Treatment of the supination deformity in the pediatric brachial plexus patient

A supination deformity of the forearm can occur after brachial plexus palsy. The initial deformity is correctable; however, a fixed deformity often develops over time. Fixed supination creates difficulties with activities of daily living, impairs tenodesis grasp and gravity release, and limits the ability to perform bimanual activities. In the supple or passively correctable forearm, restoring active supination via tendon transfer frequently leads to better function. The fixed supination deformity, however, is not amenable to tendon transfer. An osteotomy of the radius and/or ulna is necessary to reposition the limb into pronation. A biceps transfer may be performed at the same time to further balance the forearm and prevent recurrence. This article describes our preferred surgical technique for both supple and fixed supination deformities of the forearm.     

Fractional flexor tendon lengthening for advanced metacarpophalangeal flexion contracture in rheumatoid hands

This technical report discusses a subgroup of rheumatoid patients who have minimal ulnar drift but a severe fixed metacarpophalangeal joint flexion contracture for whom conventional metacarpophalangeal joint arthroplasty alone was insufficient to correct the deformity. We describe a surgical technique to deal with this clinical problem that uses fractional flexor tendon lengthening in the forearm to correct the severe flexion deformity at the metacarpophalangeal joint.     

Cerebral palsy. Management of the upper extremity

Although only a small number of children with cerebral palsy have indications for surgical treatment of dynamic or structural upper-extremity deformities, orthopedic surgery does improve function and appearance of the involved hand, particularly in spastic hemiplegia. For further assessment of the patient after careful physical examination, myoneural nerve blocks and dynamic electromyography are useful. Physical and occupational therapists have an important role as crucial links among parents, patients, and physicians. Surgeons can try to prevent deformity with splints; however, their use in prevention of deformities of the hand has not been validated by scientific studies. Shoulder deformities can be managed with myotomies, tendon transfers, and (if fixed) osteotomies; rarely is arthrodesis used. Elbow flexion and dynamic or fixed deformities greater than 60 degrees are treated by lengthening of the muscles and tendons. Pronation deformities of the forearm are managed by myotomies, lengthenings, and tendon transfers. Wrist flexion deformities can be corrected with tendon lengthenings and transfers. The best results have been obtained with transfer of the flexor carpi ulnaris to the extensor digitorum communis. Finger flexion deformities can be managed satisfactorily with Z-lengthenings of the flexor digitorum superficialis in the forearm; rarely is it necessary to lengthen the flexor digitorum profundus. For adduction deformity of the thumb, division of the proximal or distal insertions of the adductor pollicis and release of the first dorsal interosseus muscle from the first and second metacarpals are preferred.     

Reconstruction of digital deformities in rheumatoid arthritis

Digital deformities result from rheumatoid synovitis. These deformities are easier to treat in the early stage, when the deformity is passively correctable. Treatment options become limited as the disease progresses and the deformity becomes fixed. Surgical treatment of digital deformities is last in the priority of surgical procedures for the rheumatoid hand and wrist. It is therefore important to understand the patient's needs and expectations for improvement and attempt to match them with the surgical options that can predictably improve the patient's function. A close collaboration with the patient's rheumatologist is helpful in the overall management of patients.     

Tenodermodesis for established mallet finger deformity.

Sixteen patients with established mallet finger deformity as a result of extensor tendon injury were treated by tenodermodesis and fixation of the distal interphalangeal joint with a Kirshner wire. The patients were followed for a mean of 36 months (range 10-60). The results were excellent in eight patients, good in six, and fair in two. The mean extension lag was decreased from 50 degrees (range 30-70) to 9 degrees (range 0-30), but not at the expense of impaired flexion capacity. All patients were pleased with their resultant function and cosmesis. No complications were encountered. We recommend the operation for passively correctable deformities with suitable joints; it is easy to do and yields consistently successful results.     

外科手术治疗风吹手畸形

目的应用外科手术方法治疗风吹手畸形。方法对26例风吹手患者采用外科手术方法治疗，一期手术应对拇指的屈曲及内收畸形，使用Z字成形或皮瓣移植的方法开放指蹼，切断拇收肌，重建拇指外展功能。二期手术解决2—5指在掌指关节处的尺偏畸形，使用中小指的指浅屈肌腱移位方法；三期手术治疗解决手掌及手指屈曲的问题，以及屈曲纠正后造成的手掌侧皮肤软组织缺损。结果术后随访6～48月。26例患者中有15例拇指指蹼开大效果满意，外展及对掌功能恢复比较满意；12例患者2—5指的尺偏畸形得到良好的纠正；7例术后效果不满意；术后手掌及手指挛缩屈曲者有5例。结论分期手术治疗以及系统的术后康复治疗才会获得良好的效果。     

复拇术后畸形的分类与治疗

目的探讨先天性复拇术后畸形的分类和治疗方法。方法对49例( 5 4侧)复拇术后畸形患儿,参照Kawabata[1] 方法,按畸形发生水平分为三组指间关节组、掌指关节组和“Z”形畸形组,对其中41例采取不同的矫形手术,并对疗效进行评分。结果术后随访到2 6例( 2 8侧) ,15例失访;随访时间14个月～3年。术后三组畸形均明显改善,疗效评分优15侧,良13侧。结论先天性复拇畸形如手术时机、手术方案选择不当或合并拇指肌腱先天性异常等是复拇术后出现畸形的主要原因,再次矫形手术能有效的纠正畸形。     

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.     

Wiederherstellung der Daumenendgelenkbeugung durch Transposition der oberflächlichen Beugesehne des Ringfingers

Objective

Restoration of active thumb flexion at the distal joint.

Indications

Loss of active flexion of the interphalangeal (IP) joint of the thumb if there is a transection of the flexor pollicis longus (FPL) tendon at the tendon channel of the thumb or thenar and direct suture is not possible but the tendon channel is intact, as alternative procedure to a free tendon graft if the transection is proximal to the tendon channel and the muscle of the FPL is contracted/injured or the FPL tendon is unharmed but the FPL muscle is partially or complete paralyzed.

Contraindications

Insufficiency of the FPL tendon channel, impairment of the superficial or deep flexor tendon of the ring finger, limited passive motion of the proximal and distal thumb joints, acute local general infection and non-compliance or incapacity of the patient.

Surgical technique

The surgical technique depends on the necessity of transosseous refixation of the FDS IV at the base of the distal phalanx of the thumb or the possibility of woven sutures through the FPL proximal to the tendon channel. If the tendon channel is intact the distal part of the FPL tendon is shortened to 1 cm, the FDS IV tendon is cut distal to the chiasma of Camper, pulled through the carpal tunnel and moved into the channel of the FPL tendon and fixed transosseously through the base of the distal phalanx of the thumb. If the transection of the FPL tendon is located proximal to the tendon channel and muscle of the FPL is injured, FDS IV tendon will be woven using the Pulvertaft technique through the FPL tendon at the distal forearm.

Postoperative management

Postoperative 6 weeks motion of thumb flexion without resistance in relieved position of the thumb through a thermoplast splint and 6 weeks of functional use of the hand with increasing weight bearing.

Results

In this study 10 patients with FDS IV transposition to reconstruct an isolated rupture of the FPL tendon could be followed for an average of 4.1 years postoperatively. The active range of motion of the IP joint of the thumb averaged 65° (10–100°), 8/10 patients achieved an equal active and passive range of motion of the IP joint of the thumb, in 2 patients some flexion insufficiency remained, 9 patients could reach the fingertip of the small finger with the thumb and 1 patient lacked 3 mm. Contracture of the proximal thumb joint developed in two patients. After removal of the FDS IV tendon two patients developed contracture of the PIP joint of the ring finger. The grip force was reduced to 81?%, lateral grip to 83?% and pinch grip to 77?%. The DASH score averaged 18 (0–31) and 8/10 patients would choose to undergo this surgery again.     

矫正拇掌指关节过伸畸形的新术式

目的为矫正拇掌关节过伸畸形寻求一种行之有效且操作简便的手术方式。方法采用近端切断拇短伸肌腱,保护止点周围的完整,在拇掌指关节掌侧拇长屈肌腱鞘浅面“8”字交叉,最后靠近拇内收肌止点与拇内收肌腱缝合。结果治疗34例拇掌指关节过伸畸形病人,其中类风湿病15例,掌板损伤10例,尺神经损伤9例,平均随访6年,所有过伸畸形完全矫正,未再复发。结论操作简便,疗效佳,有临床应用价值。     

Verletzungen und Funktionsstörungen der Tibialis-posterior-Sehne

The function of the posterior tibial (PT) tendon is to stabilize the hindfoot against valgus and eversion forces. It functions as the primary invertor of the foot and assists the Achilles tendon in plantar flexion. The PT tendon is a stance phase muscle, firing from heel strike to shortly after heel lift-off. It decelerates subtalar joint pronation after heel contact. It functions as a powerful subtalar joint supinator and as a support of the medial longitudinal arch. The action of the tendon travels to the transverse tarsal joints, locking them and allowing the gastrocnemius to support heel rise. Acute injuries of the PT tendon are rare and mostly affect the active middle-aged patient or they are the result of complex injuries to the ankle joint complex. Dysfunction of the PT tendon following degeneration and rupture, in contrast, has shown an increasing incidence in recent years. To which extent changed lifestyle, advancing age, comorbidities, and obesity play a role has not yet been clarified in detail. Dysfunction of the PT tendon results in progressive destabilization of the hind- and midfoot. Clinically, the ongoing deformation of the foot can be classified into four stages: in stage 1, the deformity is distinct and fully correctable; in stage II, the deformity is obvious, but still correctable; in stage III, the deformity has become stiff; and in stage IV, the ankle joint is also involved in the deformity. Treatment modalities depend on stage: while conservative measures may work in stage I, surgical treatment is mandatory for the later stages. Reconstructive surgery is advised in stage II, whereas in stage III and IV correcting and stabilizing arthrodeses are advised. A promising treatment option for stage IV may be adding an ankle prosthesis to a triple arthrodesis, as long as the remaining competence of the deltoid ligament is sufficient. An appropriate treatment is mandatory to avoid further destabilization and deformation of the foot. Failures of treatment result mostly from underestimation of the problem or insufficient treatment of existing instability and deformity.     

Reconstruction of the rheumatoid thumb.

Most rheumatoid patients will present with one or more thumb deformities at some stage of their clinical history. The goal of treatment is restoration and maintenance of stable and painless motion. Treatment is based on the type and stage of the deformity. The boutonniere thumb is the most common deformity. Metacarpophalangeal arthrodesis is preferred for isolated metacarpophalangeal involvement. For advanced cases in a low-demand patient, metacarpophalangeal arthroplasty with interphalangeal arthrodesis is performed. In the higher demand hand with an uninvolved carpometacarpal joint, arthrodesis of both metacarpophalangeal and interphalangeal joints may be considered. The less common swan neck is approached by treating the carpometacarpal joint with a hemiarthroplasty or a total resection with capsulodesis or arthrodesis of the metacarpophalangeal joint. Adduction contracture is treated by Z-plasty of the skin of the first web space and release of the adductor aponeurosis. Gamekeeper's deformity is treated with reconstruction of the ulnar collateral ligament. Arthrodesis is recommended for those patients with articular erosion of the metacarpophalangeal joint. Flexor pollicis longus and extensor pollicis longus tendon ruptures are common in rheumatoid patients. Extensor pollicis longus ruptures are usually treated with EIP transfer or observation. Flexor pollicis longus ruptures are more disabling and usually require a tendon transfer, tendon graft, or an interphalangeal joint fusion in patients with radiographic destruction of that joint.     

Girdlestone's flexor to extensor tendon transfer for the correction of lesser toe deformities in adults

The role of the lesser toes in foot function is relatively small but they can lead to significant disability when painful. This is often the result of chronic impingement of deformed toes against footwear. Girdlestone's flexor to extensor tendon transfer is one of the many procedures used to correct such deformities but is applicable only if the deformity is passively fully correctable.We reviewed the outcome of this procedure in our adult population by clinical examination, review of the notes and patient questionnaire. We found disappointing levels of success and patient satisfaction.     

Conservative management of dynamic equinus in diplegic children treated by gait improvement surgery.

Multilevel surgery for gait improvement was performed on twelve ambulatory children with diplegic type of cerebral palsy and dynamic equinus deformity. Dynamic equinus deformities were defined as those who had an equinus at initial contact during preoperative gait analysis, and where the equinus deformity was correctable passively during physical examination. Ankle function was evaluated by clinical examination and gait analysis before surgery, and at least 3 years after surgery. The ankle showed an increase in dorsal flexion at initial contact, at single stance and in swing. There was an increase in dorsal flexion at the beginning of push-off, without a decrease in the range of motion of the ankle during push-off. Ankle moments demonstrated significant improvement in the maximum flexor moment in the second half of single stance. There was a change from abnormal generation of the energy in mid-stance to the normal pattern of energy absorption. Positive work during push-off was significantly increased. Conservative management of dynamic equinus deformities combined with multilevel surgery to correct other deformities of the locomotion system resulted in significant improvements in ankle function during gait.     

The lupus hand: a new surgical approach

Three patients with lupus erythematosus developed severe hand deformities which, over the course of a year, went on to fixed volar subluxation of the proximal phalanges with some ulnar drift. The flexion deformity at the metacarpophalangeal joints of nearly 90 degrees was not correctable passively, and the palmar skin became macerated. The articular cartilage of the metacarpal heads and proximal phalanges was well preserved and replacement arthroplasty was not justified. Contracture not only in the intrinsics but also in the long flexors was not relieved by operation on the soft tissues. A step-cut metacarpal shortening did correct the remaining intrinsic and long flexor contracture, corrected the volar dislocation, restored full metacarpophalangeal extension, and maintained a full range of flexion. Position of the bones was maintained by intramedullary Steinmann pins and crossed Kirschner wires and, in one patient, by a small screw. No recurrences developed in the follow up period of 18 to 96 months.     

Irreducible dislocation of the thumb interphalangeal joint due to displaced flexor pollicis longus tendon: case report and new reduction technique

Dislocation of the thumb interphalangeal (IP) joint is uncommon because of the inherent stability of the joint. Cases in which reduction was blocked by the volar plate, the flexor pollicis longus (FPL) tendon, the sesamoid bone, and an osteochondral fragment have been described in the literature. This article reports a case of closed thumb IP joint dislocation caused by the displacement of the FPL tendon. A new percutaneous reduction technique for this injury will also be presented. A 63-year-old woman presented to the emergency room with an obvious thumb deformity. Radiographs confirmed dorsal dislocation of the thumb IP joint without associated fracture. Closed reduction was not successful. Percutaneous reduction was performed under locoregional anesthesia, because the dislocation was due to an FPL tendon that had displaced dorsally and radially to the proximal phalanx. After reduction, Kirschner wire fixation was not needed, but IP joint immobilization with a splint was required for 3 weeks. Postoperatively, there were no complications in soft tissues and the operative scar was almost unrecognizable. This technique enables a mini-invasive reduction by operating percutaneously on the FPL. In addition, unlike with a volar zigzag approach, it is possible to suppress the occurrence of postoperative adhesion of the flexor tendon. This new minimally invasive reduction technique is useful for irreducible dislocation of the thumb IP joint due to a displaced FPL tendon.     

Flexion deformities of the thumb: clasped thumb and trigger thumb

Congenital clasped thumb in palm corresponds to a spectrum of anomalies leading to a loss of thumb extension and abduction. Intrinsic muscles and skin shortening are not infrequent. Conservative orthopedic treatment should be undergone as soon as possible. When this treatment fails, or when patients are seen late, surgical correction has to be customized according to the involved structures. The trigger thumb is 10 times more frequent than the trigger finger. It is bilateral in 30% of the cases. The term "congenital" remains unclear as several investigations on newborns have not evidenced trigger thumb. In children, it is very rare to find a real trigger and presentation consists in a fixed flexion deformity of the interphalangeal joint. Diagnosis is clinical, with a palpable nodule at the level of T1 pulley. Conservative treatment, consisting in a nocturnal splint, is indicated before the age of two years old. After this age, or in case of failure of splinting, surgery will be needed.     

Déformation en flexion du pouce de l’enfant : pouce flexus adductus et pouce à ressaut

Congenital clasped thumb in palm corresponds to a spectrum of anomalies leading to a loss of thumb extension and abduction. Intrinsic muscles and skin shortening are not infrequent. Conservative orthopedic treatment should be undergone as soon as possible. When this treatment fails, or when patients are seen late, surgical correction has to be customized according to the involved structures. The trigger thumb is 10 times more frequent than the trigger finger. It is bilateral in 30% of the cases. The term “congenital” remains unclear as several investigations on newborns have not evidenced trigger thumb. In children, it is very rare to find a real trigger and presentation consists in a fixed flexion deformity of the interphalangeal joint. Diagnosis is clinical, with a palpable nodule at the level of T1 pulley. Conservative treatment, consisting in a nocturnal splint, is indicated before the age of two years old. After this age, or in case of failure of splinting, surgery will be needed.     

Upper extremity surgery in stroke patients

Surgical procedures are performed on the nonfunctional upper extremity following stroke to correct spastic flexion contractures that cause pain or prevent adequate hygiene. In the upper extremity surgical procedures are most commonly performed to improve extension at the wrist, fingers or thumb. If the deformity is primarily due to spasticity rather than fixed myostatic contracture, anesthetic block of the median and/or ulnar nerve preoperatively enables the surgeon to determine that extension will be improved after the appropriate flexor tendons are lengthened. Careful presurgical evaluation of motor sensory function enables the surgeon to predictably select those patients who will benefit from surgery.     

Surgical technique for thumb-in-palm deformity in cerebral palsy

The most common surgical procedure performed by hand surgeons in cerebral palsy for thumb-in-palm deformity is release of the adductor pollicis muscle from the middle metacarpal origin, with additional release of the thenar muscles or flexor pollicis longus, as indicated, to decrease the flexion adduction forces across the first ray. Tendon transfer to augment extension and abduction of the thumb metacarpal will help avoid recurrence, and it commonly includes rerouting of the extensor pollicis longus. Stabilization of the metacarpophalangeal joint might be necessary if hyperextension deformity exists. The assessment of the patient should occur over several visits to determine the correct combination of procedures that will best help the patient achieve a more functional upper extremity or improve hygiene. With appropriate planned procedure, meticulous surgical technique, and adherence to a postoperative rehabilitation regimen, patients can obtain substantial improvement with thumb-in-palm surgical re-positioning.