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Extensor Pollicis Longus Rupture

- See: Extensor Tendon Rupture in RA

- Discussion:
    - this tendon is prone to rupture from synovitis and increases friction at Lister's tubercle second to diseases such as RA and Lupus;
    - EPL is tendon that is most frequently ruptured from distal radius frx;
         - if dorsal radial tubercle has been disrupted by Colles frx (producing irregularity), EPL  tendon may rupture due to added friction imposed upon it as it
               turns around roughned tubercle;
               - ruptures occur most often just distal to the extensor retinaculum (at Lister's tubercle)
         - rupture is far more common in assoc w/ undisplaced frx than in associated w/ displaced frxs, & it has been reported in patients who had wrist injury w/o a fracture;
               - rupture of this tendon after minimally displaced frx suggests ischemic etiology rather than attritional rupture over an osseous spike;
         - ruptures occur most often between 3 weeks and 3 months following injury;

- Exam:
     - palpate length of tendon, look for any signs of rupture;
     - ask pt to place hand flat on table, & lift only thumb off surface;
     - w/ rupture, patient will be unable to raise the thumb in line w/ the second metacarpal;

- Treatment:
     - direct repair:
          - often difficult due to tendon retraction and atrophy (or fraying) of tendon edges;
     - free tendon graft:
          - palmaris longus can be used to either augment a primary repair or can be used as a free tendon graft inorder to bridge the gap between tendon edges;
          - if a large portion of tendon edges appear degenerative, then consider resecting tendon edges and then weaving palmaris longus between the edges to bridge gap;
     - tendon transfer
          - extensor indicis  may be transferred to replace torn EPL tendon;
                 - tendon transfer using adjacent EIP provides predictable outcome;
                 - advantages include similar amplitude and direction of pull;
                 - prerequisites include independent extension of the index finger;
                 - graft should be harvested just proximal to the extensor hood, w/ care taken to anatomically repair the saggital hood (see extensor mechanism);
                         - one incision is made at the MP joint level inorder to harvest the tendon;
                         - second incision is made just distal to the extensor retinaculum (which allows the tendon to be delivered and then rerouted);
                 - incision is made over the thumb MP joint, and a subQ tunnel is created to the retinacular incision;
                 - the tendon is then delivered thru this tunnel;
                 - the most difficult part of the case is proper tensioning;
                         - inorder to achieve full extension, often the graft will have to be tensioned to the point that some IP joint flexion will be lost;
                         - many surgeons advocate slight to moderate overtensioning of this graft inorder to overcome the much stronger FPL;
                                - worst case scenario w/ this approach is slight loss of full flexion;
                         - immobilization in full extension is emphasized;
                 - main disadvantage of this transfer is that it precludes its use for other tendon transfers (should this be necessary in the future);
          - APL to EPL transfer:
                 - this may be a good choice in rheumatoid arthritis;
                 - even though the APL has decreased amplitude (3 cm vs 6 cm for the EPL), it has the same
                        direction of pull, and affords the patient good function;
     - joint arthrodesis:
          - arthrodesis improves strength & maintains f(x), where as efforts at reconstruction of joint,
                if articular surface is severely damaged, will be unsuccessful

Rupture of the extensor pollicis longus tendon.    Chmell S, et al. Orthopaedics. 1983;6:565.  

Spontaneous rupture of the extensor pollicis longus. The results of tendon transfer.

Clinical and microangiographic studies on rupture of the EPL tendon after distal radial fractures.

Rupture of the extensor pollicis longus tendon in undisplaced Colle's type fracture.

Postfracture extensor pollicis longus tenosynovitis and tendon rupture: a scientific study and personal series.

Incidence of Extensor Pollicis Longus Tendon Rupture After Nondisplaced Distal Radius Fractures