Review Question - QID 220118

This patient's distal radius fracture was treated with a volar locking plate, with a subsequent attritional rupture of the extensor pollicis longus (EPL) tendon, likely secondary to dorsal implant prominence. The most appropriate treatment is to exchange this prominent screw for a shorter one and restore thumb retropulsion by transferring the extensor indicis proprius (EIP) to the extensor pollicis longus (EPL) tendon (answer choice 4).

Rupture of the EPL tendon will present with a loss of thumb retropulsion. This well-known complication can present following nonoperative treatment of a distal radius fracture. It reportedly stems from attritional rupture of the tendon, secondary to either mechanical attrition or local ischemia in the tendon. In fact, there is a higher rate of EPL rupture with nonoperative treatment of non-displaced distal radius fractures than with operative treatment. This complication can also occur with dorsal screw penetration after volar plating of these fractures. The treatment to restore functional motion involves performing an EIP to EPL tendon transfer.

Roth et al. conducted a study to define the incidence of EPL tendon rupture following nondisplaced distal radius fractures. They found that 3 out of 61 (5%) fractures resulted in an EPL tendon rupture, and on average, these occurred 6.6 weeks from the initial injury. Their study reported an even higher incidence of this complication compared to previous literature.

Seigerman et al. wrote a review article describing common complications that can arise with the treatment of distal radius fractures and methods for treating them. The authors note that tendon injuries are not uncommon following treatment of distal radius fractures, with extensor tendon injuries being more common with nonoperative treatment and flexor tendon injuries more commonly resulting from operative treatment. They conclude that it is important to understand the complications that may arise with managing these common fractures and the treatment strategies for dealing with them.

Figures A and B are PA and lateral radiographs, respectively, of a left wrist demonstrating a displaced distal radius fracture with shortening and dorsal angulation. Figure C is a lateral intraoperative radiograph of a wrist demonstrating dorsal screw penetration from a long screw placed through a volar plate.

Incorrect answer choices:
Answer choices 1 and 2: FPL tendon rupture can present with operative treatment. However, the complication is less likely as the plate is appropriately placed proximal to the watershed line.
Answer choice 3: Primary repair is not a successful treatment option since this complication is from an attritional rupture of the tendon.
Answer choice 5: Extensor carpi ulnaris tendon entrapment is a complication that can occur in these injuries. However, it is more commonly seen with distal radioulnar joint injuries.