PPRP MANAGEMENTUPPERLIMB

DR.RAJESH PG in ORTHOPAEDICS

GMC

SHOULDER MOVEMENTS

• Flexion– Coracobrachialis

– Pect.major

– Ant. deltoid

• Extension– Lati.dorsi

– Teres major

– Post. deltoid

• Adduction– Pect.major(lower&upper)

– Coracobrachialis

– Lat.dorsi&teres major

• Abduction– Deltoid (15-90o)

– Supraspinatus(15o)– trapezius

• Int.rotation– Subscapularis– Lat.dorsi– Teres major– Ant.deltoid– Pect.major

• Ext.rotation– Infraspinatus– Teres minor– Post.deltoid

AIMS OF SURGERY

• Near normal function of hand

• Elbow flexion and forearm pronation

• Glenohumeral stability and motion

• Overall mobility and reach of upper limb

• For shoulder surgery ,– Functional elbow and

– Good hand function should be there

BIO MECHANICAL CLASSIFICATION;SAHA

• Prime movers– Deltoid

– Pectoralis major(clavicular head)

– Muscles working on long lever arm

– Exert maximum force for lifting of arm during abduction

• Choice of muscle transfer– trapezius

BIOMECHANICL CLASSIFICATION;SAHA

Steerer group1)Supraspinatus (sup.glider)

2)Subscapularis (post.glider)

3)infraspinatus

-Steer the head on glenoid surface.

-Exert a stabilizing force

Lifting force is minimal

Depressors1)Pect.major

2)Lat.dorsi

3)Teres major

Rotate humeral shaft during elevation and depress the head in late abduction

• According to saha 2 out of 3 stabilizer muscles to be functional for trapezius transfer

• For subscapularis– Sup.2 digitations of

serr. Ant– Pectoralis minor– Levator scapulae

• Supraspinatus– Levator scapulae– SCM– Scalaen.ant

• For infra spinatus– Lati.dorsi– Teres major

HENRYS FACIAL SLING OPERATION

• For paralysis of– Trapizius– Rhomboids or– Levator scapulae

• Fascia lata of thigh is used• Slings placed b/w

– 6th and 7th cervical spine to sup. Medial border of scapula

– 3rd thoracic vertebrae to lower border of scapula

TRAPEZIUS TRANSFER FOR DELTOID

• Sahas technique– Entire insertion of

trapezius along with attached

• Lat. End of clavicle• AC joint• Acromion• Adjoinig part of

scapula spine– Anchored to lat. Aspect

of humerus distal to tuberosity by 2 screws.

AFTER TREATMENT

• Spica cast applied in 45o abd.,neutral rotation,flexed in the plane of scapula

• Cast removed at 6-8 weeks

• Active exercises started• Transfer of deltoid origin for

partial paralysis ;HARMON

• Bateman trapezius transfer

SHOULDER ARTHRODESIS

• Pre requisites– Presence of strong scapulo-thorasic muscles is

mandatory– Sufficient bone stock in gleno-humeral joint– Good hand and elbow function

• Disadvantages– Imparts strength at cost of mobility– Scoliosis may be produced– Cosmetically not good– Unsuitable in b/l cases

SHOULDER ARTHODESIS

• Fused in– Abduction 25o-30o

– Flexion20o

– Int.rotation 35o-40o

• Too much flexion causes-winging of scapula

• Too little int.rotation-decreases ADL• Too much abduction-over stretch trapizius• There are four methods of arthrodesis

SHOULDER ARTHODESIS

• Extra articular arthrodesis– Watson and jones

• Extra and intra articular arthrodesis– Hill

• Intra articular arthrodesis– Cofield– steindler

• Compression arthrodesis

• Compression technique– Charnley and houston

• Using internal and external fixation

• Pins and ex-fix removed after 6weeks

• Cast continued for another 6 weeks

AO TYPE ARTHRODESIS

• Good bone stock should be there

• No need to apply spica cast

• Need to remove hardware after fusion

PPRP ELBOW MANAGEMENT

• Elbow flexors– Brachialis– Biceps brachii– Brachioradialis

• Elbow extensors– Triceps,anconeus

• Supinators– biceps and supinator

• Pronators– Pronator teres and

quadratus

ELBOW FLEXION RESTORATION

• Methods available– Steindler flexorplasty– Bunnell and Carroll anterior triceps transfer– Clarks part of pect.major transfer– Brooks and sedon pect.major transfer– Hovanean lati.dorsi transfer– Bunnels transfer of SCM

STEINDLERS FLEXORPLASTY

• Bunnell modification– Uses facial transplant– Anchors proximally

and laterally– Eliminates the

tendency of fore arm pronation

• BUNNELL ant. Transfer of triceps

• BROOKS-SEDDON pectoralis major transfer

FORE ARM

• Pronation deformity is left alone, it permits good function

• Fixed supination deformity is disabling• Results from strong biceps and wrist

extensors• Weak flexor pronators• Zancollis technique

– Re-routing biceps tendon around neck of radius

• Manual osteoclasis– Of fore arm bones if pt

is under 12 yrs– Pronation osteotomy

with plating in elderly patient

PPRP HAND MANAGEMENT

• Grasp is weakned and pinch is lost if active thumb opposition is lost

• Strong pinch (key pinch) is lost if thumb adduction is lost

• Loss of thumb apposition is common in polio and disabling

BUNNELS TECHNIQUE

• Contractures at CMC joint 1st and 2nd web spaces released

• Tendon must pass its insertion in to thumb in a direct manner to pisiform subcutaneously

• Thumb angulated forwards and towards ulna• Tendon attached to dorsi ulnar aspect of

prox.phalynx and MC head• Tendon sutured under moderate tension with

wrist in flexion

THUMB OPPOSITION

• COMPONENT MOVEMENTS– Abduction– Flexion of MCP thumb– Internal rotation– Radial deviation of

proximal phalynx over MCP

– Thumb towards finger

• Important muscle is abductor poll. brevis

TENDON TRANSFERS

• Riordan technique• Brand technique• Grooves and goldner

– FCU and FDS used

• Camitz– Uses palmaris longus– Enhances opposition

• Littler and cooley– Abd.digi.mini muscle used

RIORDAN TECHNIQUE

• FDS to ring finger divided

• Tendon is passed through FCU pulley

• Tendon anchored to abd.brevis and capsule

• Splint for three weeks• Opponent splint for

6weeks

BRAND TRANSFER

• Uses sublimus tendon to ring finger

• Pulley made in fat over hamate

• Tendon split in to two strips

• Attach one strip to MCP joint

• Another to tendons of abd.poll.bravis and EPL

RESTORATION OF ADDUCTION OF THUMB

• Adductor pollicis is paralysed

• Deformity-– MCP hyper extension– IP joint hyper flexion

• Transfer of bra.radialis or wrist extensor– Boyes tech

• ECRB transfer-smith tech• FDS for both add

&apposition-– Royle thompson

BOYES TECHNIQUE

• Brachioradialis is lengthened by additional graft

• Palmarward through 3rd interosseous space

• Carried across palm and anchored to tendon of add.pollicis

RESTORATION OF ABD OF INDEX FINGER

• Second component of pinch action

• Due to paralysis of 1st palmar int.

• Transfer of – Ext.prop.indices or– Accessory Slip of

abd.poll.longus tendon

PARALYSIS OF INTRENSICS

• Leads to extension deformity of MCP joints• Restored by BRAND technique• ECRL or ECRB with free graft(toe extensors)

used• through interosseous space• Ant. To deep transverse MC ligament• Sutured to edge of lateral band and• Extensor expansion of finger proximal to IP

joint

Restoration of intrinsic function

• REORDAN– FCR +plantaris

• Fowlers transfer• Brand trasfer

– ECRB+ free graft

• Tenodesis– fowlers and

• capsulodesis– zancollis

• In complete flexor paralysis– ECRL to FPL– ECU to deep flexor tendons used

• Carpectomy– Used for severe flexion deformity of hand

PARALYSIS OF WRIST EXTENSION

• For ECRB– Tendon of pronaror teres – FCU

• JONES operation– Ponator teres to radial wrist ext.rs– FCU to ext.digitorum– FCR to thumb extensors&abductors

TENODESIS(opponens&flexor tenodesis)

• If no finger and wrist flexors are present• Wrist extension is present• Thumb opposition obtained by

– Opponodesis– By using free graft– Through ulnar tunnel

• Combined with– Tenodesis of finger and thumb flexors– Through distal radius

ARTHRODESIS OF WRIST

• Smith Peterson technique– Distal 4cms of ulna is used

as graft

• Dorsal AO DCP plate• Capitate radius

arthrodesis– With proximal row

carpectomy

• Disadvantages– Weakness of grip,and– Holding of crutch

Take home message

• Functional ,mobile upper limb is the goal

• THANQ ALL