Vaughan-Jackson Syndrome Follow-up

  • Author: John A McAuliffe, MD; Chief Editor: Harris Gellman, MD   more...
 
Updated: Sep 17, 2010
 

Further Inpatient Care

Inpatient hospital care is seldom required following surgical treatment of ruptured extensor tendons unless these procedures are combined with other major joint reconstruction procedures.

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Further Outpatient Care

Surgery on a single upper extremity may significantly affect the functional capabilities of patients with rheumatoid arthritis. These patients frequently have limited function of the contralateral hand, as well as a need for ambulatory aids or other assistive devices that they may be incapable of using in the postoperative period. The need for increased support and home health assistance should be anticipated.

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Inpatient & Outpatient Medications

  • Most authors recommend a single dose of intravenous antibiotic (usually a cephalosporin) immediately before surgery, and some follow this with 24-48 hours of postoperative therapy as a prophylactic measure. The postoperative antibiotic can be administered orally on an outpatient basis. This author is not aware of a controlled study that demonstrates the advisability of any particular perioperative antibiotic regimen.
  • Patients treated with corticosteroids require increased doses in the perioperative period to protect against the possibility of addisonian crisis brought on by the stress of surgery.[31]
  • Adequate pain control must be ensured; occasionally, this necessitates immediate postoperative inpatient hospital admission.
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Complications

  • Wound healing problems and infection are encountered in fewer than 5% of cases.[4]
  • Extension lag at the metacarpophalangeal (MCP) joint is a frequently mentioned occurrence, although its incidence and magnitude are difficult to quantify. Most authors would agree, however, that extension contracture is very uncommon, and it generally is better to err on the side of increased tension when setting tendon transfers in the rheumatoid hand.[36]
  • Rerupture is distinctly uncommon, occurring in fewer than 5% of cases. This complication is usually related to inadequate reconstruction of the distal ulna, which allows recurrence of dorsal displacement and attritional tendon wear.[4]
  • Recurrent tenosynovitis occurs in fewer than 7% of cases with medium-term (3- to 8-year) follow-up after tenosynovectomy.[23, 24, 33]
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Prognosis

Hands with single-digit tendon ruptures exhibit better results than do those with multiple-digit involvement. In particular, extension lag seems to increase in direct proportion to the number of digits involved. A functional 70° arc of MCP joint motion is commonly restored.[4]

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Patient Education

  • The services of a certified hand therapist are invaluable in educating patients on the postoperative regimen. Splint use and activity restriction must be adhered to in order to prevent disruption of the tendon graft or transfer.
  • Perhaps the most important lesson that can be imparted to these patients is an understanding of the warning signs and risk factors that may indicate the possibility of impending tendon rupture in the contralateral limb.
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Contributor Information and Disclosures
Author

John A McAuliffe, MD  Consulting Surgeon, Department of Orthopedics, Section of Hand Surgery, Broward General Medical Center

John A McAuliffe, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Medical Association, and American Society for Surgery of the Hand

Disclosure: Nothing to disclose.

Specialty Editor Board

Joseph E Sheppard, MD  Professor of Clinical Orthopedic Surgery, Chief of Hand and Upper Extremity Service, Department of Orthopedic Surgery, University of Arizona Health Sciences Center, University Physicians Healthcare

Joseph E Sheppard, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Society for Surgery of the Hand, and Orthopaedics Overseas

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

N Ake Nystrom, MD, PhD  Associate Professor of Orthopedic Surgery and Plastic Surgery, University of Nebraska Medical Center

Disclosure: Nothing to disclose.

Dinesh Patel, MD, FACS  Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD  Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M Miller School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society

Disclosure: Nothing to disclose.

References

  1. Brooks P. Extensor mechanism ruptures. Orthopedics. Sep 2009;32(9):[Medline].

  2. Vaughan-Jackson OJ. Rupture of extensor tendons by attrition at the inferior radio-ulnar joint. Report of two cases. J Bone Joint Surg Br. 1948;30B(3):528-30. [Full Text].

  3. Vaughan-Jackson OJ. Attritional ruptures of tendons in the rheumatoid hand (abstract). J Bone Joint Surg Am. 1958;40A:1431.

  4. Moore JR, Weiland AJ, Valdata L. Tendon ruptures in the rheumatoid hand: analysis of treatment and functional results in 60 patients. J Hand Surg (Am). Jan 1987;12(1):9-14. [Medline].

  5. Mannerfelt L, Norman O. Attrition ruptures of flexor tendons in rheumatoid arthritis caused by bony spurs in the carpal tunnel. A clinical and radiological study. J Bone Joint Surg Br. May 1969;51(2):270-7. [Medline]. [Full Text].

  6. Newmeyer WL, Green DP. Rupture of digital extensor tendons following distal ulnar resection. J Bone Joint Surg Am. Feb 1982;64(2):178-82. [Medline].

  7. Teplitz GA, Bisson LJ, Weiland AJ. Rupture of digital extensor tendons following distal ulnar resection and extensor carpi ulnaris stabilization: a case report. Am J Orthop. 1996;25:230-32.

  8. Jain A, Brennan F, Troeberg L. The role of matrix metalloproteinases in rheumatoid tendon disease. J Hand Surg (Am). Nov 2002;27(6):1059-64. [Medline].

  9. Williamson SC, Feldon P. Extensor tendon ruptures in rheumatoid arthritis. Hand Clin. Aug 1995;11(3):449-59. [Medline].

  10. Ducloyer P, Leclercq C, Lisfranc R, et al. Spontaneous ruptures of the extensor tendons of the fingers in Madelung's deformity. J Hand Surg (Br). Aug 1991;16(3):329-33. [Medline].

  11. Engkvist O, Lundborg G. Rupture of the extensor pollicis longus tendon after fracture of the lower end of the radius -- a clinical and microangiographic study. Hand. Feb 1979;11(1):76-86. [Medline].

  12. Gladstone H. Rupture of the extensor digitorum communis tendons following severely deforming fractures about the wrist. J Bone Joint Surg Am. Jul 1952;24-A-3:698-700. [Medline].

  13. Inoue G. Attritional rupture of the extensor tendon due to longstanding Kienbock's disease. Ann Chir Main Memb Super. 1994;13(2):135-8. [Medline].

  14. Lowry KJ, Gainor BJ, Hoskins JS. Extensor tendon rupture secondary to the AO/ASIF titanium distal radius plate without associated plate failure: a case report. Am J Orthop. Oct 2000;29(10):789-91. [Medline].

  15. Taniguchi Y, Yoshida M, Tamaki T. Subcutaneous extensor tendon rupture associated with calcium pyrophosphate dihydrate crystal deposition disease of the wrist. J Hand Surg (Br). Jun 1997;22(3):386-7. [Medline].

  16. Niwa T, Uchiyama S, Yamazaki H, Kasashima T, Tsuchikane A, Kato H. Closed tendon rupture as a result of Kienböck disease. Scand J Plast Reconstr Surg Hand Surg. Feb 2010;44(1):59-63. [Medline].

  17. Kwon ST, Schneider LH. Extensor tendon ruptures in rheumatoid hands. In: Hunter JM, Schneider LH, Mackin EJ, eds. Tendon and Nerve Surgery in the Hand: A Third Decade. St. Louis, Mo: Mosby Year Book. 1997:434-8.

  18. Wilson RL, DeVito MC. Extensor tendon problems in rheumatoid arthritis. Hand Clin. Aug 1996;12(3):551-9. [Medline].

  19. Ryu J, Saito S, Honda T, et al. Risk factors and prophylactic tenosynovectomy for extensor tendon ruptures in the rheumatoid hand. J Hand Surg (Br). Oct 1998;23(5):658-61. [Medline].

  20. Millender LH, Nalebuff EA, Holdsworth DE. Posterior interosseous-nerve syndrome secondary to rheumatoid synovitis. J Bone Joint Surg Am. Jun 1973;55(4):753-7. [Medline].

  21. Freiberg RA, Weinstein A. The scallop sign and spontaneous rupture of finger extensor tendons in rheumatoid arthritics. Clin Orthop Relat Res. Mar-Apr 1972;83:128-30. [Medline].

  22. Yamazaki H, Uchiyama S, Hata Y, Murakami N, Kato H. Extensor tendon rupture associated with osteoarthritis of the distal radioulnar joint. J Hand Surg Eur Vol. Aug 2008;33E:469-474. [Medline].

  23. Ishikawa H, Hanyu T, Tajima T. Rheumatoid wrists treated with synovectomy of the extensor tendons and the wrist joint combined with a Darrach procedure. J Hand Surg (Am). Nov 1992;17(6):1109-17. [Medline].

  24. Thirupathi RG, Ferlic DC, Clayton ML. Dorsal wrist synovectomy in rheumatoid arthritis -- a long-term study. J Hand Surg (Am). Nov 1983;8(6):848-56. [Medline].

  25. Rubens DJ, Blebea JS, Totterman SM, et al. Rheumatoid arthritis: evaluation of wrist extensor tendons with clinical examination versus MR imaging -- a preliminary report. Radiology. Jun 1993;187(3):831-8. [Medline].

  26. De Maeseneer M, Marcelis S, Osteaux M, et al. Sonography of a rupture of the tendon of the extensor pollicis longus muscle: initial clinical experience and correlation with findings at cadaveric dissection. AJR Am J Roentgenol. Jan 2005;184(1):175-9. [Medline].

  27. Sunagawa T, Ishida O, Ishiburo M, et al. Three-dimensional computed tomography imaging: its applicability in the evaluation of extensor tendons in the hand and wrist. J Comput Assist Tomogr. Jan-Feb 2005;29(1):94-8. [Medline].

  28. Ishikawa H, Abe A, Murasawa A, Nakazono K, Horizono H, Ishii K, et al. Rheumatoid wrist deformity and risk of extensor tendon rupture evaluated by 3DCT imaging. Skeletal Radiol. May 2010;39(5):467-72. [Medline].

  29. Abe A, Ishikawa H, Murasawa A, Nakazono K. Extensor tendon rupture and three-dimensional computed tomography imaging of the rheumatoid wrist. Skeletal Radiol. Apr 2010;39(4):325-31. [Medline].

  30. Soni P, Stern CA, Foreman KB, Rockwell WB. Advances in extensor tendon diagnosis and therapy. Plast Reconstr Surg. Feb 2009;123(2):727-8. [Medline].

  31. McAuliffe JA. General clinical considerations in rheumatoid surgery. In: Weiss A-PC, Hastings H, eds. Surgery of the Arthritic Hand and Wrist. Philadelphia, Pa: Lippincott Williams & Wilkins;2002:27-37.

  32. Howe CR, Gardner GC, Kadel NJ. Perioperative medication management for the patient with rheumatoid arthritis. J Am Acad Orthop Surg. Sep 2006;14(9):544-51. [Medline].

  33. Brown FE, Brown ML. Long-term results after tenosynovectomy to treat the rheumatoid hand. J Hand Surg (Am). Sep 1988;13(5):704-8. [Medline].

  34. Bora FW Jr, Osterman AL, Thomas VJ, et al. The treatment of ruptures of multiple extensor tendons at wrist level by a free tendon graft in the rheumatoid patient. J Hand Surg (Am). Nov 1987;12(6):1038-40. [Medline].

  35. Nakamura S, Katsuki M. Tendon grafting for multiple extensor tendon ruptures of fingers in rheumatoid hands. J Hand Surg (Br). Aug 2002;27(4):326-8. [Medline].

  36. Smith RJ. Tendon Transfers of the Hand and Forearm. Boston, Mass: Little, Brown and Co. 1987:215-43.

  37. Boyes JH. Tendon transfers for radial nerve palsy. Bull Hosp Joint Dis. 1960;21:97-105.

  38. Nalebuff EA, Patel MR. Flexor digitorum sublimis transfer for multiple extensor tendon ruptures in rheumatoid arthritis. Plast Reconstr Surg. Nov 1973;52(5):530-3. [Medline].

  39. Feldon P, Terrono AL, Nalebuff EA. Rheumatoid arthritis and other connective tissue diseases. In: Green DP, Hotchkiss RN, Pederson WC, Wolfe SW, eds. Green's Operative Hand Surgery. 5th ed. New York, NY: Churchill Livingstone. 2005:2049-36.

  40. Bois AJ, Johnston G, Classen D. Spontaneous flexor tendon ruptures of the hand: case series and review of the literature. J Hand Surg [Am]. Sep 2007;32(7):1061-71. [Medline].

  41. Millender LH, Nalebuff EA, Albin R, et al. Dorsal tenosynovectomy and tendon transfer in the rheumatoid hand. J Bone Joint Surg Am. Apr 1974;56(3):601-10. [Medline].

 
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Typical appearance of the hand following rupture of the extensor tendons of the ring and small finger.
Intraoperative image of a ruptured extensor tendon with the hand to the left. Note that the tendon ends cannot be reapproximated despite maximum tension.
Anteroposterior radiograph of the wrist following wrist arthrodesis and resection of the distal ulna displays the scallop sign, which is the term used to describe the scooped-out appearance of the sigmoid notch of the radius that results from synovial proliferation and bone erosion.
Radiograph of a rheumatoid hand with metacarpophalangeal joint dislocations. These joints are incapable of extension.
 
 
 
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