ACUTE EXTENSOR TENDON

INJURIES OF HAND

DR ZAHIDAH AKHTER
(MAMC)
 Anatomy
 The basic structure of the extensor tendon mechanism was
illustrated by Albinus in 1734.
 The extensor mechanism consists of:
• Extrinsic muscles, located on the forearm and dorsum of hand
• Intrinsic muscles, located at the level of the metacarpals and
• Fibrous structures
Dorsum of the hand
 Extensor digitorum communis (EDC)
tendons are interconnected by the
juncturae tendinum.
• Facilitate combined extension of the
fingers.
• Lacerations proximal to the juncturae
may be masked
• At proximal phalanges, the extensor
tendons split up into three and merge
with the intrinsic extensor system to
form the complex extensor apparatus of
the digits.
• Parts: the central band and two lateral
• The extrinsic extensor tendons have
three insertion sites on the phalanges.
• Proximally, the tendon is f ixed at the
level of the metacarpal heads to the
palmar plate by the sagittal bands-
prevents hyperextension.
• The m ost im portant insertion is
located at the base of the middle
phalanx.
• Di st al l y, t he t e rm i nal t e nd o n i s
attached to the distal phalanx.
Intrinsic muscles
 Seven interosseous and four
lumbrical muscles
 Four dorsal interosseous - originate
with two heads each from the
adjacent sides of metacarpal bones.
• First two interosseous – 2nd and 3rd
finger from the radial side.
• Third and fourth- 3rd and 4rth finger
from the ulnar side.
• Insert at the proximal phalanges and
the interosseous hood of the
extensor apparatus before joining the
lateral bands
• Three palmar interosseous -arise
from the medial sides of the 2nd,
4rth, and 5th metacarpal bones
• Join the extensor apparatus of
the digits at the level of the
proximal phalanx after crossing
palmar to the axis of the MP
joint.
Lumbrical muscles
• Most variable muscles of the human
body
• Arise from the radial sides of the
flexor digitorum profundus tendons.
• At the level of the metacarpals.
• Join the extensor apparatus from the
radial side.
Distribution of intrinsic muscles in fingers
EXTENSOR MECHANISM
MECHANICS
 Two set of muscles:
• INTRINSIC (originating in the hand itself & innervated by the
Ulnar and Medial nerves) and
• EXTRINSIC (originating in the forearm & innervated by the
Radial nerve)
• act synergistically
• The extensor system prepares the hand for grasp & pinch by
positioning the hand in various degrees of extension.
• The most frequent activities of daily living occur in positions
close to the position of function like holding a cup or writing
with a pen.
• More specialized activities like grasping a large or a very small
• An Extensor tendon laceration results in the decrease in the
extensor force distal to the injury.

• This force is then transferred to the joint proximal to the injury,

resulting in a net increase of extensor force at that joint,

• which causes a change in that joint position leading to

characteristic deformities
TENODESIS EFFECT
• Concept of movement at one joint transmitting power to an
adjacent joint
( usually distal)
• As the wrist flexes , the extensor tendons tighten
• the flexor tendons relax,
• both actions serve to produce extension of the MP joints.
• The intrinsic tendons tighten with MP extension, augmenting
PIP extension
• The lateral bands & the ORL are lax with PIP flexion and tighten
with PIP extension.
• The Tenodesis effect of the ORL can be demonstrated by
checking passive flexion of the DIP joint with the PIP joint in
Extensor tendon injuries
 Frequently underestimated- easy access to the tendons due to:
• Thin soft-tissue envelope,
• Their extrasynovial nature, and
• Limited retraction
 However, injuries to the extensor tendon apparatus are often
more difficult to treat due to:
• Complex interactions between the long extensor tendons and
the intrinsic muscles of the hand
• The superficial, thin structures that are very close to the
underlying bones, thus prone to develop severe adhesions
• Excursion amplitude is limited, so that even subtle lengthening
or shortening will result in severe restrictions of range of motion
• Shortcomings in adequate soft-tissue coverage will inevitably
result in poor overall results, even if the tendons themselves
were addressed properly
DIAGNOSIS/PATIENT PRESENTATION
• Diagnosis of extensor tendon injuries is often evident
• Can be missed if the remaining tendon is strong enough to
create some extension force
• General rule, open lesions should therefore be surgically
explored to identify the extent of the injury and prevent
secondary ruptures
• Function of the ED tendon should be assessed ;extension of the
MP joint of the affected digit against resistance
 The EPB tendon inserts into the
extensor tendon apparatus of the
thumb at varying levels:
• may be able to extend the IP joint of
the thumb.
• If there is a questionable rupture of
the EPL tendon, it should therefore
not be tested by extension of the IP
joint.
• Instead, the patient should be asked
to lift the thumb off the table, which
will be impossible without an intact
EPL tendon.
• Kleinert and Verdan proposed a system
to classify lesions of the extensor
tendon apparatus into eight zones
according to the level of the lesion.

• Doyl e has ad d e d a ni nth z o ne b y

dividing the forearm into the distal
(zone 8) and proximal forearm (zone 9)
GENERAL PRINCIPLES OF REPAIR
• The size of the extensor tendon varies considerably during its
course from the distal forearm to its terminal insertion at the
distal phalanx.
• While the tendon is round and thick proximally, it becomes thin
and flat more distally.
• Suturing techniques therefore have to be adapted specifically to
the location of the injury.
• It should provide the best stability with the least shortening
possible.
• Minimal changes in tendon length can cause significant
alterations in range of motion because the excursion amplitude
of extensor tendons is limited.
• In zones II to IV, extensor tendons are thin and flat and,
thus, less amenable to suture techniques involving
multiple core sutures. In theses areas, epitendinous
suture techniques have demonstrated favourable results.
• Injuries proximal to zone 6 can be repaired in similar
fashion as that for flexor tendons because of their size
(core suture plus epitendinous suture).
• Closed ruptures of the extensor tendon at the level of the
DIP and PIP joints are often treated conservatively.
Zone-I injury
• Characterized by f le xion at the DIP joint without active
extension (mallet finger)
• Causes include laceration and/or avulsion
• Closed injures are treated with splinting of the DIP in extension
for 8 weeks continuously, followed by night time splinting for 2
to 6 weeks.
• Open injuries :
o In most cases, skin-only laceration repair with splinting will
allow healing strong enough for extension function.
o In avulsion injuries with bone fragments > one third of the
articular surface, K-wire fixation can be used.
o Alternative options include extension block pinning
 Zone-II injury
• Characterized by inability to extend the
DIP joint
• Caused primarily by lacerations or
crush injuries
• Treatment: explore acute lacerations
to rule out tendon involvement.
• Partial lacerations (<50% tendon
substance) do not require repair.
• Com plete lacerations (or partial
lacerations >50%) require suture repair.
• Avoid signif ic ant shortening of the
tendon as will result in lack of f lexion
at DIP joint
 Zone-III injury
• Characterized by f le xed PIP joint without
active PIP extension

• Caused by disruption of the central slip

through both closed and open injuries

• Can lead to boutonniere deformity if not

properly treated

• As the lateral bands migrate volarly , they will

lead to f le xion contracture of the PIP joint
with hyperextension of the DIP.
Central slip repair technique
• Treatment options:
• Extension splinting of the PIP, K-wire fixation with the joint in
extension, tendon reinsertion with bone anchors
• In open injuries, exploration is warranted.
• Clean injuries can be repaired primarily with sutures.
• Splint for 6weeks followed by additional intermittent and night
splinting for 4 to 6 weeks
Zone-IV injury
• Tendons becomes broader over the proximal phalanx, resulting
mainly partial lacerations.
• Tendon injuries in zone iv are often associated with proximal
phalanx fractures.
• The tendon is in close proximity to the proximal phalanx in this
zone; therefore, adhesions are relatively common and may
require secondary tenolysis.
• Treatment: Surgical repair and early active motion
• Partial lacerations of greater than 50% and complete tendon
lacerations are repaired with one or two modified Kessler
• 4-0 core braided polyester sutures and a 5-0 cross-stitch on the
dorsal side of the tendon.
• The core suture should be placed into the relatively thicker area
of the lateral bands toobtain maximal purchase .
• Dynamic splint for early motion of
extensor tendon injuries.
• Elastic traction maintains f ingers in
extension.
• Excursion of the repaired extensor
tendon is achieved by active flexion.
• Splinting is started 3 to 5 days after
surgery and is maintained for
• 5 weeks. Active f lexion is performed
10 times an hour
Zone-V Injury
• At this level, the extensor mechanism includes the tendon and
the sagittal bands.
• The tendon is relatively broad, so complete lacerations are
uncommon.
• Commonly caused by human bite injuries (“fight bite”)
• Treatment: surgical exploration and washout, especially if “fight
bite” is suspected
• If the injury occurred with a clinched fist, the tendon injury
commonly occurs proximal to the skin tear, and the proximal
tendon end will be found proximal with the hand in the open
position.
• Concomitant sagittal band injuries can be treated conservatively
with buddy taping or splinting in cases with stable tendon
injuries, partial lacerations, or closed/ spontaneous ruptures.
• In unstable tendon injuries or old sagittal band injuries, suture
repair is recommended.
 Zone-VI Injury
 Favorable prognosis for several reasons,
• They are unlikely to be associated with a joint injury.
• There is greater tendon excursion, which means that slight
limitation of motion would not lead to the signif ic ant loss of
joint motion seen with injuries over thephalanges.
• Increased subcutaneous tissue lessens the chances of
adhesion formation.
• Core sutures may be easily placed.
• Dynamic splinting can be easily performed.
Zone-VII Injury
• Typically involve open lacerations with multiple tendon
involvement or closed rupture associated with underlying
fractures or arthritis (e.g., EPL rupture associated with distal
radius fractures or rheumatoid arthritis).
• Open lacerations at this level often require opening of the
extensor retinaculum for exposure and repair.
• Concomitant nerve injury is also common; repair if present.
• Treatment: Surgical repair with core and epitendinous sutures
• Closed ruptures of the EPL tendon often cannot be repaired
primarily because of the possibility for unacceptable tendon
shortening in these cases; therefore, primary tendon transfer
(EIP to EPL) is preferred.
Zone VIII and IX Injury
• Often associated with injuries to the musculotendinous
junctions and muscle bellies

• Treatment: Surgical repair of tendons and/or fascial layers with

b ri e f p o sto p e rati v e i m m o b i l i z ati o n ( 3 to 4 w e e ks) i s
recommended.

• Concomitant nerve injuries must be repaired as well.

COMMON TYPES OF CORE SUTURE

Mattress Figure-of-eight Modified Kessler

• In order to achieve maximum core suture strength, locking
stitches are preferred over grasping stitches in order to prevent
suture pull-out and reduce gapping.

• However, grasping suture techniques have a higher tensile

strength and less gap formation in extensor tendon repair than
mattress or figure of-eight stitches.
REFERENCES :
1.Nelligan; principles of plastic surgery 4rth edition volume 6
2.Green,s Operative Hand surgery 6th edition
3.Snell,s Clinical Anatomy By Regions 10th edition