EXTENSOR
TENDON RUPTURE DUE TO OSTEOARTHRITIS OF THE DISTAL RADIO-ULNAR JOINT 1.OHSHIO,
T. OGINO, A. MINAMI, H. KATO and A. MIYAKE
From the Department
of Orthopaedic
Surgery,
Hokkaido
University, Sapporo, Japan
Five cases of closed rupture of the finger extensor tendon due to osteoarthritis of the distal radioulnar joint were studied. Difiiculty in extension began at the little finger and extended to the ring and long fingers. Pain and swelling in the dorsal aspect of the wrist preceded the tendon rupture. Osteoarthritic changes at the distal radio-ulnar joint were more severe than those at the radio-carpal and intercarpal joints. The distal end of the ulna showed the plus variant, as well as dorsal dislocation or subluxation. All patients underwent a tendon graft or tendon transfer, with excision of the distal ulna. The tendon rupture was thought to be caused mainly by friction between the displaced distal end of the ulna and osteophytes of the distal radio-ulnar joint. Journal of Hand Surgery (British Volume, 1991) 16B: 450-453
Many causes of closed tendon rupture have been reported, but there are few reports of tendon rupture following primary osteoarthritis of the distal radio-ulnar joint. We report five cases of rupture of finger extensor tendons in patients with primary osteoarthritis of the distal radioulnar joint.
Material and methods During 1980-1989, we treated five patients who had distal radio-ulnar osteoarthritis which caused rupture of extensor tendons (Table 1). Three were men and two women. Their mean age was 59.2 years (range 54-71 years). All were treated by surgical procedures. The time from tendon rupture to operation ranged between one month and 13 years. The average follow-up period was 35 months (range 6-64 months).
Results ClinicalJindings
None of the patients had a history of trauma, but all had an occupational history of hard manual labour. Laboratory tests in all patients showed negative R.A. reactions, negativity for C-reactive protein and no other signs of inflammation. In four cases, slight local swelling and
Table l-Patients Case
1 2 3 4 5
450
Age (years)
Sex
Local swelling
71 58 55 58 54
F M M M F
+ + + +
Affectedjnger
ring, little-middle little only littlejring little-ring littledring
Time from tendon rupture to operation 5 years 1 month 13 years 1 year 9 months 1 month
pain at the dorsal aspect of the wrist preceded difficulty in extending the finger. The duration of preceding local swelling ranged from one to six months. Difficulty in extending the finger developed gradually in four cases and abruptly in one. In one patient, it affected the middle, ring and little fingers. In three patients, it affected the ring and little fingers and in one patient the little finger only. When more than one finger was affected, the problem began in the little finger and extended to the ring and middle fingers.
Radiographic findings
In all cases, osteoarthritic changes without osteoporotic changes were seen in the distal radio-ulnar, ulno-carpal and radio-carpal joints, but there were none in the intercarpal joints (Table 2). The osteoarthritic changes in the distal radio-ulnar and ulno-carpal joint were always more severe than those in the radio-carpal joints. The distal end of the ulna showed the plus variant in all cases, ranging between 3 mm. and 7 mm. (average 5.2 mm.). There were two dorsal non-traumatic dislocations and three subluxations of the distal ulna.
Treatment
All patients underwent surgical procedures (Table 3). At the time of operation, synovitis of the distal radio-ulnar and radio-carpal joints was not severe. The extensor digitorum communis tendon to the little finger was ruptured in all cases; in four cases, the extensor digiti minimi tendon and the communis tendon to the ring finger were ruptured and in one case the communis tendon to the middle finger was ruptured. In all cases, when the forearm was pronated, the distal end of the ulna dislocated dorsally. Tendons were grafted in five fingers of four patients, and tendon transfers were done on five fingers of four patients. The distal ulna was excised in all patients. THE JOURNAL
OF HAND
SURGERY
EXTENSOR
TENDON
RUPTURE
DUE TO OSTEOARTHRITIS
OF THE DISTAL RADIO-ULNAR
JOINT
Table 2-Severity of roentgenographicchanges Case
Severity of O.A. Radio-carpal
1
f-t-
2
+
3 4 5
+ + ++
Distal radio-ulnar
DistaI ulna
Uhw-carpal
+++
Inter-carpal
Plus variant
+++
-
+
-
+++ ++i+++
-
5 mm. 3mm. 7mm. 6mm. 5 mm.
++
+++ +++ +++
Dislocation
++ + + + ++
Table 3-Treatment Follow-up period
Surgicalmethods
Case
E.D.C. (middle, ring, little) E.D.M.
E.I.P. s
2
E.D.C. (little) E.D.M.
E.D.C. (ring) --t E.D.C. (little) [side-k-side]
3
E.D.C. (ring, little)
P.L.
E.D.C. (ring, little)
graft
1 year 6 months
4
E.D.C. (ring, little) E.D.M. E.D.C. (ring, little) E.D.M.
E.I.P.7
:DD,(ring)
3 years 6 months
E.I.P. -\\3
E.D.C. (ring) E.D.M.
transfer graft transfer graft
5
-----+
E.D.C. (middle,ring) E.D.C. (httle)
tgrzfer
5 years 4 months
1
6 months
5 years 4 months
E.D.C. : Extensor Digitomm Communis, E.I.P. : Extensor Indicis Proprius, E.D.M. : Extensor Digitomm Minimi, P.L.: Palmaris Longus
Fig. 1
Case I. A 71-year-old woman. (a) Osteoarthritic changes in the distal radio-ulnar dislocated dorsally. The ulno-carpal joint is narrowed and sclerotic.
Results
In one case, limitation of finger flexion resulted and the patient complained of loss of grip. In the other four cases, some difficulty with finger extension in M.P. joint VOL. 16B No. 4 NOVEMBER
1991
joint. (b) The distal ulna shows the plus variant and is
remained, ranging from 10 to 40”, but there was no limitation of finger flexion. In all cases, the local swelling and pain in the dorsal aspect of the wrist disappeared after the operation. No recurrence of tendon rupture was seen at the time of the last examination. 451
I. OHSHIO, T. OGINO, A. MINAMI, H. KATO AND A. MIYAKE
Discussion
Vaughan-Jackson (1948) reported two extensor tendon ruptures by attrition at the distal radio-ulnar joint. There are no reports of extensor tendon rupture due to distal radio-ulnar osteoarthritis in the English-language literature, but a case of flexor tendon rupture was described by Minami et al. (1989). In our patients, there was no evidence of rheumatoid disease and the cause of tendon rupture was considered to be primary osteoarthritis of the distal radio-ulnar joint.
After a Colles’ fracture, the mechanism of extensor tendon rupture is considered to be not only friction at the fracture site but also fragility of the tendon caused by ischaemia (McMaster, 1932). In one case, osteophytes in the dorsal aspect of the distal radius were shown on a C.T. scan (Fig. 2). The main mechanism of tendon rupture was attrition between the dislocated distal ulna and the osteophytes on the distal radius during pronation and supination. Because end-to-end repair was impossible, tendon grafting or tendon transfer were performed. One patient,
Fig.
452
2
Case 2. A %-year-old man. (a) Localised osteoarthritic changes in the distal radio-ulnar joint. (b) The distal ulna is subluxed dorsally. (c) C.T. scan shows dorsal osteophytes on the ulna and radius. THE JOURNAL OF HAND SURGERY
EXTENSOR
TENDON
RUPTURE
DUE
TO OSTEOARTHRITIS
who had a tendon graft 13 years after tendon rupture, complained of limitation of finger flexion and function of the hand. In a long-standing case, in which myostatic contracture was suspected, tendon transfer would be a safer and easier procedure than a tendon graft. Excision of the distal ulna is necessary to prevent the recurrence of tendon rupture and for relief of local symptoms. Acknowledgement The authors express their sincere thanks to Professor Kiyoshi Kaneda of the Department of Orthopaedic Surgery, Hokkaido University School of Medicine for his suggestion and advice throughout this investigation.
VOL.
16B No. 4 NOVEMBER
1991
OF THE
DISTAL
RADIO-ULNAR
JOINT
References McMASTER, P. E. (1932). Late Ruptures of Extensor and Flexor Pollicis Longus Tendons Following Colles’s Fracture. Journal of Bone and Joint Surgery, 14: 93-101. MINAMI, A., OGINO, T. and TOHYAMA, H. (1989). Multiple Ruptures of Flexor Tendons due to Hypertrophic Change at the Distal Radio-Ulnar Joint, Journal of Bone and Joint Surgery, 71A: 2: 30&302. VAUGHAN-JACKSON, 0. J. (1948). Rupture of extensor tendons by attrition at the inferior radio-ulnar joint. Report of two cases. Journal of Bone and Joint Surgery, 30B: 3: 52X-530
Accepted: 3 April 1990 Itant Ohshio, M.D.: Department of Orthopaedic Surgery, School of Medicine, Hokkaido University,
Kita
15~0, Nishi
‘I-chome,
0 1991 The British Society for
Sappao,
060, Japan.
Surgery ofthe Hand
453
TENDON RUPTURE DUE TO OSTEOARTHRITIS OF THE DISTAL RADIO-ULNAR JOINT 1.OHSHIO,
T. OGINO, A. MINAMI, H. KATO and A. MIYAKE
From the Department
of Orthopaedic
Surgery,
Hokkaido
University, Sapporo, Japan
Five cases of closed rupture of the finger extensor tendon due to osteoarthritis of the distal radioulnar joint were studied. Difiiculty in extension began at the little finger and extended to the ring and long fingers. Pain and swelling in the dorsal aspect of the wrist preceded the tendon rupture. Osteoarthritic changes at the distal radio-ulnar joint were more severe than those at the radio-carpal and intercarpal joints. The distal end of the ulna showed the plus variant, as well as dorsal dislocation or subluxation. All patients underwent a tendon graft or tendon transfer, with excision of the distal ulna. The tendon rupture was thought to be caused mainly by friction between the displaced distal end of the ulna and osteophytes of the distal radio-ulnar joint. Journal of Hand Surgery (British Volume, 1991) 16B: 450-453
Many causes of closed tendon rupture have been reported, but there are few reports of tendon rupture following primary osteoarthritis of the distal radio-ulnar joint. We report five cases of rupture of finger extensor tendons in patients with primary osteoarthritis of the distal radioulnar joint.
Material and methods During 1980-1989, we treated five patients who had distal radio-ulnar osteoarthritis which caused rupture of extensor tendons (Table 1). Three were men and two women. Their mean age was 59.2 years (range 54-71 years). All were treated by surgical procedures. The time from tendon rupture to operation ranged between one month and 13 years. The average follow-up period was 35 months (range 6-64 months).
Results ClinicalJindings
None of the patients had a history of trauma, but all had an occupational history of hard manual labour. Laboratory tests in all patients showed negative R.A. reactions, negativity for C-reactive protein and no other signs of inflammation. In four cases, slight local swelling and
Table l-Patients Case
1 2 3 4 5
450
Age (years)
Sex
Local swelling
71 58 55 58 54
F M M M F
+ + + +
Affectedjnger
ring, little-middle little only littlejring little-ring littledring
Time from tendon rupture to operation 5 years 1 month 13 years 1 year 9 months 1 month
pain at the dorsal aspect of the wrist preceded difficulty in extending the finger. The duration of preceding local swelling ranged from one to six months. Difficulty in extending the finger developed gradually in four cases and abruptly in one. In one patient, it affected the middle, ring and little fingers. In three patients, it affected the ring and little fingers and in one patient the little finger only. When more than one finger was affected, the problem began in the little finger and extended to the ring and middle fingers.
Radiographic findings
In all cases, osteoarthritic changes without osteoporotic changes were seen in the distal radio-ulnar, ulno-carpal and radio-carpal joints, but there were none in the intercarpal joints (Table 2). The osteoarthritic changes in the distal radio-ulnar and ulno-carpal joint were always more severe than those in the radio-carpal joints. The distal end of the ulna showed the plus variant in all cases, ranging between 3 mm. and 7 mm. (average 5.2 mm.). There were two dorsal non-traumatic dislocations and three subluxations of the distal ulna.
Treatment
All patients underwent surgical procedures (Table 3). At the time of operation, synovitis of the distal radio-ulnar and radio-carpal joints was not severe. The extensor digitorum communis tendon to the little finger was ruptured in all cases; in four cases, the extensor digiti minimi tendon and the communis tendon to the ring finger were ruptured and in one case the communis tendon to the middle finger was ruptured. In all cases, when the forearm was pronated, the distal end of the ulna dislocated dorsally. Tendons were grafted in five fingers of four patients, and tendon transfers were done on five fingers of four patients. The distal ulna was excised in all patients. THE JOURNAL
OF HAND
SURGERY
EXTENSOR
TENDON
RUPTURE
DUE TO OSTEOARTHRITIS
OF THE DISTAL RADIO-ULNAR
JOINT
Table 2-Severity of roentgenographicchanges Case
Severity of O.A. Radio-carpal
1
f-t-
2
+
3 4 5
+ + ++
Distal radio-ulnar
DistaI ulna
Uhw-carpal
+++
Inter-carpal
Plus variant
+++
-
+
-
+++ ++i+++
-
5 mm. 3mm. 7mm. 6mm. 5 mm.
++
+++ +++ +++
Dislocation
++ + + + ++
Table 3-Treatment Follow-up period
Surgicalmethods
Case
E.D.C. (middle, ring, little) E.D.M.
E.I.P. s
2
E.D.C. (little) E.D.M.
E.D.C. (ring) --t E.D.C. (little) [side-k-side]
3
E.D.C. (ring, little)
P.L.
E.D.C. (ring, little)
graft
1 year 6 months
4
E.D.C. (ring, little) E.D.M. E.D.C. (ring, little) E.D.M.
E.I.P.7
:DD,(ring)
3 years 6 months
E.I.P. -\\3
E.D.C. (ring) E.D.M.
transfer graft transfer graft
5
-----+
E.D.C. (middle,ring) E.D.C. (httle)
tgrzfer
5 years 4 months
1
6 months
5 years 4 months
E.D.C. : Extensor Digitomm Communis, E.I.P. : Extensor Indicis Proprius, E.D.M. : Extensor Digitomm Minimi, P.L.: Palmaris Longus
Fig. 1
Case I. A 71-year-old woman. (a) Osteoarthritic changes in the distal radio-ulnar dislocated dorsally. The ulno-carpal joint is narrowed and sclerotic.
Results
In one case, limitation of finger flexion resulted and the patient complained of loss of grip. In the other four cases, some difficulty with finger extension in M.P. joint VOL. 16B No. 4 NOVEMBER
1991
joint. (b) The distal ulna shows the plus variant and is
remained, ranging from 10 to 40”, but there was no limitation of finger flexion. In all cases, the local swelling and pain in the dorsal aspect of the wrist disappeared after the operation. No recurrence of tendon rupture was seen at the time of the last examination. 451
I. OHSHIO, T. OGINO, A. MINAMI, H. KATO AND A. MIYAKE
Discussion
Vaughan-Jackson (1948) reported two extensor tendon ruptures by attrition at the distal radio-ulnar joint. There are no reports of extensor tendon rupture due to distal radio-ulnar osteoarthritis in the English-language literature, but a case of flexor tendon rupture was described by Minami et al. (1989). In our patients, there was no evidence of rheumatoid disease and the cause of tendon rupture was considered to be primary osteoarthritis of the distal radio-ulnar joint.
After a Colles’ fracture, the mechanism of extensor tendon rupture is considered to be not only friction at the fracture site but also fragility of the tendon caused by ischaemia (McMaster, 1932). In one case, osteophytes in the dorsal aspect of the distal radius were shown on a C.T. scan (Fig. 2). The main mechanism of tendon rupture was attrition between the dislocated distal ulna and the osteophytes on the distal radius during pronation and supination. Because end-to-end repair was impossible, tendon grafting or tendon transfer were performed. One patient,
Fig.
452
2
Case 2. A %-year-old man. (a) Localised osteoarthritic changes in the distal radio-ulnar joint. (b) The distal ulna is subluxed dorsally. (c) C.T. scan shows dorsal osteophytes on the ulna and radius. THE JOURNAL OF HAND SURGERY
EXTENSOR
TENDON
RUPTURE
DUE
TO OSTEOARTHRITIS
who had a tendon graft 13 years after tendon rupture, complained of limitation of finger flexion and function of the hand. In a long-standing case, in which myostatic contracture was suspected, tendon transfer would be a safer and easier procedure than a tendon graft. Excision of the distal ulna is necessary to prevent the recurrence of tendon rupture and for relief of local symptoms. Acknowledgement The authors express their sincere thanks to Professor Kiyoshi Kaneda of the Department of Orthopaedic Surgery, Hokkaido University School of Medicine for his suggestion and advice throughout this investigation.
VOL.
16B No. 4 NOVEMBER
1991
OF THE
DISTAL
RADIO-ULNAR
JOINT
References McMASTER, P. E. (1932). Late Ruptures of Extensor and Flexor Pollicis Longus Tendons Following Colles’s Fracture. Journal of Bone and Joint Surgery, 14: 93-101. MINAMI, A., OGINO, T. and TOHYAMA, H. (1989). Multiple Ruptures of Flexor Tendons due to Hypertrophic Change at the Distal Radio-Ulnar Joint, Journal of Bone and Joint Surgery, 71A: 2: 30&302. VAUGHAN-JACKSON, 0. J. (1948). Rupture of extensor tendons by attrition at the inferior radio-ulnar joint. Report of two cases. Journal of Bone and Joint Surgery, 30B: 3: 52X-530
Accepted: 3 April 1990 Itant Ohshio, M.D.: Department of Orthopaedic Surgery, School of Medicine, Hokkaido University,
Kita
15~0, Nishi
‘I-chome,
0 1991 The British Society for
Sappao,
060, Japan.
Surgery ofthe Hand
453
