Extensor pollicis longus tendon rupture secondary to elastic intramedullary nailing of paediatric forearm fractures: how to avoid them?

Abstract

The introduction of elastic stable intramedullary nailing (ESIN) has made operative fixation an important option in treatment of the paediatric forearm bone fractures. ESIN is an excellent treatment option, which is easy to perform. However, a considerable number of complications and problems can arise even with experienced hands. We would like to bring to the attention an important complication namely EPL rupture that has been only sporadically reported in the literature. We present our case study of 12 paediatric forearm fractures that underwent ESIN at our hospital. Mean age of the patient was 8.25 (Range: 5–12 years). Ten of them had fracture of both radius and ulna, while the remaining had isolated displaced fracture of the neck of radius. The radial fracture was stabilized with percutaneous nailing with entry point on dorsum of hand at Lister’s tubercle (9 cases)/lateral entry over anatomical snuff box (3 cases). All fractures united by 8–12 weeks, and the nails were removed at 12 weeks. Three cases had extensor pollicis longus (EPL) tendon rupture during follow-up at 8 weeks after the surgery. All these 3 cases had dorsal approach near Lister’s tubercle, and the length of the protruding nail was more than 10 mm from the dorsal cortex (20.34 mm (age-12 years), 13.88 mm (age-7 years) and 14.12 mm (age-11 years). Two of them subsequently went on to have tendon transfer operation successfully regaining the full function of the thumb, while the third patient refused any operative intervention and was lost to follow-up. We strongly feel that this EPL complication is entirely avoidable by adhering to the principles of mini-open incision rather than stab incision, nail entry under direct vision, cutting the nail close to the bone (leaving only 5 mm of nail length protruding outside) to prevent any undue soft tissue irritation and probable nail migration and bringing the patient earlier (at 2 weeks) for follow-up to identify nail migration.