Extensor Pollicis Longus Ruptures in Distal Radius Fractures: Clinical and Cadaveric Studies With a New Therapeutic Intervention
We conducted a study to evaluate aspiration of the third dorsal compartment as a therapeutic option for preventing extensor pollicis longus ruptures in association with distal radius fractures. A cadaveric model with a nondisplaced distal radius fracture was created, and radiopaque (Hypaque) dye was injected into the fracture site. Pressure readings were taken from the third dorsal compartment before and after dye injection. The compartment was aspirated with an 18-gauge needle, and compartment pressures were measured again. There was a significant decrease in pressures after aspiration.
Results in our cadaveric model were consistent with those in in vitro decompression of the third dorsal compartment. Clinical studies may determine that in-office needle aspiration is beneficial in preventing extensor pollicis longus rupture in nondisplaced distal radius fractures.
In the study by Helal and colleagues,5 Hypaque injections were given to patients with nondisplaced distal radius fractures. The dye remained in the third dorsal compartment, which implies an intact closed space. That study used a cadaveric model as well, with distal radius osteotomies performed to simulate a nondisplaced distal radius fracture. The authors noted an intact extensor retinaculum in their model. Our cadaver model is similar, except we measured pressures in the third compartment; our model indicated increased compartment pressures within the EPL sheath. Subsequent aspiration in our cadaveric study led to lower pressures in the third dorsal compartment. This cadaveric model implies that needle decompression of the third dorsal compartment may be beneficial in the setting of nondisplaced distal radius fractures and symptoms indicating a compromised EPL.
Splinting is an important factor that may help prevent EPL tendon ruptures after distal radius fractures. Synovial diffusion may be the primary mechanism for delivering nutrition to the EPL tendon.7 A splint that allows thumb metacarpophalangeal and interphalangeal flexion may provide the EPL motion needed for effective synovial nutritional pathways.9 Prodromal symptoms of tendon rupture should then be carefully monitored.
Conclusion
Results of our retrospective review are consistent with previous results elucidating the risk factors for EPL ruptures in association with distal radius fractures. In our patients who sustained EPL ruptures, findings included nondisplaced fractures, about 50% with an intra-articular component. Clinical findings included localized swelling over the third dorsal compartment, pain with resisted active EPL extension, and pain with passive flexion of the thumb interphalangeal joint. The cadaveric portion of this study indicated a significant change in pressure in the third dorsal compartment after aspiration. Preliminary outcomes in this 4-patient series are no EPL ruptures after prophylactic aspiration. Hematoma evacuation after nondisplaced distal radius fractures may become a useful addition to the surgeon’s armamentarium. Studies are needed to determine if needle aspiration of the third dorsal compartment can become an office-based procedure with value in preventing EPL ruptures in the appropriate clinical situation.
