Chẩn Đoán Và Điều Trị Phẫu Thuật Tái Tạo Hiện Đại (CURRENT Reconstructive Surgery)

COMPRESSIVE NEUROPATHIES IN THE UPPER EXTREMITY • 633
the preoperative degree of compression. When there are
constant symptoms, demyelination is present and recov-
ery may take 6-8 months. Residual sensory complaints are
common. Even though intrinsic wasting rarely recovers in
an adult, prevention of further denervation is crucial.
Early reports of RTS decompression were generally opti-
mistic. Rinker et al. reported 80% good or excellent results
in his series of 109 decompressions.5 A more recent review
by Sotereanos et al. however found good results in only
11/28 patients, with many patients experiencing residual
symptoms.6 The results were worse in patients receiving
workers compensation.
Kline et al reported their experience with 45 surgically
treated posterior interosseous nerve entrapments, tumors,
or injuries over a 27-year period.7 Most muscles inner-
vated by the PIN achieved Grade 3 or better functional
outcomes. They generally found that the PIN entrapment
or injuries responded well to PIN release and/or repair.
Dellon and MacKinnon reported on a group of
51 patients with complaints related to entrapment of the
superfi cial sensory branch of the radial nerve.8 Seven
(37%) of 19 patients treated with nonoperative modalities
after a mean of 28 months from the onset of symptoms
or their injury were improved. Of the 32 patients treated
with surgery there was excellent subjective improve-
ment in 37%, good subjective improvement in 49%, and
fair subjective improvement in 6%, and 8% were not
improved.
COMPLICATIONS
The complications for each procedure are similar. They
include wound problems related to infection, skin heal-
ing, tender scars due to injured cutaneous nerves, hema-
toma and iatrogenic injury due to rough nerve handling,
and/or retraction. These can be minimized by meticulous
hemostasis, gentle nerve handling, and precise surgical
technique. Stiffness can occur and is minimized by early
joint mobilization. The incidence of residual symptoms are
predicated by the preoperative degree of nerve injury.
REFERENCES
1. Olehnik WK, Manske PR, Szerzinski J. Median nerve com-
pression in the proximal forearm. J Hand Surg Am. 1994;19:
121–126.
2. Johnson RK, Spinner M, Shrewsbury MM. Median nerve en-
trapment syndrome in the proximal forearm. J Hand Surg
Am. 1979;4:48–51.
3. Hartz CR, Linscheid RL, Gramse RR, et al. The pronator
teres syndrome: compressive neuropathy of the median
nerve. J Bone Joint Surg Am. 1981;63:885–890.
4. Ketchum LD. A comparison of fl exor tenosynovectomy,
open carpal tunnel release, and open carpal tunnel release
with fl exor tenosynovectomy in the treatment of carpal tun-
nel syndrome. Plast Reconstr Surg. 2004;113:2020–2029.
5. Rinker B, Effron CR, Beasley RW. Proximal radial compres-
sion neuropathy. Ann Plast Surg. 52:174–180; discussion
2004;181–183.
6. Sotereanos DG, Varitimidis SE, Giannakopoulos PN, et al.
Results of surgical treatment for radial tunnel syndrome.
J Hand Surg Am. 1999;24:566–570.
7. Kim DH, Murovic JA, Kim YY, et al. Surgical treatment and
outcomes in 45 cases of posterior interosseous nerve entrap-
ments and injuries. J Neurosurg. 2006;104:766–777.
8. Dellon AL, Mackinnon SE. Radial sensory nerve entrapment
in the forearm. J Hand Surg Am. 1986;11:199–205.

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c h a p t e r54
Replantation and Revascularization
Bradon J. Wilhelmi, MD, FACS / Scott M. Schulze, MD
INTRODUCTION
Microsurgical reattachment of a severed or amputated
body part represents the culmination of plastic and recon-
structive surgery. Replantation or revascularization of
these injured body parts offers a result that is usually supe-
rior to any other type of reconstruction. The decision to
attempt a replantation or revascularization and the tech-
niques involved in replantation of amputated parts are
often extremely challenging.
The replantation of these parts involves more than
microsurgery, as successful repair of bony and tendinous
injuries must be performed as well.
Thousands of severed body parts have been reattached
since the fi rst replant was performed over 50 years ago,
which have preserved a measure of hand function supe-
rior to that of an amputation. Malt performed the fi rst
replantation on May 23, 1962, at Massachusetts General
Hospital on a 12-year-old boy who had sustained a tran-
shumeral amputation of his right arm in a train accident. 1
The repair included fi xation of the humerus using a
Kuntscher nail in addition to a repair of the brachial artery,
the brachial veins, as well as the median, ulnar, and radial
nerves. At 11 months, the patient had protective sensation
to his hand and early intrinsic function but required a wrist
arthrodesis and tendon transfers for elbow and shoulder
fl exion. 2 Technologic advances and the use of the oper-
ating microscope have enabled surgeons to replant other
body parts, including the thumb, fi ngers, ear, scalp, facial
parts, and genitalia. 3 – 27
PATIENT EVALUATION AND SELECTION
Not all amputees benefi t from or are candidates for replan-
tation. 28 The decision to replant a severed part is infl u-
enced by many factors, including the importance of the
part, the level of injury, the expected return of function,
and the mechanism of injury.29–31 Replantation is indicated
for thumb amputation at any level, multiple fi nger ampu-
tations, single-digit amputations distal to the fl exor super-
fi cialis insertion, and amputations through the carpus,
wrist, and the distal forearm ( Figure 54-1 ). 3 2 – 36 Above
elbow replantation should be attempted for elbow preser-
vation, even though the chance for nerve recovery is low.
If subsequent nerve regeneration is inadequate after upper
arm replantation, a revision amputation at the mid-fore-
arm level can then allow for a below elbow prosthesis. 32
A below elbow prosthesis with a gravity-activated grip
is more functional than an above elbow prosthesis. Less
functional recovery is expected for replantations at certain
levels, including amputations proximal to the fl exor super-
fi cialis insertion within zone II of the fi ngers and at the
muscle belly and elbow level.
Amputations in zone II proximal to the sublimus inser-
tion are relatively contraindicated since the patient is
often left with marked fi nger stiffness with minimal or no
functional benefi t and require prolonged rehabilitation
that signifi cantly delay return to work. 4 There are cultural
differences, however, that justify replantation. In many
Asian societies, it is important to have fi ve digits because a
common form of punishment for criminals in some coun-
tries is to amputate a fi nger. Replantation of zone II fi nger
amputations have been justifi ed in Japan, so that patients
can avoid being confused with Japanese mafi a members
(Yakuza) who have amputated their fi ngers as a symbol of
devotion to their mob bosses.
Perhaps, the most predictive indicator for success with
replantation is the mechanism of injury. O’Brien has dem-
onstrated signifi cantly higher success rates with replanta-
tion of guillotine versus avulsion amputations. 31 It may be
unrealistic to expect to successfully replant severely crushed
and mangled body parts. Avulsion injuries with traction
along the neurovascular bundles create intimal tears and
disruption of small branches to the skin. Small hematomas
in the skin along the course of the neurovascular bundle

636 • CHAPTER 54
are known as the “red line” sign. It heralds an injury to the
neurovascular bundle. Replantations of amputated digits
that exhibit the red line sign are often fraught with failure
because even though the anastomosis may be patent there
is no fl ow of arterial blood to the skin. Another indica-
tion of injury to the vessels of an amputated digit is the
“ribbon” sign. The ribbon sign is an indication of torsion
and stretch on a vessel. The vessel resembles a ribbon that
has been stretched and curled for decoration on a wrapped
gift. Vessels that have the ribbon sign will often throm-
bose due to the damage to the intima. When a replantation
is attempted in digits with the ribbon sign, vein grafting
proximal and distal to this zone of injury is necessary. If
this intimal injury extends distal to the trifurcation of the
FIGURE 54-1. Levels of replantation.

REPLANTATION AND REVASCULARIZATION • 637
digital artery, vein grafting distal to the zone of injury is not
possible, which precludes an attempt at replantation.
Two other relative contraindications to replantation
include multiple level injuries ( Figure 54-2 ) and mentally
unstable patients. The only absolute contraindication to
replantation exists when associated injuries or preexist-
ing illness prevent a prolonged and complex operation. In
this circumstance, temporary ectopic implantation of the
amputated part has been described for preservation of the
amputated extremity before eventual elective replantation
later. 6 , 37 , 38
PATIENT PREPARATION
Replantation of arms, hands, digits, or even fi ngertips has
become common in various institutions. Physicians, para-
medics, and patients are informed regarding the possibility
of replantation of amputated body parts. Because of this,
it is common for the patient to bring the part to the emer-
gency room. Even if not replantable, this amputated part
can provide a valuable tissue source for reconstruction.
The amputated part should be wrapped in a saline-moist-
ened gauze sponge and placed in a sealed plastic bag which
is kept on ice. The amputated part should not be placed
directly on ice because this can result in frostbite damage
to the vessels. 39 The part should not be immersed in water
because this has been demonstrated by Urbaniak et al. to
make digital vessel repair more diffi cult and less reliable,
because of cob webbing of the intima. 40 , 41 Bleeding vessels
in the stump should not be clamped. Hemostatic control
of the stump can be achieved with a compressive dressing
and elevation.
The recommended ischemia times for reliable success
with replantation are 12 hours of warm and 24 hours
of cold ischemia for the digits, and 6 hours of warm and
12 hours of cold ischemia for major replantations with large
amounts of muscle. Reports of successful replantation after
longer ischemia times do exist however. 7 , 42 – 45 Minimizing
ischemia time is more critical in replantation levels that
are proximal to the digits. In such cases, a temporary arte-
rial shunt to the amputated limb may be benefi cial. 6 , 37 , 38
Before surgery, radiographs of the amputated parts and
the stump should be performed to determine the levels of
injury and suitability for replantation. Both parts should
be photographed for documentation. An informed con-
sent should be obtained, discussing the pros and cons with
the patient and family regarding the failure rates, length
of rehabilitation, and realistic expectations of sensation,
mobility, and function. The preoperative preparation of
the patient should also include consideration for pro-
phylactic antibiotics, updating the patient’s tetanus, fl uid
resuscitation to prevent hypotension, warming the patient
to prevent hypothermia and vasoconstriction/spasm, Foley
insertion for volume monitoring, and protection for pres-
sure points during an expected long operation.
TECHNIQUE
Preparation of the Amputated Part
The preparation of the amputated part can be initiated
before the patient is brought to the operating room. This
preparation is performed on a back table under sterile con-
ditions in the operating room. The use of a microscope
assists with the assessment of the digital vessels. Signs of
arterial damage should be noted, including the telescope,
cobweb, and ribbons signs, or terminal thrombosis, which
would require resecting the damaged section of the vessel
and harvesting a vein graft. This vein graft should be har-
vested prior to osteosynthesis to minimize warm ischemia
time. If the amputated part is grossly contaminated, it
should be cleansed gently with normal saline irrigation and
foreign material should be removed. Care must be taken
not to further injure the digital vessels or soft tissue. The
neurovascular structures of the fi ngers are exposed with
bilateral longitudinal incisions in the midaxial line instead
of volar zig-zag incisions which could complicate ampu-
tation stump skin viability should the replant fail. Dorsal
incisions may be required to expose the dorsal veins. Once
these neurovascular structures have been identifi ed, label-
ing with 9-0 nylon sutures or hemoclips can facilitate and
expedite identifi cation at the time of coaptation.
Many surgeons prefer to shorten the bone to avoid the
potential need for arterial, venous, and nerve grafts later.
The tagged neurovascular structures are gently relocated
during the bone shortening, which can usually be safely
performed with a rongeur. Approximately, 5 to 10 mm
of bone shortening may be necessary for tension-free ves-
sel repairs. The bone shortening should be performed on
the amputated part if possible to retain length should the
replant fail. Bone can be resected on the stump side for the
fi ngers, but not for the thumb where length preservation
is more critical, or if the amputation level is near the joint
on the amputated part. Hand function is compromised
with thumb loss proximal to the interphalangeal (IP)
joint. If the amputation level is through the joint, fusion
in the functional position is required. Primary implant
FIGURE 54-2. This patient degloved hand in log crusher
splitter, resulting in multilevel neurovascular and bone injuries.

638 • CHAPTER 54
arthroplasty has been described in replantation but there is
an increased risk for infection. 46 Retrograde Kirschner (K-)
wires or intraosseous wires can then be placed through the
bone on the amputated part.
Preparation of the Stump
Usually there is enough time before the patient is trans-
ported to the operating room for preparation of the ampu-
tated part. Alternatively, a second team can be recruited
to begin the preparation of the stump. The neurovascular
structures are identifi ed, isolated, and tagged on the stump
side under tourniquet control. Before the arterial anasto-
mosis, the tourniquet is defl ated to assess infl ow pressure
by the spurting of blood from the proximal artery. 47 If the
spurt is inadequate, additional proximal vessel shortening
is required. Furthermore, in preparing the stump, expo-
sure of the proximal fl exor tendon for placement of a core
suture is easier at this point than after bone fi xation.
The order for repairing the various structures is indi-
vidualized. The sequence of repairing the bone, extensor,
veins, dorsal skin, artery, nerve, and fl exor is preferred, as
it effi ciently allows for repairing all the dorsal structures
before the volar structures, to reduce warm ischemia
time. 31 If the warm ischemia time is unusually long, the
artery can be repaired earlier.
Osteosynthesis
Techniques of osteosynthesis vary: many surgeons pre-
fer crossed K-wires, because they are quick and safe.
However, union rates have been reported to be better with
intraosseous wires, either in combination with a K-wire
or as 90-90 wires. 8 , 48 Ninety-ninety wires consist of two
intraosseous wires placed perpendicular to each other.
Extensor Tendon Repair
and Dorsal Vein Repair
After the osteosynthesis, the hand is pronated and the
extensor tendon is repaired next. If the amputation is at the
proximal phalanx level, it is important to repair the lateral
bands to prevent loss of extension at the IP joints. Next,
the dorsal veins are repaired. At least two veins should be
repaired in fi nger replantations, especially for replantations
proximal to the proximal IP joint. Dorsal veins are pre-
ferred because they are larger and do not interfere with
subsequent repair of volar structures ( Figure 54-3 ). If the
injury is very distal, arterial repair fi rst may be required,
because the veins become smaller and more diffi cult to
identify, and may be easier to locate by back bleeding. If a
dorsal vein cannot be located in the amputated part, cre-
ation of an arterial venous communication can be consid-
ered to avoid venous compromise. Because veins stretch
easier than arteries, vein grafts are rarely needed for venous
repairs. Once the dorsal structures have been repaired, the
dorsal skin is loosely approximated with a few small-caliber,
simple interrupted sutures.
Digital Artery Repair
The hand is then supinated to repair the injured volar struc-
tures. At least one digital artery is repaired. Several anas-
tomotic techniques have been described. One described
technique of microvascular repair involves applying a
microvascular approximating clamp then placing the fi rst
two sutures at 10 o’clock and 2 o’clock, then at 12 o’clock;
and then the vessel is turned 180 degrees and additional
simple interrupted sutures are placed in sequence. The last
two or three sutures are tied at the end to avoid catch-
ing the back wall with the fi nal sutures, which would lead
to vessel thrombosis. After the completion of the digital
artery repairs, the tourniquet is defl ated and the clamps are
removed. The patency of the arterial anastomosis can be
assessed using a patency test or fl icker test and checking the
capillary refi ll of the replanted part and bleeding after pin-
prick. If arterial fl ow seems inadequate, one should confi rm
that the patient has adequate blood pressure and volume,
and that the tourniquet actually has been defl ated. Bathing
the vessel with papaverine, lidocaine, magnesium sulfate,
FIGURE 54-3. An example of a dorsal vein repair with
10-0 nylon suture in simple interrupted fashion over the
previously repaired extensor tendon.

REPLANTATION AND REVASCULARIZATION • 639
and warm irrigation has been described to counteract the
vasospasm. 9 The hand can even be placed in the depen-
dent position to increase infl ow pressure with gravity. 49
The surgeon would allow at least 10 minutes observation
time for resolution of vasospasm before manipulating the
anastomosis with a “milk test” to demonstrate patency. It is
accomplished with two vascular forceps. The fi rst forceps
is placed just distal to the anastomosis. The second for-
ceps is used to milk blood away from the distal aspect
of the fi rst forceps, and is closed leaving a fl at, collapsed
vessel. The fi rst forceps is then released. Distention of the
vessel distal to the anastomosis confi rms that the anasto-
mosis is open. If the milk test is abnormal or if petechiae
of the measles sign or ballooning of the sausage sign is
encountered, suspect thrombosis and redo the anastomo-
sis. 47 , 50 Frequently, in redoing the anastomosis, further ves-
sel resection is necessary. If the additional vessel resection
places the vessel repair under tension, an interposition vein
graft is required. Also, a second artery should be repaired as
a safeguard measure.
Digital Nerve Repair
Located superfi cial and volar to the digital arteries, the dig-
ital nerves are coapted next. This can be performed before
or after the tourniquet has been defl ated. The epineurial
nerve repair technique is preferred and can be achieved
with as few as three sutures. A nerve conduit or graft is
required if one is unable to repair the nerve primarily.
Of the upper extremity nerve graft donors, the posterior
interosseous nerve is preferred over the medial antebra-
chial nerve because this avoids a donor sensory defi cit, but
it only yields a small 1-cm graft and is only suitable at the
distal interphalangeal level. Alternatively, a vein graft or
polyglycolic acid conduit can be used for small defects of
2 cm or less.
Flexor Tendon Repair
At this point, the fl exor tendon is repaired, tying the previ-
ously placed proximal and distal core sutures. Performing
the tendon repair later permits fi nger extension, giving
better exposure for the microsurgical repair of the digital
arteries and digital nerves.
Arterial Interposition Vein Graft
Common indications for arterial interposition vein grafts
include thumb replantations, ring avulsions, segmen-
tal artery loss, or the need to extend outside the zone
of injury because of intimal trauma. 51 – 53 Potential vein
graft harvest sites for distal digit replantations include
the palmar forearm and wrist. The wrist is preferred by
many because the volar wrist veins match the digital
vessel caliber ( Figure 54-4 ). 5 , 54 – 56 The leg or contralat-
eral arm may be used to harvest vein grafts for major
FIGURE 54-4. (A) Harvesting a vein graft from the volar distal forearm provides an
appropriate size match for a proper digital artery defect. (B) Notice the size match of a
vein graft harvested from the palmer distal forearm being used to interpose this arterial
defect between the two forceps.
A
B

640 • CHAPTER 54
replantations of the hand, forearm, or multiple fi ngers,
with a second team working simultaneously. Vein grafts
must be reversed for arterial interposition because of
valves within the veins.
Thumb Replantation
In the thumb, the ulnar digital artery is usually of larger
caliber than the radial digital artery. 57 , 58 Arterial revascu-
larization in thumb replantation is therefore more reliable
when based on the ulnar digital artery. This vessel is dif-
fi cult to expose for the microsurgical anastomosis, how-
ever, and requires extreme arm pronation or supination,
which can result in having to work at different levels of
microscopic focus. This situation can be avoided by either
repairing the ulnar digital artery before the osteosynthesis
or by using an arterial interposition graft.
If the amputation level is distal to the metacarpo-
phalangeal (MCP) joint and the proximal end of the
ulnar aspect digital artery is well exposed, a primary
arterial anastomosis can sometimes be performed with-
out the need for a graft. A technique that has been
described to optimize exposure of the ulnar digital
artery during the microanastomosis involves performing
the micro anastomosis before the osteosynthesis. 10 , 11 The
bone shortening and retrograde K-wires are placed fi rst.
The ulnar digital artery and nerve are then repaired with
the hand in supination, before the osteosynthesis, which
provides a better angle for the microscope and exposure
for the anastomosis without having to work in and out of
the fi eld of focus. The bone ends are then aligned and the
osteosynthesis is carefully completed. The digital artery
clamps are left in place until the extensor tendon and
dorsal veins are repaired. The fl exor tendon core sutures
are now tied. Then, digital artery and vein clamps are
carefully removed to establish arterial infl ow and venous
outfl ow.
When the thumb has been amputated at or near the
MCP joint and the proximal ulnar digital artery has
retracted and is diffi cult to expose, a vein graft can be used
from the ulnar digital artery distally to the radial artery
in the snuffbox, end to side ( Figure 54-5 ). Interposition
vein grafting of the thumb has been shown to increase
survival rates for thumb replantation two- to threefold.
In using this vein graft to the radial artery technique for
replantation for the thumb, the vein graft is repaired to
the distal ulnar artery fi rst on the back table, which pro-
vides a fl at surface for the microsurgery ( Figure 54-6 ). The
vein graft is then carefully pulled through the subcutane-
ous tunnel to the radial artery in the snuffbox. The digital
nerves also can be repaired at this point with better expo-
sure before the osteosynthesis. Then, the osteosynthesis
is carefully performed by passing the previously placed
K-wires retrograde through the proximal bone. At this
point, the extensor tendon and dorsal veins are repaired.
The vein graft is then repaired end to side to the radial
artery in the snuffbox. In performing thumb replant pro-
cedures one should have a low threshold for shortening the
bone to avoid tension on the digital nerves. This provides
the best chance for return of sensation, which is critical to
thumb function. Bone shortening or IP fusion should be
considered for the thumb because these patients achieve
useful motion of the thumb through the MCP and basilar
joints and this obviates the need for repairing the fl exor
pollicis longus.
Multiple Finger Replantations
In multiple fi nger replantations, the fi nger with the best
chance for successful replantation, best expected recov-
ery, and best contribution to function should be repaired
fi rst. If all the fi ngers are injured at the same level and
with the same chance for success, the authors prefer to
repair the middle fi nger, then index fi nger, then ring fi nger,
and fi nally the small fi nger ( Figure 54-7 ). If the index fi n-
ger is stiff or insensate, the patient will bypass this to use
the middle fi nger. When all the fi ngers are stiff, the index
fi nger can actually impede the function and opposition
of the other fi ngers to the thumb. Because it is essential
to minimize ischemia time with multiple digit replanta-
tions, each fi nger is replanted separately. The amputated
fi ngers should be brought to the operating room as soon
as possible, where the digital vessels, nerves and tendons
can be identifi ed and tagged with sutures or clips, to save
time and minimize ischemia. The order for repairs can
be improvised with multiple replantations. Initially, the
osteosynthesis, extensor tendon, one dorsal vein, and one
digital artery can be repaired for each fi nger to minimize
overall ischemia time. Another dorsal vein, the digital
nerves and fl exor tendon core suture can be repaired later,
once the blood fl ow to the fi ngers has been reestablished.
Major Limb Replantation
The order of the replant procedure is modifi ed for major
replantations of the hand and upper extremity. Early
use of arterial shunting has been described to minimize
muscle ischemia time. 6 , 38 , 49 It is critical to minimize warm
ischemia time to less than 4 hours to avoid muscle necro-
sis. Intravenous tubing or carotid shunts can be used to
infuse and return blood to and from the amputated part
( Figure 54-8 ). Fasciotomies are required with major limb
replantation and can be performed during the shunting
reperfusion to save time. Bone shortening may avoid the
need for nerve and vein grafting and allow for soft tissue
closure over the repairs. With humeral level replantations,
the brachial artery and brachial venae commitante are
repaired. The ulnar, median, and radial nerves are repaired.
The skin is lightly re-approximated. Skin grafts are usu-
ally required for defi nitive closure. These upper extremity
replantations may require several operating room debri-
dements at 48-hour intervals to remove devascularized
nonviable muscle at the amputation level. Amputations
at this level often denervate the biceps muscles and later
require latissimus or pectoralis muscle transfers to provide
for active elbow fl exion.

REPLANTATION AND REVASCULARIZATION • 641
FIGURE 54-5. This patient had his thumb amputated by a saw. (A) There was an
oblique fl ap that obstructed the view of the ulnar digital artery. A digital artery graft was
therefore used. (B) The vein graft was harvested from the distal volar wrist. (C) The graft
was reversed and repaired to the ulnar digital artery on the back table, which provided
a uniform fi eld of focus and fl at resting surface for the microsurgery. Then the proximal
end of the vein graft was carefully passed into the snuffbox. The ulnar digital nerve was
repaired. (D) Then the osteosynthesis was completed in retrograde fashion passing
K-wires distal to proximal. Then the radial digital nerve and two dorsal veins were repaired.
The fl exor and extensors did not require repair as the IP joint was fused. (E, F) These
photos demonstrate the thumb replant after suture removal at 8 weeks post replant.
A
B
C
D
E
F

642 • CHAPTER 54
A
B
C
D
FIGURE 54-6. (A, B) This patient amputated his thumb with a rope in a boating
accident. The replantation actually involved repairs at two levels. First K-wires were
placed in the amputated part. (C) The structures were identifi ed on the back table and
the bone was shortened. Repairs were performed on the amputated part fi rst on the
back table. Two dorsal veins, the ulnar aspect digital artery and nerve, were repaired in
the amputated part with the microscope on the back table. (D) The ulnar aspect digital
artery of the amputated part was repaired to the proximal end of the ulnar aspect digital
artery on the stump side with the microscope before osteosynthesis to avoid the struggle
for exposure often requiring extreme hand pronation. The digital nerve was repaired.
The osteosynthesis was performed carefully passing the K-wires distal to proximal.

REPLANTATION AND REVASCULARIZATION • 643
E
F
G
FIGURE 54-6. (continued ) (E, F) The amputated part, extensor pollicis longus
tendon, and two dorsal veins were repaired to the stump, before removing digital artery
clamps proximal and distal to the microanastomosis. Leaving the clamps maintains
hemostatic control and better exposure for the vein repairs. Lastly, the fl exor pollicis
longus tendon core sutures are carefully tied and the skin is loosely approximated.
(G) This photo shows survival of the thumb replant at 12 weeks postoperative.

644 • CHAPTER 54
Hand Replantation
In performing hand replantations, the vessels, nerves, and
tendons are identifi ed and tagged and K-wires are placed
in the retrograde fashion into the amputated part. This
can be done prior to the patient being transported to the
operating room, at the back table, shortening operative
time. Similarly, the ischemia time can be minimized by
shunting, during which fasciotomies can and should be per-
formed prophylactically. The most time-consuming com-
ponent of a hand replant is tendon repairs. The exposure
A
B
D
C
FIGURE 54-7. (A) This 50-year-old man amputated all four of his fi ngers in a
printing press at work. (B–D) Each fi nger is replanted separately to minimize warm
ischemia time. Two dorsal veins and one digital artery were repaired for each fi nger in
the dorsal and volar sequence described by O’Brien.31 The fi ngers were replanted in
order of functional importance. We repaired this patient’s index fi nger last because the
amputation level was the proximal interphalangeal level and would be less functional. All
four replantations survived.

REPLANTATION AND REVASCULARIZATION • 645
FIGURE 54-7. (continued ) (E, F) He did require a tenolysis procedure and
correctional osteotomy of index fi nger to regain greater than 50% total active motion.
(G) He even created this glove, which he uses to help lift weights.
E
F
G
of the proximal fl exor tendon ends can be optimized by
placing a longitudinal incision up the midportion of the
forearm. Also, tagging of the proximal and distal fl exor
tendon ends before the osteosynthesis can facilitate the
repair of the fl exor tendons later. It is important to under-
stand the stacked array of the fl exor tendons with the mid-
dle and ring fl exor digitorum sublimis tendon volar to the
index and small fi nger superfi cialis fl exors. Replantation
of hand amputations at the wrist level may necessitate
bone shortening with a proximal row carpectomy to avoid
nerve and vein grafts. Overall, the ulnar and radial arter-
ies, four veins, median, ulnar, and superfi cial radial nerves
are repaired as well as many tendons as possible. At least
the four fl exor digitorum profundus tendons, fl exor carpi
radialis, fl exor carpi ulnaris, four extensor digiti commu-
nis tendons, extensor carpi ulnaris, extensor carpi radialis,
extensor pollicis longus, and fl exor pollicis longus should
be performed. In general, replantations at this level can
achieve very good results.
COMPLICATIONS
Postoperative care has traditionally included warming the
patient’s room to avoid vasospasm and positioning the
extremity at the heart level to minimize edema but not
compromise arterial or venous fl ow. Anticoagulation is
generally not needed. Several investigators recommend the
routine use of aspirin and dextran with replantation 31 , 59 , 60
and therapeutic heparin for crush avulsion injuries. 49 , 59
Depending on the mechanism of injury, antibiotics may be
continued. Patients are encouraged to abstain from smok-
ing and caffeine use for 1 month. 61 , 62 The replanted part is
monitored by checking color, capillary refi ll, tissue turgor,
and temperature. Sympathetic blocks have been described
for high-risk replantations after crush avulsion injuries. 47
Venous insuffi ciency is considered to be the most com-
mon cause for replantation failure. Venous congestion
should be suspected with rapid capillary refi ll, increased
tissue turgor, or bleeding of wound edges. 59 Treatment
of venous congestion includes removal of tight dressings
and sutures and increasing elevation to promote venous
drainage with gravity. Leeches are also effective at treat-
ing venous congestion in replantation. Nail plate removal
and application of a heparin-soaked sponge to the nail
bed has been described for distal replantations when a
vein cannot be repaired and the patient refuses leeches. 63
Operative revision can be considered, but is less successful
than re-exploration for arterial insuffi ciency. Arterial insuf-
fi ciency is suggested by decreased capillary refi ll, tissue
turgor, and temperature. Treatment of arterial insuffi ciency
includes removal of potentially constricting dressing and
tight sutures, decreasing extremity elevation to promote
infl ow with gravity, and sympathetic blockade. Finally,
early operative intervention can be considered if there is
no improvement with the above measures. Re-exploration
to correct arterial insuffi ciency has been reported to be
successful in 50% of return visits. 31 , 59 The most common
complication of a digit replant is cold intolerance. The

646 • CHAPTER 54
FIGURE 54-8. (A, B) This 40-year-old man amputated his left arm in a rollover
car accident. His amputated arm was found in a ditch, 30 feet in front of him and his
upside-down car. The arm was brought to the operating room before the patient was
extensively irrigated. Neurovascular structures to be repaired were identifi ed and labeled.
The humerus was shortened enough to allow for skin approximation over the repairs.
(C) Then, osteosynthesis was performed with a 4.0 compression plate. The use of carotid
shunts to and from the amputated part minimized the total ischemia time to 3 hours.
(D) During this shunting reperfusion, forearm and hand fasciotomies were performed.
(E) Then, the brachial artery was repaired. Then, the median, ulnar and radial nerves
were coapted. (F) At 48-hour intervals for 2 weeks, he returned to the operating room for
debridement of portion of the triceps, distal deltoid, and biceps muscles and skin edges.
E
F
A
B
C
D

REPLANTATION AND REVASCULARIZATION • 647
most common complication of a major limb replant is
systemic infection from devitalized muscle. If leeches are
required, patients need to be prophylactically treated with
antibiotics active against Aeromonas hydrophila, which is
endogenous to the leech gut.
OUTCOMES AND ASSESSMENT
The overall success rates for replantation approach 80%.
In reviewing a number of retrospective reports with large
patient numbers, these success rates range from 54% to
82%. The Overall, success rates are signifi cantly higher
for replantations of guillotine (77%) versus crush ampu-
tations (49%). 31 , 59 Several studies have demonstrated that
approximately 50% achieve two-point discrimination less
than 10 mm. 64 – 68 Glickman reviewed 12 series of digit
replantations conducted between 1977 and 1989. Of the
327 fi ngers and 87 thumbs successfully replanted, overall
mean two-point discrimination was 12 mm in fi ngers and
11 mm in thumbs. 69 In general, younger patients with distal
guillotine amputations experienced better return of sensa-
tion. Several studies have determined the average replant to
achieve 50% of normal function (ie, 50% total active motion
and 50% grip strength). 66 , 70 – 72 Return of function was worse
for zone II injuries and for patients of advanced age. Russell
published the largest review of major limb replantations
and found 11/24 achieved greater than 50% total active
motion, and 19/24 patients were satisfi ed with the function
and appearance of their replanted part. 35
Jupiter showed the function of replanted digits could be
signifi cantly improved with tenolysis procedures. 73 In his
review, the total active motion of 37 replanted digits was
signifi cantly improved ( P , 0.001) with tenolysis and no
digits were lost. 73
SUMMARY
With the evolution of microsurgical techniques, replanta-
tion has become a common approach to the treatment of
amputation and devascularizing injuries, potentially pro-
viding superior results to other reconstructive options.
Replantation and revascularization should be attempted
for thumb, multiple digit, hand, wrist, and upper arm inju-
ries. Techniques which allow for optimizing microsurgical
exposure, back table microsurgery, rituals for preparation,
techniques for minimizing ischemia times, and avoiding
the need for grafts can maximize success rates and func-
tional return for amputation and devascularizing injuries.
Patient satisfaction rests on their level of expectation as
defi ned and explained in the preoperative discussion and
informed consent. Studies have demonstrated patients can
be expected to achieve 50% function and 50% sensation
of the replanted body part. Initially, all that was ampu-
tated was replanted, as surgeons adopted the philosophy
of George C. Ross (1843–1892): “Any fool can cut off an
arm or leg but it takes a surgeon to save one.” However,
more than 50 years after the fi rst replant in 1962, we rec-
ognize the ultimate goal—not merely to preserve all liv-
ing tissue through nonselective replantation, but rather to
preserve one’s quality of life by improving their function
and appearance.
FIGURE 54-8. (continued ) (G) At 2 months post-
operatively, he did not have any open areas or evidence of
nerve regeneration. He later required a muscle transfer with
latissimus dorsi for active elbow fl exion.
G
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648 • CHAPTER 54
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c h a p t e r55
Tendon Transfers
Paul A. Martineau, MD, FRCSC / Thomas Trumble, MD
BACKGROUND
The indications for tendon transfer are to replace func-
tional motor loss in cases where nerve, tendon, or muscle
repair is impossible or unlikely to succeed, to augment
diminished and functionally insuffi cient muscle power,
or to restore the delicate balance between the fl exor and
extensor systems of the hand.
Muscle Physiology
The physiologic parameters of the injured muscle being
replaced as well as those of the muscle to be transferred
must be taken into account when designing a tendon
transfer. The more closely the muscle and tendon to be
transferred approximate the physiologic parameters of the
muscle being replaced, the more likely the tendon transfer
is to succeed. 1
Muscle Force. Muscle force is proportional to the cross-
sectional area of the muscle. In essence, this represents
the summation of the force generated by each individual
muscle fi ber participating in a contraction.
Excursion . Excursion is proportional to the fi ber length
of the muscle. As a practical guideline, the excursion of
different muscles can be estimated using the 3-5-7 rule.
Muscles attaching at the level of the wrist have approx-
imately 3 cm of excursion; motor units attaching at the
level of the metacarpophalangeal (MCP) joint have 5 cm
of excursion; and motor units attaching at the level of the
fi nger tips have 7 cm of excursion.
Work. Work produced by a muscle is proportional to the
volume of the muscle. Work integrates muscle excursion
and force to produce work capacity.
Muscle Fiber Geometry. Muscle fi ber geometry can
infl uence the previously mentioned physiologic parame-
ters. For example, muscle length is proportional to muscle
fi ber length in spindle-shaped muscles. However, pennate
muscles generate more power with shorter fi ber length
and less excursion because they are made up of a converg-
ing pattern of muscle fi bers.
Blix Curve. The relationship between muscle length
and force was described by Magnus Blix. The Blix curve
combines the length tension curves of a muscle being
passively stretched and undergoing active contraction.
The Blix curve was subsequently modifi ed by Brand
to take into account the energy stored by stretching
the fi ber length of antagonistic muscles ( Figure 55-1 ). 1
The curve refl ects the normal function of a muscle, as it
would function in a clinical setting with an antagonistic
muscle.
PRINCIPLES OF TENDON TRANSFERS
In 1922, Starr published the principles of tendon trans-
fer surgery. 2 These principles are so frequently reiterated,
that their importance may be forgotten. However, these
principles remain essential to successful tendon trans-
fers. They can be paraphrased into the following key
principles:

1. One muscle, one function: if a muscle is asked to
perform more than one task, it will only move the
joint which has the tightest attachment.

2. The tendon transfer should have as straight a line of
action as possible, and the directions should parallel
that of the muscle fi bers of the damaged or para-
lyzed muscle that is to be replaced.

652 • CHAPTER 55

3. It is important to try to use a muscle that has excur-
sion equal to or greater than that of the injured
motor unit. However, it may not always be possible
to replace the excursion of some muscles such as
fl exor digitorum profundus (FDP) due to its tre-
mendous excursion.

4. The muscle should have the capacity of generating
a force of contraction similar to that of the injured
muscle. Replacing a strong motor with a weak one
can result in poor functional outcome.

5. The tenodesis action of the wrist should be pre-
served. A wrist arthrodesis should only be combined
with tendon transfers as a measure of last resort.
The normal tenodesis effect of the wrist passively
extends the fi ngers with the wrist maximally fl exed
and passively fl exes the fi ngers with wrist exten-
sion. The tenodesis effect enhances the function
of tendon transfers and even allows many tendon
transfers to work statically, even though they do not
actively contract.

6. Power versus positional muscles: even though some
motors may be quite strong, their main function
may be only to provide position. For example, the
thumb abductor pollicis brevis (APB) is predomi-
nantly a positional muscle to set the thumb in
opposition. Once the thumb is placed in this posi-
tion of opposition for grasping objects, the powerful
fl exor and adductor muscles then take over to pro-
vide the power pinch and grip. Therefore, occasion-
ally even fairly weak motors can be used as transfers
to replace the function of positional muscles.

7. Correction of contracture: maximum passive range
of motion of the joints must be achieved before any
tendon transfer is attempted because no tendon
transfer will move a stiff contracted joint.

8. Expendable donor motor for transfer: the harvest-
ing of a donor for transfer must not result in unac-
ceptable loss of function.

9. The effect of the tendon is determined by two vari-
ables: tension of the tendon and the moment arm or
perpendicular distance of the tendon from the axis
of rotation.
10. Tendon transfers should not pass through areas of
scar tissue or beneath skin grafts.
11. Synergism between the transferred motor and the
original motor may facilitate rehabilitation.
TENDON TRANSFERS FOR RADIAL,
MEDIAN AND ULNAR NERVE PALSIES
Tendon transfers are divided according to the specifi c
motor nerve they are designed to replace. Tendon transfers
are then classifi ed into those to reconstruct high (elbow)
level injuries to nerve or low (wrist) level injuries to nerve.
They can be further subdivided into transfers for single
nerve injury or combined nerve injuries.
Radial Nerve Palsy
Low Radial Nerve Palsy. Low radial nerve palsy occurs
as a result of injury to the posterior interosseous nerve.
Functional loss incurred as a result of this injury includes
the loss of fi nger extension as well thumb extension. These
patients maintain active wrist extension albeit with radial
deviation of the wrist due to the paralysis of the extensor
carpi ulnaris and the unopposed action of the extensor
carpi radialis longus (ECRL) and brevis (ECRB). Patients
with complete radial nerve palsy have a wrist drop, in
FIGURE 55-1. The Brand modifi cation of the Blix curve
integrates the active contraction and the elastic recoil of the
Blix curve as well as the elastic curve of the opposing muscle
subtracted from the active output of the primary muscle.
(Redrawn from Trumble TE. Principles of Hand Surgery and Therapy.
Philadelphia: WB Saunders; 2000.)
Length-tension curve
Length
Total tension
Blix curve
Contractile force
Contractile force
Passive
Passive
Resting length
Resting length
stretch
stretch
Blix curve
modified by
brand
Normal functional
region
Tension
Total tension
Passive stretch
opposing muscle
Total tension
composite pair
of muscles

TENDON TRANSFERS • 653
addition to having the loss of function of the posterior
interosseous nerve innervated motors.
There exist multiple potential options for tendon trans-
fers to reconstruct low radial nerve palsies. The three
most common transfers are the Brand, Jones and Boyes
transfers.
Technique
Brand Tendon Transfer
Wrist extension
Pronator teres-ECRB
Thumb extension
Palmaris longus-extensor pollicis
longus (EPL)
Finger extension
Flexor carpi radialis (FCR)-extensor
digitorum communis (EDC)
A longitudinal incision is made along the radial aspect
of the forearm. The wrist extensors are retracted radially
and the pronator teres is detached from the radius tak-
ing a strip of periosteum to provide additional length for
the tendon weave. Two passes using a Pulvertaft weave
technique provide the maximal amount of strength with
a minimal amount of bulk at the repair site. The proper
tension is applied to the pronator teres to ECRB trans-
fer site to allow for neutral resting position of the wrist in
the fl exion/ extension plane with the forearm suspended
( Figure 55-2 ). It is important to note that the transfer
of pronator teres to ECRB for wrist extension will pro-
duce some degree of radial deviation concurrently with
FIGURE 55-2. An incision along the radial border of the
forearm allows for exposure of the pronator teres (PT) after
the extensor carpi radialis brevis (ECRB) and longus (ECRL)
have been retracted dorsally. The pronator teres is woven into
the ECRB to reestablish wrist extension. BR, brachioradialis;
EDC, extensor digitorum communis; R, radius. (Redrawn from
Trumble TE. Principles of Hand Surgery and Therapy . Philadelphia:
WB Saunders; 2000.)
ECRB
ECRB
ECRL
ECRL
EDC
BR
BR
R
R
PT
PT
FIGURE 55-3. The extensor pollicis longus tendon is
transected proximally while the palmaris longus is transected
distally. A Pulvertaft weave is performed securing the
palmaris longus to the extensor pollicis longus to reestablish
thumb interphalangeal joint extension. (Redrawn from Trumble
TE. Principles of Hand Surgery and Therapy . Philadelphia: WB
Saunders; 2000.)
EPL cut
EPL
EPL withdrawn from
3rd compartment
PL
PL
extension since the ECRB is attached to the radial side of
the long fi nger metacarpal. In order to obtain pure wrist
extension, the insertion of the ECRB has to be centralized
to the dorsum of the metacarpal.
The palmaris longus to EPL transfer is performed after
detaching the palmaris longus from its insertion onto the
palmar fascia via a small transverse incision at the level
of the distal wrist crease. After dividing the insertion of
the palmaris longus, the tendon is mobilized and brought
out through a dorsal radial incision. The EPL is identi-
fi ed after the third dorsal compartment is released using
a dorsal midline incision. The EPL is divided as far proxi-
mally as possible, at its musculotendinous junction, and
the sheath of the third dorsal extensor compartment is
released such that the tendon may be displaced toward
the palmar side of the thumb ( Figure 55-3 ). The proper
tension for the transfer is determined by pulling the pal-
maris longus musculotendinous unit out to full length
with traction and marking the underlying tissues with an
indelible marker. Next, the palmaris longus musculoten-
dinous unit is allowed to passively retract and this new
length is marked. Finally, the EPL tendon is secured to the
palmaris longus using a Pulvertaft weave at approximately
half the resting length of the palmaris longus tendon. This
should result in the palmaris longus to EPL transfer being
placed in suffi cient tension to bring the interphalangeal
(IP) of the thumb to neutral position with the wrist having
previously been set in neutral position by the transfer of
pronator teres to ECRB.
The FCR to EDC transfer is then performed to provide
fi nger extension. The FCR is identifi ed and detached at the
level of the distal wrist crease. It is transferred to the dorsal
aspect of the distal forearm ( Figure 55-4 ). In similar fashion

654 • CHAPTER 55
to the transfers for wrist extension and thumb extension,
the tension must be adjusted for the FCR to EDC transfer
to provide fi nger extension. The tension should be set with
the fi ngers fully extended with the wrist at neutral exten-
sion, taking care to ensure that all the fi ngers are in the
same amount of extension. The tension must be set in the
wrist extensor (pronator teres to ECRB) transfer prior to
setting the tension for the fi nger extension transfer. The
extensor digiti minimi should be included with the ten-
dons of EDC because 80% of patients lack a separate ten-
don of the EDC to extend the small fi nger. The FCR is split
longitudinally and placed on either side of the digit exten-
sor tendons such that they can be sutured together using
a mattress stitch in a sandwich confi guration technique.
Although the sandwich technique is not quite as strong as
the Pulvertaft technique, it does allow for more accurate
alignment of the digits to avoid having the fi ngers extend-
ing to different degrees and creating scissoring or extensor
lag. In cases of irreversible nerve injury, we recommend
cutting the digit extensors at the level of the musculoten-
dinous junction to perform an end-to-end tendon transfer
instead of a side-to-side transfer.
Jones Tendon Transfer
Wrist extension
Pronator teres-ECRB
Thumb extension
Palmaris longus-EPL
Finger extension
Flexor carpi ulnaris (FCU)-EDC
The only difference between the Jones and Brand
transfers lies in the use of the FCU to the digit exten-
sors as opposed to the FCR. Similar to the Brand trans-
fer described above, the tension must fi rst be set in the
tendon transfer for wrist extension. The pronator teres
to ECRB and palmaris longus to EPL transfers are per-
formed and adjusted and then the FCU is exposed and
EDC
ECRL
ECRB
FCR
PT
Brand transfer
FIGURE 55-4. The fl exor carpi radialis tendon is
transferred dorsally and split into two tails so that it can be
attached in a side-to-side fashion to all four of the fi nger
extensor tendons. The extensor digiti minimi to the small
fi nger is used as a recipient tendon in this transfer because
the extensor digitorum communis to the small fi nger is
frequently absent. (Redrawn from Trumble TE. Principles of Hand
Surgery and Therapy . Philadelphia: WB Saunders; 2000.)
detached through a distal incision centered over the pisi-
form. The FCU tendon is brought out through a sepa-
rate incision on the ulnar border of the forearm at the
junction of the distal and middle thirds of the forearm.
The fi nger extensor tendons are identifi ed using a dor-
sal midline incision. The FCU is passed into this midline
incision and sutured to the EDC using a sandwich tech-
nique. Many surgeons are reluctant to sacrifi ce the FCU
to provide fi nger extension because it is the most power-
ful motor in the wrist.
Modifi ed Boyes Tendon Transfer
Wrist extension
Pronator teres-ECRB
Thumb extension
Palmaris longus-EPL
Finger extension
Flexor digitorum superfi cialis (FDS)
IV-EDC
The original Boyes tendon transfer used the long fi nger
FDS III for fi nger extension and the ringer fi nger FDS IV
for extension of the thumb and the index fi nger. 3 The FDS
IV was split and one half was transferred to the EPL and
one half to the extensor indicis proprius (EIP) in order to
attempt to achieve independent thumb and index fi nger
extension.
The modifi cation of the Boyes tendon transfer pre-
sented here takes into consideration Starr’s principle that
one transferred motor cannot provide two independent
functions. Therefore, the modifi ed Boyes transfer does
not attempt to combine thumb extension and index fi n-
ger extension. The palmaris longus to EPL transfer as
described for the Brand transfer is used to provide thumb
extension with minimal added morbidity, whereas FDS
IV is used to provide fi nger extension (FDS IV to EDC).
The FDS IV is used rather than FDS III for restoring fi n-
ger extension because FDS III plays an important role in
power grip activities. FDS IV provides more than ample
power for extension of all four fi ngers. The wrist extension
pronator teres to ECRB transfer is performed as described
previously. FDS IV is harvested through a transverse inci-
sion at the distal palmar crease. A longitudinal incision
is made along the dorsum of the distal forearm and the
FDS IV is then transferred to the EDC using a sandwich
technique.
Rehabilitation After Tendon Transfers for Radial Nerve
Palsy. A long arm splint is used to maintain the elbow
at 90 degrees of fl exion, the wrist at 15 to 20 degrees
of extension and the MCP joints in 30 degrees of fl exion
with the proximal interphalangeal (PIP) joints in com-
plete extension. Two weeks after surgery, the patient is
placed in a below elbow splint and hyperextension exer-
cises of the MCP joints that allow PIP fl exion are begun
to prevent digit stiffness. At 4 weeks, the plaster splint
is removed and the patients are started on fi nger fl exion
exercise with a dynamic extension splint, which is worn
for an additional 2 to 3 weeks. The dynamic splint holds
the wrist in 30-degree extension and provides fi nger and
thumb extension.

TENDON TRANSFERS • 655
Ring
finger
FDS
APB
APB
FDS
FIGURE 55-5. The tendon transfer of the fl exor digitorum superfi cialis of the
ring fi nger to the abductor pollicis brevis reestablishes thumb opposition. (Redrawn
from Trumble TE. Principles of Hand Surgery and Therapy . Philadelphia: WB Saunders; 2000.)
Median Nerve Palsy
Low Median Nerve Palsy. Low median nerve injuries
are common because of the exposed position of the
median nerve in the distal forearm. The major functional
defi cit resulting from a low median nerve palsy involves
the loss of thumb opposition. Opposition of the thumb
is a complex motion involving abduction, fl exion, and
pronation. The goal of tendon transfers in this setting are
mainly to reconstruct the course of the fi bers of the APB. 4
With respect to the APB, it is important to understand that
the vector of the APB intersects the pisiform. Therefore,
tendon transfers that are distal to the pisiform result in
more thumb fl exion than opposition, whereas transfers
proximal to the pisiform provide more thumb palmar
abduction. The two most commonly used tendon transfers
to compensate for the loss of thumb opposition include the
use of EIP or FDS IV as donor motors. However, of the two,
the FDS IV tendon transfer more closely approximates the
line of pull of the APB.
Technique
FDS IV Tendon Transfer for Opposition. The FDS IV ten-
don is harvested through a transverse incision at the level
of the distal palmar crease. This tendon transfer requires
a pulley near the pisiform to recreate the line of pull of
the APB muscle. The pulley can be created by fashioning
a hole in the palmar fascia just radial to the pisiform. An
alternate technique for creation of a pulley involves the
use of the FCU to make a tendon loop. A distally based
slip of the FCU tendon is mobilized and sutured back onto
itself to fashion the pulley.
A separate curvilinear incision is made over the radial
aspect of the thumb at the site where the APB inserts onto
the base of the proximal phalanx. The FDS IV tendon
is then passed through the pulley that has been created and
tunneled through the subcutaneous tissue across the palm.
The FDS IV is then inserted through the APB tendon and
sutured back upon it ( Figure 55-5 ). Although the trans-
fer of one half of the FDS tendon is classically described,
we have used the complete FDS tendon to the APB with
favorable results.
EIP Transfer for Thumb Opposition. This popular trans-
fer is performed by transferring EIP around the ulnar side
of the forearm to the APB. A curved incision is made over
the dorsum of the index fi nger MCP joint. A second inci-
sion is made over the dorsum of the wrist and the EIP
tendon is withdrawn through this incision. A third inci-
sion is made over the ulnar border of the forearm. Finally,
an incision over the APB insertion on the radial side of
the thumb MCP joint is prepared and the EIP is passed
through a subcutaneous tunnel across the palm from the
ulnar side of the forearm to the incision on the thumb. The
ulna functions as the pulley in this tendon transfer. The
EIP tendon is woven through the insertion of the APB and
secured with horizontal mattress sutures ( Figure 55-6 ). A
strip of the extensor hood mechanism must be included
with the harvested EIP if the tendon is to supply enough
length to complete the transfer.
Palmaris Longus Transfer for Opposition. The Camitz
palmaris longus tendon transfer for opposition pro-
vides mostly palmar abduction because the vector of the

656 • CHAPTER 55
palmaris longus is proximal to the pisiform. This transfer
has been used effectively in patients who have had paraly-
sis of the APB as a result of long standing carpal tunnel
syndrome. 5 The use of an extended carpal tunnel incision
provides excellent exposure to mobilize the palmaris lon-
gus tendon with a strip of palmar fascia to provide suffi -
cient length for the transfer. The palmaris longus tendon is
then passed through a subcutaneous tunnel to an incision
over the radial border of the thumb MCP joint where it is
sutured into the ABP insertion.
Abductor Digiti Minimi (ADM) Transfer for Opposition.
The Huber transfer is occasionally used for adults with low
median nerve palsy, but its main use lies in reconstruction
of the congenital hypoplastic thumb. 6
A longitudinal incision is made along the ulnar border
of the hand. Since the neurovascular bundle to the ADM
enters proximally, the muscle can be mobilized over nearly
its entire length. A second incision is made over the radial
border of the thumb MCP joint to expose the insertion of
the APB. The tendon of the ADM is inserted into the ABP
tendon after having been passed through a subcutaneous
tunnel.
Rehabilitation After Tendon Transfers for Low Median
Nerve Palsy. After tendon transfers for thumb opposition,
the hand is immobilized in a thumb spica cast that main-
tains the thumb in a position of opposition for 4 weeks
with the wrist held in fl exion for the FDS IV and the pal-
maris longus tendon transfers. The wrist can be maintained
in neutral position for the EIP tendon transfer. Wrist posi-
tion does not have an effect for the ADM transfer. After
4 weeks of immobilization in plaster, the patient is placed
in a removable splint and begins active thumb opposition
exercises. Strengthening exercises are started 2 months
after surgery.
Cut EIP with
portion of hood
EDC
EIP
U
EIP around
pisiform
APB
FIGURE 55-6. Transferring the extensor indicis proprius (EIP) around the ulnar
border of the forearm to the abductor pollicis brevis (APB) provides opposition of the
thumb. It is important to remove the EIP tendon elongated by a strip of the extensor hood
mechanism to provide adequate length to reach the insertion of the APB. EDC, extensor
digitorum communis; U, ulna. (Redrawn from Trumble TE. Principles of Hand Surgery and
Therapy . Philadelphia: WB Saunders; 2000.)

TENDON TRANSFERS • 657
High Median Nerve Palsy
High median nerve injuries involve a loss of fl exion of
the index fi nger, long fi nger and thumb due to the paraly-
sis of the FDP to fi ngers II and III and the fl exor pollicis
longus (FPL). However, since the FDP to the long fi nger
receives dual innervation from the median and ulnar nerve,
patients usually maintain some fl exion of the long fi nger
albeit weaker than in the ring fi nger.
When the ulnar nerve is intact, side to side transfer of
the index and long fi nger FDP to the FDP of the ring and
small fi ngers is a simple and effective way of restoring fl ex-
ion. In cases of combined high median nerve palsy and
ulnar nerve injury, a transfer of the ECRL can provide fl ex-
ion for all four digits. In both isolated high median palsy
and combined median and ulnar palsies the transfer of bra-
chioradialis is useful as a transfer to the FPL for thumb IP
joint fl exion.
Technique
Side-to-Side Transfers of FDP IV and V to FDP II and
III. A longitudinal incision on the volar aspect of the dis-
tal forearm provides suffi cient exposure of the profundus
tendons. The FDS tendons are retracted radially along with
the median nerve to expose the FDP tendons. Transverse
sutures locking the four FDP tendons together are per-
formed with care taken to make sure that the fi ngers are
correctly positioned with the normal fl exion arcade.
ECRL to all Four Fingers. An incision is made that curves
proximally from the radial aspect of the distal third of
the forearm to the mid aspect of the volar wrist crease.
A separate transverse incision is necessary over the sec-
ond dorsal compartment near the base of the index fi nger
metacarpal in order to transect the insertion of the ECRL.
The ECRL tendon is then transposed to lie parallel to the
fi bers of the FDP.
Brachioradialis to FPL. The brachioradialis to FPL trans-
fer can be added to either of the aforementioned tendon
transfers to restore digit fl exion. The BR is sharply elevated
from its insertion onto the radial border of the radius after
releasing the fi rst dorsal compartment underneath which
the BR inserts. The tendon can then be split and sutured to
the FPL using a Pulvertaft weave.
Rehabilitation After Tendon Transfers for High Median
Nerve Palsy. Patients are splinted for 4 weeks following
a thumb opposition transfer with the thumb held in its
position of opposition during the period of immobiliza-
tion. When tendon transfers for digit fl exion are added,
the wrist is immobilized in neutral position with the MCP
joints held in fl exion and the IP joints blocked in exten-
sion using a dorsal block splint. A program of passive digit
range of motion exercises can be used during the period of
immobilization of the hand and wrist to prevent stiffness
of the IP joints. Active fl exion exercises are started 4 weeks
after surgery, beginning with place and hold exercises with
the wrist in fl exion. At 6 weeks, the patients are allowed to
begin wrist extension and active fi nger fl exion.
Ulnar Nerve Palsy
The ulnar nerve innervates the majority of the hand intrin-
sic muscles, which provide the fi ne control for gripping
and pinching activities.
Low Ulnar Nerve Palsy. The functional defi cits result-
ing from a low ulnar nerve injury include clawing, loss of
power pinch and persistent abduction of the small fi nger.
The paralyzed muscles following ulnar nerve palsy include
the dorsal and palmar interossei, the lumbricals to the ring
and small fi nger, the adductor pollicis, and the hypothenar
muscles.
Correction of Clawing. With the loss of intrinsic func-
tion, clawing occurs because of unopposed action of the
extrinsic muscles supplying primary extension at the
MCP joints and fl exion of the distal interphalangeal and
PIP joints. Clawing produces a roll-up deformity of the
hand that makes it diffi cult to grasp objects of different
diameters.
In a low ulnar nerve palsy, the index and middle fi ngers
do not demonstrate clawing because the lumbricals to these
two fi ngers are innervated by the median nerve. Clawing
does not occur in a high ulnar nerve palsy because the FDP
to the small and ring fi ngers are also paralyzed with this
injury. Therefore, the imbalance between the extrinsics
and intrinsics muscles seen in low ulnar nerve palsy
does not occur. However, patients with high ulnar nerve
palsy lack the ability to fl ex the distal interphalangeal
joints of their small and ring fi ngers to complete grasping
functions.
Technique
Transfer of FDS IV to the Lateral Bands or Proximal
Phalanges of the Small and Ring Fingers. This ten-
don transfer is very effective for patients who have and
isolated low ulnar nerve palsy. A Brunner incision is used
to expose the FDS IV tendon at the level of its insertion
onto the middle phalanx with a radially based fl ap such
that the same approach can be used to expose the lateral
band on the radial side of the fi nger. If the tendon is to
be inserted onto the base of the proximal phalanx, then
a smaller Brunner incision is required to expose the FDS
tendon and a separate incision can be made at the level
of the distal palmar crease in order to retrieve the FDS
tendon from the ring fi nger proximal to the fi bro-osseous
sheath. The FDS tendon is then split longitudinally. The
tails are passed deep to the neurovascular bundles, but pal-
mar to the transverse intermetacarpal ligaments in order
to reconstruct the pull of the lumbrical muscles. One tail
is passed to the ring fi nger and the other tail is passed to
the small fi nger. The tendons can then be woven into the
lateral bands with enough tension to produce MCP joint

658 • CHAPTER 55
FIGURE 55-7. The fl exor digitorum superfi cialis tendon transfer to the lateral bands
of the small and ring fi nger corrects the claw deformity. (Redrawn from Trumble TE. Principles
of Hand Surgery and Therapy . Philadelphia: WB Saunders; 2000.)
Split FDS to little
finger and ring
finger tendon
sheaths
Split FDS to little
finger and ring
finger tendon
sheaths
fl exion and PIP joint extension ( Figure 55-7 ). Although
some authors recommend attaching the tendons to bone,
attachments to the lateral bands have been successful in
the senior authors’ experience.
Zancolli Lasso Procedure. Zancolli recommended a
modifi cation of the FDS to intrinsic transfer that would
function as a static tenodesis to provide MCP joint fl exion.
This technique is particularly useful in patients who have
paralysis of muscles other than those affected by the ulnar
nerve palsy.
The Zancolli modifi cation procedure is performed
in a manner very similar to the FDS to intrinsic transfer
described above, except that the slips of the FDS are passed
through the interval between the A1 and A2 pulleys. The
lasso is made by suturing the tendon slip back onto itself in
order to provide MCP joint fl exion that allows the patient’s
extrinsic extensor tendons to direct their force to the PIP
joint rather than the MCP joint. This tenodesis produces
a fi xed MCP joint contracture for the ability to grasp both
small and large diameter objects.
Brand Tendon Transfer of the ECRB to the Intrinsics.
The Brand tendon transfer for the intrinsics can be per-
formed to all four digits in patients who have combined
clawing involving all the fi ngers, such as in a C8-T1 plexus
injury or combined low median and low ulnar nerve pal-
sies. The Brand intrinsic tendon transfer is also valuable
when there has been trauma involving the fl exor ten-
dons because the surgeon can avoid the area of scar tissue
and the uncertainty of whether the transferred tendons
will glide.
The ECRB is identifi ed using a small transverse inci-
sion over the third metacarpal. A second incision is made
proximal to the extensor tendon retinaculum such that
the ECRB can be withdrawn through the proximal inci-
sion. This tendon transfer does require elongating the
ECRB using a tendon graft such as the palmaris longus or
the plantaris tendon passed through the distal end of the
ECRB tendon. By folding the graft, a two-tailed extension
of the ECRB is fashioned to transfer to both the small
and ring fi nger. By splitting each tail further into half, a
separate tendon slip can be transferred to all four digits. A
transverse incision is made at the level of the distal palmar
crease to allow the slips of the tendon grafts to be passed
in a dorsal to palmar direction to bring them out through
the palm. The tendon grafts are then passed palmar to
the transverse intermetacarpal ligament to reconstruct the
line of pull of the lumbrical muscles. Longitudinal midax-
ial incisions are made over the radial aspect of the digits
receiving the tendon transfer. The tendon transfers are
passed through small incisions in the lateral bands mak-
ing sure that the insertion site distal and dorsal enough to
produce MCP joint fl exion as well as PIP joint extension
( Figure 55-8 ).
Rehabilitation After Tendon Transfer to Correct
Clawing. The patient is placed in a plaster splint that
maintains the MCP joints in 70 degrees of fl exion and
the PIP joints in an extended position. The wrist is

TENDON TRANSFERS • 659
maintained in slight fl exion when the FDS tendon was
used and in slight extension when the ECRB tendon was
used. The splint is maintained for 4 weeks and then a
removable hand-based splint that blocks the MCP joints
in 30 to 40 degrees of fl exion is worn. The hand-based
splint is worn for an additional 4 weeks to prevent the
tendon transfer from stretching out. Eight weeks after
surgery the patients can be started on gentle strengthen-
ing exercises.
Reconstruction of Power Pinch. Power pinch occurs
by the combined action of the adductor pollicis and the
fi rst dorsal interosseous. The adductor pollicis originates
from the index and long fi nger metacarpals and inserts on
the thumb metacarpal and functions to pull the thumb
toward the index fi nger. The fi rst dorsal interosseous
muscle arises from the thumb and index metacarpals
and attaches to the radial side of the base of the index
fi nger proximal phalanx to create a powerful scissors-
type action that pulls the index and thumb towards one
another.
Patients with low ulnar nerve palsy compensate for
the loss of these muscles by using EPL. EPL is a sec-
ondary adductor of the thumb but lacks substantial
pinch power. To achieve additional power and to place
EPL under the greatest tension, patients use FPL con-
comitantly. Hence, the result is that patients develop a
hyperfl exion of the IP joint of the thumb known as the
Froment sign.
FIGURE 55-8. The Brand tendon transfer to the intrinsics uses a tendon graft that
connects the extensor carpi radialis brevis (ECRB) tendon to the lateral bands of the
small and ring fi ngers. The ECRB tendon provides enough power for a four-tailed graft
and can be used to reestablish intrinsic function to all four digits when combined nerve
injuries have produced a complete intrinsic paralysis to the hand. (Redrawn from Trumble
TE. Principles of Hand Surgery and Therapy. Philadelphia: WB Saunders; 2000.)
Tendon
grafts
ECRB
ECRL
Technique
ECRB to Adductor Pollicis with Tendon Graft. The
Smith transfer is an excellent transfer for reconstructing
power pinch, partly because wrist extension is a synergistic
action to power pinch. This transfer spares the FDS so it
can be used for other tendon transfers such as to correct
concomitant clawing. The downside of this tendon transfer
is that it does require a tendon graft, which has the poten-
tial for stretching out or forming adhesions.
The ECRB is identifi ed through a transverse incision
over the base of the third metacarpal. A separate trans-
verse incision is made proximal to the retinaculum of the
extensor tendons. The ECRB is released from the third
metacarpal and brought out through the proximal inci-
sion. A tendon graft from palmaris longus or plantaris is
obtained and sutured into the distal end of the ECRB
using a Pulvertaft technique. 7 A third incision is made
over the ulnar aspect of the thumb MCP joint. A curved
clamp is used to pass the tendon graft around the sec-
ond metacarpal to the third incision over the ulnar aspect
of the thumb. The second metacarpal becomes the pul-
ley for this tendon transfer. The tendon graft is woven
through the adductor pollicis so that the thumb lies gen-
tly along the radial border of the index fi nger with the
wrist in neutral position with the ECRB tendon at 50%
of its maximum length ( Figure 55-9 ). As a check on ten-
sion of the transfer the thumb should abduct as the wrist
goes into fl exion and adduct against the index as the wrist
moves into extension. 7

660 • CHAPTER 55
FDS IV to the Adductor Pollicis. This is a good transfer
for isolated low ulnar nerve palsies. The FDS IV provides
the necessary strength for power pinch and can easily be
directed along the course of the adductor pollicis fi bers.
When muscles other than those innervated by the ulnar
nerve have been paralyzed or when a high ulnar nerve
lesion has occurred, the surgeon may want to consider
sparing the function of the FDS IV particularly for use in
other tendon transfers.
The FDS IV tendon is harvested through a transverse
incision at the level of the PIP joint fl exion crease of the ring
fi nger in order to obtain as much length as possible for
transfer. A second incision is made at the level of the dis-
tal palmar crease and the distal end of the FDS tendon is
retrieved from this incision. The insertion of the adductor
pollicis is identifi ed using a longitudinal incision along the
ulnar border of the thumb MCP joint. The FDS tendon is
passed subcutaneously just palmar to the fl exor tendons
and neurovascular bundles. The tendon is secured to the
tendon of the adductor pollicis with a Pulvertaft tech-
nique. The tension is adjusted so that the thumb lies just
along the index fi nger with the FDS tendon at 50% of its
resting length. 8
Rehabilitation After Tendon Transfer to Reconstruct
Power Pinch. Patients are placed in a short arm splint
that maintains the thumb against the index fi nger. With
the ECRB tendon transfer, the wrist is maintained in slight
extension; whereas with the FDS tendon transfer, the wrist
is maintained in slight fl exion. Four weeks after surgery, a
removable hand-based splint is made holding the thumb in
FIGURE 55-9. In low ulnar nerve palsy, the ECRB tendon can be transferred
to the adductor pollicis to restore pinch. The tendon graft passes around the
second metacarpal, using it as the pulley for the tendon transfer. ECRB, extensor carpi
radialis brevis; ECRL, extensor carpi radialis longus; MC, metacarpal. (Redrawn from
Trumble TE. Principles of Hand Surgery and Therapy. Philadelphia: WB Saunders, 2000.)
Adductor
pollicis
Extensor
retinaculum
Tendon graft
between MC II
and MC III
Tendon
graft
ECRL
ECRB
Tendon graft routed
between adductor
pollicis and 1st
interosseous
adduction. The patient is started on gentle active exercises.
Gentle resistive exercises are started 8 weeks after surgery
and strengthening exercises are begun 10 to 12 weeks after
surgery.
High Ulnar Nerve Palsy. The major functional defi cits in
high ulnar nerve palsy include the inability to fully fl ex the
small and ring fi ngers due to paralysis of the FDP and loss
of power pinch. Clawing is not a signifi cant factor in high
ulnar nerve palsy. Tendon transfers for high ulnar nerve
palsy include transfers to the adductor pollicis to recon-
struct power pinch as well as transfers to reestablish the
function of the FDP to the small and ring fi ngers.
Tendon Transfers to Reconstruct Power Pinch.
Tendon transfers can be used as described for reconstruc-
tion of power pinch in low ulnar nerve palsy. The senior
author’s preference is to use the ECRB to the adductor
pollicis as described by Smith, since the FDS IV–based
transfers to the adductor pollicis decrease the strength of
fl exion of the ring fi nger, which is particularly apparent
in the setting of loss of FDP function in this fi nger asso-
ciated with high ulnar nerve palsy. The transfer of EIP
to the adductor pollicis is a transfer that is the “mirror
image” of EIP opponens tendon transfer, but the EIP is a
relatively weak motor that does not produce substantial
pinch strength.
Tendon Transfers to Reestablish Function of the FDP
IV and V. The side-to-side transfer of the index and mid-
dle fi nger FDP to the small and ring fi nger FDP can be

TENDON TRANSFERS • 661
performed in a manner analogous to the tendon transfers
for high median nerve palsy. For patients with an intact
median nerve, this is the preferred transfer.
Tendon Transfers for Small Finger Abduction. The
interosseous muscles are the primary muscles providing
abduction and adduction of the fi ngers. Although loss of
fi nger adduction function decreases the patients overall
hand dexterity, this is not a functional loss of high prior-
ity for reconstruction. Reconstruction of clawing and loss
of power pinch remain much more signifi cant functional
losses. The tendon transfers to the intrinsics are designed to
correct the abduction of the small fi nger by performing the
transfers to the lateral bands to the radial side of the digits.
For patients with persistent abduction of the small fi nger
despite tendon transfers to the intrinsics or in patients with
an isolated problem of small fi nger abduction, the ulnar
portion of the extensor digiti minimi can be transferred to
the radial side of the small fi nger.
COMPLICATIONS
In all tendon transfers, the main problem is in achieving
ideal tension. The surgeon also wants to avoid stretching
out the tendon transfers during the rehabilitation phase
while still allowing early motion to prevent adhesions.
Additional surgery to adjust the tension of the tendon
transfer can be helpful in patients who have lost function
because the transfer has stretched out. If adhesions form, a
tenolysis may be of benefi t to the patient. Finally, it must
be explained to the patient that they can never achieve the
same function that they had with the original muscle ten-
don units and that the tendon transfers offer a compromise
that should improve their overall hand function.
1. Brand PW, Hollister AM. Clinical Mechanics of the Hand . 3rd
ed. St-Louis, MO: Mosby; 1999.
2. Starr CL. Army experiences with tendon transference. J Bone
Joint Surg Am . 1922;4:2–3.
3. Chuinard RG, Boyes JH, Stark HH, et al. Tendon transfers
for radial nerve palsy: use of superfi cialis tendons for digital
extension. J Hand Surg Am . 1978;3:560–570.
4. Cooney WP, Linscheid RL, An KN. Opposition of the thumb:
an anatomic and biomechanical study of tendon transfers.
J Hand Surg Am . 1984;9:777–786.
5. Braun RM. Palmaris longus tendon transfer for augmenta-
tion of the thenar musculature in low median palsy. J Hand
Surg Am . 1978;3:488–491.
REFERENCES
6. Littler JW, Cooley SG. Opposition of the thumb and its res-
toration by abductor digiti quinti transfer. J Bone Joint Surg
Am . 1963;45:1389–1396.
7. Smith RJ. Extensor carpi radialis brevis tendon transfer for
thumb adduction–a study of power pinch. J Hand Surg Am .
1983;8:4–15.
8. Hamlin C, Littler JW. Restoration of power pinch. J Hand
Surg Am . 1980;5:396–401.

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56
c h a p t e r
Congenital Hand Anomalies
Brian A. Pinsky, MD / Jaimie T. Shores, MD
INTRODUCTION
Approximately 1% to 2% of neonates are born with con-
genital malformations, and 10% of these children have
involvement of the upper extremity. Most anomalies
are inherited through genetic transmission or sporadic
mutations, and relatively few are due to environmental
exposure or teratogens. Congenital hand anomalies have
both aesthetic and functional implications. Research and
experimentation in upper limb embryology has led to an
improved understanding of the molecular mechanisms
behind these abnormalities. The most widely accepted
classifi cation system was developed by Swanson in the
1960s. This system divides limb anomalies into seven cat-
egories according to the failed developmental process:
failure of formation, failure of differentiation, duplication,
overgrowth, undergrowth, constriction band syndromes,
and generalized skeletal abnormalities.
EMBRYOLOGY
Upper limb development begins at 4 weeks after fertiliza-
tion and is complete at approximately 8 weeks with the
presence of all upper limb structures. The expression of
sonic hedgehog protein by the notochord initiates limb
bud formation. The limb bud is an outgrowth of somatic
and lateral plate mesoderm into the overlying ectoderm.
Three distinct signaling centers have been identifi ed that
control the process of limb growth and differentiation. The
timing and interaction of these signaling centers are essen-
tial to normal limb development.
The apical ectodermal ridge (AER) is located between
the dorsal and ventral layers of ectoderm and controls
proximodistal development, as well as interdigital necrosis.
Members of the fi broblast growth factor family are involved
in cell signaling from the AER. 1 The zone of polarizing
activity (ZPA) is situated along the posterior aspect of the
developing limb and controls the anteroposterior limb
axis. Sonic hedgehog protein is the primary signaling mol-
ecule of the ZPA and orchestrates radial and ulnar orienta-
tion of the upper limb. Defects in ZPA signaling result in
a mirror-image duplication. Finally, the wingless-type sig-
naling center controls dorsal and volar axis development.
Wingless-type proteins cause the underlying mesoderm to
develop dorsal characteristics. 7
PATIENT EVALUATION
Many congenital hand anomalies are sporadic and occur
in isolation. However, certain upper extremity malforma-
tions are associated with developmental errors in other
organ systems that can range from mild to life-threatening.
Radial longitudinal defi ciency is associated with other con-
genital syndromes in up to 44% of affected newborns. 8
Radial longitudinal defi ciency is often seen in patients
with Holt-Oram syndrome (atrial septal defects, arrhyth-
mias), VACTERL association ( v ertebral anomalies, a nal
atresia, c ardiac abnormalities, t racheo e sophageal fi stula,
r enal agenesis, and l imb defects), Fanconi anemia (pancy-
topenia developing between 5 and 10 years of age), and
thrombocytopenia-absent radius syndrome. 7
All patients with suspected radial defi ciency require
skeletal radiographs, a renal ultrasound, echocardiogram,
and a complete blood count. Early diagnosis with chromo-
somal breakage studies is essential for patients suspected
of Fanconi anemia prior to the onset of pancytopenia. This
maximizes the amount of time available to fi nd a suitable
bone marrow donor. Bone marrow transplantation is the
only known cure for the once fatal disease. These patients
are often small in stature with feeding diffi culties.
Ulnar defi ciencies are associated with other musculosk-
eletal malformations but not anomalies in other organ sys-
tems. 7 These patients should have a general skeletal x-ray,
but do not require an extensive multisystemic workup.

664 • CHAPTER 56
Treatment of these conditions involves a coordinated,
multidisciplinary team approach. Proper diagnosis allows
for referral to the relevant specialists and appropriate fam-
ily counseling.
Transverse Defi ciency
Transverse defi ciencies are also known as congenital ampu-
tations. The etiology is thought to involve a disruption of
the AER or fi broblast growth factor proteins. 6 The mal-
formation is named for the anatomic level at which the
amputation occurs. This can range from aphalangia to
complete amelia. The most common congenital amputa-
tion occurs at the proximal third of the forearm and is
called the below-elbow defect. 6
Referral to pediatric rehabilitation medicine or pediat-
ric orthopedics is important to have the patient evaluated
for prosthetic use early. Most rehabilitation centers use the
standard of having the child “fi t to sit,” meaning fi tting of
a child with a passive prosthesis by 6 months of age (the
approximate age of sitting up) with graduation to a more
active device by 12 to 15 months of age. 3 , 10
Radial Longitudinal Defi ciency
Radial longitudinal defi ciency represents a spectrum of
hypoplasias of the forearm, wrist, and thumb. These can
range from mild hypoplasia to complete absence of radial
structures known as the “radial club hand.” The malfor-
mation is more common in males, more common on the
right side, and 40% to 60% occur bilaterally. As previously
mentioned, radial (preaxial) defi ciencies are associated
with malformations in other organ systems that may be
life-threatening and must be worked up appropriately.
The skeletal abnormalities are the most obvious; how-
ever, they are associated with defi ciencies of the accompa-
nying muscles, nerves, joints, and vessels. 8 Classifi cation is
based on the severity of the deformity. Complete absence
of the radius results in an ulna that is short and radially
bowed, with the hand medially bent and displaced due to
poor support of the wrist. 8
Thumb hypoplasia is defi ned by the Blauth classifi cation
( Table 56-1 ), which takes into account thumb size, depth
of fi rst web space, intrinsic and extrinsic muscle defi ciency,
and joint stability. 6 The thumb accounts for 40% of over-
all hand function. 8 Grade IV represents the classic pouce
fl ottant or fl oating thumb in which the remnant digit is
nonfunctioning and attached by a skin bridge containing
only neurovascular structures without any bone, tendon,
or musculature. 8
Reconstruction depends on anatomic defi ciency and
functional use. The goal is to create a stable digit for pinch,
grip, and prehension. 7 , 11 Defi cient thenar musculature is
treated with either an abductor digiti minimi transfer
(Huber opponensplasty) or ring fi nger fl exor digitorum
sublimis opponensplasty. Metacarpophalangeal joint insta-
bility is treated with capsular tightening or reinforcement
with the transferred tendon during opponensplasty. A nar-
row fi rst web space is treated with local tissue rearrange-
ment including a four-fl ap z-plasty. 8 Children with grade
IIIB or higher hypoplasias lack a stable thumb carpometa-
carpal joint. These patients are not candidates for thumb
reconstruction and are treated with ablation and polliciza-
tion ( Figure 56-1 ).
Forearm radial dyplasias are similarly classifi ed based on
severity of anatomic defi ciency. The most common presen-
tation is the Bayne and Klug classifi cation type IV, which
presents as complete absence of the radius. The ulna is
TABLE 56-1. Classifi cation of Thumb Hypoplasia
Type
Findings
Surgical Procedure
I
Generalized reduction in size, skeletal/soft tissue
components all present
Usually no treatment
II
Absence of thenar/intrinsic muscles
Narrowing of web space
UCL insuffi ciency
Huber transfer (opponensplasty)
Web space deepening/release
UCL reconstruction
III
Type II plus:
Extrinsic muscle/tendon abnormalities and skeletal
abnormalities
A: Stable CMC joint
B: Unstable CMC joint
IIIA: Reconstruction
IIIB: Ablation and Pollicization
IV
Pouce fl ottant or fl oating thumb
Pollicization
V
Complete absence of thumb
Pollicization
Five-fi ngered hand
All digits within same plane of hand
Pollicization
CMC, carpometacarpal; UCL, ulnar collateral ligament.
Modifi ed Blauth classifi cation, adapted from: Abdel-Ghani H, Amro S. Characteristics of patients with hypoplastic thumb: a prospective study of
51 patients with the results of surgical treatment. J Pediatr Orthop B . 2004;13:127–138.

CONGENITAL HAND ANOMALIES • 665
FIGURE 56-1. Type IV thumb hypoplasia ( pouce fl ottant ) with surgical markings
for pollicization (A–E) and immediate postoperative result (F).
D
C
F
E
B
A

666 • CHAPTER 56
bowed secondary to the tethering effects of the shortened
and fi brotic radial musculature and soft tissues. Forearm
length averages 60% of the contralateral normal side,
and the relative shortening remains constant throughout
growth. 8 Radial longitudinal defi ciencies are also associ-
ated with proximal radioulnar synostosis and congenital
radial head dislocation.
Forearm reconstruction involves both surgical and
nonsurgical techniques. Initial management consists
of serial splinting and stretching to lengthen the tight
radial soft tissues. The goal is to achieve passive correc-
tion of the wrist deformity prior to surgical intervention.
Surgical realignment of the wrist on the distal ulna is
achieved through centralization or radialization. 8 These
techniques involve aligning the distal ulna with either
the middle or index metacarpal, tightening or reinforce-
ment of the ulnar wrist capsule, and transfer of the radial
soft tissue structures. The extrinsic muscles are trans-
ferred ulnarly to balance the radial deforming forces.
Ulnar osteotomies may be necessary to correct any addi-
tional angular deformity. Nonsurgical management is
chosen in cases of older children with established pat-
terns of functional compensation and in cases of severe,
bilateral elbow extension contractures. 8 In these patients,
the fl exed position of the wrist and radial hand deviation
allow for movement of the hand to the face.
Central Defi ciency
Central longitudinal defi ciencies are malformations of the
central rays of the hand (index, middle, and ring fi ngers). 6
These are commonly known as cleft hand, lobster claw,
and split hand-foot malformation. 6 There are two distinct
types of central defi ciencies, typical and atypical. Each
type has unique clinical features and separate embryo-
logic etiologies. In fact, many authors suggest that they
are better classifi ed in different categories of congenital
malformations. 7
The typical cleft hand has a V-shaped deformity
( Figure 56-2 ), usually to the level of the metacarpal, with
varying degrees of long ray absence. 7 This results from a
fusion of the digital rays rather than a failure of develop-
ment. Inheritance is X-linked dominant with incomplete
penetrance. Typical cleft hand is often bilateral with associ-
ated foot anomalies, such as split hand-split foot. Cleft lip
and palate, along with border digit syndactyly, is also seen
with typical cleft hand. 7
In contrast, atypical cleft hand has a U-shaped appear-
ance with a shallower cleft that often contains rudimen-
tary digital elements. 6 Atypical cleft hand is a type of
symbrachydactyly caused by necrosis of mesenchymal
tissue with failed attempts at regeneration. 6 , 7 It is gener-
ally sporadic and unilateral without foot involvement.
Symbrachydactyly can range from short, connected fi ngers
to complete absence of the central rays. Symbrachydactyly
is often seen in Poland syndrome along with absence of the
sternal portion of the pectoralis major muscle and other
associated chest wall abnormalities. 6 , 7 This is due to vascu-
lar disruption of the developing upper limb in utero.
Reconstruction can involve both functional and aes-
thetic concerns. The fi rst web space may require deepen-
ing for improved function with z-plasty or other local fl aps.
Central reconstruction may involve soft tissue rearrange-
ment and ulnar transposition of the index ray. However,
most children will adapt to their defi ciency without sig-
nifi cant intervention.
Ulnar Defi ciency
Ulnar defi ciency involves the postaxial border of the limb
and is signifi cantly less common than radial defi ciency 6 , 7
The radius undergoes progressive bowing with lateral
hand deviation. 5 Nearly half of all patients with ulnar
defi ciency have associated musculoskeletal abnormalities,
such as clubfoot, spina bifi da, and proximal femoral focal
defi ciency. 6 However, ulnar defi ciency is not associated
FIGURE 56-2. Dorsal (A) and volar (B) appearance of cleft hand deformity.
B
A

CONGENITAL HAND ANOMALIES • 667
with the systemic malformations seen in radial longitudi-
nal defi ciencies. Therefore, a complete skeletal radiographic
survey is needed without any systemic workup.
Ulnar defi ciency is often misdiagnosed as a radial defi -
ciency. Thumb hypoplasia is often seen in ulnar defi cien-
cies. The radius often develops ulna-like characteristics,
including radiohumeral fusion that results in a proximal
radius that appears similar to an ulna. 7
FAILURE OF DIFFERENTIATION
Syndactyly
Syndactyly is one of the most common congenital anoma-
lies of the hand and can occur in up to 1:2000 live births. 6
Syndactyly is defi ned by the degree of interconnection
between two or more adjacent digits. Simple syndactyly
involves connections of only skin and soft tissue, and
complex syndactyly involves a fusion of both bone and
soft tissue. Complete syndactyly occurs when the digits
are fused along the entire length to the fi ngertip, and an
incomplete syndactyly involves only a proximal connec-
tion. Complicated syndactyly describes a bizarre collection
and orientation of normal skeletal elements and may be
associated with various syndromes.
Syndactyly may be inherited as autosomal dominant
with variable expressivity and incomplete penetrance,
and is associated with an abnormality on chromosome 2. 7
However, the vast majority of syndactyly are sporadic muta-
tions. Some specialized types of syndactyly are characteris-
tic of certain developmental syndromes. Symbrachydactyly
is seen in up to 14% of patients with Poland syndrome. 6
Acrosyndactyly is associated with constriction band syn-
drome ( Figure 56-3 ). These patients often have truncated
digits due to congenital amputations, deep transverse
grooves, small residual web space clefts, or sinuses with
distal connections between digits. 6 A constriction band
around the lower extremity is also commonly seen.
Apert syndrome, also known as acrocephalosyndactyly,
is associated with multiple suture craniosynostosis, maxil-
lary hypoplasia, hypertelorism, proptosis, developmental
delay, and complex syndactyly. 6 , 7 Apert hand patterns are
defi ned according to the position of the thumb and have
been described as spade like, spoon like, mitten like, rose-
bud like, and hoof like. 7
Reconstruction of digit syndactyly involves separation of
the digits using some variant of zig-zag skin fl aps, creation
of a web space with a local skin fl ap, and coverage of any
remaining defect with a skin graft. A variety of techniques
have been described, and most involve a dorsal proximally
based web space fl ap ( Figure 56-4 ). Full-thickness skin
grafts should be used to decrease the rate of contracture
and are most often harvested from the groin or instep of
the foot. Surgery is most often done at approximately
1 year of age; however, border digits should be released at
6 to 9 months to prevent growth disturbance secondary to
tethering from the adjacent, shorter digit. Only one side of
a fi nger should be released in a single procedure to prevent
arterial compromise and fi nger necrosis. Complicated
syndactyly in patients with functional compensation is
often left alone to avoid disrupting established patterns of
function.
Clinodactyly
Clinodactyly presents as an angular deformity of a digit in
the radioulnar plane, most commonly seen in the fi fth digit
distal phalanx. This is secondary to an abnormally shaped
articular surface of the middle phalanx. 6 X-rays will often
show a bracketed epiphysis of the middle phalanx or a
triangular-shaped delta phalanx. The angulation is usu-
ally radial toward midline and has little functional conse-
quence. Most cases are mild and require no treatment. In
severe forms of angulation greater than 25 degrees, correc-
tion can be performed with a closing wedge osteotomy or
physiolysis. 7 Most corrections are for more aesthetic than
functional concerns. 6 Inheritance is usually autosomal
dominant. Clinodactyly is seen in up to 79% of patients
with Down syndrome.
Camptodactyly
Camptodactyly is a fl exion contracture of the proximal
interphalangeal joint most commonly seen in the fi fth
fi nger. It is usually painless and gradually progressive. 6
The true etiology is unknown; however, it has been attrib-
uted to tightness of the skin and underlying fascia, or
abnormal insertion of the lumbrical or fl exor digitorum
superfi cialis tendons. 4 Most patients have no functional
defi cit. Camptodactyly is bilateral in approximately two
thirds of cases. 7
Three types of camptodactyly have been identifi ed.
Type I is present at birth, affects males and females equally,
and is usually seen only in the small fi nger. Type II is
acquired and presents in preadolescent females. Type III
often involves severe contractures of multiple digits and is
associated with many developmental syndromes, including
arthrogryposis. 7
Asymptomatic patients do not require treatment.
Symptomatic patients with severe contractures (60–
90 degrees) are initially treated with serial splinting.
Surgical outcomes are unpredictable. 4 Surgical interven-
tion addresses mostly imbalance of the fl exor, extensor,
and intrinsic forces with the fl exor digitorum sublimis and
lumbrical tendons. 2
Arthrogyposis
Arthogryposis is a disorder of stiff and immobile joints
most commonly due to a motor unit defect between the
anterior horn cells of the spinal cord and its effector mus-
cle. Decreased fetal movement in utero can result in joint
contractures. The disorder can present on a spectrum from
mild and localized (to the hand), to generalized involv-
ing both the upper and lower extremities. 6 Classically,
these patients present with symmetric, rigid joints, and

668 • CHAPTER 56
FIGURE 56-3. Amniotic band syndrome of bilateral hands with digit amputation,
bands of the ring fi nger and thumb (A) and acrosyndactyly (B, C).
C
B
A
decreased musculature. 6 Treatment is directed at overcom-
ing severe contractures with therapy and substituting for
absent muscle units.
Trigger Thumb
Pediatric trigger thumb presents with the thumb either
locked in a fl exed position at the interphalangeal joint or as
intermittent, painful catching of the interphalangeal joint. 4
This is secondary to constriction of the thumb A1 pulley
and nodular thickening of the fl exor pollicis longus tendon
(Notta’s node). Studies have shown that the triggering is
not present at birth. 4 , 6 Pediatric trigger thumb is typically
sporadic and bilateral. Nonsurgical management is initially
recommended, including stretching, as 30% to 50% will
resolve spontaneously within 1 year. 4 , 6 Some hand surgeons
recommend surgical release of the A1 pulley at age 1 year,
as the results are satisfactory with minimal morbidity.

CONGENITAL HAND ANOMALIES • 669
FIGURE 56-4. Third web space simple complete syndactyly (A, B), with markings
for reconstruction using the trilobed fl ap repair method (C, D); 1-year postoperative
results (E, F).
C
D
F
E
A
B

670 • CHAPTER 56
Radioulnar Synostosis
Radioulnar synostosis is a rare condition resulting from a
fusion of the proximal radius and ulna likely due to an
embryologic failure of separation. 4 The forearm becomes
fi xed in a pronated position with limited rotational move-
ment. It can be isolated or associated with a radial head dis-
location. 6 It is frequently associated with other congenital
syndromes, such as Apert syndrome, Carpenter syndrome,
trisomy 13 or 21, and fetal alcohol syndrome. Diagnosis
is often delayed until the child participates in more com-
plex activities such as eating or catching a ball. In addition,
shoulder and wrist movements can partially compensate
for lack of forearm rotation. Severe fi xed pronation may
require a rotational osteotomy through the fusion mass to
place the hand in a more favorable position. 4
DUPLICATION
Radial (Preaxial) Duplication
Polydactyly is a relatively common malformation with dis-
tinct ethnic differences. Radial polydactyly is much more
prevalent in white and Asian populations. 6 These include
thumb duplications, triphalangeal thumb, and index fi n-
ger duplications. Thumb duplications are usually sporadic
and unilateral malformations. The accepted classifi cation
system is the Wassel classifi cation ( Table 56-2 ), which
divides the duplicated digit according to the number of
bones and joints affected from distal to proximal. More
than half of the cases seen have duplicated distal and
proximal phalanges with a common bifi d metacarpal artic-
ulation corresponding to a Wassel type 4 duplication. 6 The
duplicated thumbs are usually hypoplastic and share some
degree of all components including neurovascular bundles,
tendons, and soft tissue.
Reconstruction of the duplicated thumb involves using
components of each digit to construct a thumb that is
properly aligned and functional 6 ( Figure 56-5 ). When both
digits are of similar size and degree of development, a tech-
nique such as the Bilhaut-Cloquet procedure can be used
that combines slightly more than half of each hypoplastic
thumb. This procedure is often complicated by residual
nail deformities with occasional epiphysiodesis, and is a
more often discussed but rarely used surgical technique.
Otherwise, the less developed digit is often excised while
maintaining the tendons and adjacent ligaments to either
reconstruct or augment the remaining digit’s tendons or
collateral ligaments. The metacarpal head may need to be
partially excised and the digit centralized. Most commonly,
the ulnar digit is maintained due to its dominance and to
avoid the need to reconstruct the ulnar collateral liga-
ment. The radial collateral ligament should be preserved
and reconstructed on the ulnar duplicate when the radial
duplicate is ablated, and vice versa.
Triphalangeal Thumb
In this malformation, the thumb presents with an extra
phalanx. The clinical presentation can be highly variable.
If the extra digit is an abnormally shaped delta phalanx
between the proximal and distal phalanx, it is often excised
TABLE 56-2. Classifi cation of Thumb Duplication
Type
Level of Duplication
Surgical Procedure
I
Bifi d distal phalanx
Historically: Bilhaut-Cloquet procedure
Most commonly: ablation of nondominant digit keeping lateral border of ablated
digit for closure
II
Duplicate distal
phalanges
Historically: Bilhaut-Cloquet procedure
Most commonly: ablation of nondominant digit keeping lateral border of ablated
digit for closure.
IP joint centralization and chondroplasty of proximal phalanx head
III
Bifi d proximal phalanx
Usually ablate radial thumb and retain ulnar thumb. Reconstruct RCL and
centralize extrinsics
IV
Duplicate proximal and
distal phalanges
Usually ablate radial thumb and retain ulnar thumb. Reconstruct RCL and
centralize MCP joints and extrinsics
V
Bifi d metacarpal
Resection of thumb metacarpal head/neck and digit. Retain ulnar digit if possible.
Centralize metacarpal head and neck if necessary
VI
Duplicate metacarpals,
proximal and distal
phalanges
Resection of a metacarpal and a digit. Consider excision of ulnar metacarpal and
radial digit with transfer of ulnar digit on top of radial metacarpal (on-top-plasty)
if ulnar metacarpal impinges upon index metacarpal and radial metacarpal has
best placement and movement
VII
Triphalangeal thumb
Dependent on individual anatomy, may require multiple stages
IP, interphalangeal; RCL, radial collateral ligament; MCP, metacarpophalangeal.
Adapted from Wassel HD. The results of surgery for polydactyly of the thumb. A review. Clin Orthop. 1969;125:175–193.

CONGENITAL HAND ANOMALIES • 671
TABLE 56-3. Classifi cations of Ulnar
(Postaxial) Polydactyly
Stelling and
Turek a
Type 1: Floating appendage linked by
a narrow skin bridge
Type 2: Partial duplication of the
digit with skeletal elements, single
metacarpal
Type 3: Complete duplication of the
metacarpals and phalanges
Temtamy and
McKusick b
Type A: Well-formed duplicate with
skeletal elements, may articulate
with fi fth metacarpal or duplicate
metacarpal
Type B: Rudimentary, poorly duplicated
remnant, usually narrowly based on a
small skin stalk
a Data from Stelling F. The upper extremity. In: Fergusun AB, ed.
Orthopaedic Surgery in Infancy and Childhood . Baltimore, MD:
Williams & Wilkins; 1963:304–308.
b Data from Temtamy SA, McKusick VA. The Genetics of Hand
Malformations. New York: Liss; 1978:364.
FIGURE 56-5. Wassel type IV thumb duplication with
preoperative (A, B) and immediate postoperative views (C).
B
A
C
Central Polydactyly
This rare type of polydactyly often presents with syndac-
tyly and can be diffi cult to diagnose. Reconstructed digits
are often stiff or deviated. Ring fi nger polysyndactyly has
been attributed to a mutation of the HOXD13 gene on
chromosome 2. 6 , 8
Ulnar (Postaxial) Polydactyly
Ulnar polydactyly involves the fi fth digit and is 10 times
more common in the African American population.
Inheritance is autosomal dominant with variable pen-
etrance. 7 Two major classifi cation systems exist, with
the Temtamy and McKusick system being most com-
monly used ( Table 56-3 ). The supernumerary digit ranges
from a well-developed, fully formed extra digit (type A)
to a small, rudimentary narrowly based digital remnant
(type B). 6 , 7 Type B digits can be ligated at the base with
a suture at the bedside. The digit will turn gangrenous
and autoamputate. The most common complication is a
residual bump or nubbin on the ulnar aspect of the hand. 7
These digits may, alternatively, be treated in the operating
room to remove the residual ulnar nubbin that can be left
after ligation. Type A digits require formal operative exci-
sion with reconstruction of the fi fth fi nger ulnar collateral
ligament. 7
UNDERGROWTH
Undergrowth generally refers to thumb hypoplasia, which
may occur alone or in conjunction with other abnormali-
ties such as radial longitudinal defi ciency.
early. Later presentations are treated by the combination
of one joint arthrodesis and wedge osteotomy. The thumb
may function like an index fi nger without opposition (the
fi ve-fi ngered hand). 6 This is treated with pollicization.

672 • CHAPTER 56
OVERGROWTH
Macrodactyly
Macrodactyly is a condition describing overgrowth of all
structures within the affected digit. This must be distin-
guished from overgrowth secondary to isolated bone growth
or vascular malformations (hemangioma, venous malforma-
tion, etc). Additionally, macrodactyly has been described in
several syndromes, including neurofi bromatosis, Beckwith-
Wiedemann syndrome, Klippel-Trenaunay-Weber syn-
drome, and Proteus syndrome. 7
Two types of macrodactyly have been described: static
and progressive. Static macrodactyly is present at birth
and subsequent growth is commensurate with the rest
of the child. Progressive macrodactyly is more common
and describes growth of the affected digit out of propor-
tion with the rest of the body. 6 The condition is usually
unilateral and may affect more than one digit. Although
the etiology is unknown, overgrowth tends to correspond
to a neurogenic distribution, most commonly the median
nerve.
Progressive growth leads to stiffness, deviation, and loss
of function. The growth continues until physeal closure at
skeletal maturity. Treatment ranges from digit shortening,
debulking, epiphysiodesis, and nerve stripping to amputa-
tion. Severe overgrowth isolated to a single digit is often
treated with amputation. Symptomatic treatment often
results in scarred and stiff digits.
CONSTRICTION RING SYNDROME
Constriction ring syndrome is also known as amniotic band
syndrome or Streeter syndrome. This sporadic syndrome is
a result of external compression of the affected part by
fi brous bands stemming from rupture of the amnionic
1. Al-Qattan MM, Yang Y, Kozin SH. Embryology of the upper
limb. J Hand Surg Am . 2009;34:1340–1350.
2. Foucher G, Lorea P, Khouri, et al. Camptodactyly as a
spectrum of congenital defi ciencies: a treatment algorithm
based on clinical examination. Plast Reconstr Surg. 2006;
117(6):1897–1905.
3. Gaebler-Spira D, Uellendahl J. Pediatric limb defi ciencies.
In: Molnar GE, Alexander MA, eds. Pediatric Rehabilitation .
Philadelphia: Hanley & Belfus; 1999:333–350.
4. Goldfarb CA. Congenital hand differences. J Hand Surg Am .
2009;34(7):1351–1356.
5. Jones NF, Hansen SL, Bates SJ. Toe-to-hand transfers for con-
genital anomalies of the hand. Hand Clin. 2007;23:129–136.
6. Linder JM, Pincus DJ, Panthaki Z, Thaller SR. Congenital
anomalies of the hand: an overview. J Craniofac Surg . 2009;
20(4):999–1004.
membrane. The clinical manifestations of the annular
band can range from minor cosmetic external compres-
sion, to distal lymphedema and congenital amputation
( Figure 56-4 ).
The extremities are involved in a majority of cases
of constriction ring syndrome. Acrosyndactyly refers to
a coalescence of the distal digits with residual proximal
web space clefts or sinuses. In these cases, the amniotic
band occurred after digit separation was complete. Severe
tight bands cause lymphedema and vascular compromise
resulting in congenital amputations distal to the band. 6
Classically, these cases have a tapered appearance of the
bone at the point of amputation.
Treatment of the constriction rings involve complete
release of the band along with the skin, subcutaneous
tissue, and fascia circumferentially with interposed fl aps,
most often a z-plasty or w-plasty. Surgical release can
usually be performed electively unless the band is severe
enough to cause acute neurovascular compromise at birth.
In these cases, early release is recommended. Constriction
rings may also result in varied clinical presentation such as
clubfeet and facial clefting.
FUTURE DIRECTIONS
Advances in imaging technology, including 3- dimensional
ultrasound, have improved the prenatal diagnosis of upper
extremity congenital anomalies. This is important given the
potential association with severe malformations in other
organ systems. The presence of an upper extremity mal-
formation on ultrasound can lead to the ultimate diagnosis
of a developmental syndrome. 9 This allows for improved
parent counseling and the development of early treatment
plans. This may eventually pave the way for in utero surgi-
cal techniques to treat these malformations.
7. Kozin SH. Upper-extremity congenital anomalies. J Bone
Joint Surg Am . 2003;85:1564–1576.
8. Maschke SD, Seitz W, Lawton J. Radial longitudinal defi cien-
cy. J Am Acad Orthop Surg . 2007;15:41–52.
9. Paladini D, Greco E, Sglavo G, et al. Congenital anomalies
of upper extremities: prenatal ultrasound diagnosis, signifi -
cance, and outcome. Am J Obstet Gynecol . 2010;202(6):596.
e1–e10.
10. Shaperman J, Landsberger SE, Setoguchi Y. Early upper limb
prosthesis fi tting: when and what do we fi t. J Prosthet Orthot .
2003;15:11–17.
11. Thatte MR, Mehta R. Treatment of radial dysplasia by a
combination of distraction, radialization, and a bilobed
fl ap—the results at 5-year follow-up. J Hand Surg Eur Vol.
2008;33(5):616–621.
REFERENCES

c h a p t e r
Brachial Plexus
Julia K. Terzis, MD, PhD, FACS, FRCS(C) / Zinon T. Kokkalis, MD
INTRODUCTION
Brachial plexus palsy in the adult population represents a
devastating injury, which has dramatically increased during
the last few years. These patients face signifi cant long-term
functional disability because of their paralyzed extremity,
socioeconomic hardship, psychological distress, and a pro-
longed recuperation time. Surgical attempts to reconstruct
the injured brachial plexus began in the early twentieth
century which led to a number of pioneering surgeons to
develop procedures for functional motor and sensory res-
toration to the paralyzed upper limb.
Brachial plexus palsy can be described as a severe neu-
rological dysfunction of the upper extremity. Although
this ailment has affected mankind for centuries, little
progress had been achieved in the management of this
type of palsy until recently reconstructive strategies,
developments, and outcomes have drastically evolved in
the past few decades. This progress has led to increasingly
successful and more aggressive microsurgical techniques,
such as nerve grafting, vascularized ulnar nerve transfer,
motor and sensory nerve transfers, and functioning free
muscle transplantation, which are now commonly used
in reconstruction of the injured brachial plexus.
Historical Review
The literature on posttraumatic brachial plexus palsy
began with devastating circumstances and much pes-
simism. Careful examination of Homer’s Iliad reveals
perhaps the fi rst description of a brachial plexus injury:
“
” 1 (Hector struck
him with that jagged rock right on the shoulder, where the
collar bones divide the neck from chest, an especially vul-
nerable spot. The rock broke the bowstring and numbed
his hands and wrists). 2
In the early nineteenth century, Thorburn 3 was the fi rst
to report his intraoperative results and direct repair of
the brachial plexus. His fi ndings were related to a woman
patient who was injured at work by a mill machine. Despite
undergoing a neuroma resection and primary nerve repair,
there was no recovery of neurologic function at her 4-year
follow-up. The fi rst case of neurotization was reported in
1903 by Harris and Low. 4 Because of the complex surgery
and poor functional outcomes, brachial plexus injuries
were looked upon with pessimism and surgery was rarely
recommended.
During World War II, numerous brachial plexus inju-
ries were encountered, which forced many medical cen-
ters in Europe to institute treatment for these lesions.
In 1947, Seddon 5 introduced the concept of using long
nerve grafts in the reconstruction of traction injuries.
Seddon’s modest outcomes, 6 led to search for suitable
extraplexus donors to be used as motor donors for avul-
sion plexopathies. Transfer of the intercostals nerves
were reported by Yeoman and Seddon in 1972; 7 the
ipsilateral cervical plexus was reported by Brunelli in
1984 ;8 the spinal accessory nerve by Kotani in 1971 9 and
Allieu in 1984 ; 10 the contralateral C7 root by Gu et al.
in 1991; 11 the selective contralateral C7 technique by
Terzis in 1992; 12 and most recently, the ulnar nerve fas-
cicles to musculocutaneous nerve transfer by Oberlin et
al. in 1994. 13 All of these transfers represented signifi cant
improvements in the microsurgical management of bra-
chial plexus injuries.
Epidemiology and Classifi cation
Young men are most commonly involved in as many
as 90% of the cases, but individuals of any age and of
either gender can be affected. Despite improvements in
the management and in the initial trauma resuscitation,
there has also been a dramatic rise in the frequency of
57

674 • CHAPTER 57
adult brachial plexus palsies due to high-velocity motor
vehicle and motorcycle accidents. In our series of 204
patients 14 with posttraumatic brachial plexus injuries,
motor vehicle accidents were responsible for the major-
ity of the cases (59%). In other studies, 15 this number
has been reported to be as high as 84%. The overall
incidence in multitrauma patients secondary to motor
vehicle accidents ranges from 0.67% to 1.3% of motor
vehicle accidents and increases to 4.2% for victims of
motorcycle accidents. 16
Other common causes include pedestrian–vehicle acci-
dents, snowmobile accidents, industrial accidents, gun-
shot or knife wounds, and other penetrating injuries. 15 , 17
Lower-velocity injuries, such as bicycling injuries, skiing,
or falling from a height, have also been encountered and
reported to have a reciprocal correlation with brachial
plexus injuries. 18 Nontraumatic lesions include tumors of
the brachial plexus, compression, and irradiation. Kim et
al. 19 reported the largest series of brachial plexus lesions
in the literature and analyzed the causes involved in 1019
operative brachial plexus injuries during a 30-year period.
The majority of the injuries were due to stretch/contu-
sions (50%) and the next most common traumatic lesions
were penetrating and were due to gunshot wounds (12%)
and lacerations (7%). Nontraumatic lesions causing dam-
age to the brachial plexus were tumors (16%) and tho-
racic outlet syndrome (16%).
Mechanisms of Injury
There are three major mechanisms of injury implicated
with brachial plexus: 20
1. The brachial plexus may be crushed between the
clavicle and the fi rst rib. This results from direct
trauma to the neck and upper extremity and is asso-
ciated with other organ system injuries, depending
on the severity of the trauma.
2. Compression of the brachial plexus by adjacent struc-
tures that have been injured, such as bone fragments
or hypertrophic callus from a clavicle fracture, hema-
toma, or pseudoaneurysms from vascular lesions.
3. Traction to the brachial plexus combined with neck
fl exion toward the contralateral side and/or hyper-
extension of the arm can also result in brachial
plexus injury. Caudal traction of the arm will usu-
ally damage the upper roots and trunks, and traction
in a cephalic direction will most likely damage the
lower plexus.
Following a traction injury, the nerve may rupture,
be avulsed at the level of the spinal cord, or be signifi -
cantly stretched but remain in continuity. 21 Root inju-
ries can be differentiated based on the location of the
lesion relative to the dorsal root ganglion (DRG). Pre-
or supraganglionic injuries occur proximal to the DRG,
whereas post- or infraganglionic injuries occur distal to
the DRG. Avulsion of one or more nerve roots, which
FIGURE 57-1. A clinical example of a preganglionic
injury (root avulsion). In this patient, three nerve roots
(C7, C8, and T1) are avulsed. The dorsal root ganglia (DRG)
are clearly seen (*).
changes the lesion from a post- to a preganglionic injury,
is common, occurring in approximately 70% of severe
brachial plexus stretch avulsion injuries 19 ( Figure 57-1 ).
Traction forces to the spinal nerve are transmitted to the
rootlet and the epidural sac, resulting in a tear of the
sac and the presence of a pseudomeningocele on cervical
myelography. 22
All of the above mechanisms can coexist simultane-
ously and portend a poor prognosis. The velocity and
degree of the impact on the brachial plexus and the posi-
tion of the arm and shoulder in relation to the neck and
the trunk at the time of the injury will infl uence the
degree and severity of the injury and will dictate the ulti-
mate prognosis. The incidence of associated injuries var-
ies, but are also frequent. In most reports, concomitant
injuries after motor vehicle and/or motorcycle accidents
often include closed head injuries, chest wall injuries
(hemopneumothorax or rib fractures), vascular injuries
to the subclavian or axillary vessels, shoulder dislocation,
intra-abdominal injuries, and fractures of the clavicle,
scapula, and long bones. 16

BRACHIAL PLEXUS • 675
PATIENT EVALUATION
Patients with a brachial plexus injury are usually admit-
ted to the emergency unit with multiple injuries and are
often medically sedated. Potentially life-threatening asso-
ciated injuries take precedence and are treated initially.
Arm paralysis is often noted after the patient is awak-
ened. The initial evaluation is usually performed by a
physician who is not experienced with this type of injury.
Evaluation by a surgeon specializing in brachial plexus
should be performed early on so that a management
strategy can be established. A detailed history is essential
for determining the mechanism of injury and arriving at
a correct diagnosis.
Physical Examination
A systematic clinical examination of a patient with a bra-
chial plexus injury is important for the proper diagnosis
and decision making. The examination usually commences
with an inspection of the involved upper extremity, trunk,
and neck regions. Any scars are noticed. Passive and active
joint range of motion is documented.
An examination of the upper extremity muscle strength
as compared with the contralateral normal side is then
carried out. Manual muscle testing starts off by observ-
ing signs of muscle atrophy, palpation of the tone of each
muscle group, and gauging muscle strength against resis-
tance. The British Medical Research Council muscle grad-
ing system 23 can be used to record the examiner’s results
on a plexus chart. In this classifi cation, M0 5 no muscle
contraction, M1 5 a fl icker of contraction, M2 5 gravity
assist, M3 5 strength against gravity, M4 5 strength against
resistance and M5 5 normal strength. In our center, we
use the British Medical Research Council grading system,
expanded further with intermediate grades of 1 and 2
(eg, M32, M3, M31). 14
The sensory examination is performed on the arm, the
forearm, and the hand; and includes light touch apprecia-
tion, two-point discrimination, testing of vibratory sense,
and joint position sense (proprioception). Patients should
also be examined for the presence or absence of a Horner
syndrome, which consists of miosis, upper eyelid ptosis,
and anhydrosis ( Figure 57-2 ). A positive Horner sign sig-
nifi es a partial or complete avulsion of the C8 and/or T1
roots. The vascularity of the upper extremity should also
be examined. Involvement of the subclavian vessels carries
a poor prognosis for neurological recovery.
The presence of a Tinel sign, which can be elicited by
tapping over the supraclavicular area, is important, as it
can differentiate between a root avulsion and root rupture.
The patient is asked to identify the area in which a tin-
gling sensation is perceived. If the Tinel sign reproduces
tingling along the course of the involved root, the root is
considered to be in continuity with the spinal cord and it
is assessed as a rupture. The absence of a Tinel sign in the
supraclavicular area carries a morbid prognosis, as it signi-
fi es a global avulsion plexopathy.
FIGURE 57-2. A patient with a right Horner syndrome
(the asterisk identifi es the injured side): miosis (small pupil),
upper eyelid ptosis, and anhydrosis (absence of facial
sweating on the affected side). A positive Horner sign implies
disruption of the sympathetic supply to the ipsilateral eye
and face through the lower roots (C8 and T1) and is a strong
indicator of avulsion of these roots.
Pain Management
Pain following an avulsion injury to the brachial plexus rep-
resents the most signifi cant impediment to rehabilitation.
Pain management is indicated in patients with unbearable
pain. A detailed history of pain and its characteristics (loca-
tion, onset, duration, frequency, and intensity) should be
obtained. Furthermore, the amount and need for analgesic
medication should be ascertained. Some patients are given
all classes of analgesic agents, including opioids, tricyclic
antidepressants, and antipsychotic drugs; but some pain is
diffi cult to treat.
Patients are asked to grade their pain from 1 to 10. The
pain is commonly described as continuous, burning, and
compressing and is usually located in the hand. Patients
with debilitating pain have poor outcomes. For this rea-
son we recommend that these patients undergo dorsal root
entry zone (DREZ) lesioning fi rst, before proceeding with
the formal brachial plexus reconstruction. This consists of
radiofrequency thermocoagulation of the dorsal root entry
zone, which includes the central segment of the dorsal
rootlets, the tract of Lissauer, and the fi ve dorsal-most lay-
ers of the dorsal horn where the primary sensory afferent
pathways terminate.
Relief of pain allows the patient to focus on extremity
rehabilitation postoperatively. The technique was intro-
duced in 1979 by Nashold and colleagues, 24 who dem-
onstrated good pain relief in 54% of 39 patients (average
follow-up, 34 months, range, 14 months to 10 years). In a
study by Samii et al., 75% of 49 patients experienced sig-
nifi cant pain reduction (average follow-up, 10 years). 25
The long-term effi cacy of this procedure strongly indi-
cates that pain after brachial plexus avulsion originates
from the deafferented, ie, disrupted (and gliotic), sensory

676 • CHAPTER 57
fi bers of the dorsal horn. 26 In a retrospective study of
204 patients, we found that early exploration and recon-
struction of the brachial plexus afforded good pain relief
in the majority of the patients. The senior author (JKT)
documented that for all types of lesions, the mean pain
score after nerve reconstruction was signifi cantly lower
( P , 0.05) than it was before surgery; 14 and for avul-
sion injuries, the mean pain score postoperatively was
reduced up to 30% as compared with the preoperative
value.
Electrophysiologic Studies
Electrophysiologic studies are of considerable assistance in
the preoperative and intraoperative evaluation of the bra-
chial plexus injury. Needle electromyography and nerve
conduction studies can be employed for the study of loca-
tion, number, and pathophysiology of lesions affecting the
brachial plexus.
Electromyography. Three weeks after the injury, after
the nerve has undergone Wallerian degeneration, needle
electrodes are inserted into a muscle to record the elec-
trical activity of individual or groups of motor units.
Denervated muscle fi bers demonstrate a reduction in the
number of motor unit potentials as well as signs of dener-
vation, which include spontaneous involuntary waveforms
such as fi brillation potentials and positive sharp waves. If
there is peripheral reinnervation from intact motor units
through peripheral sprouting, there will be polyphasic
motor unit potentials of increased amplitude and pro-
longed duration. 27 In cases of neurapraxic lesions, the pres-
ence of an increased number of motor unit potentials and
decrease in the number of fi brillation potentials correlate
with a good prognosis for spontaneous recovery. Needle
electromyography of the paraspinal muscles, which are
innervated by the dorsal rami of the spinal roots, should
also be routinely performed; fi brillation potentials in these
muscles provides strong evidence of avulsion of the cor-
responding roots. 28
Nerve Conduction Studies 29
Sensory. The presence of sensory nerve action potentials
(SNAPs) can be used to differentiate between a pre- and
postganglionic lesion. These are low amplitude (50–100
μV) waveforms that are recorded directly off the sensory
nerves after electrical stimulation. If the SNAPs are nor-
mal but there is a clinical loss of sensation, this implies
that there is an avulsion of the sensory spinal roots from
the spinal cord with preservation of the DRG where the
sensory neurons reside. Even though the sensory axons
are intact which results in a normal measured SNAP,
there is a disruption of the afferent sensory pathways
which leads to subjective loss of sensation and signifi es
a preganglionic lesion. If the injury is distal to the dorsal
root ganglion, the sensory action potentials are absent.
Clinically the upper extremity is still anesthetic because
the sensory axons have been disconnected from their cell
bodies.
Motor. A mixed or pure motor nerve is stimulated at sev-
eral sites along the nerve. The summated electrical response
of muscle fi bers innervated by the motor axons is called
the compound action potential which produces a large
amplitude waveform (.4 MV) that is typically biphasic in
appearance with large amplitude and longer duration.
Lamina Test. Electrical stimulation is applied to each
exiting spinal nerve root to determine if the patient per-
ceives any sensation in the dermatome innervated by this
root. A positive response would be strong evidence against
a nerve root avulsion.
Specialized intraoperative techniques such as motor
evoked potentials could be an effective means for inves-
tigating the functional status of anterior motor roots and
motor fi bers in exposed spinal nerves; 30 however, techni-
cal artifacts impair their reliability and they require an
increased operative time.
Radiological Studies
After a brachial plexus injury, plain x-rays can reveal
any coexisting fractures of the cervical spine, shoulder,
chest, ribs, clavicle or upper extremity. A clavicle fracture
should raise the suspicion of trauma to the underlying
brachial plexus. A fracture of the scapula may imply an
injury to the suprascapular nerve. Rib fractures may indi-
cate an injury to the underlying intercostals nerves which
may exclude their use as donors for nerve transfers. An
inspiratory and expiratory chest x-ray or fl uoroscopy is
performed to evaluate the integrity of the phrenic nerve.
A fi nding of an elevated hemi-diaphragm preoperatively
implies an injury to the phrenic nerve which is often
associated with an upper plexus lesion and lessens the
surgeon’s ability to use multiple ipsilateral intercostals
nerves as donors. This information is fundamental for any
preoperative planning. 31
A fi rst rib fracture may denote damage to the over-
lying brachial plexus and be associated with a vascular
injury. Patients who have undergone an interposition vein
graft or those that are scheduled for free muscle transfers
should undergo angiography and a Duplex scan of the
upper extremity to evaluate vessel patency. If vascular
inadequacy is reported, vascularized nerve grafts will be
required. If the arterial fl ow is insuffi cient, consultation
with a vascular surgeon is needed prior to brachial plexus
reconstruction. Current imaging studies may demon-
strate traumatic meningoceles, deformity of nerve roots
sleeves, dural scars and nerve root avulsions. The combi-
nation of a cervical myelogram, introduced by Murphey
et al. 32 in 1947, and computed tomographic (CT) myel-
ography are considered the best methods to examine
the ventral and dorsal rootlets and rule out avulsions
( Figure 57-3 ). CT myelography is best performed at least
1 month after injury to allow the pseudomeningocele

BRACHIAL PLEXUS • 677
to fully develop and seal. One should consider that the
presence of a pseudomeningocele is strongly indicative
of a nerve root avulsion; however, avulsed roots can exist
in the face of a normal myelogram. 33 Presently, CT myel-
ography has been proven to have a 95% sensitivity and
98% specifi city. 34 Combining these two imaging tech-
niques (CT myelography) improved the resolution and
gave a more accurate categorization of the level of nerve
root injury. 35
Magnetic resonance imaging (MRI) has been used to
study the cervical cord in an effort to visualize all por-
tions of the brachial plexus and predict any root avulsion.
MRI can also reveal large neuromas on T1-weighted imag-
ing and increased signal intensity on T2-weighted imaging.
It can also detect any associated infl ammation or edema.
An MRI should not be used as a routine imaging tool for
avulsion plexopathies because of the insuffi cient contrast
between the subarachnoid space and the neural structures,
a problem caused mainly by the cerebrospinal fl uid pulsa-
tion. 36 A recent retrospective study, however, comparing
MR imaging to CT myelography of 175 cervical roots in
35 patients indicated the sensitivity of detection of the
cervical nerve root avulsion was the same (92.9%) with
both modalities. 37
In contrast to conventional MRI, the more enhanced
MRI myelographic techniques are just T2-weighted MRI
sequences that emphasize the contrast between the spinal
cord and roots and the adjacent cerebrospinal fl uid. MR
myelography is noninvasive, relatively quick, requires no
contrast medium, provides imaging in multiple projections,
and is comparable in diagnostic ability to the more invasive,
time-consuming techniques of conventional myelography
and CT myelography. 38 Gasparotti et al. 39 opined that con-
ventional MRI can be supplanted by three- dimensional
MR myelography. In three-dimensional MRI with a con-
structive interference in steady state (CISS) technique
demonstrated 89% sensitivity, 95% specifi city, and 92%
diagnostic accuracy. 39
MANAGEMENT
Open Injuries
The timing of surgery for open and closed injuries is dif-
ferent. The indications for acute surgical intervention
include the following: concomitant vascular trauma, open
injuries after sharp laceration, and crush or contaminated
open wounds. In general, brachial plexus injuries asso-
ciated with open wounds are infrequent and require
early exploration, as with any open wound. Devitalized
tissue should be debrided and bony fractures stabilized,
and any associated vascular injuries should be repaired
on an emergency basis. A clean nerve transection can be
repaired primarily by an end-to-end coaptation. In crush
or contaminated open wounds, after the debridement,
tagging the divided nerve ends with sutures or approxi-
mating them, if possible, is advisable for later nerve repair.
Emergency nerve grafting procedures are not routinely
performed. Reexploration and nerve reconstruction is
planned after at least 3 weeks, when the zone of injury
FIGURE 57-3. Multiple root avulsions are clearly seen by
plain myelography. A preoperative myelogram shows three large
pseudomeningoceles (*) at C7, C8, and T1 levels (A). Excellent
visualization of an avulsed root (*) can be afforded by high-resolution
CT myelography in an axial section (B).
B
A

678 • CHAPTER 57
can be clearly defi ned and repair to relatively healthy tis-
sue can be accomplished.
Gunshot wounds involving the brachial plexus do not
always transect all the brachial plexus elements, but may
contuse, bruise, or stretch neural tissue. Acute exploration
is recommended for suspected major vascular interrup-
tion or vascular injury presenting as a pseudoaneurysm.
Gunshot wounds may result in lesions in continuity and
these may cause an incomplete loss of function of the
involved plexus element(s). Some of these injuries may
show some recovery spontaneously with time, although
more often, they may not. 40 Plexus elements that are
not in continuity should be repaired within a few weeks
( Figure 57-4 ). Gunshot wounds induced plexopathies
can be associated with severe pain and autonomic dis-
turbances, usually localized to the hand. Sympathetic
FIGURE 57-4. A 28-year-old man sustained left brachial plexus palsy from a
gunshot injury to the neck (arrow). The patient could not abduct his shoulder or fl ex his
elbow (A). Note the bullet exit wound ( arrow ) on the patient’s back (B). Two weeks after
the injury, an exploration of the left brachial plexus revealed that the bullet tract had
penetrated most of the upper trunk (UT) and completely transected the suprascapular
(SS) nerve (C).
A
B
C
Exploration
Transverse cervical
vessels
Upper trunk
Bullet tract
4 cm lesion
C7
C6
C5
Ph
LC
PC
SS
(–)
(–)
Clavicle
Accessory
blocks followed by cervical sympathectomy may offer
some relief if a pharmacological approach has failed.
Closed Injuries
The majority of patients with brachial plexus lesions have
closed traction injuries. The optimal time for reconstruc-
tion may have been the subject of controversy in the past,
but currently the consensus is that delays of longer than
3 months after injury diminish the chances of functional
recovery. 14 , 41 , 42 Prolonged denervation invites muscular
atrophy, fi brosis, and joint stiffness which mitigate against
successful functional recovery. Thus, physical therapy and
slow electrical pulse stimulation 43 should be instituted as
soon as possible to prevent soft tissue contractures and to
maintain the bulk of the denervated muscles. However,

BRACHIAL PLEXUS • 679
most patients have surgery much later usually because
of delayed referral to a specialized center. Other patients
undergo late operations either because they have other
severe associated injuries initially or they have a severe
pain syndrome. 44 We believe that aggressive early recon-
struction within 6 weeks to 3 months after injury offers
the most rewarding results. 14
Surgical Exploration
The complex reconstructive surgery of the injured bra-
chial plexus demands light general anesthesia, using
sufentanil, and an avoidance of any kind of paralytic
FIGURE 57-4. (continued) Plexus reconstruction was performed with interposition
sural nerve grafts as follows: C5 root to the SS nerve and posterior cord (axillary); and
part of C6 to the lateral cord (LC). Neurolysis was also performed on the accessory
nerve (D). Five years after surgery, he has excellent shoulder abduction (E) and excellent
external rotation and elbow fl exion (F). Note the return of symmetrical muscle bulk.
(Part A–D: From Terzis JK, Vekris MD, Soucacos PN. Outcomes of brachial plexus reconstruction in
204 patients with devastating paralysis. Plast Reconstr Surg . 1999:104(5):1221–1240. )
D
E
F
Reconstruction
Ph
1 × 4 cm
1 × 6 cm
3 × 5.5 cm sural
2 × 4 cm sural
2 × 6 cm
LP
LC
PC
SS
Clavicle
Neurolysis of
accessory
Ax
C6
C5
drugs, so that intraoperative electrophysiologic studies
can be performed. The patient is placed in the supine
position with a soft roll along their vertebral spine and
under the neck ( Figure 57-5 ). The affected upper extrem-
ity is abducted on an arm board. The sterile fi eld includes
bilateral upper extremities, both sides of the neck up to
the mandible, the anterior and posterior chest to the
midline, and bilateral lower extremities. The surgery is
executed simultaneously by two teams: the main team
explores the injured plexus to defi ne the extent and the
type of injury, and the second team harvests nerve grafts
from both lower extremities, under 43 wide fi eld loupe
magnifi cation.

680 • CHAPTER 57
A combined supraclavicular and infraclavicular approach
is used in the majority of patients ( Figure 57-6 ). For expo-
sure of the supraclavicular plexus, the incision is made
parallel to the posterior border of the sternocleidomastoid
muscle, then turns laterally over the clavicle and a poste-
riorly based triangular fl ap is raised. The supraclavicular
sensory nerves and the external jugular vein are preserved.
The sternocleidomastoid muscle is retracted medially and
the phrenic nerve is identifi ed on the anterior border of
the anterior scalene muscle. The phrenic nerve is traced
cranially to its C4-C5 origins and it is stimulated with a
direct current stimulator at 0.5, 1.0, or 2.0 mA amplitude
to verify its integrity, and the movements of the diaphragm
are recorded. A rule of thumb is that if neural tissue is
normal it will always respond to a 0.5 mA stimulus. If the
amplitude of stimulation has to be raised intraoperatively
to obtain a peripheral muscle contraction the involved
nerve segment is in the injury zone. The dissection pro-
ceeds in a caudal direction to expose the C5, C6, and C7
spinal nerves ( Figure 57-7 ). The dorsal scapular, long tho-
racic, and suprascapular nerves are identifi ed and exposed.
As the C7 root is approached, the transverse cervical ves-
sels and omohyoid muscle are isolated and retracted. The
C8 and Tl roots are identifi ed superior to the fi rst rib and
posterior to the subclavian artery and vein. On left-sided
exposures, special care should be taken to avoid injury to
the thoracic duct.
FIGURE 57-5. Positioning of patient for plexus reconstruction. Under general
anesthesia the patient is placed in the supine position with a soft roll along the vertebral
spine and a separate roll under the neck ( arrow ). The affected upper extremity is placed
on an arm board.
For exposure of the infraclavicular plexus, the previ-
ous incision continues along the deltopectoral groove to
the anterior axillary fold. The cephalic vein is circum-
ferentially dissected and preserved. The humeral inser-
tion of the pectoralis major and the coracoid insertion
of the pectoralis minor are tagged and divided for later
reapproximation. Then the muscles are raised medially
and the infraclavicular plexus is exposed ( Figure 57-8 ).
The lateral cord is encountered fi rst, and is traced dis-
tally to the exit of the musculocutaneous nerve and
the lateral cord contribution to the median nerve. The
posterior cord is found posterior and lateral to the lat-
eral cord. Proximodistal dissection leads to the origin of
the axillary and radial nerves. Some surgeons perform a
clavicular osteotomy to gain better exposure. We do not
carry out clavicular osteotomy, due to the risk of a com-
pressive osseous callous on the underlying nerve repairs.
Furthermore, bone healing in the clavicle is capricious
and malunions or nonunions can result. We routinely
connect the supraclavicular and infraclavicular exposures
by means of subclavicular blunt dissection.
During the brachial plexus exploration, electrophysi-
ologic studies are performed as soon as each nerve is
exposed and before it is manipulated. This is especially
useful in lesions in continuity, because a decision has to be
made to proceed either with neurolysis or resection and
interposition nerve grafting.

BRACHIAL PLEXUS • 681
Sensory motor differentiation is accomplished with fro-
zen nerve biopsy studies which can be simultaneously per-
formed for carbonic anhydrase histochemistry (for sensory
axons) 45 or cholinesterase staining (for motor axons). These
are taken routinely at the level of the spinal root to assess
the integrity of the neural tissue versus scar and to ascer-
tain the presence or absence of dorsal root ganglion cells.
Proximal root tissue that is found to contain ganglion cells
or scar tissue with no evidence of myelinated nerve fi bers
is not used as a proximal donor for nerve repair. According
to Malessy et al., 46 the intraoperative frozen-section exam-
ination is of potential value in decision making. If less
than 50% myelin is present, the use of C5-C6 stumps in a
grafting procedure aiming at biceps muscle reinnervation
should be abandoned in favor of a nerve transfer proce-
dure. This observation warrants further investigation.
FIGURE 57-6. Standard skin incision for exposure of
the supraclavicular and infraclavicular plexus. The incision
parallels the posterior border of the sternocleidomastoid
muscle and angles over the clavicle into the deltopectoral
groove.
FIGURE 57-7. Exposure of the supraclavicular plexus. Roots (C5-T1), trunks, and
divisions are exposed (A). In this patient, neurolysis of the entire supraclavicular plexus
was performed (B). UT, upper trunk; MT, medial trunk; LT, lower trunk; SS, suprascapular
nerve; Ph, phrenic nerve.
A
B
FIGURE 57-8. Exposure of the infraclavicular plexus.
LC, lateral cord; PC, posterior cord; MC, musculocutaneous
nerve; M, median nerve.