Claude Giroux

Cumberland, Ontario is a small town just east of Ottawa with the distinction of being home to the Camelot Golf and Country Club, an arena with water that smells like rotten eggs, and not much else. It’s also where Claude Giroux lacerated the extensor tendons in his right index finger in a freak exploding golf club incident.

Giroux was at Camelot preparing for the Ottawa Sun Scramble golf tournament, and apparently on a completely normal shot with a completely normal club the shaft of the club splintered, sending shards into his right index finger and lacerating the extensor tendons.

Oh really.

That’s an interesting injury seeing as how you hold a golf club in your palm, a place where you won’t find any extensor tendons. Those are on the backs of your fingers and hand. Giroux’s father Raymond told Le Droit that when his club splintered a piece flew up in the air and came down on his finger, causing the injury.

Oh really.

Regardless of what actually happened (a little smashy-smash of the old clubberoo?), extensor tendon injuries are fairly common and generally require surgery. Without an extensor tendon Giroux would be able to grip a hockey stick (or golf club) but straightening his fingers out to let go would be tricky.

The Anatomy

Hands are ridiculously complicated pieces of equipment. Hands are so complicated that there are surgeons who dedicate their lives strictly to the management of hand and wrist problems, adding an extra year of fellowship training to an already grueling five to seven years of orthopedics, plastics, or general surgery training. They’re probably also the number one injured body part prompting a visit to the ER after doing something really stupid.

 

There's an awful lot going on here.

There’s an awful lot going on here.

 

Extensor tendons are responsible for extending (straightening) the fingers. The index finger is a special little monster in that it has two extensor tendons. The extensor indicis (in red) originates as a muscle attached to the ulna (one of the bones in your forearm) just above your wrist. The extensor digitorum (in blue) originates as a muscle attached to the bottom of the humerus (the upper arm bone). If you bend and straighten your index finger while holding the outside (thumb side) of your elbow, you can feel the muscle at work. Weirdly enough, there aren’t actually any muscles in the fingers. The muscles doing all the work are in the hand and forearm. In between each of the bones of the hand (the metacarpals) there are also little muscles called the interossei and lumbricales that weakly extend the finger joints (the interossei are also responsible for spreading the fingers apart). In the illustration above they’re the little meaty bits at the base of the finger in the blown-up image.

 

The Injury

This is where the story falls apart. Not only is the mechanism strange (exploding flying gold club), Philadelphia GM Paul Holmgren said in a statement that Giroux injured one tendon where his index finger meets his hand. Per Raymond Giroux, four tendons were lacerated, but not fully severed. It’s hard to see how you could sever four tendons without screwing up more than one finger, even though the index finger has two major extensors (remember the red and blur arrows above?). Hacking into the extensors and the interossei would mean an almost circumferential cut (reminder: from an exploding flying golf club).

Who knows if it was one tendon or four, and who knows what really happened. The point is Giroux lacerated something, and he’s going to be out five or six weeks rehabbing it.

Generally tendons that are more than 40 or 50 percent lacerated have to be surgically repaired, even though a 90% lacerated tendon can still have function (for a while). Often the appearance of the finger announces from across the room where the extensor tendon has been damaged. A mallet finger (aka baseball finger) happens when you rip the tendon off the most distal bone of the finger, and a boutonniere deformity happens when you screw it up at the middle joint of the finger. Minor injuries can sometimes be treated with splinting, with very little agreement among the hand experts of for how long or when you can begin doing range of motion exercises  - anywhere from eight to twelve weeks. What they do agree on is that for the first six to eight weeks you’re wearing that splint 24 hours a day, including in the shower and while you sleep. Surgery suddenly doesn’t seem like such a bad option.

No extensor tendons were harmed during the taking of these pictures.

No tendons were harmed during the taking of these pictures.

 

The Repair

In Giroux’s case it sounds like the injury was at the knuckle. Maybe. We think. Or not. Usually injuries to extensor tendons at the knuckle are a result of the aptly-named and fairly disgusting fight bite, when knuckles meet teeth and teeth shred tendons. Fight bites are the exception to the FIX IT FAST rule of tendon repair because they get infected so easily (after all, the human mouth is a disgusting cesspool of filth). Those injuries get thoroughly washed out, x-rayed to make sure there’s not any teeth hiding in there, treated for infection, splinted, and given a few weeks to stop being so disgusting.

With a clean wound such as one might sustain from an exploding flying golf club, treatment is far more straightforward. A good washout, a tetanus shot, and a hand specialist consultation. These injuries can be repaired an ED doc, and often are, but it’s not a great idea. You probably want to go with the person that spends all day dealing with one specific body part.

The repair itself consists of extending the laceration to expose enough room to work, locating the tendon ends if it’s been completely severed (Giroux’s wasn’t), and suturing them back together with permanent sutures. The trick is to maintain as much tendon length as possible so that it heals with the same motion it had before a golf club exploded on it.

 

The Rehab

The convention has been that after tendon repair you’re stuck in a splint with no movement for several weeks. Early mobilization is gaining favour as studies indicate that early outcomes are better than with the traditional method of static splinting.

There are a lot of different rehab protocols after extensor tendon repair, but the majority involve beginning joint mobilization as soon as three days post-operatively with slowly increasing amounts of flexion. There’s also a variety of splints used for this purpose, ranging from a simple splint allowing a small amount of motion to complex contraptions with outriggers that hold the fingers extended at rest. As usual, they’re all weirdly available on Amazon.

If Giroux plays nice and follows the instructions of his friendly neighbourhood physiotherapist, he should be fine in five or six weeks and likely without any of the complications complete tendon severance can cause. He should probably stay off the golf course, or at least quit using composite clubs. An alternate idea would be to not smash them on the ground so hard that they splinter, which is something that theoretically could possibly happen to a person. Maybe. Allegedly.

 

The Moral of the Story

Giroux will likely be ready for the opening game of the season. His golf clubs will not.