Extensor tendon injuries: EPL rupture, rehabilitation, sagittal band and clenched-fist injuries

1. Delayed rupture of extensor pollicis longus after a distal radius fracture occurs mostly after undisplaced or minimally displaced fractures.

True

In Hove's five-year series, 14 of 18 delayed extensor pollicis longus ruptures followed a distal radius fracture, most of them undisplaced or only slightly displaced; this was 0.3% of the 4,400 distal radius fractures treated in that period. In Kondo's CT fracture-mapping study of undisplaced fractures, fracture lines in the wrists that went on to rupture were concentrated at the proximal border of Lister's tubercle.

• Hove LM. Delayed rupture of the thumb extensor tendon. A 5-year study of 18 consecutive cases. Acta Orthop Scand. 1994;65(2):199-203. PMID 8197857
• Kondo H, Saito T, Nakahara R, Nakamichi R, Shimamura Y, Harada R, et al.. Fracture Line Distributions of Undisplaced Distal Radius Fractures in Relation to Rupture of the Extensor Pollicis Longus Tendon. Acta Med Okayama. 2023;77(2):179-184. PMID 37094955

2. Pooled data show that free tendon grafting restores thumb function clearly better than extensor indicis transfer after extensor pollicis longus rupture.

False

Keating's meta-analysis of nine studies found 'very good' or 'good' Geldmacher scores in 81.8% of patients after extensor indicis transfer and 87.5% after tendon grafting, which the authors regarded as a practically equivalent return of function. They suggested that the practical limitations of grafting may favour extensor indicis transfer.

• Keating DJ, Maciburko SJ, Herle P, Berger AC. Extensor Indicis Proprius Transfers Versus Tendon Graft in Extensor Pollicis Longus Reconstruction: A Systematic Review and Meta-Analysis. ANZ J Surg. 2026;96(4):836-843. PMID 41797307

3. Early active motion in a relative motion extension orthosis is supported as safe after repair of extensor tendons in zones V and VI.

True

Shaw's systematic review of relative motion orthoses included 521 patients with extensor repairs in zones IV–VII, most with good or excellent outcomes for extension lag and flexion deficit, and concluded that the evidence for safety is good in zones V–VI but limited in zones IV and VII. An earlier systematic review by Hammond found a lower complication rate with early active motion protocols than with static or dynamic splinting.

• Shaw AV, Verma Y, Tucker S, Jain A, Furniss D. Relative motion orthoses for early active motion after finger extensor and flexor tendon repairs: A systematic review. J Hand Ther. 2023;36(2):332-346. PMID 37037728
• Hammond K, Starr H, Katz D, Seiler J. Effect of aftercare regimen with extensor tendon repair: a systematic review of the literature. J Surg Orthop Adv. 2012;21(4):246-52. PMID 23327851

4. An acute closed sagittal band injury with extensor tendon subluxation usually requires surgical repair or centralisation of the tendon.

False

Wu's systematic review concluded that acute sagittal band injuries can be treated successfully by splinting the digit in neutral or hyperextension, with surgery reserved for chronic injuries or failed non-operative treatment; the underlying evidence consists of low-quality retrospective case series and case reports. In Rayan's series, which classified injuries as type I (no instability), type II (subluxation) and type III (dislocation), non-operative treatment gave satisfactory results when started within three weeks of injury.

• Wu K, Masschelein G, Suh N. Treatment of Sagittal Band Injuries and Extensor Tendon Subluxation: A Systematic Review. Hand (N Y). 2020;16(6):854-860. PMID 31965857
• Rayan GM, Murray D. Classification and treatment of closed sagittal band injuries. J Hand Surg Am. 1994;19(4):590-4. PMID 7963312

5. Infected clenched-fist (fight-bite) injuries are typically polymicrobial, and Eikenella corrodens is a recognised pathogen.

True

In Talan's multicentre study of 50 infected human bites, 56% of them clenched-fist injuries, the median wound culture grew four organisms, and Eikenella corrodens was isolated in 30% alongside streptococci, Staphylococcus aureus and anaerobes. Many Prevotella and S. aureus strains produced beta-lactamase, and amoxicillin–clavulanic acid showed excellent in-vitro activity against the common isolates.

• Talan DA, Abrahamian FM, Moran GJ, Citron DM, Tan JO, Goldstein EJ, et al.. Clinical presentation and bacteriologic analysis of infected human bites in patients presenting to emergency departments. Clin Infect Dis. 2003;37(11):1481-9. PMID 14614671
• Goldstein EJ, Miller TA, Citron DM, Finegold SM. Infections following clenched-fist injury: a new perspective. J Hand Surg Am. 1978;3(5):455-7. PMID 359634