Extensor pollicis longus (EPL) rupture

History of present complaint

47 yo male, RHD 
Presentation: 1 week after injury 
Injury mechanism: snap in left wrist during the work-out 
Complaints: no extension in left thumb IP joint, soreness and swelling over dorsal radial wrist 

Past medical history

Non relevant

Drug history, allergies

None

Social, family history

Non-smoker, no alcohol use

Physical exam

Left upper extremity: thumb in mild flexed position at IP joint, no active extension in IP joint, skin & sensation & perfusion are intact, mild swelling and tenderness radial aspect of the wrist

Investigations

Only physical exam

Diagnosis

Left extensor pollicis longus (EPL) rupture

Treatment

Left extensor indicis proprius (EIP) to extensor pollicis longus transfer (EPL)
Operative protocol details: Axillary block, 3 incisions (index finger MP joint, thumb MP joint, radial wrist), EIP is identified and transected at MP level, delivered first to the wrist and than to the thumb incision through subQ tunnel, EPL is identified (ruptured and retracted distally). Using tendon weaver- 3 Pulvertaft weaves EIP to EPL, Tycron 4-0 suture to set the tension, tenodesis effect is checked in wrist flexion and full thumb flexion possible in wrist extension. Two loop 4-0 sutures used as a four-strands core suture, one locked distally, second proximally. Running suture from distal to proximal and vice versa.
Post-op Management: Thumb spica splint post-op. At 2 weeks -Thumb spica brace + active gentle ROM exercises. At 6 weeks- Thumb spica brace for night time (for 2 more weeks). 

Discussion

Advantages of suggested technique: 

• Minimal technical challenges
• Less nodes prevent tendon adhesions
• Smooth repair allows better gliding with tendon excursion
• Strength of the repair allows early active ROM
• No need in continues physical therapy

Described technique was used by senior author for 5+ years for all tendon transfer procedures. It is showed to be easy, fast and reliable. Efforts of suggested protocol are directed towards post-operative rehabilitation shortening and simplification.