Spontaneous Atraumatic Extensor Pollicis Longus Rupture in the Nonrheumatoid Population

Patient 1

A 46-year-old right-hand-dominant man was referred for evaluation of painful catching of the right thumb for 3 months. The patient denied any history of trauma to the hand. On physical examination, he had a nodule in the flexor policis longus (FPL) and triggering. There was no pathology on X-rays. One milliliter of 1:1 solution of triamcinolone (40 mg/mL) and bupivacaine 0.5% was injected into the patient's right thumb flexor tendon sheath at the level of metacarpal head. Three months later, he underwent a second flexor sheath injection for symptoms that had recurred 3 weeks prior. He did not get any relief from the second injection and was scheduled for A1 pulley release.

On the day of surgery, he noted a recent sudden onset of the inability to actively extend the thumb interphalangeal (IP) joint. He was tender over the anatomic snuffbox. He again denied any recent trauma. Physical examination confirmed loss of active thumb IP extension with no tenodesis effect and no evidence of scars or laceration on the hand. In the operating room, the patient's A1 pulley was released. The EPL was explored from mid-metacarpal to extensor retinaculum, and tendon rupture was noted over the carpus. Primary repair was performed. In the ensuing 3-month period, the patient recovered full IP joint (IPJ) active extension.

Patient 2

A 54-year-old right-hand-dominant woman presented with spontaneous loss of extension of the right thumb at the IPJ for the preceding 5 days. The patient denied any trauma to the hand. She stated that she was carrying less than 10 pounds of supplies at work when she felt a “pop” and discomfort in the distal dorsal forearm. The patient works as a physical therapist and performs dexamethasone and hydrocortisone iontophoresis. Her physical examination was notable for the absence of right thumb IPJ active extension. Magnetic resonance imaging (MRI) showed rupture of the EPL tendon, as well as evidence of synovitis at the third and fourth compartments of the wrist.

In the operating room, the patient had a ruptured EPL tendon with the proximal end in the mid-forearm and the distal end in the anatomic snuffbox (Fig 1). Repair was performed with an ipsilateral palmaris longus tendon graft. The synovitis noted was resected. There was no obvious bony abnormality or rough edges of Lister's tubercle; however, the third compartment turned at a sharp angle at the distal end of Lister's tubercle (Fig 2).

Figure 1. Intraoperative photograph of patient 2 demonstrating complete rupture of the right EPL tendon with proximal end in visible in the dorsal forearm. EPL indicates extensor pollicis longus.

Figure 2. Intraoperative photograph of patient 2 with a Freer elevator identifying Lister's tubercle.

At the patient's 1-month follow-up, she stated she was doing well except that she had pain in her left dorsal thumb proximally. On examination, she had normal motion of the left thumb IP and no crepitus or pain at the left third compartment of the wrist. Given her history of right EPL rupture without pain, we obtained an MRI that showed first through third compartment synovitis. Given the patient's history of right EPL rupture, left EPL synovectomy and transfer out of third compartment was recommended.

In the operating room, the EPL tendon was examined within the third dorsal compartment. There was significant fraying of the tendon (<50%) along its radial aspect where it was in contact with Lister's tubercle (Fig 3). Lister's tubercle was inspected, and no injury or rough edge was noted. The tendon was completely released and transposed radially. Synovium was removed and sent to pathology and microbiology for further evaluation.

Figure 3. Intraoperative photograph of patient 2 with visible fraying of left EPL tendon. EPL indicates extensor pollicis longus.

In the ensuing 3-month period, the patient underwent splinting and hand therapy. Her recovery was uneventful. For both surgeries, the resected synovium showed mild chronic inflammation; all cultures were negative for growth.

Patient 3

A 47-year-old right-hand-dominant man presented with pain on the dorsum of his left wrist and lateral elbow. The patient denied any past trauma to the hand and works as a machinery operator. Physical examination showed tenderness to palpation at the intersection of the tendons of the left first and second dorsal compartments. There was a separate locus of pain at the left lateral epicondyle of the humerus. We injected 40 mg each of triamcinolone into the intersection of the tendons of the left first and second dorsal compartment and into the left lateral epicondyle of the humerus. Symptoms were relieved for 8 months, at which time the patient returned to clinic and we injected both areas a second time. Seven months after this visit, he returned with recurrent lateral elbow symptoms.

Two months later, he underwent left lateral epicondylectomy with suture-repair of the extensor digitorum communis to the extensor carpi radialis longus. At his 1-month follow-up, the patient had a new onset left dorsal wrist pain and the inability to extend the thumb IPJ. Magnetic resonance imaging confirmed rupture of the EPL tendon at the third compartment (Fig 4). The patient was taken to the operating room where EPL reconstruction with a palmaris tendon graft was performed. At the patient's 1-month follow-up, elbow pain had resolved and full EPL function returned.

Figure 4. T2-weighted MRI images of patient 3 demonstrate inflammation and the absence of a tendon within the third dorsal compartment. MRI indicates magnetic resonance imaging.