Susil seminar claw hand

1. Claw hand Prof. P.P. Kotwal DR. pramod Dr. sushil

2. Definition F lattening of transverse metacarpal arch and longitudinal arches,  with hyperextension of MCP joints and flexion of PIP and DIP joints  

3. Normal anatomy Movements of MP joints and 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 Landsmeer JMF: The coordination of finger-joint motions. J Bone Joint Surg Am 1963

4. Intrinsic muscles of hand

5. Synergistic muscles Normal Grip

6. Patho -anatomy of deformity 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.‡ ‡ Mulder JD, Landsmeer JMF: The mechanism of claw finger. J Bone Joint Surg Br 1968

7. 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

8. Roll up maneuver Loss of Grasp

9. Claw thumb in Ulnar palsy 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 Brand PW, Hollister A: Mechanics of individual muscles at individual joints. Clinical Mechanics of the Hand, 2nd ed.. St. Louis: Mosby–Year Book; 1993

10. Types of claw hand 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

11. Partial Claw hand Flexion Extension Deformity MCP Joint Lumbricals paralyzed Extensor Digitorum active Hyper extension of MCP jOINT PIP Joint FDS active Interossei paralyzed ( low Ulnar palsy ) Flexion of PIP joint DIP Joint FDP active Interossei paralyzed Flexion of DIP FDP paralyzed ( high Ulnar Palsy ) Interossei paralyzed Neutral position

12. Total Claw Hand 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

13. ETIOLOGY Traumatic Compressive neuropathy Brachial plexus injury Infective ( Leprosy, Poliomyelitis ) Peripheral neuropathies Systemic diseases ( DM, Uremai , Porphyria , Malignancies ) Drugs and Toxins (Leas, Arsenic, Dapsone , etc ) Hereditary (CMTD, Syringomyelia , Lipid storage diseases ) Ischemia Primary Nerve neoplasm

14. Rare conditions showing claw hand Ampola syndrome Angiokeratoma Arthrogyropsis multiplex congenita Aural atresia Charcot Marie Disease Chondrodysplasia punctata Chromosomal anomalies Craniofacial dysostosis Frontonasal dysplasia Muller Barth Menger Syndrome Oro facial digital syndrome type 4 Pitt Hopkins syndrome Stratton Parker syndrome

15. Pattern of Injury Low mixed Ulnar and median nerve palsy High mixed Ulnar and M edian nerve palsy Low U lnar nerve palsy High Ulnar nerve palsy

16. LOW ULNAR NERVE PALSY

17. Evaluation for Surgical Reconstruction

18. Specific signs and tests for motor dysfunction 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

19. 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

20. 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)

21. Froment’s sign Bunnel O sign FPL EPL

22. Paralysis of adductor pollicis muscle Tips of t extended digits cannot be brought together into cone Impairment of precision grip

23. High ulnar palsy

24. Pollock's sign : Inability to flex distal phalanges of ring and little fingers Partial loss of wrist flexion may occur because of paralysis of FCU Weakness of ulnar side grip

25. PREOPERATIVE ANGLE MEASUREMENTS 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

26. 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

27. CLASSIFICATION OF PARALYTIC CLAW HANDS 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.

28. 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

29. Principle 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

30. Indications for surgery 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

31. 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

32. 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

33. 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

34. Tendon transfers 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

35. 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

36. Internal splints (Early Tendon Transfers ) 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

37. Contd … 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

38. Contd … 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

39. DEFORMITIES AND DEFICIENCIES CORRECTABLE BY SURGERY

40. METHODS OF CLAW HAND RECONSTRUCTION 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

41. Proximal Phalangeal Flexion Static Techniques 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

42. 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

43. 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

44. Dorsal Methods (Howard; Mikhail) To provide bony block to proximal phalangeal extension Enables 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 Mikhail IK: Bone block operation for clawhand . Surg Gynecol Obstet 1964

45. Static Tenodesis Techniques 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

46. 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

47. 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

48. Dynamic Tendon Transfers 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

49. Transfer of Extrinsic Finger Flexors 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

50. 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

51. 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

52. 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

53. 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

54. 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 )

55. Pulley system of flexor tendon of finger

56. 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

57. Interosseous Insertions ( Zancolli Palande ; Anderson) 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

58. 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;

59. 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.

60. Subcutaneous tissue opened longitudinally and neurovascular bundles retracted to either side. FDS tendon exposed 1½ cm prox to A-1 pulley.

61. Both slips of FDS identified distal to A-1 pulley.

62. PIP joint flexed to allow proximal retraction of FDS tendon.

63. Each slip of tendon is divided distal to hemostats.

64. Finger is extended and tendon slit proximally.

65. 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.

66. Anchored to itself with multiple horizontal mattress stiches creating a strong lasso

67. 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 .

68. 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

69. 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

70. Wrist-Level Motors for Proximal Phalanx Power and Integration of Finger Flexion (Brand; Burkhalter ; Brooks; Fowler; Riordan) 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)

71. 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

72. BRAND - uses ECRB/ECRL Dorsal approach Hockey stick PP incisions over tendon graft insertions over radial aspect except index finger.

73. Exposure of intrinsic mechanism

74. Dorsal retraction of intrinsic mechanism at PP level

75. 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

76. 2 transverse MC incisions over II & III; and IV MC and chevron incision centered over reticular level

77. Excision of dorsal fascial window

78. Division of ECRB insertion and withdrawal prox to extensor retinaculum

79. Rerouting of ECRB superficial to extensor retinaculum

80. 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.

81. Tendon graft seated within proximal phalanx

82. Pulvertaft weave

83. Dorsiflexion of wrist relaxes the tendon transfer and allows for full passive digital extension

84. Wrist palmer flexion tightens the transfer and impacts a tenodesis function, strongly flexing the metacarpophalangeal joints

85. 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.

86. Modifications in the Volar Route Transfer 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

87. Operation of choice 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

88. Omer single stage procedure Thumb MCP joint arthrodesis Single transfer of FDSR

89. Postoperative Hand Therapy for Claw Correction 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

90. Thumb Adduction Techniques 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)

91. 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

92. 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

93. Modified Royle -Thompson to restore thumb adduction FDSR as motor Split into 2 slips 1 slip to EPL distal to MCP joint 2 nd slip to adductor pollicis

94. ECRB as motor (Smith)

95. Restoration of Index Abduction 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) Transfer Palmaris Longus to the First Dorsal Interosseous FDSR Transfer (Graham and Riordan)

96. EPB Transfer Bruner Accessory Slip of APL Transfer ( Neviaser et al )

97. Stabilization of Thumb MP and IP Joints to Restore Pinch 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

98. 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

99. Arthrodesis of Thumb Joints 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

100. 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

101. RESTORATION OF TRANSVERSE METACARPAL ARCH 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

102. Bunnell's “Tendon T” Operation Littler's Split Superficialis Tendon Procedure Ranney's EDM Transfer

103. LITTLE FINGER ABDUCTION (Blacker et al [ ; Goldner ; Voche and Merle) 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)

104. Split-EDM Transfer 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 .

105. High Ulnar Nerve palsy Need to first restore extrinsic power before providing prehension with intrinsic muscle functional transfers FDSR must not be transferred

106. 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

107. RESTORATION OF SENSIBILITY 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

108. Digital Nerve Transfer (Lewis et al ; Stocks et al) 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

109. Neurovascular cutaneous island pedicle

110. WASTED INTERMETACARPAL SPACES 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

111. Dermal Graft Procedure (Johnson )

112. 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

113. Restoration of opposition of thumb 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 )

114. Riordon transfer Sublimis tendon of the ring finger Pulley in FCU Small tunnel for insertion of the transfer by in the abductor pollicis brevis tendon

115. Brand transfer to restore opposition FDSR as motor Tendon passed to MCP joint & attached to proximal and distal to joint after splitting its end

116. Combined High Median and Ulnar Nerve Palsy 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

117. 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

118. 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

119. Combined high ulnar and radial nerve palsy

120. Thank you