Medscape is available in 5 Language Editions – Choose your Edition here.


Vaughan-Jackson Syndrome Treatment & Management

  • Author: John A McAuliffe, MD; Chief Editor: Harris Gellman, MD  more...
Updated: Feb 01, 2016

Medical Therapy

Tendon continuity cannot be restored by means of medical therapy; in fact, the occurrence of tendon rupture may indicate that the current regimen of medical management is inadequate and that additional remittive therapy should be considered. Adequate medical control of rheumatoid disease is imperative to minimize synovial proliferation, which may otherwise jeopardize the results of surgical reconstruction, place other anatomic areas at risk, or both.

Pharmacologic preparation for surgery

Most authors recommend a single intravenous (IV) dose of an antibiotic (usually a cephalosporin) immediately before surgery, and some follow this with 24 hours of postoperative therapy as a prophylactic measure. The postoperative antibiotic can be administered orally on an outpatient basis. This author is not aware of a controlled study that demonstrates the advisability of any particular perioperative antibiotic regimen.

Patients treated with corticosteroids require increased doses in the perioperative period to protect against the possibility of addisonian crisis brought on by the stress of surgery.[40]

Adequate pain control must be ensured; occasionally, this necessitates postoperative inpatient hospital admission.


Surgical Therapy

Prevention of tendon rupture

Prophylactic procedures intended to prevent tendon rupture are generally quite effective and provide function that is superior to the function provided by any method of tendon repair or reconstruction. Patients with risk factors such as dorsal prominence of the distal ulna, radiographic erosion involving the distal radioulnar joint (DRUJ), or persistent dorsal tenosynovitis that is unresponsive to medical management over a 6-month period should be considered candidates for such surgery.[22]

Weakness or extensor lag of the small-finger metacarpophalangeal (MCP) joint may indicate that one of the tendons that motor this joint has failed; this is usually caused by rupture of the extensor digiti minimi (EDM), with residual function resulting from the intact extensor digitorum communis (EDC) tendon. This warning sign or pain over the dorsum of the wrist associated with motion of the digital extensor tendons should also prompt early exploration. Tendon rupture after prophylactic surgery, which includes tenosynovectomy and DRUJ reconstruction, is rare (0-4%).[42]

Hsueh et al, in a retrospective review of 17 episodes of spontaneous tendon rupture (15 RA patients) and 14 episodes of tenosynovitis (12 RA patients), suggested that prophylactic extended tenosynovectomy to prevent more severe extensor tendon damage should be recommended in those with the following risk factors[43] :

  • Rheumatoid disease of more than 8 years' duration
  • Persistent tenosynovitis of more than 1 year's duration
  • Larsen grade higher than 4

Tendon continuity restoration

Surgical efforts to restore tendon continuity must always include thorough dorsal tenosynovectomy with retinaculum transposition and resection or reconstruction of the DRUJ sufficient to remove the bony prominences that produced the tendon rupture.[28] As noted previously, the choice of DRUJ reconstruction may vary, depending on the status of the wrist joint and other individual patient considerations.[30] After the loss of small-finger extension, surgical exploration should be undertaken without delay to avoid sequential rupture of the adjacent tendons, which would further complicate reconstruction. (See the image below.)

Intraoperative image of a ruptured extensor tendon Intraoperative image of a ruptured extensor tendon with the hand to the left. Note that the tendon ends cannot be reapproximated despite maximum tension.

Direct repair

Direct repair of ruptured tendons is rarely possible, both because of the attritional nature of this process and because the zone of tendon injury is usually quite long.[9]

Bridge grafts

The use of bridge grafts to restore tendon continuity has been described with generally acceptable results. Bora et al reported 23 patients who recovered an average of 65° of MCP joint motion after free tendon grafting (average follow-up, 43 months).[44] However, this technique has not gained widespread acceptance, because tendon graft harvest may require additional operating time and surgical exposure, sometimes at a remote site.

Many authors have also expressed concern that tendon grafting results in two tenorrhaphy sites in what is often a less than optimal tendon bed, possibly increasing the risks of scar formation and motion-limiting adhesions.[28] In a study by Nakamura and Katsuki, grafting of multiple extensor tendon ruptures in 14 patients with rheumatoid arthritis (RA) resulted in good correction of extensor lag, but patients were dissatisfied with the accompanying loss of digital flexion. These authors postulated that this limitation of flexion is caused by contracture of the involved muscle and, thus, did not recommend tendon grafting.[45]

Chung et al reported that MCP joint extension lag correlated with patient satisfaction scores, whereas pulp-to-palm distance in flexion did not. Their study of 51 wrists with extensor tendon ruptures found no significant differences in outcome between tendon grafting and tendon transfers.[46]

Tendon transfer

Tendon transfer remains the most common method of restoring tendon continuity in the rheumatoid hand after extensor tendon rupture. However, it is associated with its own particular set of challenges, including the possibilities that the joints to be motored may be stiff or unstable, that the tendon beds may be less than ideal, that the motor tendons may have disease involvement or may be unavailable, and that tenodesis may be limited by wrist stiffness.

Despite these potential shortcomings, tendon transfer is often the best surgical alternative. The method of tendon transfer is determined primarily by the number of digits involved.[47]

Small-finger MCP joint extension may be lost after isolated rupture of the EDM in a patient without significant EDC tendon contribution to this digit, or it may follow rupture of both the EDM and a slip of the EDC. The distal tendon stump that produces strong MCP joint extension of the small finger (usually the EDM) may be transferred to the adjacent EDC of the ring finger. Occasionally, the distal stump is so short that such side-to-side suture tends to produce unacceptable abduction of the small finger. In these instances, the extensor indicis proprius (EIP) may be transferred to the EDM.[47]

Loss of ring- and small-finger MCP joint extension is usually best treated by using the EIP to motor both the EDM and the ring-finger EDC. Alternatively, the EIP may be transferred to the EDM, and the ring-finger EDC may be sutured in a side-to-side fashion to the intact long-finger EDC.[47]

Loss of long-, ring-, and small-finger MCP joint extension is usually treated by transfer of the EIP to both the EDM and the EDC of the ring finger and side-to-side suture of the long-finger EDC to the intact index-finger EDC. If the EIP is the only remaining extensor to the index finger, a flexor digitorum sublimis (FDS) tendon may be used to motor ring- and small-finger MCP joint extension in place of the EIP. Although one of the radial wrist extensors (preferably the extensor carpi radialis longus) can be considered as a motor tendon in this circumstance, it often is not long enough to reach the distal stumps of the ruptured tendons and lacks sufficient excursion to restore normal MCP joint motion.[47]

Loss of MCP joint extension of the index, long, ring, and small fingers constitutes the final stage of this process and should only be seen in neglected cases. Although one hesitates to remove power and joint stability from the volar surface of the rheumatoid hand, transfer of the FDS tendons to provide MCP joint extension, as originally described by Boyes in the treatment of radial nerve palsy,[48] is often the best alternative. Many patients feel that flexor function is improved as a result of decompressing the digital flexor sheaths by tendon harvest.

Most authors use the ring-finger FDS to motor the ring and small fingers and the long-finger FDS to motor the index and long fingers. The classic Boyes transfer routed these tendons through a window in the interosseous membrane. However, adhesions may be limited in the rheumatoid hand by using the alternative of a subcutaneous tunnel around the forearm.[47] The radial route is preferred because it tends to counteract the tendency for ulnar subluxation of the digital extensors on the dorsum of the MCP joints.[49] Other motor tendons may, of course, be used, depending on the specific clinical circumstance.


Postoperative Care

Inpatient hospital care is seldom required after surgical treatment of ruptured extensor tendons unless these procedures are combined with other major joint reconstruction procedures.

Surgery on a single upper extremity may significantly affect the functional capabilities of patients with RA. These patients frequently have limited function of the contralateral hand, as well as a need for ambulatory aids or other assistive devices that they may be incapable of using in the postoperative period. The need for increased support and home health assistance should be anticipated.

Appropriate hand therapy and splinting are crucial to the success of these procedures.[38] In the absence of supervised therapy, limitation of motion from scarring and adhesion formation may exceed the limitation that was present preoperatively. Joints adjacent to those that are being surgically treated are seldom entirely normal in the rheumatoid hand, and early motion is necessary to prevent stiffness and functional deterioration.

Although many authors advocate immobilization of the MCP joints in a position near full extension for 3-4 weeks after extensor tendon reconstruction, this author favors a program of graduated dynamic extension splinting in an attempt to maximize motion, particularly to avoid the loss of digital flexion. Therapy is usually initiated on postoperative day 3 or 4, after edema has declined and the wounds have settled. The overall pattern of patient disease and ongoing medical treatment may dictate accommodations in the usual course of postoperative therapy.[50]



Wound healing problems and infection are encountered in fewer than 5% of cases.[4]

Extension lag at the metacarpophalangeal (MCP) joint is a frequently mentioned occurrence,[26] though its incidence and magnitude are difficult to quantify. Most authors would agree, however, that extension contracture is very uncommon, and it generally is better to err on the side of increased tension when setting tendon transfers in the rheumatoid hand.[47]

Rerupture is distinctly uncommon, occurring in fewer than 5% of cases. This complication is usually related to inadequate reconstruction of the distal ulna, which allows recurrence of dorsal displacement and attritional tendon wear.[4]

Recurrent tenosynovitis develops in fewer than 7% of cases with medium-term (3- to 8-year) follow-up after tenosynovectomy.[31, 32, 42]

Contributor Information and Disclosures

John A McAuliffe, MD Consulting Surgeon, Department of Orthopedics, Section of Hand Surgery, Broward Health Medical Center

John A McAuliffe, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Society for Surgery of the Hand

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

N Ake Nystrom, MD, PhD Associate Professor of Orthopedic Surgery and Plastic Surgery, University of Nebraska Medical Center

Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M Miller School of Medicine, Clinical Professor, Surgery, Nova Southeastern School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, Arkansas Medical Society

Disclosure: Nothing to disclose.

Additional Contributors

Joseph E Sheppard, MD Professor of Clinical Orthopedic Surgery, Chief of Hand and Upper Extremity Service, Department of Orthopedic Surgery, University of Arizona Health Sciences Center, University Physicians Healthcare

Joseph E Sheppard, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Orthopaedics Overseas, American Society for Surgery of the Hand

Disclosure: Nothing to disclose.

  1. Brooks P. Extensor mechanism ruptures. Orthopedics. 2009 Sep. 32(9):[Medline].

  2. Vaughan-Jackson OJ. Rupture of extensor tendons by attrition at the inferior radio-ulnar joint. Report of two cases. J Bone Joint Surg Br. 1948. 30B(3):528-30. [Full Text].

  3. Vaughan-Jackson OJ. Attritional ruptures of tendons in the rheumatoid hand (abstract). J Bone Joint Surg Am. 1958. 40A:1431.

  4. Moore JR, Weiland AJ, Valdata L. Tendon ruptures in the rheumatoid hand: analysis of treatment and functional results in 60 patients. J Hand Surg (Am). 1987 Jan. 12(1):9-14. [Medline].

  5. Mannerfelt L, Norman O. Attrition ruptures of flexor tendons in rheumatoid arthritis caused by bony spurs in the carpal tunnel. A clinical and radiological study. J Bone Joint Surg Br. 1969 May. 51(2):270-7. [Medline]. [Full Text].

  6. Newmeyer WL, Green DP. Rupture of digital extensor tendons following distal ulnar resection. J Bone Joint Surg Am. 1982 Feb. 64(2):178-82. [Medline].

  7. Teplitz GA, Bisson LJ, Weiland AJ. Rupture of digital extensor tendons following distal ulnar resection and extensor carpi ulnaris stabilization: a case report. Am J Orthop. 1996. 25:230-32.

  8. Jain A, Brennan F, Troeberg L. The role of matrix metalloproteinases in rheumatoid tendon disease. J Hand Surg (Am). 2002 Nov. 27(6):1059-64. [Medline].

  9. Williamson SC, Feldon P. Extensor tendon ruptures in rheumatoid arthritis. Hand Clin. 1995 Aug. 11(3):449-59. [Medline].

  10. Ducloyer P, Leclercq C, Lisfranc R, et al. Spontaneous ruptures of the extensor tendons of the fingers in Madelung''s deformity. J Hand Surg (Br). 1991 Aug. 16(3):329-33. [Medline].

  11. Engkvist O, Lundborg G. Rupture of the extensor pollicis longus tendon after fracture of the lower end of the radius -- a clinical and microangiographic study. Hand. 1979 Feb. 11(1):76-86. [Medline].

  12. Gladstone H. Rupture of the extensor digitorum communis tendons following severely deforming fractures about the wrist. J Bone Joint Surg Am. 1952 Jul. 24-A-3:698-700. [Medline].

  13. Inoue G. Attritional rupture of the extensor tendon due to longstanding Kienbock''s disease. Ann Chir Main Memb Super. 1994. 13(2):135-8. [Medline].

  14. Lowry KJ, Gainor BJ, Hoskins JS. Extensor tendon rupture secondary to the AO/ASIF titanium distal radius plate without associated plate failure: a case report. Am J Orthop. 2000 Oct. 29(10):789-91. [Medline].

  15. Taniguchi Y, Yoshida M, Tamaki T. Subcutaneous extensor tendon rupture associated with calcium pyrophosphate dihydrate crystal deposition disease of the wrist. J Hand Surg (Br). 1997 Jun. 22(3):386-7. [Medline].

  16. Niwa T, Uchiyama S, Yamazaki H, Kasashima T, Tsuchikane A, Kato H. Closed tendon rupture as a result of Kienböck disease. Scand J Plast Reconstr Surg Hand Surg. 2010 Feb. 44(1):59-63. [Medline].

  17. Iwamoto T, Toki H, Ikari K, Yamanaka H, Momohara S. Multiple extensor tendon ruptures caused by tophaceous gout. Mod Rheumatol. 2010. 20:210-212.

  18. Katayama T, Ono H, Furuta K. Osteochondroma of the lunate with extensor tendons rupture of the index finger: a case report. Hand Surgery. 2011. 16:181-184.

  19. Shah NR, Wilczynski M, Gelberman R. Osteochondroma of the capitate causing rupture of the extensor digiti minimi: case report. J Hand Surgery Am. 2009. 34:46-48.

  20. Haug LC, Glodny B, Deml C, Lutz, M, Attal R. A new radiological method to detect dorsally penetrating screws when using volar locking plates in distal radius fractures -- the dorsal horizon view. The Bone and Joint Journal. August 2013. 95-B:1101-1105.

  21. Freiberg RA, Weinstein A. The scallop sign and spontaneous rupture of finger extensor tendons in rheumatoid arthritics. Clin Orthop Relat Res. 1972 Mar-Apr. 83:128-30. [Medline].

  22. Ryu J, Saito S, Honda T, et al. Risk factors and prophylactic tenosynovectomy for extensor tendon ruptures in the rheumatoid hand. J Hand Surg (Br). 1998 Oct. 23(5):658-61. [Medline].

  23. Yamazaki H, Uchiyama S, Hata Y, Murakami N, Kato H. Extensor tendon rupture associated with osteoarthritis of the distal radioulnar joint. J Hand Surg Eur Vol. Aug 2008. 33E:469-474. [Medline].

  24. Kwon ST, Schneider LH. Extensor tendon ruptures in rheumatoid hands. In: Hunter JM, Schneider LH, Mackin EJ, eds. Tendon and Nerve Surgery in the Hand: A Third Decade. St. Louis, Mo: Mosby Year Book. 1997:434-8.

  25. Sakuma Y, Ochi K, Iwamoto T, Saito A, Yano K, Naito Y, et al. Number of ruptured tendons and surgical delay as prognostic factors for the surgical repair of extensor tendon ruptures in the rheumatoid wrist. J Rheumatol. 2014 Feb. 41 (2):265-9. [Medline].

  26. Itsubo T, Uchiyama S, Yamazaki H, Hayashi M, Nakamura K, Kuniyoshi K, et al. Factors affecting extension lag after tendon reconstruction for finger extensor tendon rupture due to distal radioulnar lesion. J Orthop Sci. 2016 Jan. 21 (1):19-23. [Medline].

  27. Gong HS, Lee JO, Baek GH, Kim BS, Kim JY, Lee JS, et al. Extensor tendon rupture in rheumatoid arthriitis: a survey of patients between 2005 and 2010 at five Korean hospitals. Hand Surgery. 2012. 17:43-47.

  28. Wilson RL, DeVito MC. Extensor tendon problems in rheumatoid arthritis. Hand Clin. 1996 Aug. 12(3):551-9. [Medline].

  29. Millender LH, Nalebuff EA, Holdsworth DE. Posterior interosseous-nerve syndrome secondary to rheumatoid synovitis. J Bone Joint Surg Am. 1973 Jun. 55(4):753-7. [Medline].

  30. Murray PM. Current concepts in the treatment of rheumatoid arthritis of the distal radioulnar joint. Hand Clin. 2011. 27:49-55.

  31. Ishikawa H, Hanyu T, Tajima T. Rheumatoid wrists treated with synovectomy of the extensor tendons and the wrist joint combined with a Darrach procedure. J Hand Surg (Am). 1992 Nov. 17(6):1109-17. [Medline].

  32. Thirupathi RG, Ferlic DC, Clayton ML. Dorsal wrist synovectomy in rheumatoid arthritis -- a long-term study. J Hand Surg (Am). 1983 Nov. 8(6):848-56. [Medline].

  33. Rubens DJ, Blebea JS, Totterman SM, et al. Rheumatoid arthritis: evaluation of wrist extensor tendons with clinical examination versus MR imaging -- a preliminary report. Radiology. 1993 Jun. 187(3):831-8. [Medline].

  34. De Maeseneer M, Marcelis S, Osteaux M, et al. Sonography of a rupture of the tendon of the extensor pollicis longus muscle: initial clinical experience and correlation with findings at cadaveric dissection. AJR Am J Roentgenol. 2005 Jan. 184(1):175-9. [Medline].

  35. Sunagawa T, Ishida O, Ishiburo M, et al. Three-dimensional computed tomography imaging: its applicability in the evaluation of extensor tendons in the hand and wrist. J Comput Assist Tomogr. 2005 Jan-Feb. 29(1):94-8. [Medline].

  36. Ishikawa H, Abe A, Murasawa A, Nakazono K, Horizono H, Ishii K, et al. Rheumatoid wrist deformity and risk of extensor tendon rupture evaluated by 3DCT imaging. Skeletal Radiol. 2010 May. 39(5):467-72. [Medline].

  37. Abe A, Ishikawa H, Murasawa A, Nakazono K. Extensor tendon rupture and three-dimensional computed tomography imaging of the rheumatoid wrist. Skeletal Radiol. 2010 Apr. 39(4):325-31. [Medline].

  38. Soni P, Stern CA, Foreman KB, Rockwell WB. Advances in extensor tendon diagnosis and therapy. Plast Reconstr Surg. 2009 Feb. 123(2):727-8. [Medline].

  39. Bruyn GAW, Moller I, Garrido J, et al. Reliability testing of tendon disease using two different scanning methods in patients with rheumatoid arthritis. Rheumatology. 2012. 51:1655-1661.

  40. McAuliffe JA. General clinical considerations in rheumatoid surgery. In: Weiss A-PC, Hastings H, eds. Surgery of the Arthritic Hand and Wrist. Philadelphia, Pa: Lippincott Williams & Wilkins. 2002:27-37.

  41. Howe CR, Gardner GC, Kadel NJ. Perioperative medication management for the patient with rheumatoid arthritis. J Am Acad Orthop Surg. 2006 Sep. 14(9):544-51. [Medline].

  42. Brown FE, Brown ML. Long-term results after tenosynovectomy to treat the rheumatoid hand. J Hand Surg (Am). 1988 Sep. 13(5):704-8. [Medline].

  43. Hsueh JH, Liu WC, Yang KC, Hsu KC, Lin CT, Chen LW. Spontaneous Extensor Tendon Rupture in the Rheumatoid Wrist: Risk Factors and Preventive Role of Extended Tenosynovectomy. Ann Plast Surg. 2016 Jan 21. [Medline].

  44. Bora FW Jr, Osterman AL, Thomas VJ, et al. The treatment of ruptures of multiple extensor tendons at wrist level by a free tendon graft in the rheumatoid patient. J Hand Surg (Am). 1987 Nov. 12(6):1038-40. [Medline].

  45. Nakamura S, Katsuki M. Tendon grafting for multiple extensor tendon ruptures of fingers in rheumatoid hands. J Hand Surg (Br). 2002 Aug. 27(4):326-8. [Medline].

  46. Chung US, Kim JH, Seo WS, Lee KH. Tendon transfer or tendon graft for ruptured finger extensor tendons in rheumatoid hands. J Hand Surg Eur. 2009. 35:279-282.

  47. Smith RJ. Tendon Transfers of the Hand and Forearm. Boston, Mass: Little, Brown and Co. 1987:215-43.

  48. Boyes JH. Tendon transfers for radial nerve palsy. Bull Hosp Joint Dis. 1960. 21:97-105.

  49. Nalebuff EA, Patel MR. Flexor digitorum sublimis transfer for multiple extensor tendon ruptures in rheumatoid arthritis. Plast Reconstr Surg. 1973 Nov. 52(5):530-3. [Medline].

  50. Feldon P, Terrono AL, Nalebuff EA. Rheumatoid arthritis and other connective tissue diseases. In: Green DP, Hotchkiss RN, Pederson WC, Wolfe SW, eds. Green's Operative Hand Surgery. 5th ed. New York, NY: Churchill Livingstone. 2005:2049-36.

Typical appearance of the hand following rupture of the extensor tendons of the ring and small finger.
Intraoperative image of a ruptured extensor tendon with the hand to the left. Note that the tendon ends cannot be reapproximated despite maximum tension.
Posteroanterior radiograph of the wrist following wrist arthrodesis and resection of the distal ulna displays the scallop sign, which is the term used to describe the scooped-out appearance of the sigmoid notch of the radius that results from synovial proliferation and bone erosion.
Radiograph of a rheumatoid hand with metacarpophalangeal joint dislocations. These joints are incapable of active or passive extension.
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.