Techniques in Harid arid [Jpper Exiremil)’ Suvgen. 2(1):50-55, 1998 0 1998 Lippincoil-Rave,? Pubhrhers.

Philadelphia
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W N I w

Zone I- V Extensor Tendon Repair

MARYLYNNNEWPORT,
M.D.
Department of Orthopaedic Surgery,
University of Connecticut Health Center,
Farmington, Connecticut, U.S.A.

he extensor mechanism is as complex and intrigu-

2 sule inspected. The joint itself can be injected with meth-
ing as any in the hand. It is subject to a variety of ylene blue or saline to confirm its integrity.
imbalances and is not infrequently injured. Extensor ten- Complete laceration of the extensor tendon in zone I
don lacerations are accompanied by associated injuries, or I1 inevitably demonstrates a significant droop at the
wch fracture or joint capsule damage, approximately distal interphalangeal (DIP) joint and an inability to ex-
two-thirds of the time, making a “simple” tendon injury tend that joint. Open injuries in zone I11 can be less obvi-
significantly more complex (9). These injuries are any- ous. If there is an injury to the central slip but the lateral
thing but simple. We have been made increasingly aware bands remain intact, the patient may be able to extend
that extensor tendon injuries do not fare uniformly well fully the proximal interphalangeal (PIP) joint. There will
and that greater attention should be focused on them, be pain or weakness with resisted extension, however,
both clinically and experimentally. Newport et al. and these circumstances require the treating physician to
showed that, by using a modification of the Miller classi- prove there is no extensor injury by direct observation of
fication system, only 31% of all extensor injuries in the the entire wound. Lacerations in zone IV may provide the
distal area (I-IV) achieved good or excellent results after same diagnostic dilemma as those in zone 111if the lateral
static splinting (9). In addition, loss of flexion occurred bands are intact.
with greater frequency and to a greater degree than did Injuries to the extensor mechanism are quite common
loss of extension. Loss of flexion obviously compromises in zone V, either through laceration or through sharp
the function of the hand to a greater degree than does loss trauma against a clenched fist. Sharp laceration should
of extension. More aggressive postoperative protocol4 arouse sufficient suspicion to make the diagnosis. The
have improved the results for proximal injuries and show wound in clenched-fist injuries can be deceptively small,
promising results for the more distal injuries, especially but significant damage to the extensor mechanism and
in zones 111and IV (1-6,14). metacarpophalangeal (MP) joint capsule can occur. As
The present report discusses our treatment for both open with zone 111injuries, the wound must be thoroughly ex-
and closed injuries of the extensor mechanism in zones plored. Unrecognized capsular damage will not infre-
I-V and postoperative treatment. These rehabilitation quently lead to the devastating complication of septic
protocols are at least, or perhaps more, important than the arthritis, whereas joint capsule damage appropriately
surgical technique. treated with irrigation and debridement does not decrease
the quality of result after extensor injury (9).
Closed injuries to the extensor mechanism occur with
some frequency, especially over the joints of the finger
The diagnosis of an extensor tendon injury should be (zones I, 111, and V). In zone I, the bony or soft tissue mal-
straightforward when there is a large wound on the dor- let finger is usually not difficult to diagnose, although pa-
sum of the hand or finger. Smaller wounds demand a tients will frequently present rather late for treatment.
high index of suspicion because the initial deformity may Rupture of the central slip in zone I11 can be difficult to
be subtle or not apparent. Extensor tendon injuries over- diagnose, especially if the patient is seen very early. In
lying joints require thorough investigation to ensure that this case, the lateral bands remain intact and allow full
the laceration has not entered into the joint. If any doubt joint extension, although usually it is somewhat painful
exists, the laceration must be extended and the joint cap- and weak. These injuries frequently present with the
mechanism of injury and the clinical picture is consistent
with a “sprain” of the joint, with generalized swelling
Address correspondence and reprint requests to Dr. Mary Lynn about the joint. Unlike true sprains, however, joint tender-
Newport, Department of Orthopaedic Surgery, University of
Connecticut Health Center, 10 Talcott Notch Road, Farmington, CT ness will be dorsal rather than the usual lateral and/or
06034-4037,U.S.A. volar tenderness of the sprain. If the diagnosis is enter-

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50 Techniques in H a n d and lipper Extremity Surgery

 Zone I-V Extensor Tendon Repair

tained but unconfirmed, injection of radio-opaque dye can

show a tear in the dorsal joint capsule, which presump-
tively confirms extensor injury. These injuries are not in-
frequently seen later, after the boutonniere develops. The
sequence of events producing a boutonniere deformity is
well understood: loss of continuity in the central slip and
joint swelling produce PIP joint flexion. The untethered
lateral bands gradually slip volar to the joint axis of rota-
tion and contribute to the PIP flexion deformity and ulti-
mately produce hyperextension at the DIP as well.
Closed injuries in zone V are almost always sec-
ondary to damage of the sagittal bands rather than to the
central extensor mechanism. The radial sagittal band is
usually the one injured, allowing the tendon to slide into
the ulnar intermetacarpal valley. The long finger is the
most frequently affected, secondary to weaker and fewer
fibers inserting from the central tendon into the MP joint
capsule (7). Forced flexion or extension of the MP joints
can produce this injury, as can a blow to dorsum of the
hand. The severity of the injury is usually mild, and signs
FIG. 1. The tenodermodesis technique of extensor ten-
and symptoms are accordingly benign. The patient may don repair in zones I and II. Both tendon and skin are in-
have noted a mild snap or pop over the knuckle associ- cluded in the repair.
ated with minimal pain. They often describe difficulty or
inability to initiate actively the extension of the MP joint.
Once extended, however, patients are usually capable of weeks in a full-time dorsal alumifoam splint, which has
sustaining the joint in that position, as least early in the most but not all of the foam padding removed (13). This
postinjury period. With time, the extensor tendon can be- treatment prevents the finger from sinking into the foam
come fixed in the intermetacarpal valley and extension and being pulled into hyperextension, which may com-
can no longer be maintained. promise the blood supply to the dorsal skin. Patients
seem to appreciate having the volar touchpad available
for use. Volar splints and the Stack splint are also appro-
TECHNIQUE
priate. Stern and Kastrup showed a significant complica-
Zones I and II tion rate for dorsal splints, most of which were skin re-
Open lacerations of the extensor tendon in zone I have lated and reversible (15). Appropriate and careful patient
not been studied as extensively as extensor injuries in education for these injuries is of utmost importance if
other zones. In general, any suture technique that accu- good results are to be obtained. Another minute or two
rately apposes the tendon ends should be appropriate. 1 taken during this explanation is usually sufficient to
frequently use the tenodermodesis technique (8) because avoid potential skin complications.
it seems to tear or fray the tendon ends the least (Fig. 1). For the bony mallet, where significant volar subluxa-
The repair should be protected with a transarticular tion of the distal phalanx has occurred (Doyle type IV-C),
Kirschner wire. The substance of the tendon in this zone the joint is manipulated into appropriate alignment under
is tenuous, and the chances for repair failure are signifi- fluoroscopic control. A K-wire is inserted percutaneously
cant without careful protection. The transarticular K-wire across the joint. This treatment is usually feasible for sev-
also allows better access to the skin for wound care. The eral days after injury. The inadequacy of the fracture re-
K-wire itself must also be protected with a volar or dor- duction seldom causes a painful or stiff DIP joint, and the
sal splint to prevent wire breakage. resultant slight dorsal bump is usually acceptable to the
Direct repair with a simple or mattress technique or patient. For those patients in whom the DIP joint cannot
tenodermodesis with a supplemental K-wire is also the be reduced, an open repair of the injury should be per-
procedure of choice in zone 11. formed, with the major focus being on reduction of the
Complete treatment of mallet deformities is outside joint. After the joint is reduced and held in position with
the scope of this article. In general, however, I treat these a transarticular K-wire, the extensor mechanism is ap-
injuries as conservatively as possible. For a soft tissue posed to the distal phalanx, with a pull-out suture exiting
mallet or bony mallet without significant volar subluxa- on the volar finger tip. Anatomic reduction of the bony
tion (Doyle type I and IV-B), I treat the patient for 6 fragment is not attempted because this usually results in

Volume 2, Issue 1 51
A B

FIG. 2. A, B: Open treatment

of bone mallet with incomplete
approximation of bony frag-
ment to the distal phalanx. C,
D: Postoperative result.

C D

unreconstructable comminution that requires use of the A transarticular K-wire is generally not recom-
fame suture pull-out method (Fig. 2). mended for injuries in zones I11 and IV unless there is
bony injury to warrant it or the patient is very unreliable.
Zones III and IV Any injury to the lateral band(s) should be repaired
In zones I11 and rV, repair of the central tendon should be primarily with fine (5-0 or 6-0) absorbable suture in a
performed emergently if there has been capsular damage. simple or mattress fashion.
It can be done urgently (within 3-5 days) if no joint in- The treatment of closed injuries in zone I11 is straight-
jury has occurred. Anesthesia should be adequate to al- forward after the diagnosis is made. An alumifoam splint,
low good visualization of the tendon ends. These repairs used dorsally or volarly, is applied to the PIP joint alone.
are generally better performed in the operating room, A dorsal splint allows better DIP motion, which is needed
where there is good lighting and adequate access to ap- to keep the lateral bands mobile and pull the extensor
propriate equipment. Simple injuries, without joint in- mechanism distally, thereby decreasing tension on the in-
volvement, can be done in the emergency department but jured central slip. A dynamic outrigger can be used for
junior-level trainees should receive sufficient supervision these closed injuries, but the results of static splinting are
to perform an adequate repair. The incision used should excellent and the treatment much simpler.
provide not only adequate visualization of the central
tendon but also the lateral bands. Using 4-0 suture mate- Zone V
rial, the central tendon is repaired by a modified Bunnell As with zone 111 injuries, lacerations of the extensor
or Kessler technique. These techniques have been shown mechanism in Lone V should be handled emergently if vi-
to be the strongest and most biomechanically advanta- olation of the joint capsule has occurred and less urgently
geous for extensor repair in these zones (10). Newer it’ the joint is intact. The laceration of the skin should be
techniques that are stronger and have better failure modes extended adequately to inspect the zone of injury and to
are currently being developed and tested. be certain that there is no injury to the sagittal band(s).
 Zone I-V Extensov Tendon Repair

The extensor tendon should be repaired with the modified

Bunnell repair technique because this technique has been
shown to be the best repair method in zones V and VI
(12). After thorough irrigation, the joint capsule can be
closed with fine absorbable sutures if contamination has
been low or left open and drained when contamination is
extensive. The sagittal band(s), if injured, should be re-
paired primarily with fine (5-0) absorbable suture in a
simple or mattress fashion. Care is taken to center and an-
chor the tendon properly over the metacarpal head so it
has no tendency to sublux with MP motion.
Closed injury of the sagittal band in zone V should be
treated by surgical approximation. If the injury is diag-
FIG. 3. Hand-based resting splint for injuries in zones
nosed very early, good results can be obtained with III-v.
closed treatment in a cast (13). However, most injuries
are not identified early, and the repetitive subluxation of
the extensor tendon makes it unlikely that the ends of the are held in 0" extension. The MP joint can be included in
sagittal bands can be adequately apposed in this fashion. the splint, held at approximately 15", or it can be left free.
Therefore, I favor a surgical approach with direct ap- We prefer to include the MPjoint because it makes a more
proximation of the sagittal bands with fine (5-0) ab- comfortable, formfitting splint that is less likely to fall
sorbable suture. The repair technique is as described for off or require constricting straps to keep it in place. In ad-
laceration of these fibers. Postoperatively, a cast is ap- dition, the extensor musculature has been found to be in-
plied with the MP joints in full extension and PIP joints appropriately active with flexion or passive extension if
left free. The wrist is in neutral or slight extension. the MP is held at 0" (11). Flexing this joint slightly elimi-
nates inappropriate, and perhaps detrimental, muscle ac-
tivity. The patient 5witches to a second splint three to four
REHABILITATION
times a day for therapeutic exercises. The affected fin-
Zones I and II ger(s) is actively flexed to the splint, which is curved to
Rehabilitation after closed or open injuries in zones I and I1 allow approximately 30" of flexion at the PIP. The patient
is focused on regaining range of motion without attenuat- then actively extends the finger to neutral (Fig. 4A, B).
ing the healing process after removal of the splint or K- After 1-2 weeks, the exercise splint can be changed to al-
wire. Immediately after injury or surgery, we institute an low 40" of flexion. All splinting is discontinued 5-6
aggressive therapy regimen of active and passive range-of- weeks after repair and full active range-of-motion exer-
motion exercises so that the PIP and MP joints remain mo- cises have begun. If adhesions are the primary cause of
bile. Full-time immobilization is discontinued at approxi- poor results after extensor repair, this postoperative
mately 6 weeks for both open and closed injuries. Patients method should improve the quality of results by prevent-
then perform active range-of-motion exercises only. If there ing those adhesions from forming. In addition, no increase
is weak extension or the patient is older, the splint is worn in extensor lag has been noted with this rehabilitation
at bedtime only for an additional 6 weeks. At approxi- technique, so it would appear that the repair is not attenu-
mately 12 weeks, all immobilization is discontinued and ating. The early application of this protocol does several
passive range-of-motion exercises begun if full motion has things. It keeps adhesions from forming, thereby allowing
not already been attained. At this juncture, we also allow better flexion. By decreasing adhesions, active extension
patients back to all forceful activities without limitation. is also improved. The stress that would ordinarily be re-
quired to overcome adhesions but could cause repair at-
Zones Ill and IV tenuation with resultant extension lag is also eliminated.
It is our philosophy to move these tendon injuries as ag- The treatment of a closed rupture of the extensor
gressively as the overall injury and psychological makeup mechanism in zone 111 is theoretically simple. The PIP
of the patient allow. The repair strength of the original joint is brought to full extension and held in that position.
modified Bunnell technique has been shown theoretically If there is a flexion contracture, it must be corrected
and experimentally to be capable of withstanding typical through serial casting or through dynamic splinting. On
forces across it if short arc active motion is performed rare occasions, this conservative treatment is unsuccess-
(5,lO). The short arc active motion protocol employs a ful and surgical release of the PIP joint is required. After
volar, hand-based splint that is worn continuously be- full PIP extension has been accomplished, static splinting
tween exercise periods (Fig. 3). The DIP and PIP joints is begun. The patient is instructed in active and passive

Volume 2.Issue I 53
 M . L. Newpovt

A B

FIG. 4. A, B: Short arc active motion in postoperative treatment of extensor tendon injury in zones Ill-V,

range-of-motion exercises for the DIP joint. This regimen a repair that is strong enough to withstand active motion in
is continued for approximately 6 weeks. short arcs. This method has produced gratifying results in
our early trials, with excellent range of motion and no ex-
Zone V tensor lag or repair ruptures. The achievement of full flex-
We have traditionally treated lacerations of the extensor ion is particularly important because this is the arc most
tendons in zone V with dynamic splinting. With the advent frequently and significantly lost after extensor injury (9).
of a stronger suture technique and better understanding of The rationale for early motion should be extended to
active rehabilitation protocols, we are now using active patients with associated injury or with stable fixation of
motion as the postoperative treatment of choice for this the phalangeal or metacarpal fractures so that early ten-
zone. The MP joint is held in slight flexion and the DIP and don motion can be instituted. We know that the results af-
PIP joints are held in full extension in a hand-based splint, ter these combined injuries are significantly worse than
leaving the wrist free. The patient switches to a similar after simple tendon laceration, thus making adhesion pre-
splint that allows 30-40" of flexion at the MPjoint several vention even more important in this population (9).
times per day. Active flexion to the volar stop and active Extensor tendon injuries, although easily diagnosed
extension to neutral position are repeated several times at and often minimized, can result in significant loss of
each exercise session. No repair ruptures or extension lag hand function. Aggressive treatment of the injury with
using this method has yet occurred. The composite range meticulous repair and early mobilization improve the
of motion of the finger usually reaches normal soon after quality of the result and should cause us to focus on these
discontinuing the splint, usually within 1-2 weeks. Lacer- injuries as carefully as we do flexor tendon injuries.
ation to the sagittal band(s), when it occurs, necessitates
buddy taping of the affected finger to the appropriate adja-
cent finger(s) to prevent any radial or ulnar deviation that REFERENCES
could disrupt the repair of these delicate fibers. 1) Browne EZ Jr, Ribik CA. Early dynamic splinting for ex-
The postoperative regimen used after repair of closed tensor tendon injuries. J Hand Surg 1989;14A:72-6.
rupture of the sagittal bands is slightly different. There is lit-
2) Chow JA, Dovelle S, Thomes LF, Ho PK, Saldana J. A
tle risk of adhesion formation to affect the outcome ad- comparison of results of extensor tendon repair followed by
versely, so early motion is less critical. We typically immo- early controlled mobilization versus static immobilization.
bilize the hand and wrist in a short arm plaster that includes J Hand Suvg 1989;14B:18-20.
the MP joints, which are held in full extension. Active range 3) Doyle JR. Extensor tendons: acute injuries. In: Green DP,
of motion of the PIP joints is encouraged. After 4 weeks, Hotchkiss RN, eds. Operative hand surgery, 3rd ed. New
immobilization is discontinued. Buddy taping the affected York: Churchill Livingstone, 1993:1925-54.
finger to the adjacent radial finger is recommended for 4) Evans RB, Burkhalter WE. A study of the dynamic
heavy tasks or athletics for another 1-2 months. anatomy of extensor tendons and implications for treat-
ment. J Hand Surg 1986;IlA:74-9.
5 ) Evans, RB, Thompson DE. An analysis of factors that sup-
port early active short arc motion of the repaired central
Just as we emphasize gliding protocols after flexor tendon slip. J Hand Ther 1992;5:187-201.
injury, we also follow that philosophy after extensor ten- 6) Kerr CD, Burczak JB. Dynamic traction after extensor ten-
don injury. The extensor tendon injury itself should be don repair in zone 6,7, and 8: a retrospective study. J Hand
treated as meticulously as flexor injuries. We try to obtain Surg 1989;14B:21-2.

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54 Techi7ique.s in Hand and Upper Extremity Surgev
 Zone I-V Extensor Tendon Repair

7) Kettlekamp DB, Flatt AE, Moulds R. Traumatic dislocation namic extensor splinting. J Hand Surg 1992;17A:272-7.
of the long-finger extensor tendon: a clinical, anatomic, and 12) Newport ML, Williams CD. Biomechanical characteristics
biomechanical study. J Bone Joint Surg 1971;53A: of extensor tendon suture techniques. J Hand Surg 1992;
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8) McFarlane RM, Hampole MK. Treatment of extensor ten- 13) Rayan GM, Murray D. Classification and treatment of
don injuries of the hand. Can J Surg 1973;16:366-74. closed sagittal band injuries. J Hand Surg 1994;19A:
9) Newport, ML, Blair WF, Steyers CM Jr. Long-term results 590-4.
of extensor tendon repair. J Hand Surg 1990;15A:961-6. 14) Saldana MJ, Choban S, Westerbeck P, et al. Results of acute
10) Newport ML, Pollack GR, Williams CD. Biomechanical zone 111 extensor tendon injuries treated with dynamic ex-
characteristics of suture techniques in extensor zone IV. J tension splinting. J Hand Surg [Am] 1991;16:1145-50.
Hand Surg 1995;20A:650-6. 15) Stem PJ, Kastrup JJ. Complications and prognosis of treat-
11) Newport ML, Shukla A. Electrophysiologic bias of dy- ment of mallet finger. J Hand Surg 3998;13A:329-34.

Volume 2, Issue 1 55