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Closed Rupture of the Flexor Tendons Caused by Carpal Bone and Joint Disorders

From the Department of Orthopaedic Surgery, Shinshu University School of Medicine, Matsumoto City, Nagano, Japan, the Department of Orthopaedic Surgery, National Nagano Hospital, Ueda City, Nagano, Japan and the Department of Orthopaedic Surgery, Showainan General Hospital, Komagane City, Nagano, Japan

Correspondence: Dr Hiroshi Yamazaki, MD, Department of Orthopaedic Surgery, Shinshu University School of Medicine, 3-1-1, Asahi, Matsumoto City, Nagano 390 0304, Japan. Tel.: +81 263 37 2659; fax: +81 263 35 8844. E-mail:h-ymzk{at}hsp.md.shinshu-u.ac.jp

	Abstract

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We analysed 21 patients with closed rupture of the flexor tendons caused by carpal bone and joint disorders. The tendon that ruptured depended on the location of the bone perforation into the carpal tunnel. Radiocarpal arthrography was performed in 13 patients and capsular perforation was demonstrated by contrast medium leakage into the carpal canal in 11 patients. This proved a useful diagnostic test. The flexor tendon(s) were reconstructed with free tendon graft in 17 patients, crossover transfer of flexor tendons from adjacent digits in two and buddying to an adjacent flexor tendon in one patient. Postoperative total active range of motion in the fingers after 13 free tendon graft reconstructions averaged 213° (range 170–265°). The active range of motion of the thumb-interphalangeal joint after free tendon graft reconstruction in three cases improved from 0° to 33° on average (range 10°–40°).

Key Words: wrist • arthrography • flexor tendon • closed rupture • tendon graft

Although not common, closed flexor tendon ruptures caused by hidden pathologies of the carpal bones and joints have been reported frequently, viz fracture of the hook of the hamate (Bishop and Beckenbaugh, 1988; Boyes et al., 1960; Clayton, 1969; Crosby and Linscheid, 1974; Foucher et al., 1985; Futami et al., 1993; Hartford and Murphy, 1996; Milek and Boulas, 1990; Minami et al., 1985b; Stark et al., 1989; Takami et al., 1983; Teissier et al., 1983; Yamazaki et al., 2006; Yang et al., 1996), Kienbock’s disease (James, 1949; Masada et al., 1987; Ribbans, 1988), scaphoid non-union (McLain and Steyers, 1990; Saitoh et al., 1999), pisotriquetral osteoarthritis (Lutz and Monsivais, 1988; Saitoh et al., 1997; Takami et al., 1991), pisotriquetral instability (Corten et al., 2004), a rough surface of the hook of the hamate (Okuhara et al., 1982), lunate fracture (Minami et al., 1985a) and chronic lunate dislocations (Johnston and Bowen, 1988; Stern, 1981). Boyes et al. (1960) reported that ten of 80 flexor tendon ruptures (12.8%) had occurred in the carpal tunnel and that two of the ten had associated abnormalities of the carpal bones. Folmar et al. (1972) reported that the flexor pollicis longus (FPL) tendon and the flexor digitorum profundus (FDP) tendon of the little finger were most frequently affected in ten patients with flexor tendon ruptures.

The mechanism of these tendon ruptures is attrition from passage back and forth over a rough bone surface, the latter having perforated the dorsal wall of the carpal canal (Ertel et al., 1988; Folmar et al., 1972; Hallett and Motta, 1982). It is difficult to identify the underlying pathological lesions causing the tendon ruptures using plain radiographs, especially in the elderly or in manual labourers who have pre-existing abnormal lesions, including osteoarthritis, instability of the carpus and radiographic evidence of previous trauma. Carr and Burge (1992) reported the usefulness of arthrography in identifying a risk of extensor tendon rupture as a result of osteoarthritis of the distal radioulnar joint. Although we demonstrated capsular perforation in patients with scaphoid non-union by arthrography (Saitoh et al., 1997), the usefulness of this technique in detecting carpal pathologies intruding into the carpal tunnel and endangering the flexor tendons is not widely recognised.

The divided tendons invariably have frayed stumps, with a long defect between the ends. Tendon reconstructions have included cross transfer of flexor tendons from adjacent fingers, buddying to adjacent flexors and free tendon grafting. To our knowledge, there has been no description in the literature of the effectiveness of any of these techniques.

This study reviews 21 cases of flexor tendon rupture as a result of pathological conditions of the carpal bones and joints, identifying the relationship between the affected part of the carpus and specific digits. The role of radiocarpal arthrography in identifying the underlying pathology is examined and the results of free tendon grafting recorded.

	PATIENTS AND METHODS

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Between 1979 and 2005, we treated 21 hands of 21 patients with closed ruptures of flexor tendons, caused by pathological conditions of a carpal bone or joint (Table 1). The mean patient age was 68 (range 35–89) years. Fourteen patients were men and seven were women. Fifteen of the 21 patients were manual labourers. The affected digit was the thumb in four patients, the index finger in one patient, the ring and little fingers together in one patient, and the little finger in 15 patients.

The pathological conditions included non-union of the hook of the hamate in six patients (Yamazaki et al., 2006), pisotriquetral joint arthritis in seven patients (one of these seven cases was reported by Saitoh et al., 1997), non-union of the scaphoid in four patients (Saitoh et al., 1999), the presence of a rough surface of the hook of the hamate in two patients (one of these two cases was reported by Okuhara et al., 1982), Kienbock’s disease in one patient and the presence of an intraosseous ganglion of the lunate in one patient (Yamazaki et al., 2007).

Radiocarpal arthrography was performed in 14 of the 21 patients. Arthrography was carried out in all seven patients with pisotriquetral joint arthritis, in three of four patients with scaphoid non-union, in one patient with Kienbock’s disease, in one patient with an intraosseous ganglion, in one of six patients with hamate hook non-union and in one of two patients with a rough surface of the hamate hook.

Tendon reconstruction was performed in 20 patients (95%) (Table 2). A free palmaris longus or plantaris tendon graft was interposed between the proximal and distal stumps of the ruptured tendon in 17 patients. Tendon transfer of the flexor digitorum superficialis (FDS) tendon of the ring finger to the FDP tendon of the little finger was performed in two patients. End-to-side tendon transfer using the FDP tendon of the long finger with interposition of the palmaris longus tendon to the FDP tendons of the little and ring finger was performed in one patient. After tendon reconstruction grafting, modified Kleinert mobilisation was used for 3 to 4 weeks. In two patients who underwent tendon grafting (cases 6 and 12), tenolysis was necessary at 14 and 9 months, respectively. Follow-up was maintained for a mean of 3 years and 4 months (range 1–13 years and 6 months).

We analysed 16 cases with a follow-up of more than 1 year. At follow-up, the ranges of active metacarpophalangeal (MCP), proximal interphalangeal (PIP) and distal interphalangeal (DIP) motion in the involved finger(s) were measured and the total active range of motion (TAM) was calculated. These findings were then graded according to the American Society for Surgery of the Hand criteria (Kleinert and Verdan, 1983). The ranges of active interphalangeal (IP) motion in the four thumbs which underwent FPL tendon grafting were also measured.

	RESULTS

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The results of arthrography investigation are detailed in Table 1 and the outcome of treatment in Table 2. In all the patients, perforation of a joint capsule or the periosteum of a bone had occurred with penetration of the carpal tunnel by a sharp bone spur. The nearest tendons were ruptured. There was no obvious tenosynovitis in any case. In six patients, the next adjacent flexor tendon was also lacerated incompletely at the site of the bone/joint disorder.

The flexor tendons of the little finger were ruptured in all 15 patients with non-union of the hook of the hamate, the presence of a rough surface of the hook of the hamate or pisotriquetral joint arthritis. Both the FDP and FDS tendons were ruptured in six and only the FDP tendon ruptured in nine patients. There were no cases of isolated FDS tendon rupture. The flexor tendons of the thumb were ruptured in all four patients with non-union of the scaphoid bone. The flexor tendons of the index finger and ring finger were ruptured in the two patients with lunate abnormalities.

Plain X-ray examination of the wrist included posteroanterior and lateral views in all patients. Plain X-rays demonstrated all of the scaphoid and lunate abnormalities. However, plain X-rays were universally unhelpful in all six non-unions of the hook of the hamate, both cases with rupture on a rough surface of the hook of the hamate and all seven cases of pisotriquetral joint arthritis. Oblique lateral view in supination and carpal tunnel view plain X-rays and computed tomography were useful in identifying non-union of the hook of the hamate and pisotriquetral joint arthritis. A rough surface of the hook of the hamate was not diagnosed before surgery.

Arthrography was carried out in all seven patients with pisotriquetral joint arthritis and contrast medium leakage into the flexor tendon sheath through the palmar joint capsule (Fig 1) occurred in all seven patients. Arthrography was carried out in three patients with scaphoid non-union and leakage through the non-union occurred in all three patients. Arthrography was carried out in two patients with lunate abnormalities, one with Kienbock’s disease and one with an intraosseous ganglion, and leakage through the palmar joint capsule occurred in both. Arthrography was carried out in one patient with hamate hook non-union and leakage was revealed. Contrast medium, however, leaked through the triquetrohamate joint and not through the non-union in this patient. Arthrography was carried out in one patient with a rough surface of the hamate hook and no leakage was revealed. The leakage site on arthroscopy in all of the cases with positive findings corresponded to the perforated capsule/periosteum at surgery.

View larger version (71K): [in this window] [in a new window]   Fig 1 Radiocarpal arthrogram showing leakage of contrast medium into the flexor tendon sheath in pisotriquetral joint arthritis (case 13).

One patient in whom the transverse carpal ligament had been re-sutured developed carpal tunnel syndrome 3 months after the surgery and required carpal tunnel decompression.

	DISCUSSION

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In patients in whom spontaneous flexor tendon rupture is caused by carpal bone and joint disorders, detection of the lesion is extremely important for the treatment, because the sharp bone must be resected and the capsule/periosteum repaired to prevent flexor tendon re-rupture.

In these cases, the affected digit provides useful information about the location of the underlying disorder. Disorders with an ulnar location in the carpal tunnel, such as those of the hook of the hamate and the pisotriquetral joint, contact and may abrade the FDP tendon of the little finger, particularly. The neighbouring FDS tendon of the little finger and the FDP tendon of the ring finger may, subsequently be affected. The FPL tendon lies over the ulnar surface of the scaphoid and non-union of the scaphoid may cause FPL tendon rupture.

Plain X-ray of the wrist is often unhelpful, unless special views are taken. In the present series, most of the patients were elderly or manual labourers. Abnormalities, such as osteoarthritis, instability of the carpal bones and evidence of previous trauma, were often present on plain X-ray of the wrist. Consequently, it was often difficult to differentiate the causative lesion of the tendon rupture(s) from other abnormal lesions. In this series, arthrography was very useful in identifying the site of the lesion responsible for the flexor tendon rupture. A high percentage of cases in which this investigation was used displayed contrast medium leakage and the radiographic lesions from which contrast medium leaked subsequently corresponded to the disruption of the periosteum, or capsule, at surgery. Generally, the lesion from which contrast medium leaks will identify the tear and, hence, the bony cause of the tendon rupture.

The options of tendon reconstruction include tenodesis, tendon transfer, side-to-side suture and bridge grafting. Milek and Boulas (1990) reported surgical results in four patients, three of whom were treated by tendon transfer and one by tendon graft. They attributed variation in quality of the results largely to differences of the patients’ ages and recommended side-to-side suture. Our preferred management is to bridge graft, since use of the tendon of another finger as a tendon transfer may compromise function of the other finger unnecessarily. Independent motion of the DIP joint is only reconstructed by tendon grafting. In our series, the mean patient age was 68 years. Although this was relatively high, results were satisfactory after tendon grafting and outcome did not depend on patient’s age, or on the interval between tendon rupture and reconstruction. We believe that free tendon grafting followed by early controlled mobilisation is the treatment of choice.

Manuscript received February 5, 2006. Accepted for publication June 13, 2007.

	References

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Bishop AT, Beckenbaugh RD (1988). Fracture of the hamate hook. Journal of Hand Surgery, 13A: 135–139.[CrossRef][Medline] [Order article via Infotrieve]

Journal of Hand Surgery (European Volume), Vol. 32, No. 6, 649-653 (2007)
DOI: 10.1016/J.JHSE.2007.06.014


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