Abstract
The flexor carpi radialis is a wrist flexor and radial deviator with half the relative strength of flexor carpi ulnaris. In
the majority of patients, the flexor carpi radialis tendon is expendable and is routinely used for various reconstructive
procedures about the hand and wrist. Isolated flexor carpi radialis lacerations at the wrist are rare. Flexor carpi radialis
tendon ruptures, which have been reported in association with distal radius fractures, longstanding osteoarthritis, and percutaneous
treatment of scaphoid fractures, are usually treated non-operatively. We report a case of a traumatic laceration of the flexor
carpi radialis tendon at the wrist in a professional ice hockey player. Surgical repair and rehabilitation using established
principles for intrasynovial flexor tendon repair allowed return to sport at the professional level in 2 months.
Tension-free core suture repair was performed with a modified-Kessler, 4-strand repair using a double-stranded 4-0 Supramid
suture. A running epitendinous suture was then placed around the circumference of the tendon with 6-0 Prolene. Immobilization
of the wrist in 20° of flexion was maintained for 2 weeks. Full active and passive digital motion was allowed immediately
postoperatively and continued throughout the rehabilitation. Therapy was initiated at 2 weeks postoperatively with full passive
wrist flexion and passive wrist extension to a dorsal block of 20°. At 4 weeks postoperatively, a dorsal splint was fabricated
to keep the wrist in neutral. At this time, active extension to a dorsal block of zero and full passive flexion was allowed.
Active wrist flexion without resistance was begun at 6 weeks, and full strengthening was allowed at 8 weeks postoperatively.
The patient returned to sport at the professional level shortly thereafter. At latest follow-up, the patient has been able
to fully participate in professional ice hockey without pain or functional limitation.
Drs Hepper and Boyer are from the Department of Orthopedic Surgery, Washington University in Saint Louis, Missouri.
Drs Hepper and Boyer have no relevant financial relationships to disclose.
Correspondence should be addressed to: Clifford T. Hepper, MD, Department of Orthopedic Surgery, Washington University in
Saint Louis, 660 S Euclid Ave, Campus Box 8233, Saint Louis, MO 63108 (heppert@wudosis.wustl.edu).
There are reports of flexor carpi radialis tendon ruptures following closed and open treatment of distal radius fractures,
in the setting of longstanding carpal osteoarthritis, and in percutaneous treatment of scaphoid fractures.
1–3
The flexor carpi radialis tendon is expendable in the low demand patient population and is often not repaired acutely. The
use of flexor carpi radialis for ligament reconstruction and tendon interposition following trapeziectomy for basal joint
arthritis is well described.
4
The flexor carpi radialis has also been harvested for various other reconstructive procedures.
5,6
To our knowledge no reports exist in the literature of surgical repair of a traumatic laceration of the flexor carpi radialis
in a professional athlete. This article presents a case of a professional ice hockey player who was able to return to professional
sport following acute flexor carpi radialis repair.
Case Report
A 24-year-old right-hand-dominant professional ice hockey player sustained a transverse laceration to his right volar, radial
wrist by an opposing player’s skate. At the time of the injury, all neurovascular and tendinous structures were felt to be
intact. The skin laceration was repaired primarily by the training staff.
Subsequent examination 2 days later by the medical staff raised concern for flexor carpi radialis laceration. The laceration
lay directly over the radial wrist crease, and, on resisted wrist flexion, the flexor carpi radialis tendon was not palpable.
Sensation including two-point discrimination was intact. Flexor carpi ulnaris was intact. Full active thenar and digital motion
was noted. Palmaris longus was also not palpable and was present on the contralateral extremity.
Magnetic resonance imaging (MRI) examination confirmed flexor carpi radialis and palmaris longus tendon lacerations with 3
cm of retraction of the proximal flexor carpi radialis ().
He underwent surgical exploration and flex-or carpi radialis repair 6 days following injury. The flexor carpi radialis was
explored through the traumatic laceration and found to be completely transected transversely at the level of the wrist. Tension-free
core suture repair was performed with a modified-Kessler, 4-strand repair using a double-stranded 4-0 Supramid suture. A running
epitendinous suture was then placed around the circumference of the tendon with 6-0 Prolene.
7
The palmaris longus was not repaired. A dorsal block splint with the wrist in 20° of flexion was applied.
Immobilization of the wrist in 20° of flexion was maintained for 2 weeks. Full active and passive digital motion was allowed
immediately postoperatively and continued throughout the rehabilitation. Therapy was initiated at 2 weeks postoperatively
with full passive wrist flexion and passive wrist extension to a dorsal block of 20°. At 4 weeks postoperatively, a dorsal
splint was fabricated to keep the wrist in neutral. At this time active extension to a dorsal block of zero and full passive
flexion was allowed. Active wrist flexion without resistance was begun at 6 weeks postoperatively. Full strengthening was
allowed at 8 weeks. The patient returned to sport at the professional level shortly thereafter. At latest follow-up the patient
has been able to fully participate in professional ice hockey without pain or functional limitation.
Discussion
Reports exist of flexor carpi radialis tendon ruptures in a variety of clinical scenarios.
1–3
However, a Medline search revealed no literature reports of repair of a traumatic laceration of the flexor carpi radialis
in a professional athlete. Wang et al
8
reported a degenerative rupture of the extensor carpi ulnaris rupture in an ice hockey player that was treated successfully
with palmaris longus tendon grafting.
8
The flexor carpi radialis originates with the common flexor mass from the medial epicondyle of the humerus and inserts into
the base of the second and third metacarpals. It is innervated by median nerve. At the level of the wrist, flexor carpi radialis
lies superficial and just ulnar to the radial artery and, if present, just radial to palmaris longus tendon.
9
The flexor carpi radialis tendon is a wrist flexor and radial deviator. Flexor carpi radialis has half the relative power
of the flexor carpi ulnaris.
10
Therefore, the tendon is expendable in lower demand patients. It is often used for ligament reconstruction and/or tendon
interposition, most commonly in thumb basal joint arthroplasty.
4–6
However, professional athletes require maximal wrist function for optimal performance. Professional ice hockey athletes rely
on powerful wrist flexion for maximal velocity on slap shots and for control of the hockey stick and puck. Therefore, the
decision was made to surgically repair the lacerated wrist flexor tendon in this young, professional ice hockey player.
The current technical concepts of zone-II flexor tendon repair were translated to this unique clinical problem.
7
A 4-strand repair with a modified-Kessler configuration followed by running epitendinous suture is used to create a strong
repair and allow early range of motion. Early therapy is critical to limit adhesion formation, the most common complication
following intrasynovial tendon repair. Therefore, therapy following intrasynovial tendon repair uses high-excursion, low-force
tendon gliding within the synovial sheath to minimize tendon gapping while at the same time preventing adhesion formation.
Early, protected passive range of motion and progressive therapy allowed return to sport at a high level less than 3 months
following flexor carpi radialis tendon repair at the wrist in a professional ice hockey player.
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