- 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 treatement of ruptures of multiple extensor tendons at wrist level by a free tendon graft in the rheumatoid patient.
FW Bora et al. J. Hand Surg. Vol 12-A. 1987. p 1038-1040.
-
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. OJ Vaughn-Jackson. JBJS. Vol 40-A. 1958. p 1431.
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. A Quaba et al. J. Hand. Surg. Vol 13-B. p 66. 1989.
Rheumatoid extensor tendon ruptures. BM Leslie. Hand Clinics. Vol 5. 1989. p 191-202.
Posterior interosseous nerve palsy in a patient with rheumatoid synovitis of the elbow: a case report and review of the literature. JG Westkaemper MD et al . J. Hand Surgery. Vol 24-A No 4. July 1999. p 727.
