23: Fractional Lengthening of the Flexor Tendons

Procedure 23 Fractional Lengthening of the Flexor Tendons



Harry A. Hoyen, Patrick J. Messerschmitt


image See Video 20: Fractional Lengthening of the Flexor Tendons



Indications




image Wrist and finger flexion deformity due to spastic muscle contracture in which the fingers cannot be passively extended fully despite positioning the wrist in flexion.


image Situation in which flexor lengthening up to 15% to 20% of the muscle is required; otherwise, superficialis-to-profundus tendon transfer is necessary.


image Conditions in which finger and hand flexion is to be preserved for functional purposes. The preoperative condition is functionally limiting, especially with activities of daily living.



Examination/Imaging



Clinical Examination




image Preoperative examination is helpful in determing the contribution of the finger and wrist contracture from the spastic properties of the finger flexor tendons.


image Examine the involvement of all muscles that contribute to wrist flexion: palmaris longus, flexor carpi radialis, and flexor carpi ulnaris (FCU), and those primarily responsible for finger flexion: flexor digitorum sublimis and flexor digitorum profundus (FDP).


image Excessive flexion of distal interphalangeal (DIP) joints indicates FDP involvement.


image Excessive flexion of proximal interphalangeal (PIP) joints without significant contracture of DIP joints suggests flexor digitorum sublimis involvement.


image Examining the wrist in flexion may aid in delineating the effect of the flexor digitorum sublimis from the FDP on the contracture.


image It is also necessary to examine the small hand articulations to determine the effect of fixed joint contractures. This may represent an articular arthrofibrosis and would not improve with a muscle/tendon procedure.



Surgical Anatomy




image Pertinent surgical anatomy includes the volar forearm muscles (palmaris longus, flexor carpi radialis, flexor carpi ulnaris, flexor digitorum superficialis, FDP, pronator teres, pronator quadratus), median nerve, ulnar nerve and artery, and radial artery. Cross-sectional anatomy should be reviewed before intervention.



Positioning




image Position the patient supine with the arm extended onto a surgical arm board.


image A nonsterile tourniquet is placed high on the arm before surgical preparation to allow better visualization during the procedure.



Exposures




image A longitudinal volar incision over the junction of the mid to distal third of the forearm is used. This corresponds to the myotendinous junction of the volar flexor musculature.

Related posts:

28: Pronator Teres Rerouting 34: Reconstruction of the Central Slip with the Transverse Retinacular Ligament for Boutonnière Deformity 85: Wrist Denervation 38: Reconstruction for Congenital Thumb Hypoplasia 65: Arthroscopic Treatment for Septic Arthritis 89: Total Wrist Fusion

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Mar 5, 2016 | Posted by in Hand surgery | Comments Off on 23: Fractional Lengthening of the Flexor Tendons

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