· fracture of humerus
· fracture or dislocation of shoulder
· axillary compression
· back of chair (“Saturday night palsy”)
· crutch
· prolonged tourniquet pressure
· fracture or dislocation at elbow
· local wound
· operation on proximal radius
· inability to extend arm (triceps) uncommon
· lesion usually distal to level of triceps innervation
· wrist drop (ECRL, ECRB)
· inability to extend MCP jts of fingers (EDC)
· inability to extend thumb (EPL, EPB)
· sensory defect in anatomical snuffbox
· as above but
· triceps OK
· radial deviation with wrist extension (ECU, ECRB, with ECRL intact)
· no sensory deficit
· open injury
· explore
· closed injury
· lively splint and ROM
· EMG at 3 weeks
· explore at 4-5 months if no recovery
Requirements
· wrist extension
· finger (MCP jt) extension
· thumb extension and abduction
· ignore sensory loss
Available muscles
· all extrinsics innervated by median and ulnar nerves (many)
Transfers
· basis is use of PT for wrist flexion
· classic Jones transfer uses FCU to restore finger extension
· removes it as ulnar stabiliser
· may lead to radial deviation
· esp. if posterior interosseous palsy, as ECRL functioning
· also uses FCR for thumb extension
· thus removes both wrist flexors
· alternative is Starr transfer
· FCR for wrist extension
· PL for thumb extension
· preferred by Green
· another option is Boyes transfer
· FDS III to EDC and IV to EPL
· through interosseous membrane
· useful when PL absent
Jones transfer
· PT to ECRL and ECRB
· FCU to EDC III-V
· FCR to EIP, EDC II, EPL (+/- EPB, APL)
· problem is that both wrist flexors are transferred
FCR (Starr) transfer
· PT to ECRB
· FCR to EDC
· PL to rerouted EPL
Technique of Starr transfer
PT transfer
· origin of PT elevated with strip of periosteum
· PT freed proximally
· passed around radial border of forearm in subcutaneous tunnel to dorsal surface
· intertwined into ECRB tendon
FCR transfer
· FCR tendon transected near insertion
· passed around radial border of forearm in subcutaneous tunnel to dorsal surface
· EDC tendons divided and transposed superficially to extensor retinaculum
· EDC tendons anastomosed end-to-end with FCR
PL transfer
· PL tendon transected near insertion
· EPL tendon indentified and divided at musculotendinous junction
· rerouted out of Lister’s canal toward volar aspect across anatomical snuffbox
· makes EPL abductor and extensor
· PL and EPL anastomosed
· if PL absent, EPL joined with EDC to FCR transfer
Requirements
· as for radial nerve except wrist extension not required
Transfers
· as for radial nerve except PT transfer not required
· options are
· early exploration
· exploration at 6-8 weeks
· late exploration
· initial stages of recovery may take 4-5 months
· before function in BR or ECR detected
· best option is to wait 4-5 months and then explore if no return of function (Green)
· exceptions are
· open fractures
· failure of closed treatment to maintain satisfactory alignment
· associated vascular injuries
· loss of function after manipulation of fracture
· usually at elbow
· elbow fracture or dislocation
· compression at elbow
· esp. anaesthetised or bedridden patients
· entrapment in cubital tunnel
· esp. with valgus elbow
· usually at wrist
· laceration at wrist
· entrapment in ulnar tunnel (Guyon’s canal)
· esp. in cyclists
· penetrating forearm wound
· as for low lesion but
· less clawing (ulnar 1/2 of FDP paralysed)
· weak wrist flexion
· claw hand deformity
· hyperextension of MCP jts and flexion of IP jts of ring and little fingers
· weakness of lumbricals with loss of MCP flexion and IP extension
· unopposed MCP extension by extensors and IP flexion by flexors
· less marked in high lesion because ulnar FDP paralysed (paradoxical ulnar claw)
· weak finger abduction
· weak finger adduction
· positive paper grip test
· weak thumb adduction
· positive Froment’s sign (IP flexion)
· hypothenar and interosseous wasting
· numbness of ulnar 1 1/2 fingers
· numbness of ulnar dorsum of hand
· if lesion proximal to dorsal branch
· open injury
· explore and repair
· anterior transposition provides 5 cm length
· closed injury
· knuckle duster splint and ROM
· EMG at 3 weeks
· explore a 6 weeks
· entrapment
· observe for 3 months
· decompress if fails to settle
Requirements
· correct clawing
· index abduction
· thumb adduction
· DIP flexion of ring and little fingers
· ulnar wrist flexion (not important)
· sensation on ulnar border of hand
Transfers
Claw fingers
· Zancolli capsulodesis
· modified Bunnell FDS transfer
Thumb adduction
· ECRB (with free graft) between 2nd and 3rd metacarpals to insertion of AP
Index abduction
· EPB to tendon of 1st DI
DIP flexion
· tenodesis of middle FDP to ring and little FDP
Technique of capsulodesis
· transverse palmar incision
· each A1 pulley opened
· flexor tendons retracted
· volar plate incised beneath MC head
· two lateral incisions made
· volar capsule advanced proximally
· finger flexed to 20o
· volar plate sutured to new position
· mild flexion contracture of MCP jt created
Technique of FDS transfer
· use middle or ring finger
· midlateral incision along radial side of finger
· tendon sheath opened
· FDS tendon released
· transverse proximal incision at proximal palmar crease
· FDS tendon identified and withdrawn
· tendon split into 4 tails
· radial midlateral incision along radial side of other fingers
· extensor aponeurosis identified
· each tail of tendon passed
· through lumbrical canal
· volar to deep transverse MC ligament
· over oblique fibres of extensor apparatus
· to dorsum of extensor apparatus
· flex MCP jts 90o and PIP jts at neutral
· suture each tail to aponeurosis under some tension
Requirements
· as above except do not need DIP flexion
· elbow fracture or dislocation
· forearm fracture
· penetrating forearm wound
· laceration at wrist
· fracture of distal radius
· carpal dislocation
· entrapment in carpal tunnel
· as for low lesion PLUS
· paralysis of
· superficial finger flexors
· deep finger flexors to radial fingers
· long thumb flexor
· radial wrist flexor
· forearm pronators
· results in Benedictine sign
· index finger straight
· ulnar fingers flexed
· middle finger flexed because middle FDP closely attached to ring FDP
· interosseous nerve palsy gives
· Benedictine sign
· paralysis of radial FDP and FPL
· weakness of pronation (quadratus)
· no thenar weakness
· no sensory loss
· paralysis of AbPB
· wasting of thenar eminence
· numbness in radial 3 1/2 fingers and palm
· open
· explore and repair
· closed
· reduce fracture or dislocation
· explore if fails to improve
Requirements
· index and middle flexor power
· flexor power in thumb IP
· thumb opposition
· sensation thumb and radial index
Transfers
Extrinsic
· ECRL to FDP (index and middle)
· BR to FPL
Intrinsic
· opponensplasty
· many options
· best is transfer of EIP
Technique of opponensplasty
· incision over index MCP j
· EIP divided with some extensor hood
· hood repaired
· second incision over dorsum of hand to free EIP from EDC
· incision over dorsoulnar wrist to displace tendon ulnarward
· tendon passed subcutaneously around ulnar aspect of wrist to pisiform
· then tunnelled across palm to thumb MCP jt
· tendon interweaved into AbPB tendon and into EPL tendon
· dislocation of shoulder
· proximal humeral fracture
· brachial plexus injury
· deltoid-splitting approach
· weakness of shoulder abduction
· abduction still may be possible by supraspinatus
· numbness in regimental patch area
· usually resolves following fracture or dislocation
· exploration if fails to recover within 3 months
· may require shoulder arthrodesis
· C5,6,7
· runs down posterior axillary wall
· supplies serratus anterior
· surgery
· shoulder or neck operations
· 1st rib resection
· mastectomy
· carrying loads on shoulder
· winging of scapula
· stabilisation of scapula by transferring pectoralis major or minor to lower part
· C3,4
· supplies sternocleidomastoid
· then runs in posterior triangle of neck to supply trapezius (upper half)
· stab wounds to neck
· operations on posterior triangle
· esp. lymph node biopsy
· traction injuries
· sagging of shoulder
· inability to shrug
· if open, immediate exploration and repair
· if closed, wait 6 weeks for recovery
· if no recovery, explore to
· confirm diagnosis
· repair by suture or grafting
· C5,6
· runs through suprascapular notch
· supplies supraspinatus and infraspinatus
· fracture of scapula
· direct blow to superior border of scapula
· traction
· carrying heavy load
· scapular pain
· weakness of external rotation of shoulder
· may be confused with rotator cuff disease
· usually resolves
· may respond to decompression by division of suprascapular ligament