Rupture of extensor digitorum communis after distal ulnar styloidectomy

Rupture of extensor digitorum communis after distal ulnar styloidectomy Attrition ruptures of tendons in the hand, other than those caused by rheumatoid arthritis, are rare. We report a case in which high styloidectomy of the distal ulna caused the rupture of the extensor digitorum communis tendon to the long finger. This complication can be avoided by resection of the smallest segment of the distal ulna that is compatible with relief of the problem. Soft tissue closure over the resected end of the ulna should also be carried out. (J HAND SuRG 11A:818-22, 1986.)

Bezalel Friedman, M.D., Batia Yaffe, M.D., Moshe Kamchin, M.D., and Joel Engel, M.D., Tel-Hashomer, Israel

Clinical experience and experimental work both show that a normal tendon rarely ruptures.'· 2 Normal tendons have such an inbuilt reserve of strength that it is not the tendon that ruptures when excessive force is applied but, rather, the bony insertion or the musculotendinous junction of the tendon that gives way. Several authors have described tendon ruptures caused by bony lesions that left a rough surface against which the tendon frayed. Despite the frequency with which distal styloidectomy of the ulna is done for correction of posttraumatic conditions, we found only one report of four patients with ruptures similar to that encountered in our case. 3

Case report A 21-year-old man complained of the inability to extend his long finger on the right dominant hand after playing basketball. During childhood he had fractured the upper third of the radius on the same side and plating was performed. Two months before his last admission, about 4 cm of the distal right ulna was resected because of limitation of supination. Clinical examination suggested rupture of the extensor tendon to the long finger with a swelling on the dorsal aspect of his right hand (Fig. 1). The operative scar healed well. X-ray films showed a bony prominence of the distal ulna after a very high distal ulnar resection (Fig. 2). At operation the swelling was found to contain serosanguineous fluid. The extensor digitorum communis tendon to the long finger was From the Hand Surgery Unit, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel-Hashomer, Israel. Received for publication Oct. 21, 1985; accepted in revised form Jan. 30, 1986. Reprint requests: Joel Engel, M.D., Hand Surgery Unit, The Chaim Sheba Medical Center, Tel-Hashomer 52621, Israel.

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ruptured, and the extensor digitorum communis tendon to the ring finger was frayed but intact. Retraction of the extensor tendon at the wrist revealed a jagged spike of bone on the distal ulna (Fig. 3). Adjacent to this were the frayed distal ends of the extensor digitorum communis tendon to the long finger and the frayed tendon to the ring finger. Examination showed that the distal ulna moved easily dorsally and could have caused the frayed tendons. After the spike of bone in the distal ulna was removed, the ruptured extensor tendon of the long finger was sutured to the extensor tendon of the ring finger. The wound healed well, and after several weeks of training the patient had excellent results, with a full range of motion of the long and ring fingers (Fig. 4).

Discussion A normal tendon seldom ruptures because it is the strongest link in the musculotendon-bony insertion chain. The insertion, the musculotendinous junction, muscle substance, or even the muscle origin will almost invariably give way before the tendon itself does. 1 The intrinsic strength of the tendon is further verified by experimental work showing that at least half of the fibers require division before tendon rupture can be produced, even under extreme stress. This finding suggests that when rupture occurs within the tendon, the tendon's tensile strength has been reduced by at least 50% or more before the application of the actual distraction force. McMaster1 showed experimentally that obstruction of the blood supply of 1 cm of normal tendon will cause tendon rupture. Anzel4 believed that microtrauma to the blood supply of a tendon accounts for attrition and rupture of tendons, especially over bone prominences. Besides trauma, the conditions that have been reported to cause rupture of a tendon are rheumatoid arthritis, pyogenic infection, gout, syphilis, tu-

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Fig. 2. X-ray films show very high ulna styloidectomy with osteophyte formation. Arrows indicate the osteophyte.

Fig. I. Extension lag of the long finger, with a lump on the dorsum of the hand caused by hematoma and retracted lacerated end of the extensor tendon to the long finger. Arrows mark the site of the hematoma and the retracted tendon .

berculosis, gonorrhea, nonspecific tenosynovitis, and renal failure in patients who undergo hemodialysis. 5-9 Rough areas on the palmar surface of the carpal bone, repetitive motion, and degenerative conditions assoicated with age are contributing factors. 10 Various bone abnormalities about the wrist have been reported as the cause of ruptures of ftexor tendons. James 11 described a case of rupture of the ftexor policus longus and ftexor profundus to the index finger secondary to long-standing avascular necrosis of the lunate bone. Rupture of a ftexor tendon secondary to an unreduced perilunate dislocation and following an old anterior dislocation of the lunate were described by Spiegel 12 and Sterin. 13 Crosby and Linscheid 14 reported two cases of rupture of a profundus tendon following an old fracture of the hook of the hamate bone. Boyes, Wilson, and Smith2

suggested a roughened hook of the hamate and a bipartite capitate as a cause of the rupture of a ftexor tendon. McMaster 15 in 1932 was the first to report a case of ftexor tendon rupture.after Colles' fracture. Considering the frequency with which Coll es' fractures are encountered, it is surprising that ruptures of ftexor tendons are not more common and that there are only a few reports. 16-2°Folmar and colleagues21 reported a case of tendon rupture associated with exostosis of the distal end of the radius and nonunion of navicular fracture. In the literature there are only a few cases of extensor tendon ruptures, mostly in patients with rheumatoid arthritis. 5 · 22 -26 In 1896 Duems 27 described in detail the sudden loss of function on trivial exertion of the long extensor of the left thumb of a drummer in the German army. Von-Zander, 28 in 1891, had already reviewed Steudel's original description and pointed out that it was then an incurable condition leading to discharge from the army. Persons with other occupations, such as tailors, furniture polishers, and carpenters, were similarly affected. 29 · 30 Their problem was not a nerve palsy as originally thought but an attrition rupture of the extensor pollicis longus caused by chronic traumatic synovitis at Lister's tubercle. In 1876 Duplay 31 had described the suture of the extensor pollicis longus to the extensor carpi radialis longus with wire suture. Rupture

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Fig. 4. Final result a few weeks after extensor tendon repair, showing full range of motion. Fig. 3. Intraoperative picture. Arrows indicate the lacerated extensor tendon; hemostat indicates spike of bone of the distal ulna, which probably caused the laceration.

of extensor pollicis longus that occurs a few weeks after Colles' fracture is relatively common and was well described by Mason 8 in 1930, McMaster 15 in 1933, and others. is. 32-34 The incidence of Colles' fracture' 0 is one in 216 cases. Masons suggested that the tendon was weakened by ischemia because of interruption of the blood supply to the tendon in its sheath. Cooney's suggested that a bone spicule protruding from the radius was the cause of the rupture. The distal ulna was first resected by Darach35 at the suggestion of Dwight in 1910. Since then this procedure has been used alone or in combination with other procedures.36-39 Usually rotatory motions of the forearm are restarted , and pain is relieved within a few weeks. If the ulna is resected at a level proximal to the pronator quadratus, the distal ulna may subluxate dorsally on pronation and cause pain, disability, and other complications such as attrition of the extensor tendons at the wrist, as in our case. 40 A similar complication was described by Newmeyer and Green3 in four cases. Various procedures have been suggested to prevent the ulna

from subluxating dorsally.35-3 B.4o Considering the enormous number of excisions of the distal ulna that have been carried out over the years and that we were able to find only four more such complications, we concluded that this is not a frequent occurrence. Swanson,4 1 in advocating the use of a one-piece silicone rubber prosthesis , with an intramedullary stem and a cap to cover the distal end of the resected ulna, gave as one of the reasons for its use, the prevention "of rupture of extensor tendon over the irregular edge of the resected bone." Newmeyer and Green3 described four patients with rupture of one or more digital extensor tendons following distal ulnar resection for a traumatic problem. He treated two of these patients with the Swanson silicone rubber prosthesis and tendon grafts . It was successful in one patient, but in the other patient it was only transiently helpful; later a dislocation of the prosthesis was noted. The use of the ulnar cap by Swanson is reported to have problems, such as bony absorption beneath the prosthetic cap, angulation, and dislocation.42 For this reason we believe that there is no place for its use in such cases as this. Limiting the excision to the smallest necessary segment of the distal ulna and repairing the soft tissues over it, or strict adherence to the surgical technique originally described

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by Darrach, 36 will prevent such a complication in the

future. 18.

REFERENCES 1. McMaster PE: Tendon and muscle ruptures. Clinical and experimental studies on the causes and location of subcutaneous ruptures. J Bone Joint Surg 15:705-22, 1933 2. Boyes JH, Wilson JN, Smith JW: Flexor tendon ruptures in the forearm and hand. J Bone Joint Surg [Am] 42:63746, 1960 3. Newmeyer WL, Green DP: Rupture of digital extensor tendons following distal ulnar resection. J Bone Joint Surg [Am] 64:178-82, 1982 4. Anzel SH, Covey KW, Weiner AD, Lipscomb PR: Disruption of muscles and tendons. An analysis of 1014 cases. Surgery 45:406-14, 1959 5. Ehrlich GE, Peterson LT, Sokoloff L, Bunim IJ: Pathogenesis of rupture of extensor tendons at the wrist in rheumatoid arthritis. Arthritis Rheum 2:332-40, 1959 6. Kanavel AB: Tuberculous tenosynovitis of the hand: A report of fourteen cases of tuberculous tenosynovitis. Surg Gynecol Obstet 37:635-47, 1923 7. Melchier E: Ruptur der gemeinsamen Fingerstrecksehne in Gefolge von genorrhoischer tendovaginitis (Rupture of the common finger extensors after gonorrhea). Berline Klin Wchenschr 53: 139-41, 1916 8. Mason ML: Rupture of tendons of the hand, with a study of the extensor tendon insertion in fingers. Surg Gynecol Obstet 50:611-24, 1930 9. Rosenfield N, Rascoff JH: Tendon ruptures of the hand associated with renal dialysis. Plast Reconstr Surg 65:779, 1980 10. Hallett JP, Motta GR: Tendon ruptures in the hand with particular reference to attrition rupture in the carpal tunnel. Hand 14:283-90, 1982 11. James JIP: A case of rupture of ftexor tendons secondary to Kienbocke's disease. J Bone Joint Surg [Br] 31:5213, 1949 12. Spiegel H: Spontanruptur der Beugesehnen bei alter perilunarer Dorsalluxation der hand. Monatsschr Unfallh 52:314-6, 1949 13. Sterin PJ: Multiple ftexor tendon rupture following an old anterior dislocation of the lunate. J Bone Joint Surg [Am] 63:489-90, 1981 14. Crosby EB, Linscheid RL. Rupture of the ftexor profundus tendon of the ring finger secondary to ancient fracture of the hook of the hamate. Review of the literature and report of two cases. J Bone Joint Surg [Am] 56:1076-8, 1974 15. McMaster PE: Late ruptures of extensor and ftexor pollicis longus tendon following Colles' fracture. J Bone Joint Surg 14:93-101, 1932 16. Younger CP, Defiore JC: Rupture of ftexor tendons to the fingers after a Calles' fracture. J Bone Joint Surg [Am] 59:828-9, 1977 17. Broder H: Rupture of ftexor tendons associated with a

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malunated Calles' fracture. J Bone Joint Surg [Am] 36:404-5, 1954 Cooney WP, Dobuns JH, Linscheid RL: Complication of Calles' fractures. J Bone Joint Surg [Am] 62:615-9, 1984 Nagano Y, Imakire A, Nagamine T: Rupture of the ftexor tendon of the finger following Calles' fracture. Orthop Surg (Tokyo) 21:935-7, 1970 Southmayd WW, Millender LH, Nalebuff EA: Rupture of the ftexor tendons of the index finger after Calles' fracture-case report. J. Bone Joint Surg [Am] 57:5623, 1975 Folmar RC, Nelson CL, Phalen GS: Rupture of the ftexor tendons in the hands of nonrheumatoid patients. J Bone Joint Surg [Am] 54:579-84, 1972 Harris R: Spontaneous rupture of the tendon of extensor pollicis longus as a complication of rheumatoid arthritis. Ann Rheum Dis 10:298-306, 1951 Vunghan-Jackson OJ: Rheumatoid hand deformities as considered in the light of tendon imbalance. J Bone Joint Surg [Br] 44:764-75, 1962 Kersley GD: Spontaneous rupture of muscle as a complication of rheumatoid arthritis. Brit Med J 2:942, 1948 Freiberg RA, Weinstein A: The scallop sign and spontaneous rupture of finger extensor tendons in rheumatoid arthritis. Clin Orthop 83: 128-30, 1972 Straub LR, Wilson EH: Spontaneous rupture of the extensor tendon in the hand associated with rheumatoid arthritis. J Bone Joint Surg [Am] 38:1208-17, 1956 Duems FA: Handbuch der Militaerkrankheiten Aussere (Chirurgische) Krankheiten, Leipzig. E Besold 1896-900 Von Zander W: Trommlerlahmung. Inaugural dissertation, Berlin, G Schade, 1891 Hunt JR: Paralysis of the ungual phalanx of the thumb from spontaneous rupture of the extensor pollicis longus. The so called Drummer's Palsy. JAMA 64: 1138-40, 1915 Barnes CK: Spontaneous rupture of the extensor pollicis longus. JAMA 87:663, 1926 Duplay M: Bull Soc Chir Paris, 788-91, 1876 Ashurst APC: Rupture of tendon of extensor pollicis longus following a Calles' fracture. Ann Surg 78:398-400, 1923 Coburn DE: Delayed rupture of the extensor pollicis longus tendon following Calles' fracture. Am J Surg 68:2349, 1945 Moore T: Spontaneous rupture of extensor pollicis longus tendon associated with Calles' fracture. Brit J Surg 25:721-6, 1936 Darrach W: Partial excision of the lower shaft of ulna for deformity following Calles' fracture. Ann Surg 57:764-5, 1913 Darrach W: Anterior dislocation of the head of the ulna. Ann Surg 56:802-3, 1912 Darrach W, Dwight K: Derangement of the inferior radio ulnar articulation. Med Rec 87:708, 1915 Dingman PVC: Resection of the distal end of the ulna.

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An end result of study of twenty-four cases. J Bone Joint Surg [Am] 34:893-900, 1952 39. Douglas J: Resection of the head of the ulna for anterior displacement accompanying unreduced Colles' fracture. Ann Surg 60:388-9, 1914 40. Boyd HB, Stone MM: Resection of the distal end of the ulna. J Bone Joint Surg 26:313-21, 1944

41. Swanson AB: Implant arthroplasty for disabilities of the distal radioulnar joint. Use of a silicone rubber capping implant following resection of the ulnar head. Orthop Clin North Am 4:373-82, 1973 42. Berg E: Indication for and results with Swanson distal ulnar prosthesis. South Med J 69:858-61, 1976

Ulnar deficiency Twenty-nine patients with 34 ulnar deficient limbs were studied; the average follow-up was 7. 7 years. To permit early determination of prognosis and decisions regarding treatment, four subtypes of this condition have been identified. Progressive ulnar deviation of the wrist was not observed in any case, and the fibrocartilaginous ulnar anlage was resected only to correct fixed deformities of the wrist. The most useful operation was humeral or radial osteotomy to correct the hand on flank deformity. A group of patients who were optimally treated with prosthetic fitting is discussed. (J HAND SuRG 11A:822-9, 1986.)

Jeffrey K. Miller, M.D., Steven M. Wenner, M.D., and Leon M. Kruger, M.D., Boston and Springfield, Mass.

Longitudinal deficiency of the ulna, complete or partial, is a rare affection of the upper limbs; radial deficiency occurs ten times more frequently. Ulnar deficiency did not occur in Entin's 1 series of 61 cases of upper limb deficiency, or in the series of Henkel and Willert2 of 557 malformed upper limbs. 2 Accordingly, most series of patients with ulnar deficiency have been relatively small. 3 - 10 Several different classification systems based primarily on radiographic features have been proposed. Kummel defined three types on the basis of the radiographic appearance of the elbow joint as follows: type A, normal appearing joint; type B, radiohumeral synostosis; type C, dislocated radial head. Ogden and associates 4 proposed a system based upon the degree of ulna visible radiologically. Each of these systems From the Shriners Hospital for Crippled Children, Springfield Unit, 516 Carew St., Springfield, Mass. Received for publication July 12, 1985; accepted in revised form March 14, 1986. Reprint requests: Steven M. Wenner, M.D., 39 Mulberry St., Springfield, MA 01105.

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adequately classifies the deformities, yet they are not useful in making clinical decisions regarding prognosis and treatment. We present a classification system on the basis of our long-term follow-up of a large number (29) of patients with longitudinal deficiency of the ulna. This system is useful for formulating a prognosis and planning treatment in this condition.

Materials and methods Twenty-nine patients with 34 ulnar deficient limbs were studied. Multiple clinical and radiographic features were retrospectively reviewed to determine the influence of each one, and the combinations of different ones, on the overall prognosis and on the clinical decision making process. The patients were seen at the Shriners Hospital, Springfield Unit, over a 30-year period between 1954 and 1984. Follow-up averaged 7. 7 years, with a range of 2 months to 16 years, 8 months. In 19 cases the left side only was affected, in five cases the right side only was affected, and five cases were bilateral. There were 18 male patients and 11 female patients. There was no family history of a similar deformity in any of the cases.