Review Question - QID 211930

The patient has sustained an extensor pollicis longus (EPL) attritional rupture likely due to a left distal radius fracture treated with ORIF with a prominent dorsal screw. The patient will require hardware removal and tendon transfer which is most commonly performed with the extensor indicis proprius (EIP).

A rare complication of non-displaced or minimally displaced fractures of the distal radius treated with a cast is a delayed rupture of the EPL tendon. This complication can also occur after ORIF with volar plating with a prominent screw that penetrates the dorsal cortex. The EPL is the primary extensor of the interphalangeal joint of the thumb and also assists with metacarpophalangeal extension. Treatment of this complication involves removal of hardware and tendon transfer since attritional tears are rarely amendable to direct repair. EIP transfer to the EPL is the most widely used and reported treatment for this condition.

Benson et al. performed a review of the etiology of attritional EPL rupture following volar plate fixation of dorsally comminuted distal radius fractures. The authors note specific screw holes that direct the drill bit or prominent screw tips that may violate the extensor tendons. In addition, after reduction and plate fixation, bone fragments or dorsal gapping may predispose the EPL tendon to injury. The authors conclude that either using shorter screw lengths or leaving the implicated plate holes unfilled may help avoid this complication.

Berglund and Messer performed a review of the complications of volar plate fixation for the management of distal radius fractures. The authors note that the surgeon must be mindful of potential soft-tissue, neurovascular, extensor/flexor tendon injury, carpal tunnel syndrome, complex regional pain syndrome, loss of reduction, and hardware failure. The authors conclude that increased awareness of potential complications may lead to more prompt recognition and treatment when they do arise.

Figure A is a lateral radiograph of the wrist revealing volar plate fixation of a distal radius fracture with multiple dorsally proud distal screws.

Incorrect Answers:
Answer 1: The radial slips of the FDS can be transferred to the EPL in cases of radial nerve palsy but the EIP is the favored tendon transfer in cases of isolated EPL rupture.
Answer 2: The EPB does not have enough excursion to be used as a tendon transfer to restore the function of the EPL.
Answer 4: The EPL is the injured tendon in this scenario and can not be used as a transfer.
Answer 5: While extra slips of the EDC tendon can be transferred to restore EPL function, the EIP is the more preferred tendon since its muscle belly does not have tendon slips to other digits.