Jersey Finger Repair

Jersey finger, also known as rugby finger, is an avulsion to the flexor digitorum profundus at its insertion on the base of the distal phalanx (zone I). It is frequently caused by forceful extension of the distal interphalangeal joint while actively flexing the flexor digitorum profundus. The tendon may tear from the distal phalanx independently or may avulse with a bony fragment. A classification system has been developed to categorize distinct injury patterns based upon the level to which the flexor digitorum profundus tendon retracted and the presence or absence of a bony avulsion fracture. Flexor digitorum profundus tendon rupture has been reported in all age groups but is most common in athletes. The injury frequently occurs during contact sports, notably American football and rugby, when grabbing the jersey of an opposing player as the player pulls or runs away. Surgical repair is the definitive treatment for all cases of complete rupture of the flexor digitorum profundus tendon. This video demonstrates a surgical approach using the suture anchor technique to repair a jersey finger injury. 

Jersey finger refers to an avulsion of the flexor digitorum profundus (FDP) at its insertion on the distal phalanx, the weakest point of the tendon.¹ The injury frequently occurs during contact sports while grabbing the jersey of an opposing player as the player pulls or runs away.¹ It can occur on any digit, although 80% of cases are reported in the ring finger. Zone I flexor tendon injuries account for 4% of acute traumatic tendon injuries to the hand and wrist, which occurs at a rate of 33.2 per 100,000 person-years.²

The classification system of a jersey finger injury is based on the level of tendon retraction and the presence or absence of a fracture. Types I-III were first described by Leddy and Packer in 1977, and two additional types, IV and V, have since been added.^1, 3, 4

• Type I: FDP tendon retracts to the palm at the lumbrical origin.
• Type II: FDP tendon retracts to the A3 pulley at the proximal interphalangeal (PIP) joint.
• Type III: Avulsion of a large bony fragment. Both FDP tendon and fracture fragment retract to the A4 pulley, as the bone fragment limits further retraction.
• Type IV: Avulsion of a large bony fragment with an accompanying rupture of the FDP tendon off the bony fragment. Since the avulsed FDP is not attached to the bony fragment, the FDP retracts into the palm.
• Type V: Avulsion of a large bony fragment, accompanied by another significant fracture of the distal phalanx. 

Patients often present with pain and tenderness on the volar aspect of the finger after a sport-related trauma. Some patients may note a pop or tear that was felt in the finger at the time of injury.  

Inability to actively flex the distal interphalangeal (DIP) joint is the pathognomonic physical exam finding.⁵ Pain, ecchymosis, and edema may also be present along the volar aspect of the affected phalanx and the retracted FDP tendon proximally.^5, 6 While in the resting position, the injured finger will usually remain extended relative to the other digits.⁷ Palpation of the flexor tendon is important in providing the surgeon preoperative information on the extent of the injury, as the point of maximal tenderness often represents the distal stump of the tendon.⁵

To confirm the diagnosis of jersey finger and assess in preoperative localization, ultrasound has been reported as the most cost-effective imaging modality. Radiographs may be used to assess for fractures or bony avulsion fragments.^7, 8Magnetic resonance imaging provides the most detail and can identify the extent of proximal retraction of the flexor tendon.

Without surgical intervention, patients with a jersey finger may experience chronic pain and a permanent decrease in both range of motion and strength upon composite finger flexion.^7, 9 This may occur due to the development of scar tissue and the tendency for the tendon to continue to retract more proximally.¹⁰ 

Surgical repair is the definitive treatment for all cases of complete rupture of the FDP tendon. The degree of tendon retraction determines the urgency of surgery as a tendon that retracts further is more likely to disrupt the vincula and should be rapidly repaired. Although it is largely agreed that surgery should be performed as early as possible in almost all cases. The repair should be completed within three weeks from the injury for best postoperative outcomes.⁷ Non-surgical treatment is pursued only if the patient is unable or unwilling to undergo surgery or unable to comply with postoperative rehabilitation protocols.

There are a variety of surgical approaches used for acute surgical repair, including the pull-out button and suture anchor technique, which have not been shown to yield statistically different clinical outcomes.^11, 12 In cases of chronic injury, typically defined as greater than three months post-injury, a more complex surgical approach may be recommended, such as a single- or two-stage tendon graft versus a DIP joint arthrodesis.^1, 7, 12

Surgery is necessary to reestablish a pain-free active range of motion of the affected digit and restore blood flow.⁷ The suture anchor technique was utilized in this case due to surgeon preference as it has been shown to achieve equivalent clinical outcomes to other techniques.^11, 12 

When working with athletes, the surgeon and patient must weigh the benefits of returning to play with the risks associated with delaying treatment until the end of the season. 

This case presents a jersey finger repair, which entails reattachment of the FDP to its insertion site on the distal phalanx. Overall, patients with early diagnosis and surgical repair achieve excellent patient-reported outcomes.⁵ Patients may return to sport and normal activity within 8–12 weeks with effective postoperative rehabilitation.^7, 8 Effective postoperative rehabilitation is imperative for the prevention of scar contracture formation and is crucial to maintain finger function.⁷ Degree of postoperative function is dependent on various factors, including classification of injury, chronicity, precision of repair, and the rehabilitation protocol. 

The typical surgical time is 30–60 minutes, and the procedure can be performed under sedation or simply wide awake under local anesthesia alone. Surgeon preference is to perform jersey finger repairs under local anesthesia for ease, safety, and cost effectiveness, but also to be able to assess the repair intraoperatively. Complications associated with jersey finger repair include adhesions, joint contracture, re-rupture, loss of fixation, infection, and quadriga, the inability to flex the adjacent digit to the repair due to increased tension over the repaired tendon.^8, 13 The risk of complications can be minimized with early diagnosis, prompt repair, and effective postoperative rehabilitation.

The best technique for repair of FDP avulsion remains unclear. In this case, suture anchors are utilized in place of the more traditional pull-out button technique for potentially stronger repair, no presence of external fixation devices, avoidance of button related complications, and ease of rehabilitation.¹² Comparable clinical outcomes have been reported between these two techniques with the only difference being that the suture anchor group reported a significantly quicker return to work in one study.¹¹ The suture anchor technique enables maximal repair tension without requiring later removal. It corrects for many of the risks associated with the pull-out button technique, such as nail bed injury, and high risk of skin necrosis and infections. However, the suture anchor technique has its own limitations. This technique has shown to fail at greater rates in osteoporotic bone, and anchors typically require additional distal advancement of the FDP, which may increase the risk of postoperative contracture.^8, 10 As there is no consensus in the field as to the best surgical approach, research is ongoing and investigating a wide array of surgical techniques and equipment—including bone anchor-dorsal button combinations, and the use of biologics in both suture material and tendon wraps.^10, 12

No special equipment used.

Nothing to disclose. 

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.

The authors would like to thank the Operating Room staff for their help in making this video.