2. ANATOMY
Roots from the lateral
(C5, 6, 7) and medial
(C8, T1) cords, which
embrace the third part
of the axillary artery,
and unite anterior or
lateral to it
3. COURSE IN THE ARM
Enters the arm lateral to
the brachial artery.
Near the insertion of
coracobrachialis ,crosses in
front of the artery
Descending medial to it to
the cubital fossa where it is
posterior to the bicipital
aponeurosis and anterior
to brachialis, separated by
the latter from the elbow
joint.
4.
5. COURSE IN THE FOREARM
• Enters the forearm
between the heads of
pronator teres .
• It crosses to the lateral
side of the ulnar artery,
from which it is
separated by the deep
head of pronator teres.
6. COURSE IN THE FOREARM
Descends through the
forearm posterior and
adherent to flexor
digitorum superficialis
and anterior to flexor
digitorum profundus.
7. BRANCHES IN FOREARM
1) ANTERIOR
INTEROSSEOUS NERVE:
Arises between two heads
of pronator teres
Descends between and
deep to FPL and FDP along
with anterior interosseus
artery
Supplies FPL, index+
middle finger FDP and
Pronator quadratus
8. 2) MUSCULAR BRANCHES to:
Pronator teres
Flexor carpi radialis
Palmaris longus and
Flexor digitorum superficialis.
3) OTHER BRANCHES:
Articular branch
Palmar cutaneous branch
9. AT WRIST
5 cm proximal to the flexor
retinaculum it emerges
from behind the lateral
edge of FDS
Lies between the tendons
of flexor digitorum
superficialis and flexor
carpi radialis
Passes laterally from
beneath the tendon of PL,
deep to retinaculam
11. 3) Branches in the hand:
1) the lat .terminal branch :
A) 3 common palmer digital branches.
B) recurrent muscular branch.
2) the med . Terminal branch :
It gives 2 common palmer brs :
-The lat. Branch.
-The med. Branch.
15. -Main trunk :
All superficial muscles of the front of the forearm
except flex. Capri ulnaris.
16. - Ant. Interosseous br.:
- supplies 2 ½ muscles :
All deep muscles of the front of forearm except
the med. ½ of flex. Digit. Profound.
Lat. Terminal br : 4 muscles
i.e. the 1st lumbrical m + all thenar m (except add .poll.)
Med. Terminal br.: 2nd lumbrical m
17. -The palmer cutaneous br.: Arises in the lower
end of forearm & descends to the hand to supply the
skin of the lat. 2/3 of the palm.
Lat. Terminal br.
Gives 3 palmer digital branches
Med. Terminal br.:
Gives 2 palmer digital brs.
23. CLASSIFICATION
HIGH LOW
Lesion is at or proximal to the
origin of anterior interosseus
nerve in the proximal forearm
PL, PT, FCR, FDS, index and
middle finger FDP, FPL and
the PQ muscles are paralysed.
Lesion is distal to the origin
of anterior interosseus nerve
APB, superficial head of FPB
and Opponens pollicis are
paralysed.
24. (1) Paralysis of all muscles supplied .
(2) loss of pronation of the forearm .
(3) weak flexion of the wrist .
(4) loss of the flexion & opposition of the thumb.
25. (1) hyper-extended thumb .
(2) adduction .
(3) flat thenar eminence .
- lat. 2/3 of the palm of the hand .
-lat. 3 ½ fingers anteriorly & their distal
halves posteriorly.
26. - lat. 2/3 of the palm of the hand .
-lat. 3 ½ fingers anteriorly & their distal
halves posteriorly.
-Paralysis of the 5 hand muscles supplied by the
nerve.
-The forearm muscles escape the injury as they are
supplied at elbow.
27.
28.
29. CLINICAL EXAMINATION
Pointing index finger – FDS and FDP
Ulnar deviation of wrist while flexing it - FCR
Pen test – APB
Ape thumb deformity – Opponens Pollicis
30. Work up
Radiographs
• X ray of arm and forearm to detect or rule out a
fracture
EMG and NCV study
Performed initially to provide a baseline, but
unless the nerve is severed, no changes will be
observed for 3-6 weeks.
• Help to locate the site of injury
• Help to monitor the nerve recovery over time.
31.
32. Timing of nerve repairs
Open injuries
Require early exploration.
Sharp lacerations can be repaired immediately and directly.
Wound must be relatively clean and free of gross
contamination.
A primary repair is not recommended with injuries
secondary to a crush injury /significant soft tissue damage.
At 3 weeks (or when the wound permits), the nerve is re-
explored, and definitive repair or graft can be performed.
At that time, the zone of injury is apparent based on the
extent of scar formation.
33. Closed injuries
In closed or blunt trauma, initial management is
expectant with close observation.
If complete recovery is not observed within 6 weeks,
Electrodiagnostic studies should be obtained for
baseline evaluation.
34. Monthly clinical and EMG evaluation
If motor unit potentials are seen with EMG, ►
spontaneous reinnervation is anticipated,
Lack of clinical or electrical evidence of
reinnervation at 3 months requires operative
exploration.
35. Principles of nerve repair
The results have improved with the advent of
microsurgical techniques.
1)Quantitative pre-operative assessment of motor and
sensory systems
2)Microsurgical technique including proper
magnification, instrumentation, and microsutures
3)Tension-free repair-prime object
4)When a tension-free direct repair is not technically
possible, use of an interpositional nerve graft
5)Primary repair when the conditions permit
36. 6)Postural manuevers can’t substitute tension free repair
7)Fascicular repair when fascicular anatomy discernible
and epineural repair when it is indiscernible
8)Delay in repair for approximately 3 weeks in cases
where primary repair is not optimal (e.g, with a severe
crush, stretch, or loss of nerve tissue)
9)Early protected range of movement to allow nerve
gliding
10)Post op physiotherapy to maintain range of motion
and assist in postoperative sensory and motor re-
education and rehabilitation to maximize the clinical
outcome
37.
38. Biomechanics and deformity
Thumb opposition is a complex movement requiring
trapeziometacarpal (CMC) joint abduction, flexion, and
pronation.
Abduction, Pronation flexion at CMC joint
Abduction and flexion at MCP joint
Flexion and Extension at IP joint
Axial thumb rotation, usually 90 degrees of pronation and
60 degrees of supination.
Prime muscle of thumb opposition is the APB, although
both the opponens pollicis and FPB also produce some
opposition.
39.
40.
41.
42.
43.
44. Considerable diversity in the pattern of innervation-
reason behind intact opposition after isolated MNP
Superficial head of the FPB has dual median and ulnar
innervation in 30% of hands, whereas its deep head
has dual innervation in 79% of cases
Oblique head of the adductor pollicis has dual ulnar
and median innervation in 35% of cases
Thenar muscles sometimes do have dual nerve supply
from ulnar nerve.
45. Martin Gruber Anastomosis- motor nerve
interconnection between median (or anterior
interroseus) and ulnar nerve in proximal forearm.
17 percent of people have it.
46. Restoration of functions
Restore Sensation by primary repair of nerve
Restore thumb functions Opponens plasty
In high Median nerve lesions- Restore FPL, Index
finger Digitorum and Opponens plasty.
Restoration of all this function requires tendon
transfer
47. Tendon Transfer principle
Supple Joints
Soft tissue equilibrium
Adequate Excursion
Appropriate Strenght of Donor
Expendable Donor
Straight line of pull
Synergy
Single transfer Single Function
48.
49. Surgeon must have a clear picture of the
functional disability
Indication for an opponensplasty is loss of
function due to loss of opposition
Careful patient counselling about the possible
functional benefit, the rehabilitation process,
and the likely outcome of surgery is mandatory
If there is also loss of, or absent, sensation in the
median nerve territory, this may reduce any
potential benefit of an opponensplasty
50. Prevention and Preoperative
Treatment of Contractures
It is always easier to prevent a soft tissue contracture
than to correct an established one
Prevented by passive thumb abduction and opposition
exercises and by abduction splints
Temporary internal splintage of the thumb
metacarpal in abduction with a K wire may be
indicated
Established soft tissue contractures must be corrected
by releasing skin, fascia over Ad PL , first dorsal
interossei ,joint capsule or joint itself
51.
52. Selection of motor
Muscle selected for opponensplasty must be
expendable, and this muscle must have strength and
potential excursion similar to that of the APB and
opponens pollicis muscles
Should have a tension fraction similar to that of the
combined APB and opponens pollicis tension (1.1 + 1.9
= 3.0) and a muscle fiber length that is at least as long
as that of the APB-3.7 cm
Avoid tendon graft
53. Pulley design
Hypothenar fibrous raphe
Around FCU tendon
Hooked FCU tendon
Distal FCU strip attached to ECU
Angle between PL and flexor retinaculam
Window in flexor retinaculam
54. Four standard
opponensplasties
Superficialis opponensplasty:
1)Royle-thompson technique
2)bunnell technique
Burkhalter EIP opponensplasty
Huber ADM transfer
Camitz opponensplasty (palmaris longus)
55. SUPERFICIALIS opponensplasty
Superficialis tendon harvest:
Royle and thompson both divided ring finger
superficialis tendon at its middle phalnyx insertion
North and Littler recommended division proximal to
its bifurcation through window between A1 and A2
pulleys with finger fully flexed
56. Royle-Thompson opponensplasty:
Ring finger FDS as motor
Angle between flexor retinaculam & palmar
aponeurosis as pulley
Inserted on insertion of APB
Attachment to the thumb is then sutured while the
thumb is held in full opposition and the wrist is in
neutral for 4-6wks
57. Bunnell’s opponensplasty
Ring finger FDS through FCU pulley made from distal
4 cm of FCU tendon
Inserted with a dorsoulnar-venteroradial drill hole at
base of proximal phalanx
Thumb immobilised in full opposition with neutral
wrist for 4-6 weeks
DEMERITS OF SUPERFICIALIS TRANSFER:
Not useful for high MNP
58.
59.
60. Burkhalter EIP opponensplasty
EIP divided proximal to extensor hood, retrived
proximal to extensor retinaculam
Tunelled superficial to FCU with ulnar border of wrist
as pulley
Distal attachment:
Isolated MNP-APB
Immobilise thumb in full opposition with 30 degree
wrist flexion
61.
62.
63. Advantage:
Useful for both high and low MNP
More stable, adjustable natural pulley
Easy to perform
Disadvantage:
short fiber length of EIP
64. Huber’s ADM opponensplasty
Two insertion divided along with pisiform attachment,
leaving behind FCU attachment and pedicle
No pulley needs to be used, turned 180* to insert on APB
As having only sufficient length, invariably remain in
adequate tension. Used mostly in patients with congenital
thenar atrophy as it gives bulk to thenar territory
Splinted post op for 3-4 wks
DISADVANTAGE:
Difficult to perform
Critical blood supply
65.
66.
67. Camitz PL opponensplasty
For carpal tunnell syndrome, done simultaneous with
decompression
Conform position of tendon preop
Avoid injury to palmar cutaneous branch of median
nerve
Divide tendon with 1 cm strip of aponeurosis and
inserted on APB/ EPB/ MP joint capsule, no pulley
used
74. Post op management
Thumb immobilized in opposition for 3 wks after most
opponensplasty with cast/ cyanoacrylate glue
Wrist immobilized in neutral, as, extrinsic tendons
crosses wrist. Transfer of muscles with short
excursions, like, EIP, should be relaxed by wrist in 30*
flexion
Early thumb & wrist movement emphasised after
3wks,except, high MNP+ UNP/profound sensory loss
like in leprosy-protect Camitz PL opponensplasty for
up to 3mth
75. HIGH MEDIAN NERVE PALSY
THUMB OPPOSITION:
Pt use APL and extrinsic extensors to position their
thumb when picking up an article from flat surface
Thumb remain in supination and extension, pt
pronate hand either by pronating forearm or internally
rotating shoulder-so, can’t use sight as substitute for
sensory loss-so, few recommend early opponensplasty
EIP,EPL and EDM are most readily available
76. HIGH MEDIAN NERVE PALSY
Timing and selection of transfer:
Prime aim is to restore thumb+ index finger flexion with
opposition
BR,ECRL and ECU-available options, ECU may be required
for opponensplasty-all three having excursion less than
recipient
Sensory loss is most imp single disability, some believe it
strong contraindication
Due to poor recovery in sensory fn and opposition after
nerve repair, early transfer less recommended
Transfer only if after max recovery, pt and surgeon believe it
as cause of debility and it will improve hand function
77. INDEX FINGER FLEXION:
Only in pts who need strength on radial side of hand
ECRL to Index Profundus transfer/side-to-
sidesuturing with other finger profundus tendons in
distal forearm
For ECRL transfer, tension is adjusted when finger is
fully extended with wrist flexed 30* to avoid excess
tension
78.
79.
80. THUMB FLEXION:
To achieve 30 mm excursion , BR muscle
freed in distal 2/3 forearm
Tension set as above
Because, BR is primarily elbow flexor, weak
thumb flexion when elbow flexed
81. COMPLICATIONS
Aggravation of Swan neck deformity:
Special consideration for pts with hyperextensible
joints-
1)transfer of ECRL to index and middle finger FDS
2)transfer of ECRL to index and middle finger FDP
with FDP sutured to A4 pulleys
3)transfer of ECRL to index and middle finger FDP
with DIP joint arthrodesis
82. CONCLUSION
TENDON TRANSFER CAN RESTORESELECTEDMOTOR FN
AFTER HIGH AND LOW MNP, BUT THEIRABILITY
RESTRICTED BY SEVERITY OF SENSORY LOSS
EIP/PLTRANSFER IMP FOR LOW PALSY AND
SIMULTANEOUS BR/ECRL TRANSFER FORHIGH PALSY
87. Sensory roots
Dorsal cutaneous branch of ulnar nerve coapted with
end to side with radial side of median nerve to restore
first web space function.
Distal third webspace is end to side with ulnar nerve
90. It is compression of median n. as it passes through the
carpal tunnel.
(1) dislocation of one of the carpal bones.
(2) thickening of the tendons passing.
(3) myxoedema or tumour inside the carpal tunnel .
91. As in the injury below the elbow but there is no sensory
loss in the palm because the palmer cutaneous br . Passes
outside the carpal tunnel.
The characteristic deformity of all median n.
injuries is monkey hand.
98. PRONATOR SYNDROME
Ligament of Struthers. (Most common)
Anamolous bony spur in supracondylar process.
Bicipital aponeurosis.
Symptomatic treatment
Correction of cause
99.
100. Anterior interosseus syndrome
Accesory head of FPL
Fibrous arch of FDS
Aberrant palmaris profundus
Fascial bands of deep head of pronator teres
Symptomatic treatment
Correction of the cause