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Indications A two-stage flexor tendon reconstruction is typically used to reconstruct a severely damaged flexor tendon system in patients who cannot undergo single-stage tendon grafting. when significant joint contracture release is needed ( Fig. 79.1 A-B), or pulley reconstruction is required. The first stage requires placement of a silicone rod in the tendon bed to permit formation of a pseudosheath to receive a tendon graft in…
Indications Early surgical treatment (ideally immediate primary repair) of flexor tendon injury is preferred, but repair within 1 to 2 weeks of injury still produces good results. Surgical repair is essential for complete tendon lacerations. See specific indications under each zone of injury. In partial tendon injuries, associated symptoms such as triggering, entrapment, or delayed rupture can occur. Partially injured tendons involving less than 60% of…
Indications Many, if not all, tendon and nerve conditions can be approached using wide-awake local anesthesia. It is also common for arthritic conditions of the fingers and may be considered for digital fractures as well. The following are example conditions for which the authors find this technique to be particularly suitable. Tendon conditions, including primary and secondary tendon repair, single and two-stage tendon reconstruction, tenolysis, trigger…
Introduction Given the success of nerve transfers for the treatment of brachial plexus and peripheral nerve injuries, many surgeons also use this form of treatment to circumvent the damaged areas of the spinal cord and reestablish essential motor function ( Table 76.1 ). Nerve transfers can be performed together with tendon transfers or as the primary treatment for spinal cord injury (SCI) patients in some cases.…
Indications The goal of these procedures is to correct the absence of intrinsic function in the tetraplegic hand and to improve the functional result of extrinsic reconstruction. Intrinsic reconstruction can enhance grip in patients who have an extensor carpi radialis longus (ECRL) to flexor digitorum profundus (FDP) transfer. Although the ECRL to FDP transfer restores finger flexion, it brings the fingertips to the base of the…
Indications Performed in patients with intact wrist extension supported by the extensor carpi radialis brevis (ECRB) who require transfer for active finger flexion. Patients must be at least class 3 on the International Classification for Surgery of the Hand in Tetraplegia scale (see Table 69.2 ), with an expendable extensor carpi radialis longus (ECRL) that can be transferred without compromising wrist extension. This transfer enables active…
Indications In group 1 patients, the brachioradialis (BR) is available for tendon transfer to provide wrist extension. After restoration of wrist extension, tenodesis can create passive lateral key pinch, leading to significant improvement in a patient’s independence and ability to manipulate objects. In addition to thumb interphalangeal (IP) flexion, restoration of key pinch may require adjunctive procedures, including thumb carpometacarpal (CMC) joint fusion (see Chapter 45…
Indications Restoration of a strong, stable pinch between the pad of the thumb and the radiolateral aspect of the index finger is critical for spinal cord injury (SCI) patients. This facilitates manipulation of small objects, including pens and utensils for writing and feeding, respectively. Active key pinch can be restored in International Tetraplegia Classification (ITC) group 2 and higher patients who have intact wrist extension and…
Indications After restoration of elbow extension, wrist extension is next on the reconstructive ladder for tetraplegic patients. This procedure is suitable for International Classification of Surgery of the Hand in Tetraplegia Group 1 patients who have available brachioradialis (BR) but lack wrist extension. The ability to extend the wrist facilitates passive finger and thumb flexion via the tenodesis effect; this puts the thumb and index finger…
Indications Restoration of elbow extension is critical for patients with tetraplegia. It enables patients to perform various overhead and manual activities and sets the stage for subsequent reconstruction of the upper extremity. Patients should have a supple elbow joint on examination before transfer. Patients are typically 12 months out from the initial injury and should have a stable motor examination. Patients should have realistic expectations, be…
This chapter gives an overview of the indications, clinical exam, and principles for the surgical treatment of spinal cord patients who desire reconstruction of the upper extremity. The corresponding procedure details are found in Chapter 70, Chapter 71, Chapter 72, Chapter 73, Chapter 74, Chapter 75, Chapter 76 . Indications The most common causes of spinal cord injury (SCI) are motor vehicle collisions, sports injuries, and…
Indications An anterior interosseous nerve (AIN) transfer to the motor branch of the ulnar nerve is used to restore ulnar intrinsic hand function. It is performed for both chronic ulnar nerve compression and acute high ulnar nerve injury. For chronic nerve compression, AIN transfer is performed when patients have evidence of acute muscle denervation on electrodiagnostic studies, which indicates that muscle can be reinnervated. If a…
Indications Tendon transfers may be indicated to restore specific functions in patients with combined nerve injuries and resultant motor function loss with no expected recovery. Combined upper extremity nerve deficits typically result from severe trauma to the arm or after spinal cord injuries. Patients typically have profound disability, significant scarring, and limited remaining muscle tendon units. Another indication is high nerve lacerations that do not recover…
Indications Tendon transfers are indicated for patients with radial nerve injury who have failed to regain sufficient motor function. Critical deficits for patients with radial nerve injury include wrist extension, finger extension, and a combination of thumb extension and abduction. High radial nerve palsy is defined as an injury above the elbow; in a low radial nerve palsy (below the elbow), innervation to the upper arm…
Tendon transfers for low and high ulnar nerve injury Indications Management of ulnar nerve injuries is challenging given the distance required to reach the distal innervation targets of the ulnar nerve in the hand. Tendon transfers are indicated for patients with motor deficits without expected muscle endplate recovery. If growing axons are not expected to reach the endplates by 18 months after injury or muscle targets…
Indications In contrast to low median nerve injuries, the anterior interosseous nerve (AIN) is harmed in high median nerve injuries. This causes a loss of thumb interphalangeal (IP) joint flexion and index finger IP joint flexion. Both high and low median nerve injuries also cause sensory deficits, but these are treated with nerve transfers. In general, tendon transfer procedures are indicated for patients whose deficiencies are…
Indications Median nerve injuries are classified as “low” injuries if they arise distal to the branch of the anterior interosseous nerve, causing functional loss that is limited to the intrinsic muscles of the hand: the abductor pollicis brevis (APB), the opponens pollicis, and the superficial head of the flexor pollicis brevis (FPB). Both tendon transfers and nerve transfer options exist for patients with low median nerve…
Indications Any deficits attributable to the median nerve with an associated laceration or injury along the course of the nerve, high-energy injuries associated with blunt trauma and no appreciable median nerve recovery on examination, and prior median nerve repairs with no appreciable recovery on examination after 6 months. Simultaneous flap coverage should be considered if there is lack of soft tissue over the nerve. Contraindications A…
Indications Any deficit attributable to the ulnar nerve with an associated laceration or injury along the course of the nerve. High-energy injuries associated with blunt trauma and no appreciable recovery on examination. Prior nerve repairs with no appreciable recovery on examination after 6 months. Contraindications Closed injury with ongoing recovery and lack of soft tissue coverage. The nerve should be tagged during debridement and repaired at…