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FLEXOR TENDON AVULSION (JERSEY FINGER)

Introduction

Avulsion of the flexor digitorum profundus insertion, with or without an associated bone fragment, is an injury that can be missed easily at first presentation. Successful operative intervention requires early recognition and treatment, otherwise, complex flexor tendon surgery will be needed.  

Pathophysiology

  • An abrupt extension force applied to the flexed digit can rupture the FDP insertion at the distal phalanx.  This type of force can be generated by a sudden pull on a grasped jersey collar during an attempted tackle in football or rugby.

Related Anatomy

  • Flexor digitorum profundus
  • Distal phalanx
  • Distal interphalangeal joint (DIP)
  • Vinculum breve and vincula longa
  • Flexor tendon zone I
  • DIP volar plate
  • The oblique ligament of Landsmeer

Incidence and Related Conditions

  • 75% of cases involve the 4th digit.1
  • Leddy & Packer defined 3 types of avulsion depending on how far proximally the FDP tendon retracted. 1
  • Type II is the most common.
  • This classification has been extended to include types IV2 and V.3
TypeFDP tendon withdraws to:Concomitant pathology:
IPalm
  • Rupture of long and short vincula
IIPIP joint (FDP at distal edge of A-2 pulley)
  • Small osseous avulsion, trapping the tendon
  • Rupture of short vinculum
IIIDIP joint (A-4 pulley)
  • Large osseous avulsion, trapping the tendon
IVPalm
  • Avulsed osseous fragment trapped at DIP joint, separated from tendon
  • Rupture of long and short vincula
VDIP joint
  • Osseous avulsion + fracture of distal phalanx shaft at the metaphysis

− Va: extra-articular

− Vb: intra-articular 

DIP, distal interphalangeal; FDP, flexor digitorum profundus; PIP, proximal interphalangeal.

Differential Diagnosis

  • Trigger finger
  • Swan neck deformity
  • Anterior interosseous nerve (AIN) palsy
ICD-10 Codes

  • FLEXOR TENDON AVULSION (JERSEY FINGER)

    Diagnostic Guide Name

    FLEXOR TENDON AVULSION (JERSEY FINGER)

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    FLEXOR TENDON STRAIN (FOREARM LEVEL) (JERSEY FINGER)(AVULSION)    
    - INDEX S56.112_S56.111_ 
    - MIDDLE S56.114_S56.113_ 
    - RING S56.116_S56.115_ 
    - LITTLE S56.118_S56.117_ 
    - THUMB S56.012_S56.011_ 
    FLEXOR TENDON STRAIN (WRIST AND HAND LEVEL)    
    - INDEX S66.111_S66.110_ 
    - MIDDLE S66.113_S66.112_ 
    - RING S66.115_S66.114_ 
    - LITTLE S66.117_S66.116_ 
    - THUMB S66.012S66.011_ 

    Instructions (ICD 10 CM 2020, U.S. Version)

    THE APPROPRIATE SEVENTH CHARACTER IS TO BE ADDED TO EACH CODE FROM CATEGORY S56 AND S66
    A - Initial Encounter
    D - Subsequent Routine Healing
    S - Sequela

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
Clinical Photos FDP Rupture (Jersey Finger)
  • Four month old left ring FDP rupture in female rugby player
    Four month old left ring FDP rupture in female rugby player
  • High School football player with limited flexion ring ring after an injury in last weekend's game
    High School football player with limited flexion ring ring after an injury in last weekend's game
  • Note lack of DIP joint flexion when tenodesis affect is used to flex the football player's fingers
    Note lack of DIP joint flexion when tenodesis affect is used to flex the football player's fingers
  • Thirty-three year old carpenter who felt a pop while pushing a heavy piece of wood through the table saw
    Thirty-three year old carpenter who felt a pop while pushing a heavy piece of wood through the table saw
  • Carpenter notes that at age three a glass broke in his hand. He was told that the doctors removed glass from his palm (arrows)
    Carpenter notes that at age three a glass broke in his hand. He was told that the doctors removed glass from his palm (arrows)
  • Patient presents with a eight month old tag football injury. Patient complaining of weak grip and decreased ring finger flexion.
    Patient presents with a eight month old tag football injury. Patient complaining of weak grip and decreased ring finger flexion.
  • Pulvertaft weave repair of PL graft to intact proximal FDP is beginning
    Pulvertaft weave repair of PL graft to intact proximal FDP is beginning
  • Checking graft tightness prior to closing palm incision. Note ring slightly more lifted the adjacent fingers in the resting posture
    Checking graft tightness prior to closing palm incision. Note ring slightly more lifted the adjacent fingers in the resting posture
Pathoanatomy Photos and Related Diagrams
Flexor Tendon Rupture Imaging
  • X-ray of ringer finger jersey finger injury with avulsion fracture fragment (arrow) caught at the level of PIP vincula and chiasma of Camper
    X-ray of ringer finger jersey finger injury with avulsion fracture fragment (arrow) caught at the level of PIP vincula and chiasma of Camper
  • MRI of ringer finger jersey finger injury with distal end of FDP tendon (arrow) caught at the level of PIP vincula and chiasma of Camper
    MRI of ringer finger jersey finger injury with distal end of FDP tendon (arrow) caught at the level of PIP vincula and chiasma of Camper
Finger Flexor Tendon and Joint Anatomy
  • A. Extensor tendon; B. Central slip; C. Oblique fibers of dorsal aponeurosis; D. Lateral slip; E. Conjoined lateral band; F. Triangular ligament; G. Terminal extensor tendon; H. Flexor digitorum profundus; I. Volar plate; J. A-2 & A-4 pulleys; K. Flexor digitorum superficialis; L. Transverse retinaculum; M. Accessory collateral ligament; N. Proper collateral ligament. During a flexor tendon avulsion injury the FDP (H) is torn from its insertion into the distal phalanx
    A. Extensor tendon; B. Central slip; C. Oblique fibers of dorsal aponeurosis; D. Lateral slip; E. Conjoined lateral band; F. Triangular ligament; G. Terminal extensor tendon; H. Flexor digitorum profundus; I. Volar plate; J. A-2 & A-4 pulleys; K. Flexor digitorum superficialis; L. Transverse retinaculum; M. Accessory collateral ligament; N. Proper collateral ligament. During a flexor tendon avulsion injury the FDP (H) is torn from its insertion into the distal phalanx
  • H. Flexor digitorum profundus; I. Volar plate; J. A-2 & A-4 pulley; K. Flexor digitorum superficialis; L. Transverse retinaculum. During a flexor tendon avulsion injury the FDP (H) is torn from its insertion into the distal phalanx.
    H. Flexor digitorum profundus; I. Volar plate; J. A-2 & A-4 pulley; K. Flexor digitorum superficialis; L. Transverse retinaculum. During a flexor tendon avulsion injury the FDP (H) is torn from its insertion into the distal phalanx.
Symptoms
Swelling of the affected digit
Pain/tenderness at DIP, PIP, and or MP joints
Inability to actively flex DIP joint
Typical History

This injury is typically caused by an attempted tackle in football or rugby when clothing is grasped. The forcible extension of the digit during active flexion can result in FDP avulsion.  This forceful extension occurs as the player who is being tackled runs away from the player attempting to make the tackle so quickly that this player cannot let go.

Positive Tests, Exams or Signs
Work-up Options
Treatment Options
Conservative
  • Asymptomatic late cases can be left untreated.1
Operative
  • Timing is critical for successful repair. Some types require immediate surgery, owing to disruption of the blood supply to the distal tendon;4 others can be delayed3 (see Table).
     
TypeProcedureTime restrictions
I
  • Suture repair
7–10 days
II
  • Suture repair
3 weeks
III
  • Fixation of bone fragment
3 months
IV
  • Fixation of bone fragment
  • Suture of tendon
7–10 days
V
  • Stabilization of phalanx/DIP joint
  • Fixation of bone fragment
2 weeks
(later for undisplaced Type Va)
  • Options for late interventions
    • Two stage tendon graft
    • Fusion or capsulodesis of the DIP joint if unstable with FDP excision and FDS tenolysis1
Treatment Photos and Diagrams
Treatment Options for Rupture FDP Tendon
  • Note swollen flexor tendon sheath at PIP joint (arrow) secondary to avulsed (ruptured) left ring FDP in female rugby player.
    Note swollen flexor tendon sheath at PIP joint (arrow) secondary to avulsed (ruptured) left ring FDP in female rugby player.
  • Curciate pulley opened and FDP stump (in clamp) dissected free. Intact FDS at arrow.
    Curciate pulley opened and FDP stump (in clamp) dissected free. Intact FDS at arrow.
  • FDS tenolysis complete and FDP pulled into the palm and ready for excision.
    FDS tenolysis complete and FDP pulled into the palm and ready for excision.
  • Carpenter ruptures 30 year old FDP repair. Distal end of FDP at #1. Intact FDS repair at #2. Ruptured FDP repaired with primary PL tendon graft.
    Carpenter ruptures 30 year old FDP repair. Distal end of FDP at #1. Intact FDS repair at #2. Ruptured FDP repaired with primary PL tendon graft.
  • Patient presents with a eight month old tag football injury with incisions for reconstruction outlined.
    Patient presents with a eight month old tag football injury with incisions for reconstruction outlined.
  • Retracted scarred FDP being dissected free at distal edge of A-2 pulley after opening cruciate pulley at PIP joint.
    Retracted scarred FDP being dissected free at distal edge of A-2 pulley after opening cruciate pulley at PIP joint.
  • FDP being dissected free and ready to be brought into the palm.
    FDP being dissected free and ready to be brought into the palm.
  • Damaged FDP delivered into the palmar incision primal to the A-1 pulley which has been partially opened.
    Damaged FDP delivered into the palmar incision primal to the A-1 pulley which has been partially opened.
  • FDP stump with hypertrophic tenosynovium (1) and volar plate (2)
    FDP stump with hypertrophic tenosynovium (1) and volar plate (2)
  • Distal stump of FDP being dissected free at DIP joint level.
    Distal stump of FDP being dissected free at DIP joint level.
  • Proximal arrow FDP attached to edge of A-1 pulley with a tagging 2-0 proline suture and distal FDP stump ready to suture to Hunter rod (distal arrow).
    Proximal arrow FDP attached to edge of A-1 pulley with a tagging 2-0 proline suture and distal FDP stump ready to suture to Hunter rod (distal arrow).
  • Hunter rod passed through flexor sheath
    Hunter rod passed through flexor sheath
  • Hunter rod being sutured to volar plate and FDP stump
    Hunter rod being sutured to volar plate and FDP stump
  • Testing Hunter rod attachment to distal phalanx
    Testing Hunter rod attachment to distal phalanx
  • Excess Hunter rod removed and incisions for stage I reconstruction of FDP rupture closed.
    Excess Hunter rod removed and incisions for stage I reconstruction of FDP rupture closed.
  • Three months after stage I, Stage II of FDP reconstruction is done. Here the palmaris longs (PL) graft is being harvested through three small incisions. Tendon stripper could also be used
    Three months after stage I, Stage II of FDP reconstruction is done. Here the palmaris longs (PL) graft is being harvested through three small incisions. Tendon stripper could also be used
  • Proximal FDP in clamp and PL graft attached temporarily to the proximal end of the Hunter rod.
    Proximal FDP in clamp and PL graft attached temporarily to the proximal end of the Hunter rod.
  • PL graft being sutured to FDP stump and volar plate. Repair here to be completed and incision closed before attaching graft to the proximal FDP
    PL graft being sutured to FDP stump and volar plate. Repair here to be completed and incision closed before attaching graft to the proximal FDP
CPT Codes for Treatment Options

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Common Procedure Name
Flexor tenolysis
CPT Description
Tenolysis, simple, flexor tendon; palmar or finger, single, each tendon
CPT Code Number
26440
Common Procedure Name
Pulley reconstruction with graft
CPT Description
Reconstruction of tendon pulley, each tendon; with local tissues with tendon or fascial graft (includes obtaining graft)
CPT Code Number
26502
CPT Code References

The American Medical Association (AMA) and Hand Surgery Resource, LLC have entered into a royalty free agreement which allows Hand Surgery Resource to provide our users with 75 commonly used hand surgery related CPT Codes for educational promises. For procedures associated with this Diagnostic Guide the CPT Codes are provided above. Reference materials for these codes is provided below. If the CPT Codes for the for the procedures associated with this Diagnostic Guide are not listed, then Hand Surgery Resource recommends using the references below to identify the proper CPT Codes.

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Complications
  • In conservatively managed cases, the necrotic tendon may lead to tenderness in the digit or palm and require excision.
  • Flexor tendon advancement during repair may cause quadrigia and result in weakening of the neighboring digits and can cause chronic fixed contracture of the ring finger.
  • DIP joint and digit stiffness
  • Operative repair that damages the volar plate may occasionally lead to flexion contracture of the DIP joint.1
Outcomes
  • In one study, 100% (12/12) patients had satisfactory results after tendon reinsertion; there was a 10–15° extension deficit but good flexion and, in patients treated early, grip strength approached normal values.1
  • Although several reconstructive and repair methods have been developed, none has yet been shown to result in a consistently superior clinical outcome.5,6
Video
Active range of motion left hand ring finger after FDS excision and FDP tenolysis
Using tenodesis affect to test flexor tendon graft tensioning
Pulling palmaris longus graft into finger as the Hunter rod is removed from the finger tip
Checking for secure suturing of PL graft to the distal phalanx
YouTube Video
Flexor Digitorum Profundus Avulsion (Jersey Finger Injury)
Key Educational Points
  • Prompt diagnosis and surgical intervention is critical for successful repair and outcome.  
  • Although Leddy & Packer cautioned against damaging the volar plate, 1 a recent biomechanical study showed that fixing the avulsed tendon to the volar plate with sutures prevented gapping of the repair under loads expected during active motion rehabilitation. 7 These findings were supported by a study in an animal model.8
  • Correct classification with the use of physical examination, x-rays, and/or MRI aids in surgical preparation and execution.  
  • Various tendon and tendon to bone repair techniques exist and should be tailored to each specific patient.  These repairs should provide a strong reconstruction that will not fail during early active range of motion with the hand therapist.  
References

Cited and New Articles

  1. JP, Packer JW. Avulsion of the profundus tendon insertion in athletes. J Hand Surg Am 1977;2(1):66-9. PMID: 839056
  2. Smith JH Jr. Avulsion of a profundus tendon with simultaneous intraarticular fracture of the distal phalanx--case report. J Hand Surg Am 1981;6(6):600-1. PMID: 7310087
  3. Al-Qattan MM. Type 5 avulsion of the insertion of the flexor digitorum profundus tendon. J Hand Surg Br 2001;26(5):427-31. PMID: 11560423
  4. Leversedge FJ, Ditsios K, Goldfarb CA, et al. Vascular anatomy of the human flexor digitorum profundus tendon insertion. J Hand Surg Am 2002;27(5):806-12. PMID: 12239668
  5. Ruchelsman DE, Christoforou D, Wasserman B, et al. Avulsion injuries of the flexor digitorum profundus tendon. J Am Acad Orthop Surg 2011;19(3):152-62. PMID: 21368096
  6. Huq S, George S, Boyce DE. Zone 1 flexor tendon injuries: a review of the current treatment options for acute injuries. J Plast Reconstr Aesthet Surg 2013;66(8):1023-31. PMID: 23672773
  7. Brar R, Owen JR, Melikian R, et al. Reattachment of flexor digitorum profundus avulsion: biomechanical performance of 3 techniques. J Hand Surg Am. 2014;39(11):2214-9. PMID: 25227598
  8. Al-Dubaiban WI, Al-Abdulkarim AO, Arafah MM, Al-Qattan MM. Flexor tendon-to-volar plate repair: an experimental study and 3 case reports. J Hand Surg Am 2014;39(11):2222-7. PMID: 25282718
  9. Bachoura A, Ferikes AJ, Lubahn JD.  A review of mallet finger and jersey finger injuries in the athlete.  Curr Rev Musculoskelet Med 2017;10:1-9. PMID: 28188545

Classic Articles

  1. JP, Packer JW. Avulsion of the profundus tendon insertion in athletes. J Hand Surg Am 1977;2(1):66-9. PMID: 839056
  2. Smith JH Jr. Avulsion of a profundus tendon with simultaneous intraarticular fracture of the distal phalanx--case report. J Hand Surg Am 1981;6(6):600-1. PMID: 7310087

Review Articles

  1. Al-Qattan MM. Type 5 avulsion of the insertion of the flexor digitorum profundus tendon. J Hand Surg Br 2001;26(5):427-31. PMID: 11560423
  2. Leversedge FJ, Ditsios K, Goldfarb CA, et al. Vascular anatomy of the human flexor digitorum profundus tendon insertion. J Hand Surg Am 2002;27(5):806-12. PMID: 12239668
  3. Ruchelsman DE, Christoforou D, Wasserman B, et al. Avulsion injuries of the flexor digitorum profundus tendon. J Am Acad Orthop Surg 2011;19(3):152-62. PMID: 21368096
  4. Huq S, George S, Boyce DE. Zone 1 flexor tendon injuries: a review of the current treatment options for acute injuries. J Plast Reconstr Aesthet Surg 2013;66(8):1023-31. PMID: 23672773
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