Rupture of the flexor pollicis longus tendon after volar fixed-angle plating of a distal radius fracture: a case report

We report a case of complete rupture of the flexor pollicis longus tendon 13 months after volar fixed-angle plating of a distal radius fracture. Tendon disruption was associated with a prominent distal volar lip of the plate. The plate was placed at the volar distal lip of the radius, at the location recommended by the manufacturer. Most previous reports of flexor tendon ruptures after volar plating of distal radius fractures have been in improperly placed plates, custom-made plates that were later taken off the market, or in physiologically abnormal tendons. This may be a unique case of flexor pollicis longus rupture with a currently commercially available volar fixed-angle plate, placed at the site recommended by the manufacturer, in a patient without other predisposition to tendon rupture.     

Results of pronator quadratus repair in distal radius fractures to prevent tendon ruptures

Background:

Distal radius fractures are one of the the most common adult fractures encountered during the clinical practice of an orthopedic surgeon.^1,2 Although several methods of treatment are suggested for these fractures, there are still controversies about the best treatment approach in the literature. Volar plating of distal radius fracture is a method of treatment which has become increasingly popular. One of the complications of this technique is flexor tendon rupture. The purpose of this study was to evaluate the protectiveness of complete repair of pronator quadratus muscle against flexor tendon rupture.

Materials and Methods:

From September 2010 to September 2012, a consecutive series of 157 patients who were younger than 60 years with unstable distal radius fractures were included in the study. A standard volar approach to the distal radius was carried out. The radial and distal ends of pronator quadratus muscle were meticulously elevated from the radius and after volar plate fixation of the fracture, pronator quadratus muscle was restored to its normal insertion. We achieved full coverage of the plate with this muscle and followed the patients postoperatively.

Results:

A total of 135 patients were studied. The mean age of patients was 34 ± 10 years (range 20-60 years). One 55-year-old diabetic female patient with flexor tendon rupture was identified. The flexor pollicis longus tendon had ruptured 16 months after surgery.

Conclusions:

Pronator quadratus repair should be done in distal radius fracture to protect flexor tendons.     

Flexor tendon ruptures in the rheumatoid patient

In patients with rheumatoid arthritis, flexor tendon ruptures are much less common than extensor tendon ruptures. The most common cause of flexor tendon rupture is direct abrasion on a bony prominence. The most common flexor tendon rupture is the flexor pollicis longus (FPL) attritional rupture within the carpal canal. The best treatment for flexor tendon rupture is prevention. Flexor tenosynovectomy is indicated when medical management does not control wrist tenosynovitis. A variety of techniques are available for reconstruction of flexor tendon ruptures. Irrespective of the reconstructive method, the results of reconstruction for rheumatoid flexor tendon rupture are poor.     

Attritional flexor tendon ruptures due to distal radius fracture and associated with volar displacement of the distal ulna: a case report.

Flexor tendon rupture following distal radius fractures are rare. In this report, a volarly displaced distal ulna that perforated the volar wrist capsule caused delayed flexor tendon ruptures 25 years after a distal radius fracture. The repair with free tendon graft and the excision of the distal ulna produced a successful result.     

Delayed Rupture of Flexor Pollicis Longus after Volar Plating for a Distal Radius Fracture

Although extensor tendon rupture often occurs after volar plating for a distal radius fracture, a flexor tendon rupture is extremely rare. Most reported instances of flexor tendon ruptures after volar plating have involved improper placement of the plate, increased prominence of the distal edge of the plate because of collapse of the fracture site, use of custom-made plates, current steroid use by the patient, or a history of tendon injury. We report a case of delayed rupture of the flexor pollicis longus tendon 40 months after volar plating with a 3.5-mm T-locking compression plate for which the distal edge was located at the transverse ridge level of the distal radius. If symptoms such as tendon irritation occur in this situation, surgeons should consider removing the plate as soon as possible after bony union is achieved.     

Zone I rupture of the flexor digitorum profundus tendon caused by blunt trauma: a case report

Traumatic ruptures of flexor tendons as a result of blunt trauma without an associated pathologic condition are rare. This is a case of a midsubstance flexor tendon rupture as a result of closed direct trauma. The patient sustained a flexor digitorum profundus (FDP) rupture 1 cm proximal to its insertion on his right ring finger without any accompanying laceration. Additionally, this case highlights the utility of ultrasound in diagnosing ruptured flexor tendon, which has been demonstrated in prior studies.     

Rupture of flexor digitorum profundus to the index finger after a distal radial fracture

Attrition ruptures of flexor tendons to the fingers following Colles' fractures are very rare. In the case reported here, a protruding bony fragment caused a delayed rupture of the flexor digitorum profundus tendon to the index finger one year after a fracture of the distal end of the radius. Suture of the distal end of the tendon to the adjacent profundus tendon two years after the fracture produced a successful result.     

Flexor tendon injuries following plate fixation of distal radius fractures: a systematic review of the literature

Background

Flexor tendon rupture is a rare but major complication associated with volar plate fixation of distal radius fractures.

Materials and methods

We performed a systematic review to evaluate the demographics, clinical profile, treatment and outcome of flexor tendon rupture following volar plate fixation of distal radius fracture. Electronic searches of the MEDLINE, EMBASE, and Cochrane databases for systematic reviews and conference proceedings were performed. Studies were included if they reported flexor tendon rupture (partial or complete) as a complication of distal radius fracture plating (all levels of evidence).

Result

Our search yielded 21 studies. There were 12 case reports and 9 clinical studies. A total of 47 cases were reported. There were 11 males and 23 females (n = 16 studies). The mean age was 61 years old (range 30–85). The median interval between the surgery and flexor tendon rupture was 9 months (interquartile range, 6–26 months). Twenty-nine plates were locking and 15 were nonlocking (n = 20 studies). FPL was the most commonly ruptured tendon (n = 27 cases, 57 %), with FDP to index finger being the second most common (n = 7 cases, 15 %). Palmaris longus tendon graft and primary end-to-end repair were the most common surgical methods used in cases of FPL tendon rupture.

Conclusion

Flexor tendon rupture is a recognised complication of volar plating of distal radius fracture. Positioning of the plate proximal to the “watershed” line and early removal of the plate in cases with plate prominence or warning symptoms can reduce the risk of this complication.     

Mechanical Properties of Reconstructed Achilles Tendon with Transfer of Peroneus Brevis or Flexor Hallucis Longus Tendon

Treatment of chronic Achilles tendon ruptures can be technically difficult because of tendon retraction, atrophy, and short distal stumps. Surgical repair of chronic Achilles tendon ruptures focuses on local and free tendon transfers, as well as reconstruction with allografts or synthetic materials. This study examined the in vitro mechanical properties of a reconstructed Achilles tendon with the peroneus brevis or the flexor hallucis longus tendons in a human cadaver model. The tendons were harvested from 17 fresh-frozen human cadavers, and the same techniques were used for all of the model reconstructions. Biomechanical measurements included the failure load, stiffness, energy-to-peak load, and mode of failure. The mean failure load was significantly higher in the peroneus brevis group (P = .036), and there was no significant difference in stiffness and energy-to-peak load between the peroneus brevis and flexor hallucis longus groups. In every case, the mode of failure involved the tendon graft pulling through either the distal or proximal stump of the Achilles tendon. The greater failure loads observed with the use of peroneus brevis may not be clinically relevant, however, because of the magnitude of the peak loads observed in the cadaveric model. The present study supports the use of either peroneus brevis or flexor hallucis longus for reconstruction of chronic Achilles tendon ruptures and indicates the need for surgeons to carefully reinforce the attachment of the transferred tendon grafts to the stumps of the Achilles tendon to prevent pullout.     

Rupture of the flexor tendons on an anterior plate for distal radial fracture: four cases and a review of the literature

We report four cases of flexor tendon ruptures which occurred after distal radial fracture and reviewed the 25 other cases reported in the literature since 1932. Analysis of these 29 cases disclosed the causes of these ruptures. A deformed callus after distal radial fracture or presence of an anterior osteosynthesis plate can under certain conditions lead to secondary flexor tendon tears. It was also found that tears of the flexor pollicis longus rupture predominate, followed by injury to the flexor digitorum profundis and superficialis of the index finger. Other tendons have only been involved in only a few cases. In order to avoid this complication, we propose systematic removal of anterior plates or secondary replacement if the reduction is not totally anatomic. Surgeons should recall the importance of anatomic reduction of distal radial fractures.     

Attritional flexor tendon ruptures after a malunited intra-articular fracture of the distal radius

Rupture of the flexor tendon following Colles fracture is uncommon. In all reported cases it occurred as a complication of an extra-articular, displaced fracture of the distal radius. We report a case in which flexor tendon rupture occurred 30 years after a comminuted intra-articular fracture of the distal end of the radius. There have been no reports of delayed flexor tendon rupture after an intra-articular fracture of the distal radius in young adults.     

Trends in digital joint motion following surgical reconstruction of a tendon rupture after distal radius fracture

BackgroundTendon rupture has been recognized as a complication of distal radius fracture (DRF); however, the clinical outcome of reconstructive surgery for this injury remains unclear. We examined prognostic factors for the outcomes of reconstructive surgery in patients with a tendon rupture after DRF.MethodsThis study was a retrospective review of a case series. Seventy-five consecutive patients were treated at our institution for tendon rupture after DRF. The cohort included 14 males and 61 females with a mean age of 67.7 years at the time of tendon reconstruction. Sixty-four and eighteen tendon ruptures occurred after non-operative management for DRF and palmar locking plate fixation, respectively. Seven ruptured tendons received a free tendon graft from the palmaris longus tendon, and the others underwent tendon transfers. All patients were managed postoperatively by our hand therapy unit according to a controlled active mobilization regime.ResultsThe mean follow-up period was 28 weeks (range: 12–80 weeks). Patients with extensor tendon ruptures were significantly younger than those with flexor tendon ruptures regardless of the initial DRF treatment. The mean percentage active range of motion of the injured digits relative to normal active motion (%AROM) at the final follow-up was 70% (range: 30–101%) in all patients. The %AROM after flexor tendon reconstruction for patients after non-operative management was significantly inferior to that of other patients. Multiple regression analysis revealed that aging and non-operative management of DRF are independent risk factors for poor %AROM.ConclusionsThis study confirmed that advanced age and non-operative management of DRF were prognostic factors for digital joint motion following surgical reconstruction for tendon rupture. Our results suggest that it may be difficult to achieve good clinical outcomes in elderly patients with tendon ruptures (particularly flexor tendon ruptures) following non-operative management of DRF.     

Ruptures of flexor tendons at the wrist as a complication of fracture of the distal radius.

We report two cases of rupture of flexor tendons after fracture of the distal radius. The first case was a rupture of the flexor digitorum profundus and superficialis tendon to the index finger that happened 20 years after the fracture. The second was a rupture of the flexor pollicis longus tendon that occurred two years after, and the flexor profundus tendon to the index finger that occurred four years after the fracture. In the first case, the ruptures were caused by the bony protuberance of the radius after long interval without interference of the ulnar head.     

Ruptures of Flexor Tendons At the Wrist as a Complication of Fracture of the Distal Radius

We report two cases of rupture of flexor tendons after fracture of the distal radius. The first case was a rupture of the flexor digitorum profundus and superficialis tendon to the index finger that happened 20 years after the fracture. The second was a rupture of the flexor pollicis longus tendon that occurred two years after, and the flexor profundus tendon to the index finger that occurred four years after the fracture. In the first case, the ruptures were caused by the bony protuberance of the radius after long interval without interference of the ulnar head.     

Spontaneous flexor tendon ruptures of the hand: case series and review of the literature

Spontaneous flexor tendon ruptures within the hand are incompletely understood. We report 5 cases of spontaneous tendon rupture involving the flexor digitorum profundus tendon. One case involves an abnormal intertendinous connection between the ring and small finger profundus tendons and another involves a lumbrical muscle variant. To our knowledge, the latter has not been reported in association with spontaneous tendon rupture. In reviewing the literature for spontaneous flexor tendon ruptures, a total of 50 spontaneous ruptures in 43 cases was found. The majority involve the profundus tendon of the small finger in the palm. The ruptures most often occur during periods of peak strain but can also occur without identifiable trauma. The pathogenesis of spontaneous tendon ruptures is still unclear and is likely multifactorial. Spontaneous flexor tendon ruptures of the hand occur more often than one might recognize.     

Acute tibialis posterior tendon rupture associated with a distal tibial fracture

Tibialis posterior tendon ruptures associated with closed medial malleolar fractures are rare. This article describes the association of tibialis posterior tendon ruptures with closed, high-energy, distal tibia fractures. Tendon ruptures are likely to be identified intraoperatively or missed if clinical evaluation at acute injury is limited. A high index of suspicion is required to diagnose this injury. The consequences of an unrecognized tibialis posterior tendon rupture include progressive, painful pes planus deformities due to the unopposed action of the peroneus brevis muscle and lack of support of the medial longitudinal arch. Secondary operative intervention may be required. This article describes an intraoperative tenodesis technique between the tibialis posterior and flexor digitorum longus tendons when direct repair is not possible.A 48-year-old woman sustained a closed AO/Orthopaedic Trauma Association type 43A right lower-extremity distal tibia fracture and a traumatic left knee arthrotomy. Temporary stabilization with an external fixator was performed, followed by open reduction and internal fixation of the distal tibial fracture 6 days later. A periarticular nonlocking medial plate was applied, and the tibialis posterior tendon was shortened. We performed a direct tenodesis to the flexor digitorum longus tendon. At 1-year follow-up, the patient had made excellent progress, with no detectable muscle weakness, and was able to perform a single-leg toe raise.A review of the literature suggested which features of radiological evidence of tendon rupture should be examined, which may be useful in the current era considering most high-energy distal tibia or pilon fractures undergo examination with computed tomography.     

Flexor tendon injuries following locked volar plating of distal radius fractures

We present 2 cases showing that flexor pollicis longus and flexor digitorum profundus index injury can occur after placement of 2 commonly used locked volar plates. In contrast with the literature, the radii healed in an anatomic position without plate lift-off. The patients presented 6 and 8 months after surgery with new onset of radial wrist pain and tenderness at the site of the plate and absence or weakness of the flexor pollicis longus. In both cases, the plate was positioned anterior to the distal radial rim on the lateral radiograph. We suggest close follow-up of all fractures in which the distal end of the plate is anterior to the radial rim and removal of hardware if symptoms suggest tendon irritation.     

Complications following internal fixation of unstable distal radius fracture with a palmar locking-plate

OBJECTIVES: The increasing number of fixed-angle plate systems used to treat distal radius fractures carries with it the problem of determining the optimal fixation for unstable fractures. Our goal was to analyze the clinical and radiological outcomes of patients with displaced, unstable distal radius fractures treated with a palmar fixed-angle plate. DESIGN: Prospective protocol; multicenter clinical study; retrospective analysis. SETTING: Level 1 university trauma centers. PATIENTS: Over a mean 15-month period (range, 12 to 27 months), 141 consecutive patients were treated for an unstable dorsally displaced distal radius fracture of which 114 or 81% were followed for 1 year or longer. INTERVENTION: Open reduction and palmar internal fixation with a fixed-angle plate (2.4 mm LCP Distal Radius Plates; Synthes, Salzburg, Austria). Indication for surgical treatment was the inability to obtain or maintain fracture or articular alignment after initial closed reduction. MAIN OUTCOME MEASURES: In a follow-up period, which had to be longer than 12 months, objective and subjective functional results (active range of motion; strength; Disabilities of the Arm, Shoulder, and Hand (DASH) score; visual analog scale (VAS); Green and O'Brien Score) and radiographic assessment (palmar tilt, radial inclination, ulnar variance, fracture union) were assessed. Potentials for complications were given special attention. RESULTS: In the 114 patients followed for a minimum of 12 months, there were 21 men and 93 women with a mean age of 57 years (17 to 79 years). Fractures were classified according to the AO/ASIF classification system as type A2 (n = 39), A3 (n = 16), C1 (n = 24), C2 (n = 30), or C3 (n = 5). The modified Green and O'Brien Score revealed 31 excellent, 54 good, 23 fair, and 6 poor results. Active wrist motion averaged 54 degrees extension (82% as compared with the uninjured side) and 46 degrees flexion (72% as compared with the uninjured side). The average pronation was 81 degrees (95% as compared with the uninjured side), and the average supination was 82 degrees (95% as compared with the uninjured side). Mean grip strength at final follow-up was 70% of the uninjured side. Low residual pain values in the wrist were demonstrated: 81 patients (71%) were pain free, 17 patients (15%) had mild pain, 10 patients (9%) had moderate pain, and 6 patients (5%) had severe pain. The DASH score averaged 13 points (range, 0 to 39 points). Fracture union was achieved in all patients. A mean loss of palmar tilt of 3.4 degrees (range, 0 to 8 degrees), radial inclination of 0.4 degrees (range 0 to 2 degrees), and of the ulnar variance of 1.2 mm (range, 0 to 6 mm) was measured. The overall complication rate was 27% (31/114). The most frequent problems were flexor and extensor tendon irritation (57% of the total number of complications), including 2 ruptures of the flexor pollicis longus tendon, 2 ruptures of the extensor pollicis longus tendon, 4 cases of extensor tendon tenosynovitis, and 9 cases of flexor tendon tenosynovitis. Carpal tunnel syndrome was observed in 3 patients, and complex regional pain syndrome occurred in 5 patients. In 2 cases, loosening of a single screw was seen. Delayed fracture union occurred in 3 patients, and intraoperative intraarticular screw displacement was recognized in 1 patient. Neither clinical outcome nor complication rate were dependent on fracture type (intraarticular versus extraarticular). CONCLUSION: Fixation of unstable dorsally displaced distal radius fractures with a fixed angle plate provides sufficient stability with minimal loss of reduction. Nevertheless, very distal palmar plate position can interfere with the flexor tendon system, too long screws can penetrate the extensor compartments, and distal screws in comminuted fracture patterns can cut through the subchondral bone and penetrate into the radiocarpal joint. Mindful of these problems, we consider that the complex fracture pattern of an unstable distal radius fracture cannot be treated by a single plate system and approach.     

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.     

Delayed Rupture of the Flexor Pollicis Longus Tendon After Inappropriate Placement of the π Plate on the Volar Surface of the Distal Radius

The π plate (Synthes Ltd, Paoli, PA) was designed to fit the unique contour of the dorsal aspect of the distal radius. Complications of π plate fixation of the dorsal distal radius have been previously reported to include both extensor tenosynovitis and delayed extensor tendon rupture. We report a case of rupture of the flexor pollicis longus tendon associated with inappropriate placement of the π plate on the volar surface of the distal radius. (J Hand Surg 1999; 24A:1279–1280.