A possible mechanism of direct injury to the EPL tendon at Lister's tubercle during falls with the wrist fully extended

We present three cases of pathology of the extensor pollicis longus tendon at the level of Lister's tubercle after falls with the wrist fully extended. A small anatomical study demonstrates the possibility of the base of the third metacarpal impacting this area in hyperextension. This mechanism of injury to the tendon may explain the clinical findings.     

Delayed rupture of the extensor pollicis longus tendon after nonunion of a fracture of the dorsal radial tubercle

Several apparently conflicting mechanisms have been proposed to explain the seemingly spontaneous delayed rupture of the extensor pollicis longus tendon (EPL). The following case, the first of its kind of which we are aware, may help to clarify the relationships between these mechanisms. Traumatic hyperextension of a patient's wrist brought the styloid process of the third metacarpal into contact with Lister's tubercle, fracturing it. Chronic chafing of the EPL on the nonunited fracture's jagged surface seemed to cause its spontaneous rupture 18 months later. The long period between accident and rupture is evidence that rupture was not caused by crush injury. Because a fracture of Lister's tubercle will not normally be visible on radiographs, after accidents in which this may have occurred or when the EPL ruptures more than 3 months after injury, we recommend that special radiographs of Lister's tubercle be taken to determine if such a fracture exists.     

Repair of extensor tendon injuries of the hand

We have presented methods for treating extensor tendon injuries from the interphalangeal joint to the wrist and the musculotendinous junction in the forearm. Early and proper splinting in the treatment of extensor tendon injuries is more important than a specific method of surgical repair. We emphasize the need for prolonged splinting, up to eight weeks in distal injuries. Immobilizing the finger in full extension or hyperextension is necessary at the distal and proximal interphalangeal joints. Correct splinting is mandatory in any method of treatment. Reconstruction of the extensor mechanism is difficult and the results are unpredictable.     

The Incidence of Acute Traumatic Tendon Injuries in the Hand and Wrist: A 10-Year Population-based Study

Background

Acute traumatic tendon injuries of the hand and wrist are commonly encountered in the emergency department. Despite the frequency, few studies have examined the true incidence of acute traumatic tendon injuries in the hand and wrist or compared the incidences of both extensor and flexor tendon injuries.

Methods

We performed a retrospective population-based cohort study of all acute traumatic tendon injuries of the hand and wrist in a mixed urban and rural Midwest county in the United States between 2001-2010. A regional epidemiologic database and medical codes were used to identify index cases. Epidemiologic information including occupation, year of injury, mechanism of injury and the injured tendon and zone were recorded.

Results

During the 10-year study period there was an incidence rate of 33.2 injuries per 100,000 person-years. There was a decreasing rate of injury during the study period. Highest incidence of injury occurred at 20-29 years of age. There was significant association between injury rate and age, and males had a higher incidence than females. The majority of cases involved a single tendon, with extensor tendon injuries occurring more frequently than flexor tendons. Typically, extensor tendon injuries involved zone three of the index finger, while flexor tendons involved zone two of the index finger. Work-related injuries accounted for 24.9% of acute traumatic tendon injuries. The occupations of work-related injuries were assigned to major groups defined by the 2010 Standard Occupational Classification structure. After assigning these patients'' occupations to respective major groups, the most common groups work-related injuries occurred in construction and extraction occupations (44.2%), food preparation and serving related occupations (14.4%), and transportation and material moving occupations (12.5%).

Conclusions

Epidemiology data enhances our knowledge of injury patterns and may play a role in the prevention and treatment of future injuries, with an end result of reducing lost work time and economic burden.     

The sagittal band: anatomic and biomechanical study

Forty-eight digits from 12 human adult fresh-frozen and formalin-preserved cadaveric hands were used to study the anatomy and biomechanics of the sagittal band (SB) and to investigate the mechanism of its injury. The SB was observed to be part of a complex retinacular system in proximity to the metacarpophalangeal (MCP) joint collateral ligaments and the palmar plate. Dynamic changes in SB fiber orientation were observed with different positions of the MCP and wrist joints. The fibers were perpendicular (0 degrees ) to the extensor tendon in neutral position, distally angulated 25 degrees at 45 degrees of MCP flexion, and 55 degrees with full flexion. Swan-Ganz catheter measurements were obtained deep to the SB in varying positions of the MCP joint. The average pressure generation was greatest (50 mm Hg) during full MCP joint flexion and least (30 mm Hg) during 45 degrees flexion. When MCP joint radial or ulnar deviation was added the average measurement was greatest (57) in neutral MCP position and least (35 mm Hg) in 45 degrees flexion. Serial sectioning of the ulnar SB produced no extensor tendon instability. Partial proximal but not distal sectioning of the radial SB produced tendon subluxation. Complete sectioning of the radial SB produced tendon dislocation. Wrist flexion increased tendon instability after radial SB sectioning. We conclude that (1) extensor tendon instability following SB disruption is most common in the long finger and least common in the small finger; (2) ulnar instability of the extensor tendon is due to partial or complete radial SB disruption, (3) the degree of extensor tendon instability is determined by the extent of SB disruption, (4) proximal rather than distal SB compromise contributes to extensor tendon instability, (5) great forces are inflicted on the SB while the MCP joint is in full extension or less frequently in full flexion, which may be the mechanism of its injury, and (6) wrist flexion contributes to extensor tendon instability after SB disruption and may exacerbate the severity of its injury.     

Rupture of the extensor pollicis longus tendon without fracture after wrist trauma: case reports.

Four cases of rupture of the tendon of the extensor pollicis longus without detectable fracture after wrist injury are reported. The clinical features of this condition did not differ materially from those of rupture occurring after a Colles fracture. All patients were rather young, the average age being 40 years. In one patient rupture occurred a day after injury. In all patients satisfactory thumb function was restored with extensor indicis proprius tendon transfer.     

Modified extensor carpi radialis brevis adductorplasty for ulnar nerve palsy

Residual paralysis or irreparable injury to the ulnar nerve results in considerable impairment of hand function and posture that directly affect daily living. Usually, claw hand deformity and loss of key pinch become problematic, but tendon transfer can be used to restore the lost functions. Adductorplasty using a wrist extensor tendon can restore thumb adduction strength without a significant loss of wrist extension strength, but the short length of the wrist extensor necessitates a free tendon graft to reach the thumb. Here, the authors present a modified extensor carpi radialis brevis adductorplasty technique that does not need a tendon graft by elongating the tendinous portion.     

A modified technique of two-staged extensor tendon reconstruction in zones 6–8 in a patient with absent palmaris/plantaris tendons: A case report

IntroductionThe indications for two-staged extensor tendon reconstruction are rare and only 14 previously reported cases were found in the literature. In these cases, silicone rods are inserted in the first stage. Few months later, the palmaris longus / plantaris tendon grafts are usually used to replace the silicone rods.Case reportwe encountered a patient with major defects of the extensor tendons of all fingers extending from the proximal one third of zone 6 to zone 8. The patient had no palmaris or plantaris tendons. We utilized a modified technique of reconstruction using the split flexor carpi radialis as the tendon graft and the flexor carpi ulnaris as the motor tendon. At final follow-up, there was full active extension of the fingers. However, there was limitation of wrist flexion because of the harvesting of both wrist flexors.DiscussionWe describe a modified technique of two-staged extensor tendon reconstruction which may be used in patients with absent palmaris/ plantaris tendons.ConclusionIn patients with absent palmaris/ plantaris tendons and major defects of the extensor tendons of all fingers, the use of split flexor carpi radialis is an adequate alternative for reconstruction and gives a good functional outcome.     

重度虎口挛缩的改良修复

目的探讨重度虎口挛缩行虎口开大皮瓣修复术同时拇对掌功能重建的治疗效果。方法12例病人分别用食指近节背侧皮瓣、鼻烟窝皮瓣、前臂骨间背侧动脉逆行岛状皮瓣修复虎口，同时用环指指屈浅肌腱、尺侧伸腕肌腱 拇短伸肌腱、尺侧伸腕肌腱 掌长肌腱，行拇对掌功能重建，术后配合训练。结果12例病人皮瓣全部成活，经6～15个月随访，拇指内收得到彻底或部分矫正，对掌和抓握力获得了很好的恢复。结论重度虎口挛缩在行虎口开大皮瓣修复同时一期拇对掌功能重建，术后功能恢复好，操作技术容易，值得推广。     

Strecksehnenverletzungen der Hand

The treatment of extensor tendon injuries of the hand is based on Verdan’s division of the different sections into eight zones. Taking the anatomic characteristics of those zones into consideration, good functional results can be achieved in most cases by differentiating between indications for operative or conservative treatment. The most frequent extensor tendon injury of the hand is the closed tendon rupture over the DIP joint. In almost all cases it can be completely cured by immobilization for at least 8 weeks. Open extensor tendon injuries on the other hand require surgical therapy. This paper gives a clearly arranged overview of the different therapeutic options.     

Extensor tendon injuries of the hand

The treatment of extensor tendon injuries of the hand is based on Verdan's division of the different sections into eight zones. Taking the anatomic characteristics of those zones into consideration, good functional results can be achieved in most cases by differentiating between indications for operative or conservative treatment. The most frequent extensor tendon injury of the hand is the closed tendon rupture over the DIP joint. In almost all cases it can be completely cured by immobilization for at least 8 weeks. Open extensor tendon injuries on the other hand require surgical therapy. This paper gives a clearly arranged overview of the different therapeutic options.     

Bilateral extensor digitorum brevis manus

Dorsal wrist pain and swelling is commonly attributed to a dorsal wrist ganglion. However, based on the authors' experience, a cautious surgeon should keep the uncommonly symptomatic diagnosis of an extensor digitorum brevis manus in their differential despite classic ganglion presentation and suggestive advanced imaging.This article describes a case of a young patient who presented with bilateral symptomatic extensor digitorum brevis manus anomalies that required surgical intervention. An extensor digitorum brevis manus is present in 3% of the population in a classic anatomy study from Japan and is most commonly symptomatic with heavy activity and extremes of wrist extension. Anatomically, the extensor digitorum brevis manus is located in the fourth wrist compartment and most commonly inserts on the index finger extensor mechanism. Examination often reveals a spindle-shaped mass that is palpable distal to the extensor mechanism and moves with extensor tendon motion. Magnetic resonance imaging shows a typical dorsal mass distal to the common extensors with a similar signal as muscle with all image sequencing. Treatment includes activity alterations to relieve symptoms or surgical excision of the muscle belly for refractory cases with care taken to preserve the index extensor mechanism.     

The burned small finger.

Postburn deformities are common in the small finger. A boutonniere-like deformity may develop when no injury has been noted in the central slip of the extensor tendon. Attention to the anatomic differences of the fifth digit and principles of graft contraction make this deformity preventable. In the long-standing burn hyperextension deformity of the metacarpophalangeal joint, recurrence of the deformity may occur after reconstruction. Evaluation of extrinsic extensor tightness may indicate an alteration in the soft tissue-to-skeleton relationship. Composite tissue expansion of the tendon and overlying skin graft provides an alternative reconstruction method.     

Acute true trigger wrist following partial extensor carpi radialis brevis tendon rupture

Triggering in association with movements of the wrist or “true trigger wrist” due to the extensor tendon is rare. There are only few case reports in literature, but none were associated with the acute partial tendon rupture. We present a case of true trigger wrist originating from partial rupture of extensor carpi radialis brevis tendon (ECRB). In contrast to the other reports, the interval between an initial injury and development of triggering was short because the partial tendon rupture was bunching and forming a nodule. The triggering was attributed to the snapping of the nodule under the extensor pollicis longus tendon (EPL).     

Ulnar neuropathy at the wrist associated with aberrant flexor carpi ulnaris insertion

A 36-year-old man who sustained an industrial hyperextension injury of the wrist complained of dysesthesia and pain in the ulnar nerve distribution, aggravated for months by wrist movement until exploration. The operation revealed an anomalous insertion of the flexor carpi ulnaris tendon disrupting a major portion of the ulnar nerve proximal to the pisiform. the symptoms were relieved completely after neurolysis and modification of the insertion of the tendon.     

Effects of extensor pollicis longus transposition and extensor indicis proprius transfer to extensor pollicis longus on thumb mechanics

PURPOSE: The spatial relationship of the extensor pollicis longus (EPL) to the thumb carpometacarpal (CMC) joint may be altered by its transposition from the third dorsal wrist compartment and by subcutaneous extensor indicis proprius (EIP) to EPL tendon transfer. Changes in tendon position could alter thumb function. This study examined changes in the EPL adduction moment arm after EPL tendon transposition from its extensor compartment or EIP transfer. METHODS: The EPL adduction moment arm at the thumb carpometacarpal joint was determined under 4 tendon conditions: (1) intact extensor pollicis longus, (2) transposed extensor pollicis longus, (3) extensor indicis proprius to extensor pollicis longus tendon transfer through an extensor retinacular pulley, and (4) extensor indicis proprius tendon transfer through a subcutaneous route. Each tendon condition was tested in 2 wrist positions: neutral and 40 degrees of flexion. RESULTS: The wrist neutral/flexion moment arms for the 4 tendon conditions, in millimeters, were 9.2/7.3, 3.6/1.2, 8.3/5.1, and 4.8/1.0. CONCLUSIONS: EPL transposition produces a significant decrease of its adduction moment arm at the thumb CMC joint, an effect exacerbated by wrist flexion. The moment arm mechanics of the pulley and subcutaneous EIP tendon transfer resemble those of the intact and transposed EPL, respectively. Diminution of the adduction moment arm could impair thumb function, especially adduction.     

Wrist position and extensor tendon amplitude following repair.

After primary repair of severed extensor tendons, various methods are used to limit tendon adhesions and avoid rupture. Early passive digital motion with wrist extension (a "reverse Kleinert" protocol) has been advocated. However, there are no data to support an optimum wrist position or to indicate how much finger motion may safely be permitted. In this study we used eight fresh cadaver limbs to measure extensor tendon gliding in Verdan's zones 3 to 8 when active grip and passive extension were simulated at different wrist positions. We found that if the wrist is extended more than 21 degrees, the extensor tendon glides with little or no tension in zones 5 and 6 throughout full simulated grip to full passive extension, permitting "passive motion" exercises to minimize tendon adhesions without risking rupture. In addition, we found that up to 6.4 mm of tendon can be debrided safely and full grip can still be permitted postoperatively if the wrist is splinted at 45 degrees extension.     

Traumatic boutonniere deformity of the thumb

We report three patients who presented 3 to 8 months after sustaining a closed injury to the dorsoradial aspect of the metacarpophalangeal joint of the thumb. All three patients had an extensor lag of the metacarpophalangeal joint and paradoxical hyperextension of the interphalangeal joint. There were no collateral ligament injuries. The patients required surgical treatment which included advancement and reattachment of the extensor pollicis brevis insertion and imbrication of the dorsoradial capsule to restore the anatomical alignment of the extensor pollicis longus. Surgical treatment of dorsoradial injuries to the thumb metacarpophalangeal joint may be required for injuries that result in subluxation of the extensor pollicis longus tendon and a boutonnière deformity of the thumb.     

拇长伸肌腱自发性断裂桡侧腕短伸肌腱替代术的临床应用

目的 探讨腕部拇长伸肌腱自发性断裂,采用桡侧腕短伸肌腱替代术的临床疗效.方法 1996年2月-2005年7月,对12例拇长伸肌腱自发性断裂的患者采用桡侧腕短伸肌腱移位替代术.其中桡骨远端骨折愈合后肌腱断裂6例,类风湿骨关节炎4例,不明原因2例.术后均不用石膏固定,术后2d开始练习伸手、伸腕、伸拇动作,2～3次/d;术后7d停止练习;术后4～5周可缓慢伸手持物.结果 12例术后随访均在1年以上,12个月后平均伸拇肌力已达4～5级,腕背肌腱滑动时无障碍.术后无肌腱再断裂者,伸腕、伸指时拇指末节过伸2°～5°,平均3°,拇对掌、对指功能正常.根据中华医学会手外科学会手部肌腱修复后功能评定标准评价,优良率达100%.全部患者对术后功能满意.结论 拇长伸肌腱自发性断裂,应用桡侧腕短伸肌腱移位替代术,对供区损伤小,操作方便,肌腱缝合牢固,有利早期功能恢复.