A method of restoration of the abduction of the thumb in traumatic tetraplegic patients

A method of restoring extension and abduction of the thumb in traumatic tetraplegia is described. This method includes tenodesis of the abductor pollicis longus, transfer of the distal stump of the extensor pollicis brevis tendon to the flexor carpi radialis tendon, and transfer of the distal stump of the extensor pollicis longus tendon to the brachioradialis tendon. I performed this procedure on 6 hands in 5 patients and monitored each patient for 6 to 12 months. A significant increase in radial abduction of the thumb (0.5 +/- 0.2 cm to 2.8 +/- 0.2 cm) occurred in all hands.     

Partial extensor carpi radialis longus turn-over tendon transfer for reconstruction of the extensor pollicis longus tendon in the rheumatoid hand: case report

Reconstruction of a distally ruptured extensor pollicis longus tendon in the rheumatoid patient generally involves a tendon transfer or intercalary graft. We present an alternative technique using the radial half of the extensor carpi radialis longus as a turn-over graft. Using the turn-over technique with a half-slip of the extensor carpi radialis longus avoids the traditional limitations of the extensor carpi radialis longus tendon in distal extensor pollicis longus tendon repairs and precludes the need for a free tendon graft.     

Common variations of the radial writs extensors

An anatomical study of the extensor carpi radialis longus (ECRL) and brevis (ECRB) in 173 upper limbs demonstrated abnormalities in 50%. Interconnecting tendons between the longus and brevis were found in 35% of limbs, the most common variation (26%) being a tendon arising proximally from the ECRL and inserting distally with the ECRB. In 42 limbs (24%) an extra muscle (the extensor carpi radialis intermedius) was present; many were large enough to activate a tendon transfer. Two case reports illustrate the use of extra muscles in the surgical rehabilitation of patients with paralytic disorders.     

Reconstruction of the thumb in tetraplegia following spinal cord injury

Functional positioning of the thumb is paramount to the restoration of lateral pinch to the hands in patients with tetraplegia as the result of spinal cord injury. Useful lateral pinch can be provided to patients with at least wrist extension control preserved by use of a combination of flexor pollicis longus tenodesis or transfer and carpometacarpal and inter phalangeal joint stabilization. In patients who retain function in the brachioradialis, extensor carpi radialis longus and brevis, pronator teres, and flexor carpi radialis, strong grasp as well as effective lateral pinch can be restored to the hand by surgery. Thumb control for flexion and extension is provided by tendon transfer to the flexor pollicis longus and tenodesis or transfer to the extensor pollicis longus. Proper positioning for lateral pinch can be accomplished by either arthrodesis of the first metacarpal-trapezial joint or tendon transfer to restore adduction-opposition to the thumb. The surgical concepts presented in this paper have been applied to the functional reconstruction of the hands of more than 50 patients with spinal cord injury during the last 15 years. The patients have been pleased with the significant improvement in function, strength, and speed that has resulted from surgery and have been cooperative advocates as the alternate methods of thumb control have been evaluated.     

Closed tendon injuries of the hand

Cases of subcutaneous tendon ruptures of the hand were compiled over a period of 10 years; the lesions were all traumatic rather than due to degenerative illness. The 914 injuries fall into two categories: 867 extensor and 47 flexor tendon ruptures. The localisation of the lesions is most often distal. The extensor tendon lesion is accompanied more often by a ruptured bony fragment; the distal flexor tendon is mostly torn-off bony fragment. The extensor tendon ruptures can be subdivided as follows: distal injuries of the extensor aponeurosis in the DIP joint (751 cases), IP joint (31), tractus intermedius (27), ext. carpi radialis longus (5) and brevis (1), ext. carpi ulnaris (6); proximal ruptures of the ext. pollicis longus (42), ext. digitorum communis II and indicis (1 each) and ext. carpi radialis longus and brevis (1 each). The flexor tendon lesions are as follows: distal injuries to flex. digitorum profundus (32 cases), flex. pollicis longus (9), and the opponens pollicis, which is classified under this heading (2). Proximal lesions to flex. pollicis longus (2) and flex. digitorum profundus and superficialis (1 each).     

Restoration of pinch in intrinsic muscles of the hand

The primary intrinsic muscles responsible for key and tip pinch are the adductor pollicis, first dorsal interosseous and flexor pollicis brevis muscles. Numerous conditions can lead to their dysfunction. Non-operative treatment consists of exercises of the compensating extensor pollicis longus and flexor pollicis longus muscles and use of adaptive devices, such as larger grips. Operative treatments include tendon transfers and joint fusions. The most common tendon transfer procedures include transfering of the extensor carpi radialis brevis to the adductor pollicis muscle or transfering of the abductor pollicis longus to the first dorsal interosseous muscle. Both require use of extension tendon grafts. In cases of joint instability or arthrosis, arthrodesis of the thumb and index finger MP or IP joints, alone or in combination, may be indicated.     

A single-stage operation for reconstruction of hand flexion, extension, and intrinsic function in tetraplegia: the alphabet procedure

Surgical reconstruction is an established method to restore grip and grasp function after traumatic cervical spinal cord injury and tetraplegia. It can offer the patient improved ability to perform activities of daily living. Traditionally, surgical reconstruction of hand function has required separate operations for flexors and extensors. Here, we present a combination of procedures that provides key pinch and finger flexion together with opening of hand as a 1-stage operation. This reconstruction includes 7 individual operations that are performed in the following order: (1) split flexor pollicis longus-extensor pollicis longus distal thumb tenodesis, (2) reconstruction of passive interossei, (3) thumb CMC arthrodesis (4) brachioradialis-flexor pollicis longus tendon transfer, (5) extensor carpi radialis longus-flexor digitorum profundus tendon transfer, (6) EPL tenodesis, and (7) extensor carpi ulnaris tenodesis. We have chosen to entitle this reconstruction the alphabet or ABCDEFG procedure, an abbreviation for Advanced Balanced Combined Digital Extensor Flexor Grip reconstruction. To reduce the risk of adhesions after this extensive surgery and to facilitate relearning the activation of transferred muscles with new functions, early active training is performed. It is concluded that this 1-stage combination of operations can reliably provide grip, grasp, and release function in persons with C6 tetraplegia, patient satisfaction is high, time and effort for patient and caregivers are less, and incidence of complications is comparable with other published treatment modalities.     

肌肉再分布技术应用于智能仿生手的解剖学研究

目的:研究肌肉再分布技术中关键肌肉-肌腱运动单元的外科腱腹交界部位,为不同平面截肢病例选择合理的肌肉再分布手术方案提供解剖学依据。方法:取新鲜上肢标本6侧,对前臂关键肌肉-肌腱运动单元,包括拇长屈肌、示指指深屈肌、肱桡肌、桡侧腕屈肌、拇长伸肌、示指固有伸肌、桡侧腕长伸肌、尺侧腕伸肌,分别测量其外科腱腹交界部位距肱骨内上...     

Long-term results of tendon transfers in radial and posterior interosseous nerve paralysis

Eighteen cases of tendon transfer for isolated radial or posterior interosseous nerve palsy have been carried out in our unit over a period of 21 years. Fifteen patients were reviewed with a mean follow-up of 9.5 years. Nine had sustained high and six low radial nerve injury. We achieved 11 excellent, two good, one fair and one bad result. The main problems were loss of power of gripping and the occurrence of radial deviation, particularly in patients with flexor carpi ulnaris transfer to the extensor digitorum communis. During this time, our technique has evolved, including changes of the tendons transferred. Our final preference is a modified Tsuge procedure, using the pronator teres to restore extension of the wrist, the flexor carpi radialis for extension of the fingers and the palmaris longus for extension of the thumb. Abduction of the thumb is restored by a tenodesis of the abductor pollicis longus to the brachioradialis. This review justifies the final policy, in particular the preservation of flexor carpi ulnaris to maintain wrist stability and flexion.     

Biomechanical changes of the wrist flexor and extensor tendons following loss of scaphoid integrity

Loss of integrity of the scaphoid may change the motion center of the entire carpus, and deformities from scaphoid fractures may alter the location of motor tendons of the wrist, thus altering their biomechanics. The goal of this study was to clarify biomechanical changes in these tendons following loss of scaphoid integrity. Excursions and moment arms of the principal flexor and extensor tendons of the wrist were investigated in seven cadaveric upper extremities in intact wrists after simulation of scaphoid waist fracture and after removal of the proximal scaphoid. Excursions of the flexor carpi radialis and ulnaris extensor carpi radialis longus and brevis, and extensor carpi ulnaris tendons were measured with rotary potentiometers during wrist flexion-extension and radioulnar deviation. Simultaneously, wrist joint angulation was recorded. Moment arms of the tendons were derived from tendon excursions and joint motion. After scaphoid fracture, the moment arms of the flexor carpi radialis and extensor carpi ulnaris tendons increased significantly during wrist flexion-extension, whereas the moment arms of the extensor carpi radialis longus and brevis tendons decreased significantly. After proximal scaphoid excision, the moment arms of the extensor carpi radialis longus and brevis tendons again decreased significantly during wrist flexion-extension. The moment arms of the flexor carpi radialis and extensor carpi radialis brevis tendons increased significantly during radioulnar deviation, whereas those of the wrist motors on the ulnar side decreased. These findings indicate the importance of the integrity of the scaphoid in maintaining normal biomechanics of motor tendons of the wrist. An increase in the moment arm of the radial wrist flexor along with a decrease in moment arms of the radial extensors constitutes an etiology for persistent angulation of the scaphoid and the hump-back deformity. In addition, disturbing the biomechanics of the wrist motor tendons predisposes the carpal joints to abnormal loading, potentially contributing to the development of carpal joint degeneration.     

拇对掌功能重建的新方法

目的 介绍一种简单、有效的拇对掌功能重建新方法。方法 对8例拇对掌功能丧失的患者，采用尺侧腕伸肌为动力肌，拇长伸肌腱改道后(沿拇短展肌方向作一皮下隧道，将拇长伸肌腱沿皮下隧道引至腕上1cm处掌尺侧直切口内)，牵拉改道后之拇长伸肌腱，使拇指呈对掌旋前伸拇位时，将拇长伸肌腱与尺侧腕伸肌腱作编结缝合重建拇对掌功能。结果 术后随访4～11个月，平均8．5个月，8例的拇对掌功能均恢复，达100％的有效率。除1例伸拇功能有轻微影响外，余7例均无明显障碍。结论 该术式是一种简单、有效而可靠的重建拇对掌功能的新方法。     

Twenty-five-year follow-up evaluation of an active silicone/Dacron tendon interposition prosthesis: A case report

A 19-year-old man sustained a severe avulsion wound of the dominant distal forearm, dividing the radial and ulnar arteries, median and ulnar nerves, and all flexor tendons. Initial treatment consisted of revascularization. Shortly thereafter he had sural nerve grafting of the median and ulnar nerves. This was followed by insertion of a silicone/Dacron tendon interposition prosthesis to reconstruct a 4-cm deficit in the flexor profundus tendons and the flexor pollicis longus tendon. Six weeks thereafter an opposition transfer using the extensor indicis proprius and a Brand type 2 intrinsic transfer using the extensor carpi radialis longus and a plantaris tendon graft were performed. Several months later an attempt was made to remove the prosthesis. It was encased in scar tissue, however, and left in place. Evaluation 25 years later revealed that the flexor tendons and prosthesis were functioning well.     

A new modification of trapeziectomy and soft tissue interposition arthroplasty with abductor pollicis longus advancement

A new modification of trapeziectomy, soft-tissue interposition arthroplasty with a one-half slip of the flexor carpi radialis tendon and advancement of the abductor pollicis longus tendon for treatment of thumb carpometacarpal degenerative arthritis and instability is presented. This procedure facilitates tenodesis of the flexor carpi radialis slip at the first metacarpal and realigns and rebalances the thumb posture by using and advancing the abductor pollicis longus tendon. Therefore, this new modification eliminates the need for perioperative pin fixation of the first metacarpal, offers better soft tissue tenodesis of the ligament reconstruction component of the procedure, and results in improved intraoperative thumb alignment.     

自发性手指伸肌腱断裂的修复重建

目的探讨不同部位手指伸肌腱自发断裂的治疗方案及其疗效。方法29例患者总结如下：伸肌腱Ⅰ区22例、中环小指伸肌腱Ⅵ区3例、拇长伸肌腱4例，修复重建后配合功能锻炼。结果Ⅰ区原位直接缝合修复，优良率100％；食指固有伸肌腱移位拇长伸肌腱，优良率85％；桡侧腕短伸肌腱修复中环小指伸肌腱Ⅵ区，优良率75％。结论伸肌腱自发断裂常伴有炎症侵蚀或骨折端磨损的病理基础，在伸肌腱Ⅰ区时首选原位直接缝合修复，无条件修复时可行远指间关节融合术；对于中环小指伸肌腱Ⅵ区及拇长伸肌腱断裂行相邻协同肌肌腱转位修复，疗效确切。     

Upper-limb surgery for tetraplegia.

We reviewed the results of reconstruction of 97 upper limbs in a consecutive series of 57 tetraplegic patients, treated from 1982 to 1990. Of these, 49 had functional and eight had cosmetic reconstructions. The principal functional objectives were to provide active elbow extension, hook grip, and key pinch. Elbow extension was provided in 34 limbs, using deltoid-to-triceps transfer. Hook grip was provided in 58 limbs, mostly using extensor carpi radialis longus to flexor pollicis longus transfer, and key pinch in 68, mostly using brachioradialis to flexor pollicis longus transfer. Many other procedures were employed. At an average follow-up of 37 months, 70% had good or excellent subjective results, and objective measurements of function compared favourably with other series. Revisions were required for 11 active transfers and three tenodeses, while complications included rupture of anastomoses and problems with thumb interphalangeal joint stabilisation and wound healing. We report a reliable clinical method for differentiating between the activity of extensor carpi radialis longus and brevis and describe a successful new split flexor pollicis longus tenodesis for stabilising the thumb interphalangeal joint. Bilateral simultaneous surgery gave generally better results than did unilateral surgery.     

Restoration of strong grasp and lateral pinch in tetraplegia due to cervical spinal cord injury.

Patients with tetraplegia who have "strong" sixth cervical neurologic (C-6) function often can be given active grasp and strong lateral pinch by tendon transfers and tenodeses. Wrist control can be retained by the extensor carpi radialis brevis and flexor carpi radialis and can permit transfer of the extensor carpi radialis longus to provide finger flexion. Either the brachioradialis or pronator teres then is available for transfer to restore adduction-opposition of the thumb with an in situ tendon graft of a paralyzed flexor superficialis rerouted to the thumb through a palmar fascial pulley. The other motor can provide thumb flexion for strong lateral pinch. Extrinsic extension can be provided by tendoeses. With seventh cervical neurologic (C-7) function retained, active digital extension is present and functional expectations are better. Ten hands in seven patients with traumatic tetraplegia from injuries at C-6 or C-7 level have been reconstructed. The average grasp and pinch force after operation was 5.5 and 3.0 Kg., respectively. All patients but one were pleased with the increased function a     

Trapeziometacarpal joint instability affects the moment arms of thumb motor tendons

This study measured the changes in moment arm length of thumb motor tendons after simulated ligamentous instability and subsequent reconstruction of the trapeziometacarpal joint. Excursions of thumb motor tendons were measured simultaneously with the trapeziometacarpal joint angulation during flexion to extension and abduction to adduction motion. Tendon moment arms were calculated based on joint and tendon displacement techniques in the intact joint, after sequential sectionings of the capsuloligamentous restraints, and after the reconstruction procedure of Eaton and Littler. The results showed that moment arms of the abductor pollicis longus and extensor pollicis brevis tendons increased significantly as compared with those for normal joints during flexion to extension motion after sectioning the palmar capsuloligamentous components. After the ulnopalmar structures were cut, the moment arm of the extensor pollicis longus tendon had a statistically significant increase during abduction to adduction motion, and those of the extensor and flexor pollicis longus tendons decreased significantly during flexion to extension motion. Changed moment arms were restored to a normal level after the ligamentous reconstruction. These results indicate that ligamentous disruptions alter the mechanical balance of thumb motor tendons, which may contribute to joint deformities observed in trapeziometacarpal joint arthritis. Restoring joint stability is important to correct mechanical imbalance of the tendons.     

Optimum tensioning position for extensor indicis to extensor pollicis longus transfer.

This study evaluates various wrist and thumb positions for tensioning the extensor indicis proprius when transferred to the extensor pollicis longus tendon to determine which positions provide optimum passive range of flexion and extension of the thumb. In five adult cadaver upper limbs, transfer of the extensor indicis proprius to the extensor pollicis longus was simulated. The limbs were fixed with the elbow in 90 degrees flexion and the forearm and wrist in neutral. Surface bone markers were digitized to determine the thumb and wrist positions in three-dimensional space and their intersegmental joint angles. Twelve combinations of thumb (the interphalangeal and metacarpophalangeal joints) and wrist positions for tensioning were tested. A fixed tension of 80 N was applied to the tendon ends for each of the tensioning positions and during the transfer to ensure that the tendon remained taut. A wrist tenodesis effect was used subsequently to assess the passive range of thumb motion as an indicator of the outcome of the transfer. The results showed that the better tensioning position was with the thumb fully extended and the wrist in neutral. In six patients in whom an extensor indicis proprius to extensor pollicis longus transfer was done, the tendons were tensioned with the thumb in full extension and the wrist in neutral. A prospective review and functional assessment at an average of 18.6 months' followup was done. No significant differences between the surgically treated and normal thumbs were seen for the Jebsen Taylor, 9-peg, and grip and pinch strength tests. The study suggests that in an extensor indicis proprius to extensor pollicis longus transfer, tensioning of the tendons with the thumb in full extension and the wrist in neutral gives good thumb flexion and extension range.     

Delayed rupture of the thumb extensor tendon:A 5-year study of 18 consecutive cases

18 consecutive cases of delayed rupture of the extensor pollicis iongus tendon were recorded during 5 years; 4 were spontaneous, and 14 after distal radius fracture, most of which were undisplaced or only slightly displaced. 15 cases were operated upon with tendon transfers: 13 had extensor indicis pro-prius transfer, 1 transfer of the extensor carpi radialis Iongus, and 1 reoperated with the extensor communis to the little finger as a motor unit. Subjectively, nearly complete satisfaction was reported; all patients were able to elevate the thumb to the level of the palm and full independent index finger movements were noted.

In this 5-year-period 4,400 patients with distal radius fractures were treated, giving an incidence of delayed tendon rupture after distal radius fracture of 0.3 percent     

Intersynovial communication between the tendon sheaths of the extensor pollicis longus and extensor carpi radialis brevis muscles

A communication was found between the synovial sheaths of the extensor pollicis longus and the extensor carpi radialis brevis tendons. The opening was at the level of the proximal row of carpal bones and permits passage of synovial fluid between the sheaths of these muscles.