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Surgical treatment of the non-functional spastic hand
Surgical Treatment of the Non-Functional Spastic Hand S. SUSO, P. VICENTE and F. ANGLES From the Centro M6dico Salus, Barcelona, Spain. The authors use Zancolli's classification for the surgical evaluation of the spastic upper limb. The paper describes the surgical technique used by the authors in the treatment of twenty-six patients grade III, having a "non-functional hand". After justifying the treatment, the technique is described which includes a time for the elbow to relax the antebrachii flexors and M. Epitrochlearis, a time for defunctioning the pronators and relaxing the flexors by intramuscular tenotomy. Transplantation of the flexors of the wrist is carried out to the extensors of the wrist and fingers. The thumb-in-palm is corrected by a tenotomy of the Adductor and Flexor Pollicis Brevis and transplanting the Brachioradialis to the tendons of the first dorsal compartment.
From the surgical point of view, evaluation of the upper limb of patients affected by spastic paralysis allows us to classify two main groups. We call the first group, "Functional Hands" which is formed by grades I and II of Zancolli's classification (Zancolli, 1968). This paper ifocuses on the second group of patients, formed by those belonging to grade III of Zancolli's classification. For them we present and justify our surgical treatment. In this group are usually found patients with the effects of cerebral palsy, vascular hemiplegias, tumours of the central nervous system and head injury. The affected extremities have a predominant muscular spasm that leads to permanent severe deformities and even contractures. Some of these patients, who have been rejected from surgical treatment after classifying their hands as "useless", present serious problems of hygiene, aesthetics, clothing and social relations (Figure I). Our opinion is that after a rigorous analysis of the operative risk, one must try to improve those severe deformities by means of a simple technique which needs only a short stay in hospital and lets the patient return quickly to his daily life. Candidates for this treatment are those patients with no high anaesthesic risk, having a hand sensitive to pain and capable of recognizing objects. Surgical technique As a routine guideline in all the spastic hands before deciding the surgical technique, we anaesthetise the Ulnar nerve in order to analyze the spastic component of the intrinsic musculature of the hand (Caldwell, 1969). In this group of patients only the adduction of the thumb experiences a measurable improvement, in such a way that all the hands studied until now have been listed as prevailing extrinsic spasticity type. Received for publication February. 1984. S. Suso. M.D., Ganduxer 133 2"B, Barcelona 22, Spain.
54
Fig. 1
"Useless hand".
We perform operation under general anaesthesia, without venous exsanguination so as to identify and have a maximum preservation of the peripheral venous network. The flexion deformity of the elbow is reduced partially after sectioning the distal biceps tendon near the Lacertus fibrosus. A proximal aponeurotomy of the common flexor origin, according to Zancolli's technique (Zancolli, 1968), is carried out. All the tracts and intermuscular sepia must be sectioned from their osseus attachments. By means of a short radial incision (Figure 2), the Pronator Teres is sectioned from its insertion. Next, by an S-shaped incision in the distal third of the arm, the tendons of the Flexor Carpi Radialis, Brachioradialis and Flexor Carpi Ulnaris to be used as transfers are displayed to their insertions (Figure 2). The relaxation of the flexor muscles of the fingers is performed by means of the technique we call "Intramuscular Tenotomies" derived from the original idea of fractionated lengthening by sliding (Inglis, T H E J O U R N A L OF t l A N D SURGERY
SPASTIC IIAND
tl ,I
.~---S.-T Fig. 4 Fig. 2
Left: Incisions (1) to reach the Pronator Teres. (2) site of the S italica incision. Right: (3) tendon of Brachioradialis. (4) tendon of Flexor Carpi Radialis. (5) tendon of Flexor Carpi Ulnaris.
1966). It is made by cross-sectioning the tendinous portion at the level of the zone of the tendinous muscle junction of the flexors. Having perfoi'med the tenotomies of the Flexor Digitorum Superficialis, Flexor Digitorum Profundus and Flexor Pollicis Longus muscles, passive extension of the fingers is done while checking the actual elongation. Displacing radially the flexor tendons, we perform next the functional and anatomic defunctioning of the Pronator Quadratus by means of cross-section of the Anterior Interosseous nerve and the total disinsertion of this muscle from the ulna. A window of about 6 cm. is opened then in the interosseous membrane, in order to offer an easy path for the Flexor Carpi Radialis to the back of the wrist (Figure 4).
Division of the Pronator Quadratus. (1) Flexor Muscles of the lingers. (2) Interosseous Nerve. (3) Pronator Quadratus.
To increase the power of the wrist extensors, we transplant the Flexor Carpi Ulnaris to Extensor Digitorum Communis around the lateral side of the ulna; the Flexor Carpi Radialis to Extensor Carpi Radialis Longus and Brevis through the window in the interosseous membrane and the Brachioradialis to the tendons of the first dorsal compartment (Abductor Pollicis Longus and Extensor Pollicis Brevis) by means of a lateral end suture at the level of the styloid process of the radius (McCue, 1970). The degree of tension at which the transfers must be sutured is undoubtedly the most delicate point of the 6peration, given the impossibility to foresee the degree of residual spasticity of those muscles being transplanted. As a rule we accept an attitude of 20" extension of the wrist, 30 ~ of flexion of the metacarpophalangeal and 20 ~ flexion on the interphalangeal joints. In order to correct the thumb-in-palm deformity, a tenotomy of the Adductor Pollicis and Flexor Pollicis Brevis is done by means of a small incision in the fold near to the digit. The thumb must be placed in abduction and the phalanges in flexion (Figure 5).
'__ Fig. 3
Intramuscular tenotomies. Left: (I) tendon of Brachioradialis. (2) tendon of Flexor Carpi Radialis. (3) tendon of Flexor Carpi Ulnaris. (4) Flexor Digitorum Superficialis. Right: (1) (2) (3) and (4), same as in left. (5) gap in the tendinous portion of Flexor Digitorum. (6) passive extension of fingers.
VOL. IO-BNo. I FEBRUARY1985
I Fig. 5
Transplants. Left: (1) tendon of Brachioradialis. (2) Abductor Pollicis Longus and Extensor Pollicis Brevis. (3) Flexor Carpi Ulnaris. (4) Extensor Digitorum Communis. (5) Flexor Carpi Radialis. (6) Extensor Carpi Radialis Longus and Brevis. 55
S. SUSO, P. VICENTE AND F. ANGLES
With a small compression bandage and a palmar plaster we immobilized the upper limb for three weeks in elbow extension, supination of the forearm, extension of the wrist and fingers and the thumb in abduction and extension. When we remove stitches, we fit the forearm plastic splint that is used continuously for three weeks. The patient takes it off only for physiotherapy and personal toilet. This surgical treatment represents oniy a three weeks break in the total rehabilitation programme of the patient and a few days more of alteration in the rhythms of his normal life.
56
References CALDWELL, C. B., WILSON, D. J. and BRAUN, R. M. (1969). Evaluation and Treatment of the Upper Extremity in the Hemiplegic Stroke Patient. Clinical Orthopaedics and Related Research 63: 69-93. INGLIS, A. E. and COOPER, W. 0966). Release of the Flexor-Pronator Origin for Flexion Deformities of the Hand and Wrist in Spastic Paralysis. A Study of Eighteen Cases. The Journal of Bone and Joint Surgery. 48-A: 847-857. McCUE, F. C., ttONNER, R. and CttAPMAN, W. C. (1970). Transfer of the Brachioradialis for }/ands Deformed by Cerebral Palsy. The Journal of Bone and Joint Surgery 52-A: 1171-1180. ZANCOLLI, E. The Structural and Dynamic Bases of tIand Surgery. Philadelphia and Toronto J. B. f]ppincott Company. i Ed. 1968. 2 Ed. 1979.
THE JOURNAL OF HAND SURGERY
From the surgical point of view, evaluation of the upper limb of patients affected by spastic paralysis allows us to classify two main groups. We call the first group, "Functional Hands" which is formed by grades I and II of Zancolli's classification (Zancolli, 1968). This paper ifocuses on the second group of patients, formed by those belonging to grade III of Zancolli's classification. For them we present and justify our surgical treatment. In this group are usually found patients with the effects of cerebral palsy, vascular hemiplegias, tumours of the central nervous system and head injury. The affected extremities have a predominant muscular spasm that leads to permanent severe deformities and even contractures. Some of these patients, who have been rejected from surgical treatment after classifying their hands as "useless", present serious problems of hygiene, aesthetics, clothing and social relations (Figure I). Our opinion is that after a rigorous analysis of the operative risk, one must try to improve those severe deformities by means of a simple technique which needs only a short stay in hospital and lets the patient return quickly to his daily life. Candidates for this treatment are those patients with no high anaesthesic risk, having a hand sensitive to pain and capable of recognizing objects. Surgical technique As a routine guideline in all the spastic hands before deciding the surgical technique, we anaesthetise the Ulnar nerve in order to analyze the spastic component of the intrinsic musculature of the hand (Caldwell, 1969). In this group of patients only the adduction of the thumb experiences a measurable improvement, in such a way that all the hands studied until now have been listed as prevailing extrinsic spasticity type. Received for publication February. 1984. S. Suso. M.D., Ganduxer 133 2"B, Barcelona 22, Spain.
54
Fig. 1
"Useless hand".
We perform operation under general anaesthesia, without venous exsanguination so as to identify and have a maximum preservation of the peripheral venous network. The flexion deformity of the elbow is reduced partially after sectioning the distal biceps tendon near the Lacertus fibrosus. A proximal aponeurotomy of the common flexor origin, according to Zancolli's technique (Zancolli, 1968), is carried out. All the tracts and intermuscular sepia must be sectioned from their osseus attachments. By means of a short radial incision (Figure 2), the Pronator Teres is sectioned from its insertion. Next, by an S-shaped incision in the distal third of the arm, the tendons of the Flexor Carpi Radialis, Brachioradialis and Flexor Carpi Ulnaris to be used as transfers are displayed to their insertions (Figure 2). The relaxation of the flexor muscles of the fingers is performed by means of the technique we call "Intramuscular Tenotomies" derived from the original idea of fractionated lengthening by sliding (Inglis, T H E J O U R N A L OF t l A N D SURGERY
SPASTIC IIAND
tl ,I
.~---S.-T Fig. 4 Fig. 2
Left: Incisions (1) to reach the Pronator Teres. (2) site of the S italica incision. Right: (3) tendon of Brachioradialis. (4) tendon of Flexor Carpi Radialis. (5) tendon of Flexor Carpi Ulnaris.
1966). It is made by cross-sectioning the tendinous portion at the level of the zone of the tendinous muscle junction of the flexors. Having perfoi'med the tenotomies of the Flexor Digitorum Superficialis, Flexor Digitorum Profundus and Flexor Pollicis Longus muscles, passive extension of the fingers is done while checking the actual elongation. Displacing radially the flexor tendons, we perform next the functional and anatomic defunctioning of the Pronator Quadratus by means of cross-section of the Anterior Interosseous nerve and the total disinsertion of this muscle from the ulna. A window of about 6 cm. is opened then in the interosseous membrane, in order to offer an easy path for the Flexor Carpi Radialis to the back of the wrist (Figure 4).
Division of the Pronator Quadratus. (1) Flexor Muscles of the lingers. (2) Interosseous Nerve. (3) Pronator Quadratus.
To increase the power of the wrist extensors, we transplant the Flexor Carpi Ulnaris to Extensor Digitorum Communis around the lateral side of the ulna; the Flexor Carpi Radialis to Extensor Carpi Radialis Longus and Brevis through the window in the interosseous membrane and the Brachioradialis to the tendons of the first dorsal compartment (Abductor Pollicis Longus and Extensor Pollicis Brevis) by means of a lateral end suture at the level of the styloid process of the radius (McCue, 1970). The degree of tension at which the transfers must be sutured is undoubtedly the most delicate point of the 6peration, given the impossibility to foresee the degree of residual spasticity of those muscles being transplanted. As a rule we accept an attitude of 20" extension of the wrist, 30 ~ of flexion of the metacarpophalangeal and 20 ~ flexion on the interphalangeal joints. In order to correct the thumb-in-palm deformity, a tenotomy of the Adductor Pollicis and Flexor Pollicis Brevis is done by means of a small incision in the fold near to the digit. The thumb must be placed in abduction and the phalanges in flexion (Figure 5).
'__ Fig. 3
Intramuscular tenotomies. Left: (I) tendon of Brachioradialis. (2) tendon of Flexor Carpi Radialis. (3) tendon of Flexor Carpi Ulnaris. (4) Flexor Digitorum Superficialis. Right: (1) (2) (3) and (4), same as in left. (5) gap in the tendinous portion of Flexor Digitorum. (6) passive extension of fingers.
VOL. IO-BNo. I FEBRUARY1985
I Fig. 5
Transplants. Left: (1) tendon of Brachioradialis. (2) Abductor Pollicis Longus and Extensor Pollicis Brevis. (3) Flexor Carpi Ulnaris. (4) Extensor Digitorum Communis. (5) Flexor Carpi Radialis. (6) Extensor Carpi Radialis Longus and Brevis. 55
S. SUSO, P. VICENTE AND F. ANGLES
With a small compression bandage and a palmar plaster we immobilized the upper limb for three weeks in elbow extension, supination of the forearm, extension of the wrist and fingers and the thumb in abduction and extension. When we remove stitches, we fit the forearm plastic splint that is used continuously for three weeks. The patient takes it off only for physiotherapy and personal toilet. This surgical treatment represents oniy a three weeks break in the total rehabilitation programme of the patient and a few days more of alteration in the rhythms of his normal life.
56
References CALDWELL, C. B., WILSON, D. J. and BRAUN, R. M. (1969). Evaluation and Treatment of the Upper Extremity in the Hemiplegic Stroke Patient. Clinical Orthopaedics and Related Research 63: 69-93. INGLIS, A. E. and COOPER, W. 0966). Release of the Flexor-Pronator Origin for Flexion Deformities of the Hand and Wrist in Spastic Paralysis. A Study of Eighteen Cases. The Journal of Bone and Joint Surgery. 48-A: 847-857. McCUE, F. C., ttONNER, R. and CttAPMAN, W. C. (1970). Transfer of the Brachioradialis for }/ands Deformed by Cerebral Palsy. The Journal of Bone and Joint Surgery 52-A: 1171-1180. ZANCOLLI, E. The Structural and Dynamic Bases of tIand Surgery. Philadelphia and Toronto J. B. f]ppincott Company. i Ed. 1968. 2 Ed. 1979.
THE JOURNAL OF HAND SURGERY