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Late Repair of Combined Extensor Carpi Radialis Longus and Brevis Avulsion FracturesRichard W. Gurich Jr, MD; John A. Tanksley Jr, MD; Nick D. Pappas, MD

Combined extensor carpi radialis longus (ECRL)

and extensor carpi radialis bre-vis (ECRB) avulsion fractures are relatively rare, with fewer than 5 incidents reported in the literature.1,2 These injuries can be difficult to diagnose in the acute setting and are often missed on initial presentation. Once diagnosed, appropriate management of these injuries

is a subject of debate, with some surgeons advocating closed treatment and others ad-vocating operative fixation. In the few reports of concomitant ipsilateral ECRL and ECRB avulsion fractures, early op-erative fixation has generally been favored, with techniques ranging from suture anchor to K-wire fixation.3,4 However, a late repair using suture anchor

fixation of the ERCB into the third metacarpal base with te-nodesis of the retracted ECRL to the ECRB has not been re-ported in the literature.

Case RepoRtA 33-year-old right-hand–

dominant automobile plant worker presented to an outside facility with right dorsal wrist pain and limited wrist exten-sion after a fall from a standing position. He described a mech-anism whereby his extended wrist was forced into flexion

by the fall. Initial radiographs showed minimally displaced fractures of the second and third metacarpal bases with a bony fragment of unknown etiology over the radiocarpal joint (Figure 1). No tendon injury was suspected, and the arm was immobilized using a short arm cast while placed in the neutral position.

After 2 weeks, the cast was removed. The patient contin-ued to report dorsal right wrist pain with limited active wrist extension. Magnetic resonance

The authors are from the Department of Orthopaedic Surgery, Greenville Health System, Greenville, South Carolina.

The authors have no relevant financial relationships to disclose.Correspondence should be addressed to: Nick D. Pappas, MD, Depart-

ment of Orthopaedic Surgery, Greenville Health System, 701 Grove Rd, 2nd Floor Support Tower, Greenville, SC 29605 (npappas@ghs.org).

doi: 10.3928/01477447-20130920-03

Abstract: Concomitant avulsion fractures of the extensor carpi radialis longus and brevis tendons are relatively rare in-juries. The usual injury mechanism is forced hyperflexion to an actively extended wrist. No consensus exists regarding the appropriate management of this injury, with some surgeons advocating closed treatment and others favoring operative fix-ation. The authors describe a novel surgical technique for the late repair of combined extensor carpi radialis longus and bre-vis tendon avulsion using suture anchor repair of the extensor carpi radialis brevis and tenodesis of the retracted extensor carpi radialis longus to the brevis.

Figure 1: Preoperative lateral (A) and posteroanterior (B) radiographs of the injured wrist.

1A 1B

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Cover Story

Cover illustration © Jennifer Fairman

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imaging of the wrist showed bony avulsion of the ECRL with 3 cm of retraction and avulsion of the ECRB with 5 mm of retraction.

Approximately 5 weeks after the initial injury, the pa-tient presented to the authors’ institution for surgical consul-tation. He reported continued dorsal wrist pain with limited wrist extension. On physical examination, the patient had 60° of passive wrist extension but only 20° of active exten-sion. In addition, his wrist de-viated ulnarly during attempt-ed wrist extension. The patient was unsatisfied with this level of function and was concerned that his potential future with a lack of active wrist exten-sion could prohibit him from returning to his job at the au-tomobile plant. After thorough discussion of the nature of his injury and the risks of surgery, operative fixation of the avul-sion fractures was planned.

suRgiCal teChniqueA 6-cm longitudinal inci-

sion was made over the dorsum of the hand centered over List-

er’s tubercle. Dissection was carried through the floor of the third dorsal compartment. On dissection over the radiocarpal joint, a large fragment of bone still attached to the distal as-pect of the ECRL was encoun-tered. The ECRL and attached bone had retracted approxi-mately 3 cm from its normal insertion on the second meta-carpal base. Due to the degree of contracture and chronicity of the injury, the ECRL could not be repaired to its anatomic insertion despite extensive mo-bilization. On distal dissection, it was noted that the ECRB was also avulsed from its in-sertion on the third metacarpal base, but it had only retracted approximately 5 mm. It also contained attached bone.

The remaining bony frag-ments attached to both the ECRL and ECRB were de-brided. The ECRL was teno-desed to the ECRB using a side-to-side technique with an 3-0 Ethibond suture (Ethi-con, San Angelo, Texas). The ECRB was then anatomically reinserted onto its insertion on the third metacarpal using

2 mini-Mitek suture anchors (DePuy Mitek, Raynham, Massachusetts). The first su-ture anchor was placed in the third metacarpal fracture bed and the second was placed slightly distal to provide ad-ditional repair strength for the construct (Figure 2). First, the suture from the more proximal anchor was woven through the ECRB tendon using a Krack-ow stitch. Next, the suture from the more distal anchor was woven through the ECRB tendon in a volar-to-dorsal di-rection using a horizontal mat-tress pattern (Figure 3).

The wrist was then placed in full extension. The suture from the more proximal anchor was tensioned and tied first to enable anatomic fixation of the ECRB into its footprint. The suture from the more dis-tal anchor was tensioned and tied next. Due to its horizon-tal mattress configuration, the suture from the second anchor enabled dorsal-to-volar com-pression of the tendon to its in-sertion site. At the conclusion of the procedure, the arm was placed in a volar splint with the wrist in full extension.

The patient was examined 1 week postoperatively. His

sutures were removed, and he was placed in a thermoplastic splint in approximately 40° of wrist extension. He began oc-cupational therapy the follow-ing day, with instructions to begin passive wrist extension from 20° to 60°. At 4 weeks postoperatively, passive wrist extension was advanced from 0° to 60°. Active wrist exten-sion and active wrist flexion were started 6 weeks postop-eratively, followed by wrist extension against resistance at 8 weeks postoperatively.

At 4 months postopera-tively, the patient had no pain over the fracture sites and 55° of active wrist extension with-out ulnar deviation. Overall, the patient was satisfied with his result and returned to his regular job at the automobile plant. Figure 4 shows his wrist extension at 12 weeks postop-eratively.

DisCussionCombined avulsion frac-

tures of the base of the second and third metacarpals are rare injuries. The typical history is one of forced wrist flexion with resulting wrist extensor weak-ness and a painful lump on the dorsum of the hand. However, these injuries can be subtle and are often missed on initial presentation. For the current patient, magnetic resonance imaging assisted in making a definitive diagnosis.

No conclusive guidelines exist for the management of combined ECRL and ECRB avulsions. Some studies have shown that both operative and nonoperative management of these injuries can restore

Figure 2: Intraoperative lateral radio-graph of the hand showing anatomic restoration with suture anchors.

2Figure 3: Intraoperative photograph showing final repair with suture an-chors.

3

Figure 4: Photograph showing wrist extension 12 weeks postoperatively.

4

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full wrist extensor function,5 whereas others argue that open reduction and internal fixation better restores wrist extensor strength.6

The current patient was offered surgical fixation due to his severely compromised wrist extension and potential problems from the bony frag-ment located over the dor-sum of his radiocarpal joint. Overall, he did well after his surgery and was pleased with

the result. By his 4-month postoperative examination, he had gained active wrist exten-sion to 55° and had already re-turned to his regular job at the automobile plant.

This report is the first to de-scribe late repair of the ERCB into the third metacarpal base with tenodesis of the retracted ECRL to the ECRB using su-ture anchor fixation. Given the patient’s overall good outcome, the authors advocate use of this

technique in similar late wrist extensor tendon repairs.

RefeRenCes 1. Breeze SW, Ouellette T, Mays

MM. Isolated avulsion fracture of the extensor carpi radialis brevis insertion due to a boxer’s injury. Orthopedics. 2009; 32(3):210.

2. Boles SD, Durbin RA. Simul-taneous ipsilateral avulsion of the extensor carpi radialis and brevis insertions: case report and review of literature. J Hand Surg Am. 1999; 24(4):845-849.

3. Treble N, Arif S. Avulsion fracture of the index metacar-

pal. J Hand Surg Br. 1987; 12(1):38-39.

4. Vandeputte G, De Smet L. Avulsion of both extensor carpi radialis tendons: a case report. J Hand Surg Am. 1999; 24(6):1286-1288.

5. Clark D, Amirfeyz R, McCann P, Bhatia R. Extensor carpi radialis longus avulsion: A lit-erature review and case report. Hand Surg. 2008; 13(3):187-192.

6. DeLee JC. Avulsion fracture of the base of the second meta-carpal by the extensor carpi ra-dialis longus. J Bone Joint Surg Am. 1979; 61(3):445-446.