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Flexor Pollicis Longus Rupture

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(Redirected from Mannerfelt Syndrome)

Other Names

  • Mannerfelt Syndrome
  • Flexor Pollicis Longus (FPL) Rupture
  • FPL rupture
  • Flexor pollicis longus tendon rupture
  • Attritional FPL rupture
  • Attritional rupture of the flexor pollicis longus
  • Spontaneous FPL rupture
  • Rheumatoid FPL rupture
  • Volar wrist attritional tendon rupture
  • Mannerfelt lesion
  • Rheumatoid attritional thumb flexor rupture

Background

History

  • First described by Mannerfelt in 1969[1]

Epidemiology

  • Rare condition, primarily limited to case reports and case series
  • The vast majority of patients are male with a median age of 31[2]

Introduction

Illustration of flexor pollicis longus (red)[3]
Trajectory of the flexor pollicis longus between the 2 heads of the flexor pollicis brevis[4]
Eight weeks after surgery for a distal radius fracture, the patient experienced an FPL rupture[5]
A preoperative photograph depicts the inability of the patient to flex the interphalangeal joint of the right thumb (a). A lateral radiograph of the right wrist shows the lifting of the distal edge of the locking plate from the volar aspect of the distal radius (b)[6]

General

  • Rare injury that can occur from a variety of mechanisms and etiologies
  • Characterized by inability to flex the thumb interphalangeal joint[7]
  • Diagnosis is confirmed by MRI or ultrasound
  • Treatment is surgical, with primary repair having the best outcomes

Etiologies

  • Spontaneous midbustance rupture
    • Typically occurs in men aged 30-60 years during manual labor involving forceful or resisted thumb flexion
    • Rare cases involve degenerative changes such as tendolipomatosis
  • Iatrogenic rupture
    • Most commonly follows volar plate fixation of distal radius fractures[8]
  • Attrition rupture
  • Traumatic rupture
    • Rare closed ruptures can occur from hyperextension mechanisms or longitudinal traction on contracted muscle[10]

Associated Conditions

Anatomy of the Flexor Pollicis Longus

Risk Factors

  • Rheumatoid Arthritis[13]
  • Volar plating of distal radius fracture fixation [14]
  • Tendolipomatosis[7]
  • Scaphoid nonunion fracture [15]
  • Advanced age
  • Repetitive or forceful use of the thumb
  • Prior corticosteroid use

Differential Diagnosis

General

  • Anterior interosseous nerve syndrome (AINS)
  • Trigger thumb
  • Carpal tunnel syndrome
  • IP joint arthritis

Differential Diagnosis Finger And Hand Pain

Clinical Features

Positive mannerfelt sign in a patient with FPL rupture[16]

History

  • Sudden loss of thumb flexion
  • Mechanism can vary a lot, but onset is often sudden
  • May occur during activities of daily living, manual labor or sport

Physical Exam: Physical Exam Hand

  • Cardinal finding: loss of active flexion at the IP joint
  • Chronic cases may show thenar eminence atrophy
  • Neurovascular injury occurs in 82% of acute traumatic lacerations[17]

Special Tests

Evaluation

a. Ultrasound assessment of the flexor pollicis longus dilacerations b. Skin marking of tendon stump area c. WALANT and skin incision areas.[18]
(A, B) Coronal T2-weighted MRI of the left thumb, showing complete FPL rupture at the level of the distal one-third of the proximal phalanx; the proximal end of the ruptured tendon was retracted to the level of the MP joint (arrows).[7]

General

  • Primarily a diagnosis made on history and physical exam
  • Inability to flex the IP joint at the thumb is diagnostic

Radiographs

  • Standard Radiographs Hand
    • Typically normal
    • May identify underlying structural causes of attrition rupture
  • Potential findings
    • Associatessociated fractures (particularly scaphoid nonunion or distal radius fractures)
    • Bony avulsion fragments
    • Hardware complications following volar plating

Ultrasound

  • Highly accurate for diagnosing FPL rupture
    • High resolution ultrasound can be used to localize the site of injury[19][20]
    • 100% sensitive/ specific for fullt thickness tear[19]
  • Potential findings
    • Dynamic real time assessment
    • Can also evaluate tenosynovitis and otehr tendon abnormalities
  • Can evaluate FPL following volare plate fixation
    • Provides immediate results at lower cost than MRI and can guide clinical management decisions, including hardware removal[21]

MRI

  • Provides excellent evaluation of soft tissue abnormalities
    • Particularly if ultrasound is inconclusive or more information is needed
  • Allows comprehensive evaluation of surrounding structures

Classification

  • Partial/ Incomplete rupture
  • Complete rupture

Management

Long Thumb Spica Brace

Flexor pollicis longus (FPL) tendoscopy of the left hand. The patient is in supine position. The surface anatomy of the FPL tendon at the thumb, the flexor retinaculum of the wrist, and the flexor carpi radialis (FCR) tendon just proximal to the flexor retinaculum (FR) are marked. The phalangeal portal (PP) is located close to the phalangeal insertion of the FPL tendon and just proximal to the volar interphalangeal crease of the thumb. The wrist portal (WP) is located at the ulnar side of the FCR tendon and 1 cm proximal to the proximal edge of the flexor retinaculum.[22]

Nonoperative

Operative

Rehab and Return to Play

FPL rehab exercise: Use the tip of your thumb to touch the tip of each finger in turn

Rehabilitation

  • Main goals:
    • Protect the tendon repair
    • Prevent adhesions with controlled tendon excursion to prevent adhesions
    • Gradual restoration of thumb range of motion and strength [25]
  • General Guidelines
    • Protective dorsal splint for 6 weeks
    • Active digital motion at 3-5 days post-repair [26]
    • Active wrist motion at 3 weeks
    • Stretching at 6 weeks
    • Nighttime extensor splinting at 6 weeks[25]

Rehab Exercise Program PDFs

Return to Play

  • Timeline
    • Light functional activity at 6 weeks
    • Return to normal activities at 10–12 weeks[25]
    • Non-contact sports/activities: 12-16 weeks
    • Contact sports: 16-20 weeks minimum
    • High-demand gripping sports (rock climbing, gymnastics): 20-24 weeks
  • Criteria to advance to return to activity rehab phase
    • Full or near-full active range of motion (>80% TAM)
    • Adequate strength for intended activities
    • No pain with resistive activities
    • No signs of repair failure or triggering
  • Criteria for Full Return to Play
    • >85% total active motion compared to contralateral side
    • >80% grip and pinch strength compared to contralateral side
    • Pain-free with sport-specific activities
    • Clearance from hand surgeon and therapist

Prognosis and Complications

Prognosis

  • Nonsurgical
    • Partial lacerations involving up to 90% of tendon cross-sectional area managed non-surgically demonstrate excellent outcomes[23]
    • Late rupture after non-surgical management is extremely rare
  • Surgical - primary repair
    • Following primary repair with modern techniques and early active mobilization, 87% of patients achieve good or excellent outcomes[27]
  • Surgical - delayed reconstruction
    • Both tendon grafting and tendon transfer yield acceptable functional outcomes with final total active motion of 80-84%[28]

Complications

  • Repair Rupture[27]
    • Historical 2-strand repairs: 26% rupture rate
    • Modern 4- or 6-strand repairs with early active motion: 2% rupture rate
    • Zero ruptures reported with out-of-splint early active motion protocols in recent series
  • Adhesion Formation and Tenolysis
    • Occur uncommonly
  • Triggering and Entrapment
  • Neurovascular injury[29]
    • Neurovascular injury accompanies 82% of traumatic FPL lacerations
    • Both digital nerves and arteries transected in 21% of case
  • Chronc Regional Pain Syndrome (CRPS)
  • Infection

See Also

References

  1. ↑ Mannerfelt L. Rupture of the flexor pollicis longus tendon in rheumatoid arthritis. Acta Orthopaedica Scandinavica. 1969;40(6):734–742.
  2. ↑ Mawhinney, Jamie A., et al. "Epidemiology of acute flexor tendon injury and an analysis of outcomes–a study of 91,239 patients in England and Wales." Journal of Hand Surgery (European Volume) (2025): 17531934251342419.
  3. ↑ Image courtesy of teachmeanatomy.info
  4. ↑ Image courtesy of musculoskeletalkey.com
  5. ↑ Kim, Do-Young, et al. "Flexor Pollicis Longus Tendon Rupture as a Complication of a Closed Distal Radius Fracture-A Case Report." Journal of the Korean Fracture Society 24.2 (2011): 191-194.
  6. ↑ Uemura, Takuya, et al. "Flexor pollicis longus tendon rupture by sandwiched underlying volar locking plate and distal radius." Journal of Medical Ultrasonics 45.4 (2018): 647-651.
  7. ↑ 7.0 7.1 7.2 Lee, Young-Keun, and Malrey Lee. "Spontaneous rupture of flexor pollicis longus tendon by tendolipomatosis in proximal phalanx: a case report." Medicine 97.37 (2018): e12157.
  8. ↑ Klug, Raymond A., Cyrus M. Press, and Mark H. Gonzalez. "Rupture of the flexor pollicis longus tendon after volar fixed-angle plating of a distal radius fracture: a case report." The Journal of hand surgery 32.7 (2007): 984-988.
  9. ↑ Netscher DT, Badal JJ. Closed flexor tendon ruptures. J Hand Surg Am. 2014;39(11):2315-2323. doi:10.1016/j.jhsa.2014.04.005
  10. ↑ Nho, Jae-Hwi, et al. "Closed rupture of flexor tendon by hyperextension mechanism in wrist level (zone V): a report of three cases." Archives of orthopaedic and trauma surgery 133.7 (2013): 1029-1032.
  11. ↑ Selvan, D. R., et al. "The role of post-operative radiographs in predicting risk of flexor pollicis longus tendon rupture after volar plate fixation of distal radius fractures–A case control study." Injury 45.12 (2014): 1885-1888.
  12. ↑ SAITOH, S. "Scaphoid nonunion and flexor pollicis longus tendon rupture." J. Hand Surg, A 24 (2007): 91-93.
  13. ↑ 13.0 13.1 Spar I. Flexor tendon ruptures in the rheumatoid hand: bilateral flexor pollicis longus rupture. Clin Orthop Relat Res. 1977;(127):186-188.
  14. ↑ Lv YX, Chen MM, Su CX, Ye HN, Yang J, Li J. Analysis of risk factors associated with flexor pollicis longus injury after volar plating of distal radius fractures. J Int Med Res. 2021;49(8):3000605211031438. doi:10.1177/03000605211031438
  15. ↑ Saitoh S, Hata Y, Murakami N, Nakatsuchi Y, Seki H, Takaoka K. Scaphoid nonunion and flexor pollicis longus tendon rupture. J Hand Surg Am. 1999;24(6):1211-1219. doi:10.1053/jhsu.1999.1211
  16. ↑ Image courtesy of handsurgeryresource.net
  17. ↑ Nuley, James A., et al. "Direct end-to-end repair of flexor pollicis longus tendon lacerations." The Journal of hand surgery 17.1 (1992): 118-121.
  18. ↑ Gueffier, X., D. Lalonde, and Amir Adham Ahmad. "Flexor pollicis longus zone 2 tendon repair under WALANT with ultrasound assistance." Trauma Case Reports 32 (2021): 100446.
  19. ↑ 19.0 19.1 Bekhet CNH, Ghaffar MKA, Nassef MA, Khattab RT. Role of Ultrasound in Flexor Tendon Injuries of the Hand: A New Insight. Ultrasound Med Biol. 2021;47(8):2157-2166. doi:10.1016/j.ultrasmedbio.2021.02.023
  20. ↑ Clavero JA, Alomar X, Monill JM, et al. MR imaging of ligament and tendon injuries of the fingers. Radiographics. 2002;22(2):237-256. doi:10.1148/radiographics.22.2.g02mr11237
  21. ↑ Sun, Simon, et al. "Diagnostic ultrasound of tendon injuries in the setting of distal radius fractures." Skeletal Radiology 51.7 (2022): 1463-1472.
  22. ↑ Lui, Tun Hing. "Flexor pollicis longus tendoscopy." Arthroscopy Techniques 6.1 (2017): e249-e254.
  23. ↑ 23.0 23.1 Lineberry, Kyle D., Shirley Shue, and Kyle J. Chepla. "The management of partial zone II intrasynovial flexor tendon lacerations: a literature review of biomechanics, clinical outcomes, and complications." Plastic and Reconstructive Surgery 141.5 (2018): 1165-1170.
  24. ↑ Chattopadhyay A, McGoldrick R, Umansky E, Chang J. Principles of tendon reconstruction following complex trauma of the upper limb. Semin Plast Surg. 2015;29(1):30-39. doi:10.1055/s-0035-1544168
  25. ↑ 25.0 25.1 25.2 Howell JW, Peck F. Rehabilitation of flexor and extensor tendon injuries in the hand: current updates. Injury. 2013;44(3):397-402. doi:10.1016/j.injury.2013.01.022
  26. ↑ Moriya K, Yoshizu T, Maki Y. Early active mobilization after primary repair of the flexor pollicis longus tendon. J Orthop Sci. 2021;26(5):792-797. doi:10.1016/j.jos.2020.08.003
  27. ↑ 27.0 27.1 Pan, Zhang Jun, et al. "Outcomes of 200 digital flexor tendon repairs using updated protocols and 30 repairs using an old protocol: experience over 7 years." Journal of Hand Surgery (European Volume) 45.1 (2020): 56-63.
  28. ↑ Zukawa, Mineyuki, et al. "Wide-awake flexor pollicis longus tendon reconstruction with evaluation of the active voluntary contraction of the ruptured muscle-tendon." Plastic and Reconstructive Surgery 143.1 (2019): 176-180.
  29. ↑ Nuley, James A., et al. "Direct end-to-end repair of flexor pollicis longus tendon lacerations." The Journal of hand surgery 17.1 (1992): 118-121.
Created by:
Elexia Wright on 8 July 2025 18:49:03
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Last edited:
26 February 2026 15:02:20
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