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Upper Limb: M. Al-Rashid, K. Theivendran, and M. A. C. Craigen Delayed ruptures of the extensor tendon secondary to the use of volar locking compression plates for distal radial fractures J Bone Joint Surg Br 2006; 88-B: 1610-1612 [Abstract] [Full text] [PDF]

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Delayed extensor tendon rupture with volar plating

David M.G Machin, John Casaletto, Ria Leung, Daniel J. Brown   (7 March 2007)

Prevention of extensor tendon rupture when using volar locking plates for distal radial fractures

Timothy E Hems   (13 February 2007)

Authors' reply:

Kanthan Theivendran, Michael Craigen   (19 January 2007)

Volar locking plate: Is it really responsible for delayed rupture of extensor tendon?

Bhavuk Garg, Rajesh Malhotra, P P Kotwal   (12 January 2007)

Delayed extensor tendon rupture with volar plating 7 March 2007
David M.G Machin, SHO Orthopaedics Royal Liverpool University Hospital, John Casaletto, Ria Leung, Daniel J. Brown Send letter to journal: Re: Delayed extensor tendon rupture with volar plating davidmachin{at}doctors.net.uk David M.G Machin, et al.	Sir, We read this paper with interest. The authors describe three such ruptures representing 8.6% of their patients treated with these plates. We have a very similar series of 137 patients treated with volar locking compression plates of whom three (2.2%) have had extensor tendon ruptures. One screw was noted to be in the Extensor Pollicis Longus groove, leading to an attrition rupture whilst the other two had no features of the fixation to explain the rupture. As alluded to by the authors, it is accepted in the literature that a dorsally displaced fractured distal radius is a risk factor for extensor tendon rupture due to mechanical bending and attrition with decreased tendon vascularity.1,2 The incidence is between 0.3% in Hove’s study of 4400 patients2 and 3% in Skoff’s study of 200 patients.3 We agree that it is extremely important to drill and place the screws carefully and suggest taking oblique image intensifier views as well as the usual antero-posterior and lateral to ensure the screws are of the correct length. Mr D.M.G. Machin MRCS, Senior House Officer, Orthopaedics, Mr J. Casaletto MRCS, Specialist Registrar, Orthopaedics, Dr R. Leung, Senior House Officer, Orthopaedics, Mr D. J. Brown FRCS (Orth), Consultant Hand and Orthopaedic Surgeon, The Royal Liverpool University Hospital, Liverpool, UK. 1. Hirasawa Y, Katsumi Y, Akiyoshi T, Tamai K, Tokioka T. Clinical and microangiographic studies on rupture of the E.P.L. tendon after distal radial fractures. J Hand Surg [Br] 1990;15:51-7. 2. Hove LM. Delayed rupture of the thumb extensor tendon. A 5-year study of 18 consecutive cases. Acta Orthop Scand 1994;65:199-203. 3. Skoff HD. Postfracture extensor pollicis longus tenosynovitis and tendon rupture: a scientific study and personal series. Am J Orthop 2003;32:245-7.
Prevention of extensor tendon rupture when using volar locking plates for distal radial fractures 13 February 2007
Timothy E Hems, Hand and Orthopaedic Surgeon The Victoria Infirmary, Glasgow Send letter to journal: Re: Prevention of extensor tendon rupture when using volar locking plates for distal radial fractures t.e.j.hems{at}doctors.org.uk Timothy E Hems	Sir, I read this paper with interest. It reports the important complication of extensor tendon rupture. With the recent enthusiasm for the use of volar locking plates it is important to be aware of this complication. I have been aware of the dangers of screws protruding on the dorsal aspect of the distal radius for some years. When inserting the distal locking screws into a volar locking plate, I routinely subtract 2 mm from the measured screw length and carefully check screw lengths with the image intensifier. There have been no failures of fixation using slightly short screws and so far we have not encountered an extensor tendon rupture. Al-Rashid et al state, “Leaving the screws a little short is not desirable because engagement of the dorsal cortex allows compression of dorsal intra-articular fragments”. However, for most fractures, the important fixation is in the subchondral bone. Locking screws do not themselves compress fragments. In the case of complex intra-articular fractures, full visualisation and reduction of the joint surface requires a dorsal incision. If a volar locking plate is used for fixation, the screw lengths can be very accurately checked as the screw tips can be seen. T.E. Hems, Consultant Hand and Orthopaedic Surgeon, The Victoria Infirmary, Glasgow, UK.
Authors' reply: 19 January 2007
Kanthan Theivendran, Orthopaedic Trainee Selly Oak Hospital, Birmingham, UK, Michael Craigen Send letter to journal: Re: Authors' reply: kanthan{at}hotmail.co.uk Kanthan Theivendran, et al.	Sir, We would like to thank Mr Garg, Mr Malhotra and Mr Kotwal for their interest in our paper. It was not our intention to point out that this complication was exclusive to locking plates, although the need to place the screws and pins subchondrally with dorsally unstable fractures means the drilling and the tips of protruding screws are more distal. Thus, when the wrist flexes, the extensor tendons are pulled tight against the distal part of the radius where the screws might protrude. The more modern self-tapping screws used in locking plates make tendon damage more likely as the flutes of the screw are sharp and are designed to protrude more, so that the threads engage, increasing the risk. We agree that, in fractures where the distal fragment is one piece there is no need to engage the dorsal cortex and this should be discouraged. In intra-articular fractures the ulnar fragment is split coronally,1 and closing of this split requires engagement of the dorsal cortex as the cancellous bone is frequently soft or absent. This of course can be done independently of the plate, although there is little room, but the screws may still protrude. Failure to drill the dorsal cortex runs the risk of pushing away the dorsal fragment as the screw or pin is inserted, causing gapping of the articular surface. A major argument against dorsal plating was extensor tendon damage. Despite the assertion of Constantine et al,2 our cases suggest volar plating is not immune to this complication. K. Theivendran, MRCS(Ed), M. Craigen, FRCS(Orth), DIP Hand Surg(Eur), Birmingham Hand Centre, Selly Oak Hospital, Birmingham, UK. 1. Melone CP Jr. Articular fractures of the distal radius. Orthop Clin North Am 1984;15:217-36. 2. Constantine KJ, Clawson MC, Stern PJ. Volar neutralization plate fixation of dorsally displaced distal radius fractures. Orthopedics 2002;25:125-8.
Volar locking plate: Is it really responsible for delayed rupture of extensor tendon? 12 January 2007
Bhavuk Garg, Resident All India Institute of Medical Sciences, Rajesh Malhotra, P P Kotwal Send letter to journal: Re: Volar locking plate: Is it really responsible for delayed rupture of extensor tendon? drbhavukgarg{at}gmail.com Bhavuk Garg, et al.	Sir, We read this article with great interest. We want to emphasise that this complication is not secondary to the volar locking plate itself. This can happen with any sort of plate. Although the authors have mentioned it, the title and abstract create a wrong impression. "Leaving the screws a little short is not desirable because engagement of the dorsal cortex allows compression of dorsal intra-articular fragments, preventing gapping or intra-articular steps." We would like to emphasise that the volar locking plate is not a compressive device but a a fixed angle device. It helps to maintain the reduction; it does not compress the dorsal intra-articular fragment. The intra-articular step has to be reduced first and then the plate maintains reduction. It is essential to engage the dorsal fragment but not the dorsal cortex as it provides strong fixation even with unicortical fixation. B. Garg, Resident, R. Malhotra, P.P. Kotwal, All India Institute of Medical Sciences, New Delhi, India.