A Case Report & Literature Review Fracture of the Radial Styloid and Concomitant First Dorsal Compartment Musculotendinous Injuries Jon-Paul DiMauro, MD, and W. Andrew Eglseder, MD presented a case series of 3 patients with athletic injuries who Abstract suffered ruptures of the EPB tendon at its distal insertion, with In the absence of preexisting inflammatory condi- tearing of the dorsoradial capsule and concomitant rupture of tions, pure traumatic rupture of the extensor pol- the radial collateral ligament of the thumb. Additional reports licis brevis (EPB) and abductor pollicis longus (APL) have noted damage to the tendon distal to the extensor reti- tendons are rare injuries. We present a report of 2 naculum.10-12 We present a report of 2 cases with injuries to the cases of extensor tendon ruptures at the musculoten- extensor tendons of the first dorsal compartment, proximal to dinous junction occurring after concomitant fractures the extensor retinaculum at the MTJ, with concomitant frac- of the radial styloid in patients who were involved in tures of the radial styloid after high-energy trauma. high-energy trauma. The presence of a radial styloid The patients provided written informed consent for print fracture should raise suspicion for a greater spec- and electronic publication of this case report. trum of injury that can contribute to multidirectional instability. The spectrum might even include proximal Case Series damage to the EPB and APL tendons. Although the Case 1 A 55-year-old woman was transported to the emergency associated tendon injuries might or might AJOnot contrib- dapartment for evaluation of bilateral upper extremity in- ute to functional loss, their presence should be noted juries after being involved in a motor vehicle collision. The when evaluating a patient with this injury pattern. findings of an initial examination were significant for swell- ing and tenderness over the right distal radius, without gross deformity or obvious dislocation. In addition, swelling and endon rupture of the extensor pollicis longus (EPL) is a ecchymosis were present over the left elbow, with minimal DOwell-described phenomenon NOT that has been frequently deformity. COPY Except for chronic sensory deficits from bilateral T reported in association with fractures of the distal radi- carpal tunnel syndrome, the patient had preserved motor and us or with predisposing conditions, including chronic tendon- sensory function distal to her injuries. itis.1-3 Unlike ruptures of the EPL ten- don, ruptures of the extensor tendons in the first dorsal compartment, including Figure 1. Posteroanterior (A), oblique (B), and lateral (C) view radiographs of the distal the extensor pollicis brevis (EPB) and radius showing a minimally displaced avulsion fracture of the radial styloid. abductor pollicis longus (APL) tendons, A B C have not been commonly described in the literature. In the absence of predis- posing conditions, such as rheumatoid arthritis or other pathological states,4-6 pure traumatic EPB tendon rupture has been reported only a handful of times. Although intrasubstance tears are com- mon with chronic inflammatory con- ditions, traumatic rupture typically occurs at the bony insertion, muscu- lotendinous junction (MTJ), muscle substance, or muscle origin.7,8 Failla9 Authors’ Disclosure Statement: The authors report no actual or potential conflict of interest in relation to this article. www.amjorthopedics.com February 2014 The American Journal of Orthopedics®3 8 Fracture of the Radial Styloid and Concomitant First Dorsal Compartment Musculotendinous Injuries J. P. DiMauro and W. A. Eglseder A A to release the transverse carpal ligament. A dorsal incision was then made and a W-shaped release of the first dorsal com- partment performed. Tendons of the APL and EPB were identified, with laxity of the EPB tendon being noted. With ulnar deviation, the radial styloid fracture was easily identified and injuries to the pal- mar ligamentous structures were noted. The majority of the damage was isolated to the long radiolunate ligament (LRL), and additional injury to a portion of the radioscaphocapitate (RSC) ligament was Figure 2. Stress (ulnar deviation) fluoroscopic views of the distal radius showing sub- observed. The palmar incision was ex- stantial ulnar translation (A) and displacement (B). tended proximally into the forearm to ac- cess the transverse ligamentous injuries. Fixation of the radial styloid was per- A B formed first, with a tension band tech- nique.13-16 A 2.0-mm drill bit was used to create a transverse hole in the proximal bone, and a 24-gauge wire was inserted. After appropriate reduction, two 0.045- inch Kirschner wires (K-wires) were passed from distal to proximal, to se- cure the avulsed portion of styloid, and the 24-gauge wire was passed around AJO the K-wires (Figures 3A, 3B). Repair of the transverse ligamentous injuries and first dorsal compartment was performed with 2-0 polydioxanone suture (PDS; Ethicon, Somerville, NJ). During closure of the first dorsal compartment, laxity of the EPB tendon was further explored. DO NOT COPYWith slight traction, the proximal por- tion of the tendon with muscle attached Figure 3. Intraoperative anteroposterior (A) and lateral (B) view radiographs showing ten- was delivered through the retinaculum. sion band wiring. The musculotendinous injury was ir- reparable, and appropriate debridement of the tendon was performed. Intraop- Radiographs were obtained and showed an isolated radial erative imaging revealed preserved anatomic relationships; styloid avulsion fracture of the right wrist (Figures 1A-1C) however, the repair was not stressed. Injuries to the left upper and comminuted fractures of the left olecranon and coronoid extremity were addressed simultaneously by a second surgical process. Displacement of the styloid seen on static and trac- team. At the conclusion of the operation, a palm-based, thumb tion films raised concern for a possible radiocarpal fracture- spica splint was applied with the wrist in slight extension. dislocation with associated ligamentous injury. The patient Four weeks postoperatively, the patient was allowed full was optimized for the operating room, and after anesthetic range of motion and was weaned out of her splints. By 6 weeks induction, stress radiographs with intraoperative fluoroscopy after surgery, the patient was allowed full activity with both were obtained to evaluate the stability of the radiocarpal joint. upper extremities. She did require hardware removal from her Concern for a self-reduced radiocarpal dislocation was initially left elbow. Four months after the original surgery, the patient dispelled after the wrist was shown to have stability with pal- was discharged from our care because she was fully functional, mar and dorsal-directed force. However, with ulnar deviation, had no limitations or complaints, specifically regarding her extensive gapping and translation occurred (Figures 2A, 2B). right hand or her right thumb. The decision was made to proceed with open reduction and internal fixation of the avulsed radial styloid fragment, Case 2 ligamentous repair, and carpal tunnel release for the preexisting A 57-year-old woman sustained an injury to her left wrist. At condition. A standard palmar carpal tunnel incision was used the time of presentation to the emergency department, she 84 The American Journal of Orthopedics® February 2014 www.amjorthopedics.com Fracture of the Radial Styloid and Concomitant First Dorsal Compartment Musculotendinous Injuries J. P. DiMauro and W. A. Eglseder A B C Figure 4. Posteroanterior (A), oblique (B), and lateral (C) view radiographs of the distal radius showing scaphoid fossa displacement and palmar displacement. had significant swelling and angular deformity.AJO Radiographs A B showed a left radial styloid fracture with involvement of almost the entire scaphoid fossa and anterior translation of the carpus (Figures 4A-C). Closed reduction was performed with the patient under a hematoma block, and operative fixation was indicated. A dorsal approach was used over the first compart- ment, and a W-shaped release of the extensor retinaculum wasDO performed. No tendons wereNOT identified within the com- COPY partment. With additional subcutaneous dissection, the APL tendon was found in the fracture and had a proximal stump with its muscle belly still attached. With gentle traction on the APL, a second tendon was visualized and identified to be EPB. This tendon was also avulsed proximally and was observed to have a portion of muscle belly attached to the stump. The musculotendinous nature of the avulsions deemed the injuries irreparable. After confirmation of extensor carpi radialis longus, exten- sor carpi radialis brevis, and EPL tendon continuity, the stumps were excised at the level of the styloid in the first compartment. Fixation of the styloid fragment was achieved by using a com- bination of a 4-hole 1.5-mm T-plate and a 2.7-mm lag screw (Figures 5A, 5B). Anatomic reduction, without ulnar trans- location, was confirmed with fluoroscopy. The retinaculum Figure 5. Posteroanterior (A) and lateral (B) view radiographs was repaired with 4-0 Vicryl suture (Ethicon), and the wrist obtained 9.5 months after ORIF of a radial styloid fracture. was placed into a plaster sugar tong splint in slight supination. Despite a rigorous therapy program that began immediately after her surgery, the patient developed complex regional pain range of motion. She continued to have problems with stiffness