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SURGICAL TREATMENT FOR RECURRENT DISLOCATION OF THE EXTENSOR CARPI ULNARIS TENDON
SURGICAL TREATMENT FOR RECURRENT DISLOCATION OF THE EXTENSOR CARPI ULNARIS TENDON G. INOUE and Y. TAMURA From the Department of Orthopaedic Surgery, Toyohashi Municipal Hospital, Toyohashi, Japan
Twelve patients with recurrent dislocation of the extensor carpi ulnaris tendon were treated with repair or reconstruction of its tendon sheath, and each had a satisfactory result. We found three types of disruption of the fibro-osseous sheath. Type A: the fibro-osseous sheath ruptured ulnarly and the torn sheath lay superficial to the tendon (n ¼ 5). These were treated by reconstruction of the sheath using a piece of the extensor retinaculum. Type B: the fibro-osseous sheath ruptured radially and the torn sheath lay in the ulnar groove beneath the tendon (n ¼ 3). These were treated by direct suture of the sheath over the tendon. Type C: detachment of the periosteum from the ulnar side of the ulna in continuity with the fibro-osseous sheath formed a false pouch into which the tendon easily dislocated (n ¼ 4). These were treated by reattachment of the periosteum. Journal of Hand Surgery (British and European Volume, 2001) 26B: 6: 556–559 Traumatic recurrent dislocations of the extensor carpi ulnaris tendon are rare injuries and are characterized by a painful snapping on the ulnodorsal aspect of the wrist, particularly during forearm supination and wrist flexion. Many operative methods of stabilization have been reported (Burkhart et al., 1982; Eckhardt and Palmer, 1981; Rayan, 1983; Spinner and Kaplan, 1970; Vulpius, 1964), but little has been written about the nature of the tendon sheath lesion. We have previously reported five patients with this condition resulting from an athletic injury and described two different types of lesion (Inoue and Tamura, 1998). We describe three different methods of repair of the fibro-osseous sheath, the choice of which depends on the type of lesion.
ulnaris tendon in an ulnar and palmar direction was confirmed with the forearm in supination and the wrist in flexion. The fibro-osseous sheath was found to be torn
PATIENTS AND METHODS Between 1990 and 2000, we treated 12 patients with recurrent dislocation of the extensor carpi ulnaris tendon. Eight were men and four were women, with an age range of 19–40 years. Eight of the injuries were sustained during sporting activities (three playing tennis, three playing golf and two playing volley ball). Three injuries occured after falling onto the wrist and one occured after twisting in a forklift. Six patients recalled that their injuries occurred in an ulnar deviationhypersupination injury to the wrist and was accompanied by an audible click over the dorsoulnar aspect of the wrist. Seven cases involved the right wrist and five the left wrist. The average duration of symptoms was 17 months (range, 10 days–84 months). All patients could reproduce the dislocation of the extensor carpi ulnaris tendon with the forearm in supination and the wrist in palmar flexion, with or without ulnar deviation. Surgical exploration was done using axillary block anaesthesia under pneumatic tourniquet control. The extensor retinaculum was found to be intact and was opened longitudinally. Dislocation of the extensor carpi
Fig 1 The three types of disruption of the fibro-osseous sheath (transverse sections of the distal end of the ulna). Type A: the fibro-osseous sheath is disrupted from the ulnar wall and the extensor carpi ulnaris tendon may lie beneath the fibro-osseous sheath. Type B: the fibro-osseous sheath is disrupted from the radial wall and the tendon may overlie it and prevent healing. Type C: the extensor carpi ulnaris tendon dislocates into a false pouch formed by stripping of the periosteum from the ulna. 556
RECURRENT ECU TENDON DISLOCATION
557
Fig 2 Type A injury. a) The extensor carpi ulnaris tendon is dislocated in an ulnar and palmar direction. The arrow indicates the attenuated edge of the torn fibro-osseous sheath. b) The fibro-osseous sheath is reconstructed using a piece of the extensor retinaculum.
Fig 3 Type B injury. a) The extensor carpi ulnaris tendon (arrow) is dislocated palmarly and ulnarly. The asterisk shows the torn fibro-osseous sheath overlying the ulnar head. The white arrow indicated the extensor retinaculum (reflected). b) The torn fibro-osseous sheath is retrieved from under the extensor carpi ulnaris tendon (arrow). The forceps are holding the torn edge of the fibro-osseous sheath. c) The fibro-osseous sheath is fastened to the radial side of the ulnar groove over the extensor carpi ulnaris tendon (arrow).
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THE JOURNAL OF HAND SURGERY VOL. 26B No. 6 DECEMBER 2001
Fig 4 Type C injury. a) The fibro-osseous sheath has been incised and its edge and the periosteum are retracted to show the false pouch (asterisk). The extensor carpi ulnaris tendon (arrow) is in its normal position. b) The extensor carpi ulnaris tendon is now dislocated into the false pouch. c) Sutures are passed through the periosteal flap and drill holes at the margin of the ulnar groove, to close the false pouch. d) The incision in the fibro-osseous sheath is closed.
through its entire length from the ulnar retaining wall in five cases (Type A) and from the radial wall in three cases (Type B) (Fig 1). In Type A cases, the sheath reconstruction was done using a strip of fascia from the extensor retinaculum because direct suture of the torn edges of the sheath was difficult due to contracture or attenuation of the structures (Fig 2). In Type B cases, the fibro-osseous flap lay on the floor of the compartment beneath the extensor carpi ulnaris tendon (Fig 3a, b). The sheath could be repaired anatomically, by direct suture of the free edge of the flap to the adjacent soft tissue of the radial side of the compartment (Fig 3c). In four cases the periosteum had been torn from its attachment to the ulna (Type C), but remained in continuity with the fibro-osseous sheath. The detachment of the periosteum extended forward to the lateral margin of the ulna (Fig 4a), forming a false pouch into which the ECU tendon easily dislocated (Fig 4b); this appearance is similar to that of Bankart’s lesion in recurrent dislocation of the shoulder. After incising the
true fibro-osseous sheath and scarifying the outer surface of the ulna, four drill holes were made in the lateral edge of the ulnar groove, and sutures were passed through the fibro-osseous flap and drill holes and tied, so as to obliterate the pouch (Fig 4c). The incision in the fibro-osseous sheath was then closed (Fig 4d). After all three types of operation, the wrist was placed in a long arm cast with the elbow in 908 of flexion and neutral forearm rotation for 6 weeks. Athletic and vigorous activities were restricted for an additional 3 months. Follow-up evaluation consisted of a combination of clinical visits and/or responses to a short-answer questionnaire, with an average follow-up period of 20 months (range, 6–48 months).
RESULTS All patients claimed a normal range of motion of the forearm and wrist with no pain, and did well at their
RECURRENT ECU TENDON DISLOCATION
previous work and sports activities. There were no cases of recurrent dislocation of the extensor carpi ulnaris tendon. DISCUSSION Spinner and Kaplan (1970) described the anatomical details of the extensor compartments of the wrist and observed that the extensor carpi ulnaris tendon possessed a unique fibro-osseous sheath deep to the extensor retinaculum. They believed that this deep fibrous layer maintained the tendon in its normal position and that division or attenuation of it allowed dislocation of the tendon even if the overlying extensor retinaculum was intact. Taleisnik et al. (1984) and Palmer et al. (1985) support this opinion. There is general agreement that this injury may occur with hypersupination of the forearm and ulnar deviation and flexion of the wrist, with active voluntary contraction of the extensor carpi ulnaris muscle (Burkhart et al., 1982; Eckhardt and Palmer, 1981; Rayan, 1983; Rowland, 1986; Vulpius, 1964). The extensor carpi ulnaris tendon runs through the sixth extensor compartment of the wrist at an ‘‘ulnarly-directed’’ obtuse angle that results in ulnar translational stress during muscle contraction. In full supination and wrist ulnar deviation, this angle may become more acute, resulting in a greater force vector against the fibro-osseous sheath. With complete disruption of this sheath, the tendon may bowstring and dislocate across the ulnar styloid. We observed three types of disruption of the fibroosseous sheath. When a tear of the fibro-osseous sheath occurs at the ulnar wall, the extensor carpi ulnaris tendon lies deep to the torn fibro-osseous sheath when relocated in its ulnar groove (Type A). Burkhart et al. (1982) and Rayan (1983) suggested that acute injuries can be treated by cast immobilization with the forearm in pronation and the wrist in radial deviation. Rowland (1986), however, operated on an acute case and found that there was a considerable gap between the torn edges of the fibro-osseous sheath, regardless of the position of the wrist. This suggests that unsatisfactory healing of the fibro-osseous sheath may occur after an acute disloca-
559
tion of the extensor carpi ulnaris tendon (Type A). When a tear occurs at the radial wall, the extensor carpi ulnaris tendon may lie superficial to the torn fibroosseous sheath, thus eliminating any chance of the sheath healing (Type B). In Type C lesions, the stripped periosteum may have the potential to heal anatomically if treated early (within 2 to 3 weeks of injury). However, as it is impossible to clinically distinguish between the types of lesion, we recommend surgical exploration of all symptomatic dislocations of the extensor carpi ulnaris tendon, even in an acute case. Careful inspection of the lesion at the time of surgery should determine the type of repair. Acknowledgement Fig 1-A,B, Fig 2-b, and Fig 3-a,b,c are reproduced with the permission of the BMJ Publishing Group from British Journal of Sports Medicine 32: 172–174.
References Burkhart SS, Wood MB, Linscheid RL (1982). Posttraumatic recurrent subluxation of the extensor carpi ulnaris tendon. Journal of Hand Surgery, 7: 1–3. Eckhardt WA, Palmer AK (1981). Recurrent dislocation of extensor carpi ulnaris tendon. Journal of Hand Surgery, 6: 629–631. Inoue G, Tamura Y (1998). Recurrent dislocation of the extensor carpi ulnaris tendon. British Journal of Sports Medicine, 32: 172–174. Palmer AK, Skahen JR, Werner FW, Glisson RR (1985). The extensor retinaculum of the wrist: an anatomical and biomechanical study. Journal of Hand Surgery 10B: 11–16. 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. Spinner M, Kaplan B (1970). Extensor carpi ulnaris: Its relationship to the stability of the distal radio-ulnar joint. Clinical Orthopaedics and Related Research, 68: 124–129. Taleisnik J, Gelberman RH, Miller BW, Szabo RM (1984). The extensor retinaculum of the wrist. Journal of Hand Surgery, 9A: 495–501. Vulpius J (1964). Habitual dislocation of the extensor carpi ulnaris tendon. Acta Orthopaedica Scandinavica, 1: 105–108.
Received: 15 December 2000 Accepted after revision: 6 April 2001 Dr Goro Inoue, Department of Orthopaedic Surgery, Toyohashi Municipal Hospital, 50 Hatikennishi, Aotake, Toyohashi, 441-8570, Japan. E-mail: [email protected] # 2001 The British Society for Surgery of the Hand doi: 10.1054/jhsb.2001.0615, available online at http://www.idealibrary.com on
Twelve patients with recurrent dislocation of the extensor carpi ulnaris tendon were treated with repair or reconstruction of its tendon sheath, and each had a satisfactory result. We found three types of disruption of the fibro-osseous sheath. Type A: the fibro-osseous sheath ruptured ulnarly and the torn sheath lay superficial to the tendon (n ¼ 5). These were treated by reconstruction of the sheath using a piece of the extensor retinaculum. Type B: the fibro-osseous sheath ruptured radially and the torn sheath lay in the ulnar groove beneath the tendon (n ¼ 3). These were treated by direct suture of the sheath over the tendon. Type C: detachment of the periosteum from the ulnar side of the ulna in continuity with the fibro-osseous sheath formed a false pouch into which the tendon easily dislocated (n ¼ 4). These were treated by reattachment of the periosteum. Journal of Hand Surgery (British and European Volume, 2001) 26B: 6: 556–559 Traumatic recurrent dislocations of the extensor carpi ulnaris tendon are rare injuries and are characterized by a painful snapping on the ulnodorsal aspect of the wrist, particularly during forearm supination and wrist flexion. Many operative methods of stabilization have been reported (Burkhart et al., 1982; Eckhardt and Palmer, 1981; Rayan, 1983; Spinner and Kaplan, 1970; Vulpius, 1964), but little has been written about the nature of the tendon sheath lesion. We have previously reported five patients with this condition resulting from an athletic injury and described two different types of lesion (Inoue and Tamura, 1998). We describe three different methods of repair of the fibro-osseous sheath, the choice of which depends on the type of lesion.
ulnaris tendon in an ulnar and palmar direction was confirmed with the forearm in supination and the wrist in flexion. The fibro-osseous sheath was found to be torn
PATIENTS AND METHODS Between 1990 and 2000, we treated 12 patients with recurrent dislocation of the extensor carpi ulnaris tendon. Eight were men and four were women, with an age range of 19–40 years. Eight of the injuries were sustained during sporting activities (three playing tennis, three playing golf and two playing volley ball). Three injuries occured after falling onto the wrist and one occured after twisting in a forklift. Six patients recalled that their injuries occurred in an ulnar deviationhypersupination injury to the wrist and was accompanied by an audible click over the dorsoulnar aspect of the wrist. Seven cases involved the right wrist and five the left wrist. The average duration of symptoms was 17 months (range, 10 days–84 months). All patients could reproduce the dislocation of the extensor carpi ulnaris tendon with the forearm in supination and the wrist in palmar flexion, with or without ulnar deviation. Surgical exploration was done using axillary block anaesthesia under pneumatic tourniquet control. The extensor retinaculum was found to be intact and was opened longitudinally. Dislocation of the extensor carpi
Fig 1 The three types of disruption of the fibro-osseous sheath (transverse sections of the distal end of the ulna). Type A: the fibro-osseous sheath is disrupted from the ulnar wall and the extensor carpi ulnaris tendon may lie beneath the fibro-osseous sheath. Type B: the fibro-osseous sheath is disrupted from the radial wall and the tendon may overlie it and prevent healing. Type C: the extensor carpi ulnaris tendon dislocates into a false pouch formed by stripping of the periosteum from the ulna. 556
RECURRENT ECU TENDON DISLOCATION
557
Fig 2 Type A injury. a) The extensor carpi ulnaris tendon is dislocated in an ulnar and palmar direction. The arrow indicates the attenuated edge of the torn fibro-osseous sheath. b) The fibro-osseous sheath is reconstructed using a piece of the extensor retinaculum.
Fig 3 Type B injury. a) The extensor carpi ulnaris tendon (arrow) is dislocated palmarly and ulnarly. The asterisk shows the torn fibro-osseous sheath overlying the ulnar head. The white arrow indicated the extensor retinaculum (reflected). b) The torn fibro-osseous sheath is retrieved from under the extensor carpi ulnaris tendon (arrow). The forceps are holding the torn edge of the fibro-osseous sheath. c) The fibro-osseous sheath is fastened to the radial side of the ulnar groove over the extensor carpi ulnaris tendon (arrow).
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THE JOURNAL OF HAND SURGERY VOL. 26B No. 6 DECEMBER 2001
Fig 4 Type C injury. a) The fibro-osseous sheath has been incised and its edge and the periosteum are retracted to show the false pouch (asterisk). The extensor carpi ulnaris tendon (arrow) is in its normal position. b) The extensor carpi ulnaris tendon is now dislocated into the false pouch. c) Sutures are passed through the periosteal flap and drill holes at the margin of the ulnar groove, to close the false pouch. d) The incision in the fibro-osseous sheath is closed.
through its entire length from the ulnar retaining wall in five cases (Type A) and from the radial wall in three cases (Type B) (Fig 1). In Type A cases, the sheath reconstruction was done using a strip of fascia from the extensor retinaculum because direct suture of the torn edges of the sheath was difficult due to contracture or attenuation of the structures (Fig 2). In Type B cases, the fibro-osseous flap lay on the floor of the compartment beneath the extensor carpi ulnaris tendon (Fig 3a, b). The sheath could be repaired anatomically, by direct suture of the free edge of the flap to the adjacent soft tissue of the radial side of the compartment (Fig 3c). In four cases the periosteum had been torn from its attachment to the ulna (Type C), but remained in continuity with the fibro-osseous sheath. The detachment of the periosteum extended forward to the lateral margin of the ulna (Fig 4a), forming a false pouch into which the ECU tendon easily dislocated (Fig 4b); this appearance is similar to that of Bankart’s lesion in recurrent dislocation of the shoulder. After incising the
true fibro-osseous sheath and scarifying the outer surface of the ulna, four drill holes were made in the lateral edge of the ulnar groove, and sutures were passed through the fibro-osseous flap and drill holes and tied, so as to obliterate the pouch (Fig 4c). The incision in the fibro-osseous sheath was then closed (Fig 4d). After all three types of operation, the wrist was placed in a long arm cast with the elbow in 908 of flexion and neutral forearm rotation for 6 weeks. Athletic and vigorous activities were restricted for an additional 3 months. Follow-up evaluation consisted of a combination of clinical visits and/or responses to a short-answer questionnaire, with an average follow-up period of 20 months (range, 6–48 months).
RESULTS All patients claimed a normal range of motion of the forearm and wrist with no pain, and did well at their
RECURRENT ECU TENDON DISLOCATION
previous work and sports activities. There were no cases of recurrent dislocation of the extensor carpi ulnaris tendon. DISCUSSION Spinner and Kaplan (1970) described the anatomical details of the extensor compartments of the wrist and observed that the extensor carpi ulnaris tendon possessed a unique fibro-osseous sheath deep to the extensor retinaculum. They believed that this deep fibrous layer maintained the tendon in its normal position and that division or attenuation of it allowed dislocation of the tendon even if the overlying extensor retinaculum was intact. Taleisnik et al. (1984) and Palmer et al. (1985) support this opinion. There is general agreement that this injury may occur with hypersupination of the forearm and ulnar deviation and flexion of the wrist, with active voluntary contraction of the extensor carpi ulnaris muscle (Burkhart et al., 1982; Eckhardt and Palmer, 1981; Rayan, 1983; Rowland, 1986; Vulpius, 1964). The extensor carpi ulnaris tendon runs through the sixth extensor compartment of the wrist at an ‘‘ulnarly-directed’’ obtuse angle that results in ulnar translational stress during muscle contraction. In full supination and wrist ulnar deviation, this angle may become more acute, resulting in a greater force vector against the fibro-osseous sheath. With complete disruption of this sheath, the tendon may bowstring and dislocate across the ulnar styloid. We observed three types of disruption of the fibroosseous sheath. When a tear of the fibro-osseous sheath occurs at the ulnar wall, the extensor carpi ulnaris tendon lies deep to the torn fibro-osseous sheath when relocated in its ulnar groove (Type A). Burkhart et al. (1982) and Rayan (1983) suggested that acute injuries can be treated by cast immobilization with the forearm in pronation and the wrist in radial deviation. Rowland (1986), however, operated on an acute case and found that there was a considerable gap between the torn edges of the fibro-osseous sheath, regardless of the position of the wrist. This suggests that unsatisfactory healing of the fibro-osseous sheath may occur after an acute disloca-
559
tion of the extensor carpi ulnaris tendon (Type A). When a tear occurs at the radial wall, the extensor carpi ulnaris tendon may lie superficial to the torn fibroosseous sheath, thus eliminating any chance of the sheath healing (Type B). In Type C lesions, the stripped periosteum may have the potential to heal anatomically if treated early (within 2 to 3 weeks of injury). However, as it is impossible to clinically distinguish between the types of lesion, we recommend surgical exploration of all symptomatic dislocations of the extensor carpi ulnaris tendon, even in an acute case. Careful inspection of the lesion at the time of surgery should determine the type of repair. Acknowledgement Fig 1-A,B, Fig 2-b, and Fig 3-a,b,c are reproduced with the permission of the BMJ Publishing Group from British Journal of Sports Medicine 32: 172–174.
References Burkhart SS, Wood MB, Linscheid RL (1982). Posttraumatic recurrent subluxation of the extensor carpi ulnaris tendon. Journal of Hand Surgery, 7: 1–3. Eckhardt WA, Palmer AK (1981). Recurrent dislocation of extensor carpi ulnaris tendon. Journal of Hand Surgery, 6: 629–631. Inoue G, Tamura Y (1998). Recurrent dislocation of the extensor carpi ulnaris tendon. British Journal of Sports Medicine, 32: 172–174. Palmer AK, Skahen JR, Werner FW, Glisson RR (1985). The extensor retinaculum of the wrist: an anatomical and biomechanical study. Journal of Hand Surgery 10B: 11–16. 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. Spinner M, Kaplan B (1970). Extensor carpi ulnaris: Its relationship to the stability of the distal radio-ulnar joint. Clinical Orthopaedics and Related Research, 68: 124–129. Taleisnik J, Gelberman RH, Miller BW, Szabo RM (1984). The extensor retinaculum of the wrist. Journal of Hand Surgery, 9A: 495–501. Vulpius J (1964). Habitual dislocation of the extensor carpi ulnaris tendon. Acta Orthopaedica Scandinavica, 1: 105–108.
Received: 15 December 2000 Accepted after revision: 6 April 2001 Dr Goro Inoue, Department of Orthopaedic Surgery, Toyohashi Municipal Hospital, 50 Hatikennishi, Aotake, Toyohashi, 441-8570, Japan. E-mail: [email protected] # 2001 The British Society for Surgery of the Hand doi: 10.1054/jhsb.2001.0615, available online at http://www.idealibrary.com on