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EXTENSOR TENDON( ECRL&B) AVULSION

Introduction

Avulsion fractures involving the extensor carpi radialis longus (ECRL) and extensor carpi radialis brevis (ECRB) tendons are very rare. The mechanism of injury is typically hyperflexion of the wrist with the fist clenched and elbow in full extension, either from a fall on an outstretched hand (FOOSH) or traumatic collision with another object. Common symptoms include pain, swelling/tenderness, weakened grip, and impaired wrist flexion and extension. Treatment may be conservative or surgical based on the patient’s presentation. Open reduction and internal fixation (ORIF) of the avulsion fracture fragment from the base of the metacarpal is the most frequently recommended operative procedure.1,2

Pathophysiology

  • The mechanism of injury for most extensor tendon avulsions typically consists of an awkward acute forceful flexion on the wrist while simultaneously trying to maintain a neutral wrist posture with the elbow in full extension3
  • The rigidity with which the base of the third metacarpal is held in place explains why an avulsion fracture occurs rather than a carpometacarpal dislocation.  The ECRB has greater involvement in wrist extension than the ECRL, and it stabilizes the wrist in extension during gripping2

Related Anatomy

  • Extensor tendons are anatomically divided into intrinsic and extrinsic groups4
  • In the forearm, extrinsic extensor tendons can be further divided into superficial and deep muscular components
    • Superficial group: ECRL, ECRB, the extensor digitorum communis (EDC), extensor digiti minimi (EDM), and extensor carpi ulnaris (ECU)5
    • Deep group: abductor pollicis longus (APL), extensor pollicis brevis (EPB), extensor pollicis longus (EPL), and extensor indicis proprius (EIP)
    • Extensor tendons travel through 6 fibro-osseous tunnels on the dorsal side of the wrist to gain access to the hand5

Incidence and Related Conditions

  • Avulsion fractures of both the ECRB and ECRL are extremely rare injuries, and their incidence has not been reported in the literature.

Differential Diagnosis

  • Other radial wrist injuries
ICD-10 Codes

  • EXTENSOR TENDON AVULSION

    Diagnostic Guide Name

    EXTENSOR TENDON AVULSION

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    EXTENSOR TENDON STRAIN (FOREARM LEVEL) (AVULSION)    
    - INDEX S56.412_S56.411_ 
    - MIDDLE S56.414_S56.413_ 
    - RING S56.416_S56.415_ 
    - LITTLE S56.418_S56.417_ 
    - THUMB S56.312_S56.311_ 

    Instructions (ICD 10 CM 2020, U.S. Version)

    THE APPROPRIATE SEVENTH CHARACTER IS TO BE ADDED TO EACH CODE FROM CATEGORY S56
    A - Initial Encounter
    D - Subsequent Routine Healing
    S - Sequela

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
Wrist Extensor Avulsion Sites
  • Site of ECRB avulsion (arrow)
    Site of ECRB avulsion (arrow)
  • Site of ECRL avulsion (arrow)
    Site of ECRL avulsion (arrow)
Symptoms
Radial wrist Pain, swelling and/or tenderness
Impaired wrist range of motion
Visible hard lump at dorsal radial aspect of the wrist
Visible hard lump
Typical History

A 32-year old, left-handed man was playing soccer when he suffered a fall on the outstretched right hand. During the fall, his wrist was in flexion with his fist clenched, his elbow was in full extension, and his forearm was in pronation. Immediately after the injury, he experienced severe pain and noticed swelling and a visible hard lump on the dorsum of his injured wrist. He also reported a weak grip and difficulty with both wrist flexion and extension.

Positive Tests, Exams or Signs
Work-up Options
Treatment Options
Conservative
  • Cast or fracture brace immobilization
Operative
  • ORIF with anatomic repair of the detached tendon
    • Simple avulsion fractures can be reduced by tension-band wiring or by screw fixation
    • When the tendon is also avulsed from the fragment, both injuries must be addressed; this can be accomplished with a 2-mm screw to fix the bony fragment and a suture anchor to reattach the ECRB tendon2
    • In cases in which the tendons are avulsed in the absence of bone, both tendons should be reinserted into their anatomic insertion as soon as possible, since tendon retraction occurs with time and makes anatomic repositioning of the tendons extremely difficult6
  • Closed reduction
  • Post-surgical rehabilitation
CPT Codes for Treatment Options

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Common Procedure Name
Extensor tendon repair
CPT Description
Repair, tendon or muscle, extensor, forearm and/or wrist; primary, single, each tendon or muscle
CPT Code Number
25270
Common Procedure Name
Extensor tendon repair (with graft)
CPT Description
Repair, tendon or muscle, extensor, secondary with tendon graft, forearm
CPT Code Number
25274
CPT Code References

The American Medical Association (AMA) and Hand Surgery Resource, LLC have entered into a royalty free agreement which allows Hand Surgery Resource to provide our users with 75 commonly used hand surgery related CPT Codes for educational promises. For procedures associated with this Diagnostic Guide the CPT Codes are provided above. Reference materials for these codes is provided below. If the CPT Codes for the for the procedures associated with this Diagnostic Guide are not listed, then Hand Surgery Resource recommends using the references below to identify the proper CPT Codes.

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CPT 2021 Professional Edition: Spiralbound

Hand Therapy
  • Post-surgical rehabilitation
Complications
  • Infection
  • Wrist pain
  • Decreased grip strength
  • Loss of wrist flexion and extension
  • Carpal boss (painful bony prominence)
Outcomes
  • Some patients with extensor avulsion fractures have been treated successful with conservative interventions only, while other cases were unsuccessful and required surgical fixation or correction1,6
  • Several different methods of ORIF has been found to elicit positive outcomes by restoring joint surface integrity and grip stability, while preventing complications such as tendon rupture, carpal boss, and reduced wrist power and movement1
Key Educational Points
  • Due to its rarity, there is a paucity of high-level evidence regarding the optimal treatment option for extensor tendon avulsions1
  • Extensor tendons are particularly difficult for surgeons to repair due to their reduced size compared with the flexors and their lack of collagen-bundle linkage, which reduces the amount of strong tissue available for the sutures grip4
  • ORIF is conceptually and technically simple, and the risks are manageable with appropriate patient selection, surgical technique, and appropriate postoperative rehabilitation7
References

Cited

  1. Najefi A, Jeyaseelan L, Patel A, et al. Avulsion Fractures at the Base of the 2nd Metacarpal Due to the Extensor Carpi Radialis Longus Tendon: A Case Report and Review of the Literature. Arch Trauma Res 2016; 5(1):e32872. PMCID: PMC4852314
  2. Tsiridis E, Kohls-Gatzoulis J, Schizas C. Avulsion fracture of the extensor carpi radialis brevis insertion. J Hand Surg Br 2001;26(6):596-8. PMID: 11884121
  3. Breeze SW, Ouellette T, Mays MM. Isolated avulsion fracture of the extensor carpi radialis brevis insertion due to a boxer's injury. Orthopedics 2009;32(3):210. PMID: 19309050
  4. Griffin M, Hindocha S, Jordan D, et al. Management of extensor tendon injuries. Open Orthop J 2012;6:36-42. PMID: 22431949
  5. Matzon JL, Bozentka DJ. Extensor tendon injuries. J Hand Surg Am 2010;35(5):854-61. PMID: 20439000
  6. Vandeputte G, De Smet L. Avulsion of both extensor carpi radialis tendons: a case report. J Hand Surg Am 1999;24(6):1286-8. PMID: 10584955
  7. Johnson AE, Puttler EG. Avulsion of the extensor carpi radialis brevis insertion: a case report and review of the literature. Mil Med 2006;171(2):136-8. PMID: 16578983

 New Articles

  1. Najefi A, Jeyaseelan L, Patel A, et al. Avulsion Fractures at the Base of the 2nd Metacarpal Due to the Extensor Carpi Radialis Longus Tendon: A Case Report and Review of the Literature. Arch Trauma Res 2016; 5(1): e32872. PMCID: PMC4852314

Reviews

  1. Griffin M, Hindocha S, Jordan D, et al. Management of extensor tendon injuries. Open Orthop J 2012;6:36-42. PMID: 22431949
  2. Matzon JL, Bozentka DJ. Extensor tendon injuries. J Hand Surg Am 2010;35(5):854-61. PMID: 20439000
  3. Johnson AE, Puttler EG. Avulsion of the extensor carpi radialis brevis insertion: a case report and review of the literature. Mil Med 2006;171(2):136-8. PMID: 16578983
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