Rupture of extensor pollicis longus after distal radius fracture may be preventable via aspiration

BOSTON — Aspiration — just ulnar to Lister’s tubercle — may help protect the extensor pollicis longus from rupturing after distal radius fracture, according to a study presented here.

Andrew Putman

The findings were presented by Andrew Putman, MD, at the 2010 Annual Meeting of the American Society for Surgery of the Hand.

“Distal radius fractures are a very common injury, and multiple complications exist with regards to treating this injury,” Putman said. “We wanted to look specifically at the [extensor pollicis longus] tendon.”

Patients and cadavers

Putman’s team reviewed the radiographs of 19 patients who had distal radius fractures and established or impending extensor pollicis longus (EPL) ruptures for anatomic findings, including location of the fracture and presence of intra-articular involvement.

The team also created a 6-forearm cadaveric model with a nondisplaced distal radius and hypaque die injected into the fracture site. Pressure measurements were taken from the third dorsal compartment before and after injection, and aspiration was performed with an 18 gauge needle. Final pressure measurements were then recorded.

The data collected from this model was used in the treatment of four patients with the same presentation. The patients underwent therapeutic aspiration of the third compartment, and the results were analyzed.

Study results and findings

The team reviewed 11 radiographs and found that all patterns were nondisplaced, usually transverse and within 2.5cm of the radial styloid. Putman reported that over 50% of the radiographs had intra-articular involvement, with each case displaying a line that existed through the scapho-lunate facet.

The cadaveric model displayed average initial third compartment pressures of 0.77mmhg. This increased to 25.5mmhg after hypaque injection and dropped to 1.61mmhg after simulated therapeutic aspiration.

Four of the patients with characteristic radiographic findings and pain on resisted EPL function underwent prophylactic aspiration just ulnar to Lister’s tubercle and found complete pain relief and improvement in EPL function. None of the patients went on to rupture.

Putman noted that patients with nondisplaced extra- or intra-articular radius fractures seen within 2.5cm of the styloid or extension into the scaph-lunate facet should be evaluated for EPL function and pain on resistance. If those factors are present, Putman said, the possibility of impending rupture should be discussed.

“The morbidity of this complication is significant,” Putman concluded. “There have been no studies that have really finalized a way to decrease this complication, but we do feel that aspiration offers hope for this … we feel this could be an effective option.”

Reference:
Putman A, Lourie GM, Cates T, Peliovich AE. Extensor pollicis longus ruptures in distal radius fractures: A clinical and cadaveric study with a new therapeutic intervention. Paper #23. Presented at the 2010 Annual Meeting of the American Society for Surgery of the Hand. Oct. 7-9, 2010. Boston, Mass.

The scientist in me says that is a little bit of a messy paper, but the clinician in me really applauds this study because clearly there was a hypothesis driven by the clinical practice. I think several appropriate and very interesting — albeit small — studies were done both in patients and in cadavers, and then the knowledge was applied to treat a small cohort of patients.

— Edward Diao, MD
American Society for Surgery of the Hand moderator

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