CASE REPORT

Spontaneous recovery of extensor pollicis longustendon rupture following intra-articular distalradius fracture

S. Wimsey *, J. Kurian, I.T.A. Jeffery

Injury Extra (2006) 37, 331—333

www.elsevier.com/locate/inext

Department of Orthopaedic Surgery, Queen Alexandra Hospital, Portsmouth, PO6 3LY, UK

Accepted 19 December 2005

Introduction

Extensor pollicis longus (EPL) tendon rupture isa well-documented complication of distal radialfractures. We report a case of conservative man-agement and spontaneous recovery of a rupturedEPL tendon following intra-articular fracture of thedistal radius. Recommended treatment for EPLtendon rupture is surgical tendon transfer and toour knowledge spontaneous recovery of the tendonruptured with this aetiology has not been reportedpreviously.

Case report

An 18-year-old man sustained a closed intra-articu-lar fracture of the left distal radius on 15 May 2003(Fig. 1). This was manipulated under anaesthesiaand placed in a below elbow cast for 6 weeks(Fig. 2). The recovery was uneventful until he pre-sented to his general practitioner on 27 August 2003with the sudden inability to extend his left thumbinterphalangeal joint since the 20 August 2003.There had been no history of further injury since

* Corresponding author. Tel.: +44 7944 202 545.E-mail address: swimsey@hotmail.com (S. Wimsey).

1572-3461/$ — see front matter # 2006 Elsevier Ltd. All rights resedoi:10.1016/j.injury.2005.12.033

his distal radius fracture. It was advised that he beplaced in a mallet splint until his clinic appoint-ment. The patient was subsequently seen in clinic on15 October where it was observed that he stilllacked 108 of full extension of his left thumb inter-phalangeal joint. Treatment in a mallet splint wascontinued and the patient was followed up onceagain on 26 November 2003 where it had beenanticipated that he would require extensor indicisproprius to EPL tendon transfer surgery. However,the left EPL tendon had fully recovered with noextensor lag clinically and thus did not necessitatesurgery or any further action (Fig. 3).

The patient was subsequently discharged. On alloccasions he was seen and assessed by the seniorauthor. A Disabilities Of The Arm, Shoulder AndHand Questionnaire (DASH) score was recordedboth shortly after the EPL tendon rupture and thensubsequently at the most recent follow up. Thescore immediately following rupture in August 2003was 15 (out of 100), then at the latest follow upwhen the patient was asymptomatic in September2005 was 1.7 (out of 100). This demonstrates quan-titatively that the patient has achieved a verysatisfactory outcome following conservative treat-ment of his EPL rupture, and that he has nearnormal upper limb function now, compared withmild disability immediately following rupture.

rved.

332 S. Wimsey et al.

Figure 1 X ray showing fracture distal radius.

Figure 2 X ray with plaster treatment.

Discussion

Rupture of the EPL tendon after distal radius frac-ture is an uncommon but well reported event, andhas an incidence of 3%.7 The first reported case ofrupture of the EPL was by Duplay in 1876.2 A Colles’

Figure 3 Photograph showing full extension at thumbinterphalangeal joint.

fracture of the radius is the most common singlecause of EPL rupture, accounting for one in 300cases. Other causes include laceration, directtrauma, rheumatoid arthritis, and rotational inju-ries of the forearm.4 Two main theories exist toexplain the pathogenesis of posttraumatic rupturefollowing Colles’ fracture: friction over sharpportions of the bone,1 and tearing of the meso-tendon compromising the vascular supply to thetendon,9 resulting in avascular necrosis. There isusually an interval of 4—8 weeks between injuryand rupture.8

Primary end-to-end repair is not possible becauseof the attenuated and frayed consistency of thetendon in the zone of injury. Tendon transfer usingthe abductor pollicis brevis, the extensor carpiradialis longus, and, principally, the extensor indicisproprius has been advocated for early and late EPLtendon rupture.6

Impending rupture has also been describedwhereby following distal radius fracture, a patientdeveloped painful active and passive thumb retro-flexion, indicating a prerupture extensor tenosyno-vitis. The treatment advocated for this wasobservation for 2 weeks followed by a third dorsalcompartment release if still symptomatic. If at

Spontaneous recovery of extensor pollicis 333

surgery, greater than 50% of the width of the EPLtendon has been attenuated, then a retinacularreinforcement patch is performed.7 Conservativetreatment of mallet thumb has been described asan alternative to primary surgical repair in closedinjuries.5 This consists usually of static splinting for4—6 weeks.3

Conclusion

As has been discussed, this is the first casereported of spontaneous recovery of the EPL ten-don following distal radius fracture. The tendonusually retracts, necessitating surgery, but in thiscase, simple splinting for a period of 12 weeksenabled full tendon recovery. We do not advocatenon-surgical treatment for all patients, but we dobelieve this is evidence that certainly in theyounger population, conservative management ofa proximal EPL tendon rupture with a static splintmay prove curative, thus avoiding surgery.

References

1. Axhausen G. Die spatruptur der sehne der extensor pollicislongus lier der typischen radiusfraktur. Beitr Klin Chir 1925;133:78.

2. Duplay M. Rupture sous-cutanee du tendon du long extenseurdu pouce de la main droite au niveau de la tabatiere anato-mique. Bull Mem Soc Chir 1876;2:788.

3. Khandwala AR, Blair J, Harris SB, Foster AJ, Elliott D. Immedi-ate repair and early mobilisation of the extensor pollicislongus tendon in zones 1 to 4. J Hand Surg 2004;29B(3):250—8.

4. Milch E, Epstein MD. Traumatic rupture of the extensor pollicislongus tendon. Ann Plast Surg 1987;5:460—2.

5. Primiano GA. Conservative treatment of two cases of malletthumb. J Hand Surg (Am) 1986;11A:233—5.

6. Riddell DM. Spontaneous rupture of the extensor pollicislongus. J Bone Joint Surg 1963 Aug;45:506—10.

7. Skoff HD. Postfracture extensor pollicis longus tenosynovitisand tendon rupture; a scientific study and personal series.Am J Orthop 2003 May;32(5):245—7.

8. Trevor D. Rupture of the extensor pollicis longus tendonafter Colles’ fracture. J Bone Joint Surg 1950 August;32-B(3):370—5.

9. Weigeldt W. Uber die spontanrupturen der fingersehnen. BeitrKlini Chir 1914;94:310.