Table of Contents
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.
- Leddy JP, Packer JW. Avulsion of the profundus tendon insertion in athletes. J Hand Surg Am. 1977;2(1):66-69. https://doi.org/10.1016/s0363-5023(77)80012-9
- de Jong JP, Nguyen JT, Sonnema AJ, Nguyen EC, Amadio PC, Moran SL. The incidence of acute traumatic tendon injuries in the hand and wrist: A 10-year population-based study. Clin Orthop Surg. 2014;6(2):196-202. https://doi.org/10.4055/cios.2014.6.2.196
- Smith JH, Jr. Avulsion of a profundus tendon with simultaneous intraarticular fracture of the distal phalanx--case report. J Hand Surg Am. 1981;6(6):600-601. https://doi.org/10.1016/s0363-5023(81)80141-4
- Al-Qattan MM. Type 5 avulsion of the insertion of the flexor digitorum profundus tendon. J Hand Surg Br. 2001;26(5):427-431. https://doi.org/10.1054/jhsb.2001.0619
- Tuttle HG, Olvey SP, Stern PJ. Tendon avulsion injuries of the distal phalanx. Clin Orthop Relat Res. 2006;445:157-168. https://doi.org/10.1097/01.blo.0000205903.51727.62
- Leggit JC, Meko CJ. Acute finger injuries: Part i. Tendons and ligaments. Am Fam Physician. 2006;73(5):810-816.PMID: 16529088.
- Abrego MO, Shamrock AG. Jersey finger. StatPearls. Treasure Island (FL): StatPearls Publishing Copyright © 2020, StatPearls Publishing LLC.; 2020.
- Bachoura A, Ferikes AJ, Lubahn JD. A review of mallet finger and jersey finger injuries in the athlete. Curr Rev Musculoskelet Med. 2017;10(1):1-9. https://doi.org/10.1007/s12178-017-9395-6
- Elzinga KE, Chung KC. Finger injuries in football and rugby. Hand Clin. 2017;33(1):149-160. https://doi.org/10.1016/j.hcl.2016.08.007
- Ruchelsman DE, Christoforou D, Wasserman B, Lee SK, Rettig ME. Avulsion injuries of the flexor digitorum profundus tendon. J Am Acad Orthop Surg. 2011;19(3):152-162. https://doi.org/10.5435/00124635-201103000-00004
- McCallister WV, Ambrose HC, Katolik LI, Trumble TE. Comparison of pullout button versus suture anchor for zone i flexor tendon repair. J Hand Surg Am. 2006;31(2):246-251. https://doi.org/10.1016/j.jhsa.2005.10.020
- Polfer EM, Sabino JM, Katz RD. Zone i flexor digitorum profundus repair: A surgical technique. J Hand Surg Am. 2019;44(2):164.e161-164.e165. https://doi.org/10.1016/j.jhsa.2018.08.015
- Gillig JD, Smith MD, Hutton WC, Jarrett CD. The effect of flexor digitorum profundus tendon shortening on jersey finger surgical repair: A cadaveric biomechanical study. J Hand Surg Eur Vol. 2015;40(7):729-734. https://doi.org/10.1177/1753193415585311
Cite this articleRachel M. Drummey, MSc, Asif M. Ilyas, MD, FACS. Jersey finger repair. J Med Insight. 2021;2021(297). https://doi.org/10.24296/jomi/297
Table of Contents
- 1. Introduction and Surgical Approach
- 2. Incision
- 3. Dissection to Flexor Sheath
- 4. Locate and Mobilize Flexor Tendon
- 5. Tag Flexor Tendon
- 6. Pass Flexor Tendon Through Pulleys
- 7. Preparation of Flexor Tendon Insertion Site on Distal Phalanx
- 8. Reattachment of Flexor Tendon to Insertion Site on Distal Phalanx
- 9. Closure and Reinspection of Motion and Integrity
- 10. Dressing and Splint
- Place Over-the-Top Sutures Through Tendon Stump
- Place Suture Anchor
- Place Anchor Sutures Through Tendon Stump
- Use Keith Needle to Pass Over-the-Top Sutures Around Distal Phalanx
- Bury and Tie Over-the-Top Sutures Directly over the Base of the Dorsal Distal Phalanx
- Assessment of Integrity and Quality of Repair
- Tie Anchor Sutures
Jersey fingers represent a rupture of the flexor digitorum profundus tendon off of its insertion at the base of the distal phalanx. Generally a repair of the tendon is recommended in order to restore DIP flexion and composite flexion. Repair is typically recommended using a Bruner approach to the finger as demonstrated here, and also using a wide-awake local anesthesia technique. Generally the anesthesia consists of 9 cc of 1% Lidocaine and 1 cc of bicarbonate prepared and injected pre-prep and drape. Typically 5 cc are placed over the level of the A1 pulley, 2 cc over the level of the proximal phalanx, 2 cc over the middle phalanx, and 1 cc at the level of the distal phalanx. This is a re-injection of those same sites intraoperatively to augment the prior injection preoperatively.
Once the finger is anesthetized, and the incision is marked, the incision is placed. The level of the tendon can sometimes be determined on preoperative examination and radiographs. As in this case, the tendon was identified to be at the level of the A2 pulley with a small piece of avulsed bone traveling with the tendon that was identified on radiographs. However, in some cases when there is no bony avulsions the tendon can be ruptured and sit as far proximally as the level of the A1 pulley. The more proximal the tendon is retracted, the more likely the vincula have been disrupted, and the more urgent the surgery is.
Once the incision is made, dissection is performed down to the flexor sheath. It's also helpful to identify the neurovascular bundle, so that it can be protected throughout the case.
Based on preoperative exam and upon inspection of the pulley system, it appears that the tendons sitting just distal to the A2 pulley, a small window is made at the level of the A3 pulley, and the tendon is pulled out without any difficulty.
Once the ruptured tendon is retrieved and fully mobilized, a tag stitch is placed using a modified Kessler technique. In this case, a 3-0 Ethibond suture is being used to tag the tendon.
With the tendon tagged, it is now time to pass the tendon through the pulleys. In this case, the A4 pulley is being exposed. With the aid of a hemostat, the tendon is passed across the A4 pulley. A freer is used to guide the tendon through the pulley, using a shoehorn technique. In this case, the A5 pulley is maintained, and the tendon is passed through this pulley as well. Again, a shoehorn technique is used to pass the tendon through this far pulley. Now with the flexor tendon back within the pulley system, it can be held in place with the needle run through the pulley and the tendon.
Next, the base of the distal phalanx is exposed, and the footprint of the flexor tendon insertion site is developed. The repair technique demonstrated here, essentially is a pants-over-vest technique with a suture anchor repair on the volar side, and a over-the-top, pull-out repair on the dorsal side.
Prior to placing the suture anchor in the distal phalanx, the over-the-top sutures are placed in the tendon stump. In this case a 3-0 PDS suture is used, and a double modified locking Kessler technique as shown here.
Next a suture anchor is placed in the base of the distal phalanx on the volar side. In this case, a micro-suture anchor, using a non-metallic anchor is used with a 4-0 non-absorbable suture, as shown here.
Next, the 2 suture ends from the suture anchor are placed through the tendon stump in a mattress fashion, as shown here.
Next, a Keith needle is used to pass the over-the-top, or dorsal, sutures around the distal phalanx, as shown here. The Keith needle travels just along the sides of the base of the distal phalanx, exiting dorsally through the skin making sure to be adequately proximal or lateral to avoid injury to the nail matrix. The over-the-top, or dorsal, sutures provides considerable strength to the repair and allows excellent tension of the tendon up onto its insertion site at the base of the distal phalanx.
The dorsal sutures, or pull-out sutures, have traditionally been repaired over a button or a bolster. My preference, however, is to place these sutures deep by creating an incision and a pocket to retrieve these sutures and then repair them directly over the base of the distal phalanx dorsally. This allows both maximal repair tension, while also burying the sutures and not requiring their removal later. Once satisfied that the tendon sits comfortably upon its footprint upon tensioning of the dorsal sutures, the dorsal sutures are then repaired over the top of the dorsal distal phalanx.
Once the preliminary repair of the tendon has been achieved by the dorsal sutures, the integrity and quality of the repair can be assessed with active motion by the patient and observation of restoration of motion, flexion, and cascade. Once satisfied, the rest of the repair can be completed by sewing down the suture anchor sutures running through the distal stump in a mattress fashion to further reinforce the tendon repair to its footprint.
Once satisfied, all the suture tails can be cut beginning with the suture anchor sutures, the tag sutures, and the dorsal sutures as well.
Once the wound is washed, the wound can be closed. 5-0 chromic is typically utilized.
Prior to final dressing application, the motion can be checked once more...
All right Matt, do me a favor - make a gentle fist for me.
...to make sure that full-motion and integrity was maintained.
And open up. Good, perfect.
Once the wound is closed, a dressing and splint is applied. Specifically, a dorsal extension block splint is applied. This is left on until the patient starts formal supervised hand therapy. Typically therapy is initiated within a few days of the procedure. In addition to the supervised therapy, a dorsal orthoplast extension block splint is also fabricated, and the patient has to wear that full-time for the next 6 weeks postoperatively. After 6 weeks, the splint can be eliminated, and full-motion, including extension of the finger, can be allowed. However, strengthening is held to at least 6 to 8 weeks postoperatively. Thank you for watching this repair of a Jersey finger.