Injury: the British Journal of Accident Surgery (1991) Vol. 22/No.
2
153
Flexor pollicis longus rupture after fracture of the distal radius G. Ashall Northern
Ireland Plastic and Maxillofacial
Service, Belfast, UK
patient returned to work 6 weeks postoperatively with 30" of strong active flexion at the thumb interphalangeal joint.
Introduction Flexor tendor rupture is an extremely rare complication of fractures of the distal radius. Only four cases affecting flexor pollicis longus have previously been described (McMaster, 1932; Cooney et al., 1980; Wong and Pho, 1984; Diamond and Newman, 1987).
Case report Anl&year-old carpenter sustained a hyperextension injury of his left wrist resulting in posterior
displacement of the distal radial epiphysis (Figwe I). The fracture was reduced and splinted in a plaster cast for 6 weeks. Four weeks after removal of the plaster, while lifting a carpet, the patient felt sudden pain in his left wrist and forearm and noticed that he was unable to flex his left thumb. The wrist was explored (Fimre 2) after physiotherapy to regain full passive movements of the thumb. There was fibrosis in the deep part of the flexor compartment. The flexor pollicis longus (FPL) was frayed and ruptured, the distal end lying beneath the thenar muscles and the proximal end firmly adherent to the index profundus tendon which was roughened. A bony step, visible in preoperative radiographs (Figure3), was present on the volar
Discussion Previously reported cases of flexor tendon rupture after injury to the distal radius are summarized in Tabkl. The rarity of such phenomena is confirmed by their low incidence in large series of Colles’ fractures (Green and Gay, 1956; Frykman, 1967; Cooney et al., 1980; Stewart et al., 1985). Normal tendons rarely rupture. McMaster (1933)
The bony step was smoothed with a rasp. In view of the large gap between the ends of FPL it was decided to transfer the superficialis tendon of the ring finger to the distal end of FPL. The
showed that a muscle/tendon/bone unit subjected to severe strain would only rupture through tendon if the tendon was already weakened by partial division or ischaemia. Four theoretical mechanisms by which weakening of flexor tendons may occur in association with injury to the distal radius are listed in Tablea Depending on the mechanisms involved, the tendons may be weakened acutely or progressively. This is demonstrated by the wide range of delay between injury and rupture in published cases (Table I). Sudden hyperextension occurs in most fractures of the lower end of the radius and while this is unlikely to cause complete rupture of a flexor tendon it may be sufficient to damage some fibres especially if the tendon is stretched over the displaced fractures. Extensor tendons rupture more frequently than flexor
Figure 1. Prereduction radiographs showing displacement of distal radial epiphysis.
Figure 2. Findings at operation - (A) proximal and (B) distal end of FPL; (C) index FDP; (D) bony step at radial epiphysis.
aspect of the radius distal to pronator quadratus.
0020-1383/91/020153-02 0 1991 Butterworth-Heinemann
Ltd
marked posterior
Case reports
154
Table I. Previous reports of flexor tendon rupture following fracture of distal radius
Authors
No. of cases __.___~~~~_
Year
_.
Age
Sex
McMaster Broder
1932 1954
1 1
35 71
M M
Boyes et al. Nagano et al.
1960 1970
2 1
7 20
? M
Southmayd et al.
1975
1
27
M
Younger and De Fiore
1977
1
60
F
Cooney et al.
1980
Wong and Pho
1984
2(i) (ii) 1
? ? 60
? ? M
Diamond and Newman
1987
1
70
F
Rymaszewski and Walker
1987
1
18
M
Tendons FPL FDP- M,R,L FDS - R,L ? FDP-I FPL FDP-M FDP-I FDS-I FDP-L FDS - R,L FDP-I FPL FDP-I FPL FDP- I,M,R,L FDS - I,M,R.L FPL FDP-I
Delay to rupture 3m 2Y 7 2m 4m 4m 4h 10d 1Y 3m 3m 4w 12-28 w
lY
I = Index. M = Middle, R = Ring, L= Little h = hours, d = days, w = weeks, m = months, y= years FPL: Flexor Pollicis Longus; FDS: Flexor Digitorum Superficialis; FDP: Flexor Digitorum Profundus
Table II. Potential causes of weakening injury of the distal radius 1 2 3 4
of flexor tendons
in
Damage by forces (crush/tensile) which injure bone Laceration by sharp bone edges before reduction Attrition on bony irregularities after reduction Interference with vascular or synovial supply of tendon by laceration or compression
after Colles’ fracture even though sharp bone edges are more likely to be directed towards the latter. Several authors have repeated McMaster’s (1932) suggestion that fendons
this is because the pronator quadratus protects the flexor tendons from injury by the bone. It is interesting to note that in the case reported by Broder (1954) radiographs showed a volar bony projection but the bed in which the ruptured tendons were found was smooth. In the case presented here the bony step was at the epiphyseal line distal to the pronator quadratus and was easily palpable at operation. Engkvist and Lundborg (1979) confirmed that rupture of the extensor pollicis longus occurs most commonly after tlndisp~ucedfractures of the distal radius. They suggested that effusion or bleeding within an intact fibrous extensor sheath
Figure 3. Preoperative at lower end of radius.
radiographs
showing
residual deformity
reduces tendon blood flow or production of synovial fluid or both. Flexor tendons are not so rigidly encased over the lower end of the radius and may therefore be protected from this mode of interference with their nutrition. The fact that 20 of the 29 ruptured tendons which have been reported (including this case) are those which lie deeply at the wrist suggests that injury by bone is the dominant aetiological factor. By whatever mechanism the tendons are weakened, the likelihood and timing of rupture will finally be determined by the severity of strain applied to them.
Acknowledgements I should like to thank Mr John Colville for permission to report on his patient and for criticism of the manuscript. I am grateful to Mr Norman Ervine of the Department of Medical Photography at the Ulster Hospital for the photographs.
References Boyes J. H., Wilson J. N. and Smith J. W. (1960) Flexor tendon
ruptures in the forearm and hand. 1. BoneJoint 5.~. 42.4, 637. Broder H. (1954) Rupture of flexor tendons associated with a malunited Colles’ fracture. J &e Joint Srcrg. 36A, 404. Cooney W. P., Dobyns J. H. and Linsfield R. L. (1980) Complications of Colles’ fractures. 1. BoneJoint %rg. 62A, 613. Diamond J. P. and Newman J. H. (1987) Multiple flexor tendon ruptures following Colles’ fracture: a case report. 1. Hund Surg. 12B, 112. Engkvist 0. and Lundborg G. (1979) Rupture of the extensor pollicis longus tendon after fracture of the lower end of the radius - a clinical and microangiographic study. The Hana’ 11, 76. Frykman G. (1967)Fracture of the distal radius including sequelae shoulde&nger-hand syndrome, disturbance of the distal radio-ulnar joint and impairment of nerve function. A clinical and experimental study. Acta Or&p. Stand. Suppl. 108. Green J. T. and Gay F. H. (1956) Colles’ fracture - residual disability. Am. 1, Surg. 91, 636.
Injury: the British Journal of Accident Surgery (1991) Vol. 22/No.
2
155
Stewart H. D., lnnes A. R. and Burke F. D. (1985) The hand complications of Colles’ fractures. 1. I-I& Sm. IOB, 103. Wong F. H. Y. and Pho R. W. H. (1984) Median nerve compression, with tendon ruptures, after Colles’ fracture. 1. find Strrg. 9B, 139. Younger C. P. and De Foire J. C. (1977) Rupture of flexor tendons to the fingers after a Colles’ fracture. J. BonejointSurg. 59A, 828.
M&laster P. E. (1932) Late ruptures of extensor and flexor pollicis longus tendons following Cofles’ fracture. 1. Bone Joint Sq. 14, 93. McMaster P. E. (1933) Tendon and muscle ruptures. Clinical and experimental studies on the causes and location of subcutaneous ruptures. j. BovlpJoint Surg. 15, 705. Nagano Y., Imakire A. and Nagamine Y. (1970) Rupture of the flexor tendon of the finger following Colles’ fracture. ortkop. St&g. (Tokyo) 21,935. Rymaszewski L. A. and Walker A. P. (1987) Rupture of flexor digitorum profundus to the index finger after a distal radial fracture. J. tiand Surg. 12B, 115. Southmayd W. W., Millender L. H. and Nalebuff E. A. (1975) Rupture of the flexor tendons of the index finger after Colles’ fracture. 1. Bone Joint Surg. 5 7A, 562.
Paper accepted
4 June 1990.
Requtxfs forreprints shod beaddressed to: G. Ashall FRCSmcsEd, Locum Senior Registrar, Northern Ireland Plastic and Maxillofacial Service, The Ulster Hospital, Dundonald, Belfast BT16 ORH, UK.
Fracture of the body of the talus M. F. Pearse, J. L. Fowler and D. J. Bracey Orthopaedic
Department,
Royal
Cornwall
(City) Hospital,
Truro, Cornwall, UK
A 69-year-old man fell approximately 1.2m off a ladder taking most of his weight onto his right foot. He was unable to bear
weight. On examination there was swelling and tenderness below the malleoli of the right ankle. In addition he was unable to dorsiflex his hallux which was held in 30" of plantar flexion. Radiographic examination revealed a displaced fracture of the posterior process of the talus (Figure I). The articular surface of the talus was severely displaced. At operation the posterior tibia1 neurovascular bundle was dissected via a IO-cmposteromedial incision and protected with a sling. The talar fragment had been driven posteriorly causing bowstringing of the flexor hallucis longus tendon. The fragment was freed after exposing the tendons of flexor hallucis longus, flexor digitonun longus and tibialis posterior. The exposure did not provide an adequate view of the fracture reduction and access was improved by an osteotomy of the medial malleous which was then reflected inferiorly. The fracture reduc-
Figure I. Radiographs of the right ankle showing fracture of the talar body.
Figure 2. Radiographs showing internal fixation with 4.0mm A0 cancellous screws and union of the malleolar osteotomy and talar fracture.
Introduction of the body of the talus are extremely rare injuries and are reported as accounting for about 0.1 per cent of all fractures (Sneppen et al., 1977). Like injuries to the talar neck, they are associated with a high rate of complications including malunion, avascular necrosis and degenerative arthritis (Rockwood and Green, 1984). We report a case of a displaced sagittal shear fracture (Sneppen Type C) successfully treated by internal fixation. Fractures
Case report
0020-1383/91/020155-01 0 1991 Butterworth-Heinemann
Ltd
the displaced
2
153
Flexor pollicis longus rupture after fracture of the distal radius G. Ashall Northern
Ireland Plastic and Maxillofacial
Service, Belfast, UK
patient returned to work 6 weeks postoperatively with 30" of strong active flexion at the thumb interphalangeal joint.
Introduction Flexor tendor rupture is an extremely rare complication of fractures of the distal radius. Only four cases affecting flexor pollicis longus have previously been described (McMaster, 1932; Cooney et al., 1980; Wong and Pho, 1984; Diamond and Newman, 1987).
Case report Anl&year-old carpenter sustained a hyperextension injury of his left wrist resulting in posterior
displacement of the distal radial epiphysis (Figwe I). The fracture was reduced and splinted in a plaster cast for 6 weeks. Four weeks after removal of the plaster, while lifting a carpet, the patient felt sudden pain in his left wrist and forearm and noticed that he was unable to flex his left thumb. The wrist was explored (Fimre 2) after physiotherapy to regain full passive movements of the thumb. There was fibrosis in the deep part of the flexor compartment. The flexor pollicis longus (FPL) was frayed and ruptured, the distal end lying beneath the thenar muscles and the proximal end firmly adherent to the index profundus tendon which was roughened. A bony step, visible in preoperative radiographs (Figure3), was present on the volar
Discussion Previously reported cases of flexor tendon rupture after injury to the distal radius are summarized in Tabkl. The rarity of such phenomena is confirmed by their low incidence in large series of Colles’ fractures (Green and Gay, 1956; Frykman, 1967; Cooney et al., 1980; Stewart et al., 1985). Normal tendons rarely rupture. McMaster (1933)
The bony step was smoothed with a rasp. In view of the large gap between the ends of FPL it was decided to transfer the superficialis tendon of the ring finger to the distal end of FPL. The
showed that a muscle/tendon/bone unit subjected to severe strain would only rupture through tendon if the tendon was already weakened by partial division or ischaemia. Four theoretical mechanisms by which weakening of flexor tendons may occur in association with injury to the distal radius are listed in Tablea Depending on the mechanisms involved, the tendons may be weakened acutely or progressively. This is demonstrated by the wide range of delay between injury and rupture in published cases (Table I). Sudden hyperextension occurs in most fractures of the lower end of the radius and while this is unlikely to cause complete rupture of a flexor tendon it may be sufficient to damage some fibres especially if the tendon is stretched over the displaced fractures. Extensor tendons rupture more frequently than flexor
Figure 1. Prereduction radiographs showing displacement of distal radial epiphysis.
Figure 2. Findings at operation - (A) proximal and (B) distal end of FPL; (C) index FDP; (D) bony step at radial epiphysis.
aspect of the radius distal to pronator quadratus.
0020-1383/91/020153-02 0 1991 Butterworth-Heinemann
Ltd
marked posterior
Case reports
154
Table I. Previous reports of flexor tendon rupture following fracture of distal radius
Authors
No. of cases __.___~~~~_
Year
_.
Age
Sex
McMaster Broder
1932 1954
1 1
35 71
M M
Boyes et al. Nagano et al.
1960 1970
2 1
7 20
? M
Southmayd et al.
1975
1
27
M
Younger and De Fiore
1977
1
60
F
Cooney et al.
1980
Wong and Pho
1984
2(i) (ii) 1
? ? 60
? ? M
Diamond and Newman
1987
1
70
F
Rymaszewski and Walker
1987
1
18
M
Tendons FPL FDP- M,R,L FDS - R,L ? FDP-I FPL FDP-M FDP-I FDS-I FDP-L FDS - R,L FDP-I FPL FDP-I FPL FDP- I,M,R,L FDS - I,M,R.L FPL FDP-I
Delay to rupture 3m 2Y 7 2m 4m 4m 4h 10d 1Y 3m 3m 4w 12-28 w
lY
I = Index. M = Middle, R = Ring, L= Little h = hours, d = days, w = weeks, m = months, y= years FPL: Flexor Pollicis Longus; FDS: Flexor Digitorum Superficialis; FDP: Flexor Digitorum Profundus
Table II. Potential causes of weakening injury of the distal radius 1 2 3 4
of flexor tendons
in
Damage by forces (crush/tensile) which injure bone Laceration by sharp bone edges before reduction Attrition on bony irregularities after reduction Interference with vascular or synovial supply of tendon by laceration or compression
after Colles’ fracture even though sharp bone edges are more likely to be directed towards the latter. Several authors have repeated McMaster’s (1932) suggestion that fendons
this is because the pronator quadratus protects the flexor tendons from injury by the bone. It is interesting to note that in the case reported by Broder (1954) radiographs showed a volar bony projection but the bed in which the ruptured tendons were found was smooth. In the case presented here the bony step was at the epiphyseal line distal to the pronator quadratus and was easily palpable at operation. Engkvist and Lundborg (1979) confirmed that rupture of the extensor pollicis longus occurs most commonly after tlndisp~ucedfractures of the distal radius. They suggested that effusion or bleeding within an intact fibrous extensor sheath
Figure 3. Preoperative at lower end of radius.
radiographs
showing
residual deformity
reduces tendon blood flow or production of synovial fluid or both. Flexor tendons are not so rigidly encased over the lower end of the radius and may therefore be protected from this mode of interference with their nutrition. The fact that 20 of the 29 ruptured tendons which have been reported (including this case) are those which lie deeply at the wrist suggests that injury by bone is the dominant aetiological factor. By whatever mechanism the tendons are weakened, the likelihood and timing of rupture will finally be determined by the severity of strain applied to them.
Acknowledgements I should like to thank Mr John Colville for permission to report on his patient and for criticism of the manuscript. I am grateful to Mr Norman Ervine of the Department of Medical Photography at the Ulster Hospital for the photographs.
References Boyes J. H., Wilson J. N. and Smith J. W. (1960) Flexor tendon
ruptures in the forearm and hand. 1. BoneJoint 5.~. 42.4, 637. Broder H. (1954) Rupture of flexor tendons associated with a malunited Colles’ fracture. J &e Joint Srcrg. 36A, 404. Cooney W. P., Dobyns J. H. and Linsfield R. L. (1980) Complications of Colles’ fractures. 1. BoneJoint %rg. 62A, 613. Diamond J. P. and Newman J. H. (1987) Multiple flexor tendon ruptures following Colles’ fracture: a case report. 1. Hund Surg. 12B, 112. Engkvist 0. and Lundborg G. (1979) Rupture of the extensor pollicis longus tendon after fracture of the lower end of the radius - a clinical and microangiographic study. The Hana’ 11, 76. Frykman G. (1967)Fracture of the distal radius including sequelae shoulde&nger-hand syndrome, disturbance of the distal radio-ulnar joint and impairment of nerve function. A clinical and experimental study. Acta Or&p. Stand. Suppl. 108. Green J. T. and Gay F. H. (1956) Colles’ fracture - residual disability. Am. 1, Surg. 91, 636.
Injury: the British Journal of Accident Surgery (1991) Vol. 22/No.
2
155
Stewart H. D., lnnes A. R. and Burke F. D. (1985) The hand complications of Colles’ fractures. 1. I-I& Sm. IOB, 103. Wong F. H. Y. and Pho R. W. H. (1984) Median nerve compression, with tendon ruptures, after Colles’ fracture. 1. find Strrg. 9B, 139. Younger C. P. and De Foire J. C. (1977) Rupture of flexor tendons to the fingers after a Colles’ fracture. J. BonejointSurg. 59A, 828.
M&laster P. E. (1932) Late ruptures of extensor and flexor pollicis longus tendons following Cofles’ fracture. 1. Bone Joint Sq. 14, 93. McMaster P. E. (1933) Tendon and muscle ruptures. Clinical and experimental studies on the causes and location of subcutaneous ruptures. j. BovlpJoint Surg. 15, 705. Nagano Y., Imakire A. and Nagamine Y. (1970) Rupture of the flexor tendon of the finger following Colles’ fracture. ortkop. St&g. (Tokyo) 21,935. Rymaszewski L. A. and Walker A. P. (1987) Rupture of flexor digitorum profundus to the index finger after a distal radial fracture. J. tiand Surg. 12B, 115. Southmayd W. W., Millender L. H. and Nalebuff E. A. (1975) Rupture of the flexor tendons of the index finger after Colles’ fracture. 1. Bone Joint Surg. 5 7A, 562.
Paper accepted
4 June 1990.
Requtxfs forreprints shod beaddressed to: G. Ashall FRCSmcsEd, Locum Senior Registrar, Northern Ireland Plastic and Maxillofacial Service, The Ulster Hospital, Dundonald, Belfast BT16 ORH, UK.
Fracture of the body of the talus M. F. Pearse, J. L. Fowler and D. J. Bracey Orthopaedic
Department,
Royal
Cornwall
(City) Hospital,
Truro, Cornwall, UK
A 69-year-old man fell approximately 1.2m off a ladder taking most of his weight onto his right foot. He was unable to bear
weight. On examination there was swelling and tenderness below the malleoli of the right ankle. In addition he was unable to dorsiflex his hallux which was held in 30" of plantar flexion. Radiographic examination revealed a displaced fracture of the posterior process of the talus (Figure I). The articular surface of the talus was severely displaced. At operation the posterior tibia1 neurovascular bundle was dissected via a IO-cmposteromedial incision and protected with a sling. The talar fragment had been driven posteriorly causing bowstringing of the flexor hallucis longus tendon. The fragment was freed after exposing the tendons of flexor hallucis longus, flexor digitonun longus and tibialis posterior. The exposure did not provide an adequate view of the fracture reduction and access was improved by an osteotomy of the medial malleous which was then reflected inferiorly. The fracture reduc-
Figure I. Radiographs of the right ankle showing fracture of the talar body.
Figure 2. Radiographs showing internal fixation with 4.0mm A0 cancellous screws and union of the malleolar osteotomy and talar fracture.
Introduction of the body of the talus are extremely rare injuries and are reported as accounting for about 0.1 per cent of all fractures (Sneppen et al., 1977). Like injuries to the talar neck, they are associated with a high rate of complications including malunion, avascular necrosis and degenerative arthritis (Rockwood and Green, 1984). We report a case of a displaced sagittal shear fracture (Sneppen Type C) successfully treated by internal fixation. Fractures
Case report
0020-1383/91/020155-01 0 1991 Butterworth-Heinemann
Ltd
the displaced
