The Centers for Advanced Orthopaedics
Maryland Orthopedic Specialists
A Division of The Centers for Advanced Orthopaedics
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Hand & Wrist

Extensor Tendon Rupture

Extensor tendon rupture (spontaneous or traumatic loss of extensor tendon continuity) results in sudden inability to extend one or more fingers. Unlike a tendon laceration caused by a sharp object, spontaneous ruptures can occur without obvious injury, particularly in patients with rheumatoid arthritis or after a wrist fracture. Prompt diagnosis and appropriate repair or tendon transfer are needed to restore function. The hand surgeons at Maryland Orthopedic Specialists manage all types of extensor tendon rupture at their Bethesda and Germantown offices.

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What is extensor tendon rupture?

Extensor tendon ruptures disrupt the tendons that straighten the fingers, wrist, or thumb, causing an inability to fully extend the affected joint. Common causes include lacerations, closed trauma, rheumatoid arthritis, and chronic tendon attrition over bony prominences. Treatment ranges from splinting for closed mallet-type injuries to surgical repair or reconstruction for lacerations and ruptures, followed by structured hand therapy.

Extensor tendons run along the dorsum (back) of the hand and wrist, straightening the fingers and extending the wrist. Ruptures can be classified as:

Spontaneous (Attritional) Rupture

Rheumatoid Arthritis — Vaughan-Jackson Syndrome: The most important cause of spontaneous extensor tendon rupture. In rheumatoid arthritis (RA), the dorsal wrist synovium becomes hypertrophied and inflamed. The distal ulna (particularly in cases of distal radioulnar joint (DRUJ) involvement and caput ulnae deformity) erodes through the extensor tendon compartments like a blade, progressively cutting through the extensor tendons from ulnar to radial. This is Vaughan-Jackson syndrome, classically beginning with the extensor digiti minimi (EDM) and progressing to the ring, middle, and index finger extensors (EDC tendons). Patients notice a progressive inability to extend their ulnar fingers — often initially dismissed as joint disease.

Early recognition of impending rupture (tenosynovitis with attritional fraying on MRI, subcutaneous ulnar head prominence) allows preventive synovectomy and Darrach resection (ulnar head excision) before ruptures occur.

EPL Rupture After Distal Radius Fracture: The extensor pollicis longus (EPL) tendon, which extends the thumb IP joint, runs through Lister's tubercle on the dorsum of the radius. Even after non-displaced or minimally displaced distal radius fractures (including those treated non-operatively), the EPL is at risk for attritional rupture due to disruption of its blood supply or mechanical abrasion at the fracture site. EPL rupture typically occurs 6–8 weeks after the original fracture. The patient notices sudden inability to extend the thumb IP joint. Once recognized, surgical treatment is required. Direct repair is rarely feasible, and EIP-to-EPL tendon transfer (using the extensor indicis proprius, which extends the index finger and is expendable) is the standard reconstruction.

Traumatic Rupture

Closed traumatic extensor tendon ruptures are less common than lacerations but occur with:

  • Forced flexion against active extension (analogous to mallet finger, but at a more proximal level)
  • Crush injuries over the dorsal wrist or hand
  • Bony spurs or hardware erosion in post-surgical patients

Symptoms — do you recognize these?

  • Sudden loss of ability to extend one or more fingers (or the thumb IP joint)
  • May or may not be painful
  • Drooping posture of the affected finger(s) — similar to mallet finger but at the MCP level for EDC/EDM ruptures
  • Swelling and synovial hypertrophy over the dorsal wrist in RA-related ruptures
  • In Vaughan-Jackson syndrome: progressive inability to extend ulnar fingers first, then radial fingers

Call us at (301) 515-0900. Same-day appointments available at our Bethesda and Germantown locations.

How we diagnose it

  • Clinical examination: Testing active extension of each finger individually at the MCP level; testing thumb IP joint extension for EPL integrity. Loss of active extension with preserved passive extension confirms the tendon diagnosis.
  • X-rays: Assess for distal radius fracture, ulnar head deformity (caput ulnae), or implant hardware.
  • MRI or ultrasound: Confirms the level and extent of rupture; identifies fraying or tenosynovitis in at-risk RA patients before complete rupture occurs.
  • Important: In RA patients with finger extension loss, the differential includes tendon rupture vs. extensor tendon subluxation over the metacarpal head vs. MCP joint arthritis-related deformity. Each requires a different management approach.

Treatment options

Non-Operative

Splinting while awaiting surgery is appropriate; complete ruptures do not heal without repair.

Surgical Repair

If the tendon ends are fresh and healthy, direct repair restores finger extension. Most spontaneous ruptures require a tendon transfer, where a nearby expendable tendon is rerouted to take over the function of the ruptured one.

Rehabilitation

Hand therapy is essential after repair; a protective splint allows the repair to heal while gradually restoring finger movement and strength.

Recovery & rehabilitation

  • Tendon transfer (EPL, EIP-to-EPL): Splint for 4–6 weeks; full rehabilitation over 3–4 months; excellent functional outcomes in most patients.
  • Multiple EDC repairs/transfers (Vaughan-Jackson): More extended rehabilitation. 4–6 months for maximal recovery. Functional outcomes depend on underlying joint disease and degree of MCP arthritis.

Frequently Asked Questions

I have RA and my little finger won't straighten. Is this a tendon rupture or joint disease?
This distinction is critical and cannot be made without examination. Inability to extend the finger at the MCP joint while passive extension is normal strongly suggests tendon rupture. An inability to extend passively suggests joint contracture. Our hand surgeons can differentiate these on examination, often supplemented by ultrasound or MRI.
Can EPL rupture after wrist fracture happen even if the fracture was treated with a cast?
Yes. EPL rupture after distal radius fracture occurs even with non-operative treatment. Any patient who has had a distal radius fracture and notices new inability to extend the thumb IP joint at 4–12 weeks should be evaluated promptly.
Is the EIP tendon important? Will I miss it after transfer?
The EIP allows independent extension of the index finger. After transfer, the index finger retains EDC function, so extension remains possible. The loss of independent index extension is rarely noticed in normal daily activities.
How is an extensor tendon rupture repaired, and will I need surgery?
Treatment depends on which tendon is involved and the cause of the rupture. A mallet finger (rupture of the terminal extensor tendon at the fingertip) is typically managed non-surgically with continuous splinting for six to eight weeks. Ruptures of major hand or wrist extensor tendons (including those caused by RA or sharp laceration) almost always require surgical repair or tendon transfer to restore the ability to straighten the affected finger. Your MOS hand surgeon will determine the best reconstructive approach based on the number of tendons involved, tendon quality, and underlying conditions.
What is the recovery process after extensor tendon surgery?
After extensor tendon repair or transfer, the hand is typically splinted for three to six weeks to protect the repair. Early controlled mobilization with a hand therapist, beginning as soon as the repair is deemed safe, is critical for preventing scar tissue formation and restoring gliding function. Full hand therapy continues for two to four months, and most patients regain good finger extension within three to four months. Complex cases involving multiple tendons or tendon transfers may require a longer rehabilitation period.

Meet the specialists

Peter G. Fitzgibbons, MD

Peter G. Fitzgibbons, MD

Hand Surgery · Orthopedic Surgery

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Related conditions

Tendon LacerationMallet FingerHand & Wrist ArthritisHand & Wrist Fractures
Medically reviewed by Peter G. Fitzgibbons, MD
Last reviewed May 1, 2026

References

  1. Vaughan-Jackson OJ. Rupture of extensor tendons by attrition at the inferior radio-ulnar joint: report of two cases. Journal of Bone and Joint Surgery (British). 1948;30B(3):528–530. doi:10.1302/0301-620X.30B3.528
  2. Magnell TD, Pochron MD, Condit DP. The interrupted suture repair of extensor pollicis longus tendon. Journal of Hand Surgery (American Volume). 1988;13(5):722–725. doi:10.1016/S0363-5023(88)80139-3
  3. Williamson SC, Feldon P. Extensor tendon ruptures in rheumatoid arthritis. Hand Clinics. 1995;11(3):449–459.
  4. Moore JR, Weiland AJ, Valdata L. Tendon ruptures in the rheumatoid hand: analysis of treatment and functional results in 60 patients. Journal of Hand Surgery (American Volume). 1987;12(1):9–14. doi:10.1016/S0363-5023(87)80150-6
  5. Hackel JG, Newman JB. Extensor tendon injury. In: Wolfe SW, et al. Green's Operative Hand Surgery, 7th ed. Philadelphia: Elsevier; 2017. AAOS OrthoInfo Reference: https://orthoinfo.aaos.org
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