Small flake, big problem: an unreported cause of extensor pollicis longus tendon rupture

Abstract

Avulsion fracture at the insertion of either of the radial extensors of the wrist is a rare injury. Isolated avulsion of the extensor carpi radialis longus (ECRL) tendon from the base of the second metacarpal has been described in the literature only 10 times.1,2 Isolated avulsion of the insertion of the extensor carpi radialis brevis (ECRB) tendon from the base of the third metacarpal has been described only 6 times. 3,4 Rupture of the extensor pollicis longus (EPL) tendon is a well-known injury, with a multifactorial aetiology. 5Attrition rupture of the EPL caused by an avulsed fragment of bone from the long radial wrist extensor (ECRL) has been reported in the literature only twice. 6,7 We report, for the first time, a rupture of the EPL tendon caused by the avulsed fragment of bone attached to the ipsilateral ECRB tendon. Case historyA 35-year-old man was performing a martial arts manoeuvre and punched a plank of wood with the his right, dominant hand. His forearm was pronated, his elbow straight, and his wrist slightly flexed. He felt immediate pain in his wrist. He attended the local accident and emergency department where he was found to be bruised and swollen over the dorsum of his right hand and wrist. X-ray showed a fracture at the base of the third metacarpal (Fig. 1). This was treated conservatively in a full cast, extending from the proximal forearm to the mid-palm, immobilising the wrist. The cast remained for 5 weeks. Two weeks following removal of the cast, the patient was tying his shoelaces and felt a sudden sharp pain at the base of his right thumb radiating to his elbow. He was immediately unable to extend the interphalangeal joint of his right thumb.He was referred to the Hand Trauma Clinic where he was found to have tenderness in the anatomical snuffbox that radiated to the common extensor origin. He was unable to retropulse his right thumb, with clinical rupture of the EPL tendon (Fig. 2). A true lateral radiograph of the wrist showed an avulsed flake of bone at the level of the proximal carpal row. An ultrasound scan of the area

An unusual presentation of metacarpophalangeal joint instability of the thumb

“…When further examining extensor injuries to the thumb, rupture of the extensor pollicis longus is commonly reported but is usually associated with UCL tears, Stener lesions and injuries to the Abductor Pollicis Longus (APL). 6 , 7 However, our patient presents with an isolated avulsion of the EPB tendon that has not been previously recorded in literature. Previous literature has only shown a slight injury to the EPB and the Abductor Pollicis Longus (APL) as a result of a radial styloid fracture.…”

Peri-articular fractures of the hand

“…Non-operative treatment has demonstrated variable success, but we agree with Clark et al (2008), that avulsed fragments can have consequences outside of tendon avulsion. These include compression neuropathy to the superficial radial nerve (Alnaif et al, 2018) and EPL attrition caused by a bone fragment (Durrant and Bantick, 2010).…”

Tendon injuries of the hand in athletes

“…Bununla birlikte sporcularda en sık kapalı EPL tendon kopması görülür. [37,38] Tendonun kopmasından tendon kan akımının bozulması ve kırık parçalarının tendonu yaralaması sorumlu tutulmaktadır. Tedavide tendon grefti ile tamir veya EİP tendon transferi yapılmaktadır.…”