Presentation
Two separate right hand injuries involving a leash or rope pulling on the middle finger (8 weeks prior) and then ring finger (6 weeks prior). Both fingers are now swollen and painful and have limitation in flexion.
Patient Data
Intraarticular fractures involve the volar aspects of the distal phalangeal bases of the third and fourth digits (middle/long and ring fingers). The fragments appear corticated, indicating subacute to chronic age. Both fragments are proximally displaced. The fracture of the third digit involves half of the articular surface for the distal interphalangeal joint.
There is a permeative appearance to the bone of the third and fourth digits that most likely represents regional osteopenia/hyperemia secondary to the fractures.
Ossific fragment distal to the ulnar styloid represents an old avulsion fracture versus ossification of the triangular fibrocartilage complex. Degenerative changes are scattered along the interphalangeal joints and first carpometacarpal joint.
Red arrows point to the avulsed fracture fragments at the volar side of the bases of the middle/long and ring finger distal phalanges.
A marker is placed dorsal to the space between the distal third and fourth digits.
Third digit (middle/long finger):
- Complete rupture of the third flexor digitorum profundus tendon at its insertion on the distal phalanx with retraction to the level of the proximal interphalangeal joint
- Near complete rupture of the third flexor digitorum profundus tendon at the level of the mid metacarpal
- Chronic appearing comminuted fracture of the base of the distal phalanx
- Normal flexor digitorum superficialis tendons
- Soft tissue edema in the volar aspect of the digit
Fourth digit (ring finger):
- Comminuted fracture of the base of the distal phalanx, with
- 4 mm displacement of the osseous fragment
- marrow edema within the distal phalanx
- involvement of the volar plate
- Normal flexor digitorum profundus and superficialis tendons
- Soft tissue edema in the volar aspect of the digit
- Chronic avulsion fractures of the bases of the third and fourth distal phalanges, unchanged
- Third finger distal interphalangeal joint appears held in hyperextension
- Persistent soft tissue swelling of the third finger
Interval fusion of the long finger distal interphalangeal joint by means of two K wires and a cerclage/tension wire.
Case Discussion
Distal phalangeal volar base fractures are consistent with jersey finger. The mechanism of injury is hyperextension, such as pulling on the jersey of a football opponent running away from you, or in this case a rope or leash. Jersey finger represents an avulsion-type injury involving the flexor digitorum profundus, at its distal osseous insertion and/or more proximally in the tendon itself.
The patient was initially managed conservatively, with buddy taping and then occupational therapy. MRI was obtained to assess whether the tendon was still attached to the osseous fragment (Leddy and Packer type III vs. type IV), which affects surgical planning. The middle/long finger was a Leddy IV injury ("double avulsion" with retraction of tendon from fracture fragment) and the ring finger was a Leddy III injury (large avulsion fracture fragment, which cannot retract beyond the A4 pulley of the middle phalanx).
Tendon repair/reconstruction was offered but declined. The patient developed a mild boutonniere deformity of the long finger, which was bothersome and treated with fusion of the distal interphalangeal joint.
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