RUPTURE

OF

THE

EXTENSOR

AFTER

COLLES

DAVID

Subcutaneous in 1876. so

far

rupture

His

patient,

as could

be

ascertained,

cases

and

added

This

after

a further

paper

lower

by

Smith

personal

end

The

clinical

was

features

(see Table

involved

by

reduction

in

recorded

I).

1940

Kwedor five

experience

of the

the

fracture,

five.

in the

did

not

All

the

the

literature

was

fallen

and

first

reported

injured reviewed

of

Mitchell in

nine

hand, the

literature

of Colles literature.

were

able

Duplay without,

to

in

fracture; Moore in

trace

seventy

1946.

patients

with

rupture

of the

tendon

FEATURES

materially

patients

the

patients

being

were

cent

from

posterior

displacement

is 60 per

and more

by

her

radius.

differ

In all nine

tendon

had

Kleinschmidt

added

CLINICAL

literature

longus

years,

of the rupture as a late complication found twenty-seven others in the

but

the

of the

TENDON

ENGLAND

a fracture.

examples in 1932, one.

records

fracture

pollicis

thirty-six

sustaining

1929 and found twenty-five McMaster, reporting a case 1936 recorded three examples,

LONDON,

extensor

aged

LONGUS

FRACTURE*

TREVOR,

of the

a woman

POLLICIS

those aspect

minimal

women

: it

female

is

and

previously of the

in four, notable

40 per

but

end

the

male.

in the

of the

sufficient

that

cent

recorded

lower

radius

to warrant

sex

distribution

Six

patients

were

over fifty years of age ; the youngest was twenty-three and the oldest sixty-four. McMaster (1932) stated that although the condition can occur at any age and has been recorded at fourteen years, it is more common after the age of thirty. The interval between the fracture and the tendon rupture varied from four weeks to one year, with an average of eleven weeks. Suture

had pain

was

undertaken

from

one

the prodromal symptoms in this area radiating into

week

to five

of swelling the thumb.

months

Case

OF

NINE

Occupation

Age

OF

SPONTANEOUS

Reduction of fracture

Side

RUPTURE

Time after fracture (weeks)

OF

d r

- Residual -

TENDON

Suture removed

gap (inches)

Followup (years)

later

Pain

3

4

No

4

4

-

4

4

Yes

3

Yes

8

-

4

4

Yes

3

L

No

4

-

12

4

Yes

2

L

Yes

6

-

2

4

Yes

2

L

No

6

Pain

2

4

No

2

Housewife

35

R

Yes

5

3

Housewife

57

R

No

4

Housewife

23

L

5

Housewife

63

6

Housewife

54

7

Manageress

-

::

-----

read

LONGUS

5

-

Paper

or

suddenly

No

-

*

patients wrist

4

8

:

three

20

No

44

till

(weeks)

L

-

Dlay suture

“

63

-

Only

P0LLIcI5

EXTENSOR

1

ro

Violinist

-

rupture.

I

-

2

370

CASES

the

radial side of the back of the patients the tendon “snapped”

TABLE ANALYSIS

after

over the In several

at

the

1949

1 52 Spring

N:

-

Swelling Meeting

of the

British THE

Orthopaedic JOURNAL

OF

Association. BONE

AND

JOINT

SURGERY

of

RUPTURE

wllile

they

were

example, is

OF

movement

a baby’s

napkin

TENDON

LONGUS

POLLICIS

a simple

on

1:igurc

1

EXTENSOR

doing

putting

sllown

THE

requiring

or

.-FTER

no the

brushing

COLLES

undue

hair.

exertion The

371

FRACTURE

of

typical

the

thumb-for

clinical

appear;tnce

I

I

/

-II

‘I

/

-

,; -4

S1

11 t alIe(

l(

Ill telili

Il 5 I’ll

t’a

I a Ian

(1

11t ii It’

I j (lilt

tile

‘xl

1(111

l( )5

a 11(1

)

oil S( lI

t (‘11(11)11

1 11111 OX t(’Il

si

in

hllt’I’e

.

t I it’

at

l( 55

l Illet

lea

)O at

1 tX t(’Ilsi(

(

1’

tilt’

PiI1tlZuIlitt’ltl

lilt

PATHOLOGY

.A normal bone

is very

or pt’riosteun

rupture

its

iii

abnormal the

tendon at ow’n

eitller

rel)eated

of the

end

length.

Spontaneous

injuries of the

of

was

caused

the

period

that

the

wrist

the

tendon

of

the

surface

that

direct

considered

that

fraying

of is often

most

generally

They

believed blood

causes the

to

Operative end, of

tile

though

tendon

appeared 32 B, F

No.

AUGUST

away

have

from been

1951)

and although

the drawn

to

this

o#{241}tinto

after theory,

ruptured, of the a

age the

by

thin,

for

ends. Hauck

(1923). Witil

of twenty-five)

and

tendon tendon,

another smooth

Tile

interferes then case

similar case strip

SO

causes

particularly

in a personal

In

(1925)

hypothesis,

injury

presented

radius. long,

and

bone

in gradual

tendon

weakened for

But the

Axhausen

initial

tile

defective

muscle. of

this

an

during

was the

resulted

ruptured

the

that

disturbance

(1914)

Further,

not

of

are

a fracture

healed

healing

support

of tile on

bruised.

fracture

not

W’eigeldt

decreases

this

groove

of the

time

that for example

after

improbable. radial

do

the

tendons

than

considered

cases

little

been

fraying

contraction

support

yellowish

digitorum,

well

case

so

a\’ulse

rather

ruptures (1929)

in which

in the

by at

muscle lend

no

in

contraction

with have

suggested

in any

cases

operation

mesotendon (it

swollen,

to 3,

and

a sudden

extensor

it was

at

groove

that in most

sudden

of bone

findings

tendon

few by

must

the

findings

appears

tendon

is that

the

that

usually

or of trauma,

tendon

but

patients

fragment

of the

tile

in

occurs

Kieinschmidt

area

of the theory

tearing necrosis;

rupture.

tendons

VOL.

accepted

supply

proximal

even

But

roughness

that

the

a sharp

The

of bone, weak

it w’ill junction,

rupture

‘ ‘

; in

the

strain

tenosynovitis,

palsy.

occurred of

over

tendon.

avascular

often

laceration

no

at

pathological

abnormal.

immobilised

way

has

friction

the

there

tile

tendon

drummer’s a fragment

was

gave

to excessive musculo-tendinous

tile

as tuberculous

is likewise by

at

or

sucil

‘ ‘

radius

tear

suddenly

subjected

or rupture

of disease

incomplete

rupture

; s’hen

insertion,

because minor

lower

its

strong

the

one

of the

appearances the

ruptured

not

unlike

a

372

D.

piece

of stretched

taken

place.

fibres

with

chewing

gum,

Microscopic

and

section

thrombosis

of the

TiEVOi

suggesting

of the

capillary

that

elongated

gradual

tissue

vessels

within

softening

showed

the

and

evidence

tendon

(Fig.

elongation

had

of necrosis

of

the

2).

TREATMENT .:

s’.’.

‘-:.---‘‘

-.

:_-‘

-S.

The

4’:.

-

treatment

conservative

-

function

of

is to

-

extend

the

-.4

to

The

interphalangeal

to be

the

tendon

joint

and

as

a whole,

thumb

successful,

double

longus

any

more as

reconstructive

‘..

)‘f7’

-

I

.;.r;1.’

-:.;AZ

:‘

.‘

must

restore

past

have

been

there of

the

distal

end

but

fails

end

of

often

2

FIG.

showing evidence with thrombosis

of the tendon.

proprius

thin,

smooth strip of tendon, of necrosis of tendon fibres of the intra-tendonal capillary vessels. (: 125.)

the

The method with

author

believes

that

as long

as five

months

has any

the

Technique to the

weakness

of

of

occupied

by and

or

to

the

tendon

of

each a

criss-cross

the

end

suture

crosses

on

is then

emerging under

was to the

of an

inch,

of

extensor

a straight

itself

passed

by

and

in into

the the

inch

with

the

this

method usually side

sutured

indicis regarding

some 4)

J)erfllalleflt A free

varying

with

The

almost

point and

to coapt about half

surgeon

either

to

tendon

success.

success,

even

operation

after

is simple

to normal

is

without

the

the

an

and

tile

interference

a quarter

of an

tubercle.

In one

an

of The

in extension ends inch,

the (Fig.

of

the

the

tile

gap

the

of

fact

as

The

n\’lon

surface.

firml\’

suture and

in one

patient

other

eight

in the the

as great

tile

tendon

tile

a mattress up

Only that

to

threaded

ruptured

is drawn

was

is

end.

tendon 4).

ruptured of fracture, up

6) part

on

tendon;

despite

patient

site

ruptured

suture

is preser’ed

is mobilised

proximal

emerges

stump

the

distal

pre\’iouSly

of the

(number

the

and

of rupture. ruptured

above end

the

from

which end

nylon

into

distal

well

just

groove

of tissue

proximal

mdl

found

Tile

proximal

strong

tendon

thumb

the

radius

inserted

the

strip

to

tile

is easily

inches.

a thin

of

one

tendon a half

Tile

least of

the joint

and

suture

of

substance

wrist

ruptured

it is found

and at

beyond

the of one

the

A

substance

of Lister’s

in another

of

digitorum. 3).

needle starting

one

a gap, radial

end

adherent (Fig.

manner,

tension

there

be

of

finger.

with

trans-

extensor results

cost

has

completely, of the

ofthe

index used

suture.

is restored

; it leads

become

tendons to

fully

it possible

and

\\-‘ithin

upon

junction

in

always

a distance

is examined.

have

musculo-tendinous

It

distal for

pulled

may

at

can rupture

anatomy

tile

is mobilised

gently

which one

that

operation-The and

carefully

tendon

between

the

carpi distal

tilere

thumb

excursion

the

thumb

to the

satisfactory at

been

of the

tendon.

radius

tendon

advantage

other

the

given

This

extensor

Again

tile

3) Transfer

but

longus.

of

tendon. to lift

been

extensor

mterphlalangeal

transferred

inadequate

has

thumb has

tendon

ruptured

planted

the

pollicis

been

inability

because

graft interval

tile

been

tendon 1 ) The

extension

The

the

direct

has

of of the

to restore has

cases

tendon

abductor

2)

longior

most

of

undertaken.

extension

a whole.

radialis

in

tendons

and

In

functions.

instances

ruptured

the

active

joint as

the

brevis

restores

of a long,

been

into

pollicis

Section

but

has of

inserted

both isolated

tendon

transplantation

“

.4

-4

operation

suture

r

.,-.‘,,

lay

is operative;

useless. pollicis

elevate

grasping;

condition

are

extensor

tile

important, in

of the

measures

sutured

tied w’as cases

tendon

as three-quarters

inch. THE

JOURNAl.

(IF

1/ONE

ANt)

J()INT

SURGERY

RUPTURE

OF

THE

EXTENSOR

POLLICIS

LONGUS

FIG. Both

ends

of

tile

tendon

have

FIG.

The Ilvion inches and

suture

tied

Ilas

i)eell

securely

illserted

tInder of

VOL.

32 B,

NO.

3,

AUGUST

1950

a

into

tension (luarter

of

the \vitll an

inch

TENDON

AFTER

COLLES

373

FRACTURE

3 i)een

located

and

mobilised.

4

distal part the thunlh

of alld

i)etwet’fl

tile

the tendon wrist in tendon

for

a

dorsitlexion. ends.

distance

of

Note

I the

to

IA gap

374

1).

TREVOR

Fit;.

(‘ase was

1. live

Suture IllOnths.

of

thle

The

long

extensor

residual

gap

tendon was half

of thle left an inch.

5

tilullib.

‘l’he

The phlotograpils

illterval

between rupture the result blur

show

and oars

suture later.

( c FIG. Case

4.

Suture an inch.

of long extensor The suture

has

tendon been

8

FIG. of left removed.

thumb. The

Tile residual photographs

THE

gap silow

JOURNAL

at

9

operation tile result

OF

BONE

was three-quarters two years later.

AND

JOINT

of

SURGERY

OF

RUPTURE

After of

THE

suture

of the

flexion-extension

between and

the

tendon

and

without

The

nylon

stitch

was

simple

skin

and

of

are

suture

to

may

removed each

to

occasion

the

plaster

persuasion

rise

to a sinus or

weeks

full

several

more

found

which

allows

sufficient

to

later

the

375

FRACTURE

COLLES

a few

prevent

degrees

adhesions

plaster

is removed

mobility

of the

thumb

is gradually

after

operation

; on

Removal

of the

treatment.

months it was

is applied

Three

physical

AFTER

joint,

structures. \Vith

give

TENDON

interphalangeal

special

three

LONGUS

padded

the

begun.

resorting

on

in thickness

a lightly

surrounding

movements

regained

POLLICIS

movement

the active

EXTENSOR

weeks

after

that

the

operation. gap

had

filled

in with

four

occasions suture

fibrous

tissue

was similar

tendon. RESULTS

In every by

tile

are

shown

case

full

operation

function

described

in Figures

(1925):

(;.

(1876) G.

HAUcK,

(1923): T.,

T. F.

E.

REFE

RENCES

: Beitrage

said

obtained.

impossible

in the

continuity

by

end-to-end

apposition

if this

was The

bear

most

tendon

by

fingers.

that An

there

to the

of tension,

excursion,

normal

arrangement

\‘JL.

32 B,

No.

into was

but

3,

the

the in some

AUGUST

where

tiley

tile

proxinlal

1950

primates.

310.

of the Paper) the

technique

adhered

of operation

suture

in

there

to

the

usually

material

however, firmly

and

continuity

of suture

; unless,

not

yet

tile

worked

been

occur-a take

to promote was

surrounding

by

and

In

thereby ; the

meticulous tissue,

even

for some,

lie close

would

this being

flexing

the

over

was

admirably,

no

the

tip

of

the

the

metacarpal.

was,

of

motor course,

patient. pollicis Grasping

thumb

against

the

is arboreal. must the

and new

action

longus

muscle.

results suture

This to the

heavy,

to

The

metiiod. active

wrist.

specific

IleutraliSed and

other

the flexor

excellent been

phalanx.

any

be satisfactory

though

these

together

at

animal

there

has

phalanx terminal

by

in fact--apparent

flexion

chimpanzee,

by

equalled

tenodesis,

place

radius,

explanation favoured

system

429.

FURLONG

on

function

of the well

to extend

J.

chimpanzee.

wrist,

works

insertion

desired

end

of

brevis

could

of perfect

operation,

muscle

I had should

in the

lower

22,

sheath.

joint

is a comparable

extensor

the

brevis

the

arrangement

alternative

tendon

line

Surgery,

49.

of a scaffolding

suture

in Table

found

dorsiflexion

This

thought

of the

to

use

Joint

end-to-end

the

hall-marks

be

94,

only

ingenious

fibrous

28,

Chirurgie,

found

The

530.

and

721.

reading

was

thumb

of the

could

is attached

is achieved

cases

14, 93.

Surgery,

original

had

if adherence

terminal

A parallel

treated

11, 788.

Paris,

146,

Surgery,

R.

tissue

shown even

MR

to comment

described.

not

results

the

he

of tendon, and

Joint

BY

de

of Bone

Joint 23,

Kiiniscilen

wished

of fibrous

that

of the

patient Illustrative

78.

Chirurgie,

and

zur

i’revor,

of case

paratenon

extension would

type

fortunate

first

years.

81.

: Journal

and

after

he Mr

growth

excellent

It was

five

123,

124,

Klinischen (1940)

Bone

: Beitrage

that Like

Chlirurgie,

of Surgery,

of

(Contributed Furlong

The

than

Ia Soci#{233}t#{233} (IC Chirurgie

of Bone

Journal

: Journal

(1914)

W.

zur

DISCUSSION

Mr

regained.

more

Chirtirgie,

C. L.

: Journal

British

(1946)

Kiinischen

M#{233}moires de

MITcHELL,

(1932)

(1936): i’d.

\VEIGELDT,

results

been

for

f#{252}r Kiinische

(1929)

and

P.

McMAsTER,

SitIITH,

has

observed

zur

et

Archliv 15.

A.

MooRE,

Beitrage

: Bulletins

1LEINScHMIDT, KWEDAR,

thumb

tile

been

5 to 9.

AXHAUSEN,

DUPLAY,

of has

The

occur.

extensor By

the

longus

adjustment

effective

had

not

known

action quite

the

to

the

be