Extensor pollicis longus tendon rupture caused by a displaced dorsal “beak” fragment of Lister’s tubercle in distal radius fractures

Abstract

Introduction Ruptures of the extensor pollicis longus (EPL) tendon are a well-known complication of distal radius fractures (DRF). There are a lot of suspected mechanisms, including mechanical friction, vascular impairment, injury associated with reduction, and local adhesion. However, there have been limited reports about a closed rupture of the EPL tendon associated with a relatively large, displaced dorsal “beak” fracture fragment. We report about the management outcomes and clinical significance of closed ruptures of the EPL tendon caused by a displaced dorsal fracture fragment of beak-like appearance in DRF.

Patients/Material and Methods Our study included 7 cases of a complete closed rupture of the EPL tendon after open reduction internal fixation. All cases showed a similar pattern involving a relatively large dorsal beak fragment originating from Lister’s tubercle, and we treated them with a palmar locking plate within 7 days from the initial fracture without separate dorsal fragment management. All patients were diagnosed with a delayed EPL tendon rupture.

Results The study included 5 female and 2 male patients. Mean patient age was 59 years. In all cases we explored the extensor compartment III to verify the exact cause of the EPL rupture. Six patients underwent an extensor indicis transfer and one patient underwent tendon grafting.

Mean fragment width and length were 7.0 mm and 13.3 mm, respectively. The fragments were dorsally elevated (mean, 2.4 mm) and distally displaced (mean, 3.5 mm). At the last follow-up, the mean DASH score was 4.4. Mean thumb MP joint flexion and extension were 4 degrees and 62 degrees, respectively.

Conclusion We support the possibility of EPL tendon rupture caused by displaced sharp Lister’s tubercle fracture fragments.

Zusammenfassung

Hintergrund Die Ruptur der Sehne des M. extensor pollicis longus (EPL) ist eine bekannte Komplikation distaler Radiusfrakturen. Bzgl. der Ursache gibt es etliche Vermutungen, angefangen von mechanischen Irritationen der Sehne, über Beeinträchtigung ihrer Durchblutung und Verletzungen der Sehne im Rahmen der Reposition, bis hin zu lokalen Verklebungen. Wenig wurde bisher berichtet über EPL-Rupturen durch ein disloziertes, relativ großes, „schnabelartig“ aussehendes Fragment des Lister’schen Tuberkulums.

Ziel Wir berichten über EPL-Rupturen bei distalen Radiusfrakturen durch ein disloziertes Fragment des Lister’schen Tuberkulums, ihre Behandlung und Ergebnisse.

Patienten und Methoden Bei 7 Patienten, 5 Männern und 2 Frauen mit einem Durchschnittsalter von 59 Jahren, mit distaler Radiusfraktur, versorgt innerhalb von 7 Tagen nach dem Unfall mit einer palmaren winkelstabilen Platte, wurden sekundäre EPL-Rupturen, verursacht durch ein relativ großes, „schnabelartiges“ Fragment des Lister’schen Tuberkulums, das primär nicht angegangen wurde, beobachtet. In allen Fällen erfolgte die operative Revision unter Inspektion des 3. Strecksehnenfaches und Dokumentation des Befundes.

Ergebnisse In allen Fällen fand sich ein Knochensporn mit einer durchschnittlichen Länge und Breite von 13,3 mm mal 7,0 mm als Ursache für die EPL-Ruptur mit einer Dislokation nach distal im Mittel von 3,5 mm und nach dorsal um 2,4 mm. Bei 6 der Patienten erfolgte ein Extensor indicis-Transfer, einmal eine Sehneninterposition. Bei der letzten Nachuntersuchung lag der DASH-Score bei 4,4 Punkten, die durchschnittliche Daumengrundgliedextension/flexion betrug 62–0–4 Grad.

Schlussfolgerung Insbesondere größere, dislozierte Fragmente des Lister’schen Tuberkulums können zu sekundären EPL-Rupturen führen und bedürfen bei der Versorgung distaler Radiusfrakturen von der Beugeseite der Beachtung.

Key words

Distal radius fracture - Lister’s tubercle - EPL rupture

Schlüsselwörter

Distale Radiusfraktur - Lister’sches Tuberkulum - EPL-Ruptur

• References

• 1 McMaster PE. Late ruptures of extensor and flexor pollicis longus tendons following colles’fracture. J Bone Joint Surg [Am] 1932; 14: 93-101
• 2 Smith FM. Late rupture of extensor policis longus tendon following Colles’s fracture. J Bone Joint Surg [Am] 1946; 28: 49-59
• 3 White BD, Nydick JA, Karsky D. et al. Incidence and clinical outcomes of tendon rupture following distal radius fracture. J Hand Surg [Am] 2012; 37: 2035-2040
• 4 McKay SD, MacDermid JC, Roth JH. et al. Assessment of complications of distal radius fractures and development of a complication checklist. J Hand Surg [Am] 2001; 26: 916-922
• 5 Skoff HD. Postfracture extensor pollicis longus tenosynovitis and tendon rupture: a scientific study and personal series. Am J Orthop (Belle Mead, NJ) 2003; 32: 245-247
• 6 Wolfe SW. Distal radius fractures. In: Wolfe SW, Hotchkiss RN, Pederson WC. et al, Hrsg. Green’s operative hand surgery. Philadelphia: Wolfe, Scott W.; 2017: 516-587
• 7 Denman EE. Rupture of the extensor pollicis longus--a crush injury. The Hand 1979; 11: 295-298
• 8 Zenke Y, Sakai A, Oshige T. et al. Extensor pollicis longus tendon ruptures after the use of volar locking plates for distal radius fractures. Hand surgery 2013; 18: 169-173
• 9 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. The Hand 1979; 11: 76-86
• 10 Helal B, Chen SC, Iwegbu G. Rupture of the extensor pollicis longus tendon in undisplaced Colles’ type of fracture. The Hand 1982; 14: 41-47
• 11 Tubiana R. The Hand. 1st. Aufl.. Philadelphia: WB Saunders; 1981
• 12 Bonatz E, Kramer TD, Masear VR. Rupture of the extensor pollicis longus tendon. Am J Orthop (Belle Mead, NJ) 1996; 25: 118-122
• 13 Hirasawa Y, Katsumi Y, Akiyoshi T. et al. Clinical and microangiographic studies on rupture of the E.P.L. tendon after distal radial fractures. J Hand Surg [Br] 1990; 15: 51-57
• 14 Caruso G, Vitali A, del Prete F. Multiple ruptures of the extensor tendons after volar fixation for distal radius fracture: a case report. Injury 2015; 46 (Suppl. 07) S23-27
• 15 Diep GK, Adams JE. The Prodrome of Extensor Pollicis Longus Tendonitis and Rupture: Rupture May Be Preventable. Orthopedics 2016; 39: 318-322
• 16 Naito K, Sugiyama Y, Dilokhuttakarn T. et al. A survey of extensor pollicis longus tendon injury at the time of distal radius fractures. Injury 2017; 48: 925-929
• 17 Hove LM. Delayed rupture of the thumb extensor tendon. A 5-year study of 18 consecutive cases. Acta Orthop Scand 1994; 65: 199-203
• 18 Roth KM, Blazar PE, Earp BE. et al. Incidence of extensor pollicis longus tendon rupture after nondisplaced distal radius fractures. J Hand Surg [Am] 2012; 37: 942-947
• 19 Lee J-K, Hong I-T, Kwon Y-W. et al. Radiologic Analysis of Distal Radius Fracture Accompanying Spontaneous Extensor Pollicis Longus Rupture. Journal of the Korean Fracture Society 2017; 30: 63
• 20 Benson EC, DeCarvalho A, Mikola EA. et al. Two potential causes of EPL rupture after distal radius volar plate fixation. Clin Orthop Relat Res 2006; 451: 218-222
• 21 Mahylis JM, Burwell AK, Bonneau L. et al. Drill Penetration Injury to Extensor Tendons: A Biomechanical Analysis. Hand (New York, NY) 2017; 12: 301-306
• 22 Figl M, Mayer M, Lederer S. et al. Extensor pollicis longus rupture after distal radius fracture: results of reconstruction by transposition of the extensor indicis tendon and postoperative dynamic splinting. Wiener klinische Wochenschrift 2011; 123: 485-487
• 23 Abe Y, Tsue K, Nagai E. et al. Extensor pollicis longus tenosynovitis mimicking de Quervain’s disease because of its course through the first extensor compartment: a report of 2 cases. J Hand Surg [Am] 2004; 29: 225-229
• 24 Nishijo K, Kotani H, Miki T. et al. Unusual course of the extensor pollicis longus tendon associated with tenosynovitis, presenting as de Quervain disease--a case report. Acta Orthop Scand 2000; 71: 426-428