27: Flexor Carpi Ulnaris–to–Extensor Carpi Radialis Brevis Transfer

Procedure 27 Flexor Carpi Ulnaris–to–Extensor Carpi Radialis Brevis Transfer



Sandeep J. Sebastin, Kevin C. Chung



Indications




image Cerebral palsy patient with a hyperactive flexor carpi ulnaris (FCU) and weak or absent wrist extension


image Late presentation of neonatal brachial plexus palsy with an ulnar deviation deformity and absent wrist extension



Examination/Imaging



Clinical Examination




image Cerebral palsy: The flexion deformity in cerebral palsy can be due to spasticity of the wrist flexors, weak wrist extensors, and/or a volar wrist capsular contracture. It is important to differentiate among these causes. An attempt at overcoming muscle spasticity should be done by applying gentle sustained resistance to the spastic force. If the wrist can be extended passively, it rules out capsular contracture. If the wrist cannot be extended passively, but the wrist flexors do not feel spastic, it suggests a wrist capsular contracture. If the spasticity cannot be overcome, a median and ulnar nerve block at the elbow can temporarily eliminate the flexor spasticity and allow an assessment of active and passive wrist extension. An FCU-to–extensor carpi radialis brevis (ECRB) transfer is indicated in patients who have a spastic FCU and good passive wrist extension (no capsular contracture) but lack active wrist extension. Before considering an FCU-to-ECRB transfer, one must ensure that the patient has the following:


• A functioning FCR, or the transfer will result in a wrist extension deformity

• Active digital extension with the wrist held in slight extension. If there is some active digital extension, but it is limited by the tight digit flexors owing to the wrist extension, a concomitant lengthening of the digital flexors will be required (Fig. 27-1). If there is no active digital extension, the patient will need lengthening of the digital flexors and augmentation of digital extension with a long finger FDS-to-EDC transfer.

image Neonatal brachial plexus palsy (NBPP): The ulnar deviation deformity in this group of patients can be due to the FCU or the extensor carpi ulnaris (ECU). Either one of these tendons can be used for obtaining wrist extension depending on the predominant cause of the ulnar deviation deformity. In NBPP, the FCU is passed around the radius to the extensor carpi radialis longus (ECRL) to get some radial balance to the hand at the wrist. In cerebral palsy, the transfer is made around the ulna to the ECRB. This chapter describes the procedure in cerebral palsy.


image

FIGURE 27-1



Surgical Anatomy




image The purely tendinous portion of the FCU is quite short as the muscle extends distally along the tendon. In addition, the muscle is attached along the ulna over a long distance. The muscle must be detached quite proximally to have adequate excursion of the transferred FCU (Fig. 27-2).


image The ulnar artery and nerve are very closely related to the undersurface of the FCU and must be protected during mobilization of the FCU (Fig. 27-3).


image

FIGURE 27-2


image

FIGURE 27-3



Positioning


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Mar 5, 2016 | Posted by in Hand surgery | Comments Off on 27: Flexor Carpi Ulnaris–to–Extensor Carpi Radialis Brevis Transfer

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