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Anatomy

Upper Limb

Question 147 of 239

A 34 year old patient presents to ED having sustained an injury to her right hand whilst playing cricket. She is unable to fully straighten her right middle finger as the distal phalanx remains flexed. A picture of her hand is shown below. Which of the following structures within the digit was most likely injured:

By Howcheng (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0) or GFDL (http://www.gnu.org/copyleft/fdl.html)], via Wikimedia Commons

By Howcheng (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0), via Wikimedia Commons

Answer:

Damage to the insertion of the terminal extensor digitorum tendon would result in loss of extension at the distal interphalangeal joint causing a fixed flexion deformity, called the Mallet deformity.

Extensor Tendon Injury

Anatomy / Upper Limb / Digital Attachment of Long Tendons

Last Updated: 10th April 2019

Table: Clinical Features of Extensor Tendon Injury

Structure Terminal Extensor Tendon Central Slip of Extensor Tendon
Attachment Distal phalanx Middle phalanx
Movements affected in injury Loss of extension at distal interphalangeal joint Loss of extension at proximal interphalangeal joint and flexion at distal interphalangeal joint
Deformity in injury Mallet deformity: Distal phalanx held in fixed flexion Boutonniere deformity: Middle phalanx held in fixed flexion with hyperextension of distal phalanx

The tendons of the extensor digitorum (and extensor pollicis longus) pass onto the dorsal aspect of the digits and expand over the proximal phalanges to form complex extensor hoods. The central slip inserts into the base of the middle phalanx, and distally the tendon inserts into the distal phalanx of each digit.

Modified by FRCEM Success. Original by Henry Vandyke Carter [Public domain], via Wikimedia Commons

Extensor Tendons. (Image modified by FRCEM Success. Original by Henry Vandyke Carter [Public domain], via Wikimedia Commons)

Central Slip

Division of the central slip of the extensor tendon will result in the Boutonniere deformity, with loss of extension of the proximal interphalangeal joint and loss of flexion of the distal interphalangeal joint. The middle phalanx is held in forced flexion, with hyperextension of the distal phalanx.

Terminal Tendon

Division of the terminal extensor tendon will result in the Mallet deformity, with loss of extension at the distal interphalangeal joint as in this case; the distal phalanx is held in forced flexion due to unopposed action of the flexor digitorum profundus muscle.

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  • Biochemistry
  • Blood Gases
  • Haematology
Biochemistry Normal Value
Sodium 135 – 145 mmol/l
Potassium 3.0 – 4.5 mmol/l
Urea 2.5 – 7.5 mmol/l
Glucose 3.5 – 5.0 mmol/l
Creatinine 35 – 135 μmol/l
Alanine Aminotransferase (ALT) 5 – 35 U/l
Gamma-glutamyl Transferase (GGT) < 65 U/l
Alkaline Phosphatase (ALP) 30 – 135 U/l
Aspartate Aminotransferase (AST) < 40 U/l
Total Protein 60 – 80 g/l
Albumin 35 – 50 g/l
Globulin 2.4 – 3.5 g/dl
Amylase < 70 U/l
Total Bilirubin 3 – 17 μmol/l
Calcium 2.1 – 2.5 mmol/l
Chloride 95 – 105 mmol/l
Phosphate 0.8 – 1.4 mmol/l
Haematology Normal Value
Haemoglobin 11.5 – 16.6 g/dl
White Blood Cells 4.0 – 11.0 x 109/l
Platelets 150 – 450 x 109/l
MCV 80 – 96 fl
MCHC 32 – 36 g/dl
Neutrophils 2.0 – 7.5 x 109/l
Lymphocytes 1.5 – 4.0 x 109/l
Monocytes 0.3 – 1.0 x 109/l
Eosinophils 0.1 – 0.5 x 109/l
Basophils < 0.2 x 109/l
Reticulocytes < 2%
Haematocrit 0.35 – 0.49
Red Cell Distribution Width 11 – 15%
Blood Gases Normal Value
pH 7.35 – 7.45
pO2 11 – 14 kPa
pCO2 4.5 – 6.0 kPa
Base Excess -2 – +2 mmol/l
Bicarbonate 24 – 30 mmol/l
Lactate < 2 mmol/l

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