273Bulletin of the NYU Hospital for Joint Diseases 2012;70(4):273-5

Ward JP, Kim S, Rettig ME. Extensor indicis proprius and extensor digitorum communis rupture after volar locked plating of the distal radius: a case report. Bull NYU Hosp Jt Dis. 2012;70(4):273-5.

Abstract

Distal radius fractures are among the most commonly en-countered fractures in the extremities. Volar plating of distal radius fracture has gained popularity in recent years with the introduction of the locked plating system. Complications of volar plating include extensor and flexor tendon rupture. Here we present a case report of an extensor indicis proprius and extensor digitorum communis to index finger tendon rupture after open reduction and internal fixation of distal radius fracture with locked plate.

Distal radius fractures are among the most com-monly encountered fractures in the extremities. Court-Brown and colleagues estimated that

17.5% of all fractures presenting to the emergency room are distal radius fractures.1 Volar plating of distal radius fracture has gained popularity in recent years with the introduction of the locked plating system. Since 1996, there has been a five-fold increase in operatively treated distal radius fractures in elderly patients.2 Complications of volar plating include extensor and flexor tendon rup-ture. Extensor indicis proprius and extensor digitorum communis to index finger tendon rupture after open re-duction and internal fixation of distal radius fracture with locked plate is a rare complication, reported only twice previously in the literature. We present a novel approach to the treatment of this complication with transfer of the

extensor digiti minimi to the ruptured tendons, a method not previously described.

Case ReportA 74-year-old, right hand dominant female sustained a comminuted displaced left distal radius fracture four years prior to her evaluation. She underwent open reduction and internal fixation with a volar distal radius locking plate at an outside institution. After fracture healing, she regained pain-free function of her left hand and wrist. Six months prior to evaluation, she began to have dorsal radial wrist pain. Oral nonsteroidal antiinflammatory medi-cations were recommended. Five days prior to evaluation, she noted inability to ac-tively extend her index finger. Physical examination of the left wrist revealed a well healed volar radial incision. She was unable to actively extend the index finger. There was no pain with resisted long, ring, and little finger extension. Radiographic evaluation of the left wrist revealed a healed fracture of the distal radius in satisfactory position. One of the volar locking screws was protruding through the dorsal cortex (Fig. 1). Surgical exploration revealed rupture of the extensor indicis proprius (EIP) and the extensor digitorum communis (EDC) to her index finger. Attenuation of the EDC to her long finger was also observed. This finding made tenodesis of the ruptured distal stumps to this tendon a less desirable option. A locking screw was found to be protruding through the dorsal cortex into the floor of the fourth extensor compartment (Fig. 2). The plate and screws were removed through the previous volar incision. The attenuated EDC tendon to the long finger was repaired. An extensor digiti minimi (EDM) to EIP transfer was per-formed using a Pulvertaft weave method of tendon transfer (Fig. 3). On follow-up examination, the patient was noted to have painless independent extension of the previously affected

Extensor Indicis Proprius and Extensor Digitorum Communis Rupture after Volar Locked Plating of the Distal RadiusA Case Report

James P. Ward, M.D., LT Suezie Kim, M.D., M.C., U.S.N., and Michael E. Rettig, M.D.

James P. Ward, M.D., and Michael E. Rettig, M.D., are in the De-partment of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York. LT Suezie Kim, M.D., M.C., U.S.N., is in the Department of Orthopaedic Surgery, Naval Hospital Camp Pendleton, Box 555191, Camp Pendleton, California.Correspondence: James P. Ward, M.D., Dept. of Orthopaedic Surgery, NYU Hospital for Joint Diseases, 301 East 17th Street, Suite 1402, New York, New York 10003; jamespward@gmail.com.

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index finger and of the small finger, the digit from which the tendon transfer was obtained.

DiscussionExtensor pollicis longus (EPL) and flexor pollicis longus (FPL) rupture have been described as complications as-sociated with locked volar plate fixation of distal radius fractures. Arora and associates reported a 2% incidence

of FPL and EPL rupture in their retrospective review of 141 patients. When including tenosynovitis with tendon rupture, this value increased to 17%.3 Al-Rashid and col-leagues retrospectively reviewed 35 patients with distal radius fractures and found an 8.6% incidence of extensor tendon injuries, most commonly the EPL tendon. This is compared with a 0.07% to 0.88% incidence of EPL ruptures in conservatively treated patients.4 EDC and EIP tendon ruptures are far less common but can occur after volar plate fixation when the screws are prominent dorsally. There are two prior reports of similar ruptures. Al-Rashid and col-leagues reported extensor tendon injuries, which included EIP and EDC injury, in JBJS British in 2006.5 Rampoldi and Marisco reported on this injury in Acta Orthopaedica Belgica in 2007.6

Jupiter and coworkers concurred that it is essential to avoid penetration of the dorsal cortex with the distal screws to avoid extensor tendon complications.7 The locked con-struct does not rely on the screw-bone purchase for fixation but rather the screw-plate interface for its strength.8 Placing the locked screw into the dorsal cortex is not required for sta-bility of fracture fixation. Maschke and associates found in a cadaveric and radiographic evaluation of distal radius plating that AP and lateral fluoroscopic images are inadequate for determining dorsal cortical penetration. They recommend using pronation and supination views to more adequately evaluate screw placement, especially near Lister’s tubercle.9

Persistent dorsal or volar wrist pain after radiographic fracture union may indicate flexor or extensor tenosynovitis or impending tendon rupture. Clinical examination may demonstrate tenderness along the flexor or extensor tendons with swelling or painful digit flexion or extension. Removal of hardware should be strongly considered to avoid the potential complication of tendon rupture requiring tendon transfer.

Figures 1 Preoperative lateral radiograph showing a healed distal radius fracture with hardware in place.

Figure 3 Demonstrates the EDM to EIP transfer using the Pulver-taft weave method. The extensor retinaculum is reapproximated.

Figure 2 A prominent screw tip is observed after ulnar retraction of the EDC tendons. This screw tip likely caused attenuation and rupture of the EIP and EDC to the index finger. The EDC to the long finger was also attenuated but not ruptured.

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A CT scan also may be considered to assess screw length and dorsal prominence in these patients. Because of the po-tential complication of proud screws in the dorsal cortex of the distal radius, we recommend drilling to, but not through, the dorsal cortex and subtracting 2 mm from the measured depth to avoid penetration. If intraoperative determination requires a screw of a certain length to capture a comminuted dorsal fragment, then planned early removal of hardware after fracture healing may be considered.

Disclosure StatementNone of the authors have a financial or proprietary interest in the subject matter or materials discussed, including, but not limited to, employment, consultancies, stock ownership, honoraria, and paid expert testimony.

References1. Court-Brown C, Caesar B. Epidemiology of adult fractures:

A review. Injury. 2006;37:691-7.2. Chung KC, Shauver MJ, Birkmeyer JD. Trends in the United

States in the treatment of distal radius fractures in the elderly. JBJS (Am). 2009;9:1868-73.

3. Arora R, Lutz M, Hennerbichler A, et al. Complications fol-lowing internal fixation of unstable distal radius fracture with a palmar locking-plate. J Orthop Trauma. 2007;21(5):316-22.

4. Hove LM. Delayed rupture of the thumb extensor tendon. A 5 year study of 18 consecutive cases. Acta Orthop Scand. 1994;65:199-203.

5. Al-Rashid M, Theivendran K, Craigen MA. Delayed ruptures of the extensor tendon secondary to the use of volar locking compression plates for distal radius fractures. JBJS (Br). 2006;88(12):1610-2.

6. Rampoldi M, Marsico S. Complications of volar plating of distal radius fractures. Acta Orthop Belg. 2007;73(6):714-9.

7. Jupiter JB, Marent-Huber M. Operative management of distal radial fractures with 2.4-Millimeter locking plates: a multicenter prospective case series. Surgical technique. JBJS (Am). 2010;92:96-106.

8. Egol KA, Kubiak EN, Fulkerson E, et al. Biomechanics of locked plates and screws. J Orthop Trauma. 2004;18(8):488-93.

9. Maschke SD, Evans PJ, Schub D, et al. Radiographic evalua-tion of dorsal screw penetration after volar fixed-angle plating of the distal radius: a cadaveric study. Hand. 2007;2(3):144-50.