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MANAGEMENT OF CLAWHANDDR.PRASHANTH KUMAR 2ND YR PG

DefinitionFlattening of transverse metacarpal arch and longitudinal arches, with hyperextension of MCP joints and flexion of PIP and DIP joints

Normal anatomy Movements of MP joints and IP joints independent

Movements of 2 IP joints coordinated ; flexion of DIP joint brings about flexion of PIP joint

(1) Flexion of distal phalanx draws dorsal expansion distally by loosening tension on central tendon (2) Flexion of DIP joint tenses oblique retinacular ligament causing this ligament to slide volarward and impart flexion force to PIP joint

Intrinsic Plus HandCaused by muscles imbalance between spastic intrinsics(interosseoi and lumbricals)weak extrinsics (FDS, FDP, EDC)Characterized by MCP flexion PIP & DIP extension

Intrinsic Minus Hand (Claw Hand)

Caused by imbalance between strong extrinsics and deficient intrinsics Characterized by MCP hyperextensionPIP & DIP flexion

Patho-anatomy of deformity Paralysis of interossei and lumbricals Unopposed MCP joint extension & IP joint flexion by digital extensors & flexors Without stabilization of MCP joints in neutral/slight flexed position, long extensor function blocked at MP joint by diversion of this tension to sagittal band, producing hyperextension and effectively blocking the extensor's ability to extend PIP joint.

Middle and distal phalanges collapse into flexionNormal cascade of digital extension disrupted, in that during any attempt to actively open finger, MP joint extends first and will extend more than the PIP joint, Normal sequence of digital closure also reversed, in that IP joint flexion precedes MP joint flexion Independence of MP and IP joint motion lost

Claw thumb in Ulnar palsy CMC joint affected by paralysis of adductor pollicis, FPB, and first dorsal interosseous

MP and IP joints of thumb under control of extrinsic flexors and extensors, with proximal phalanx behaving like intercalated bone. MP joint will go into hyperextension and IP joint into flexion because of the greater extensor moment at the MP joint and the lesser extensor moment at the IP joint, respectively. Z-thumb deformity

Types of claw handComplete : Involving all digits and resulting from combined Ulnar and Median Nerve palsy

Incomplete : Involving only ulnar 2 digits as in isolated Ulnar Nerve palsy

Partial Claw handFlexionExtensionDeformityMCP JointLumbricals paralyzedExtensor Digitorum activeHyper extension of MCP jOINTPIP JointFDS activeInterossei paralyzed ( low Ulnar palsy )Flexion of PIP jointDIP JointFDP activeInterossei paralyzedFlexion of DIPFDP paralyzed( high Ulnar Palsy )Interossei paralyzedNeutral position

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Total Claw HandFlexionExtensionDeformityMCP JointLumbricals paralyzedExtensor digitorum activeHyper extension at MCPPIP JointFDS paralyzedExtensor digitorum activeExtension of PIPDIP JointFDP paralyzedExtensor digitorum activeExtension of DIP

ETIOLOGY TraumaticCompressive neuropathyBrachial plexus injuryInfective ( Leprosy, Poliomyelitis )Peripheral neuropathies Systemic diseases ( DM, Porphyria, Malignancies ) Drugs and Toxins (Lead, Arsenic, Dapsone, etc ) Hereditary (CMTD, Syringomyelia, Lipid storage diseases ) Ischemia Primary Nerve neoplasm

Rare conditions showing claw hand

Ampola syndromeAngiokeratomaArthrogyropsis multiplex congenitaAural atresiaCharcot Marie DiseaseChondrodysplasia punctataChromosomal anomaliesCraniofacial dysostosisFrontonasal dysplasiaMuller Barth Menger SyndromeOro facial digital syndrome type 4Pitt Hopkins syndromeStratton Parker syndrome

Pattern of Injury

Low mixed Ulnar and median nerve palsy

High mixed Ulnar and Median nerve palsy

Low Ulnar nerve palsy

High Ulnar nerve palsy

LOW ULNAR NERVE PALSY

Evaluation for Surgical Reconstruction

Specific signs and tests for motor dysfunction Bouviers maneuver : Dorsal pressure over proximal phalanx to passively flex MP joint results in straightening of distal joints and temporary correction of claw deformity Extensor digitorum tendon can extend middle and distal phalanges when proximal phalanx stabilized

Duchenne's sign : Hyperextension at MCP joints & flexion at IP jointsAndre-Thomas sign : On palmar -flexon of wrist exaggeration of deformity

Pitres-Testut sign : Inability to actively move long finger s in radial and ulnar deviation with palm placed flat Cross your fingers test : Inability to cross middle finger dorsally over index finger, or index over middle fingerMasse's sign: Flattened metacarpal arch and loss of hypothenar elevation

Jeannes sign : Hyperextension of MP joint of thumb during key pinch or gross grip

Bunnells O sign : Combined hyperextension at MP joint and hyperflexion of IP joint (noticed when patient makes a pulp to pulp pinch with thumb and index finger)

FPLEPLFroments sign : Thumb IP joint flexion while attempting to perform lateral pinch

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

High ulnar palsy

Pollock's sign : Inability to flex distal phalanges of ring and little fingers Partial loss of wrist flexion may occur because of paralysis of FCUWeakness of ulnar side grip

PREOPERATIVE ANGLE MEASUREMENTS Measured at PIP joint of each finger and IP joint of thumb using a goniometer placed on dorsal aspect of jointUnassisted angle : Maintain lumbrical-plus position of MP flexion and IP extension, and extension deficit at PIP joint measured Assisted angle : Proximal segment of finger supported to maintain flexion at the MP joint and instructs the patient to extend IP joints ;In absence of contracture of IP joints, this angle o

Contracture angle : Incomplete passive extension ,contracture with deficiency of volar skin and volar plate and/or capsule PIP joint

Adaptive shortening angle of extrinsic flexors : Habitual posturing of wrist in flexion to minimize the claw deformity ; increased angulation at PIP joint as wrist is passively moved into extension

Hypermobile angle: Ligamentous laxity ; hypermobile joints with passive hyperextension of PIP joints > 20

CLASSIFICATION OF PARALYTIC CLAW HANDS

Type I: Supple claw hands with no hypermobile joints and no contractures at IP joints

Type II: Hypermobile joints; PIP joints hyperextension > 20 degrees

Type III: Mobile joints in association with adaptive shortening of long flexors, usually superficialis tendons , with no IP joint contracture

Type IV: Contracted claw hands ; PIP joint flexion contracture of 15 degrees or more, due to volar skin, joint capsule, or volar plate contracture adaptive shortening of long flexors

Type V: Claw hands with attrition of dorsal extensor apparatus at PIP joint with hooding deformity, fibrous or bony ankylosis of PIP joint, and MP joint extension contracture

PrincipleClawing principal longitudinal axial deformity and loss of independence of movement at MP and PIP joints principal disability Third muscle-tendon unit needs to run volar to center of curvature of MP joint and dorsal to center of curvature of head of PIP joint to counterbalance system and provide equilibrium and independence of normally functioning intrinsic musclesAlternatively, MP joint needs to be statically prevented from hyperextension to allow long extensors to extend IP joints

Indications for surgery

Nerve InjuriesPatient referred late ( 1 year )

After nerve repair, if electrodiagnostic tests show no signs of reinnervation within 6 to 9 months

Leprosy Understanding of stage and activity of disease, presence of intact, healthy skin, patient motivation.*Recommended when patient's medical treatment optimized skin smears for the bacillus negative bacteriological index negative on two successive tests disease activity quiescent for at least a year before date of intended surgery, paralysis established patient free of corticosteroid treatment for several months before surgery

Poliomyelitis Ulnar innervated lumbricals can be paralyzed, sparing a part of or whole of interosseous muscles or vice versa Paralysis typically nonprogressive and with no loss of sensationChildren affected, and joints hypermobile Surgery be delayed until child is at least 5 years of age, so that child will be able to cooperate with postoperative re-education program

Appropriate use of splints, fabricated for each patient and altered or changed whenever indicated can help to manage claw deformitySplints interfere with rehabilitation of sensibility and are generally used intermittently

Tendon transfers Principles and biomechanics Homeostasis of involved extremity established * Soft tissues free of scar contractureVascularity of extremity adequateChronic wounds fully settled for 3 months before surgery Proper physiotherapy, occupational therapy and splintingMobile joints and correct alignment of bone

Power of transferred muscle : Good or normal (4 or 5)Muscle should be expendableSynergestic muscles Path of Tendon: Best in straight line; If change in direction necessary - PulleyAbsolute contraindication: Non-compliant patient with poor motivation who will not follow appropriate postop rehabilitation

Internal splints (Early Tendon Transfers)

Allow early function of hand while awaiting nerve regeneration Can prevent deformities that lead to contractures Improve coordination of residual muscle-tendon units

Stimulate sensory re-education during nerve recovery Inhibition of trick movements

Functions as internal splints for paralyzed muscles

In the event of a failure of nerve recovery will remain and function as a permanent solution

Proximal phalanx flexion for ring and little fingers : Ulnar half of FDSR with split insertion to ring and little fingers to lateral band of DEE or A1, A2, or A1 + A2a pulleys Restoration of transverse metacarpal arch and adduction of little finger : FDSR Y insertionThumb adduction for key pinch : FDSR radial half to abductor tubercle, FDSL to hypothenar insertion, near fifth MP joint

DEFORMITIES AND DEFICIENCIES CORRECTABLE BY SURGERY

METHODS OF CLAW HAND RECONSTRUCTION

Static and Dynamic procedures

Static procedures :

To maintain MP joint in some degree of flexion or to limit MP joint hyperextension claw posture reversed by functioning long extensors Flexion of MP joint unrestricted in static procedures Disadvantages : restore normal finger coordination and sequence but do not provide an additional motor to restore MP flexion. Recurrence : rule unless there is radical change in patient's work style and paralyzed hand more protected than used

Proximal Phalangeal Flexion Static Techniques Flexor Pulley Advancement ( Bunnell )* Each side of proximal pulley system split 1.5 to 2.5 cm up to middle of the proximal phalanx. Flexor tendons then bow string, to bring about flexion at MP joint

Fasciodermadesis ( Zancolli ) Excision of 2 cm of the palmar skin (dermadesis) at MP joint level combined with shortening of pretendinous band of palmar aponeurosis (fasciodermadesis) to correct claw hands with weak extensors

Zancolli Capsulodesis

Volar MP joint Capsulodesis A1 pulley release with MP joint volar plate advancement Complicated claw hands with MP joint contracture Zancolli incorporated collateral ligament release on both sides of MP joint with volar capsuloplasty

Omer advanced volar plate by cutting away a triangular portion of the deep transverse metacarpal ligament (DTML) on each side of volar plate flap

Dorsal Methods (Howard; Mikhail)To provide bony block to proximal phalangeal extensionEnables long extensors to extend IP joints and correct deformity.Mikhail inserted bone block on dorsum of the metacarpal head Howard suggested elevation of bone wedge as block from the dorsal aspect of the metacarpal head itself

Static Tenodesis Techniques Riordan One half of ECRL and ECU tendons made use of as grafts to prevent hyperextension of MP joint while remaining half continue to actively extend wrist

Parkes Static Tenodesis (Volar Side)With Free Tendon Grafts 2 free tendon grafts, from plantaris tendon, palmaris tendon, or toe extensors, required for four fingers

Integration of Finger Flexion Fowler tenodesis

Wrist Tenodesis Technique Fowler Incorporates active wrist motion to tension static tendon grafts Free tendon grafts sutured to extensor retinaculum of wrist and passed in a dorsal to palmar direction through the intermetacarpal spaces, volar to the DTML, through the lumbrical canals, and onto the lateral bands of dorsal extensor expansion of 4 fingers

Dynamic Tendon Transfers

First reported by Sir Harold Stiles and Forrester-Brown in 1922

By passing tendon graft slips volar to deep transverse metacarpal ligament and into lateral band of dorsal extensor apparatus, procedure designed to improve synchronous motion of the finger joints and duplicate lumbrical muscle action

Transfer of Extrinsic Finger Flexors

Superficialis Tendon Transfer Techniques and Modifications (Stiles; Bunnell; Littler) FDS detached , splitted, & transferred to dorsum of fingers to extensors tendons Removes powerful flexor of PIP joint & converts it into extensorIntrinsic plus deformity

Bunnell (1942) : rerouted both slips of all superficialis tendons through lumbrical canals and anchored them to both sides of lateral band of dorsal extensor expansion (Stiles-Bunnell procedure)

Transfer involved passage of

Split FDSI for radial side of lateral bands of index and middle fingersSplit FDSM for ulnar side lateral band of index, middle, and ring fingersSplit FDSR to radial side of ring and little fingersSplit FDSL to the ulnar side of little finger

Disadvantages PIP flexion contractures and DIP extension lag in donor finger most frequent when superficialis removed through conventional midlateral approachMidlateral approach exposed distal part of lateral band to injury and contributed to DIP extension lagHigh incidence of swan neck deformity in one or more of operated fingers owing to excessive tension on transferred tendon slipLoss of PIP joint flexion due to adhesions between profundus and superficialis tendon remnant

To prevent these complications, North and Littler : removal of superficialis through volar incision between A1 and A2 pulleys Brand : Ulnar nerve palsy results in claw deformities in all four fingers, Weakness is not limited only to fingers with obvious clawing. Recommendation : surgery be done in all fingers of a claw hand

Modification of BunnellLittler proposed modification of the Stiles-Bunnell procedure by using FDSM Referred to as modified Stiles-Bunnell procedureTendon slips sutured under correct tension, that is, with wrist in neutral , MP joints in 45 to 55 degrees of flexion, and IP joints in neutral position.

4 primary insertion sites of FDS are classified as:A. Lateral band insertionintrinsic replacement (Stiles and Forrester-Brown , Bunnell , Littler , Brand , Riordan , Lennox-Fritschi )

B. Phalangeal insertion (Burkhalter )

C. Pulley insertion (Riordan , Zancolli , Brooks and Jones , Anderson )

D. Interosseous insertion (Zancolli , Palande , Anderson )

Pulley system of flexor tendon of finger

Phalangeal Insertion ( Burkhalter )

Insertion of superficialis tendon slips directly to proximal phalanx Avoid risk of PIP joint hyperextension noted with transfers to lateral band of the dorsal apparatus Increased distance of moment with increased flexion of MP joint

Interosseous Insertions (Zancolli Palande; Anderson)

Interosseous tendons used as insertion sites with different motors: superficialis tendon, ECRL ,or palmaris longus Zancolli : first and second dorsal interosseous as insertion sites to attach slips of a superficialis tendon with goal of obtaining proximal phalangeal flexion and restore digital abduction ( direct interosseous activation) Palande : extended this principle to correct intrinsic-minus hands associated with reversal of the transverse metacrapal arch

Pulley Insertions (Zancolli's Lasso)

Delineated A1 pulleys through a transverse skin incision at level of the distal palmar crease. Flexor superficialis tendon sectioned in the finger and divided into two slips Each tendon slip retained volar to deep transverse metacarpal ligament and looped through the A1 proximal pulley and sutured to itself

Lasso procedure (ZANCOLLI) - Transfer of FDS to A-1 pulleys, index, long, ring and small fingers.Transverse incision made at level of first A-1 pulley, beginning at prox. palmar crease of index finger and ending ulnarly at distal palmar crease of little finger.

Subcutaneous tissue opened longitudinally and neurovascular bundles retracted to either side.FDS tendon exposed 1 cm prox to A-1 pulley.

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

PIP joint flexed to allow proximal retraction of FDS tendon.

Each slip of tendon is divided distal to hemostats.

Finger is extended and tendon slit proximally.

Two slips of FDS tendon (distal) folded down volarly over A-1 pulley and ends separately interwoven into prox portion of FDS using tendon braider.

Anchored to itself with multiple horizontal mattress stiches creating a strong lasso

Anderson : Extended pulley insertion (EPI) by looping slip of superficialis tendon around both the A1 and proximal A2 pulleys in each finger

. Anderson GA: Analysis of paralytic claw finger correction using flexor motors into different insertion sites. Master's thesis, University of Liverpool, 1988.

Finger Level Extensor Motor

Fowler transfer

Extensor Indicis Proprius and Extensor Digiti Minimi Transfer (Fowler )EIP and EDM tendons as transfers lateral bands of the dorsal apparatus

May produce excessive tension in extensor apparatus and lead to intrinsic-plus deformities. May cause reversal of normal metacarpal arch and, occasionally, extensor weakness in the little finger

Riordan Modification Splitting EIP into 2 slips and transferring them through intermetacarpal space between the ring and little digits, routed palmar to the transverse metacarpal ligament and onto radial lateral bands of the ring and little fingers

Wrist-Level Motors for Proximal Phalanx Power and Integration of Finger Flexion (Brand; Burkhalter; Brooks; Fowler; Riordan)

To simultaneously correct claw deformity and gain grip strength, add additional muscle-tendon unit to power train for flexion of proximal phalanx Best achieved by transferring wrist motor or brachioradialis to flex proximal phalangesRequire free grafts to provide sufficient length to reach insertion site( plantaris, palmaris, fascia lata, or toe extensors)

Dorsal Route Transfer of ECRB (Brand) ECRL or ECRB lengthened by plantaris tendon that was split into four tailsTendon slips passed through intermetacarpal spaces, into the lumbrical canal and palmar to the DTML, to be attached to radial lateral bands of the long, ring, and little fingers and ulnar lateral band of the index fingerDid not improve flattened transverse metacarpal arch or weakness of grip

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

Exposure of intrinsic mechanism

Dorsal retraction of intrinsic mechanism at PP level

Periosteal longitudinal incision dorsal to distal edge of A-2 pulley 2.0 mm drill hole through far cortex and 2.7 mm drill hole through near cortex

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

Excision of dorsal fascial window

Division of ECRB insertion and withdrawal prox to extensor retinaculum

Rerouting of ECRB superficial to extensor retinaculum

Plantaris tendon divided into 4 slips and passed through lumbrical canal and fixed to PP long tone.Then tendon grafts are sutured to ECRB tendon which is passed dorsal to extensor retinaculam.

Tendon graft seated within proximal phalanx

Pulvertaft weave

Dorsiflexion of wrist relaxes the tendon transfer and allows for full passive digital extension

Wrist palmer flexion tightens the transfer and impacts a tenodesis function, strongly flexing the metacarpophalangeal joints

Wrist is held is full dorsiflexion, MCP joints in complete flexion.Sutures removed at 14 days and a splint reapplied to hold wrist in 45 of extension. MCP joints in full flexion and IP joints in extension. Splinting until 6 weeks postop.

Modifications in the Volar Route Transfer

ECRL Volar Transfer With Proximal Phalanx Insertion (Burkhalter and Strait). Brooks and Jones Volar Route Transfer to A2 Pulley Insertion SitePalmaris Four-Tail (PL4T) Transfer (Lennox-Fritschi )

Operation of choice Finger flexors & wrist flexors, extensors strong, no habitual wrist flexion : Modified Bunnell (FDSR )Habitual wrist flexion/flexion contracture of joint/sparing wrist flexor : Riordan transfer (FCR)Wrist extensors strong, weak flexors : Brand transfer (ECRL )FDS/wrist flexor Fowler tenodesis/or extensor unavailable : Fowler ( EPI)/ Riordan modification of FowlerNo muscle available, supple joints : Zancolli capsulodesis / Riordon tenodesis

Omer single stage procedure Thumb MCP joint arthrodesis Single transfer of FDSR

Postoperative Hand Therapy for Claw Correction In first week patient supervised to attain and maintain lumbrical-plus position and use a thermoplastic splint between exercises Over next 7 to 10 days active IP joint flexion begun while MP joints remain in flexion At no point during first and second stages patient allowed to extend MP joints During third stage patient encouraged to maintain IP joint in absolute neutral extension and then extend MP joints Exercises at this stage combined with supervised light functional activities that encourage lumbrical posture

Thumb Adduction Techniques

Adduction of thumb necessary for strong pinchAdductor pollicis paralyzed

Brachioradialis (Boyes)FDSR ( Brand)FDSR (Royle Thompson )FDSM as Motor With Dual Insertion to the Thumb (Goldner)ECRB (Smith)Combination of EI and ED (Little) Tendon Transfers for Pinch (Robinson et al)

Brachioradialis as Motor (Boyes )

Tendon graft attached to adductor tubercle of proximal phalanx Free end routed along volar surface of paralyzed adductor to third intermetacarpal space Graft passed deep to extensor tendons to emerge in a subcuticular plane on radial side of forearmBrachioradialis detached through separate incision and attached to distal graft

Brand transfer for Thumb adductionSublimis of ring finger as motorTraverses palm superficial to fascia and inserts on radial aspect at MCP joint of thumb

Modified Royle-Thompson to restore thumb adduction FDSR as motorSplit into 2 slips1 slip to EPL distal to MCP joint2nd slip to adductor pollicis

Restoration of Index Abduction

Thumb more important in pinch , but index finger needs to be stabilized to provide effective pinch For tip pinch, index finger in abduction and slight radial rotationProvides substitute for first dorsal interosseous muscle

Accessory Slip of APL Transfer (Neviaser et al ) EIP to first dorsal interosseous muscle (Bunnell) Extensor Pollicis Brevis (EPB) TransferPalmaris Longus to the First Dorsal Interosseous FDSR Transfer (Graham and Riordan)

EPB Transfer BrunerAccessory Slip of APL Transfer (Neviaser et al )

Stabilization of Thumb MP and IP Joints to Restore Pinch

Split FPL to EPL Transfer-Tenodesis (Tsuge and Hashizume ; House and Walsh) To make pulp pinch possible with thumb, necessary to correct problem of IP joint hyperflexion & MP joint stabilization Split transfer of FPL neutralizes IP joint without weakening pinch power

Half of FPL tendon transfer to the EPL tendon for restoring stability to the MP joint and IP joint of thumb to improve pinch

Zigzag incision on the volar aspect of the thumb to expose the FPL Radial half of FPL sectioned distal to A2 pulley, and slit farther proximally to the distal end of A1 pulley Transferred dorsally and sutured to EPL tendon just proximal to IP joint

Arthrodesis of Thumb Joints

Stabilizes key pinch and improve tip pinch Simultaneously restore complex flexor-pronator function of FPB and adductor-supinator function of adductor pollicis with tendon transfers Enable extrinsic flexor and extensors to better stabilize remaining joint Fixed deformity of remaining joint ia contraindication for arthrodesis of either one

Arthrodesis of MP joint

Indicated when there is severe hyperextension contracture or excessive Jeanne's sign with pain and instability. Indicated when positive Jeanne sign develops after FDS transferPlace MP joint in 15 degrees of flexion, 5 degrees of abduction, and 15 degrees of pronation

RESTORATION OF TRANSVERSE METACARPAL ARCH

Normal stability of distal transverse metacarpal arch lost owing to paralysis of the interossei, and the hypothenar muscles

Metacarpals remain together as though held by transverse sling, strong deep transverse metacarpal ligaments, while fingers are in collapsed state

Abolishes ability of palsied hand to contour itself around object placed within its domain

Simple act of opening lid of a jar or turning a valve becomes clumsy and palm is unable to be cupped to hold fluid, gather grain, or mold dough.

Even claw hand corrected by lumbrical replacement procedure likely to recur if transverse metacarpal arch remains unstable or flat

Bunnell's Tendon T Operation

Littler's Split Superficialis Tendon Procedure

Ranney's EDM Transfer

LITTLE FINGER ABDUCTION (Blacker et al[; Goldner ; Voche and Merle)

EDM has potential to abduct little finger through its indirect insertion into abductor tubercle on proximal phalanx. Third palmar interosseous counters this effect in normal hands

In ulnar nerve palsy intrinsic paralysis leaves the EDM unopposed (Wartenberg's sign)

Split-EDM Transfer

Ulnar half of tendon is directed volar to the deep transverse metacarpal ligament and sutured to the phalangeal attachment of the radial collateral ligament of the MP joint of the little finger

If little finger is clawed as well as abducted, the other half tendon is inserted through the A2 pulley of the flexor sheath.

High Ulnar Nerve palsyNeed to first restore extrinsic power before providing prehension with intrinsic muscle functional transfersFDSR must not be transferred

Side-to-side transfer of FDPM to FDPR and FDPL just proximal to flexor zone V in distal forearmAfter 3 weeks of immobilization, muscle strengthening exercises supervised for next 4 weeks, knuckle bender splint wornPalmaris longus to FCU, in absence of palmaris longus, section ulnar half of FCR just proximal to wrist crease and split it proximally for 10 to 12 cm before transferring this to FCU

RESTORATION OF SENSIBILITY Loss of sensibility in ulnar border of hand and loss of proprioception in little finger significant functional limitations Repeated ulceration at tips of digits can lead to absorption and shortening In patients who have leprosy, successful medical treatment does not restore sensation and their insensate digits remain liability for life

Digital Nerve Transfer (Lewis et al ; Stocks et al)

Lewis Transferred functioning median-supplied digital nerve to a nonfunctioning ulnar digital nerve of little finger to restore sensationAdvantages in late-presenting ulnar nerve injuries and in cases in which patients already show telltale signs of trophic changesTransfer of neurovascular cutaneous island flap from ulnar side of pulp of middle finger to pulp of little finger in selected patients with history of chronic ulnar nerve injury due to trauma or burns

Neurovascular cutaneous island pedicle

WASTED INTERMETACARPAL SPACES

Disfiguring and disturbing to patients, despite successful functional restoration

Surgical insertion of dermal graft can mask interosseous wasting and most successful between thumb and index metacarpals

Suitable candidates : who had motor component of deformities corrected 2 to 3 months previously with appreciable functional restoration

Dermal Graft Procedure (Johnson )

Combined low median and ulnar palsy

Complete anesthesia of palm and loss of function of all intrinsics of the fingers If untreated, skin and joint contractures develop, and total claw hand

Restoration of opposition of thumbNecessary for pinchOpposition of thumb : abdduction of thumb, flexion of MCP joint, pronation of thumb,radial deviation of proximal phalanx of thumb on metacarpal, motion of thumb towards fingersAbductor pollicis brevis FDSR ( Riordan, Brand )EIP ( Burkhalter)FCU +FDSR (Groves and Goldner )PL (Camitz )Abductor Digiti Quinti ( Huber, Littler )

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

Brand transfer to restore opposition

FDSR as motorTendon passed to MCP joint & attached to proximal and distal to joint after splitting its end

Combined High Median and Ulnar Nerve Palsy Entire hand anesthetic except for the dorsal surfaceMuscles available for transfer are muscles innervated by the radial nervethe brachioradialis, the extensor carpi radialis brevis, the extensor carpi radialis longus, the extensor carpi ulnaris, and the extensor indicis proprius

Omer recommended Arthrodesis of MCP joint of thumb; Zancolli capsulodesis of MCP joints of all fingers Release of flexor tendon sheaths Transfer of ECRL around radial side of wrist to FDP Transfer of brachioradialis to FPL Transfer of ECU, prolonged with a free graft, around the ulnar border of the forearm to EPB

To restore sensibility to the palm, Omer suggested amputating the index finger and its metacarpal and folding the radially innervated dorsal flap into the palm