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Late rupture of the extensor pollicis longus tendon: The case against attrition
LATE
RUPTURE THE
OF THE EXTENSOR POLLICIS LONGUS TENDON: CASE AGAINST ATTRITION N. H. JENKINS and I. G. MACKIE
From the Department of Orthopaedic and Traumatic Surgery, University of Wales College of Medicine
The authors report the case of a 2fyear-old man who sustained ipsilateral volar Barton’s and scaphoid fractures which were complicated by a late rupture of the extensor pollicis longus tendon. The anatomy of the injury precluded attrition as the cause of the tendon rupture and the alternative theory of ischaemic rupture is examined. Clinicians should be aware that injuries other than the Colles’ fracture may be complicated by rupture of extensor pollicis longus. Whilst late rupture of the extensor pollicis longus tendon is a well-recognised, albeit uncommon, complication of the Colles’ fracture, its aetiology remains obscure. Various theories which apportion different emphases to the two most likely pathologies of mechanical attrition and ischaemic necrosis have been advanced (McMaster, 1932; Engkvist, 1979; Helal, 1982) but, because of a lack of experimental evidence, these necessarily remain speculative. We report a case of delayed rupture of the extensor pollicis longus tendon after ipsilateral volar Barton’s and scaphoid fractures, the anatomy of the bony injury precluding attritional rupture and thus demanding consideration of alternative theories. Case report A 23-year-old man suffered his wrist during a fall onto Radiographic examination fracture of the distal radius
Fig. 1
a hyper-extension injury of his outstretched right hand. revealed a volar Barton’s plus a fracture through the
waist of the scaphoid (Fig. 1). The fractures were treated by open reduction and internal fixation with a buttress T-plate and a Herbert screw via a single volar incision (Fig. 2). Post-operatively the man received physiotherapy and made a slow but satisfactory recovery. Three months later, he noticed a sudden snapping within the wrist followed by inability to actively extend the distal phalanx of the thumb. Clinical examination confirmed the lack of active extension at the interphalangeal joint, and also revealed a palpable defect within the extensor pollicis longus tendon immediately distal to Lister’s tubercle. A clinical diagnosis of late rupture of the extensor pollicis longus tendon was made and this was later confirmed at the subsequent extensor indicis to extensor pollicis longus tendon transfer procedure. Discussion The anatomical proximity of the extensor pollicis longus tendon to the Colles’ fracture site dictated that the earliest attempts to explain the rupture’s occurrence would concentrate upon the tendon’s mechanical
(a) and (b) P.A. and lateral radiographs showing a volar Barton’s fracture and a fracture through the scaphoid waist. The appearance of the dorsal rim of the radius on the lateral film is due to the underlying shadow of the ulnar styloid.
Received: 10 November 1987 Mr. I. G. Mackie, F.R.C.S., Consultant Orthopaedic Newport Road, Cardiff CF2 1SZ.
448
Surgeon, Cardiff Royal Infirmary,
Fig. 2
The fractures have been internally fixed with a T-plate and Herbert screw. THE JOURNAL
OF HAND SURGERY
LATE RUPTURE OF EXTENSOR POLLICIS LONGUS
attrition (McMaster, 1923). Unfortunately the literature has been slow to discard this theory (Grimes, 1979; Benjamin, 1982) despite the absence of roughened bone at exploration (Trevor, 1950; Bunata, 1983) and the inability to explain adequately the complication’s predilection for the undisplaced fracture. Indeed, even when operative or experimental evidence has favoured an alternative pathology, workers have continued to suggest mechanical explanations (Helal et al., 1982; Bunata, 1983). The bony anatomy of the present case is, however, unique in that it entirely precludes attritional rupture by either the fracture or the surgical implants (Lugger and Pechlander, 1984), and demands that alternative theories be examined. A vascular aetiology for the tendon’s rupture was suggested as long ago as 1914 (Weigeldt) and is the most popular alternative to the mechanical theory (Engkvist, 1979). Because of its unusual length, the extensor pollicis longus tendon receives a segmental vascular supply. The musculo-tendinous junction receives its supply from the anterior interosseous artery and its muscular branches, the distal portion of the tendon receives direct branches from the radial artery, whilst the mid-tendon (within the tendon sheath) obtains its supply from proximal and distal meso-tendons arising from the superficial dorsal carpal network and the posterior branch of the anterior interosseous artery (Zbrodowski et al., 1982). The injection studies of Engkvist and Lundborg (1979) demonstrated that the supplies from the two mesotendons fail to anastomose, resulting in a poorly nourished area of tendon in the region of Lister’s tubercle (Fig. 3). Helal injected radiological contrast medium into the tendon sheath of Colles’ fracture patients and confirmed London’s (1967) assumption that the sheath remains intact in minimally displaced fractures but is disrupted in more severe injuries. Should
Fig. 3
The arterial supply of the extensor pollicis longus tendon. The musculo-tendinous junction receives branches from the anterior interosseous artery (1) whilst the distal tendon receives direct branches (2) from the radial artery. The midtendon is supplied by branches of the anterior interosseous artery and the superficial dorsal carpal network (3) which run in proximal and distal meso-tendons within the tendon sheath. These latter two supplies fail to anastomose, leaving an avascular area immediately distal to Lister’s tubercle (4) (Extensor carpi radialis longus and brevis: (5).
VOL. 13-B No. 4 NOVEMBER 1988
the extensor pollicis longus tendon be direct blow (Simpson, 1977), or be crushed. between Lister’s tubercle and the styloid process of the third metacarpal in an extension injury (Benman, 1979), then the resultant effusion or haematoma within the intact tendon sheath may tamponade the already precarious blood supply of the damaged tendon. The consequent ischaemia might prevent repair or even produce further necrosis resulting in delayed rupture, the time of which would presumably be related to the extent of the tendon’s initial injury. That the tendon be damaged during the injury is central to the argument because, as the proponents of the attritional theory correctly state, an avascular transplanted tendon, which is otherwise normal, does not rupture (Benjamin, 3982). The case presented is unique because, to our knowledge, it is the first reported instance of rupture of the extensor pollicis longus tendon complicating ipsilateral volar Barton’s and scaphoid fractures. Our purpose in presenting the case is two-fold: first the anatomy of the injury allows an attempt to explain the aetiology of tendon rupture; and second, we wish to alert clinicians to the possibility of the rupture complicating wrist injuries other than the Colles’ fracture. Acknowledgments We wish to thank Mr. Keith Bellamy (Medical pnotographer, Cardiff Royal Infirmary) and Mrs. Janice Sharp (Medical illustrator, University Hospital of Wales) for their help in illustrating this paper.
References BENJAMIN, A. Injuries of the Forearm. in: Wilson, J. N. (Ed.). WatsonJones’ Fractures and joint injuries. Edinburgh: Churchill Livingstone, 1982: Vol2: 696. BUNATA, R. E. (1983). Impending Rupture of the Extensor Pollicis Longus Tendon after a Minimally Displaced Colles Fracture. Journal of Bone and Joint Surgery, 65A: 3: 401-402. DENMAN, E. E. (1979). Rupture of the extensor pollicis longus - a crush injury. The Hand, 11: 3: 295-298. ENGKVIST, 0. and LUNDBORG, G. (1979). Rupture of the extensor pollicis longus tendon after fracture of the lower end of the radius - a clinical and microangiographic study. The Hand, 11: 1: 76-86. GRIMES, A. H. (1979). Spontaneous Rupture of Muscles, Tendons and Insertions of the Same. Journal of the Arkansas Medical Society, 75: 11: 433.434. HELAL, B., CHEN, S. C. and IWEGBU, 6. (1982). Rupture of the extensor pollicis longus tendon in undisplaced Colles’ type of fracture. The Hand, 14: 1: 41-47. LONDON, P. S. A practicalguide to the care of the injured. Edinburgh: E & S Livingstone Ltd, 1967: 278. LUGGER, L. J. and PECHLANER, S. (1984). Tendon ruptures as a complication after osteosynthesis in the distal radius. Unfallchirurgie, 10: 266-270. McMASTER, P. E. (1932). Late Ruptures of Extensor and Flexor Pollicis Longus Tendons Following Colles’s Fracture. Journal of Bone and Joint Surgery, 14: 93-101. SIMPSON, R. G. (1977). Delayed rupture of extensor pollicis longus tendon following closed injury. The Hand, 9: 2: 160-161. TREVOR, D. (1950). Rupture of the Extensor Pollicis Longus Tendon after Colles Fracture. Journal of Bone and Joint Surgery, 32-B: 370-375. WEIGELDT, W. (1914). Uber die Spontanrupturen der Fingersehnen. Beitrage zur Klinischen Chirurgie, 94: 310-338. (Cited by McMaster, 1932). ZBRODOWSKI, A., GAJISIN, S. and GRODECKI, J. (1982). Yascularisation of the tendons of the extensor, pollicis longus, extensor carpi radialis longus and extensor carpi radialis brevis muscles. Journal of Anatomy, 135: 2: 235-244.
449
RUPTURE THE
OF THE EXTENSOR POLLICIS LONGUS TENDON: CASE AGAINST ATTRITION N. H. JENKINS and I. G. MACKIE
From the Department of Orthopaedic and Traumatic Surgery, University of Wales College of Medicine
The authors report the case of a 2fyear-old man who sustained ipsilateral volar Barton’s and scaphoid fractures which were complicated by a late rupture of the extensor pollicis longus tendon. The anatomy of the injury precluded attrition as the cause of the tendon rupture and the alternative theory of ischaemic rupture is examined. Clinicians should be aware that injuries other than the Colles’ fracture may be complicated by rupture of extensor pollicis longus. Whilst late rupture of the extensor pollicis longus tendon is a well-recognised, albeit uncommon, complication of the Colles’ fracture, its aetiology remains obscure. Various theories which apportion different emphases to the two most likely pathologies of mechanical attrition and ischaemic necrosis have been advanced (McMaster, 1932; Engkvist, 1979; Helal, 1982) but, because of a lack of experimental evidence, these necessarily remain speculative. We report a case of delayed rupture of the extensor pollicis longus tendon after ipsilateral volar Barton’s and scaphoid fractures, the anatomy of the bony injury precluding attritional rupture and thus demanding consideration of alternative theories. Case report A 23-year-old man suffered his wrist during a fall onto Radiographic examination fracture of the distal radius
Fig. 1
a hyper-extension injury of his outstretched right hand. revealed a volar Barton’s plus a fracture through the
waist of the scaphoid (Fig. 1). The fractures were treated by open reduction and internal fixation with a buttress T-plate and a Herbert screw via a single volar incision (Fig. 2). Post-operatively the man received physiotherapy and made a slow but satisfactory recovery. Three months later, he noticed a sudden snapping within the wrist followed by inability to actively extend the distal phalanx of the thumb. Clinical examination confirmed the lack of active extension at the interphalangeal joint, and also revealed a palpable defect within the extensor pollicis longus tendon immediately distal to Lister’s tubercle. A clinical diagnosis of late rupture of the extensor pollicis longus tendon was made and this was later confirmed at the subsequent extensor indicis to extensor pollicis longus tendon transfer procedure. Discussion The anatomical proximity of the extensor pollicis longus tendon to the Colles’ fracture site dictated that the earliest attempts to explain the rupture’s occurrence would concentrate upon the tendon’s mechanical
(a) and (b) P.A. and lateral radiographs showing a volar Barton’s fracture and a fracture through the scaphoid waist. The appearance of the dorsal rim of the radius on the lateral film is due to the underlying shadow of the ulnar styloid.
Received: 10 November 1987 Mr. I. G. Mackie, F.R.C.S., Consultant Orthopaedic Newport Road, Cardiff CF2 1SZ.
448
Surgeon, Cardiff Royal Infirmary,
Fig. 2
The fractures have been internally fixed with a T-plate and Herbert screw. THE JOURNAL
OF HAND SURGERY
LATE RUPTURE OF EXTENSOR POLLICIS LONGUS
attrition (McMaster, 1923). Unfortunately the literature has been slow to discard this theory (Grimes, 1979; Benjamin, 1982) despite the absence of roughened bone at exploration (Trevor, 1950; Bunata, 1983) and the inability to explain adequately the complication’s predilection for the undisplaced fracture. Indeed, even when operative or experimental evidence has favoured an alternative pathology, workers have continued to suggest mechanical explanations (Helal et al., 1982; Bunata, 1983). The bony anatomy of the present case is, however, unique in that it entirely precludes attritional rupture by either the fracture or the surgical implants (Lugger and Pechlander, 1984), and demands that alternative theories be examined. A vascular aetiology for the tendon’s rupture was suggested as long ago as 1914 (Weigeldt) and is the most popular alternative to the mechanical theory (Engkvist, 1979). Because of its unusual length, the extensor pollicis longus tendon receives a segmental vascular supply. The musculo-tendinous junction receives its supply from the anterior interosseous artery and its muscular branches, the distal portion of the tendon receives direct branches from the radial artery, whilst the mid-tendon (within the tendon sheath) obtains its supply from proximal and distal meso-tendons arising from the superficial dorsal carpal network and the posterior branch of the anterior interosseous artery (Zbrodowski et al., 1982). The injection studies of Engkvist and Lundborg (1979) demonstrated that the supplies from the two mesotendons fail to anastomose, resulting in a poorly nourished area of tendon in the region of Lister’s tubercle (Fig. 3). Helal injected radiological contrast medium into the tendon sheath of Colles’ fracture patients and confirmed London’s (1967) assumption that the sheath remains intact in minimally displaced fractures but is disrupted in more severe injuries. Should
Fig. 3
The arterial supply of the extensor pollicis longus tendon. The musculo-tendinous junction receives branches from the anterior interosseous artery (1) whilst the distal tendon receives direct branches (2) from the radial artery. The midtendon is supplied by branches of the anterior interosseous artery and the superficial dorsal carpal network (3) which run in proximal and distal meso-tendons within the tendon sheath. These latter two supplies fail to anastomose, leaving an avascular area immediately distal to Lister’s tubercle (4) (Extensor carpi radialis longus and brevis: (5).
VOL. 13-B No. 4 NOVEMBER 1988
the extensor pollicis longus tendon be direct blow (Simpson, 1977), or be crushed. between Lister’s tubercle and the styloid process of the third metacarpal in an extension injury (Benman, 1979), then the resultant effusion or haematoma within the intact tendon sheath may tamponade the already precarious blood supply of the damaged tendon. The consequent ischaemia might prevent repair or even produce further necrosis resulting in delayed rupture, the time of which would presumably be related to the extent of the tendon’s initial injury. That the tendon be damaged during the injury is central to the argument because, as the proponents of the attritional theory correctly state, an avascular transplanted tendon, which is otherwise normal, does not rupture (Benjamin, 3982). The case presented is unique because, to our knowledge, it is the first reported instance of rupture of the extensor pollicis longus tendon complicating ipsilateral volar Barton’s and scaphoid fractures. Our purpose in presenting the case is two-fold: first the anatomy of the injury allows an attempt to explain the aetiology of tendon rupture; and second, we wish to alert clinicians to the possibility of the rupture complicating wrist injuries other than the Colles’ fracture. Acknowledgments We wish to thank Mr. Keith Bellamy (Medical pnotographer, Cardiff Royal Infirmary) and Mrs. Janice Sharp (Medical illustrator, University Hospital of Wales) for their help in illustrating this paper.
References BENJAMIN, A. Injuries of the Forearm. in: Wilson, J. N. (Ed.). WatsonJones’ Fractures and joint injuries. Edinburgh: Churchill Livingstone, 1982: Vol2: 696. BUNATA, R. E. (1983). Impending Rupture of the Extensor Pollicis Longus Tendon after a Minimally Displaced Colles Fracture. Journal of Bone and Joint Surgery, 65A: 3: 401-402. DENMAN, E. E. (1979). Rupture of the extensor pollicis longus - a crush injury. The Hand, 11: 3: 295-298. ENGKVIST, 0. and LUNDBORG, G. (1979). Rupture of the extensor pollicis longus tendon after fracture of the lower end of the radius - a clinical and microangiographic study. The Hand, 11: 1: 76-86. GRIMES, A. H. (1979). Spontaneous Rupture of Muscles, Tendons and Insertions of the Same. Journal of the Arkansas Medical Society, 75: 11: 433.434. HELAL, B., CHEN, S. C. and IWEGBU, 6. (1982). Rupture of the extensor pollicis longus tendon in undisplaced Colles’ type of fracture. The Hand, 14: 1: 41-47. LONDON, P. S. A practicalguide to the care of the injured. Edinburgh: E & S Livingstone Ltd, 1967: 278. LUGGER, L. J. and PECHLANER, S. (1984). Tendon ruptures as a complication after osteosynthesis in the distal radius. Unfallchirurgie, 10: 266-270. McMASTER, P. E. (1932). Late Ruptures of Extensor and Flexor Pollicis Longus Tendons Following Colles’s Fracture. Journal of Bone and Joint Surgery, 14: 93-101. SIMPSON, R. G. (1977). Delayed rupture of extensor pollicis longus tendon following closed injury. The Hand, 9: 2: 160-161. TREVOR, D. (1950). Rupture of the Extensor Pollicis Longus Tendon after Colles Fracture. Journal of Bone and Joint Surgery, 32-B: 370-375. WEIGELDT, W. (1914). Uber die Spontanrupturen der Fingersehnen. Beitrage zur Klinischen Chirurgie, 94: 310-338. (Cited by McMaster, 1932). ZBRODOWSKI, A., GAJISIN, S. and GRODECKI, J. (1982). Yascularisation of the tendons of the extensor, pollicis longus, extensor carpi radialis longus and extensor carpi radialis brevis muscles. Journal of Anatomy, 135: 2: 235-244.
449