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Correction of ulnar subluxation of the extensor communis
Correction of Ulnar Subluxation of the Extensor Communis-Eugene S. Kilgore, William P. Graham, William L. Newmeyer and Lionel G. Brown
CORRECTION OF ULNAR SUBLUXATION OF THE EXTENSOR COMMUNIS E U G E N E S. K I L G O R E , W I L L I A M P. G R A H A M , W I L L I A M L. N E W M E Y E R and L I O N E L G. BROWN, San Francisco SUMMARY
An effective technique for correcting ulnar subluxation of the extensor communis tendon off the head of the metacarpal has been described. A pedide of the involved tendon with a distal base is developed on its radial side. This is anchored to the radial collateral ligament without compromising extensor tendon function. INTRODUCTION The extensor communis tendon is normally held over the apex of the metacarpal head by the sagittal bands of the extensor hood (Fig. 1). Without adequate tension of the radial sagittal band, the tendon subluxes ulnarward as the metacarpophalangeal joint flexes. Normal tension of the band is assured by two anatomical factors of the metacarpal head, the cam effect and the radial prominence: in full flexion, these make the radial band taut enough to draw the extensor tendon 2 to 3 millimetres radialward. Lack of integrity of the radial band results in ulnar subluxation of the tendon. Such subluxation may be only at the moment of greatest tension in terminal flexion, and is manifested with a snap which may be audible and symptomatic. This type of case is seen congenitally, but more often following trauma or due to degenerative disorders. Acute or repeated blunt trauma to the knuckle may result in softening and attenuation of the hood and the radial band allowing the subluxation to develop insidiously. Immediate subluxation may follow a
n,rg.~//d
Fig. I. Fig. 2.
272
The normal anatomy of the extensor apparatus over the metacarpal-phalangeal joint. Distorted anatomy with attenuated radial sagittal band in a patient with subluxation of the central extensor tendon over the metacarpal phalangeal joint. The Hand--Vol.
7
No. 3
1975
Correction of Ulnar Subluxation of the Extensor C o m m u n i s m Eugene S. Kilgore, William P. Graham, William L. Newmeyer and Lionel G. Brown
tendon
reverse [e.a~ f]afl
radial colMerall~ament
~ . Fig. 3. Development of the reverse tendon flap from the radial border of the extensor communis tendon. Fig. 4. and Fig. 5. Reverse tendon flap passed about the radial collateral ligament and sutured back to itself restraining the extensor communis tendon centrally over the metacarpal head. laceration of the radial sagittal band. R h e u m a t o i d synovitis is the most c o m m o n cause of ulnar subluxation of the tendon. T h e tendon subluxes chronically and contributes to the ulnar drift deformity (Fig. 2). This tendon subluxation can be corrected by an operation in which an extensor tendon pedicle based distally at the border of the extensor h o o d is threaded a r o u n d the radial collateral ligament. This technique was described by M i c h o n and Vichard (1961) but is not widely k n o w n by British and A m e r i c a n surgeons. The Hand--Vol. 7
No. 3
1975
273
Correction o[ Ulnar Subluxation o[ the Extensor C o m m u n i s - Eugene S. Kilgore, William P. Graham, William L. N e w m e y e r and Lionel G. Brown PROCEDURE
Through a curved, longitudinal, 4 cm. incision, a skin flap is raised over the metacarpophalangeal joint. The reverse tendon pedicle is cut from the radial margin of the extensor communis. It is made three to four millimetres wide and three centimetres long (Fig. 3).. The junctura tendinum to the adjacent extensor is not divided. The pedicle is threaded under the radial collateral ligament with a curved mosquito clamp and folded back on itself.. Tension is adjusted so that the extensor communis is securely positioned over the apex of the metacarpal head when the metacarpophalangeal joints are all simultaneously flexed. Interrupted figure-of-eight 5-0 nylon sutures are then placed so that the knots will be off the apex of the knuckle (Figs. 4 and 5). The wound is then closed and the hand is immobilised with the wrist in 30 ° of extension and all the metacarpophalangeal joints in 45 ° of flexion for four weeks. The interphalangeal joints are freed for gentle daily motion. This technique secures the dislocated extensor tendon with a flap of itself to a relatively unyielding structure--the collateral ligament--which readily resists stresses of flexion. Since it is a tendon pedicle with a d i s t a l b a s e , the tenodesis does not compromise the function of the parent extensor communis. Because the angle of transfer of the pedicle is acute from the parent tendon, it does not tend to tear away. Such might be the case if one were to anchor the pedicle to the intermetacarpal (intervolar plate) ligament. It is simpler procedure than the one described by McCoy et al (1969) that secures a comparable flap to the lumbrical tendon. REFERENCES
MICHON, J. and VICHARD, P. (1961) Luxations Lat6rales Des Tendons Extenseurs En Regard De L'Articulation M~tacarpo-Phalangienne. Revue Medicale de Nancy, 86" 595-601. McCOY, F. J. and WINSKY, A. J. (1969) Lumbrical Loop Operation For Luxation Of The Extensor Tendons Of The Hand. Plastic and Reconstructive Surgery, 44: 142-146.
274
The H a n d - - V o l . 7
No. 3
1975
CORRECTION OF ULNAR SUBLUXATION OF THE EXTENSOR COMMUNIS E U G E N E S. K I L G O R E , W I L L I A M P. G R A H A M , W I L L I A M L. N E W M E Y E R and L I O N E L G. BROWN, San Francisco SUMMARY
An effective technique for correcting ulnar subluxation of the extensor communis tendon off the head of the metacarpal has been described. A pedide of the involved tendon with a distal base is developed on its radial side. This is anchored to the radial collateral ligament without compromising extensor tendon function. INTRODUCTION The extensor communis tendon is normally held over the apex of the metacarpal head by the sagittal bands of the extensor hood (Fig. 1). Without adequate tension of the radial sagittal band, the tendon subluxes ulnarward as the metacarpophalangeal joint flexes. Normal tension of the band is assured by two anatomical factors of the metacarpal head, the cam effect and the radial prominence: in full flexion, these make the radial band taut enough to draw the extensor tendon 2 to 3 millimetres radialward. Lack of integrity of the radial band results in ulnar subluxation of the tendon. Such subluxation may be only at the moment of greatest tension in terminal flexion, and is manifested with a snap which may be audible and symptomatic. This type of case is seen congenitally, but more often following trauma or due to degenerative disorders. Acute or repeated blunt trauma to the knuckle may result in softening and attenuation of the hood and the radial band allowing the subluxation to develop insidiously. Immediate subluxation may follow a
n,rg.~//d
Fig. I. Fig. 2.
272
The normal anatomy of the extensor apparatus over the metacarpal-phalangeal joint. Distorted anatomy with attenuated radial sagittal band in a patient with subluxation of the central extensor tendon over the metacarpal phalangeal joint. The Hand--Vol.
7
No. 3
1975
Correction of Ulnar Subluxation of the Extensor C o m m u n i s m Eugene S. Kilgore, William P. Graham, William L. Newmeyer and Lionel G. Brown
tendon
reverse [e.a~ f]afl
radial colMerall~ament
~ . Fig. 3. Development of the reverse tendon flap from the radial border of the extensor communis tendon. Fig. 4. and Fig. 5. Reverse tendon flap passed about the radial collateral ligament and sutured back to itself restraining the extensor communis tendon centrally over the metacarpal head. laceration of the radial sagittal band. R h e u m a t o i d synovitis is the most c o m m o n cause of ulnar subluxation of the tendon. T h e tendon subluxes chronically and contributes to the ulnar drift deformity (Fig. 2). This tendon subluxation can be corrected by an operation in which an extensor tendon pedicle based distally at the border of the extensor h o o d is threaded a r o u n d the radial collateral ligament. This technique was described by M i c h o n and Vichard (1961) but is not widely k n o w n by British and A m e r i c a n surgeons. The Hand--Vol. 7
No. 3
1975
273
Correction o[ Ulnar Subluxation o[ the Extensor C o m m u n i s - Eugene S. Kilgore, William P. Graham, William L. N e w m e y e r and Lionel G. Brown PROCEDURE
Through a curved, longitudinal, 4 cm. incision, a skin flap is raised over the metacarpophalangeal joint. The reverse tendon pedicle is cut from the radial margin of the extensor communis. It is made three to four millimetres wide and three centimetres long (Fig. 3).. The junctura tendinum to the adjacent extensor is not divided. The pedicle is threaded under the radial collateral ligament with a curved mosquito clamp and folded back on itself.. Tension is adjusted so that the extensor communis is securely positioned over the apex of the metacarpal head when the metacarpophalangeal joints are all simultaneously flexed. Interrupted figure-of-eight 5-0 nylon sutures are then placed so that the knots will be off the apex of the knuckle (Figs. 4 and 5). The wound is then closed and the hand is immobilised with the wrist in 30 ° of extension and all the metacarpophalangeal joints in 45 ° of flexion for four weeks. The interphalangeal joints are freed for gentle daily motion. This technique secures the dislocated extensor tendon with a flap of itself to a relatively unyielding structure--the collateral ligament--which readily resists stresses of flexion. Since it is a tendon pedicle with a d i s t a l b a s e , the tenodesis does not compromise the function of the parent extensor communis. Because the angle of transfer of the pedicle is acute from the parent tendon, it does not tend to tear away. Such might be the case if one were to anchor the pedicle to the intermetacarpal (intervolar plate) ligament. It is simpler procedure than the one described by McCoy et al (1969) that secures a comparable flap to the lumbrical tendon. REFERENCES
MICHON, J. and VICHARD, P. (1961) Luxations Lat6rales Des Tendons Extenseurs En Regard De L'Articulation M~tacarpo-Phalangienne. Revue Medicale de Nancy, 86" 595-601. McCOY, F. J. and WINSKY, A. J. (1969) Lumbrical Loop Operation For Luxation Of The Extensor Tendons Of The Hand. Plastic and Reconstructive Surgery, 44: 142-146.
274
The H a n d - - V o l . 7
No. 3
1975