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Traumatic avulsion of the tendon of extensor carpi radialis longus
Vol. 12A, No.6 November 1987
7. Kaplan EB. Functional and surgical anatomy of the hand. 3rd ed. Philadelphia: JB Lippincott, 1984: 153-78. 8. Spinner M, Kaplan E. Extensor carpi ulnaris: Its relationship to the stability of the distal radioulnar joint. Clin Orthop 1970;68:124-9. 9. Palmer AK, Skahen FW, Glisson RR. The extensor ret-
Chronic ulnar wrist pain
inaculum of the wrist: An anatomical and biomechanical study. J HAND SURG 1985;lOB:11-16. 10. Taleisnik J, Gelberman RH, Miller BW, Szabo RM. Extensor retinaculum of wrist. J HAND SURG 1984;9A:495501.
Traumatic avulsion of the tendon of extensor carpi radialis longus A case of isolated traumatic avulsion of the tendon of extensor carpi radialis longus (ECRL) is described. Surgical repair was attempted 12 days later, but an early contracture of the muscle was encountered. The tendon could not be pulled down to its insertion and was sutured side to side to the tendon of extensor carpi radialis brevis (ECRB). A year later the patient had residual weakness of wrist extension and hand grip. The likely cause of the early contracture of the muscle and the need for early and accurate reposition of extensor carpi radialis longus tendon are described. (J HAND SURG 1987;12A:I035-7.)
Bahman Sadr, F.R.C.S. Eng., F.R.C.S. Ed. (Orth), and Manouchehr Lalehzarian, M.D., Washington, D.C.
Closed ruptures and avulsions of tendons are commonplace in various anatomical sites, but an isolated avulsion of the tendon of extensor carpi radialis longus (ECRL) is unusual.
Case report A 55-year-old right-handed laborer came to the Veterans Administration Medical Center with a 10-day history of painful right wrist and a swelling in the extensor muscle mass below the right elbow. The problem had begun with a fist fight in which he struck his opponent's jaw with his right hand and experienced immediate pain in his wrist. SubseFrom the Orthopaedic Department, Veterans Administration Medical Center, Washington, D.C. Received for publication Dec. I, 1986; accepted in revised form March 31, 1987. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Bahman Sadr, F.R.C.S. Eng. F.R.C.S. Ed. (Orth), Orthopaedic Department, Veterans Administration Medical Center, 50 Irving St., N.W., Washington, D.C. 20422.
quently he had noted a soft swelling in the extensor muscle mass below his elbow (Fig. 1). Over the following 3 to 4 days the discomfort in his wrist had diminished, but the swelling in his forearm remained unchanged. The weakness of his wrist interfered with his work as a laborer. He denied any previous injury. Clinical examination revealed a mobile wrist that was weak (4/5) in extension. There was tenderness over the base of the index metacarpal dorsally. A soft tissue swelling was evident in the extensor muscle mass below the elbow. X-ray films of the wrist revealed a fragment of bone approximately 8 cm proximal to the base of the index metacarpal (Fig. 2). Avulsion of the tendon of extensor carpi radialis longus was diagnosed and 2 days later (12 days after injury) he was operated on under an axillary block. A small incision was made over the base of the index metacarpal and another curved incision proximal to the radial styloid overlying the stump of the tendon. A bony fragment was seen attached to the distal end of the tendon of ECRL. This corresponded to a deficit in the base of the index metacarpal and had the appearance of an acute injury. In addition the base of the index metacarpal had lost another large fragment that was reduced and fixed with two Kirschner wires. An attempt was then made to pull the tendon of ECRL down to its insertion
THE JOURNAL OF HAND SURGERY
1035
1036
The Journal of HAND SURGERY
Sadr and Lalehzarian
Fig. 1. Swelling in the extensor muscle mass of the elbow after avulsion of the tendon of ECRL and contraction of the muscle belly.
Fig. 2. X-ray film of the forearm showing the avulsed frag ment to bone (arrow) 8 cm proximal to the base of the second metacarpal .
in the base of the index metacarpal but despite release of the tourniquet, flexion of the elbow, extension of the wrist, and sustained traction on the tendon this was found to be impossible . Consequently the tendon was sutured side to side to the tendon of extensor carpi radialis brevis (ECRB) after excision of the bony fragment and division of the second extensor compartment, approximately 1.5 cm proximal to the base of the index metacarpal. During this maneuver the muscle swelling in the upper forearm was seen to diminish in size but not completely disappear. The wrist was then splinted in extension . The patient made an uneventful recovery. Physical therapy was started after removal of the splint 3 weeks postoperatively. He returned to work 3 weeks later. He was examined 13 months later at which time he expressed satisfaction with the result of the operation stating that he had regained most , but not all, of his strength in the right wrist and hand . He was fully employed as a laborer but was aware of some weakness of grip in his right hand during heavy lifting and discomfort in his wrist when using a hammer. On clinical examination he had a mobile wrist that lacked 15° of flexion and 10° of ulnar
deviation compared with the other side . Grip strength on the right (dominant) side was diminished by 25% and there was a clinical impression of weakness in the wrist extensors. Isokinetic testing with Cybex revealed a relative loss of strength in the right wrist extensors (wrist flexor/ wrist extensor strength ratio: 216% on right, 117% on left) but no significant loss of power. The swelling at the elbow was still present although it was smaller than before surgery.
Discussion While avulsion of the tendon of ECRL is known to occur in association with severe trauma to the hand' an isolated avulsion of the tendon attached to a fragment of bone is rare. 2 The likely mechanism of injury in this patient was axial loading of the index metacarpal on impact with the opponent's jaw, comminution of the base of the metacarpal as it was driven into the carpus, and subsequent retraction of a fragment of bone by the attached tendon of ECRL. The unique feature of this case is the amount of retraction, 8 cm as measured on
Vol. 12A, No.6 November 1987
the radiograph, which is considerably greater than previously reported cases. Our dilemma with this patient was whether or not to treat the lesion surgically. In the presence of an intact ECRB and extensor carpi ulnaris (ECU) it may be assumed that reattachment of the ECRL tendon would be of little value. DeLee 2 however recommended reattachment of the bony fragment both to restore the congruity of the base of the index metacarpal and also to replace the insertion of the tendon. Brand, Beach, and Thompson 3 found the excursion and tension in the ECRL to be comparable to those in the ECRB or ECU suggesting that the ECRL contributes significantly to the strength of wrist extension. In this case we failed to restore normal resting length and tension in the ECRL and the patient subsequently had residual weakness in his grip and wrist extension. Our inability to pull down the ECRL tendon to its insertion only 12 days after injury was surprising. There is experimental evidence4 that muscle can rapidly adapt to a change in resting length by a loss or gain of sarcomeres resulting in a change of fiber length. This is possibly the mechanism responsible for the early contracture of this muscle although early adhesion formation around the fascial origin of this muscle may have also contributed. Another possibility is that we were dealing with an older injury. However, we had little reason to doubt the patient's history and the appearance of the fracture at the base of the index metacarpal was consistent with an acute injury.
Traumatic avulsion of tendon of ECRL
1037
In retrospect we wonder if our case should have been managed differently and if faced with a similar situation in the future any other action should be undertaken. From a purely theoretical viewpoint it may be possible to reverse the adaptive shortening in muscle fiber length by gradual and staged elongation (Brand PW, personal communication). In other words the retracted tendon can be pulled out to the limit of excursion and attached temporarily to an adjacent structure, perhaps another tendon. At the second stage, 3 to 4 weeks later, further traction can be applied on the tendon to bring it to its original insertion. However, to our knowledge no experience exists with this technique and it is not known whether it would be of any practical value. REFERENCES 1. Weiland AJ, Lister AD, Villarreal-Rios A. Volar fracture
dislocation of the second and third carpometacarpal joints associated with acute carpal tunnel syndrome. J Trauma 1976;16:672-5. 2. DeLee JC. Avulsion fracture of the base of the second metacarpal by the extensor carpi radialis longus. J Bone Joint Surg [Am] 1979;61:445-6. 3. Brand PW, Beach RB, Thompson DE. Relative tension and potential excursion of muscles in the forearm and hand. J HAND SURG 1981;6:209-19. 4. Brand PW. Clinical mechanics of the hand. St. Louis: The CV Mosby Co, 1985;26-7.
7. Kaplan EB. Functional and surgical anatomy of the hand. 3rd ed. Philadelphia: JB Lippincott, 1984: 153-78. 8. Spinner M, Kaplan E. Extensor carpi ulnaris: Its relationship to the stability of the distal radioulnar joint. Clin Orthop 1970;68:124-9. 9. Palmer AK, Skahen FW, Glisson RR. The extensor ret-
Chronic ulnar wrist pain
inaculum of the wrist: An anatomical and biomechanical study. J HAND SURG 1985;lOB:11-16. 10. Taleisnik J, Gelberman RH, Miller BW, Szabo RM. Extensor retinaculum of wrist. J HAND SURG 1984;9A:495501.
Traumatic avulsion of the tendon of extensor carpi radialis longus A case of isolated traumatic avulsion of the tendon of extensor carpi radialis longus (ECRL) is described. Surgical repair was attempted 12 days later, but an early contracture of the muscle was encountered. The tendon could not be pulled down to its insertion and was sutured side to side to the tendon of extensor carpi radialis brevis (ECRB). A year later the patient had residual weakness of wrist extension and hand grip. The likely cause of the early contracture of the muscle and the need for early and accurate reposition of extensor carpi radialis longus tendon are described. (J HAND SURG 1987;12A:I035-7.)
Bahman Sadr, F.R.C.S. Eng., F.R.C.S. Ed. (Orth), and Manouchehr Lalehzarian, M.D., Washington, D.C.
Closed ruptures and avulsions of tendons are commonplace in various anatomical sites, but an isolated avulsion of the tendon of extensor carpi radialis longus (ECRL) is unusual.
Case report A 55-year-old right-handed laborer came to the Veterans Administration Medical Center with a 10-day history of painful right wrist and a swelling in the extensor muscle mass below the right elbow. The problem had begun with a fist fight in which he struck his opponent's jaw with his right hand and experienced immediate pain in his wrist. SubseFrom the Orthopaedic Department, Veterans Administration Medical Center, Washington, D.C. Received for publication Dec. I, 1986; accepted in revised form March 31, 1987. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Bahman Sadr, F.R.C.S. Eng. F.R.C.S. Ed. (Orth), Orthopaedic Department, Veterans Administration Medical Center, 50 Irving St., N.W., Washington, D.C. 20422.
quently he had noted a soft swelling in the extensor muscle mass below his elbow (Fig. 1). Over the following 3 to 4 days the discomfort in his wrist had diminished, but the swelling in his forearm remained unchanged. The weakness of his wrist interfered with his work as a laborer. He denied any previous injury. Clinical examination revealed a mobile wrist that was weak (4/5) in extension. There was tenderness over the base of the index metacarpal dorsally. A soft tissue swelling was evident in the extensor muscle mass below the elbow. X-ray films of the wrist revealed a fragment of bone approximately 8 cm proximal to the base of the index metacarpal (Fig. 2). Avulsion of the tendon of extensor carpi radialis longus was diagnosed and 2 days later (12 days after injury) he was operated on under an axillary block. A small incision was made over the base of the index metacarpal and another curved incision proximal to the radial styloid overlying the stump of the tendon. A bony fragment was seen attached to the distal end of the tendon of ECRL. This corresponded to a deficit in the base of the index metacarpal and had the appearance of an acute injury. In addition the base of the index metacarpal had lost another large fragment that was reduced and fixed with two Kirschner wires. An attempt was then made to pull the tendon of ECRL down to its insertion
THE JOURNAL OF HAND SURGERY
1035
1036
The Journal of HAND SURGERY
Sadr and Lalehzarian
Fig. 1. Swelling in the extensor muscle mass of the elbow after avulsion of the tendon of ECRL and contraction of the muscle belly.
Fig. 2. X-ray film of the forearm showing the avulsed frag ment to bone (arrow) 8 cm proximal to the base of the second metacarpal .
in the base of the index metacarpal but despite release of the tourniquet, flexion of the elbow, extension of the wrist, and sustained traction on the tendon this was found to be impossible . Consequently the tendon was sutured side to side to the tendon of extensor carpi radialis brevis (ECRB) after excision of the bony fragment and division of the second extensor compartment, approximately 1.5 cm proximal to the base of the index metacarpal. During this maneuver the muscle swelling in the upper forearm was seen to diminish in size but not completely disappear. The wrist was then splinted in extension . The patient made an uneventful recovery. Physical therapy was started after removal of the splint 3 weeks postoperatively. He returned to work 3 weeks later. He was examined 13 months later at which time he expressed satisfaction with the result of the operation stating that he had regained most , but not all, of his strength in the right wrist and hand . He was fully employed as a laborer but was aware of some weakness of grip in his right hand during heavy lifting and discomfort in his wrist when using a hammer. On clinical examination he had a mobile wrist that lacked 15° of flexion and 10° of ulnar
deviation compared with the other side . Grip strength on the right (dominant) side was diminished by 25% and there was a clinical impression of weakness in the wrist extensors. Isokinetic testing with Cybex revealed a relative loss of strength in the right wrist extensors (wrist flexor/ wrist extensor strength ratio: 216% on right, 117% on left) but no significant loss of power. The swelling at the elbow was still present although it was smaller than before surgery.
Discussion While avulsion of the tendon of ECRL is known to occur in association with severe trauma to the hand' an isolated avulsion of the tendon attached to a fragment of bone is rare. 2 The likely mechanism of injury in this patient was axial loading of the index metacarpal on impact with the opponent's jaw, comminution of the base of the metacarpal as it was driven into the carpus, and subsequent retraction of a fragment of bone by the attached tendon of ECRL. The unique feature of this case is the amount of retraction, 8 cm as measured on
Vol. 12A, No.6 November 1987
the radiograph, which is considerably greater than previously reported cases. Our dilemma with this patient was whether or not to treat the lesion surgically. In the presence of an intact ECRB and extensor carpi ulnaris (ECU) it may be assumed that reattachment of the ECRL tendon would be of little value. DeLee 2 however recommended reattachment of the bony fragment both to restore the congruity of the base of the index metacarpal and also to replace the insertion of the tendon. Brand, Beach, and Thompson 3 found the excursion and tension in the ECRL to be comparable to those in the ECRB or ECU suggesting that the ECRL contributes significantly to the strength of wrist extension. In this case we failed to restore normal resting length and tension in the ECRL and the patient subsequently had residual weakness in his grip and wrist extension. Our inability to pull down the ECRL tendon to its insertion only 12 days after injury was surprising. There is experimental evidence4 that muscle can rapidly adapt to a change in resting length by a loss or gain of sarcomeres resulting in a change of fiber length. This is possibly the mechanism responsible for the early contracture of this muscle although early adhesion formation around the fascial origin of this muscle may have also contributed. Another possibility is that we were dealing with an older injury. However, we had little reason to doubt the patient's history and the appearance of the fracture at the base of the index metacarpal was consistent with an acute injury.
Traumatic avulsion of tendon of ECRL
1037
In retrospect we wonder if our case should have been managed differently and if faced with a similar situation in the future any other action should be undertaken. From a purely theoretical viewpoint it may be possible to reverse the adaptive shortening in muscle fiber length by gradual and staged elongation (Brand PW, personal communication). In other words the retracted tendon can be pulled out to the limit of excursion and attached temporarily to an adjacent structure, perhaps another tendon. At the second stage, 3 to 4 weeks later, further traction can be applied on the tendon to bring it to its original insertion. However, to our knowledge no experience exists with this technique and it is not known whether it would be of any practical value. REFERENCES 1. Weiland AJ, Lister AD, Villarreal-Rios A. Volar fracture
dislocation of the second and third carpometacarpal joints associated with acute carpal tunnel syndrome. J Trauma 1976;16:672-5. 2. DeLee JC. Avulsion fracture of the base of the second metacarpal by the extensor carpi radialis longus. J Bone Joint Surg [Am] 1979;61:445-6. 3. Brand PW, Beach RB, Thompson DE. Relative tension and potential excursion of muscles in the forearm and hand. J HAND SURG 1981;6:209-19. 4. Brand PW. Clinical mechanics of the hand. St. Louis: The CV Mosby Co, 1985;26-7.