . Diag-
nosis and treatme nt must b e precise and based on
an int imatt' knowl edge of functi o nal dynamics o f
the norm al and of th; disorde r t:>d ex te nsor tendon
mechanism .
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19 7 .S
 - ------- - - - -
2112 O perative Hand Surge ry / 52
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