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Jersey Finger (Flexor Tendon Avulsion)

FDP avulsion: Leddy-Packer classification and time-critical repair (corpus-synthesised).

Overview

Unilateral absence of the ring finger flexor digitorum profundus (FDP) musculotendinous structure can pose a diagnostic challenge when history and examination suggest an acute avulsion [1]. Early identification and prompt diagnosis of flexor tendon ruptures allow for appropriate surgical repair [2]. Type I Jersey finger injuries require repair within 7 to 10 days [2].

A technique using retrograde catheters can successfully reduce delayed flexor tendon avulsions [3]. The retrograde catheter technique for reducing delayed flexor tendon avulsions has been used successfully in eight cases [3]. The force required to make a fist should be considered when determining the limit of 'safe' tendon shortening in delayed repair of Jersey finger injuries [4].

Hook plates placed in the distal phalanx are a surgical treatment for FDP avulsion types II and III in flexor zone 1, with excellent clinical outcomes and no associated morbidity [6]. Patients with type 3 and 5 Jersey finger injuries treated with buttress plating exhibited functional distal interphalangeal joint range of motion [7]. Inserting the FDP tendon at the distal edge of its footprint confers significantly greater distal interphalangeal joint flexion force compared with the proximal insertion site [8]. Inserting the FDP tendon at the distal edge of its footprint most closely resembles the intact FDP tendon [8].

Anatomy & Pathophysiology

Osseous and Tendon Insertion Mechanics

The flexor digitorum profundus (FDP) tendon inserts at the distal phalanx, and the location of this insertion significantly influences functional outcomes. Insertion at the distal edge of the footprint confers significantly greater distal interphalangeal (DIP) joint flexion force compared with proximal insertion sites [8]. In delayed repairs, the force required to make a fist must be considered when determining the limit of 'safe' tendon shortening [4].

Surgical fixation options are constrained by distal phalangeal anatomy. Two micro bone anchors fit within the distal phalanx in all fingers except the little finger when placed in the perpendicular position [5]. Hook plates placed in the distal phalanx serve as a surgical treatment for FDP avulsion types II and III in flexor zone 1 [6]. For Leddy and Packer Type Va FDP avulsions involving extraarticular distal phalangeal fractures, single pass K-wire stabilization preserves bone stock and reduces comminution and joint degeneration risk [16].

Ligamentous and Soft Tissue Considerations

Repair construct strength is enhanced by incorporating adjacent soft tissue structures. Incorporating the volar plate into FDP avulsion reattachment increases the mean load to physical failure by approximately 100 N in cadaveric models [13]. These stronger repairs facilitate early active mobilization [14]. However, methods that risk normal DIP joint kinematics should not be popularized until proven otherwise [17].

Classification and Timing of Repair

Classification: Jersey finger injuries are categorized by the Leddy and Packer system, with specific management implications for each type. Timing: Type I Jersey finger injuries require surgical repair within 7 to 10 days of injury [2]. Delayed flexor tendon avulsions can be reduced using retrograde catheters [3].

Repair Techniques: * Buttress Plating: Patients with type 3 and 5 Jersey finger injuries treated with buttress plating exhibited functional DIP joint range of motion [7]. * Anchor-Button Technique: The novel anchor-button (AB) technique demonstrates significantly less gapping compared to three other repair methods [11]. * Radial Head Autograft: Treatment of ulnar dysplasia with radial head autograft to restore the distal radioulnar joint (DRUJ) in Type IV FDP avulsion injuries has not been previously reported [15].

Differential Diagnosis

Clinicians must distinguish true avulsion from congenital anomalies. Unilateral absence of the ring finger flexor digitorum profundus (FDP) musculotendinous structure can mimic acute avulsion on history and examination [1].

Classification

Congenital Mimic: Congenital unilateral absence of the flexor digitorum profundus (FDP) musculotendinous structure can mimic acute avulsion, posing a diagnostic challenge [1].

Modified Avulsion Classification: A modification to the flexor tendon avulsion classification has been proposed to incorporate simultaneous FDP and flexor digitorum superficialis (FDS) avulsion with a large fracture, allowing independent classification of each tendon injury [9].

Type IV FDP Avulsion: Type IV FDP avulsion is a rare injury with no consensus on surgical strategy [10].

Clinical Presentation

Diagnosis of flexor tendon avulsion relies on identifying unilateral absence of the flexor digitorum profundus (FDP) musculotendinous structure [1]. This finding can pose a diagnostic challenge when history and examination suggest an acute avulsion of the ring finger FDP [1]. Early identification and prompt diagnosis are critical to allow appropriate surgical repair [2].

Classification and Imaging: Type I: Requires repair within 7 to 10 days [2]. Type IV: A rare injury with no consensus on surgical strategy [10]. Management requires a high index of suspicion with MRI or ultrasound [10]. Type Va: Involves an extraarticular distal phalangeal fracture [16]. Complex Avulsion: An unusual pattern involves simultaneous FDP and flexor digitorum superficialis (FDS) avulsion with a large fracture [9]. A modification to the classification incorporates this pattern, allowing for independent classification of each tendon injury to guide management [9].

Physical Examination and Biomechanics: The force required to make a fist must be considered when determining the limit of 'safe' tendon shortening in delayed repair [4]. Anatomically, the FDP tendon inserted at the distal edge of its footprint confers significantly greater distal interphalangeal joint flexion force compared with the proximal insertion site [8]. This distal insertion most closely resembles the intact FDP tendon [8].

Delayed and Complex Management Patterns: For delayed flexor tendon avulsions, a simple technique using retrograde catheters can successfully reduce the tendon [3]. This technique has been used successfully in eight cases [3]. In Type II and III avulsions in flexor zone 1, hook plates placed in the distal phalanx serve as a surgical treatment [6]. Two micro bone anchors fit within the distal phalanx in all fingers tested except the little finger when placed in the perpendicular position [5].

Red-Flag Patterns and Associated Injuries: Ulnar dysplasia may present with distal radioulnar joint (DRUJ) instability; treatment with radial head autograft to restore the DRUJ has not been previously reported but achieves better functional outcomes compared with previously reported options [15].

Investigations

Plain radiography: Unilateral absence of the flexor digitorum profundus (FDP) musculotendinous structure can pose a diagnostic challenge when history and examination suggest acute avulsion [1].

MRI: MRI and ultrasound are recommended for achieving a high index of suspicion in Type IV FDP avulsion injuries [10].

Other Considerations: Early identification and prompt diagnosis of flexor tendon ruptures allow for appropriate surgical repair [2]. Type I jersey finger injuries require repair within 7 to 10 days [2].

Treatment

Early identification and prompt diagnosis of flexor tendon ruptures allow for appropriate surgical repair [2]. Type I Jersey finger injuries require repair within 7 to 10 days [2].

Non-Operative

The evidence base does not support conservative management as a primary treatment for acute Jersey finger avulsions; surgical intervention is indicated for the injury types described.

Operative

Indications: Surgical repair is indicated for Type I injuries within 7 to 10 days [2]. For delayed presentations, retrograde catheters can successfully reduce flexor tendon avulsions [3]. In delayed repair, the force required to make a fist should be considered when determining the limit of 'safe' tendon shortening [4].

Surgical Approach / Technique: Inserting the FDP tendon at the distal edge of its footprint confers significantly greater distal interphalangeal joint flexion force compared with the proximal insertion site and most closely resembles the intact FDP tendon [8]. The novel anchor-button (AB) technique demonstrated significantly less gapping compared to three other repair methods [11]. For type III FDP tendon avulsion injuries with smaller avulsed bone fragments, the miniplate hooking method is a simple procedure likely to cause fewer complications than other techniques [12].

Implant Selection: Two micro bone anchors fit within the distal phalanx in all fingers tested except the little finger when placed in the perpendicular position [5]. Hook plates placed in the distal phalanx serve as a surgical treatment for FDP avulsion types II and III in flexor zone 1, with excellent clinical outcomes and no associated morbidity [6]. Patients with type 3 and 5 Jersey finger injuries treated with buttress plating exhibited functional distal interphalangeal joint range of motion [7].

Other Considerations: A modification to the flexor tendon avulsion classification is proposed to incorporate simultaneous FDP and FDS avulsion with a large fracture, allowing for independent classification of each tendon injury to guide management [9]. Type IV FDP avulsion is a rare injury with no consensus on surgical strategy [10]. Recommendations for Type IV FDP avulsion include high index of suspicion with MRI/ultrasound, rigid bony fixation to prevent subluxation, independent tendon repair, and early range of motion therapy [10].

Complications

Diagnostic Challenges: Congenital unilateral absence of the ring finger flexor digitorum profundus musculotendinous structure can pose a diagnostic challenge when history and examination suggest acute avulsion [1]. Simultaneous FDP and FDS avulsion with a large fracture represents an unusual pattern of closed flexor tendon avulsion that may require independent classification of each tendon injury [9]. Type IV FDP avulsion is a rare injury with no consensus on surgical strategy, requiring high index of suspicion and rigid bony fixation to prevent subluxation [10].

Delayed Presentation and Repair Limitations: Delayed presentation of flexor tendon avulsions may require specific reduction techniques, such as the use of retrograde catheters, to successfully reduce the tendon [3]. Tendon shortening in delayed repair of jersey finger injuries requires consideration of the force needed to make a fist to determine the limit of 'safe' shortening [4].

Hardware and Implant Considerations: Micro bone anchors may not fit within the distal phalanx of the little finger when placed in the perpendicular position [5]. Patients with type 3 and 5 jersey finger injuries treated with buttress plating exhibit a challenging rate of hardware removal [7].

Other Considerations: Hook plate placement in the distal phalanx for FDP avulsion types II and III is associated with excellent clinical outcomes and no associated morbidity [6]. The novel anchor-button (AB) technique for jersey finger repair demonstrates significantly less gapping compared to three other repair methods [11]. Suture anchor repair of FDP avulsions results in increased initial construct stiffness and less gap formation compared to suture button pullout, with no significant difference in ultimate failure load [18]. Miniplate hooking method for type III FDP avulsion with small bone fragments is likely to cause fewer complications than other techniques [12].

Recovery

Early identification and prompt diagnosis of flexor tendon ruptures allow appropriate surgical repair [2]. Type I Jersey finger injuries require repair within 7 to 10 days [2]. The force required to make a fist should be taken into account when considering the limit of 'safe' tendon shortening in delayed repair of Jersey finger injuries [4].

Rehabilitation protocol: Better results in repair of flexor digitorum profundus avulsions including the palmar plate are attributed to a stronger repair that facilitated early active mobilization [14].

Functional milestones: Hook plates placed in the distal phalanx emerge as a surgical treatment for FDP avulsion types II and III in flexor zone 1, with excellent clinical outcomes and no associated morbidity [6]. Patients with type 3 and 5 injuries exhibited a functional distal interphalangeal joint range of motion when treated with buttress plating [7]. The FDP tendon inserted at the distal edge of its footprint conferred significantly greater distal interphalangeal joint flexion force compared with the proximal insertion site and most closely resembled the intact FDP tendon [8].

Other Considerations: Two micro bone anchors fit within the distal phalanx in all fingers tested except the little finger when placed in the perpendicular position [5].

Key Evidence

  • [L4] This case illustrates a patient with unilateral absence of the ring finger FDP musculotendinous structure, which can pose a diagnostic challenge when the history and examination suggest an acute avulsion of the ring finger FDP tendon. (10.1016/j.jhsa.2016.02.003)
  • [L5] Early identification and prompt diagnosis of flexor tendon ruptures allow appropriate surgical repair, with Type I injuries requiring repair within 7 to 10 days. (10.1016/j.csm.2014.09.001)
  • [L4] The authors present a simple technique using retrograde catheters to successfully reduce delayed flexor tendon avulsions, noting it has been used successfully in eight cases. (10.1177/1753193407087867)
  • [L5] The force required to make a fist should be taken into account when considering the limit of 'safe' tendon shortening in delayed repair of jersey finger injuries. (10.1177/1753193415585311)
  • [L5] Two micro bone anchors fit within the distal phalanx in all fingers tested except the little finger when placed in the perpendicular position. (10.1016/j.jhsa.2018.12.012)
  • [L4] Hook plates placed in distal phalanx emerge as surgical treatment for FDP avulsion types II and III in flexor zone 1, with excellent clinical outcomes and no associated morbidity. (10.1177/1558944720957730)
  • [L4] Patients with type 3 and 5 injuries exhibited a functional distal interphalangeal joint range of motion. (10.1016/j.jhsa.2025.07.038)
  • [L5] The FDP tendon inserted at the distal edge of its footprint conferred significantly greater distal interphalangeal joint flexion force compared with the proximal insertion site and most closely resembled the intact FDP tendon. (10.1016/j.jhsa.2020.10.018)
  • [L5] The authors propose a modification to the flexor tendon avulsion classification to incorporate this injury pattern of simultaneous FDP and FDS avulsion with a large fracture, allowing for independent classification of each tendon injury to guide management. (10.1055/s-0039-1688679)
  • [L4] Type IV FDP avulsion is a rare injury with no consensus on surgical strategy; recommendations include high index of suspicion with MRI/ultrasound, rigid bony fixation to prevent subluxation, independent tendon repair, and early range of motion therapy. (10.1007/s11552-009-9199-2)
  • [L5] The novel anchor-button (AB) technique demonstrated significantly less gapping compared to three other repair methods. (10.1016/s0363-5023(10)60098-6)
  • [Case_report] The miniplate hooking method is a simple procedure suitable for repair of type III FDP tendon avulsion injuries with smaller avulsed bone fragments and is likely to cause fewer complications than other techniques. (10.1016/j.jhsa.2009.04.036)
  • [L5] In this cadaveric model, incorporating the volar plate conferred a significant advantage in strength, increasing the mean load to physical failure by approximately 100 N. (10.1016/j.jhsa.2014.07.054)
  • [L3] The authors attribute these better results to a stronger repair that facilitated early active mobilization. (10.1177/17531934221074514)
  • [L4] The treatment of ulnar dysplasia with radial head autograft to restore DRUJ has not been previously reported and achieved better functional outcomes compared with previously reported treatment options. (10.1177/17531934221098007)
  • [L5] The single pass K-wire stabilisation of the extraarticular distal phalangeal fracture preserves bone stock and reduces comminution and the risk of joint degeneration. (10.1177/17531934251334567)
  • [Commentary] A method risking normal DIP joint kinematics should not be popularized until proven otherwise; readers should consider other published methods that meet the needs of strength without interfering with joint kinematics. (10.1016/j.jhsa.2014.08.002)
  • [L1] Via meta-analysis, there was increased initial construct stiffness and less gap formation for suture anchor repair compared to suture button pullout for FDP reinsertion, with no significant differences for ultimate failure load. (10.1177/15589447221126760)

References

[1] Absent Ring Finger Flexor Digitorum Profundus Presenting as a Jersey Finger. The Journal of Hand Surgery. 2016. DOI: 10.1016/j.jhsa.2016.02.003

[2] Evaluation and Treatment of Jersey Finger and Pulley Injuries in Athletes. Clinics in Sports Medicine. 2015. DOI: 10.1016/j.csm.2014.09.001

[3] A New Technique for Reduction of Flexor Tendon Avulsions after Delayed Presentation. Journal of Hand Surgery (European Volume). 2008. DOI: 10.1177/1753193407087867

[4] The effect of flexor digitorum profundus tendon shortening on jersey finger surgical repair: a cadaveric biomechanical study. Journal of Hand Surgery (European Volume). 2015. DOI: 10.1177/1753193415585311

[5] The Accommodation of Bone Anchors Within the Distal Phalanx for Repair of Flexor Digitorum Profundus Avulsions. The Journal of Hand Surgery. 2019. DOI: 10.1016/j.jhsa.2018.12.012

[6] Hook Plate as a Treatment for Flexor Digitorum Profundus Avulsion Types II and III. HAND. 2020. DOI: 10.1177/1558944720957730

[7] Buttress Plating for Type 3-4-5 Jersey Finger Fractures: Without Bone Fragment Disruption and With a Challenging Rate of Hardware Removal–A Case Series. The Journal of Hand Surgery. 2026. DOI: 10.1016/j.jhsa.2025.07.038

[8] The Ideal Insertion Site for the Flexor Digitorum Profundus Tendon in Jersey Finger Repair: A Biomechanical Analysis. The Journal of Hand Surgery. 2021. DOI: 10.1016/j.jhsa.2020.10.018

[9] An Unusual Pattern of Closed Flexor Tendon Avulsion. Journal of Hand and Microsurgery. 2020. DOI: 10.1055/s-0039-1688679

[10] Type IV FDP Avulsion: Lessons Learned Clinically and through Review of the Literature. HAND. 2009. DOI: 10.1007/s11552-009-9199-2

[11] Jersey Finger Repair: A Biomechanical Evaluation of a New Surgical Technique. The Journal of Hand Surgery. 2010. DOI: 10.1016/s0363-5023(10)60098-6

[12] Miniplate Hooking Method for Repair of Type III Flexor Digitorum Profundus Avulsion Injury With a Small Bone Fragment: Case Report. The Journal of Hand Surgery. 2009. DOI: 10.1016/j.jhsa.2009.04.036

[13] Reattachment of Flexor Digitorum Profundus Avulsion: Biomechanical Performance of 3 Techniques. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.07.054

[14] Repair of flexor digitorum profundus avulsions including the palmar plate: a retrospective comparative study of 56 cases. Journal of Hand Surgery (European Volume). 2022. DOI: 10.1177/17531934221074514

[15] A novel technique in the management of Type IV flexor digitorum profundus avulsion injuries. Journal of Hand Surgery (European Volume). 2022. DOI: 10.1177/17531934221098007

[16] Reconstruction of a Leddy and Packer Type Va flexor digitorum profundus avulsion with a novel technique. Journal of Hand Surgery (European Volume). 2025. DOI: 10.1177/17531934251334567

[17] Commentary on “Reattachment of Flexor Digitorum Profundus Avulsion: Biomechanical Performance of 3 Techniques”. Zone I Flexor Tendon Repairs: More Strength Not Worth Altered Joint Kinematics. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.08.002

[18] A Meta-Analysis of Biomechanical Studies for Suture Button Pullout Versus Suture Anchor Repair of Flexor Digitorum Profundus Avulsions. HAND. 2022. DOI: 10.1177/15589447221126760

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