claw hand dr akbar
DESCRIPTION
claw hand mechanism and surgeriesTRANSCRIPT
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CLAW HAND
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Definition
Flattening of transverse metacarpal arch and longitudinal arches,
Hyperextension of MCP joints Flexion of PIP and DIP joints
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3 BASIC FUNCTIONS OF HAND
* HOOK* GRASP* PINCH
All functions of the hand are combinations of these three functions
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Movements of MCP joints & IP joints independent
Movements of 2 IP joints coordinated ; flexion of DIP joint brings about flexion of PIP joint
(1)Flexion of distal phalanx draws dorsal expansion distally by loosening tension on central tendon
(2)Flexion of DIP joint tenses oblique retinacular ligament causing this ligament to slide volarward and impart flexion force to PIP joint
Normal anatomy
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Intrinsic muscles of hand
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Paralysis of interossei and lumbricals Unopposed MCP joint extension & IP joint
flexion by digital extensors & flexors Without stabilization of MCP joints in
neutral/slight flexed position, long extensor function “blocked” at MP joint by diversion of this tension to sagittal band, producing hyperextension and effectively blocking the extensor's ability to extend PIP joint.
Patho-anatomy of deformity
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Middle and distal phalanges collapse into flexion
Normal cascade of digital extension disrupted, in that during any attempt to actively open finger, MP joint extends first and will extend more than the PIP joint,
Normal sequence of digital closure also reversed, in that IP joint flexion precedes MP joint flexion
Independence of MP and IP joint motion lost
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Synergistic muscles Normal Grip
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ROLL UP MANEUVER
LOSS OF GRASP
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Paralysis of adductor pollicis muscle Tips of extended digits cannot be brought together into cone Impairment of precision grip
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CMC joint affected by paralysis of adductor pollicis, FPB, and first dorsal interosseous
MP and IP joints of thumb under control of extrinsic flexors and extensors, with proximal phalanx behaving like intercalated bone.
MP joint will go into hyperextension and IP joint into flexion because of the greater extensor moment at the MP joint and the lesser extensor moment at the IP joint, respectively.
“Z”-thumb deformity
Claw thumb in Ulnar palsy
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Complete : Involving all digits and resulting from combined Ulnar and Median Nerve palsy
Incomplete : Involving only ulnar 2 digits as in isolated Ulnar Nerve palsy
Types of claw hand
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Flexion Extension Deformity
MCP Joint Lumbricals paralyzed
Extensor Digitorum active
Hyper extension of MCP joint
PIP Joint FDS active Interosseous paralyzed ( low Ulnar palsy )
Flexion of PIP joint
DIP Joint FDP active Interosseous paralyzed
Flexion of DIP
FDP paralyzed( high Ulnar Palsy )
Interosseous paralyzed
Neutral position
Partial Claw hand
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Flexion Extension Deformity
MCP Joint Lumbricals paralyzed
Extensor digitorum active
Hyper extension at MCP
PIP Joint FDS paralyzed Extensor digitorum active
Extension of PIP
DIP Joint FDP paralyzed Extensor digitorum active
Extension of DIP
Total Claw Hand
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TraumaticCompressive neuropathyBrachial plexus injuryInfective ( Leprosy, Poliomyelitis )Peripheral neuropathiesSystemic diseases(DM, Uremia, Porphyria,
Malignancy)Drugs and Toxins (Leas, Arsenic, Dapsone, etc )Hereditary(CMTD, Syringomyelia, Lipid storage
disease)IschemiaPrimary Nerve neoplasm
ETIOLOGY
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Ampola syndromeAngiokeratomaArthrogyropsis multiplex congenitaAural atresiaCharcot Marie DiseaseChondrodysplasia punctataChromosomal anomaliesCraniofacial dysostosisFrontonasal dysplasiaMuller Barth Menger SyndromeOro facial digital syndrome type 4Pitt Hopkins syndromeStratton Parker syndrome
Rare conditions showing claw hand
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Low mixed Ulnar and Median nerve palsy
High mixed Ulnar and Median nerve palsy
Low Ulnar nerve palsy
High Ulnar nerve palsy
Pattern of Injury
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LOW ULNAR NERVE PALSY
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Evaluation for Surgical Reconstruction
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Duchenne's sign : Hyperextension at MCP joints & flexion at IP joints
Bouvier’s maneuver : Dorsal pressure over proximal phalanx to passively flex MP joint results in straightening of distal joints and temporary correction of claw deformity
Extensor digitorum tendon can extend middle and distal phalanges when proximal phalanx stabilized
Andre-Thomas sign : On palmar -flexon of wrist exaggeration of deformity
Specific signs and tests for motor dysfunction
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Pitres-Testut sign : Inability to actively move long finger s in radial and ulnar deviation with palm placed flat
Cross your fingers test : Inability to cross middle finger dorsally over index finger, or index over middle finger
Masse's sign: Flattened metacarpal arch and loss of hypothenar elevation
Wartenberg's sign : Inability to adduct extended little finger to extended ring finger
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Jeanne’s sign : Hyperextension of MP joint of thumb during key pinch or gross grip
Froment’s sign : Thumb IP joint flexion while attempting to perform lateral pinch
Bunnell’s O sign : Combined hyperextension at MP joint and hyperflexion of IP joint (noticed when patient makes a pulp to pulp pinch with thumb and index finger)
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Froment’s sign Bunnel O sign
FPL
EPL
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BENEDICTION TEST
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High ulnar palsy
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Pollock's sign : Inability to flex distal
phalanges of ring and little fingers Partial loss of wrist flexion may occur
because of paralysis of FCUWeakness of ulnar side grip
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Measured at PIP joint of each finger and IP joint of thumb using a goniometer placed on dorsal aspect of joint
Unassisted angle : Maintain “lumbrical-plus” position of MP flexion and IP extension, and extension deficit at PIP joint measured
Assisted angle : Proximal segment of finger supported to maintain flexion at the MP joint and instructs the patient to extend IP joints ;In absence of contracture of IP joints, this angle o
PREOPERATIVE ANGLE MEASUREMENTS
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Contracture angle : Incomplete passive extension ,contracture with deficiency of volar skin and volar plate and/or capsule PIP joint
Adaptive shortening angle of extrinsic flexors : Habitual posturing of wrist in flexion to minimize the claw deformity ; increased angulation at PIP joint as wrist is passively moved into extension
Hypermobile angle: Ligamentous laxity ; hypermobile joints with passive hyperextension of PIP joints > 20
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Type I: Supple claw hands with no hypermobile joints and no contractures at IP joints
Type II: Hypermobile joints; PIP joints hyperextension > 20 degrees
Type III: Mobile joints in association with adaptive shortening of long flexors, usually superficialis tendons , with no IP joint contracture
Anderson GA: Analysis of paralytic claw finger correction using flexor motors into different insertion sites. Master's thesis, University of Liverpool, 1988.
CLASSIFICATION OF PARALYTIC CLAW HANDS
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Type IV: Contracted claw hands ; PIP joint flexion contracture of 15 degrees or more, due to volar skin, joint capsule, or volar plate contracture ± adaptive shortening of long flexors
Type V: Claw hands with attrition of dorsal extensor apparatus at PIP joint with “hooding deformity,” fibrous or bony ankylosis of PIP joint, and MP joint extension contracture
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Clawing principal longitudinal axial deformity and loss of independence of movement at MP and PIP joints principal disability
Third muscle-tendon unit needs to run volar to center of curvature of MP joint and dorsal to center of curvature of head of PIP joint to counterbalance system and provide equilibrium and independence of normally functioning intrinsic muscles
Alternatively, MP joint needs to be statically prevented from hyperextension to allow long extensors to extend IP joints
Principle
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Nerve Injuries Patient referred late ( 1 year )
After nerve repair, if electrodiagnostic tests show no signs of reinnervation within 6 to 9 months
*Jobe MT, Wright PE: Peripheral nerve injuries. In: Canale ST, ed. Campbell's Operative Orthopaedics, 4. 9th ed.. St. Louis: Mosby; 1992
Indications for surgery
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Leprosy Understanding of stage and activity of disease, presence of intact,
healthy skin, patient motivation.* Recommended when patient's medical treatment optimized skin smears for the bacillus negative bacteriological index negative on two successive tests disease activity quiescent for at least a year before date of intended
surgery, paralysis established patient free of corticosteroid treatment for several months before
surgery
*Enna CD: Preoperative evaluation. In: McDowell F, Enna CD, ed. Surgical rehabilitation in leprosy and in other peripheral nerve disorders, Baltimore: Williams & Wilkins; 1974
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Poliomyelitis Ulnar innervated lumbricals can be paralyzed, sparing
a part of or whole of interosseous muscles or vice versa Paralysis typically nonprogressive and with no loss of
sensation Children affected, and joints hypermobile Surgery be delayed until child is at least 5 years of
age, so that child will be able to cooperate with postoperative re-education program
Anderson GA: The child's hand in the developing world. In: Gupta A, Kay SPJ, Scheker LR, ed. The Growing Hand: Diagnosis and Management of the Upper Extremity in Children, London: Mosby; 2000
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Appropriate use of splints, fabricated for each patient and altered or changed whenever indicated can help to manage claw deformity
Splints interfere with rehabilitation of sensibility and are generally used intermittently
North ER, Littler JW: Transferring the flexor superficialis tendon: Technical considerations in the prevention of proximal interphalangeal joint disability. J Hand Surg [Am] 1980
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Principles and biomechanics
Homeostasis of involved extremity established *
Soft tissues free of scar contracture
Vascularity of extremity adequate
Chronic wounds fully settled for 3 months before surgery
Proper physiotherapy, occupational therapy and splinting
Mobile joints and correct alignment of bone
Omer Jr GE: The technique and timing of tendon transfers. Orthop Clin North Am 1974
Tendon transfers
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Power of transferred muscle : Good or normal (4 or 5)
Muscle should be expendable
Synergestic muscles
Path of Tendon: Best in straight line; If change in direction necessary - Pulley
Absolute contraindication: Non-compliant patient with poor motivation who will not follow appropriate postop rehabilitation
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Burkhalter
Allow early function of hand while awaiting nerve regeneration
Can prevent deformities that lead to contractures
Improve coordination of residual muscle-tendon units
Burkhalter WE: Early tendon transfers in upper extremity peripheral nerve injury. Clin Orthop 1974
Internal splints (Early Tendon Transfers)
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Stimulate sensory re-education during nerve recovery
Inhibition of trick movements
Functions as internal splints for paralyzed muscles
In the event of a failure of nerve recovery will remain and function as a permanent solution
Contd…
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Proximal phalanx flexion for ring and little fingers : Ulnar half of FDSR with split insertion to ring and little fingers to lateral band of DEE or A1, A2, or A1 + A2a pulleys
Restoration of transverse metacarpal arch and adduction of little finger : FDSR Y insertion
Thumb adduction for key pinch : FDSR radial half to abductor tubercle, FDSL to hypothenar insertion, near fifth MP joint
Contd…
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DEFORMITIES AND DEFICIENCIES CORRECTABLE BY SURGERY
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Static and Dynamic procedures Static procedures : To maintain MP joint in some degree of flexion or to
limit MP joint hyperextension claw posture reversed by functioning long extensors Flexion of MP joint unrestricted in static procedures Disadvantages : restore normal finger coordination and
sequence but do not provide an additional motor to restore MP flexion.
Recurrence : rule unless there is radical change in patient's work style and paralyzed hand more protected than used
METHODS OF CLAW HAND RECONSTRUCTION
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Flexor Pulley Advancement ( Bunnell )* Each side of proximal pulley system split 1.5 to 2.5 cm up to
middle of the proximal phalanx. Flexor tendons then “bow string,” to bring about flexion at MP joint
Fasciodermadesis ( Zancolli )‡ Excision of 2 cm of the palmar skin (dermadesis) at MP joint level
combined with shortening of pretendinous band of palmar aponeurosis (fasciodermadesis) to correct claw hands with weak extensors
*Bunnell S: Surgery of the intrinsic muscles of the hand other than those producing opposition of the thumb. J Bone Joint Surg 1942
‡Zancolli EA: Structural and Dynamic Bases of Hand Surgery, 2nd ed.. Philadelphia: JB Lippincott; 1979
Proximal Phalangeal Flexion Static Techniques
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Zancolli Capsulodesis
Volar MP joint Capsulodesis A1 pulley release with MP
joint volar plate advancement Complicated claw hands with
MP joint contracture Zancolli incorporated collateral ligament release on both sides of MP joint with volar capsuloplasty
Zancolli EA: Claw-hand caused by paralysis of the intrinsic muscles: A simple surgical procedure for its correction. J Bone Joint Surg Am 1957
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Omer advanced volar plate by cutting away a triangular portion of the deep transverse metacarpal ligament (DTML) on each side of volar plate flap
Omer Jr GE, Spinner M, ed. Management of Peripheral Nerve Problems, Philadelphia: WB Saunders; 1980
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Dorsal Methods (Howard; Mikhail)To provide bony block to proximal
phalangeal extensionEnables long extensors to extend IP joints
and correct deformity.Mikhail inserted bone block on dorsum of
the metacarpal head Howard suggested elevation of bone wedge
as block from the dorsal aspect of the metacarpal head itself
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Riordan One half of ECRL and ECU tendons made use of
as “grafts” to prevent hyperextension of MP joint while remaining half continue to actively extend wrist
Riordan DC: Tendon transfers for nerve paralysis of the hand and wrist. Curr Pract Orthop Surg 1964
Static Tenodesis Techniques
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Parkes Static Tenodesis (Volar Side)—With Free Tendon Grafts 2 free tendon grafts, from plantaris tendon, palmaris tendon, or toe extensors, required for four fingers
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Integration of Finger Flexion
Fowler tenodesis
Wrist Tenodesis Technique Fowler
Incorporates active wrist motion to tension static tendon grafts
Free tendon grafts sutured to extensor retinaculum of wrist and passed in a dorsal to palmar direction through the intermetacarpal spaces, volar to the DTML, through the lumbrical canals, and onto the lateral bands of dorsal extensor expansion of 4 fingers
Fowler SB: Extensor apparatus of the digits
(abstract). J Bone Joint Surg Br 1949
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RIORDAN OPPOSITION
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BRANDS
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First reported by Sir Harold Stiles and Forrester-Brown in 1922
By passing tendon graft slips volar to deep transverse metacarpal ligament and into lateral band of dorsal extensor apparatus, procedure designed to improve synchronous motion of the finger joints and duplicate lumbrical muscle action
Stiles HJ, Forrester-Brown MF: Treatment of Injuries of Peripheral Spinal Nerves, London: H Frowde & Hodder & Stoughton; 1922
Dynamic Tendon Transfers
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Superficialis Tendon Transfer Techniques and Modifications (Stiles; Bunnell; Littler)
FDS detached , splitted, & transferred to dorsum of fingers to extensors tendons
Removes powerful flexor of PIP joint & converts it into extensor
Intrinsic plus deformity
Transfer of Extrinsic Finger Flexors
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Bunnell (1942) : rerouted both slips of all superficialis tendons through lumbrical canals and anchored them to both sides of lateral band of dorsal extensor expansion (Stiles-Bunnell procedure)
Transfer involved passage of Split FDSI for radial side of lateral bands of index and middle
fingers• Split FDSM for ulnar side lateral band of index, middle, and ring fingers• Split FDSR to radial side of ring and little fingers• Split FDSL) to the ulnar side of little finger
Bunnell S: Surgery of the intrinsic muscles of the hand other than those producing opposition of the thumb. J Bone Joint Surg 1942
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Disadvantages PIP flexion contractures and DIP extension lag in donor
finger most frequent when superficialis removed through conventional midlateral approach
Midlateral approach exposed distal part of lateral band to injury and contributed to DIP extension lag
High incidence of swan neck deformity in one or more of operated fingers owing to excessive tension on transferred tendon slip
Loss of PIP joint flexion due to adhesions between profundus and superficialis tendon remnant
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To prevent these complications, North and Littler : removal of superficialis through volar incision between A1 and A2 pulleys
Brand : Ulnar nerve palsy results in claw deformities in all four
fingers, Weakness is not limited only to fingers with obvious clawing.
Recommendation : surgery be done in all fingers of a claw hand
North ER, Littler JW: Transferring the flexor superficialis tendon: Technical considerations in the prevention of proximal interphalangeal joint disability. J Hand Surg [Am] 1980
Brand PW: The reconstruction of the hand in leprosy (Hunterian lecture). Ann R Coll Surg Engl 1952
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Modification of Bunnell
Littler proposed modification of the Stiles-Bunnell procedure by using FDSM
Referred to as modified Stiles-Bunnell procedure
Tendon slips sutured under correct tension, that is, with wrist in neutral flexion-extension, MP joints in 45 to 55 degrees of flexion, and IP joints in neutral position.
Littler JW: Tendon transfers and arthrodesis in combined median and ulnar nerve palsies. J Bone Joint Surg Am 1949
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4 primary insertion sites of FDS are classified as: A. Lateral band insertion—intrinsic replacement (Stiles
and Forrester-Brown , Bunnell , Littler , Brand , Riordan , Lennox-Fritschi )
B. Phalangeal insertion (Burkhalter )
C. Pulley insertion (Riordan , Zancolli , Brooks and Jones , Anderson )
D. Interosseous insertion (Zancolli , Palande , Anderson )
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Pulley system of flexor tendon of finger
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Phalangeal Insertion ( Burkhalter )
Insertion of superficialis tendon slips directly to proximal phalanx
Avoid risk of PIP joint hyperextension noted with transfers to lateral band of the dorsal apparatus
Increased distance of moment with increased flexion of MP joint
Burkhalter WE, Strait JL: Metacarpophalangeal flexor replacement for intrinsic-muscle paralysis. J Bone Joint Surg Am 1965
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Interosseous tendons used as insertion sites with different motors: superficialis tendon, ECRL ,or palmaris longus
Zancolli : first and second dorsal interosseous as insertion sites to attach slips of a superficialis tendon with goal of obtaining proximal phalangeal flexion and restore digital abduction ( direct interosseous activation)
Palande : extended this principle to correct intrinsic-minus hands associated with reversal of the transverse metacrapal arch
Interosseous Insertions (Zancolli Palande; Anderson)
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Pulley Insertions (Zancolli's “Lasso”)
Delineated A1 pulleys through a transverse skin incision at level of the distal palmar crease.
Flexor superficialis tendon sectioned in the finger and divided into two slips
Each tendon slip retained volar to deep transverse metacarpal ligament and looped through the A1 proximal pulley and sutured to itself
Zancolli EA: Claw-hand caused by paralysis of the intrinsic muscles: A simple surgical procedure for its correction. J Bone Joint Surg Am 1957;
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Lasso procedure (ZANCOLLI) - Transfer of FDS to A-1 pulleys, index, long, ring and small fingers.
Transverse incision made at level of first A-1 pulley, beginning at prox. palmar crease of index finger and ending ulnarly at distal palmar crease of little finger.
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Subcutaneous tissue opened longitudinally and neurovascular bundles retracted to either side.
FDS tendon exposed 1½ cm prox to A-1 pulley.
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Both slips of FDS identified distal to A-1 pulley.
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PIP joint flexed to allow proximal retraction of FDS tendon.
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Each slip of tendon is divided distal to hemostats.
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Finger is extended and tendon slit proximally.
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Two slips of FDS tendon (distal) folded down volarly over A-1 pulley and ends separately interwoven into prox portion of FDS using
tendon braider.
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Anchored to itself with multiple horizontal mattress stiches creating a
strong lasso
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Anderson : Extended pulley insertion (EPI) by looping slip of superficialis tendon around both the A1 and proximal A2 pulleys in each finger
. Anderson GA: Analysis of paralytic claw finger correction using flexor motors into different insertion sites. Master's thesis, University of Liverpool, 1988.
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Finger Level Extensor Motor
Fowler transfer
Extensor Indicis Proprius and Extensor Digiti Minimi Transfer (Fowler )
EIP and EDM tendons as transfers lateral bands of the dorsal apparatus
May produce excessive tension in extensor apparatus and lead to intrinsic-plus deformities.
May cause reversal of normal metacarpal arch and, occasionally, extensor weakness in the little finger
Fowler SB: Extensor apparatus of the digits (abstract). J Bone Joint Surg Br
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Riordan Modification
Splitting EIP into 2 slips and transferring them through intermetacarpal space between the ring and little digits, routed palmar to the transverse metacarpal ligament and onto radial lateral bands of the ring and little fingers
Riordan DC: Tendon transplantations in median-nerve and ulnar-nerve paralysis. J Bone Joint Surg Am 1953
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To simultaneously correct claw deformity and gain grip strength, add additional muscle-tendon unit to power train for flexion of proximal phalanx
Best achieved by transferring wrist motor or brachioradialis to flex proximal phalanges
Require free grafts to provide sufficient length to reach insertion site( plantaris, palmaris, fascia lata, or toe extensors)
Wrist-Level Motors for Proximal Phalanx Power and Integration of Finger Flexion (Brand; Burkhalter; Brooks;
Fowler; Riordan)
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Dorsal Route Transfer of ECRB (Brand)
ECRL or ECRB lengthened by plantaris tendon that was split into four tails
Tendon slips passed through intermetacarpal spaces, into the lumbrical canal and palmar to the DTML, to be attached to radial lateral bands of the long, ring, and little fingers and ulnar lateral band of the index finger
Did not improve flattened transverse metacarpal arch or weakness of grip
Brand PW: Hand reconstruction in leprosy. British Surgical Practice: Surgical Progress, London: Butterworth; 1954
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BRAND - uses ECRB/ECRL Dorsal approachHockey stick PP incisions over tendon graft insertions over radial aspect except index finger.
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Exposure of intrinsic mechanism
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Dorsal retraction of intrinsic mechanism at PP level
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Periosteal longitudinal incision dorsal to distal edge of A-2 pulley 2.0 mm drill hole through far cortex and 2.7 mm drill hole through
near cortex
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2 transverse MC incisions over II & III; and IV MC and chevron incision
centered over reticular level
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Excision of dorsal fascial window
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Division of ECRB insertion and withdrawal prox to extensor
retinaculum
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Rerouting of ECRB superficial to extensor retinaculum
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Plantaris tendon divided into 4 slips and passed through lumbrical canal and fixed to PP long tone.
Then tendon grafts are sutured to ECRB tendon which is passed dorsal to extensor retinaculam.
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Tendon graft seated within proximal phalanx
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Pulvertaft weave
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Dorsiflexion of wrist relaxes the tendon transfer and allows for full
passive digital extension
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Wrist palmer flexion tightens the transfer and impacts a tenodesis
function, strongly flexing the metacarpophalangeal joints
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Wrist is held is full dorsiflexion, MCP joints in complete flexion.
Sutures removed at 14 days and a splint reapplied to hold wrist in 45° of extension. MCP joints in full flexion and IP joints in extension. Splinting until 6 weeks postop.
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ECRL Volar Transfer With Proximal Phalanx Insertion (Burkhalter and Strait). *
Brooks and Jones Volar Route Transfer to A2 Pulley Insertion Site‡
Palmaris Four-Tail (PL4T) Transfer (Lennox-Fritschi )†
*Burkhalter WE, Strait JL: Metacarpophalangeal flexor replacement for intrinsic-muscle paralysis. J Bone Joint Surg Am 1965
‡Brooks AL, Jones DS: A new intrinsic tendon transfer for the paralytic hand. J Bone Joint Surg Am 1975
†Fritschi EP: Nerve involvement in leprosy; the examination of the hand; the restoration of finger function. Reconstructive Surgery in Leprosy, Bristol: John Wright & Sons; 1971
Modifications in the Volar Route Transfer
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Finger flexors & wrist flexors, extensors strong, no habitual wrist flexion : Modified Bunnell (FDSR )
Habitual wrist flexion/flexion contracture of joint/sparing wrist flexor : Riordan transfer (FCR)
Wrist extensors strong, weak flexors : Brand transfer (ECRL )
FDS/wrist flexor Fowler tenodesis/or extensor unavailable : Fowler ( EPI)/ Riordan modification of Fowler
No muscle available, supple joints : Zancolli capsulodesis / Riordon tenodesis
Operation of choice
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Omer single stage procedure
Thumb MCP joint arthrodesis
Single transfer of FDSR
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In first week patient supervised to attain and maintain lumbrical-plus position and use a thermoplastic splint between exercises
Over next 7 to 10 days active IP joint flexion begun while MP joints remain in flexion
At no point during first and second stages patient allowed to extend MP joints
During third stage patient encouraged to maintain IP joint in absolute neutral extension and then extend MP joints
Exercises at this stage combined with supervised light functional activities that encourage lumbrical posture
Postoperative Hand Therapy for Claw Correction
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Adduction of thumb necessary for strong pinch Adductor pollicis paralyzed
Brachioradialis (Boyes)FDSR ( Brand)FDSR (Royle –Thompson )FDSM as Motor With Dual Insertion to the Thumb
(Goldner)ECRB (Smith)Combination of EI and ED (Little) Tendon Transfers for
Pinch (Robinson et al)
Thumb Adduction Techniques
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Brachioradialis as Motor (Boyes )
Tendon graft attached to adductor tubercle of proximal phalanx
Free end routed along volar surface of paralyzed adductor to third intermetacarpal space
Graft passed deep to extensor tendons to emerge in a subcuticular plane on radial side of forearm
Brachioradialis detached through separate incision and attached to distal graft
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Brand transfer for Thumb adduction
Sublimis of ring finger as motor
Traverses palm superficial to fascia and inserts on radia aspect at MCP joint of thumb
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Modified Royle-Thompson to restore thumb adduction
FDSR as motor Split into 2 slips 1 slip to EPL distal to
MCP joint 2nd slip to adductor
pollicis
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ECRB as motor (Smith)
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Thumb more important in pinch , but index finger needs to be stabilized to provide effective pinch
For tip pinch, index finger in abduction and slight radial rotation
Provides substitute for first dorsal interosseous muscle
Accessory Slip of APL Transfer (Neviaser et al ) EIP to first dorsal interosseous muscle (Bunnell) Extensor Pollicis Brevis (EPB) TransferPalmaris Longus to the First Dorsal Interosseous FDSR Transfer (Graham and Riordan)
Restoration of Index Abduction
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EPB Transfer Bruner
Accessory Slip of APL Transfer (Neviaser et al )
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Split FPL to EPL Transfer-Tenodesis (Tsuge and Hashizume ; House and Walsh)
To make pulp pinch possible with thumb, necessary to correct problem of IP joint hyperflexion & MP joint stabilization
Split transfer of FPL neutralizes IP joint without weakening pinch power
Tsuge K, Hashizume C: Reconstruction of opposition in the paralyzed thumb. In: McDowell F, Enna CD, ed. Surgical rehabilitation in leprosy, Baltimore: Williams & Wilkins; 1974:
House JH, Walsh T: Two-stage reconstruction of the tetraplegic hand. In: Strickland JW, ed. The Hand—Master Techniques in Orthopedic Surgery, Philadelphia: Lippincott-Raven; 1998
Stabilization of Thumb MP and IP Joints to Restore Pinch
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Half of FPL tendon transfer to the EPL tendon for restoring stability to the MP joint and IP joint of
thumb to improve pinch
Zigzag incision on the volar aspect of the thumb to expose the FPL
Radial half of FPL sectioned distal to A2 pulley, and slit farther proximally to the distal end of A1 pulley
Transferred dorsally and sutured to EPL tendon just proximal to IP joint
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Stabilizes key pinch and improve tip pinch Simultaneously restore complex flexor-
pronator function of FPB and adductor-supinator function of adductor pollicis with tendon transfers
Enable extrinsic flexor and extensors to better stabilize remaining joint
Fixed deformity of remaining joint ia contraindication for arthrodesis of either one
Arthrodesis of Thumb Joints
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Arthrodesis of MP joint
Indicated when there is severe hyperextension contracture or excessive Jeanne's sign with pain and instability.
Indicated when positive Jeanne sign develops after FDS transfer
Place MP joint in 15 degrees of flexion, 5 degrees of abduction, and 15 degrees of pronation
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Normal stability of distal transverse metacarpal arch lost owing to paralysis of the interossei, and the hypothenar muscles
Metacarpals remain together as though held by transverse sling, strong deep transverse metacarpal ligaments, while fingers are in collapsed state
Abolishes ability of palsied hand to contour itself around object placed within its domain
Simple act of opening lid of a jar or turning a valve becomes clumsy and palm is unable to be “cupped” to hold fluid, gather grain, or mold dough.
Even claw hand corrected by lumbrical replacement procedure likely to recur if transverse metacarpal arch remains unstable or flat
RESTORATION OF TRANSVERSE METACARPAL ARCH
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Bunnell's “Tendon T” Operation
Littler's Split Superficialis Tendon Procedure
Ranney's EDM Transfer
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EDM has potential to abduct little finger through its indirect insertion into abductor tubercle on proximal phalanx.
Third palmar interosseous counters this effect in normal hands
In ulnar nerve palsy intrinsic paralysis leaves the EDM unopposed (Wartenberg's sign)
LITTLE FINGER ABDUCTION (Blacker et al[; Goldner ; Voche and Merle)
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Ulnar half of tendon is directed volar to the deep transverse metacarpal ligament and sutured to the phalangeal attachment of the radial collateral ligament of the MP joint of the little finger
If little finger is clawed as well as abducted, the other half tendon is inserted through the A2 pulley of the flexor sheath.
Split-EDM Transfer
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High Ulnar Nerve palsy
Need to first restore extrinsic power before providing prehension with intrinsic muscle functional transfers
FDSR must not be transferred
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Side-to-side transfer of FDPM to FDPR and FDPL just proximal to flexor zone V in distal forearm
Exaggerate claw deformity After 3 weeks of immobilization, muscle
strengthening exercises supervised for next 4 weeks, knuckle bender splint worn
Palmaris longus to FCU, in absence of palmaris longus, section ulnar half of FCR just proximal to wrist crease and split it proximally for 10 to 12 cm before transferring this to FCU
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Loss of sensibility in ulnar border of hand and loss of proprioception in little finger significant functional limitations
Repeated ulceration at tips of digits can lead to absorption and shortening
In patients who have leprosy, successful medical treatment does not restore sensation and their insensate digits remain liability for life
RESTORATION OF SENSIBILITY
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Lewis Transferred functioning median-supplied digital nerve to a
nonfunctioning ulnar digital nerve of little finger to restore sensation
Advantages in late-presenting ulnar nerve injuries and in cases in which patients already show telltale signs of trophic changes
Transfer of neurovascular cutaneous island flap from ulnar side of pulp of middle finger to pulp of little finger in selected patients with history of chronic ulnar nerve injury due to trauma or burns
Lewis Jr RC, Tenny J, Irvine D: The restoration of sensibility by nerve translocation. Bull Hosp Jt Dis Orthop Inst 1984
Digital Nerve Transfer (Lewis et al ; Stocks et al)
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Neurovascular cutaneous island pedicle
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Disfiguring and disturbing to patients, despite successful functional restoration
Surgical insertion of dermal graft can mask interosseous wasting and most successful between thumb and index metacarpals
Suitable candidates : who had motor component of deformities corrected 2 to 3 months previously with appreciable functional restoration
WASTED INTERMETACARPAL SPACES
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Dermal Graft Procedure (Johnson )
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Combined low median and ulnar palsy
Complete anesthesia of palm and loss of function of all intrinsics of the fingers
If untreated, skin and joint contractures develop, and total claw hand
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Necessary for pinch Opposition of thumb : abdduction of thumb, flexion of
MCP joint, pronation of thumb,radial deviation of proximal phalanx of thumb on metacarpal, motion of thumb towards fingers
Abductor pollicis brevis FDSR ( Riordan, Brand ) EIP ( Burkhalter) FCU +FDSR (Groves and Goldner ) PL (Camitz ) Abductor Digiti Quinti ( Huber, Littler )
Restoration of opposition of thumb
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Sublimis tendon of the ring finger Pulley in FCUSmall tunnel for insertion of the transfer by in the abductor pollicis brevis tendon
Riordon transfer
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Brand transfer to restore opposition
FDSR as motorTendon passed to
MCP joint & attached to proximal and distal to joint after splitting its end
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Entire hand anesthetic except for the dorsal surface
Muscles available for transfer are muscles innervated by the radial nerve—the brachioradialis, the extensor carpi radialis brevis, the extensor carpi radialis longus, the extensor carpi ulnaris, and the extensor indicis proprius
Combined High Median and Ulnar Nerve Palsy
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Omer recommended Arthrodesis of MCP joint of thumb; Zancolli capsulodesis of MCP joints of all fingers Release of flexor tendon sheaths Transfer of ECRL around radial side of wrist to
FDP Transfer of brachioradialis to FPL Transfer of ECU, prolonged with a free graft,
around the ulnar border of the forearm to EPB
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To restore sensibility to the palm, Omer suggested amputating the index finger and its metacarpal and folding the radially innervated dorsal flap into the palm
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Combined high ulnar and radial nerve palsy
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Thank you