Tendon Transfer Versus Tendon Graft Reconstruction of Flexor Pollicis Longus Attritional Ruptures Secondary to Volar Plating of Distal Radius Fractures

Background: Attritional rupture of the flexor pollicis longus (FPL) after volar plating of distal radius fractures is an uncommon but morbid complication, secondary to plate prominence at or distal to the watershed zone. No consensus exists regarding the optimal reconstruction, as both tendon grafting and tendon transfer are routinely utilized. This study evaluated clinical outcomes of tendon transfer versus tendon grafting for FPL rupture following volar plate fixation and compared presenting features, radiographic prominence, and complications between cohorts. Methods: A retrospective review identified 38 reconstructions in 37 patients (2010-2024) following FPL rupture after volar plating. Demographics, plate prominence, timing, presentation, and outcomes were analyzed using Mann-Whitney U, chi-square, or Fisher’s exact tests. Results: Twenty-five tendon grafts (21 palmaris longus, 2 flexor carpi radialis, 1 allograft, 1 index flexor digitorum superficialis [FDS]) and 13 tendon transfers (12 ring FDS, 1 long FDS) were performed. Groups were demographically comparable. Volar wrist pain at presentation was less frequent in tendon transfer (23%) versus graft (48%). The rupture-to-reconstruction interval was shorter for grafts (median 40 vs 72 days; P = .032). Soong grade 1 predominated (78.8%) without significance. Both techniques restored thumb interphalangeal flexion > 30° ( P = .901) and achieved clinically meaningful Quick Disabilities of the Arm, Shoulder, and Hand improvement. Overall complication rate was 18.4% (7/38), with 1 re-rupture in each cohort related to noncompliance. Conclusions: Both tendon grafting and tendon transfer restore thumb flexion with comparable complication rates. Chronic rupture, poor proximal FPL quality, or limited excursion may favor tendon transfer. Prophylactic hardware removal in at-risk patients remains prudent.