Turkish Journal of Plastic Surgery

CASE REPORT
Year
: 2021  |  Volume : 29  |  Issue : 5  |  Page : 61--63

Surgical options in chronic extensor tendon subluxation: A case report and a literature review


Gokce Yildiran, Cemil Isik, Osman Akdag, Zekeriya Tosun 
 Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery Division, Selcuk University Medical Faculty, Konya, Turkey

Correspondence Address:
Dr. Gokce Yildiran
Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery Division, Selcuk University Medical Faculty, Konya
Turkey

Abstract

Ulnar subluxation of the extensor tendons at the metacarpophalangeal joint level after damage to the sagittal bands is a rare problem in nonrheumatoid patients. It is aimed to discuss the treatment options for the extensor tendon subluxation and present a rare chronic case. A 25-year-old male patient presented with the complaint of stucking and snapping feeling in the middle finger when moving it after falling as a child. Type 2 sagittal band injury was detected in which the extensor tendon was subluxated to the ulnar side, and the sagittal band was strengthened with a junctura tendinum flap harvested from the adjacent finger. The patient returned to his daily life, and no recurrence was detected. Extensor tendon subluxation is the instability that occurs in the tendon as a result of damage to the sagittal bands. Many techniques have been described since the ideal technique is not available yet. Techniques that provide realignment by centralizing the extensor tendon are successful ones that can be preferred in chronic sagittal band ruptures and in professional athletes in whom primary repair is not possible.



How to cite this article:
Yildiran G, Isik C, Akdag O, Tosun Z. Surgical options in chronic extensor tendon subluxation: A case report and a literature review.Turk J Plast Surg 2021;29:61-63


How to cite this URL:
Yildiran G, Isik C, Akdag O, Tosun Z. Surgical options in chronic extensor tendon subluxation: A case report and a literature review. Turk J Plast Surg [serial online] 2021 [cited 2022 May 25 ];29:61-63
Available from: http://www.turkjplastsurg.org/text.asp?2021/29/5/61/311432


Full Text



 Introduction



Ulnar subluxation of the extensor tendons at the metacarpophalangeal joint level after damage to the sagittal bands is a rare problem in nonrheumatoid patients.[1] Sagittal bands begin from the volar plate and deep transverse metacarpal ligaments, and they are the primary stabilizers of the extensor tendon. Sagittal bands are not in the form of a real band, as they are a thick deep layer similar to a groove at the base of the extensor tendon and a thin superficial layer on the surface of the extensor tendon.[2] In case of a traumatic rupture, a spontaneous rupture, or a congenital absence of sagittal bands, instability occurs in the extensor tendon. As the radial side bands tend to be ruptured, ulnar tendon instability is more common than radial.[2]

Rayan and Murray divided sagittal band injuries into three types: Type 1 is characterized by tenderness, and there is no tendon instability. Type 2 is characterized by tendon subluxation, but it is in contact with the metacarpal head. In type 3, tendon dislocation is severe enough to be between two metacarpals[3] [Figure 1].{Figure 1}

Many surgical techniques have been described in the literature, such as splinting, realignment and primary repair, and tendon reconstruction and its modifications.

In acute injuries, surgery is required in sagittal band injuries that can be treated with splinting for up to 3 weeks, in type 3 injuries, and in failed nonoperative treatments. If possible, directly repairing the sagittal bands is the first option. When not possible, tendon reconstruction is performed.

It is aimed to discuss the treatment options for the extensor tendon subluxation and present a rare chronic case.

 Case Report



A 25-year-old male patient presented with the complaint of his finger feeling stuck when moving it after falling as a child. In the physical examination of the patient who described the third finger extensor tendon slip and tendon snapping, type 2 sagittal band injury was detected in which the extensor tendon was subluxated to the ulnar side [Figure 2]a and [Figure 2]b. In the surgical treatment, the extensor tendon was explored, a flap was harvested from the junctura tendineum to the adjacent finger, and the radial side was strengthened by positioning the tendon to its normal central location [Figure 3]a, [Figure 3]b and [Figure 4]. After 1 week of plaster splint and 2 weeks of thermoplastic splinting, hand physiotherapy was initiated, and the patient returned to his daily life [Figure 5]a and [Figure 5]b. No recurrence was detected in the postoperative 2-year follow-up.{Figure 2}{Figure 3}{Figure 4}{Figure 5}

 Discussion



Extensor tendon subluxation is the instability that occurs in the tendon as a result of damage to the sagittal bands. Many techniques have been described since the ideal technique is not available yet. Anatomical studies have shown that the third finger extensor tendon has a more rounded structure and looser fibrous connections than others.[1] For this reason, the third finger is more likely to have extensor tendon subluxation.

The surgical treatment of old extensor tendon dislocations was described by Haberern in 1902, as primary suturation. The treatment of the extensor tendon was reported to be successful by recirculating the radial side of the hood.[1],[4] Afterward, many authors have provided good results with primary suturation and a full joint motion without dislocation.[3],[5],[6],[7] Brewood and Menon prevented instability using a volar capsule and radial collateral ligament repair.[8]

Another repair technique is to reconstruct a check rein using a palmaris longus tendon graft or a fascia strip to prevent recurrent subluxation.[9],[10],[11] Reconstruction, such as the use of a piece of the extensor tendon in the form of a flap, has also been performed for the sagittal band reconstruction. The Elson technique is a rigid reconstruction technique, and its modifications have been reported in the literature.[12] Wheeldon sutured a flap from the adjacent finger's junctura tendineum to the ruptured sagittal band over the extensor tendon for sagittal band rupture. Fernández-Vázquez and Ayala-Gamboa identified 21 dislocations in 18 fingers and used the repair with Wheeldon's technique in seven patients, combined sagittal band repair and Wheeldon's technique in four patients, and the primary repair of the sagittal band and Carroll's technique in others.[13] All these techniques are based on the repair or reconstruction of the tendon and the sagittal band.

In the presented case, Wheeldon's technique was preferred, and the junctura tendineum flap was used to centralize the tendon [Figure 4]. As it is not an acute injury, primary suturation could not be used. In an injury to the long finger, the junctura tendineum, which goes to the ring finger, is cut from its place close to the ring finger. In addition, aggressive techniques are not required for ligament reconstruction in patients with an existing sagittal band stump. In chronic extensor tendon subluxation, although a reconstructive technique is usually required, Wheeldon's technique as a surgical method is an easy reconstruction procedure in experienced hands. Suturation of the junctura tendineum flap on the extensor tendon to the sagittal band remnant is an effective method.

Watson et al. looped around the deep transverse ligament using the radial strip and immobilized the metacarpophalangeal joint with a K-wire for 3 weeks at 15°–30°.[14] Almost all the usually preferred nonoperative treatments in acute ruptures include a 3–5-week immobilization period.[2] However, a 3-week immobilization is quite a long period for each hand and wrist, especially for young people and athletes. Splinting is also required when ligament reconstruction is performed because this period is necessary for the reconstructed ligament complex to adhere. Although there are various rehabilitation regimens, resting splint for 0–4 weeks, motion splint for the next 2 weeks, and strengthening exercises for the next 1–2 months are the minimum.

Magnetic resonance imaging or ultrasound is not required in the diagnosis or treatment planning of extensor tendon subluxation. It may show synovitis in the presence of an underlying rheumatoid arthritis that causes rupture, but it is not an absolute necessity. Some patients, especially those with type 1 sagittal band injury, can be treated as if they are triggered as they describe restrictions in flexion. However, especially in types 2 and 3 injuries, patients usually feel and see the extensor tendon slide over the metacarpal head. Although its diagnosis is easy by experienced clinicians, it is a disease in which many surgical techniques are defined for its repair, indicating many difficulties in the treatment. Undoubtedly, the most important complication of all these surgical treatments is relapse. However, the recurrence rate is low when splinting and physiotherapy are conducted. Vaccaro et al. encountered recurrence in one of 26 patients.[15] No recurrence was encountered during the follow-up of the presented case.

 Conclusion



The sagittal band is the primary structure that stabilizes the extensor tendon at the level of the metacarpophalangeal joint, as it must be able to resist the ulnar deviations of the extensor tendon. Techniques that provide realignment by centralizing the extensor tendon are successful ones that can be preferred in chronic sagittal band ruptures and in professional athletes in whom primary repair is not possible. Stucking, snapping, and triggering are the main complaints for the patients, and the surgical techniques should be kept in mind in chronic tendon subluxation cases.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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