Corequest
Hand Tendons- 2004

A 4-year-old girl has a fixed flexion deformity of the thumb of the dominant right hand as well as a palpable nodule at the volar metacarpophalangeal joint that has been present since birth. Which of the following interventions is the most appropriate initial step?

(A) A1 pulley release
(B) Aspiration of the mass
(C) Biopsy of the nodule
(D) Injection of cortisone into the mass
(E) Transfer of the extensor indicis proprius tendon to the extensor pollicis longus tendon


The correct response is Option A.


The first step in management of this deformity is A1 pulley release. The patient has a congenital trigger thumb, the most common cause of congenital thumb flexion deformity. The flexed position of the thumb can also be seen in patients with congenital clasped thumb, absent or aberrant extensor tendons, arthrogryposis, and spasticity. Patients with congenital trigger thumb commonly have thickening of the tendon, referred to as “Notta’s node.” In patients younger than age 3 years, the spontaneous resolution rate is 30%. Splinting and observation are options when the condition is diagnosed early, but most patients require surgery. During release of the pulley, no attempt is made to excise or reduce the nodule in the tendon. Aspiration is not appropriate for the nodule in the flexor tendon.

Aspiration can be used to manage retinacular cysts, which are ganglion cysts on the tendon sheath seen at the volar metacarpophalangeal joint, but patients with such cysts do not have flexion deformity. Biopsy is not necessary for Notta’s node, which is a pathologic thickening of the flexor sheath. Such pathologic changes in the flexor tendon are more common in children than in adults, who more commonly have involvement of the tendon sheath.

Trigger digit injection is into the flexor sheath and not the mass. Risk of rupture is higher with direct injection into the mass. Injecting a child would require at least monitored deep sedation if not general anesthesia. Tendon transfer is appropriate for treatment in patients with absent or aberrant thumb extensor tendons.


References:
1. Wolfe SW. Tenosynovitis. In: Green DP, Hotchkiss RN, Pederson WC, eds. Green’s Operative Hand Surgery. Vol 2. 4th ed. New York: Churchill Livingstone, 1998:2022-2044.
2. Gropper PT. Small joint contractures. In: Peimer CA, ed. Surgery of the Hand and Upper Extremity. Vol 2. New York: McGraw-Hill Professional Publishing; 1996:1583-1600.




A 16-year-old football player sustains an injury to the right ring finger when he tries to tackle another player during a game. On the sideline, physical examination shows tenderness along the proximal interphalangeal and distal interphalangeal joints and inability to flex the distal phalanx. Radiographs show no abnormalities. The most likely diagnosis is avulsion of which of the following?

(A) Flexor digitorum profundus tendon in Zone I
(B) Flexor digitorum profundus tendon in Zone II
(C) Flexor digitorum superficialis tendon in Zone I
(D) Flexor digitorum superficialis tendon in Zone II
(E) One slip of the flexor digitorum superficialis tendon in Zone II

The correct response is Option A.

This patient has sustained a “jersey finger” injury. The digital cascade is disrupted because there is no flexion force at the distal phalanx of the ring finger. In this patient, the flexor digitorum profundus tendon became avulsed from the distal phalanx (Zone I) when the patient attempted to actively flex the distal interphalangeal joint with the finger in forced extension. Three types of avulsion injuries to the flexor digitorum profundus tendon have been described:

Type I: The flexor digitorum profundus tendon retracts into the palm
Type II: The flexor digitorum profundus tendon retracts to the proximal interphalangeal joint
Type III: The flexor digitorum profundus tendon is entrapped at the A4 pulley

The patient is still able to flex the proximal interphalangeal joint, but the joint may be tender if there is blood in the flexor sheath or if he has sustained a Type II injury. The distal phalanx is drawn into extension because of the unopposed pull of the terminal tendon.

Rupture of one slip of the flexor digitorum superficialis tendon would not result in loss of function of the flexor digitorum profundus tendon or flexion of the distal interphalangeal joint.

References:
1. Schneider LH. Flexor tendonsClate reconstruction. In: Green DP, Hotchkiss RN, Pederson WC, eds. Green’s Operative Hand Surgery. Vol 2. 4th ed. New York: Churchill Livingstone, 1998:1935.
2. Britton EN, Kleinhart JM. Acute flexor tendon injury: repair and rehabilitation. In: Peimer CA, ed. Surgery of the Hand and Upper Extremity. New York: McGraw-Hill Professional Publishing; 1996.




A 27-year-old woman has pain and instability on radial-directed stress in the right thumb eight months after sustaining an injury to the ulnar collateral ligament. Initial management of the injury consisted of thumb spica casting for six weeks. In this patient, which of the following anatomic structures is most likely interposed between the ulnar collateral ligament and the proximal phalanx?

(A) Abductor tendon
(B) Adductor aponeurosis
(C) First dorsal interosseous muscle
(D) Flexor pollicis longus
(E) Joint capsule


The correct response is Option B.

This patient has a classic Stener lesion, in which the adductor aponeurosis becomes interposed between the ruptured ulnar collateral ligament and the base of the proximal phalanx. This lesion cannot heal spontaneously because reattachment of the ulnar collateral ligament to the proximal phalanx is blocked by the interposed tendon. It is important to identify this condition at the time of the initial injury so that operative repair can be performed without delay. Without surgical correction, the patient will have painful instability to radial stress of the metacarpophalangeal joint. The abductor tendon, the first dorsal interosseous muscle, and the flexor pollicis longus are not involved because they are not in the vicinity of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb. Tearing of the joint capsule is a potential complication of a Stener lesion, and an unrepaired capsular tear can be associated with relative supination of the proximal phalanx in relation to the metacarpal. Although the joint capsule should always be inspected, and repaired if necessary, at the time of ligament repair, it is not involved with blocking of the ulnar collateral ligament. In this injury, only the adductor aponeurosis becomes interposed between the ulnar collateral ligament and the proximal phalanx.

References:
1. Glickel SZ, Barron OA, Eaton RG. Dislocations and ligament injuries in the digits. In: Green DP, Hotchkiss RN, Pederson WC, eds. Green=s Operative Hand Surgery. Vol 1. 4th ed. New York: Churchill Livingstone, 1998:788-794.
2. Durham JW. Thumb metacarpophalangeal ulnar collateral ligament repair with local tissues. In: Blair WF, ed. Techniques in Hand Surgery. Baltimore: Williams & Wilkins; 1996:533-537.