What specialist should a patient with extensor tendinous ligament laxity consult for evaluation and management?

Specialist Referral for Extensor Tendinous Ligament Laxity

Patients with extensor tendinous ligament laxity should be referred to an orthopedic hand surgeon or sports medicine specialist for definitive evaluation and management, as these injuries require specialized assessment to determine whether surgical repair or conservative management is indicated.

Primary Specialist Recommendation

• Orthopedic hand surgeon is the most appropriate specialist for extensor tendon and ligament injuries, as they possess the surgical expertise required for potential repair and reconstruction 1, 2
• Sports medicine specialists with hand/upper extremity fellowship training are also appropriate, particularly for athletes requiring rapid return to play 3

Initial Diagnostic Approach

Before specialist referral, the following imaging should be obtained:

• Plain radiographs are the initial imaging study to rule out associated fractures or bony avulsion injuries 1

• MRI without IV contrast is the preferred advanced imaging modality for evaluating extensor tendon injuries and ligament laxity when radiographs are normal or indeterminate 1

  • MRI sensitivity for extensor hood injuries ranges from 28% to 85%, though it has not been as well studied as flexor system imaging 1
  • MRI is ideal for surgical planning and assessing the extent of tendon retraction and quality of tendon stumps 1

• Ultrasound is an acceptable alternative to MRI for tendon and ligament assessment, particularly when dynamic evaluation is needed 1

  • US allows direct visualization of joint malalignment and can assess ligamentous laxity with dynamic stress maneuvers 1
  • US has strong interrater reliability for collateral ligament injuries in acute settings 1

Zone-Specific Management Considerations

The specialist will determine treatment based on the anatomic zone of injury:

• Zone I-III injuries (distal finger) may be managed conservatively with splinting unless there is displaced avulsion fracture or joint instability 2
• Zone IV-VII injuries (hand and wrist) typically require surgical primary repair followed by 6 weeks of extension splinting 2
• Ligamentous laxity causing joint instability often requires surgical reconstruction, particularly when conservative management fails 1

Critical Pitfalls to Avoid

• Delayed referral can result in tendon retraction, making primary repair impossible and necessitating more complex reconstruction with tendon grafts or transfers 4, 2
• Untreated volar plate or collateral ligament injuries can result in permanent contractures or chronic joint laxity 1
• Missed Stener lesions (in thumb ulnar collateral ligament injuries) require surgical intervention and will not heal with conservative management alone 1

Timing of Referral

• Acute injuries should be referred within 24-48 hours for optimal surgical timing if repair is indicated 2
• Chronic laxity with functional impairment warrants semi-urgent referral within 1-2 weeks 1