Download Extensor Indicis Proprius and Extensor Digitorum Communis

Bulletin of the NYU Hospital for Joint Diseases 2012;70(4):273-5
273
Extensor Indicis Proprius and Extensor Digitorum
Communis Rupture after Volar Locked Plating of
the Distal Radius
A Case Report
James P. Ward, M.D., LT Suezie Kim, M.D., M.C., U.S.N., and Michael E. Rettig, M.D.
Abstract
Distal radius fractures are among the most commonly encountered fractures in the extremities. Volar plating of distal
radius fracture has gained popularity in recent years with
the introduction of the locked plating system. Complications
of volar plating include extensor and flexor tendon rupture.
Here we present a case report of an extensor indicis proprius
and extensor digitorum communis to index finger tendon
rupture after open reduction and internal fixation of distal
radius fracture with locked plate.
D
istal radius fractures are among the most commonly encountered fractures in the extremities.
Court-Brown and colleagues estimated that
17.5% of all fractures presenting to the emergency room
are distal radius fractures.1 Volar plating of distal radius
fracture has gained popularity in recent years with the
introduction of the locked plating system. Since 1996,
there has been a five-fold increase in operatively treated
distal radius fractures in elderly patients. 2 Complications
of volar plating include extensor and flexor tendon rupture. Extensor indicis proprius and extensor digitorum
communis to index finger tendon rupture after open reduction and internal fixation of distal radius fracture with
locked plate is a rare complication, reported only twice
previously in the literature. We present a novel approach
to the treatment of this complication with transfer of the
James P. Ward, M.D., and Michael E. Rettig, M.D., are in the Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases,
New York, New York. LT Suezie Kim, M.D., M.C., U.S.N., is in
the Department of Orthopaedic Surgery, Naval Hospital Camp
Pendleton, Box 555191, Camp Pendleton, California.
Correspondence: James P. Ward, M.D., Dept. of Orthopaedic
Surgery, NYU Hospital for Joint Diseases, 301 East 17th Street,
Suite 1402, New York, New York 10003; [email protected].
extensor digiti minimi to the ruptured tendons, a method
not previously described.
Case Report
A 74-year-old, right hand dominant female sustained a
comminuted displaced left distal radius fracture four years
prior to her evaluation. She underwent open reduction and
internal fixation with a volar distal radius locking plate at
an outside institution. After fracture healing, she regained
pain-free function of her left hand and wrist.
Six months prior to evaluation, she began to have dorsal
radial wrist pain. Oral nonsteroidal antiinflammatory medications were recommended.
Five days prior to evaluation, she noted inability to actively extend her index finger. Physical examination of the
left wrist revealed a well healed volar radial incision. She
was unable to actively extend the index finger. There was
no pain with resisted long, ring, and little finger extension.
Radiographic evaluation of the left wrist revealed a healed
fracture of the distal radius in satisfactory position. One of
the volar locking screws was protruding through the dorsal
cortex (Fig. 1). Surgical exploration revealed rupture of the
extensor indicis proprius (EIP) and the extensor digitorum
communis (EDC) to her index finger. Attenuation of the
EDC to her long finger was also observed. This finding
made tenodesis of the ruptured distal stumps to this tendon
a less desirable option. A locking screw was found to be
protruding through the dorsal cortex into the floor of the
fourth extensor compartment (Fig. 2). The plate and screws
were removed through the previous volar incision. The
attenuated EDC tendon to the long finger was repaired.
An extensor digiti minimi (EDM) to EIP transfer was performed using a Pulvertaft weave method of tendon transfer
(Fig. 3).
On follow-up examination, the patient was noted to have
painless independent extension of the previously affected
Ward JP, Kim S, Rettig ME. Extensor indicis proprius and extensor digitorum communis rupture after volar locked plating of the distal radius: a case
report. Bull NYU Hosp Jt Dis. 2012;70(4):273-5.
274
Bulletin of the NYU Hospital for Joint Diseases 2012;70(4):273-5
Figures 1 Preoperative lateral radiograph showing a healed distal
radius fracture with hardware in place.
index finger and of the small finger, the digit from which
the tendon transfer was obtained.
Discussion
Extensor pollicis longus (EPL) and flexor pollicis longus
(FPL) rupture have been described as complications associated with locked volar plate fixation of distal radius
fractures. Arora and associates reported a 2% incidence
Figure 2 A prominent screw tip is observed after ulnar retraction
of the EDC tendons. This screw tip likely caused attenuation and
rupture of the EIP and EDC to the index finger. The EDC to the
long finger was also attenuated but not ruptured.
of FPL and EPL rupture in their retrospective review of
141 patients. When including tenosynovitis with tendon
rupture, this value increased to 17%.3 Al-Rashid and colleagues retrospectively reviewed 35 patients with distal
radius fractures and found an 8.6% incidence of extensor
tendon injuries, most commonly the EPL tendon. This is
compared with a 0.07% to 0.88% incidence of EPL ruptures
in conservatively treated patients.4 EDC and EIP tendon
ruptures are far less common but can occur after volar plate
fixation when the screws are prominent dorsally. There are
two prior reports of similar ruptures. Al-Rashid and colleagues reported extensor tendon injuries, which included
EIP and EDC injury, in JBJS British in 2006.5 Rampoldi
and Marisco reported on this injury in Acta Orthopaedica
Belgica in 2007.6
Jupiter and coworkers concurred that it is essential to
avoid penetration of the dorsal cortex with the distal screws
to avoid extensor tendon complications.7 The locked construct does not rely on the screw-bone purchase for fixation
but rather the screw-plate interface for its strength.8 Placing
the locked screw into the dorsal cortex is not required for stability of fracture fixation. Maschke and associates found in a
cadaveric and radiographic evaluation of distal radius plating
that AP and lateral fluoroscopic images are inadequate for
determining dorsal cortical penetration. They recommend
using pronation and supination views to more adequately
evaluate screw placement, especially near Lister’s tubercle.9
Persistent dorsal or volar wrist pain after radiographic
fracture union may indicate flexor or extensor tenosynovitis
or impending tendon rupture. Clinical examination may
demonstrate tenderness along the flexor or extensor tendons
with swelling or painful digit flexion or extension. Removal
of hardware should be strongly considered to avoid the
potential complication of tendon rupture requiring tendon
transfer.
Figure 3 Demonstrates the EDM to EIP transfer using the Pulvertaft weave method. The extensor retinaculum is reapproximated.
Bulletin of the NYU Hospital for Joint Diseases 2012;70(4):273-5
A CT scan also may be considered to assess screw length
and dorsal prominence in these patients. Because of the potential complication of proud screws in the dorsal cortex of
the distal radius, we recommend drilling to, but not through,
the dorsal cortex and subtracting 2 mm from the measured
depth to avoid penetration. If intraoperative determination
requires a screw of a certain length to capture a comminuted
dorsal fragment, then planned early removal of hardware
after fracture healing may be considered.
Disclosure Statement
None of the authors have a financial or proprietary interest
in the subject matter or materials discussed, including, but
not limited to, employment, consultancies, stock ownership,
honoraria, and paid expert testimony.
References
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A review. Injury. 2006;37:691-7.
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JBJS (Am). 2009;9:1868-73.
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Arora R, Lutz M, Hennerbichler A, et al. Complications following internal fixation of unstable distal radius fracture with
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Hove LM. Delayed rupture of the thumb extensor tendon.
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Al-Rashid M, Theivendran K, Craigen MA. Delayed ruptures
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