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Open Traumatic Avulsion of the
Flexor Pollicis Longus Tendon
From the Musculotendinous Area:
A Case Report
Panagiotis Givissis, MD, PhD, Dimitrios Karataglis, MD,
Anastasios Christodoulou, MD, PhD, Ioannis Terzidis, MD,
John Pournaras, MD, PhD, Thessaloniki, Greece
A traumatic avulsion of the flexor tendon at the musculotendinous junction in nonamputated digits
is a very rare injury. We present a 14-year-old girl who sustained a longitudinal, tensile, injurious
force directly to the flexor pollicis longus tendon after an open thenar injury resulting in its avulsion
at the musculotendinous junction. In an effort to minimize soft-tissue damage and preserve the
transverse ligament of the carpus the tendon was retrieved through a separate forearm incision.
Direct repair was made by encapsulation of the tendon into the muscle belly. The functional result
30 months after surgery was satisfactory. (J Hand Surg 2005;30A:850 – 853. Copyright 2005 by
the American Society for Surgery of the Hand.)Key words:
Flexor pollicis longus, avulsion, musculotendinous area.
The musculotendinous junction together with the bony
very rare for the flexor pollicis where avul-
insertion are considered the weakest links of the mus-
sions of the entire tendon length in any given digit can
culotendinous chain, the former being by far the more
occur, including the tMoreover the anatomy
common site of Despite this only 6 closed
and profound functional importance of this tendon ren-
flexor tendon ruptures at the musculotendinous area
have been reported to Of these 6 ruptures 3
We present a case of traumatic avulsion of the
ruptures involved the flexor digitorum superficialis and
flexor pollicis longus tendon from its musculotendi-
the remaining 3 ruptures involved the flexor pollicis
nous junction resulting from extreme longitudinal
With the exception of traumatic conditions
force applied to the tendon after an open hand injury.
associated with digit amputations this type of injury is
The chosen technique for direct repair led to a verysatisfactory functional outcome without the need fora tendon transfer.
From the A’ Orthopaedic Department, Aristotelian University of Thes-saloniki, “G. Papanikolaou” General Hospital, Exohi, 570 10, Thessal-
Received for publication November 11, 2003; accepted in revised form
A 14-year-old girl sustained direct trauma to the right
dominant hand when she slipped while climbing a
No benefits in any form have been received or will be received from
fence and a pointed spear-like bar entered her palm at
a commercial party related directly or indirectly to the subject of thisarticle.
the thenar eminence just underneath the tendon of the
Corresponding author: Panagiotis Givissis, MD, PhD, 33 Abatzoglou str.,
flexor pollicis longus. She impulsively released her
40 Eklissies, 546 36, Thessaloniki, Greece; e-mail: firstname.lastname@example.org.
grip and that left her momentarily hanging from the
Copyright 2005 by the American Society for Surgery of the Hand
FPL tendon. This resulted in complete proximal
avulsion of the flexor pollicis longus tendon from its
Givissis et al / Avulsion of the Flexor Pollicis Longus Tendon
the tendon stump was sutured side to side to the distaledge of the catheter. In a modification of the tech-nique described by Sourmelis and thetendon subsequently was rerouted through the carpaltunnel to the proximal wound at the level of its owntorn muscle belly at the musculotendinous junction.
The tendon stump was sutured back to the musclebelly with 4 interrupted 3-0 sutures (Ethibond; John-son & Johnson, St Stevens-Woluve, Belgium) placedthrough the tendon and the muscle fibers. Length andtension restoration were checked during surgery byusing the tenodesis test. Because the flexor pollicislongus is a unipinate muscle, encapsulation of thetendon stump within the muscle belly was addition-ally performed to reinforce the repair. The techniqueused was that of draping the replaced tendon withmuscle substance using the same suture materialSubsequently the A1 pulley was recon-structed and augmented using part of the flexor pol-licis brevis tendon. The radial digital nerve of thethumb was sutured end to end with 2 epineural in-terrupted 8-0 sutures (Prolene; Johnson & Johnson)under microscope magnification. Finally the skin wasclosed with a 4-flap Z-plasty at the site of the basalskin crease of the thumb to avoid skin contracture.
Cefuroxime in conjunction with amikasin and met-ronidazole were administered for 3 days. An above-elbow plaster cast was used for 3 weeks, followed bybelow-elbow immobilization for a further 3-weekperiod with the thumb held in moderate flexion andabduction. Passive continuous motion as postopera-tive rehabilitation was commenced the second post-operative day and active mobilization was initiated 6weeks after surgery.
Preoperative view of avulsion of the entire tendon
of the flexor pollicis longus through the thenar wound.
The wounds healed promptly and no complica-
muscle belly and laceration of the flexor pollicisbrevis, the A1 pulley, and the radial digital nerve tothe thumb
She was admitted to our hospital within 4 hours of
the initial injury and was taken immediately to theoperating room. General anesthesia was induced anda tourniquet was used after administration of intra-venous antibiotics. After thorough wound debride-ment and copious irrigation a second incision wasmade in the volar aspect of the distal third of theforearm to access the muscle belly of the flexorpollicis longus. The site of avulsion at the musculo-tendinous junction was identified and a catheter was
Tendon reconstruction and augmentation with en-
introduced from the thenar wound through the carpal
capsulation of the tendon in the flexor pollicis longus muscle
tunnel to the forearm wound. The proximal end of
The Journal of Hand Surgery / Vol. 30A No. 4 July 2005
The hand 30 months after surgery. Thumb movement regarding (A) extension, (B) flexion, and (C) opposition at both
the metacarpophalangeal and interphalangeal joints returned very close to normal.
tions were observed. Thumb movement at both the
pollicis The rarity of this injury to the
metacarpophalangeal and interphalangeal joints re-
flexor pollicis longus combined with the anatomy
turned very close to normal within 4 months (full
and profound functional importance of this tendon—
flexion, 10° extension deficit of the interphalangeal
because the thumb provides more than 40% of the
joint of the involved side, full opposition)
entire hand’s function—render this injury unique and
On final follow-up evaluation 30 months after sur-
justify every effort for primary Only 3 such
gery the functional result as evaluated according to
cases of closed rupture of the flexor pollicis longus
the criteria of Fitoussi et was excellent with a
tendon at the musculotendinous junction have been
score of 9 of 9. Grip strength was tested with a
reported to date: 2 by Boyes et in which no further
dynamometer (5030 J1 Jamar Hand Dynamometer;
details were provided by the authors and 1 by Takami
Sammons and Preston, Bolingbrook, IL) and reached
et in a 23-year-old woman who had closed rupture
93.7% of the strength of the uninjured side. Key,
of the flexor pollicis longus while bowling. None of
pulp, and tripod grip strengths were tested with a
the earlier-described 3 cases was open, nor did these
pinch meter (Baseline Link Pinch meter; Waldemar
patients have immediate surgery. In the last case a
Link, Hamburg, Germany) and reached 81%, 97.7%,
direct repair was impossible, necessitating a tendon
and 90.2% of the strength of the uninjured side,
transfer in which the flexor digitorum superficialis
respectively. Two-point discrimination on the pa-
tendon to the ring finger was transferred to that of the
tient’s thumb was 5 mm at the sensory area of the
flexor pollicis longus. Furthermore the 2 cases de-
repaired digital nerve compared with 4 mm on the
scribed by Boyes et aloccurred through diseased
tendons. Our case seems to be the second that oc-
curred through apparently normal tendon. In our case
Avulsion-type injuries of the flexor tendons at their
the hand injury was open and the injurious force was
bony insertion and disruptions in the musculotendi-
extreme. The force was applied directly to the tendon
nous junction associated with traumatic digit ampu-
itself, leading to its avulsion from the musculature of
tations have been well documented in the litera-
the flexor pollicis longus. It is well known from the
normal flexor tendons occurs infrequently and little
mal muscle–tendon system is subjected to severe
has been reported about these ruptures. Isolated
strain the tendon does not rupture. Instead rupture
flexor tendon rupture at the musculotendinous junc-
may occur at the insertion of the tendon to bone, at
tion in the absence of digit amputation is a very
the musculotendinous junction, through the belly of
unusual injury pattern and is believed to result from
the muscle, or at its origin from the bone. In our case
the original soft-tissue trauma involved the thenar
have been reported to date, 3 involving the flexor
region and the base of the thumb. In an effort to
digitorum superficialis and 3 involving the flexor
minimize further induced soft-tissue trauma and to
Givissis et al / Avulsion of the Flexor Pollicis Longus Tendon
preserve the carpal tunnel we used a modification of
chance of speedy return of good function and there-
a technique described by Sourmelis and Mc-
for retrieving retracted flexor tendons with
the aid of a catheter. We believe that in the context of
to retrieve the proximal stump of retracted flexor
extensive soft-tissue trauma in the region, preserva-
tendons with the aid of a catheter was used success-
tion of the carpal tunnel, which is an all-important
fully in a vice versa manner to repair the musculo-
pulley, and minimizing surgical trauma provided a
tendinous chain with the least possible soft-tissue
more favorable environment for tissue healing and
functional recovery. Healing of the muscle–tendoncomplex was successful, which to a certain extent
The authors thank Dr Konstantinos Ditsios for assistance in the final
can be attributed to the rich vascularization of the
editing of the manuscript and Dr Aggeliki Lambanari for assistance withthe drawings.
There was no evidence of adhesion forma-tion and one could argue that the chosen method of
repair, in which soft-tissue trauma was minimized,
1. Boyes JH, Wilson JN, Smith JW. Flexor-tendon ruptures in
might have contributed to that. The A1 pulley was
the forearm and hand. Am J Orthop 1960;42A:637– 646.
repaired in an effort to avoid bowstringing of the
2. Culver JE Jr. Flexor digitorum superficialis rupture: a case
tendon and to allow better functional recovery. It is
report. Bull Hosp Joint Dis 1976;37:30 –33.
well known that the repair of digital flexor pulleys
3. Takami H, Takahashi S, Ando M, Kabata K. Rupture of the
increases the risk for adhesion formation but it was
flexor pollicis longus tendon at the musculotendinous junc-tion in a bowler. Arch Orthop Trauma Surg 1998;117:277–
believed that the advantages that the A1 pulley repair
offers in function restoration far outweighed the po-
4. Earley MJ, Watson JS. Twenty four thumb replantations.
tential risks, especially in view of the fact that no
further surgical trauma was induced with the repair
5. Vlastou C, Earle AS. Avulsion injuries of the thumb. J Hand
The exact type and length of postoperative immo-
6. Stevanovic MV, Vucetic C, Bumbasirevic M, Vuckovic C.
Avulsion injuries of the thumb. Plast Reconstr Surg 1991;
bilization after flexor tendon repair remains a matter
of contention. Fitoussi et showed better func-
7. Soucacos PN, Beris AE, Touliatos AS, Korobilias AB, Gelalis
tional results in patients with above-elbow immobi-
J, Sakas G. Complete versus incomplete nonviable amputations
lization for 4 to 6 weeks. The severity of soft-tissue
of the thumb. Comparison of the survival rate and functional
injury in our case led us to follow a rather conserva-
results. Acta Orthop Scand 1995;264(Suppl):16 –18.
8. Soucacos PN. Indications and selection for digital amputa-
tive postoperative rehabilitation regimen of above-
tion and replantation. J Hand Surg 2001;26B:572–581.
elbow immobilization of the thumb for 3 weeks
9. Sourmelis SG, McGrouther DA. Retrieval of the retracted
followed by a further 3-week period of below-elbow
flexor tendon. J Hand Surg 1987;12B:109 –111.
immobilization with the thumb in moderate abduc-
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tion and flexion before active movements were com-
GF. Repair of the flexor pollicis longus tendon in children.
menced. On the other hand passive movements were
J Bone Joint Surg 2000;82B:1177–1180.
11. Lister G The hand: diagnosis and indications. 3rd ed.
started on the second postoperative day. This did not
Edinburgh: Churchill Livingstone, 1993:1–155.
lead to functional compromise of any kind.
12. Madhavan P, Nadim Y, Cutting C. Complete avulsion of a
The case presented is rare with regard to the mech-
tendon of flexor digitorum profundus from its myotendinous
anism of injury. The patient had surgery within 4
hours and the tendon stump was rerouted and refixed
13. McMaster PE. Tendon and muscle ruptures. Clinical and
to its original position with subsequent encapsulation
experimental studies on the causes and location of subcuta-neous ruptures. J Bone Joint Surg 1933;15A:705–722.
of the tendon into the muscle belly in an effort to
14. Zbrodowski A, Gajisin S, Bednarkiewicz M. Mesotendons of
reinforce the repair. Primary repair of all injured
the flexor pollicis longus muscle. Acta Anat (Basel) 1994;151:
tendons regardless of the injury site offers the best
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