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.     

Small flake,big problem: an unreported cause of extensor pollicis longus tendon rupture

Fracture of the base of the third metacarpal with associated avulsion of the extensor carpi radialis brevis tendon is a rare injury. We report such a fracture and the unusual resulting complication of division of the extensor pollicis longus tendon by the avulsed bony fragment. Careful monitoring using lateral radiographs is needed to make the diagnosis and displacement of the avulsed fragment warrants open reduction and internal fixation.     

Spontaneous rupture of extensor pollicis longus in isolated trapeziometacarpal arthritis

A spontaneous rupture of the extensor pollicis longus (EPL) tendon occurred in a patient with trapeziometacarpal arthritis. We hypothesize that a mechanical attrition by protrusion at the trapeziometacarpal joint alone was responsible of a spontaneous rupture of the extensor pollicis longus tendon.     

Postfracture extensor pollicis longus tenosynovitis and tendon rupture: a scientific study and personal series

Rupture of the extensor pollicis longus (EPL) tendon after a distal radius fracture is an uncommon event; the incidence is 3%,according to a review of treatment of 200 consecutive patients with Colles fractures. Diagnosis is based on persistent dorsal wrist pain and a positive retroflexion sign. Recommended treatments in the prerupture setting include a third dorsal compartment release with or without an extensor retinacular patch graft. Also recommended are a palmaris longus graft in the acute rupture setting and a transfer from the extensor indicis proprius to the EPL tendon in the subacute or chronic setting. Results of all treatments seem to be clinically satisfactory.     

Extensor pollicis brevis tendon can hyperextend thumb interphalangeal joint in absence of extensor pollicis longus:Case report and review of the literature

We are reporting a case of extensor pollicis longus tendon rupture which did not require tendon transfer owing to the ability of the intact extensor pollicis brevis(EPB) to fully hyperextend the thumb interphalangeal joint. The thumb metacarpophalangeal joint was also able to be fully actively extended by the EPB. Previous anatomical studies have demonstrated that the insertional anatomy of the EPB tendon is highly variable and sometimes inserts onto the extensor hood and distal phalanx, which is likely the mechanism by which our patient was able to fully extend the thumb interphalangeal joint. Despite the potential for the EPB to extend the IP joint of the thumb, virtually all previously reported cases of extensor pollicis longus(EPL) tendon rupture had deficits of thumb IP extension requiring tendon transfer. This case highlights the potential ability of the EPB tendon to completely substitute for the function of the EPL tendon in providing thumb IP joint extension.     

Extensor pollicis longus tendon rupture as a result of scapholunate dissociation: a case report.

A 39-year-old patient was presented with, to our knowledge, the first ever diagnosed case of extensor pollicis longus (EPL) tendon rupture as a result of scapholunate (S-L) dissociation. Arthroscopic findings showed that the dorsal aspect of the S-L ligament was ruptured and severe synovitis was revealed around the S-L joint. Direct observation revealed synovium at the rupture site of the EPL tendon. After careful resection of this synovium, an aperture in the S-L joint was observed. Thus, it was considered that the synovium in the S-L joint was connected to the rupture site of the EPL tendon, passing through the dorsal capsule of the S-L joint. The ruptured EPL tendon was reconstructed with extensor indicis proprius tendon transfer, and S-L dissociation was treated with a bone-retinaculum-bone autograft taken from the third dorsal compartment region.     

Irreducible volar subluxation of the metacarpophalangeal joint of the thumb

An unusual case of irreducible volar metacarpophalangeal (MCP) joint subluxation of the thumb is described. The tendon of the extensor pollicis longus (EPL) was trapped palmar to the metacarpal head and open reduction was necessary.     

Sehnenrupturen in der Folge distaler Radiusfrakturen

After distal radial fractures, closed ruptures of the extensor pollicis longus (EPL) tendon may be caused by protruding screws of a volar plate but also occur after conservative fracture treatment. The time interval between accident and rupture is a few weeks to a few months. Tendon transfer of the extensor indicis tendon or a tendon interposition graft are good options for reconstruction. Fusion of the IP joint is not a solution, as the second function of the EPL tendon is to withdraw the thumb ray out of volar abduction. Closed ruptures of the flexor pollicis longus (FPL) tendon exclusively occur after volar plate ORIF, the time interval being years to more than a decade. Volar plates of the distal radius should generally be removed after bone healing and urgently when the patient reports tendon crepitation or pain. A ruptured FPL tendon may be reconstructed by tendon interpositional graft or by tendon transfer but IP joint fusion is a good alternative as the flexor pollicis brevis muscle shows a good thumb metacarpophalangeal joint flexion.     

Spontaneous rupture of extensor pollicis longus tendon with tophaceous gout infiltration

Introduction Spontaneous rupture of the extensor pollicis longus (EPL) tendon has been reported in the literature. Various mechanisms have been proposed to account for this problem, but gouty infiltration is a rare mechanism. Here we report a patient with a long-standing history of gout who presented with sudden loss of interphalangeal extension of the left thumb. Spontaneous rupture of the EPL tendon caused by gout was discovered.Materials and methods The successful treatment done involved surgical exploration and extensor indicis proprius tendon transfer. Postoperative thumb spica immobilization for 6 weeks was applied.Results Pathology disclosed urate crystals deposited within the ruptured EPL tendon. The functional recovery is satisfactory at the 1-year follow-up. Conclusion Spontaneous rupture of the EPL tendon caused by gout is rare. Successful treatment was done with surgical management. Life-long medical follow-up to prevent a repeated acute attack can lower the risk of a large amount of tophaceous gout infiltration in tendons and may possibly prevent acute spontaneous tendon rupture.     

Rupture of the extensor pollicis longus--a crush injury

It is suggested that rupture of a previously normal tendon of extensor pollicis longus after Colles fracture may be due in some cases to crushing of the tendon between the styloid process of the third metacarpal and the dorsal tubercle of the radius, when the wrist is forced into extreme extension.     

Ultrasound changes in the extensor pollicis longus tendon following fractures of the distal radius--a preliminary report

Extensor pollicis longus tendon rupture occurs in 0.2% to 3% of fractures of the distal radius. The underlying mechanism, or mechanisms, of rupture are unknown. This study evaluated this tendon and its surrounding structures using high-resolution ultrasound in 62 patients with distal radius fracture at 6 weeks after injury. The uninjured wrist was examined as a control. The ultrasound measurements at 6 weeks were then correlated with the patients' presenting X-rays. Significant findings included a reduced peak velocity of tendon movement and an increased thickness of both the extensor retinaculum and the tendon sheath on the fractured side. In respect of tendon sheath thickness, these changes were particularly associated with intraarticular fractures. We postulate that the increased thickness of the EPL tendon sheath may further impair an already tenuous blood supply and/or affect the diffusion of nutrients to the tendon within the third extensor compartment, leading to tendon attrition and rupture.     

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.     

Concomitant Rupture of Extensor Pollicis Longus and Index Extensor Tendons following Distal Radius Plating—Report of Two Cases and Their Clinical Implication for Tendon Transfer Surgery

Extensor indicis proprius (EIP) tendon transfer is a standard operation for restoration of the thumb extension following rupture of extensor pollicis longus (EPL). In its standard form often the EIP is transferred to the EPL without inspection of the extensor tendons in the fourth compartment and it is retained in its anatomical fourth compartment. However, in a setting of EPL rupture in relation to the distal radius fracture (with or without fixation), concomitant injury to the extensor tendons to the index finger may result in failure of the transfer and even a loss of index finger extension (index finger drop) further complicating the reconstruction and resulting in immense patient dissatisfaction. We herein present two such rare cases to highlight this clinical scenario and how an awareness of this possibility and inspection of the extensor tendons to the index finger before EIP transfer allowed us to prevent this complication. In essence, if we know it, we can prevent it.     

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).     

Measurement of gliding resistance of the extensor pollicis longus and extensor digitorum communis II tendons within the extensor retinaculum

PURPOSE: The etiology of spontaneous extensor pollicis longus (EPL) tendon rupture is still largely unknown. It is possible that friction within the sheath may play a role. The purposes of this study were to compare gliding resistance of the EPL tendon with that of the extensor digitorum communis tendon of the index finger (EDC II) and to find the wrist position that gives the EPL tendon the lowest gliding resistance. METHODS: Fifteen fresh-frozen cadavers were used. Gliding resistance was measured directly in 7 different wrist positions. RESULTS: The mean gliding resistance of the EPL tendon was 0.16 +/- 0.08 N and that of the EDC II tendon was 0.11 +/- 0.06 N. This difference was significant. There was also a significant effect on gliding resistance due to wrist position. For the EPL tendon, the gliding resistance was significantly greater in 60 degrees wrist flexion compared with all other wrist positions tested. Additionally the gliding resistance of the EPL in 30 degrees flexion, 60 degrees extension, and 15 degrees radial deviation was significantly higher than wrist positions of 30 degrees extension, neutral, and 30 degrees ulnar deviation. CONCLUSIONS: Positioning the wrist close to neutral flexion/extension and in some ulnar deviation minimizes the friction within the EPL sheath. Such positions may be advantageous for splinting patients at risk for EPL rupture.     

Extensor pollicis longus dysfunction associated with non-united fracture of the trapezium

A 26 year old man was referred to us with extensor pollicis longus dysfunction (EPL), and investigation revealed a fracture of the trapezium (left) and carpo-metacarpal joint dislocation of the thumb. Operative exploration revealed mechanical displacement of the tendon secondary to fracture dislocation of the trapezium as the cause for EPL dysfunction. The lesion was managed with an open reduction and screw fixation resulting in good functional outcome.     

Unusual case of closed rupture of both extensor tendons of the index finger

Extensor tendon rupture is a common condition following penetrating injuries, whereas closed rupture is rare unless in a mallet finger. We describe an unusual case of closed rupture of both extensor tendons to the index finger. The extensor indicis proprius and extensor digitorum longus were avulsed proximal to the extensor retinaculum in a 23-year-old male patient due to forced hyperflexion of his index finger. Investigation was done in the Department of Orthopaedic Surgery at the Notre Dame Des Secours University Hospital, Byblos Lebanon.     

Traumatic rupture of the extensor pollicis longus tendon

Rupture of the extensor pollicis longus tendon is rather rare, attributable in about half of all cases to rheumatoid arthritis affecting the wrist or to a Colles' fracture. In the remainder of cases, either a direct closed injury to the wrist or a hyperextension injury of the wrist is most often responsible. Far more unusual is a rotational injury which can cause complete avulsion of the EPL tendon at the musculotendinous junction. A delayed rupture is most probably caused by an avascular necrosis secondary to traumatic disruption of the mesotendon. Surgical correction of the injury is best accomplished by tendon transfer, using the extensor indicis proprius. Postoperative immobilization, hyperextension of the thumb, and adequate resting tension are all necessary to assure good return of function. Postoperatively, the patient may experience a slight decrease in extensor strength of the index finger which may or may not be accompanied by a minimal loss in extensor range.     

A survey of extensor pollicis longus tendon injury at the time of distal radius fractures

BackgroundThe purpose of this study is to investigate the presence or absence, incidence, and degree of extensor pollicis longus (EPL) tendon injury by visual confirmation of the EPL at the time of osteosynthesis for distal radius fractures.MethodsThe subjects were 25 patients (5 males and 20 females; mean age: 56 years) with distal radius fracture that had a dorsal roof fragment. During osteosynthesis using a volar locking plate, the third compartment was exposed in order to determine the EPL injury. The survey items in this study were: incidences of the forms of EPL injury (1: absent, 2: tendon floor fibrillation, and 3: laceration), and the presence or absence of periosteal rupture on the EPL tendon floor. In addition, on the final follow-up, the presence or absence of EPL rupture, the range of wrist motion, grip strength, Visual Analog Scale (VAS) score, Quick Disabilities of the Arm, Shoulder and Hand (Q-DASH) score, and the Mayo wrist score were investigated.ResultsDuring the operation, EPL injury was classified as: 1) absent (12%), 2) tendon floor fibrillation (52%), or 3) laceration (36%). In the EPL tendon floor, periosteal rupture was observed in all patients. The mean postoperative follow-up period was 8 months (6–12 months) and no EPL rupture was observed in any patient. The wrist range of motion was 71° for flexion, 75° for extension, 84° for pronation, and 85° for supination, and the grip (% compared with the unaffected side) was 79%. The VAS, Q-DASH and Mayo scores were 1, 10 and 93 respectively.ConclusionThis study showed a high incidence of EPL tendon injury at the time of distal radius fractures (88%). To improve the ambient environment of the damaged tendon may be useful in terms of the prevention of tendon injury.     

Bilateral rupture of the extensor pollicis longus tendon. A case report

Bilateral rupture of the extensor pollicis longus (EPL) is a rare entity and the few cases that have been reported were associated with an underlying systemic condition such as rheumatoid arthritis or following an injury. We present the case of a patient who was referred to us with a spontaneous rupture of the EPL tendon of the right wrist and that of the left side observed 2 months after tenosynovectomy. The patient had not any pathologic condition or evidence of trauma in both wrists. In the left side, he was operated on and a tenolysis and subcutaneous tendon transposition was performed. Despite this preventive surgery, the patient suffered from a tendon rupture. The possible causes of surgery failure are discussed.