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Closed Traumatic Rupture of the Extensor Digitorum Communis and Extensor Indicis Proprius at the Musculo-Tendinous JunctionFrom the Harvard Medical School, Orthopaedic Hand Service, Massachusetts General Hospital, Boston, MA, USA, Harvard Medical School, Division of Occupational Medicine, Cambridge Health Alliance, Cambridge, MA, USA Correspondence: Chaitanya S. Mudgal, MD, Orthopaedic Hand Service, Massachusetts General Hospital, Yawkey Center, Suite 2100, 55 Fruit Street, Boston, MA 02114, USA. Tel.: +1 617 643 3945; fax: +1 617 724 8532. E-mail:cmudgal{at}partners.org
This report describes a closed rupture of the entire extensor digitorum communis and extensor indicis proprius.
Key Words: closed traumatic rupture • digital • extensors
A 51 year-old white male engineer caught his glove in a high-speed drill on an oil rig, causing a sudden forced flexion of his non-dominant, left wrist. After extricating himself, he noted severe pain over the wrist and forearm. When seen at another hospital on the same day, a diagnosis of wrist sprain was made. He presented to us a week later with ongoing pain and inability to extend his fingers actively at the metacarpophalangeal joints. Examination revealed a well circumscribed, tender, soft, non-fluctuant swelling over the dorsal aspect of the wrist and diffuse tenderness over the dorsal forearm. He displayed full forearm movements but wrist motion, especially flexion, was limited and painful. He was unable to demonstrate independent extension of the metacarpophalangeal joints of his index, middle and ring fingers. Weak extension of the MCP joint of the little finger was maintained, suggesting function only of the extensor digiti minimi. He displayed normal extension of his wrist and thumb. Passive flexion of the wrist was not accompanied by extension of the metacarpophalangeal joints of the fingers. Plain X-rays were unremarkable apart from showing the dorsal soft-tissue swelling of the wrist, particularly on the lateral view. Magnetic resonance imaging (MRI) confirmed a diagnosis of closed rupture of his extensor digitorum communis (EDC) and extensor indicis proprius (EIP) tendons, with the ruptures being located within the proximal third of the forearm. Surgical exploration through a dorsal incision centred over the wrist revealed that the EDC and EIP tendons had been avulsed from their proximal muscle attachments, with variable amounts of muscle attached to each tendon, and were curled up under the extensor retinaculum, which had a transverse rent in it (Figs 1 and 2). As repair was not feasible, a tendon transfer of the flexor carpi radialis (FCR) tendon to the distal ends of the extensor tendons was performed. The limb was immobilised in a long-arm cast for 3 weeks, and, then, in a long dorsal outrigger splint for a further three weeks. Active motion was then commenced. Twelve weeks after surgery, the patient returned to his previous occupation on the oil rig, having recovered good active extension of the metacarpophalangeal joints of all his fingers, adequate digital flexion and a 60° arc of motion in his wrist. He declined any further follow-up.
Ruptures of extensor tendons are known to occur at the level of the wrist after undisplaced fractures of the distal radius (Anwar et al., 2006; Bonatz et al., 1996; Cheema et al., 2006; Engkvist and Lundborg, 1979; Mannerfelt et al., 1990) and in patients with rheumatoid arthritis (Vaughan-Jackson, 1948; Wilson and DeVito, 1996). In patients who have no predisposing factors, such an injury is very rare and very few cases are described in English literature. The largest reported series is of ten patients who sustained a closed traumatic rupture of the extensor tendons at the musculotendinous junction (Takami et al., 1995). Of these, five patients had a mechanism of injury similar to that in our patient. However, only one patient demonstrated an injury to the EDC of the long, ring and small fingers, with the other four patients sustaining injury to the tendons of the index finger only. An injury affecting all of the tendons of the EDC as well as the EIP has not been previously described. The sequence of events that lead to this injury remains speculative. It is possible that the wrist and metacarpophalangeal joints were in extension, thereby implying actively contracting muscles, when the fingers and wrist are pulled into sudden flexion, leading to extensor rupture. This mechanism would be akin to that of an Achilles tendon rupture, occurring when the foot is poised for forward movement, with the ankle in plantar flexion and a step backwards is taken, causing sudden dorsiflexion of the ankle, with rupture of this tendon. On the other hand, rupture might have been caused by a sudden and violent reflex contraction of the extensor muscles in response to a sudden flexion force, to withdraw the hand rapidly from the glove and drill. Under these sudden loading conditions, and with no predisposing factors, the musculotendinous junction appears to be the weakest link in the musculotendinous unit. Either of these sequences of events would also account for the injuries in the other five patients described by Takami et al. (1995). These patients, all gymnasts, sustained ruptures after getting their wrist straps entangled in the high bar during gymnastic routines. The clinical diagnosis can be confirmed by MRI. Ultrasonography has also been shown to be effective in the diagnosis of tendon and muscle ruptures and is a less expensive alternative (Bianchi et al., 2005). Repair of such injuries is not usually possible as the muscle is shredded, oedematous and there may be a variable degree of muscle retraction. Tendon grafting is difficult as there is often little tendinous material of substance within the muscles to hold a tendon weave or, even, sutures and the alternative of tendon transfer is more satisfactory. Takami et al. (1995), used the extensor carpi radialis longus (ECRL) as a motor but noted only a fair outcome in their patients. They did not elaborate on the reasons for this. The FCR, which we chose to transfer, has an excursion similar to that of the ECRL (Smith and Hastings, 1980). The FCR may be transferred around the radius as was done in this case, or through the interosseous membrane to obtain a straighter line of pull, as described by Tsuge (1980). In the experience of the senior author (CSM), the FCR is easily accessible, provides sufficient length of tendon, is simple to train and demonstrates predictable recovery of digital extension at the metacarpophalangeal joints.
Manuscript received December 29, 2006. Accepted for publication July 9, 2007.
Anwar I, Owers KL, Eckersley R (2006). Spontaneous rupture of the extensor pollicis longus tendon. Journal of Hand Surgery, 31B: 457–458.Bianchi S, Martinoli C, Abdelwahab IF (2005). Ultrasound of tendon tears. Part 1: general considerations and upper extremity. Skeletal Radiology, 34: 500–512.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]Bonatz E, Kramer TD, Masear VR (1996). Rupture of the extensor pollicis longus tendon. American Journal of Orthopaedics, 25: 118–122.Cheema TA, De Carvalho AF, Bosch P, Saleh E (2006). Calamities of the extensor pollicis longus following wrist fractures in children. Journal of Hand Surgery, 31B: 578–579.Engkvist O, Lundborg G (1979). Rupture of the extensor pollicis longus tendon after fracture of the lower end of the radius: a clinical and microangiographic study. Hand, 11: 76–86.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]Mannerfelt L, Oetker R, Ostlund B, Elbert B (1990). Rupture of the extensor pollicis longus tendon after Colles fracture and by rheumatoid arthritis. Journal of Hand Surgery, 15B: 49–50.Smith RJ, Hastings II. H (1980). Principles of tendon transfers to the hand. Instructional Course Lectures, 29: 129–152.Takami H, Takahashi S, Ando M, Suzuki K (1995). Traumatic rupture of the extensor tendons at the musculotendinous junction. Journal of Hand Surgery, 20A: 474–477.[CrossRef][Medline] [Order article via Infotrieve]Tsuge K (1980). Tendon transfers for radial nerve palsy. Australian and New Zealand. Journal of Surgery, 50: 267–272.Vaughan-Jackson OJ (1948). Rupture of extensor tendons by attrition at the inferior radio-ulnar joint: report of two cases. Journal of Bone and Joint Surgery, 30B: 528–530.Wilson RL, DeVito MC (1996). Extensor tendon problems in rheumatoid arthritis. Hand Clinics, 12: 551–559.[Web of Science][Medline] [Order article via Infotrieve]
Journal of Hand Surgery (European Volume), Vol. 32, No. 6,
675-676 (2007) This article has been cited by other articles:
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Abstract
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