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May have multiple sub-sheaths that must be identified and released for adequate pain relief
5%
19/400
Primary action is to extend and radially deviate the wrist
7%
27/400
Wraps around Lister's tubercle at the level of the wrist
12%
50/400
Lies within the same compartment as the posterior interosseous nerve
72%
289/400
Can cause a snapping sensation and ulnar wrist pain with supination
2%
8/400
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The extensor indicis proprius (EIP) is the most common donor tendon utilized for the reconstruction of an attritional rupture of the extensor pollicis longis (EPL), as demonstrated in this case. The EIP lies in the fourth dorsal compartment with the extensor digitorum communis (EDC) tendons and the posterior interosseous nerve (PIN; Answer 4). Attritional rupture of the EPL can occur in the setting of distal radius fractures secondary to (1) formation of a dorsal osteophyte in nonoperatively managed injuries or (2) dorsal screw penetration in operatively managed injuries (as in this case). Due to the chronic, degenerative (i.e. “attritional) nature of the tendon rupture, the EPL is most often irreparable secondary to tendon shortening and poor tissue quality. Even when a primary repair can be performed, there is a high rate of reoperation due to recurrent rupture. This is purported to be due to poor tendon vascularity and quality from chronic degeneration. Thus, a tendon transfer (i.e. the EIP) is necessitated for these patients. Simple and effective methods employed to avoid injury to extensor tendons during volar-locked plating of distal radius fractures include (1) using pegs instead of screws for articular block fixation and (2) capturing only 75% of the volar-dorsal bone with these pegs/screws (Illustration A). Both methods have been shown to decrease iatrogenic extensor tendon irritation. Berglund and Messer provided a comprehensive review of the complications encountered after volar plate fixation for the treatment of distal radius fractures. The authors discuss complications including flexor pollicis longus/EPL attritional ruptures, carpal tunnel syndrome, loss of reduction, and hardware failure. They review appropriate plate and screw/peg fixation to maximize biomechanical stability while minimizing complications. The authors conclude that a thorough knowledge of the anatomy and fracture pattern is required to anticipate and prevent complications. Sperati and Ceri performed a retrospective case series on 12 patients treated with an EIP to EPL transfer for atraumatic (i.e. attritional) EPL ruptures. With an average follow-up of 32.4 months, the authors report the full return of thumb extensor function in all patients without any failures/reoperations. The authors conclude that EIP to EPL transfers lead to high patient satisfaction, excellent return of function, and minimal donor site complications. Hove performed a retrospective case series review regarding the incidence of delayed rupture of EPL and outcomes of tendon transfers. Among the 18 patients included, the majority (n=14) occurred after nonoperatively managed distal radius fractures. 15 patients underwent tendon transfers with the majority being EIP to EPL (n=13). The authors reported nearly complete patient satisfaction and full return of all pre-injury functions without donor-related deficits. The authors conclude that EIP to EPL transfers are safe and highly effective for delayed EPL rupture. Figures A and B demonstrate radiographic imaging of a distal radius fracture managed with volar-locked plating. There are multiple screws penetrating the dorsal cortex, risking extensor tendon injuries. Illustration A demonstrates the appropriate placement of a volar-locked plate with unicortical, locked pegs filling 75% of the volar-dorsal distance within the distal articular block. Incorrect Answer Choices:Answer 1: The abductor pollicis longis (APL) and extensor pollicis brevis (EPB) lie within the first dorsal compartment and are implicated in DeQuervain tenosynovitis. There is variable anatomy among patients and failure to decompress the multiple APL tendon slips or distinct EPB sub-sheaths may result in recalcitrant symptoms after surgery due to inadequate release. Answer 2: The extensor carpi radialis brevis (ECRB) and extensor carpi radialis longus (ECRL) both serve as the primary wrist extensor muscles and lie in the second dorsal compartment. The ECRL inserts on the second metacarpal whereas ECRB inserts onto the third metacarpal. Given the ECRB’s more central tendon insertion and therefore more centrally located force vector, it is more commonly utilized as a recipient for tendon transfers in permanent radial nerve dysfunction.Answer 3: As discussed above, the extensor pollicis longus (EPL) lies in the third dorsal compartment and is the ruptured tendon in this case; it serves as the recipient tendon.Answer 5: The extensor carpi ulnaris (ECU) lies in the sixth dorsal compartment. Patients experience subluxation “snapping” events when the wrist moves from pronation to supination (i.e. swinging a tennis racquet) as the tendon is placed on tension through increasing supination. Nonoperative management includes casting in a position of ECU relaxation (wrist pronation and extension) whereas operative management includes dorsal compartment sub-sheath reconstruction.
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