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Wrist Flexion Contracture: An Unusual Complication Following Palmaris Longus Tendon HarvestFrom the Department of Orthopaedic Surgery, Ogori Daiichi General Hospital and Yamaguchi University School of Medicine, Shimogo, Ogori, Yamaguchi City, Japan Correspondence: Yasunori Hattori, MD PhD Department of Orthopaedic Surgery, Ogori Daiichi General Hospital, 862–3, Shimogo, Ogori, Yamaguchi City, Yamaguchi Prefecture 754 0002, Japan. Tel.: 81 839 72 0333, fax: 81 839 73 4909. E-mail:yhattori{at}saikyo.or.jp
We describe a case of 3-year-old girl in whom flexion contracture of the wrist developed following harvest of the palmaris longus tendon with a tendon stripper.
Key Words: wrist • flexion contracture • palmaris longus The palmaris longus tendon is commonly used for tendon and ligament reconstruction of the hand because it is of adequate length for most needs, it is easy of harvest and there is likely to be little morbidity of the donor site. We report an unusual case of postoperative flexion contracture of the wrist after harvesting a palmaris longus tendon graft using a tendon stripper.
A 3-year-old right handed girl presented with a cleft is of the right hand in which the phalanges of the long finger were missing but the metacarpal was present. The patient had no other associated anomalies. The wrist and elbow function of the right upper extremity was normal. The cleft was closed with the technique described by Miura and Komada (1979). Palmaris longus tendon was harvested from the right forearm using a tendon stripper to reconstruct the intermetacarpal ligament between the second and fourth metacarpals. The distal insertion of the palmaris longus tendon was identified and transected through a 1 cm transverse incision at the wrist crease, and the distal tendon threaded through a tendon stripper. The tendon stripper was advanced slowly until the musculotendinous connection was severed and the tendon was retrieved through the wrist incision. The postoperative course was uneventful. The wrist joint was immobilised in the neutral position using a plastic splint. Three weeks after surgery, the splint was removed and active motion of wrist and fingers was commenced. The patient was referred to another hospital for postoperative rehabilitation. Two years after surgery, the patient returned to our hospital for postoperative follow-up. Although the function and the cosmetic appearance of the hand were good, the patient had a flexion contracture of the wrist. Active and passive wrist extension were –20 and –10 degrees, respectively. A fibrous band on the volar aspect of the forearm seemed to be restricting wrist extension (Fig 1). At revision surgery, a well-defined fibrous band, reproducing the path of the original palmaris longus tendon, was identified. Macroscopically, the band seemed to be a hypertrophic tendon, originating from the belly of palmaris longus muscle and inserting onto the palmar aponeurosis (Fig 2). Although the palmaris longus muscle was present, a part of the muscle on the radial side was replaced by scar tissue and the colour of the muscle on the ulnar side was darker than the adjacent muscles. Other structures in the forearm were intact and normal. After complete resection of this fibrous band, 60 ° degrees of passive wrist extension was achieved during surgery. Histological examination of the band revealed collagen bundles oriented along a longitudinal axis. One year after surgery, 45 ° degrees of active wrist extension was obtained.
Possible complications of harvesting the palmaris longus tendon include injuries to the median nerve or the adjacent tendons, viz. flexor carpi radialis and flexor digitorum superficialis, adhesion of the remaining palmaris longus muscle to the adjacent fascia, which may cause discomfort on gripping and division, or tethering, in scar of subcutaneous nerves in the proximal, or distal, wound. Proximally, the palmaris longus tendon is approached through subcutaneous fat in which pass the branches of the medial cutaneous nerve of the forearm. Distally, the wound made to harvest the tendon is very close to the palmar branch of the median nerve. Either may be damaged or become tethered in scar as a result of harvesting of the palmaris longus tendon. Perhaps the most dramatic of these complications was reported by Toros et al. (2006). These authors treated a patient in whom another hospital had harvested the median nerve instead of the palmaris longus tendon for use as a spacer, or ‘anchovy’, after trapezectomy. To the best of our knowledge, the complication of wrist flexion contracture following palmaris longus tendon harvesting by a tendon stripper has not been reported. The exact cause of this complication is unknown. However, there were two findings at secondary surgery which suggest possible causes. Firstly, although the palmaris longus muscle remained, it was partly replaced by fibrous tissue. Secondly, a well-defined fibrous band was identified which reproduced the path of the original palmaris longus tendon through the compartment of the fascia which normally holds this tendon alone. The most likely cause of this phenomenon was either contracture of the scarred palmaris longus muscle pulling through this band or through a remnant of the tendon left in situ following partial harvesting of the tendon as a result of accidental splitting of the tendon, or through a missed accessory slip or second part of a bifid tendon. To avoid the possibility of further such cases in children, we now harvest the palmaris longus tendon by the open method using three or four transverse incisions, to avoid direct injury to the muscle and to confirm the complete harvesting of the tendon.
Manuscript received August 16, 2006. Accepted for publication June 14, 2007.
Miura T, Komada T (1979). Simple method for reconstruction of the cleft hand with an adducted thumb. Plast Reconstr Surg, 64: 65–67.[Web of Science][Medline] [Order article via Infotrieve]Toros T, Vatansever A, Ada S (2006). Accidental use of the median nerve as an interposition material in first carpometacarpal joint arthroplasty. Journal of Hand Surgery, 31B: 574–575.
Journal of Hand Surgery (European Volume), Vol. 32, No. 6,
694-696 (2007)
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Abstract
CASE REPORT
