Repair of a Chronic Degenerative Sagittal Band Rupture of the Right Ring Finger

CHAPTER 1

Sagittal band ruptures represent an extensor tendon injury resulting in subluxation of the extensor tendon over the metacarpal head with active flexion and then active extension. Here, you can see the snapping tendon over the middle metacarpal head. Here is an intraoperative example of the same thing. The surgery is being performed under a local anesthesia. When the patient's finger is extended against resistance, you can see the subluxation of the extensor tendon. Sagittal band ruptures can either be traumatic in origin as in this case, or degenerative in origin as in the first example.

CHAPTER 2

The video case being presented here consists of a chronic degenerative sagittal band rupture of the ring finger. The procedure is being performed under just a local anesthesia in a wide awake hand surgery fashion. An initial injection of the surgical site with lidocaine, with epinephrine, buffered with bicarbonate was applied in the preoperative area. The patient is now being prepared for surgery in the operating room.

The surgical site is being marked out directly over the metacarpal head. The surgical site is being augmented with some additional local anesthetic.

CHAPTER 3

The incision is placed directly over the MP joint, consistent with a zone five of the extensor mechanism.

CHAPTER 4

Blunt dissection is then performed down to the extensor mechanism until the extensor tendon and the sagittal band is fully exposed. Once adequately exposed, active motion by the patient confirms a subluxation of the extensor tendon in the ulnar direction upon active flexion followed by active extension. The ulnar subluxation of the extensor tendon implies that the radial sagittal band is incompetent as being examined here. In cases of acute ruptures, the ends of the sagittal band are readily reapproximated and repaired. In chronic ruptures, adequate tissue may not be available for primary repair and may require augmentation with either a graft or a transfer from the bordering digit sagittal band. In this case, adequate tissue is confirmed for primary repair along the radial side.

CHAPTER 5

Prior to proceeding with the repair, the ulnar sagittal band is also examined. In chronic sagittal band rupture cases, the competent side often becomes contracted and may require release to help with the centering of the extensor mechanism as shown here. The release of the contracted side should be performed sharply from proximal to distal on a slow progressive basis until satisfied that adequate recentralization of the tendon has been achieved. Note, upon release of the contracted side, that active motion of the finger has already restored centralization of the extensor tendon even before repair or imbrication of the ruptured side.

CHAPTER 6

Next, repair of the injured side is performed. Again, in the case of acute ruptures, a direct repair is possible. In the case of chronic ruptures, an imbrication of the extensor mechanism, as in this case, is required. A non-absorbable 2-0 or 3-0 suture is being used, in a figure-of-eight fashion. Two to three sutures typically will be adequate. In this case, two figure-of-eights using 3-0 Ethibond were used to repair the sagittal band.

CHAPTER 7

Once repaired, the finger is taken through an active range of motion by the patient to confirm a centralized motion of the extensor tendon without subluxation.

CHAPTER 8

Once satisfied with the repair, the wound is washed and closed.

CHAPTER 9

Once closed, perhaps the most important part of the case is the splinting postoperatively. I recommend utilizing an Orthoplast yoke splint to be worn full-time for the next four to six weeks postoperatively. These splints are made from Orthoplast in the office by our therapist. However, exiting the operating room today, a temporary plaster yoke splint is being applied as demonstrated here. This is a hand-based splint that will place the MP joint in extension to offload the repair. The purpose of the yoke is to keep the operative MP joint extended relative to the other MP joints while still allowing for tendon excursion to occur. This is being performed here in the operating room, shown here by inserting rolled up Webril between the operative finger and the plaster, so that the MP joint is held in extension relative to the other fingers. However, both the DIP and PIP joints are free.

CHAPTER 10

This splint is kept on as is until seen in the office. The patient is allowed to move their fingers within the splint as shown here. Once in the office, they are converted to a yoke splint. Once seen in the office, they are removed from their postoperative splint and placed in this Orthoplast yoke or relative motion splint as shown here. These images are from handsurgeryresources.com. I recommend motion within the splint for four to six weeks postoperatively. Thereafter, they can be weaned out of the splint.