Skip to content

Clinicians › Hand

Jersey Finger (Flexor Tendon Avulsion)

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

51 citationsUpdated Sep 2026
Illustration: Jersey Finger (Flexor Tendon Avulsion)

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Jersey finger represents a flexor digitorum profundus (FDP) avulsion injury that requires prompt diagnosis to facilitate timely surgical repair and prevent complications [5]. While closed rupture of both flexor tendons in the little finger is rare and may be missed on initial presentation [4], FDP avulsions remain difficult injuries where surgical treatment necessitates that the patient be sidelined [17]. Although repair restores strength and range of motion, excision results in permanent disability [17]. The primary objective of repair is to achieve normal or near-normal function, a goal that consistently remains a problem which has not yet been solved [1].

The outcome of flexor tendon repair is influenced by many factors that cannot be controlled intraoperatively [16]. Specifically, the outcome of repair for clean-cut flexor tendon lacerations in zone 2 is related to the psychological and biologic characteristics of the patient [13]. Additionally, several risk factors for reoperation after finger flexor surgery have been identified, including age, sex, and type of tendon injury [24]. When considering delayed repair, the force required to make a fist should be taken into account when determining the limit of 'safe' tendon shortening [3].

Recent advancements in technique and rehabilitation have improved reliability. Recent repair and motion protocols lead to remarkably more reliable repairs, with over 80% good or excellent outcomes achieved rather consistently after Zone 2 repair along with infrequent need of tenolysis [126]. The wide-awake approach to flexor tendon repair has decreased rupture and tenolysis rates and permitted consistently good results in cooperative patients [45]. Active motion regimens are desirable after repair of the flexor tendons in all zones [43], with the partial-range active flexion protocol recommended as a safe, efficient, and generalizable framework for rehabilitation, particularly where therapist assistance is unavailable [69].

Anatomy & Pathophysiology

Joint Anatomy and Kinematics

The finger articulations form a triarticular chain that flexes toward the thumb and palm to facilitate grasp [71]. The digit is designed to function in flexion, with the volar tendinous apparatus being considerably stronger than the dorsal extensor apparatus [71]. Flexion ranges are approximately 85 degrees at the metacarpophalangeal joint, 115 degrees at the proximal interphalangeal joint, and 80 degrees at the distal interphalangeal joint [71]. The interphalangeal articulations possess trochlear-shaped surfaces that remain closely congruent throughout flexion–extension excursion [71]. Normal ulnar inclination of the fingers occurs at the metacarpophalangeal joints and is most marked in the index finger [76]. This inclination results from anatomical factors including asymmetry of metacarpal heads and collateral ligaments, ulnar-side tendon crossing, and intrinsic muscle forces [76].

Tendon Anatomy and Mechanics

Extensor tendons traverse from the forearm to the dorsum of the hand through six compartments beneath the extensor retinaculum [75]. The extensor mechanism exhibits less excursion than the flexor system, with only 2 to 5 mm of movement in the region of the proximal interphalangeal joint [34]. The lumbrical muscles extend the two distal phalanges regardless of metacarpophalangeal joint position [82]. Conversely, interosseous muscles demonstrate a decreasing extensor effect at the interphalangeal joints as metacarpophalangeal flexion increases [82]. Lumbricals contribute to distal phalanx extension by pulling distally on the flexor profundus tendon when that muscle is at rest [82]. Biomechanical analysis indicates that inserting the flexor profundus tendon at the distal edge of its footprint confers significantly greater distal interphalangeal joint flexion force compared with proximal insertion [109]. This distal insertion most closely resembles the intact flexor profundus tendon [109]. In all fingers tested except the little finger, two micro bone anchors fit within the distal phalanx when placed in the perpendicular position [64].

Pathophysiology and Complications

Shortening and closing an injury that causes proximal migration of the flexor profundus tendon from its insertion at the base of the distal phalanx may result in a lumbrical-plus finger [48]. In this condition, the retracted flexor profundus tendon creates tension on the extensor mechanism via the lumbrical originating from the flexor profundus tendon [48]. A lumbrical-plus finger presents with paradoxical interphalangeal joint extension during active digit flexion [48]. Treatment involves release of the radial lateral band [48]. Injuries in distal zones 1 through 5 of the extensor mechanism result in poorer outcomes and greater postoperative extension deficits [34]. Extensor tendon injuries carry a significantly worse prognosis when associated with underlying fractures [34]. If significant shortening occurs following extensor repair while the lateral bands and oblique retinacular ligament remain intact, leaving the central extensor mechanism unrepaired may avoid flexion loss without producing a proximal or distal interphalangeal extension lag [34]. Loss of long extensor function can destabilize the metacarpophalangeal joint, resulting in a loss of active finger abduction-adduction [34].

Classification

Adult Zone Classification: Flexor tendon injuries in adults are classified into five zones [113]. Sub-classifications of Zone 1 and Zone 2 are considered important for management [113]. Zone 1A is defined as the area distal to the A5 pulley [113]. In Zone 1A injuries, there is not enough distal tendon length to provide adequate suture purchase [113]. Consequently, Zone 1A lacerations are usually treated similarly to flexor profundus avulsion injuries with tendon re-insertion into bone [113]. Zone IIC is defined as the area under the A2 pulley [113]. The distal two-thirds of the A2 pulley is the narrowest area in Zone II [113]. The flexor digitorum superficialis bifurcates within the middle part of the A2 pulley [113].

Tang’s Classification: Tang’s classification of Zone II defines Zone IIA as the area of insertion of the superficialis tendon [121]. Zone IIB is defined as the area between Zones IIA and IIC [121]. Zone IIC is defined as the area covered by the A2 pulley [121]. Zone IID is defined as the area covered by the A1 pulley [121].

Boyes Classification: The Boyes classification identifies five degrees of flexor tendon problems [35]. Boyes Grade 1 is defined as minimal scarring [35]. Boyes Grade 2 is defined as deep scarring due to injury or prior surgery or infection, with loss of motion due to the scar rather than joint [35].

Pediatric Classification: In children, flexor tendon injuries are often classified into three groups according to age: preschoolers (less than 5 years), children (between 5–10 years), and teenagers (11–15 years) [113]. The age of the child influences the size of the tendon, suture technique, size of sutures used in repair, and post-operative rehabilitation [113].

Other Considerations: A modification to the flexor tendon avulsion classification has been proposed to incorporate simultaneous FDP and FDS avulsion with a large fracture [66]. This proposed modification allows for independent classification of each tendon injury to guide management [66].

Clinical Presentation

History and Diagnostic Challenges: The clinical presentation of flexor tendon injuries often presents diagnostic difficulties due to atypical mechanisms or concurrent pathologies. Avulsion of the flexor digitorum profundus (FDP) accompanied by a separate intraarticular fracture of the distal phalanx is a rare entity that is frequently misdiagnosed [62]. In cases of closed blunt injury, the inability to flex the distal interphalangeal joint may initially be attributed to pain rather than structural failure, as observed in a 38-year-old man whose ring finger FDP rupture was only diagnosed later [98]. Furthermore, a unilateral absence of the ring finger FDP musculotendinous structure can mimic an acute avulsion when history and examination suggest recent trauma, posing a significant diagnostic challenge [11]. Combined ruptures of the flexor pulleys and avulsion of the flexor digitorum superficialis (FDS) tendon should be regarded as a single pathology resulting from sudden forceful contraction [10].

Physical Examination and Imaging: Inspection may reveal passive hyperextension of the affected digit, such as the ring finger noted to be passively hyperextended at 10 weeks post-injury in a case of missed FDP rupture [98]. When pain is pronounced or the patient is not cooperative for preoperative examination, ultrasonography is conducted to assess tendon continuity [100]. Real-time ultrasound serves to determine whether a flexor tendon is ruptured or entrapped in scar tissue, particularly in patients presenting 10 weeks after injury [98]. If doubt regarding tendon continuity persists after ultrasonography, magnetic resonance imaging (MRI) is performed [100].

Classification and Complex Patterns: Management is guided by specific injury patterns that may require modified classification systems. Authors have proposed a modification to the flexor tendon avulsion classification to incorporate simultaneous FDP and FDS avulsion with a large fracture, allowing for the independent classification of each tendon injury to guide management [66].

Investigations

Plain radiography: Clinical assessment combined with plain radiography demonstrates high accuracy in identifying flexor digitorum profundus (FDP) avulsions, particularly when associated with distal phalanx fractures [138]. Early diagnosis and treatment of these injuries yield satisfactory results, whereas delayed diagnosis may necessitate tenolysis to restore function [29].

MRI: Magnetic resonance imaging is recommended for Type IV FDP avulsion, a rare injury lacking consensus on surgical strategy [131]. A high index of suspicion is required to guide appropriate management in these cases [131].

Ultrasound: Dynamic high-resolution ultrasonography serves as a valuable tool for accurately assessing early changes in climber's finger [137]. This modality should be performed to select appropriate therapeutic management, especially when clinical evaluation is difficult [137].

Other Considerations: Type IV FDP avulsion management recommendations include rigid bony fixation to prevent subluxation, independent tendon repair, and early range of motion therapy [131]. Diagnostic challenges may arise in patients with unilateral absence of the ring finger FDP musculotendinous structure, where history and examination may suggest an acute avulsion despite the congenital anomaly [11].

Treatment

Non-Operative

The provided evidence does not support specific conservative management protocols such as weight loss, physical therapy regimens, NSAIDs, or injections for flexor tendon avulsion.

Operative

Indications: Surgical intervention is indicated for flexor digitorum profundus (FDP) avulsions, particularly in Zone 1 (Types II and III) and Zone 2 lacerations. FDP avulsions are difficult injuries where surgical treatment requires the patient to be sidelined; while repair restores strength and range of motion, excision results in permanent disability [17]. Secondary repair is one of the most challenging procedures in hand or digit surgery, with poor results often observed due to extensive scar formation and tendon adhesion, particularly in severe hand trauma [35]. Indications for flexor tendon function restoration are mainly represented by failure of primary repair and complex lesions according to the Boyes classification [35].

Surgical Approach / Technique: For Zone 1 FDP avulsions (Types II and III), hook plates placed in the distal phalanx emerge as a surgical treatment with excellent clinical outcomes and no associated morbidity [21]. In Zone 2, the outcome of repair for clean-cut flexor tendon lacerations is related to the psychological and biologic characteristics of the patient, as evidenced by uniform outcomes in all four fingers for every patient [13]. For young children, there was no statistically significant difference in active ranges of finger motion achieved with two-strand and four-strand repairs in Zone 2 [6]. The AB repair might allow for early active postoperative motion after repair of FDP avulsion injuries and tendon reconstruction procedures, though the soft tissue effects of this multistrand technique are unknown in clinical repairs [18]. A new technique using retrograde catheters has been used successfully in eight cases to reduce delayed flexor tendon avulsions [9]. Flexor tendon repair was followed by good function in cases of simultaneous dislocation of both interphalangeal joints and flexor tendon tear [2].

Implant Selection: Active tendon implants (prostheses) may represent an effective alternative option in patients with a poor prognosis, as well as whenever classical techniques fail [35].

Adjuncts: WALANT may not be superior to general anesthesia in regards to function, rates of rupture, and patient-reported outcomes in repair of Zone II flexor tendon lacerations [120].

Other Considerations: Pulley rupture or insufficiency is a diagnostic and therapeutic dilemma owing to the overall rarity of the injury as well as the lack of comparative clinical studies describing its diagnosis, treatment, and outcome [42]. Repair ruptures were documented in most reports with rates ranging from 4%-10% in finger flexors and 3%-17% in FPL of thumbs [7]. Patient’s age and associated pathologies appear to influence the potential of biological repair, while patient’s motivation and rehabilitation compliance always play a fundamental role in the final clinical result [35]. One stage or two-stage tendon grafts are indicated when the integrity of flexor tendon is compromised, depending on whether the scarring in the palmar side of the hand is minimal or extensive [35]. The primary reconstruction of an active functional flexor tendon system may be difficult [35].

Rehabilitation and Postoperative Care: Passive protocols have a higher risk of decreased postoperative digit range of motion, while early active motion protocols have a higher risk of rupture [57]. Early passive motion appeared to be an effective technique to improve the results of flexor tendon repairs in Zone II [44]. Hand therapy programs for the proximal interphalangeal joint must address the specific disorder, timing of injury, and phases of healing to prevent stiffness and dysfunction [26].

Complications

Tendon Rupture and Adhesions: Ruptures and adhesions around the repaired tendon requiring tenolysis are found in approximately 5% each [114]. Consequently, further surgery for rupture or adhesions is required in around 6% of cases [114]. Poor results can be observed due to extensive scar formation and tendon adhesion, particularly in severe hand trauma [35].

Risk Factors: Age, smoking, zone of injury, multiple finger injuries, associated flexor digitorum superficialis (FDS) tendon injury, nerve injuries, and delayed treatment have previously been reported to adversely affect outcomes [114]. Patient’s age and associated pathologies also appear to influence the potential of biological repair [35]. Patient’s motivation and rehabilitation compliance always play a fundamental role in the final clinical result [35].

Surgical Technique Complications: Transosseous repair of zone I flexor digitorum profundus injuries with a buried dorsal suture is associated with a high rate of clinical complications [123]. The soft tissue effects of the AB repair multistrand technique are unknown in clinical repairs [18].

Other Considerations: Excision results in permanent disability [17]. When last seen 4 months after the accident, there was still some swelling and aching, but no deformity and full passive movements, although active flexion was limited by adherence of the flexor tendon at the fracture site [32].

Recovery

Rehabilitation protocol: Postoperative management of Zone II flexor tendon repairs involves distinct protocols regarding immobilization and motion initiation. In a study of 50 consecutive digits in 37 patients, one protocol involved 3 weeks of immobilization followed by gradually increased motion [44]. An alternative protocol initiated intermittent passive motion within the first 5 days, with active flexion commenced at 4 weeks [44]. The tendon healing and strength of repair are adequate for immediate postoperative motion, as evidenced by good results and the absence of ruptures in protocols utilizing early motion [125].

Functional milestones: Outcomes vary significantly based on the rehabilitation protocol employed. In the immobilization group (3 weeks immobilization followed by gradual motion), four ruptures occurred, with no excellent results; 12% were rated good, 28% fair, and 11% poor [44]. In the early motion group (intermittent passive motion within 5 days, active flexion at 4 weeks), one rupture occurred; results included 36% excellent, 20% good, 16% fair, and 24% poor [44]. Flexor tendon repair is generally followed by good function [2]. There is no statistically significant difference in the active ranges of finger motion achieved with two-strand and four-strand repairs [6].

Other Considerations: The time elapsed between injury and surgery is not an important risk factor for a good outcome; rather, outcomes depend on proper surgical methods, the surgeon's experience, and early mobilization [136]. Pulley reconstruction can be performed using either looped or nonencircling techniques, though the clinical relevance of biomechanical strength differences remains unclear [20].

Key Evidence

  • [L5] Repair of the divided flexor tendon to achieve normal or near-normal function consistently remains a problem which has not yet been solved. [1] (10.1054/jhsb.2002.0800)
  • [L5] Flexor tendon repair was followed by good function. [2] (10.1016/s0020-1383(97)00202-7)
  • [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. [3] (10.1177/1753193415585311)
  • [L4] Closed rupture of both flexor tendons in the little finger is rare and may be missed on initial presentation. [4] (10.1177/1753193409356033)
  • [L5] Jersey finger injuries should be promptly diagnosed to allow timely surgical repair and prevention of complications. [5] (10.1016/j.csm.2019.12.004)
  • [L2] There was no statistically significant difference in the active ranges of finger motion achieved with two-strand and four-strand repairs. [6] (10.1177/1753193408090761)
  • [L4] Repair ruptures were documented in most reports with rates ranging from 4%-10% in finger flexors and 3%-17% in FPL of thumbs. [7] (10.1016/j.hcl.2004.11.005)
  • [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. [9] (10.1177/1753193407087867)
  • [L4] This is the first clinical report of a combined rupture of the flexor pulleys and avulsion of the flexor digitorum superficialis tendon, which should be regarded as a single pathology caused by sudden forceful contraction. [10] (10.1054/jhsb.2001.0559)
  • [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. [11] (10.1016/j.jhsa.2016.02.003)
  • [L4] The outcome of repair of clean-cut flexor tendon lacerations in zone 2 is related to the psychological and biologic characteristics of the patient, as evidenced by the uniform outcome in all four fingers for every patient. [13] (10.1177/1753193410387333)
  • [L4] The outcome of a flexor tendon repair is influenced by many factors that cannot be controlled intraoperatively. [16] (10.1016/j.jhsa.2022.01.015)
  • [L5] FDP avulsions are difficult injuries where surgical treatment requires the player to be sidelined, and while repair restores strength and range of motion, excision results in permanent disability. [17] (10.1016/j.hcl.2012.05.043)
  • [L5] The AB repair might allow for early active postoperative motion after repair of flexor digitorum profundus avulsion injuries and tendon reconstruction procedures; however, the soft tissue effects of this multistrand technique are unknown in clinical repairs. [18] (10.1016/j.jhsa.2011.07.017)
  • [L5] Pulley reconstruction can be performed using either looped or nonencircling techniques, though the clinical relevance of biomechanical strength differences remains unclear. [20] (10.1016/j.csm.2014.09.001)
  • [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. [21] (10.1177/1558944720957730)
  • [L3] This study identified several risk factors for reoperation after finger flexor surgery, including age, sex, and type of tendon injury. [24] (10.1177/17531934221101563)
  • [Paper] Hand therapy programs for the proximal interphalangeal joint must address the specific disorder, timing of injury, and phases of healing to prevent stiffness and dysfunction. [26] (10.1016/j.hcl.2018.01.001)
  • [L4] Early diagnosis and treatment of flexor digitorum profundus avulsion with associated distal phalanx fracture yield satisfactory results, whereas delayed diagnosis may require tenolysis to restore function. [29] (10.1007/bf00387588)
  • [L3] Both bridge tendon grafts and end-to-side tendon transfers have comparable and satisfactory outcomes after surgical treatment of closed rupture of the flexor tendons in the little finger. [31] (10.1177/17531934211073751)
  • [L5] When last seen 4 months after the accident, there was still some swelling and aching, but no deformity and full passive movements, although active flexion was limited by adherence of the flexor tendon at the fracture site. [32] (10.1016/s0020-1383(79)80086-8)
  • [L5] [34] (10.1016/s0749-0712(02)00130-0)
  • [L5] [35] (10.1016/j.injury.2013.01.023)
  • [L5] Pulley rupture or insufficiency is a diagnostic and therapeutic dilemma owing to the overall rarity of the injury as well as the lack of comparative clinical studies describing its diagnosis, treatment, and outcome. [42] (10.1016/j.jhsa.2012.07.021)
  • [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. [43] (10.1016/j.injury.2013.01.022)
  • [L3] [44] (10.1016/j.jhsa.2025.05.017)
  • [L5] The wide-awake approach to flexor tendon repair has decreased rupture and tenolysis rates and permitted consistently good results in cooperative patients. [45] (10.1016/j.hcl.2013.02.009)
  • [L4] Passive protocols have a higher risk of decreased postoperative digit range of motion, while early active motion protocols have a higher risk of rupture. [57] (10.1016/j.jhsa.2013.06.025)
  • [L4] Avulsion of the flexor digitorum profundus with a concomitant and separate intraarticular fracture of the distal phalanx is a rare and frequently misdiagnosed problem. [62] (10.1177/036354658701500413)
  • [L5] Two micro bone anchors fit within the distal phalanx in all fingers tested except the little finger when placed in the perpendicular position. [64] (10.1016/j.jhsa.2018.12.012)
  • [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. [66] (10.1055/s-0039-1688679)
  • [L5] The author recommends the partial-range active flexion protocol as a safe, efficient, and generalizable framework for rehabilitation after flexor tendon repair and other hand disorders, particularly where therapist assistance is unavailable. [69] (10.1177/17531934211037112)
  • [Case_report] [98] (10.1016/j.jhsa.2007.09.018)
  • [L3] [100] (10.1177/17531934221074514)
  • [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. [109] (10.1016/j.jhsa.2020.10.018)
  • [L5] [113] (10.1177/1753193413498207)
  • [L3] [114] (10.1177/1753193416657758)
  • [L1] WALANT may not be superior to GA in regards function, rates of rupture, and patient-reported outcomes in repair of zone II flexor tendon lacerations. [120] (10.1016/j.jhsa.2024.06.008)
  • [L4] [121] (10.1177/1753193410395837)
  • [L4] Transosseous repair of zone I flexor digitorum profundus injuries with a buried dorsal suture is associated with a high rate of clinical complications. [123] (10.1016/j.jhsa.2020.05.025)
  • [L4] The good results and absence of ruptures suggest that the tendon healing and strength of repair are adequate for immediate postoperative motion. [125] (10.1177/17531934221076270)
  • [L5] Recent repair and motion protocols lead to remarkably more reliable repairs, with over 80% good or excellent outcomes achieved rather consistently after Zone 2 repair along with infrequent need of tenolysis. [126] (10.1177/17531934211053757)
  • [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. [131] (10.1007/s11552-009-9199-2)
  • [L4] The time elapsed between injury and surgery is not an important risk factor for a good outcome; rather, outcomes depend on proper surgical methods, the surgeon's experience, and early mobilization. [136] (10.1177/17531934211024435)
  • [L4] Dynamic high-resolution ultrasonography is a valuable tool for accurate assessment of early changes in climber's finger and should be performed to select appropriate therapeutic management, especially when clinical evaluation is difficult. [137] (10.1177/03635465990270060801)
  • [L4] Clinical assessment and plain radiography were very accurate in our series. [138] (10.1177/1753193411409125)

See Also

References

[1] Primary Flexor Tendon Repair – Operative Repair, Pulley Management and Rehabilitation. Journal of Hand Surgery. 2002. DOI: 10.1054/jhsb.2002.0800

[2] Simultaneous dislocation of both interphalangeal joints and flexor tendon tear in a finger. Injury. 1998. DOI: 10.1016/s0020-1383(97)00202-7

[3] 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

[4] Closed ruptures of both flexor tendons of the little finger. Journal of Hand Surgery (European Volume). 2010. DOI: 10.1177/1753193409356033

[5] Evaluation and Treatment of Flexor Tendon and Pulley Injuries in Athletes. Clinics in Sports Medicine. 2020. DOI: 10.1016/j.csm.2019.12.004

[6] Zone 2 Flexor Tendon Repair in Young Children: A Comparative Study of Four-Strand Versus Two-Strand Repair. Journal of Hand Surgery (European Volume). 2008. DOI: 10.1177/1753193408090761

[7] Clinical Outcomes Associated with Flexor Tendon Repair. Hand Clinics. 2005. DOI: 10.1016/j.hcl.2004.11.005

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

[10] Closed Traumatic Rupture of the Flexor Pulleys of a Long Finger Associated with Avulsion of the Flexor Digitorum Superficialis. Journal of Hand Surgery. 2001. DOI: 10.1054/jhsb.2001.0559

[11] 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

[13] Zone 2 lacerations of both flexor tendons of all fingers in the same patient. Journal of Hand Surgery (European Volume). 2010. DOI: 10.1177/1753193410387333

[16] Outcomes of Wide-Awake Flexor Tendon Repairs in 58 Fingers and 9 Thumbs. The Journal of Hand Surgery. 2023. DOI: 10.1016/j.jhsa.2022.01.015

[17] Tendon Ruptures: Mallet, FDP in Football. Hand Clinics. 2012. DOI: 10.1016/j.hcl.2012.05.043

[18] Repair of Flexor Digitorum Profundus to Distal Phalanx: A Biomechanical Evaluation of Four Techniques. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2011.07.017

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

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

[24] Risk factors for reoperation after flexor tendon repair: a registry study. Journal of Hand Surgery (European Volume). 2022. DOI: 10.1177/17531934221101563

[26] Therapy Concepts for the Proximal Interphalangeal Joint. Hand Clinics. 2018. DOI: 10.1016/j.hcl.2018.01.001

[29] Flexor digitorum profundus avulsion with associated fracture of the distal phalanx. Archives of Orthopaedic and Trauma Surgery. 1997. DOI: 10.1007/bf00387588

[31] Comparison of bridge graft and end-to-side transfer for treatment of closed rupture of the flexor tendons in the little finger. Journal of Hand Surgery (European Volume). 2022. DOI: 10.1177/17531934211073751

[32] Letter to the editor. Injury. 1979. DOI: 10.1016/s0020-1383(79)80086-8

[34] Biomechanics and hand trauma: what you need. Hand Clinics. 2003. DOI: 10.1016/s0749-0712(02)00130-0

[35] Secondary repair of flexor tendon injuries. Injury. 2013. DOI: 10.1016/j.injury.2013.01.023

[42] A2 Pulley Insufficiency. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2012.07.021

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

[44] Digital function following flexor tendon repair in Zone II: A comparison of immobilization and controlled passive motion techniques. The Journal of Hand Surgery. 2025. DOI: 10.1016/j.jhsa.2025.05.017

[45] Wide-awake Flexor Tendon Repair and Early Tendon Mobilization in Zones 1 and 2. Hand Clinics. 2013. DOI: 10.1016/j.hcl.2013.02.009

[48] Miller S Review Of Orthopaedics. 4. Fingertip injuries with tissue loss.

[57] Flexor Tendon Repair Rehabilitation Protocols: A Systematic Review. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2013.06.025

[62] Flexor digitorum profundus avulsions with associated distal phalanx fractures. The American Journal of Sports Medicine. 1987. DOI: 10.1177/036354658701500413

[64] 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

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

[69] Rehabilitation after flexor tendon repair and others: a safe and efficient protocol. Journal of Hand Surgery (European Volume). 2021. DOI: 10.1177/17531934211037112

[71] Exam Of The Hand Wrist 2Ed. Movements of the fingers > Articulations of the fingers.

[75] Campbell S Operative Orthopaedics 4 Volume Set. RECONSTRUCTION OF FINGER FLEXORS: SINGLE-STAGE TENDON GRAFT > EXTENSOR TENDONS.

[76] Exam Of The Hand Wrist 2Ed. Movements of the fingers > Normal ulnar inclination of the fingers.

[82] Exam Of The Hand Wrist 2Ed. Mechanisms of finger flexion and extension > Actions of the intrinsic muscles.

[98] Zone I Rupture of the Flexor Digitorum Profundus Tendon Caused by Blunt Trauma: A Case Report. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2007.09.018

[100] 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

[109] 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

[113] Flexor tendon injuries in the child. Journal of Hand Surgery (European Volume). 2013. DOI: 10.1177/1753193413498207

[114] Predictors of outcome after primary flexor tendon repair in zone 1, 2 and 3. Journal of Hand Surgery (European Volume). 2016. DOI: 10.1177/1753193416657758

[120] Outcomes of Zone II Flexor Tendon Repair Under General Versus Wide Awake Local Anesthesia: A Randomized Controlled Trial. The Journal of Hand Surgery. 2024. DOI: 10.1016/j.jhsa.2024.06.008

[121] Finger zone II flexor tendon repair in children (5–10 years of age) using three ‘figure of eight’ sutures followed by immediate active mobilization. Journal of Hand Surgery (European Volume). 2011. DOI: 10.1177/1753193410395837

[123] Complications Following Transosseous Repair of Zone I Flexor Tendon Injuries. The Journal of Hand Surgery. 2020. DOI: 10.1016/j.jhsa.2020.05.025

[125] Flexor digitorum profundus tendon injuries in Zone 2 repaired with a modified Mantero technique. Journal of Hand Surgery (European Volume). 2022. DOI: 10.1177/17531934221076270

[126] Flexor tendon repair: recent changes and current methods. Journal of Hand Surgery (European Volume). 2021. DOI: 10.1177/17531934211053757

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

[136] Up to five-week delay in primary repair of Zone 2 flexor tendon injuries: outcomes and complications. Journal of Hand Surgery (European Volume). 2021. DOI: 10.1177/17531934211024435

[137] Finger Injuries in Extreme Rock Climbers. The American Journal of Sports Medicine. 1999. DOI: 10.1177/03635465990270060801

[138] Novel method for wound exposure using a sutureless, self-retaining system. Journal of Hand Surgery (European Volume). 2011. DOI: 10.1177/1753193411409125

Creative Commons BY-NC 4.0

CC Creative Commons licence
BY Attribution — you must credit the source
NC NonCommercial — not for commercial use

Attribution-NonCommercial 4.0 International

Creative Commons Corporation ("Creative Commons") is not a law firm and does not provide legal services or legal advice. Distribution of Creative Commons public licenses does not create a lawyer-client or other relationship. Creative Commons makes its licenses and related information available on an "as-is" basis. Creative Commons gives no warranties regarding its licenses, any material licensed under their terms and conditions, or any related information. Creative Commons disclaims all liability for damages resulting from their use to the fullest extent possible.

Using Creative Commons Public Licenses

Creative Commons public licenses provide a standard set of terms and conditions that creators and other rights holders may use to share original works of authorship and other material subject to copyright and certain other rights specified in the public license below. The following considerations are for informational purposes only, are not exhaustive, and do not form part of our licenses.

Considerations for licensors: Our public licenses are intended for use by those authorized to give the public permission to use material in ways otherwise restricted by copyright and certain other rights. Our licenses are irrevocable. Licensors should read and understand the terms and conditions of the license they choose before applying it. Licensors should also secure all rights necessary before applying our licenses so that the public can reuse the material as expected. Licensors should clearly mark any material not subject to the license. This includes other CC- licensed material, or material used under an exception or limitation to copyright. More considerations for licensors: wiki.creativecommons.org/Considerations_for_licensors

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.