- See:
Extensor Tendon Rupture in RA
- Discussion:
- this tendon is prone to rupture from synovitis and increases friction at Lister's tubercle second to diseases such as RA and Lupus;
- EPL is tendon that is most frequently ruptured from distal radius frx;
- if dorsal radial tubercle has been disrupted by
Colles
frx (producing irregularity),
EPL
tendon may rupture due to added
friction imposed upon it as it turns around roughned tubercle;
- ruptures occur most often just distal to the extensor retinaculum (at Lister's tubercle)
- rupture is far more common in assoc w/ undisplaced frx than in associated w/ displaced frxs, & it has been reported in patients who
had wrist injury without a fracture;
- rupture of this tendon after minimally displaced frx suggests ischemic etiology rather than attritional
rupture over an osseous spike;
- ruptures occur most often between 3 weeks and 3 months following injury;
- Exam:
- palpate length of tendon, look for any signs of rupture;
- ask pt to place hand flat on table, & lift only thumb off surface;
- w/ rupture, patient will be unable to raise the thumb in line w/ the second metacarpal;
- Treatment:
- direct repair:
- often difficult due to tendon retraction and atrophy (or fraying) of tendon edges;
- free tendon graft:
-
palmaris longus can be used to either augment a primary repair or can be used as a free
tendon graft inorder to bridge the gap between tendon edges;
- if a large portion of the tendon edges appear degenerative, then consider resecting the tendon edges and then weaving
the palmaris longus between the edges to bridge the gap;
- tendon transfer
-
extensor indicis
may be transferred to replace torn
EPL tendon;
- tendon transfer using adjacent
EIP provides predictable outcome;
- advantages include similar amplitude and direction of pull;
- prerequisites include independent extension of the index finger;
- graft should be harvested just proximal to the extensor hood, w/ care taken to anatomically repair the saggital hood (see
extensor mechanism);
- one incision is made at the MP joint level inorder to harvest the tendon;
- second incision is made just distal to the extensor retinaculum (which allows the tendon to be delivered and then rerouted);
- incision is made over the thumb MP joint, and a subQ tunnel is created to the retinacular incision;
- the tendon is then delivered thru this tunnel;
- the most difficult part of the case is proper tensioning;
- inorder to achieve full extension, often the graft will have to be tensioned to the point that some IP joint flexion will be lost;
- many surgeons advocate slight to moderate overtensioning of this graft inorder to overcome the much stronger FPL;
- worst case scenario w/ this approach is slight loss of full flexion;
- immobilization in full extension is emphasized;
- main disadvantage of this transfer is that it precludes its use for other tendon transfers (should this be necessary in the future);
- APL to EPL transfer:
- this may be a good choice in rheumatoid arthritis;
- even though the APL has decreased amplitude (3 cm vs 6 cm for the EPL), it has the same
direction of pull, and affords the patient good function;
- joint arthrodesis:
-
arthrodesis improves strength & maintains f(x), where as efforts at reconstruction of joint,
if articular surface is severely damaged, will be unsuccessful;
Rupture of the extensor pollicis longus tendon.
S. Chmell et al.
Orthopaedics. Vol 6. p 565.
1983.
Spontaneous rupture of the extensor pollicis longus.
The results of tendon transfer.
D. Riddell.
JBJS Vol 45-B. p 506. 1963.
Clinical and microangiographic studies on rupture of the EPL tendon after distal radial fractures.
Y. Hirasawa et al.
J. Hand Surgery. Vol 15-B. p 51. 1990.
Rupture of the extensor pollicis longus tendon in undisplaced Colle's type fracture.
B. Heal.
Hand Vol 14. p 41. 1982.
Postfracture extensor pollicis longus tenosynovitis and tendon rupture: a scientific study and personal series.
