Flexor Digitorum Profundus Avulsion of a Collegiate Football Player: A Case Report

1. Flexor Digitorum Profundus Avulsion of a Collegiate Football Player: A Case Report Angela Perkins, Laurel Petersen, Niki Lanier, David C. Berry, PhD, ATC, EMT-B, Joel Bass, MS, ATC Department of Health Promotion and Human Performance and Athletics* Jerry & Vickie Moyes College of Education Objective • According to the literature, the best delayed treatment plans include leaving the lesion alone, fusing the DIP for stability, tenodesis, or tendon graft. However, the tendon graft has shown a high risk of complications. 4,5 • Clinicians need to be aware of the complications and risks that could potentially develop in a tendon graft of an old FDP avulsion. Other surgical interventions need to be considered for repair. Also, it is important to educate your athletes on the complications and benefits of different surgical interventions so that they are aware and may make the appropriate decision for their needs. • Increased awareness of possible serious injuries to the fingers from a simple “jam” is necessary among athletes. By alerting athletic trainers immediately after initial injury occurs, proper diagnosis can be made and appropriate steps can be taken, including prompt surgical intervention for the best possible outcomes. • Present the case of a collegiate football player that sustained a non-traumatic closed flexor digitorum profundus (FDP) tendon avulsion who underwent a digitorum profundus repair. • Tendon ruptures, including flexor digitorum profundus (FDP) (Figure 1) are a fairly common injuries occurring predominately in young adult males engaged in contact sports such as football and rugby. 1 • FDP injuries (Figure 2) occur when • an athlete’s fingers are maximally • flexed while the fingers are forced • into sudden hyperextension (grabbing • a jersey) causing the tendon to • avulse off of the bone.2 Hence, this • injury is often referred to as a "jersey • finger.” 1,3,4,5, • “Jammed fingers” are also very common and often overlooked. Pain, swelling, loss of motion and strength associated with jammed fingers can mask more serious underlying injuries such as avulsions or fractures.6 When overlooked the optimal time frame for repair may pass, leading to potential loss of finger motion. • Subject • 20-year-old African American wide receiver for an NCAA division 1 football team. • Background • The athlete suffered a closed rupture of the • FDP tendon at the A2 pulley level (Figure 3) • after a blunt trauma to the volar aspect of • the right 4th digit. • However, initial care was delayed approximately 2-3 weeks because the athlete believed he merely jammed his finger. He reported to the athletic trainer upon a secondary jamming of his finger. • Differential Diagnosis • Interphalangeal joint dislocation, phalanx fracture, or flexor digitorum superficialis avulsion. • Treatment • A surgical repair to reattach FDP tendon to the distal phalanx was recommended. However , the surgeon discovered the avulsion was significantly older, resulting in tendon scarring down to the proximal interphalangeal joint. It was decided that a palmaris longus primary graft would be performed (Figures 4 and 5). • The athlete then underwent a flexor tendon rehab protocol focusing on passive range of motion (ROM) (1st 4 weeks) to active ROM and then strength. • Phase I • Goal - Increase range of motion with passive ROM or the DIP, PIP, MCP, and wrist. • Phase I (after 4 weeks) • Goal - Increase active ROM, scar tissue massage, continued passive ROM exercises and add active flexion and extension for the DIP, PIP, MCP, and wrist. • Phase II • Goal - Continued scar massage, passive and active ROM exercises, adding strengthening exercises and nerve glides. • Phase III • Goal – Continue with phase II exercises, joint mobilizations of the wrist and digits, high level strengthening (open-close chain) exercises. • Nevertheless, after 8 weeks post-operative the athlete was unable to actively flex his DIP (Figure 6) and only 50° active flexion at the PIP joint. The incision was healed but there was a significant amount of hardening into the palm underneath incision. The repair was considered a failure. • The mechanism of injury was atypical , as the usual mechanism occurs by grabbing of opponents jersey, and the athlete’s ability to tolerate pain delayed the initial care. • During surgery, it was discovered the involved tendon died two weeks prior, requiring a palmaris longus graft despite its know high failure rate. 4,5 • Postoperatively, the athlete has lost the ability to flex not only the distal interphalangeal joint, but now has limited ability to flex the proximal interphalangeal joint and metacarpal joint as well. • When sustaining an FDP avulsion early recognition and surgical intervention are crucial to the function of the DIP joint. Often the tendon will retract into the palm which require immediate surgical intervention optimally within 7-10 days for the best results. 4,7,8 Figure 6. DIP Joint Figure 4. Figure 5. Uniqueness References Figure 1. • Masson JA. Hand III: Flexor tendons. Selected Readings In Plastic Surgery. 2003;9(34):1-39. • Simman R, Fietti VG. Closed Rupture of the Flexor Digitorum Profundus Tendon of the Left Little Finger. Hospital Physician. 2000: 55-57. • Fu FH, Stone DA. Sports injuries: Mechanisms, prevention, treatment. 2nd ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2001:1097 • Nicholas JA, Hershman EB. The Upper Extremity in Sports Medicine. St. Louise, MI: C.V. Mosby Company; 1990: 595-604 • Reider B. Sports medicine: the school age athlete. Philadelphia, PA; W.B. Saunders company; 1991:221-222 • Minnesota Sports Medicine. The MSM Jammed Fingers, Finger Sprains Common in Sports page. Available at: http://www.msmc.org/consumer/health_info/c_351920.asp. Accessed February 12, 2009. • Anderson MK, Hall SJ, Marin M. Sports injury management. 2nd ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2000:367. • Garrett WE, Kirkendall DT, Squire DL. Principles and practice of primary care: sports medicine.Philadelphia, PA; Lippincott Williams and Wilkins; 2001: 415. Figure 2. Case Report Discussion/Conclusion Figure 3.