Orthopedics

Case Report 

Repair of Flexor Carpi Radialis Tendon Laceration at the Wrist in a Professional Ice Hockey Player

Clifford T. Hepper, MD; Martin Boyer, MD

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.

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.

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…

Repair of Flexor Carpi Radialis Tendon Laceration at the Wrist in a Professional Ice Hockey Player

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).
Posted Online: June 14, 2011

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 ().

T1-Coronal MRI of the Right Wrist Demonstrates Complete, Transverse Laceration of the Flexor Carpi Radialis Tendon with 3 cm of Retraction.

Figure:. T1-Coronal MRI of the Right Wrist Demonstrates Complete, Transverse Laceration of the Flexor Carpi Radialis Tendon with 3 cm of Retraction.

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.

References

  1. 1. Allred DW, Rayan GM. Flexor carpi radialis tendon rupture following chronic wrist osteoarthritis: a case report. J Okla State Med Assoc. 2003; 96(5):211–212.
  2. 2. DiMatteo L, Wolf JM. Flexor carpi radialis tendon rupture as a complication of a closed distal radius fracture: a case report. J Hand Surg Am. 2007; 32(6):818–820. doi: 10.1016/j.jhsa.2007.03.014 [CrossRef]
  3. 3. Ducharne G, Frick L, Schoofs M. Flexor carpi radialis tendon rupture following percutaneous osteosynthesis of the scaphoid: a case report [in French] [published online ahead of print November 14, 2008]. Chir Main. 2009; 28(1):50–52. doi: 10.1016/j.main.2008.10.001 [CrossRef]
  4. 4. Vermeulen GM, Slijper H, Feitz R, Hovius SE, Moojen TM, Selles RW. Surgical management of primary thumb carpometacarpal osteoarthritis: a systematic review. J Hand Surg Am. 2011; 36(1):157–159. doi: 10.1016/j.jhsa.2010.10.028 [CrossRef]
  5. 5. Levy HJ, Mashoof AA, Morgan D. Repair of chronic ruptures of the distal biceps tendon using flexor carpi radialis tendon graft. Am J Sports Med. 2000; 28(4):538–540.
  6. 6. Salvà-Coll G, Garcia-Elias M, Llusà-Pérez M, Rodríquez-Baeza A. The role of the flexor carpi radialis muscle in scapholunate instability [published online ahead of print November 18, 2010]. J Hand Surg Am. 2011; 36(1):31–36. doi: 10.1016/j.jhsa.2010.09.023 [CrossRef]
  7. 7. Kim HM, Nelson G, Thomopoulos S, Silva M, Das R, Gelberman RH. Technical and biological modifications for enhanced flexor tendon repair. J Hand Surg. 2010; 35(6):1031–1037. doi: 10.1016/j.jhsa.2009.12.044 [CrossRef]
  8. 8. Wang C, Gill TJ, Zarins B, Herndon JH. Extensor carpi ulnaris tendon rupture in an ice hockey player. Am J Sports Med. 2003; 31(3):459–461.
  9. 9. Leversedge FJ, Boyer MI, Goldfarb CA. A Pocketbook Manual of Hand and Upper Extremity Anatomy: Primus Manus. Philadelphia, Pa: Lippincott Williams and Wilkins; 2010.
  10. 10. Brand PW, Beach RB, Thompson DE. Relative tension and potential excursion of muscles in the forearm and hand. J Hand Surg Am. 1981; 6(3):209–219.

10.3928/01477447-20110427-31

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