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Extensor Pollicis Longus Ruptures Following Distal Radius Osteotomy
Michael Rivlin, MD1; Diego L. Fernandez, MD2; Ladislav Nagy, MD3; Gabriel López Gabriel, MD4; Jesse Jupiter, MD5
1Department of Orthopaedics, Massachusetts General Hospital, Harvard University, Boston, MA; 2Orthopedics, Lindenhoff Hospital, Berne, Switzerland; 3Department of Orthopedics, Balgrist University Hospital, Zurich, Switzerland; 4Rosario Hospital, Madrid, Spain; 5Orthopaedice Hand and Upper Extremity Service, Massachusetts General Hospital, Boston, MA

Introduction: Extensor tendon ruptures may occur from closed as well as open treatment of distal radius fractures. Although rare, surgical corrections of malunited distal radii with volar osteotomy may carry a potential risk of rupture of the extensor tendons, most commonly the extensor pollicis longus (EPL). To investigate the etiology and pathological process involved in these complications we had surgeons from multiple centers contribute cases for evaluation.

Materials and Methods: In this case series we included patients with EPL ruptures who underwent distal radius osteotomies performed through a volar approach. Data was pooled from multiple surgical centers and compiled. Demographics, initial injury parameters, imaging studies, pre and postoperative examination, intra-operative findings, surgical technique and patient outcomes were compared and analyzed. Pre and post-operative radiographs were evaluated and compared.

Results: Six cases from 5 surgeons in 4 institutions were evaluated. Length of follow up ranged between 1 to over 4 years. Initial injuries included intra and extra articular fractures. All patients were initially treated with cast immobilization. Every patient in the study had limitation of range of motion pre-operatively, most with primary loss of flexion. All malunions were healed in extension (20-60 degrees) and with shortening. During the reconstructive operation deformity correction in the sagittal plane was 25-55 degrees. All osteotomies were fixed with volar locking plates with autologous bone graft except one patient that received calcium phosphate based bone void filler. Postoperative xrays suggested prominent osteotomy resection edges, osteophytes, or dorsal bony prominence due to healed callous. Every osteotomy united during the follow up period. Average time from osteotomy to EPL rupture was 10 weeks [2-17 weeks]. Two patients initially refused to undergo tendon transfers. One was pleased with the outcomes despite the ruptured EPL. The other patient ruptured 2 other extensor tendons and then underwent tendon transfers with good results. One patient ruptured the transferred tendon as well after 2 months and underwent successful tendon grafting.

Conclusion: Although extensor tendon ruptures following distal radius volar osteotomies are rare they are a known complication of these corrective surgical procedures. In the absence of screw prominence, it is likely that dorsal callus, prominent osteotomy resection edges and osteophytes may attribute to attritional rupture of the EPL tendon.

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