Proximal row carpectomy with muscle transfers for spastic paralysis Fourteen patients with spastic paralysis from various causes (eight with cerebral palsy) who needed minimal two handed activities to assist in self-care and who desired improvement in appearance were treated by proximal row carpectomy. In twelve transfer offlexor carpi ulnaris to extensor carpi radialis brevis was done, and in two the extensors of the wrist were shortened. Various other procedures were done in some patients. Prolonged splinting was carried out. Better extension of the wrist was obtained and supination improved more when the transfer was subcutaneous around the ulnar border than when through the interosseus membrane. Less tendency for the carpus to displace ulnarward was seen when the distal half of the scaphoid was not removed. Strength of grasp and pinch improved, but ability to release objects was diminished due to the more dorsijiexed position of the wrist. Subjective use for two handed activities was improved and the patients were satisfied with the appearance.
George E. Orner, M.D., and David A. Capen, M.D. Albuquerque, N. M.
A
common postural attitude in the upper limb of patients with spastic paralysis is flexion of the elbow, wrist, and fingers,!' 2 usually associated with forearm pronation. Surgical procedures to correct the pronation deformity of the forearm and the flexion of the wrist are designed either to lengthen the spastic flexor muscletendon units or to shorten the skeletal lever arms. Muscle-tendon procedures have included denervation of the flexor muscles,3'6 release of the flexor-pronator muscle origins,1'12 lengthening of the flexor tendons,13, 14 and transfer of a wrist flexor into a wrist extensor muscle-tendon unit. 15 Colzi resected a portion of the radius and ulna in 1892 16 in order to shorten the forearm and to allow the wrist to be brought up into extensionY' 18 Arthrodesis of the wrist shortens the skeletal lever arm L 8, 18·21 but eliminates the tenodesing effect on the extensor tendons which occurs during active wrist flexion and may result in complete loss of finger extension. The wrist position can be improved and the From the Division of Hand Surgery, The University of New Mexico, Albuquerque, and Affiliated Hospitals, including The Carrie Tingley Hospital for Crippled Children, Truth or Consequences, N. M. Presented at Thirty-First Annual Meeting, American Society for Surgery of the Hand, New Orleans, La., Jan. 28·30, 1976. Received for publication Jan. 7, 1976. Revised for publication Aug. 30, 1976. Reprint requests: George E. Orner, M.D., Department of Orthopaedics. University of New Mexico, Health Sciences Center. Albuquerque, N. M. 87131.
Vol. 1, No.3. pp. 197-204
skeletal lever arm shortened by either a total carpectomy22 or by a proximal row carpectomy. We selected the proximal row carpectomy procedure to obtain an identical relative lengthening of all the multiple flexor muscle-tendon units that cross the wrist and to avoid the potential neurovascular complications associated with extensive release of the origins of the flexor muscles. Simultaneous transfer of the flexor carpi ulnaris tendon to the extensor carpi radialis brevis tendon was done to strengthen wrist extension and forearm supination and to remove the effect of a strong wrist flexor.
Clinical material Fourteen patients with spastic paralysis have undergone this procedure (Table I). Eight had cerebral palsy and four had cardiovascular accidents. One patient was spastic secondary to a fracture-dislocation at the fifth to sixth cervical level, and one patient was paralyzed secondary to a viral encephalitis. Nine patients were hemiparetic, and five were quadriparetic. There were nine female and five male patients (Patients 2, 7, 8, 12, and 13). Nine patients had normal mentality, and five were mentally retarded. These latter had impaired functional levels of achievement based on several testing aids, including the Peabody Picture Vocabulary Test, the Schlossen Intelligence Test, the Gesell Developmental Scale, the Beery Test (copying figures), and the Frostig
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Table I. Clinical material Patient No.
Cause and extent of spasticity
Coordination potential
Age at operation
I.
Cerebral palsy-quadriparetic (R) greater than (L)
Motor function age 5 yr. 8 mo .; mentally retarded
19yr.4mo.
2.
Cardiovascular accident-age I yr.; hemiparetic (R)
Normal
14 yr. 10 mo.
3.
Cerebral palsy-quadriparetic (L) greater than (R)
Motor function age I yr. 6 mo. ; mentally Retarded
II yr. II mo.
4.
Encephalitis-age 16 mo.; hemiparetic (R)
Normal
34 yr. 6 mo.
5.
Cardiovascular accident-age 38 yr.; hemiparetic (R)
Normal
47 yr. 2 mo.
6.
Cerebral palsy; hemiparetic (R)
Motor function age 5 yr.; mentally retarded
II yr. I mo.
7.
Cardiovascular accident-age 27 yr.; hemiparetic (L)
Normal
29 yr. 5 mo.
8.
Fracture-dislocation 5th to 6th cervical level-age 43 yr.; quadriparetic (R) greater than (L)
Normal
45 yr. 4 mo.
9.
Cerebral palsy-hemiparetic (R)
Normal
16 yr. 5 mo.
10.
Cardiovascular accident-three episodes, last age 29 yr.; quadriparetic (L) greater than (R)
Normal
35 yr. I mo.
II.
Cerebral palsy-hemiparetic (R)
Normal
13 yr. 4 mo.
12.
Cerebral palsy-hemiparetic (L)
Motor function age to yr.; mentally retarded
19 yr. 2 mo.
13.
Cerebral palsy-quadriparetic (R) greater than (L)
Mentally retarded
II yr. 2 mo.
i4 .
Cerebral palsy-hemipare tic (R)
Normal
12yr.3mo.
Visual Motor Coordination Test. Three of the mentally retarded patients (Patients I, 3, and 6) had visual, vocal, and learning deficits in addition to their severe motor incoordination (Table I). In all patients the operated extremity had less dexterity than did the contralateral extremity, which had become the dominant extremity. No specific treatment had been given to the involved upper extremity in seven patients . Six other patients had received infrequent stretching exercises or night splints in order to maintain the wrist in extension. The remaining patient (Patient I) had a release of the flexor
carpi ulnaris tendon with transfer to the extensor carpi radialis longus tendon 15 months before our treatment. After operation, splinting was not maintained, and the tendon transfer was not effective. All these patients would be excluded as candidates for a surgical procedure intended to gain motor function of the involved extremity. Only one patient (Patient 7) had active finger extension. However, all of the patients were living outside of an institution , had personal and family responsibilities, and needed minimal two handed activities to assist in self-hygiene and private tasks. The operation was performed on the minor
Vol. I No.3 November, 1976
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199
Table II. Surgery for wrist flexion deformity-results
Patient No. I.
2. 3.
4. 5. 6. 7.
8. 9. 10. II.
12. 13. 14.
* FCU =
Carpectomy and transfer techniques*
Carpal deviation Before
After
Carpal shift None
10° ulnar 15° radial 0°
10 6
Volar subluxation
0°
SO
0
None
0°
ulnar 10° ulnar
0
None
Total scaphoid out; no FCU transfer Total scaphoid out; FCU thru 1M to ECRB Total scaphoid out FCU thru 1M to ECRB
35° ulnar 35° ulnar 0°
Proximal scaphoid out FCU thru 1M to ECRB Proximal scaphoid out; no FCU transfer Proximal scaphoid out; FCU thru 1M to ECRB Proximal scaphoid out; FCU thru 1M to ECRB
Proximal scaphoid out; FCU around ulna to ECRB Proximal scaphoid out; FCU thru 1M to ECRB Total scaphoid out; FCU around ulna to ECRB Proximal scaphoid out; FCU around ulna to ECRB Proximal scaphoid out FCU thru 1M to ECRB Proximal scaphoid out; FCU around ulna to ECRB Proximal scaphoid out; FCU around ulna to EDC
I
Capitate slide (mm.) 0
Ulnarward
0° Patient lost to follow-up after one mo. after operation. 10° Some remodeling 0 radial distal radius Patient's preoperative x-ray films lost. 0° 10° ulnar 15° radial 25° ulnar 0° 0°
5° ulnar 6° radial 5° radial 7° ulnar 2° radial 0°
0
None
3
None
4
None
2
None
2
None
0
None
0° Too soon for definitive measurements at 4 mo.
X-ray flexion deformity Radiuslcapitate angle Before
I
After
20° volar 80° volar 100°
55° dorsal 20° dorsal 20°
65° volar 75° volar 65° volar
60° dorsal 25° dorsal
60° volar 30° volar 50° volar 60° volar 60° volar 70° volar 65° after volar operation
I
Change 75° 100° 120°
125° 100°
50° dorsal
20° dorsal 35° dorsal 50° dorsal 30° dorsal 40° dorsal 30° dorsal
80° 65° 100° 90° 100° 100°
flexor carpi ulnaris; 1M = interosseous membrane; ECRB = extensor carpi radialis brevis; EDC = extensor digitorum communis.
extremity in all patients, although three of the four patients who had suffered strokes had changed hand dominance. The primary indication for operation was the patient's strong desire for cosmetic improvement. In no patient was there an expectation of functional gain! One of us (G. E. 0.) supervised all surgical procedures, and one of us (D. A. C.) evaluated the results independently.
Surgical technique A longitudinal incision was made over the dorsum of the wrist. The distal edge of the dorsal carpal ligament was identified, and the common digital extensor tendons were retracted ulnarward. A T-shaped incision was made in the dorsal capsule to expose the carpal bones. The lunate was excised and the proximal half of the scaphoid was exposed and removed, leaving the distal half of the bone with its capsular attachments in-
tact so that the distal half of the scaphoid would act as a buttress to prevent lateral displacement of the hand. The triquetrum was excised, but the pisiform was not removed. A longitudinal incision was made over the volar aspect of the wrist, beginning at the pisiform and extending proximally over the flexor carpi ulnaris muscle. The neurovascular bundle was protected, and the flexor carpi ulnaris was freed from the intermuscular septum. The tendon of the flexor carpi ulnaris was divided near its insertion. The tendon of the flexor carpi ulnaris was passed through a window in the interosseous membrane in seven patients and subcutaneously around the ulna in five patients. The tendon of the flexor carpi ulnaris was sutured to that of the extensor carpi radialis brevis with No. 3-0 monofilament wire in II patients and to the four tendons of the extensor digitorum communis in one patient. The flexor carpi ulnaris tendon was not
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HAND SURGERY
Table III. Functional ranges of motion Volar flexion beyond neutral
Time since operation (mo.)
Before
I.
54
90°
0°
2.
48
0°
3.
46
4.
Patient No.
I
After
Dorsal extension beyond neutral
I
Pronation beyond neutral
After
Before
0°
25°
0°
00
0°
00
45
0°
5.
40
7.
Supination beyond neutral
I
After
Bef ore
90°
90°
0°
45"
25°
90°
90°
0°
0°
0°
25°
0°
0°
0°
0°
0°
0°
300
60°
90°
0°
300
55°
5°
0°
200
70°
90°
100
300
31
30°
0°
30°
85°
45°
90°
45°
90°
8.
24
40°
10°
0°
10°
90°
80°
0°
70°
9.
22
60°
0°
0°
40°
60°
90°
0°
0°
10.
21
80°
0°
45°
80°
90°
70°
80°
II.
18
0°
10°
15°
45°
90°
0°
15°
Before
0° 0°
transferred in two patients (Patients I and 5); instead, the radial wrist extensor tendons were shortened by imbrication. The wrist was placed in maximum passive dorsiflexion when the tendon transfer was completed , and the dorsal capsule of the wrist was imbricated to support the tendon junction. Additional procedures were done in all but two patients (Patients II and 12) . In the forearm the radial wrist extensor tendons were shortened by imbrication in five patients, and tenotomy of the pronator teres tendon was done in three patients . Two patients had the extensor pollicis longus tendon shortened, and one patient had Z-step lengthening of the flexor carpi radialis tendon . Two patients had tenotomy of the biceps tendon . . The pronator teres tendon was transferred to the extensor carpi radialis longus tendon in one patient. In the hand the metacarpophalangeal joint of the thumb was arthrodesed in seven patients, whereas the origins of the adductor pollicis muscle and the abductor pollicis brevis muscle were released in two patients. Additional treatment to the hand was planned for most patients. Following operation the upper extremity was placed in a bulky compress'ion dressing with a volar plaster splint to maintain dorsiflexion of the wrist and fingers . If there was no excessive swelling, a long-arm circular plaster dressing was applied on the fifth day after
I
After
Self-care minimal joint ranges Before: 2/4 After: 3/4 Before: 1/4 After 2/4 Before: 0/4 After: 1/4 Before: 0/4 After: 2/4 Before: 1/4 After: 3/4 Before: 3/4 After: 3/4 Before: 2/4 After: 2/4 Before: 1/4 After: 2/4 Before: 2/4 After: 3/4 Before: 0/4 After: 1/4
operation. The cast extended to the finger tips, holding the elbow flexed, the forearm in supination, the wrist in dorsiflexion, and the fingers in extension. After 6 weeks a short-arm circular plaster was used, incorporating outriggers for extension of the fingers . We believe the extremity should be in a circular plaster dressing for at least 4 months and that a static night splint should be used thereafter for an indefinite time period.
Correction of wrist flexion deformity Preoperative and postoperative roentgenograms were obtained in II patients in an attempt (I) to measure the change in wrist position from palmar flexion to dorsiflexion, (2) to measure any change in osseous carpal relations , and (3) to determine if there was any loss of cartilage with associated subchondral bone changes (Table II). As measured by the axes of the radius and capitate through the third metacarpal joint, there was an average change of 96° in passive wrist position from palmar flexion to dorsiflexion at least 4 months after operation. For the ten patients followed 12 months or longer, the active motion retained in wrist flexion and extension averaged 25°, whereas the retained passive motion in wri st flexion and extension averaged 70°. To note ulnar and radial deviation of the carpus , the angle made by the axes of the radius and second me-
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201
Table IV. Functional power and patterns Power grip (lb.)
Key pinch (lb.)
Patient No.
Time since operation (mo.)
Before
I.
54
0
5
0
3
2.
48
0
0
0
0.5
3.
46
0
0
0
0
4. 5.
45 40
0 0
2.5 4
0 0
2.5 0.5
7.
31
0
20
0
10
Before: small objects; after: good use of ulnar 3 fingers
8.
24
0
3
0
3
9.
22
0
10
0
2
Before: absent; after: uses thumb to index and long fingers; can grasp key, coins, objects 1/2" to 3/4" in diameter Before: absent; after: uses ulnar 3 fingers for I 1/4" dowel
10.
21
0
5
0
2.5
II.
18
1.5
5
1.5
3
I After
Before
I After
tacarpal was measured. When the flexor carpi ulnaris was transferred through the interosseous membrane, radial deviation of the hand resulted; transfer around the ulna resulted in ulnar deviation of the hand. Six of II patients with comparative x-rays demonstrated some ulnarward slide of the capitate. Three patients had a shift of the capitate of 4 mm. or more (Patients 2, 3, and 10); these three had had a resection of the entire scaphoid with transfer of the flexor carpi ulnaris through the interosseous membrane. The carpal slides did not increase during the time of the study (Table II). One patient (Patient 7) had minimal subchondral bone changes without apparent cartilage loss 31 months after operation. The follow-up period may be too short to demonstrate significant bone changes resulting from the proximal row carpectomy. However, we have done proximal row carpectomy for Volkmann's ischemic contracture of forearm muscles and osteonecrosis of the lunate without residual degenerative arthritis and longterm studies 23 , 24 of proximal row carpectomy follow-
Grasp pattern
Before: absent; after: uses ulnar 3 fingers against palm Before: absent; after: uses ulnar 2 fingers against palm Before: absent; after: ulnar side of hand against adducted thumb Before: absent; after: absent Before: absent; after: uses ulnar side of hand
Before: absent; after: 3 fingers-objects in diameter Before: absent; after: 3 fingers-objects diameter
uses ulnar 1/2 to 3/4" uses ulnar 1/2" in
Release pattern
Before: absent; after: absent Before: absent; after: absent Before: absent; after: absent
Before: absent; after: absent Before: absent; after: releases very small objects (1/4 to 3/8" in diameter) Before: inconsistent; after: releases small objects (4/8 to 5/8" in diameter) Before: absent; after: releases small objects less than 1/2" in diameter
Before: absent; after: sometimes will release small objects 3/8" in diameter Before: releases small objects; after: releases objects 3/8" in diameter Before: absent; after: absent
ing trauma indicate that degenerative arthritis is not a common result of this procedure.
Clinical results The follow-up time for the 14 patients ranged from one to 54 months. Four patients (Patients 6, 12, 13, and 14) have been followed less than one year. Ten patients were followed 18 months or longer, and evaluation studies were performed on those patients. All ten patients and their families were satisfied with the cosmetic result. We attempted to quantitate sensibility by testing for (I) position sense, (2) texture and object stereognosis, and (3) two point discrimination distance. Two patients (Patients 5 and 7) with cardiovascular accidents had normal sensibility before and after operation. One patient (Patient 9) with cerebral palsy had decreased sensibility (two point discrimination distance of 10 mm.) before and after operation. One patient (Patient 8) with fracture dislocation of the cervical spine at the fifth to
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Orner and Capen
sixth cervical level improved positIOn sense, texture stereognosis, and two point discrimination distance after operation. The operation did not change the abnormal sensibility found in the other six patients. The operation was designed to increase wrist extension and forearm supination, but it also decreased wrist flexion because the arc of active motion in flexion-extension was moved toward extension . According to Caldwell , Wilson , and Braun , 13 the mini mal ranges of active joint motion for the performance of self-care activities are 20° of extension and 20° of flexion for the wrist and 20° of supination and 90° of pronation for the forearm. Before operation only two patients (Patients 7 and 10) had adequate active supination, whereas after operation six patients had 20° or more of forearm supination (Table III). Three of the four patients (Patients 2, 3, and 9) with inadequate supination after operation had had the flexor carpi ulnaris tendon transferred through the interosseous membrane instead of around the ulna. The average range of supination increased from 12.SO before to 36° after operation. Prior to operation only three patients (Patients I, 2, and 8) had an adequate range of active forearm pronation, whereas after operation eight patients had 90° of pronation (Table III). The average range of pronation increased from 63° before operation to 80° after operation. Before operation only one patient (Patient 7) had adequate wrist extension, but following operation eight patients had 20° or more of extension beyond neutral. The procedure should have reduced the range of active wrist flexion and did so in six patients, but in one patient (Patient II) active wrist flexion increased. No patient had 20° or more of wrist flexion from neutral after operation (Table III). The average amount of active flexion-extension motion for th e wrist after operation was 25°; this was entirely in the extension arc from neil,tral . After operation four of the patients (Patients I , 5, 7 , and 10) had adequate ranges of joint motion for selfcare activities in three of the four motions studied (supination, pronation, flexion, extension), and four other patients (Patients 2, 4, 8, and 9) had adequate range in two of the four motions (Table III). For all patients the average range of motion increased in forearm supination and pronation and wrist extension, but the range of wrist flexion was decreased. We tried to evaluate two handed activities as a qualitati ve measure of function and questioned the patients, their families, and therapists concerning helping , holding , hygiene, eating, and dressing with the involved
The Journal of HAND SURGERY
extremity. Before operation all four patients with cerebral palsy had ignored the hand, as did two cardiovascular accident patients (Patients 2 and 10) and the postencephalitis patient (Patient 4) . The two cardiovascular accident patients (Patients 5 and 7) with normal sensibility and the patient (Patient 8) with fracture dislocation of the cervical spine claimed the involved hand had been a hindrance and tried to conceal it as much as possible . After operation only one patient (Patient 3) did not use the involved extremity as a holder and helper. Dressing became a two handed activity for seven patients, and three patients (Patients 7, 8, and II) used both hands for hygienic activities such as shaving. Three patients (Patients 8, 9, and II) had used only the uninvolved hand for eating before operation but used both hands following operation . Although there was quantitative improvement of sensibility in only one patient (Patient 8) , there was a change in functional activity in nine patients that suggested improved sensibility. An example would be the treatment notes for a cerebral palsy patient (Patient 9): before operation the involved extremity was ignored; after operation the involved hand became a helper in activities such as washing dishes, using a broom, or carrying a food tray-dressing, eating, and hygiene were two handed activities. The involved hand performed limited one handed functions such as opening a refrigerator door. Only one patient (Patient II) had a measurable power grip or key pinch before operation, but five patients had a power grip of at least 5 pounds and four had a key pinch of 3 pounds or more following operation (Table I V). None of the ten patients had an effective grasp before operation, but nine developed some prehension of the ulnar side of the involved hand and could grasp small objects. In spastic hemiparesis the pattern of finger extension to allow release requires active wrist flexion. Prior to operation four of our patients (Patients 2, 3,4, and II) had no active extension at the metacarpophalangeal joints, and one patient (Patient I) had only a trace of extension of the fingers with full wrist flexion. After operation none of these five patients had active or passive extension at the metacarpophalangeal joints. Five patients (Patients 5, 7, 8, 9, and 10) had some extension at the metacarpophalangeal joints before operation, either by active muscles or passive tenodesis, but only one (Patient 7) could obtain metacarpophalangeal extension to neutral without simultaneous wrist flexion. The four patients (Patients 5, 8, 9, and 10) who required the tenodesing action of wrist flexion for finger extension lost an average of 59° of wrist flexion
Vol. I No.3 November, 1976
beyond neutral and lost an average of 30° of metacarpophalangeal extension following operation. We did not anticipate any improvement in the release pattern of the involved hands after operation, and all patients demonstrated inability to actively and consistently release most objects tested (Table I V). The five patients (Patients 5, 7,8,9, and 10) who had some metacarpophalangeal extension before operation were the only ones to demonstrate any release pattern after it. The release pattern was impaired further in some patients (Patients 1, 2, 3, 10, 11) by intrinsic muscle contractures and instability of the interphalangeal joints with resulting thumb-in-palm and swan-neck deformities. In other patients with nonspastic but shortened forearm flexor muscle-tendon units, such as Volkmann's ischemic contracture, we have performed proximal row carpectomies and have seen a prompt return of finger extension both in range of motion and power. We maintained the wrist in too much extension for an optimal return of finger extension because the wrist position averaged 36.5° after operation in the ten patients (Table II). Perry and Waters 5 suggested a wrist position between 10° of flexion to 15° of extension after operation, whereas Braun 7-l4 suggested 30° of wrist flexion with the metacarpophalangeal joints maintained in neutral extension. One must be careful to evaluate both wrist and finger motion in assessing function. It must be emphasized that in a spastic upper extremity an operation that maintains the wrist in extension will compromise extension of the fingers. A more functional transfer for the flexor carpi ulnaris may be to the tendons of the extensor digitorum communis, as was done in one patient (Patient 14). This augments extension of the fingers without fixing the wrist in dorsiflexion.
Conclusions I. A proximal row carpectomy (not including excision of the pisiform) combined with transfer of the flexor carpi ulnaris either to the extensor carpi radialis brevis or the extensor digitorum communis tendons will uniformly increase the relative length of all flexor muscle-tendon units that cross the wrist joint. 2. This surgical procedure will produce increased wrist extension and forearm supination and maintain forearm pronation. Supination is greater when the flexor carpi ulnaris tendon transfer is subcutaneous around the ulna rather than through the interosseous membrane. 3. Postoperative carpal slide is enhanced by total excision of the scaphoid, and only the proximal half of the bone should be removed.
Proximal row carpectomy
203
4. An operation that maintains the wrist in marked extension with a minimal range of carpal motion will compromise extension of the fingers. 5. The increased wrist extension improved grasp and pinch strength for small objects but diminished the ability to release objects. 6. Subjective use of the operated extremity for two handed activities was improved by this operation. 7. All patients in this study were satisfied with the cosmetic results. REFERENCES 1. Milford, L.: The hand, in Campbell's operative orthopaedics, ed. 5, St. Louis, The C. Y. Mosby Company, chap. 4. 2. Samilson, R. L., and Morris, J. M.: Surgical improvement of the cerebral-palsied upper limb. Electromyographic studies and results of 128 operations, J. Bone Joint Surg. 46A: 1203, 1964. 3. Dowd, C. N.: Tendon transfer for correction of spastic hand deformity, Med. Rec. 78: 175, 1910. 4. Mooney, V., Frykman, G., and McLamb, J.: Current status of intraneural phenol injections, Clin. Orthop. 63: 122, 1969. 5. Perry, J., and Waters, R. L.: Orthopaedic evaluation and treatment of the stroke patient, upper extremity surgery, A. A. O. S. Instruct. Course Lect. 24: 51, 1975. 6. Swanson, A. B.: Surgery of the hand in cerebral palsy and the swan-neck deformity, J. Bone Joint Surg. 42A: 951,1960. 7. Braun, R. M., Mooney, Y., and Nickel, V. L.: Flexororigin release for pronation-flexion deformity of the forearm and hand in the stroke patient, J. Bone Joint Surg. 52A: 907, 1970. 8. Goldner, J. L.: Reconstructive surgery of the upper extremity affected by cerebral palsy or brain or spinal cord trauma, Curro Prac. Orthop. Surg. 3: 125, 1966. 9. Inglis, A. E., and Cooper, W.: Release of the flexorpronator origin for flexion deformities of the hand and wrist in spastic paralysis, J. Bone Joint Surg. 48A: 847, 1966. 10. Page, C. M.: An operation for the relief of flexion-contracture in the forearm, 1. Bone Joint Surg. 5: 233,1923. 11. Williams, R., and Haddad, R. 1.: Release of flexor origin for spastic deformities of the wrist and hand, South. Med. J. 60: 1033, 1967. 12. Zancolli, E.: Structural and dynamic bases of hand surgery, Philadelphia, 1968, J. B. Lippincott Company. 13. Caldwell, C. B., Wilson, D. J., and Braun, R. M.: Evaluation and treatment of the upper extremity in the hemiplegic stroke patient, Clin. Orthop. 63: 69, 1969. 14. Caldwell, C. B., and Braun, R. M.: Spasticity in the upper extremity, Clin. Orthop. 104: 80, 1974 IS. Green, W. T.: Tendon transplantation of the flexor carpi ulnaris for pronation-flexion deformity of the wrist, Surg. Gynecol. Obstet. 75: 337, 1942.
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16. Steindler, A.: The traumatic deformities and disabilities of the upper extremity, Springfield, Ill., 1946. Charles C Thomas, Publisher. 17. Floyd, W. E.: Relative tendon lengthening for flexion contractu res of the wrist, Newsletter 1975-19, The American Society for Surgery of the Hand. 18. Jones, R.: Volkmann's ischemic contracture, with special reference to treatment, Br. Med. J. 2: 639, 1928. 19. Carroll, R. E., and Craig, F. S .: The surgical treatment of cerebral palsy-the upper extremity, Surg. Clin. North Am. 31: 385, 1951. 20. Goldner, J. L.: Reconstructive surgery of the hand in cerebral palsy and spastic paralysis resulting from injury to the spinal cord, J. Bone Joint Surg. 37A: 1141,1955.
21. Stelling, F. H., and Meyer, L. C.: Cerebral palsy: The upper extremity, Clin. Orthop. 14: 70, 1959. 22. White, J. W., and Stubbins, S. G.: Carpectomy for intractable flexion deformities of the wrist, J. Bone Joint Surg. 26: 131, 1944. 23. Inglis, A. E., and Jones , E. c.: Proximal row carpectomy for disease of the proximal row, presented at the Thirtieth Annual Meeting, The American Society for Surgery of the Hand , San Francisco, 1975. 24. Jorgensen, E. c.: Proximal row carpectomy, J. Bone Joint Surg. 51A: 1104, 1969.
From Keith, Sir Arthur: Menders of the maimed, limited edition, Philadelphia, J. B. Lippincott Company, p. 141 (original edition, London, 1919, Oxford University Press) . Every step taken by a surgeon to restore continuity to a nerve must be based on (I) the discovery by His that a nerve is an outgrowth from, and part of, a nerve cell; (2) the discovery made by Waller that the part of a nerve fibre lying distal to the point of division always dies and can only be replaced by an outgrowth from the end of the fibre which lies proximal to the point of division; (3) on the discovery made by Flourens, elaborated by Philipeaux and Vulpeau in Paris in 1863 and onwards, and later, in Cambridge , by Langley and Anderson, that if the proximal end of one nerve is sutured to the distal end of another, the fibres of the proximal nerve will invade and gain dominion over the area of the distal nerve; (4) the path of outgrowing nerve fibres must be paved with living sheath cells.
George E. Orner, M.D., and David A. Capen, M.D. Albuquerque, N. M.
A
common postural attitude in the upper limb of patients with spastic paralysis is flexion of the elbow, wrist, and fingers,!' 2 usually associated with forearm pronation. Surgical procedures to correct the pronation deformity of the forearm and the flexion of the wrist are designed either to lengthen the spastic flexor muscletendon units or to shorten the skeletal lever arms. Muscle-tendon procedures have included denervation of the flexor muscles,3'6 release of the flexor-pronator muscle origins,1'12 lengthening of the flexor tendons,13, 14 and transfer of a wrist flexor into a wrist extensor muscle-tendon unit. 15 Colzi resected a portion of the radius and ulna in 1892 16 in order to shorten the forearm and to allow the wrist to be brought up into extensionY' 18 Arthrodesis of the wrist shortens the skeletal lever arm L 8, 18·21 but eliminates the tenodesing effect on the extensor tendons which occurs during active wrist flexion and may result in complete loss of finger extension. The wrist position can be improved and the From the Division of Hand Surgery, The University of New Mexico, Albuquerque, and Affiliated Hospitals, including The Carrie Tingley Hospital for Crippled Children, Truth or Consequences, N. M. Presented at Thirty-First Annual Meeting, American Society for Surgery of the Hand, New Orleans, La., Jan. 28·30, 1976. Received for publication Jan. 7, 1976. Revised for publication Aug. 30, 1976. Reprint requests: George E. Orner, M.D., Department of Orthopaedics. University of New Mexico, Health Sciences Center. Albuquerque, N. M. 87131.
Vol. 1, No.3. pp. 197-204
skeletal lever arm shortened by either a total carpectomy22 or by a proximal row carpectomy. We selected the proximal row carpectomy procedure to obtain an identical relative lengthening of all the multiple flexor muscle-tendon units that cross the wrist and to avoid the potential neurovascular complications associated with extensive release of the origins of the flexor muscles. Simultaneous transfer of the flexor carpi ulnaris tendon to the extensor carpi radialis brevis tendon was done to strengthen wrist extension and forearm supination and to remove the effect of a strong wrist flexor.
Clinical material Fourteen patients with spastic paralysis have undergone this procedure (Table I). Eight had cerebral palsy and four had cardiovascular accidents. One patient was spastic secondary to a fracture-dislocation at the fifth to sixth cervical level, and one patient was paralyzed secondary to a viral encephalitis. Nine patients were hemiparetic, and five were quadriparetic. There were nine female and five male patients (Patients 2, 7, 8, 12, and 13). Nine patients had normal mentality, and five were mentally retarded. These latter had impaired functional levels of achievement based on several testing aids, including the Peabody Picture Vocabulary Test, the Schlossen Intelligence Test, the Gesell Developmental Scale, the Beery Test (copying figures), and the Frostig
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Table I. Clinical material Patient No.
Cause and extent of spasticity
Coordination potential
Age at operation
I.
Cerebral palsy-quadriparetic (R) greater than (L)
Motor function age 5 yr. 8 mo .; mentally retarded
19yr.4mo.
2.
Cardiovascular accident-age I yr.; hemiparetic (R)
Normal
14 yr. 10 mo.
3.
Cerebral palsy-quadriparetic (L) greater than (R)
Motor function age I yr. 6 mo. ; mentally Retarded
II yr. II mo.
4.
Encephalitis-age 16 mo.; hemiparetic (R)
Normal
34 yr. 6 mo.
5.
Cardiovascular accident-age 38 yr.; hemiparetic (R)
Normal
47 yr. 2 mo.
6.
Cerebral palsy; hemiparetic (R)
Motor function age 5 yr.; mentally retarded
II yr. I mo.
7.
Cardiovascular accident-age 27 yr.; hemiparetic (L)
Normal
29 yr. 5 mo.
8.
Fracture-dislocation 5th to 6th cervical level-age 43 yr.; quadriparetic (R) greater than (L)
Normal
45 yr. 4 mo.
9.
Cerebral palsy-hemiparetic (R)
Normal
16 yr. 5 mo.
10.
Cardiovascular accident-three episodes, last age 29 yr.; quadriparetic (L) greater than (R)
Normal
35 yr. I mo.
II.
Cerebral palsy-hemiparetic (R)
Normal
13 yr. 4 mo.
12.
Cerebral palsy-hemiparetic (L)
Motor function age to yr.; mentally retarded
19 yr. 2 mo.
13.
Cerebral palsy-quadriparetic (R) greater than (L)
Mentally retarded
II yr. 2 mo.
i4 .
Cerebral palsy-hemipare tic (R)
Normal
12yr.3mo.
Visual Motor Coordination Test. Three of the mentally retarded patients (Patients I, 3, and 6) had visual, vocal, and learning deficits in addition to their severe motor incoordination (Table I). In all patients the operated extremity had less dexterity than did the contralateral extremity, which had become the dominant extremity. No specific treatment had been given to the involved upper extremity in seven patients . Six other patients had received infrequent stretching exercises or night splints in order to maintain the wrist in extension. The remaining patient (Patient I) had a release of the flexor
carpi ulnaris tendon with transfer to the extensor carpi radialis longus tendon 15 months before our treatment. After operation, splinting was not maintained, and the tendon transfer was not effective. All these patients would be excluded as candidates for a surgical procedure intended to gain motor function of the involved extremity. Only one patient (Patient 7) had active finger extension. However, all of the patients were living outside of an institution , had personal and family responsibilities, and needed minimal two handed activities to assist in self-hygiene and private tasks. The operation was performed on the minor
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Proximal row carpectomy
199
Table II. Surgery for wrist flexion deformity-results
Patient No. I.
2. 3.
4. 5. 6. 7.
8. 9. 10. II.
12. 13. 14.
* FCU =
Carpectomy and transfer techniques*
Carpal deviation Before
After
Carpal shift None
10° ulnar 15° radial 0°
10 6
Volar subluxation
0°
SO
0
None
0°
ulnar 10° ulnar
0
None
Total scaphoid out; no FCU transfer Total scaphoid out; FCU thru 1M to ECRB Total scaphoid out FCU thru 1M to ECRB
35° ulnar 35° ulnar 0°
Proximal scaphoid out FCU thru 1M to ECRB Proximal scaphoid out; no FCU transfer Proximal scaphoid out; FCU thru 1M to ECRB Proximal scaphoid out; FCU thru 1M to ECRB
Proximal scaphoid out; FCU around ulna to ECRB Proximal scaphoid out; FCU thru 1M to ECRB Total scaphoid out; FCU around ulna to ECRB Proximal scaphoid out; FCU around ulna to ECRB Proximal scaphoid out FCU thru 1M to ECRB Proximal scaphoid out; FCU around ulna to ECRB Proximal scaphoid out; FCU around ulna to EDC
I
Capitate slide (mm.) 0
Ulnarward
0° Patient lost to follow-up after one mo. after operation. 10° Some remodeling 0 radial distal radius Patient's preoperative x-ray films lost. 0° 10° ulnar 15° radial 25° ulnar 0° 0°
5° ulnar 6° radial 5° radial 7° ulnar 2° radial 0°
0
None
3
None
4
None
2
None
2
None
0
None
0° Too soon for definitive measurements at 4 mo.
X-ray flexion deformity Radiuslcapitate angle Before
I
After
20° volar 80° volar 100°
55° dorsal 20° dorsal 20°
65° volar 75° volar 65° volar
60° dorsal 25° dorsal
60° volar 30° volar 50° volar 60° volar 60° volar 70° volar 65° after volar operation
I
Change 75° 100° 120°
125° 100°
50° dorsal
20° dorsal 35° dorsal 50° dorsal 30° dorsal 40° dorsal 30° dorsal
80° 65° 100° 90° 100° 100°
flexor carpi ulnaris; 1M = interosseous membrane; ECRB = extensor carpi radialis brevis; EDC = extensor digitorum communis.
extremity in all patients, although three of the four patients who had suffered strokes had changed hand dominance. The primary indication for operation was the patient's strong desire for cosmetic improvement. In no patient was there an expectation of functional gain! One of us (G. E. 0.) supervised all surgical procedures, and one of us (D. A. C.) evaluated the results independently.
Surgical technique A longitudinal incision was made over the dorsum of the wrist. The distal edge of the dorsal carpal ligament was identified, and the common digital extensor tendons were retracted ulnarward. A T-shaped incision was made in the dorsal capsule to expose the carpal bones. The lunate was excised and the proximal half of the scaphoid was exposed and removed, leaving the distal half of the bone with its capsular attachments in-
tact so that the distal half of the scaphoid would act as a buttress to prevent lateral displacement of the hand. The triquetrum was excised, but the pisiform was not removed. A longitudinal incision was made over the volar aspect of the wrist, beginning at the pisiform and extending proximally over the flexor carpi ulnaris muscle. The neurovascular bundle was protected, and the flexor carpi ulnaris was freed from the intermuscular septum. The tendon of the flexor carpi ulnaris was divided near its insertion. The tendon of the flexor carpi ulnaris was passed through a window in the interosseous membrane in seven patients and subcutaneously around the ulna in five patients. The tendon of the flexor carpi ulnaris was sutured to that of the extensor carpi radialis brevis with No. 3-0 monofilament wire in II patients and to the four tendons of the extensor digitorum communis in one patient. The flexor carpi ulnaris tendon was not
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HAND SURGERY
Table III. Functional ranges of motion Volar flexion beyond neutral
Time since operation (mo.)
Before
I.
54
90°
0°
2.
48
0°
3.
46
4.
Patient No.
I
After
Dorsal extension beyond neutral
I
Pronation beyond neutral
After
Before
0°
25°
0°
00
0°
00
45
0°
5.
40
7.
Supination beyond neutral
I
After
Bef ore
90°
90°
0°
45"
25°
90°
90°
0°
0°
0°
25°
0°
0°
0°
0°
0°
0°
300
60°
90°
0°
300
55°
5°
0°
200
70°
90°
100
300
31
30°
0°
30°
85°
45°
90°
45°
90°
8.
24
40°
10°
0°
10°
90°
80°
0°
70°
9.
22
60°
0°
0°
40°
60°
90°
0°
0°
10.
21
80°
0°
45°
80°
90°
70°
80°
II.
18
0°
10°
15°
45°
90°
0°
15°
Before
0° 0°
transferred in two patients (Patients I and 5); instead, the radial wrist extensor tendons were shortened by imbrication. The wrist was placed in maximum passive dorsiflexion when the tendon transfer was completed , and the dorsal capsule of the wrist was imbricated to support the tendon junction. Additional procedures were done in all but two patients (Patients II and 12) . In the forearm the radial wrist extensor tendons were shortened by imbrication in five patients, and tenotomy of the pronator teres tendon was done in three patients . Two patients had the extensor pollicis longus tendon shortened, and one patient had Z-step lengthening of the flexor carpi radialis tendon . Two patients had tenotomy of the biceps tendon . . The pronator teres tendon was transferred to the extensor carpi radialis longus tendon in one patient. In the hand the metacarpophalangeal joint of the thumb was arthrodesed in seven patients, whereas the origins of the adductor pollicis muscle and the abductor pollicis brevis muscle were released in two patients. Additional treatment to the hand was planned for most patients. Following operation the upper extremity was placed in a bulky compress'ion dressing with a volar plaster splint to maintain dorsiflexion of the wrist and fingers . If there was no excessive swelling, a long-arm circular plaster dressing was applied on the fifth day after
I
After
Self-care minimal joint ranges Before: 2/4 After: 3/4 Before: 1/4 After 2/4 Before: 0/4 After: 1/4 Before: 0/4 After: 2/4 Before: 1/4 After: 3/4 Before: 3/4 After: 3/4 Before: 2/4 After: 2/4 Before: 1/4 After: 2/4 Before: 2/4 After: 3/4 Before: 0/4 After: 1/4
operation. The cast extended to the finger tips, holding the elbow flexed, the forearm in supination, the wrist in dorsiflexion, and the fingers in extension. After 6 weeks a short-arm circular plaster was used, incorporating outriggers for extension of the fingers . We believe the extremity should be in a circular plaster dressing for at least 4 months and that a static night splint should be used thereafter for an indefinite time period.
Correction of wrist flexion deformity Preoperative and postoperative roentgenograms were obtained in II patients in an attempt (I) to measure the change in wrist position from palmar flexion to dorsiflexion, (2) to measure any change in osseous carpal relations , and (3) to determine if there was any loss of cartilage with associated subchondral bone changes (Table II). As measured by the axes of the radius and capitate through the third metacarpal joint, there was an average change of 96° in passive wrist position from palmar flexion to dorsiflexion at least 4 months after operation. For the ten patients followed 12 months or longer, the active motion retained in wrist flexion and extension averaged 25°, whereas the retained passive motion in wri st flexion and extension averaged 70°. To note ulnar and radial deviation of the carpus , the angle made by the axes of the radius and second me-
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201
Table IV. Functional power and patterns Power grip (lb.)
Key pinch (lb.)
Patient No.
Time since operation (mo.)
Before
I.
54
0
5
0
3
2.
48
0
0
0
0.5
3.
46
0
0
0
0
4. 5.
45 40
0 0
2.5 4
0 0
2.5 0.5
7.
31
0
20
0
10
Before: small objects; after: good use of ulnar 3 fingers
8.
24
0
3
0
3
9.
22
0
10
0
2
Before: absent; after: uses thumb to index and long fingers; can grasp key, coins, objects 1/2" to 3/4" in diameter Before: absent; after: uses ulnar 3 fingers for I 1/4" dowel
10.
21
0
5
0
2.5
II.
18
1.5
5
1.5
3
I After
Before
I After
tacarpal was measured. When the flexor carpi ulnaris was transferred through the interosseous membrane, radial deviation of the hand resulted; transfer around the ulna resulted in ulnar deviation of the hand. Six of II patients with comparative x-rays demonstrated some ulnarward slide of the capitate. Three patients had a shift of the capitate of 4 mm. or more (Patients 2, 3, and 10); these three had had a resection of the entire scaphoid with transfer of the flexor carpi ulnaris through the interosseous membrane. The carpal slides did not increase during the time of the study (Table II). One patient (Patient 7) had minimal subchondral bone changes without apparent cartilage loss 31 months after operation. The follow-up period may be too short to demonstrate significant bone changes resulting from the proximal row carpectomy. However, we have done proximal row carpectomy for Volkmann's ischemic contracture of forearm muscles and osteonecrosis of the lunate without residual degenerative arthritis and longterm studies 23 , 24 of proximal row carpectomy follow-
Grasp pattern
Before: absent; after: uses ulnar 3 fingers against palm Before: absent; after: uses ulnar 2 fingers against palm Before: absent; after: ulnar side of hand against adducted thumb Before: absent; after: absent Before: absent; after: uses ulnar side of hand
Before: absent; after: 3 fingers-objects in diameter Before: absent; after: 3 fingers-objects diameter
uses ulnar 1/2 to 3/4" uses ulnar 1/2" in
Release pattern
Before: absent; after: absent Before: absent; after: absent Before: absent; after: absent
Before: absent; after: absent Before: absent; after: releases very small objects (1/4 to 3/8" in diameter) Before: inconsistent; after: releases small objects (4/8 to 5/8" in diameter) Before: absent; after: releases small objects less than 1/2" in diameter
Before: absent; after: sometimes will release small objects 3/8" in diameter Before: releases small objects; after: releases objects 3/8" in diameter Before: absent; after: absent
ing trauma indicate that degenerative arthritis is not a common result of this procedure.
Clinical results The follow-up time for the 14 patients ranged from one to 54 months. Four patients (Patients 6, 12, 13, and 14) have been followed less than one year. Ten patients were followed 18 months or longer, and evaluation studies were performed on those patients. All ten patients and their families were satisfied with the cosmetic result. We attempted to quantitate sensibility by testing for (I) position sense, (2) texture and object stereognosis, and (3) two point discrimination distance. Two patients (Patients 5 and 7) with cardiovascular accidents had normal sensibility before and after operation. One patient (Patient 9) with cerebral palsy had decreased sensibility (two point discrimination distance of 10 mm.) before and after operation. One patient (Patient 8) with fracture dislocation of the cervical spine at the fifth to
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Orner and Capen
sixth cervical level improved positIOn sense, texture stereognosis, and two point discrimination distance after operation. The operation did not change the abnormal sensibility found in the other six patients. The operation was designed to increase wrist extension and forearm supination, but it also decreased wrist flexion because the arc of active motion in flexion-extension was moved toward extension . According to Caldwell , Wilson , and Braun , 13 the mini mal ranges of active joint motion for the performance of self-care activities are 20° of extension and 20° of flexion for the wrist and 20° of supination and 90° of pronation for the forearm. Before operation only two patients (Patients 7 and 10) had adequate active supination, whereas after operation six patients had 20° or more of forearm supination (Table III). Three of the four patients (Patients 2, 3, and 9) with inadequate supination after operation had had the flexor carpi ulnaris tendon transferred through the interosseous membrane instead of around the ulna. The average range of supination increased from 12.SO before to 36° after operation. Prior to operation only three patients (Patients I, 2, and 8) had an adequate range of active forearm pronation, whereas after operation eight patients had 90° of pronation (Table III). The average range of pronation increased from 63° before operation to 80° after operation. Before operation only one patient (Patient 7) had adequate wrist extension, but following operation eight patients had 20° or more of extension beyond neutral. The procedure should have reduced the range of active wrist flexion and did so in six patients, but in one patient (Patient II) active wrist flexion increased. No patient had 20° or more of wrist flexion from neutral after operation (Table III). The average amount of active flexion-extension motion for th e wrist after operation was 25°; this was entirely in the extension arc from neil,tral . After operation four of the patients (Patients I , 5, 7 , and 10) had adequate ranges of joint motion for selfcare activities in three of the four motions studied (supination, pronation, flexion, extension), and four other patients (Patients 2, 4, 8, and 9) had adequate range in two of the four motions (Table III). For all patients the average range of motion increased in forearm supination and pronation and wrist extension, but the range of wrist flexion was decreased. We tried to evaluate two handed activities as a qualitati ve measure of function and questioned the patients, their families, and therapists concerning helping , holding , hygiene, eating, and dressing with the involved
The Journal of HAND SURGERY
extremity. Before operation all four patients with cerebral palsy had ignored the hand, as did two cardiovascular accident patients (Patients 2 and 10) and the postencephalitis patient (Patient 4) . The two cardiovascular accident patients (Patients 5 and 7) with normal sensibility and the patient (Patient 8) with fracture dislocation of the cervical spine claimed the involved hand had been a hindrance and tried to conceal it as much as possible . After operation only one patient (Patient 3) did not use the involved extremity as a holder and helper. Dressing became a two handed activity for seven patients, and three patients (Patients 7, 8, and II) used both hands for hygienic activities such as shaving. Three patients (Patients 8, 9, and II) had used only the uninvolved hand for eating before operation but used both hands following operation . Although there was quantitative improvement of sensibility in only one patient (Patient 8) , there was a change in functional activity in nine patients that suggested improved sensibility. An example would be the treatment notes for a cerebral palsy patient (Patient 9): before operation the involved extremity was ignored; after operation the involved hand became a helper in activities such as washing dishes, using a broom, or carrying a food tray-dressing, eating, and hygiene were two handed activities. The involved hand performed limited one handed functions such as opening a refrigerator door. Only one patient (Patient II) had a measurable power grip or key pinch before operation, but five patients had a power grip of at least 5 pounds and four had a key pinch of 3 pounds or more following operation (Table I V). None of the ten patients had an effective grasp before operation, but nine developed some prehension of the ulnar side of the involved hand and could grasp small objects. In spastic hemiparesis the pattern of finger extension to allow release requires active wrist flexion. Prior to operation four of our patients (Patients 2, 3,4, and II) had no active extension at the metacarpophalangeal joints, and one patient (Patient I) had only a trace of extension of the fingers with full wrist flexion. After operation none of these five patients had active or passive extension at the metacarpophalangeal joints. Five patients (Patients 5, 7, 8, 9, and 10) had some extension at the metacarpophalangeal joints before operation, either by active muscles or passive tenodesis, but only one (Patient 7) could obtain metacarpophalangeal extension to neutral without simultaneous wrist flexion. The four patients (Patients 5, 8, 9, and 10) who required the tenodesing action of wrist flexion for finger extension lost an average of 59° of wrist flexion
Vol. I No.3 November, 1976
beyond neutral and lost an average of 30° of metacarpophalangeal extension following operation. We did not anticipate any improvement in the release pattern of the involved hands after operation, and all patients demonstrated inability to actively and consistently release most objects tested (Table I V). The five patients (Patients 5, 7,8,9, and 10) who had some metacarpophalangeal extension before operation were the only ones to demonstrate any release pattern after it. The release pattern was impaired further in some patients (Patients 1, 2, 3, 10, 11) by intrinsic muscle contractures and instability of the interphalangeal joints with resulting thumb-in-palm and swan-neck deformities. In other patients with nonspastic but shortened forearm flexor muscle-tendon units, such as Volkmann's ischemic contracture, we have performed proximal row carpectomies and have seen a prompt return of finger extension both in range of motion and power. We maintained the wrist in too much extension for an optimal return of finger extension because the wrist position averaged 36.5° after operation in the ten patients (Table II). Perry and Waters 5 suggested a wrist position between 10° of flexion to 15° of extension after operation, whereas Braun 7-l4 suggested 30° of wrist flexion with the metacarpophalangeal joints maintained in neutral extension. One must be careful to evaluate both wrist and finger motion in assessing function. It must be emphasized that in a spastic upper extremity an operation that maintains the wrist in extension will compromise extension of the fingers. A more functional transfer for the flexor carpi ulnaris may be to the tendons of the extensor digitorum communis, as was done in one patient (Patient 14). This augments extension of the fingers without fixing the wrist in dorsiflexion.
Conclusions I. A proximal row carpectomy (not including excision of the pisiform) combined with transfer of the flexor carpi ulnaris either to the extensor carpi radialis brevis or the extensor digitorum communis tendons will uniformly increase the relative length of all flexor muscle-tendon units that cross the wrist joint. 2. This surgical procedure will produce increased wrist extension and forearm supination and maintain forearm pronation. Supination is greater when the flexor carpi ulnaris tendon transfer is subcutaneous around the ulna rather than through the interosseous membrane. 3. Postoperative carpal slide is enhanced by total excision of the scaphoid, and only the proximal half of the bone should be removed.
Proximal row carpectomy
203
4. An operation that maintains the wrist in marked extension with a minimal range of carpal motion will compromise extension of the fingers. 5. The increased wrist extension improved grasp and pinch strength for small objects but diminished the ability to release objects. 6. Subjective use of the operated extremity for two handed activities was improved by this operation. 7. All patients in this study were satisfied with the cosmetic results. REFERENCES 1. Milford, L.: The hand, in Campbell's operative orthopaedics, ed. 5, St. Louis, The C. Y. Mosby Company, chap. 4. 2. Samilson, R. L., and Morris, J. M.: Surgical improvement of the cerebral-palsied upper limb. Electromyographic studies and results of 128 operations, J. Bone Joint Surg. 46A: 1203, 1964. 3. Dowd, C. N.: Tendon transfer for correction of spastic hand deformity, Med. Rec. 78: 175, 1910. 4. Mooney, V., Frykman, G., and McLamb, J.: Current status of intraneural phenol injections, Clin. Orthop. 63: 122, 1969. 5. Perry, J., and Waters, R. L.: Orthopaedic evaluation and treatment of the stroke patient, upper extremity surgery, A. A. O. S. Instruct. Course Lect. 24: 51, 1975. 6. Swanson, A. B.: Surgery of the hand in cerebral palsy and the swan-neck deformity, J. Bone Joint Surg. 42A: 951,1960. 7. Braun, R. M., Mooney, Y., and Nickel, V. L.: Flexororigin release for pronation-flexion deformity of the forearm and hand in the stroke patient, J. Bone Joint Surg. 52A: 907, 1970. 8. Goldner, J. L.: Reconstructive surgery of the upper extremity affected by cerebral palsy or brain or spinal cord trauma, Curro Prac. Orthop. Surg. 3: 125, 1966. 9. Inglis, A. E., and Cooper, W.: Release of the flexorpronator origin for flexion deformities of the hand and wrist in spastic paralysis, J. Bone Joint Surg. 48A: 847, 1966. 10. Page, C. M.: An operation for the relief of flexion-contracture in the forearm, 1. Bone Joint Surg. 5: 233,1923. 11. Williams, R., and Haddad, R. 1.: Release of flexor origin for spastic deformities of the wrist and hand, South. Med. J. 60: 1033, 1967. 12. Zancolli, E.: Structural and dynamic bases of hand surgery, Philadelphia, 1968, J. B. Lippincott Company. 13. Caldwell, C. B., Wilson, D. J., and Braun, R. M.: Evaluation and treatment of the upper extremity in the hemiplegic stroke patient, Clin. Orthop. 63: 69, 1969. 14. Caldwell, C. B., and Braun, R. M.: Spasticity in the upper extremity, Clin. Orthop. 104: 80, 1974 IS. Green, W. T.: Tendon transplantation of the flexor carpi ulnaris for pronation-flexion deformity of the wrist, Surg. Gynecol. Obstet. 75: 337, 1942.
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16. Steindler, A.: The traumatic deformities and disabilities of the upper extremity, Springfield, Ill., 1946. Charles C Thomas, Publisher. 17. Floyd, W. E.: Relative tendon lengthening for flexion contractu res of the wrist, Newsletter 1975-19, The American Society for Surgery of the Hand. 18. Jones, R.: Volkmann's ischemic contracture, with special reference to treatment, Br. Med. J. 2: 639, 1928. 19. Carroll, R. E., and Craig, F. S .: The surgical treatment of cerebral palsy-the upper extremity, Surg. Clin. North Am. 31: 385, 1951. 20. Goldner, J. L.: Reconstructive surgery of the hand in cerebral palsy and spastic paralysis resulting from injury to the spinal cord, J. Bone Joint Surg. 37A: 1141,1955.
21. Stelling, F. H., and Meyer, L. C.: Cerebral palsy: The upper extremity, Clin. Orthop. 14: 70, 1959. 22. White, J. W., and Stubbins, S. G.: Carpectomy for intractable flexion deformities of the wrist, J. Bone Joint Surg. 26: 131, 1944. 23. Inglis, A. E., and Jones , E. c.: Proximal row carpectomy for disease of the proximal row, presented at the Thirtieth Annual Meeting, The American Society for Surgery of the Hand , San Francisco, 1975. 24. Jorgensen, E. c.: Proximal row carpectomy, J. Bone Joint Surg. 51A: 1104, 1969.
From Keith, Sir Arthur: Menders of the maimed, limited edition, Philadelphia, J. B. Lippincott Company, p. 141 (original edition, London, 1919, Oxford University Press) . Every step taken by a surgeon to restore continuity to a nerve must be based on (I) the discovery by His that a nerve is an outgrowth from, and part of, a nerve cell; (2) the discovery made by Waller that the part of a nerve fibre lying distal to the point of division always dies and can only be replaced by an outgrowth from the end of the fibre which lies proximal to the point of division; (3) on the discovery made by Flourens, elaborated by Philipeaux and Vulpeau in Paris in 1863 and onwards, and later, in Cambridge , by Langley and Anderson, that if the proximal end of one nerve is sutured to the distal end of another, the fibres of the proximal nerve will invade and gain dominion over the area of the distal nerve; (4) the path of outgrowing nerve fibres must be paved with living sheath cells.
