1.Claw handProf. P.P. KotwalDR. pramodDr. sushil

2. Definition Flattening of transversemetacarpal arch andlongitudinal arches, withhyperextension of MCPjoints and flexion of PIPand DIP joints 3. Normal anatomy Movements of MP joints and IP joints independent Movements of 2 IP joints coordinated ; flexion of DIPjoint 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 extensors ability to extend PIP joint.Mulder JD, Landsmeer JMF: The mechanism of claw finger. J Bone JointSurg 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 extrinsicflexors and extensors, with proximal phalanx behaving likeintercalated bone. MP joint will go into hyperextension and IP joint intoflexion because of the greater extensor moment at the MPjoint and the lesser extensor moment at the IP joint,respectively. Z-thumb deformityBrand PW, Hollister A: Mechanics of individual muscles at individual joints. Clinical Mechanics of the Hand, 2nd ed.. St. Louis: MosbyYear Book; 1993 10. Types of claw hand Complete : Involving all digits and resulting fromcombined Ulnar and Median Nerve palsy Incomplete : Involving only ulnar 2 digits as inisolated Ulnar Nerve palsy 11. Partial Claw handFlexionExtensionDeformityMCP Joint Lumbricals Extensor Hyper extension ofparalyzedDigitorum active MCP jOINTPIP Joint FDS active Interossei Flexion of PIP paralyzed ( lowjoint Ulnar palsy )DIP Joint FDP active Interossei Flexion of DIP paralyzedFDP paralyzed( Interossei Neutral positionhigh Ulnar Palsy ) paralyzed 12. Total Claw HandFlexion ExtensionDeformityMCP Joint LumbricalsExtensor Hyper extension atparalyzed digitorum active MCPPIP Joint FDS paralyzed Extensor Extension of PIPdigitorum activeDIP Joint FDP paralyzed Extensor Extension of DIPdigitorum active 13. ETIOLOGY Traumatic Compressive neuropathy Brachial plexus injury Infective ( Leprosy, Poliomyelitis ) Peripheral neuropathiesSystemic 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 Median nerve palsy Low Ulnar nerve palsy High Ulnar nerve palsy 16. LOW ULNAR NERVE PALSY 17. Evaluation for Surgical Reconstruction 18. Specific signs and tests for motor dysfunction Duchennes sign : Hyperextension at MCP joints &flexion at IP joints Bouviers maneuver : Dorsal pressure over proximalphalanx to passively flex MP joint results instraightening of distal joints and temporarycorrection of claw deformity Extensor digitorum tendon can extend middle anddistal phalanges when proximal phalanx stabilized Andre-Thomas sign : On palmar -flexon of wristexaggeration of deformity 19. Pitres-Testut sign : Inability to actively move longfinger s in radial and ulnar deviation with palm placedflat Cross your fingers test : Inability to cross middlefinger dorsally over index finger, or index overmiddle finger Masses sign: Flattened metacarpal arch and loss ofhypothenar elevation Wartenbergs sign : Inability to adduct extendedlittle finger to extended ring finger 20. Jeannes sign : Hyperextension of MP joint of thumb during key pinch or gross grip Froments sign : Thumb IP joint flexion while attempting to perform lateral pinch Bunnells 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. Froments signBunnel O signFPLEPL 22. Paralysis ofadductor pollicismuscle Tips of t extendeddigits cannot bebrought togetherinto cone Impairment ofprecision grip 23. High ulnar palsy 24. Pollocks sign : Inability to flex distal phalanges ofring and little fingers Partial loss of wrist flexion may occur because ofparalysis of FCU Weakness of ulnar side grip 25. PREOPERATIVE ANGLE MEASUREMENTSMeasured at PIP joint of each finger and IP joint of thumbusing a goniometer placed on dorsal aspect of joint Unassisted angle : Maintain lumbrical-plus position ofMP flexion and IP extension, and extension deficit at PIPjoint measured Assisted angle : Proximal segment of finger supported tomaintain flexion at the MP joint and instructs the patientto 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 jointsand no contractures at IP joints Type II: Hypermobile joints; PIP joints hyperextension >20 degrees Type III: Mobile joints in association with adaptiveshortening of long flexors, usually superficialis tendons ,with no IP joint contractureAnderson GA: Analysis of paralytic claw finger correction using flexor motors into differentinsertion sites. Masters 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 andloss of independence of movement at MP and PIPjoints principal disability Third muscle-tendon unit needs to run volar tocenter of curvature of MP joint and dorsal to center ofcurvature of head of PIP joint to counterbalancesystem and provide equilibrium and independence ofnormally functioning intrinsic muscles Alternatively, MP joint needs to be staticallyprevented from hyperextension to allow longextensors to extend IP joints 30. Indications for surgeryNerve Injuries Patient referred late ( 1 year ) After nerve repair, if electrodiagnostic tests show nosigns of reinnervation within 6 to 9 months*Jobe MT, Wright PE: Peripheral nerve injuries. In: Canale ST, ed. Campbells OperativeOrthopaedics, 4. 9th ed.. St. Louis: Mosby; 1992 31. Leprosy Understanding of stage and activity of disease, presence of intact,healthy skin, patient motivation.* Recommended whenpatients medical treatment optimized skin smears for the bacillus negative bacteriological index negative on two successive testsdisease activity quiescent for at least a year before date of intendedsurgery,paralysis establishedpatient free of corticosteroid treatment for several months beforesurgery*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 apart of or whole of interosseous muscles or vice versa Paralysis typically nonprogressive and with no loss ofsensation Children affected, and joints hypermobile Surgery be delayed until child is at least 5 years of age, sothat child will be able to cooperate with postoperative re-education program Anderson GA: The childs 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 patientand altered or changed whenever indicated can help tomanage claw deformity Splints interfere with rehabilitation of sensibility andare 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 directionnecessary - Pulley Absolute contraindication: Non-compliant patientwith poor motivation who will not follow appropriatepostop rehabilitation 36. Internal splints (Early Tendon Transfers) Burkhalter Allow early function of hand while awaiting nerveregeneration Can prevent deformities that lead to contractures Improve coordination of residual muscle-tendonunits 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 remainand function as a permanent solution 38. Contd Proximal phalanx flexion for ring and littlefingers : Ulnar half of FDSR with split insertion toring and little fingers to lateral band of DEE or A1, A2,or A1 + A2a pulleys Restoration of transverse metacarpal arch andadduction of little finger : FDSR Y insertion Thumb adduction for key pinch : FDSR radial halfto abductor tubercle, FDSL to hypothenar insertion,near fifth MP joint 39. DEFORMITIES AND DEFICIENCIES CORRECTABLEBY SURGERY 40. METHODS OF CLAW HAND RECONSTRUCTION Static and Dynamic procedures Static procedures : To maintain MP joint in some degree of flexion or tolimit MP joint hyperextensionclaw posture reversed by functioning long extensorsFlexion of MP joint unrestricted in static proceduresDisadvantages : restore normal finger coordinationand sequence but do not provide an additional motor torestore MP flexion. Recurrence : rule unless there is radical change inpatients work style and paralyzed hand more protectedthan 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 jointlevel combined with shortening of pretendinous band of palmaraponeurosis (fasciodermadesis) to correct claw hands with weakextensors *Bunnell S: Surgery of the intrinsic muscles of the hand other than those producing opposition ofthe thumb. J Bone Joint Surg 1942 Zancolli EA: Structural and Dynamic Bases of Hand Surgery, 2nd ed.. Philadelphia: JB Lippincott;1979 42. ZancolliCapsulodesis Volar MP joint Capsulodesis A1 pulley release with MPjoint volar plate advancement Complicated claw hands withMP joint contracture Zancolliincorporated collateral ligamentrelease on both sides of MP jointwith 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 volarplate by cutting away atriangular portion of thedeep transversemetacarpal ligament(DTML) on each side ofvolar plate flapOmer Jr GE, Spinner M, ed.Management of PeripheralNerve Problems,Philadelphia: WB Saunders;1980 44. Dorsal Methods (Howard; Mikhail) To provide bony block to proximal phalangealextension Enables long extensors to extend IP joints and correctdeformity. Mikhail inserted bone block on dorsum of themetacarpal head Howard suggested elevation of bone wedge as blockfrom the dorsal aspect of the metacarpal head itselfMikhail IK: Bone block operation for clawhand. Surg Gynecol Obstet 1964 45. Static Tenodesis Techniques Riordan One half of ECRL and ECU tendons made use ofas grafts to prevent hyperextension of MP joint whileremaining half continue to actively extend wristRiordan DC: Tendon transfers for nerve paralysis of the hand and wrist. Curr Pract Orthop Surg 1964 46. Parkes Static Tenodesis(Volar Side)With FreeTendon Grafts 2 free tendon grafts,from plantaris tendon,palmaris tendon, or toeextensors, required forfour fingers 47. Integration of Finger Flexion Fowler tenodesis Wrist Tenodesis TechniqueFowler Incorporates active wrist motionto tension static tendon grafts Free tendon grafts sutured toextensor retinaculum of wristand passed in a dorsal to palmardirection through theintermetacarpal spaces, volar tothe DTML, through the lumbricalcanals, and onto the lateral bandsof dorsal extensor expansion of 4fingers 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 FlexorsSuperficialis Tendon Transfer Techniques andModifications (Stiles; Bunnell; Littler) FDS detached , splitted, & transferred to dorsum offingers to extensors tendons Removespowerful flexor of PIP joint & converts it intoextensor Intrinsic plus deformity 50. Bunnell (1942) : rerouted both slips of all superficialis tendonsthrough lumbrical canals and anchored them to both sides oflateral band of dorsal extensor expansion (Stiles-Bunnellprocedure) Transfer involved passage of Split FDSI for radial side of lateral bands of index and middlefingers Split FDSM for ulnar side lateral band of index, middle, andring 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 donorfinger most frequent when superficialis removed throughconventional midlateral approach Midlateral approach exposed distal part of lateral band toinjury and contributed to DIP extension lag High incidence of swan neck deformity in one or more ofoperated fingers owing to excessive tension on transferredtendon slip Loss of PIP joint flexion due to adhesions betweenprofundus and superficialis tendon remnant 52. To prevent these complications, North and Littler : removalof superficialis through volar incision between A1 and A2pulleys Brand : Ulnar nerve palsy results in claw deformities in all fourfingers, Weakness is not limited only to fingers withobvious clawing. Recommendation : surgery be done in all fingers of a clawhand North ER, Littler JW: Transferring the flexor superficialis tendon: Technical considerations in the prevention ofproximal 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 ofthe Stiles-Bunnell procedure byusing FDSM Referred to as modified Stiles-Bunnell procedure Tendon slips sutured undercorrect tension, that is, withwrist in neutral flexion-extension, MP joints in 45 to 55degrees of flexion, and IP jointsin neutral position. Littler JW: Tendon transfers and arthrodesis incombined median and ulnar nerve palsies. J Bone JointSurg Am 1949 54. 4 primary insertion sites of FDS are classified as:A. Lateral band insertionintrinsic replacement (Stilesand 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 tendonslips directly to proximalphalanx Avoid risk of PIP jointhyperextension noted withtransfers to lateral band of thedorsal apparatus Increased distance of momentwith increased flexion of MPjoint Burkhalter WE, Strait JL:Metacarpophalangeal flexorreplacement for intrinsic-muscleparalysis. J Bone Joint Surg Am 1965 57. Interosseous Insertions (Zancolli Palande; Anderson) Interosseous tendons used as insertion sites withdifferent motors: superficialis tendon, ECRL ,orpalmaris longus Zancolli : first and second dorsal interosseous asinsertion sites to attach slips of a superficialis tendonwith goal of obtaining proximal phalangeal flexionand restore digital abduction ( direct interosseousactivation) Palande : extended this principle to correct intrinsic-minus hands associated with reversal of the transversemetacrapal arch 58. Pulley Insertions (Zancollis 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 itselfZancolli EA: Claw-hand caused by paralysis of theintrinsic muscles: A simple surgical procedure forits correction. J Bone Joint Surg Am 1957; 59. Lasso procedure (ZANCOLLI) - Transfer of FDS to A-1pulleys, index, long, ring and small fingers. Transverse incision made at level of first A-1 pulley,beginning at prox. palmar crease of index finger andending ulnarly at distal palmar crease of little finger. 60. Subcutaneous tissue openedlongitudinally and neurovascular bundles retracted to either side. FDS tendon exposed 1 cm prox to A-1 pulley. 61. Both slips of FDS identified distal to A-1 pulley. 62. PIP joint flexed to allow proximalretraction of FDS tendon. 63. Each slip of tendon is divided distal tohemostats. 64. Finger is extended and tendon slitproximally. 65. Two slips of FDS tendon (distal) folded down volarlyover 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 : Extendedpulley insertion (EPI) bylooping slip ofsuperficialis tendon aroundboth the A1 and proximalA2 pulleys in each finger. Anderson GA: Analysis of paralytic clawfinger correction using flexor motors intodifferent insertion sites. Masters thesis,University of Liverpool, 1988. 68. Finger Level Extensor MotorFowler transferExtensor Indicis Propriusand Extensor DigitiMinimi Transfer(Fowler ) EIP and EDM tendons as transferslateral bands of the dorsal apparatus May produce excessive tension inextensor apparatus and lead tointrinsic-plus deformities. May cause reversal of normalmetacarpal arch and, occasionally,extensor weakness in the little finger Fowler SB: Extensor apparatus of the digits (abstract).J Bone Joint Surg Br 69. Riordan ModificationSplitting EIP into 2 slipsand transferring themthrough intermetacarpalspace between the ring andlittle digits, routed palmarto the transversemetacarpal ligament andonto radial lateral bandsof the ring and littlefingersRiordan DC: Tendon transplantations in median-nerve and ulnar-nerve paralysis. J Bone Joint SurgAm 1953 70. Wrist-Level Motors for Proximal Phalanx Power and Integration ofFinger Flexion (Brand; Burkhalter; Brooks; Fowler; Riordan) To simultaneously correct claw deformity and gaingrip strength, add additional muscle-tendon unit topower train for flexion of proximal phalanx Best achieved by transferring wrist motor orbrachioradialis to flex proximal phalanges Require free grafts to provide sufficient length to reachinsertion site( plantaris, palmaris, fascia lata, or toeextensors) 71. Dorsal Route Transfer of ECRB (Brand) ECRL or ECRB lengthened byplantaris tendon that was splitinto four tails Tendon slips passed throughintermetacarpal spaces, into thelumbrical canal and palmar tothe DTML, to be attached toradial lateral bands of the long,ring, and little fingers and ulnarlateral band of the index finger Did not improve flattenedtransverse metacarpal arch orweakness of grip Brand PW: Hand reconstruction in leprosy. BritishSurgical Practice: Surgical Progress, London:Butterworth; 1954 72. BRAND - uses ECRB/ECRLDorsal approachHockey stick PP incisions over tendon graft insertionsover radial aspect except index finger. 73. Exposure of intrinsic mechanism 74. Dorsal retraction of intrinsic mechanism atPP 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 overreticular level 77. Excision of dorsal fascial window 78. Division of ECRB insertion and withdrawal prox to extensorretinaculum 79. Rerouting of ECRB superficial to extensorretinaculum 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 ispassed dorsal to extensor retinaculam. 81. Tendon graft seated within proximalphalanx 82. Pulvertaft weave 83. Dorsiflexion of wrist relaxes the tendontransfer and allows for full passive digital extension 84. Wrist palmer flexion tightens the transferand 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 45of 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 PulleyInsertion Site Palmaris Four-Tail (PL4T) Transfer (Lennox-Fritschi )*Burkhalter WE, Strait JL: Metacarpophalangeal flexor replacement for intrinsic-muscle paralysis. J Bone Joint Surg Am 1965Brooks AL, Jones DS: A new intrinsic tendon transfer for the paralytic hand. J Bone Joint Surg Am 1975Fritschi 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, nohabitual wrist flexion : Modified Bunnell (FDSR ) Habitual wrist flexion/flexion contracture ofjoint/sparing wrist flexor : Riordan transfer (FCR) Wrist extensors strong, weak flexors : Brand transfer(ECRL ) FDS/wrist flexor Fowler tenodesis/or extensorunavailable : Fowler ( EPI)/ Riordan modification ofFowler No muscle available, supple joints : Zancollicapsulodesis / 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 forPinch (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 toMCP joint 2nd slip to adductorpollicis 94. ECRB as motor (Smith) 95. Restoration of Index Abduction Thumb more important in pinch , but index finger needsto be stabilized to provide effective pinch For tip pinch, index finger in abduction and slight radialrotation 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 Accessory Slip of APL TransferBruner (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 tocorrect problem of IP joint hyperflexion & MP jointstabilization Split transfer of FPL neutralizes IP joint withoutweakening pinch powerTsuge 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 HandMaster Techniques in Orthopedic Surgery, Philadelphia: Lippincott-Raven; 1998 98. Half of FPL tendon transfer to the EPL tendon for restoring stabilityto the MP joint and IP joint of thumb to improve pinch Zigzag incision on thevolar aspect of thethumb to expose the FPL Radial half of FPLsectioned distal to A2pulley, and slit fartherproximally to the distalend of A1 pulley Transferred dorsally andsutured to EPL tendonjust proximal to IP joint 99. Arthrodesis of Thumb Joints Stabilizes key pinch and improve tip pinch Simultaneously restore complex flexor-pronatorfunction of FPB and adductor-supinator function ofadductor pollicis with tendon transfers Enable extrinsic flexor and extensors to better stabilizeremaining joint Fixed deformity of remaining joint ia contraindicationfor arthrodesis of either one 100. Arthrodesis ofMP joint Indicated when there is severe hyperextension contracture or excessive Jeannes 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 owingto paralysis of the interossei, and the hypothenar muscles Metacarpals remain together as though held by transverse sling,strong deep transverse metacarpal ligaments, while fingers arein collapsed state Abolishes ability of palsied hand to contour itself around objectplaced within its domain Simple act of opening lid of a jar or turning a valve becomesclumsy and palm is unable to be cupped to hold fluid, gathergrain, or mold dough. Even claw hand corrected by lumbrical replacement procedurelikely to recur if transverse metacarpal arch remains unstable orflat 102. Bunnells Tendon T Operation Littlers Split Superficialis Tendon Procedure Ranneys EDM Transfer 103. LITTLE FINGER ABDUCTION (Blacker et al[; Goldner ; Voche and Merle) EDM has potential to abduct little finger through itsindirect insertion into abductor tubercle on proximalphalanx. Third palmar interosseous counters this effect innormal hands In ulnar nerve palsy intrinsic paralysis leaves the EDM unopposed (Wartenbergs sign) 104. Split-EDM TransferUlnar half of tendon isdirected volar to the deeptransverse metacarpalligament and sutured to thephalangeal attachment of theradial collateral ligament ofthe MP joint of the littlefingerIf little finger is clawed aswell as abducted, the otherhalf tendon is insertedthrough the A2 pulley of theflexor sheath. 105. High Ulnar Nerve palsy Need to first restoreextrinsic power beforeproviding prehensionwith intrinsic musclefunctional transfers FDSR must not betransferred 106. Side-to-side transfer of FDPM to FDPR and FDPL justproximal to flexor zone V in distal forearm Exaggerate claw deformity After 3 weeks of immobilization, muscle strengtheningexercises supervised for next 4 weeks, knuckle bendersplint worn Palmaris longus to FCU, in absence of palmaris longus,section ulnar half of FCR just proximal to wrist creaseand split it proximally for 10 to 12 cm beforetransferring this to FCU 107. RESTORATION OF SENSIBILITY Loss of sensibility in ulnar border of hand and loss ofproprioception in little finger significant functionallimitations Repeated ulceration at tips of digits can lead toabsorption and shortening In patients who have leprosy, successful medicaltreatment does not restore sensation and theirinsensate digits remain liability for life 108. Digital Nerve Transfer (Lewis et al ; Stocks et al) Lewis Transferred functioning median-supplied digital nerve toa nonfunctioning ulnar digital nerve of little finger torestore sensation Advantages in late-presenting ulnar nerve injuries and incases in which patients already show telltale signs oftrophic changes Transfer of neurovascular cutaneous island flap from ulnarside of pulp of middle finger to pulp of little finger inselected patients with history of chronic ulnar nerve injurydue to trauma or burns Lewis Jr RC, Tenny J, Irvine D: The restoration of sensibility by nerve translocation. Bull Hosp Jt DisOrthop Inst 1984 109. Neurovascular cutaneous island pedicle 110. WASTED INTERMETACARPAL SPACES Disfiguring and disturbing to patients, despite successfulfunctional restoration Surgical insertion of dermal graft can mask interosseouswasting and most successful between thumb and indexmetacarpals Suitable candidates : who had motor component ofdeformities corrected 2 to 3 months previously withappreciable 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 ofMCP joint, pronation of thumb,radial deviation ofproximal phalanx of thumb on metacarpal, motion ofthumb towards fingers Abductor pollicis brevis FDSR ( Riordan, Brand ) EIP ( Burkhalter) FCU +FDSR (Groves and Goldner ) PL (Camitz ) Abductor Digiti Quinti ( Huber, Littler ) 114. Riordon transferSublimis tendonof the ring fingerPulley in FCUSmall tunnel forinsertion of thetransfer by in theabductor pollicisbrevis 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 nervethe brachioradialis, the extensor carpi radialis brevis, the extensor carpi radialis longus, the extensor carpi ulnaris, and the extensor indicis proprius 117. Omer recommendedArthrodesis 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 FDPTransfer of brachioradialis to FPLTransfer of ECU, prolonged with a free graft,around the ulnar border of the forearm to EPB 118. To restore sensibilityto the palm, Omersuggestedamputating theindex finger and itsmetacarpal andfolding the radiallyinnervated dorsalflap into the palm 119. Combined high ulnar and radial nerve palsy 120. Thank you