CLAW HAND

Definition

Flattening of transverse metacarpal arch and longitudinal arches,

Hyperextension of MCP joints Flexion of PIP and DIP joints 

3 BASIC FUNCTIONS OF HAND

* HOOK* GRASP* PINCH

All functions of the hand are combinations of these three functions

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

Intrinsic muscles of hand

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

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

Synergistic muscles Normal Grip

ROLL UP MANEUVER

LOSS OF GRASP

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

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

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

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

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

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

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

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

LOW ULNAR NERVE PALSY

Evaluation for Surgical Reconstruction

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

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

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)

Froment’s sign Bunnel O sign

FPL

EPL

BENEDICTION TEST

High ulnar palsy

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

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

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

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

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

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

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

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

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

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

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

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

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)

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…

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…

DEFORMITIES AND DEFICIENCIES CORRECTABLE BY SURGERY

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

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

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

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

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

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

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

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

RIORDAN OPPOSITION

BRANDS

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

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

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

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

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

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

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 )

Pulley system of flexor tendon of finger

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

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)

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;

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.

Subcutaneous tissue opened longitudinally and neurovascular bundles retracted to either side.

FDS tendon exposed 1½ cm prox to A-1 pulley.

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

PIP joint flexed to allow proximal retraction of FDS tendon.

Each slip of tendon is divided distal to hemostats.

Finger is extended and tendon slit proximally.

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.

Anchored to itself with multiple horizontal mattress stiches creating a

strong lasso

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.

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

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

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)

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

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

Exposure of intrinsic mechanism

Dorsal retraction of intrinsic mechanism at PP level

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

2 transverse MC incisions over II & III; and IV MC and chevron incision

centered over reticular level

Excision of dorsal fascial window

Division of ECRB insertion and withdrawal prox to extensor

retinaculum

Rerouting of ECRB superficial to extensor retinaculum

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.

Tendon graft seated within proximal phalanx

Pulvertaft weave

Dorsiflexion of wrist relaxes the tendon transfer and allows for full

passive digital extension

Wrist palmer flexion tightens the transfer and impacts a tenodesis

function, strongly flexing the metacarpophalangeal joints

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.

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

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

Omer single stage procedure

Thumb MCP joint arthrodesis

Single transfer of FDSR

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

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

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

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

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

ECRB as motor (Smith)

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

EPB Transfer Bruner

Accessory Slip of APL Transfer (Neviaser et al )

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

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

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

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

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

Bunnell's “Tendon T” Operation

Littler's Split Superficialis Tendon Procedure

Ranney's EDM Transfer

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)

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

High Ulnar Nerve palsy

Need to first restore extrinsic power before providing prehension with intrinsic muscle functional transfers

FDSR must not be transferred

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

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

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)

Neurovascular cutaneous island pedicle

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

Dermal Graft Procedure (Johnson )

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

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

Sublimis tendon of the ring finger Pulley in FCUSmall tunnel for insertion of the transfer by in the abductor pollicis brevis tendon

Riordon transfer

Brand transfer to restore opposition

FDSR as motorTendon passed to

MCP joint & attached to proximal and distal to joint after splitting its end

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

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

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

Combined high ulnar and radial nerve palsy

Thank you