Abstract
Background
Volar plate fixation for distal radial fractures is the most common cause of closed rupture of the flexor pollicis longus tendon (FPL). For treating a closed FPL rupture, transferring the fourth flexor digitorum superficialis or a tendon graft from the palmaris longus (PL) can be performed. This study reports the results of tendon grafting using the PL in closed FPL rupture and discusses the provision of optimal tendon tension.
Methods
This retrospective study included 11 out of 20 patients who underwent PL tendon graft for closed FPL rupture between 2013 and 2022, with a follow-up period of more than 12 months. There were 4 men and 7 women, with an average age of 62 years. The average period from the date of rupture to surgery was 39 days. Ruptures occurred due to volar plate fixation in 7 cases, ithout a specific cause in 2 cases, and after a steroid injection for trigger thumb in 2 cases. The rupture site was in zone 2 in 4 cases and zone 5 in 7 cases. The mean follow-up period was 59 months. Optimal tension for the grafted tendon was determined by comparing the intraoperative angles of the interphalangeal (IP) and metacarpophalangeal (MCP) joints with the angles of the same joints at the final follow-up.
Results
At the final follow-up, the mean IP joint motion was 61.0°, which was 81.5% of the contralateral side. The average range of motion of the MCP joint was 43.6°, which was 80.0% of the contralateral side. The pinch power was 90.8% of the contralateral side. Cases with > 70° IP joint motion were those in which the IP joint angle was > 45° during surgery. Moreover, the greater the flexion of the IP and MCP joints intraoperatively, the better the range of motion of the IP joints.
Conclusions
Tendon grafting using the PL is recommended as an effective surgical method to achieve 81.5% of contralateral IP joint motion in cases of closed FPL tendon rupture. Over-tensioning of the tendon graft with IP Joint flexion more than 45° during surgery is recommended.
Keywords: Tendon injuries, Thumb, Tendon transfer, Wrist fractures, Tendinopathy
Closed rupture of the flexor pollicis longus (FPL) tendon can occur due to various causes. In the past, rheumatoid arthritis was commonly caused by erosion and bony spurs of the scaphoid and trapezium.1) Additionally, a direct blow2) and corticosteroid injection3) can cause a closed rupture of the FPL. Since open reduction and internal fixation with a volar plate has become the standard treatment approach for distal radius fractures,4,5) FPL tendon irritation with a volar plate has become a common cause.6,7) In particular, the frequency increases when the volar plate is placed distally and is not completely covered by the pronator quadratus muscle.7)
In most cases, a closed rupture of the FPL cannot be treated with primary tenorrhaphy at the time of diagnosis8) but can be treated using a palmaris longus (PL) interpositional graft9) or fourth flexor digitorum superficialis (FDS) transfer.10) Although there are some reports on PL interpositional grafts,11,12) there is limited information on the factors contributing to successful outcomes or methods for ensuring the appropriate tension of the graft tendon. In this study, we report the results of interpositional tendon graft for a closed FPL rupture and investigate various factors influencing surgical outcomes.
METHODS
The study protocol was approved by the Public Institutional Review Board designated by the Ministry of Health and Welfare (approval No. P01-202405-01-024), and the need for informed consent was waived during the deliberation process. This study complied with the principles of the Declaration of Helsinki.
Among the 20 patients who underwent interpositional grafting of the PL for closed rupture of the FPL between February 2013 and May 2022, 11 patients who were followed up for more than 12 months were retrospectively analyzed. Patients aged 19 years or older and who were not able to undergo direct tenorrhaphy with opened rupture such as laceration were included. On the other hand, patients with a history of previous FPL surgery and patients with confirmed FPL infection were excluded.
There were 4 men and 7 women and their average age was 62 years (range, 48–80 years). The average time from the date of rupture to surgery was 39 days (range, 2–150 days). Six patients had the rupture on the right side and 5 on the left side, with the right side being the dominant hand in all cases. Ruptures occurred due to volar plate fixation in 7 cases, without a specific cause in 2 cases, and after steroid injection for trigger thumb in 2 cases. The rupture site was in zone 2 in 4 cases and zone 5 in 7 cases. The mean follow-up period was 59 months (range, 12–120 months) (Table 1).
Table 1. Demographic Information of the Patients.
| Variable | Value | |
|---|---|---|
| Age (yr) | 62 (48–80) | |
| Sex | ||
| Male | 4 (36.4) | |
| Female | 7 (63.6) | |
| Period from rupture to surgery (day) | 39 (2–150) | |
| Side | ||
| Right | 11 (100.0) | |
| Left | 5 (45.5) | |
| Dominant hand | ||
| Right | 11 (100.0) | |
| Left | 0 | |
| Cause of rupture | ||
| Spontaneous | 2 (18.2) | |
| Volar plate fixation | 7 (63.6) | |
| Steroid injection | 2 (18.2) | |
| Site | ||
| Zone 2 | 4 (36.4) | |
| Zone 4 | 7 (63.6) | |
| Follow-up period (mo) | 59 (12–120) | |
Values are presented as median (range) or number (%).
In addition to the patients’ basic information, the rupture site and defect size were confirmed through magnetic resonance imaging and ultrasonography before surgery, and the flexion angles of the interphalangeal (IP) and metacarpophalangeal (MCP) joints were assessed using clinical photographs after the completion of tendon grafting intraoperatively. At the final follow-up, the range of motion (ROM), degree of opposition, and pinch power of the active IP and MCP joints on the affected and unaffected sides were measured, and functional outcomes were investigated using the shortened Disabilities of the Arm, Shoulder and Hand (Quick DASH) score.13) The degree of opposition was measured using the score designed by Kapandji,14) and pinch power was measured using a pinch gauge (Jamar hand dynamometer, North Coast Medical).
Surgical Techniques
In all patients, preoperative ultrasonography was performed to mark the distal and proximal ends of the ruptured FPL. In addition, the presence of PL was confirmed through an opposition test. The patients underwent surgery in the supine position under general anesthesia or brachial plexus block with tourniquet control. A curved skin incision centered on the marked FPL defect was made, with additional skin incisions made more proximally and distally than the length of the defect. The proximal and distal ends of the FPL were dissected while paying attention to avoiding neurovascular damage. The length of the defect was measured, and the palmaris longus was harvested from the ipsilateral side to ensure it was longer than the defect. In 4 cases where the rupture occurred in zone 2, the oblique pulley was preserved as much as possible, and tendon suture was performed using the Pulvertaft method more distally than the oblique pulley. In 7 cases where there was a rupture in zone 5, it was sutured distally using the Pulvertaft method. Subsequently, the proximal portion was sutured using the Pulvertaft method. At this stage, the wrist was neutrally positioned, and tension was applied to achieve greater than 45° of IP joint flexion before securing sutures. After completing tendon grafting in all patients, clinical photographs were taken and saved.
After surgery, a thumb spica splint was used according to the angle of the thumb IP joint, and active thumb flexion and extension exercises were initiated the day after the surgery. Stitch-out was performed 2 weeks after surgery, and flexion and extension exercises were encouraged more intensely from 4 weeks after surgery. At 6 weeks after surgery, the splint was removed and the patient was allowed to hold light objects. Strengthening exercises were initiated 3 months after surgery.
Statistical Analysis
IBM SPSS Statistics version 26 (IBM Corp.) was used for statistical analysis. The Pearson correlation coefficient was used to determine the relationship between each factor and the ROM of the finger joints. Additionally, the Wilcoxon signed-rank test was used to compare the outcomes between the unaffected and affected sides. Meanwhile, for multivariable analysis, multiple linear regression analyses were performed for each variable. Statistical significance was set at p-value < 0.05.
RESULTS
At the final follow-up, the average range of active IP joint motion was 61.0° (range, 10°–80°), which was 81.5% of the unaffected side. The average active MCP joint motion was 43.6° (range, 30°–60°), which was 80.0% of the unaffected joint. The pinch power was 90.8% of that of the unaffected subjects and all patients’ thumbs were fully extended, without any difference from the contralateral side. In 1 case, the ROM of the IP joint was 10°; in 2 cases, it was 40° and 45°; and in the remaining 8 cases, the ROM of > 70° was recovered. In cases where the IP joint motion was less than 45° at the final follow-up, the IP joint angles after intraoperative tendon grafting were 10°, 30°, and 35°. Cases with IP joint motion > 70° were those in which the IP joint angle was > 45° during surgery (Figs. 1 and 2). The Quick DASH score at the final follow-up was 1.39 (range, 0–4.25). The IP joint ROM and pinch power did not decrease significantly when compared with the unaffected side (Table 2). Detailed information on each patient is presented in Table 3.
Fig. 1. (A) An 80-year-old female patient developed a flexor pollicis longus tendon rupture in zone 5 after volar plate fixation for a distal radius fracture. (B) Palmaris longus interpositional graft was performed using the Pulvertaft method. (C) Tension was applied, resulting in an interphalangeal (IP) joint flexion of 50°. (D) At the last follow-up, the active IP joint range of motion was 70°.
Fig. 2. (A) Palmaris longus interpositional graft was performed using the Pulvertaft method for a flexor pollicis longus tendon rupture that occurred without a specific cause in zone 2 in a 58-year-old female patient. (B) Tension was applied, resulting in an interphalangeal joint (IP) flexion of 55°. (C) At the last follow-up, the active IP joint rang of motion was 70°.
Table 2. Outcomes of the Operation.
| Operated side | Contralateral side | % of contralateral side | p-value | |
|---|---|---|---|---|
| IP joint ROM (°) | 61.0 (10–80)* | 73.6 (70–80) | 81.5 | 0.062 |
| MCP joint ROM (°) | 43.6 (30–60) | 54.1 (40–60) | 80.8 | 0.011 |
| Pinch power (kg) | 5.45 (3.8–7.9) | 5.95 (3.5–9.1) | 90.8 | 0.075 |
| Quick DASH score | 1.39 (0–4.25) | |||
Values are presented as average (range).
IP: interphalangeal, ROM: range of motion, MCP: metacarpophalangeal, Quick DASH: shortened Disabilities of the Arm, Shoulder and Hand.
*10° in 1 case, 40° and 45° in 2 cases, and > 70° in 8 Cases.
Table 3. Detailed Information of Each Patient.
| Case No. | Age (yr) | Sex | Side | Cause of rupture | Rupture site (zone) | Duration between rupture and op. (day) | Defect size (mm) | Intraoperative IP angle (°) | Intraoperative MCP angle (°) | Postoperative IP angle (°) | Postoperative MCP angle (°) | Opposition (Kapandji score) | Pinch power (kg) | Functional outcome (quick DASH score) |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 50 | M | L | Steroid injection | 2 | 104 | 25 | - | - | 80 | 30 | 4 | 6.9 | 0 |
| 2 | 73 | F | R | Distal radius ORIF | 5 | 22 | 25 | 60 | 30 | 70 | 50 | 10 | 5.0 | 2.27 |
| 3 | 49 | M | L | Spontaneous | 2 | 4 | 15 | 20 | 10 | 10 | 30 | 6 | 6.3 | 0 |
| 4 | 45 | M | R | Distal radius ORIF | 5 | 15 | 20 | 65 | 35 | 75 | 60 | 10 | 7.9 | 0 |
| 5 | 68 | F | L | Distal radius ORIF | 5 | 91 | 30 | 50 | 35 | 75 | 55 | 9 | 5.0 | 2.27 |
| 6 | 82 | F | R | Distal radius ORIF | 5 | 26 | 15 | 45 | 20 | 70 | 50 | 10 | 5.4 | 0 |
| 7 | 55 | F | R | Steroid injection | 2 | 5 | 40 | 35 | 10 | 40 | 30 | 6 | 3.8 | 4.25 |
| 8 | 58 | F | R | Spontaneous | 2 | 2 | 40 | 55 | 30 | 70 | 50 | 9 | 5.0 | 2.50 |
| 9 | 48 | M | L | Distal radius ORIF | 5 | 150 | 50 | 30 | 25 | 45 | 40 | 6 | 5.5 | 1.50 |
| 10 | 77 | F | L | Distal radius ORIF | 5 | 5 | 30 | 50 | 55 | 70 | 50 | 8 | 4.2 | 2.50 |
| 11 | 80 | F | R | Distal radius ORIF | 5 | 7 | 20 | 50 | 20 | 70 | 35 | 7 | 5.0 | 0 |
| Average | 62.27 | 39.18 | 28.18 | 46.00 | 27.00 | 61.36 | 54.09 | 7.73 | 5.45 | 1.39 |
IP: interphalangeal, MCP: metacarpophalangeal, Quick DASH: shortened Disabilities of the Arm, Shoulder and Hand, L: left, R: right, ORIF: open reduction and internal fixation.
The active motion angle of the IP joint at the final follow-up was significantly and positively correlated with the intraoperative IP joint flexion angle (correlation coefficient, 0.903; p < 0.01) and the intraoperative MCP joint flexion angle (correlation coefficient, 0.648; p = 0.043) (Fig. 3). The MCP joint movement angle also had a statistically significant positive correlation with the intraoperative IP joint flexion angle (correlation coefficient, 0.796; p < 0.01) and intraoperative MCP joint flexion angle (correlation coefficient, 0.729; p = 0.017) (Fig. 4). The opposition test showed a significant positive correlation with the intraoperative IP joint flexion angle (correlation coefficient, 0.827; p < 0.01) but did not show a significant correlation with the intraoperative MCP joint flexion angle (Fig. 5). Meanwhile, the period from the date of rupture to surgery and defect size did not significantly affect the results. Multiple linear regression analyses showed that only the intraoperative IP joint flexion angle (β = 0.893, p = 0.009) had a significant positive effect on the active motion angle of the IP joint. On the other hand, intraoperative MCP joint flexion angle, period from the date of rupture to surgery, and defect size did not have a statistically significant effect in linear regression analysis. Furthermore, multiple linear regression analyses excluding the intraoperative IP joint flexion angle did not identify any statistical significance with the other variables.
Fig. 3. The relationship between the interphalangeal (IP) joint range of motion (ROM) and the intraoperative IP and metacarpophalangeal (MCP) joint angles. (A) IP joint ROM–intraoperative IP joint angle: correlation coefficient, 0.903; p < 0.01. (B) IP joint ROM–intraoperative MCP joint angle: correlation coefficient, 0.648, p = 0.043.
Fig. 4. The relationship between the metacarpophalangeal (MCP) joint range of motion (ROM) and the intraoperative interphalangeal (IP) and MCP joint angles. (A) MCP joint ROM–intraoperative IP joint angle: correlation coefficient; 0.796, p < 0.01. (B) MCP joint ROM–intraoperative MCP joint angle: correlation coefficient, 0.729; p = 0.017.
Fig. 5. The relationship between opposition and the intraoperative interphalangeal (IP) joint angle. Correlation coefficient, 0.827; p < 0.01.
DISCUSSION
Closed FPL rupture is a common complication of internal fixation with volar plating of distal radius fractures6,7) and is known to occur in a wide range from 0.3% to 12%, depending on the literature.15) Additionally, the prevalence is reported to increase more when internal fixation is performed than when the distal radius is treated nonsurgically.16) Therefore, it is commonly recommended to perform hardware removal, even if there is a debate about the optimal time.17)
At the time of diagnosis of a closed FPL tendon rupture, attritional changes in the tendon tissue have already progressed; therefore, direct repair is difficult in most cases.8) Therefore, tendon graft or tendon transfer is required, but the treatment of choice has not been established. Zukawa et al.18) reported the reconstruction results of tendon graft when the defect size was greater than 30 mm, and fourth FDS tendon transfer when it was smaller in FPL rupture. In this study, they stated that since the excursion of the FPL was 27 to 35 mm and the mean active contraction distance was 15 mm, tendon graft would be available for defect sizes greater than 30 mm. Accordingly, in this study, tendon graft was performed regardless of the defect size, and it did not produce statistically significant differences on the clinical outcome. In addition, a wideawake tendon reconstruction study by this group in 2017 showed that the active contraction distance of the FPL did not show a significant relationship with the time elapsed before operation,19) which is consistent with our results.
In a systematic review6) of 21 studies reporting flexor tendon injuries after volar plate fixation for distal radius fractures, there were 47 cases of flexor tendon rupture, of which 27 (57%) were FPL ruptures. Surgical treatment was performed in 25 cases, end-to-end repair in 8 cases, PL tendon graft in 9 cases, and tendon transfer in 4 cases. Among these, 8 cases reported information about postoperative ROM, and full ROM was achieved in only 1 case of repair and 1 case of PL tendon transfer. This study showed that the results of PL tendon grafts were poor.
Yamak et al.7) reported that 3 cases of FPL rupture occurred in 109 cases of volar plate fixation for distal radius fractures and that the ROM of the IP joint of the thumb was 55° for direct repair, 45° for PL tendon graft, and 25° for fourth FDS tendon transfer. In 2006, a report9) on the 2-stage reconstruction of the FPL tendon reported that the average active IP joint motion of the thumb was 32° (range, 10°–70°). In this study, the degree of tendon tension during the graft was not mentioned. A comparative study of FDS transfer and tendon grafting for FPL ruptures was reported in 1983.10) In this study, surgery was performed with the tendon tension in neutral wrist and thumb MCP joint abduction, with the IP joint flexed to 35° during transfer. Active flexion of the IP joint was > 60° in 8 cases, between 30° and 60° in 4 cases, less than 30° in 1 case, and no motion in 1 case.
In 2017, Berger and Duerinckx20) performed PL tendon graft in 4 cases of FPL rupture and reported that the average active IP joint flexion was 44°. They reported that during the surgery, the degree of tension was adjusted such that the IP joint of the thumb was more flexed than that on the normal side, and tension was applied to enable the thumb pulp to touch the base of the ring finger in the wrist in a neutral position. This group reported 14 additional cases in 2022.11) They reported that the average IP joint active motion was 49° (normal, 75°), and even though the ROM and opposition of the IP joint were not in full range after the PL interpositional graft, the functional outcome of the DASH score was not inferior to that of the normal population.11) In comparison, the outcomes of our study were better, showing an average IP joint ROM of 61°, with no statistically significant difference from the healthy side. This was thought to be because the authors adjusted the degree of tendon tension during surgery to a state in which the IP joint was flexed by more than 45°.
In our study, we focused on comparing the IP joint ROM to evaluate the results. The flexion of the MCP joint is performed by the actions of FPL and flexor pollicis brevis (FPB), and the opposition is performed by the actions of abductor pollicis brevis, FPL, opponens pollicis, and FPB.21) Since the remaining tendons were not damaged except FPL, we considered it was reasonable to compare the IP joint ROM to prevent disturbance and interference with the function of other muscles. In addition, the distribution of Quick DASH score and pinch power of the subjects were relatively even overall and did not show a distinct difference from the normal population,22,23) which also led us to compare IP joint ROM.
Generally, the degree of tendon tension during grafting is high. The degree of tendon tension application during PL tendon grafting in FPL ruptures has not yet been clearly established. Methods have been introduced to bend the IP joint more than the normal side20) or to bend the IP joint to 35 degrees during surgery.10) However, in the current study, we performed tendon grafting with a bend of more than 45°, which was more flexed than 35°, and achieved good results. Our study showed that the larger the intraoperative IP and MCP joint angles, the better the expected IP and MCP joint ROM and opposition scores after surgery.
Our study has several limitations. First, it has a small sample size and is retrospective in nature. Second, the cause of rupture is a mixture of attrition ruptures, spontaneous intratendinous ruptures, and drug-related ruptures classified by Netscher and Badal.24) However, all 3 types of ruptures are closed ruptures, making direct tenorrhaphy impossible, and they share the common surgical approach of aiming for healing at the proximal and distal sites, not at the ruptured site. In this respect, this study is meaningful despite the differences in the causes of rupture. Meanwhile, one of the patients could not have intraoperative IP and MCP angles measured due to the absence of clinical photos (Table 3). Although some of the factors influencing the outcome cannot be explained within the objectives of our study, the patient was included because of helpfulness in introducing the clinical outcome, another objective of this study.
Nevertheless, this study is considered meaningful because it recommends applying tendon tension during surgery to achieve IP joint flexion of more than 45° to obtain a good outcome when performing tendon graft using the PL in closed FPL rupture.
Footnotes
CONFLICT OF INTEREST: No potential conflict of interest relevant to this article was reported.
References
- 1.Mannerfelt L, Norman O. Attrition ruptures of flexor tendons in rheumatoid arthritis caused by bony spurs in the carpal tunnel: a clinical and radiological study. J Bone Joint Surg Br. 1969;51(2):270–277. [PubMed] [Google Scholar]
- 2.Uekubo K, Itoh S, Yoshioka T. Closed traumatic rupture of the flexor pollicis longus tendon in zone T I: a case report. Hand Surg. 2015;20(1):145–147. doi: 10.1142/S021881041572003X. [DOI] [PubMed] [Google Scholar]
- 3.Cigna E, Ozkan O, Mardini S, Chiang PT, Yang CH, Chen HC. Late spontaneous rupture of the extensor pollicis longus tendon after corticosteroid injection for flexor tenosynovitis. Eur Rev Med Pharmacol Sci. 2013;17(6):845–848. [PubMed] [Google Scholar]
- 4.Sander AL, Leiblein M, Sommer K, Marzi I, Schneidmuller D, Frank J. Epidemiology and treatment of distal radius fractures: current concept based on fracture severity and not on age. Eur J Trauma Emerg Surg. 2020;46(3):585–590. doi: 10.1007/s00068-018-1023-7. [DOI] [PubMed] [Google Scholar]
- 5.Schneppendahl J, Windolf J, Kaufmann RA. Distal radius fractures: current concepts. J Hand Surg Am. 2012;37(8):1718–1725. doi: 10.1016/j.jhsa.2012.06.001. [DOI] [PubMed] [Google Scholar]
- 6.Asadollahi S, Keith PP. Flexor tendon injuries following plate fixation of distal radius fractures: a systematic review of the literature. J Orthop Traumatol. 2013;14(4):227–234. doi: 10.1007/s10195-013-0245-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Yamak K, Karahan HG, Karatan B, Kayali C, Altay T. Evaluation of flexor pollicis longus tendon rupture after treatment of distal radius fracture with the volar plate. J Wrist Surg. 2020;9(3):219–224. doi: 10.1055/s-0040-1702931. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Ertel AN, Millender LH, Nalebuff E, McKay D, Leslie B. Flexor tendon ruptures in patients with rheumatoid arthritis. J Hand Surg Am. 1988;13(6):860–866. doi: 10.1016/0363-5023(88)90260-2. [DOI] [PubMed] [Google Scholar]
- 9.Unglaub F, Bultmann C, Reiter A, Hahn P. Two-staged reconstruction of the flexor pollicis longus tendon. J Hand Surg Br. 2006;31(4):432–435. doi: 10.1016/j.jhsb.2006.02.014. [DOI] [PubMed] [Google Scholar]
- 10.Schneider LH, Wiltshire D. Restoration of flexor pollicis longus function by flexor digitorum superficialis transfer. J Hand Surg Am. 1983;8(1):98–101. doi: 10.1016/s0363-5023(83)80065-3. [DOI] [PubMed] [Google Scholar]
- 11.Peters T, Caekebeke P, Duerinckx J. Reconstruction of flexor pollicis longus tendon with palmaris longus interposition graft: results in 14 patients. Acta Orthop Belg. 2022;88(4):757–760. doi: 10.52628/88.4.03. [DOI] [PubMed] [Google Scholar]
- 12.Shih YS, Chang YJ, Cheng YT, Chang CS, Lin YH. Flexor pollicis longus tendon rupture: a case series on palmaris longus tendon graft reconstruction after volar plate fixation. J Surg Case Rep. 2023;2023(7):rjad399. doi: 10.1093/jscr/rjad399. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Gummesson C, Ward MM, Atroshi I. The shortened disabilities of the arm, shoulder and hand questionnaire (QuickDASH): validity and reliability based on responses within the full-length DASH. BMC Musculoskelet Disord. 2006;7:44. doi: 10.1186/1471-2474-7-44. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Kapandji A. Clinical test of apposition and counter-apposition of the thumb. Ann Chir Main. 1986;5(1):67–73. doi: 10.1016/s0753-9053(86)80053-9. [DOI] [PubMed] [Google Scholar]
- 15.Lv YX, Chen MM, Su CX, Ye HN, Yang J, Li J. Analysis of risk factors associated with flexor pollicis longus injury after volar plating of distal radius fractures. J Int Med Res. 2021;49(8):3000605211031438. doi: 10.1177/03000605211031438. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.White BD, Nydick JA, Karsky D, Williams BD, Hess AV, Stone JD. Incidence and clinical outcomes of tendon rupture following distal radius fracture. J Hand Surg Am. 2012;37(10):2035–2040. doi: 10.1016/j.jhsa.2012.06.041. [DOI] [PubMed] [Google Scholar]
- 17.Brown DJ, Ormsby N, Brown OC, Cheung G. Incidence of tendon ruptures after locking plate fixation of distal radial fractures: are the cited rates still accurate. J Hand Surg Eur Vol. 2021;46(2):167–171. doi: 10.1177/1753193420948466. [DOI] [PubMed] [Google Scholar]
- 18.Zukawa M, Osada R, Makino H, Kimura T. Wide-awake flexor pollicis longus tendon reconstruction with evaluation of the active voluntary contraction of the ruptured muscle-tendon. Plast Reconstr Surg. 2019;143(1):176–180. doi: 10.1097/PRS.0000000000005092. [DOI] [PubMed] [Google Scholar]
- 19.Zukawa M, Osada R, Makino H, Kimura T. Active voluntary contraction of the ruptured muscle tendon during the wide-awake tendon reconstruction. Plast Reconstr Surg Glob Open. 2017;5(12):e1597. doi: 10.1097/GOX.0000000000001597. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Berger P, Duerinckx J. Flexor pollicis longus tendon rupture after volar wrist plating : reconstruction with palmaris longus interposition graft. Acta Orthop Belg. 2017;83(3):467–472. [PubMed] [Google Scholar]
- 21.Tonkin M. Thumb opposition: its definition and my approach to its measurement. J Hand Surg Eur Vol. 2020;45(3):315–317. doi: 10.1177/1753193419889504. [DOI] [PubMed] [Google Scholar]
- 22.Aasheim T, Finsen V. The DASH and the QuickDASH instruments: normative values in the general population in Norway. J Hand Surg Eur Vol. 2014;39(2):140–144. doi: 10.1177/1753193413481302. [DOI] [PubMed] [Google Scholar]
- 23.Angst F, Drerup S, Werle S, Herren DB, Simmen BR, Goldhahn J. Prediction of grip and key pinch strength in 978 healthy subjects. BMC Musculoskelet Disord. 2010;11:94. doi: 10.1186/1471-2474-11-94. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Netscher DT, Badal JJ. Closed flexor tendon ruptures. J Hand Surg Am. 2014;39(11):2315–2323. doi: 10.1016/j.jhsa.2014.04.005. [DOI] [PubMed] [Google Scholar]