Clinical and Microangiographic Studies on Rupture of the E.P.L. Tendon after Distal Radial Fractures

Etiology of Traumatic Causes of Extensor Pollicis Longus Tendon Rupture: A Systematic Review

Introduction

The extensor pollicis longus (EPL) is a muscle that follows a complex anatomical course in the hand to allow for thumb extension. Almost all manual activities require the use of the EPL; therefore, when ruptured it can be very disabling for patients. The etiologies behind traumatic EPL rupture were mostly attributed to distal radius fracture in the literature. However, EPL rupture remains uncommon, and other traumatic etiologies exist. Therefore, this systematic review aimed to provide a holistic view of the traumatic etiologies behind the EPL rupture and fill the global lack of knowledge regarding this rare injury.

Materials and Methods

We searched among Cochrane Central Register of Controlled Trials (CENTRAL) Embase, Medline, and Cochrane Database of systematic review register databases via Ovid, with no restriction on the date, including studies containing data about the etiology of traumatic causes of EPL tendon rupture with available full text, and excluding non-English and animal studies.

Results

A total of 37 articles with 371 cases constituted the basis of this review. We classified the etiology of the EPL rupture into three groups according to the affected anatomical structure that caused the EPL rupture (fracture-related, soft tissue-related, and mallet thumb).

Conclusion

Distal radius fractures remain the most common cause of EPL rupture; however, other causes, such as lacerations, blunt trauma, and direct cuts to the EPL tendon, should be considered.

Diagnostic ultrasound of tendon injuries in the setting of distal radius fractures

OBJECTIVE

Describe tendon injuries and their structural causes seen on ultrasound in wrists with distal radius fractures and estimate the accuracy of ultrasound and its impact on clinical management.

MATERIALS AND METHODS

Ultrasounds of 226 wrists (221 patients) with distal radius fractures were retrospectively reviewed. Ultrasound findings of tendon injuries and their structural causes were correlated with surgery and clinical outcome. Accuracy and inter- and intra-observer reproducibilities were calculated.

RESULTS

Twenty-five wrists were treated non-operatively while 201 underwent surgery. Ultrasound demonstrated hardware contact with flexor pollicis longus (FPL) in 76 wrists, extensor pollicis longus (EPL) in 21, and other tendons in 94. Ultrasound identified tendon ruptures in 23 wrists (13 EPL/8 FPL/2 extensor indicis proprius (EIP)), most of which were surgically confirmed. Among 12 wrists with confirmed EPL ruptures, distal radius fracture had been treated with volar plating in 6 and non-operatively in 6, and ultrasound showed osseous irregularity at the rupture site in 8. All FPL ruptures occurred in wrists with volar plating. Ultrasound findings were concordant with subsequent clinical management in most. In 2, ultrasound findings led to the decision to remove hardware despite lack of symptoms. Ultrasound had sensitivity/specificity/accuracy of 88/99/98% for identifying a specific tendon as ruptured and 88/87/88% for tendon abnormalities in general. Inter- and intra-observer reproducibilities were excellent (kappa = 0.85 ~ 1.0).

CONCLUSION

Certain wrist tendons, particularly EPL and FPL, are vulnerable after distal radius fractures. Ultrasound is accurate and useful for detecting tendon injury and sources of tendon irritation and can guide clinical management.

A Rare Presentation of Extensor Pollicis Longus Tendon Rupture After Nondisplaced Scaphoid Fracture

Extensor pollicis longus tendon rupture is a reported complication after nondisplaced distal radius fractures. These are thought to occur secondary to mechanical irritation or compromised blood supply. We present a case of extensor pollicis longus rupture after a healed nondisplaced scaphoid fracture, which may have involved a similar attritional process. We are unaware of any prior reports of extensor pollicis longus rupture after this type of injury.

Middorsal Wrist Pain in the High-Level Athlete: Causes, Treatment, and Early Return to Play

Wrist injuries in the competitive athlete are a common reason for evaluation related to an acute injury or after symptoms have become chronic. While radius- and ulna-sided wrist pain are common topics covered in the literature, middorsal wrist pain is more common than the available literature would suggest. Missed diagnoses and inadequate treatment can significantly increase athlete morbidity and delay return to play. The goal of this article was to review the differential diagnosis of middorsal wrist pain in the athlete and discuss the diagnosis, treatment, and early return to play for each condition.

Spontaneous rupture of the extensor pollicis longus tendon in systemic lupus erythematosus: A case report and literature review

Spontaneous tendon rupture is a rare entity. Herein, we report a case of spontaneous rupture of the extensor pollicis longus (EPL) tendon in a 61-year-old woman with systemic lupus erythematosus (SLE). The patient worked as an aesthetician and had a 42-year history of SLE that was well controlled using oral steroids. She presented with an inability to extend her left thumb, with no prior history of trauma or symptoms. On imaging, there was no evidence of degenerative changes or osteophyte formation in the gliding area of the EPL tendon. Intraoperatively, there was evidence of tendon rupture around Lister's tubercle. We performed a tendon transfer of the extensor indicis proprius for repair. The patient recovered active thumb extension and returned to work 4 months after surgery without any complications. We suspected that spontaneous EPL tendon rupture was caused by a combination of disease-related factors, including long-term steroid use, chronic inflammation, and continuous mechanical stress from her work and daily activity. This case report demonstrates the multifactorial aetiology of spontaneous tendon rupture in patients with SLE and the importance of monitoring for this complication during routine follow-up.

Revisiting spontaneous rupture of the extensor pollicis longus tendon: eight cases without identifiable predisposing factor

INTRODUCTION

Rupture of the extensor pollicis longus (EPL) tendon has been reported in the setting of distal radius fracture, chronic inflammatory arthritis, following steroid injection, and with excessive or repetitive activities. Truly, spontaneous EPL rupture, without an identifiable predisposing factor, has rarely been reported.

METHODS

We present a retrospective case series of eight patients with spontaneous EPL rupture who were treated in our institution.

RESULTS

The majority of the cases were female (75 %, n = 6), and the nondominant (75 %, n = 6) hand was most commonly involved. No identifiable predisposing factor could be identified in four patients. While four patients reported a history of a fall, radiographs failed to demonstrate skeletal abnormality in all four cases. No additional pathology could be identified at the time of surgery. Patients were treated using tendon transfer (n = 7) or interpositional graft (n = 1). There has been no case of clinical recurrence in the mean of 74.8 months (range 23-140 months) follow-up period.

CONCLUSION

The EPL tendon is at risk for spontaneous rupture even in the absence of identifiable predisposing risk factor. Rather than pure mechanical irritation, vascular and metabolic factors may also play a substantial role in the etiology of this uncommon diagnosis.

Ultrasound changes in the extensor pollicis longus and flexor pollicis longus tendons following open reduction and internal fixation of displaced intra-articular fractures of the distal radius

A previous ultrasound study showed inflammation around the extensor pollicis longus tendon and surrounding structures at 6 weeks after manipulation, with or without pin fixation, and immobilization for distal radius fracture. Ultrasound examination after plating of distal radius fracture followed by early active mobilization of the wrist showed a short-lived inflammatory response, evident at 2 weeks but not at 6 weeks, around the extensor pollicis longus tendon (26 wrists examined) and flexor pollicis longus tendon (18 wrists examined). Early active mobilization of the wrist appears to limit the duration of inflammation around these tendons.

Extensor Indicis Proprius Tendon Transfer for Extensor Pollicis Longus Rupture

Six of 13 patients who underwent extensor indicis proprius (EIP) tendon transfer for extensor pollicis longus (EPL) rupture between 1985 and 1998 were available for long term assessment of the function of the thumb. The presenting problem was the inability to extend the thumb at the interphalangeal (IP) joint. Postoperatively, there was no extension lag at the IP joint of the thumb. Three patients had slightly reduced flexion at the IP joint compared with the unaffected thumb. Five patients showed no extension lag at the metacarpophalangeal (MCP) joint, whereas one patient had an extension lag of 28°. The mean active flexion at the IP joint of the thumb was 64.5° (range 50° to 77.5°). The mean extension deficit of the index finger at the MCP joint was 7° (range 0° to 20°) compared with the unaffected side that was 5° (range 0° to 12°). Measurements of key pinch and pinch grip were 94% and 82% in the unaffected hand, respectively. Subjective assessment by the patients was rated as excellent by four patients and good by two patients. This particular tendon transfer is recommended for the treatment of EPL rupture.