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Flexor tendon rupture 55 years following a wrist laceration
Journal of Plastic, Reconstructive & Aesthetic Surgery (2006) 59, 529–531
CASE REPORT
Flexor tendon rupture 55 years following a wrist laceration Steven L. Petersona,b,*, Kagan Ozera,b a
Hand Surgery Section, Department of Orthopedics, Denver Health Medical Center, 777 Bannock St, MC 0188, Denver, CO 80204-4507, USA b Departments of Orthopedics and Surgery, University of Colorado Health Sciences Center, Denver, CO, USA Received 30 June 2004; accepted 11 January 2005
KEYWORDS Tendon; Rupture; Attritional; Neuroma
Summary Flexor tendon rupture at the wrist or palm is rare. We present a case of index flexor digitorum profundus rupture at the level of the wrist associated with the site of a laceration 55 years earlier. Associated pathology included a large neuromain-continuity of the median nerve and adhesions involving the flexor digitorum superficialis tendons. The rupture was treated by tenodesis to the relatively unaffected flexor digitorum profundus to the adjacent long finger. q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved.
Flexor tendon rupture in the palm or wrist in the absence of rheumatoid synovitis is rare. Boyes, in 1960, reported on 80 ruptures in 78 patients accrued over a 14-year period and, in this classic paper, was able to associate indirect and direct trauma with 80% of the ruptures.1 Since that time case reports have associated flexor tendon rupture with gout,2 anatomical variation,3 and a number of bony abnormalities.4–9 Ruptures associated with direct closed tendon trauma are usually acute. However, flexor tendon rupture associated with distal radial fractures has occurred as late as 44 years after initial injury when associated with bony * Corresponding author. Address: Hand Surgery Section, Department of Orthopedics, Denver Health Medical Center, 777 Bannock St, MC 0188, Denver, CO 80204-4507, USA. Tel.: C1 303 436 6031; fax: C1 303 436 3123. E-mail address: [email protected] (S.L. Peterson).
protuberances on the radius,7 and 25 years when attributed to volar displacement of the ulna.9 In this report we describe attritional rupture of the index flexor digitorum profundus (FDP) 55 years following a childhood wrist laceration with no associated bony injury.
Case report A 61-year-old, right-hand dominant woman was referred 7 days after acute onset of inability to flex the left index finger. The injury occurred when the patient reached to open the refrigerator door with her left index finger and had felt a pop and pain at the level of the distal interphalangeal (DIP) joint. Immediately after this, the patient was unable to flex the DIP joint and had only weak flexion of proximal interphalangeal (PIP) joint of the left
S0007-1226/$ - see front matter q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2005.01.024
530 index finger. After no improvement over the course of 1 week, the patient presented to her primary care physician who referred her for hand surgery evaluation. On presentation to hand clinic, in addition to the above history, the otherwise healthy patient gave a history of being cut in the left wrist at 6 years of age by a falling piece of porcelain china. Her paediatrician repaired the laceration in his office immediately following the injury. Several months after the injury a painful sensitive mass developed at the volar wrist crease that was diagnosed as a cyst. Throughout her life the patient had decreased sensibility in the radial side digits of her left hand. Physical examination showed an altered cascade with the left index finger held in extension, and only very weak flexion of the PIP joint evident with effort. A nontransilluminating mass was present at the wrist crease and a Tinel’s sign was elicited with even slight manipulation. A static two-point sensory exam showed 6 mm discrimination in the left thumb, ring and small finger, but absence of twopoint discrimination in the index and long finger. Radiographs of the finger failed to demonstrate a bony fragment from the distal phalanx and a presumptive diagnosis of Type I Jersey Finger was made. The patient was brought to the operating room for exploration under Bier blockade, and a Brunner incision was made at the level of the DIP joint. An intact FDP tendon was identified. A counter incision was then made at the A-1 pulley level and again intact flexor tendons were identified. The A-1 pulley was resected but the FDP could not be pulled into the wound. At this point a decision was made to explore the hand at the level of the scarred wrist crease. An extended carpal tunnel incision was carried out and the soft tissues carefully dissected from the now confirmed neuroma-in-continuity of the median nerve. The flexor digitorum superficialis (FDS) tendons were found to be encompassed in the scar associated with the neuroma and to be attritional in character. The distal end of the ruptured FDP to the index finger was identified (Fig. 1) and a tenodeses to the normal appearing long finger FDP tendon via a Pulvertaft weave was performed (Fig. 2).
S.L. Peterson, K. Ozer
Figure 1
Ruptured index flexor digitorum profundus.
the point of insertion, followed by the carpal tunnel, midsegment of the digit, and musculotendinous junction.1 An additional point of tendon weakness appears to exist at the lumbrical origin on the FDP leading to rupture within the palm.10,11 The flexor tendons of the small finger may be more susceptible to rupture than the other digits.12 This increased frequency of FDP rupture in the small finger may be due to the inherent weakness of the FDS of this digit, its unique location making it a highly mobile border digit, or the presence of anatomical variation. Prior trauma to the tendon itself or the region does predispose tendons to later rupture, as has been demonstrated with partial laceration,13 or trauma associated with distal radial fractures.7–9 Trauma may lead to interruption of the tendons blood supply, cause haemorrhage into the tendon substance leading to softening or necrosis of the
Discussion Normal tendon seldom ruptures mid-substance because its high tensile strength makes it the strongest link in the musculotendinous chain. When rupture occurs, the most frequent site is
Figure 2 Pulvertaft weave of index flexor digitorum profundus to long finger flexor digitorum profundus. *The neuroma-in-continuity of median nerve.
Flexor tendon rupture 55 years following a wrist laceration tendon, or result in alteration of an adjacent structure, such as bone, that precipitates abnormal wear on the tendon. All these mechanisms eventually result in tendon rupture. In this case, the only anatomical alteration was the presence of adhesions associated with a 55year-old neuroma in-continuity of the median nerve and precipitated by the initial tendon trauma. Presumably the area of adhesion and scar represented an area of hypovascularity that, when combined with the normal changes associated with aging,14 predisposed this area to rupture when suddenly loaded by the weight of the refrigerator door. While the historical injury and neuroma at the wrist were appreciated preoperatively, the initial exploratory incision was made at the level of the DIP joint. This was based on a presumed diagnosis of rupture at the site of tendon insertion based on the clinical history of pain at the DIP level, and the known predilection for rupture at the site of tendon insertion. This distal incision was contradictory to Naam’s recommendation that when the site of FDP tendon rupture is uncertain, the first incision should be made at the level of the PIP joint.11 This will allow the surgeon to determine if the rupture occurred in zone I or II. If the tendon is intact at the PIP level a palm incision is recommended. Alternatively, preoperative ultrasound evaluation may have helped more precisely determine the site of rupture by demonstrating continuity of the tendon in the finger prior to exploration.15,16 The tendon rupture presented here 55 years following the initial trauma emphasises the need for a careful history targeting prior injury when evaluating tendon rupture. This was a principle established in Boyes seminal report,1 when he demonstrated a history of prior direct or indirect trauma could be elicited in 64 of his 80 reported tendon ruptures.
531
References 1. Boyes JH, Wilson JN, Smith JW. Flexor-tendon ruptures in the forearm and hand. J Bone Joint Surg Am 1960;42:637–46. 2. Wurapa RK, Zelouf DS. Flexor tendon rupture caused by gout: a case report. J Hand Surg [Am] 2002;27:591–3. 3. Davis C, Armstrong J. Spontaneous flexor tendon rupture in the palm: the role of a variation of tendon anatomy. J Hand Surg [Am] 2003;28:149–52. 4. Thomsen S, Falstie-Jensen S. Rupture of the flexor pollicis longus tendon associated with an ununited fracture of the Scaphoid. J Hand Surg [Am] 1988;13:220–2. 5. Milek MA, Boulas HJ. Flexor tendon ruptures secondary to hamate hook fractures. J Hand Surg [Am] 1990;15:740–4. 6. Johnston GHF, Bowen CVA. Attritional flexor tendon ruptures by an old lunate dislocation. J Hand Surg [Am] 1988;13:701–3. 7. Minami A, Ogino T, Tohyama H. Multiple ruptures of flexor tendons due to hypertrophic change at the distal radio-ulnar joint. J Bone Joint Surg Am 1989;71:300–2. 8. Kato N, Nemoto K, Arino H, Ichikawa T, Fujikawa K. Ruptures of flexor tendons at the wrist as a complication of fracture of the distal radius. Scan J Plast Reconstr Surg Hand Surg 2002; 36:245–8. 9. Wada A, Ihara F, Hideyuki S, Nomura S. Attritional flexor tendon ruptures due to distal radius fracture and associated volar displacement of the distal ulna: a case report. J Hand Surg [Am] 1999;24:534–7. 10. Wray RC, Parlin LS. Spontaneous flexor tendon rupture in the palm. Ann Plast Surg 1989;23:352–3. 11. Naam NH. Intrateninous rupture of the flexor digitorum profundus in zones II and III. J Hand Surg [Am] 1995;20: 478–83. 12. Imbriglia JE, Goldstein SA. Intratendinous ruptures of the flexor digitorum profundus tendon of the small finger. J Hand Surg [Am] 1987;12:985–91. 13. Schlenker JD, Lister GD, Kleinert HE. Three complications of untreated partial laceration of flexor tendon-entrapment, rupture, and triggering. J Hand Surg [Am] 1981;6:392–8. 14. Carmeli E, Patish H, Coleman R. The aging hand. J Gerontol A Biol Sci Med Sci 2003;58:M146–M52. 15. Wang PT, Banavita JA, Delone Jr FX, McClellan RM, Witham RS. Ultrasonic assistance in the diagnosis of hand flexor tendon injuries. Ann Plast Surg 1999;42:403–7. 16. Middleton WD, Teefy SA, Boyer MI. Hand and wrist sonography. Ultrasound Q 2001;17:21–36.
CASE REPORT
Flexor tendon rupture 55 years following a wrist laceration Steven L. Petersona,b,*, Kagan Ozera,b a
Hand Surgery Section, Department of Orthopedics, Denver Health Medical Center, 777 Bannock St, MC 0188, Denver, CO 80204-4507, USA b Departments of Orthopedics and Surgery, University of Colorado Health Sciences Center, Denver, CO, USA Received 30 June 2004; accepted 11 January 2005
KEYWORDS Tendon; Rupture; Attritional; Neuroma
Summary Flexor tendon rupture at the wrist or palm is rare. We present a case of index flexor digitorum profundus rupture at the level of the wrist associated with the site of a laceration 55 years earlier. Associated pathology included a large neuromain-continuity of the median nerve and adhesions involving the flexor digitorum superficialis tendons. The rupture was treated by tenodesis to the relatively unaffected flexor digitorum profundus to the adjacent long finger. q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved.
Flexor tendon rupture in the palm or wrist in the absence of rheumatoid synovitis is rare. Boyes, in 1960, reported on 80 ruptures in 78 patients accrued over a 14-year period and, in this classic paper, was able to associate indirect and direct trauma with 80% of the ruptures.1 Since that time case reports have associated flexor tendon rupture with gout,2 anatomical variation,3 and a number of bony abnormalities.4–9 Ruptures associated with direct closed tendon trauma are usually acute. However, flexor tendon rupture associated with distal radial fractures has occurred as late as 44 years after initial injury when associated with bony * Corresponding author. Address: Hand Surgery Section, Department of Orthopedics, Denver Health Medical Center, 777 Bannock St, MC 0188, Denver, CO 80204-4507, USA. Tel.: C1 303 436 6031; fax: C1 303 436 3123. E-mail address: [email protected] (S.L. Peterson).
protuberances on the radius,7 and 25 years when attributed to volar displacement of the ulna.9 In this report we describe attritional rupture of the index flexor digitorum profundus (FDP) 55 years following a childhood wrist laceration with no associated bony injury.
Case report A 61-year-old, right-hand dominant woman was referred 7 days after acute onset of inability to flex the left index finger. The injury occurred when the patient reached to open the refrigerator door with her left index finger and had felt a pop and pain at the level of the distal interphalangeal (DIP) joint. Immediately after this, the patient was unable to flex the DIP joint and had only weak flexion of proximal interphalangeal (PIP) joint of the left
S0007-1226/$ - see front matter q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2005.01.024
530 index finger. After no improvement over the course of 1 week, the patient presented to her primary care physician who referred her for hand surgery evaluation. On presentation to hand clinic, in addition to the above history, the otherwise healthy patient gave a history of being cut in the left wrist at 6 years of age by a falling piece of porcelain china. Her paediatrician repaired the laceration in his office immediately following the injury. Several months after the injury a painful sensitive mass developed at the volar wrist crease that was diagnosed as a cyst. Throughout her life the patient had decreased sensibility in the radial side digits of her left hand. Physical examination showed an altered cascade with the left index finger held in extension, and only very weak flexion of the PIP joint evident with effort. A nontransilluminating mass was present at the wrist crease and a Tinel’s sign was elicited with even slight manipulation. A static two-point sensory exam showed 6 mm discrimination in the left thumb, ring and small finger, but absence of twopoint discrimination in the index and long finger. Radiographs of the finger failed to demonstrate a bony fragment from the distal phalanx and a presumptive diagnosis of Type I Jersey Finger was made. The patient was brought to the operating room for exploration under Bier blockade, and a Brunner incision was made at the level of the DIP joint. An intact FDP tendon was identified. A counter incision was then made at the A-1 pulley level and again intact flexor tendons were identified. The A-1 pulley was resected but the FDP could not be pulled into the wound. At this point a decision was made to explore the hand at the level of the scarred wrist crease. An extended carpal tunnel incision was carried out and the soft tissues carefully dissected from the now confirmed neuroma-in-continuity of the median nerve. The flexor digitorum superficialis (FDS) tendons were found to be encompassed in the scar associated with the neuroma and to be attritional in character. The distal end of the ruptured FDP to the index finger was identified (Fig. 1) and a tenodeses to the normal appearing long finger FDP tendon via a Pulvertaft weave was performed (Fig. 2).
S.L. Peterson, K. Ozer
Figure 1
Ruptured index flexor digitorum profundus.
the point of insertion, followed by the carpal tunnel, midsegment of the digit, and musculotendinous junction.1 An additional point of tendon weakness appears to exist at the lumbrical origin on the FDP leading to rupture within the palm.10,11 The flexor tendons of the small finger may be more susceptible to rupture than the other digits.12 This increased frequency of FDP rupture in the small finger may be due to the inherent weakness of the FDS of this digit, its unique location making it a highly mobile border digit, or the presence of anatomical variation. Prior trauma to the tendon itself or the region does predispose tendons to later rupture, as has been demonstrated with partial laceration,13 or trauma associated with distal radial fractures.7–9 Trauma may lead to interruption of the tendons blood supply, cause haemorrhage into the tendon substance leading to softening or necrosis of the
Discussion Normal tendon seldom ruptures mid-substance because its high tensile strength makes it the strongest link in the musculotendinous chain. When rupture occurs, the most frequent site is
Figure 2 Pulvertaft weave of index flexor digitorum profundus to long finger flexor digitorum profundus. *The neuroma-in-continuity of median nerve.
Flexor tendon rupture 55 years following a wrist laceration tendon, or result in alteration of an adjacent structure, such as bone, that precipitates abnormal wear on the tendon. All these mechanisms eventually result in tendon rupture. In this case, the only anatomical alteration was the presence of adhesions associated with a 55year-old neuroma in-continuity of the median nerve and precipitated by the initial tendon trauma. Presumably the area of adhesion and scar represented an area of hypovascularity that, when combined with the normal changes associated with aging,14 predisposed this area to rupture when suddenly loaded by the weight of the refrigerator door. While the historical injury and neuroma at the wrist were appreciated preoperatively, the initial exploratory incision was made at the level of the DIP joint. This was based on a presumed diagnosis of rupture at the site of tendon insertion based on the clinical history of pain at the DIP level, and the known predilection for rupture at the site of tendon insertion. This distal incision was contradictory to Naam’s recommendation that when the site of FDP tendon rupture is uncertain, the first incision should be made at the level of the PIP joint.11 This will allow the surgeon to determine if the rupture occurred in zone I or II. If the tendon is intact at the PIP level a palm incision is recommended. Alternatively, preoperative ultrasound evaluation may have helped more precisely determine the site of rupture by demonstrating continuity of the tendon in the finger prior to exploration.15,16 The tendon rupture presented here 55 years following the initial trauma emphasises the need for a careful history targeting prior injury when evaluating tendon rupture. This was a principle established in Boyes seminal report,1 when he demonstrated a history of prior direct or indirect trauma could be elicited in 64 of his 80 reported tendon ruptures.
531
References 1. Boyes JH, Wilson JN, Smith JW. Flexor-tendon ruptures in the forearm and hand. J Bone Joint Surg Am 1960;42:637–46. 2. Wurapa RK, Zelouf DS. Flexor tendon rupture caused by gout: a case report. J Hand Surg [Am] 2002;27:591–3. 3. Davis C, Armstrong J. Spontaneous flexor tendon rupture in the palm: the role of a variation of tendon anatomy. J Hand Surg [Am] 2003;28:149–52. 4. Thomsen S, Falstie-Jensen S. Rupture of the flexor pollicis longus tendon associated with an ununited fracture of the Scaphoid. J Hand Surg [Am] 1988;13:220–2. 5. Milek MA, Boulas HJ. Flexor tendon ruptures secondary to hamate hook fractures. J Hand Surg [Am] 1990;15:740–4. 6. Johnston GHF, Bowen CVA. Attritional flexor tendon ruptures by an old lunate dislocation. J Hand Surg [Am] 1988;13:701–3. 7. Minami A, Ogino T, Tohyama H. Multiple ruptures of flexor tendons due to hypertrophic change at the distal radio-ulnar joint. J Bone Joint Surg Am 1989;71:300–2. 8. Kato N, Nemoto K, Arino H, Ichikawa T, Fujikawa K. Ruptures of flexor tendons at the wrist as a complication of fracture of the distal radius. Scan J Plast Reconstr Surg Hand Surg 2002; 36:245–8. 9. Wada A, Ihara F, Hideyuki S, Nomura S. Attritional flexor tendon ruptures due to distal radius fracture and associated volar displacement of the distal ulna: a case report. J Hand Surg [Am] 1999;24:534–7. 10. Wray RC, Parlin LS. Spontaneous flexor tendon rupture in the palm. Ann Plast Surg 1989;23:352–3. 11. Naam NH. Intrateninous rupture of the flexor digitorum profundus in zones II and III. J Hand Surg [Am] 1995;20: 478–83. 12. Imbriglia JE, Goldstein SA. Intratendinous ruptures of the flexor digitorum profundus tendon of the small finger. J Hand Surg [Am] 1987;12:985–91. 13. Schlenker JD, Lister GD, Kleinert HE. Three complications of untreated partial laceration of flexor tendon-entrapment, rupture, and triggering. J Hand Surg [Am] 1981;6:392–8. 14. Carmeli E, Patish H, Coleman R. The aging hand. J Gerontol A Biol Sci Med Sci 2003;58:M146–M52. 15. Wang PT, Banavita JA, Delone Jr FX, McClellan RM, Witham RS. Ultrasonic assistance in the diagnosis of hand flexor tendon injuries. Ann Plast Surg 1999;42:403–7. 16. Middleton WD, Teefy SA, Boyer MI. Hand and wrist sonography. Ultrasound Q 2001;17:21–36.