A Novel Technique for the Treatment of Jersey Fingers

May 9, 2018 | Surgery

Nathan Patrick, MD ; Kent Weinheimer, MD ; Michael Darowish, MD

TAKE-HOME POINTS

Transosseous repair of FDP has been long utilized, tying the sutures over a polyethylene button at the nail plate, which is associated with significant complications.
Avoiding use of a button decreases these complications, eliminating damage to the nailbed and eliminating external sutures, thus decreasing infection risk.
Keith needles can be utilized to pass the sutures from volar to dorsal, and can be inserted using a wire drive; their position can be checked fluoroscopically prior to suture passage.
This technique can be used in conjunction with skeletal fixation of associated fractures.
This technique can be utilized in pediatric patients, placing the sutures distal to the physis.

Bone suture anchor techniques were later utilized to repair FDP avulsions in an attempt to decrease complications associated with the external suture-button construct.⁷ The use of a transosseous suture without external button fixation has also been proposed. Sood and Elliot⁸ described a technique where the suture is passed through a hole, drilled transversely through the tuft of the distal phalanx, and affixed to the other limb. In 1999, Schultz and colleagues⁹ described a technique where transosseous tunnels are placed in the distal phalanx in a dorsal-to-volar direction. The suture is then passed through and tied on the dorsal surface. In this article, we propose a transosseous suture technique that may provide advantages over previously described methods.

SURGICAL TECHNIQUE

TYPES I, II, AND III

A Bruner incision is performed on the volar aspect of the affected finger, and full thickness flaps are elevated off the flexor sheath (Figures 1A-1C).

The avulsed FDP tendon is retrieved in the usual fashion, and its insertion is identified. A 2-0 braided polyester suture is run in a Krakow fashion along the distal aspect of the FDP tendon and passed along its normal course under the A4 pulley (Figure 1B). Using a K-wire driver, 2 Keith needles are then driven through the base of the distal phalanx. The needles exit dorsally proximal to the germinal matrix. Once the appropriate positioning of the Keith needles is confirmed through fluoroscopic imaging (Figure 2), a dorsal counterincision is made, and the skin flaps are bluntly elevated.

Each limb of the 2-0 suture is passed individually through 1 of the Keith needles, and the FDP tendon is inspected to ensure that it can be brought distally to its insertion with good tendon-to-bone contact (Figure 1C). The finger is brought into flexion, and the sutures are securely tied dorsally over the distal phalanx and the extensor tendon (Figure 3).

The incisions are closed, and a dorsal blocking splint is applied with the wrist and fingers in flexion.

TYPES IV AND V

In cases of type IV or V injury (Figure 4A), a screw or plate construct is first used to allow for the successful reduction and fixation of the fracture (Figure 4B).

Once completed, the tendon avulsion is addressed in the same fashion as previously described, with the repair being performed atop the affixed fragment.

DISCUSSION

The avulsion of the FDP tendon from its insertion (zone I) on the distal phalanx is commonly called “jersey finger” and is a well-described injury that occurs most commonly in the ring finger.¹⁰ These injuries can be difficult to treat and are associated with a complication rate of as high as 60%.^11,12 Bunnell’s initial description of a suture passed through the fingernail and then tied over a polypropylene button has been associated with multiple complications. Kang and colleagues¹³ reported abnormal nail growth, nail fold necrosis, fingertip deformity, stiffness, infection, and amputation, 43% of all complications were directly related to the button. As an alternative to the button, sutures may be tied directly over the nail plate itself via 2 separate holes.¹⁴ While this technique eliminates the complications directly associated with the button, the potential for infection remains. Additionally, increased direct pressure is placed on the nail plate and nail bed, thus potentially increasing the risk of nail deformity.

In 1994, Hallock⁷ initially described the use of bone anchors as an “internal fixation” alternative and cited the “expense of the apparatus” as the major drawback of this technique. McCallister and colleagues¹⁵ compared the clinical outcome of suture anchor fixation with that of the button-over-nail technique. Although they ultimately demonstrated that the clinical outcomes of the 2 techniques are not significantly different, they noted that suture anchor fixation is associated with decreased infection rate (7% vs 0%) and time to return to work. Poor bone mineral density and low cortical thickness are correlated with anchor pull-out, thus limiting its universal use.¹⁶ Furthermore, the universal use of many commonly available anchors is limited given that they are too large to be accommodated within many phalanges, particularly in women and in the small and ring fingers.¹⁷ The use of microanchors rather than mini anchors not only decreases this risk but also decreases construct strength, thus necessitating the use of 2 anchors to restore adequate fixation strength. Anchor use is associated with specific risks, including the dorsal migration of the anchor, the osteolysis of the surrounding bone, as well as the perforation of the dorsal cortex and the possible extrusion of the anchor through the phalanx and into the nail bed.^18,19 Additionally, in the wake of a changing healthcare system, the cost of suture anchors, as initially noted by Hallock,⁷ must be considered. This consideration is particularly relevant to the use of a 2 microanchor construct, which has been advocated given its biomechanical advantage.^20,21

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References