Tendon ruptures of the hand and fingers

Anatomy: extensor and flexor tendons of the hand

Finely tuned tendon movements control the hand and fingers. The extensor tendons are on the back of the hand and the flexor tendons are on the palm of the hand. They slide in tendon sheaths and under connective tissue structures that keep the tendons close to the bone.

• Flexor tendons: Superficial flexor (FDS) and deep flexor (FDP) flex finger and end joints; In the thumb, the flexor pollicis longus tendon (FPL) takes over the flexion.
• Extensor tendons: Common extensors stretch the base and middle joints; the terminal tendon straightens the end joint. The extensor pollicis longus (EPL) is particularly important on the thumb.
• Guidance structures: Ring and cruciate ligaments (A2/A4 pulley) hold flexor tendons to the bone. At the base joint, sagittal bands stabilize the extensor tendon in the middle position.
• Supply: Tendons have a relatively poor blood supply. This promotes adhesions and makes healing more difficult - which makes precisely fitting splints and hand therapy all the more important.

Depending on the injured zone (classic zones I-V for extensor tendons, I-V for flexor tendons), the procedure, prognosis and rehabilitation protocols differ.

Causes and risk factors

Tendons rupture due to acute peak forces, sharp cuts or as a result of chronic degeneration. Often several factors come into play.

• Cut/stab injuries (glass, knife, sheet metal): often complete ruptures of several structures (tendons, nerves, vessels).
• Sports accidents: jerky pulling on the finger (e.g. jersey grip in rugby → jersey finger), ball impact on the fingertip (mallet finger), boxing (sagittal band lesion).
• Fall and crush trauma: sudden hyperextension/flexion, avulsion fractures at the base of the tendon insertion.
• Degenerative previous damage: rheumatoid arthritis, arthrosis, chronic tendovaginitis; rarely spontaneous ruptures (e.g. EPL after distal radius fracture).
• Medication and metabolism: repeated cortisone injections near tendons, fluoroquinolone antibiotics, diabetes mellitus; Smoking reduces healing.
• Occupational/everyday stress: repeated, powerful gripping and stretching movements without compensation.

Symptoms and warning signs

• Sudden pain with audible/tactile “snapping” or tearing.
• Acute loss of function: Finger can no longer be actively stretched or bent.
• Malposition: hanging fingertip (mallet), beak-shaped PIP flexion with central extensor tendon rupture (boutonnière).
• swelling, bruising; Possibly open wound with visible tendon.
• Accompanying symptoms: numbness, tingling (nerve involvement), pale/cold finger (circulatory disorder) – emergency signs.

Not every rupture hurts badly. The functional test is crucial: Can the affected joint be actively moved against resistance?

Common injury patterns to the hand and fingers

• Mallet finger (end phalanx extensor tendon rupture or bony avulsion): End joint hangs in a flexed position, active extension is not possible. Often can be treated conservatively with a special stack splint over 6-8 weeks.
• Jersey Finger (avulsion of the deep flexor FDP at the distal phalanx): inability to flex the distal joint; Ring finger often affected. Immediate surgery is usually required for refixation.
• Central slip rupture (Boutonnière deformity): PIP flexion due to hyperextension in the DIP. Depending on the extent, splint treatment or surgical reconstruction.
• Sagittal band lesion (“Boxer’s knuckle”): Extensor tendon jumps to the side at the base joint, painful instability when stretched. Immobilization, if necessary surgical stabilization.
• Flexor tendon injury zone II (“no man’s land”): complex cuts in the palm/fingers; i. d. R. surgical suture and structured follow-up treatment necessary.
• EPL rupture of the thumb: can occur after a distal radius fracture or with an inflammatory tendon sheath; often surgical treatment (tendon transfer).

The specific strategy depends on the injury pattern, degree of rupture (partial vs. complete rupture), accompanying injuries and your activity profile.

Diagnostics in our practice

The aim is to carry out a precise functional analysis and classify the injury in order to avoid unnecessary operations and not miss necessary procedures.

The time window is important: early presentation improves the chances of functional care and structured rehabilitation.

Conservative therapy: splint, protection, hand therapy

Many extensor tendon injuries and partial ruptures can be successfully treated without surgery. The prerequisites are a coherent rail concept, consistent cooperation and close control.

• Rail supply: e.g. B. Stack splint for the mallet finger (continuous extension of the end joint over 6-8 weeks, then another 2-4 weeks at night).
• Immobilization and protection: temporary relief, adapted taping, avoidance of tension/flexion of the affected tendon.
• Pain and inflammation management: cooling, elevation, as-needed analgesics as recommended by a doctor.
• Early, guided mobilization of the unaffected joints to avoid stiffness.
• Hand therapy/occupational therapy: Instructions for home exercises, edema control, scar care, later strength and coordination training.

Limitations of conservative therapy exist particularly in the case of complete flexor tendon ruptures, severely retracted tendon ends, unstable bony avulsions or persistent tendon dislocation.

Surgical treatment – ​​when does it make sense?

Surgery is considered if the tendon is completely torn, severely retracted, there are associated injuries, or if conservative measures do not allow adequate function. The decision and timing are made individually, after information about the benefits and risks.

• Primary tendon suture: end-to-end suture with epitendinous reinforcement, ideal within the first few days.
• Refixation with suture anchors/screws in the case of bony avulsion (e.g. Jersey finger).
• Secondary reconstruction: tendon transfer or tendon graft when primary suturing is not possible (e.g. late EPL rupture).
• Tenodesis/shortening techniques in selected situations.
• Accompanying procedures: annular ligament/sagittal ligament reconstruction, wound revision, treatment of accompanying fractures.

Risks include: Infection, impaired wound healing, adhesions (adhesions), stiffness, re-rupture, scarring problems or complex regional pain syndrome (CRPS). Structured follow-up treatment reduces these risks.

Follow-up treatment and rehabilitation

The follow-up treatment is just as important as the procedure or the choice of splint. It is carried out according to standardized, individually adapted protocols and in close coordination with hand therapists.

• Rail protocols: e.g. B. continuous stretching splint for the mallet finger; Often protected early mobilization after flexor tendon suturing (Duran/Kleinert protocol).
• Movement structure: initially passive, then assistive and active movements; Strength training only after medical clearance at the earliest.
• Check-up appointments: regular function and splint checks, adjustment of the load if necessary.
• Scar care, edema control, sensitivity training.
• Return to work/sport: variable depending on the activity, usually gradually from 6-12 weeks, full load often after 3-6 months.

The goal is stable, pain-free function in everyday life. Depending on the initial findings, absolute freedom from pain or complete recovery of strength cannot be guaranteed.

Course, prognosis and possible complications

The prognosis depends on the area of ​​injury, degree of rupture, start of treatment, accompanying injuries and individual factors such as smoking, diabetes or connective tissue quality.

• Good prospects for early treated extensor tendon ruptures without retraction - splint therapy is often sufficient.
• Flexor tendon ruptures often require surgery and consistent hand therapy; Adhesions can temporarily limit movements.
• Possible complications: Stiffness, extension/flexion deficits, re-rupture, painful scars, tendon dislocation, CRPS, persistent swelling.
• Older, overlooked ruptures can often be improved - sometimes with secondary reconstructions. However, expectations should remain realistic.

Self-management and prevention

• Acutely after injury: Immobilize in a functional position, cool, elevate your hand, remove rings, seek medical advice early.
• Ergonomic adjustments for work and sport; protective tape or splint solutions for risky sports.
• Warm up and progressive increase in load during training.
• Address risk factors: quitting smoking, good blood sugar control, cautious use of local cortisone injections on stressed tendons.
• Regular exercises for mobility, coordination and grip strength - guided by hand therapy if necessary.

When do you need to see a doctor urgently?

• Open cut/stab injury to the hand or finger.
• Sudden loss of function: Finger cannot be actively stretched or bent.
• Significant misalignment (hanging fingertip, “beak-shaped” middle joint position).
• Numbness, tingling, pale/cold finger or severe pain despite immobilization.
• Increasing swelling/hematoma after trauma.

If there are any warning signs, please see orthopedic/hand surgery as soon as possible. Early assessment improves treatment options.

Your treatment in Hamburg

At Dorotheenstrasse 48, 22301 Hamburg, we offer evidence-based assessment and treatment of tendon injuries of the hand. We rely on high-resolution sonography, practical splint concepts and close cooperation with hand therapy networks in Hamburg. We discuss surgical options transparently and, if necessary, promptly refer you to experienced hand surgical partners.

We would be happy to advise you personally on your findings, the advantages and disadvantages of conservative and surgical measures, as well as realistic goals for everyday life, work and sport.