January 14, 2015
2:36:13pm
WSPC/135-HS
FA1
1572003
Hand Surgery, Vol. 20, No. 1 (2015) 145–147 © World Scientific Publishing Company DOI: 10.1142/S021881041572003X
Hand Surg. 2015.20:145-147. Downloaded from www.worldscientific.com by UNIVERSITY OF AUCKLAND LIBRARY - SERIALS UNIT on 06/10/15. For personal use only.
CLOSED TRAUMATIC RUPTURE OF THE FLEXOR POLLICIS LONGUS TENDON IN ZONE T I: A CASE REPORT Kazuaki Uekubo,* Soichiro Itoh*,† and Taro Yoshioka* *Department
of Orthopaedic Surgery, Kawakita General Hospital 1-7-3 Asagaya-kita, Suginami-ku Tokyo 166-8588, Japan
†
Department of Orthopaedic Surgery, Sakurakai Hospital 2-11-8 Senju Sakuragi, Adachi-ku Tokyo 120-0045, Japan
Received 30 May 2014; Revised 7 July 2014; Accepted 7 July 2014; Published 20 January 2015 ABSTRACT A healthy 41-year-old male suffered a direct blow on the palmar side of his right thumb when folding a table, which slipped along his thumb until it was stopped at the inter-phalangeal (IP) joint, resulting in a complete rupture of the flexor pollicis longus (FPL) tendon in zone T I. The proximal tendon stump was passed through the oblique pulley, fixed to the base of the distal phalanx with a pull-out wire technique and augmented on it using a part of the distal tendon remnant. After removal of the cast and the pull-out wire three weeks postoperatively, range of motion exercise was initiated and good functional recovery was obtained. Keywords: Flexor Pollicis Longus; Tendon; Closed Traumatic Rupture.
INTRODUCTION
actively; however, he could fully flex it passively. There was no fracture on the radiographs nor combined nerve injury. The FPL tendon was explored by a zig-zag skin incision under brachial block. The proximal part of the tendon was found in zone T III, and clotted blood in the synovium was adhered to the proximal tendon stump (Fig. 1A). The distal end of the ruptured tendon with clotted blood was found in zone T I as a remnant of 8 mm (Fig. 1B). The proximal tendon stump was passed through the oblique pulley, fixed to the base of the distal phalanx with a pull-out wire technique and augmented on it using a part of the distal tendon remnant (Fig. 1C). A thumb spica cast was used with 30 degree wrist flexion, and the
We present a case of unusual traumatic zone T I rupture of the flexor pollicis longus (FPL) tendon resulting from direct force applied to the thumb and discuss the mechanism of this injury.
CASE REPORT A healthy 41-year-old male suffered a direct blow on the palmar side of his right thumb when folding a table, which slipped along his thumb until it was stopped at the inter-phalangeal (IP) joint, resulting in a complete rupture of the FPL tendon in zone T I. On examination, he could not flex his thumb IP joint
Correspondence to: Dr. Soichiro Itoh, Department of Orthopaedic Surgery, Sakurakai Hospital, 2-11-8 Senju Sakuragi, Adachi-ku, Tokyo 120-0045, Japan. Tel: (+81) 03-3883-9211, Fax: (+81) 03-3881-2774, E-mail: [email protected] 145
January 14, 2015
Hand Surg. 2015.20:145-147. Downloaded from www.worldscientific.com by UNIVERSITY OF AUCKLAND LIBRARY - SERIALS UNIT on 06/10/15. For personal use only.
146
2:36:14pm
WSPC/135-HS
FA1
1572003
K. Uekubo, S. Itoh & T. Yoshioka
(A)
(B)
(C)
Fig. 1 (A) The proximal part of the ruptured FPL tendon in which clotted blood is adhered in the synovium (arrow). (B) The distal end of the ruptured FPL tendon with clotted blood is found in zone T I (arrow). Arrow head: The proximal part of the ruptured tendon. (C) The proximal tendon stump is passed through the oblique pulley, fixed to the base of the distal phalanx with a pull-out wire technique and augmented using part of the distal tendon remnant (arrow).
thumb was held in moderate flexion and abduction. After removal of the cast and the pull-out wire three weeks postoperatively, active mobilisation was initiated, followed by assisted range of motion exercise after five weeks. No complications were observed. Active extension/flexion of the metacarpophalangeal (MP) and IP joints was 0 /65 and 0 /50 , respectively, and the grip power of the right and left hands was 58 and 50 kg, respectively, after 20 weeks.
DISCUSSION Nonrheumatologic closed rupture of the FPL tendon in zone T I is a very unusual injury. The rarity of this type of injury may be due to the anatomical particularity of the FPL tendon. Because the thumb is used with an opposite position and support to pinch and grip, force is usually applied directly to the flexor digitorum superficialis (FDS) and FDP tendon in the palm. Marco et al. performed a biomechanical study on 21 cadaveric fingers to measure the mechanical force in these flexor tendons, in which the tension in the tendon was increased until the tendon or osseous failure.1 In 19 fingers, the A2, A3 or A4 pulley ruptured and in 2 fingers avulsion fracture occurred as the initial failure event. In our case, clotted blood was observed on both the proximal and distal tendon stumps without a pulley avulsion. These
findings may support such a mechanism of the injury; when the table slipped along the palmar side and stopped at the IP joint with flexion, the FPL tendon suffered an abrasion followed by a shear stress instead of a tensile force. As a result, complete rupture of the FPL tendon in zone T I occurred. Another possible mechanism may be a similar one to the \jersey finger injury",2 in which FDP muscle belly contracts maximally when the distal inter-phalangeal (DIP) joint is hyperextended while the proximal inter-phalangeal (PIP) joint is flexed, and rupture of the FDP tendon occurs at its insertion into the distal phalanx base as a result. When the traction force is large enough, avulsion fracture occurs on which fragment the FDP tendon remains attached. In the case of FPL tendon rupture, resembling injury in mode of onset may occur with the IP joint hyperextended while the MP joint flexed. Although we did not perform ultrasound examination preoperatively, high-frequency ultrasonographic findings may be effective to diagnose the location of the ruptured tendon stumps and evaluate the gap length.3
CONFLICT OF INTEREST K. Uekubo, S. Itoh and T. Yoshioka declare that we have no conflict of interest.
January 14, 2015
2:36:14pm
WSPC/135-HS
1572003
FA1
Closed Traumatic Rupture of the Flexor Pollicis Longus Tendon in Zone T I
References
Hand Surg. 2015.20:145-147. Downloaded from www.worldscientific.com by UNIVERSITY OF AUCKLAND LIBRARY - SERIALS UNIT on 06/10/15. For personal use only.
1. Marco RA, Sharkey NA, Smith TS, Zissimos AG, Pathomechanics of closed rupture of the flexor tendon pulleys in rock climbers, J Bone Joint Surg 80A:1012–1019, 1998. 2. Goodson A, Morgan M, Rajeswaran G, Lee J, Katsarma E, Current management of Jersey finger in rugby players: Case series and literature review, Hand Surg 15:103–107, 2010.
147
3. Zhang GY, Zhuang HY, Wang LX, Value of high frequency ultrasonography in diagnosis and surgical repair of traumatic finger tendon ruptures, Med Princ Pract 21:472–475, 2012, doi: 10.1159/ 000336405.
2:36:13pm
WSPC/135-HS
FA1
1572003
Hand Surgery, Vol. 20, No. 1 (2015) 145–147 © World Scientific Publishing Company DOI: 10.1142/S021881041572003X
Hand Surg. 2015.20:145-147. Downloaded from www.worldscientific.com by UNIVERSITY OF AUCKLAND LIBRARY - SERIALS UNIT on 06/10/15. For personal use only.
CLOSED TRAUMATIC RUPTURE OF THE FLEXOR POLLICIS LONGUS TENDON IN ZONE T I: A CASE REPORT Kazuaki Uekubo,* Soichiro Itoh*,† and Taro Yoshioka* *Department
of Orthopaedic Surgery, Kawakita General Hospital 1-7-3 Asagaya-kita, Suginami-ku Tokyo 166-8588, Japan
†
Department of Orthopaedic Surgery, Sakurakai Hospital 2-11-8 Senju Sakuragi, Adachi-ku Tokyo 120-0045, Japan
Received 30 May 2014; Revised 7 July 2014; Accepted 7 July 2014; Published 20 January 2015 ABSTRACT A healthy 41-year-old male suffered a direct blow on the palmar side of his right thumb when folding a table, which slipped along his thumb until it was stopped at the inter-phalangeal (IP) joint, resulting in a complete rupture of the flexor pollicis longus (FPL) tendon in zone T I. The proximal tendon stump was passed through the oblique pulley, fixed to the base of the distal phalanx with a pull-out wire technique and augmented on it using a part of the distal tendon remnant. After removal of the cast and the pull-out wire three weeks postoperatively, range of motion exercise was initiated and good functional recovery was obtained. Keywords: Flexor Pollicis Longus; Tendon; Closed Traumatic Rupture.
INTRODUCTION
actively; however, he could fully flex it passively. There was no fracture on the radiographs nor combined nerve injury. The FPL tendon was explored by a zig-zag skin incision under brachial block. The proximal part of the tendon was found in zone T III, and clotted blood in the synovium was adhered to the proximal tendon stump (Fig. 1A). The distal end of the ruptured tendon with clotted blood was found in zone T I as a remnant of 8 mm (Fig. 1B). The proximal tendon stump was passed through the oblique pulley, fixed to the base of the distal phalanx with a pull-out wire technique and augmented on it using a part of the distal tendon remnant (Fig. 1C). A thumb spica cast was used with 30 degree wrist flexion, and the
We present a case of unusual traumatic zone T I rupture of the flexor pollicis longus (FPL) tendon resulting from direct force applied to the thumb and discuss the mechanism of this injury.
CASE REPORT A healthy 41-year-old male suffered a direct blow on the palmar side of his right thumb when folding a table, which slipped along his thumb until it was stopped at the inter-phalangeal (IP) joint, resulting in a complete rupture of the FPL tendon in zone T I. On examination, he could not flex his thumb IP joint
Correspondence to: Dr. Soichiro Itoh, Department of Orthopaedic Surgery, Sakurakai Hospital, 2-11-8 Senju Sakuragi, Adachi-ku, Tokyo 120-0045, Japan. Tel: (+81) 03-3883-9211, Fax: (+81) 03-3881-2774, E-mail: [email protected] 145
January 14, 2015
Hand Surg. 2015.20:145-147. Downloaded from www.worldscientific.com by UNIVERSITY OF AUCKLAND LIBRARY - SERIALS UNIT on 06/10/15. For personal use only.
146
2:36:14pm
WSPC/135-HS
FA1
1572003
K. Uekubo, S. Itoh & T. Yoshioka
(A)
(B)
(C)
Fig. 1 (A) The proximal part of the ruptured FPL tendon in which clotted blood is adhered in the synovium (arrow). (B) The distal end of the ruptured FPL tendon with clotted blood is found in zone T I (arrow). Arrow head: The proximal part of the ruptured tendon. (C) The proximal tendon stump is passed through the oblique pulley, fixed to the base of the distal phalanx with a pull-out wire technique and augmented using part of the distal tendon remnant (arrow).
thumb was held in moderate flexion and abduction. After removal of the cast and the pull-out wire three weeks postoperatively, active mobilisation was initiated, followed by assisted range of motion exercise after five weeks. No complications were observed. Active extension/flexion of the metacarpophalangeal (MP) and IP joints was 0 /65 and 0 /50 , respectively, and the grip power of the right and left hands was 58 and 50 kg, respectively, after 20 weeks.
DISCUSSION Nonrheumatologic closed rupture of the FPL tendon in zone T I is a very unusual injury. The rarity of this type of injury may be due to the anatomical particularity of the FPL tendon. Because the thumb is used with an opposite position and support to pinch and grip, force is usually applied directly to the flexor digitorum superficialis (FDS) and FDP tendon in the palm. Marco et al. performed a biomechanical study on 21 cadaveric fingers to measure the mechanical force in these flexor tendons, in which the tension in the tendon was increased until the tendon or osseous failure.1 In 19 fingers, the A2, A3 or A4 pulley ruptured and in 2 fingers avulsion fracture occurred as the initial failure event. In our case, clotted blood was observed on both the proximal and distal tendon stumps without a pulley avulsion. These
findings may support such a mechanism of the injury; when the table slipped along the palmar side and stopped at the IP joint with flexion, the FPL tendon suffered an abrasion followed by a shear stress instead of a tensile force. As a result, complete rupture of the FPL tendon in zone T I occurred. Another possible mechanism may be a similar one to the \jersey finger injury",2 in which FDP muscle belly contracts maximally when the distal inter-phalangeal (DIP) joint is hyperextended while the proximal inter-phalangeal (PIP) joint is flexed, and rupture of the FDP tendon occurs at its insertion into the distal phalanx base as a result. When the traction force is large enough, avulsion fracture occurs on which fragment the FDP tendon remains attached. In the case of FPL tendon rupture, resembling injury in mode of onset may occur with the IP joint hyperextended while the MP joint flexed. Although we did not perform ultrasound examination preoperatively, high-frequency ultrasonographic findings may be effective to diagnose the location of the ruptured tendon stumps and evaluate the gap length.3
CONFLICT OF INTEREST K. Uekubo, S. Itoh and T. Yoshioka declare that we have no conflict of interest.
January 14, 2015
2:36:14pm
WSPC/135-HS
1572003
FA1
Closed Traumatic Rupture of the Flexor Pollicis Longus Tendon in Zone T I
References
Hand Surg. 2015.20:145-147. Downloaded from www.worldscientific.com by UNIVERSITY OF AUCKLAND LIBRARY - SERIALS UNIT on 06/10/15. For personal use only.
1. Marco RA, Sharkey NA, Smith TS, Zissimos AG, Pathomechanics of closed rupture of the flexor tendon pulleys in rock climbers, J Bone Joint Surg 80A:1012–1019, 1998. 2. Goodson A, Morgan M, Rajeswaran G, Lee J, Katsarma E, Current management of Jersey finger in rugby players: Case series and literature review, Hand Surg 15:103–107, 2010.
147
3. Zhang GY, Zhuang HY, Wang LX, Value of high frequency ultrasonography in diagnosis and surgical repair of traumatic finger tendon ruptures, Med Princ Pract 21:472–475, 2012, doi: 10.1159/ 000336405.
