- Email: [email protected]
Tendon transfer in partially anaesthetic hands
TENDON TRANSFER PARTIALLY ANAESTHETIC
IN HANDS
N. CITRON and JANE TAYLOR From the Royal National Orthopaedic Hospital, London Stereognosis and sensory localisation were studied in hands of patients with partial anaesthesia due to peripheral nerve injury both before and after tendon transfer to impart movement to the anaesthetic part. One patient showed a marked improvement in stereognosis and localisation, but in general little was gained in terms of improved sensation. Function was improved more in the dominant than in the non-dominant hand. Earlier tendon transfer in cases of peripheral nerve injury might decrease cortical exclusion.
Sensibility of the hand is inextricably bound up with movement of the hand. Sir Charles Bell noted this in 1833 as he stated in his classic Bridgewater Treatise “the motion of the fingers is especially necessary to the sense of touch. These bend, extend or expand, moving in all directions like palpa, with the advantage of embracing the object, and feeling it on all its surfaces, sensible to its solidity and to its resistance when grasped, moving around it, and gliding over its surfaces, and, therefore, feeling every asperity”.
osteotomy, in order to improve the mobility of the affected part. Nine patients were eventually found who had received formal functional assessment of hand sensibility, and these patients were seen in a special clinic where they were re-examined and had their sensory testing repeated. The sensory testing methods have been described in detail elsewhere (Wynn Parry and Salter, 1976). The test falls into two parts.
Thus, in order to make full use of the cutaneous receptors in the hand, objects are presented in different ways to the fingertips, the fingers press with differing firmness to gauge the hardness of objects, and they may also be used to elicit auditory cues from the objects, as for example scratching the surface and listening to the sound so as to gain information about surface texture. The hand which has suffered the effects of peripheral nerve injury is both anaesthetic and paralysed; doubly handicapped in its sensibility. This study was an attempt to see whether sensibility of the anaesthetic part of the hand was improved by tendon transfers which gave mobility to that part. It might be thought that where cutaneous receptors have been denervated, that part of the body would be completely insensate, but information may still be relayed centrally by sympathetic afferent fibres around blood vessels or by joint position receptors for more proximal joints whose innervation is intact. Materials and Methods
The case records of the Royal National Hospital were examined for patients peripheral nerve injury affecting the hand, there had been little eventual recovery despite nerve repair or grafting. Some of had undergone tendon transfer, or in
Orthopaedic who had a and in whom of sensation these patients one case an
Received for publication 14th August 1986. N. Citron, Royal National Orthopaedic Hospital, 45-51 Bolsover Street, London WIP SAQ.
14
Fig.
I
Form
used for evaluation
of sensory
THE
localisation
JOURNAL
OF HAND
in the hand.
SURGERY
TENDON
TRANSFER
IN PARTIALLY
In the sensory localisation test, the examiner touches the skin of the hand lightly with a metal point and records where the patient subjectively feels the touch. This is repeated for a total of 35 different zones of the hand (Figure 1) and the result expressed as a fraction correct. In our experience this has proved to be a more useful measure of hand sensory function where there is severe sensory loss, than formal two-point discrimination testing. In the functional recognition test, the patient is blindfolded, and the part of the hand which has normal sensibility is masked so as to prevent its use by the patient (Figure 2). The patient is then presented with a series of small objects, large objects and different textures to feel. He is allowed to use whatever strategy he wishes to elicit the information, and is given a soft flat surface on which to manipulate the objects. The surface is soft so as to eliminate auditory cues. The time taken to identify each object is recorded, as is the number identified correctly. At our hospital this has been shown
ANAESTHETIC
HANDS
to be a reliable and reproducible test of sensory function of the hand, and is in everyday routine clinical use. Results
Patient I: This right-handed man had cut the volar aspect of his left wrist at the age of 15, severing the median nerve, and the tendons of FPL, FCR and FDP to the index. He underwent primary repair of all the structures, but one year later was noted to have incomplete sensory recovery (2PD = 12 mm on the thumb and 10 mm on the index finger). An opposition tendon transfer was performed using FDS of the ring finger, but without subjective sensory improvement, although his two-point discrimination improved somewhat to 5mm for thumb and 7 mm for index. When examined at the age of 37 for this study, he stated that he had become more right-handed, and that he still injured the anaesthetic parts of his left hand. On sensory testing he scored 35/35 on localisation, but poorly on the recognition of objects and textures, despite good motor control and a well functioning transfer. Patient 2: This right-handed man cut the volar aspect of his right wrist at the age of 23, severing the ulnar and median nerves. He underwent primary repair, following which he unfortunately developed an intrinsic contracture secondary to tight bandaging. He was treated by an intrinsic release followed, one year later, by a nerve graft to a neuroma at the median nerve repair site, where two fascicles were noted to be intact. Six months later he was noted to have disordered spatial representation in the median nerve territory, but adequate protective sensation. An opposition tendon transfer was then performed, but there was little improvement in his sensory localisation score which had been 21/35 before the nerve graft and 24/35 just after the tendon transfer. However, by the age of 30 his score had improved to 3 l/35 and in the sensory interpretation, all scores had improved except for object recognition. He was noted to manipulate the objects with all digiits during testing. His recovery might have been attributable of the nerve graft being slow to appear.
to the results
Patient 3: This 25-year-old right-handed man cut the right median and ulnar nerves on the volar surface of his wrist at the age of 20. He had a primary repair with excellent return of function in the ulnar innervated intrinsics, but with poor sensory recovery. Fig. 2
VOL.
12-B
Method fingertips No.
of
“masking” are covered
1 FEBRUARY
1987
the normal part of the hand. over at the actual time of testing.
The
Electrical testing suggested there would be no further sensory recovery, and 18 months after the initial 15
N. CITRON
AND
accident, he underwent an opposition tendon transfer. The results of his sensory testing are shown below:Before Tendon Transfer 29/35 l/5 73” 7/12 5/11 (Average 27”) 15/16 (Average 14”)
3 years after Tendon Transfer Localisation 35/35 Coins 3/3 Shapes(al1 correct) 9” Textures 3/7 Small objects 5/6 (Average 9”) Large objects 5/6 (Average 9”)
He was noted to have a better power grip, but not to have improved precision handling. He tended to push small objects towards the ulnar side of his hand when manipulating them, using his anaesthetic thumb. Nevertheless there seems to have been an improvement of his sensibility, especially stereognosis. Patient 4: At the age of 44, this right-handed man had a partial division of his right median nerve and complete division of his brachial artery. The artery was repaired and he underwent a neurolysis of the nerve later that same year. The following year he had guanethidine blocks, release of a Volkmann’s contracture and MCPJ capsulotomies, followed by release of an adduction contracture of the thumb. At the age of 45 he had an opposition tendon transfer which, he says, has not improved his sensibility, but has improved his function a little so that he can now drive a car and can just about open a bottle. On examination he had severe dysaesthesia in the median distribution and a two-point discrimination greater than 20 mm. Despite the opposition tendon transfer, that side of his hand is completely excluded in normal use, because of the dysaesthesia and hyperpathia. He has to use an ulnar claw grip to get small objects into his hand, and never uses a pinch grip, although he has the ability to pinch. His localisation score, which was 29/35 just after the tendon transfer, had slightly declined to 25/35 at two years postoperatively. His sensory scores remained the same or worse after the tendon transfer and did not improve with time. Patient 5: This right-handed man sustained a complete division of his right ulnar and median nerves together with the brachial artery at the age of 45. The ulnar nerve was used as a graft to bridge a gap in the median nerve. Two years later he had a stellate ganglion block for pain, and later 16
JANE
TAYLOR
that year, clear signs of median sensory recovery were noted. He then had a high median tendon transfer consisting of transfer of ECRL to FDP and FDP to FPL. He still has constant pain in his right hand, the sensibility of which was, he stated, not improved by the tendon transfer. He states that his function is much improved after the transfer. His localisation scores have remained disappointing at about 6/35 at all stages of treatment. Unfortunately a full sensibility assessment was not done earlier in his treatment. Patient 6: At the age of 27 this right-handed man sustained a high left median nerve and brachial artery injury, both of which were repaired primarily. At one year after the injury there was some return of sensation. At age 29 he underwent an opposition tendon transfer to his thumb with which he tends to oppose to the ulnar two fingers. He has a poor grip on the radial side due to loss of power in the deep flexors and statges that the only thing for which he definitely uses the left hand is to release the shuttlecock at badminton. He has otherwise become completely right-handed. If he has to use the left hand, for instance holding a nail which is to be hammered in, he holds it between the little and ring fingers. His localisation scores improved slightly as shown below, but sensibility testing showed no change following the tendon transfer. During testing, however, it was noted that he was able to manipulate objects between middle finger and thumb, with the index finger assisting. His localisation scores were as follows: Pre-op. 33135
Immediately
Post-
%35
6 Years Post-op. 35/35
Patient 7: This right-handed boy sustained a supracondylar fracture of the left humerus at the age of 13 years, which was followed by a Volkmann’s ischaemic contracture affecting the forearm flexors, and both median and ulnar nerves. When he was 19, he was observed to lack even protective sensation in his median nerve territory, and the whole hand was dry. He underwent lengthening of the flexor tendons and, although subjectively his sensation was not improved, objectively some return of protective sensation in the median nerve territory was noted. At the age of 20 he underwent a transfer of brachioradialis to the flexor tendons, and thereafter started to feel improvement in all five fingers, which improvement continues to date. He has since had two further operations to improve opposition of this thumb, and can now take coins out of his trouser pocket with his THE
JOURNAL
OF HAND
SURGERY
TENDON
TRANSFER
IN PARTIALLY
left hand. His localisation and sensory charts show a great improvement as shown below:
After Flexor Tenotomies
After Brachioradialis
Transfer
3 l/7/84 7/12/84 13/3/84 Localisation 12/35 35/35 35/35 23/35 Tended to use the better Needed opponens splint parts of his hand to pick up object to (thenar and hypothenar identify. Tended to claw objects towards the eminences) to identify objects by rolling them more sensitive part of on the pad provided. his hand. (Fuller details are shown in Table 1).
After Flexor 6/9/82
Shapes Coins Textures Small Objects Large Objects
TABLE 1 7: Stereognosis Tenotomies 13/3/84
With Opponens Splint 2/4 l/4 Not tested l/3 2/4 2/6 2/4 2/6 719 4/6
Testing After
Brachioradialis 31/7/84 Without 4/4 2/3 6/6 616 5/l
Transfer 7/12/84
Opponens Splint 4/4 3/3 516 S/6 616
This was the most spectacular recovery following a tendon transfer that was seen. The recovery seems inexplicable, but perhaps there is some facilitating effect of movement on reinnervation. Alternatively, regrowth had long before-occurred, but sensory retraining was in fact enormously delayed by his deformities.
Patient 8: At the age of 30, this right-handed panel beater was involved in a road traffic accident which left him with multiple injuries which included a high left median and radial nerve deficit. He was left with a hand which had loss of sensation in the median distribution, and with the thumb adducted into the palm. Two tendon transfer operations were undertaken at the age of 32 to regain opposition and extension of the thumb and to regain finger flexion; the thumb metacarpophalangeal joint was fused at the same time. A year later, an abduction/ extension osteotomy was performed to bring the thumb out of the palm and enable him to use the mass flexor action of his ulnar four fingers. He is now able to use these fingers in a suitcase grip, and has returned to work, although not yet as a panel beater. He is able to pinch to the side of his index middle phalanx, but tends to use the thumb to pinch across to the normal ulnar side of his hand to pick up small objects. The patient has not himself noted much subjective sensory improvement, VOL.
12-B No. 1 FEBRUARY
1987
HANDS
and despite the functional improvement in the hand, sensory testing confirms the patient’s impression: 2 Months
6/9/82
Patient
ANAESTHETIC
Localisation Score Shapes Coins Textures Small Objects Large Objects
Pre-Op.
Post-op.
14 Months Post-op.
21/35 4/4 l/3 5/6 2/6 4/6
24/35 4/4 l/3 3/6 3/6 5/6
25/35 4/4 o/3 6/6 5/6 4/6
Patient 9: This right-handed sheet-metal worker sustained a laceration of his left median nerve at the wrist in an accident at work at the age of 37. He had a good recovery of localisation into the median territory, but did not regain fine touch sensibility and remained unable to oppose his thumb. He underwent an opposition tendon transfer one year after the original injury: this was successful in restoring pinch grip although it was felt that a bit more rotation of the thumb would be desirable. The lack of rotation did not seem sufficient to warrant another operation: The patient claimed not to have gained any functional benefit from the tendon transfer and had not noted any improvement in the sensation in the median territory. On examination, he was indeed able to accomplish a functional opposition, but admitted he did not make use of this in his everyday life. The static two point discrimination in the median nerve territory was unmeasurable as was the moving 2PD except on the index where it measured one centimetre. 35/35 4/4 in o/3 5/6 in 3/6 in 6/6 in
20” 20” 50” 21’
Localisation Shapes Coins Textures Objects Large Objects
33/35 4/4 in l/3 in 5/6 in 3/6 in 4/6 in
10” 27” 27” 31” 29”
Discussion The selection of patients for study was quite difficult for several reasons: firstly, it is difficult to say when exactly an end-point in sensory recovery has been reached. In cleanly divided peripheral nerves in the forearm, recovery has been said to continue in functional terms for up to four years after injury. The common practice at our hospital has not been to wait that long, but to reoperate if recovery is not proceeding as expected, although the detailed guidelines depend on the type of injury. Secondly, as a result of this policy, the sensory recovery has in general been extremely good, and the tests employed would not be able to pick up any slight 17
N. CITRON
AND
improvements. Thirdly, all the patients studied had unilateral injuries and were able to use the good hand to substitute to a very large extent despite intensive sensory retraining. The cases studied therefore represent definite failures of primary repair. Some authors have been optimistic about the results of tendon transfers in anaesthetic hands, although they do not quote any objective evidence to this effect. Burkhalter (1982) says that “a mobile opposable thumb that can reach the normal sensible areas of the hand is much more useful than one that cannot be used and cannot even reach the areas of normal sensibility”. Omer et al (1970) state that “the purpose of tendon transfers in a hand with total loss of a nerve is not so much to gain strength, as to gain the ability to place the hand in position to make use of the remaining functional units”. Omer (1983) has noted that “abnormal patterns of motor activity enhance the distortion of sensibility that accompanies a peripheral nerve deficit”, and suggests that tendon transfer be undertaken before sensory reconstruction. Previous reports of good results following tendon transfers in anaesthetic hands were often on patients with leprosy who were forced to use the hand because of symmetrical bilateral loss. Patients with brachial plexus injuries ,were not included in our study because when recovery into the hand takes place, it is nearly always from the lesion in continuity whose prognosis is rather variable.
JANE
TAYLOR
A patient who experiences painful sensations on touching a partially denervated area of the hand (dysaesthesia) will naturally avoid the use of that part of the hand. Despite all efforts, dysaesthesia persisted in two of our patients. Pain can, however, often be controlled by transcutaneous nerve stimulation which has been found to improve hand sensibility and stereognosis (Wynn Parry, 1981). The conclusions to be drawn from this very small study appear rather gloomy: 1. Where a patient has dysaesthesia or hyperpathia in a nerve territory, then tendon transfer to impart motion will not be of advantage because the patient will still avoid use of that part. 2. In a unilateral partial hand anaesthesia, little is gained by tendon transfer in terms of sensibility. 3. Improvement in hand function is more likely after a transfer in a dominant hand than a non-dominant one. An alternative explanation may be that operation was carried out too late: perhaps more aggressive attempts to bring back hand function would prevent cortical exclusion of the abnormal part. Acknowledgments I would like to thank Dr. C. B. Wynn-Parry and Mr. R. Birch of the Royal National Orthopaedic Hospital for their advice and helpful criticism.
References
It might be thought that with the additional sensory input provided by movement, the sensory cortex might become more efficient at interpreting the input of information. This type of phenomenon has been shown to apply in, for instance, braille readers, who can develop a much finer two-point discrimination than a normal subject. This is not due to an increase in the number of skin receptors, but to more efficient central processing of the information. Unfortunately, in the cases we studied, an improvement in sensibility was not consistently found.
18
BELL, C. The Hand. Its Mechanisms and Vital Endowments As Envincing Design. London. William Pickering 1833. Reprinted. The Pilgrims Press, Brentwood, England. (1979) p 205. BURKHALTER, W. E. Operative Hand Surgery. Vol. 2. (ed) D.P. Green, Churchill Livingstone, London, 1982; p 1053. OMER, G. E., DAY, D. J., RATLIFF, H. and LAMBERT, P. (1970). Neurovascular Cutaneous Island Pedicles for Deficient Median Nerve Sensibilitv. New Techniaue and Results of Serial Functional Tests. The Journal df Bone Joint Sdrgery, 52A: 1181-l 192. OMER, G. E. Surgery of the Musculoskeletal System. Vol. I. (ed) C. McCollister Evans, London. Churchill Livingstone 1983, 2: 426. WYNN PARRY. C. B. and SALTER. M. (1976). Sensorv Re-education after median n&z lesions. The Hand, s: 3: i50-257. . WYNN PARRY, C. B. Rehabilitation of the Hand. Fourth Ed. London, Butterworths, (1981): 141
THE
JOURNAL
OF HAND
SURGERY
IN HANDS
N. CITRON and JANE TAYLOR From the Royal National Orthopaedic Hospital, London Stereognosis and sensory localisation were studied in hands of patients with partial anaesthesia due to peripheral nerve injury both before and after tendon transfer to impart movement to the anaesthetic part. One patient showed a marked improvement in stereognosis and localisation, but in general little was gained in terms of improved sensation. Function was improved more in the dominant than in the non-dominant hand. Earlier tendon transfer in cases of peripheral nerve injury might decrease cortical exclusion.
Sensibility of the hand is inextricably bound up with movement of the hand. Sir Charles Bell noted this in 1833 as he stated in his classic Bridgewater Treatise “the motion of the fingers is especially necessary to the sense of touch. These bend, extend or expand, moving in all directions like palpa, with the advantage of embracing the object, and feeling it on all its surfaces, sensible to its solidity and to its resistance when grasped, moving around it, and gliding over its surfaces, and, therefore, feeling every asperity”.
osteotomy, in order to improve the mobility of the affected part. Nine patients were eventually found who had received formal functional assessment of hand sensibility, and these patients were seen in a special clinic where they were re-examined and had their sensory testing repeated. The sensory testing methods have been described in detail elsewhere (Wynn Parry and Salter, 1976). The test falls into two parts.
Thus, in order to make full use of the cutaneous receptors in the hand, objects are presented in different ways to the fingertips, the fingers press with differing firmness to gauge the hardness of objects, and they may also be used to elicit auditory cues from the objects, as for example scratching the surface and listening to the sound so as to gain information about surface texture. The hand which has suffered the effects of peripheral nerve injury is both anaesthetic and paralysed; doubly handicapped in its sensibility. This study was an attempt to see whether sensibility of the anaesthetic part of the hand was improved by tendon transfers which gave mobility to that part. It might be thought that where cutaneous receptors have been denervated, that part of the body would be completely insensate, but information may still be relayed centrally by sympathetic afferent fibres around blood vessels or by joint position receptors for more proximal joints whose innervation is intact. Materials and Methods
The case records of the Royal National Hospital were examined for patients peripheral nerve injury affecting the hand, there had been little eventual recovery despite nerve repair or grafting. Some of had undergone tendon transfer, or in
Orthopaedic who had a and in whom of sensation these patients one case an
Received for publication 14th August 1986. N. Citron, Royal National Orthopaedic Hospital, 45-51 Bolsover Street, London WIP SAQ.
14
Fig.
I
Form
used for evaluation
of sensory
THE
localisation
JOURNAL
OF HAND
in the hand.
SURGERY
TENDON
TRANSFER
IN PARTIALLY
In the sensory localisation test, the examiner touches the skin of the hand lightly with a metal point and records where the patient subjectively feels the touch. This is repeated for a total of 35 different zones of the hand (Figure 1) and the result expressed as a fraction correct. In our experience this has proved to be a more useful measure of hand sensory function where there is severe sensory loss, than formal two-point discrimination testing. In the functional recognition test, the patient is blindfolded, and the part of the hand which has normal sensibility is masked so as to prevent its use by the patient (Figure 2). The patient is then presented with a series of small objects, large objects and different textures to feel. He is allowed to use whatever strategy he wishes to elicit the information, and is given a soft flat surface on which to manipulate the objects. The surface is soft so as to eliminate auditory cues. The time taken to identify each object is recorded, as is the number identified correctly. At our hospital this has been shown
ANAESTHETIC
HANDS
to be a reliable and reproducible test of sensory function of the hand, and is in everyday routine clinical use. Results
Patient I: This right-handed man had cut the volar aspect of his left wrist at the age of 15, severing the median nerve, and the tendons of FPL, FCR and FDP to the index. He underwent primary repair of all the structures, but one year later was noted to have incomplete sensory recovery (2PD = 12 mm on the thumb and 10 mm on the index finger). An opposition tendon transfer was performed using FDS of the ring finger, but without subjective sensory improvement, although his two-point discrimination improved somewhat to 5mm for thumb and 7 mm for index. When examined at the age of 37 for this study, he stated that he had become more right-handed, and that he still injured the anaesthetic parts of his left hand. On sensory testing he scored 35/35 on localisation, but poorly on the recognition of objects and textures, despite good motor control and a well functioning transfer. Patient 2: This right-handed man cut the volar aspect of his right wrist at the age of 23, severing the ulnar and median nerves. He underwent primary repair, following which he unfortunately developed an intrinsic contracture secondary to tight bandaging. He was treated by an intrinsic release followed, one year later, by a nerve graft to a neuroma at the median nerve repair site, where two fascicles were noted to be intact. Six months later he was noted to have disordered spatial representation in the median nerve territory, but adequate protective sensation. An opposition tendon transfer was then performed, but there was little improvement in his sensory localisation score which had been 21/35 before the nerve graft and 24/35 just after the tendon transfer. However, by the age of 30 his score had improved to 3 l/35 and in the sensory interpretation, all scores had improved except for object recognition. He was noted to manipulate the objects with all digiits during testing. His recovery might have been attributable of the nerve graft being slow to appear.
to the results
Patient 3: This 25-year-old right-handed man cut the right median and ulnar nerves on the volar surface of his wrist at the age of 20. He had a primary repair with excellent return of function in the ulnar innervated intrinsics, but with poor sensory recovery. Fig. 2
VOL.
12-B
Method fingertips No.
of
“masking” are covered
1 FEBRUARY
1987
the normal part of the hand. over at the actual time of testing.
The
Electrical testing suggested there would be no further sensory recovery, and 18 months after the initial 15
N. CITRON
AND
accident, he underwent an opposition tendon transfer. The results of his sensory testing are shown below:Before Tendon Transfer 29/35 l/5 73” 7/12 5/11 (Average 27”) 15/16 (Average 14”)
3 years after Tendon Transfer Localisation 35/35 Coins 3/3 Shapes(al1 correct) 9” Textures 3/7 Small objects 5/6 (Average 9”) Large objects 5/6 (Average 9”)
He was noted to have a better power grip, but not to have improved precision handling. He tended to push small objects towards the ulnar side of his hand when manipulating them, using his anaesthetic thumb. Nevertheless there seems to have been an improvement of his sensibility, especially stereognosis. Patient 4: At the age of 44, this right-handed man had a partial division of his right median nerve and complete division of his brachial artery. The artery was repaired and he underwent a neurolysis of the nerve later that same year. The following year he had guanethidine blocks, release of a Volkmann’s contracture and MCPJ capsulotomies, followed by release of an adduction contracture of the thumb. At the age of 45 he had an opposition tendon transfer which, he says, has not improved his sensibility, but has improved his function a little so that he can now drive a car and can just about open a bottle. On examination he had severe dysaesthesia in the median distribution and a two-point discrimination greater than 20 mm. Despite the opposition tendon transfer, that side of his hand is completely excluded in normal use, because of the dysaesthesia and hyperpathia. He has to use an ulnar claw grip to get small objects into his hand, and never uses a pinch grip, although he has the ability to pinch. His localisation score, which was 29/35 just after the tendon transfer, had slightly declined to 25/35 at two years postoperatively. His sensory scores remained the same or worse after the tendon transfer and did not improve with time. Patient 5: This right-handed man sustained a complete division of his right ulnar and median nerves together with the brachial artery at the age of 45. The ulnar nerve was used as a graft to bridge a gap in the median nerve. Two years later he had a stellate ganglion block for pain, and later 16
JANE
TAYLOR
that year, clear signs of median sensory recovery were noted. He then had a high median tendon transfer consisting of transfer of ECRL to FDP and FDP to FPL. He still has constant pain in his right hand, the sensibility of which was, he stated, not improved by the tendon transfer. He states that his function is much improved after the transfer. His localisation scores have remained disappointing at about 6/35 at all stages of treatment. Unfortunately a full sensibility assessment was not done earlier in his treatment. Patient 6: At the age of 27 this right-handed man sustained a high left median nerve and brachial artery injury, both of which were repaired primarily. At one year after the injury there was some return of sensation. At age 29 he underwent an opposition tendon transfer to his thumb with which he tends to oppose to the ulnar two fingers. He has a poor grip on the radial side due to loss of power in the deep flexors and statges that the only thing for which he definitely uses the left hand is to release the shuttlecock at badminton. He has otherwise become completely right-handed. If he has to use the left hand, for instance holding a nail which is to be hammered in, he holds it between the little and ring fingers. His localisation scores improved slightly as shown below, but sensibility testing showed no change following the tendon transfer. During testing, however, it was noted that he was able to manipulate objects between middle finger and thumb, with the index finger assisting. His localisation scores were as follows: Pre-op. 33135
Immediately
Post-
%35
6 Years Post-op. 35/35
Patient 7: This right-handed boy sustained a supracondylar fracture of the left humerus at the age of 13 years, which was followed by a Volkmann’s ischaemic contracture affecting the forearm flexors, and both median and ulnar nerves. When he was 19, he was observed to lack even protective sensation in his median nerve territory, and the whole hand was dry. He underwent lengthening of the flexor tendons and, although subjectively his sensation was not improved, objectively some return of protective sensation in the median nerve territory was noted. At the age of 20 he underwent a transfer of brachioradialis to the flexor tendons, and thereafter started to feel improvement in all five fingers, which improvement continues to date. He has since had two further operations to improve opposition of this thumb, and can now take coins out of his trouser pocket with his THE
JOURNAL
OF HAND
SURGERY
TENDON
TRANSFER
IN PARTIALLY
left hand. His localisation and sensory charts show a great improvement as shown below:
After Flexor Tenotomies
After Brachioradialis
Transfer
3 l/7/84 7/12/84 13/3/84 Localisation 12/35 35/35 35/35 23/35 Tended to use the better Needed opponens splint parts of his hand to pick up object to (thenar and hypothenar identify. Tended to claw objects towards the eminences) to identify objects by rolling them more sensitive part of on the pad provided. his hand. (Fuller details are shown in Table 1).
After Flexor 6/9/82
Shapes Coins Textures Small Objects Large Objects
TABLE 1 7: Stereognosis Tenotomies 13/3/84
With Opponens Splint 2/4 l/4 Not tested l/3 2/4 2/6 2/4 2/6 719 4/6
Testing After
Brachioradialis 31/7/84 Without 4/4 2/3 6/6 616 5/l
Transfer 7/12/84
Opponens Splint 4/4 3/3 516 S/6 616
This was the most spectacular recovery following a tendon transfer that was seen. The recovery seems inexplicable, but perhaps there is some facilitating effect of movement on reinnervation. Alternatively, regrowth had long before-occurred, but sensory retraining was in fact enormously delayed by his deformities.
Patient 8: At the age of 30, this right-handed panel beater was involved in a road traffic accident which left him with multiple injuries which included a high left median and radial nerve deficit. He was left with a hand which had loss of sensation in the median distribution, and with the thumb adducted into the palm. Two tendon transfer operations were undertaken at the age of 32 to regain opposition and extension of the thumb and to regain finger flexion; the thumb metacarpophalangeal joint was fused at the same time. A year later, an abduction/ extension osteotomy was performed to bring the thumb out of the palm and enable him to use the mass flexor action of his ulnar four fingers. He is now able to use these fingers in a suitcase grip, and has returned to work, although not yet as a panel beater. He is able to pinch to the side of his index middle phalanx, but tends to use the thumb to pinch across to the normal ulnar side of his hand to pick up small objects. The patient has not himself noted much subjective sensory improvement, VOL.
12-B No. 1 FEBRUARY
1987
HANDS
and despite the functional improvement in the hand, sensory testing confirms the patient’s impression: 2 Months
6/9/82
Patient
ANAESTHETIC
Localisation Score Shapes Coins Textures Small Objects Large Objects
Pre-Op.
Post-op.
14 Months Post-op.
21/35 4/4 l/3 5/6 2/6 4/6
24/35 4/4 l/3 3/6 3/6 5/6
25/35 4/4 o/3 6/6 5/6 4/6
Patient 9: This right-handed sheet-metal worker sustained a laceration of his left median nerve at the wrist in an accident at work at the age of 37. He had a good recovery of localisation into the median territory, but did not regain fine touch sensibility and remained unable to oppose his thumb. He underwent an opposition tendon transfer one year after the original injury: this was successful in restoring pinch grip although it was felt that a bit more rotation of the thumb would be desirable. The lack of rotation did not seem sufficient to warrant another operation: The patient claimed not to have gained any functional benefit from the tendon transfer and had not noted any improvement in the sensation in the median territory. On examination, he was indeed able to accomplish a functional opposition, but admitted he did not make use of this in his everyday life. The static two point discrimination in the median nerve territory was unmeasurable as was the moving 2PD except on the index where it measured one centimetre. 35/35 4/4 in o/3 5/6 in 3/6 in 6/6 in
20” 20” 50” 21’
Localisation Shapes Coins Textures Objects Large Objects
33/35 4/4 in l/3 in 5/6 in 3/6 in 4/6 in
10” 27” 27” 31” 29”
Discussion The selection of patients for study was quite difficult for several reasons: firstly, it is difficult to say when exactly an end-point in sensory recovery has been reached. In cleanly divided peripheral nerves in the forearm, recovery has been said to continue in functional terms for up to four years after injury. The common practice at our hospital has not been to wait that long, but to reoperate if recovery is not proceeding as expected, although the detailed guidelines depend on the type of injury. Secondly, as a result of this policy, the sensory recovery has in general been extremely good, and the tests employed would not be able to pick up any slight 17
N. CITRON
AND
improvements. Thirdly, all the patients studied had unilateral injuries and were able to use the good hand to substitute to a very large extent despite intensive sensory retraining. The cases studied therefore represent definite failures of primary repair. Some authors have been optimistic about the results of tendon transfers in anaesthetic hands, although they do not quote any objective evidence to this effect. Burkhalter (1982) says that “a mobile opposable thumb that can reach the normal sensible areas of the hand is much more useful than one that cannot be used and cannot even reach the areas of normal sensibility”. Omer et al (1970) state that “the purpose of tendon transfers in a hand with total loss of a nerve is not so much to gain strength, as to gain the ability to place the hand in position to make use of the remaining functional units”. Omer (1983) has noted that “abnormal patterns of motor activity enhance the distortion of sensibility that accompanies a peripheral nerve deficit”, and suggests that tendon transfer be undertaken before sensory reconstruction. Previous reports of good results following tendon transfers in anaesthetic hands were often on patients with leprosy who were forced to use the hand because of symmetrical bilateral loss. Patients with brachial plexus injuries ,were not included in our study because when recovery into the hand takes place, it is nearly always from the lesion in continuity whose prognosis is rather variable.
JANE
TAYLOR
A patient who experiences painful sensations on touching a partially denervated area of the hand (dysaesthesia) will naturally avoid the use of that part of the hand. Despite all efforts, dysaesthesia persisted in two of our patients. Pain can, however, often be controlled by transcutaneous nerve stimulation which has been found to improve hand sensibility and stereognosis (Wynn Parry, 1981). The conclusions to be drawn from this very small study appear rather gloomy: 1. Where a patient has dysaesthesia or hyperpathia in a nerve territory, then tendon transfer to impart motion will not be of advantage because the patient will still avoid use of that part. 2. In a unilateral partial hand anaesthesia, little is gained by tendon transfer in terms of sensibility. 3. Improvement in hand function is more likely after a transfer in a dominant hand than a non-dominant one. An alternative explanation may be that operation was carried out too late: perhaps more aggressive attempts to bring back hand function would prevent cortical exclusion of the abnormal part. Acknowledgments I would like to thank Dr. C. B. Wynn-Parry and Mr. R. Birch of the Royal National Orthopaedic Hospital for their advice and helpful criticism.
References
It might be thought that with the additional sensory input provided by movement, the sensory cortex might become more efficient at interpreting the input of information. This type of phenomenon has been shown to apply in, for instance, braille readers, who can develop a much finer two-point discrimination than a normal subject. This is not due to an increase in the number of skin receptors, but to more efficient central processing of the information. Unfortunately, in the cases we studied, an improvement in sensibility was not consistently found.
18
BELL, C. The Hand. Its Mechanisms and Vital Endowments As Envincing Design. London. William Pickering 1833. Reprinted. The Pilgrims Press, Brentwood, England. (1979) p 205. BURKHALTER, W. E. Operative Hand Surgery. Vol. 2. (ed) D.P. Green, Churchill Livingstone, London, 1982; p 1053. OMER, G. E., DAY, D. J., RATLIFF, H. and LAMBERT, P. (1970). Neurovascular Cutaneous Island Pedicles for Deficient Median Nerve Sensibilitv. New Techniaue and Results of Serial Functional Tests. The Journal df Bone Joint Sdrgery, 52A: 1181-l 192. OMER, G. E. Surgery of the Musculoskeletal System. Vol. I. (ed) C. McCollister Evans, London. Churchill Livingstone 1983, 2: 426. WYNN PARRY. C. B. and SALTER. M. (1976). Sensorv Re-education after median n&z lesions. The Hand, s: 3: i50-257. . WYNN PARRY, C. B. Rehabilitation of the Hand. Fourth Ed. London, Butterworths, (1981): 141
THE
JOURNAL
OF HAND
SURGERY