Case Report
Can another Surgical Approach for the Cerebrospinal Fluid Fistulas Change the Rehabilitative Outcome in a Significant Way?
Jonathan James T Eno MD1* and Jeffrey Yao MD2
1Department of Orthopaedic Surgery, Stanford University Medical Center, USA
2Stanford Medicine Outpatient Center, USA
*Corresponding author: Jonathan James T Eno MD, Department of Orthopaedic Surgery, Stanford University Medical Center, Pasteur Drive, Room R144 Stanford, CA 94305-5341, USA
Published: 27 Jan, 2017
Cite this article as: Eno JJT, Yao J. Bilateral Spontaneous
Delayed Extensor Pollicus Longus
Ruptures Following Distal Radius
Fractures: A Case Report and Review
of the Literature. Ann Clin Case Rep.
2017; 2: 1243.
Abstract
Spontaneous delayed rupture of the extensor pollicis longus (EPL) is a rare complication following distal radius fracture. Bilateral EPL rupture following bilateral distal radius fractures is even rarer. A case report of bilateral EPL rupture following bilateral non-displaced distal radius fractures is presented along with a review of the literature regarding pathophysiology, treatment options, and technical surgical variations.
Introduction
Spontaneous rupture of the EPL is a well-described complication, with many reports of unilateral rupture with various associated pathophysiology. First reported by Duplay in 1876, there have been many cases of unilateral EPL rupture with associated underlying systemic inflammatory conditions, systemic or local corticosteroid use, trauma, and iatrogenic causes including dorsal and volar plate and screw fixation of distal radius fractures [1]. Bilateral spontaneous EPL rupture is a much more rare complication, with few reported cases of varying etiology. The authors have obtained the patient's informed written consent for print and electronic publication of the case report.
Case Presentation
A 59-year-old, right-hand dominant female without history of systemic inflammatory disease
was referred for consultation 4.5 weeks after sustaining bilateral non-displaced extra-articular
distal radius fractures after falling while playing tennis. She underwent closed treatment of the
bilateral distal radius fractures with splint immobilization. Four weeks post-injury, she developed
spontaneous rupture of the left EPL. Initial evaluation of the left hand and wrist demonstrated an
inability to retropulse her thumb and no tone with attempted IP extension, consistent with EPL
rupture.
Her right hand and wrist demonstrated minimal tenderness of the distal radius as well as more
pronounced tenderness over the dorsal aspect of the wrist in the area of Lister’s tubercle and the
path of the EPL tendon. She maintained full active range of motion of the right hand and wrist.
Radiographs of the left hand and wrist demonstrated a healing non-displaced extra-articular
two-part distal radius fracture. The diagnosis of a ruptured left EPL was determined based upon
physical examination. She was offered and agreed to a reconstructive procedure in the form of
extensor indicis proprius (EIP) to EPL transfer to restore thumb retropulsion and IP extension.
The patient underwent successful left EIP to EPL transfer using standard tensioning technique at
five weeks post-injury. The patient returned to clinic three weeks postoperatively, at which point she
had already successfully regained partial left thumb retropulsion and began hand therapy for further
retraining of the transfer. Interestingly at that point (six weeks post-injury), she then reported
the spontaneous inability to retropulse her right thumb that was confirmed upon examination,
consistent with a new rupture of the right EPL. She also continued to have ulnar-sided wrist pain
with positive fovea and triangular fibro cartilage complex (TFCC) grind tests, consistent with a
right TFCC injury. She agreed to undergo a right EIP to EPL transfer and wrist arthroscopy with
TFCC debridement eight weeks after the left EIP to EPL transfer to allow adequate healing and
rehabilitation prior to surgery on the contralateral limb.
Eight weeks following the right EPL rupture and 14 weeks
following the right distal radius fracture, the patient underwent
successful right EIP to EPL transfer and wrist arthroscopy with
TFCC debridement. At most recent follow up, three and five months
postoperatively on the left and right hands, respectively, the patient
had regained full ability to retropulse both thumbs (Figures 1 and
2) while maintaining proper resting tension (Figure 3) and thumb
palmar abduction (Figure 4). Strength testing revealed right-handed
grip and key pinch strengths of 45 and 10 pounds and left-handed
grip and key pinch strengths of 52 and 12 pounds, respectively.
Figure 1
Figure 2
Figure 3
Figure 3
Intraoperative picture after excision of tumor, showing direction
and arc of rotation of temporalis muscle to cover palatal defect.
Discussion
There have been few reported cases in the literature of bilateral
spontaneous EPL rupture. Galluci reported a case of EPL rupture
following tenosynovectomy for persistent EPL tenosynovitis in one
wrist with subsequent rupture of the contralateral EPL following
prophylactic subcutaneous EPL transposition for a prominent
osteophyte at Lister’s tubercle [1]. Anwar reported bilateral ruptures
in a patient with ankylosing spondylitis on prolonged systemic
corticosteroid therapy [2]. Mills reported on an elite-level athlete
who underwent multiple local corticosteroid injections for extensor
tenosynovitis with subsequent spontaneous EPL rupture bilaterally
[3]. Each of these cases of bilateral ruptures were identified in an
atraumatic setting and due to some intervention.
The incidence of spontaneous unilateral EPL rupture following distal radius fracture has been reported between 0.3% and 5% and
more commonly in minimally-displaced than displaced fractures [4].
EPL rupture most commonly occurs between three weeks and three
months after a distal radius fracture [5]. The incidence of delayed
spontaneous bilateral EPL rupture following distal radius fracture has
previously been reported only twice. Haher initially reported a case in
1987 where the patient sustained bilateral EPL ruptures separated by
18 months following separate episodes of unilateral wrist sprains [5].
More recently in 2000, Payne reported a case of bilateral delayed EPL
ruptures following non-displaced distal radius fractures, however
each unilateral rupture occurred two years apart following separate
isolated unilateral distal radius fractures [6]. To our knowledge, there
have been no reports of spontaneous bilateral EPL ruptures following
bilateral distal radius fractures sustained at the same setting.
Multiple pathophysiologic mechanisms of spontaneous EPL
rupture following distal radius fracture have been proposed, including
attenuation and eventual failure of the tendon after repeated excursion
over sharp trabecular bone [4]. Higher incidence of EPL rupture
following non-displaced than displaced fracture is believed to be
secondary to an intact extensor retinaculum that maintains a closed
third dorsal compartment. Fracture hematoma, edema, and eventual
fracture callus lead to decreased space for EPL tendon excursion
in the third compartment. The lack of mesotendon and decreased
vascularity of the EPL tendon leads to a relative watershed area at
the level of Lister’s tubercle, where primary nutritional exchange
occurs via diffusion from the surrounding synovial fluid. Decreased
volume and increased intra compartmental pressure resulting from
the aforementioned sequelae of fracture with an intact extensor
retinaculum leads to decreased synovial fluid nutritional exchange,
eventually resulting in necrosis and EPL tendon rupture [1].
Once the diagnosis is confirmed, various treatment options may
be considered. Primary repair, tendon transfer, free intercalated
autologous tendon grafting, and thumb IP joint arthrodesis have all
been described as treatment options for EPL ruptures. Primary endto-
end repair was utilized in the past; however this has fallen out of
favor due to poor tendon quality and retraction in the chronic setting.
More recently, both tendon transfer and free grafting have been
shown to yield favorable postoperative results, thus reserving thumb
IP joint arthrodesis as a secondary procedure in most cases. However,
arthrodesis may be considered in heavy laborers who require only a
firm base for gross movements and grasping.
EIP to EPL tendon transfer is the most widely utilized procedure
[7]. Potential extensor lag of the index finger following EIP transfer
has led some surgeons to favor free grafting over transfer, especially
in patients who require high dexterity of the index finger such as
musicians or surgeons. Postoperative weakness and extensor lag has been shown following EIP to EPL transfer. However subjective
limitation does not appear to be clinically relevant in most patients
[5]. Furthermore, Schaller found no clinical nor statistically significant
difference in each of the Geldmacher criterion between patients who
underwent EIP to EPL transfer versus free palmaris longus tendon
autograft at a mean follow up of 4.3 years [8].
Different techniques of EIP to EPL transfer have also been
described, with the main variation between intra-compartmental
versus subcutaneous placement of the tendon transfer. Shah studied
the effect of an extra-retinacular tendon transfer on the adduction
moment arm (AdMA) at the thumb CMC joint and resting muscle
fiber length compared to an intra-compartmental transfer with
a pulley system through the extensor retinculum [9]. Their study
found that in a cadaver model, subcutaneous EIP to EPL transfer
resulted in a significantly decreased AdMA compared to an intact
EPL. However, with the EIP to EPL transfer maintained through a
retinacular pulley, a statistically similar AdMA was maintained. To
date, there has been no data to suggest any clinical difference between
intra-compartmental versus subcutaneous tendon transfer.
Variation in tensioning of the EIP to EPL transfer has also
been evaluated. Postoperative extension lag of the thumb has
been reported with standard tensioning, therefore leading some to
advocate over-tensioning of the transfer [7]. Jung found that there
was significantly greater thumb range of motion, less thumb elevation
deficit, and greater thumb extension strength with no difference in
thumb flexion deficit in the over-tensioned group compared to the
standard tensioned group at 12 months postoperatively. However,
the majority of both groups achieved favorable outcomes with no
functional difference between the two groups with similar DASH
scores [7].
The postoperative protocol consists of immobilization with
gradual initiation of range of motion and strengthening exercises.
Duration of immobilization varies with surgeon preference but has
traditionally ranged between three and five weeks, with some authors
advocating early dynamic range of motion to hasten the recovery
period and return to work [10].
Spontaneous delayed rupture of the EPL remains a rare
complication following distal radius fracture. Cognizance toward
the possibility of delayed spontaneous EPL rupture is important at
each clinical follow up, especially in patients with other risk factors
including systemic inflammatory disease or a history of corticosteroid therapy. EIP to EPL tendon transfer has shown to produce excellent postoperative outcomes and continues to be the most commonly utilized treatment.
Disclosure
Neither author has any relevant disclosures. They have not received grant support or research funding, and they do not have any proprietary interests in the materials described in the article.
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