Delayed rupture of the flexor pollicis longus tendon after inappropriate placement of the π plate on the volar surface of the distal radius

doi:10.1053/jhsu.1999.1279

The Journal of Hand Surgery

Volume 24, Issue 6, November 1999, Pages 1279-1280

https://doi.org/10.1053/jhsu.1999.1279 Get rights and content

Abstract

The π plate (Synthes Ltd, Paoli, PA) was designed to fit the unique contour of the dorsal aspect of the distal radius. Complications of π plate fixation of the dorsal distal radius have been previously reported to include both extensor tenosynovitis and delayed extensor tendon rupture. We report a case of rupture of the flexor pollicis longus tendon associated with inappropriate placement of the π plate on the volar surface of the distal radius. (J Hand Surg 1999;24A:1279–1280. Copyright © 1999 by the American Society for Surgery of the Hand.)

Section snippets

Case report

A 72-year-old right-handed woman sustained a comminuted, intra-articular distal radial fracture after a fall onto her outstretched right hand. She was initially treated with closed reduction and external fixation and was referred for rehabilitation. The follow-up visit 10 days later showed that the fracture reduction was lost, and open reduction and internal fixation was suggested. The patient sought another opinion; 3 weeks after injury she underwent open reduction and internal fixation at

Discussion

One of the goals of the low-profile π plate design was to minimize extensor tendon irritation when used for fixation on the dorsal surface of the distal radius.² The design was primarily intended to fit the unique contour of the dorsal distal radius. It was not designed for fixation of the volar surface of the distal radius. The existing angled T plate is an appropriate choice for volar buttressing of the distal radius.

Tendon irritation has been reported after use of the π plate on the dorsum

References (2)

GK Kambouroglou et al.
Complications of the AO/ASIF titanium distal radius plate system (π plate) in internal fixation of the distal radius: a brief report
J Hand Surg
(1998)
D Ring et al.
Prospective multicenter trial of a plate for dorsal fixation of distal radius fractures
J Hand Surg
(1997)

Cited by (70)

Location of distal pronator quadratus repair in distal radius fractures: A cadaveric biomechanical study
2023, Clinical Biomechanics
We aimed to biomechanically evaluate the distal pronator quadratus and compare two locations of distal transection on the strength of the subsequent repair.
Eighteen fresh-frozen cadaveric specimens were dissected to the pronator quadratus muscle. Specimens were randomly allocated for transection of the pronator quadratus at the myotendinous junction (red group) or parallel to the myotendinous junction at the midsection of the distal tendinous zone (white group). For both groups, repair of the muscle was performed using two figure-of-8 sutures. The radius and ulna were positioned in 90° of wrist extension. The proximal muscular pronator quadratus was fixed in a cryo-clamp. Load-to-failure testing of the repair was performed at 1 mm/s with maximum amount of force applied to the pronator quadratus recorded for each specimen.
The pronator quadratus had a mean width, height, and area of 31.41 ± 5.74 mm, 53.79 ± 7.46 mm, and 1604.27 ± 429.20 mm² respectively. The pronator quadratus distal tendinous zone had a mean width, height, and area of 29.71 ± 5.83 mm, 12.22 ± 2.79 mm, 282.94 ± 148.30 mm² respectively. There was no significant difference between the two groups for pronator quadratus height, width, total area, or tendinous zone height, width, or total area. The average load to failure for the white group was significantly higher than that of the red group (29.46 ± 4.24 N vs. 13.78 N ± 6.66 N).
Incision and repair of the pronator quadratus in the distal tendinous region is stronger than incision and repair at the red myotendinous junction of the distal PQ.
Changes in Distance Between the Flexor Pollicis Longus Tendon and Volar Locking Plate: An Ultrasonographic Study
2023, Journal of Hand Surgery
Flexor pollicis longus rupture is a major complication after volar locking plate fixation of distal radius fractures. Although the distance between the flexor pollicis longus tendon and the plate (plate–tendon distance) measured by ultrasonography is used to predict tendon rupture risk, the timing of the ultrasonography can affect the measurements. Therefore, this study aimed to analyze the chronological change of the plate–tendon distance between the tendon and plate.
A total of 166 wrists underwent the plate–tendon distance measurement twice or more times within 15 months after surgery. Longitudinal ultrasonography scans with the wrist in a neutral position and the thumb flexed were used to measure the plate–tendon distance. The plate–tendon distances at 0–5 months, 5–10 months, and 10–15 months after surgery were compared. A multiple linear regression analysis was performed to evaluate the influence of the interval between surgery and examination, Soong grade, and plate type on the plate–tendon distance.
The plate–tendon distance decreased as the interval between surgery and examination increased. The plate–tendon distance was an average of 2.0 ± 1.1 mm, 1.4 ± 0.9 mm, and 1.2 ± 0.9 mm at 0–5 months, 5–10 months, and 10–15 months after surgery, respectively. Significant differences were observed between 0–5 months and 5–10 months and between 5–10 months and 10–15 months after surgery. A multiple linear regression showed that significant predictors of the plate–tendon distance were the intervals between surgery and examination and Soong grade.
The plate–tendon distance decreased as the time since surgery increased. When ultrasonography is used for the assessment of tendon rupture risk, it should be considered that the plate–tendon distance decreases as the interval between the surgery and examination increases.
Prognosis IV.
Flexor tendon rupture after volar plating of distal radius fracture: A systematic review of the literature
2021, Hand Surgery and Rehabilitation
Citation Excerpt :
The most common technique is palmaris longus graft, with satisfactory results [19,71]. If the injury is old, FPL belly atrophy may be significant; in this case, tendon transfer is judicious, especially that of the FDS4, which is the most widely used [23,72–74]. Interphalangeal thumb joint fusion is also an effective solution.
Flexor tendon rupture after volar plate fixation of distal radius fracture (DRF) is rare. There is no consensus as to how to prevent them. The aim of our study was to identify the pathological mechanisms, and to establish the clinical and epidemiological profile of patients suffering from this complication. We carried out a systematic review using the PubMed, Scopus and Cochrane databases. Studies were included if they described complete or partial flexor tendon rupture following volar plate fixation of DRF. Forty-six 46 were included, for a total of 145 patients were reported: 138 from the literature, and 7 from our personal experience. Etiology was usually mechanical, by impingement with either the plate or protruding screws. Plate impingement was due to positioning beyond the watershed line, consolidation with posterior tilt, plate thickness, or low palmar cortical angle. Mean patient age was 62.4 years (range, 23–89 years). Median postoperative interval was 8 months (range, 3–120 months). Flexor pollicis longus was the most frequently injured tendon. The plate should be positioned proximally to the watershed line if possible, to ensure good initial reduction. Hardware should be removed 4 months after surgery if the plate is causing impingement according to the Soong criteria or if signs of tenosynovitis appear.
Les ruptures de tendon fléchisseur après ostéosynthèse par plaque antérieure des fractures de l’extrémité distale du radius sont rares. Il n’existe pas de consensus pour les prévenir. L’objectif de notre étude était d’en identifier les mécanismes physiopathologiques, puis d’identifier le profil clinique et épidémiologique des patients souffrant de cette complication. Nous avons donc réalisé une revue de la littérature. Nous avons utilisé les bases de données PubMed, Scopus et Cochrane. Les études présentant des cas de rupture(s) complète(s) ou partielle(s) après ostéosynthèse par plaque antérieure des fractures de l’extrémité distale du radius ont été incluses. Quarante-six études ont été incluses rassemblant 145 patients: 138 de la littérature, 7 de notre expérience. L’origine des ruptures était le plus souvent mécanique, par conflit soit avec la plaque, soit avec les vis. Le conflit avec la plaque peut être dû à un positionnement au-delà de la “watershed line”, une consolidation du radius en bascule postérieure, l’épaisseur du matériel ou un angle cortical palmaire faible. L’âge moyen des patients était de 62,4 années (23–89). La médiane de l’intervalle entre l’ostéosynthèse et la rupture était de 8 mois (3–120). Le flexor pollicis longus était le tendon le plus touché. Il faut s’assurer d’une bonne réduction initiale, de positionner la plaque proximalement à la “watershed line” si possible. L’ablation du matériel doit être envisagée à 4 mois si la plaque est conflictuelle selon les critères de Soong ou si des signes de ténosynovite apparaissent.
Do we really need to repair the pronator quadratus after distal radius plating?
2019, Chinese Journal of Traumatology - English Edition
Fractures of distal radius are one of the common orthopaedic injuries. Placing the plate on volar surface requires release of underlying pronator quadratus (PQ) muscle. No consensus is present in the literature about the repair or not of the PQ. The purpose of this study was to evaluate the influence of PQ repair on functional outcome and complications.
Retrospectively 83 patients of distal radius fractures managed with volar plating between 2014 and 2016 were evaluated. Demographic data, operative notes and physical therapy records were retrieved. Patients were divided into group A where PQ repair was done and group B where no repair was done. Functional data such as range of motion (ROM), grip strength, visual analogue scale (VAS) score and disabilities of arm, shoulder and hand (DASH) score at 4 weeks, 3 months, 6 months and finial follow-up were retrieved.
Totally 63 patients (n = 29 in group A and n = 34 in group B) with the mean age of 51.64 years were examined. Patients were followed up for a mean of 35.2 months (range 27.2–47.1 months) in group A and 38.6 months (range 28.6–51.0 months) in group B. Though functional outcome of the affected limb was not significantly different between two groups after 3 months, PQ repair did affect the recovery at an early stage. Repair group had significantly better ROM (p = 0.0383) and VAS score at 4 weeks (p = 0.017) while grip strength (p = 0.014) was significantly better at 3 months.
Repair of PQ may provide pain relief and increased ROM in early postoperative period and hence every attempt should be made to achieve the repair.
Volar locking plate vs epibloc system for distal radius fractures in the elderly
2016, Injury
To compare clinical outcomes of ORIF with volar locking plates and the Epibloc system (ES) in the treatment of distal radius fractures (DRFs) in patients aged over 65 years.
We retrospectively examined a consecutive series of 100 patients with intra-articular or extra-articular DRF who were admitted to our Department of Orthopaedics and Traumatology between January 2007 and January 2013. Fifty patients were treated using the Epibloc System; and the other 50 patients using ORIF with volar locking plates. In all patients, functional evaluation (wrist range of motion [ROM], grip strength and Disability of the Arm, Shoulder and Hand [DASH] Score) and radiographic assessment (radial inclination, volar tilt, ulnar variance and articular congruity) were performed at 2 and 6 weeks, and 3, 6 and 12 months postoperatively; then every 12 months thereafter.
ORIF with volar locking plates was associated with better outcome than ES in the intra-articular and extra-articular DRF groups, generating higher average ROM, DASH and visual analogue scale (VAS) scores. Grip strength mean values, however, were quantified over the minimum level for a functional wrist ( > 60%) in both groups. There were no differences between the two techniques in X-ray parameters, and no further correlation was found with functional outcome and ROM.
In a low-functioning patient with multiple medical comorbidities, minimally-invasive surgery with the ES is a safe option, enables early mobilisation of the wrist and is likely to produce acceptable clinical outcomes.
Danger zones for flexor tendons in volar plating of distal radius fractures
2015, Journal of Hand Surgery
To define a danger zone for volar plates using magnetic resonance imaging by analyzing the position of the flexor tendons at risk around the watershed line.
We analyzed 40 wrist magnetic resonance images. The location of the flexor pollicus longus (FPL) and index flexor digitorum profundus (FDPi) tendons was recorded at 3 and 6 mm proximal to the watershed line of the distal radius. We measured the distance between the volar margin of the distal radius and the FPL and FDPi tendons, and the coronal position of the tendons.
At a point 3 mm proximal to the watershed line, FPL and FDPi were located on average 2.6 and 2.2 mm anterior to the volar margin of the distal radius. This distance increased to 4.7 and 5.3 mm at a point 6 mm proximal to the watershed line. The FPL and FDPi were located at 57% and 42% of the total width of the distal radius from the sigmoid notch at 3 mm from the watershed, and at 66% and 46% at 6 mm from the watershed.
Surgeons should be aware of the close proximity of the flexor tendons to the volar cortex of the distal radius proximal to the watershed line and their radial to ulnar position. Three millimeters proximal to the watershed line, plate placement more than 2 mm anterior to the volar cortex or the use of plates thicker than 2 mm poses a high risk for directly contacting flexor tendons.
This article may prove to be helpful in avoiding flexor tendon injury during volar plate fixation.

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^*: No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

^**: Reprint requests: James A. Nunley, MD, Department of Orthopaedic Surgery, Duke University Medical Center, Box 2923, Durham, NC 27710.

^*: J Hand Surg 1999;24A:1279–1280

^**: 0363-5023/99/24A06-0024$3.00/0

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Original CommunicationsDelayed rupture of the flexor pollicis longus tendon after inappropriate placement of the π plate on the volar surface of the distal radius*,**,*,**

Abstract

Section snippets

Case report

Discussion

Complications of the AO/ASIF titanium distal radius plate system (π plate) in internal fixation of the distal radius: a brief report

J Hand Surg

Prospective multicenter trial of a plate for dorsal fixation of distal radius fractures

J Hand Surg

Original Communications
Delayed rupture of the flexor pollicis longus tendon after inappropriate placement of the π plate on the volar surface of the distal radius*,**,*,**