Delayed rupture of flexor tendons caused by protrusion of a screw head of a volar plate for distal radius fracture: a case report

Flexor tendon rupture after volar plating of distal radius fracture: A systematic review of the literature

Flexor tendon rupture after volar plate fixation of distal radius fracture (DRF) is rare. There is no consensus as to how to prevent them. The aim of our study was to identify the pathological mechanisms, and to establish the clinical and epidemiological profile of patients suffering from this complication. We carried out a systematic review using the PubMed, Scopus and Cochrane databases. Studies were included if they described complete or partial flexor tendon rupture following volar plate fixation of DRF. Forty-six 46 were included, for a total of 145 patients were reported: 138 from the literature, and 7 from our personal experience. Etiology was usually mechanical, by impingement with either the plate or protruding screws. Plate impingement was due to positioning beyond the watershed line, consolidation with posterior tilt, plate thickness, or low palmar cortical angle. Mean patient age was 62.4 years (range, 23-89 years). Median postoperative interval was 8 months (range, 3-120 months). Flexor pollicis longus was the most frequently injured tendon. The plate should be positioned proximally to the watershed line if possible, to ensure good initial reduction. Hardware should be removed 4 months after surgery if the plate is causing impingement according to the Soong criteria or if signs of tenosynovitis appear.

Evaluation of flexor pollicis longus tendon attrition using color Doppler imaging after volar plate fixation for distal radius fracture

PURPOSE

Early diagnosis of attritional wear of the flexor pollicis longus (FPL) tendon is essential in preventing subsequent tendon rupture. There are currently few objective methods of assessing FPL attrition. We hypothesized that color Doppler imaging could visibly detect FPL tendon attrition, and analyzed our results.

METHODS

We evaluated ultrasound imaging of the contact between the FPL tendon and a volar locking plate using the real-time B-mode and Doppler waveforms of the FPL tendon using the continuous Doppler wave mode in 40 patients who underwent fixation of the distal volar locking plate for distal radius fracture. Twenty out of 40 patients underwent plate removal surgery after ultrasound evaluation. We also assessed the relationship between the Doppler waveforms and attrition of the FPL tendon in these 20 patients.

RESULTS

Based on the ultrasound findings (n = 40), we divided Doppler waveforms of the FPL tendon into three categories: type 1, spindle wave; type 2, spindle wave with spike; and type 3, spike wave. There were 23, 11, and six patients with type 1, 2, and 3 waveforms in the affected hand, respectively. There were 37 patients with type 1, three with type 2, and no patient with type 3 waveforms in the contralateral wrist. Of the 20 patients who underwent plate removal, five had type 3 waveforms. We found tendon fraying or partial tears in three of these five patients. In addition, all five patients showed changes to type 1 or 2 waveforms after plate removal. None of the other 15 patients with type 1 or 2 waveforms had any tendon injuries during plate removal.

CONCLUSIONS

Spike Doppler waveform can indicate abnormal findings, and may be a useful method to predict tendon attrition, because of its visibility.

DIAGNOSTIC STUDY

Level III evidence.

Do volar locking plates fit the volar cortex of the distal radius?

The purpose of this study was to measure the volar cortical angles of the commercially available volar locking plates and evaluate how well they fit the distal radius. We measured the volar cortical angles of the radial and intermediate columns of eight volar locking plates and compared them with the volar cortical angles of 90 cadaver distal radii. The mean radial and intermediate column volar cortical angles of the wider plates were significantly larger than those of narrower plates. The mean radial and intermediate column volar cortical angles were significantly larger in wider radii than narrower radii. The width of the distal radius did not correlate well with the mean volar cortical angles of the radial and intermediate columns.

LEVEL OF EVIDENCE

IV.

Titanium versus Stainless-Steel Plating in the Surgical Treatment of Distal Radius Fractures: A Randomized Trial

Our purpose was to compare postoperative complications and rate of plate removal in titanium and stainless-steel plating of distal radius fractures (DRF). Patients following DRF were randomly fixed with titanium or stainless-steel plates using the same plating system. Complications, second surgeries, and plate prominence were documented. A total of 41 patients were treated with stainless-steel and 22 with titanium plates. Average follow-up was 60 ± 5.6 months. There was no difference in demographics, fracture characteristics, or follow-up between the groups. Plate prominence was found in 50% of radiographs (mean distance: 1.4 mm). Four titanium plates and three stainless-steel plates were removed (11%). Mean time to plate removal was 18.4 ± 4.6 months. There was no difference in removal rates between the groups. Plate material and prominence, age, fracture comminution and smoking status were not associated with plate removal. Our results support using volar and dorsal plates regardless of the plate material.

Pearls and Pitfalls of the Volar Locking Plating for Distal Radius Fractures

Volar locking plate fixation has been widely accepted method for the treatment of unstable distal radius fractures. Although the results of volar locking plate fixation are encouraging, it may cause implant-related complications such as flexor or extensor tendon injuries. In depth understanding of anatomy of the distal radius is mandatory in order to obtain adequate fixation of the fracture fragments and to avoid these complications. This article will review the anatomic characteristics of the distal radius because selecting proper implant and positioning of the plate is closely related to the volar surface anatomy of the distal radius. The number and the length of distal locking screws are also important to provide adequate fixation strength to maintain fracture fixation. We will discuss the pros and cons of the variable-angle locking plate, which was introduced in an effort to provide surgeons with more freedom for fixation. Finally, we will discuss about correcting radial length and volar tilt by using eccentric drill holes and distal locking first technique.

Risk Assessment of Tendon Attrition Following Treatment of Distal Radius Fractures With Volar Locking Plates Using Audible Crepitus and Placement of the Plate: A Prospective Clinical Cohort Study

PURPOSE

To identify risk factors for tendon attrition after volar locking plate fixation of distal radius fractures.

METHODS

We prospectively assessed attrition of the flexor pollicis longus tendon at volar plate removal in 127 hands in 126 patients. We also evaluated preoperative lateral wrist radiographs, sonographs, and crepitus with flexor pollicis longus tendon motion and compared the demographic and radiographic characteristics of patients with and without tendon attrition. Multivariate logistic regression analysis was employed to identify the factors independently associated with tendon attrition.

RESULTS

We found 12 cases of tendon attrition (10%) and 1 that presented with tendon rupture in our cohort. Crepitus was recognized in 14 patients (11%): 6 cases (50%) were among the 12 hands in 12 patients with tendon attrition whereas 8 (7%) were detected in the remaining 114 hands in 113 patients. Logistic regression examination revealed that audible crepitus and volar placement of the plate in lateral radiographs were independent predictors of tendon attrition.

CONCLUSIONS

Crepitus and volar placement of hardware in lateral radiographs were independent risk factors for flexor tendon attrition after volar plating for distal radius fracture. These results may facilitate surgical decisions regarding early plate removal to prevent possible tendon rupture.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic II.

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.

Zone 2 flexor digitorum profundus and superficialis rupture treated with single-stage tendon reconstruction using an Active Hunter Rod Implant

To our knowledge, no report has been published of a flexor tendon rupture as a result of a closed phalangeal fracture.A 58-year-old woman with multiple medical comorbidities presented with a closed, apex volar fracture of her long finger proximal phalynx with clinically intact flexor digitorum profundus and superficialis tendons in zone 2 of the flexor tendon sheath. After 5 weeks of nonoperative treatment, the patient reported hearing a pop in her finger, and clinical findings suggested rupture of the flexor digitorum profundus and superficialis tendons. Intraoperatively, the nonreparable attritional rupture was underneath the A2 pulley. A bony prominence in the tendon sheath floor from the healed phalynx fracture made rerupture a concern with a tendon graft. A Hunter Active Tendon Implant (Wright Medical Technology, Inc, Arlington, Tennessee) was used to reconstruct the flexor digitorum profundus tendon to avoid a second procedure. The patient progressed well and had regained a functional arc of active finger range of motion by 2 months postoperatively.The Hunter Active Tendon Implant provided a suitable alternative to a 2-staged procedure, with the added benefit that a good tendon bed was developed in the event that a second procedure was needed.

The cadaveric anatomy of the distal radius: implications for the use of volar plates

INTRODUCTION

Fractures of the distal radius are common upper limb injuries, representing a substantial proportion of the trauma workload in orthopaedic units. With ever increasing advancements in implant technology, operative intervention is becoming more frequent. As growing numbers of surgeons are performing operative fixation of distal radial fractures, an accurate understanding of the relevant surgical anatomy is paramount. The flexor carpi radialis (FCR) tendon forms the cornerstone of the Henry approach to the volar cortex of the distal radius. A number of key neurovascular structures around the wrist are potentially at risk during this approach, especially when the FCR is mobilised and placed under retractors.

METHODS

In order to clarify the safe margins of the FCR approach, ten fresh frozen human cadaver limbs were dissected. The location of the radial artery, the median nerve, the palmar cutaneous branch of the median nerve and the superficial branch nerve were measured with respect to the FCR tendon. Measurements were taken on a centre-to-centre basis in the coronal plane at the watershed level. In addition, the distances between the tendons of brachioradialis, abductor pollicis longus and flexor pollicis longus, and the radial artery and median nerve were measured to create a complete picture of the anatomy of the FCR approach to the distal radius.

RESULTS

The structure most at risk was the palmar cutaneous branch of the median nerve. It was located on average 3.4mm from the FCR tendon. The radial artery and the main trunk of the median nerve were located 7.8mm and 8.9mm from the tendon. The superficial branch of the radial nerve was 24.4mm from the FCR tendon and 11.1mm from the brachioradialis tendon.

CONCLUSIONS

Operative intervention is not without complication. We believe a more accurate understanding of the surgical anatomy is key to the prevention of neurovascular damage arising from the surgical management of distal radial fractures.

Rupture of Flexor Pollicis Longus Tendon: A Complication of Volar Locking Plating of the Distal Radius

We report an unusual case of complete rupture of the flexor pollicis longus tendon following volar locking plating for a distal radius fracture. We believe that the prominence of a distal locking screw head predisposed to the rupture of the tendon. We highlight that correctly attaching the distal locking screws to the plate is essential for obtaining the correct biomechanics of the device and preventing flexor tendon rupture.