Surgical treatment of the non-functional spastic hand

Seminars in plastic surgery, 2016

The wrist and hand are essential in the placement of the upper extremity in a functional position for grasp, pinch, and release activities. This depends on the delicate balance between the extrinsic and intrinsic muscles of the wrist and hand. Spasticity alters this equilibrium, limiting the interaction of the upper limb with the environment. Classically, pediatric patients with upper limb spasticity present with a flexed wrist, thumb-in-palm, and flexed finger posture. These contractures are typically secondary to spasticity of the extrinsic flexor muscles of the wrist and hand and intrinsic muscles of the thumb and digits. Tendon release, lengthening, or transfer procedures may help correct the resultant abnormal postures. A total wrist arthrodesis with or without proximal row carpectomy may help address the severely flexed wrist deformity. With proper diagnosis, a well-executed surgical plan, and a consistent hand rehabilitation regimen, successful surgical outcomes can be achieved.

Operative Techniques in Neurosurgery, 2004

Selective peripheral neurotomies are proposed for the management of refractory upper limb spasticity, when spastic muscles correspond to a single or a few peripheral nerves. Careful selection of patients for surgery is necessary to obtain appreciable results, and preoperative block tests are crucial in this regard. Surgical planning of the procedure is an important step, requiring an assessment of the spasticity in each muscle or group of muscles in the upper limb. Spasticity pattern is in internal rotation and adduction for the shoulder (depending on collateral branches of the brachial plexus), in flexion for the elbow (depending on the musculocutaneous nerve), in pronation for the forearm (depending on the median nerve), in flexion and sometimes ulnar deviation for the wrist (depending on the median and ulnar nerve), in flexion for the fingers (depending on the median and ulnar nerve), and in flexion and sometimes adduction for the thumb (depending on the median and ulnar nerve). An operative program includes designation of spastic muscles to be targeted and the amount of denervation needed for the respective muscles. During surgery, distal muscular branches are individualized and recognized, not only by descriptive anatomy but also by observing muscular responses to bipolar electrical stimulation. Fine microsurgery is essential, and the neurotomy procedure is performed by resection of fascicles 5 mm long from the proximal stump. Additional orthopedic surgery, whether during the same procedure or a different one, is performed when deformities are irreversible. Selective peripheral neurotomy is a safe and valuable neurosurgical procedure in well-trained surgical hands.

Alexandria Journal of Medicine, 2011

Objective This study was done to evaluate the functional results of SPN of median and ulnar nerves in 10 patients who had spastic hyperflexion of the wrist and fingers. Methods All patients preoperatively had spasticity either G3 or G4 as measured by modified Ashworth ...

Journal of Neurosurgery, 2000

Object. This study was conducted to evaluate the effects of dorsal rhizotomy on upper-limb spasticity, functional improvement, coordination, and hand sensibility.Methods. Fifteen spastic upper limbs in 13 patients were selected and prospectively studied. Brachial plexus dorsal rhizotomy was performed in which two, three, or four dorsal roots were completely sectioned. Patients were followed up for at least 12 months after surgery; the mean follow-up period was 15.6 months and the maximum period was 30 months. A remarkable relief of spasticity was observed in all cases. Recurrence was observed in only one patient and was caused by insufficient dorsal root section. Functional improvement was observed in all cases, and functional improvement in the hand was found to be related to the presence of active finger extension in the preoperative period. Even when extended dorsal root section was performed, no hand anesthesia, either total or partial, was observed. No patient lost movement abi...

Additional services and information for Journal of Hand Surgery (European Volume) can be found at: Methods: The anatomical study was performed on 15 elbows of fresh unprepared cadavers. Results: Medial compartment: The anterior medial compartment of the elbow joint is innervated by two direct capsulo-periosteal branches of the median nerve. The medial epicondyle is innervated by branches of the medial cutaneous nerve of the forearm coming from its middle third. The region between trochlea humeri and the olecranon is innervated by direct capsular branches of the ulnar nerve. The posterior medial compartment of the elbow is innervated by a proximal branch of the radial nerve, which partially follows the trajectory of the ulnar nerve. Lateral compartment: The anterior lateral compartment of the elbow is innervated by an inconstant capsular branch of the musculocutaneous nerve, which begins 4 to 7 cm proximally to the joint in close contact with the humerus. In some cases, a branch of t...

Journal of Hand Therapy, 1990

The journal of hand surgery, 1997

Journal of Hand Surgery (European Volume), 2015

Open Journal of Orthopedics, 2016

The use of tendon transfer to restore functions of extremities was initially recognised in the 19th century, and its advancement was further amplified by the polio epidemic towards the turn of that century. Tendon transfer surgery extended to the use for traumatic reconstructive surgery during World War I, with key surgical pioneers, including Mayer, Sterling Bunnell, Guy Pulvertaft and Joseph Boyes. In 1921, Robert Jones first described the transfer of pronator teres (PT) to the wrist extensors for irreparable radial nerve paralysis in infantile hemiplegia. Although, a detailed description of its indication and surgical outcomes were not published until 1959 and 1970 by Stelling and Meyer, and Keats, respectively. Pronator teres is often the tendon of choice for reconstructing wrist extensors, and used in a multiple of pathologies, including radial nerve palsy, cerebral palsy, and tetraplegia. Reconstruction of finger extensors are less straightforward and options include flexor carpi radialis (FCR), flexor carpi ulnaris (FCU), and flexor digitorum superficialis (FDS). Our article describes the techniques and outcomes of 25 patients that undergone pronator teres transfer. A good understanding of the pronator teres anatomical location and potential variations, aids efficient harvesting and limits unnecessary tissue dissection. Pronator teres tendon harvest is best performed through a systematic and anatomic approach.