paralytic hand

8/2/2019 Paralytic Hand

1/11

PARALYT IC CLAW HAND

W ith Specia l R eference to Para lysis in L eprosyand T reatm en t by th e Sublim is T ran sfer of S tile s and Bunne ll

PAUL W . BRAND , V ELLOR E , IN D IA

P rofe sso r o f O r tho pae dic S urgery, C hristia n M ed ica l C o lle ge an d H ospita l, V ellore , Sou th Ind ia

I t is o n ly o ccasion ally tha t the h um an h and is used fo r sc ratch ing . In th is ac tion thefinge r n ails a re the essen tia l in strum en ts , and the pu lp s a re on ly in the w ay . A n im als o f thecat trib e w ho depend so m uch on the ir c law s in ba ttle , and an im als w ho u se them for d ig g ing ,lik e the m o le, depend m ain ly on th eir p ro fu ndu s m u sc les to b rin g the ir c law s in to ac tion .They co u ld p rob ab ly fig h t an d d ig w itho u t the ir in trin s ic m uscle s . Th e sp read an d re trac tion ,bu t no t th e e ffec tiv en ess , o f the ir c law s w ou ld b e los t.

In the h um an h and th e fun ctio n of the na ils has been sup erseded by tha t o f the p u lp .Th is beau tifu l o rgan o f d isc r im ina tion an d pow er b ring s to ou r know led ge th e tex tu re o f o u renv ironm en t ; it is a lso the m eans by w h ich w e im pose o ur w ill o n the too ls tha t sub due an dtran sfo rm the w o rld fo r ou r p lea su re .

W hen the in tr in sic m u sc le s o f the hum an hand a re pa ra lysed , the p ow er o f the g rasp isno t m uch affec ted . T he re a re fo u r m a in d isab ilitie s: 1 ) Th e fing ers can no t b e opened ou t fu llyat the in te rph a lan geal jo in ts ; 2 ) the p ow er o f abdu ctio n and ad duc tion is lo st; 3 ) in g ra sp in gan ob jec t, f lex ion b eg ins a t th e te rm ina l jo in ts , c lo sing the fing ers o n them se lves ra the r thanon th e pa lm ; 4 ) the effec tive pa rt o f the fin ge r becom es the tip and th e n ail (c law ) ra the r th anth e pu lp .

Th e firs t tw o d isab ilitie s h av e rece ived m ost o f th e a tten tion in the lite ratu re . C onsid eredfun ctio na lly , how ev er , the la st tw o m atte r m os t.

ANATOMYThe ana tom y o f in trin sic m usc le ac tion h as been fu lly an d beau tifu lly an aly sed by B unne ll

(194 8) , K ap lan (195 3), L ittle r (19 49) an d o th ers . W e do no t need to a ttem pt an ana lysis he re ,b u t the fo llow ing po in ts need em phasis .Metacarpo -pha langea l f o i n t - -The in tr in sic m usc le s a re the o n ly p rim e flexo rs o f the m e tacarpo -ph alang ea l jo in ts . T he lon g flexo r m uscle s do flex these jo in ts , bu t on ly secon da rily ; th eirf irs t ac tion is on the in te rp ha lan geal jo in ts . In in tr in sic p alsy the m e tacarpo -ph a lan geal jo in tshave no prim e flexo r, bu t reta in a p ow erfu l ex tenso r , the ex ten so r d ig ito rum .In te rph a lan gea l jo in ts-In th e no rm al hand th ese jo in ts m ay b e ex ten ded by the una idedactio n of the in tr in sic m uscle s ac tin g th roug h the la tera l band , w h ich lies ju st do rsa l to thejo in t fu lc rum . T hey m ay be ex ten ded a lso by the ac tio n of the long ex tenso rs , p ro v ided thein trin s ic m u sc les stab ilise the m e taca rpo -ph alang ea l jo in t.

In th e absen ce of the in trin sic m uscle s the in te rp ha langea l jo in ts h av e no prim e ex ten so r .T he a ttem pt to stra ig h ten the w ho le hand leads on ly to hyp erex tension of the m e taca rp o -p ha lan gea l jo in ts un til the ir an te r io r cap su le s lim it the backw ard m ov em en t. A t th is stag eth e re sidu al pow er o f the lo ng ex tenso rs m ay pa rtly ex tend the in terph alang ea l jo in ts aga ins tth e re sis tance o f the ove rstre tched lo ng flexo rs . A s soon as the m e taca rpo -pha lang ea lhyp erex tensio n is re lax ed in b eg inn in g to c lose the hand , the in te rph a lan geal jo in ts aga in losea ll ex ten so r pow er. T he p atien t th ere fo re alw ays c lose s h is h and by c los ing h is te rm ina ljo in ts f irs t. T h is m eans tha t un le ss an o b ject is sm a ll eno ugh to be g ra sped b y the cu rve o f61 8 TH E JOURNA L OF BON E AND JO IN T SURGERY


2/11

FIG . 5

PARALYT IC CLAW HAND 62 3

VOL . 40 B , NO . 4, NOVEMBER 1958

set up in fron t o f h im and is to ld to im ita te th e p ic tu re s on th e cha rt. T h e p ho to g rap he r a lsodem onstrate s w ith h is ow n hand the pos ition he is to attem p t. Th e s ix standa rd po sitionsa re : 1 ) H old y our h an d qu ite stra igh t a t a ll jo in ts . 2 ) B end a t th e m etacarpo -ph a lan gealjo in ts and s tra igh ten all in te rp ha lan gea l jo in ts . 3 ) C lo se y our fis t. 4 ) H old up you rthum b a t rig h t ang le s to y our h an d . 5) P in ch firm ly b etw een index finge r an d th um b .6 ) B ring your th um b ac ross you r p alm to th e b ase o f the little f ing er . Th e pho tog raph sinc lud e a card w ith d ate and num ber.

W ooden cy linders fo r assessing grasp index . It is im portan t tha t th e cy lin ders shou ld no t be fix ed o rstab ilised fo r the p atien t. O therw ise he w ill u se the cy lind ers as a fu lc rum and ex tend h is f in ge rs p as si ve ly .

RESULTSI t is no t ea sy to g roup toge the r a m ass o f f igu re s o f ang les so tha t they m ean som e th in g

in tellig ib le in te rm s o f succes s an d fa ilu re. In th is stu dy w e have group ed the re su lts a sE xcellen t, G ood , F a ir an d Poor.

The d iv ision is bou nd to be a rb itra ry and to depend upon ou r ow n concep tion of w h atw e a re try in g to ach ieve . It a lso d ep ends u pon w ha t on e con side rs it po ssib le to ach ieve .F or exam p le , it cou ld b e a rg ued th at it is n o t rea so nab le to expec t a ten don transfe r to m ov ea jo in t beyond its p re-op era tive passiv e ran ge . The re fo re , an excellen t resu lt w ou ld beto p rodu ce activ e m ovem en t th rou gh the w ho le ran ge o f p re-ope rativ e p ass ive m ovem en t.T h is is rea son ab le , b u t o u r late r re su lts have som etim es show n be tte r- than -excellen t re su lts byth is stan da rd .

W e have chosen in th is s tudy to w ork to abso lu te standa rds an d no t to ca ll a re su ltex ce llen t un les s fu ll rang e h as b een ob ta ined , h ow ev er bad the con trac tu re at th e tim e o fo pe ra tion . W e have ana lysed sepa ra te ly the resu lts o f o pe ra tion on d iffe ren t p re-op era tivetypes o f hands. Results h ave b een ana lysed to sh ow : I) T he ab ility o f the pa tien t to openh is hand fu lly ; 2 ) the ab ility o f the pa tien t to c lose h is f is t fu lly ; 3 ) th e re sto ratio n of th e co rrectm echan ic s o f c lo sing th e h and (lum brica l m ovem en t) ; 4 ) absence of abn orm a l la tera l d ev iatio n ;5) th e pa tien ts ow n op in io n ; and 6) the sum m ation of all the ab ove in an o ve ra ll im p ressio n .

TH E OPEN H AND ASSESSM ENT

To sco re exce llen t a p atien t, w ith hand p rev iou sly claw ed , m ust be ab le to op en h ish an d abso lu te ly stra igh t w ith no sing le degree o f re sid ua l f lex ion a t the p rox im a l in te rp ha lan gealjo in t. In pos itio n 1 o f the stan da rd d iag ram s fo r ph o tog raph s h e is a llow ed to a ttem p t th ism ov em en t free ly , b u t in p osition 2 an d du rin g m easu rem en t he h as the re str ictio n tha t he isno t a llow ed to ex tend th e m etacarpo -p ha lan gea l jo in t w h ile ex ten d ing the in terpha lang ea l


3/11

11 1

THE JOURNAL OF BON E AN D JO IN T SU RGERY

62 4 P. W. BRAND

L I __________ __________FIG. 6A typ ica l pho to graph ic reco rd . E v ery pa tien t h as ex ac tly th is ty pe of ph o tograph ic record . C o lum n 1 , d iag ram s .Co lumn 2 , befo re opera tion . C o lum n 3 , a fte r opera tion . C o lum n 4 , fo llow -u p (tw o years late r). N o tice how theresu lts im prove w ith tim e . In row 2 , illu stra ting m etacarpo -pha langea l flex ion w ith in te rph alangea l ex tens io n , thepo st-opera tive resu lt m igh t b e c lassed as go od . In the la te r fo llow -up it w ou ld b e exce llen t if it w ere no t fo rcomm enc ing in trinsic p lus d efo rm ity . In row 3 , illu stra tin g the c lo sed fist, th e pos t-opera tive pho tographshow s som e residua l stiffness. A la te r fo llow -up show s a norm al fis t. In row 5, the late r fo llow -up d em ons tra testhe in trins ic p lus defo rm ity of the m idd le finger. T h is p atien t has a lso had an abduc to r rep lacem ent opera tionfo r h is th um b. (A ction of the thum b has no t been co nsidered in th is p ub lica tion , an d the re levan t ph o tographsare the re fo re om itted .)


4/11

PA RA LY T IC C LAW H AND 62 5jo in ts-th a t is , it ha s to b e a tru e lum brica l ac tion . Th e title to exce llence is lo st if thefing e r bend s b ackw ard s ( m ore than stra igh t ) o n attem p ting to straig h ten the fing er , o r ifth ere is s ign if ican t u lna r o r rad ia l dev ia tion of the fin ge r on stra igh ten ing .

To sco re good th e h and sh ou ld op en ou t eno ugh fo r a ll o rd in ary func tion , and enoughto ap pear n o rm a l a t re st. A norm al re stin g h an d m ay be 30 degrees flex ed w hen m easu reda lon g th e dorsum . I t is uncom m on to requ ire m ore th an 150 d eg rees o f o pen ing at thein te rph a lan geal jo in ts in g ra sp in g the largest o b jec ts . T o sco re good in o u r se rie s a fin ge rm ust op en ou t to a t lea st 15 0 d eg rees un assis ted . A good fin ge r m ay sh ow percep tib le b u tno t g ro ss te rm ina l jo in t f lex ion , o r it m ay show s lig h t la te ra l dev ia tion if it c an be fu lly an dnorm a lly stra igh tened , bu t if it show s th e s ligh te st lim itatio n of ex tensio n an d h as la te ra ldev ia tion , th en it is c lassed as fa ir .

To sco re fair a f ing er m us t show im prov em en t o ve r p re -ope rativ e fig u res , and m ustex tend to 1 20 d eg rees w ith ou t la tera l dev ia tion . A fu lly straig h t f inge r sco re s on ly fa irif the re is a de fin ite la tera l dev ia tion , o r if it bends backw ards in to m arked in tr in sicp lus.

A ny finge r tha t do es no t s co re fa ir even if it is b ette r than b efo re op era tio n is c la ssedas po or.

T ab le II is an ana lysis o f the su ccess o f the su b lim is transfer to p rodu ce a fu lly o pen handw ith stra igh t, und ev ia ted finge rs: 73 pe r cen t o f f inge rs have sco red a g ood or ex ce llen t re su lt.T h is m ay be fu rth e r ana lysed in an a ttem pt to u nde rstan d th e cau ses o f fa ilu re an d to be ab leto p red ic t th e degree o f p ro bab le success in an y g iven case .

TABLE IIOPEN HAND ASSESSMENT

F in er E xce llen t G ood Fa ir Poo rg (p er cen t) (p er ce n t) (per ce n t) (pe r ce n t)

Index (130) 2 9 48 21 2M idd le (1 34) 3 2 43 23 2R ing (15 0) 36 39 21 4Little (150) 26 38 30 6A verage 3 1 42 24 3

F ing ers th at w ere stif f be fo re ope ratio n show ed a m uch h igh er p ropo rtio n of ex tens ionlim itatio n a fte r ope ratio n than the m ob ile fin ge rs . T h is is no t su rp ris ing . F urthe r ana lysisshow s th a t 76 pe r cen t o f a ll p a tien ts ach ieved a post-op era tive unassis ted ang le tha t w as asgo od as, o r be tte r than , th e p re-op era tive assis ted ang le. N ine ty pe r cen t show ed a post-ope rativ e an g le th at w as w ith in 20 deg rees o f the p re -op e ra tive ass is ted an g le . The failu re s(1 0 pe r cen t) a s judg ed by th is stand ard w ere fu rthe r stud ied , an d in an un se lec ted grou p off ive case s in w h ich th ere w as a po st-ope rativ e con trac tu re m ore g ross th an the p re -op e ra tiveassis ted an g le ex p lo ra tion w as ca rr ied ou t. In eve ry case it w as fo und tha t the s tum p s o f thesu b lim is tendo ns lef t b eh ind in the flex o r shea th had grow n ac ro ss the in te rpha langea l jo in tand a ttach ed them se lves to th e shea th , p rox im a l to the jo in t. T h ey thu s fo rm ed a so rt o fb ow str in g acros s the jo in t, p reven tin g ex tensio n . O n cu ttin g and ex cisin g th e b ow strin g thejo in t cou ld b e ex tended . T h is com p lica tion has been pred ic ted b y B unn ell in h is w ritin gs.W e h av e fou nd tha t it ha s occu rred le ss freq uen tly sin ce w e h av e tak en ca re to d iv ide thesub lim is ex ac tly a t its in ser tion .VOL . 40 B , NO . 4, NOVEMBER 1958


5/11

Contrac tedH yperm ob ile M ob ile D efec tiveFinger (p er ce n t) (p er c en t) (p er cen t ) M ild M arked

(p er ce n t) (pe r ce n t)Index (130) 8 44 22 17 9M iddle (13 4) 14 32 34 10 10R in g (1 50) 12 30 31 17 10L ittle (1 50 ) 4 3 4 35 17 10A ve rag e 9 35 31 15 10

62 6 P. W. BRAND

THE JOURNA L OF BONE AND JO INT SU RGERY

A part from th is com p lica tion , it appea rs tha t really the o n ly cause o f fa ilu re to p rod ucefu ll ex ten sion by th is op era tion is the p re sen ce o f p re-op era tive con trac tu re o r p re -o pe ra tivede fec t in the co n tinu ity o f the do rsa l ex pansio n (F ig . 7 ). T h is la ter de fec t is som etim es p resen tin lep rom a tou s case s, an d a lso occurs as a re su lt o f o ld in ju ry o r in fectio n on the do rsum of

-J _F IG . 7 FIG. 8

F igure 7 -Incom p lete ex ten sion of the in te rp ha lan geal jo in ts in a hand w h ich had pre-o pera tiv econ trac tu res. T h is is a comm on com p lica tio n . F igu re 8-Im p erfect c losu re of th e fist af te rope ratio n in a patien t w ho befo re opera t ion h ad u lna r p ro fun du s w eakness.

the f inge r. S uch a d e fec t can b e assum ed to b e p re sen t w h en the p re-ope ra tiv e as sis tedang le is very d iffe ren t f rom the co n tractu re ang le . T h e defec t m us t be repa ired or theope ra tion w ill be a fa ilu re.

In T ab le III w e have grou ped our case s acco rd ing to th eir p re -o pe ra tive m ob ility .Hypermob i l e im p lies a g ood finge r w ith jo in ts th at w ill bend backw ard s s ligh tly o n p assive

TABLE IIISTATE OF F INGERS BEFOR E OPERA T ION

pressu re . S uch fing ers a re very comm on in Ind ia w here s lim , m ob ile fingers a re h igh ly prized .F inge r gym nastic s fo rm a comm on p a rt o f Ind ian c la ssica l dan cin g . Th is danc ing d em andssup p le , f lu id fing e r m ov em en ts w h ich m ost w es terne rs fin d im possib le to im ita te. Th e mobi l egro up inc ludes fing ers tha t cou ld be fu lly s tra ig h tened pass ive ly . T he defect ive gr ou p c omp ri se d


6/11

F IG . 9 F IG . 10F igure 9 -R ad ia l dev ia tion o f the fin ge rs . A n o ccasion a l com plicatio n a fte r the su b lim is has beensu tu red to th e rad ial s ide o f the fin ge r. F igu re 10 -T e rm in al jo in t f lex ion . Th is occurs in a lm ostev e ry su bl imi s re pl ac em en t o per at io n af te r a y ea r or tw o.

I

PA RA LY TIC CLAW H AND 62 7

VOL . 40 B, NO . 4, NOVEMBER 1958

F IG . 11 FIG . 12F igure 11 -M odera te d eg ree of in tr in sic plu s. H yperex tens ion of the pro x im al in terp ha lan gea ljo in t an d flex ion of the te rm ina l jo in t. T h is com plica tion is fairly comm on in m obile hands .Figure 12-S evere degree of in trins ic p lus . T h is h and in th e first yea r a fte r o pera tion w as c lassedas an excellen t resu lt. In the fo llow in g tw o years it has d ev e lo ped an ug ly and d isab lin g defo rm ity .

T hi s de gr ee o f in trins ic p lus is u ncomm on.


7/11

62 8 P . W . BRA NDfin ge rs w ith a fu ll range of passiv e m ovem en t b u t w ith a fa ilu re in the assis ted an g le -tha t is ,d e fec t in th e do rsa l exp an sion . A m ild co ntra ctu re w as c la ssed as a lack of p as sive ex tensio nle ss th an 30 degrees. A m arked co n trac tu re was one o f m o re than 3 0 d eg rees.Complica t ions-The in trinsic p lu s d efo rm ity is a ve ry in te restin g on e, an d its m anagem en td eserves sepa ra te con side ratio n , b u t a few po in ts m us t b e m en tio ned h e re . T he nam e in tr in sic p lu s w as firs t u sed b y B unn ell to desc r ibe the e ffec t o n the han d of an isch aem icco n trac tu re o f the in trin s ic m usc le s . T he fea tu re s o f the co nd itio n (F ig s. 10 to 12 ) a re asfo llow s : 1 ) the p ro x im a l in te rpha langea ljo in t is hy pe rex tend ed . 2 ) Ifth e m e taca rpo -ph alang ea ljo in t is he ld in ex tensio n it b ecom es im possib le to f lex the p rox im a l in te rp ha lan gea l jo in t,ev en p ass ive ly . T h is is the in tr in sic p lu s sign .

If a su b lim is tend on is rem ov ed from its in ser tion in an o th erw ise no rm a l f ing er (as incase s w h ere it is to be u sed as an abdu cto r o f the thum b), the re o ften fo llow s a sligh t de fo rm itym arked by a tenden cy to flex ion of the te rm ina l jo in t and a s ligh t hy pe rex tens ion at thep ro x im a l in te rpha lang ea l jo in t. T h is de fo rm ity n ev e r go es on to a fu lly dev elo ped in tr in sicp lus and th e in te rp ha langea l jo in ts ca n be fu lly f lex ed p as sive ly , ev en w ith the m e taca rpo -p ha langea l jo in ts ex tended . If , h ow eve r, the su b lim is is trans fe rred to the lum b rica l in se rtion ,a s fo r in tr in sic pa lsy , a v ery p ow erfu l m u scle tha t w as p rev io usly a flexo r now becom es anex tenso r o f th e sam e jo in t and leaves tha t jo in t w ith n o prim e flex o r . The pro fu nd us m u scletak es ove r the f lex o r fu nc tion , b u t is now an oppon en t o f th e sub lim is, w ith w hich it p rev ious lyac ted sy ne rg istica lly . R e -ed ucatio n of th e su b lim is and pro fun dus to ac t recip roca lly a fte rth e S tile s-B unne ll o pe ra tion is ve ry d iff icu lt. In m any cases true rec ip rocal ac tion neve r occu rs ,even tho ugh lum brica l actio n is ach ieved . If th e tend on transfe r is m ade w ith the sub lim isa t neu tral ten sion th e ope ratio n is a fa ilu re. If the su b lim is is su tu red at h igh er tension thanthe p ro fu ndu s th e op era tion is a succes s in tha t the c law hand is co rrec ted b u t the re seem s tobe a co n tinu ed to nus o f th e sub lim is as a backg rou nd to a ll f ing er m ovem en t. D uring c losu reo f th e fing ers the p ro fun dus seem s to have to ov e rcom e the re sis tan ce o f the su b lim is at th eprox im al in te rph alangea l jo in t b e fo re tha t jo in t w ill bend . It succeeds because the m echan icaladvan tag e of the flexo r ten don s a t th at jo in t is g rea ter th an th at o f the la te ra l band .

If th e fin ge r is a stou t an d stab le one th is m uscle co nflict do es no t seem to m atte r , and ifthe re is som e degree o f stiffne ss in the c law ed positio n the re m ay b e d efin ite ad van tage in th iscon tinuo us co rrec tive pu ll by a pow erfu l m u sc le. In a flex ib le , m ob ile fin ge r, how eve r, w eregu la r ly see a year-by -yea r tend en cy to deve lop hyp erex tensio n of the p rox im al in te rp ha lan gea ljo in t an d flex ion of the term in al jo in t. If the pa tien t keeps hi s fin ge rs m ob ile by exe rcise s an dp as sive m ovem en t h e m ay avo id the seco nd fea tu re o f in tr in sic p lu s, the inab ilityto flex th e in te rp ha langea l jo in t even p as sive ly w hen the m e taca rpo -ph alang ea l jo in ts a reex ten ded . In th e absen ce of such regu la r m ovem en ts , the fu ll in trin sic p lu s p ictu re m ay bedeveloped .

C ons ide red func tio na lly , the in trin s ic p lus h an d is fa irly use fu l, an d fa r b ette r th anth e c law h and tha t it ha s rep laced . It is u g ly , how eve r, and a de fin ite so u rce o f w eakness,e sp ec ia lly in p inch aga ins t the thum b (F ig . 1 2 ). T he se riou sness o f th is de fo rm ity w as n o treco gn ised early because it is se ldom noticeab le du ring th e firs t y ea r . T h e w o rst cases a reseen in the th ird and fou rth y ears , an d m o st really m ob ile h an ds deve lop a t lea st a m ilddegree o f it af te r a few y ea rs . T he d efo rm ity is co rrec tab le to som e ex ten t. W e h ave fou ndtha t L ittle rs o pe ra tion is s atisfac to ry fo r these case s, bu t it n eeds to be su pp lem en ted bya teno desis o f the p ro fun dus tend on in the m idd le segm en t o f the f ing er , w ith th e te rm ina ljo in t n ea rly ex ten ded , o r els e the d efo rm ity w ill recu r . (Th is ten odesis w ou ld no t b e necessa ryin the con trac tu re cases fo r w h ich L ittle rs ope ratio n w as firs t de sign ed .)Commen t -A s th is com p lica tion o ccu rs in the best and m ost m ob ile han ds and those tha tsho u ld carry th e best p rog nos is , w e h av e fe lt it r igh t to aban don th e sub lim is tran sfe r ope ratio ncom ple tely fo r m ob ile hand s du rin g the p ast y ea r . T he o pe ra tion is p robab ly s till the best fo rth e claw hand w ith con trac tu re becau se it p ro v ides a ve ry pow erfu l co rrec tive , bu t fo r m ob ile

THE JOURNAL OF BONE AND JO INT SUR GER Y


8/11

PARALYT I C CLAW H AND 62 9hands it sho u ld b e d isp laced by Fow le rs o pe ra tion o r by a new ope ra tion d ev elo ped in th isun it. W e now use free g ra fts from the ex tenso r ca rp i rad ia lis b rev is . N eith er o f these o pe ra tion srequ ire s the rem ova l o f the su b lim is an d n eith er o f th em is fo llow ed by in trin sic p lu sd efo rm ity . A n ana lysis o f the re su lts o f th e se ope ratio ns w ill be pu b lished sho rtly .

W e are in a p osition to say , h ow ev er , tha t F ow le rs op era tion is no t a s good as theS tile s-B unn ell ope ratio n fo r the stiff h an d , an d it is som e tim es d isapp o in tin g fo r a few m onthsa fte r ope ratio n . T he re su lts im prov e w ith tim e , how eve r, e spec ially if the tendo n is su tu redu nde r fa ir ly h igh ten sion (enough to m ake m e taca rpo -ph alang eal ex tensio n d iff icu lt in theea rly po st-o pe ra tive p hase ), and if ca re is tak en to p ro v ide adequ ate ex ten so r comm unisac tion fo r the little f inge r , af te r rem ova l o f the ex ten so r d ig iti m in im i.

O ur ow n ope ra tion uses the sam e princ ip le a s the Fow le rs p rocedu re , in tha t the n ewtend on is passed from the d orsum of the hand th ro ugh the in te ro sseous space, an te r io r to thetransve rse m e tacarpa l ligam en t an d su tu red to the lum brical in se rtion . W e use th e ex ten so rca rp i rad ia lis b rev is a s th e m oto r m u scle and ex ten d its ten don w ith a fou r- tailed free g ra ft.T he ac tion o f a w rist ex tenso r can ve ry easily d ev elo p a n atu ra l syn erg ism w ith lum b rica lm ovem en t. In th is o pe ra tion , a lso , the ac tion of the hand im p ro ves w ith tim e . In a ll ou r handreco nstruc tions so fa r the m ost pe rfect ap pro x im a tion s to no rm a l fin ge r ac tion hav e fo llow edth is new p ro cedu re .L a te ra l dev ia tio n (F ig . 9 )-A bduc tion and addu ctio n m ovem en ts o f the fin ge rs a re fu nc tionso f the in tr in sic m usc le s . T o pro du ce an excel len t resu lt o ne sho u ld pe rh ap s re sto re thesem ov em en ts a lso .

In B unn ells accoun t o f h is ope ra tio n he sug gested th at the su b lim is tend ons m igh t besp lit so tha t each tendon is a ttached on ly to the rad ial, o r on ly to th e u lna r sid e o f ad jacen tfin ge rs . In th is w ay la te ra l m ovem en t m igh t be res to red . I t w as an in gen io us sugg es tion ,b u t he d id n o t sta te w he the r h e h ad ev er ac tua lly ach ieved th is ob jec t. W e tried th is m e tho d afew tim es som e y ea rs ago and gave it up b ecause abdu ctio n and ad duc tion m ov em en ts w ereno t ob ta in ed . A s w e look ed at the o pe ra tive f ield and saw sp lit tendo n-slip s cr iss-cross ingeach o the r in th e p a lm w itho u t in te rven in g so ft tissue , it seem ed im probab le tha t each slipw ou ld m ove ind ependen tly o f the o the rs . It m ay be th a t re-educa tion w as a t fau lt. W e w ouldbe g lad to hea r o f the expe rien ce o f o the rs . S ince 19 51 w e have been transfe rr ing on ly on esub lim is slip to each finge r and a ttach ing it to the rad ial s ide o f the d orsa l exp ansion .

W e are sa tisfied w ith th is m e thod fo r these rea sons : 1 ) I t o bv ia te s the need fo r fou rinc ision s o n the fin ge rs and sh orten s o pe ra ting and tou rn iq ue t tim e; 2 ) it sav es a sub lim isten don w hich can be used fo r re sto r ing opposition and abdu ctio n to the thum b; 3 ) it a llow san o the r sub lim is to be le f t in the little f ing er in case o f p ro fu ndu s w eakness, o r in the in dexfin ge r to streng th en its pow er o f p inch .

O n rev iew ing our case s on a lon g-term basis w e find th at 19 pe r cen t sh ow a sign ifican trad ia l dev ia tion an d 4 pe r cen t dev ia te en ough to g ive a de fo rm ed appea rance . T he reaso nw e firs t chose th e rad ia l-s ide inse rtio n w as tha t it seem ed reasonab le to h av e the index finge rstab ilised on the rad ial-s ide to re sis t the ten dency o f th e thum b to pu sh it m ed ially in p in ch ing .

It h as o ften been s tre ssed tha t if the firs t do rsal in terosseo us m u sc le is w eak a rad ial-s idem u scle tran sfe r to th e ind ex fin ge r is need ed to rein fo rce th e p inch b y re sto r ing abduc tion totha t f inge r .

W e have fo und tha t o ne of the d is ab ilitie s in hands th at have b een recon stru cted a fteru lna r-m ed ian pa lsy is tha t the index and m id d le f inge rs ten d to sep ara te from each o the r.T he anaes the tic tip o f th e thum b slip s in be tw een th e index and m id d le f ing ers . W e h av eth e re fo re recen tly b eg un to in ser t the ind ex fing er sub lim is transfe r in to the u ln a r side o f theindex finge r and a ll the o the r su b lim is slip s in to the rad ia l s id e o f th e o th er fin ge rs . T h is hask ep t the in dex and m idd le fing e rs to ge the r an d m ad e a ve ry go od tripo d p in ch be tw een thum b,index and long fing ers . I t also g iv es a m uch be tte r ap pea rance to the h and as a w ho le . T heeffec t o f th is ch an ge on th e s treng th o f the p in ch w ill b e ana lysed in a la ter com m un ica tio n .VOL . 40 B, NO . 4, NOVEMBER 1958


9/11

E xce llen t G ood F a ir P o or(per c en t) (pe r c en t) (per c en t) (per c en t)

63 0 P . W . BRAND

TH E JOU RNAL O F BONE AND JO INT SURGERY

The ch an ge in inse r tion is to o recen t to a ffec t the resu lts in th is stu dy , w h ich rep re sen tsth e re su lts o f rad ia l-s id e inse r tion of the tran sfe rred ten don .

C LO SED F IST A NA LYSISM os t pa tien ts w ith c law hand can clo se the ir f inge rs fu lly be fo re o pe ra tion excep t

w h en pro fu ndu s w eakness in the ring and little f ing ers m ak es it d ifficu lt to flex th e te rm ina lpha lang es (F ig . 8 ) .If th e f inge rs canno t c lose a fter op era tion th e fa ilu re m us t be d ue to the o pe ra tion .

S om e tim es it m ay be d ue to lo ss o f flex io n pow er ow ing to the trans fe ren ce o f the sub lim isfrom its u sua l p lace . Th is is true on ly o f those cases in w hich the re is an add itio na l p ro fun dusw eakn ess in tw o finge rs .

A n exce llen t categ ory im p lie s a tig h t fis t, w ith th e fing er tip s fu lly tucked in to theb ase o f each finge r . A kn itting need le m us t b e g rasp ed an d he ld firm ly in the cu rve o f thefing er . A good asse ssm en t m ean s tha t the f inge r clo se s fu lly b u t n o t tig h tly eno ugh toh o ld a need le in its cu rv e. F a ir m eans tha t a gap is v isib le b e tw een base o f f inge r and tipb u t th e tip m ee ts the pa lm fa rth er d ow n . Poor m ean s tha t the f inge r tip do es no t m ee tth e pa lm (Tab le IV ).

TABLE IVC LOSED FIST

Excellen t G ood Fa ir Po or(pe r cen t) (p er cen t) (pe r cen t) (per cen t)

39 33 23 5

MECHANI SM O F C LO SINGTh is is a v ita lly im portan t assessm en t so fa r a s fu nc tion is con ce rned . R esu lts w ere g rad ed

as fo llow s: Excel lent-Start ing from th e p osition of m ax im a l stra igh tness o f tha t f inge r(even if tha t is no t exce llen t), the p a tien t can flex the finge r f irs t a t the m e taca rpo -pha lang ea ljo in ts an d can com p lete its m etaca rpo -p ha lan gea l flex io n b efo re th e in te rp ha lan gea l jo in tsb eg in to f lex .

TABLE VM ECHAN ISM OF C LO SING

A fing e r tha t can no t be fu lly stra igh ten ed bu t w h ich c lose s w ith the co rrec t sequence ofm ovem en t is m ore use fu l th an a straig h t fing er tha t c lose s its in terph alang ea l jo in ts f irs t w henbeg inn ing to grasp .G ood -O ne in w h ich in terph alang eal flex io n beg ins just be fo re m e tacarpo -ph alan geal f lex ioni s c om p le te .F air-O n e in w h ich in te rp ha lan geal f lex ion beg in s and con tinues a long w ith m e taca rp o -p ha lan gea l flex io n . Fa ir is q u ite satis fac to ry fo r m ost ac tiv ity . In fact, it is the m ech an ismused in the norm a l hand fo r g ra sp ing sm a ll ob jects . H ow eve r, it rep re sen ts a fa ilu re to reach ade fin ed stan da rd a fte r o pe ra tion .Poor-Metacarpo-phalangeal flexion is d elay ed b eh ind in terpha lang ea l f lex ion . T he re su ltsa re sh ow n in T ab le V .


10/11

PARALYT IC CLAW HAND 63 1It w ill be no ticed tha t the S tile s-B unne ll p roced ure g ives a v e ry good m echan ism of

c losin g . A d efect in som e of these hand s w hich w e have no t reco rd ed is th a t th e p atien tcanno t clo se h is in terph alang ea l jo in ts b efo re the m e tacarpo -ph a lan geal jo in ts even if he w an tsto (la ten t fo rm of in trin sic p lus ). It is a sso cia ted w ith the lo ss o f the su b lim is from itsno rma l situa tion . T h is de fec t is no ticed in typ in g an d p ian o p lay ing .

DISCUSS IONIn rev iew ing th e sta tis tic s o f th e re su lts o f the sub lim is tran sfe r o pe ra tion on e m ay fee l

it ha s b een h igh ly su ccessfu l. T hree -qua rters o f a ll ca se s have g iven an ex ce llen t o r goo d re su ltco nside red in te rm s o f th e op en h an d , irre spec tive o f the fac t tha t m any p atien ts have hadp re -ope rativ e con tractu re . Th e correc t m echan ism of clo sing has b een re sto red in m o re than9 0 pe r cen t o f ca se s. O ne m ay feel tha t the se f igu re s w ou ld b e ha rd to be tter w ith any o th eroperat ion .

H ow eve r, as w e lo ok b ack on these 1 50 cases and a lso o n the m any o the r hands th at w eh ave seen afte r op era tion bu t w h ich w e w ere no t ab le to re -exam in e fo r th is stud y , w e do no tfe el s atis fie d.

Th e reason fo r the rem arkab le success o f th e ope ratio n is a lso th e sou rce o f its g rea testw eakness. A ve ry pow erfu l m u scle , w ith a b ig am p litude , like th e sub lim is d ig ito rum , is u sedto do th e w o rk of a ve ry sm a ll m usc le , th e lum b rica l, w h ich has a short rang e of actio n .T he su b lim is transfe r, the re fo re, n ea rly a lw ay s ach iev es its pu rpo se . A s tim e go es on , how eve r ,it o ften m ore than ach ieves it and p ro duces second ary de fo rm itie s . C onve rse ly , th e absenceo f the su b lim is from its no rm al situa tion produ ces a w eakn es s in p inch and to a le sse r ex ten tin g rasp th at is s ig n ifican t. W e feel th at w e are now in a p ositio n to lay dow n de fin ite ind ica tion sfo r th e use o f th e S tile s-B unne ll o pe ra tion .

In all ca se s in w h ich the re is a sign if ican t con tractu re a t th e p rox im al in te rp ha lan gea ljo in t and in w h ich the con tractu re can no t be fu lly ove rcom e be fo re op era tion , th e su b lim istransfe r is the ope ratio n o f cho ice . I ts pow erfu l co rrec tive e ffec t m ay produ ce re su lts tha t areb e tte r than cou ld b e pred icted from the lim ited p re-ope ra tiv e rang e of m ovem en t. In stab leh ands w ith no ran ge of passiv e h ype rex ten sion of the in te rpha langea l jo in ts a su b lim is transfe ru nde r m ode rate ten sion w ill u su ally g ive a go od re su lt a lthou gh an op era tio n w hich avo id sth e rem ova l o f the su b lim is tendo n w ou ld g iv e a strong er and m ore use fu l hand .

F or hy pe rm ob ile , f lex ib le f ing ers the su b lim is transfer is co n tra - ind ica ted . F or th is typ eo f hand be tter re su lts w ill be ach ieved by Fow le rs o pe ra tion or by the fou r-ta iled g raf t fromth e ex ten so r carp i rad ia lis b rev is re ferred to ea rlie r .

S UMMARY1 . T he in tr in sic pa raly sis tha t o ccu rs in lep rosy has been trea ted b y the sub lim is tran sfe r o fS tile s and B unne ll fo r th e past n ine y ea rs . S in ce 19 51 30 0 han ds h ave been op e ra ted up on ,and 150 p atien ts se lec ted geograph ica lly have been fo llow ed up in th is stu dy .2 . Th e pa tien ts have been asse ssed by a s tan da rd m eth od in vo lv ing : 1 ) M easu rem en t o f ran geof m ovem en t o f the in te rp ha lan geal jo in t (un ass is ted m ov em en t, as sis ted ac tive m ovem en tan d p ass ive m ov em en t); 2 ) g ra sp in dex ; an d 3 ) p ho to g rap hs o f each hand in six stan da rdposi t ions.3. Asse ssm en t o f the open han d-T he S tile s-B unn ell p ro ced ure is effec tive in ach iev ing afu lly o pen h an d : 73 p er cen t o f the f inge rs sco red good or ex cellen t resu lts . A de fec t in theo pe ra tion is th a t it som e tim es hyp erex tends the in te rp ha lan gea l jo in t, p ro duc in g an in trin sicp lus hand .4. A sse ssm en t o f seq uence o f jo in t fle x ion -T he S tile s-B unne ll ope ratio n re sto res sa tisfac to rym echan ism of c losu re o f the hand in 93 p er cen t o f ca ses -tha t is , th e m etaca rpo -p ha langea ljo in ts flex be fo re th e in te rpha langea l jo in ts .VOL . 40 B , NO . 4, NOVEMBER 1958

B


11/11

63 2 P . W . BRA N D5 . T h e c lo sed fis t a sse ssm en t-A b ou t 30 p er cen t o f p atien ts had som e de fec t in the com ple tec losu re o f th e f is t a fte r ope ratio n . In 5 pe r cen t o f ca se s the fin ge rs d id no t reach th e pa lma fte r op era tion .6. Compl i ca t i ons -The in tr in sic p lus de fec t is com m ones t in the best and m o st m ob ilehand s. T h is is a la te com plica tion w hich ge ts w orse in succeed ing years . It c an be co rrec tedby L ittle rs ope ratio n tog e the r w ith a p ro fu ndu s teno desis in th e m idd le segm en t o f the fin ge r.L a tera l d ev iatio n of f inge rs d ue to rad ia l-s ide a ttachm en t o f the transfe rred tendon can beav o ided by u ln ar-side attachm en t o f th e ten don used fo r the in dex fin ge r. B ow str ing ingo f th e su b lim is s tum p in th e flex o r shea th m ay be av o id ed b y d iv ision o f th e su b lim is at itsin se rtio n . W eakn es s o f g ra sp and p inch from loss o f sub lim is m ay be av o ided by usin g o n lyo ne o r tw o sub lim is ten don s sp lit in to seve ral s tran ds. Th e in dex fin ge r sub lim is sh ou ld be le ftin po sition .7 . It is conc luded th at the sub lim is transfe r o f S tile s and Bunne ll is a very pow erfu l co r rectiveo f in tr in s ic p ara lysis o f the f inge rs . I ts ch ief d efect is tha t it is to o p ow erfu l and p ro ducesth e o ppo site de fo rm ity . Fo r th is rea son the use o f th is ope ratio n sh ou ld be res tric ted tof inge rs in w hich the re is som e lim ita tion o f passiv e ex tensio n . F or fu lly m ob ile fing e rs ano pe ra tion sh ou ld b e se lec ted w hich does no t rem ove the sub lim is from its no rm a l positio n .M ost o f these ope ra tion s have b ee n p erfo rm ed by a se rie s o f a ssis tan ts an d tra inees in hand su rgery . I w ish tothank th em for the en th usia sm and m eticu lous ca re in reco rd keep in g w hich h as m ade th is study possib le . I a lsow ish to reco rd m y apprec ia tion of th e ste rling w ork of our records c le rk , M r Fu rness , w ho h as trave lled m anym ile s in seek in g o u t chan ged ad dresses. I w ou ld like to th ank M r G uy Pulverta ft fo r h is he lp fu l c ritic ism ofth is a rtic le .

REFERENCESBR AND , P . W . (195 2): T h e R econs tru c tion of the H and in L eprosy . (H un te rian L ectu re.) A nn als o f the R oya lC o lleg e of Surg eons of E ng land , 11 , 350 .BR AND , P . W . (19 54): H and R econ struc tion in L eprosy . In B ritish Surg ical P rac tice . S u rg ica l P rog re ss 1 954 ,p . 1 17 . L ondon : B u tte rw orth & Co. (Pu b lishers ) L td .BR UN ER , J. M . (1953 ): P ro b lem s of P os to pera tive P os ition and M otio n in S urg ery of the H and . Journ al o fB on e and Jo in t S urgery , 35-A , 35 5 .BUNNELL , S . (1942) : S urgery of the In tr in sic M usc les o f the H and O ther T h an Those Pro duc ing O pposition ofthe T hum b. Jou rna l of Bon e an d Jo in t Surgery , 2 4 , 1 .BUNNELL , S . (194 8): S u rg ery o f the H and . S econd ed ition . P h ilade lph ia: J . B . L ipp in co tt C om pany .BUNNELL , S . (1 953 ): Ischaem ic C on trac tu re , Local, in the H and . Jou rn al o f B on e and Jo in t S u rg ery , 35 -A , 8 8 .DEHI0 , K . (1 897 ): U ebe r d ie L ep ra a na es th et ic a und d en pa tho gene tischen Z usamm enhang ih rer K rank-he itse rsch ein ung en . M itth eilu ngen und V erhand lu ngen de r in terna tion alen w issen scha ftlichen Lepra -C onfe ren zzu B erlin im O ctober 1897 . B and 2 , p . 85 . B erlin : A ugu st H irschw ald .EY LER , D . L ., and MARKEE , J. E . (1 954): T h e A natom y and Func tion of th e In tr in sic M uscu la tu re o f the F ingers .Jou rna l o f B one an d Jo in t Su rge ry , 36 -A , 1.FOWLER , S . B . (1 949): E x tensor A ppara tus o f th e d ig its . Jo urna l o f B one and Jo in t Su rgery , 31-B , 47 7 .GOLDN ER , J . L . (195 3): Deformit ies of the H and Inc iden ta l to P a tho log ica l C h an ges o f the Ex ten so r an dIn tr in s ic M u sc le M echan ism s. Jou rna l o f B one an d Jo in t S urg e ry , 35 -A , 1 15 .HARR IS , C . Jun ., and R IOR DAN , D . C . (195 4): In trin sic C on tractu re in the H and and its S urg ical T rea tm en t.Journal of Bon e and Jo in t S urg ery , 36 -A , 10 .KA P LA N , E . B . (1953) : Func tiona l an d Surg ical A na tom y of the H and . P h ilade lph ia : J . B . L i pp i nc o tt C o mp a ny .LAGRANGE , J. , an d VIETTE , M . (1954) : L e t ra it em en t c hi ru rg ic al de s g riffes d ig ita les d e la l#{232}pre . Sem ain e desH #{ 244} pitau x de Paris , 30 , 2 ,984 .LITTLER , J. W . (194 9): T endon T ransfe rs an d A rth ro deses in C om bined M edian U lnar N erve P ara lysis . Jo urna lof B one and Jo in t Su rgery , 31 -A , 2 25 .MAYER , L . (19 16): T he Phy sio log ica l M eth od o f T endon T ransp lan tatio n . S u rg ery , G yneco logy an d O b ste tric s ,22 , 182 .N EY , K . W . (1 931 ): T endon T ransp lan t fo r In trin sic H and M u sc le P a raly sis . S u rg ery , G yn eco lo gy andO bste tr ic s , 33 , 34 2 .S LOCUM , D . B ., an d PRATT , D . R . (1926): D isab ility Ev alua tio n fo r the H and . Jo urn al o f B one an d Jo in tSurg e ry , 28 , 49 1 .ST IL E S , S ir H . J. , an d FORRESTER -BROWN , M . F . (19 22): Tre atm en t of In jurie s of th e P erip he ral S p in al N erves ,p . 180 . L ondon : H enry F row de and H odde r & S tough ton .

THE JOURNAL OF BONE AND JO IN T SU RGERY

paralytic hand

Documents