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27 January 2025: Articles  Japan

Acute Extensor Pollicis Longus Tendon Injury Associated with a Distal Radius Fracture: A Case Report

Challenging differential diagnosis, Diagnostic / therapeutic accidents, Unusual setting of medical care, Unexpected drug reaction, Rare disease, Educational Purpose (only if useful for a systematic review or synthesis)

Kenjiro Kawamura12BCDEF, Kiyohito Naito12ABCDEF*, Yasuhiro Yamamoto1CDF, So Kawakita1ABC, Takamaru Suzuki12BCD, Norizumi Imazu12BCDF, Muneaki Ishijima ORCID logo12AF

DOI: 10.12659/AJCR.946399

Am J Case Rep 2025; 26:e946399

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Abstract

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BACKGROUND: Extensor pollicis longus (EPL) tendon rupture is a potential complication following distal radius fracture, typically occurring several weeks after injury. Herein, we present a rare case of acute extensor pollicis longus tendon rupture associated with a distal radius fracture.

CASE REPORT: A 35-year-old woman visited our hospital with a distal radius fracture. At the time of examination, the thumb could be moved, although there was pain in the wrist. Computed tomography (CT) revealed a fracture line extending to the ulnar side of Lister’s tubercle. During volar locking plate fixation, visual confirmation of the EPL tendon injury was conducted. According to the intraoperative finding, the EPL tendon was 70% ruptured and elongated, and the extension mechanism of the thumb was disrupted. Based on these findings, direct suture of the EPL tendon, including elongation of the ruptured tendon, was performed. One year after surgery, the EPL tendon excursion was smooth, with no limitations in thumb mobility, and the patient had returned to work.

CONCLUSIONS: This case highlights the importance of recognizing that EPL tendon injury can occur in conjunction with distal radius fractures. The risk of the EPL tendon injury is particularly high when the fracture line extends to the ulnar side of Lister’s tubercle, which serves as the EPL tendon floor. When an EPL tendon injury is suspected based on preoperative examination and fracture type, it is important to obtain adequate informed consent and to prepare for potential EPL tendon reconstruction before surgery.

Keywords: Fractures, Bone, Tendon Injuries

Introduction

Extensor pollicis longus (EPL) tendon injury is a potential complication of distal radius fractures. Reported incidences of this complication vary from 0.2% to 4.0% [1,2]. Previously reported causes of this complication are degenerative necrosis due to reduction in the blood supply to the tendon [3,4], and interference with the screws of the volar locking plate (VLP) [3–5]. EPL tendon injury typically occurs after the injury rather than at the time of injury.

In our previous study, we performed visual confirmation of the EPL tendon during osteosynthesis for distal radius fractures to test our hypothesis that the EPL tendon is damaged at the time of fracture injury [6]. The subjects were patients with fractures on the ulnar side of Lister’s tubercle, which acts as the floor of the EPL tendon. We found periosteal rupture on the ulnar side of Lister’s tubercle in all cases. Furthermore, 88% of the patients showed EPL tendon injury at the time of the fracture [6]. Based on these findings, we concluded that the EPL tendon can be injured at the time of fracture in patients who present with a dorsal roof fragment on CT axial imaging. Since the publication of this study, the risk of EPL tendon injury has been explained to patients preoperatively.

Other studies have reported that this complication rarely occurs at the time of injury, instead typically developing several weeks after the injury. In this report, we present a case of a distal radius fracture that required EPL tendon reconstruction concurrently with VLP fixation.

Case Report

The patient was a 35-year-old, right-handed woman with no significant past medical history, who sustained a left dorsal displaced distal radius fracture after falling down the stairs. At the previous hospital on the day of the injury, swelling and pain in her left wrist were observed on physical examination. Plain X-ray revealed a distal radius fracture, and she was referred to our hospital on the second day after the injury. On physical examination, in addition to swelling and pain in the left wrist, there was a pain in the wrist when the thumb was moved. The thumb could be extended from the table with pain when her palm was placed on the table to examine EPL tendon function; then, the pain appeared around her wrist when her thumb was adducted volarly, pulling on the EPL tendon. Plain X-ray revealed a dorsally displaced distal radius fracture with a fracture line partially extending into the joint (AO classification Type C1) (Figure 1A, 1B). CT further demonstrated a fracture line extending to the ulnar side of Lister’s tubercle (Figiure 1C). Based on these findings, a diagnosis of EPL tendon injury at the time of the distal radius fracture was considered most likely. We decided to perform a visual confirmation of the EPL tendon injury during VLP fixation, which was scheduled for the fifth day after the injury. The fracture had not been reduced before surgery.

The VLP fixation was performed under brachial plexus block by mini-invasive approach, as previously reported by our research group [7]. A 10-mm skin incision was made over the flexor carpi radialis (FCR) tendon. All tendons (FCR, flexor pollicis longus, flexor digital superficial, and flexor digital profundus) and the median nerve were retracted ulnarly, and the pronator quadratus (PQ) was transected distally. The PQ was elevated from distal to proximal using an elevatorium. The proximal part of the plate was slipped under the PQ and then the distal bone fragment and the distal part of the plate were fixed with locking screws. The proximal bone fragment and the proximal part of the plate were fixed with cortical screws, taking special care to ensure that no flexor tendons or the median nerve were interposed between the plate and the bone (Figure 2A, 2B).”

Next, from the dorsal side, the third compartment was exposed to assess the extent of the EPL injury. Although some continuity of the tendon was observed (70% ruptured), failure of the extensor mechanism of the thumb was observed (Figure 3A). Additionally, periosteal rupture on the ulnar side of Lister’s tubercle, which forms the floor of the EPL tendon, was also noted. Moreover, the tips of locking screws were not observed in the floor of the EPL tendon. To repair the EPL tendon injury, we employed the technique described by El Shewy et al, which allows end-to-end suturing by elongating the ruptured tendon [8]. A slit was made at the distal end of the EPL tendon, which was then partially cut. The flap was twisted 180° to elongate the ruptured tendon (Figure 3B). The elongated distal end of the EPL tendon was then directly sutured end-to-end with the proximal end of the ruptured tendon (Figure 3C). The EPL tendon was transposed to the dorsal side of the extensor retinaculum to prevent irritation between the EPL and the fracture line (Figure 3D).

Postoperatively, the patient wore a volar splint for 3 weeks to prevent thumb flexion. Active thumb movements were permitted from 3 weeks after surgery. At 6 months after surgery, the EPL tendon excursion was smooth, with no limitations in thumb mobility (Video 1). Bone union was also achieved, and the hardware was removed. At 1 year after surgery, the wrist range of motion was flexion 85°, extension 85°, pronation 90°, and supination 90°. The grip strength ratio was 83.3% (unaffected side: 30 kg, affected side: 25 kg). Visual analog scale score was 1/10; quick disabilities of the arm, shoulder, and hand score was 2.27/100; and the Mayo wrist score was 95/100. The patient returned to work.

Discussion

We report a case of distal radius fracture requiring EPL tendon reconstruction performed concurrently with VLP fixation due to an EPL tendon rupture that occurred at the time of injury. EPL tendon reconstruction was performed by direct suturing after tendon elongation, resulting in satisfactory postoperative outcomes.

Previous studies reported that EPL tendon rupture occurs more frequently in nondisplaced and minimally displaced distal radius fractures, typically manifesting more than 6 weeks after the injury [1,9]. The delayed onset is thought to be due to reduced blood supply to the tendon caused by increased pressure within the third compartment [1,3,4]. Furthermore, interference with screws from VLP has been identified as a potential cause of EPL tendon rupture [10]. However, there are few reports of acute EPL tendon ruptures associated with distal radius fractures. Kizilay and Turan reported a case of acute EPL tendon rupture in a 56-year-old woman following bilateral distal radius fracture [11]. The patient was unable to extend both thumbs, and the EPL tendon could not be palpated. Plain X-ray revealed a distal metaphyseal dorsal cortical spike on the lateral view of both distal radius fractures. The patient underwent VLP fixation and extensor indicis proprius (EIP) tendon transfer for EPL tendon reconstruction, which resulted in good postoperative outcomes. Thus, EPL tendon ruptures can occur in conjunction with distal radius fractures in the acute phase. It is important to consider the possibility of EPL tendon rupture based on fracture type and physical examination during the initial consultation and to provide appropriate treatment. Since 88% of the patients with fractures on the ulnar side of Lister’s tubercle, which acts as the floor of the EPL tendon, showed EPL tendon injury according to our previous study [6], informed consent should be obtained regarding the risk of EPL tendon injury from patients with this kind of fracture. CT axial images can be useful in detecting these fractures when it is difficult to determine if there are these fractures on plain X-ray.

Tendon transfer surgery using the EIP tendon is often selected for treatment of EPL tendon ruptures complicated with distal radius fractures and idiopathic EPL tendon ruptures [12]. In cases of chronic EPL tendon rupture, direct suturing is not possible because of tendon retraction and extensive damage to the EPL tendon [13]. Tendon transfer using the EIP tendon is an established treatment method for such patients [13,14].

However, in the present case, because the preoperative explanation included “confirmation of tendon injury” but did not cover “tendon reconstruction,” adding an EIP tendon transfer during surgery would have been inappropriate. According to the intraoperative finding, the EPL tendon was 70% ruptured and elongated, and the extension mechanism of the thumb was disrupted, although some continuity remained (Figure 3A). Therefore, we performed direct suturing after tendon elongation, which resulted in a satisfactory postoperative outcome. Although direct suturing is challenging in chronic EPL tendon ruptures due to extensive damage, often requiring tendon transfer or grafting, it is feasible for acute EPL tendon ruptures. Even if tendon transfer or grafting was not discussed preoperatively, and direct suturing is considered difficult during surgery, tendon elongation can facilitate direct suturing.

Conclusion

This case report suggests that EPL tendon injury can occur associated with a distal radius fracture. The likelihood is particularly high when the fracture line extends to the ulnar side of Lister’s tubercle, which serves as the EPL tendon floor. If EPL tendon rupture is a possibility based on preoperative examination and fracture type, it is important to provide adequate informed consent to the patient and to prepare for EPL tendon reconstruction prior to surgery.

Figures

Distal radius fracture with fracture line on the ulnar side of Lister’s tubercle. (A) Frontal view on plain radiography at the first hospital visit. (B) Lateral view on plain radiography at the first hospital visit. (C) Axial view on CT at the first hospital visit. At the first hospital visit, plain radiography shows the fracture line extended into the articular surface and dorsal dislocation (A, B). CT showing the fracture line on the ulnar side of Lister’s tubercle (C).Figure 1.. Distal radius fracture with fracture line on the ulnar side of Lister’s tubercle. (A) Frontal view on plain radiography at the first hospital visit. (B) Lateral view on plain radiography at the first hospital visit. (C) Axial view on CT at the first hospital visit. At the first hospital visit, plain radiography shows the fracture line extended into the articular surface and dorsal dislocation (A, B). CT showing the fracture line on the ulnar side of Lister’s tubercle (C). Plain radiography after volar locking plate fixation. (A) Frontal view on plain radiography. (B) Lateral view on plain radiography.Figure 2.. Plain radiography after volar locking plate fixation. (A) Frontal view on plain radiography. (B) Lateral view on plain radiography. Intraoperative photograph of the EPL tendon. (A) The EPL tendon was damaged. (B) The flap was twisted 180º and tendon extended. (C) End-to-end suture. (D) The EPL tendon was transposed to the dorsal side of the extensor retinaculum. The extensor tendon third compartment was deployed from the dorsal wrist joint to confirm the EPL tendon. The EPL tendon was 70% ruptured, and the extension mechanism of the thumb was disrupted, although some continuity remained (A). The distal end of the EPL tendon was hemisected. The flap was twisted 180º and tendon extended (B). The tendon was long enough to suture end-to-end (C). To prevent interference between the tendon suture and the fracture, the EPL tendon was transposed to the dorsal side of the extensor retinaculum (D).Figure 3.. Intraoperative photograph of the EPL tendon. (A) The EPL tendon was damaged. (B) The flap was twisted 180º and tendon extended. (C) End-to-end suture. (D) The EPL tendon was transposed to the dorsal side of the extensor retinaculum. The extensor tendon third compartment was deployed from the dorsal wrist joint to confirm the EPL tendon. The EPL tendon was 70% ruptured, and the extension mechanism of the thumb was disrupted, although some continuity remained (A). The distal end of the EPL tendon was hemisected. The flap was twisted 180º and tendon extended (B). The tendon was long enough to suture end-to-end (C). To prevent interference between the tendon suture and the fracture, the EPL tendon was transposed to the dorsal side of the extensor retinaculum (D). Six months after surgery, there was no limited range of motion of the thumb.Video 1.. Six months after surgery, there was no limited range of motion of the thumb.

References:

1.. Roth KM, Blazar PE, Earo BE, Incidence of extensor pollicis longus tendon rupture after nondisplaced distal radius fractures: J Hand Surg Am, 2012; 37(5); 942-47

2.. McKay SD, MacDermid JC, Roth JH, Richards RS, Assessment of complications of distal radius fractures and development of a complication checklist: J Hand Surg Am, 2001; 26(5); 916-22

3.. Bickert B, Kremer T, Kneser U, [Secondary tendon reconstruction on the thumb.]: Unfallchirurg, 2016; 119(12); 986-92 [in German]

4.. Ağır I, Aytekin MN, Küçükdurmaz F, Anatomical localization of Lister’s tubercle and its clinical and surgical importance: Open Orthop J, 2014; 8; 74-77

5.. Maschke SD, Evans PJ, Schub D, Radiographic evaluation of dorsal screw penetration after volar fixed-angle plating of the distal radius: A cadaveric study: Hand (N Y), 2007; 2(3); 144-50

6.. Naito K, Sugiyama Y, Dilokhuttakarn T, A survey of extensor pollicis longus tendon injury at the time of distal radius fractures: Injury, 2017; 48(4); 925-29

7.. Naito K, Zemirline A, Sugiyama Y, Possibility of fixation of a distal radius fracture with a volar locking plate through a 10mm approach: Tech Hand Up Extrem Surg, 2016; 20(2); 71-76

8.. El Shewy MT, El Barbary HM, Abdel-Ghani H, Repair of chronic rupture of the achilles tendon using 2 intratendinous flaps from the proximal gastrocnemius-soleus complex: Am J Sports Med, 2009; 37(8); 1570-77

9.. Turner RG, Faber KJ, Athwal GS, Complications of distal radius fractures: Orthop Clin North Am, 2007; 38(2); 217-28

10.. Seigerman D, Lutsky K, Fletcher D, Complications in the management of distal radius fractures: How do we avoid them?: Curr Rev Musculoskelet Med, 2019; 12(2); 204-12

11.. Kizilay YO, Turan K, Acute bilateral extensor pollicis longus tendon rupture following bilateral displaced distal radius fracture: A case report: Acta Orthop Traumatol Turc, 2023; 57(1); 46-49

12.. Lister RC, Bradford HC, Joo A, Spontaneous rupture of the extensor pollicis longus tendon: A systematic review: Hand (NY), 2023; 2 15589447231175513

13.. Bullón A, Bravo E, Zarbahsh S, Barco R, Reconstruction after chronic extensor pollicis longus ruptures: A new technique.: Clin Orthop Relat Res, 2007; 462; 93-98

14.. Lobo-Escolar L, LÒpez Moreno I, Montoya MP, Bosch-Aguilá M, Functional recovery following an L-lengthening local tendon flap for extensor pollicis longus chronic ruptures: J Hand Surg Am, 2017; 42(1); e41-e47

Figures

Figure 1.. Distal radius fracture with fracture line on the ulnar side of Lister’s tubercle. (A) Frontal view on plain radiography at the first hospital visit. (B) Lateral view on plain radiography at the first hospital visit. (C) Axial view on CT at the first hospital visit. At the first hospital visit, plain radiography shows the fracture line extended into the articular surface and dorsal dislocation (A, B). CT showing the fracture line on the ulnar side of Lister’s tubercle (C).Figure 2.. Plain radiography after volar locking plate fixation. (A) Frontal view on plain radiography. (B) Lateral view on plain radiography.Figure 3.. Intraoperative photograph of the EPL tendon. (A) The EPL tendon was damaged. (B) The flap was twisted 180º and tendon extended. (C) End-to-end suture. (D) The EPL tendon was transposed to the dorsal side of the extensor retinaculum. The extensor tendon third compartment was deployed from the dorsal wrist joint to confirm the EPL tendon. The EPL tendon was 70% ruptured, and the extension mechanism of the thumb was disrupted, although some continuity remained (A). The distal end of the EPL tendon was hemisected. The flap was twisted 180º and tendon extended (B). The tendon was long enough to suture end-to-end (C). To prevent interference between the tendon suture and the fracture, the EPL tendon was transposed to the dorsal side of the extensor retinaculum (D).Video 1.. Six months after surgery, there was no limited range of motion of the thumb.

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American Journal of Case Reports eISSN: 1941-5923
American Journal of Case Reports eISSN: 1941-5923