claw hand mechanism and surgeries

1. CLAW HAND

2. Definition
Flattening of transverse metacarpal
arch and longitudinal arches,
Hyperextension of MCP joints
Flexion of PIP and DIP joints

3. 3 BASIC FUNCTIONS OF HAND
HOOK
GRASP
PINCH
 All functions of the hand are combinations of these three
functions

4. Normal anatomy
Movements of MCP joints & IP joints
independent
Movements of 2 IP joints coordinated ;
flexion of DIP joint brings
about flexion of PIP joint
(1)Flexion of distal phalanx draws
dorsal expansion distally by loosening
tension on central tendon
(2)Flexion of DIP joint tenses oblique
retinacular ligament causing this

6. Intrinsic muscles of
hand

9. 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.

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

14. Synergistic muscles Normal Grip

15. ROLL UP
MANEUVER
LOSS OF
GRASP

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

17. 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.

18. Types of
claw hand
 Complete : Involving all digits and
resulting from combined Ulnar and
Median Nerve palsy
 Incomplete : Involving only ulnar 2
digits as in isolated Ulnar Nerve palsy

19. Partial Claw
Flexion Extension Deformity
MCP Joint Lumbricals paralyzed Extensor Digitorum
active
Hyper extension of
MCP joint
PIP Joint FDS active Interosseous
paralyzed ( low Ulnar
palsy )
Flexion of PIP joint
DIP Joint FDP active Interosseous
paralyzed
Flexion of DIP
FDP paralyzed( high
Ulnar Palsy )
Interosseous
paralyzed
Neutral position
hand

20. Total Claw
Flexion Extension Deformity
MCP Joint Lumbricals paralyzed Extensor digitorum
active
Hyper extension at
MCP
PIP Joint FDS paralyzed Extensor digitorum
active
Extension of PIP
DIP Joint FDP paralyzed Extensor digitorum
active
Extension of DIP
Hand

21. ETIOLOGY
Traumatic
Compressive neuropathy
Brachial plexus injury
Infective ( Leprosy, Poliomyelitis )
Peripheral neuropathies
Systemic diseases(DM, Uremia, Porphyria,
Malignancy)
Drugs and Toxins (Leas, Arsenic, Dapsone,
etc )
Hereditary(CMTD, Syringomyelia, Lipid
storage disease)
Ischemia

22. Rare conditions showing claw
hand
Ampola syndrome
Angiokeratoma
Arthrogyropsis multiplex congenita
Aural atresia
Charcot Marie Disease
Chondrodysplasia punctata
Chromosomal anomalies
Craniofacial dysostosis
Frontonasal dysplasia
Muller Barth Menger Syndrome
Oro facial digital syndrome type 4
 Pitt Hopkins syndrome
 Stratton Parker syndrome

23. 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

24. LOW ULNAR NERVE
PALSY

25. Evaluation for Surgical
Reconstruction

26. Specific signs and tests for motor dysfunction
Duchenne's sign : Hyperextension at MCP joints & flexion at
IP joints
 Bouvier’s maneuver : Dorsal pressure over proximal phalanx
proximal phalanx to passively flex MP joint results in
results in straightening of distal joints and temporary
temporary correction of claw deformity
 Extensor digitorum tendon can extend middle and distal
and distal phalanges when proximal phalanx stabilized
stabilized
Andre-Thomas sign : On palmar -flexon of wrist
exaggeration of deformity

27.  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
dorsally over index finger, or index over
middle finger
Masse's sign : Flattened metacarpal arch and
hypothenar elevation
 Wartenberg's sign : Inability to adduct
extended little finger to extended ring finger

28.  Jeanne’s sign : Hyperextension of MP
joint of thumb during key pinch or gross
grip
Froment’s sign : Thumb IP joint flexion while
attempting to perform lateral pinch
Bunnell’s O sign : Combined hyperextension
joint and hyperflexion of IP joint (noticed
when patient makes a pulp to pulp pinch
with thumb and index finger)

31. Froment’s sign Bunnel O sign
FPL
EPL

32. BENEDICTION TEST

33. High ulnar
palsy

34.  Pollock's sign : Inability to flex distal
ring and little fingers
 Partial loss of wrist flexion may occur
because of paralysis of FCU
Weakness of ulnar side grip

35. PREOPERATIVE ANGLE
MEASUREMENTS
 Measured at PIP joint of each finger and
IP joint of thumb using a goniometer
placed on dorsal aspect of joint
Unassisted angle : Maintain “lumbrical-plus”
of MP flexion and IP extension, and
extension deficit at PIP joint measured
Assisted angle : Proximal segment of finger
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

36. Contracture angle : Incomplete passive extension
,contracture with deficiency of volar skin and volar plate

37. 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
Anderson GA: Analysis of paralytic claw finger correction using flexor
motors into different insertion sites. Master's thesis, University of Liverpool, 1988.

38. 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

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

40. Indications for
surgery
Nerve Injuries
 Patient referred late ( 1 year )
 After nerve repair, if electrodiagnostic tests
show no signs of reinnervation within 6 to 9
months
*Jobe MT, Wright PE: Peripheral nerve injuries . In: Canale ST, ed. Campbell's
4. 9th ed.. St. Louis: Mosby; 1992

41. Leprosy
 Understanding of stage and activity of disease, presence
of intact, healthy skin, patient motivation.*
 Recommended when
 patient's medical treatment optimized
 skin smears for the bacillus negative
 bacteriological index negative on two successive
tests
 disease activity quiescent for at least a year before
date of intended surgery,
 paralysis established
 patient free of corticosteroid treatment for several
months before surgery
*Enna CD: Preoperative evaluation . In: McDowell F, Enna CD, ed. Surgical rehabilitation in leprosy
and in other peripheral nerve disorders , Baltimore: Williams & Wilkins; 1974

42. Poliomyelitis
 Ulnar innervated lumbricals can be paralyzed,
sparing a part of or whole of interosseous
muscles or vice versa
 Paralysis typically nonprogressive and with
no loss of sensation
 Children affected, and joints hypermobile
 Surgery be delayed until child is at least
5 years of age, so that child will be able to
cooperate with postoperative re-education
program
Anderson GA: The child's hand in the developing world. In: Gupta A, Kay
SPJ, Scheker LR, ed. The Growing Hand: Diagnosis and Management of the
Upper Extremity in Children, London: Mosby; 2000

43. Appropriate use of splints, fabricated for
each patient and altered or changed
whenever indicated can help to manage
claw deformity
Splints interfere with rehabilitation of
sensibility and are generally used
intermittently
North ER, Littler JW: Transferring the flexor superficialis
Technical considerations in the prevention of proximal
joint disability. J Hand Surg [Am] 1980

44. Tendon transfers
Principles and biomechanics
 Homeostasis of involved extremity established *
 Soft tissues free of scar contracture
 Vascularity of extremity adequate
 Chronic wounds fully settled for 3 months before surgery
 Proper physiotherapy, occupational therapy and splinting
 Mobile joints and correct alignment of bone
 Omer Jr GE: The technique and timing of tendon transfers. Orthop Clin North Am 1974

45. Power of transferred muscle : Good or normal
(4 or 5)
Muscle should be expendable
Synergestic muscles
Path of Tendon: Best in straight line; If change
in direction necessary - Pulley
Absolute contraindication: Non-compliant patient
motivation who will not follow appropriate postop
rehabilitation

46. Internal splints (Early Tendon
 Burkhalter
 Allow early function of hand while
awaiting nerve regeneration
 Can prevent deformities that lead to
contractures
 Improve coordination of residual muscle-tendon
units
 Burkhalter WE: Early tendon transfers in upper extremity peripheral nerve injury.
Clin Orthop 1974
Transfers)

47. Contd…
 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

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

49. DEFORMITIES AND DEFICIENCIES
CORRECTABLE BY SURGERY

50. 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

51. Proximal Phalangeal Flexion Static
Techniques
 Flexor Pulley Advancement ( Bunnell ) *
 Each side of proximal pulley system split 1.5 to 2.5 cm up to
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
flexion at MP joint
 Fasciodermadesis ( Zancolli )‡
 Excision of 2 cm of the palmar skin (dermadesis) at MP joint level
at MP joint level combined with shortening of pretendinous band of

52. Zancolli
Capsulodesis
 Volar MP joint Capsulodesis
 A1 pulley release with MP joint volar
plate advancement
 Complicated claw hands with MP
joint contracture Zancolli incorporated
collateral ligament release on both sides of
MP joint with volar capsuloplasty
 Zancolli EA: Claw-hand caused by paralysis of the intrinsic muscles:
A simple surgical procedure for its correction. J Bone Joint Surg Am
1957

53. Omer advanced volar plate by cutting
away a triangular portion of the deep
transverse metacarpal ligament (DTML) on
each side of volar plate flap
Omer Jr GE, Spinner M, ed. Management of Peripheral
Problems , Philadelphia: WB Saunders; 1980

54. Dorsal Methods (Howard; Mikhail)
To provide bony block to proximal
phalangeal extension
Enables 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

55.  Riordan
Static Tenodesis
Techniques
One half of ECRL and ECU
tendons made use of as “grafts” to prevent
hyperextension of MP joint while remaining
half continue to actively extend wrist
Riordan DC: Tendon transfers for nerve paralysis of the hand
and wrist. Curr Pract Orthop Surg 1964

56.  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

57. Integration of Finger Flexion
Fowler tenodesis
 Wrist Tenodesis Technique Fowler
 Incorporates active wrist motion to tension
static tendon grafts
 Free tendon grafts sutured to extensor
retinaculum of wrist and passed in a dorsal
to palmar direction through the
intermetacarpal spaces, volar to the DTML,
through the lumbrical canals, and onto the
lateral bands of dorsal extensor expansion of
4 fingers
Fowler SB: Extensor apparatus of the digits (abstract). J Bone
Joint Surg Br 1949

58. RIORDAN OPPOSITION

59. BRANDS

61. 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
Stiles HJ, Forrester-Brown MF: Treatment of
Injuries of Peripheral Spinal Nerves , London: H Frowde
& Hodder & Stoughton; 1922

62. Transfer of Extrinsic Finger Flexors
Superficialis Tendon Transfer Techniques and
Modifications (Stiles; Bunnell; Littler)
 FDS detached , splitted, & transferred to dorsum of
dorsum of fingers to extensors tendons
 Removes powerful flexor of PIP joint & converts it
& converts it into extensor
Intrinsic plus deformity

63.  Bunnell (1942) : rerouted both slips of all
superficialis tendons through lumbrical canals and
anchored them to both sides of lateral band of
dorsal extensor expansion (Stiles-Bunnell procedure )
 Transfer involved passage of
 Split FDSI for radial side of lateral bands of
index and middle fingers
• Split FDSM for ulnar side lateral band of index,
middle, and ring fingers
• Split FDSR to radial side of ring and little fingers
• Split FDSL) to the ulnar side of little finger
 Bunnell S: Surgery of the intrinsic muscles of the hand other than those
producing opposition of the thumb. J Bone Joint Surg 1942

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

65.  To prevent these complications, North and
Littler : removal of superficialis through volar
incision between A1 and A2 pulleys
 Brand :
 Ulnar nerve palsy results in claw deformities
in all four fingers, Weakness is not limited
only to fingers with obvious clawing.
Recommendation : surgery be done in all
fingers of a claw hand
North ER, Littler JW: Transferring the flexor superficialis tendon: Technical
considerations in the prevention of proximal interphalangeal joint disability. J
Hand Surg [Am] 1980

66. Modification of Bunnell
 Littler proposed modification of
the Stiles-Bunnell procedure
by using FDSM
 Referred to as modified
Stiles-Bunnell procedure
 Tendon slips sutured under
correct tension, that is, with
wrist in neutral flexion-extension,
MP joints in 45 to
55 degrees of flexion, and
IP joints in neutral position.
Littler JW: Tendon transfers and
arthrodesis in combined median and ulnar
nerve palsies. J Bone Joint Surg Am 1949

67. 4 primary insertion sites of FDS are classified
as:
A. Lateral band insertion—intrinsic replacement
(Stiles and Forrester-Brown , Bunnell , Littler ,
Brand , Riordan , Lennox-Fritschi )
B. Phalangeal insertion (Burkhalter )
C. Pulley insertion (Riordan , Zancolli , Brooks
and Jones , Anderson )
D. Interosseous insertion (Zancolli , Palande ,
Anderson )

68. Pulley system of flexor
tendon of finger

69. Phalangeal Insertion (
Burkhalter )
 Insertion of superficialis
tendon slips directly to
proximal phalanx
 Avoid risk of PIP joint
hyperextension noted with
transfers to lateral band of
the dorsal apparatus
 Increased distance of
moment with increased
flexion of MP joint
Burkhalter WE, Strait JL:
Metacarpophalangeal flexor
replacement for intrinsic-muscle
paralysis. J Bone Joint Surg Am
1965

70. 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

71. Pulley Insertions (Zancolli's
“Lasso”)
 Delineated A1 pulleys through
a transverse skin incision at
level of the distal palmar
crease.
 Flexor superficialis tendon
sectioned in the finger and
divided into two slips
 Each tendon slip retained
volar to deep transverse
metacarpal ligament and looped
through the A1 proximal pulley
and sutured to itself
Zancolli EA: Claw-hand caused by
paralysis of the intrinsic muscles: A
simple surgical procedure for its correction.
J Bone Joint Surg Am 1957;

72.  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
pulley, beginning at prox. palmar crease of index finger and
finger and ending ulnarly at distal palmar crease of little finger.
of little finger.

73. Subcutaneous tissue opened
longitudinally and neurovascular bundles
retracted to either side.
FDS tendon exposed 1½ cm prox to A-1
pulley.

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

75. PIP joint flexed to allow proximal
retraction of FDS tendon.

76. Each slip of tendon is divided distal to
hemostats.

77. Finger is extended and tendon slit
proximally.

78. 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.

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

82. 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.

83. Finger Level
Extensor Motor
Fowler transfer
Extensor Indicis
Proprius and Extensor
Digiti Minimi Transfer
(Fowler )
 EIP and EDM tendons as transfers
lateral bands of the dorsal apparatus
 May produce excessive tension in
extensor apparatus and lead to
intrinsic-plus deformities.
 May cause reversal of normal
metacarpal arch and, occasionally,
extensor weakness in the little finger
 Fowler SB: Extensor apparatus of the digits
(abstract). J Bone Joint Surg Br

84. Riordan
Modification
Splitting EIP into 2
slips and transferring
them through
intermetacarpal space
between the ring and
little digits, routed palmar
to the transverse
metacarpal ligament and
onto radial lateral bands
of the ring and little
fingers
Riordan DC: Tendon transplantations in
median-nerve and ulnar-nerve paralysis. J
Bone Joint Surg Am 1953

85. 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
phalanges
Require free grafts to provide sufficient
length to reach insertion site( plantaris,
palmaris, fascia lata, or toe extensors)

86. Dorsal Route Transfer of
ECRB (Brand)
 ECRL or ECRB lengthened
by plantaris tendon that was
split into four tails
 Tendon slips passed through
intermetacarpal spaces, into
the lumbrical canal and
palmar to the DTML, to be
attached to radial lateral
bands of the long, ring, and
little fingers and ulnar lateral
band of the index finger
 Did not improve flattened
transverse metacarpal arch or
weakness of grip
Brand PW: Hand reconstruction in leprosy .
British Surgical Practice: Surgical Progress ,
London: Butterworth; 1954

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

88. Exposure of intrinsic mechanism

89. Dorsal retraction of intrinsic mechanism at
PP level

90. 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

91. 2 transverse MC incisions over II & III; and
IV MC and chevron incision centered over
reticular level

92. Excision of dorsal fascial window

93. Division of ECRB insertion and
withdrawal prox to extensor
retinaculum

94. Rerouting of ECRB superficial to extensor
retinaculum

95. 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.

96. Tendon graft seated within proximal
phalanx

97. Pulvertaft weave

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

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

100. 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.

101. 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 Site‡
 Palmaris Four-Tail (PL4T) Transfer (Lennox-
Fritschi )†
*Burkhalter WE, Strait JL: Metacarpophalangeal flexor replacement for
intrinsic-muscle paralysis. J Bone Joint Surg Am 1965
‡Brooks AL, Jones DS: A new intrinsic tendon transfer for the paralytic
hand. J Bone Joint Surg Am 1975
†Fritschi EP: Nerve involvement in leprosy; the examination of the
hand; the restoration of finger function . Reconstructive Surgery in
Leprosy , Bristol: John Wright & Sons; 1971

102. 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 Fowler
 No muscle available, supple joints : Zancolli

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

104. 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

105. Thumb Adduction
Techniques
 Adduction of thumb necessary for strong
pinch
 Adductor pollicis paralyzed
Brachioradialis (Boyes)
FDSR ( Brand)
FDSR (Royle –Thompson )
FDSM as Motor With Dual Insertion to the
Thumb (Goldner)
ECRB (Smith)
Combination of EI and ED (Little) Tendon
Transfers for Pinch (Robinson et al)

106. Brachioradialis as Motor
(Boyes )
 Tendon graft attached
to adductor tubercle of
proximal phalanx
 Free end routed
along volar surface of
paralyzed adductor to
third intermetacarpal
space
 Graft passed deep
to extensor tendons to
emerge in a subcuticular
plane on radial side of
forearm
 Brachioradialis detached
through separate incision
and attached to distal
graft

107. Brand transfer for
Thumb adduction
Sublimis of ring
finger as motor
Traverses palm
superficial to fascia
and inserts on radia
aspect at MCP joint
of thumb

108. Modified Royle-Thompson to restore thumb
adduction
 FDSR as motor
 Split into 2 slips
 1 slip to EPL distal
to MCP joint
 2nd slip to adductor
pollicis

109. ECRB as motor (Smith)

110. 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 rotation
 Provides substitute for first dorsal interosseous
muscle
 Accessory Slip of APL Transfer (Neviaser et al )
 EIP to first dorsal interosseous muscle (Bunnell)
 Extensor Pollicis Brevis (EPB) Transfer
 Palmaris Longus to the First Dorsal Interosseous
 FDSR Transfer (Graham and Riordan)

111. EPB Transfer
Bruner
Accessory Slip of APL
Transfer (Neviaser et al )

112. 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
Tsuge K, Hashizume C: Reconstruction of opposition in the
paralyzed thumb . In: McDowell F, Enna CD, ed. Surgical
rehabilitation in leprosy , Baltimore: Williams & Wilkins; 1974:
House JH, Walsh T: Two-stage reconstruction of the tetraplegic
hand . In: Strickland JW, ed. The Hand—Master Techniques in
Orthopedic Surgery , Philadelphia: Lippincott-Raven; 1998

113. 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

114. 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

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

116. 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

117. Bunnell's “Tendon T” Operation
 Littler's Split Superficialis Tendon
Procedure
Ranney's EDM Transfer

118. 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)

119. Ulnar half of tendon
is directed Split-EDM
volar to the
deep metacarpal Transfer
transverse
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.

120. High Ulnar Nerve
palsy
Need to first restore
extrinsic power
before providing
prehension with
intrinsic muscle
functional transfers
FDSR must not be
transferred

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

122. 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

123. 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 sensation
 Advantages in late-presenting ulnar nerve injuries
and in cases in which patients already show telltale
signs of trophic changes
 Transfer of neurovascular cutaneous island flap from
ulnar side of pulp of middle finger to pulp of
little finger in selected patients with history of
chronic ulnar nerve injury due to trauma or burns
Lewis Jr RC, Tenny J, Irvine D: The restoration of sensibility by nerve
translocation. Bull Hosp Jt Dis Orthop Inst 1984

124. Neurovascular cutaneous
island pedicle

125. 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

126. Dermal Graft Procedure
(Johnson )

127. 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

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

129. Riordon
transfer
Sublimis tendon of
the ring finger
Pulley in FCU
Small tunnel for
insertion of the
transfer by in the
abductor pollicis
brevis tendon

130. Brand transfer to
restore opposition
FDSR as motor
Tendon passed to
MCP joint &
attached to proximal
and distal to joint
after splitting its end

132. Combined High Median and
Ulnar Nerve Palsy
 Entire hand anesthetic except for the
dorsal surface
Muscles available for transfer are muscles
innervated by the radial nerve—the
brachioradialis, the extensor carpi radialis
brevis, the extensor carpi radialis longus,
the extensor carpi ulnaris, and the extensor
indicis proprius

133. 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

134. 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

136. Combined high ulnar and radial nerve
palsy

137. Thank you