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Introduction: Although flexor pollicis longus (FPL) rupture following volar plate fixation of distal radius fractures is a well-known complication, no consensus exists on the optimal treatment method. The purpose of this study is to develop a treatment algorithm for attritional FPL rupture due to volar plate fixation.

Materials & Methods: Cases of volar distal radial plate removal at one hand surgery practice were retrospectively reviewed. The study period ranged from 2010 to 2017 and involved 4 hand surgeons. When hardware removal was associated with treatment of an FPL rupture, the medical records were further investigated. Patient demographics, Soong volar plate prominence classification, volar plate type, and surgical technique were reviewed.

Results: 93 volar plates were removed for various reasons. In 7 cases, this was due to FPL rupture, and in 1 case, this was due to impending FPL rupture. The FPL ruptures occurred at a mean of 3.1 years (range, 0.5-9.9 years) following volar plate fixation (6 cases) or distal radial osteotomy (1 case). Mean patient age at the time of FPL treatment was 59.6 years (range, 41-75 years). Plate designs included 2 Acumed DVR plates, 2 Synthes volar rim plate, 1 Synthes Volar locking plate, 1 Small Bone Innovations volar metadiaphyseal plate and a small nonlocking t-shaped volar plate. Two cases were Soong grade 1, and 5 cases were grade 2. In all cases, the plates were removed. In patients with retracted tendon ends and scarred tendon edges, FPL reconstruction with a palmaris longus or a strip of flexor carpi radialis graft was performed (n=4). In these cases, Pulvertaft tendon weaves were used. In one case, with a chronically retracted tendon, z-lengthening and primary repair of the tendon was performed. When the tendon edges were robust and could be brought out to length, primary side-to-side repair was performed (n=1). One elderly patient underwent thumb interphalangeal fusion.

Conclusion: While hardware removal is the essential step, in this clinical series, the surgical management of attritional FPL rupture was based on patient factors including functional demands, as well as the chronicity of the rupture, the degree of tendon retraction and the soft tissue quality of the ruptured tendon. Patients may experience FPL rupture up to 10 years following volar plate fixation. Patient counselling regarding the dangers of loss to follow-up and early hardware removal for at-risk patients are encouraged. The acquisition of clinical outcomes is ongoing.