Extensor pollicis longus tendon penetration by a screw post-distal radius fracture plating in a young woman: A case report

Abstract

Introduction

Due to its ability to provide stable fixation and permit early mobilization, volar plating has become the recommended technique for the surgical stabilization of distal radius fractures. The extensor pollicis longus (EPL) tendon may be injured or ruptured as a result of undetected screw penetration or drill plunging. During surgery, it is critical to detect any potential screw penetration so that it can be corrected.

Case presentation

A 32-year-old woman presented six weeks post-distal radius plating with an inability to extend her left thumb. Clinical examination revealed loss of extension at the interphalangeal joint, stiff wrist, tender point over the dorsal aspect of the wrist, and an intact sensory nerve function.

Discussion

Dynamic ultrasound and magnetic resonance imaging (MRI) both revealed no evidence of tendon rupture or EPL tendon movement. X-rays revealed the distal epiphyseal screws penetrating the far cortex. Intraoperatively, the EPL tendon was found to be impinged by a screw. The tendon was released, tenolysis was performed, and the distal screws were shortened.

Conclusion

In order to assess screw penetration into the far cortex, volar plating for distal radius fractures should be performed using intraoperative imaging views such as lateral, 45-degree supination, 45-degree pronation, dorsal tangential, and skyline views. Timely interventions after distal radius fracture fixation preserve tendon function, and early detection of tendon compromise is essential to preventing additional damage.

Highlights

• •Volar plating for distal radius fractures poses a risk to the EPL tendon due to potential dorsal screw protrusion.
• •Intraoperative skyline view imaging is crucial for assessing screw placement during volar plating.
• •Loss of thumb extension post-surgery suggests tendon injury from volar plating screws, needing prompt evaluation.
• •Early tendon compromise detection is crucial to prevent damage and preserve function after distal radius fracture fixation.

1. Introduction

Given its stable biomechanical construct, minimal soft tissue disturbance, and ability to facilitate early wrist mobilization, volar plating has become the preferred technique for the surgical stabilization of distal radius fractures [1]. This method reduces the high frequency of extensor tendon injuries linked to dorsal plating, even in fractures with dorsally displaced fragments [2].

With incidence rates ranging from 2 to 6 %, extensor tendon irritation and rupture are among the most commonly reported side effects following using locked volar plates (LVPs) [3]. Extensor mechanism damage is primarily caused by long screws that protrude through the segmented dorsal cortex [4]. This complication is widely known to occur after distal radius fractures are plated dorsally; however, it is now being reported more frequently as a result of improper screw placement during volar fixed-angle plating [5].

Owing to differences in the extensor tendon grooves' depth, the screw length determined by lateral fluoroscopic view may be inaccurate. In this view, screws might seem to be inside the bone, yet they could also be penetrating the dorsal cortex. The rationale for this discrepancy is that the screws may appear more prominent than expected because the fluoroscopic lateral view does not take into account the different depths of the extensor tendon valleys [6].

After a review of the literature, cases of volar locked plating [8] or conservative management of nondisplaced distal radius fractures [7] were found to have resulted in Extensor Pollicis Longus (EPL) tendon rupture. But this is the first case of EPL penetration before rupture that has been reported. This work has been reported in line with the SCARE criteria [9].

2. Case presentation

A 32-year-old woman with no prior medical history presented to the hospital after a fall onto an outstretched hand. She sustained a displaced extra-articular fracture of the left radius, which was surgically treated with a plate and screws at another facility.

When she attended our clinic six weeks later, she reported that she couldn't extend her left thumb (Video 1). Examining her further revealed stiffness in the wrist during passive and active movement, as well as an inability to extend the left thumb at the interphalangeal joint. Over the dorsal aspect of the radius, a tender point was observed. Neuronal function was unaltered.

Epiphyseal screws were clearly visible through the dorsal cortex on plain radiographs (Fig. 1A). After conducting an MRI and ultrasound, there was no sign of a ruptured tendon. Still, a dynamic ultrasound was requested for. The radiologist employed passive thumb movements throughout the procedure and noted that there was no movement of the Extensor Pollicis Longus (EPL) tendon. As a result, there was suspicion that a screw had penetrated the EPL tendon.

Fig. 1.

A shows distal radius fracture plating with epiphyseal screw penetration through the dorsal cortex. B shows all the distal screws being replaced with shorter ones.

These results led to her being scheduled for surgery. At the most tender spot, where screw penetration was suspected, a dorsal incision was made. The EPL tendon was meticulously dissected out and found to have been punctured by the screw (Fig. 2). Tenolysis of the tendon was then carried out after the tendon was released from the screw's entrapment (Fig. 3), ensuring the restoration of its functional integrity. In addition, all distal screws were replaced with shorter ones (Fig. 1B). The degree of stiffness in the wrist was noticeably reduced after the trapped tendon was released.

Fig. 2.

The Extensor Pollicis Longus (EPL) tendon penetrating by a screw.

Fig. 3.

The released Extensor Pollicis Longus (EPL) tendon from the screw's entrapment. Note the length of the screw.

The patient tolerated the procedure well, and there were no intraoperative complications. Post-operative care included wrist immobilization in wrist support and rehabilitation to restore thumb function. At the first postoperative appointment, she maintained thumb extension (Video 1) and was instructed to continue her rehabilitation regimen.

3. Discussion

Distal radius fractures are now frequently treated with volar plating, which uses volar locking plates to increase the stability and rigidity that can be achieved in osteoporotic bone [10]. The Extensor Pollicis Longus (EPL) tendon, like the other dorsal extensor tendons, is covered by the extensor retinaculum and located in the third dorsal compartment of the wrist at the level of the distal radius, just ulnar to Lister's tubercle. The tendon is especially vulnerable to long screws penetrating or rupturing it because of its close proximity to the bone cortex [11]. After internal fixation of distal radial fractures, the incidence of EPL rupture has been reported to vary between 2 % and 12.5 % [12,13].

The aim of numerous radiographic studies has been to identify the best X-ray views for determining screw prominence. According to recent research, lateral and anteroposterior (AP) views are frequently insufficient to identify screw penetration, requiring additional views or imaging. For instance, postoperative computed tomography identified previously undetected screw prominence in 63 % of the patients in a cohort in which no screw prominence was found intraoperatively using lateral and AP views [14]. Several views have been proposed to improve the visibility of periarticular screws in the distal periarticular row of volar plates [15]. These comprise horizon views and lateral views at different pronation and supination angles [16,17]. For example, according to Hill et al. (2015), physicians should use dorsal tangential, lateral, 45-degree supination, and 45-degree pronation views to evaluate dorsal screw penetration after volar plating [4]. They suggested that to prevent going over the dorsal cortex, they might also think about deducting a few millimeters from the measured screw lengths [4]. In a study published in 2014, Vaiss examined 75 patients with displaced distal radius fractures treated with volar locked plate fixation. According to the study's findings, during postoperative evaluations, the skyline view is superior to the lateral view for identifying screw protrusion [18].

In order to lower the risk of extensor pollicis longus (EPL) rupture after volar plate fixation of distal radial fractures, Hara et al. [19] recommended a simple surgical technique. This involves making a small incision, approximately 2 cm in length, on the ulnar side of Lister's tubercle to partially open the third compartment. If a screw protrudes into the compartment, they recommend fully opening it, extracting the EPL tendon from its groove, and closing the compartment by suturing the retinaculum.

Additionally, Ohno et al. recommended the use of smaller-sized screws to reduce the risk of extensor pollicis longus (EPL) injury. This resulted in a high rate of bone healing, little loss of reduction, and a low incidence of complications [20].

4. Conclusion

Though effective, volar plating for distal radius fracture fixation requires careful consideration of potential complications, such as extensor pollicis longus tendon damage. To ensure precise screw placement and avoid tendon damage, intraoperative imaging techniques such as lateral view, oblique views (45-degree supination, 45-degree pronation), and dorsal views (including dorsal tangential and skyline views) are crucial.

It is essential to monitor patients following surgery for signs such as decreased thumb extension in order to quickly detect and treat any tendon-related complications. Tendon function can be protected by prompt intervention in cases of suspected screw penetration, emphasizing the significance of careful postoperative care in maximizing patient outcomes after this routine surgical procedure.

The following is the supplementary data related to this article.

Video 1

Preoperative and two weeks postoperative assessment: Observing changes in thumb extension.

Patient consent

Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

Ethical approval is not required for the reporting of case reports at our institution, Burjeel Medical City. However, publication of this report has been approved by the institution.

Funding

No funding.

Author contribution

Jaber AlKhyeli: Writing the paper, Reviewing and Editing.

Ahmed M. Y. Mohamed: Writing the paper, Reviewing and Editing.

Mohanad Abdulgadir: Writing the paper, Reviewing and Editing.

All authors read and approved the final manuscript. All authors contributed equally and should be regarded as co-first authors.

Guarantor

Ahmed Mohamed Yousif Mohamed.

Research registration number

Not applicable.

Conflict of interest statement

The authors declare no competing interest.