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Extensor Carpi Ulnaris Problems at the Wrist–Classification, Surgical Treatment and Results
ARTICLE IN PRESS EXTENSOR CARPI ULNARIS PROBLEMS AT THE WRIST–CLASSIFICATION, SURGICAL TREATMENT AND RESULTS C. ALLENDE and D. LE VIET1 From the Institut de la Main, Clinique Jouvenet, Paris, France and Department of Orthopedic Surgery and Rehabilitation, Division of Upper Extremity, Sanatorio Allende. Cordoba, Argentina
Twenty-eight extensor carpi ulnaris lesions at the wrist were treated surgically between 1990 and 2002. Fifteen patients had an isolated extensor carpi ulnaris tenosynovitis or tendinopathy, five had extensor carpi ulnaris dislocation, four had an extensor carpi ulnaris subluxation and four had an extensor carpi ulnaris rupture. Seventeen patients first developed their symptoms while playing sports. At a mean follow-up of 23 months, twenty-two patients had returned to their previous activities. Seven of the 27 patients had lost more than 30% of their grip strength and five had restricted wrist motion. Two needed an extensor carpi ulnaris tenolysis. Pure isolated extensor carpi ulnaris lesions are rare and associated ulnar sided lesions (eleven triangular fibrocartilage complex tears and four lunotriquetral ligament tears), as well as possible predisposing factors (seven anomalous tendon slips, four ulnar styloid non-unions and one flat extensor carpi ulnaris tendon groove), were frequent. A classification of extensor carpi ulnaris tendon and subsheath lesions was developed to allow the surgeon to adequately evaluate the different components of these lesions. Journal of Hand Surgery (British and European Volume, 2005) 30B: 3: 265–272 Keywords: extensor carpi ulnaris, classification, tenosynovitis, tendonitis, subluxation, dislocation, rupture
or partial palmar tendon displacement. When ECU subluxation or dislocation is symptomatic, the patient usually complains of clicking during forearm rotation, and the subluxation can be visibly palpated and observed. Most ECU tenosynovitis can be successfully treated non-operatively with proper medical treatment, immobilization techniques, equipment modification, proper conditioning and alteration of athletic techniques or habits (Dickson and Luckey, 1948; Futami and Itoman, 1995; Lapidus and Fenton, 1952; Wood and Dobyns, 1986). However, cases requiring surgical treatment must be promptly recognized because they may result in chronic discomfort or permanent disability (Crimmins and Jones, 1995; Osterman et al., 1988). Surgical treatment is generally indicated for ECU tenosynovitis or tendinopathy that does not respond to rest, medical treatment and changes in hand usage, young active patients with symptomatic ECU tendon dislocation or subluxation and ECU tendon ruptures. This study was performed to analyse and assess the outcomes after surgery for different types of ECU lesions.
INTRODUCTION The sixth dorsal wrist compartment is complex. The extensor carpi ulnaris (ECU) tendon is enclosed in an independent osteofibrous tunnel which lies on the distal 1.5 to 2 cm of the ulna, to which it is fixed by its subsheath (Kaplan, 1965; Taleisnik, 1987). The transverse fibers of the medial wall of the sixth compartment extend proximally to become confluent with the epimysium of the ECU, and are reinforced by the ‘‘linea jugata’’ (Taleisnik et al., 1984) which prevents ECU tendon subluxation in a medial and palmar direction during full supination (Fig 1). The arrangement of the extensor retinaculum and the sixth extensor compartment allow unrestricted rotation of the radius and ulna at the distal radio-ulnar joint (Kaplan, 1965; Spinner and Kaplan, 1970). Extensor carpi ulnaris lesions produce pain at the dorso-ulnar aspect of the wrist, particularly during wrist supination, and wrist flexion and ulnar deviation. They have been described mainly in association with sports overuse syndromes (Wang et al., 2003). ECU tendon dislocation may be associated with instability of the distal radioulnar joint and is frequently seen in rheumatoid disease (Boyes, 1964; Spinner and Kaplan, 1970). When there is ECU subluxation or dislocation, the retinaculum usually remains intact, but the subsheath is torn, stripped or attenuated, allowing complete 1
PATIENTS AND METHODS We retrospectively reviewed 28 wrists (27 patients) with ECU tendon lesions which were treated surgically between 1990 and 2002. The mean age at surgery was 34 (range, 17–69) years. Patients with rheumatoid
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Fig 1 The transverse fibres of the medial wall of the sixth compartment extend proximally to become confluent with the epimysium of the ECU, and are reinforced by the ‘‘linea jugata’’, which provides a dynamic reinforcement against tendon subluxation in a medial and palmar direction during full supination.
arthritis, systemic connective tissue diseases, ECU insertion pathology, and ECU lesions secondary to direct external trauma were excluded from this study. All 27 patients had pain on the dorsoulnar aspect of the wrist that was aggravated by wrist supination, flexion and ulnar deviation and had not responded to medical treatment. There were 15 women and 12 men. The right wrist was affected in 19 patients and the left wrist in nine patients (one patient had bilateral wrist involvement). The dominant side was affected in 23 patients. Fifteen patients had isolated ECU tenosynovitis or tendinopathy, five an ECU dislocation, four an ECU subluxation and four an ECU rupture (two were professional tennis players and one was a professional judoka). One patient had scapholunate ligament repair 6 months before the procedure. Seventeen patients first developed the symptoms while practicing sports, ten at a professional level (seven tennis players, one golf player, one basketball player and one judoka). Seven patients were found at surgery to have a tendon slip between the extensor carpi ulnaris and the extensor apparatus of the little finger (Fig 2). Previous treatments consisted of rest and non-steroidal anti-inflammatory medication in all cases, physiotherapy in 19 cases, local steroid injections in 21 cases and splint immobilization in 11 cases. The time between the onset of symptoms and surgery averaged 11 (range, 4–58) months. The four patients who had an ECU tendon rupture underwent surgery 4 to 9 months after the onset of their symptoms. Anteroposterior, lateral and dynamic (in the extremes of pronation and supination) radiographs were performed in all cases. Arthrograms were done on five, CT scans in seven and MRIs in 16 wrists. Wrist arthroscopy was never performed.
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Fig 2 Image showing a tendon slip between the extensor carpi ulnaris and the extensor apparatus of the fifth finger.
A classification of the different possible lesions of the ECU tendon and osteofibrous sheath was developed based on the lesions found in this series of patients and on other previously published series (Fig 3) (Tables 1 and 2). The different types of ECU lesions found in this series of patients are shown in Table 3.
Surgical technique The ECU tendon was approached through a dorsolateral approach. The sensory branches of the ulnar nerve were protected and the dorsal retinaculum was opened over the sixth compartment. The surgical technique depended on the patient’s age and functional requirements, the degree of tendon inflammation, and the stability of the ECU tendon during pronation and supination: (1) If the ECU osteofibrous sheath was intact and normal (15 cases) a synovectomy was performed; (2) If the osteofibrous sheath was intact but enlarged due to periosteum stripping from its ulnar insertion (four cases), the periosteum was reattached using trans-osseous sutures (two or three drill holes were made at the lateral edge of the ulnar groove and sutures were passed through the periosteum and tied so as to obliterate the pouch) and a synovectomy was performed; (3) If the ECU osteofibrous sheath was ruptured (five cases), it was reconstructed (Fig 4) and a synovectomy was performed; and (4) the four cases with ECU tendon rupture were treated with a palmaris longus tendon graft (because chronic friction damaged the tendon over a long distance). The tendon graft averaged 8 cm in length and, although the ECU osteofibrous sheath was preserved in all four cases, it needed to be reconstructed because it was contracted. Seven osteofibrous sheaths were reconstructed using a square piece of extensor retinaculum (Eckhardt and Palmer, 1981) and two were reconstructed using a
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Fig 3 Extensor carpi ulnaris lesions at the wrist – classification system. (A) Extensor carpi ulnaris osteofibrous sheath lesions classification. (B) Extensor carpi ulnaris tendon lesions classification.
Table 1—Classification of extensor carpi ulnaris osteofibrous sheath lesions Groups
Osteofibrous sheath
A B
Normal False sheath formed by stripping of periosteum at the ulnar insertion of the osteofibrous sheath Rupture of the osteofibrous sheath at its ulnar wall Rupture of the osteofibrous sheath at its radial wall Preserved but contracted osteofibrous sheath
C1 C2 D
Table 3—Extensor carpi ulnaris tendon and osteofibrous sheath lesions at the wrist found in this series of patients and their results Type of ECU lesion 1 1 1 2 2 2 3 4
Type of osteofibrous sheath lesion A B C1 A B C1 A D
Table 2—Classification of extensor carpi ulnaris tendon lesions
Total
Groups
Tendon
E: excellent, G: good, F: fair.
0 1 2
Normal Tenosynovitis Tendinopathy (longitudinal internal lesions and tendon enlargement) Partial rupture Complete rupture Insertion tenosynovitis/tendinopathy Tendon avulsion
3 4 5a 5b
radially based sling of the extensor retinaculum (Burkhart et al., 1982). Chronic tendinopathy and internal longitudinal tendon lesions (seen on magnetic resonance imaging or peroperatively) were found in 19 wrists and were treated by longitudinal division of the ECU tendon, so as to find
Number of patients
Results
1 1 2 13 3 3 1 4
1F 1E 2G 7 E, 2 G, 4 F 2 E, 1G 2 E, 1G 1G 3 E, 1G
28
15 E, 8G, 5F
the intratendinous lesions, remove the necrotic tissue and decrease the size of the inflamed tendon. Any tendon slips between the ECU and the extensor apparatus of the little finger were excised (seven patients). Eleven patients had a concomitant triangular fibrocartilage complex tear or degeneration. In two cases there was associated ulna plus variance and, in these, an ulnar shortening was performed. In three cases, the triangular fibrocartilage complex lesion was reinserted onto the ulnar styloid and, in four cases, in which the lesion found intraoperatively was not significant, as well as in two wrists with central degeneration of the triangular fibrocartilage complex, debridement of the injured area of the triangular fibrocartilage complex was performed. Four patients had lunotriquetral ligament
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Table 4—Results evaluation system Result
Excellent Good Fair Fig 4 Extensor carpi ulnaris osteofibrous sheath reconstruction using a free flap of extensor retinaculum.
Poor
Return to previous activities
Wrist mobility
Grip
Pain
Normal Normal
Normal Limitation o151 Limitationo301
Normal 470%
None None
Limitation 4301
o50%
Limited Occasional Impossible
450% Constant
In ulnar/radial deviation and flexion/extension. Compared to the contralateral side.
pain and return to previous activities were evaluated at the final follow-up (Table 4).
RESULTS
Fig 5 Image showing a flat extensor carpi ulnaris groove and recurrent tendon subluxation.
tears diagnosed by magnetic resonance imaging, but none had dissociative instability or degenerative changes. In these four cases, the lunotriquetral joint was explored, but only one tear was significant and required repair. In one case, with a lunotriquetral ligament tear and positive ulnar variance, an ulnar shortening was undertaken. The distal ulnar styloid fragment was excised in the four cases of non-union. One patient, who had recurrent ECU tendon dislocation and a flat ECU tendon groove (Fig 5) had this groove deepened. The periosteum was then closed over the floor of the reconstructed groove and the osteofibrous sheath was reconstructed. Postoperative management varied according to the surgical procedure performed. When synovectomy with or without tendon debridement was performed, but there was no ECU sheath reconstruction, the patients wore a wrist splint for 2 weeks. When a osteofibrous sheath reconstruction was performed the patients wore a long arm cast with the elbow in 901 of flexion and neutral forearm rotation for 4 weeks and avoided strenuous activities for 3 months. Mobility, strength,
After the mean follow-up of 23 (range, 6–140) months the results were excellent in 15 wrists, good in eight wrists and fair in five wrists (Table 3). Twenty-two of the 27 patients returned to their previous activities but five had persistent restrictions. The ten professional sportsmen and sportswomen returned to their previous level of sport performance after an average of 8 (range, 3–21) months. Seven patients had a reduction in grip strength of 30% or more when compared to the contralateral side and five patients had reduced wrist motion. Four patients had occasional pain but there were no cases of recurrent ECU tendon dislocation. One patient, who had undergone previous surgery for scapholunate ligament reconstruction, developed a complex regional pain disorder that resolved with physiotherapy. Although she had no residual pain and had resumed her previous activities by her last followup, there was a 20o loss of supination and a 25% reduction in grip strength. Two patients needed further tendon tenolyses and synovectomies, 8 and 11 months after the initial intervention. Two years later, one of these still experiences pain after intense or prolonged exercise. Four of the five patients with a fair result had been treated for an isolated ECU tendinopathy and one of these had an anomalous tendon slip between the ECU and extensor digiti minimi tendons and had had previous scapholunate ligament surgery. The fifth patient with a fair result had ECU tenosynovitis and an associated ulnar styloid non-union. None of these five patients pursued sports regularly and their average age was 46 (range, 29–67) years. Surgical release of the sixth compartment at its radial aspect and a tight repair of the extensor retinaculum (Hajj and Wood, 1986) would have probably improved the results in these cases.
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DISCUSSION Extensor carpi ulnaris tendon injuries are becoming increasingly common in young, high demand athletes who often require specialized management. The results of this series of 28 wrists revealed 23 good or excellent results after surgical treatment. Our classification of ECU lesions at the wrist was developed to allow the surgeon to adequately identify the different components of these lesions and to establish guidelines for their treatment (Table 5). The main limitations of this study are that patients were evaluated retrospectively, that different types of ECU tendon lesions are included, and that there was no control group. Extensor carpi ulnaris tendon stenosing tenosynovitis was first described by Stein (1927). Wood and Dobyns (1986) suggested that the sixth compartment is, after the first compartment, the second most common site of tenosynovitis at the wrist. Hajj and Wood (1986) reported on three young patients with stenosing tenosynovitis of the ECU in which surgical release of the sixth compartment at its radial aspect and a ‘‘tight repair of the extensor retinaculum’’ were curative, with no subsequent subluxation. However this technique attaches the retinaculum to the ulna, which could limit forearm rotation (Kaplan, 1965; Spinner and Kaplan, 1970; Taleisnik et al., 1984). Nachinolcar and Khanolkar (1988) briefly reported on 72 cases of ECU stenosing tenovaginitis, of which only nine responded to medical treatment. The remaining 63 were treated surgically by excision of the thickened sheath of the ECU so that the tendon was completely freed. Uniformly good results were achieved, with complete relief of symptoms and no complications. Kip and Peimer (1994) reported on 22 cases in which release of ECU osteofibrous sheath was performed. Twelve of the 22 were available for follow-
Table 5—Recommended surgical treatment for each particular lesion Lesion type
Recommended surgical treatment
Extensor carpi ulnaris tendon 1 Active patients: synovectomy. Non-active patients: synovectomy +/ surgical release of the sixth compartment at its radial aspect and ‘‘tight repair of the extensor retinaculum’’. 2 Longitudinal tendon division +/ synovectomy. 3 Treatment of the predisposing factor +/ synovectomy. 4 Active patient: Tendon grafting (Palmaris Longus) +/ osteofibrous sheath reconstruction (retinacular free flap). Non-active patient: medical treatment. Osteofibrous sheath B Periosteum reattachment using transosseous sutures. C1 Osteofibrous sheath reconstruction (retinacular free flap) C2 Direct reattachment (when possible), if not osteofibrous sheath reconstruction (retinacular free flap). D Osteofibrous sheath reconstruction (retinacular free flap).
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up and subjective results in this group were excellent in six cases, good in three cases and fair in three cases. When performing a simple release of the sixth compartment for ECU stenosing tenosynovitis it is possible to destabilize the tendon and allow it to subluxate (Burkhart et al., 1982; Hajj and Wood, 1986), or destabilize the distal radioulnar joint (Spinner and Kaplan, 1970). This is especially the case when the procedure is performed in young active patients. Numerous variations and anomalies of the dorsal tendons and muscles of the hand have been described (Tan and Smith, 1999). An accessory tendon which arises from the lower part of the ECU tendon has been observed in 34% of cases (Nakashima, 1993) and its insertion into the extensor mechanism is considered a common variant (Hollister, 1987). The possible clinical significance of an anomalous ECU tendon slip was first described by Barfred and Adamsen (1986). They considered that the existence of an anomalous tendon slip between the ECU and the extensor digiti minimi probably makes medical treatment less effective, because the ECU tendon has an excursion of 3 cm, while the excursion of the extensor digiti minimi tendon is 5 cm. In our series of patients an anomalous tendon slip between the ECU and extensor digiti minimi was present in seven of the 27 patients, all of whom regularly played sports (two professionally). The anomalous tendon slip had two patterns of distribution; in three cases it began proximal to the ECU osteofibrous sheath, passed under it and perforated the wall between the sixth and fifth compartments to join the extensor digiti minimi tendon. In the other four cases the anomalous tendon slip began under the ECU osteofibrous sheath, perforated the wall between the sixth and fifth compartments and joined with the ulnar border of the extensor digiti minimi tendon. We feel that a tendon slip running to the extensor digiti minimi must be carefully looked for during surgery for ECU tenosynovitis and, if present, excised so as to avoid recurrences. Isolated recurrent traumatic ECU tendon dislocation at the wrist was first described by Schlesinger (1907). Burkhart et al. (1982) and Rayan (1983) suggested that closed treatment in a long arm cast was appropriate for the treatment of an acute ECU tendon subluxation at the wrist, but Rowland (1986) suggested that surgical repair of the osteofibrous sheath is preferable. Beckenbaugh (1987) reported on two cases which ‘‘illustrated the absence of necessity for operative intervention’’ after ECU osteofibrous sheath rupture. Inoue and Tamura (2001) suggested that type B ECU osteofibrous sheath lesions may have the potential to heal if treated early and categorized osteofibrous sheaths ruptures into those in which the rupture occurred at the radial insertion of the osteofibrous sheath and could be repaired directly (Type C2 lesions), and those in which it occurred at its ulnar insertion and needed reconstruction (Type C1 lesions). In our experience, direct osteofibrous sheath repair is not possible with any type C lesions because of
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tendon thickening and osteofibrous sheath retraction. We recommend surgical treatment of all acute dislocations in young active patients, as it is difficult to distinguish between the different types of osteofibrous sheath lesions, because surgical treatment provides good results and because nonoperative management of acute lesions is not always effective. Surgical repair also restores the stabilizing role of the ECU at the distal radioulnar joint (Eckhardt and Palmer, 1981; Loty et al., 1986; Rowland, 1986). Conservative treatment might be indicated in non-active and elderly patients. In chronic ECU dislocations and subluxations, treatment will vary according to patient’s symptoms and demands. When the subluxation or dislocation produces disability or pain, surgical treatment is a reliable option. Different techniques of ECU osteofibrous sheath reconstruction have been described, Markees (1937) suggested using a flap of periosteum elevated from the distal ulna, while Obrant (1946) suggested excision of the redundant portion of the extensor retinaculum over the sixth compartment and tightly imbricating the remainder of the retinaculum over the dorsoulnar aspect of the wrist. Burkhart et al. (1982) reported three cases of ECU dislocation. A direct repair of the ulnar septum of the sixth compartment was possible in two cases and was supplemented by a radially based sling of the extensor retinaculum which went around the tendon and prevented its translation. In the other case, a portion of the flexor carpi ulnaris tendon was used to reconstruct the ECU osteofibrous sheath. Eckhardt and Palmer, (1981) suggested the use of a free graft of the extensor retinaculum for ECU subsheath reconstruction and we favour its use because its deep surface allows optimal tendon gliding and reduces adhesion formation. Flat and convex ECU tendon grooves have a higher risk of subluxation or dislocation (Fig 5). One patient with recurrent dislocation and a flat tendon groove had a bony procedure performed (the ECU groove was deepened). Although the time to complete recovery was long (1 year), a good final result was obtained. We have found no other reports of ECU groove deepening and do not think that it can be recommended on the basis of our single case. ECU tendon partial rupture is associated with ulnar styloid nonunion (Crimmins and Jones, 1995; Kiyono et al., 2002), exposed bone (Crimmins and Jones, 1995), impingement of the tendon against the ulnar ridge (Angermann, 1993), ECU tenovaginitis (Kip and Peimer, 1994) and an attenuated ECU subsheath, tendon subluxation and a prominent ulnar ridge (Chun and Palmer, 1987). An ulnar styloid nonunion can be treated by open reduction and internal fixation or by excision of the fragment and reattachment of the triangular fibrocartilage complex to the distal ulna if the distal radioulnar joint is unstable. If the distal radio-ulnar joint is stable then excision of the
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distal fragment is all that is required (Hauck et al., 1996). When there is a complete or partial rupture of the ECU tendon secondary to a protruding bony ridge, the floor of the compartment must be adequately
Fig 6 Magnetic resonance images showing: (A) extensor carpi ulnaris tenosynovitis. (B) An internal longitudinal extensor carpi ulnaris tendon lesion. (C) Extensor carpi ulnaris dislocation.
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reconstructed, so as to allow tendon gliding without abrasion. Four cases of non-rheumatoid closed complete ruptures of the ECU tendon have been described. Moran and Ruby (1992) reported on two cases, one with an associated triangular fibrocartilage complex tear and a distal ulnar osteophyte, and Wang et al. (2003) described a single case in an ice hockey player. We have treated four cases, three of which were in professional athletes of which one has been previously published (Xarchas and Le Viet, 2002). In all these seven reported cases, a palmaris longus free tendon graft was used and the ECU osteofibrous sheath required reconstruction in five cases, including the four cases reported in this study. Reconstruction of the ECU tendon using palmaris longus tendon graft is not justified in elderly or inactive patients. Magnetic resonance imaging now has a large role in the workup of this sometimes confusing problem (Zlatkin et al., 1989) (Fig 6). Its advantages over conventional arthrography for the assessment of ECU problems are that it is non-invasive, allows multiplanar projections, and clearly demonstrates inflammation associated with tendonitis as well as intratendinous lesions. ECU tendon dislocation or subluxation can be detected in dynamic forearm rotation studies, and the type of ECU groove in the distal ulna can be clearly assessed. Magnetic resonance imaging studies have shown that internal longitudinal tendon lesions occur more frequently than previously recognized (19 cases in this study). Extensor carpi ulnaris tendon lesions generally respond to medical treatment and changes in hand usage. However when such measures fail our classification of extensor carpi ulnaris lesions at the wrist allows the surgeon to adequately evaluate its different components and provides guidelines for treatment (Table 5). Isolated extensor carpi ulnaris lesions are rare, and associated triangular fibrocartilage complex tears and lunotriquetral ligament tears are frequently found, as are other pathologies such as an anomalous tendon slip, an ulnar styloid non-union or a flat ECU tendon groove. These problems must be addressed simultaneously.
References Angermann P (1993). Post-traumatic partial rupture of the extensor carpi ulnaris tendon. Scandinavian Journal of Plastic and Reconstructive Hand Surgery, 27: 321–322. Barfred T, Adamsen S (1986). Duplication of the extensor carpi ulnaris tendon. Journal of Hand Surgery, 11A: 423–425. Beckenbaugh RD (1987). Acute traumatic subluxation. Letters to Editor. Journal of Hand Surgery, 12A: 810–811. Boyes JH (1964). Special situations affecting tendons. In: Bunnell’s surgery of the hand, Ed. 4. Philadelphia, J.B. Lippincott Company, 470–471. Burkhart SS, Wood MB, Linscheid RL (1982). Posttraumatic recurrent subluxation of the extensor carpi ulnaris tendon. Journal of Hand Surgery, 7A: 1–3.
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Chun S, Palmer AK (1987). Chronic ulnar wrist pain secondary to partial rupture of the extensor carpi ulnaris tendon. Journal of Hand Surgery, 12A: 1032–1035. Crimmins CA, Jones NF (1995). Stenosing tenosynovitis of the extensor carpi ulnaris. Annals of Plastic Surgery, 35: 105–107. Dickson DD, Luckey AC (1948). Tenosynovitis of the extensor carpi ulnaris tendon sheath. Journal of Bone and Joint Surgery, 30-A: 903–907. Eckhardt WA, Palmer AK (1981). Recurrent dislocation of extensor carpi ulnaris tendon. Journal of Hand Surgery, 6A: 629–631. Futami T, Itoman M (1995). Extensor carpi ulnaris syndrome. Findings in 43 patients. Acta Orthopaedica Scandinavica, 66: 538–539. Hajj AA, Wood MB (1986). Stenosing tenosynovitis of the extensor carpi ulnaris. Journal of Hand Surgery, 11A: 519–520. Hauck RM, Skahen III. J, Palmer AK (1996). Classification and treatment of ulnar styloid nonunion. Journal of Hand Surgery, 21A: 418–422. Hollister A (1987). Duplication of extensor carpi ulnaris. Letter to editor. Journal of Hand Surgery, 12A: 809–810. Inoue G, Tamura Y (2001). Surgical treatment for recurrent dislocation of the extensor carpi ulnaris tendon. Journal of Hand Surgery, 26B: 556–559. Kaplan EB. In: Functional and surgical anatomy of the hand, 2nd Edn, Philadelphia and Montreal, Lippincott Company, 1965: 191–194. Kip PC, Peimer CA (1994). Release of the sixth dorsal compartment. Journal of Hand Surgery, 19A: 599–601. Kiyono Y, Nakatsuchi Y, Saitoh S (2002). Ulnar–styloid nonunion and partial rupture of extensor carpi ulnaris tendon: two case reports and review of the literature. Journal of Orthopaedic Trauma, 16: 674–677. Lapidus PW, Fenton R (1952). Stenosing tenovaginitis at the wrist and fingers. AMA Archives of Surgery, 64: 475–487. Loty B, Meunier B, Mazas F (1986). Luxation traumatique isolee du tendon cubital posterieur. Revue de Chirurgie Orthopedique et Reparatrice de l’Appareil Moteur, 72: 219–222. Markees J (1937). Luxation der sehne des musc. Extensor Carpi ulnaris. Schweizerische Medizinische Wochenschrift, 67: 637. Moran S, Ruby LK (1992). Nonrheumatoid closed rupture of extensor carpi ulnaris tendon. Journal of Hand Surgery, 17A: 281–283. Nachinolcar UG, Khanolkar KB (1988). Stenosing tenovaginitis of extensor carpi ulnaris: brief report. Journal of Bone and Joint Surgery, 70B: 842. Nakashima T (1993). An accessory extensor digiti minimi arising from extensor carpi ulnaris. Journal of Anatomy, 182: 109–112. Obrant O (1946). Fall av senluxation i handleden. Nordisk Medicin, 29: 656. Osterman AL, Moskow L, Low DW (1988). Soft-tissue injuries of the hand and wrist in racquet sports. Clinics in Sports Medicine, 7: 329–348. Rayan GM (1983). Recurrent dislocation of the extensor carpi ulnaris in athletes. American Journal of Sports Medicine, 11: 183–184. Rowland SA (1986). Acute traumatic subluxation of the extensor carpi ulnaris tendon at the wrist. Journal of Hand Surgery, 11A: 809–811. Schlesinger J (1907). Vorstellung zweier falle von sehnenluxation. Deutsche Medizinische Wochenschrift, 23: 236. Spinner M, Kaplan EB (1970). Extensor carpi ulnaris. Its relationship to the stability of the distal radio–ulnar joint. Clinical Orthopaedics, 68: 124–129. Stein HC (1927). Stenosing tendovaginitis. American Journal of Surgery, 3: 77–78. Taleisnik J (1987). Pain on the ulnar side of the wrist. Hand Clinics, 3: 51–68.
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Taleisnik J, Gelberman RH, Miller BW, Szabo RM (1984). The extensor retinaculum of the wrist. Journal of Hand Surgery, 9A: 495–501. Tan ST, Smith PJ (1999). Anomalous extensor muscles of the hand: a review. Journal of Hand Surgery, 24A: 449–455. Wang C, Gill TJ, Zarins B, Herndom JH (2003). Extensor carpi ulnaris tendon rupture in an ice hockey player: a case report. American Journal of Sports Medicine, 31: 459–461. Wood MB, Dobyns JH (1986). Sports-related extraarticular wrist syndromes. Clinical Orthopaedics, 202: 93–102. Xarchas KC, Le Viet D (2002). Non rheumatoid closed rupture of extensor carpi ulnaris tendon. Report of a case in a professional athlete. Acta Orthopaedica Belga, 68: 399–402.
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Zlatkin MB, Chao PC, Osterman AL, Schnall MD, Dalinka MK (1989). Chronic wrist pain: evaluation with high-resolution MR imaging. Radiology, 173: 723–729. Received: 8 July 2003 Accepted after revision: 6 December 2004 Dr Christian Allende M.D., Sanatorio Allende, Hipolito Yrigoyen 384, Cordoba 5000, Argentina. Tel.: +54 351 4269240; fax: +54 351 4269209 E-mail: [email protected]
r 2005 The British Society for Surgery of the Hand. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhsb.2004.12.007 available online at http://www.sciencedirect.com
Twenty-eight extensor carpi ulnaris lesions at the wrist were treated surgically between 1990 and 2002. Fifteen patients had an isolated extensor carpi ulnaris tenosynovitis or tendinopathy, five had extensor carpi ulnaris dislocation, four had an extensor carpi ulnaris subluxation and four had an extensor carpi ulnaris rupture. Seventeen patients first developed their symptoms while playing sports. At a mean follow-up of 23 months, twenty-two patients had returned to their previous activities. Seven of the 27 patients had lost more than 30% of their grip strength and five had restricted wrist motion. Two needed an extensor carpi ulnaris tenolysis. Pure isolated extensor carpi ulnaris lesions are rare and associated ulnar sided lesions (eleven triangular fibrocartilage complex tears and four lunotriquetral ligament tears), as well as possible predisposing factors (seven anomalous tendon slips, four ulnar styloid non-unions and one flat extensor carpi ulnaris tendon groove), were frequent. A classification of extensor carpi ulnaris tendon and subsheath lesions was developed to allow the surgeon to adequately evaluate the different components of these lesions. Journal of Hand Surgery (British and European Volume, 2005) 30B: 3: 265–272 Keywords: extensor carpi ulnaris, classification, tenosynovitis, tendonitis, subluxation, dislocation, rupture
or partial palmar tendon displacement. When ECU subluxation or dislocation is symptomatic, the patient usually complains of clicking during forearm rotation, and the subluxation can be visibly palpated and observed. Most ECU tenosynovitis can be successfully treated non-operatively with proper medical treatment, immobilization techniques, equipment modification, proper conditioning and alteration of athletic techniques or habits (Dickson and Luckey, 1948; Futami and Itoman, 1995; Lapidus and Fenton, 1952; Wood and Dobyns, 1986). However, cases requiring surgical treatment must be promptly recognized because they may result in chronic discomfort or permanent disability (Crimmins and Jones, 1995; Osterman et al., 1988). Surgical treatment is generally indicated for ECU tenosynovitis or tendinopathy that does not respond to rest, medical treatment and changes in hand usage, young active patients with symptomatic ECU tendon dislocation or subluxation and ECU tendon ruptures. This study was performed to analyse and assess the outcomes after surgery for different types of ECU lesions.
INTRODUCTION The sixth dorsal wrist compartment is complex. The extensor carpi ulnaris (ECU) tendon is enclosed in an independent osteofibrous tunnel which lies on the distal 1.5 to 2 cm of the ulna, to which it is fixed by its subsheath (Kaplan, 1965; Taleisnik, 1987). The transverse fibers of the medial wall of the sixth compartment extend proximally to become confluent with the epimysium of the ECU, and are reinforced by the ‘‘linea jugata’’ (Taleisnik et al., 1984) which prevents ECU tendon subluxation in a medial and palmar direction during full supination (Fig 1). The arrangement of the extensor retinaculum and the sixth extensor compartment allow unrestricted rotation of the radius and ulna at the distal radio-ulnar joint (Kaplan, 1965; Spinner and Kaplan, 1970). Extensor carpi ulnaris lesions produce pain at the dorso-ulnar aspect of the wrist, particularly during wrist supination, and wrist flexion and ulnar deviation. They have been described mainly in association with sports overuse syndromes (Wang et al., 2003). ECU tendon dislocation may be associated with instability of the distal radioulnar joint and is frequently seen in rheumatoid disease (Boyes, 1964; Spinner and Kaplan, 1970). When there is ECU subluxation or dislocation, the retinaculum usually remains intact, but the subsheath is torn, stripped or attenuated, allowing complete 1
PATIENTS AND METHODS We retrospectively reviewed 28 wrists (27 patients) with ECU tendon lesions which were treated surgically between 1990 and 2002. The mean age at surgery was 34 (range, 17–69) years. Patients with rheumatoid
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Fig 1 The transverse fibres of the medial wall of the sixth compartment extend proximally to become confluent with the epimysium of the ECU, and are reinforced by the ‘‘linea jugata’’, which provides a dynamic reinforcement against tendon subluxation in a medial and palmar direction during full supination.
arthritis, systemic connective tissue diseases, ECU insertion pathology, and ECU lesions secondary to direct external trauma were excluded from this study. All 27 patients had pain on the dorsoulnar aspect of the wrist that was aggravated by wrist supination, flexion and ulnar deviation and had not responded to medical treatment. There were 15 women and 12 men. The right wrist was affected in 19 patients and the left wrist in nine patients (one patient had bilateral wrist involvement). The dominant side was affected in 23 patients. Fifteen patients had isolated ECU tenosynovitis or tendinopathy, five an ECU dislocation, four an ECU subluxation and four an ECU rupture (two were professional tennis players and one was a professional judoka). One patient had scapholunate ligament repair 6 months before the procedure. Seventeen patients first developed the symptoms while practicing sports, ten at a professional level (seven tennis players, one golf player, one basketball player and one judoka). Seven patients were found at surgery to have a tendon slip between the extensor carpi ulnaris and the extensor apparatus of the little finger (Fig 2). Previous treatments consisted of rest and non-steroidal anti-inflammatory medication in all cases, physiotherapy in 19 cases, local steroid injections in 21 cases and splint immobilization in 11 cases. The time between the onset of symptoms and surgery averaged 11 (range, 4–58) months. The four patients who had an ECU tendon rupture underwent surgery 4 to 9 months after the onset of their symptoms. Anteroposterior, lateral and dynamic (in the extremes of pronation and supination) radiographs were performed in all cases. Arthrograms were done on five, CT scans in seven and MRIs in 16 wrists. Wrist arthroscopy was never performed.
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Fig 2 Image showing a tendon slip between the extensor carpi ulnaris and the extensor apparatus of the fifth finger.
A classification of the different possible lesions of the ECU tendon and osteofibrous sheath was developed based on the lesions found in this series of patients and on other previously published series (Fig 3) (Tables 1 and 2). The different types of ECU lesions found in this series of patients are shown in Table 3.
Surgical technique The ECU tendon was approached through a dorsolateral approach. The sensory branches of the ulnar nerve were protected and the dorsal retinaculum was opened over the sixth compartment. The surgical technique depended on the patient’s age and functional requirements, the degree of tendon inflammation, and the stability of the ECU tendon during pronation and supination: (1) If the ECU osteofibrous sheath was intact and normal (15 cases) a synovectomy was performed; (2) If the osteofibrous sheath was intact but enlarged due to periosteum stripping from its ulnar insertion (four cases), the periosteum was reattached using trans-osseous sutures (two or three drill holes were made at the lateral edge of the ulnar groove and sutures were passed through the periosteum and tied so as to obliterate the pouch) and a synovectomy was performed; (3) If the ECU osteofibrous sheath was ruptured (five cases), it was reconstructed (Fig 4) and a synovectomy was performed; and (4) the four cases with ECU tendon rupture were treated with a palmaris longus tendon graft (because chronic friction damaged the tendon over a long distance). The tendon graft averaged 8 cm in length and, although the ECU osteofibrous sheath was preserved in all four cases, it needed to be reconstructed because it was contracted. Seven osteofibrous sheaths were reconstructed using a square piece of extensor retinaculum (Eckhardt and Palmer, 1981) and two were reconstructed using a
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Fig 3 Extensor carpi ulnaris lesions at the wrist – classification system. (A) Extensor carpi ulnaris osteofibrous sheath lesions classification. (B) Extensor carpi ulnaris tendon lesions classification.
Table 1—Classification of extensor carpi ulnaris osteofibrous sheath lesions Groups
Osteofibrous sheath
A B
Normal False sheath formed by stripping of periosteum at the ulnar insertion of the osteofibrous sheath Rupture of the osteofibrous sheath at its ulnar wall Rupture of the osteofibrous sheath at its radial wall Preserved but contracted osteofibrous sheath
C1 C2 D
Table 3—Extensor carpi ulnaris tendon and osteofibrous sheath lesions at the wrist found in this series of patients and their results Type of ECU lesion 1 1 1 2 2 2 3 4
Type of osteofibrous sheath lesion A B C1 A B C1 A D
Table 2—Classification of extensor carpi ulnaris tendon lesions
Total
Groups
Tendon
E: excellent, G: good, F: fair.
0 1 2
Normal Tenosynovitis Tendinopathy (longitudinal internal lesions and tendon enlargement) Partial rupture Complete rupture Insertion tenosynovitis/tendinopathy Tendon avulsion
3 4 5a 5b
radially based sling of the extensor retinaculum (Burkhart et al., 1982). Chronic tendinopathy and internal longitudinal tendon lesions (seen on magnetic resonance imaging or peroperatively) were found in 19 wrists and were treated by longitudinal division of the ECU tendon, so as to find
Number of patients
Results
1 1 2 13 3 3 1 4
1F 1E 2G 7 E, 2 G, 4 F 2 E, 1G 2 E, 1G 1G 3 E, 1G
28
15 E, 8G, 5F
the intratendinous lesions, remove the necrotic tissue and decrease the size of the inflamed tendon. Any tendon slips between the ECU and the extensor apparatus of the little finger were excised (seven patients). Eleven patients had a concomitant triangular fibrocartilage complex tear or degeneration. In two cases there was associated ulna plus variance and, in these, an ulnar shortening was performed. In three cases, the triangular fibrocartilage complex lesion was reinserted onto the ulnar styloid and, in four cases, in which the lesion found intraoperatively was not significant, as well as in two wrists with central degeneration of the triangular fibrocartilage complex, debridement of the injured area of the triangular fibrocartilage complex was performed. Four patients had lunotriquetral ligament
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Table 4—Results evaluation system Result
Excellent Good Fair Fig 4 Extensor carpi ulnaris osteofibrous sheath reconstruction using a free flap of extensor retinaculum.
Poor
Return to previous activities
Wrist mobility
Grip
Pain
Normal Normal
Normal Limitation o151 Limitationo301
Normal 470%
None None
Limitation 4301
o50%
Limited Occasional Impossible
450% Constant
In ulnar/radial deviation and flexion/extension. Compared to the contralateral side.
pain and return to previous activities were evaluated at the final follow-up (Table 4).
RESULTS
Fig 5 Image showing a flat extensor carpi ulnaris groove and recurrent tendon subluxation.
tears diagnosed by magnetic resonance imaging, but none had dissociative instability or degenerative changes. In these four cases, the lunotriquetral joint was explored, but only one tear was significant and required repair. In one case, with a lunotriquetral ligament tear and positive ulnar variance, an ulnar shortening was undertaken. The distal ulnar styloid fragment was excised in the four cases of non-union. One patient, who had recurrent ECU tendon dislocation and a flat ECU tendon groove (Fig 5) had this groove deepened. The periosteum was then closed over the floor of the reconstructed groove and the osteofibrous sheath was reconstructed. Postoperative management varied according to the surgical procedure performed. When synovectomy with or without tendon debridement was performed, but there was no ECU sheath reconstruction, the patients wore a wrist splint for 2 weeks. When a osteofibrous sheath reconstruction was performed the patients wore a long arm cast with the elbow in 901 of flexion and neutral forearm rotation for 4 weeks and avoided strenuous activities for 3 months. Mobility, strength,
After the mean follow-up of 23 (range, 6–140) months the results were excellent in 15 wrists, good in eight wrists and fair in five wrists (Table 3). Twenty-two of the 27 patients returned to their previous activities but five had persistent restrictions. The ten professional sportsmen and sportswomen returned to their previous level of sport performance after an average of 8 (range, 3–21) months. Seven patients had a reduction in grip strength of 30% or more when compared to the contralateral side and five patients had reduced wrist motion. Four patients had occasional pain but there were no cases of recurrent ECU tendon dislocation. One patient, who had undergone previous surgery for scapholunate ligament reconstruction, developed a complex regional pain disorder that resolved with physiotherapy. Although she had no residual pain and had resumed her previous activities by her last followup, there was a 20o loss of supination and a 25% reduction in grip strength. Two patients needed further tendon tenolyses and synovectomies, 8 and 11 months after the initial intervention. Two years later, one of these still experiences pain after intense or prolonged exercise. Four of the five patients with a fair result had been treated for an isolated ECU tendinopathy and one of these had an anomalous tendon slip between the ECU and extensor digiti minimi tendons and had had previous scapholunate ligament surgery. The fifth patient with a fair result had ECU tenosynovitis and an associated ulnar styloid non-union. None of these five patients pursued sports regularly and their average age was 46 (range, 29–67) years. Surgical release of the sixth compartment at its radial aspect and a tight repair of the extensor retinaculum (Hajj and Wood, 1986) would have probably improved the results in these cases.
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DISCUSSION Extensor carpi ulnaris tendon injuries are becoming increasingly common in young, high demand athletes who often require specialized management. The results of this series of 28 wrists revealed 23 good or excellent results after surgical treatment. Our classification of ECU lesions at the wrist was developed to allow the surgeon to adequately identify the different components of these lesions and to establish guidelines for their treatment (Table 5). The main limitations of this study are that patients were evaluated retrospectively, that different types of ECU tendon lesions are included, and that there was no control group. Extensor carpi ulnaris tendon stenosing tenosynovitis was first described by Stein (1927). Wood and Dobyns (1986) suggested that the sixth compartment is, after the first compartment, the second most common site of tenosynovitis at the wrist. Hajj and Wood (1986) reported on three young patients with stenosing tenosynovitis of the ECU in which surgical release of the sixth compartment at its radial aspect and a ‘‘tight repair of the extensor retinaculum’’ were curative, with no subsequent subluxation. However this technique attaches the retinaculum to the ulna, which could limit forearm rotation (Kaplan, 1965; Spinner and Kaplan, 1970; Taleisnik et al., 1984). Nachinolcar and Khanolkar (1988) briefly reported on 72 cases of ECU stenosing tenovaginitis, of which only nine responded to medical treatment. The remaining 63 were treated surgically by excision of the thickened sheath of the ECU so that the tendon was completely freed. Uniformly good results were achieved, with complete relief of symptoms and no complications. Kip and Peimer (1994) reported on 22 cases in which release of ECU osteofibrous sheath was performed. Twelve of the 22 were available for follow-
Table 5—Recommended surgical treatment for each particular lesion Lesion type
Recommended surgical treatment
Extensor carpi ulnaris tendon 1 Active patients: synovectomy. Non-active patients: synovectomy +/ surgical release of the sixth compartment at its radial aspect and ‘‘tight repair of the extensor retinaculum’’. 2 Longitudinal tendon division +/ synovectomy. 3 Treatment of the predisposing factor +/ synovectomy. 4 Active patient: Tendon grafting (Palmaris Longus) +/ osteofibrous sheath reconstruction (retinacular free flap). Non-active patient: medical treatment. Osteofibrous sheath B Periosteum reattachment using transosseous sutures. C1 Osteofibrous sheath reconstruction (retinacular free flap) C2 Direct reattachment (when possible), if not osteofibrous sheath reconstruction (retinacular free flap). D Osteofibrous sheath reconstruction (retinacular free flap).
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up and subjective results in this group were excellent in six cases, good in three cases and fair in three cases. When performing a simple release of the sixth compartment for ECU stenosing tenosynovitis it is possible to destabilize the tendon and allow it to subluxate (Burkhart et al., 1982; Hajj and Wood, 1986), or destabilize the distal radioulnar joint (Spinner and Kaplan, 1970). This is especially the case when the procedure is performed in young active patients. Numerous variations and anomalies of the dorsal tendons and muscles of the hand have been described (Tan and Smith, 1999). An accessory tendon which arises from the lower part of the ECU tendon has been observed in 34% of cases (Nakashima, 1993) and its insertion into the extensor mechanism is considered a common variant (Hollister, 1987). The possible clinical significance of an anomalous ECU tendon slip was first described by Barfred and Adamsen (1986). They considered that the existence of an anomalous tendon slip between the ECU and the extensor digiti minimi probably makes medical treatment less effective, because the ECU tendon has an excursion of 3 cm, while the excursion of the extensor digiti minimi tendon is 5 cm. In our series of patients an anomalous tendon slip between the ECU and extensor digiti minimi was present in seven of the 27 patients, all of whom regularly played sports (two professionally). The anomalous tendon slip had two patterns of distribution; in three cases it began proximal to the ECU osteofibrous sheath, passed under it and perforated the wall between the sixth and fifth compartments to join the extensor digiti minimi tendon. In the other four cases the anomalous tendon slip began under the ECU osteofibrous sheath, perforated the wall between the sixth and fifth compartments and joined with the ulnar border of the extensor digiti minimi tendon. We feel that a tendon slip running to the extensor digiti minimi must be carefully looked for during surgery for ECU tenosynovitis and, if present, excised so as to avoid recurrences. Isolated recurrent traumatic ECU tendon dislocation at the wrist was first described by Schlesinger (1907). Burkhart et al. (1982) and Rayan (1983) suggested that closed treatment in a long arm cast was appropriate for the treatment of an acute ECU tendon subluxation at the wrist, but Rowland (1986) suggested that surgical repair of the osteofibrous sheath is preferable. Beckenbaugh (1987) reported on two cases which ‘‘illustrated the absence of necessity for operative intervention’’ after ECU osteofibrous sheath rupture. Inoue and Tamura (2001) suggested that type B ECU osteofibrous sheath lesions may have the potential to heal if treated early and categorized osteofibrous sheaths ruptures into those in which the rupture occurred at the radial insertion of the osteofibrous sheath and could be repaired directly (Type C2 lesions), and those in which it occurred at its ulnar insertion and needed reconstruction (Type C1 lesions). In our experience, direct osteofibrous sheath repair is not possible with any type C lesions because of
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tendon thickening and osteofibrous sheath retraction. We recommend surgical treatment of all acute dislocations in young active patients, as it is difficult to distinguish between the different types of osteofibrous sheath lesions, because surgical treatment provides good results and because nonoperative management of acute lesions is not always effective. Surgical repair also restores the stabilizing role of the ECU at the distal radioulnar joint (Eckhardt and Palmer, 1981; Loty et al., 1986; Rowland, 1986). Conservative treatment might be indicated in non-active and elderly patients. In chronic ECU dislocations and subluxations, treatment will vary according to patient’s symptoms and demands. When the subluxation or dislocation produces disability or pain, surgical treatment is a reliable option. Different techniques of ECU osteofibrous sheath reconstruction have been described, Markees (1937) suggested using a flap of periosteum elevated from the distal ulna, while Obrant (1946) suggested excision of the redundant portion of the extensor retinaculum over the sixth compartment and tightly imbricating the remainder of the retinaculum over the dorsoulnar aspect of the wrist. Burkhart et al. (1982) reported three cases of ECU dislocation. A direct repair of the ulnar septum of the sixth compartment was possible in two cases and was supplemented by a radially based sling of the extensor retinaculum which went around the tendon and prevented its translation. In the other case, a portion of the flexor carpi ulnaris tendon was used to reconstruct the ECU osteofibrous sheath. Eckhardt and Palmer, (1981) suggested the use of a free graft of the extensor retinaculum for ECU subsheath reconstruction and we favour its use because its deep surface allows optimal tendon gliding and reduces adhesion formation. Flat and convex ECU tendon grooves have a higher risk of subluxation or dislocation (Fig 5). One patient with recurrent dislocation and a flat tendon groove had a bony procedure performed (the ECU groove was deepened). Although the time to complete recovery was long (1 year), a good final result was obtained. We have found no other reports of ECU groove deepening and do not think that it can be recommended on the basis of our single case. ECU tendon partial rupture is associated with ulnar styloid nonunion (Crimmins and Jones, 1995; Kiyono et al., 2002), exposed bone (Crimmins and Jones, 1995), impingement of the tendon against the ulnar ridge (Angermann, 1993), ECU tenovaginitis (Kip and Peimer, 1994) and an attenuated ECU subsheath, tendon subluxation and a prominent ulnar ridge (Chun and Palmer, 1987). An ulnar styloid nonunion can be treated by open reduction and internal fixation or by excision of the fragment and reattachment of the triangular fibrocartilage complex to the distal ulna if the distal radioulnar joint is unstable. If the distal radio-ulnar joint is stable then excision of the
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distal fragment is all that is required (Hauck et al., 1996). When there is a complete or partial rupture of the ECU tendon secondary to a protruding bony ridge, the floor of the compartment must be adequately
Fig 6 Magnetic resonance images showing: (A) extensor carpi ulnaris tenosynovitis. (B) An internal longitudinal extensor carpi ulnaris tendon lesion. (C) Extensor carpi ulnaris dislocation.
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reconstructed, so as to allow tendon gliding without abrasion. Four cases of non-rheumatoid closed complete ruptures of the ECU tendon have been described. Moran and Ruby (1992) reported on two cases, one with an associated triangular fibrocartilage complex tear and a distal ulnar osteophyte, and Wang et al. (2003) described a single case in an ice hockey player. We have treated four cases, three of which were in professional athletes of which one has been previously published (Xarchas and Le Viet, 2002). In all these seven reported cases, a palmaris longus free tendon graft was used and the ECU osteofibrous sheath required reconstruction in five cases, including the four cases reported in this study. Reconstruction of the ECU tendon using palmaris longus tendon graft is not justified in elderly or inactive patients. Magnetic resonance imaging now has a large role in the workup of this sometimes confusing problem (Zlatkin et al., 1989) (Fig 6). Its advantages over conventional arthrography for the assessment of ECU problems are that it is non-invasive, allows multiplanar projections, and clearly demonstrates inflammation associated with tendonitis as well as intratendinous lesions. ECU tendon dislocation or subluxation can be detected in dynamic forearm rotation studies, and the type of ECU groove in the distal ulna can be clearly assessed. Magnetic resonance imaging studies have shown that internal longitudinal tendon lesions occur more frequently than previously recognized (19 cases in this study). Extensor carpi ulnaris tendon lesions generally respond to medical treatment and changes in hand usage. However when such measures fail our classification of extensor carpi ulnaris lesions at the wrist allows the surgeon to adequately evaluate its different components and provides guidelines for treatment (Table 5). Isolated extensor carpi ulnaris lesions are rare, and associated triangular fibrocartilage complex tears and lunotriquetral ligament tears are frequently found, as are other pathologies such as an anomalous tendon slip, an ulnar styloid non-union or a flat ECU tendon groove. These problems must be addressed simultaneously.
References Angermann P (1993). Post-traumatic partial rupture of the extensor carpi ulnaris tendon. Scandinavian Journal of Plastic and Reconstructive Hand Surgery, 27: 321–322. Barfred T, Adamsen S (1986). Duplication of the extensor carpi ulnaris tendon. Journal of Hand Surgery, 11A: 423–425. Beckenbaugh RD (1987). Acute traumatic subluxation. Letters to Editor. Journal of Hand Surgery, 12A: 810–811. Boyes JH (1964). Special situations affecting tendons. In: Bunnell’s surgery of the hand, Ed. 4. Philadelphia, J.B. Lippincott Company, 470–471. Burkhart SS, Wood MB, Linscheid RL (1982). Posttraumatic recurrent subluxation of the extensor carpi ulnaris tendon. Journal of Hand Surgery, 7A: 1–3.
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Chun S, Palmer AK (1987). Chronic ulnar wrist pain secondary to partial rupture of the extensor carpi ulnaris tendon. Journal of Hand Surgery, 12A: 1032–1035. Crimmins CA, Jones NF (1995). Stenosing tenosynovitis of the extensor carpi ulnaris. Annals of Plastic Surgery, 35: 105–107. Dickson DD, Luckey AC (1948). Tenosynovitis of the extensor carpi ulnaris tendon sheath. Journal of Bone and Joint Surgery, 30-A: 903–907. Eckhardt WA, Palmer AK (1981). Recurrent dislocation of extensor carpi ulnaris tendon. Journal of Hand Surgery, 6A: 629–631. Futami T, Itoman M (1995). Extensor carpi ulnaris syndrome. Findings in 43 patients. Acta Orthopaedica Scandinavica, 66: 538–539. Hajj AA, Wood MB (1986). Stenosing tenosynovitis of the extensor carpi ulnaris. Journal of Hand Surgery, 11A: 519–520. Hauck RM, Skahen III. J, Palmer AK (1996). Classification and treatment of ulnar styloid nonunion. Journal of Hand Surgery, 21A: 418–422. Hollister A (1987). Duplication of extensor carpi ulnaris. Letter to editor. Journal of Hand Surgery, 12A: 809–810. Inoue G, Tamura Y (2001). Surgical treatment for recurrent dislocation of the extensor carpi ulnaris tendon. Journal of Hand Surgery, 26B: 556–559. Kaplan EB. In: Functional and surgical anatomy of the hand, 2nd Edn, Philadelphia and Montreal, Lippincott Company, 1965: 191–194. Kip PC, Peimer CA (1994). Release of the sixth dorsal compartment. Journal of Hand Surgery, 19A: 599–601. Kiyono Y, Nakatsuchi Y, Saitoh S (2002). Ulnar–styloid nonunion and partial rupture of extensor carpi ulnaris tendon: two case reports and review of the literature. Journal of Orthopaedic Trauma, 16: 674–677. Lapidus PW, Fenton R (1952). Stenosing tenovaginitis at the wrist and fingers. AMA Archives of Surgery, 64: 475–487. Loty B, Meunier B, Mazas F (1986). Luxation traumatique isolee du tendon cubital posterieur. Revue de Chirurgie Orthopedique et Reparatrice de l’Appareil Moteur, 72: 219–222. Markees J (1937). Luxation der sehne des musc. Extensor Carpi ulnaris. Schweizerische Medizinische Wochenschrift, 67: 637. Moran S, Ruby LK (1992). Nonrheumatoid closed rupture of extensor carpi ulnaris tendon. Journal of Hand Surgery, 17A: 281–283. Nachinolcar UG, Khanolkar KB (1988). Stenosing tenovaginitis of extensor carpi ulnaris: brief report. Journal of Bone and Joint Surgery, 70B: 842. Nakashima T (1993). An accessory extensor digiti minimi arising from extensor carpi ulnaris. Journal of Anatomy, 182: 109–112. Obrant O (1946). Fall av senluxation i handleden. Nordisk Medicin, 29: 656. Osterman AL, Moskow L, Low DW (1988). Soft-tissue injuries of the hand and wrist in racquet sports. Clinics in Sports Medicine, 7: 329–348. Rayan GM (1983). Recurrent dislocation of the extensor carpi ulnaris in athletes. American Journal of Sports Medicine, 11: 183–184. Rowland SA (1986). Acute traumatic subluxation of the extensor carpi ulnaris tendon at the wrist. Journal of Hand Surgery, 11A: 809–811. Schlesinger J (1907). Vorstellung zweier falle von sehnenluxation. Deutsche Medizinische Wochenschrift, 23: 236. Spinner M, Kaplan EB (1970). Extensor carpi ulnaris. Its relationship to the stability of the distal radio–ulnar joint. Clinical Orthopaedics, 68: 124–129. Stein HC (1927). Stenosing tendovaginitis. American Journal of Surgery, 3: 77–78. Taleisnik J (1987). Pain on the ulnar side of the wrist. Hand Clinics, 3: 51–68.
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Taleisnik J, Gelberman RH, Miller BW, Szabo RM (1984). The extensor retinaculum of the wrist. Journal of Hand Surgery, 9A: 495–501. Tan ST, Smith PJ (1999). Anomalous extensor muscles of the hand: a review. Journal of Hand Surgery, 24A: 449–455. Wang C, Gill TJ, Zarins B, Herndom JH (2003). Extensor carpi ulnaris tendon rupture in an ice hockey player: a case report. American Journal of Sports Medicine, 31: 459–461. Wood MB, Dobyns JH (1986). Sports-related extraarticular wrist syndromes. Clinical Orthopaedics, 202: 93–102. Xarchas KC, Le Viet D (2002). Non rheumatoid closed rupture of extensor carpi ulnaris tendon. Report of a case in a professional athlete. Acta Orthopaedica Belga, 68: 399–402.
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Zlatkin MB, Chao PC, Osterman AL, Schnall MD, Dalinka MK (1989). Chronic wrist pain: evaluation with high-resolution MR imaging. Radiology, 173: 723–729. Received: 8 July 2003 Accepted after revision: 6 December 2004 Dr Christian Allende M.D., Sanatorio Allende, Hipolito Yrigoyen 384, Cordoba 5000, Argentina. Tel.: +54 351 4269240; fax: +54 351 4269209 E-mail: [email protected]
r 2005 The British Society for Surgery of the Hand. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhsb.2004.12.007 available online at http://www.sciencedirect.com