Sieg & Adams, Illustrated Essentials of Musculoskeletal
Anatomy (1996)
Slide 4
Etiology High Lesion: Proximal to elbow Recovery of intrinsic
function rare due to long distance from site of injury
TraumaCompressiveOther LacerationCubital Tunnel SyndromePeripheral
Neuropathy (i.e. Diabetes) Gunshot/stab woundProlonged or
repetative compression at Guyons Canal (i.e. bicycling, tennis)
Charcot-Marie-Tooth disease Fracture/dislocationTumor
Slide 5
Compression at Guyons Canal
sportinjuriesandwellnessottawa.blogspot.com
Slide 6
Muscle Loss Low: Intrinsic musculature Palmar Interossei Dorsal
interossei 3 rd and 4 th Lumbricals Adductor Pollicis Flexor
Pollicis Brevis (deep head) Flexor Digiti Minimi Opponens Digiti
Minimi Abductor Digiti Minimi High: Intrinsic + Extrinsic
musculature Flexor Digitorum Profundus of Ring and Small Flexor
Carpi Ulnaris
Slide 7
Muscle Loss: Presentation Claw hand low nerve palsy only
Froments Sign Jeannes Sign Swan Neck Boutonniere Deformity
Slide 8
Functional Loss Decreased grip strength- often as much as
60-80% Key Pinch- as much as 70-80% Relies on the adductor
pollicis, 1 st dorsal interossei, and flexor pollicis brevis for
stability and strength Froments Sign Hyperflexion of the thumb IP
joint during pinch Jeannes Sign Hyperextension of the thumb MP
joint during pinch Dell, P et al, JHT (2005)
Slide 9
Froments Sign www.studyblue.com
Slide 10
Jeannes Sign www.ehealthstar.com
Slide 11
Boutonniere and Swan Neck www.merckmanuals.com
Slide 12
Sensory Loss Ulnar of Ring Finger, Small finger, hypothenar
eminence, and similar on dorsum of hand Dorsal sensory branch of
the ulnar nerve originates approximately 7 cm proximal to ulnar
styloid www.rch.org.au
Slide 13
Pre-Operative Therapy Objectives Prepare patient, physically
& psychologically, for surgery Enable patient to be as
functional as possible prior to surgery
Slide 14
Splinting for Function Objectives: Reduce MP joint
hyperextension due to normal function of the EDC unopposed by the
intrinsic flexors Stability of thumb for key pinch Hand Based:
Dorsal Knuckle Bender Figure 8 or Lumbrical Bar Hand based thumb
spica for pinch Thumb MP stabilizer for Jeannes sign Oval 8 for
Froments sign
Slide 15
Dorsal Knuckle Bender ncmedical.com
Slide 16
Figure 8 or Lumbrical bar
Slide 17
Hand based thumb spica
Slide 18
MP blocking fingers & thumb
Slide 19
Thumb MP stabilizer
Slide 20
Oval 8 for IP stabilization
Slide 21
Splint for function Forearm Based: if high ulnar nerve lesion
may need to stabilize forearm Ulnar gutter allegromedical.com
Slide 22
Splinting to Prevent or Correct Deformity Objective: Prevent or
reduce PIP joint contractures of ring and small fingers Prevent or
reduce Boutonniere & Swan Neck deformities Reduce pain in thumb
due to imbalance in pinch
Slide 23
Serial Casting To reduce PIP contractures prior to surgery
www.msdlatinamerica.com
Slide 24
Silver Ring Splint For Boutonniere and Swan Neck
Slide 25
Functional Adaptations/Modifications Increase ability to
complete tasks with weak pinch Use of adaptive equipment Elastic
shoelaces Adaptive light switch Compensation Modified writing
position Adaptive key pinch for car
Slide 26
Interventions Maintain full PROM for involved joints Manual
Muscle Testing Electrical Stimulation Persistent pain
management/education Patient Education regarding realistic
expectations related to function, timing, and rehab needs
Slide 27
Specific Transfers and Indications Goal to RegainFrom: Donor
Tendon (working) To: Recipient Tendon (deficient) Thumb
AdductionFDS, ECRB or ECRL, EIP, or Brachioradialis Adductor
pollicis Finger Abduction (index most important) APL, ECRL, or EIP1
st dorsal interossei Reverse Clawing effect FDS, ECRL (must pass
volar to transverse metacarpal ligament to flex proximal phalanx)
Lateral bands of ulnar digits www.orthobullets.com
Slide 28
Tendon Transfers: Thumb Adduction Use of ECRB or ECRL w/ free
tendon graft (usually Palmaris Longus) to restore Adductor Pollicis
function Advantage: Strong motor component and avoids sacrificing
finger flexor Good excursion Disadvantage: Doesnt reproduce same
line of pull Dell, P. JHT (2005);
http://www.msdlatinamerica.com/ebooks/HandSurgery/sid731790.html
Slide 29
Tendon Transfer: Finger Abduction Objective: provide more
stability to index during pinch than strength Transfers typically
provide 25- 50% of normal pinch strength Dell, P. JHT (2005);
http://www.msdlatinamerica.com/ebooks/HandSurgery/sid731790.html
Slide 30
Tendon Transfer: Reduce clawing effect ProcedureConcept
BunnellRelease of A1 & A2 pulleys to allow flexors to
bowstring, often combined with tightening of volar capsule
ZancolliVolar plate advanced proximally to produce flexion
contracture of MP Stiles-BunnellSplits FDS (usually MF) and
transfers to radial lateral bands of RF/SF Zancolli lassoFDS of MF,
passed through A1 pulley and sutured onto self FowlerActive
tenodesis w/ 2 tendon grafts sutured to lateral bands Must have
active wrist flexion to elicit tightening for MP flexion and IP
extension BrandECRB or ECRL to radial lateral bands Dell, P. JHT
(2005)
Slide 31
Tendon Transfer: Reduce clawing effect Flexor digitorum
superficialis (FDS) tendon transfers for correction of clawing. The
FDS can be sewn to the lateral band (A), to bone (B), or on itself
in the Zancolli lasso (C).
http://www.msdlatinamerica.com/ebooks/HandSurgery/sid731790.html
Slide 32
Post Op Protocol For Brand procedure: 3 weeks post-op Splint:
Volar routing: Dorsal Blocking splint with wrist in 30 degrees
flexion, MP 60 degrees flexion, and IP neutral Dorsal routing:
Dorsal Blocking splint with wrist in 30 degrees of extension, MP
blocked in 60 degrees of flexion, and IP extended ROM AROM w/ in
splint 10 minutes every hour Passive extension to PIP and DIP
Passive flexion-only if tendon inserted into bone; for insertion
into lateral bands: no passive flexion until 6 wks due to risk of
stretching out transfer NMES to facilitate excursion Scar
Management Indiana Hand Protocol (2001)
Slide 33
Post Op Protocol 6 weeks post-op Splint Reduced to MP block
with palmar bar in 45 degrees of flexion to be worn at all times If
PIP extensor lag-continue with dorsal blocking splint ROM PROM to
MPs, PIPs, and DIP joints All completed within the restrains of the
MP block Indiana Hand Protocol (2001)
Slide 34
Post Op Protocol 7-8 weeks post-op Dynamic flexion initiated
prn Monitor for PIP extensor lags 10-12 weeks post-op MP blocking
splint discontinued if hyperextension not present and minimal
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