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Delayed rupture of the flexor pollicis longus tendon after inappropriate placement of the π plate on the volar surface of the distal radius
Delayed Rupture of the Flexor Pollicis Longus Tendon After Inappropriate Placement of the p Plate on the Volar Surface of the Distal Radius James A. Nunley, MD, Peter R. Rowan, MD, Durham, NC The p plate (Synthes Ltd, Paoli, PA) was designed to fit the unique contour of the dorsal aspect of the distal radius. Complications of p plate fixation of the dorsal distal radius have been previously reported to include both extensor tenosynovitis and delayed extensor tendon rupture. We report a case of rupture of the flexor pollicis longus tendon associated with inappropriate placement of the p plate on the volar surface of the distal radius. (J Hand Surg 1999;24A:1279 –1280. Copyright © 1999 by the American Society for Surgery of the Hand.) Key words: Distal radius, tendon, rupture.
The p plate (Synthes Ltd, Paoli, PA) is a recently developed low-profile plate for use in the fixation of distal radius fractures. The design allows contouring to fit the unique surface of the dorsum of the distal radius. There is an angled T plate well suited for volar fixation of distal radial fractures. There has been a recent report of delayed extensor tendon rupture after dorsal fixation of a distal radial fracture,1 but there are no reports of an injury to the flexor tendons after use of the plate on the volar surface. We report a delayed rupture of the flexor pollicis longus tendon after inappropriate volar fixation of a distal radial fracture using a p plate.
From the Division of Orthopaedic Surgery, Duke University Medical Center, Durham, NC. Received for publication March 3, 1999; accepted in revised form July 7, 1999. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: James A. Nunley, MD, Department of Orthopaedic Surgery, Duke University Medical Center, Box 2923, Durham, NC 27710. Copyright © 1999 by the American Society for Surgery of the Hand 0363-5023/99/24A06-0024$3.00/0
Case Report A 72-year-old right-handed woman sustained a comminuted, intra-articular distal radial fracture after a fall onto her outstretched right hand. She was initially treated with closed reduction and external fixation and was referred for rehabilitation. The follow-up visit 10 days later showed that the fracture reduction was lost, and open reduction and internal fixation was suggested. The patient sought another opinion; 3 weeks after injury she underwent open reduction and internal fixation at another institution, with a p plate placed on the volar surface. She was referred to our institution for postoperative follow-up assessment and rehabilitation. When the patient was first seen at our institution, approximately 8 weeks after the open reduction and internal fixation, she was doing well. She had received regular supervised hand therapy, including a volar wrist splint, which she removed for range of motion exercises for the fingers and wrist. She had excellent digital ranges of motion, including nearfull thumb flexion, and she had normal sensibility. There was 45° of both wrist flexion and extension. She was told to continue hand therapy and to wean the splint gradually. One month later, she had imThe Journal of Hand Surgery 1279
1280 Nunley and Rowan / Rupture FPL Tendon on p Plate
proved wrist flexion– extension and full digital range of motion. The fracture had united, the reduction was maintained, and there was no loosening or failure of the fixation device noted on radiographs. The patient was examined again 1 month later, approximately 18 weeks after open reduction and internal fixation. She reported recent onset of pain in the thumb and an inability to flex the interphalangeal joint. All other flexor tendons were intact and there was no sensory deficit. No anterior interosseous nerve palsy was evident. Union of the distal radius in a satisfactory position was again confirmed with radiographs and there was no change in the position of the plate. The diagnosis of rupture of the flexor pollicis longus tendon was made and treatment options were discussed. The patient initially did not desire surgery but she later experienced significant functional deficit and requested surgery. At the time of surgery, approximately 10 months after the open reduction and internal fixation, the rupture of the flexor pollicis longus tendon was noted at the level of the distal radius. The proximal end of the tendon was adherent to the profundus mass. There was marked synovitis around the p plate and the flexor tendons at the level of the wrist. The plate was removed and a flexor tenosynovectomy was performed. The flexor pollicis longus tendon, which was identified in the carpal tunnel, was adherent to its flexor sheath, requiring a distal tenolysis through a separate palmar incision. A transfer of the flexor digitorum superficialis tendon from the ring finger to the flexor pollicis longus tendon, just proximal to the A1 pulley, was performed. The postoperative course was uneventful. At the last follow-up examination, 4 months after surgery, the patient reported satisfactory function; the tendon transfer was functioning well, with 60° of active interphalangeal flexion. Histologic examination of specimens obtained during surgery revealed degenerative changes within the excised proximal stump of the flexor pollicis longus tendon and reactive papillary hyperplasia of the synovium.
radius. The existing angled T plate is an appropriate choice for volar buttressing of the distal radius. Tendon irritation has been reported after use of the p plate on the dorsum of the distal radius. In a report of a prospective multicenter trial of the p plate for dorsal fixation of distal radial fractures, 5 of 22 patients (23%) developed extensor tendinitis within the follow-up period.2 The investigators felt that because of the low-profile design and “in view of the fact that a substantial majority of patients did not develop this problem,” routine removal of the plate should not be necessary. It was recommended that the plate be placed subperiosteally under the fourth dorsal compartment and a retinacular flap fashioned to protect the tendons of the second dorsal compartment. Kambourglou and Axelrod1 recently reported 2 patients who had extensor tendon rupture and p plate breakage following fixation of the dorsal distal radius. In 1 case, rupture of the extensor indicis proprius tendon and the extensor digitorum communis tendon to the index finger was preceded by extensive extensor tenosynovitis affecting the fourth dorsal compartment. The plate had broken and 1 screw was prominent. It was felt that the tendons had abraded against the sharp edge of the screw. Another similar case was also reported.1 Our case is different from the previous reports because the p plate had been used for volar fixation of a distal radial fracture. We feel its indication should be for dorsal fixation of distal radial fractures, for which it was originally designed. An angled T plate is ideal for use on the volar aspect of the distal radius. The delayed rupture of the flexor pollicis longus tendon was associated with pain and was likely due to the marked tenosynovitis, which also involved the flexor digitorum profundus tendons. We did not find a mechanical cause for the rupture and there were no sharp edges on the plate or screws. The p plate and screws are made of titanium.
Discussion
References
One of the goals of the low-profile p plate design was to minimize extensor tendon irritation when used for fixation on the dorsal surface of the distal radius.2 The design was primarily intended to fit the unique contour of the dorsal distal radius. It was not designed for fixation of the volar surface of the distal
1. Kambouroglou GK, Axelrod TS. Complications of the AO/ ASIF titanium distal radius plate system (p plate) in internal fixation of the distal radius: a brief report. J Hand Surg 1998;23A:737–741. 2. Ring D, Jupiter JB, Brennwald J, Buchler U, Hastings H. Prospective multicenter trial of a plate for dorsal fixation of distal radius fractures. J Hand Surg 1997;22A:777–784.
The p plate (Synthes Ltd, Paoli, PA) is a recently developed low-profile plate for use in the fixation of distal radius fractures. The design allows contouring to fit the unique surface of the dorsum of the distal radius. There is an angled T plate well suited for volar fixation of distal radial fractures. There has been a recent report of delayed extensor tendon rupture after dorsal fixation of a distal radial fracture,1 but there are no reports of an injury to the flexor tendons after use of the plate on the volar surface. We report a delayed rupture of the flexor pollicis longus tendon after inappropriate volar fixation of a distal radial fracture using a p plate.
From the Division of Orthopaedic Surgery, Duke University Medical Center, Durham, NC. Received for publication March 3, 1999; accepted in revised form July 7, 1999. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: James A. Nunley, MD, Department of Orthopaedic Surgery, Duke University Medical Center, Box 2923, Durham, NC 27710. Copyright © 1999 by the American Society for Surgery of the Hand 0363-5023/99/24A06-0024$3.00/0
Case Report A 72-year-old right-handed woman sustained a comminuted, intra-articular distal radial fracture after a fall onto her outstretched right hand. She was initially treated with closed reduction and external fixation and was referred for rehabilitation. The follow-up visit 10 days later showed that the fracture reduction was lost, and open reduction and internal fixation was suggested. The patient sought another opinion; 3 weeks after injury she underwent open reduction and internal fixation at another institution, with a p plate placed on the volar surface. She was referred to our institution for postoperative follow-up assessment and rehabilitation. When the patient was first seen at our institution, approximately 8 weeks after the open reduction and internal fixation, she was doing well. She had received regular supervised hand therapy, including a volar wrist splint, which she removed for range of motion exercises for the fingers and wrist. She had excellent digital ranges of motion, including nearfull thumb flexion, and she had normal sensibility. There was 45° of both wrist flexion and extension. She was told to continue hand therapy and to wean the splint gradually. One month later, she had imThe Journal of Hand Surgery 1279
1280 Nunley and Rowan / Rupture FPL Tendon on p Plate
proved wrist flexion– extension and full digital range of motion. The fracture had united, the reduction was maintained, and there was no loosening or failure of the fixation device noted on radiographs. The patient was examined again 1 month later, approximately 18 weeks after open reduction and internal fixation. She reported recent onset of pain in the thumb and an inability to flex the interphalangeal joint. All other flexor tendons were intact and there was no sensory deficit. No anterior interosseous nerve palsy was evident. Union of the distal radius in a satisfactory position was again confirmed with radiographs and there was no change in the position of the plate. The diagnosis of rupture of the flexor pollicis longus tendon was made and treatment options were discussed. The patient initially did not desire surgery but she later experienced significant functional deficit and requested surgery. At the time of surgery, approximately 10 months after the open reduction and internal fixation, the rupture of the flexor pollicis longus tendon was noted at the level of the distal radius. The proximal end of the tendon was adherent to the profundus mass. There was marked synovitis around the p plate and the flexor tendons at the level of the wrist. The plate was removed and a flexor tenosynovectomy was performed. The flexor pollicis longus tendon, which was identified in the carpal tunnel, was adherent to its flexor sheath, requiring a distal tenolysis through a separate palmar incision. A transfer of the flexor digitorum superficialis tendon from the ring finger to the flexor pollicis longus tendon, just proximal to the A1 pulley, was performed. The postoperative course was uneventful. At the last follow-up examination, 4 months after surgery, the patient reported satisfactory function; the tendon transfer was functioning well, with 60° of active interphalangeal flexion. Histologic examination of specimens obtained during surgery revealed degenerative changes within the excised proximal stump of the flexor pollicis longus tendon and reactive papillary hyperplasia of the synovium.
radius. The existing angled T plate is an appropriate choice for volar buttressing of the distal radius. Tendon irritation has been reported after use of the p plate on the dorsum of the distal radius. In a report of a prospective multicenter trial of the p plate for dorsal fixation of distal radial fractures, 5 of 22 patients (23%) developed extensor tendinitis within the follow-up period.2 The investigators felt that because of the low-profile design and “in view of the fact that a substantial majority of patients did not develop this problem,” routine removal of the plate should not be necessary. It was recommended that the plate be placed subperiosteally under the fourth dorsal compartment and a retinacular flap fashioned to protect the tendons of the second dorsal compartment. Kambourglou and Axelrod1 recently reported 2 patients who had extensor tendon rupture and p plate breakage following fixation of the dorsal distal radius. In 1 case, rupture of the extensor indicis proprius tendon and the extensor digitorum communis tendon to the index finger was preceded by extensive extensor tenosynovitis affecting the fourth dorsal compartment. The plate had broken and 1 screw was prominent. It was felt that the tendons had abraded against the sharp edge of the screw. Another similar case was also reported.1 Our case is different from the previous reports because the p plate had been used for volar fixation of a distal radial fracture. We feel its indication should be for dorsal fixation of distal radial fractures, for which it was originally designed. An angled T plate is ideal for use on the volar aspect of the distal radius. The delayed rupture of the flexor pollicis longus tendon was associated with pain and was likely due to the marked tenosynovitis, which also involved the flexor digitorum profundus tendons. We did not find a mechanical cause for the rupture and there were no sharp edges on the plate or screws. The p plate and screws are made of titanium.
Discussion
References
One of the goals of the low-profile p plate design was to minimize extensor tendon irritation when used for fixation on the dorsal surface of the distal radius.2 The design was primarily intended to fit the unique contour of the dorsal distal radius. It was not designed for fixation of the volar surface of the distal
1. Kambouroglou GK, Axelrod TS. Complications of the AO/ ASIF titanium distal radius plate system (p plate) in internal fixation of the distal radius: a brief report. J Hand Surg 1998;23A:737–741. 2. Ring D, Jupiter JB, Brennwald J, Buchler U, Hastings H. Prospective multicenter trial of a plate for dorsal fixation of distal radius fractures. J Hand Surg 1997;22A:777–784.