ulnar nerve palsy

INTRODUCTIONThis chapter discusses the various techniquesthat can be used to correct the hand with paral-ysis of the ulnar-innervated muscles. For a rel-evant understanding of the anatomy of thehand and the pathokinesiology of the ‘intrinsicminus’ hand the reader may also want to referto Chapter 5. First, the functional impairmentsof the hand will be briefly discussed. Theauthor then will discuss the procedures to cor-rect the hand which can be divided in what arecommonly called static (passive) and dynamic(active) procedures or tendon transfers.

The mixed nerve trunk most often damagedby leprosy in the upper extremity is the ulnarnerve. Less often the median nerve is involved,usually in combination with the ulnar nerve.The radial nerve is rarely involved. With paral-ysis of the intrinsic muscles, the hand adoptsthe typical posture of clawing, initially maybeonly the ring and little fingers (Fig. 6-1), even-tually often all fingers (Fig. 6-2). Latent or 'hid-den' clawing is usually present in the index andmiddle fingers in a recent ulnar palsy.

The clawing of the fingers can be very stig-matizing in leprosy endemic areas, and is espe-cially obvious when greeting in almost any cul-ture. It becomes also evident when eating incultures that use their fingers.

The important loss of sensation in ulnarnerve palsy is in the ulnar border of the hand.This may not seem important but most of ouractivities at home and at work are with thehand on surfaces like a desk, carpentry bench,working on a car motor or with tools in the gar-den. These activities all require the fine feed-back of the little finger exploring first the areaswhere the hand is going to act. The loss of sen-sation therefore greatly increases the dis-abilityof the already paralyzed hand.

PATHOPHYSIOLOGY OF DISABILITIES INTHE INTRINSIC MINUS HANDWith ulnar nerve palsy all interosseous musclesare paralyzed and therefore the primary flexors

6Ulnar Nerve Palsy

� F. DUERKSENR. SCHWARZ

FIGURE 6-1 Ulnar nerve paralysis with overtclawing confined to the ring and little fingers.

FIGURE 6-2 Ulnar nerve palsy with clawing of allfour fingers.

6 Chapter New 29/9/05 14:12 Page 47

of the metacarpophalangeal (MCP) joints are absent. This leads to the hyperextensiondeformity of the MCP’s when the extensor digitorum communis tries to extend the fingerto open the hand. Since the extensor digitorumis tethered by the sagittal bands, there is hyperextension of the MCP (Fig. 6-3), and thedistal part of the extensor loses excursion overthe distal joints and therefore the flexion posture of the proximal interphalangeal joint(PIP) and distal interphalangeal joint (DIP)occurs. 12,14,16,20,23

The intrinsic minus hand loses power ingrip but has also a decrease in control of thefine coordinated movements necessary in deli-cate work. With ulnar nerve palsy the handloses 40-70% of power.15,19,33 The ulnar nerveprovides most of the strong motor power to thehand through the flexor digitorum profundus,hypothenar muscles, all interossei and theadductor- and flexor pollicis muscles.

By not being able to spread the fingers thehand loses span of grasp. Surgery is indicatedwhen there is disability in grasp, grip, pinch,greeting, eating, flat hand, human contact andwhen the deformities caused by the intrinsicparalysis lead to stigma and handicap. 26,28-30

If the median nerve is still intact, the lum-bricals to index and long fingers, together withthe tissue restraint of the volar structures of theMCP joint, can maintain extension for some

time, with normal appearance, but there is veryminimal primary MCP flexion strength. It is forthese reasons that tendon transfers shouldalways be done to all four fingers, even if theparalysis is only ulnar.4,13

The distal palmar arch is lost or reversed inulnar nerve palsy mainly due to loss ofhypothenar muscle function. This does notallow for cupping of the hand and keeping ofwater or other substances. For a secure grasp itis also essential to have a transverse distalmetacarpal arch.22,24,25

The fine finger coordination and sequenceof joint movements or synergism is lost withparalysis of the intrinsic muscles.20,28 The nor-mal hand initiates flexion at the MCP joints,followed by flexion at the proximal interpha-langeal (PIP) and distal interphalangeal (DIP)joints. In the ulnar palsied hand this sequenceis reversed (Figs. 6-2, 6-4b). This represents lossof a great part of normal hand function.

The intrinsic minus or claw position, predis-poses to high pressure points on the finger tipsand the metacarpal heads area. (Fig. 6-4a and 6-4b) Flexion contractures predispose to fissureswhen fingers are stretched. With loss of protec-tive sensation, this can lead to wounds andinfection. Therefore, by correcting the clawhand, wounds can be prevented. Almost allreconstructive operations done on leprosypatients have a preventive aspect.

48 Surgical Reconstruction & Rehabilitation in Leprosy

Figure 6-3 Ulnar-median palsy with metacar-pophalangeal hyperextension.

FIGURE 6-4a Normal grasp with pressureequally distributed over surface of the palm.


It is important to emphasize the importanceof the flexor digitorum profundus of the 5thand 4th fingers in grasp, as in closing the fistand also the importance of the strong flexorcarpi ulnaris stabilizing the wrist in ulnar devi-ation in all power functions. These muscles arealso innervated by the ulnar nerve in the fore-arm and are often totally or partially paralyzed.

The patient needs to be informed in detailabout what surgery will most likely achieve.Only then can and should he or she make thedecision to have surgery. It is also mandatorythat a plan for the whole person should bemade, not only for the hands. Patients alsohave to demonstrate that they have learned tocare for hands that have loss of protective sen-sation. It is tragic to sometimes see a handbeautifully reconstructed by tendon transfers,rapidly being destroyed by the new forcesbecause the patient has not incorporated careof the anaesthetic hand. We also need to assessif the patient can understand what the tendontransfer will do and if he or she will cooperatefully i.e. is motivated.

It is important to stress the absolute needfor physiotherapy and/or occupational thera-py in the pre-and postoperative period.2,13

Contractures need to be corrected, and themuscle to be transferred must be isolated andlater re-educated in its new function. As a gen-

eral rule, if contractures of PIP and/or DIPjoints are severe, even after full correction itwill be necessary to splint these fingers also inthe post operative period to prevent recur-rence.

Once the decision to operate has been made,the next step is to decide on the surgical tech-nique to be used.

SURGICAL PROCEDURESThe surgical techniques can be classified asStatic and Dynamic procedures. The dynamictechniques can further be classified accordingto the muscle used, the insertion of the trans-ferred tendon and/or the route the transfertakes.

STATIC PROCEDURESThese procedures basically provide a staticblock preventing MCP hyperextension. In thisposition the sagittal bands move distally andthe extensor digitorum has enough excursionto extend the PIP and DIP joints. These proce-dures do not provide an active MCP joint flex-or. The normal synergistic closure mechanismis not restored, but some of the mechanics andposition of the hand are restored as well as theappearance. These procedures are normallynot used in leprosy, unless there is a triple orhigh median paralysis and there are notenough muscles available for transfer. Staticprocedures are used mostly in quadriplegia orbrachial plexus paralysis. Some surgeons havea preference for static procedures and reportgood results. Static surgical procedures do notrequire much re-education and avoid compli-cations that may happen with a dynamic pro-cedure e.g. an intrinsic plus or swan neckdeformity.

Many procedures have been described. Allfollow the same principle of limiting MCPextension.

Ulnar Nerve Palsy 49

FIGURE 6-4b Grasp in ulnar palsy with pressureconcentrated over fingertips and MCP joints.


Parkes graft tenodesis22

A fascia lata tendon graft is sutured into thedistal edge of the transverse ligament of thecarpal tunnel, then divided into four slips andtunneled through the lumbrical canals andinserted into the lateral band of each finger.Tension is regulated so that the MCP joints arein 15 to 20 degrees of flexion with the wrist inneutral. With wrist action some control can begained over the degree of tension in the ten-odesis.

Zancolli’s volar MCP capsulodesis

In this operation the volar plate of the fingerMCP’s is sectioned transversally or in a longi-tudinal flap and then re-sutured, overlappingin such a way that the MCP is held in 20° offlexion.1,17,21 This surgical technique does notrestore normal hand kinetics, but allows theEDC to open the hand for grasp. The mainproblem encountered is that the capsulestretches with time. Tenodesis are easier to per-form if one prefers a static procedure.Technically the volar MCP capsulodesis is noteasy. It requires good surgical experience.

Pulley advancement (Bunnell – Palande)

In combination with volar capsulodesis oralone, advancement of the proximal edge of theA1 pulley creates a semi-active flexion of theMCP.1,3,8,9,17,21 Through a volar approach, theA1 pulley is cut longitudinally at each side,close to the insertion of the pulley into bone,for a distance of 1-1.5 cm (Fig. 6-5), until theflexors bowstring on contraction. If not enoughpulley is liberated, the moment arm of the flex-or is not enough to flex the MCP. For this rea-son the pulley advancement works best incombination with volar capsulodesis. Somesurgeons report good results with this opera-tion.

There are many other static proceduresusing tendon graft as tenodesis to block the

MCP joints in some degree of flexion.28-30 Aninteresting technique is Srinivasan’s extensordiversion graft.31 Four fascia lata strips aretunneled through the interosseous spaces fromthe dorsum of the hand, volar to the transverseintermetacarpal ligament and again to the dor-sum of the proximal finger. The tendon graft issutured to the extensor tendon on the dorsumof the hand and to the lateral bands in the fin-ger. Tension is such, that the MCP’s are held in20° of flexion. There is a small dynamic compo-nent in this tenodesis that initiates MCP flex-ion. A more dynamic tenodesis described byWarren (personal communication) is to attach agraft to the lateral bands and fix the proximalend to the palmaris longus or flexor carpi radi-alis insertion with the MCP joints at 20 degreeswith the wrist in the neutral position. Thistransfer will give some MCP flexion on wristextension.

In general, static surgical procedures forcorrection of the intrinsic minus hand are poorsubstitutes for normal intrinsic action. Forthese reasons I recommend a dynamic transferwhenever possible.

DYNAMIC PROCEDURESWrist MotorsBrand extensor to flexor four tailed (EF4T)

The motor or muscle used is the extensor carpiradialis longus (ECRL).2,4 Since this tendon istoo short to reach the fingers, a graft is needed.


FIGURE 6-5 Pulley advancement procedure. TheA1 pulley has been cut close to the bone on eachside.


Brand proposed the use of the plantaris tendonbut it is often absent. For this reason we usefascia lata graft routinely which gives similarresults.13 There are special tendon strippers forplantaris and for fascia lata that can be used tominimize the incisions. An open tensor fascialata graft can also be taken if the stripper is notavailable, although it is easy to use ladder-likesmall incisions and long Metzenbaum scissorsto harvest the graft. The distal insertion of thetransferred tendon is into the lateral bands ofthe extensor mechanism of the fingers.

TechniqueIncisions: The recipient area should be pre-pared first as this will minimize the exposuretime of the transferred tendon if the insertionsites are exposed at the end of the procedure.

Incisions 1-4 are made on the dorsilateralborder of the proximal phalanx on each finger(Fig. 6-6). Care is taken to preserve the dorsal

vein. The incision is on the radial side of little,ring and long finger and on the index it is doneon the ulnar side. This facilitates the three fin-ger (chuck) pinch with the thumb. This is themost commonly used form of pinch and is veryimportant for people who eat with their hands.Note that the Chinese often prefer the indexinsertion on the radial side to facilitate holdingchopsticks. The extensor mechanism isexposed, especially the lateral bands and thecentral tendon. The thin synovial film that cov-ers the extensor mechanism is removed in thearea where the transfer will be sutured, other-wise the synovial film might prevent firmadhesions of the transferred tendon.

Incision 5 - A 2-3 cm transverse incision ismade on the dorsiradial aspect of the wrist.Feel for the insertion of ECRL and make theincision just over this. Protect the radial cuta-neous nerve branches. Dissect the tendon of theextensor carpi radialis longus free (make sure it

is not the brevis or extensor pollicuslongus!) and transect the tendon nearits insertion, grasping the proximalend with a hemostat.

Pulling on the tendon you can feelthe movement in the mid forearm (onthe radial side) and make incision N°6 which is transverse and 2 cm long10 cm proximal to the radial styloid.Free the extensor carpi radialis longustendon from the brevis and with ablunt instrument pull the distal partof the tendon out through the inci-sion. Sometimes there are tendonstrips crossing from ECRL to ECRBand the tendon cannot be extracted.Pulling to hard on the ECRL tendoncan damage or disrupt the musculo-tendinous junction. It is best to makea longitudinal incision near the wristand free the tendons. Sometimes it isalso possible to push the tendon fromdistal to proximal.


FIGURE 6-6 Incisions for EF4T. a. Dorsal aspect b. Palmaraspect.

123

4

5

6 6

7

8

6 Chapter New 29/9/05 14:12 1

Incision N° 7: This is made in the distalthird on the volar forearm, opening theaponeurosis. With the tunneller coming fromincisions 7 to 6 under the fascia, grasp the endof the ECRL and exteriorize it in the volar inci-sion.

The graft is now anastomosed to the graftaccording to Brand’s technique. The plantarisor tensor fascia lata are most commonly used.If the plantaris longus is used, the motor ten-don is incised longitudinally for about 1 cmand through 2/3 of its thickness (Fig. 6-7). Thesite is near the end of the tendon or more prox-imal so that the anastomosis does not enter thecarpal tunnel, although it has not created prob-lems if it does.6 With a scalpel, the tendon isthen pierced from side to side in the middle ofthe opening created and the plantaris graftpassed through at 90° to the ECRL. With finemonofilament sutures the graft is sutured tothe deep fibers in the longitudinal incision. Thegraft should have two halves of the samelength.

The incision in the ECRL is now closed with5/0 or 6/0 monofilament nylon and the suture

left in the field. The suture should be invagi-nating, so that knots and sutures are buried.One of the plantaris tendons is spread out bypulling the tendon transversally with hooks orstay sutures. The plantaris and palmaris havethis quality of being able to stretch out like afilm. The end of the ECRL is trimmed to sizewith a long oblique cut. Next the stretchedplantaris is wrapped around the ECRL stump.Again 3 or 4 sutures fix the ECRL stump to theplantaris. The same fine nylon suture used toclose the incision in the ECRL is now used toclose the graft around the motor tendon goingwell beyond the end of the ECRL.

If fascia lata is used, the distal end of thegraft is cut in a pointed fashion and introducedinto the ECRL tendon through a hole made atthe distal end of the longitudinal incision. Thegraft is sutured deep to the fibers of the ECRLwith 3-4 fine stitches (Fig. 6-8a). The longitudi-nal incision is closed as described above. TheECRL is trimmed obliquely and the fascia latais wrapped around the tendon stump andsutured into a tube, after fixing the motor ten-don to the graft with interrupted sutures (Fig.6-8b). The ECRL tendon and the graft are now


FIGURE 6-7 Brand anastomosis using plantaristendon. a. 1.5 cm boat-shaped opening made inECRL and plantaris tendon passed through theECRL tendon at this level and sutured at its base.b. ECRL opening closed, plantaris stretched outflat. c. Plantaris tendon wrapped around the endof ECRL tendon and sutured. FIGURE 6-8 Brand anastomosis using fascia lata.

a. Fascia lata passed into boat-shaped opening nearthe end of ECRL tendon and sutured. b. ECRLopening closed, fascia lata wrapped around end ofECRL and sutured in continuity with ECRL closure.

FasciaLata

FasciaLata

6/0 Nylon

ECRL ECRL

ECRL

Hooks

Plantaris(a) (b)

(a) (b)

(c)


united to each other by 6-8 sutures and thewrap around reinforces this even more. Thisgives a very strong anastomosis. The graft isthen tunnelled deep to all structures to incisionN° 8, a 2cm incision in the proximal palm inline with the thenar crease. The tendon graftanastomosis should not enter the carpal tun-nel.6 The anastomosis should therefore beplaced proximally enough on the ECRL tendonand the graft long enough to reach the dorsumof the fingers. Care is taken that the superficialvascular palmar arch is not compromised. It isbest to come out with the tendon distal to thevascular arch. The graft is now divided in 4slips (strands or tails) (Fig. 6-9). Each slip isnow tunneled from the palm to the dorsal inci-sions on the fingers (Fig. 6-10). Care is taken to

pass volar to the transverse intermetacarpal lig-ament to ensure MCP joint flexion (Fig. 6-11).Passing the tunneller from the dorsal incisionto the palm, the ligament can be easily feltmoving the tunneller tip volar to dorsal, backand forth. Holding the finger with the MCP inflexion will facilitate this maneuver. Possibleerrors are also to tunnel subcutaneously orbridge part of the palmar aponeurosis. The tun-neller has to come out exactly in the middle ofthe incision. It is important to probe aroundwhen tunnelling to find a route with minimalresistance. All incisions, except those for thefingers, are now closed.

Important in all tendon transfers is the ten-sion given to the transfer. Experience hasshown that by using a standard position for thehand, more consistent tension can be judged.Recommended is to position the hand with thewrist in 30° of flexion and MCP’s at 80°-90° andthe DIP and IP joints at 0° or neutral extension.There are special splints designed which caneasily be made out of metal (Fig. 6-12) or wood,but it can easily be arranged with rolled upgreen towels or a sterilized can of pop or beer.The total tendon excursion will be about 2 cm.


FIGURE 6-9 EF4T procedure. a. Passing graftinto palmar incision using Anderson tunneler. b.

Graft divided into 4 slips (from Fritschi13, used

with permission).

FIGURE 6-11 EF4T procedure, showing passage ofgraft palmar to the transverse metacarpal ligament.

FIGURE 6-10 EF4T procedure, showing route ofgrafts from wrist to fingers (from Fritschi13, usedwith permission).

Lumbrical tendon

Transverse metacarpal ligament

Extensor(a) (b)


For a stiff hand more then half the total excur-sion for tension should be used. In mobilehands almost no tension is adequate. Usuallythe index transfer is done first and then the lit-tle finger which always receives 1 cm more ten-sion to assist in restoring the distal transversemetacarpal arch.

By dividing the tendon graft in 5 bands, oneslip can be tunnelled to the ulnar side of the lit-tle finger and sutured to the abductor digitiminimi tendon with slightly more tension. Thisextra step usually results in a good transversemetacarpal arch if the hand is mobile.

If the fingers are in a Boutonniere positionthat does not correct with physiotherapy, wehave used very successfully a technique shownto me by Dr. Ernest Fritschi, referred to as dor-sal fixation of the lateral band (see Chapter 9).The recipient lateral band of the tendon trans-

fer, is freed from all underlying tissue to themiddle of the mid phalanx and is folded onitself 180°. The band should cross the PIP in themiddle. It is sutured to the central tendon andextensor apparatus. The tendon transfer is nowsutured to the doubled up lateral band. Thisleaves a stiff PIP in extension initially, butphysiotherapy will usually correct this.

If the DIP is fixed in extension, a tenotomyof the distal extensor tendon is done. A N° 15knife is pushed under the skin, flat, to the DIP.It is then turned 90° with the blade towards thebone and a long oblique tenotomy of the exten-sor is done from the DIP proximally. Check forrelease of the DIP to be sure that all fibers havebeen cut. The DIP joint should flex to at least 45degrees. Early mobilization of the DIP is start-ed in the post-operative period. The tendonwill heal in a stretched position. Mallet finger isseldom seen. Sometimes I have also cut the col-lateral ligaments at the PIP joint partially andreleased the volar plate as well.

The tourniquet is now released, finger inci-sions closed and a strong plaster splint isapplied with wrist slightly in flexion, fingersstraight and MCP in maximum flexion. Someuse a full cast. It is essential to keep the operat-ed hand elevated at all times for at least 72hours.

The initial cast stays on until physiotherapystarts at about 3-4 weeks, unless there are com-plications. This transfer is one of the best. Itadds a strong muscle to the flexor group. It isnot difficult to re-educate and removing theextensor carpi radialis longus leaves very littleloss of function if the radial nerve is normal.Pre- and postoperative views are seen in Fig. 6-13 a,b.

Complications of EF4T: Swan neck or“Intrinsic plus” can occasionally be seen if thetension is too strong or when the fingers arehypermobile. Unequal tension on the 4 bandscan be very disabling (quadriga effect).


FIGURE 6-12 EF4T procedure/ sublimus transfer,showing hand on splint with grafts coming out ofthe dorsal finger incisions ready to suture to later-al bands.


Palmaris longus transfer (PMT, palmarismany tailed)

Fritschi and Ranney reported on the use of thepalmaris longus with a tendon graft13,28,29,30

(fascia lata or plantaris) for intrinsics replace-ment of the fingers. The tendon graft anasto-mosis can be difficult because of the small sizeof the palmaris, although a Brand anastamosisshould deal with this problem. It is ideal forhypermobile hands. It is not as powerful as theother motors used in the other techniques. Thepalmaris has a tension fraction similar to thatof the lumbricals, and so can just produce pri-mary MCP flexion in the mobile hand but withminimal strength.

Another approach to the hypermobile handis to insert the tendon slips of FDS into the A1pulley or as Palande has shown, into the ten-dons of the interossei.22

Extensor Extensor Many Tailed (EEMT)

Before using the volar route, Brand firstdescribed the same operation, transferring thetendon through the interosseous spaces.2 Fromthe palm each tendon is then tunnelled volar tothe intermetacarpal ligament to the lateralbands. The main problems encountered areadhesions to the interosseous aponeurosis,reverse metacarpal arch and tenodesis effect

with wrist flexion. Adhesions can be avoidedby carefully probing for a defect in the fasciallayers when doing the tunnelling as describedabove. Some surgeons still prefer to use thissurgical technique, reporting good results (per-sonal communication).

Flexor Carpi Radialis Transfer

Riordan uses the flexor carpi radialis asmotor.26,27,28 This also needs a tendon graft. Here-routes to the dorsum of the forearm, thenperforates the interosseous spaces and thenroutes the transfer from the palm to the lateralbands for insertion. It is a strong transfer.Perforating both interossei fascia may causeadhesions. This technique uses the principalwrist stabilizer which may leave a seriousweakness. This problem can be avoided byrouting it on the flexor side of the wrist as apalmaris longus transfer, which will keep itsrole as a wrist flexor.

Finger MotorsFlexor Sublimis Transfer

The reason we use the sublimis transfer as rou-tine in South America, is to avoid having to dothe tendon anastomosis. It takes a skilled anddelicate surgeon to perform the EF4T proce-dure. Our aim is to include as many surgeonsas possible and it is easier and faster to performthe sublimis transfer. [RS: I would suggesttraining surgeons to do the best procedure pos-sible for each patient if the skill level is pres-ent.] The types of hands are also generally thestrong stiff European hands and severe con-tractures are also common. The aboriginalshave hypermobile hands similar to that seen inIndia or Asia.

Usually the long finger flexor superficialis isused as the motor and the insertion can be intothe lateral bands in the same manner asdescribed for the EF4T, or the insertion can beinto the A1 pulley as described by Zancolli orBrooks.4,5,13,25,26,27,28,29


FIGURE 6-13 Claw hand. a. Pre-operatively. b. Following EF4T procedure with restoration ofprimary MCP flexion.


Lateral Band Insertion: (Stiles - Bunnell -Brand)8,9,32 Incisions in the fingers are the sameas described in the EF4T. The tendon of thelong finger sublimis is harvested through anoblique incision on the volar aspect of the prox-imal phalanx. The tendon on one side is tran-sected just proximal to the vinculae longa. Ifthe vinculae is transected then complete hemo-stasis must be achieved to avoid scarring andlater flexion contracture of the PIP (check rein).Fritschi recommends to cut the flexor superfi-cialis as close as possible to its insertion.13 Theother tendon can be visualized and cut bypulling on the first tendon. The second tendonwill appear underneath the flexor profundus.

The decussation of the tendon has to bedivided, otherwise it slings around the flexorprofundus and the flexor sublimis can not bewithdrawn. This is done by flexing the wristand MCP’s and pulling on the two tendon slipswith hemostats. A closed scissor is passedalong the flexor superficialis until a window isfelt. Pulling on the scissor hooked into the win-dow, the union between the two slips is visual-ized and can be transected.

The sublimis tendon can also be harvestedthrough a transverse incision just proximal tothe flexion crease at the MCP joint. The tendonis withdrawn through the interval between A1and A2 pulley or an interval is created. Pullinghard the sublimis tendon can usually be exteri-orized and cut just proximal to the decussationand vincula.

Through a 2 cm incision at the base of thepalm in line with the thenar crease, the flexorsuperficialis of the long finger is withdrawn,preferably distal to the superficial palmar vas-cular arch. The sublimis is divided into 4 equalslips (Fig. 6-14). This is not difficult because the fibers are very parallel and straight.Maintaining strong tension on the tendon, aknife can be passed from proximal to distal.

The remainder of the surgical technique isas described for the EF4T with similar tensions(Fig. 6-15). Pre-and post-operative results areseen in Fig. 6-16 a,b.


FIGURE 6-14 Sublimis transfer with sublimis ten-don split into four tails in palm.

FIGURE 6-15 Route of sublimis transfer to later-al bands.

TendonTransfer

Flexorsublimis

Transverseintermetacarpalligament


Insertion into Flexor Pulley (Zancolli Lasso-Brooks)7,13,27,28,29,33

The area of insertion is the distal palm. Acurved, transverse incision is made in the palmfrom the radial border to the ulnar border,about 1 cm proximal to the MCP flexion creas-es.

The flexor tendon sheaths are dissected freeand the proximal border of the A1 pulley iden-tified. The synovial sheaths are opened justproximal to the A1 pulley border with scalpelor pointed scissors, care taken not to injure theflexor digitorum superficialis.

The flexor superficialis of the long finger istransected distally as described above. It caneasily be withdrawn through the long trans-verse incision. The tendon is withdrawnthrough a small separate incision at the base ofthe palm and divided into 4 slips or bands asdescribed before. A fifth slip can be divided.

The 4 slips are tunneled close to the radialside of each flexor sheath into the transverse

incision (Fig. 6-17). Each slip is then pulledthrough the proximal 5-7 mm of the A1 pulley(Fig. 6-18). A small gallbladder hemostat isquite helpful. Grinding the tips of a gallblad-der forceps or a curved mosquito hemostatmakes it easier to pierce through the pulley.With the hand flat on the table and the fingersin extension, the slips are sutured to itselfunder maximum tension. The little fingerreceives about 1 cm more tension. Some sur-geons insert the tendon into the A2 pulley toincrease the moment arm. The problem is thatthe tendon bowstrings. I have seen patientswith large calluses at the volar MCP and alsowith problems in grasping small objects liketool handles, especially brooms. [RS: I routine-ly use the A2 pulley without seeing the prob-lems noted above. It has the same moment armas the interossei insertion.4]

A 5th slip can be created and inserted intothe ulnar side of the MCP of the little finger toincrease the transverse arch.32


FIGURE 6-17 Zancolli “Lasso” procedure, showingsublimis tendon split into four slips and havingbeen passed from palmar incision back to trans-verse palmar incision.

FIGURE 6-18 Zancolli “lasso” procedure, showingtransferred sublimis slip looped around the A1 pul-ley and sutured to itself.

FIGURE 6-16 Ulnar/ median palsied hand. a. Pre-operatively. b. Following sublimis transferto lateral bands and opponensplasty, with fullrestoration of primary MCP flexion.


Complications: Check rein (scarring at PIPlevel) presents as a PIP fexure contracture, andis dealt with in chapters 7 and 22. MCP flexioncontracture can rarely be seen if sutures of thetendon slips are done with fingers in flexion.Intrinsic plus, superficialis minus or profundusplus deformity at the donor or other fingers arefairly common. These are all swan-neck-likedeformities but are the result of too muchpower in the transfer, taking the superficialisaway or of the FDP creating a flexion deformi-ty at the DIP, respectively (see chapters 7, 9 and22).

Extensor Proprius Transfer

Fowler uses as motor the extensor indicis pro-prius and extensor digiti quinti minimi, eachdivided into two slips and the same as Riordan,perforates the interosseous membranes.13,28,29,30

I have used this technique in my initial years ofleprosy work. The results were consistentlypoor. Adhesions and difficulty in re-educationwere the main problems.

Intrinsic Reactivation Technique

Palande, in this technique, uses the extensorcarpi radialis longus as motor, with fascia latagraft. The insertion is into the adjacentinterosseous tendons in the interdigital space.It reactivates the primary flexors of the MCPjoints leaving extension for the extrinsic exten-sors. The results seen by these techniques inPalande’s patients are really excellent, but it isan operation for the well experienced hand sur-geon.

The Contracted Claw HandIf the contracture of the PIP is less than 45°, andphysiotherapy is of no help, tendon transferscan still be done for claw hand deformity.Function increases greatly. Surgical methodsreleasing skin and ligaments can also be usedsuccessfully. When the contracture is near 90°soft tissue release may be attempted and

arthrodesis of the PIP gives a functional hand(chapter 9). As Dr. Paul Brand so often said “anarthrodesed hand loses a lot of its humanness”and there is seldom a patient happy with anarthrodesis. Especially in interpersonal contacta rigid finger feels very unnatural.

The long standing paralysis of the intrinsicsin the hand can lead to fixed contractures withMCP’s in extension and PIP and DIP’s in fullflexion. Function of the hand is severelyreduced and the patient basically uses thehands as paddles. Physiotherapy shouldalways be attempted for 2 or 3 months. It is sur-prising how often contractures improve.

The surgical solution is to arthrodese thePIP and DIP in extension. This leaves the fingerat half its length because of the amount of boneto be resected. Non union and mal union arecommon (see chapter 9).

One patient showed me another way. Byhacking off the 4 fingers of both hands with amachete at the PIP level, he forced me to tidyup his surgery. He was a bricklayer and laterhad improved function of the hands with onlyproximal phalanges. Observing other patients Inoticed that when finger injuries reach the PIPlevel, often no more injuries occurred. Thelength is the same as the arthrodesed finger.The only thing missing is the fingernail whichis important to some patients, especiallyfemales. The proximal phalanx is well paddedand the long flexors act now as MCP flexors,improving function greatly as compared to therigid claw position. I now prefer the PIP levelamputation.

Summary- intrinsic lossWe have used the Brand EF4T transfer withinsertion into the A1 pulley in hands that need-ed a strong transfer, but were hypermobile.There is often discussion as to which techniqueis better: the A1 pulley or the extensor inser-tion. We believe each has its place. In hypermo-bile hands the insertion in the A1 pulley pro-



vides an active MCP flexor and restores thenormal sequence in closing the hand used ingrasp without acting on the extensor mecha-nism. The danger of producing a swan neck isless. But the extending of the fingers has to bedone by the extensor digitorum communis,which in turn will act against the transfer. Thismay need extra attention in re-education. It iseasy to recognize a “Zancolli” hand, becausethe fingers are seldom fully extended whenadopting the intrinsic position. Functionallythis is not important, but it may be cosmetical-ly.

The insertion of the transfer into the lateralbands restores most of the intrinsic functionand is reserved for stronger, stiff hands, or withresidual contractures.

With the EF4T and the two FDS transfers wehave been able to solve most problems with theintrinsic minus hand. The palmaris longustransfer for hypermobile hands is also reason-able.

FLEXOR DIGITORUM AND FLEXORCARPI ULNARIS WEAKNESSWhen the FDP of the long finger is weak, all 4flexor digitorum profundus tendons can besutured together in the distal forearm in thenatural finger cascade position. HoweverBrand did not consider this a major problemand only recommended surgery if the FDS tothe little finger was weak or absent.4 If the longfinger FDP is strong, the index FDP does notneed to be included. Use a strong non-absorbable suture like 3/0 nylon and free thetendons of synovium at the transfixing suturesite. In this situation it would be advisable touse a wrist motor procedure such as the EF4Tas opposed to an FDS transfer.

Rarely a patient may complain of significanteffect of the loss of wrist ulnar deviation (dueto loss of FCU) on his ability to function well.In this case the FCR tendon could be trans-

ferred to the FCU insertion, and use brachiora-dialis to attach to the FCR stump, as Brand sug-gests.4 This is seldom a problem.

ULNAR NERVE PARALYSIS IN THETHUMBIn ulnar nerve paralysis the adductor pollicis,the first dorsal interosseous and often flexorpollicis brevis (FPB) are paralyzed. Loss ofadductor pollicis causes marked weakening ofkey pinch. Loss of FPB causes interphalangeal(IP) hyperflexion (Froment’s sign) or metacar-pophalangeal hyperextension (Z-thumb),depending on the individual hand. Prolongeduncorrected ulnar/median palsy is not infre-quently associated with trapezio-metacarpalsubluxation.

Restoration of Key PinchApproximately 25 percent of thumb adductionstrength is provided by the extensor pollicislongus (EPL) and flexor pollicis longus (FPL)and as such most patients do not request inter-vention to strengthen key pinch. However, apatient with particular work requirements withan ulnar palsy in the dominant hand mayrequest increased thumb adduction strength.The infrequency of this procedure being per-formed may be partly due to the surgeon fail-ing to either examine the hand at work or toactually measure pinch strength, as Brand haspointed out6, and the defect may go unrecog-nized. Adductor pollicis (AP) is a powerfulmuscle with a tension fraction (TF) of 3.0, withFPB providing an additional 1.3. For compari-son the FPL has a tension fraction of only 2.7.For those who do require strengthening of keypinch, either extensor carpi radialis brevis (TF4.2) or flexor digitorum superficialis (m) (TF3.4) can be used. Extensor indicis proprius hasbeen used7 but with a tension fraction of only1.0 this seems rather weak to be very effectual,although Palande also confirms its usefulness



(personal communication). Brand suggestsusing two tendon grafts to the thumb in ulnar/median nerve palsy, using FDS to the adductorand extensor indicis proprius for opposition.3

Boyes1 has used the brachioradialis extendedwith a graft, taking this through the thirdmetacarpal space, but this can be difficult to re-educate.

Extensor Carpi Radialis Longus to AdductorTransfer-Technique (Omer)

This technique was originally described bySmith7 and modified by Omer.6 The extensorcarpi radialis brevis (ECRB) tendon is dividedat its insertion and extended with a free tendongraft using a Brand anastomosis. The graft isthen tunnelled through the third inter-metacarpal space to the palm. It is then broughtvolar to the AP and dorsal to the flexor tendonsand neurovascular bundle to be attached to theabductor pollicis brevis insertion. The tensionis adjusted so that the thumb is just palmar tothe index finger when the wrist is straight.Immobilization is continued for three to fourweeks after which therapy is commenced.Wrist flexion allows thumb abduction, andwhen the wrist is extended the thumb isadducted against the palm. The key pinchstrength is doubled on average by this opera-tion.7 This operation has the disadvantages ofusing ECRB, the principle wrist extensor, andan angle at the pulley of 90°. Smith stoppedusing this transfer subsequent to his publica-tion (personal communication).

Flexor Digitorum Superficialis to AdductorPollicis Transfer- Technique

Littler first described this procedure.19 The dis-advantage of this procedure is the loss of oneflexor digitorum superficialis (FDS), especiallyif another is going to be used for intrinsicreplacement for the fingers. This will furtherweaken power grip. The FDS is divided

through a distal palmar incision just proximalto its decussation. It is brought out in the palmand then tunnelled across the palm volar to theadductor pollicis (AP) to be attached to the APinsertion (Fig. 6-19). The palmar fascia where ithas been split serves as the pulley. Tensionagain is set so that the thumb lies close to theindex finger with the wrist in neutral. Plaster isapplied with the wrist in 30° of flexion with thethumb adducted, and the hand kept immobi-lized for three to four weeks. Brand prefersattachment to abductor pollicus brevis inser-tion or to extensor pollicus longus halfwayalong the proximal phalanx in patients withmedian/ulnar palsy. This will give both adduc-tion/flexion and also improve thumb prona-tion.3 A separate tendon such as extensor indi-cis proprius is then used for thumb opposition.Hamlin and Littler4 reported a pinch power of70 percent of the opposite hand following thisprocedure.


FIGURE 6-19 Flexor digitorum superficialis to

adductor pollicus transfer (from Omer25, used with

permission).


Restoration of Primary thumb MCPFlexionPatients with isolated ulnar nerve palsy usual-ly have adequate primary MCP flexion and donot require further surgery. With combinedulnar- median paralysis primary MCP flexionis lost, which may produce variable amounts ofI-P hyper-flexion as well as MCP hyper-exten-sion. This in turn may produce an unstablepinch as the grip surface is the tip rather thanthe pulp. Often the double-insertion FDS(Brand) opponensplasty as described in chap-ter 7 adequately stabilizes the thumb to preventIP hyper-flexion. If not, there are five ways thisproblem can be corrected.

Metacarpophalangeal joint arthrodesis.Half flexor pollicus longus to extensor

pollicus longus transfer.Additional slip from ‘Lasso’ to AP inser-

tion.Interphalangeal joint arthrodesis.Flexor- adductor replacement.

The best technique depends on the patient,the thumb and the hand (see below). For a Z-thumb deformity, the most reliable technique ismetacarpal-phalangeal joint arthrodesis. Forisolated interphalangeal joint hyperflexion,half FPL to EPL transfer gives the best result.

1) Metacarpophalangeal Arthrodesis

Similar to the fingers, when the metacarpopha-langeal joint of the thumb is stabilized theinterphalangeal joint is able to extend. As well,fixing the metacarpophalangeal joint in slightflexion will allow the distal joint to flex inde-pendently, avoiding the hyperflexion producedwhen the proximal joint is hyperextended. Themetacarpophalangeal joint functionally has alimited range of movement, from 0-20° in theflexion-extension plane. The loss of this move-ment does not result in any functional impair-ment, and arthrodesis will restore control of the

distal joint. For this reason for a patient with amobile interphalangeal joint the MCP jointshould be arthrodesed, and the distal jointshould only be arthrodesed when there is afixed flexion deformity present. This is the pro-cedure of choice for a fixed deformity of theMCP joint such as a fixed hyperextension.

Technique

There are many ways to fuse a digital joint. Thefollowing technique I have found quite satis-factory. A 4 cm dorsal incision is made over thedorsum of the MCP joint, displacing the exten-sor tendon and then proceeding to cut down tobone. The fibres of the extensor brevis aredivided and the joint capsule is opened. Thecollateral ligaments are divided to allow dislo-cation of the joint. The joint surfaces are cutwith either a saw or bone cutters so that whenopposed the joint will be in 15° of flexion and5° of abduction (Fig. 6-20a). A Chevron cut (Fig.6-20b) will give a larger surface area and morestable fixation. Two crossed K-wires are thenadvanced into the proximal phalanx to exit theskin. The two bone surfaces are then opposedwith the thumb in 15° of pronation and the K-wires drilled into the metacarpal. The thumb isimmobilized in a short thumb spica for 8 weeksand then active motion of the thumb is permit-ted. The K-wires are removed at 8 weeks orwhen bone healing is seen on X-ray.

2) Half Flexor Pollicus Longus to extensorpollicus longus transfer.

This procedure, described by Malaviya20 stabi-lizes the interphalangeal joint by making theflexor pollicus longus both a flexor and exten-sor of the joint, but a pure flexor of the MCPjoint. This prevents extension of the MCP jointduring thumb flexion and corrects the inter-phalangeal hyperflexion resulting from this. Itis the procedure of choice in a patient with amobile IP joint with Froment’s sign.



TechniqueThe flexor pollicus longus is identified thougha small transverse incision along the interpha-langeal joint crease and again through a secondincision along the metacarpal joint crease.From the first incision the radial half of the ten-don is separated and cut off its insertion. It isthen separated as proximally as possible byflexing wrist and thumb and pulling on bothslips. The cut slip is then identified and with-drawn from the proximal incision. It is thenbrought around the radial aspect of the proxi-mal phalanx to be inserted into the extensorpollicis longus at the mid-point of the proximalphalanx (Fig. 6-21). Tension should be adjustedso that in full interphalangeal extension and20° of metacarpophalangeal flexion the twoslips of the flexor pollicus longus are at thesame tension. The dorsal slip thereforebecomes taut in flexion, and because the ten-don is volar to the MCP joint it will then flex


FIGURE 6.20 Metacarpophalangeal joint arthrodesis. a. Flat surfaces. Oblique cuts made through bone.Angle of cut determines amount of joint flexion. Fixation with cross K-wires. b. Chevron arthrodesis.

(a) (b)

FIGURE 6.21 Half FlexorPollicus Longus (FPL) toExtensor Pollicus Longus(EPL) transfer. Radial half ofFPL divided at insertion,brought out at MCP joint andthen across phalanx to insertinto EPL at neutral tension.


this joint. A thumb spica including the wrist isplaced with the thumb in full opposition andthe wrist in 20° flexion for three weeks.

3) Additional slip from ‘Lasso’

When a lasso procedure is being carried out forintrinsic loss replacement (see intrinsic replace-ment section of this chapter), a fifth tail can beadded to the transfer to provide first MCP flex-ion. The radial-most slip from the superficialistendon is brought radially over the adductorpollicis and deep to the digital vessels to insertinto the abductor pollicus brevis insertion. Thedistal edge of the palmar fascia thereforebecomes the pulley. It is sutured with thethumb in near full abduction. If this is too tightthe grip span will be reduced. This will pro-duce thumb adduction, pronation and MCPflexion. This may be expecting too much of asingle transfer in some hands and detract fromthe intrinsic function of the transfer on the fin-gers.

4) Arthrodesis of Interphalangeal Joint

This procedure is only indicated in the pres-ence of a relatively severe fixed flexion contrac-ture of the IP joint. It is rather disabling as itdoes not allow the patient to adjust the thumbtip angle in pinch, yet if the MCP joint is mobilepatients cope well. It is preferable to a fixedcontracture in which the nail is part of the con-tact surface, which predisposes to ulceration. Amild flexion contracture is usually best notinterfered with.

The technique is as for finger I-P fusion. Theideal position is straight or even in slight exten-sion, although in the presence of shortened dig-its slight flexion may be necessary to facilitatecontact.

5) Flexor-adductor replacementThe adductor replacements described abovealso provide primary MCP flexion and can beused as such.

SUMMARYIn general, surgery for the ulnar deficit hand inleprosy is most rewarding and if good physio-therapy is available, most patients have excel-lent results, the hands look better and functionbetter and are less likely to have injuries.

Do not embark on surgical correction ofclaw hands without the presence of experi-enced hand therapists. Preparing the handsand re-educating the transferred muscle, is anessential part in the rehabilitation of any para-lyzed hand.

Ideally, nerve function loss should be pre-vented in leprosy patients. If present, the sec-ondary complications such as contracturesshould be prevented so that dynamic tendontransfer procedures can be employed to givemaximum functional and cosmetic benefit tothe hand. Only if hands are very badly con-tracted need the surgeon resort to arthrodesisand other operations to restore some function-ality to the hand.

REFERENCES1. Bourrel P: Raccourcissement capsulaire

metacarpo-phalangien et avancement despoulies des flechisseurs dans les paralysies desmuscles intrinseques des doigts. Ann Chir Plast15:27-33, 1970

2. Brand PW: Tendon grafting. Illustrated by anew operation for intrinsic paralysis of the fin-gers. J Bone Joint Surg 43B:444-453, 1961

3. Brand PW: Discussion, capsulodeses and pulleyadvancement for correction of claw-fingerdeformity. J Bone Joint Surg 54A:1470, 1972

4. Brand PW, Hollister A: Operations to restoremuscle balance to the hand. Clinical Mechanicsof the Hand. 2nd ed. St. Louis: Mosby, 170-222,1995

5. Brand PW: Paralytic hand claw: with special ref-erence to paralysis in leprosy and treatment bythe sublimis transfer of Stiles and Bunnell. JBone Joint Surg 40B:618-632, 1958

6. Brandsma JW, Brand PW: Median nerve func-tion after tendon transfer for ulnar paralysis. JHand Surg 10B:30-32, 1985

7. Brooks AG, Jones DS: A new intrinsic transferfor the paralytic hand. J Bone Joint Surg57A:730, 1975



8. Bunnell S: Surgery of the intrinsic muscles of thehand other than those producing opposition ofthe thumb. J Bone Joint Surg 24:1-31, 1942

9. Bunnell S: Surgery of the Hand. ed.3,Philadelphia, J.B. Lippincott Co., 1956

10. Chacko V, Mall B, Shukla RK, Gupta AK:Assessment of sublimis transfer operation inleprosy. Lepr India 45:146-150, 1973

11. Enna CD, Riordan DC: The Fowler procedurefor correction of the paralytic claw hand. PlastRec Surg 52:352-360, 1973

12. Eyler DL, Markee JE: The anatomy and func-tion of the intrinsic musculature of the fingers. JBone Joint Surg 36A:1, 1954

13. Fritschi EP: Surgical Reconstruction andRehabilitation in Leprosy. The Leprosy MissionNew Delhi. 1984

14. Hastings H. II, McCollam SM: Flexor digitorumsuperficialis lasso tendon transfer in isolatedulnar nerve palsy: A functional evaluation. JHand Surg 19A:275-280, 1994

15. Kozin SH, Porter Scott, Clark P, Thoder JJ: Thecontribution of the intrinsic muscles to grip andpinch strength. J Hand Surg 24A:64-72, 1999

16. Landsmeer JMF: Power grip and precision han-dling. Ann Rheum Dis 21:164, 1962

17. Leddy JP, Stark HH, Ashworth CR, Boyes JH:Capsulodesis and pulley advancement for thecorrection of claw-finger deformity. J Bone JointSurg 54A:1465-71, 1972

18. Lee DH, Rodriguez JA: Tendon transfer forrestoring hand intrinsic muscle function: A bio-mechanical study. J Hand Surg 24A:609-13, 1999

19. Linscheid RL, An KN, Gross MR: Quantitativeanalysis of the intrinsic muscles of the hand.Clin Anat 265-284, 1991

20. Mulder JD, Landsmeer MF: The mechanism ofclaw finger. J Bone Joint Surg 50A:664-668, 1968

21. Palande DD: Correction of paralytic claw fingerin leprosy by capsulorrhaphy and pulleyadvancement. J Bone Joint Surg 58A:9-66, 1976

22. Palande DD: Correction of intrinsic-minushands associated with reversal of the transversemetacarpal arch. J Bone Joint Surg 65A:514-521,1983

23. Parkes AR: Paralytic claw fingers - a graft ten-odesis operation. Hand 5:192, 1973

24. Ranney DA: The mechanism of arch reversal inthe surgically corrected claw hand. J Hand Surg6:266-272, 1974

25. Ranney DA: Reconstruction of the transversemetacarpal arch in ulnar palsy by transfer of theextensor digiti minimi. Plast Rec Surg 52:406-412, 1973

26. Riordan DC: Tendon transplantations in medi-an-nerve and ulnar-nerve paralysis. J Bone JointSurg 35:312-320, 1953

27. Riordan DC: Surgery of the paralytic hand. In:Am Ac Orthop Surg: Instructional CourseLectures. 16, St. Louis, CV Mosby, 79-90, 1959

28. Smith RJ: Intrinsic muscles of the fingers: func-tion, dysfunction, and surgical reconstruction.In Am Ac Orthop Surg: Instructional CourseLectures. 24, St. Louis 1975, CV Mosby 200-220,1975

29. Smith RJ: Surgical treatment of the clawhand.In AAOS: Symposium on tendon surgery in thehand. St. Louis 1975, CV Mosby Co., 181-203,1975

30. Smith RJ: Tendon transfers of the hand and fore-arm. Boston, Little, Brown: 103-133, 1987

31. Srinivasan H: The extensor diversion graft oper-ation for correction of intrinsic minus fingers inleprosy. J Bone Joint Surg 55B:58-65, 1973

32. Stiles HJ, Forrester-Brown MF: Treatment ofinjuries of the peripheral spinal nerves.London, H Frowde: 166, 1922

33. Talsania JS, Kozin SH: Normal digital contribu-tion to grip strength assessed with a computer-ized digital dynamometer. J Hand Surg 23B:162-166, 1998

34. Zancolli E: Correccion de la “garra” digital porparalisis intrinseca; la operacion del “lazo” ActaOrthop Latino Am 1: 65, 1974

Ulnar Nerve Paralysis in the thumb1. Boyes JH: Bunnell's Surgery of the Hand. 4th

Ed. p.514. JB Lippincott, Philadelphia, 1964 2. Brown PW: Reconstruction for pinch in ulnar

nerve palsy. Orthop Clin North Am 5:323-342,1974

3. Edgerton MT, Brand PW: Restoration of abduc-tion and adduction to the unstable thumb inmedian and ulnar nerve paralysis. PlastReconstr Surg 36:150-164, 1965

4. Hamlin C, Littler JW: restoration of powerpinch. Orthop Trans 3:319-320, 1979

5. Littler JW: Restoration of power and stability inthe partially paralyzed hand. pp 1674-1695. InConverse JM: Reconstructive Plastic Surgery,Vol. IV. WB Saunders, Philadelphia, 1964

6. Omer GE Jr: Reconstruction of a balancedthumb through tendon transfers. Clin Orthop195: 104-116, 1985

7. Smith RJ: Extensor carpi radialis brevis tendontransfer for thumb adduction- a study of powerpinch. J Hand Surg 8:4-15, 1983



INTRODUCTIONThe simian hand is defined by the presence of athumb, which is able to oppose against theother digits in a “pinch grip.” Two basic typesof functional pinch are described the key pinchand the pulp-to-pulp pinch (Fig. 7-1). In thekey pinch the pulp of the thumb is opposed tothe side of the index finger. This action requiresstrong adduction of the index finger by the firstdorsal interosseous and adductor pollicis,which is only possible if the ulnar nerve isfunctional . This type of pinch is used in hold-ing a key, lifting heavy objects such as booksetc.. The pulp-to-pulp pinch is stressed byBrand5 as being the most important function ofthe thumb. This action is used for picking upsmall objects, buttoning etc. It requires slightrotation of the index finger to face the thumb.This movement is carried out by the first pal-mar interosseous. Fritschi14 has emphasizedthe three-finger pulp-to-pulp pinch, whichinvolves the pulp of the thumb opposing to thepulp of the index and long fingers. This posi-tion is used for picking up small objects, hold-ing a pen and eating with the hand. It requires

slight adduction/abduction of the long andindex fingers against each other. Antia3 alsodescribes the short thrust pinch in which thethumb interphalangeal joint is hyperextended,providing both increased stability and greaterstrength in pinch.

Mechanism of PinchThumb opposition occurs mainly throughmovements at the carpometacarpal (CMC)joint. Opposition of the thumb is a compoundmovement involving simultaneous abductionand flexion at the CMC joint. The movementcan best be described as that of movementaround a cone, although it superficiallyappears to be a rotation movement (Fig. 7-2).The thumb pulp when beside the palm lies atabout 45° supination and when fully opposedhas moved to about 40° of pronation. Thispronation is probably a secondary passivemovement brought about by a combination ofintrinsic muscle pull and joint ligamentous sta-bility.9

7Median Nerve Palsy

� R. SCHWARZ

FIGURE 7-1 Three types of pinch (from Fritschi14,used with permission.) a. Key Pinch, b. Two fingerpulp-to-pulp pinch, c. Three finger pinch.

FIGURE 7-2 Thumbmovement around the axisof a cone (from Brand5,used with permission.)

(a)

(b)(c)


Thumb opposition requires the action ofseveral muscles. Abductor pollicis brevis andthe opponens carry out the abduction compo-nent along with the flexor pollicis brevis super-ficial head. Abductor pollicis longus effectsretroposition of the metacarpal and has littlerole in thumb opposition. The flexion compo-nent is carried out by the flexors pollicis brevis(FPB) and longus (FPL). Simultaneously thelumbrical, interossei and long flexors of theindex and middle fingers are activated alongwith the adductor pollicis to complete thepinch. In pure median nerve palsy, only theabductor brevis and opponens muscle will benon-functional in most cases, as in 73% ofpatients FPB has at least partial innervationfrom the ulnar nerve.24 Zancolli and Cozzi26

state that the superficial head of FPB has dualulnar/ median nerve supply in 30 percent ofhands while the deep head is supplied by theulnar nerve exclusively in 19 percent and hasdual supply in 79 percent of hands. Thisexplains why pure median nerve palsy willoften maintain functional opposition.

Deficit in Low Median Nerve Palsy andCombined Ulnar/Median PalsyThe variability of innervation described aboveexplains why many patients with pure mediannerve loss maintain opposition function.Patients with isolated median nerve injurywithout recovery will often not require oppo-nens reconstruction.11,13 However with com-bined ulnar/median nerve palsy, as is usuallyseen in leprosy, the FPB as well as adductorpollicis and the intrinsics of the index fingerswill be paralysed. This leads to retropositionand supination of the thumb by the unopposedextrinsic muscles of the thumb. In combinedulnar and median nerve palsy the intrinsicmuscles to the fingers are also paralyzed, caus-ing instability of the fingers, loss of adductionof the index finger and loss of primary MCPflexion (Chapter 6). In the context of thumb

function combined ulnar/ median paralysismay make the squeeze pinch the only pinchmechanism possible, that is contact of the sideof the thumb to the side of the hand or indexfinger. At best an ineffective key pinch will bepossible. This severe disability requires a dif-ferent approach than a pure median nervepalsy. These patients will all require restorationof opposition with effective pronation of thethumb tip to allow pulp-to-pulp pinch.

SURGICAL TREATMENT OF MEDIANNERVE PALSY

Management of ContracturesFirst web space contractures are occasionallyassociated with median nerve palsy, especiallyin association with ulnar nerve palsy. This maybe due to associated trauma and scarring, ormore commonly due to the chronically retropo-sitioned thumb. Pre-operatively the web spacemust be fully opened with stretching exercisesand any IP or MCP joint contractures correctedwith therapy. Practically it is difficult to open aseverely contracted webspace with therapyalone. If the patient presents early these shouldbe prevented with first web space splints andexercises. If there is an established first webspace contracture which fails to respond totherapy it must be corrected prior to or prefer-ably simultaneous with the opponensplasty.Web space contracture is easy to detect clinical-ly. Passive abduction/opposition will demon-strate limitation with tightness of the dorsalskin of the first web space. Carpometacarpaljoint contracture is more difficult to detect. Inthis situation abduction is possible but opposi-tion is restricted. The conditions may be pres-ent simultaneously.

With a moderate web contracture a simplelarge Z-plasty will usually suffice with the dor-sal flap based distally and the palmar flapbased proximally (Fig. 7-3). Dorsal fascia is



divided completely down to the level of theCMC joint and any restraining bands felt forand divided. In case of combined median/ulnar palsy the adductor pollicis is often con-tracted and the transverse head at least shouldbe divided. A single large Z-plasty will give abetter release than multiple Z-plasties as thecontracture extends to the base of themetacarpal. This procedure also gives theadvantage of deepening the web space, whichcan be of benefit if the thumb is short. It can bedone concomitantly with an opponensplasty. Itmay be combined with full-thickness skingrafting on the dorsum to complete the release.An alternative is to release the contracturethrough a dorsal incision and apply a full-thickness graft (Fig. 7-4). An incision is madethrough skin and fat from the radial side of theindex MCP joint, curving dorsally and endingover the first CMC joint. The skin is thenundermined towards the thumb, and the dor-sal fascia, thus exposed, is divided along its fulllength such that the skin flap will cover the fas-cial defect. Any restraining bands are felt forand divided. A full-thickness skin graft, usual-ly from the groin, is then harvested to size andsutured in place with a bulky dressing tiedover it. This procedure should be done prior tothe opponensplasty and as soon as the graft ishealed the opponensplasty should be carriedout before the graft has a chance to contract.

Alternatively it can be done at the same time asthe opponensplasty.

For more severe contractures a dorsal flapwebplasty may be required (Chapter 10).

Opponensplasty TechniquesGeneral principles of tendon transfer apply(Chapter 1). Four standard methods will bedescribed followed by two other methods forspecial situations. It is advisable for a surgeonto become proficient in the performance andproblems of only two or three of these tech-niques rather than attempt all available trans-fers. For combined ulnar/median palsy theflexor digitorum superficialis (FDS) transfer isthe most commonly used transfer. Some recom-mend a two tendon transfer, using extensorindicis proprius (EIP) for abduction and FDS orextensor carpi radialis brevis (ECRB) for shortflexor replacement.5 For isolated median nervepalsy, especially a high palsy, the EIP transfer isideal. Others should be used only in special sit-uations as described below.

Standard Opponensplasties

1. Superficialis transfer.2. Extensor indicis proprius transfer.

Median Nerve Palsy 67

FIGURE 7-3 Simple Z-plasty (from Kleinman andStrickland16, used with permission).

FIGURE 7-4 First webspace webplasty with full-thickness skin grafting (from Fritschi14, used withpermission).

A

(A) (B) (C)

AA

B

B B


3. Palmaris longus transfer (Camitz proce-dure).

4. Extensor pollicis longus re-routing.

Other Opponensplasties

1. Flexor pollicis longus transfer.2. Abductor pollicis longus re-routing.3. Abductor Digiti Minimi Transfer.

1. Superficialis Transfer

The ring finger superficialis tendon is usuallychosen. It is less important in pinch functionthan the long FDS and being more ulnar givesa slightly less acute angle at the pulley. Thelong sublimus is an acceptable alternative. Theindex FDS is too important in pinch function tobe sacrificed and that of the little finger is tooweak to be used and is sometimes absent. Thefunction of flexor digitorum profundus mustbe checked and should be at least 4/5 on theMRC scale. The strength of the ring sublimus isusually maintained even in the presence of ahigh ulnar nerve palsy due to cross-over of fas-ciculi in the main muscle belly.

Traditionally the FDS was harvestedthrough a lateral incision at the level of theproximal interphalangeal (PIP) joint. This wasto maximize the length of the tendon. Howeverthis was found to lead to a number of checkreinor swan-neck deformities. North and Littler20

felt that division of the FDS near its insertionmay cause trauma to the PIP joint capsule. Itmay also destroy the distal vinculae and dis-rupt the blood supply to the FDP. They recom-mended division of the FDS through an open-ing between the A1 and A2 pulleys, proximalto its bifurcation. Anderson et al2 comparedharvesting FDS through either a mid-lateral ora palmar incision. Extension lag at the distalinterphalangeal (DIP) joint (swan-neck defor-mity) developed in 44% of cases with the mid-lateral incision compared with 8% with the pal-mar approach. Likewise, check-rein deformitydeveloped in 8% of cases having had the later-

al approach compared with 0 percent in thosehaving had the palmar approach. He suggestedthat the higher incidence of complications wasdue to adhesions to the lateral bands, which areexposed during this procedure. In our experi-ence harvesting over 400 FDS tendons via anopening between the A1 and A2 pulleys, fewhave developed significant checkrein deformi-ty. It would seem that given the evidence ofincreased complications with the lateralapproach and the fact that adequate length canbe obtained through a distal palmar approach,that it would be prudent to cut the tendonthrough the latter incision.

As stated above most patients with mediannerve palsy secondary to leprosy also have anulnar nerve palsy. While some authors havestated that finger intrinsic and opponens oper-ations should be done separately, in our experi-ence and that of Mehta et al18, combining oppo-nens replacement with a “Lasso” procedureshortens the rehabilitative process withoutcompromise in results. We obtained a good orexcellent result in 93% of those undergoingopponens replacement regardless of whetherthey had a simultaneous “Lasso” procedure ornot. Therefore if the surgeon is well experi-enced and the patient is intelligent and a candi-date for each procedure, then both can be per-formed in the same operation.

Technique: An axillary block is usually used. Asmall transverse incision is made just proximalto the ring MCP crease and a small transverseopening made between the A1 and A2 pulleys.The FDS tendon is then divided as far distallyas possible. Four more incisions are then made(Fig. 7-5). An 8 mm incision is made 1 cm. dis-tal and radial to the pisiform, and deepeneduntil the loose large fat lobules of Guyon’scanal are seen protruding up from the smallfirm fat globules typical of the palm. A1 cmincision just palmar to the mid-point of thethumb MCP joint is made on the lateral surface.



A third, 1.5 cm curved incision, is made overthe insertion of the adductor pollicis, and thefourth, an L-shaped incision, is made over thedorsum of the I-P joint.

A 1.5 cm transverse incision is then madeabout 3 cm proximal to the distal wrist crease.The ring finger FDS is the identified and thenbrought out of this incision. There are frequent-ly vinculae between the FDS and flexor digito-rum profundus (FDP), which may need to bedivided from both incisions. If necessaryanother incision can be made mid-palm. Asmall curved tendon tunneller is then passedfrom the pisiform incision to the forearm inci-sion, passing deep to the piso-hamate ligamentand emerging in the same plane as the ulnarnerve and artery. The tendon is then with-drawn into the palm and checked for easy glid-ing. It is then passed deep subcutaneously intothe thumb MCP incision and again checked forfree gliding. A wide passage is not created, asthis will increase the likelihood of adhesions.

Alternative Routes: It has been shown that theroute of the tendon transfer can be altered tobest suit the patient’s needs10 (Fig. 7-6). Placingthe pulley more distally in the palm producesmore thumb flexion and may be appropriate inpatients with combined ulnar/ median nervepalsy. Similarly, placing the pulley more proxi-

mally will produce more abduction at theexpense of flexion and opposition. Placing thepulley near the pisiform will produce maximalabduction/opposition. Alternate routes aredescribed as follows:


FIGURE 7-5 Incisions forFDS opponensplasty.

FIGURE 7-6 Potential routes of FDS opponensplasty.The arc of possibility is indicated by broken semicir-cle marked ADD (uction), ABD (uction) and OPP (osi-tion). The most frequently used types of transferare: a. Adductor replacement. Pulley is metacarpaltwo or three. b. Thompson route. Pulley is palmarfascia. True opponens action. c. Guyon's canal. Pulleyis palmaris brevis/ palmar fascia. d. Pulley is at pisi-form (on FCU). e. Camitz route. Weak abductor with-out pulley. Full adduction is type A, opposition is typeB, C and D, and type E is full abduction. (fromWarren25, used with permission.)

ADD

A

B

C

D FR

OPP

E

E B C D

P


Campbell-Thompson Route

The FDS is withdrawn via a 3 cm incision justradial to the hypothenar eminence. The ulnarborder of the palmar aponeurosis is exposedand the FDS tendon withdrawn just distal tothe flexor retinaculum and then tunnelledacross to the thumb MCP with the insertion asdescribed below. This will give greater MCPflexion but not full abduction and may needcombined abductor pollicis longus re-routing.(See below)

Bunnell’s Flexor Carpi Ulnaris (FCU) Pulley

A 4 cm incision is made just medial to the FCUinsertion. Half the FCU is cut across 4 cm fromits insertion and then the tendon is split distal-ly to leave a distally based strip. This is thensutured back to the FCU insertion at the pisi-form to create a fixed pulley. Some have foundthat this pulley tends to drift medially.14

Transverse Carpal Ligament (TCL)

An incision is made over the TCL and a win-dow made at the desired level, more proximal-ly for greater abduction and distally for greaterflexion. The FDS tendon is brought out in theforearm and passed through the TCL windowand then across to the thumb.

Insertion: In a pure medial nerve palsy, thumbMCP flexion is preserved and so pure abduc-tion-opposition only is sought. This can beobtained simply by encircling the insertion ofabductor pollicis brevis and suturing the ten-don to itself. To set the tension, the thumbshould be put into full opposition with thewrist in neutral position. The tendon should bepulled 1 cm past zero tension, and suturedwith three to four sutures in this position withthe wrist flexed to relieve tension.

Insertion into bone has been described byBunnell 6, but there is no advantage to this andit does add to both time and potential morbidi-ty.

In combined ulnar/ median nerve palsy it isdesirable to stabilize the thumb MCP joint aswell. This can be accomplished by a doubleinsertion technique as described by Brand.5 Inthis procedure, the transferred tendon at theMCP incision is divided into two slips up to 5cm proximally (Fig. 7-7). One slip is passed justdistal to the MCP joint over the dorsal aspectand is then looped around the adductor inser-tion adjacent to bone. It is important to keepthis slip distal to the MCP to prevent a Z-thumb deformity (Fig. 7-7). The other slip isrouted palmar to the MCP joint to insert with atriple weave on the Extensor pollicis longus(EPL). This serves as a MCP flexor as well as IPextensor to correct the deformity arising fromthe FPB paralysis. With a dual insertion onlythe insertion with the shortest moment arm orunder the highest tension is activated.5 As suchthe tensions are adjusted to make the adductorinsertion functional and the EPL insertion func-tions largely to prevent any Z-thumb deformityrather than to create active IP extension. Thetransfer functions very well in this dual role. Toset the tension the adductor slip is sutured with1 cm tension with the thumb in full opposition


FIGURE 7-7 Double inser-tion of FDS opponensplasty.Shows recommended routewith insertion into adductorpollicis insertion and EPL.Note how slip to adductorpollicis lies just distal to theMCP joint.


as described for the ABP insertion technique.The IP slip is sutured at neutral tension.

If a fixed I-P joint flexion deformity is pres-ent, an I-P fusion should be carried out.

The hand is placed in POP with the wristflexed 15-20° and the thumb in full opposition-abduction. This is kept in place for three weeksafter which careful therapy is commenced.

2. Extensor Indicis Proprius (EIP)Opponensplasty

This is very useful in high median paralysiswhere FDS tendons are not available, and isvery popular for pure low median palsy as wellas it does not create a secondary deformity onthe donor finger and does not weaken grip.7

(ed. note (WB): It also can create a defect on thedonor finger. In leprosy I have rarely seen con-sistent good results of an EIP transfer). In com-bined ulnar-median palsy Brand recommendscombining it with an FDS to adductor pollicistransfer to provide adduction/pronation inulnar/median palsy (chapter 6).5

Technique: A 2 cm incision is made over theindex MCP joint and the EIP cut away from itsattachment to the extensor expansion. A con-tiguous slip of extensor hood is not required.10

It is withdrawn through a 4 cm dorsal forearmincision starting 2 cm proximal to the wristcrease and muscle attachments freed (Fig. 7-8).It is quite deep here and may be entirely mus-cular, and if adhesions to index communis ten-don are present it may have to be withdrawnvia an incision at the proximal metacarpallevel. Small incisions are then made just medialto the pisiform and over the dorsoradial aspectof the thumb MCP joint. The tendon is tun-nelled around the ulnar border of the wrist,superficial to FCU to the pisiform incision, andthence across the palm to the thumb. In puremedian palsy it is attached to the FPB insertionwith the thumb in full opposition and the wristin 30° flexion. In combined ulnar/median

palsy a split insertion to adductor pollicis andEPL can be used as described above. Riordanattaches the tendon in sequence to abductorpollicis bravis (APB) insertion, the MCP cap-sule and the extensor pollicis longus tendonover the proximal phalanx.23 Alternatively, thetendon can be routed through the interosseousmembrane, although some feel that the risk ofadhesions is greater and the amount of opposi-tion obtained may be decreased. Mehta et al17

add a radial half FPL to EPL transfer to stabi-lize the MCP joint. Post-operatively a POP isapplied with the thumb in full opposition andthe wrist in 40° flexion for 3 weeks.Rehabilitation can be difficult with somepatients and the patient should focus on oppo-sition to middle and ring fingers.

Anderson et al1,2 reported the use of thistransfer in 13 high and 38 low median nervepalsies. Excellent or good results were reportedin 89% of patients. They then compared theirresults with those of superficialis transfer andconcluded that EIP transfer is indicated only in


FIGURE 7-8 Extensor Indicis Proprius (EIP) transfer.a. Tendon is divided and delivered into a dorso-ulnarincision. b. Tendon is passed around ulnar side ofwrist to an incision medial to the pisiform and thenby a subcutaneous tunnel to the MCP joint.

(a) (b)


those patients with supple hands. This is prob-ably explained by the fact that FDS of the ringfinger has a tension fraction (strength) doublethat of the EIP muscle, and is thus better able toovercome the resistance in stiff hands.

3. Palmaris Longus Opponensplasty

This relatively simple procedure is best suitedto those patients with severe carpal tunnel syn-drome and isolated median nerve palsy as itcan be done simultaneous with a tunnel releasewith little excess morbidity. With a tension frac-tion of 1.0 it is not powerful enough by itself incombined ulnar- median palsy. It should be combined with FDS transfer for adduc-tion/pronation as described for EIP transfer. Asdescribed by Camitz9 it produces principallyabduction, but by a simple modification it canalso produce opposition (see below). The pres-ence of palmaris longus (PL) muscle can bechecked by cupping the tips of the fingers withthe wrist flexed.

Technique: A longitudinal incision is made justulnar to the PL extending from 2 cm proximalto the wrist crease to the proximal palmarcrease in line with the index finger. The pal-maris is then dissected along with 1 cm of pal-mar fascia in continuity with the tendon. A tun-nel is then created to an incision over the inser-tion of abductor pollicis brevis (APB). The ten-don with its attached fascia is then passed tothe thumb incision and the fascia loopedaround the insertion of APB and sutured at 1cm tension with the wrist neutral and thethumb in maximum opposition. Foucher et al13

recommended insertion to the extenson pollicisbrevis tendon or the dorsal capsule of the MCPjoint to produce opposition and abductionalthough he found that this caused a slightreduction in MCP joint mobility in somepatients. Alternatively the tendon can bepassed up Guyon’s canal and then across thepalm, across the palmar incision to the thumb,

which will also produce greater opposition.The hand is placed in a plaster for three

weeks with the thumb in full opposition andthe wrist slightly flexed after which therapy isstarted. This is a relatively weak muscle with atension fraction of 1.2 and should only be usedin supple hands. Excellent results have beenreported in series of patients with carpal tunnelsyndrome. These results may not apply toother causes of median palsy. Therapy is rela-tively simple for most patients.

4. Extensor Pollicis Longus Re-Routing

The extensor pollicis longus functions a both athumb extensor and adductor. As such it worksagainst thumb opposition and can be the causeof long-term failure of opponensplasty, espe-cially with a weak motor such as EIP.22 Thisprocedure effectively transforms the EPL froman extensor/adductor to an extensor/abductor.While excellent results have been reported withthis procedure in patients with various etiolo-gies19,22, in our experience the therapy can bedifficult. There is a definite learning curve tothis procedure for the whole hand team, andshould only be done in a patient of reasonableintelligence and motivation. This transfer isespecially helpful in those patients with adeficit of donor tendons.

Technique: The extensor pollicis longus (EPL) isdivided through a 2 cm incision just proximalto the MCP joint (Fig. 7-9). It is then broughtout from a 3 cm incision 5 cm proximal to thewrist crease, where the tendon is quite deep. A1 cm defect is then created in the interosseousmembrane, after which the tendon is passedthrough the interosseous membrane (IOM) to a2 cm incision on the radial side of the flexorcarpi ulnaris, keeping radial to the ulnar arteryand nerve. Unrestricted gliding through theIOM should be checked. It is then passed sub-cutaneously along the line of the metacarpal(palmar-dorsal junction) back to the original



incision, routing it deep to extensor pollicisbrevis. This prevents future palmar subluxa-tion. It is then sutured back to the stump of EPLwith a 1 cm overlap, which will adjust the ten-sion. Riley and Burkhalter22 pass the tendonaround the ulnar border of the wrist and addan arthrodesis of the MCP joint. I also believethat it is necessary to stabilize the thumb incases of combined ulnar/median palsy andusually add a half FPL to EPL transfer (see Part2 below) in place of MCP arthrodesis withgood results.

A short arm thumb spica is then appliedwith the thumb in full opposition and the wristflexed at 30°. The plaster is removed at 4 weeksand therapy commenced. The patient shouldattempt thumb opposition with the I-P jointextended, activating the transfer. Extensionand opposition are not necessarily contradicto-ry movements. The EPL should continue to

function as an extensor after this procedure. Adynamic opposition splint is helpful at thistime. Good or excellent results were reportedby Mennen et al19 in 31/35 patients. Clinicalresults are shown in Fig. 7-10.


FIGURE 7-9 Extensor Pollicis Longus (EPL) re-routing. a.The tendon has been divided proximal to theMCP joint, and is being brought out on the dorsum of the wrist before being passed through the inter-osseous membrane. b. It is brought through just radial to the FCU and then tunneled in a subcutaneousplane along the junction of palmar and dorsal skin to the original MCP joint incision. c. It is passed underthe extensor pollicis brevis and sutured to itself with 1 cm overlap.

FIGURE 7-10 EPL re-routing post-operatively.Note excellent abduction obtained.

(a) (b) (c)


Other Opponensplasties

1. Flexor Pollicis Longus Transfer

This transfer is indicated in those patients witha combined ulnar/median palsy with a fixedflexion contracture of the IP joint. In this situa-tion the IP joint must be fused. As such movingthe FPL insertion to the FPB insertion does notdiminish thumb function nor decreasestrength, as the moment arm on the MCP jointfor the FPL tendon sheath and the FPB inser-tion are almost identical. It is especially usefulin those patients with a severely affected handsuch as a triple nerve palsy where there is adeficit of tendons available for transfer.Routing through the carpal tunnel as describedby Davis11 produces limited pronation of thethumb but routing via Guyon’s canal will givesatisfactory opposition as well as short flexoraction. This transforms a thumb extrinsic mus-cle that was contributing to the deformity intoone that improves function, similar in conceptto the EPL re-routing described above. Thisprocedure also has the obvious benefit of creat-ing no donor deficit, although the risk of weak-ening thumb flexion power must be recog-nized.

Technique: The insertion of FPL into the distalphalanx is exposed through a volar V-incisionand then divided. The FPL tendon is with-drawn into the wound as much as possible toenable division of vinculae. A more proximalincision at the level of the A1 pulley is some-times required to divide the rest of these. A lon-gitudinal incision is then made over the dor-sum of the IP joint and an arthrodesis carriedout as described in chapter 9. I use K-wires forfixation. Through a 3 cm incision starting 3 cmfrom the wrist crease the FPL is identified andwithdrawn. A 1 cm incision is then made 1 cmdistal and radial to the pisiform, and deep dis-section done until the large fat globules ofGuyon’s canal are seen. The tendon is thenpassed to this incision, and then passed

through a small subcutaneous tunnel to an inci-sion on the dorso-radial aspect of the MCPjoint. It is then looped around the FPB tendonand sutured with 1 cm tension with the wristneutral and the thumb fully opposed. As thereis a wide excursion of the FPL setting the ten-sion is relatively easy. It is important not toinsert the transfer onto the abductor pollicisbrevis insertion, as this would give principallythumb abduction with insufficient power inflexion. The routing through the ulnar side ofthe wrist produces the necessary oppositionand insertion into the FPB insertion will givethe MCP flexion action that is necessary for apowerful pinch grip.

2. Re-Routing Abductor Pollicis Longus

This does not produce true opposition butrather turns the abductor pollicis longus (APL)from a thumb supinator/extensor into anabductor. I have not found it to produce a greatdeal of abduction and is better combined withanother procedure. This procedure can be use-ful in those patients with functional flexor pol-licis brevis needing only more thumb abduc-tion for grasping large objects. It is also indicat-ed in some patients with extensive deficits inwhom donor tendons are limited and donordeficits may be very detrimental to overallhand function.

Technique: The APL is divided 1 cm proximalto its insertion into the base of the metacarpaland brought out 6 cm proximal to the first inci-sion. It is then passed to a small incision 3 cmproximal to the wrist crease over the palmarislongus (PL) tendon, looped around the PL ten-don, passed to the first incision and sutured tothe APL stump with 1 cm overlap. This isimmobilized for 3-4 weeks before therapy iscommenced.

3. Abductor Digiti Minimi Transfer

This is a good procedure for isolated mediannerve palsy. It is a technically demanding pro-



cedure, and the reader is referred to a textbookof hand surgery for a description.

Potential Pitfalls of Opponens Surgery

1. Use of Extensor Pollicis Longus in Pinch

In long-standing ulnar/median paralysis thepatient often has learned to use the extensorpollicis longus as an adductor to effect a lateralsqueeze to hold objects between the side of histhumb and index finger. This can become aproblem after the surgery if he uses this trickmovement to grasp objects. This trick move-ment produces thumb supination and willoverpower an attempt at thumb opposition bythe transferred tendon. The patient may use thetransfer well in therapy, but may habitually usethe EPL lateral squeeze to pinch objects due tohabit and simplicity. It is important that thepatient is observed during regular activities ofdaily living to see whether he is using thetransfer in pinch grip or whether he is using hisEPL. If not detected in time the transfer may belost due to neglect.

Brand proposes four ways of dealing withthis problem.5 Firstly, one should do the oppo-nensplasty soon, before the patient has time todevelop this trick movement. Obviously thisdepends upon the patient presenting in a time-ly fashion. Secondly, the patient requires thor-ough re-education with therapy carried out atthe workbench as well as through exercises.Thirdly, in more established cases, the surgeonshould consider re-routing the EPL at the sametime as the opponensplasty. With this tech-nique the EPL is freed from its retinaculum andtransposed over the course of the abductor pol-licis longus and anchored here with a pulleymade from fascia. The incision extends fromthe MCP joint to 4 cm above the radial styloid.Two or three small incisions on this line areadequate. This procedure can also be usedwhen the problem is detected following anopponensplasty. Finally, in very established

cases, the EPL can be used as the opponensmotor by re-routing it through the inter-osseous membrane as described above.

2. Crank handle action

This problem can occur following an opponen-splasty when complete pronation of the thumbis not obtained at surgery. This complicationoccurs when the metacarpophalangeal joint isflexed and the interphalangeal joint is extend-ed, such as following an interphalangeal jointarthrodesis for a severe Froment’s sign or anopponensplasty with insertion on the EPL ten-don. With incomplete pronation, the pulp ofthe index finger makes contact with the ulnarside of the thumb. When pinch is attempted,the distal part of the thumb functions as a crank handle, forcing the thumb into supina-tion (Fig. 7-11). The moment arm of thissupinating force is large, and will overpowerthe small moment arm of the opponens trans-fer as it attempts to pronate the digit. Thethumb will gradually be forced into more andmore supination and the opponensplasty willhave failed. Brand has several suggestions toprevent this.5 Firstly, complete pronation of thethumb must be obtained at surgery. Often awebplasty will be required to accomplish this,and possibly a carpometacarpal joint release. If


FIGURE 7-11 Crank handle action (from Brand5,used with permission).


it is not possible to obtain full pulp-to-pulppinch, a tip pinch should not be used andrather the patient should be trained to use akey pinch. This will not lead to a crank handleaction on the thumb, but rather the index fin-ger. This is not a significant problem and can beprevented by teaching key pinch with all fin-gers held together to support the index.Secondly, therapy must be aimed at pulp-to-pulp pinch and not pulp-to-side of thumb.Arthrodesis of the interphalangeal joint shouldbe avoided if possible. In a patient withFroment’s sign and a mobile interphalangealjoint there are better options such as metacar-pophalangeal joint fusion. If the MCP joint ischronically flexed and causing problems againMCP arthrodesis should be considered. Finally,the EPL can be re-routed over the abductor pol-licis longus as described above to eliminate itssupinating moment.

HIGH MEDIAN NERVE PALSYIn this situation all muscles in the flexor com-partment of the forearm are paralyzed apartfrom the FCU and the profundi to the little andring fingers. Flexion of the long finger is usual-ly satisfactory although weak. Functionallyflexion of the thumb and index interphalangealjoints are absent while flexion of the wrist andulnar three fingers is present. In leprosy theulnar nerve is also usually affected and there-fore these too are usually paralyzed, leaving nofunctioning flexors below the elbow. Thissevere deficit is fortunately quite rare in lep-rosy. When present it may be associated withradial nerve palsy as well. The goals of surgeryare to restore thumb flexion and oppositionand finger flexion. Opposition can be restoredby EPL re-routing or by EIP transfer asdescribed above if the radial nerve is intact.Thumb flexion can be restored by brachioradi-alis transfer to the FPL (see below). Finger flex-ion can be restored by tenodesis of the ring andlittle FDP to those of the index and middle fin-

gers if the ulnar nerve is intact. This is accom-plished by side to side suturing of all profun-dus tendons in the distal forearm. This willgive index flexion but little strength. If strengthis required the extensor carpi radialis longus(ECRL) can be transferred to the index FDP(see below). The transfer techniques describedinvolve end-to-end anastomosis. If there is achance of nerve recovery then end-to-sideanastomosis should be performed. If the radialnerve is also involved options are severely lim-ited, with all wrist and digit extensors alsoabsent. In this situation brachioradialis can beused to power the finger flexors with stabiliza-tion of the wrist and thumb to provide somepinch function. In leprosy the pronator teres isoften preserved, in which case pronator terescan be used to activate extensor carpi radialisbrevis, with a tenodesis of the thumb to givethumb opposition/flexion on wrist extension(hinge hand procedure, see chapter 8).

Brachioradialis to Flexor Pollicis LongusTransfer8,11

An incision is made on the radial side of thevolar forearm from the wrist crease to 8 cm dis-tal to the elbow. The brachioradialis is thendivided at its insertion. Muscle fibres arestripped off the deep fascia of the forearm tofree the tendon up until well proximal to themusculo-tendinous junction. The whole distalaponeurosis must be divided, and this is thenfolded in on itself and approximated with acontinuous fine nylon suture to decrease adhe-sion formation. Dissection of the muscle fromits attachments proximally can increase excur-sion by more than 100%.5 The dissectionshould be carried up to the proximal third ofthe forearm, releasing all attachments of ten-don to investing fascia and radius. The tensionis set so that the transfer will function at itsmaximal efficiency when the elbow is straight.With the wrist flexed 30 degrees the tension isset so that the thumb can be fully extended butwill flex the thumb on wrist extension.



Excessive tension must be avoided, as other-wise the thumb will end up positioned useless-ly across the palm. A Brand anastomosis is car-ried out between the brachioradialis and theFPL tendon, which has been divided 5 cmproximal to the wrist (Fig. 7-12). It is thenimmobilized in elbow, wrist and thumb flex-ion. As the brachioradialis is primarily anelbow flexor, the transfer will be weakened byelbow flexion. It should therefore be used infull elbow extension.

Extensor Carpi Radialis Longus to FlexorDigitorum Profundus Transfer8,11

The ECRL is divided at its insertion through asmall transverse incision. An 8 cm incision ismade on the radial side of the volar forearm

from the wrist crease extending proximally.The ECRL is then brought around the radialaspect of the radius. The FDP to the index andlong fingers is divided 5 cm proximal to thewrist and a Brand anastomosis is carried out tothe ECRL tendon (Fig. 7-13). If this is carriedout in conjunction with the brachioradialis toEPL transfer these two anastomoses should bedone at different levels to decrease the risk ofadhesions. Setting the tension correctly is diffi-cult but important. The excursion of the ECRLis only about 30 mm in comparison to about 50mm for the profundus muscles. As such exces-sive tension on the transfer will lead to a flex-ion contracture of the fingers. The same prob-lem holds for the brachioradialis to FPL trans-fer. For both transfers a “dynamic tenodesis”


FIGURE 7-12 Brachioradialis to flexor pollicis longus transfer (from Davis and Barton,11 used with permis-sion).

FIGURE 7-13 Extensor carpi radialis longus transfer to flexor digitorum profundi of long and index fingers(from Davis and Barton,11 used with permission).

Fl. Policis Longus

Ext. Carpi Radialis

Fl. DigitorumProfundus


approach is used, using wrist motion toenhance the function of the transfer.8 Full wristvolar flexion will allow full finger extensionwhile full wrist extension will allow full fingerclosure. To check for correct tension, 30 degreesof wrist flexion should give full finger exten-sion, while 30 degrees of wrist flexion shouldproduce passive finger closure so that thetransfer can then use its power with the fingersclosed. Arthrodesis of the DIP joints canenhance the function of this transfer. The arm isimmobilized in 30 degrees of wrist flexion withMCP joints flexed at 80 degrees and the inter-phalangeal joints straight.

CARPOMETACARPAL JOINT DISORDERSThe thumb carpometacarpal (CMC) joint con-sists of two saddle shaped surfaces of trapezi-um and metacarpal bones with the axes of thetwo near perpendicular to each other. There islittle bony stability, and stability depends on astrong volar plate with ligaments on the othersides. The dorsal ligament is reinforced by theabductor pollicis longus. There is normallyminimal laxity. Adduction/ abduction occuralong the length of the trapezial “saddle” whileflexion/ extension occurs across the saddle.The small amount of true rotation at the CMCjoint is due to incongruency of the radial andulnar aspects of the trapezial joint surface. TheCMC joint is where opposition of the thumboccurs, and it is therefore integral to the func-tion of the thumb.

Contracture of the CarpometacarpalJointThe most common disorder seen in thetrapezio-metacarpal joint is contracture of theintermetacarpal ligaments. This is usually asso-ciated with longstanding ulnar-median nervepalsy where prolonged retroposition of the

thumb causes progressive ligament shortening,which in turn causes restriction of passiveopposition. There is often associated web con-tracture and/or dorsal skin deficiency.

Treatment

Prolonged therapy by web space stretchingand CMC mobilization by forced oppositionmay be necessary. In established CMC jointcontracture conservative measures will oftennot suffice. If full opposition is not obtainedthen surgical release is indicated. A webplastyis usually also required and the CMC releasemay be able to be accomplished through thisincision. Otherwise a separate incision is neces-sary.

Technique: A 3 cm incision is made just medialto the extensor pollicis longus tendon. The jointcapsule is opened in a longitudinal directionuntil full opposition is obtained. A fat graftmay be placed to prevent recurrence. A K-wiremay be required to maintain position. Thethumb is placed in a spica for three weeks infull opposition after which full motion isallowed but night splinting is continued forthree months. This may be combined with anopponensplasty.

Carpometacarpal DislocationThis condition is often unrecognized, but isreported in 20% of ulnar-median nerve palsyhands.4 If looked for it is easy to diagnose. Thethumb is forcibly retroflexed using themetacarpal as a fulcrum and the joint can beseen to dislocate in a radial direction. Beine4

felt that it is more common after MCP fusion oropponensplasty, but I have not noted this. Withloss of adductor pollicis and the first dorsalinterosseous, the extensor pollicis longusassumes the adductor role with the fulcrum atthe tip of the thumb, causing radial stress at the



CMC joint. The flexor pollicis longus also caus-es radiovolar stress at the CMC joint when thethumb is retropositioned. The abductor pollicislongus as well causes radial stress as itattempts abduction of the thumb. All thesestresses lead to attenuation of the inter-metacarpal ligament and radiovolar subluxa-tion. In most cases this creates no functionaldeficit. In about a third of patients it can pre-vent full opposition by locking of the CMCjoint, and in these cases surgical intervention iswarranted.4

1) Joint Arthrodesis

Intracapsular arthrodesis such a performed intetraplegia patients is technically difficult. Ahigh non-union rate is reported in non-tetraplegic patients14, perhaps due to theincreased hand power with resultant increasedstress on the joint. Fritschi describes an inter-metacarpal bone block.14 However it is likelythat an arthrodesis would cause a greater dis-ability than the CMC dislocation and it is notrecommended.

2) Capsular Reconstruction

In this procedure, described by Eaton12, thetendon of the flexor carpi radialis (FCR) is usedto reinforce the weakened dorsal ligament andwill only minimally restrict normal CMCmovement.

Technique: An ‘L’ shaped incision is used withone limb along the thumb metacarpal and theother extending along the distal wrist crease(Fig. 7-14). The superficial radial artery and thebranches of the dorsal sensory branch of theradial nerve must be preserved. The thenarmuscles are elevated and the capsule excised. Asubchondral (i.e. 5 mm distal to the metacarpaljoint surface) channel is created in themetacarpal perpendicular to the thumbnailusing a drill or gouge. The FCR tendon isexposed through a small transverse incision 8

cm proximal to the wrist crease and the radialhalf mobilized proximally using one or twodistal incisions until the radial strip is leftattached only to the trapezium. This strip isthen passed through the channel in themetacarpal base to emerge on the dorsal sur-face. This is facilitated with a wire or nylonsuture. It is then sutured to the dorsal perios-teum with the joint reduced and the thumbopposed under neutral tension. It is thenpassed under the insertion of the abductor pol-licis longus on the metacarpal and sutured toreinforce the dorsal aspect of the joint. It is thenpassed under the insertion of the FCR and backonto the radial aspect of the joint capsulewhere it is again sutured to strengthen thisaspect of the joint. It must not be sutured sotight as to restrict movement of the joint. Thethenar muscles are reattached. Eaton uses a K-


FIGURE 7-14 Reconstruction of thumb CMC jointusing half flexor carpi radialis (FCR).


wire to fix the MCP joint in 20° flexion.12 Thethumb is immobilized in opposition for fourweeks after which gradual mobilization is com-menced. Opponensplasty can be carried outwithin three months of surgery.

SUMMARYThe balanced reconstruction of the thumbrequires a good understanding of thumb anato-my and function to obtain good results. Eachhand presents with its own unique impair-ments. These impairments and the patient'sdesires and expectations must all be taken intoaccount while preparing a treatment program,which is unique for each patient. While the sur-geon should not use a uniform procedure forall patients, he/she should use procedures thatare familiar to both him/herself and the thera-pists on the team. With appropriate planningand good pre- and post-operative therapyresults should be excellent for opponens recon-struction. In high median paralysis, transfers toprovide extrinsic replacement will produce afunctional hand satisfactory to the patient. Thesensory deficit, while a significant disability,will not be a major obstacle in the use of thehand in a motivated and trained patient.

REFERENCES1. Anderson GA, Lee V, Sundararaj GD: Extensor

indicis proprius opponensplasty. J Hand Surg16B:334-338, 1991

2. Anderson GA, Lee V, Sundararaj GD:Opponensplasty by extensor indicis and flexordigitorum superficialis tendon transfer. J HandSurg 17B:611-14, 1992

3. Antia NH, Enna, CD and Daver BM: TheSurgical Management of Deformities in Leprosy.Oxford University Press, Bombay, 1992

4. Beine A: Abductor pollicis longus deviationgraft operation: a new procedure on the thumbcum low median palsy for correction of subluxa-

tion of carpometacarpal (CMC) joint. Ind J Lepr68:143-148, 1996

5. Brand PW. Clinical Mechanics of the Hand. CVMosby, St. Louis, 1985

6. Bunnell S: Opposition of the thumb. J Bone JointSurg 20:269-284, 1938

7. Burkhalter W, Christensen RC, Brown P:Extensor indicis proprius opponensplasty. JBone joint Surg 55A: 725-732, 1973

8. Burkhalter WE: Tendon transfer in median nerveparalysis. Orthop Clin North Am, 5: 271, 1974

9. Camitz H: Uber die Behandlung der Oppo-sitionslähmung. Acta Chir Scand 65:77-81, 1929

10. Cooney WP, Linscheid RL, An KN: Oppositionof the thumb: An anatomical and biomechanicalstudy of tendon transfers. J Hand Surg 9A:777-786, 1984

11. Davis TRC, Barton NC: Median Nerve Palsy. pp1497-1525. In Green DP, Hotchkiss RN andPederson WC (eds): Operative Hand Surgery.Churchill Livingstone, New York, 1993

12. Eaton RG, Lane LB, Littler JW, Keyser JJ:Ligament reconstruction for the painful thumbcarpometacarpal joint. A long-term assessment. JHand Surg 9A:692-699, 1984

13. Foucher G, Malizos C, Sammut D, Braun FM,Michon J: Primary palmaris longus transfer asan opponensplasty in carpal tunnel release. Aseries of 73 cases. J Hand Surg 16B:56-60, 1991

14. Fritschi, EP: Surgical Reconstruction andRehabilitation in Leprosy. The Leprosy Mission,New Delhi, 1984

15. Jensen EG: Restoration of opposition of thethumb. Hand 10:161-167, 1978

16. Kleinman WB, Strickland JW: Thumb recon-struction. pp. 2068-2170. In Green DP, HotchkissRN and Pederson WC (eds): Operative HandSurgery. Churchill Livingstone, New York, 1993

17. Malaviya GN, Husain S, Shantagunam P:Correction of “Z” pinch in ulnar paralysis of lep-rosy by transfer of flexor pollicis longus toextensor pollicis longus. Eur J Plast Surg 14:120-125, 1991

18. Mehta R, Malaviya GN, Husain S: Extensor indi-cis opposition transfer in the ulnar and medianpalsied thumb in leprosy. J Hand Surg 21B: 617-621, 1996



19. Mennen U: Extensor pollicis longus oppositiontransfer. J Hand Surg 17A:809-811, 1992

20. North ER, Littler JW: Transferring the flexorsuperficialis tendon: Technical considerations inthe prevention of proximal interphalangeal jointinstability. J Hand Surg 5:498-501, 1980

21. Omer GE Jr: Ulnar nerve palsy. pp. 1526-1541. InGreen DP, Hotchkiss RN and Pederson WC(eds): Operative Hand Surgery. ChurchillLivingstone, New York, 1993

22. Riley WB, Mann RJ, Burkhalter WE: Extensorpollicis longus opponensplasty. J Hand Surg5:217-220, 1980

23. Riordan DC: Tendon transfers of the hand andwrist. Curr Pract Orthop Surg 5:217-220, 1980

24. Rowntree T: Anomalous innervation of the handmuscles. J Bone and Joint Surg 52A:178-179, 1970

25. Warren G: Tendon Transfers. pp. 215-222. InConally WB (ed): Atlas of Hand Surgery.Churchill Livingstone, 1997

26. Zancolli EA, Cozzi EP: Atlas of SurgicalAnatomy of the Hand. Churchill Livingstone,New York, 1992



INTRODUCTIONRadial nerve palsy is a serious functionalimpairment, causing loss of wrist, finger andthumb extension. The loss of wrist extensioncauses wrist instability and forces the fingers toflex at a mechanical disadvantage due to thefinger flexors commencing action in a short-ened position. This greatly reduces the strengthin power grip. The loss of finger and thumbextension deprives the hand of the ability tograsp large objects. In leprosy, radial nervepalsy is often associated with median and/orulnar palsy, which greatly compounds theimpairment and limits the number of tendonsavailable for transfer. The usual combinationseen is a high radial palsy, a high ulnar palsyand a low median palsy. Many combinations oftransfers have been developed for the treat-ment of radial nerve palsy.2,3,8,9,18,21,26,31 Theactions that need to be restored are wrist exten-sion, finger extension, and thumb extension-abduction. In triple nerve palsy thumb abduc-tion and primary finger metacarpophalangealflexion must be restored. The standard trans-fers that will be described in this chapter areshown in Table 8-2. While the standard trans-fers are very successful when performed cor-rectly, Riordan correctly points out that "thereis usually only one chance to obtain goodrestoration of function in such a paralyzedhand."28 If the first procedure is not performedwell, with excellent follow-up care, the chanceof making a good functional hand is small.

The surgeon must have a good understand-ing of the three-dimensional anatomy of the

forearm and should review this prior to sur-gery. The principles of tendon transfer surgeryas outlined in Chapter 1 must be followed care-fully.

The issues involving nerve repair, in case oftrauma, will not be addressed here. The readeris referred to Green's discussion of this ifdesired.15 While some advocate early transferas a splint to prevent contracture. I would sug-gest that the therapy team should be able toprevent such problems during the time ofpotential nerve recovery.7,22

8Radial Nerve Palsy

� R. SCHWARZJ. JOSHUA

G. WARREN

TABLE 8-1: List of abbreviations used in thischapter.

ECRB Extensor carpi radialis brevisECRL Extensor carpi radialis longusECU Extensor carpi ulnarisEDM Extensor digiti minimiEPL Extensor pollicis longusFCR Flexor carpi radialisFCU Flexor carpi ulnarisFDS Flexor digitorum superficialisPL Palmaris longusPT Pronator teres

TABLE 8-2: Tendon transfer program fortriple nerve palsy.

First StagePT to ECRB yoked to re-routed ERCLFCR to EDC (and possible EPL)PL to re-routed EPL

Second StageFDS (long) to lateral bandsFDS (ring) opponensplasty


Pre-Operative TreatmentIt is essential that the therapy team obtains andmaintains joint mobility prior to tendon trans-fer and also to 'stretch' the long flexors out tofull length. Thumb webspace contracture, ifpresent, must also be corrected. Splinting isrequired, both to prevent contractures and toprovide the mechanical advantage that wristextension gives. Burkhalter notes that a simplecockup wrist splint can increase grip strengthby three to five times.23 More complex splintscan be designed that provide dynamic exten-sion of the thumb and fingers using outriggerswith rubber bands that allow full flexion.12

However these are very conspicuous andwould probably only be used by those whowill need to continue doing fine manual workprior to definitive surgery. Brand recommendsthat if only a cockup wrist splint is used then atnight a splint that keeps the fingers also inextension should be used to prevent long flex-or contractures.4

RECONSTRUCTION OF WRISTEXTENSIONThere have been many modifications of thebasic Pronator Teres (PT) to Extensor CarpiRadialis Brevis (ECRB) transfer since Jones firstdescribed the procedure in 1916.18 A fewauthors have advocated wrist arthrodesis.11,18

However the advantages of active wrist exten-sion are so strong and the results of an activetendon transfer are generally so good that thereis little reason to do a wrist arthrodesis as a pri-mary procedure unless there are inadequatemuscle-tendon units available for transfer.Brand has extensively studied the momentarms for the muscle tendon groups of the handand has devised a procedure which is a modi-fication of Jones' original procedure.4 We rec-ommend this procedure as the most sound andmost likely to function without complications.

Pronator Teres to Extensor Carpi RadialisBrevis Transfer

The ECRB has a strong moment arm for wristextension but it also has a moment arm forradial deviation. Therefore a simple PT toECRB transfer may lead to the development ofradial deviation of the wrist, which wastes thePT movement in a non-useful direction ofmovement. FCU (if present) can resist this butthis will weaken wrist extension. Three of four-teen patients undergoing PT to ECRB surgeryin our series developed radial deviationadversely affecting function21, and 5 of 40patients in Chotigavanich's series developedradial deviation.9 Some have also advocatedyoking ECRB to ECRL.18 ECRL has a greatermoment arm for radial deviation then wristextension, thereby further aggravating theproblem. Brand has shown well, when twotendons are yoked together, the one with thesmaller moment arm will be preferentially acti-vated by the transfer (Fig. 8-1).4 As ECRL has ashorter moment arm than ECRB for radialabduction, it will be the prime wrist mover,thereby pulling the hand into radial deviationfollowing surgery. Brand tried yoking ECRB toECU, but found that ECU had a small momentarm for wrist extension, and none when thewrist was pronated. He recommends yokingECRB to ECRL, detaching ECRL from its inser-tion in the base of the second metacarpal andreinserting it into the base of the fourthmetacarpal.4 This insertion has the samemoment arm for extension as the ECRB , andwill therefore give balanced extension. Tubianadescribes a similar procedure using the samerationale.31 This transfer is the key to success ofa rehabilitation program for someone withcombined nerve palsies. Good wrist extensionis necessary for effective finger flexion and willoptimize the function of tendon grafts forintrinsic and opponens transfers. Interestingly,the muscle fibre excursion for the PT (25 mm)is only half that of the wrist extensors (59 mm).The fact that many patients undergoing PT



transfers for wrist extension eventually achievea full range of motion implies that the excur-sion of the pronator muscle actually increasesfollowing surgery.29 Brand suggests that sar-comeres are added or removed in response to achange in the tension of a muscle at rest, butthat this process is slow.5

Technique: The PT to ECRB transfer is usuallycombined with the FCR- to-EDC (Flexor CarpiRadialis to Extensor Digitorum Communis)transfer. Only the incisions for the wrist exten-sion part of the procedure will be describedhere (Fig.8-2). An 8-10 cm curved incision (1) ismade over the convex part of the middle of theradial border of the forearm to expose theinsertion of the PT and the tendons of ECRBand ECRL. At this level the ECRB tendon isusually surrounded by muscle but the tendonis easily found inside.

The insertion of PT is identified by follow-ing the muscle down to its fanlike insertion

onto the radius. The end is grasped and cut offthe radius, taking care to include a 1-2 cm stripof periosteum with it to use for the anastamo-

Radial Nerve Palsy 85

FIGURE 8-1 a. Two pulley wheels fixed to a common axle. b. For a given amount of rotation, the largerrope releases a longer length of rope (tendon) c. Both ropes are fixed together, similar to a double tendoninsertion. d. Pulling on common rope (tendon) causes the rope on the wheel with the larger moment armto become slack. Only the smaller wheel is functional (from Brand4, used with permission).

FIGURE 8-2 Incisions for PT to ECRB transfer(dark lines) and FCR to EDC transfer/ PL to EPLtransfer (light lines). a. Volar aspect b. Dorsalaspect. Incisions are numbered as in text.

(a)

(c) (d)

(b)

1

2

3

4

5

68 7


sis. It is easy to miss some of the upper attach-ments of PT to the radius. The PT is thenbrought around, superficial to the brachioradi-alis, to avoid adhesions to the radius (Fig. 8-3a).The wrist is put in a 45° extension splint. Asmall transverse incision (2) is then made overthe insertion of ECRL, making sure it is not theextensor pollicus longus. The ECRL is detachedand brought out through the proximal incisionand then passed down superficial to deep fas-cia to a small incision (3) over the base of thefourth metacarpal (Fig. 8-3b). Attachments of

the ECRL to radius are freed to allow it to lie onthe ulnar side of the ECRB. Here a distallybased flap of periosteum is elevated and theend of the ECRL is fixed to periosteum withbraided nylon suture. If finger and thumbextension transfers are being done in the sameoperation they are completed at this point.

The ECRB is then sutured side to side to theECRL while applying equal tension on bothtendons. The PT is passed through the joinedECRB/ECRL tendon as far distally as possibleand sutured with braided nylon with moderate(1 cm) tension. The end is buried in the muscleand the anastamosis is covered with 6-0monofilament nylon. The skin incisions arethen closed. The wrist is immobilized in 45degrees of extension for four weeks beforemobilization is commenced (see Chapter 21 forspecific therapy techniques).

RECONSTRUCTION OF FINGER/THUMB EXTENSION

Thumb extensionBrand advocates the use of the palmaris longus(PL), when available, as the active tendon, toreplace the extensor pollicis longus (EPL).4 Inthe absence of the PL, the FCR is the tendon ofhis choice. The replacement of the abductorpollicis longus (APL) is also stressed by Brand,as it acts as an extensor of the metacarpal of thethumb, providing for a “circle” pinch. Toachieve this, the preferred active muscle is theFCR. However in these instances, Brand is con-sidering the radial paralysis alone with nor-mally functioning intrinsic muscles.

However in cases of leprosy, we normallyencounter a triple nerve paralysis, where theadductor pollicis and other intrinsic muscles ofthe hand are paralysed and consequently, themuscle imbalance is different. Moreover thenumber of active muscles available for thetransfer is limited.


FIGURE 8-3 a. The PT is elevated with a strip ofperiosteum and transferred above the brachioradialis.b. ECRL is transferred to base of the ring metacarpal,ECRL is attached to ECRB and the PT is attached toECRB (from Warren33, used with permission).

MC2

PT moves

Pron

ator

tere

s

ECRB

ECRL

ECRL

ECRL

ECRL

ECRB

Belly

of

pron

ator

tere

s

ECRB

Barch

iorad

ialis

ECRB

ECRL


Finger ExtensionMany active muscles have been used in thereplacement of finger extensors. Jones advocat-ed the use of the FCU18, while Brand has usedthe FCR for four-finger extension.3,4 Clezy,11

and later Fritschi,13 have advocated the use ofthe FCR for the restoration of four-finger andthumb extension. Goldner and Kelly14 and laterBoyes2 and Chuinard,8 have recommended theuse of the FDS muscles of the ring and/or mid-dle fingers for finger extension. However thisis acceptable only if the radial nerve is the onlyparalysed nerve. If there is associated ulnarand median nerve palsy (triple nerve palsy), asis usually the case in leprosy, these tendons areneeded for intrinsic muscle replacements.

Advantages and disadvantages of variousproceduresThe PL, if present, is an ideal muscle to use forthumb extension. The EPL tendon may be re-routed more radially to be attached to the PL toimprove the direction of action.

The FCU as the extensor of the fingers hasthe advantage of being strong and well able toprovide the necessary action. However, it lacksthe excursion required to provide a completerange of motion. (Its ulnar side fibres are only 4cms long). It is also too bulky and causes anunsightly bulge as it crosses over on the ulnarborder of the wrist from the flexor to the exten-sor aspect. It is an important muscle in its ownright, causing essential ulnar deviation in activ-ities like hammering and cutting vegetables.Use of this muscle for the transfer deprives thewrist and hand of these effective actions.

The FCR has the advantage of havinggreater excursion than the FCU and thereforecan cross more than one joint. It is also lessbulky and therefore is not as unsightly ontransfer. It has the disadvantage of having thescar of all tendon junctions at the region of theextensor retinaculum. This can cause problemswith mobilization in the post-operative perioddue to adhesions.

The FDS muscles to the ring and middle fin-gers have the advantages of good length so thatthe tendon sutures lie well distal to the retinac-ulum reducing the risk of adhesions. The FDShas adequate excursion to allow full range andindependent movement of the wrist and fin-gers. The relative disadvantage is that the FDSare antagonists to the movement they arerequired to produce making re-education moredifficult.

This transfer is usually done in combinationwith the previously described procedure forextension of the wrist; that is, in the same sit-ting it will follow Pronator Teres transfer to theECRB.

Palmaris Longus to Extensor Pollicis Longusand Flexor Carpi Radialis to ExtensorDigitorum Communis Transfer

Indication: Radial nerve paralysis in isolationor in combination with a high ulnar and lowmedian paralysis.

Technique: Following the PT to ECRB transfer, asmall incision (4) (Fig. 8-2) is made over thewrist crease over the visible PL tendon. Thetendon is identified, isolated and withdrawn inthe forearm via incision 5, about 10 cms proxi-mally. Through a longitudinal incision (7) justproximal to Lister’s tubercle over the level ofthe extensor retinaculum, the EPL is identifiedand isolated. It is divided at its musculo-tendi-nous junction. This tendon is withdrawn distal-ly, just proximal to the metacarpophalangealjoint of the thumb. It is tunneled subcutaneous-ly to lie over the tendon of the APL. The PL ten-don is then tunneled subcutaneously to meetthe EPL at this point, incision 6. It will lie basi-cally in line with the first metacarpal. The twotendons are sutured here with a short interlace,under high tension, with the thumb positionedin extension in the same plane as the palm (Fig.8-4).



Through the same incision over the wristcrease, just proximal to the insertion of theFCR, the tendon is isolated and detached fromits insertion and recovered in the forearmthrough a transverse incision (8) about 7 cmproximally. A longitudinal incision (7) is madeon the midpoint of the dorsum of the wrist andthe extensor retinaculum is cut along the sameline to expose the EDC. The FCR is tunneledsubcutaneously into this incision, finding thepath of least resistance using a blunt instru-ment.4 Setting the tension correctly is difficult,especially in triple nerve palsy. With the wristin about 45 degrees extension, and the fingersextended fully at the metacarpophalangealjoints, the FCR tendon is passed through the

individual slips of the extensor digitorum asdistally as possible after taking up the slack. Itis sutured in such a manner as to incorporateall the tendons in the stitch (Fig. 8-5). Anothermethod is to insert the FCR into the extensortendons of the ring and middle fingers andthen to attach the tendon of the index to that ofthe middle and the tendon of the little finger tothat of the ring finger. Most authors do notinclude the EDM for fear of creating too muchextension/abduction in the little finger.1 Greensuggests pulling on the EDC to assess the ade-quacy of little finger extension.15 If there is anextensor lag of the little finger, the EDM is alsoincluded in the transfer.

The transfer should then be tested passively.Wrist flexion should produce MCP joint exten-sion but not hyperextension. With the wristextended it should be possible to achieve full


FIGURE 8-4 Route of PL to EPL transfer. Movingthe EPL tendon to the radial side of the wrist willproduce both abduction and extension.

FIGURE 8-5 FCR to EDC transfer. A single weaveis carried out obliquely, and the unsatisfied end isburied in one of the extensor tendons. A similar joinis carried out for an FDS transfer but comes eitherthrough he interosseous membrane around theulnar border.

EPL

EPL

EPL

PL

EPI EDQ

Extensorretinaculum

EDC, EDQand EPI

EPL

FCR


finger flexion. The tourniquet is now released,haemostasis achieved and the wounds closed.

In case the PL is absent, Brand advises theuse of one of the FDS tendons for extension ofthe thumb.3 This however can be done only ifthe paralysis is confined to the radial nerve, asthe FDS tendons will be needed for intrinsicreplacement procedures in a triple nerve palsy.Fritschi,14 and McEvitt and Schwarz21 however,advocate the use of the FCR divided in twoslips, one for thumb extension and the otherfor four-finger extension even when the pal-maris longus is present. The EPL can be takenout of the dorsal retinaculum as shown in Fig.8-5 to give more abduction. They advise leav-ing the palmaris longus in situ as a flexor of thewrist.

Multiple Flexor Digitorum Superficialis toExtensor Pollicis Longus and ExtensorDigitorum Communis Transfer

Indication: Isolated radial nerve paralysis

Technique: The FDS of the ring finger and/ormiddle finger are detached from their inser-tions through incisions in the respective fingersand recovered in the mid forearm. Here theyare tunneled through a window in theinterosseous membrane passing on either sideof the flexor tendon mass. The tendons arereceived in the dorsum and then tunneled sub-cutaneously to the dorsum of the wrist. Theextensor retinaculum is opened. The EDC ten-dons and the EPL are identified. The middlefinger superficialis is attached to the EDC andthat of the ring finger is attached to the EPL.The postoperative immobilization regime is thesame as that described for the FCR and PLtransfers (see below), although specific therapytechniques will obviously differ.

When the PL is available for the thumb, theFDS of the middle finger alone can be used forthe four fingers.

Post-operatively: Place the arm in a full plasterfrom the fingertips to the upper arm, with theforearm fully pronated and the elbow at 90°.The wrist is kept at 45° of extension with thefingers kept fully extended. The plaster isbivalved at three weeks and cut off below theelbow. Gentle range of motion and transferactivation exercises are commenced. By sevenweeks post-op a full unrestricted range ofmotion should be achieved (see Chapter 21).Physiotherapy should be continued until ade-quate wrist extension is achieved. Schreuderset al demonstrated continued improvement inactive range of movement following a PT toECRB transfer up to one year following the sur-gery.24 This is probably because therapy notonly trains the patient to effectively use thetransfer, but also trains the muscle to increaseits excursion as noted above. It appears to takesome time for a muscle to increase its excur-sion.

Wrist Arthrodesis: Arthrodesis of the wristshould be reserved as a last option, as loss ofmovement of the wrist adversely affects thefunctioning of the hand. Even with a triplepalsy with a high median nerve involvement, amore functional hand can be obtained with the'hinge hand' operation (see below) than with anarthrodesis. Weiss et al33 report that efficiencyof hand function decreases by only about 20%following wrist fusion, but it should be notedthat these were patients with normal neurolog-ic status. Patients with multiple nerve paralysiswould be expected to have a greater negativeimpact on hand function from wrist arthrode-sis.

Indications:1. Wrist instability, subluxation or neuropathic

degeneration.2. Failed PT to ECRB transfer without hope of

successful revision.3. Triple nerve palsy with high median

involvement (relative).



There are now several methods of internalfixation available, which can be used if theequipment is obtainable. ArbeitsgemeinschaftOsteosynthesefragen (AO) techniques of plat-ing have reported non-union rates of 0-2%.17,33

The following method requires only K-wire fix-ation, is easy to perform and has a very highsuccess rate.13 If tendon transfers are plannedin the same hand, the arthrodesis should becarried out before the transfer to avoid disuseand further adhesions of the transfer. The idealposition of wrist fusion has not been deter-mined. In one study common activities of dailyliving were found to use an arc between 10degrees of flexion and 35 degrees of extension.6

Most authors recommend a position of about10 degrees of extension.16 Pryce25 reported thatpower grip was greatest in slight extension andulnar deviation, and Kraft and Detels19 foundthat grip strength was similar from 0-30degrees of extension but was weakened in flex-ion. It would seem that a position of between 0and 10 degrees would be ideal.

Technique: A lazy S incision is made from thebase of the third metacarpal to a point 7 cmproximal to the tip of the radial styloid in thecenter point of the dorsal forearm. The skin ismobilized at the level of the deep fascia, pre-serving as many of the veins as possible. Thedeep fascia and retinaculum are then raised asan ulnar- based flap along the full length of theincision. This can be difficult to keep as onepiece, especially over the distal radius. Theextensor tendons are now exposed. The exten-sor digitorum tendons are retracted ulnar-wards and the extensor pollicus longus tendonradially. The periosteum is then stripped off ofthe radius. A strip of bone graft is harvestedfrom the distal end of radius by cutting agroove 5 cm long, 5 mm deep and 6 mm wide,tapering distally. An oscillating or circular sawis best for this, although I (RS) usually use osteotomes. The joint spaces of the

radioscaphoid, radiolunate, capitolunate jointsare opened and the articular cartilage of eachjoint surface is removed with bone nibblers,saw or a gouge. Some also include the thirdCMC joint.

With the wrist held in 30° extension, thegroove in the radius is extended through thelunate and scaphoid using a gouge or fine nib-blers. This groove is then continued directlyinto the head of the capitate, gouging a holewith a gouge or a drill with the wrist in flexion(Fig. 8-6). This extends up into the base of thethird metacarpal and must be wide enough tofit the bone graft. The distal end of the bonegraft is then gently hammered into the hole,after which the wrist is slowly extended untilthe graft fits back into the groove. Cross K-wires are used to stabilize the wrist. Anyremaining cancellous bone is used as bonegraft. The periosteum is then sutured over thegraft and the fascial flap sutured over the ten-dons and skin closed.

A plaster extending from the PIP joints toabove the elbow is placed for 10 weeks total. Acheck X-ray must be taken prior to plasterremoval. The plaster can be trimmed to allowfinger movement at four weeks. If not buriedthe K-wires should be removed at one month.

The finger and thumb extension procedurescan be carried out when there are 3 weeksremaining until plaster removal.


FIGURE 8-6 Wrist arthrodesis. The bone graft isharvested from the distal dorsal radius and placedin the carpus and inserted into the base of thethird metacarpal after creation of a groove throughthe lunate, scaphoid and capitate.

Daves


Complications: Infections and skin edge necro-sis are unusual. The most common, and seri-ous, complication is delayed or non-union. Therate of non-union has been reported at 5-18% using techniques not utilizing plates.10,16

AO plate methods of fusion however havereported non-fusion rates of 0-2%.16 Adhesionsof extensor tendons can occur. Carpal tunnelsyndrome has been reported in 4-10% ofarthrodeses using the AO plate fixation.16

COMBINED NERVE PALSIESAs mentioned, in leprosy radial nerve palsy isusually seen in combination with median and/or ulnar palsies. Combined nerve palsies maybe seen in other peripheral neuropathies aswell. A complete hand assessment is mandato-ry to determine which muscles are still avail-able for transfer. In the presence of a low medi-an/high ulnar palsy, the most usual presenta-tion, the usual plan is a two or three stagereconstruction to carry out the procedures out-lined in Table 8-2. In the first stage the wristand finger/thumb extension replacement pro-cedures are performed. There is concern thatremoving the PL would leave the wrist withouta dedicated flexor. Zachary has demonstratedthat the PL alone is not adequate to providewrist flexion in a hand with a simple radialnerve palsy.34 While it appears to be adequatein a triple nerve palsy hand, removing it willleave the wrist without an independent flexor.For this reason we usually use FCR to activateextension in both fingers and thumb. Howeverthe finger flexors will also stabilize the wrist inflexion. Therefore if independent thumb exten-sion is needed the PL could be used in this sit-uation. In the second stage a sublimus transfer(FDS to lateral bands, see Chapter 6) is carriedout for intrinsic replacement, and an opponensreplacement is performed using flexor digito-rum superficialis (Chapter 7). It is important toavoid making the sublimus replacement so

tight that the finger extensor transfer is unableto extend the metacarpophalangeal joints.l It isbest to do a Bunnell type transfer to the lateralbands as opposed to the flexor pulleys, as withthe latter the finger extensors have to extendthe interphalangeal joints on their own.Arthrodesis of the thumb metacarpopha-langeal joint or a half flexor pollicus longustransfer would be appropriate for stabilizingthe thumb (Chapter 6).

It should be noted that not all patients witha triple nerve palsy will be candidates for allprocedures. In our study 18 of 21 patientsundergoing reconstructive surgery for radialnerve palsy secondary to leprosy reactions hadinvolvement of all three nerves.21 Of these 18,only eight had intrinsic reconstruction and tenhad opponens reconstruction. Reasons for thiswere partial nerve palsy, refusal of further sur-gery, or unsuitability for further reconstruction.Some patients presented with severe contrac-tures or shortened digits and were not consid-ered candidates for reconstruction of all func-tions.

In combined low median and high radialnerve palsy with an intact ulnar nerve, an FCRto EDC transfer should be carried out. The FCUwill maintain wrist flexion. The PL should thenbe used with a re-routed EPL to provide thumbextension and abduction. This procedure mayprovide enough abduction that the patient maynot desire to proceed with an opponensplasty.Combined high median and radial nerve palsywith intact ulnar nerve is virtually never seenin leprosy. If it does present, Omer recom-mends wrist arthrodesis, or PT to ECRB trans-fer if available, for wrist extension with theFCU transferred to EDC and EPL forfinger/thumb extension.22,23 A tenodesis ofFDP tendons of the index and middle finger toFDP of ring and little fingers is carried out togive active finger flexion of all fingers. Thethumb is stabilized by thumb MCP arthrodesis,



tenodesis of FPL across the IP joint and tenode-sis of the APL tendon to the radius.

If the median nerve is intact with a com-bined radial/ulnar palsy then a Bunnell typesublimus transfer is carried out as second stageprocedure. Again, arthrodesis of the thumbmetacarpophalangeal joint or a half flexor pol-licus longus transfer would be appropriate forstabilizing the thumb.

The hinge hand procedure

It is not uncommon to be requested to reacti-vate a hand in which there are very few mus-cles functioning. The patient desires appear-ance, social acceptability and as much functionas possible. There are many options aimed atproviding the maximum possible function andappearance. Transfers for tetraplegic patientsare described elsewhere.16 However there is arelatively simple procedure that often gives asatisfactory result in the severely motor defi-cient hand.

If there is only one muscle of reasonablestrength that can be used in isolation, it can beused to activate wrist extension to provide a“hinge hand”. The hand at rest should be in anormal posture and when the wrist is extendedthe fingers close for grasp. Patients do not havea lot of strength but there is usually enough sta-bility to hold large light objects especially ifthey have a stem for easy holding. If this mus-cle can be used to provide a good wrist exten-sion it is possible by tenodesis of the flexors toprovide a hand that grasps, albeit weakly.

A normal strength ECRB or ECRL is usuallyadequate although the wrist extension may bestabilised by yoking one tendon to the 4thmetacarpal base to give pure wrist extension.No other active transfer will be needed. Ifthere is no active wrist extensor it is necessaryto transfer some other muscle, yoked to givebetter wrist extension stability. Suitable mus-cles need to be relatively strong and theyinclude brachioradialis, pronator teres, flexorcarpi radialis and FDS.

It is desirable to tenodese any extensor ten-dons at the same time as the active transfer isinserted. This allows a uniform tension to beachieved across all extensors. The techniquedescribed is similar to that of Zancolli.35 Theflexor tendons are tenodesed 3 months orlonger before the extensors are dealt with sothat they can be put in more tightly than wouldbe possible if extensors were done first. A ten-odesis of thumb opposition can also be per-formed, usually at the time of the flexor ten-odesis. This will alter the ability to graspobjects of wide diameter but will improve theability to hold something like a drinking glasswith a narrow stem as the rim of the glass willbe supported all around. Alternately, theabductor and long flexor of the thumb can betenodesed.

Technique-flexors: Initially the flexor side isoperated on. The FDS tendons are locatedabout 2-3 cm above the wrist on the radial sideof the forearm, and sutured together, side byside, when the fingers are straight. For attach-ment to the radius, use a small 2-3 mm diame-ter drill or burr and drill a series of 3 smallholes, the distal two being 0.5 cm apart and thethird one some 1 cm proximal. The bridge ofbone between these two distal holes isremoved so a cavity down to the marrow is dis-played (Fig. 8-7). The flexor tendons are identi-fied and pulled tight with the fingers extended,and wrist straight or up to 10 degrees flexion.


FIGURE 8-7 Tenodesis tech-nique. Three holes are drilled inthe distal radius. Then the bonebetween the distal two holes isnibbled to create a larger singlehole. A sub-cortical tunnel is thencreated between these two holesthrough which a single tendonwill then be passed.

0.5

1.0

R


They are sutured together at the site of the dis-tal hole. The long finger tendon is then cut andpassed into the distal hole and out through theproximal hole. A strong Silk or braided nylon isused to pass this tendon into the distal cavityand out through the proximal hole so the ten-don can be sutured back to itself, (Fig. 8-8). Thismeans that only 3-4 weeks immobilisation is

required for enough healing to start physio-therapy. If the tendon is inserted in bone via aBunnell suture so that the tendon just ends inthe bone a much longer immobilisation isrequired. This tenodesis ought to result in thefingers being flexed at the MCP and PIP jointswhen the wrist is extended (Fig. 8-9). Thedegree of flexion will depend on the position ofthe wrist when the tendon length is cut beforesuturing.

The long extensor of the thumb can beattached similarly but it is often better to divideEPL and attach it to the insertion of FCR so thatthe thumb automatically pulls out straight andinto abduction when the wrist extends. Thisshould be done at the same time as the flexortendon tenodesis. McDowell and House rec-ommend stabilizing the thumb by car-pometacarpal joint fusion, combined with ahalf flexor pollicus longus to extensor pollicuslongus transfer to stabilize the interphalangealjoint.20 After this procedure the arm is plas-tered with the wrist flexed, the fingers straightand the thumb fully opposed and abducted.

Technique-extensor: The methodology fortransferring the basic active motor (PT or ifabsent brachioradialis) into ECRB is asdescribed above.

For the finger extensors it is necessary toopen the forearm for about 5 cm proximal tothe wrist with an incision that allows dissectiononto the ulna bone about 2-3 cm proximal tothe wrist joint, where the tendons will beattached. The attachment technique is the sameas for the FDS (Fig. 8-10). The tension for thissuture is fixed at neutral when the fingers arestraight and wrist extended about 10-15degrees. This should allow the fingers tostraighten when the wrist is allowed to droptowards flexion (Fig. 8-11), but to flex at theMCP and IP joints when the wrist is extended.


FIGURE 8-8 Tenodesis technique.A single flexor tendon is passedfrom the distal hole back throughthe proximal to be sutured backto itself and the remaining tendonends are buried in the distal hole.

FIGURE 8-9 Hinge handprocedure. Extension ofwrist produces flexion of thefingers (from Warren33, usedwith permission).

FIGURE 8-10 Hinge hand procedure. Attachmentof finger extensors to ulna (from Warren33, usedwith permission).

R


The exact tension that can be applied willdepend on what the tension is in the flexortendons. This can easily be tested on the tablebefore final suturing and closure.

The arm is plastered with wrist fullyextended and the fingers straight as is done forthe pronator teres splint. If the thumb has alsobeen operated on it will require to be held inabduction and opposition. The plaster ought tobe above elbow especially if ECRB or BR is theused motor.

Physiotherapy is relatively easy. The cast isleft on for 4 weeks and then the transferredwrist extensor is re-educated. The fingers willautomatically activate so that when the wristextends the fingers flex, and when the wristflexes the fingers extend and the thumb isabducted and extended.

SUMMARYWhile radial nerve palsy, and especially com-bined nerve palsies, are a serious disability,surgery for these conditions is usually veryrewarding. Careful attention to technique isessential to achieve correct balance, and skilledtherapy is necessary to achieve a good result.

REFERENCES1. Beasley RW: Tendon transfers for radial nerve

palsy. Orthop Clin North Am 1:439-445, 1970

2. Boyes JH: Tendon transfers for radial palsy. BullHosp Joint Dis 21:97-105, 1960

3. Brand PW: Tendon Transfer Reconstruction forRadial, Ulnar, Median and CombinationParalysis: Principles and Techniques. pp 4923-4965 In McCarthy.J.G: Plastic Surgery, Vol 8. WBSaunders Company, Philadelphia, 1990

4. Brand PW: Biomechanics of Tendon Transfer. pp190-213. In Lamb DW (ed): The Hand and UpperLimb, Vol. 2. The Paralysed Hand. ChurchillLivingstone, Edinburgh, 1987

5. Brand PW: Biomechanics of balance in the hand.J Hand Ther 6: 247-251, 1993

6. Brumfield RH, Champoux JA: A biomechanicalstudy of normal functional wrist motion. ClinOrthop 187:23-25, 1984

7. Burkhalter WE: Early tendon transfer in upperextremity peripheral nerve injury. Clin Orthop104:68-79, 1974

8. Chuinard RG, Boyes JH, Stark, HH et al: Tendontransfers for radial nerve palsy: use of superfi-cialis tendons for digital extension. J Hand Surg3: 560-570, 1990

9. Chotigavanich C: Tendon transfer for radialnerve palsy. Bull Hosp Joint Dis 50):1-10, 1990

10. Clendenin MB, Green DP: Arthrodesis of thewrist- complications and their management. JHand Surg 6:253-257, 1981

11. Clezy JKA. Triple paralysis of the hand. pp 263-268 In McDowell F, Enna CD (eds): Surgicalrehabilitation in leprosy. Williams and Wilkins,Baltimore, 1974

12. Colditz JC: Splinting for radial nerve palsy. JHand Ther 1:18-23, 1987

13. Fritchi EP: Surgical Reconstruction andRehabilitation in Leprosy. The Leprosy Mission,New Delhi, 1984

14. Goldner, JL, Kelly, JM: Radial nerve injuries.South Med J, 51:873,1958

15. Green DP: Radial nerve palsy. pp 1481-1496 . InGreen DP, Hotchkiss RN and Pederson WC(eds): Operative Hand Surgery. ChurchillLivingstone, New York, 1993

16. Hastings H: Wrist arthrodesis. pp 131-146. InGreen DP, Hotchkiss RN and Pederson WC(eds): Operative Hand Surgery. ChurchillLivingstone, New York, 1993

17. Hastings H: Arthrodesis of the OsteoarthriticWrist. pp 345-360. In Gelberman RH (ed): TheWrist. Raven Press, New York, 1994

18. Jones R: Tendon transplantation in cases of mus-culospiral injuries not amenable to suture. Am JSurg 35:333-335, 1921


FIGURE 8-11 Hinge hand procedure. Flexion ofwrist produces finger extension and thumb exten-sion and abduction (from Warren33, used with per-mission).


19. Kraft GH, Detels PE: Position of function of thewrist. Arch Phys Med Rehabil 53:272-275, 1972

20. McDowell CL, House JH: Tetraplegia. pp 1588-1606. In Green DP, Hotchkiss RN and PedersonWC (eds): Operative Hand Surgery. ChurchillLivingstone, New York, 1993

21. McEvitt, Schwarz RJ: Tendon transfer for triplenerve palsy. Lep Rev 73: 319-322, 2002

22. Omer GE Jr : Tendon transfers for reconstructionof the forearm and hand following peripheralnerve injuries. pp 817-846. In Omer GE Jr,Spinner M (eds): Management of PeripheralNerve Problems. WB Saunders, Philadelphia,1980

23. Omer GE: Combined nerve palsies. pp 1542-1555. In Green DP, Hotchkiss RN and PedersonWC (eds): Operative Hand Surgery. ChurchillLivingstone, New York, 1993

24. Parker D: Radial nerve paralysis treated by ten-don transplant and arthrodesis of the wrist(abstract). J Bone Joint Surg 45B: 626, 1963

25. Pryce JC: The wrist position between neutraland ulnar deviation that facilitates the maxi-mum power grip strength. J Biomech 13:505-511,1980

26. Raskin KB, Wilgis EF: Flexor carpi ulnaris trans-fer for radial nerve palsy: functional testing oflong term results. J Hand Surg 20:737-42, 1995

27. Reid RL. Radial nerve palsy. Hand Clin 4:179-85,1988

28. Riordan DC: Tendon transfers in hand surgery. JHand Surg 8:748-753, 1983

29. Schreuders TAR, Stam HJ, Hovius SER: Trainingof muscle excursion after tendon transfer. JHand Ther 9:243-245, 1996

30. Sundararaj GD, Mani K: Surgical reconstructionof the hand with triple nerve palsy. J Bone JointSurg 66B:260-4, 1984

31. Tubiana R, Miller HW, Reed S: Restoration ofwrist extension after paralysis. Hand Clin 5:53-67, 1989

32. Warren G: Tendon Transfers for Radial NervePalsy. pp. 241-249. In Conally WB (ed): Atlas ofHand Surgery. Churchill Livingstone, 1997

33. Weiss APC, Hastings H: Wrist arthrodesis fortraumatic conditions: A study of plate and localbone graft application. J Hand Surg 20A:50-56,1995

34. Zachary RB: Tendon transplantation for radialparalysis. Br J Surg 23:358-364, 1946

35. Zancolli E: Surgery for the quadraplegic handwith active strong wrist extension preserved. Astudy of 97 cases. Clin Orthop 112:101-113, 1975



INTRODUCTION Hand surgery in nerve injury aims to restorefunction and cosmesis. Undoubtedly, tendontransfers and nerve decompression are themost common and needed operations in a sur-gical program aiming to physically rehabilitateneuropathic hands. However, surgeons dealingwith leprosy patients will be faced with a vari-ety of conditions: from a preserved hand withjust mobile clawed ulnar fingers to a grosslydeformed and destroyed hand (Fig. 9-1). Thefirst condition is easily resolved with a simpletendon transfer. The latter could lead surgeonsto a feeling of frustration and hopelessness inthe sense that nothing can be done for suchconditions. The aim of this chapter is to presentsome suggestions for selected techniquesdevised to correct and/or ameliorate some ofthese deformities not covered elsewhere in thetextbook.

The leading philosophy is that, in many

instances, something can be done to improvethe function of a badly deformed hand.Sometimes, a minor arthrodesis may result in adramatic improvement in the daily life activi-ties of a patient. However, it is most importantbefore the operation, to carefully examine thehand, select an adequate intervention and fullydiscuss with the patient the possible resultsand operate only if the patient understandsand agrees with the procedure.

The cosmetic appearance of the handshould not be neglected. Some surgeons con-sider these aspects as non-priority. However,one should remember that this decision shouldbe given to the patient and not to the surgeon.It is intriguing to realize that some patientswith longstanding ulnar paralysis are, by far,more concerned with wasting of the first webthan with clawed fingers. They can often over-come the functional disadvantage with a vari-ety of tricks but hardly can conceal a depressedweb other than keeping the hand in the pocket.This attitude may lead to socially embarrassingsituations.

ContracturesCollateral ligaments, volar plate and joint cap-sules are structures to provide a stable link thatallows efficient transmission of muscular forceacross the joints. These structures are main-tained in their optimal flexibility and length bya normal joint. Muscle weakness or palsy inter-feres greatly with this intricate mechanism andthe final result can be soft tissues and joint con-tractures. Longstanding muscle palsy is com-

9Management of Miscellaneous

Conditions in the Paralysed Hand� M. VIRMOND

H. DA ROSA PEREIRA

FIGURE 9-1 A grossly deformed hand. Unattendedacute reactions may lead to severe deformations inthe hand due to myositis, arthritis, joint contracturesand scarring of skin wounds after necrotizing erythe-ma nodosum.


mon in leprosy and thus joint contractures arealso frequent if preventive measures are nottimely. The sensory loss may lead to woundsthat may become infected, compromising deepstructures and resulting in tendon, bone andjoint involvement. There may be loss of inser-tion of the tendons, bone sequestra and jointdestruction.

The end result may be shortened fingerswith contracted joints that interfere with nor-mal function of the hand. A careful analysis ofeach hand may lead to the indication of surgi-cal techniques that can improve the function. Itis important to note that these cases are of long-standing contractures and not recent condi-tions as we commonly see after trauma. Forthis reason, possibilities for surgical correctionare very limited. In many cases the surgicaltechniques are restricted to release skin con-tractures and arthrodesis in order to simplyimprove the position of the finger and therebyimprove hand function.

Distal interphalangeal joint contractures

To the clawed fingers contractures of the distalinterphalangeal joint (DIP) may cause addi-tional difficulty for pinch and grasp.Arthrodesis of the DIP joint can improve theoverall function of the hand (Fig. 9-2).Frequently in leprosy the amount of bone at thedistal phalanx is not enough to allow adequatefusion. Therefore it is useful to shape the boneends to increase the bony surface (Fig. 9-3).

Operative technique: After a wrist or fingeranesthetic block, incise deeply and longitudi-nally in the dorsal aspect of the distal fingerincluding the terminal slip of the extensor ten-don. Preserve as much as possible the dorsalvenous drainage. Expose the capsule and col-lateral ligaments and release these structurescarefully with a #15 blade.

Fully expose both the articular facets and

remove the cartilaginous tissue with a thinosteotome and shape the proximal end of thedistal phalanx and the distal portion of themiddle phalanx in order to obtain an angle of15° to 20°. Carefully remove debris between thefacets and firmly fix both phalanxes with twoKirschner wires keeping the bones compressedas the wires are inserted (Fig. 9-4).

Proceed with hemostasis and close the


FIGURE 9-2 The contracted distal phalan madegrasping of objects difficult. A DIP arthrodesis hasimproved function of the hand.

FIGURE 9-3 DIP arthrodesis with reshaping of thedistal bone, which increased the surface contactbetween the remaining distal phalanx and themedial phalanx.


wound with separate sutures of nylon 6/0.Immobilize with a plaster cast, which shouldbe removed after 4 weeks.

Proximal interphalangeal joint contractures

Contractures of the PIP joint are the most com-

mon in hands of patients affected by leprosy.Contractures following recent paralysis shouldbe treated with adequate physical therapyand/or surgical release of ligaments and volarplate by conventional techniques.19 It is alsoadvisable to consider the use of distractors,which has the advantage of allowing progres-sive and slow lengthening of soft tissues andcollateral vessels.14 However, this section willdescribe only treatment for longstanding con-tractures in which most of the conventionaltechniques are not successful. The surgicaltechnique is similar as that for DIP arthrodesis(Fig. 9-5a,b). Besides these standard tech-niques, others can be advocated depending onthe experience of the surgeon.1,12,16 How-ever,its is important to stress that, due to the accom-panying severe contracture of skin, the amountof bone to be removed to allow good position-ing may severely shorten the finger. In order toavoid this problem it is advisable prior to

arthrodesis to release soft tissue contrac-tures.A good technique for this purpose is the oneproposed by Fritschi described below (Fig. 9-6,9-7 and 9-8).

Operative technique

With a marking pencil outline a “Y” in eachside of the joint which legs should join at thevolar aspect of the joint. Incise along the draw-ing and make sure to keep the knife superficial– do not incise deeply, that is, beyond the der-mis.

With fine scissors, undermine distally andproximally to the volar incision in order todraw areolar tissue to your surgical wound tocover the flexor tendon sheet, which will beexposed along with the progressive release ofthe joint and skin contracture.

Through the “V” portion of the “Y” incision,release the collateral ligament on both sidesand the volar synovial pouch if it is obliterated.

The Management of Miscellaneous Conditions 99

FIGURE 9-5a,b PIP arthrodesis. (A) Chevron-type tech-nique. (B) Cup and cone type arthrodesis allows ade-quate bone-to-bone contact and, most of all, makes thefinal adjustment of the phalanx position before the fixa-tion with K-wire easier.

FIGURE 9-4 DIP arthrodesis. If the distal phalanxhas enough bone, a conventional two K-wirearthrodesis can be done. Bone parts should be keptunder compression while inserting the wires.

(a) (b)



FIGURE 9-6 Fritschi’s Y technique for skin and joint contracture. a. The "Y" is marked in the skin. The dotis intended as the fulcrum of the PIP joint. b. A careful superficial undermining is made both distally andproximally releasing contracted tissue and drawing areolar tissue to the open surgical wound.

FIGURE 9-7 Fritschi’s Y technique for skin and joint contracture. a. Pre-operative view with passive exten-sion. b. Passive opening of the finger after surgery.

FIGURE 9-8 Fritschi’s Y technique for skin and joint contracture. a. Pre-operative view – active extension.b. Postoperative view – active extension.

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As the release proceeds, notice that the surgicalwound becomes wider. This is actually the gainin the passive range of movement of the PIPand it also shows the amount of skin necessaryto cover the gap.

Harvest the needed amount of full-thick-ness skin graft and apply the graft over the sur-gical wound at the volar aspect of the joint.Before suturing the skin graft, insert at leastone Kirschner wire to effectively immobilizethe joint while, in the post-operative period,the skin graft takes and retracts.

Full-thickness skin grafts are preferable torepair the surgical gap due to the smallerdegree of contraction in the post-operativeperiod and because the quality of skin is betterthan in split-skin grafts. For all skin graftingtechniques in this chapter it is recommended toharvest the donor skin from the antecubitalspace. In this space it is possible to harvest areasonably amount of good quality hairlessskin yet allowing easy closure of the transversedefect. If there is need for a larger piece of skin,it must be harvested at the groin.

According to the severity of the contracturethe surgical wound may prove to be inade-quate for a skin graft. This happens when, afterrelease, the joint becomes exposed and theamount of areolar tissue is not enough to pro-vide a recipient bed for the graft. In this case aflap may be used. A cross finger flap is a satis-factory choice to cover the remaining defect(Fig. 9-9) and it is easy and safe to perform. Theinconvenience is that the fingers must be keptimmobilized for 2 weeks and there is need for asecond operation to release the pedicle.

Metacarpophalangeal joint contractures

Flexion contracture of the MP joints is seldomseen in leprosy. However, extension contrac-tures may occur as a result of a severe andinadequately treated “reactional” hand. This isa challenging condition to the surgeon. Thedorsal skin may become shiny, immobile and

fragile with poor blood supply. The capsule iscontracted as well as the extensor hood, whichmay additionally be laterally dislocated. Thejoint itself may be affected e.g. exostosis andcompromise of the cartilaginous facets.Extension contractures of MP joints are highlydysfunctional since they prevent adequategrasping or pinching. If possible, release ofskin and joint contracture should be undertak-en to allow the distal joints to perform basictasks of daily life activities.

Operative technique

Place a transverse incision at least 3 cm proxi-mal to the knuckle of the MP joints. It is ofutmost importance to preserve dorsal veins atthis stage. Undermine carefully the distal bor-der of the incision to expose the MP joint area.If necessary, complete the incision with anextended “V” in both radial and ulnar sides(Fig. 9-10).

Expose and incise the two collateral liga-ments and release the volar plate pouch with asmall curved elevator. If exostoses are present,remove them with a fine nibbler.

At this stage, sufficient flexion should beobtained (50°-60°). Immobilize the affectedjoints with a longitudinal Kirschner wire takingcare to maintain the finger properly aligned onits longitudinal axis.

Apply a full-thickness graft to repair thewidened dorsal surgical wound. Immobilize


FIGURE 9-9 Fritschi’s Y technique for skin andjoint contracture. A cross-finger flap can be usedto improve coverage of the surgical wound.

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the hand with a volar plaster cast including apadded dressing in the dorsum to ensure mildcompression over the skin graft.

Soft tissue contractures

Soft tissue contractures can be severely limitingto the function of the hand in leprosy. Thesecontractures can be treated by physical therapy.For finger contractures the choice treatmentincludes exercises, splinting and serial cylindercasting. The latter is particularly efficient torestore adequate range of movement (ROM),but requires a carefull follow-up and completepatient compliance. However, in some long-standing contractures, surgical interven-tion isnecessary.

Release of soft tissue contractures in the fin-gers can be treated by skin graft or pedicle flapand the various techniques have been previ-ously discussed in this chapter. Skin contrac-tures in others sites of the hand need a carefulanalysis and the surgical technique should bedecided on each specific situation. Again, skingrafts are, in most cases, the preferable optionafter release of the contracture. Z-plasty is agoodprecious technique that should be consid-ered whenever applicable (Fig.9-11a and b).

Intrinsic plus deformity (Swan-neck)In this deformity there is hyper-extension ofthe PIP and some degree of flexion in the ter-

minal joint (Fig. 9-12).13,15 Most frequently, theOne cause for intrinsic plus deformity in lep-rosy is contracture of the intrinsic muscles dueto myositis as a result of reactions. The degreeof severity depends on the time elapsed with-out adequate treatment and the severity of thereaction. Sometimes it is possible to see “acute”swan neck during an acute reactional state dueto spasm of the intrinsic muscles (lumbricaland interosseous).5 On the other hand, follow-ing a severe reaction without proper treatmentor with delayed attention (drugs, splinting andphysical therapy), the fine structures of thedorsal expansion become contracted andfibrotic, the skin contracts and the joint devel-ops stiffness. Contracture of the oblique reti-nacular ligament is also a common feature oflongstanding intrinsic plus deformity. Anothercommon cause for “intrinsic plus” deformity isthe removal of the flexor sublimis for tendontransfer in the hand (sublimis-minus).2,13 A


FIGURE 9-10 Technique for dorsal release. A skingraft is applied to cover the defect.

FIGURE 9-11 Z-plasty for skin contracturerelease. a. pre-operative view. b. a multiple Z wasdone along the axis of the scarred tissue.

(a)

(b)

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third cause is following intrinsic replacementsurgery in an excessively mobile hand. Analternative in these hands is to employ theLasso technique of Zancolli19, which correctsthe clawed fingers without direct attachment oftendon slips in the extensor apparatus, therebygreatly reducing the risk of swan-neck defor-mity.

In mild deformities where flexion of the PIPjoint can be actively achieved and there is nogross contracture, there should be no need forsurgical correction. If necessary, a simple der-madesis (Fig. 9-13) may be sufficient to reversethe deformity though the correction proves tobe not longstanding in my experience.

Correction of Swan-neck deformity

The traditional technique for correction of“intrinsic plus” was described by Littler.10 Hesuggests excision of a triangle of the obliquefibers in the dorsal expansion at the level of themiddle or proximal third of the proximal pha-lanx. This technique is indicated in those casesin which the flexion of the PIP is restrained(Fig. 9-14). Another possibility is an incision ofthe lateral band at the proximal third leavingthe band attached to the distal end. The band isthen rerouted volarly to the ligament ofCleland and sutured to the flexor tendonsheath. In this way, the tension on the bandallows extension of the DIP and preventshyperextension of the PIP (Fig. 9-15).

Fritschi3,8 recommended a longitudinal inci-sion along the expansion, which divides theoblique fibers and continues distally dividingthe lateral band (Fig. 9-16). After release of thehyperextension of the PIP, the lateral band isreattached to the oblique fiber in the new posi-tion.

Tenodesis of the flexor sublimis is analternative that may give good results.7 A slipof the flexor sublimis is cut in the proximal endof the proximal phalanx. The slip is passedthrough a small opening made in the distalportion of the A2 pulley and sutured to itself(Fig. 9-17). This method prevents the hyperex-tension of the PIP.

In severe cases of intrinsic-plus deformity itmay be necessary to release skin contracturewith Z-plasty and reconstruction with flaps.The dorsal expansion should be released aswell as the lateral band. Finally, the PIP isarthrodesed in slight flexion. This is almost asalvage procedure that should be fully dis-cussed with the patient before operation.

Boutonniere deformityThe extensor apparatus of the finger is a fine


FIGURE 9-12 Swan-neck deformity. Note the hyper-extension of the PIP and flexion of the DIP joint.

FIGURE 9-13 Dermadesis at PIP joint. An ellipticskin resection is made. The incision should beplaced in order that the final suture lies in thenatural PIP volar crease.

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complex of bands, slips and ligaments that con-tributes to a smooth and coordinated move-ment of extension and flexion of the finger.

Damage to any of its portions may inducesevere imbalance in both movements.

Disruption of the integrity of the extensorapparatus at the level of the middle joint mayresult in a boutonniere (button-hole) deformity.Actually division of the central slip of theextensor tendon alone is not enough for a bou-


FIGURE 9-17 Tenodesis for correction of Swan-neckdeformity. A slip of the flexor sublimus is cut proximallyto its insertion at the base of the medial phalanx. Theslip is threaded through a small opening made in thedistal part of A2 pulley and sutured to itself after flex-ing the PIP joint. During flexion of the fingers the slipbecomes loose but as the finger attempts to extend,the slip becomes tight and prevents hyperextension ofthe joint beyond the adjusted angle of the PIP joint.

FIGURE 9-16 Swan-neck correction. Fritschi’smodification of Littler’s operation. The lateral bandis sectioned. The PIP joint is flexed at 60º and thelateral band is re-sutured to the cut oblique fibersin the new position.

FIGURE 9-14 Littler’s technique for Swan-neckcorrection. Using a triangular resection, the lateralband and oblique fibers of the dorsal aponeurosisare removed at the level of the middle or proximalthird of the proximal phalanx.

FIGURE 9-15 Swan-neck correction by rerouting ofthe lateral band. The lateral band is detached at theproximal end and reattached to the flexor sheathafter having been threaded volarly through Cleland’sligament, which prevents its dorsal excursion. Thenew route of the lateral band avoids hyperextensionof the PIP joint while still allowing extension of theDIP.

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tonniere deformity to occur. Also required issome involvement of the retinacular compo-nent of the dorsal apparatus.3 This conceptshould be borne in mind to understand thepathogenesis of the deformity in leprosy.

The most common cause of boutonniere inulnar palsy is the chronic abnormal position ofthe various structures of the extensor appara-tus as a result of longstanding clawed fingers.The lateral bands migrate volarly resulting incontracture of the oblique retinacular ligamentof Landsmeer. Sometimes this is referred to as“hooding deformity”. It is important to notethat clawed fingers greatly expose the ofteninsensitive skin of the knuckles of the finger torepetitive trauma which may lead to woundsthat may become infected and destroy the ten-don apparatus on the dorsum of the middlejoint. In other instances, the granulomatouscomponent of a reaction can also compromisethese fine structures. As a result, the bouton-niere (hooding) deformity in leprosy is basical-ly characterized by volar displacement of thelateral bands and contracture of the obliqueretinacular ligament. The final picture is flexionof the PIP joint with mild extension of the DIPjoint (Fig. 9-18).

To assess contracture of the oblique retinac-ular ligament the PIP is passively extended andthen the distal phalanx is flexed. In the pres-

ence of a boutonniere deformity there will bemarked resistance to flexion of the DIP. Withthe PIP flexed it will be easier to flex the DIPjoint (Fig. 9-19). Before considering surgicallycorrecting a recent boutonniere, the patientshould be asked to actively flex the DIP whileextending the PIP with the other hand.

Surgical treatment of boutonniere in leprosydepends on the severity of the case. Differentfrom fresh or traumatic boutonniere9 the defor-mity in leprosy is commonly chronic withintense residual fibrosis and disorganization ofthe fine extensor apparatus structures – there-fore, results are often unrewarding.

Central Slip Advancement

In mild cases with rupture of the central slip anadvancement of this structure can be per-formed.

Operative technique

After a wrist, or even a finger block, make anincision on the dorsal aspect of the middle andproximal phalanx, fully exposing the region ofthe PIP.

Identify and remove the fibrotic callus onthe central slip over the PIP. Sometimes it is dif-ficult to recognize the difference between the


FIGURE 9-18 Severe Boutonniere deformity. FIGURE 9-19 Restrained flexion of the DIP joint isa characteristic of advanced Boutonniere. The testshould be made before any attempt for physicaltherapy or surgery treatment.

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tendon (central slip) and the fibrotic tissue. Theformer has a shine pearl aspect and the latter islight gray and transparent.

While removing the fibrotic callus, leave acuff of tissue attachment to the base of the mid-dle phalanx, which will help later inthe reat-tachment of the advanced central slip to thedorsum of the medial phalanx.

In order to advance the extensor tendon,make two lateral and parallel incisions in thecentral slip towards the MP joint. While incis-ing, be careful not to harm the underlying tis-sues to prevent adhesion of the tendon to thebone phalanx.

Suture the lengthened central slip to theattachment in the base of the middle phalanx.If no attachment is present, fix the central slipto the periosteum of the middle phalanx. Thefinger should assume slightly the shape of aswan neck. Tenotomy of the distal tendon torelease retinacular contracture is advocated bysome authors and contraindicated by others.

A Kirschner wire may be inserted in the PIPto guarantee adequate immobilization of thejoint. Immobilize the hand for 4 weeks andthen start gentle physical therapy.

Dorsal Fixation of Lateral Bands

In cases with a marked relaxation of the exten-sor structures but still with no fixed contrac-tures, it is possible to reconstruct the extensorapparatus.

Operative technique

Incise the skin in the dorsal aspect of the mid-dle and proximal phalanx exposing the tendi-nous structures, including the displaced lateralbands.

If the central slip is loose it may be requiredto excise a few millimeters of the slip and reat-tach it distally in order to shorten the centralslip.

The displaced lateral bands should be freedof attachments, including its connections withthe oblique retinacular ligament. Thus, thebands are brought to their original physio-logi-cal position and sutured to the central slip with2 fine 6-0 nylon sutures (Fig. 9-20). If necessary,the triangular ligament should also be recon-structed.

Immobilize the PIP joint with a Kirschnerwire for 4 weeks.

In severe long-standing boutonniere defor-mities with marked contractures and joint stiff-ness a PIP arthrodesis of the most con-tractedfingers can be performed using one of the stan-dard techniques described elsewhere in thischapter.

A mild anterior displacement of the lateralbands without severe contracture of theoblique retinacular ligament is a common find-ing in hands with clawed finger. This displace-ment results in a poor extension of the distalphalanx after intrinsic replacement. It is impor-tant while correcting clawed finger by any ofthe flexor to extensor tendon transfer tech-niques to restore the lateral bands to their orig-inal position while performing the insertion of


FIGURE 9-20 Mild Boutonniere. The central callus should be removed. The freed central slip is advanced andsutured in the base of the middle phalanx.

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the transfered slip into the lateral bands.Fritschi8 has devised a simple procedure

that aims to correct this problem (Fig. 9-21a)and consists in an additional step to the Stiles-Bunnel sublimis transfer, which can apply toany of the techniques involving insertion intothe lateral bands. While suturing the tendonslip in each finger, one should pass the suturingneedle through the central slip and then in thefree border of the lateral band and finally in thetendon transfer slip (Fig. 9-21b). When thesuture is concluded the lateral band will bebrought dorsally to its original position allow-ing adequate extension of the finger. This is asimple procedure that should be kept in mindwhen performing intrinsic replacement for cor-recting clawed fingers with a mild hoodingdeformity.

Extensor Tendon Guttering Guttering is the ulnarward subluxation of theextensor tendon of the fingers (Fig. 9-22). Theextensor tendons lay in the gutter between theknuckles of two adjacent fingers. This is a com-mon finding in hands with rheumatoid arthri-tis. In the normal hand fingers show more lat-eral mobility towards the ulnar than the radialside. The index finger normally tends to beulnarly deviated at rest. Although common in

rheumatoid arthritis, guttering deformity inleprosy is seldom seen and also difficult toexplain. It can occur due to spasm of the intrin-sic muscles and thus there may be a connectionwith intrinsic-plus deformity. However, hyper-mobility of joints, looseness of the dorsal appa-ratus and flexion contracture of MP joints alsoseem to play an important role in the patho-genesis of this deformity.

As in rheumatoid arthritis, there are threedegrees of ulnar deviation. When mild thepatient can actively reduce the deformity.When more severe the deformity can only bepassively reduced. Lastly, the guttering is notpassively reducible.


FIGURE 9-21 Lateral band dorsal fixation: Fritschi’s technique. In selected cases this procedure should be carried outduring a Bunnell’s flexor to extensor tendon transfer for claw hand correction. a. Drawing of the basic procedure proposedby Fritschi. b. The intra-operative photograph shows the lateral band being taken by the needle that has been previouslypassed through the central slip of the extensor tendon (dorsal). While fixing the suture the lateral band is moved dorsally.

FIGURE 9-22 "Guttering" deformity of the fingerswith marked ulnar deviation.

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Guttering Repair

For mild guttering Boyes recommends a flap ofthe dorsal expansion aponeurosis at the ulnarside of the extensor tendon that is sutured tothe same aponeurosis in the radial side.4 Thisflap acts as a pulley that brings the extensortendon back to its original position on the crestof the knuckle of the affected finger. This sameprocedure is advocated by Fritschi with aminor modification consisting of placing anindividual longitudinal incision for each affect-ed finger to prevent damage to the dorsalveins.8 Milford proposes a different approachthat is easy to perform and results are not dis-appointing for mild guttering (Fig. 9-23).12

Operative technique

Expose each affected extensor tendon througha single incision on the ulnar side of the MPjoint of each finger and not a single transverse

incision. After incision, expose the extensortendon and the extensor hood at the knuckle.Make a short and longitudinal incision at theradial side of the extensor hood and a relaxingincision in the ulnar side of the hood. Place theextensor tendon in its normal position on thecrest of the knuckle and suture the radial inci-sion with fine separate sutures of nylon 6/0. Ifnecessary, overlap the edges of the radial sideincision to better position the central tendon.The incision on the ulnar side should not besutured.

Suture the skin incisions and apply a mildcompressive dressing. The hand should beimmobilized in a plaster cast with mild exten-sion of the metacarpophalangeal joints.

Correction of muscular wasting in thefirst webAtrophy of the first dorsal interosseous andadductor pollicis muscles is common followingulnar nerve paralysis resulting in a shallowaspect of the first web. In many countries thisdeformity is considered as one of the most stig-matizing signs of leprosy (Fig. 9-24).

Many techniques have been described torestore the bulky contour of the first web spaceto correct the cosmetic problem. Dermal grafts,silicon rubber and fat graft have been usedwith results ranging from good to disappoint-ing. These techniques have their own advan-tages and disadvantages. Dermal grafts areproblematic due to complications such as der-


FIGURE 9-23 Technique for correction of mild gut-tering. (Left) An incision is made on the radial side ofthe hood and a small relaxing incision in the ulnarside. (Right) The relaxing incision permits reposition-ing of the extensor tendon. The radial side incision isthen closed after its edges are overlapped.

FIGURE 9-24 Wasting of the first web is quite notice-able and recognized as a sign of leprosy.

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mal cysts and the need for a reasonable amountof dermis to adequately fill the web space. Fatgrafts are likely to lose up to one half of theiroriginal bulk. Recently, it has been suggested touse fat graft harvested by liposuction that isinjected in the web pocket. There are no report-ed data on its results although the idea seemsinteresting. The use of carvable silicon rubberimplants has been recommended and resultsare promising although the consistency of theimplant is harder than the normal muscle.6 Theencapsulated silicone gel implants are moreappropriate for procedures such as testicularimplants.18

Silicone Implant Insertion

A special encapsulated silicone gel implant forthe first web was designed by Dr. Adenaur M.Goes (unpublished data) from Brazil. Theimplant is commercially available in four sizesat an affordable price (Fig. 9-25). Operative technique

Select the implant according to the size of thehand. Manufacturers provide a set of 4 samplesfor this purpose (7, 9, 11 and 13), #13 being thelargest one. Implant # 9 is the most suitable forthe average hand (manufacturer: SILIMED Inc.

Rua Figueiredo Rocha 374. Rio de JaneiroBrazil.

Use local anesthesia. It is advisable to infil-trate the superficial branch of the radial nervedistal to the wrist. The procedure does not

require use of a tourniquet and, a bloodlessfield is not necessary nor desirable, since per-fect hemostasis is mandatory before closing theincision.

Incise along the first web no longer than 4cm following the interdigital line and close tothe index finger (Fig 9-26).

Create a pocket through this incision byblunt dissection between the paralyzed fibersof the adductor pollicis and first dorsalinterosseous muscles. The size of the pocketshould be enough to receive the implant (Fig.9-26 b). Proceed carefully while dissecting toprevent damage to vessel, particularly in thedeep portion of the pocket and obtain hemosta-sis.

Rinse the implant and the pocket withsaline. Introduce the implant deeply into thepocket. If necessary, introduce a guiding suture(nylon 3-0) from proximal to distal, pass thesuture through the loop included in theimplant and back to the proximal dorsal skin.

This is seldom necessary.Close the fascia with 2 to 3 sutures of nylon

6/0 and then suture the skin with 3 or 4 sepa-rated fine nylon stitches.


FIGURE 9-25 Encapsulated silicone gel implant.

FIGURE 9-26 Silicone gel implant. A short inci-sion is made in the first web along the line sepa-rating the dorsal and palmar skin. After careful tis-sue dissection between the fibres of the first dor-sal interosseous and the adductor pollicis, thepocket is ready to receive the implant.

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Apply a bulky padded dressing or a plastercast to immobilize the first web for 2 weeks.Allow free movement after that period.

The main advantages of the encapsulatedgel implant are the muscle-like consistency andreadiness of the implant. There is no need forshaping. In a 12 month follow-up in a group of14 cases results are good and no complicationshave been reported.6 Patient’s satisfaction ishigh (Fig. 9-27 a,b and Fig. 9-28).

ConclusionThe techniques described in this chaptershould serve as a complement to the otherchapters on hand surgery in this book to givethe reconstructive surgeon a broad range ofskills to re-enable the paralyzed hand. With thedramatic reduction of prevalence of leprosyworldwide as a result of MDT implementation,the number of disabled patients appears to bereducing. Many of the procedures described inthis chapter apply to patients with nerve injurywho present late with established secondarydeformities. In developing countries thesetypes of patients will continue to be seen, espe-cially among patients affected by leprosy. Assuch these surgical skills will be needed foryears to come. Fortunately, most of the proce-dures discussed in this chapter are related to avery limited number of patients. Patients in

need for these secondary techniques are thosethat could not have an early diagnosis, an ade-quate treatment, a careful follow-up and effec-tive health education. Certainly we must bestriving to prevent patients from developingsuch late severe disabilities. However whenthese patients present, surgeons should be pre-pared to cope with theses situations in order toassist patients in improving the functional con-dition of their hands, aiming to restore dignityand self-respect to their life. It is to this pur-pose that this chapter has been included, toassist even those with severely disabled handsto regain some of the independence they hadlost through their hand deformity.

BIBLIOGRAPHIC REFERENCES1. Ayres JR, Goldstrohm GL, Miller GJ, Dell PC:


FIGURE 9-28 Silicone gel implant. The left handhas not been operated. Compare with the righthand in which the implant was included.

FIGURE 9.27 Silicone gel implant. a. preoperative view. b. postoperative view.

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Proximal interphalangeal joint arthrodesis withthe Herbert screw. J Hand Surg; 13A: 600-603,1988

2. Beine A: Prevention of post-operative “sublimis-minus” deformity by modified surgical proce-dure at the donor finger. Ind J Lepr 69: 33-41,1997

3 Boyer MI, Gelberman RH: Operative correctionof swan-neck and boutonniere deformities in therheumatoid hand. J Am Acad Orthop Surg 7:92-100, 1999

4. Bunnell S: Surgery of the Hand, 5th ed. J.B.Lippincott, Philadelphia, 1970

5. Carayon A, Bourrel P, Languillon J: Contractureof the instrinsic muscles. Pp. 139-147. In: Surgeryin Leprosy. Paris, Masson et Cie. Éditeurs, 1964

6. Duerksen F, Virmond M: Carvable silicon rubberimplant for atrophy of the first web in the hand .Lepr Rev 61: 267-272, 1990

7. Duerksen F, Virmond M: Cirurgia reparadora ereabilitação em Hanseníase. TALM ILEP, Bauru,1997

8. Fritschi EP: Reconstructive Surgery in Leprosy.John Wright & Sons Ltd., Bristol, 1971

9 Le Bellc Y, Loy S, Touam C, Alnot JY, MasmejeanE: Traitement chirurgical de la déformation enboutonnière des doigts longs. Etude d'une sérierétrospective de 47 patients. Chir Main 20:362-7,2001

10. Littler JW: Restoration of the oblique retinacularligament for correcting hyperextension deformi-ty of the proximal interphalangeal joints. Pp. 39-42. In La Main rheumatoide. Groupe d’Etude dela Main Expansion Scientifique Français, Paris,1968

11. McGlinn JT, Smith RA, Bougumill GP:Arthrodesis of small joints of the hand: A rapid

and effective technique. J Hand Surg 13A: 595-599, 1988

12. Milford L: The Hand. Pp. 331-333. In EdmonsonAS, Crewshaw AH (eds): Campbell’s OperativeOrthopaedics, 6th ed. C.V. Mosby Co. St. Louis,1980

13. Palande DD: Surgical correction of intrinsicminus fingers. Ind J Lepr 58:537-542, 1986.

14. Salafia A, Chauahn G: Joshi external stabilizingsystem (JESS) in proximal interphalangeal joint(PIP) contractures in leprosy. Ind J Lepr 69: 331-339, 1997

15. Smrcka V, Dylevski I: Treatment of congenitalswan neck deformity with dynamic tenodesis ofproximal interphalangeal joint. J Hand Surg26B:165-7, 2001

16. Stern PJ, Gates NR, Jones TB: Tension bandarthrodesis of small joints in the hand. J HandSurg 18 A: 194-197, 1993

17. Watson HK, Turkeltaub SH: Stiff Joints. Pp. 537-552. In Green DG (ed): Green’s Operative HandSurgery, 2nd edition. Churchill Livingstone,Melbourne, 1988

18. Zacharia AG, Gelber RR: Silastic implant of thefirst dorsal interosseous space (correspondence).Int J Lepr, 53: 643-4, 1985

19. Zancolli EA: Structural and Dynamic Bases ofHand Surgery. The C.V. Mosby Co. St. Louis,1974


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ulnar nerve palsy

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