Jersey Finger

Introduction
Refers to an avulsion injury of FDP from insertion
at base of distal phalanx
a Zone I flexor tendon injury
Epidemiology
ring finger involved in 75% of cases
during grip ring fingertip is 5 mm
more prominent than other digits in
~90% of patients
therefore ring finger exposed
to greater average force than other fingers during pull-away
Pathophysiology
FDP muscle belly in maximal contraction during forceful DIP extension

Anatomy
Muscles
Flexor Digitorum Profundus (ulnar n. and
AIN n.)
Flexor zones
zone I extends from insertion of FDS
distally

Classification

Leddy and Packer classification

(based on level of tendon retraction and presence of fracture)
Type Description Treatment Images
Type I FDP tendon retracted to palm. Leads to Prompt surgical treatment within 2
disruption of the vascular supply 1 7 to 10 days
Type II FDP retracts to level of PIP joint Attempt to repair within several
weeks for opitmal outcome
Type III Large avulsion fracture limits retraction to Attempt to repair within several 3
the level of the DIP joint weeks for opitmal outcome
Type IV Osseous fragment and simultaneous If tendon separated from fracture 4
avulsion of the tendon from the fracture fragment, first fix fracture via
fragment ("Double avulsion with ORIF then reattach tendon as for
subsequent retraction of the tendon Type I/II injuries
usually into palm)

Presentation
Physical exam
pain and tenderness over volar distal finger
finger lies in slight extension relative to other fingers in resting position 5,6
no active flexion of DIP
may be able to palpate flexor tendon retracted proximally along flexor sheath
 1 2

4
Imaging
Radiograhs
may see avulsion fragement 7

Treatment
Operative
direct tendon repair or tendon reinsertion with dorsal button
indications
acute injury (< 3 weeks)
technique
advancement of > 1 cm carries risk of a DIP flexion contracture or
quadrigia
postoperative rehab should include either
early patient assisted passive ROM (Duran) or
dynamic splint-assisted passive ROM (Kleinert)
ORIF fracture fragment
indications
types III and IV (for type IV then repair as for Type I/II injuries)
techniques
 with K-wire, mini frag screw or pull out wire
examine for symmetric cascade once fixation completed
two stage flexor tendon grafting
indications
chronic injury (> 3 months) in patient with full PROM of the DIP
joint
DIP arthrodesis
indicated as salvage procedure in chronic injury (> 3 months) with chronic
stiffness

Complications
Quadrigia
advancement of > 1 cm carries risk of a DIP flexion contracture or quadrigia

7
5
6

(OBQ06.52) A 22-year-old rugby player presents with a mass at the base of his ring finger 5 months
after sustaining an injury while making a tackle. Physical examination demonstrates a lack of active
distal interphalangeal joint flexion, but full passive range of motion of all joints of the ring finger.
Radiographs are normal. What is the most appropriate treatment to regain normal finger
function? Review Topic

1. excision of the palmar mass and 2-stage tendon grafting

2. excision of the palmar mass and single stage tendon grafting
3. excision of the palmar mass and distal interphalangeal joint fusion
4. active silicone rod implantation
5. flexor digitorum profundis repair

PREFERRED RESPONSE 1
This patient has a chronic jersey finger (flexor digitorum profundis avulsion). With the chronicity of
the injury, it would be more amenable to grafting rather than direct repair given retraction of the
FDP tendon that occurs with time that makes direct repair impossible. According to Greens text,
active silicone tendon rod implants have not proven to be effective. A 2-stage tendon grafting is the
treatment of choice in cases of neglected or chronic (>3mo) tendon injuries or when previous
surgery has failed. Two-stage flexor tendon grafting involves implanting a silicone rod (flexible
siliconeDacron-reinforced gliding implant) in the first stage and a free tendon graft (usually
palmaris longus or plantaris) through the pseudosheath formed around the silicone in the second
stage as intitially described by Hunter and Salisbury in 1971. In single-stage flexor tendon grafting,
the tendon graft notoriously adheres to the surrounding fibro-osseous tunnel significantly limiting
range of motion, but in 2-staged tendon grafting the pseudosheath that is formed around the silicone
implant in the first stage greatly reduces the formation of post-operative adhessions to the tendon
graft in the second stage.

Amadio et al showed at 6 month follow-up of staged flexor tendon reconstruction, patients

expressed 54% good to excellent results, but 16% of patients required tenolysis following the
second stage of the procedure. LaSalle et al followed 43 flexor tendon 2 stage reconstructions by
comparing passive ROM after stage 1 to postop active ROM after stage 2. They reported 16%
excellent results, 23% good, 26% fair, and 35% poor. They stated that tenolysis following the
second stage improved results on the patients reporting poor outcomes. A distal interphalangeal
fusion would be reserved for failed reconstruction or a patient that does not desire/will not be
compliant with likely lengthy postoperative therapy needed for a staged tendon grafting.

(OBQ05.246) A 16-year-old football player sustains an injury to his ring finger after making a
tackle. A clinical photograph is shown in Figure A. What is the most likely diagnosis? Review
Topic

FIGURES: A

1. Flexor digitorum superficialis avulsion

2. Central slip rupture
3. Sagittal band rupture
4. Distal extensor tendon rupture
5. Flexor digitorum profundus avulsion

PREFERRED RESPONSE 5
The photograph demonstrates the inability to flex the ring finger DIP. Based on the mechanism and
clinical findings this injury represents a "rugby jersey finger", which is an avulsion of the flexor
digitorum profundus (FDP) tendon.

Tuttle et al reviewed these injuries and concluded treatment for an acute injury is FDP tendon
reinsertion. For chronic injuries, a 2-staged tendon grafting is required