Rupture of Extensor Pollicis Longus tendon

What is Rupture of EPL?

Extensor pollicis Longus  (EPL) is a tendon which runs on the back side of the wrist and is confined to a tight tunnel. This tendon helps to straighten the end joint of the thumb and is essential to maintain hand span and to position the thumb in relation to the other fingers. This tendon is prone to damage and rupture due to its position and its utilization. Rupture of EPL happens due to a injury, fracture of the distal radius (forearm bone) at its bony prominence (Lister’s tubercle), following surgery for distal radius fracture (prominent screw) and rheumatoid arthritis.

The incidence of rupture of EPL tendon is 0.2- 5% in patients with a fracture in distal radius (forearm bone at its end towards the thumb). It usually occurs after 6-8 weeks of fracture. It may occur due to chronic inflammation as in rheumatoid arthritis or prior steroid injections.

 

What are the symptoms of Rupture of EPL?

Pain and tenderness are usually felt at the wrist when EPL gets ruptured. However some may not feel any pain and some might felt a ping when the tendon ruptured. You will not be able to straighten the end joint of the thumb which results in an abnormal posture of the thumb. You will struggle to keep your thumb off when picking things.

 

How is it diagnosed?

Your orthopaedic surgeon will ask for your symptoms and medical history. He will examine your thumb and its posture. He may also ask you for X-rays of hand and wrist. An ultrasound may be performed to confirm the diagnosis.

 

What happens if nothing is done?

If rupture in EPL tendon is not treated, it can reduce your hand span. Besides, a malfunctioning thumb can significantly affect the function of the hand.

 

How is it treated?

Treatment of EPL rupture is usually surgical, however in selected cases (significant co-morbidities, patient coping well etc) this could be treated non-operatively.

 Surgery is indicated in

  • Tendon rupture more than 50%
  • Complete tear
  • Significant functional deficit
  • Sharp bone spike

 

What are the non-operative treatments?

It involves-

  • Activity modification.
  • Splint or cast – your surgeon can instruct you to wear a splint or cast to help optimise the function of your thumb..
  • Hand therapy- gentle exercises are started after the removal of the cast usually after 4 weeks. It is followed by stretching and strengthening exercises so that you can regain the full function of the thumb. It is done under the guidance of the surgeon and physiotherapists.

 

What does the operation involve?

It is impossible to repair the frayed ends of the tendon following rupture. Surgical treatment can be done either placing a tendon graft in between the two ruptured ends (tendon grafting) or transferring another tendon ( extensor Indicis propricius) from the index finger in its place (tendon transfer).

  • The operation is performed as a day case under anaesthesia. A tourniquet is applied on your upper arm to avoid bleeding.
  • Tendon transfer– Three cuts are made on the skin, one on the back of index finger knuckle (1cm), one on the back of the wrist (2cm) and one on the back of the base of the thumb (3cm).

The extensor indices proprius is divided and taken. It is passed to the wrist incision and is then passed forward to the thumb incision. It is then woven with the original EPL tendon with care to maintain proper tension.

  • Tendon graft– Could be performed in acute rupture, where, a free tendon graft could be used to bridge the gap. The tendon graft is usually harvested from Palmaris longus.
  • The cuts are stitched with dissolvable suture and your surgeon will apply a half cast to the palm side of the wrist and thumb. Most patients are discharged on the same day.

 

What happens after surgery?

  • The local anaesthetic wears off 4-10 hrs after surgery; patients are encouraged to start taking painkillers before the pain starts i.e. on return home and for at least 48 hours from there. This way most of our patients report little or any pain.
  • Your thumb is rested in a half cast for 10-14 days to protect it from injury and allow proper healing.
  • You have to keep your hand and wrist elevated (a
  • bove the level of your heart) and keep moving your fingers, elbow and shoulder to maintain the flexibility and prevent stiffness of the joints.
  • You are reviewed again after the period of two weeks to check the wound and hand therapy. The therapist apply splint and teach you exercises.
  • The wound should be massaged (typically after 2 weeks) using moisturising cream by the patient 3 times a day for 3 months once the wound is well healed. This reduces the scar sensitivity and scar-related complications (tenderness; helps scar to mature).
  • After 6 weeks of immobilization, the splint is removed.

 

Are there any risks?

  • Wound infections < 1%
  • Injury to nerves, blood vessels and tendons
  • Scar tenderness.
  • Inability to fully extend thumb
  • Stiffness
  • Chronic Regional Pain Syndrome “CRPS”.
  • Any surgery can end up with rare complications and leave a patient worse than before surgery and is rare in this surgery

 

What are the results of the operation?

Most patients regain normal posture and function of the thumb after surgery.

 

When can I return to driving and work?

You can resume work after 6 weeks. However it may take another 3-6months for full recovery. Your surgeon can give you the correct estimation.

Rupture of EPL

  1. Injury to EPL following wrist fracture.
  2. Three months after tendon transfer.

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