Traumatic index extensor tendon attenuation mimicking closed tendon rupture: two case reports

Abstract

Background While some traumatic closed index extensor tendon ruptures at the musclotendinous junction have been previously reported, closed index extensor tendon pseudorupture due to intertendinous attenuation is exceedingly rare with only one case report of a gymnastics-related sports injury in the English literature. Herein, we report two non-sports injury related cases of traumatic index extensor tendon attenuation mimicking closed tendon rupture, including the pathological findings and intraoperative video of the attenuated extensor indicis proprius tendon. Case presentation A 28-year-old man and a 30-year-old man caught their hands in a high-speed drill and lathe, respectively, which caused a sudden forced flexion of their wrists. They could not actively extend the metacarpophalangeal joints of their index fingers. Intraoperatively, although the extensor indicis proprius and index extensor digitorum communes tendons were in continuity without ruptures, both tendons were attenuated and stretched. The attenuated index extensor tendons were reconstructed either with shortening by plication or step-cut when the tendon damage was less severe or, in severely attenuated tendons, with tendon grafting (ipsilateral palmaris longus) or tendon transfer. Six months after the operation, the active extension of the index metacarpophalangeal joints had recovered well. Conclusions Two cases of traumatic index extensor tendon attenuation were treated successfully by shortening the attenuated tendon in combination with tendon graft or transfer. We recommend WALANT (wide-awake local anesthesia and no tourniquet) in the reconstruction surgery of index extensor tendon attenuation to determine the appropriate amount of tendon shortening or optimal tension for tendon grafting or transfer. Intraoperative voluntary finger movement is essential, as it is otherwise difficult to judge the stretch length of intratendinous elongation and extent of traumatic intramuscular damage affecting tendon excursion.

Wide Awake Local Anesthetic No Tourniquet in Hand and Wrist Surgery: Current Concepts, Indications, and Considerations

“…Phalangeal fracture Tang, 30 Khor 31 Flexor tendon repair/transfer Gueffier, 32 Mohammed, 33 Woo, 34 Tang, 30 Khor 31 Extensor tendon repair/transfer Miyashima, 35 Abdullah, 24 Mohammed, 33 Woo, 34 Tang, 30 Khor 31 Digital nerve Sawhney, 36 Tang, 30 Khor 31 Trigger finger Mohd, 27 Maliha, 37 Gunasagaran, 26 Hernandez, 29 Codding, 38 Ki Lee, 39 Shulman, 3 Rhee, 40 Tang, 30 Burn 41…”

“…A unique benefit of WALANT is the ability to conduct intraoperative assessments of repairs. 24 , 35 Currently, intraoperative assessment of flexor tendon repair is limited to subjective means, highly dependent on operator skill and experience. 35 With a patient unable to perform active movements under regional or general anesthesia, it is difficult to accurately assess tendon gapping, bunching and glide, and their effect on the need for venting of pulleys, which may affect overall function.…”

“… 24 , 35 Currently, intraoperative assessment of flexor tendon repair is limited to subjective means, highly dependent on operator skill and experience. 35 With a patient unable to perform active movements under regional or general anesthesia, it is difficult to accurately assess tendon gapping, bunching and glide, and their effect on the need for venting of pulleys, which may affect overall function. 57 Excessive pulley venting may lead to tendon bowstringing, whereas under-venting may result in reduced glide.…”