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| Allieu Y., Coulet B., Chammas M. Functional
surgery of the upper limb in high level tetraplegia. |
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| In this clinical case, EPL tendon was missing at the
level of the wrist and forearm, but not at the level of the thumb. EPL
function of retropulsion was obviously replaced with EPB tendon.
Therefore, the following atypical tenodesis was performed with EPB
and FPL.
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Incision is gently curved at the radial side of
the wrist.
It begins in the snuffbox, at the proximal end of
the first web, and is extended for approximately 10 to 12 cm in
a line convex to the radial side of the wrist.
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The branches of the
radial nerve must be protected.
The skin flap is raised
under the superficial veins, and it
should be dissected up to the ulnar
head.
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The distal edge
of the extensor retinaculum is rather easy to find.
Distally from this edge,
the loose dorsal fascia
over the metacarpal region of the hand is removed on 3 to 5 cm,
in order to see ECRL, ECRB and EPL tendons. In
this case, EPL tendon is missing.
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Because EPL tendon is missing, EPB tendon is dissected,
and its function is tested by a gentle proximal traction, which
fortunately produces a retropulsion of the thumb in this case. |
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Superficial fascia is incised between radial vessels and
FCR tendon. Then deep fascia is incised and FPL tendon is then easily
recognised and dissected. |
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Periosteum of the distal radius is incised at each
part of the BR tendon, under APL tendons. |
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A dorsal periosteum flap is raised under ECRL and ECRB
tendons, which are left undisturbed. |
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In the same way, a palmar periosteum flap is raised
under the PQ muscle. |
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A transversal tunnel is drilled into the distal radius,
from palmar to dorsal side. The size of this tunnel must fit the size of
EPB and FPL tendons. |
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The palmar hole is shown here. |
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The dorsal hole is shown here, between ECR and APL
tendons. |
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EPB tendon is passed through the tunnel, from dorsal to
palmar side. FPL tendon is passed in the same way, from palmar to
dorsal side. |
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EPB and FPL tendons are sutured to each other, either at
the palmar and at the dosal aspect of the wrist. It is of paramount
importance to check the proper tension of this suture. Pinch must be
opened in retropulsion when the wrist is passively flexed, and the
key-grip is activated when the wrist is passively extended (see further). |
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Palmar and dorsal periosteum flaps are sutured to each
other and/or to the BR tendon. It covers the tenodesis and increases its
adhesions. Furthermore, it restores the pathway of ECR tendons, which
must be left undisturbed. |
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Opening of the pinch when wrist is passively flexed,
with retropulsion of the thumb. |
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Closure of the pinch when wrist is passively extended. |
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