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Extensor Tendon Repair

46 citationsUpdated Aug 2026

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Overview

Extensor tendon injuries are common [1]. Early recognition and treatment are key to the management of extensor tendon injuries [1]. However, a lack of evidence-based knowledge is observed in the surgical treatment and postoperative management of extensor tendon injuries [2]. Current real-world practices for extensor tendon repair lag behind expert recommendations, with significant discrepancies in splinting methods, repair techniques, and early motion protocols across continents [7]. Active motion regimens are desirable after repair of flexor tendons in all zones but are not always suitable for all extensor tendon repairs [21]. The included studies on zone IV extensor tendon early active mobilization programs reported minimal data on outcomes specific to zone IV extensor tendon repairs [5].

Nonsurgical treatment is supported for the majority of mallet finger injuries, although surgical indications remain unclear [14]. Surgical repair of the extensor mechanism brought good results in a case of Boutonniere deformity of the second toe after plantar dislocation of the proximal interphalangeal joint [4]. Extensor tendon salvage and reconstruction using a tendon from an unsalvageable finger may be a reasonable remedy for reconstruction of tendon loss or gaps in zone I, offering advantages over other traditional techniques in certain cases [3]. The Wyndell Merritt Immediate Controlled Active Motion (ICAM) Protocol provides a safe, low-profile, cost-effective alternative for post-operative treatment of zone IV–VII extensor tendon repairs [17].

Extensor indicis proprius to EPL tendon transfers result in good long-term functional and patient-reported outcomes [10]. In cases where direct repair of EIP rupture is not possible, a tendon transfer technique allowing independent extension of the index finger is recommended [12]. Both tendon transfer and tendon graft for extensor tendon ruptures in rheumatoid hands achieve satisfactory results that are maintained for an average of 14 years [13].

Anatomy & Pathophysiology

Injuries to the finger extensor apparatus are very common and may produce chronic deformity and loss of function [16]. Injury to the extensor mechanism, specifically the central slip, can lead to snapping or catching at the proximal interphalangeal (PIP) joint in the finger [48]. In acute Boutonniere deformity, extension of the PIP joint decreases as structures are progressively damaged [50].

Complete section of the sagittal bands in the little finger caused ulnar dislocation of the extensor tendon in only one out of seven hands [28]. In controlled conditions, there is a variation in resistance to flexion of the distal interphalangeal joint following central slip injury, but the amplitude of the forces is likely imperceptible clinically [37]. Improvement in digit range of motion following nonoperative treatment of Boutonniere deformity was associated with initiation of treatment within 6 weeks, but not with any particular type or length of conservative treatment [53].

Classification

Early recognition and treatment are key to managing extensor tendon injuries [1]. Injuries to the finger extensor apparatus may produce chronic deformity and loss of function [16]. Understanding extensor tendon anatomy, variations, and mechanisms of injury is crucial for analyzing and treating injuries to the system [15].

Anatomic Zoning: The extrinsic extensor tendons represent the terminal extensions of muscles that arise proximally from the lateral forearm and receive innervation from the proper radial nerve or its posterior interosseous branch [26]. At the level of the wrist, extrinsic extensor tendons are delineated into six compartments ordered in a radial-to-ulnar fashion [26]. The first compartment contains the abductor pollicis brevis (APB) and extensor pollicis brevis (EPB) [26]. The fifth compartment contains the extensor digiti minimi (EDM) [26]. The sixth compartment contains the extensor carpi ulnaris (ECU) [26]. The thumb has its own separate classification system consisting of five zones [26]. The extensor tendon apparatus of the fingers and wrist has been divided into nine anatomic zones to help guide management and injury rehabilitation [26].

Closed Rupture Classification: Closed extensor tendon ruptures are well-described following traumatic hand and wrist injuries such as distal radius fractures [26]. Subacute or delayed rupture of the EPL, EDC, or EIP has been reported in up to 5% of patients following distal radius fractures [26]. Ruptures often occur more than 6 weeks from the initial traumatic injury [26]. EPL rupture is often attributable to hematoma and swelling in the tight tendon sheath at a vascular watershed area, which weakens the tendon and predisposes it to rupture [26]. ECU overuse or instability is a frequent source of ulnar-sided wrist pain [26].

Sagittal Band Classification: Sagittal band injuries can be difficult to treat, particularly in the setting of delayed presentations [55]. A modification to the sagittal band classification system aims to incorporate the spectrum of disease seen, guide treatment, and allow standardization when documenting and describing injuries [55].

Other Considerations: A panel recommends adapting a simpler classification system resembling that for flexor tendons to facilitate surgical decision-making and rehabilitation [8]. The authors propose a simpler classification system for extensor tendon zones to align with current treatment strategies, such as conservative splinting for closed injuries and strong surgical repair for open injuries [36]. A classification of extensor tendon zones based on the presence of the extensor retinaculum is preferable to those based on the wrist joint, as it simplifies treatment discussion and aligns with flexor tendon zoning [43].

Clinical Presentation

Extensor tendon injuries are more common than flexor injuries due to their exposed superficial location [34]. In the United States, over 45,000 such injuries are seen in emergency departments annually, corresponding to a rate of 14/100,000 [35]. Common etiologies include sports, physical altercations, farm equipment, self-mutilation, crush injuries, and other trauma [34].

Etiology and Presentation Patterns: * Acute Trauma: Most closed extensor tendon injuries can be treated conservatively in the acute phase [11]. * Chronic/Delayed Rupture: Subacute or delayed rupture of the extensor pollicis longus (EPL), extensor digitorum communis (EDC), or extensor indicis proprius (EIP) occurs in up to 5% of patients following distal radius fractures, often more than 6 weeks from the initial injury [26]. * Chronic Instability: Chronic extensor tendon injuries often require operative intervention [11]. * Ulnar-Sided Pain: Overuse or instability of the extensor carpi ulnaris (ECU) is a frequent source of ulnar-sided wrist pain [26].

A detailed history and physical examination is crucial in the management of extensor tendon injuries [34]. Extensor tendon injuries are divided into 8 anatomic zones, with each zone having a unique combination of anatomic elements and cross-sectional tendon size that dictates the approach to treatment [35]. Specific compartment anatomy includes: * First Compartment: Contains the abductor pollicis brevis (EPB) and extensor pollicis longus (EPL) [26]. * Thumb Extension: The thumb's MP and IP joint extension is driven by two extrinsic extensor tendons, the extensor pollicis brevis (EPB) and longus (EPL) [26]. * Fifth Compartment: Contains the extensor digiti minimi (EDM) [26]. * Sixth Compartment: Contains an additional extensor of the wrist, the extensor carpi ulnaris (ECU) [26]. * Thumb Classification: A separate classification system consisting of five zones has been described with respect to the thumb [26].

Extensor tendon injuries in the pediatric population require careful evaluation and treatment [34]. Treatment of pediatric extensor tendon injuries depends largely on the site of injury [34]. A majority of pediatric extensor tendon injuries may be treated with splinting or primary repair [34]. Treatment methods requiring high compliance must be adjusted for young children [34]. Children with extensor tendon injuries typically have excellent to good results with good functional outcomes [34]. Children have the ability to heal rapidly and regain motion easily despite prolonged immobilization [34].

Investigations

Plain radiography: Advanced imaging may be considered when tendon irritation is clinically suspected [59]. Carpal boss excision may be indicated to prevent attrition or rupture of digital extensor tendons [59].

Treatment

Extensor tendon injuries require early recognition and treatment for effective management [1]. However, there is a lack of evidence-based knowledge regarding the surgical treatment and postoperative management of these injuries [2]. A consensus panel recommends adapting a simpler classification system resembling that for flexor tendons and outlines specific treatment approaches for acute extensor tendon injuries in each zone to facilitate surgical decision-making and rehabilitation [8].

Non-Operative

Most closed extensor tendon injuries can be treated conservatively in the acute phase, but chronic injuries often require operative intervention [11]. Early active motion protocols and dynamic extension orthosis fabrication result in increased grip strength and better functional results compared to static orthosis fabrication [9]. Relative motion extension (RME) orthoses plus management for finger zones V-VI extensor tendon repairs are non-inferior to dynamic WHFO orthoses in terms of total active motion, therapy and orthotic satisfaction, QuickDASH scores, and grip strength [45].

Operative

Indications: Surgical intervention is indicated for chronic closed injuries and open injuries. The terminal tendon hemilateral band technique is used for patients with open injuries at the level maintained for 8 weeks, after which occupational therapy is initiated [29]. Limited literature exists on the use of allograft for extensor tendon reconstruction, with available evidence purporting comparable results with traditional autograft [29].

Surgical Approach / Technique: A modified Becker extensor tendon repair with 1 cross-stitch provides superior mechanical properties for loads seen with postoperative rehabilitation compared with 2 and 3 cross-stitches for similar loads [57]. The modified technique using a distally based flexor digitorum superficialis slip provides a robust repair that anatomically mimics the extensor central slip while maintaining the function of the donor FDS tendon [6]. Extensor indicis proprius to EPL tendon transfers yield good long-term functional and patient-reported outcomes [10]. Traumatic index extensor tendon attenuation can be treated successfully by shortening the attenuated tendon in combination with tendon graft or transfer [18]. Two-staged extensor tendon reconstruction is suitable for long tendon defects in zone 6 with or without zone 7 defects, providing full or near-full active flexion at the MCP joints, though minor extension lags (10°–15°) are common [19].

Zone 3 Considerations: Satisfactory results can be obtained after open extensor injuries in Zone 3 using early debridement, tendon grafting, and vascularized skin cover [24]. There is no significant difference in outcomes between patients who had tendon repair immediately and those who had surgery between 1 to 11 days after their injury in open Zone 3 extensor tendon injuries [24]. There is no significant difference in outcomes between patients with partial disruption of the central slip and those with complete tears in open Zone 3 extensor tendon injuries [24]. There is no significant difference in outcomes between patients who sustained a bone injury and those who did not in open Zone 3 extensor tendon injuries [24].

Other Considerations: Literature describing surgical, post-operative management, and outcomes following EDC repairs in close proximity to or within the extensor retinaculum is limited [23]. With modern anesthesia techniques, tendon lacerations in a healthy neonate can be managed in a timely and safe manner [58].

Complications

Extensor tendon injuries are common, and early recognition and treatment are key to management [1]. Literature describing surgical, post-operative management, and outcomes following extensor digitorum communis (EDC) repairs in close proximity to or within the extensor retinaculum is limited [23].

Stiffness / Arthrofibrosis: Patients must be counseled on the likelihood of limited range of motion and the possibility of repeat procedures for swan neck and boutonniere deformities [60].

Poor Outcomes: Patients should be counseled about the difficult nature of central slip fractures (volar fracture subluxations/dislocations of the proximal interphalangeal joint) and the expected poor outcomes [63].

Other Considerations: Patients with chronic extensor tendon injuries or those failing nonoperative management may benefit from surgical exploration [61]. Complete extensor tendon failure due to drill penetration is rare [62]. Ciprofloxacin-induced tendon rupture appears to be possible in the extensor digitorum communis tendons of the hand [64].

Recovery

Light activity (weeks): Specific week ranges for light activity are not provided in the current evidence base.

Full activity (months): Specific month ranges for full activity are not provided in the current evidence base.

Complete recovery / outcome plateau (months): Specific month ranges for complete recovery are not provided in the current evidence base.

Rehabilitation protocol: The panel recommends adapting a simpler classification system resembling that for flexor tendons to facilitate surgical decision-making and rehabilitation [8]. Active motion regimens are desirable after repair of the flexor tendons in all zones but are not always suitable for all extensor tendon repairs [21]. For surgical repairs of the central slip in zone III, the use of a single orthosis throughout the entire protected phase of rehabilitation is an easy, cost-effective, and successful way to treat these injuries [39].

Functional milestones: Two-staged extensor tendon reconstruction is suitable for long tendon defects in zone 6 with or without zone 7 defects, providing full or near-full active flexion at the MCP joints [19]. Minor extension lags (10°–15°) are common following two-staged extensor tendon reconstruction for zone 6 defects [19]. Extensor tendon reconstruction using WALANT surgery allowed intraoperative measurement of active ROM, confirming near-complete extension and flexion after reconstruction [31]. Extensor indicis proprius to EPL tendon transfers show good long-term functional and patient reported outcomes [10]. Surgical repair of the extensor mechanism brought good results in a case of Boutonniere deformity of the second toe after planter dislocation of the proximal interphalangeal joint [4]. The use of an adipofascial flap to repair the dorsal capsule after capsulotomy may allow for primary healing, reducing relapse caused by secondary fibrosis and providing a better gliding surface for the extensor tendon in chronic boutonnière deformity reconstruction [30].

Other Considerations: No additional recovery-relevant content outside the specified labels is present in the evidence base.

Key Evidence

  • [L5] Extensor tendon injuries are common and early recognition and treatment are key to the management of such injuries. [1] (10.1016/j.hcl.2014.12.006)
  • [L4] Despite recent research findings, a lack of evidence-based knowledge is still observed in surgical treatment and postoperative management of extensor tendon injuries. [2] (10.1055/s-0036-1572534)
  • [L4] Extensor tendon salvage and reconstruction using a tendon from an unsalvageable finger may be a reasonable remedy for reconstruction of tendon loss or gaps in zone I, offering advantages over other traditional techniques in certain cases. [3] (10.1016/j.jhsa.2014.01.029)
  • [Case_report] Surgical repair of the extensor mechanism brought good results. [4] (10.1007/s00402-009-0816-x)
  • [L1] The included studies reported minimal data on outcomes specific to zone IV extensor tendon repairs. [5] (10.1016/j.jht.2022.12.001)
  • [L4] The modified technique provides a robust repair that anatomically mimics the extensor central slip yet maintains the function of the donor FDS tendon. [6] (10.1016/j.jhsa.2009.01.025)
  • [L4] Current real-world practices for extensor tendon repair lag behind expert recommendations, with significant discrepancies in splinting methods, repair techniques, and early motion protocols across continents. [7] (10.1177/17531934251408725)
  • [L5] The panel recommends adapting a simpler classification system resembling that for flexor tendons and outlines specific treatment approaches for acute extensor tendon injuries in each zone to facilitate surgical decision-making and rehabilitation. [8] (10.1177/17531934251363138)
  • [L4] Early active motion protocols and dynamic extension orthosis fabrication result in increased grip strength and better functional results compared to static orthosis fabrication. [9] (10.1016/j.jhsa.2014.06.136)
  • [L4] This series shows good long-term functional and patient reported outcomes in patients following extensor indicis proprius to EPL tendon transfers at a single center. [10] (10.1016/j.jht.2024.02.004)
  • [L5] Most closed extensor tendon injuries can be treated conservatively in the acute phase, but chronic injuries often require operative intervention. [11] (10.1016/j.csm.2014.09.005)
  • [L4] In cases where direct repair of EIP rupture is not possible, a tendon transfer technique allowing independent extension of the index finger is recommended. [12] (10.1007/s11552-014-9709-8)
  • [L4] Both tendon transfer and tendon graft for extensor tendon ruptures in rheumatoid hands achieve satisfactory results that are maintained for an average of 14 years. [13] (10.1186/s12891-022-05815-7)
  • [L5] This article presents an overview of the treatment of extensor tendon injuries, with a focus on recent developments, noting that while nonsurgical treatment is supported for the majority of mallet finger injuries, surgical indications remain unclear. [14] (10.1016/j.jhsa.2010.03.002)
  • [L5] Injuries to the finger extensor apparatus are very common and may produce chronic deformity and loss of function. [16] (10.1016/j.hcl.2013.03.003)
  • [L4] This protocol provides a safe, low-profile, cost-effective alternative for post-operative treatment of zone IV–VII extensor tendon repairs. [17] (10.1007/s11552-012-9488-z)
  • [L4] Two cases of traumatic index extensor tendon attenuation were treated successfully by shortening the attenuated tendon in combination with tendon graft or transfer. [18] (10.1186/s12891-020-03692-6)
  • [L4] Two-staged extensor tendon reconstruction is suitable for long tendon defects in zone 6 with or without zone 7 defects, providing full or near-full active flexion at the MCP joints, though minor extension lags (10°–15°) are common. [19] (10.1177/1753193413517626)
  • [L5] Active motion regimens are desirable after repair of the flexor tendons in all zones but are not always suitable for all extensor tendon repairs. [21] (10.1016/j.injury.2013.01.022)
  • [Paper] Literature describing surgical, post-operative management and outcomes following EDC repairs in close proximity to or within the extensor retinaculum is limited. [23] (10.1007/s12593-010-0008-5)
  • [L4] [24] (10.1177/1753193420950655)
  • [L4] [26] (10.5435/jaaos-d-25-00927)
  • [L5] Complete section of the sagittal bands in the little finger caused ulnar dislocation of the extensor tendon in only one out of seven hands. [28] (10.1177/1753193420963257)
  • [L5] [29] (10.5435/jaaos-d-18-00218)
  • [L4] The use of an adipofascial flap to repair the dorsal capsule after capsulotomy may allow for primary healing, reducing relapse caused by secondary fibrosis and providing a better gliding surface for the extensor tendon. [30] (10.1177/1753193419899042)
  • [L4] Extensor tendon reconstruction using WALANT surgery allowed intraoperative measurement of active ROM, confirming near-complete extension and flexion after reconstruction. [31] (10.1016/j.jhsa.2023.09.014)
  • [L5] [34] (10.1007/s11552-014-9706-y)
  • [L2] [35] (10.1016/j.jht.2017.02.013)
  • [L5] The authors propose a simpler classification system for extensor tendon zones to align with current treatment strategies, such as conservative splinting for closed injuries and strong surgical repair for open injuries. [36] (10.1177/17531934241274112)
  • [L5] In controlled conditions, there is a variation in resistance to flexion of the distal interphalangeal joint, but the amplitude of the forces is likely imperceptible clinically. [37] (10.1016/j.jhsg.2021.08.004)
  • [Case_report] The use of a single orthosis throughout the entire protected phase of rehabilitation after zone III extensor tendon repair is an easy, cost-effective, and successful way to treat surgical repairs of the central slip. [39] (10.1016/j.jht.2019.03.014)
  • [L5] The author suggests that a classification of extensor tendon zones based on the presence of the extensor retinaculum is preferable to those based on the wrist joint, as it simplifies treatment discussion and aligns with flexor tendon zoning. [43] (10.1177/17531934241232066)
  • [L1] RME plus management of finger zones V-VI extensor tendon repairs is non-inferior to dynamic WHFO in %TAM, therapy and orthotic satisfaction, QuickDASH, and %Grip. [45] (10.1016/j.jht.2023.02.010)
  • [Case_report] Hand surgeons should be aware that injury to the extensor mechanism and specifically the central slip can lead to snapping or catching at the PIP joint in the finger. [48] (10.1177/15589447221081876)
  • [Paper] Extension of the PIP joint decreases as these structures are progressively damaged. [50] (10.1016/s0363-5023(12)60014-8)
  • [L3] Improvement in digit ROM was associated with initiation of treatment within 6 weeks, but not with any particular type or length of conservative treatment. [53] (10.1016/j.jht.2025.02.013)
  • [L4] [55] (10.1016/j.jhsa.2021.09.011)
  • [L5] A modified Becker extensor tendon repair with 1 cross-stitch provides superior mechanical properties for loads seen with postoperative rehabilitation compared with 2 and 3 cross-stitches for similar loads. [57] (10.1016/j.jhsa.2011.10.004)
  • [L4] With modern anesthesia techniques, tendon lacerations in a healthy neonate can be managed in a timely and safe manner. [58] (10.1016/j.jhsa.2010.09.015)
  • [L4] Advanced imaging may be considered when tendon irritation is clinically suspected, and carpal boss excision may be indicated to prevent rupture. [59] (10.1016/j.jhsa.2014.02.010)
  • [L4] Patients must be counseled on the likelihood of limited ROM and the possibility of repeat procedures. [60] (10.1016/j.hcl.2017.12.006)
  • [L4] Patients with chronic injuries or those failing nonoperative management may benefit from surgical exploration. [61] (10.1177/1558944719895622)
  • [L5] Complete extensor tendon failure due to drill penetration was rare. [62] (10.1177/1558944716668824)
  • [L4] Patients should be counseled about the difficult nature of this fracture and the expected poor outcomes. [63] (10.1016/j.jhsa.2017.03.030)
  • [L5] Ciprofloxacin-induced tendon rupture appears to be possible in the extensor digitorum communis tendons of the hand. [64] (10.2106/jbjs.cc.n.00059)

See Also

References

[1] Management of Complications of Extensor Tendon Injuries. Hand Clinics. 2015. DOI: 10.1016/j.hcl.2014.12.006

[2] Traumatic Extensor Tendon Injuries to the Hand: Clinical Anatomy, Biomechanics, and Surgical Procedure Review. Journal of Hand and Microsurgery. 2016. DOI: 10.1055/s-0036-1572534

[3] Zone I Extensor Reconstruction With Tendon Salvaged From Another Finger. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.01.029

[4] Boutonniere deformity of the second toe after planter dislocation of proximal interphalangeal joint: a case report. Archives of Orthopaedic and Trauma Surgery. 2009. DOI: 10.1007/s00402-009-0816-x

[5] Systematic review: Zone IV extensor tendon early active mobilization programs. Journal of Hand Therapy. 2023. DOI: 10.1016/j.jht.2022.12.001

[6] Reconstruction of the Extensor Central Slip Using a Distally Based Flexor Digitorum Superficialis Slip. The Journal of Hand Surgery. 2009. DOI: 10.1016/j.jhsa.2009.01.025

[7] How current extensor tendon repair practices differ from expert recommendations. Journal of Hand Surgery (European Volume). 2026. DOI: 10.1177/17531934251408725

[8] Extensor tendon repairs: consensus, current guidelines and recommendations. Journal of Hand Surgery (European Volume). 2025. DOI: 10.1177/17531934251363138

[9] Open Extensor Tendon Injuries. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2014.06.136

[10] Extensor tendon transfer for fracture-related extensor pollicis longus rupture: Long-term outcome case series. Journal of Hand Therapy. 2024. DOI: 10.1016/j.jht.2024.02.004

[11] Extensor Tendons Injuries. Clinics in Sports Medicine. 2015. DOI: 10.1016/j.csm.2014.09.005

[12] Spontaneous Rupture of Extensor Tendons of the Index Finger. A Report of Two Cases. HAND. 2014. DOI: 10.1007/s11552-014-9709-8

[13] Long-term clinical outcome of tendon transfer and tendon graft for extensor tendon ruptures in rheumatoid hands. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05815-7

[14] Extensor Tendon Injuries. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2010.03.002

[15] Extensor Tendon Injuries. 2021.

[16] Diagnosis and Treatment of Finger Deformities Following Injuries to the Extensor Tendon Mechanism. Hand Clinics. 2013. DOI: 10.1016/j.hcl.2013.03.003

[17] Wyndell Merritt Immediate Controlled Active Motion (ICAM) Protocol following Extensor Tendon Repairs in Zone IV–VII: Review of Literature, Orthosis Design, and Case Study—A Multimedia Article. HAND. 2013. DOI: 10.1007/s11552-012-9488-z

[18] Traumatic index extensor tendon attenuation mimicking closed tendon rupture: two case reports. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-03692-6

[19] Two-staged extensor tendon reconstruction for zone 6 extensor tendon loss of the fingers: indications, technique and results. Journal of Hand Surgery (European Volume). 2013. DOI: 10.1177/1753193413517626

[21] Rehabilitation of flexor and extensor tendon injuries in the hand: Current updates. Injury. 2013. DOI: 10.1016/j.injury.2013.01.022

[23] Complications of extensor tendon repairs at the extensor retinaculum. Journal of Hand and Microsurgery. 2010. DOI: 10.1007/s12593-010-0008-5

[24] Outcome of primary tendon grafts for open Zone 3 extensor tendon injuries. Journal of Hand Surgery (European Volume). 2020. DOI: 10.1177/1753193420950655

[26] Spontaneous Closed Extensor Tendon Ruptures in the Nonrheumatoid Hand and Wrist. Journal of the American Academy of Orthopaedic Surgeons. 2026. DOI: 10.5435/jaaos-d-25-00927

[28] Functional anatomy of the sagittal bands and mechanisms of extensor tendon dislocation: a cadaveric study. Journal of Hand Surgery (European Volume). 2020. DOI: 10.1177/1753193420963257

[29] Failed Extensor Tendon Repairs: Extensor Tenolysis and Reconstruction. Journal of the American Academy of Orthopaedic Surgeons. 2019. DOI: 10.5435/jaaos-d-18-00218

[30] Dynamic transfer with the flexor digitorum superficialis for chronic boutonnière deformity reconstruction: a report of two cases. Journal of Hand Surgery (European Volume). 2020. DOI: 10.1177/1753193419899042

[31] Wide-Awake Local Anesthesia No Tourniquet Surgery for Zone VII Extensor Tendon Reconstruction: Stages in Active Range of Motion From Intraoperative to Final Recovery. The Journal of Hand Surgery. 2025. DOI: 10.1016/j.jhsa.2023.09.014

[34] A Brief Review of Extensor Tendon Injuries Specific to the Pediatric Patient. HAND. 2014. DOI: 10.1007/s11552-014-9706-y

[35] The optimal orthosis and motion protocol for extensor tendon injury in zones IV-VIII: A systematic review. Journal of Hand Therapy. 2017. DOI: 10.1016/j.jht.2017.02.013

[36] Extensor tendons: can we design a simpler classification zone system?. Journal of Hand Surgery (European Volume). 2024. DOI: 10.1177/17531934241274112

[37] Experimental Evaluation of the Elson Test Efficiency Following Central Slip Injury. Journal of Hand Surgery Global Online. 2021. DOI: 10.1016/j.jhsg.2021.08.004

[39] Treatment of a zone III extensor tendon injury using a single relative motion with dorsal hood orthosis and a modified short arc motion protocol—A case report. Journal of Hand Therapy. 2021. DOI: 10.1016/j.jht.2019.03.014

[43] Clarification and classification of extensor tendon zones in the hand. Journal of Hand Surgery (European Volume). 2024. DOI: 10.1177/17531934241232066

[45] Are the outcomes of relative motion extension orthoses non-inferior and cost-effective compared with dynamic extension orthoses for management of zones V-VI finger extensor tendon repairs: A randomized controlled trial. Journal of Hand Therapy. 2023. DOI: 10.1016/j.jht.2023.02.010

[48] Longitudinal Tear of the Central Slip Causing Painful and Unusual Snapping of the Finger: A Case Report. HAND. 2022. DOI: 10.1177/15589447221081876

[50] Biomechanics of the Acute Boutonniere Deformity. The Journal of Hand Surgery. 2012. DOI: 10.1016/s0363-5023(12)60014-8

[53] Nonoperative treatment of the Boutonniere deformity: Is there a difference in outcomes?. Journal of Hand Therapy. 2025. DOI: 10.1016/j.jht.2025.02.013

[55] Sagittal Band Injuries: A Review and Modification of the Classification System. The Journal of Hand Surgery. 2022. DOI: 10.1016/j.jhsa.2021.09.011

[57] The Effect of the Number of Cross-Stitches on the Biomechanical Properties of the Modified Becker Extensor Tendon Repair. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2011.10.004

[58] Extensor Tendon Injury During Cesarean Delivery. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2010.09.015

[59] Attrition or Rupture of Digital Extensor Tendons Due to Carpal Boss: Report of 2 Cases. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.02.010

[60] Treating the Proximal Interphalangeal Joint in Swan Neck and Boutonniere Deformities. Hand Clinics. 2018. DOI: 10.1016/j.hcl.2017.12.006

[61] Treatment of Sagittal Band Injuries and Extensor Tendon Subluxation: A Systematic Review. HAND. 2020. DOI: 10.1177/1558944719895622

[62] Drill Penetration Injury to Extensor Tendons: A Biomechanical Analysis. HAND. 2016. DOI: 10.1177/1558944716668824

[63] The Central Slip Fracture: Results of Operative Treatment of Volar Fracture Subluxations/Dislocations of the Proximal Interphalangeal Joint. The Journal of Hand Surgery. 2017. DOI: 10.1016/j.jhsa.2017.03.030

[64] Ciprofloxacin-Induced Extensor Tendon Rupture in the Hand. JBJS Case Connector. 2015. DOI: 10.2106/jbjs.cc.n.00059

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Considerations for the public: By using one of our public licenses, a licensor grants the public permission to use the licensed material under specified terms and conditions. If the licensor's permission is not necessary for any reason--for example, because of any applicable exception or limitation to copyright--then that use is not regulated by the license. Our licenses grant only permissions under copyright and certain other rights that a licensor has authority to grant. Use of the licensed material may still be restricted for other reasons, including because others have copyright or other rights in the material. A licensor may make special requests, such as asking that all changes be marked or described. Although not required by our licenses, you are encouraged to respect those requests where reasonable. More considerations for the public: wiki.creativecommons.org/Considerations_for_licensees

Creative Commons Attribution-NonCommercial 4.0 International Public License

By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.