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RA: Extensor Tendon Rupture: (Vaughn-Jackson syndrome)

- See:
      - Rheumatoid Arthritis
      - Extensor Tendon Lacerations
      - Mallet Finger
      - Rheumatoid Wrist
      - Teno-synovectomy

- Discussion:
    - ulnar side of wrist is most common site of extensor tendon ruptures;
    - pathophysiology: (caput ulnae syndrome)
             - this most often due to attritional changes due to caput ulnae syndrome;
             - volar subluxation of the ECU causes in loss of ulnar deviation and extension and the wrist begins to deviate radially;
             - this brings the ulnar-sided extensor tendons directly over the prominent ulna;
             - radial deformity of wrist results from volar subluxation of ECU and increases potential for attrition ruptures of extensor tendons (Vaughn-Jackson syndrome);
             - futher, erosion of the distal ulna causes its edge to sharpen leading to rupture of extensor tendons;
    - clinical findings:
             - dorsal subluxation of ulna associated w/ tenderness on resisted extension of thumb & fingers should raise possibility of tendon rupture;
             - rupture of EDC to 4th & 5th digits from caput ulna
             - tendons to the middle and index fingers are less often ruptured;
             - thickening of the dorsal synovium is also present;
             - patients will lose tenodesis effect with wrist flexion and extension;
             - EDQ rupture (w/ intact little EDC):
                    - EDQ tendon is most prone to rupture in a patient with rheumatoid arthritis of the wrist;
                    - rupture is diagnosed with the Texas long horn sign,  in which the index and little finger are extended while ring and little fingers are flexed;
                    - this requires intact extensor indicis and EDQ tendons, respectively;
             - EPL rupture:
                    - commonly injured is EPL, where it passes over Lister's tubercle,
                    - deformity at level of MP joint of thumb may occur secondary to rupture of the EPB and displacement of the dorsal hood;
    - diff dx:
             - failure of digit extension from chronic dislocation of MCP
                    - pt can maintain extension achieved passively, also use Bouvier's test
             - PIN syndrome:
                    - tenodesis effect present - not present with rupture;
             - trigger finger (no passive movement possible);

- Treatment Options

- Treatment Considerations:
    - caput ulnae syndrome
          - needs to be adressed at the time of tendon repair/reconstruction;
          - radial deviation of the wrist that is passively correctable may not require treatment;

- Primary Tendon Repair:
    - dorsal approach to the wrist;
    - should be performed early (within 4-6 wks);
    - for a single tendon rupture, end to side repair is prefered using adjacent extensor tendon;
          - do not expect execellent individual function;
    - when possible the repaired tendon should be passed above the extensor retinaculum to avoid scarring;
    - alternatively consider use of a free jump graft (palmaris longus) for tendon repair;

- Tendon Transfers:
    - when ruptures occur proximal to the junctura, the tendon will contract which precludes a primary repair (in delayed cases);
          - primary repair of contracted tendons may lead to loss of finger flexion and loss of flexion;
    - ensure that there is passive ROM (w/ full extension) prior to managing this condition;
    - transfers (EIP to EDQ & ring finger EDC to long finger) are best choice since tendon grafts may become adherent;
    - multiple ruptures:
          - multiple ruptures pose a severe problem;
          - combined extensor tendon ruptures to the ring and little fingers;
                 - EIP is not strong enough to extend more than a single digit, and most often, the proprius is transfered to the EDQ;
                       - EIP is harvested just proximal to the saggital band insertion;
                 - extensor slip(s) to the ring finger are then transfered to the EDC of the long finger;
                 - always check the tenodesis effect following tendon repair or transfer;
          - triple rupture:
                 - FDS from ring finger can be rerouted to the dorsum of the hand and will provide satisfactory extension;
                 - free tendon graft:
                       - outcomes are controversial but good results are reported in the litterature;
                       - ref: The treatment of ruptures of multiple extensor tendons at wrist level by a free tendon graft in the rheumatoid patient.
          - adjusting tension:
                 - tension is adjusted so that the fingers come out into extension when the wrist is flexed 20-30 deg;
          - w/ radial deviation deformity of the wrist, the ECRL can be transferred to extensor carpi ulnaris;
                 - w/ a stiff wrist & more advanced disease, radiolunate arthrodesis can be used & is more predictable;
    - EPL rupture:
          - commonly injured is EPL, where it passes over Lister's tubercle,
          - deformity at level of MP joint of thumb may occur secondary to rupture of the EPB and displacement of the dorsal hood;
          - management:
                 - avoid tendon repair if articular surface is severely damaged;
                 - consider EIP transfer;
                 - joint arthrodesis rather than direct repair of tendon improves strength & maintains f(x)

Attrition ruptures of tendons in the rheumatoid hand.  

Rheumatoid wrists treated with synovectomy of the extensor tendons and the wrist joint combined with a Darrach procedure.

Year Book: Long-Term Results of Extensor Tendon Repair.

Biomechanical characteristics of extensor tendon suture techniques.

Long term hand function without long finger extensors: A clinical study.   

Posterior interosseous nerve palsy in a patient with rheumatoid synovitis of the elbow: a case report and review of the literature.

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