Traumatic rupture of the extensor tendons at the musculotendinous junction

Pull-in suture: a novel reconstruction technique for tendon avulsion injury at the musculotendinous junction associated with forearm open fracture

We present three cases of strong one-staged tendon reconstruction for musculotendinous junction avulsion tendon injuries, and called it a ‘pull-in suture’. The clinical outcomes of this method are comparable to those of tendon transfer; it is an effective reconstruction method that should be considered as an initial treatment procedure.

Injuries in Muscle-Tendon-Bone Units: A Systematic Review Considering the Role of Passive Tissue Fatigue

Background:

Low-cycle fatigue damage accumulating to the point of structural failure has been recently reported at the origin of the human anterior cruciate ligament under strenuous repetitive loading. If this can occur in a ligament, low-cycle fatigue damage may also occur in the connective tissue of muscle-tendon units. To this end, we reviewed what is known about how, when, and where injuries of muscle-tendon units occur throughout the body.

Purpose:

To systematically review injuries in the muscle-tendon-bone complex; assess the site of injury (muscle belly, musculotendinous junction [MTJ], tendon/aponeurosis, tendon/aponeurosis–bone junction, and tendon/aponeurosis avulsion), incidence, muscles and tendons involved, mechanism of injury, and main symptoms; and consider the hypothesis that injury may often be consistent with the accumulation of multiscale material fatigue damage during repetitive submaximal loading regimens.

Methods:

PubMed, Web of Science, Scopus, and ProQuest were searched on July 24, 2019. Quality assessment was undertaken using ARRIVE, STROBE, and CARE (Animal Research: Reporting In Vivo Experiments, Strengthening the Reporting of Observational Studies in Epidemiology, and the Case Report Statement and Checklist, respectively).

Results:

Overall, 131 studies met the inclusion criteria, including 799 specimens and 2,823 patients who sustained 3,246 injuries. Laboratory studies showed a preponderance of failures at the MTJ, a viscoelastic behavior of muscle-tendon units, and damage accumulation at the MTJ with repetitive loading. Observational studies showed that 35% of injuries occurred in the tendon midsubstance; 28%, at the MTJ; 18%, at the tendon-bone junction; 13%, within the muscle belly and that 6% were tendon avulsions including a bone fragment. The biceps femoris was the most injured muscle (25%), followed by the supraspinatus (12%) and the Achilles tendon (9%). The most common symptoms were hematoma and/or swelling, tenderness, edema and muscle/tendon retraction. The onset of injury was consistent with tissue fatigue at all injury sites except for tendon avulsions, where 63% of the injuries were caused by an evident trauma.

Conclusion:

Excluding traumatic tendon avulsions, most injuries were consistent with the hypothesis that material fatigue damage accumulated during repetitive submaximal loading regimens. If supported by data from better imaging modalities, this has implications for improving injury detection, prevention, and training regimens.

Traumatic index extensor tendon attenuation mimicking closed tendon rupture: two case reports

Background

While some traumatic closed index extensor tendon ruptures at the musclotendinous junction have been previously reported, closed index extensor tendon pseudorupture due to intertendinous attenuation is exceedingly rare with only one case report of a gymnastics-related sports injury in the English literature. Herein, we report two non-sports injury related cases of traumatic index extensor tendon attenuation mimicking closed tendon rupture, including the pathological findings and intraoperative video of the attenuated extensor indicis proprius tendon.

Case presentation

A 28-year-old man and a 30-year-old man caught their hands in a high-speed drill and lathe, respectively, which caused a sudden forced flexion of their wrists. They could not actively extend the metacarpophalangeal joints of their index fingers. Intraoperatively, although the extensor indicis proprius and index extensor digitorum communes tendons were in continuity without ruptures, both tendons were attenuated and stretched. The attenuated index extensor tendons were reconstructed either with shortening by plication or step-cut when the tendon damage was less severe or, in severely attenuated tendons, with tendon grafting (ipsilateral palmaris longus) or tendon transfer. Six months after the operation, the active extension of the index metacarpophalangeal joints had recovered well.

Conclusions

Two cases of traumatic index extensor tendon attenuation were treated successfully by shortening the attenuated tendon in combination with tendon graft or transfer. We recommend WALANT (wide-awake local anesthesia and no tourniquet) in the reconstruction surgery of index extensor tendon attenuation to determine the appropriate amount of tendon shortening or optimal tension for tendon grafting or transfer. Intraoperative voluntary finger movement is essential, as it is otherwise difficult to judge the stretch length of intratendinous elongation and extent of traumatic intramuscular damage affecting tendon excursion.

Acute Compartment Syndrome of Upper Extremities with Tendon Ruptures

BACKGROUND

It is well known that acute compartment syndrome is associated with fracture of the forearm, while involvement of soft tissue injury including musculotendinous injury remains unclear. The purpose of this study was to evaluate the soft tissue involvement, including musculotendinous ruptures, in acute compartment syndrome of the upper limb.

METHODS

We retrospectively enrolled 16 patients who underwent surgical treatment for acute compartment syndrome of the upper extremity. The average age of the patients was 47 years (range, 14 to 79) and the mean follow-up period after the surgery was 15 months (range, 12 to 29). Complications included at least one presentation at the final follow up of sensory disturbances or motor disturbances. We examined the presence of musculotendinous injury mechanism of injury, presence of fracture, the performance of skin grafting, and complications.

RESULTS

Mechanism of injury of "caught in a machine" was found in six cases. Three of these patients had musculotendinous ruptures and all muscle tears were revealed by intraoperative findings. No patients had muscle ruptures with other injury mechanisms. Seven out of 16 patients (44%) developed complications at final follow-up. Skin grafting was performed in six patients, and five of these patients developed complications. Only one of the nine patients without complications underwent skin grafting.

CONCLUSIONS

In cases of high-energy injuries, the surgeon should suspect the presence of a musculotendinous injury prior to surgery.

Traumatic Extensor Tendon Injuries to the Hand: Clinical Anatomy, Biomechanics, and Surgical Procedure Review

The extensor apparatus is a complex muscle-tendon system that requires integrity or optimal reconstruction to preserve hand function. Anatomical knowledge and the understanding of physiopathology of extensor tendons are essential for an accurate diagnosis of extensor tendon injuries (ETIs) of the hand and wrist, because these lesions are complex and commonly observed in clinical practice. A careful clinical history and assessment still remain the first step for the diagnosis, followed by US and MR to confirm the suspect of ETI or to investigate some doubtful conditions and rule out associate lesions. During last decades the evolution of surgical techniques and rehabilitative treatment protocol led to gradual improvement in clinical results of ETI treatment and surgical repair. Injury classification into anatomical zones and the evaluation of the characteristics of the lesions are considered key points to select the appropriate treatment for ETI. Both conservative and surgical management can be indicated in ETI, depending on the anatomical zone and on the characteristics of the injuries. As a general rule, an attempt of conservative treatment should be performed when the lesion is expected to have favorable result with nonoperative procedure. Many surgical techniques have been proposed over the time and with favorable results if the tendon injury is not underestimated and adequately treated. Despite recent research findings, a lack of evidence-based knowledge is still observed in surgical treatment and postoperative management of ETI. Further clinical and biomechanical investigations would be advisable to clarify this complex issue.

Extensor tendon injuries in athletes

Extensor tendon injuries of the hand and wrist in high-level athletes can cause a delay in return to play and permanently affect their performance. Given the inherent demand for a speedy and complete recovery, orthopedic surgeons must have an understanding of how to best direct an athlete's treatment for these injuries. The extensor anatomy is very intricate and a thorough understanding of the anatomy can help with both diagnosis and treatment. However, untreated or poorly managed injuries are at risk of leading to chronic deformities. We will discuss the diagnosis and management of the most common extensor tendon injuries and tendinopathies of the hand found in athletes: mallet fingers, swan-neck deformities, boutonniere deformities, central slip ruptures, sagittal band ruptures, intersection syndrome, extensor carpi ulnaris tendinitis, and extensor carpi ulnaris subluxation.

Acute Compartment Syndrome in the Forearm with Extensor and Flexor Tendon Ruptures: A Case Report

CASE

While working in a factory, a thirty-five-year-old man injured his right forearm and was then diagnosed with acute compartment syndrome. Ruptures of the flexor and extensor tendons were revealed via single volar and dorsal incisions. End-to-side transfer with use of the remaining extensor tendons was performed; the end of the extensor indicis proprius tendon was sutured to the side of the extensor digitorum communis tendon of the middle finger, and the extensor pollicis longus tendon was sutured to the extensor pollicis brevis tendon.

CONCLUSION

In cases of high-energy injuries, associated tendon rupture should be considered.

Grip lock injury resulting in extensor tendon pseudorupture: case report

Grip lock injuries are uncommon, potentially devastating occurrences in male gymnasts performing high bar routines, and typically cause severe wrist sprains or forearm fractures. We retrospectively reviewed medical records of a 24-year-old former collegiate gymnast surgically treated for complete loss of index and long finger extension (pseudorupture) after a grip lock injury. Intraoperative evaluation 3 weeks after injury revealed profound intratendinous attenuation of index and long finger extensors with adhesions in the fourth compartment. We performed tenolysis and imbrication of the affected tendons. At 12-month follow-up, the patient had no pain, full digital range of motion with the wrist in neutral, but residual extensor lag with the wrist in extension. He had returned to gymnastics with some apprehension. This case broadens the known spectrum of grip lock injuries.

Grip lock injury in male gymnasts

Background:

Grip lock is a high bar injury in male gymnastics and occurs while the gymnast is rotating around the high bar. Its mechanism and treatment have been poorly documented.

Study Design:

Case reports.

Results:

One gymnast sustained an extensor tendon injury and ulnar styloid fracture and was treated nonoperatively. The second gymnast sustained open fracture of the radius and ulna with extensor tendon ruptures and was surgically treated. Both gymnasts healed and were able to return to collegiate gymnastics despite residual finger extensor lag.

Conclusions:

Grip lock is a physically and psychologically devastating injury on the men’s high bar that can cause forearm fractures and extensor tendon injuries at the wrist (Zone 8), which may result in residual extensor tendon lag. Injuries may be prevented with proper grip fit, appropriate maintenance of grips, and limited duration of use, as well as education of athletes, athletic trainers, and coaches

Management of digital tendon avulsion at the musculotendinous junction of the forearm: a systematic review

BACKGROUND

Tendon avulsion at the musculotendinous junction caused by digit avulsion amputation or closed injury is a challenging problem, for which the literature lacks definitive recommendations regarding treatment. We have provided a systematic review and developed an algorithm to delineate optimal management of this injury.

METHODS

Two independent reviewers undertook a systematic review of the literature to identify articles discussing management of forearm tendons avulsed at their musculotendinous junction. Patient demographics, injury mechanism, injury pattern, type of repair, and outcome were investigated. These data were analyzed to reveal tendencies in management, which were then organized into an algorithm.

RESULTS

Twenty articles fit our criteria for a total of 91 tendons. Cases were mostly males involved in work accidents. Treatment options were tendon resection, reattachment to muscle, tendon transfer, and side-to-side repair. When the digit was replanted, tendons avulsed through avulsion amputations were preferentially treated by reattachment in the case of the thumb, transfers for the index and long fingers, and resection for the ring and small fingers. Reattachment was favored for metacarpophalangeal level amputations, while transfer was selected for proximal phalanx levels. For closed avulsion injuries, flexors were preferentially treated with reattachment or transfer, while extensors underwent transfer or side-to-side repair.

CONCLUSIONS

In the management of tendon avulsions at the musculotendinous junction, specific procedures are favored depending on the mechanism of injury, the type of tendon and digit involved, and the level of bone amputation. An algorithm is presented to facilitate optimal treatment based on these injury characteristics.

Fascial augmentation tenorrhaphy for extensor tendon lacerations in the forearm

Proximal lacerations of the extensor tendon apparatus can pose a surgical challenge, especially when located at the musculotendinous junction or in patients presenting late. We describe a technique to augment the suture repair of these injuries utilizing local harvested strips of dorsal forearm fascia.

Lacerations to Zones VIII and IX: It Is Not Just a Tendon Injury

Extensor tendon injuries are widely believed to be straightforward problems that are relatively simple to manage. However, these injuries can be complex and demand a thorough understanding of anatomy to achieve the best functional outcomes. When lacerations occur in the forearm as in Zones VIII and IX injury, the repair of the extensor tendon and muscle, and posterior interosseous nerve (PIN) is often challenging. A review of the literature shows little guidance and attention for these injuries. We present four patients with injuries to Zones VIII and IX as well as a review of surgical technique, postoperative rehabilitation, and pearls that may be of benefit to those managing these injuries.

Traumatic closed index extensor tendon rupture at the musclotendinous junction: a report of two cases

This report describes two cases of traumatic closed index extensor tendon rupture at the musclotendinous junction. Both patients were injured when their work gloves were caught in the revolving parts of machines, and both were treated surgically. One of the patients completely ruptured the index extensor digitorum communis (EDC) and the extensor indicis proprius (EIP) tendons at the musclotendinous junction of dorsal forearm. In this patient, the distal stump of the index EDC tendon was sutured to the middle EDC tendon in an end-to-side juncture. The other patient completely ruptured the EIP tendon and partially ruptured the index EDC tendon at the musclotendinous junction. In this patient, tendon transfer of the extensor digiti minimi (EDM) to the EIP tendon and plication of the index EDC tendon were performed. In both cases, surgical intervention enabled the patients to extend their index fingers almost normally; however, the former complained of inability to extend his index finger independently. Tendon transfer of the EDM in cases of index extensor tendon rupture at the musclotendinous junction is a good method to restore ability to independently extend the index finger. However, consideration should be given to anatomical variation in the little finger. The EDC tendon is sometimes absent leaving the EDM tendon as the only extensor tendon to the little finger.

[Subcutaneous avulsion of the flexor digitorum profundus muscle]

The diagnostic and treatment of a closed avulsion of the flexor digitorum profundus muscle at its insertion of the little finger is presented. This happened as a 41-year-old woman wanted to hold a dog lead in her left hand and suddenly the dog started to run. In the literature the flexor digitorum profundus (FDP) and flexor pollicis longus (FPL) tendons were found to be more frequently ruptured than the flexor digitorum superficialis tendon. Closed ruptures of the FDP have been rarely reported. In the case described here there was no torn fragment at the distal end of the FDP tendon and the bone structure of the phalanx distales was intact. The operative treatment, postoperative care and clinical course are presented.

Closed traumatic rupture of the extensor digitorum communis and extensor indicis proprius at the musculo-tendinous junction

This report describes a closed rupture of the entire extensor digitorum communis and extensor indicis proprius.

Sequential traumatic bilateral extensor pollicis brevis rupture: a case report

We present an interesting and rare case of a sequential bilateral traumatic rupture of the extensor pollicis brevis tendons distal to the first extensor compartment in a patient with no underlying systemic condition or pathology around the wrist. Satisfactory thumb function was restored by bilateral transfer of the extensor indicis proprius.

Spontaneous rupture of extensor pollicis longus tendon in a kick boxer

A 23 year old male kick boxer presented with a 24 hour history of pain and being unable to extend the interphalangeal joint of the left thumb. There was no history of trauma or any other risk factor for spontaneous rupture of the extensor pollicis longus tendon. On the previous day, he had been doing reverse press ups on the dorsum of his hands with his wrists hyperflexed as part of his training for kick boxing. At operation the extensor pollicis longus tendon was found to be divided at the level of the dorsal tubercle of the radius and was not directly repairable. The treatment was an extensor indicis proprius transfer. We suggest that the cause of the tendon rupture was direct pressure on the dorsal tubercle of the radius sustained while performing reverse press ups.