Jersey Finger Repair
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 it's 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 it's 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.