SPONTANEOUS

RUPTURE

OF THE TENDON

M. A. TONKIN Hand and Microsurgery

FLEXOR

CARP1

RADIALIS

and H. S. STERN

Unit, Royal North Shore Hospital, Sydney, New South Wales, Australia

Three cases of closed rupture of the flexor carpi radialis tendon associated with scapho-trapeziotrapezoidal arthritis are reported. Carpal tunnel surgery preceded all three ruptures. Local steroid injection preceded two ruptures. Long-term disability was minimal. Journal of Hand Surgery (British Volume, 1991) 16B: 72-74 Closed spontaneous rupture of the long flexor tendons of the fingers is well-described and is associated with various aetiological factors in both rheumatoid (Moberg, 1965; Mannerfelt and Norman, 1967; Moore et al., 1987; Terranova and Morgan, 1987) and non-rheumatoid hands (McMaster, 1933; Broder, 1954; Anzelet al., 1959; Boyes and Wilson, 1960; Folmar et al., 1972; Minami et al., 1985; Masada et al., 1987). Rupture of the flexor carpi radialis tendon is an uncommon finding in either group, having been previouslyreported inonly five hands to the author’s knowledge (Anzel et al., 1959; Bowe et al., 1984; Moore et al., 1987). This paper reports three cases of closed rupture of the F.C.R. tendon with common aetiological factors.

had retracted 3 cm. The osteophytes were removed and reactive synovitis excised from the tendon ends and the S.T.T. joint. The tendon was not repaired. At review 18 months later, the patient complained of mild intermittent pain at the base of the thumb on activities such as turning taps and door handles. She also described a minimal weakness of grip strength. Wrist motion was decreased by 25% and grip strength by 20% (Table 1).

Case reports Case 1 A 55-year-old right-handed woman presented with a fivemonth history of a swelling on the palmar aspect of the base of the right thumb. Subsequently she described an acute episode of pain at the radial aspect of the right wrist whilst doing normal activities. The past medical history included a right carpal tunnel decompression 23 years earlier. Examination revealed a soft tender swelling adjacent to the scaphoid tubercle. Compression and rotation of the basal thumb joints caused pain, as did radial deviation of the wrist. X-rays and C.T. scan revealed scapho-trapezio-trapezoidal arthritis with osteophyte formation (Figs 1 and 2). At surgical exploration, the F.C.R. tendon was ruptured at the S.T.T. joint level, where osteophytes protruded into the “F.C.R. tunnel”. The proximal end of the tendon Table

l-Functional

results

after conservative

1

X-ray of right with osteophyte

wrist of Case formation.

1, showing

S.T.T.

joint

arthritis

management

Patient *Denotes injured hand Wrist flexion (degrees) Wrist extension (degrees) Radial deviation (degrees) Ulnar deviation (degrees) Grip strength (kg) Forearm circumference (cm)

72

Fig.

Case I

Case 2

Case 3

Right*

Left

Right

Left*

Right*

LKft

60 51 11 25 22 24.0

15 65 21 28 29 24.3

54 12 22 30 32 26.0

66 15 28 30 21 25.3

48 59 12 35 16 25.5

48 65 15 35 18 24.4

THE

JOURNAL

OF HAND

SURGERY

SPONTANEOUS

Fig. 2

RUPTURE

OF THE

FLEXOR

CARP1

RADIALIS

TENDON

CT scan of Case 1.

Case 2

A 46-year-old right handed woman presented with a one month history of left wrist pain associated with a firm swelling at the palmar aspect of the S.T.T. joint. A carpal tunnel decompression had been performed 12 years earlier. Radiological examination revealed very early degenerative changes of the S.T.T. joint. No osteophytes were obvious (Fig. 3). A corticosteroid injection into the palmar wrist swelling, presumed to be a ganglion cyst, relieved symptoms. Three weeks later the patient experienced acute pain at the radial aspect of the left wrist when closing a heavy drawer. Examination revealed bruising over the distal half of the flexor aspect of the forearm. There was a palpable defect measuring 3 cm in the line of the F.C.R. tendon proximal to the wrist. The wrist was splinted intermittently in the neutral position for three weeks. At review 16 months after presentation, the patient denied any pain, weakness, or loss of function. There was no decrease in wrist motion and a minimal decrease in grip strength (Table 1). Power of wrist flexion with radial deviation was Grade 5.

Fig. 3

X-ray joint.

of Case 2, showing

early

degenerative

changes

in S.T.T.

9 cm proximal to the distal wrist crease. The F.C.R. tendon was not palpable at the wrist. The basal thumb joints were painful when stressed. Radiological assessment revealed Stage 4 carpometacarpal joint osteoarthritis (pan-trapezia1 degenerative changes), shown in Figure 4. The wrist was splinted intermittently in a neutral position for three months, with full relief of forearm and wrist pain. After three months, there was a slight decrease in extension and radial deviation but the power of wrist flexion with radial deviation was Grade 5. Grip strength was decreased minimally (Table 1). As the patient continued to complain of pain related to the pan-trapezia1 arthritis, excision of the trapezium and silastic replacement is planned.

Case 3

A 72-year-old right handed woman presented with a 15 month history of pain at the base of the right thumb. A swelling had appeared at the palmar aspect of this area six weeks earlier. This swelling had been injected with corticosteroid on two occasions. Three days after the second injection, the patient experienced acute pain in the wrist and forearm and developed extensive bruising on the forearm. Ten years before this, she had undergone bilateral carpal tunnel decompression. Examination revealed resolving bruising on the flexor aspect of the forearm. A tender swelling was palpable VOL.

16B No.

1 FEBRUARY

1991

Discussion

There are five previous cases of spontaneous FCR rupture reported in the English literature. Moore et al. (1987) described two cases associated with severe rheumatoid carpal collapse. These were treated by surgical debridement and synovectomy. No follow-up results were reported. Bowe et al. (1984) reported good functional results from simple splinting in a case of bilateral partially ruptured F.C.R. tendons secondary to pantrapezial osteoarthritis. The fifth previously reported case was within a series of 1014 various tendon 73

M. A. TONKIN

AND

H. S. STERN

documented (Eversmann, 1988). The role this alteration may play in the development of degenerative intercarpal joint disease is unclear. Changes in the excursion and tension of the F.C.R. tendon secondary to carpal settling after carpal tunnel surgery could also play a role in attrition rupture. These three cases show that long-term disability after F.C.R. tendon rupture is minimal. Therefore F.C.R. is attractive as a donor in tendon transfer surgery. Brand (1975) has suggested that its use leaves less disability than the use of flexor carpi ulnaris tendon in the management of radial nerve palsy. Reference;

Fig. 4

X-ray

of Case 3, showing

severe

pan-trapezialjoint

destruction.

disruptions (Anzel et al., 1959). There were no details of aetiology, treatment or final function. All three of our patients had radiological degenerative changes in the S.T.T. joint, although the changes were mild in Case 2. Corticosteroid injection preceded rupture in Cases 2 and 3. However a palpable lump adjacent to the S.T.T. joint was present in all three cases, and preceded injection. Surgical exploration in Case 1 revealed this to be a reactive synovitis associated with S.T.T. osteoarthritis and tenosynovitis of the F.C.R. tendon at the point of attrition against osteophyte penetration into the F.C.R. tunnel. Surgery was not indicated in Cases 2 and 3, as the functional deficit and symptoms were minimal. It, is presumed that attrition rupture was the primary aetiological factor in Cases 1 and 3 and possibly in Case 2 (mild degenerative changes only). Corticosteroid injection may have contributed to the final event in Cases 2and3. Interestingly, carpal tunnel release had been performed in all cases. Alteration in carpal bone configuration following division of the flexor retinaculum is well

74

ANZEL, S. H., COREY, K. W., WEINER, A. D. and LIPSCOMB, P. R. (1959). Disruption of muscles and tendons. An analysis of 1014 cases. Surgery, 45: 406-414. BOWE, A., DOYLE, L. and MILLENDER, L. H. (1984). Bilateral partial ruptures of the flexor carpi radialis tendon secondary to trapezia1 arthritis. Journal of Hand Surgery, 9A: 5: 738-739. BOYES, J. H., WILSON, J. N. and SMITH, J. W. (1960). Flexor-Tendon Ruptures in the Forearm and Hand. Journal of Bone and Joint Surgery, 42A : 4 : 637-646. BRAND, P. W. Tendon Transfers in the Forearm. In: Flynn, J. E. (Ed) Hand Surgery, 2nd edn. Baltimore, Williams and Wilkins, 1975: 189. BRODER, H. (1954). Rupture of flexor tendons, asdociated with a malunited Colles fracture. Journal of Bone and Joint Surgery, 36A: 2: 404-405. EVERSMANN, W. W. Entrapment and Compression Neuropathies. In: Green, D. P. (Ed.) Operatiue Hand Surgery, 2nd edn. New York, Churchill Livingstone, 1988: 1423-1479. FOLMAR, R. C., NELSON, C. L. and PHALEN, G. S. (1972). Ruptures of the Flexor Tendons in Hands of Non-Rheumatoid Patients. Journal of Bone and Joint Surgery, 54A : 3 : 579-584. MANNERFELT, L. and NORMAN, 0. (1969). Attrition ruptures of Aexor tendons in rheumatoid arthritis caused by bony spurs in the carpal tunnel. A clinical and radiological study. Journal of Bone and Joint Surgery, 51B: 2: 270-277. MASADA, K., KAWABATA, H. and ONO, K. (1987). Pathologic rupture of flexor tendons due to longstanding KienbGck’s disease. Journal of Hand Surgery, 12A : 1: 22-25. McMASTER, P. E. (1933). Tendon and muscle ruptures. Clinical and experimental studies on the causes and location of subcutaneous ruptures. Journal of Bone and Joint Surgery, 15 : 705-722. MINAMI, A., OGINO, T., USUI, M. and ISHII, S. (1985). Finger tendon rupturesecondaryto fractureofthe hamate. Acasereport. ActaOrthopaedica Scandinavica, 56: 96-97. MOBERG, E. (1965). Tendon Grafting and Tendon Suture in Rheumatoid Arthritis. American Journal of Surgery, 109: 375-376. MOORE, J. R., WEILAND, A. J. and VALDATA, L. (1987). Tendon ruptures in the rheumatoid hand: Analysis of treatment and functional results in 60 patients. Journal of Hand Surgery, 12A: 1: 9-14. TERRANOVA, W. and MORGAN, R. F. (1987). Late rupture of the flexor tend&s as a complication of replacement arthroplasty. Journal of Hand Surgery, 12A: 1: 15-17.

Accepted: 30 June 1989. M. A. Tonkin, FRCS(Ed. Orth), FRACS Hand&Microsurgery Unit, Royal North Shore Hospital, St. Leonards N.S.W. 2065, Australia, Ph. (02)438 7778. 0 1991 The British Society for Surgery of the Hand

THE

JOURNAL

OF HAND

SURGERY

Spontaneous rupture of the flexor carpi radialis tendon.

Three cases of closed rupture of the flexor carpi radialis tendon associated with scapho-trapezio-trapezoidal arthritis are reported. Carpal tunnel su...
704KB Sizes 0 Downloads 0 Views