Secondary Tendinopathy After Distal Radius Volar Plate Fixation

Abstract

Objective: The aim of this article is to analyze the incidence of tendon complications in patients with distal radius fractures treated with volar locking plates and the clinical results after plate removal. Materials and Methods: We retrospectively reviewed 992 patients with distal radial fractures treated in our institution with volar locking plates between January 2007 and June 2015. Cases with plate removal due to tendon complication (rupture/irritation) were included in this study. Tendon irritation was diagnosed clinically by the presence of pain over the tendon or crepitation in the wrist with finger flexion and extension. We only included patients initially operated on in our hospital. When complications were in flexor tendons, lateral radiographs with the plate were analyzed using Soong’s criteria for plate positioning. When extensor tendons were the problem, dorsal screw protrusion was checked in lateral radiographs. Clinical results after volar plate removal were evaluated using different scores: Disabilities of the Arm, Shoulder and Hand (DASH) score and Visual Analog Scale (VAS) for pain at rest, VAS for pain in activity, and functional VAS. Results: Thirty-four patients (3.3%) had tendon complications 22 months after fracture fixation: 20 flexor tendonitis (2%), 13 extensor tendonitis (1.3%), and 1 flexor tendon rupture. All cases with tendonitis were treated only with implant removal and the flexor rupture with adjuvant tendon transfer. The time elapsed between volar plate implant and flexor tendonitis was 11 months (range, 3-58 months) and for extensor tendonitis was 5 months (range, 3-10 months). In the flexor tendonitis group, 2 patients had Soong grade 0 (10%), 12 had grade 1 (60%), and 6 had grade 2 (30%). In the extensor tendonitis group, we found 4 patients with a screw protrusion of 1 mm, 4 patients with 2 mm, and 1 patient with 3 mm dorsal screw protrusion. In all cases, a proximal screw was involved. There were 4 patients with dorsal tendon irritation without dorsal screw protrusion. Final evaluation was 9 months after plate removal in the flexor tendonitis group and 15 months in the extensor group. Mean final subjective results after plate removal were as follows: (1) flexor tendonitis group: VAS for pain at rest 1, VAS for pain in activity 1, functional VAS 8, and DASH 13; and (2) extensor tendonitis group: VAS for pain at rest 0, VAS for pain in activity 3, functional VAS 9, and DASH 15. Conclusion: Tendon complications are infrequent in patients with distal radial fractures treated with volar locking plates. Avoiding plate prominence, distal position, and dorsal screw protrusion does not guarantee absence of tendon complications. Complications may be related to either extensor or flexor tendons, and may be as late as 5 years after volar plate implant. Patient education in tendon irritation symptoms is essential for early diagnosis, treatment, and ultimately tendon rupture prevention. Early implant removal with no associated procedures improves tendon irritation symptoms and returns the limb to excellent and pain-free functional results.