What is the treatment for a central slip rupture, particularly in patients with a history of underlying conditions such as rheumatoid arthritis?

Central Slip Rupture Treatment

For acute central slip ruptures, immobilize the PIP joint in full extension for 6 weeks, followed by controlled mobilization; for chronic ruptures with boutonniere deformity, surgical repair using direct anatomic end-to-end repair with suture anchor augmentation is the treatment of choice.

Acute Central Slip Injuries

Initial Management

• Immobilize the PIP joint in full extension using a cylinder splint for 3 weeks, while allowing DIP joint motion to prevent lateral band adhesions 1
• After initial immobilization, transition to controlled mobilization using a Capener coil splint for an additional 3 weeks 1
• This 6-week protocol (3 weeks immobilization + 3 weeks controlled mobilization) achieves excellent or good recovery in all cases, with mean PIP flexion of 94° and minimal extension deficits 1

Surgical Indications for Acute Injuries

• Open central slip lacerations require immediate surgical repair followed by the immobilization protocol described above 1
• Displaced central slip attachment fractures (avulsion fractures) require open reduction and internal fixation to prevent boutonniere deformity and allow early mobilization 2
• These fractures should be recognized as disruptions of the dynamic extensor mechanism and treated surgically to achieve anatomic reduction 2

Chronic Central Slip Ruptures with Boutonniere Deformity

Surgical Technique

• Direct anatomic end-to-end repair using a loop suture technique with supplemental suture anchor augmentation is the preferred surgical approach for chronic deformities 3
• First, excise elongated scar tissue to expose the ruptured central slip 3
• The suture anchor provides additional stability and reduces the risk of re-rupture during rehabilitation 3
• Alternative technique: Use autologous palmaris longus tendon graft for reconstruction when direct repair is not feasible due to tissue quality 4

Patient Selection for Surgery

• Surgery is most effective for Burton stage I deformities (supple and passively correctable joints) 3
• Patients with fixed contractures or advanced joint destruction are poor surgical candidates 3
• Set realistic expectations: 77% achieve fair to excellent outcomes, but residual extension lag and recurrence risk must be discussed preoperatively 3

Expected Outcomes

• Mean PIP extension lag improves from 43.5° to 21.6° at final follow-up 3
• Mean DIP hyperextension (19.2°) corrects to near-neutral position 3
• Average total active motion of 220° is achievable 3
• Recurrence occurs in approximately 23% of cases, typically during range of motion exercises 3

Special Considerations for Rheumatoid Arthritis Patients

Critical Pitfall

• In RA patients, central slip rupture may occur spontaneously or with minimal trauma due to chronic synovitis weakening the tendon 5
• The guidelines emphasize that surgical interventions such as tendon repair may be necessary to prevent further tendon rupture in RA patients with active disease 5
• Peri-tendon injections around the patellar and quadriceps tendons should be avoided due to rupture risk, and this principle extends to finger extensor tendons 5

Disease Activity Management

• Control underlying RA disease activity before or concurrent with tendon repair using treat-to-target approach with DMARDs 5
• Target remission (SDAI ≤3.3) or low disease activity (SDAI ≤11) to minimize ongoing inflammatory damage to repaired structures 5, 6
• Regular monitoring every 1-3 months during active disease is essential to prevent further tendon complications 5

Multidisciplinary Approach

• Coordinate care between hand surgery and rheumatology to optimize both local tendon repair and systemic disease control 5
• Physiotherapy and occupational therapy are critical adjuncts for joint protection education and rehabilitation 5
• Avoid local glucocorticoid injections near the repair site given the increased tendon rupture risk 5

Rehabilitation Protocol

Post-Surgical Rehabilitation

• Immobilize PIP joint in extension for 3 weeks immediately post-operatively 1
• Transition to controlled mobilization with Capener coil splint for weeks 4-6 1
• Begin active range of motion exercises under therapist supervision after week 6 3, 1
• Athletes may return to sport by week 3-6 depending on injury severity and sport demands, though full recovery typically requires 6 weeks 7

Common Complications

• Extension lag at PIP joint is the most common residual deficit (occurs in 16% of cases) 1
• Recurrence of deformity during rehabilitation occurs in approximately 23% of surgical cases 3
• DIP joint flexion limitation may develop in some patients 3