The Guitarist Plays Again A Rare Tendon Injury with an Excellent Surgical Outcome

Gregory Horner, M.D. 

The Case: A 22 year old right handed man was in his usual state of good health until attempting a power grasp activity at work. He then felt a snapping sensation and a sharp minor pain in his small finger and hand. Immediately, he noticed that he was unable to bend his small finger. “It was easy to straighten the finger but when I make a fist, the pinky was straight” (see photo A). He knew it was a tendon injury. After a few days, he realized that the problem would not improve and sought medial attention.

The Anatomy: There are two joints in each finger and one in the thumb. The joint closest to the finger nail is the Distal InterPhalangeal Joint (DIP) and the joint closest to the hand is the Proximal InterPhalangeal Joint (PIP). There are two tendons in each finger, as well. The “profundus” acts at the DIP and PIP joints simultaneously. It causes the joints to bend or “flex.” The “sublimus” acts at the PIP joint, onlyand causes flexion as well. These “flexor tendons” work together with the other tendons to give us our amazing dexterity in order to make a fist and open your hand (see photos B & C).

Diagnosis: The patient was seen at an urgent care clinic. The physicians there recognized a tendon injury had occurred and immediately sought to refer him for Hand Surgery consultation. In the office of Tri-Valley Orthopedic Specialists (TVO), Gregory Horner, M.D. fully diagnosed this rare injury. The patient had ruptured both of the flexor tendons in his small finger.

Such an injury is exceedingly rare. Dr. Horner reviewed the entire literature on this topic and states “there was only one full report of treating this injury, and a only a very few others related to gout, arthritis, and other causes, reported in the past 50 years!”

Treatment: The one report from the Hospital for Special Surgery in New York described a repair of only one of the two tendons. With this limited medical information available, Dr. Horner relied on 8 years and 700 cases per year of surgical experience. “As a orthopedic ‘subspecialist,’ many of the cases referred to me are from other surgeons,” Dr. Horner states. “…as a result, many of these cases are not ‘textbook’, if you will.”

The patient underwent surgery. Surprisingly, the tendons had ruptured at different levels. The profundus ruptured at its attachment at the distal phalanx. The sublimus had ruptured at mid-substance in the finger base. The finger base in known as “surgical no-man’s land.” This name was earned because the results of surgery in this area have been uniformly poor, even in the hands of the best surgeon.

The Risks: The patient was a guitarist and was very concerned about his dexterity. He had good reason to be concerned. The sublimus has more individual control than the profundus. In the only full report in the medical literature, the sublimus could not be repaired. This would be disastrous for a guitarist because he would not have use of his fifth finger in the manner illustrated in photo D. Therefore, the decision was made before surgery to repair both tendons.

The Result: After careful rehabilitation, integrated with Tri-Valley Orthopedic Specialists Occupational Therapy, the patient graduated from his splint in 6 weeks. He was allowed full use of his hand at 8weeks. Today, he has essentially normal use. His guitar playing is back to normal. The sublimus tendon works normally.

This is a first in hand surgery!