Spontaneous Idiopathic Bilateral Sagittal Band Rupture: A Case Report

Introduction

Extensor tendon subluxation or dislocation resulting from sagittal band rupture can be associated with snapping, catching, locking, pain, and swelling of the finger. Several etiologies were reported in the literature, with frequent mention of a traumatic rupture caused by a direct blow at the level of the metacarpophalangeal joint (MCPJ). The other causes of sagittal band injuries are degenerative disease, congenital infection, and rheumatoid arthritis. To our knowledge, we report the first case of spontaneous idiopathic bilateral sagittal band rupture.

Case Report

We, herein, present the case of a seronegative 29-year-old female who presented with pain and swelling in the dominant hand for 4 days.

Conclusion

Upon examination, she was found to have bilateral dislocation of the extensor tendons at the level of the (MCPJ) of the third and fourth digits. Any underlying cause was excluded, and the diagnosis was confirmed with a dynamic ultrasound study.

Wide awake surgery for rupture of the lateral expansion of the long-finger extensor tendon: A case report

Spontaneous extensor digitorum communis (EDC) tendon rupture is uncommon but easily confusing injury that lead to functional impairment. There is no any strict first-line treatment for nonrheumatoid EDC tendon rupture. We report a kidney transplant recipient with spontaneous rupture of the lateral expansion of the long-finger extensor tendon treated by wide awake surgery. Surgical repair with wide-awake local anesthesia was performed to realign the tendon for the patient. Three months following surgery, the patient obtained a full pain-free range of motion of the hand without recurrent dislocation.

Sagittal Band Injury and Extensor Tendon Realignment

The sagittal bands are structurally important, aiding in the central alignment of the extensor tendons over the heads of each metacarpal. They resist the deviation of the tendon with flexion of the metacarpophalangeal (MCP) joint. Injury to the sagittal band can cause the extensor tendon to lose its alignment leading to pain, tendon subluxation, or dislocation. Generally, if these injuries are recognized and treated within 3 weeks of injury, they will not require surgery. The goal of surgery is to restore the anatomic alignment of the extensor tendon by either direct repair of the sagittal band or reconstruction.

Functional anatomy of the sagittal bands and mechanisms of extensor tendon dislocation: a cadaveric study

We investigated the functional anatomy of the radial sagittal band and possible mechanisms involved in its spontaneous and traumatic rupture using seven cadaveric hands. First, the extensor tendon excursion and the change in angle between the sagittal bands and the tendon path were measured during metacarpophalangeal joint flexion. The radial bands were then divided in two different ways that mimicked spontaneous or traumatic rupture. We found no significant correlation between the extensor tendon excursion and the change in angle of the sagittal bands in the middle and ring fingers. Dislocation could occur when the radial sagittal band was only partially divided. This may explain why conservative treatment of tendon dislocation in the middle and ring fingers is feasible. Complete section of the sagittal bands in the little finger caused ulnar dislocation of the extensor tendon in only one out of seven hands.

Two case reports-Use of relative motion orthoses to manage extensor tendon zones III and IV and sagittal band injuries in adjacent fingers

STUDY DESIGN

Case report.

INTRODUCTION

Injuries to adjacent fingers with differing extensor tendon (ET) zones and/or sagittal band pose a challenge to therapists as no treatment guidelines exist.

PURPOSE OF THE STUDY

This report highlights how the relative motion flexion/extension (RMF/RME) concepts were combined into one orthosis to manage a zone IV ET repair (RME) and a zone III central slip repair (RMF) in adjacent fingers (Case 1); and how a single RME orthosis was adapted to limit proximal interphalangeal joint motion to manage multi-level ET zone III-IV injuries and a sagittal band repair in adjacent fingers (case 2).

METHODS

Adapted relative motion orthoses allowed early active motion and graded exercises based on clinical reasoning and evidence. Outcomes were standard TAM% and Miller's criteria.

RESULTS

'Excellent' and 'good' outcomes were achieved by twelve weeks post surgery. Both cases returned to unrestricted work at 6 and 7 weeks. Neither reported functional deficits at discharge.

DISCUSSION

Outcomes in 2 cases involving multiple digit injuries exceeded those previously reported for ET zone III-IV repairs.

CONCLUSIONS

Relative motion orthoses can be adapted and applied to multi-finger injuries, eliminating the need for multiple, bulky or functionally-limiting orthoses.

LEVEL OF EVIDENCE

4.

Relative motion orthoses in the management of various hand conditions: A scoping review

STUDY DESIGN

Scoping review.

INTRODUCTION

The relative motion (RM) concept and immediate controlled active motion (ICAM) program, originally applied after zones IV-VII extensor tendon repairs, have been modified and extended to a variety of hand conditions, such as sagittal band injury, boutonniere deformity, and extensor lag.

PURPOSE OF THE STUDY

To scope the published and unpublished literature to review ICAM modifications, hand conditions for which the RM concept is used, and describe the preferred degree of relative metacarpophalangeal joint extension/flexion reported and spectrum of orthosis design.

METHODS

Electronic and manual searches of scientific and gray literature and expert consultation were conducted. Documents with quantitative data were assessed with Oxford Levels of Evidence and the Structured Effectiveness Quality Evaluation Scale.

RESULTS

Fifteen references met the inclusion criteria; 1 was level III evidence, and others were level IV evidence. RM-ICAM modifications, preferred degree of relative extension/flexion, orthotic design, management of other hand conditions and knowledge gaps were identified.

CONCLUSION

RM orthoses may improve outcomes in a variety of hand conditions; however, high-quality studies that contribute to the evidence base for its use are needed.

LEVEL OF EVIDENCE

Not applicable.

Sagittal band, boutonniere, and pulley injuries in the athlete

PURPOSE OF REVIEW

While hand injuries occur frequently in the athletic population, sagittal band ruptures, boutonniere deformities, and pulley ruptures are infrequently encountered. These injuries represent diagnostic challenges and can result in significant impairment. Early recognition with appropriate treatment is necessary to maximize recovery and minimize return to athletic competition. This review will focus on the underlying mechanism, pathophysiology of injury, diagnosis, and treatment of each of these injuries.

RECENT FINDINGS

With respect to sagittal band ruptures, boutonniere deformities, and pulley ruptures, the recent literature has been limited in scope. For sagittal band injuries, current efforts have focused on alternative techniques for sagittal band reconstruction. Little progress has been made in recent years with respect to boutonniere injuries in the athletic population; prevention of fixed deformities remains the backbone of treatment. The exact contribution from individual and combined pulley injuries in the creation of bowstringing remains controversial. Recent anatomical studies have failed to definitively answer the question of what degree of rupture is necessary to create symptomatic bowstringing. Favorable outcomes, with respect to both preventing bowstringing and returning to full athletic participation, have been newly reported following pulley reconstruction in rock climbers. Due to the infrequent nature of sagittal band ruptures, boutonniere deformities, and pulley ruptures, current treatment is mostly guided by historically established methods, limited case series, and case reports. Nonsurgical treatment remains the mainstay for most injuries and, if employed early, often precludes the need for surgery. Further anatomical and clinical research, including outcome studies, is necessary in guiding treatment algorithms.

Extensor Tendon Instability Due to Sagittal Band Injury in a Martial Arts Athlete: A Case Report

A Taekwondo participant sustained a hand injury from punching an opponent that resulted in painful instability of the ring finger extensor digitorum communis tendon due to sagittal band damage. His symptoms resolved after reconstructive surgery on the sagittal band (SB) with stabilization of the extensor tendon over the metacarpophalangeal joint.

Traumatic Thumb Radial Sagittal Band Injury Mimicking EPL Rupture

We present the case of a closed traumatic disruption of the thumb radial sagittal band (RSB) that sonographically mimicked rupture of the extensor pollicis longus (EPL) tendon. This injury was treated with primary repair of the RSB and lead to a good functional outcome for the patient. This case report highlights how early recognition and treatment can lead to a good functional outcome.

Relationship Between Juncturae Tendinum and Sagittal Bands

The juncturae tendinum and sagittal bands transmit precise forces through the dorsum of the hand. Both structures are integral in the mechanics of normal digital extension and in stabilization of the metacarpophalangeal (MCP) joints. Extensor tendon injury, or rupture/attenuation of sagittal bands and/or juncturae tendinum, may disrupt the kinematic chain and lead to a number of abnormal hand postures and motions. Early treatment of extensor tendon and/or sagittal band injury is dependent upon proper recognition of primary pathology. Proper evaluation and the use of special clinical tests should be implemented to rule out other pathologies. Once diagnosed, treatment may consist of relative motion splinting and standard pain/edema control measures to increase joint motion, tendon excursion, and functional use of the hand.

Subluxation of the extensor carpi ulnaris tendon associated with the extensor digitorum tendon subluxation of the long finger

A twenty-year-old male visited our clinic with wrist and long finger metacarpophalangeal (MP) joint pain. Dynamic ultrasonography revealed sagittal band (SB) ulnar subluxation and extensor carpi ulnaris (ECU) volar subluxation. Magnetic resonance imaging showed longitudinal splitting and dislocation of the volar half slip of the ECU tendon. The redundant radial SB was augmented and ECU sheath was advanced to the periosteum using suture anchors. He was able to perform his previous activities at the last follow-up. We encountered a case of "simulateous" ECU dislocation with extensor tendon subluxation of the long finger at the MP joint. Therefore, we report this case with a review of the relevant literature.