Central Slip Extensor Tendon Injury

Last updated: February 8, 2026Reviewed date: February 8, 2026Reading time: 5 min read
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A central slip is a section of an extensor tendon that straightens the middle joint of your finger. Extensor injuries of the hand are common in young, otherwise healthy males. Various injury mechanisms include hyperflexion, direct blunt trauma, and penetrating trauma. A central slip injury can...

For severe symptoms, danger signs, pregnancy, child illness, or sudden worsening, seek urgent medical care.

বাংলা রোগী নোট এখনো যোগ করা হয়নি। পোস্ট এডিটরে “RX Bangla Patient Mode” বক্স থেকে সহজ বাংলা সারাংশ যোগ করুন।

এই তথ্য শিক্ষা ও সচেতনতার জন্য। এটি ডাক্তারি পরীক্ষা, রোগ নির্ণয় বা প্রেসক্রিপশনের বিকল্প নয়।

Article Summary

A central slip is a section of an extensor tendon that straightens the middle joint of your finger. Extensor injuries of the hand are common in young, otherwise healthy males. Various injury mechanisms include hyperflexion, direct blunt trauma, and penetrating trauma. A central slip injury can be due either to a fracture at the base of the middle bone (avulsion) or from tears in the fibres of...

Key Takeaways

  • This article explains Pathophysiology in simple medical language.
  • This article explains Causes in simple medical language.
  • This article explains Diagnosis in simple medical language.
  • This article explains Management in simple medical language.
Educational health guideWritten for patient understanding and clinical awareness.
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Emergency safety firstUrgent warning signs are highlighted below.

Seek urgent medical care if you notice

These warning signs are general safety guidance. Local emergency numbers and clinical judgment should always come first.

  • Severe symptoms, breathing difficulty, fainting, confusion, or rapidly worsening illness.
  • New weakness, severe pain, high fever, or symptoms after a serious injury.
  • Any symptom that feels urgent, unusual, or unsafe for the patient.
1

Emergency now

Use emergency care for severe, sudden, rapidly worsening, or life-threatening symptoms.

2

See a doctor

Book a professional medical evaluation if symptoms persist, worsen, recur often, affect daily activities, or occur in a high-risk patient.

3

Learn safely

Use this article to understand possible causes, tests, treatment options, prevention, and questions to ask your clinician.

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Definition

A central slip is a section of an extensor tendon that straightens the middle joint of your finger. Extensor injuries of the hand are common in young, otherwise healthy males. Various injury mechanisms include hyperflexion, direct blunt trauma, and penetrating trauma. A central slip injury can be due either to a fracture at the base of the middle bone (avulsion) or from tears in the fibres of the central slip itself (tendinous). When left untreated, disruption of the extensor mechanism over zone III and detachment of the central slip leads to a Boutonniere deformity. This deformity is characterized by flexion of the proximal interphalangeal joint (PIP) and hyperextension of the distal interphalangeal joint (DIP) due to the volar subluxation of the lateral bands. It is an extensor tendon injury over zone III. It is also referred to as a “buttonhole deformity.

If they are also torn, a deformity is produced at the PIP joint. In this case, all extensor force will be transmitted to the distal phalanx by intact lateral bands, producing hyperextension of the DIP joint. The PIP joint buckles into flexion and protrudes through the breach in the extensor hood.

Other Names
  • Central Slip Extensor Tendon Injury

Pathophysiology

Illustration of normal anatomy and central slip ulcer. সহজ বাংলা: শরীরের অস্বাভাবিক দাগ, ক্ষত বা ফোলা অংশ।" data-rx-term="lesion" data-rx-definition="A lesion is an abnormal area of tissue such as a spot, wound, patch, lump, or ulcer. সহজ বাংলা: শরীরের অস্বাভাবিক দাগ, ক্ষত বা ফোলা অংশ।">lesion
  • General
    • Typically occurs as a result of forced passive PIP flexion against active extension
    • Subsequent disruption of the central slip of the extensor tendon.
  • Closed injury: hyperflexion, direct blunt trauma
  • Open injury: penetrating trauma
  • Extensor Tendon
    • Trifurcates into 1 central slip and 2 lateral bands
    • Central slip attaches to the dorsal side of the middle phalanx
    • Lateral bands attach to the sides of the distal phalanx

Causes

  • Fractures
    • Phalanx Fractures (Hand)
    • Metacarpal Fractures
      • Boxer’s Fracture
      • Rolando Fracture
      • Bennett Fracture
  • Dislocations
    • Metacarpophalangeal Joint Dislocation
    • Proximal Interphalangeal Joint Dislocation
    • Distal Interphalangeal Joint Dislocation
    • Carpometacarpal Joint Dislocation
  • Tendinopathies
    • Extensor Tendon Injuries (Hand)
    • Central Slip Extensor Tendon Injury
    • Flexor Tendon Injuries (Hand)
    • Boutonniere Deformity
    • Swan Neck Deformity
    • Jersey Finger
    • Mallet Finger
    • Trigger Finger
    • De Quervains Tenosynovitis
  • Ligament Injuries
    • Gamekeepers Thumb (UCL)
    • Radial Collateral Ligament of the Thumb Injury (RCL)
    • Volar Plate Avulsion Injury
  • Neuropathies
    • Wartenbergs Syndrome
    • Carpal Tunnel Syndrome
    • Guyon Canal Syndrome
  • Arthropathies
    • Carpometacarpal pain, swelling, stiffness, or reduced movement. সহজ বাংলা: জয়েন্টের প্রদাহ।" data-rx-term="arthritis" data-rx-definition="Arthritis means joint inflammation causing pain, swelling, stiffness, or reduced movement. সহজ বাংলা: জয়েন্টের প্রদাহ।">Arthritis
    • Finger pain, swelling, stiffness, or reduced movement. সহজ বাংলা: জয়েন্টের প্রদাহ।" data-rx-term="arthritis" data-rx-definition="Arthritis means joint inflammation causing pain, swelling, stiffness, or reduced movement. সহজ বাংলা: জয়েন্টের প্রদাহ।">Arthritis
    • pain, swelling, stiffness, or reduced movement. সহজ বাংলা: জয়েন্টের প্রদাহ।" data-rx-term="arthritis" data-rx-definition="Arthritis means joint inflammation causing pain, swelling, stiffness, or reduced movement. সহজ বাংলা: জয়েন্টের প্রদাহ।">arthritis: Rheumatoid arthritis is an autoimmune joint disease causing infection, or irritation, often causing pain, swelling, heat, or redness. সহজ বাংলা: শরীরের প্রদাহ; ব্যথা, ফোলা বা লালভাব হতে পারে।" data-rx-term="inflammation" data-rx-definition="Inflammation is the body’s response to injury, infection, or irritation, often causing pain, swelling, heat, or redness. সহজ বাংলা: শরীরের প্রদাহ; ব্যথা, ফোলা বা লালভাব হতে পারে।">inflammation, pain, and swelling. সহজ বাংলা: রোগপ্রতিরোধ ব্যবস্থার ভুল আক্রমণে জয়েন্টের প্রদাহ।" data-rx-term="rheumatoid arthritis" data-rx-definition="Rheumatoid arthritis is an autoimmune joint disease causing inflammation, pain, and swelling. সহজ বাংলা: রোগপ্রতিরোধ ব্যবস্থার ভুল আক্রমণে জয়েন্টের প্রদাহ।">Rheumatoid Arthritis
  • Nail Bed Injuries
    • Nail Bed Lacerations
    • Nail Bed Avulsions
    • Subungual Hematoma
    • Paronychia
    • Felon
  • Pediatric Considerations
    • Proximal Phalanx Avulsion Fracture (Thumb)
    • Middle and Distal Phalanx Avulsion Fracture
  • Other
    • Dupuytrens Contracture

Diagnosis

  • History
    • Typically describe some form of trauma
    • Reports pain, swelling, ecchymosis
  • General: Physical Examination Hand
    • Inability to extend at PIPJ of affected joint

Radiographs

  • Standard Radiographs Hand
    • Typically normal
    • May show avulsion fracture

MRI

  • Can consider if the diagnosis is uncertain or to further clarify the injury

US

  • It May be used to help confirm tendon injury

Special Tests

Special tests that help in identifying injury to the extensor mechanism include:

  1. Elson Test – Fixing PIP Joint at 90° and asking the patient to extend the DIP joint. A lax DIP joint, despite the patient’s effort to extend, is a negative or normal finding (if the central slip is intact, the loose lateral bands/slips when the PIP is flexed prevent DIP extension). A positive finding is a rigid DIP joint because of increased unopposed pull through the lateral bands/slips.
  2. Modified Elson Test – The injured digit and its normal counterpart are placed in full proximal interphalangeal flexion, with the dorsum of each middle phalanx firmly against each other. If the injured digit has visibly better distal interphalangeal extension than the uninjured digit, a central slip injury is likely.
  3. Boyes Test – Extend PIP and ask to flex DIP; positive is unable to flex DIP actively

Boyes test may become positive only in the late stages.

 

Management

Nonoperative

  • Indications
    • Most cases
  • Immobilization
    • PIP Extension Splinting, DIP in partial flexion
    • Dynamic splinting vs progressive static splinting (serial splinting)
  • Typically for 6 weeks

Operative

  • Indications
    • Open injury
    • Some avulsion fractures
  • Technique[2]
    • Acute central slip repair
    • Open reduction and internal fixation (ORIF)
    • Tendon reconstruction
    • Arthrodesis

Post-Surgical Rehabilitation of Central Slip Repairs

Geoghegan et al (2018) recently conducted a systematic review on treatments of central slip extensor tendon injuries. Different rehabilitation regimes are reported in the literature and these can be broadly classified into

  • PIP joint immobilisation, followed by an isolated PIP flexion-extension exercise
  • Controlled early active short arc motion
  • PIP joint immobilisation followed by mobilisation with a dynamic spring coil finger splint

Evans et al (1994) reported significantly better functional results in a cohort of early short arc motion compared to a cohort of prolonged immobilisation.

Early Short Arc Motion Regime

The basis for the early short arc motion regime is that sufficient tendon excursion is necessary to prevent adhesions. An arc of 30° of flexion at the PIP joint will achieve the desired amount of (3 -5 mm) of tendon excursion. With this protocol patients need to be seen on a weekly basis to monitor progress and monitor for an extensor lag. It is also necessary to remould the exercise splint.

Splinting

Patients who have had a surgical repair of a central slip tendon injury will require different splints

  • Full finger volar extension splint – worn at all times, except for during exercises
  • Exercise splints:
    • Volar slab from distal metacarpophalangeal (MCP) joint to the end of the finger – allowing 30° PIP joint flexion and 20° DIP flexion
    • Short volar splint with PIP in neutral, but allowing DIP to flex over the top of the splint
Rehabilitation Exercises

These exercises are done in the different exercise splints usually made out of thermoplastic. The splints are also remoulded as the flexion angles increase.

  • Week 1: 30° PIP and 20° DIP flexion
  • Week 2: 40° PIP and DIP flexion (if no extensor lag present)
  • Week 3: 50° PIP and DIP flexion
  • Week 4: 70° – 80° PIP and DIP flexion
  • Week 5: full composite flexion
  • Week 6 -8: light functional use allowed
  • Week 8: Strengthening with Theraputty
  • Perform exercises 3 times a day and 10 repetitions of each exercise
  • Scar management is crucial for post-surgical zone III tendon repairs to prevent adhesions.
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Safety note: This is not a prescription or diagnosis. For severe symptoms, pregnancy danger signs, children with serious illness, chest pain, breathing difficulty, stroke-like weakness, or major injury, seek urgent care.

Which doctor may help?

Start with a registered doctor or the nearest qualified health center.

What to tell the doctor

  • Write when the problem started and how it changed.
  • Bring old prescriptions, investigation reports, and current medicines.
  • Write allergies, pregnancy status, diabetes, kidney/liver disease, and major past illnesses.
  • Bring one family member if the patient is weak, elderly, confused, or a child.

Questions to ask

  • What is the most likely cause of my symptoms?
  • Which danger signs mean I should go to hospital quickly?
  • Which tests are necessary now, and which can wait?
  • How should I take medicines safely and what side effects should I watch for?
  • When should I come for follow-up?

Tests to discuss

  • Vital signs: temperature, pulse, blood pressure, oxygen saturation
  • Basic physical examination by a clinician
  • CBC, urine test, blood sugar, or imaging only when clinically needed

Avoid these mistakes

  • Do not use antibiotics, steroid tablets/injections, or strong painkillers without proper medical advice.
  • Do not hide pregnancy, kidney disease, ulcer, allergy, or blood thinner use.
  • Do not delay emergency care when danger signs are present.

Medicine safety and first-aid guide

This section is for patient education only. It does not replace a doctor, pharmacist, or emergency care.

Safe first steps

  • Rest, drink safe water, and observe symptoms carefully.
  • Keep a written note of symptoms, duration, temperature, medicines already taken, and allergy history.
  • Seek medical care quickly if symptoms are severe, worsening, or unusual for the patient.

OTC medicine safety

  • For mild pain or fever, ask a registered pharmacist or doctor before using common over-the-counter pain/fever medicines.
  • Do not combine multiple pain medicines without advice, especially if you have kidney disease, liver disease, stomach ulcer, asthma, pregnancy, or take blood thinners.
  • Do not give adult medicines to children unless a qualified clinician advises it.

Avoid these mistakes

  • Do not start antibiotics without a proper medical decision.
  • Do not use steroid tablets or injections casually for quick relief.
  • Do not delay emergency care because of home remedies.

Get urgent help if

  • Severe symptoms, confusion, fainting, breathing difficulty, chest pain, severe dehydration, or sudden weakness need urgent medical care.
Medicine names, dose, and timing must be decided by a qualified clinician or pharmacist after checking age, pregnancy, allergy, other diseases, and current medicines.

For rural patients and family caregivers

Patient health record and symptom diary

Write your symptoms, medicines already taken, test results, and questions before visiting a doctor. This note stays on your device unless you print or copy it.

Doctor to discuss: Doctor / qualified healthcare provider
Tests to discuss with doctor
  • Basic vital signs: temperature, pulse, blood pressure, oxygen level if needed
  • Relevant blood, urine, imaging, or specialist tests only after clinical assessment
Questions to ask
  • What is the most likely cause of my symptoms?
  • Which warning signs mean I should go to emergency care?
  • Which tests are really needed now?
  • Which medicines are safe for my age, pregnancy status, allergy, kidney/liver/stomach condition, and current medicines?

Emergency warning signs such as chest pain, severe breathing difficulty, sudden weakness, confusion, severe dehydration, major injury, or loss of bladder/bowel control need urgent medical care. Do not wait for online information.

Safe pathway to proper treatment

Care roadmap for: Central Slip Extensor Tendon Injury

Use this simple roadmap to understand the next safe steps. It is educational and does not replace examination by a doctor.

Go to emergency care if you notice:
  • Severe or rapidly worsening symptoms
  • Breathing difficulty, chest pain, fainting, confusion, severe weakness, major injury, or severe dehydration
Doctor / service to discuss: Qualified healthcare provider; specialist depends on symptoms and examination.
  1. Step 1

    Check danger signs first

    If danger signs are present, seek emergency care and do not wait for online information.

  2. Step 2

    Record the symptom story

    Write when symptoms started, severity, medicines already taken, allergies, pregnancy status, and test results.

  3. Step 3

    Visit a qualified clinician

    A doctor, nurse, or qualified healthcare provider can examine you and decide which tests or treatment are needed.

  4. Step 4

    Do only useful tests

    Do tests after clinical assessment. Avoid unnecessary tests, random antibiotics, or repeated medicines without diagnosis.

  5. Step 5

    Follow up and return early if worse

    If symptoms worsen, new warning signs appear, or treatment is not helping, return for review quickly.

Rural patient practical tips
  • Take a written symptom diary and all previous prescriptions/test reports.
  • Do not hide medicines already taken, even herbal or over-the-counter medicines.
  • Ask which warning signs mean urgent referral to hospital.

This roadmap is for education. A real diagnosis and treatment plan requires history, examination, and clinical judgment.

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Emergency first: Severe chest pain, breathing trouble, unconsciousness, stroke signs, severe injury, heavy bleeding, or rapidly worsening symptoms need urgent local medical care now.

Frequently Asked Questions

Is this article a replacement for a doctor?

No. It is educational content only. Patients should consult a qualified clinician for diagnosis and treatment.

When should I seek urgent care?

Seek urgent care for severe symptoms, rapidly worsening condition, breathing difficulty, severe pain, neurological changes, or any emergency warning sign.

References

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