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Hand Surgery, Vol. 18, No. 2 (2013) 169173 © World Scientific Publishing Company DOI: 10.1142/S0218810413500196
EXTENSOR POLLICIS LONGUS TENDON RUPTURES AFTER THE USE OF VOLAR LOCKING PLATES FOR DISTAL RADIUS FRACTURES
Hand Surg. 2013.18:169-173. Downloaded from www.worldscientific.com by CHINESE UNIVERSITY OF HONG KONG on 02/22/15. For personal use only.
Yukichi Zenke,*,† Akinori Sakai,* Toshihisa Oshige,* Shiro Moritani,† Kunitaka Menuki,* Yoshiaki Yamanaka,* Kayoko Furukawa* and Toshitaka Nakamura* *Department
of Orthopaedic Surgery, School of Medicine University of Occupational and Environmental Health Kitakyushu 807-8555, Japan
†
Department of Orthopaedic Surgery, Kagawa Rosai Hospital Marugame 763-8502, Japan
Received 14 November 2012; Revised 16 December 2012; Accepted 18 December 2012 ABSTRACT Currently, volar locking plates are commonly used to treat distal radius fractures (DRF) because of their stable biomechanical construct and because they cause less soft tissue disturbance and allow early mobilisation of the wrist. Complications such as rupture of tendons have been reported to occur with use of volar locking plates. We describe six cases of rupture of extensor pollicis longus (EPL) tendons after the use of volar locking plates. EPL tendon injuries occurred in 2.1% (6/286) of cases after DRF surgery. The causes of EPL rupture after DRF surgery were protrusion of the head tip and insufficient reduction of the dorsal roof fragment of the distal radius. These were considered iatrogenic problems. The cause of EPL rupture was unknown in three cases. We should be extremely careful when determining optimum screw length and reducing displaced dorsal roof fragments to prevent damaging the EPL tendons. Keywords: Distal Radius Fractures; Volar Locking Plate; Extensor Pollicis Longus Tendon Injury; Dorsal Roof Fragment; Screw Length.
INTRODUCTION
that are sometimes associated with dorsal plating.4 Extensor tendon injuries associated with use of volar locking plates are not so common, although they can occur when undisplaced DRF is treated conservatively. In this study, we investigated the risk factors for EPL rupture after DRF treated with volar locking plate at our hospital. Lister’s tubercle, especially, can mask prominent screw tips in standard dorsal fluoroscopic images.
Rupture of the extensor pollicis longus (EPL) tendon is a well-recognised complication of distal radius fractures (DRF). However, the incidence of EPL tendon rupture with conservative treatment of DRF is not very high (0.07% to 3.0%).13 One of the purposes of the design of volar locking plates for DRF is to avoid the complications involving dorsal soft tissues
Correspondence to: Dr. Yukichi Zenke, Department of Orthopaedic Surgery, School of Medicine, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-Ku, Kitakyushu 807-8555, Japan. Tel: (þ81) 93-691-7444, Fax: (þ81) 93-692-0184, E-mail: [email protected] 169
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Therefore, we calculated the optimal screw length for volar locking plate as criterion. Furthermore, we should recognise the existence of displaced dorsal roof fragments,5 which may lead to bad clinical results due to rupture of the EPL tendon.
Hand Surg. 2013.18:169-173. Downloaded from www.worldscientific.com by CHINESE UNIVERSITY OF HONG KONG on 02/22/15. For personal use only.
PATIENTS AND METHODS We retrospectively reviewed data from 286 patients with DRF who had been treated with volar locking plates (DRV plate: Mizuho Medical Technologies, Inc, Tokyo, Japan; Stellar plate: Japan Universal Technologies, Inc, Tokyo, Japan) from April 2006 through March 2010. Postoperative EPL tendon rupture occurred in six cases (2.1%; one man and five women; mean age, 57.0 years; range, 3370 years). The AO (Arbeitsgemeinschaft für Osteosynthesefragen)/OTA (Orthopaedic Trauma Association) fracture classifications were A2, one case; A3, four cases; and C2, one case. The average waiting period for surgery was 2.7 days (range, 15 days) (Table 1). We investigated the time after which EPL rupture occurred, the presence of protruding screws, and the presence and degree of displacement of dorsal roof fragments5 of the distal radius.
Surgical Treatment and Rehabilitation Surgery was performed while patients were under brachial plexus block anaesthesia or general anaesthesia. The procedure commenced with a longitudinal skin incision along the flexor carpi radialis tendon. The latter tendon and the flexor pollicis longus muscle were retracted toward the ulna. The radial border of the pronator quadratus muscle was cut longitudinally. The volar aspect of the radius was exposed subperiosteally. The plate was placed directly on the radius after
fracture reduction using the condylar stabilising method.6 No bone graft was used. After fixation, the pronator quadratus was repaired over the plate with absorbable suture materials. No plaster cast was applied after surgery. Active motion exercise was commenced as early as the patients’ pain allowed. Patients were discharged from the hospital a few days after surgery. Patients began forearm rotation and active and activeassisted motion of the wrist joint within four to five days after surgery, as tolerated. Passive exercises began at two weeks. Active treatment, including grip power exercise and training to reduce swelling of the hand, began no later than the 12th week after surgery.
RESULTS The average time from operation to EPL rupture was 49.8 days (range, 1122 days). Of the six patients with EPL rupture, four presented complete rupture and two incomplete rupture. The common symptom among all six cases was persistent pain (unlike fracture pain) on the dorsum of the wrist exacerbated by retroflexion of the thumb. Five EPL tendon ruptures (including two incomplete and three complete ruptures) were treated by transfer from the extensor indicis proprius (EIP) tendon to the EPL tendon. One complete rupture case was still observed for the patient’s hope in spite of our suggestion. All patients who underwent tendon transfer regained full extension of the thumb during an average follow-up period of 12.7 months. The outcomes of these procedures were clinically satisfactory and equivalent. In one case (16.7%), rupture was caused by a protruding screw. The dorsal roof fragment was displaced in two (33.3%) cases. Furthermore, both of the latter cases showed a high
Table 1 Clinical Data for Patients with Extensor Pollicis Longus Tendon Ruptures after Volar Locking Plates for Distal Radius Fractures. Case No. 1 2 3 4 5 6 Mean
Age (y)
Sex
Injured Side
AO/OTA Classification
Op. Waiting Time (d)
EPL Rupture Time (d)
64 70 70 39 33 66 57.0
F F F F M F
Left Right Right Left Left Left
C2 A3 A2 A3 A3 A3
5 2 2 2 1 4 2.7
93 12 41 30 122 1 49.8
Notes: Abbreviations: AO, Arbeitsgemeinschaft für Osteosynthesefragen; OTA, Orthopaedic Trauma Association; EPL, extensor pollicis longus.
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degree of displacement. The cause of rupture in the other three cases was unknown.
CASE REPORT
Hand Surg. 2013.18:169-173. Downloaded from www.worldscientific.com by CHINESE UNIVERSITY OF HONG KONG on 02/22/15. For personal use only.
A 33-year-old man sustained a distal radius fracture in a fall (Fig. 1). The fracture was treated with volar locking plate fixation two days after injury (Fig. 2), and then with simple casting for one week. At the beginning of treatment, the patient had no difficulty with retroflexion of the thumb. After clinical
Fig. 2
(A)
(B) Fig. 1
(A) At the injury Xp. (B) At the injury 3D-CT.
Just after operation Xp.
healing of the fracture, he suddenly had difficulty with thumb retroflexion four months after the operation, and he continued to experience dorsal wrist pain. Tenderness was found over the third dorsal compartment of the wrist at Lister tubercle, and a disparity was found between active and passive retroflexion of the thumb. Radiography showed that the fracture was healed in a satisfactory position, but a callus had formed around the EPL tendon near Lister tubercle (Fig. 3). The patient underwent an exploratory operation of the extensor compartment, which revealed a rupture of the EPL tendon but no evidence of screw protrusion. However, the tendon was elongated and ruptured in the callus at the corner of Lister tubercle. The tendon injury was treated by EIP-to-EPL tendon transfer, with a satisfactory result. One year after operation, the canal-like callus was resected and the implant was stable (Fig. 4).
Fig. 3 Four months after the operation CT. The callus had formed around the EPL tendon near Lister’s tubercle.
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Fig. 4
One year after the operation Xp.
DISCUSSION Local irritation or rupture of an extensor tendon is a serious complication of treatment of fractures of the distal radius. Fixation with a volar plate is an attractive strategy because of the direct restoration of the anatomy of the joint, stable internal fixation, decreased period of immobilization, and early return of wrist function. The rate of extensor tendon rupture in a previously reported7 series of cases managed with volar locking plates was 8.6%. In one of our cases, the screw was too long (Fig. 5). We believe that the size of Lister’s tubercle combined with the depth of the EPL groove may at times impede a surgeon’s assessment of the degree of past-pointing of the distal screws during volar plating of the radius. This is compounded by the difficulty of getting a proper profile view of the dorsal cortex due to the dihedral nature of the dorsal distal radius (i.e. it is not clearly visible in a lateral view on the image intensifier), as well as the fact that the tendons are in direct contact with the radius and are constrained by their compartments. Although standard texts mention Lister’s tubercle and often show the EPL groove, the literature contains little information about the size of Lister’s tubercle and the depth of the EPL groove.8,9 We measured EPL groove depth during 23 operations, and the mean value was 2.4 mm (1.3 SD). Clement et al.8 noted that the depth of the EPL groove varied from 1 to 5 mm (mean, 2.8 mm). These results are consistent with our own data. Arora et al.10 noted that because of the triangle shape of the dorsal cortex, most ulnar and radial screws are shorter than central screws. Therefore, we should consider the prominent portion
Fig. 5
The complication case that the screw was too long.
and determine screw length to be less than about 2 mm smaller than observed in the image intensifier. To determine optimum screw length, we measured the distance from the EPL tendon groove to the volar cortical line. We calculated optimum screw length as body height divided by 86. We found that body height and EPL tendon groove to volar cortical line distance were positively correlated (p ¼ 0:008, R 2 ¼ 0:29) (Fig. 6). However, currently there were some studies about the dorsal tangential view for detecting the screw penetration after volar plating of the distal radius fractures.11 From now, we are
Fig. 6 Body height and EPL tendon groove to volar cortical line distance were positively correlated.
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Hand Surg. 2013.18:169-173. Downloaded from www.worldscientific.com by CHINESE UNIVERSITY OF HONG KONG on 02/22/15. For personal use only.
Extensor Pollicis Longus Tendon Ruptures after use of Volar Locking Plates
supposed to use this intraoperative procedure in order to check the correct screw length. Furthermore, dorsal roof fragments5 should be anatomically reduced for avoiding rupture of the EPL. In two cases, the dorsal roof fragments were greatly displaced. Therefore, the EPL tendon was elongated and ruptured at the displaced EPL groove area because of the prominent and irregular surface of the dorsal roof fragment. Benson et al.12 proposed two theories for the mechanism of EPL rupture: bone spurs and/or dorsal bone edges protruding into the undersurface or into the third extensor compartment and into the EPL tendon. Mushrooming or dorsal protrusion of bone after a DRF along with a raw dorsal bone edge after reestablishment of the volar inclination of the joint surface may leave a sharp bone edge that causes problems of attrition.13 We suggest consideration of open assessment of the third extensor compartment, if indicated, through a small dorsal incision on the ulnar side of Lister tubercle for prevention of secondary EPL rupture. In another three cases, the cause was unknown (no evidence of screw protrusion or drill penetration and no displacement of dorsal roof fragment). According to previous reports,1,14 ruptures of the EPL can occur after minimally displaced fractures, because the attachment of the extensor retinaculum to Lister’s tubercle remains intact, and together with callus formation it leads to narrowing of the third compartment. This can cause reduction in the blood supply to the tendon, degenerative necrosis, and eventual rupture. Furthermore, Hirasawa et al.1 noted that the EPL tendon within the third compartment at Lister’s tubercle is subject to mechanical bending and attrition, has no mesotendon, has a poorly vascularised portion about 5 mm long within the tendon and visceral layer of the tendon sheath, and has a richly vascularised synovial tendon sheath. The poorly vascularised area of the EPL tendon becomes even more avascular because of narrowing and entrapment of the tendon. Degenerative necrosis of the tendon results, as it is deprived of both sources of nourishment, resulting in eventual rupture. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
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References 1. Hirasawa Y, Katsumi Y, Akiyoshi T, Tamai K, Tokioka T, Clinical and microangiographic studies on rupture of the EPL tendon after distal radial fractures, J Hand Surg [Br] 15:5157, 1990. 2. Skoff HD, Postfracture EPL tenosynovitis and tendon rupture: a scientific study and personal series, Am J Orthop Surg 32:245247, 2003. 3. Cooney WP 3rd, Dobyns JH, Linscheid RL, Complications of Colles’ fractures, J Bone Joint Surg [Am] 62:613619, 1980. 4. Orbay JL, Fernandez DL, Volar fixation for dorsally displaced fractures of the distal radius: a preliminary report, J Hand Surg [Am] 27:205215, 2002. 5. Yamanaka K, Sasaki T, Matsui H, Ashida T, Fracture of the distal radius with dorsal roof fragment, J Jpn Soc Surg Hand 24:605608, 2008. 6. Kiyoshige Y, Condylar stabilizing technique with AO/ASIF distal radius plate for Colles’ fracture associated with osteoporosis, Tech Hand Up Extrem Surg 6:205208, 2002. 7. Al-Rashid M, Theivendran K, Craigen MAC, Delayed ruptures of the extensor tendon secondary to the use of volar locking compression plates for distal radial fractures, J Bone Joint Surg [Br] 88:16101612, 2006. 8. Clement H, Pichler W, Nelson D, Hausleitner L, Tesch NP, Grechenig W, Morphometric analysis of Lister’s tubercle and its consequences on volar plate fixation of distal radius fractures, J Hand Surg [Am] 33:17161719, 2008. 9. Tubbs RS, Custis JW, Salter EG, Wellons JC III, Blount JP, Oakes WJ, Quantitation of and superficial surgical landmarks for the anterior interosseous nerve, J Neurosurg 104:787791, 2006. 10. Arora R, Luts M, Hennerbichler A, Krappinger D, Espen D, Gabl M, Complications following internal fixation of unstable distal radius fracture with a palmar locking-plate, J Orthop Trauma 21:316322, 2007. 11. Ozer K, Wolf JM, Watkins B, Hak DJ, Comparison of 4 fluoroscopic views for dorsal cortex screw penetration after volar plating of the distal radius, J Hand Surg [Am] 37:963967, 2012. 12. Benson EC, DeCarvalho A, Mikola EA, Veitch JM, Moneim MS, Two potential causes of EPL rupture after distal radius volar plate fixation, Clin Orthop Relat Surg 451:218222, 2006. 13. Stahl S, Wolff TW, Delayed rupture of the extensor pollicis longus tendon after nonunion of a fracture of the dorsal radial tubercle, J Hand Surg 13:338341, 1988. 14. Helal B, Chen SC, Iwegbu G, Rupture of the extensor pollicis longus tendon in undisplaced Colles’ type of fracture, Hand 14:4147, 1982.
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Hand Surgery, Vol. 18, No. 2 (2013) 169173 © World Scientific Publishing Company DOI: 10.1142/S0218810413500196
EXTENSOR POLLICIS LONGUS TENDON RUPTURES AFTER THE USE OF VOLAR LOCKING PLATES FOR DISTAL RADIUS FRACTURES
Hand Surg. 2013.18:169-173. Downloaded from www.worldscientific.com by CHINESE UNIVERSITY OF HONG KONG on 02/22/15. For personal use only.
Yukichi Zenke,*,† Akinori Sakai,* Toshihisa Oshige,* Shiro Moritani,† Kunitaka Menuki,* Yoshiaki Yamanaka,* Kayoko Furukawa* and Toshitaka Nakamura* *Department
of Orthopaedic Surgery, School of Medicine University of Occupational and Environmental Health Kitakyushu 807-8555, Japan
†
Department of Orthopaedic Surgery, Kagawa Rosai Hospital Marugame 763-8502, Japan
Received 14 November 2012; Revised 16 December 2012; Accepted 18 December 2012 ABSTRACT Currently, volar locking plates are commonly used to treat distal radius fractures (DRF) because of their stable biomechanical construct and because they cause less soft tissue disturbance and allow early mobilisation of the wrist. Complications such as rupture of tendons have been reported to occur with use of volar locking plates. We describe six cases of rupture of extensor pollicis longus (EPL) tendons after the use of volar locking plates. EPL tendon injuries occurred in 2.1% (6/286) of cases after DRF surgery. The causes of EPL rupture after DRF surgery were protrusion of the head tip and insufficient reduction of the dorsal roof fragment of the distal radius. These were considered iatrogenic problems. The cause of EPL rupture was unknown in three cases. We should be extremely careful when determining optimum screw length and reducing displaced dorsal roof fragments to prevent damaging the EPL tendons. Keywords: Distal Radius Fractures; Volar Locking Plate; Extensor Pollicis Longus Tendon Injury; Dorsal Roof Fragment; Screw Length.
INTRODUCTION
that are sometimes associated with dorsal plating.4 Extensor tendon injuries associated with use of volar locking plates are not so common, although they can occur when undisplaced DRF is treated conservatively. In this study, we investigated the risk factors for EPL rupture after DRF treated with volar locking plate at our hospital. Lister’s tubercle, especially, can mask prominent screw tips in standard dorsal fluoroscopic images.
Rupture of the extensor pollicis longus (EPL) tendon is a well-recognised complication of distal radius fractures (DRF). However, the incidence of EPL tendon rupture with conservative treatment of DRF is not very high (0.07% to 3.0%).13 One of the purposes of the design of volar locking plates for DRF is to avoid the complications involving dorsal soft tissues
Correspondence to: Dr. Yukichi Zenke, Department of Orthopaedic Surgery, School of Medicine, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-Ku, Kitakyushu 807-8555, Japan. Tel: (þ81) 93-691-7444, Fax: (þ81) 93-692-0184, E-mail: [email protected] 169
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Therefore, we calculated the optimal screw length for volar locking plate as criterion. Furthermore, we should recognise the existence of displaced dorsal roof fragments,5 which may lead to bad clinical results due to rupture of the EPL tendon.
Hand Surg. 2013.18:169-173. Downloaded from www.worldscientific.com by CHINESE UNIVERSITY OF HONG KONG on 02/22/15. For personal use only.
PATIENTS AND METHODS We retrospectively reviewed data from 286 patients with DRF who had been treated with volar locking plates (DRV plate: Mizuho Medical Technologies, Inc, Tokyo, Japan; Stellar plate: Japan Universal Technologies, Inc, Tokyo, Japan) from April 2006 through March 2010. Postoperative EPL tendon rupture occurred in six cases (2.1%; one man and five women; mean age, 57.0 years; range, 3370 years). The AO (Arbeitsgemeinschaft für Osteosynthesefragen)/OTA (Orthopaedic Trauma Association) fracture classifications were A2, one case; A3, four cases; and C2, one case. The average waiting period for surgery was 2.7 days (range, 15 days) (Table 1). We investigated the time after which EPL rupture occurred, the presence of protruding screws, and the presence and degree of displacement of dorsal roof fragments5 of the distal radius.
Surgical Treatment and Rehabilitation Surgery was performed while patients were under brachial plexus block anaesthesia or general anaesthesia. The procedure commenced with a longitudinal skin incision along the flexor carpi radialis tendon. The latter tendon and the flexor pollicis longus muscle were retracted toward the ulna. The radial border of the pronator quadratus muscle was cut longitudinally. The volar aspect of the radius was exposed subperiosteally. The plate was placed directly on the radius after
fracture reduction using the condylar stabilising method.6 No bone graft was used. After fixation, the pronator quadratus was repaired over the plate with absorbable suture materials. No plaster cast was applied after surgery. Active motion exercise was commenced as early as the patients’ pain allowed. Patients were discharged from the hospital a few days after surgery. Patients began forearm rotation and active and activeassisted motion of the wrist joint within four to five days after surgery, as tolerated. Passive exercises began at two weeks. Active treatment, including grip power exercise and training to reduce swelling of the hand, began no later than the 12th week after surgery.
RESULTS The average time from operation to EPL rupture was 49.8 days (range, 1122 days). Of the six patients with EPL rupture, four presented complete rupture and two incomplete rupture. The common symptom among all six cases was persistent pain (unlike fracture pain) on the dorsum of the wrist exacerbated by retroflexion of the thumb. Five EPL tendon ruptures (including two incomplete and three complete ruptures) were treated by transfer from the extensor indicis proprius (EIP) tendon to the EPL tendon. One complete rupture case was still observed for the patient’s hope in spite of our suggestion. All patients who underwent tendon transfer regained full extension of the thumb during an average follow-up period of 12.7 months. The outcomes of these procedures were clinically satisfactory and equivalent. In one case (16.7%), rupture was caused by a protruding screw. The dorsal roof fragment was displaced in two (33.3%) cases. Furthermore, both of the latter cases showed a high
Table 1 Clinical Data for Patients with Extensor Pollicis Longus Tendon Ruptures after Volar Locking Plates for Distal Radius Fractures. Case No. 1 2 3 4 5 6 Mean
Age (y)
Sex
Injured Side
AO/OTA Classification
Op. Waiting Time (d)
EPL Rupture Time (d)
64 70 70 39 33 66 57.0
F F F F M F
Left Right Right Left Left Left
C2 A3 A2 A3 A3 A3
5 2 2 2 1 4 2.7
93 12 41 30 122 1 49.8
Notes: Abbreviations: AO, Arbeitsgemeinschaft für Osteosynthesefragen; OTA, Orthopaedic Trauma Association; EPL, extensor pollicis longus.
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degree of displacement. The cause of rupture in the other three cases was unknown.
CASE REPORT
Hand Surg. 2013.18:169-173. Downloaded from www.worldscientific.com by CHINESE UNIVERSITY OF HONG KONG on 02/22/15. For personal use only.
A 33-year-old man sustained a distal radius fracture in a fall (Fig. 1). The fracture was treated with volar locking plate fixation two days after injury (Fig. 2), and then with simple casting for one week. At the beginning of treatment, the patient had no difficulty with retroflexion of the thumb. After clinical
Fig. 2
(A)
(B) Fig. 1
(A) At the injury Xp. (B) At the injury 3D-CT.
Just after operation Xp.
healing of the fracture, he suddenly had difficulty with thumb retroflexion four months after the operation, and he continued to experience dorsal wrist pain. Tenderness was found over the third dorsal compartment of the wrist at Lister tubercle, and a disparity was found between active and passive retroflexion of the thumb. Radiography showed that the fracture was healed in a satisfactory position, but a callus had formed around the EPL tendon near Lister tubercle (Fig. 3). The patient underwent an exploratory operation of the extensor compartment, which revealed a rupture of the EPL tendon but no evidence of screw protrusion. However, the tendon was elongated and ruptured in the callus at the corner of Lister tubercle. The tendon injury was treated by EIP-to-EPL tendon transfer, with a satisfactory result. One year after operation, the canal-like callus was resected and the implant was stable (Fig. 4).
Fig. 3 Four months after the operation CT. The callus had formed around the EPL tendon near Lister’s tubercle.
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Fig. 4
One year after the operation Xp.
DISCUSSION Local irritation or rupture of an extensor tendon is a serious complication of treatment of fractures of the distal radius. Fixation with a volar plate is an attractive strategy because of the direct restoration of the anatomy of the joint, stable internal fixation, decreased period of immobilization, and early return of wrist function. The rate of extensor tendon rupture in a previously reported7 series of cases managed with volar locking plates was 8.6%. In one of our cases, the screw was too long (Fig. 5). We believe that the size of Lister’s tubercle combined with the depth of the EPL groove may at times impede a surgeon’s assessment of the degree of past-pointing of the distal screws during volar plating of the radius. This is compounded by the difficulty of getting a proper profile view of the dorsal cortex due to the dihedral nature of the dorsal distal radius (i.e. it is not clearly visible in a lateral view on the image intensifier), as well as the fact that the tendons are in direct contact with the radius and are constrained by their compartments. Although standard texts mention Lister’s tubercle and often show the EPL groove, the literature contains little information about the size of Lister’s tubercle and the depth of the EPL groove.8,9 We measured EPL groove depth during 23 operations, and the mean value was 2.4 mm (1.3 SD). Clement et al.8 noted that the depth of the EPL groove varied from 1 to 5 mm (mean, 2.8 mm). These results are consistent with our own data. Arora et al.10 noted that because of the triangle shape of the dorsal cortex, most ulnar and radial screws are shorter than central screws. Therefore, we should consider the prominent portion
Fig. 5
The complication case that the screw was too long.
and determine screw length to be less than about 2 mm smaller than observed in the image intensifier. To determine optimum screw length, we measured the distance from the EPL tendon groove to the volar cortical line. We calculated optimum screw length as body height divided by 86. We found that body height and EPL tendon groove to volar cortical line distance were positively correlated (p ¼ 0:008, R 2 ¼ 0:29) (Fig. 6). However, currently there were some studies about the dorsal tangential view for detecting the screw penetration after volar plating of the distal radius fractures.11 From now, we are
Fig. 6 Body height and EPL tendon groove to volar cortical line distance were positively correlated.
June 25, 2013
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Hand Surg. 2013.18:169-173. Downloaded from www.worldscientific.com by CHINESE UNIVERSITY OF HONG KONG on 02/22/15. For personal use only.
Extensor Pollicis Longus Tendon Ruptures after use of Volar Locking Plates
supposed to use this intraoperative procedure in order to check the correct screw length. Furthermore, dorsal roof fragments5 should be anatomically reduced for avoiding rupture of the EPL. In two cases, the dorsal roof fragments were greatly displaced. Therefore, the EPL tendon was elongated and ruptured at the displaced EPL groove area because of the prominent and irregular surface of the dorsal roof fragment. Benson et al.12 proposed two theories for the mechanism of EPL rupture: bone spurs and/or dorsal bone edges protruding into the undersurface or into the third extensor compartment and into the EPL tendon. Mushrooming or dorsal protrusion of bone after a DRF along with a raw dorsal bone edge after reestablishment of the volar inclination of the joint surface may leave a sharp bone edge that causes problems of attrition.13 We suggest consideration of open assessment of the third extensor compartment, if indicated, through a small dorsal incision on the ulnar side of Lister tubercle for prevention of secondary EPL rupture. In another three cases, the cause was unknown (no evidence of screw protrusion or drill penetration and no displacement of dorsal roof fragment). According to previous reports,1,14 ruptures of the EPL can occur after minimally displaced fractures, because the attachment of the extensor retinaculum to Lister’s tubercle remains intact, and together with callus formation it leads to narrowing of the third compartment. This can cause reduction in the blood supply to the tendon, degenerative necrosis, and eventual rupture. Furthermore, Hirasawa et al.1 noted that the EPL tendon within the third compartment at Lister’s tubercle is subject to mechanical bending and attrition, has no mesotendon, has a poorly vascularised portion about 5 mm long within the tendon and visceral layer of the tendon sheath, and has a richly vascularised synovial tendon sheath. The poorly vascularised area of the EPL tendon becomes even more avascular because of narrowing and entrapment of the tendon. Degenerative necrosis of the tendon results, as it is deprived of both sources of nourishment, resulting in eventual rupture. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
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