Common Flexor Research Articles

Flexor tendon ruptures in the rheumatoid patient

In patients with rheumatoid arthritis, flexor tendon ruptures are much less common than extensor tendon ruptures. The most common cause of flexor tendon rupture is direct abrasion on a bony prominence. The most common flexor tendon rupture is the flexor pollicis longus (FPL) attritional rupture within the carpal canal. The best treatment for flexor tendon rupture is prevention. Flexor tenosynovectomy is indicated when medical management does not control wrist tenosynovitis. A variety of techniques are available for reconstruction of flexor tendon ruptures. Irrespective of the reconstructive method, the results of reconstruction for rheumatoid flexor tendon rupture are poor.

A muscle-splitting approach to the ulnar collateral ligament of the elbow. Neuroanatomy and operative technique.

The standard surgical approach for repair or reconstruction of the ulnar collateral ligament of the elbow involves lifting off of the tendon of the common flexor bundle at its origin on the medial epicondyle. However, a more limited muscle-splitting approach may be feasible. A muscle-splitting approach is less traumatic to the flexor-pronator muscle mass, and it could decrease operative time and lessen immediate morbidity after surgery. A proposed muscle-split through the common flexor bundle extends from the medial humeral epicondyle to a point distal to the tubercle of the ulna such that repair or reconstruction can be performed on the ulnar collateral ligament. To examine the feasibility of this approach, we performed a study combining anatomic dissections with clinical observations. We dissected 15 fresh-frozen adult cadaveric elbows to examine the neuroanatomy of the medial side of the elbow. All pertinent nerves were identified and mapped. From these data, we defined a "safe zone" for a muscle-splitting approach to the ulnar collateral ligament that allows adequate room for repair or reconstruction of the ligament without risking denervation of the surrounding musculature. The safe zone extends from the medial humeral epicondyle to approximately 1 cm distal to the insertion of the ulnar collateral ligament on the tubercle of the ulna. Twenty-two patients with ulnar collateral ligament tears underwent either a direct repair or a reconstruction of the ligament using the proposed muscle-splitting approach. With a minimum followup of 1 year, there was no clinical evidence of muscle denervation. From the combined anatomic study and clinical data, we believe that a less traumatic muscle-splitting approach to the ulnar collateral ligament affords a safe and simple surgical approach for repair or reconstruction of the ligament.

Magnetic resonance imaging of the musculoskeletal system: Part 3. The elbow.

Magnetic resonance imaging provides clinically useful information in assessing the elbow joint. Superior depiction of muscles, ligaments, and tendons as well as the ability to directly visualize nerves, bone marrow, and hyaline cartilage are advantages of magnetic resonance imaging relative to conventional imaging techniques. Ongoing improvements in surface coil design and newer pulse sequences have resulted in higher quality magnetic resonance images of the elbow. Traumatic and degenerative disorders of the elbow are well seen with MR imaging. The sequelae of medial traction and lateral compression from valgus stress include medial collateral ligament injury, common flexor tendon pathology, medial traction spurs, ulnar neuropathy, and osteochondritis dissecans. These conditions as well as lateral collateral ligament injury and lateral epicondylitis may be characterized with magnetic resonance imaging. Posttraumatic osseous abnormalities well seen by magnetic resonance imaging include radiographically occult fractures, stress fractures, bone contusions, and apophyseal avulsions. Magnetic resonance imaging also can be used to assess cartilaginous extension of fractures in children. Intraarticular loose bodies can be identified with magnetic resonance imaging, especially if fluid or contrast material is present within the elbow joint. Biceps and triceps tendon injuries can be diagnosed and characterized. Magnetic resonance imaging also can provide additional information regarding entrapment neuropathies about the elbow. Magnetic resonance imaging is perhaps most useful when patients have not responded to conservative therapy and therefore surgery and additional diagnoses are being considered.

The results of operative treatment of medial epicondylitis.

The results of the operative treatment of medial epicondylitis in forty consecutive elbows (thirty-eight patients) were assessed retrospectively on the basis of the subjective outcome, pain noted during resisted palmar flexion of the hand and wrist, satisfaction of the patient, and grip strength. The mean age of the patients at the time of the operation was forty-two years (range, twenty-two to fifty-six years). Coexistent ulnar neuritis was identified preoperatively in twenty-four elbows. The operative procedure involved release of the attachment of the common flexor muscle of the forearm at the medial epicondyle in all of the elbows and release of the retinaculum over the cubital tunnel in seventeen of the twenty-four elbows that had coexistent ulnar neuritis. The patients were followed for a mean of forty-four months (range, twenty-four to sixty-seven months). Twenty-five elbows had a good over-all subjective outcome. The preoperative pain had resolved in twenty-eight elbows. The over-all subjective outcome was less favorable for the elbows that had had coexistent ulnar neuritis (p < 0.05). Eleven of the sixteen elbows that had had isolated medial epicondylitis and had been treated with a flexor release were free of symptoms at the time of follow-up, compared with only three of the twenty-four elbows that had had coexistent ulnar neuritis. This difference was significant (p < 0.01). Moreover, in fifteen elbows, the symptoms of ulnar neuritis persisted. There was no difference in grip strength between the treated and contralateral extremities.(ABSTRACT TRUNCATED AT 250 WORDS)

Medial epicondylitis of the elbow

Ninety-five cases of medial epicondylitis are reported in 83 patients; 90% were related to work and only 10% to sport or leisure activities. Most recovered with conservative treatment. Operation was needed in 12%, which compared with under 4% of patients with lateral epicondylitis over the same period. The results of open release of the common flexor origin were good, with only one exception.

Musculus comitans nervi mediani (M. palmaris profundus)

Palmaris profundus muscles were found in two cadavers during routine dissection of the upper limb. This rare muscle was found in two forms. In the first case, the muscle resembled a diminutive palmaris longus with the belly arising from the common flexor tendon. In the second case however, a reversed muscle with the belly emerging from beneath the transverse carpal ligament and its long thin tendon extended to and inserted in the common flexor tendon. The similarity therefore of these muscles to variable forms of palmaris longus is remarkable but they differed in one very important aspect from palmaris longus. The muscles are of special interest because, in both cases, the muscles were found enclosed in a common fascial sheath with the median nerve. These unusual muscles, in spite of mimicking palmaris longus, may perhaps, be better named "musculus comitans nervi mediani" to denote their very important relationship to the median nerve, that of being the intimate traveling companion of the median nerve through the forearm and into the hand by way of the carpal canal beneath the transverse carpal ligament. In one case, a well developed median artery was also found which also entered the carpal canal along with the median nerve and its muscular companion.

Endoscopic carpal tunnel release: An atomic study

Endoscopic carpal tunnel release has been shown to decrease postoperative recovery time in patients undergoing surgery for carpal tunnel syndrome. There is, however, some controversy concerning the safety and reliability of the procedure. We performed endoscopic carpal tunnel release utilizing the two portal technique described by Chow on 20 fresh cadaver specimens. There were no injuries noted in any of the vital structures including the ulnar artery, superficial palmar arch, third common digital nerve or flexor tendons. The transverse carpal ligament was found to be completely transected in 95% of the specimens. Hyperextension of the wrist significantly displaces the vital structures both dorsally and distally. The use of a slotted cannula and specially designed blades protect the surrounding structures during the procedure. Based on this study, endoscopic carpal tunnel release using the technique described by Chow may be performed reliably without injury to any of the vital structures.

Tenosynovial Lipochondromatosis of the Flexor Hallucis, Common Toe Flexor, and Posterior Tibial Tendons

Presented is a case report of a girl with a lipomatous lesion of the medial ankle with chondromatous transformation of the sheath of the common and great tow flexor tendons. The lesion was completely excised. Histologic examination confirmed the diagnosis of tenosynovial lipochondromatosis of the involved tendons. The patient was symptom free at the 18-month follow-up examination.

Influence of wrist position on the performance of fast isometric contractions of human hand muscles

AbstractThe influence of wrist position on the motor control of intrinsic and extrinsic hand muscles during the performance of fast isometric precision‐grip contractions was evaluated. Ten male and female subjects, aged 17–28 years, attempted to produce accurately 75%, 50%, 25%, and 10% of a predetermined maximum criterion force level with the wrist in the flexed, functional, and extended positions. Feedback on the accuracy of each contraction was provided by a visual error display after each trial. Trials selected for analysis fell within ± 5% error of the required force level. Surface electromyograms were recorded from the first dorsal interosseous, adductor pollicis, abductor pollicis brevis, common flexor muscles and the extensor digitorum. Wrist position was shown to influence significantly the integrated electromyographic values representing the activity of the first dorsal interossous but not the adductor pollicis. Significant alterations in the onset time of the antagonist extensor digitorum were also detected. On the basis of the these results we suggest that the intrinsic muscles of the hand can be classified as either wrist position dependent or independent.

Acute carpal tunnel syndrome resulting from haemorrhage into the carpal tunnel in a patient on Warfarin

A case of acute compression neuropathy of the median nerve associated with haemorrhage into the carpal tunnel is presented. The condition occurred spontaneously in a patient on Warfarin for previous deep venous thrombosis. The signs and symptoms were those of acute tenosynovitis originating in the common flexor synovial sheath at the wrist with associated paraesthesia in the distribution area of the median nerve in the hand. The patient was afebrile and blood tests were normal.

Acute Carpal Tunnel Syndrome Resulting from Haemorrhage into the Carpal Tunnel in a Patient on Warfarin

A case of acute compression neuropathy of the median nerve associated with haemorrhage into the carpal tunnel is presented. The condition occurred spontaneously in a patient on Warfarin for previous deep venous thrombosis. The signs and symptoms were those of acute tenosynovitis originating in the common flexor synovial sheath at the wrist with associated paraesthesia in the distribution area of the median nerve in the hand. The patient was afebrile and blood tests were normal.

An unusual injury of the lower humeral epiphysis in a child—a case report

INTRODUCTION ISOLATED fractures of the medial epicondyles of the humerus are not uncommon (Boyd and Attenberg, 1944). Up to the age of 18, when the medial epicondyle fuses with the humerus, the growth plate is a potential source of weakness. Avulsion by traction of the common flexor muscles due to valgus strain of the joint is one of the commonest injuries of the elbow joint (Watson-Jones, 1955). The other common injury is a fracture of the lateral condyle resulting from a fall on an outstretched arm (Watson-Jones, 1955). A violent varus force with the elbow in complete extension avulses the condyle with the lateral ligament and the extensor muscles (Jacob et al., 1975). However, a combination of injuries may present diagnostic and therapeutic problems (Delee et al., 1980; Holda et al., 1980). We report the rare combination of a fracture of the medial epicondyle associated with a fracture of the lateral condyle and medial subluxation of the elbow joint. CASE REPORT A 7-year-old boy injured his left elbow by falling onto his outstretched hand from a moving bicycle. Examination revealed gross swelling around the left elbow with tenderness over the medial and lateral condyles of the humerus and a wider intercondylar distance than on the opposite side. There was no neurovascular damage. Radiographs revealed a fractureseparation of the medial epicondyle, a fracture of the lateral condyle and medial subluxation of the elbow (Fig. 1). Closed manipulation was followed by splintage in plaster-of-Paris with the elbow in 30” flexion for 6 weeks, after which active, supervised physiotherapy was started. Radiographs at 12 weeks revealed complete bony union (Fig. 2). After 2.5 years (Fig. 3) there was good functional recovery, with the carrying angle 8” less than on the unaffected side; the range of flexion and extension was 5-130” (Fig. 4) with full supination and pronation.

Some thoughts on the current state of treatment of the upper limb in traumatic tetraplegia

Traumatic tetraplegia often affects healthy young men. The medullary lesion is located at C6 in 75% of cases. The author on the basis of 20 years of experience believes it possible to improve independence and life quality by surgical procedures such as tendon transfers, which are the most often used, for restoring two important functions: active elbow extension and active hand grip. The restoration of elbow extension is accomplished by Moberg's procedure of transferring the posterior tendon of the deltoid onto the triceps. The results are very satisfactory. To restore hand grip the author makes use of the first radial tendon transferred onto the deep common flexor, and for the thumb, the long supinator onte the long flexor of the thumb. Definite functional improvement was found in 33 of 45 cases.

Treatment of compression neuropathy of the ulnar nerve at the elbow by epicondylectomy and neurolysis

Compression neuropathy of the ulnar nerve at the elbow is treated by neurolysis and excision of the medial humeral epicondyle without transposing the ulnar nerve anteriorly. Removal of the medial humeral epicondyle is not associated with loss of motion at the elbow or reduction in strength of finger or wrist flexion because of the multiple muscle origins, as well as the firm healing of the common flexor origin to the resected bone surface. Thirty cases were treated between 1965 and 1977. Treatment halted progression of the disease in all patients. Discomfort and pain subsided in every instance. All 12 of the grade 1 patients had return of normal nerve function. Four of the 12 grade II patients were left with some weakness. Four of the six grade III patients improved to grade II status. None required secondary procedures on the ulnar nerve.

Innervation of the crayfish thoracic deep flexor musculature

AbstractThe innervation and neuromuscular physiology of the deep flexor muscles in the thorax of the crayfish, Orconectes rusticus are described. Four muscles arise ventrally from the endophragmal shelf and join at segmental inscriptions to form a single functional mass. Deep flexor 1 (DF1) extends from the anterior thoracic endoskeleton to be joined by DF2, DF3, and DF4 in more posterior segments. The mass inserts on the abdominal flexor at the common flexor inscription.Motor axons from thoracic ganglionic third roots 1–3 innervate the deep flexor muscles. Light and electron microscopical examination indicates that the third root of the first thoracic ganglion contains only three or four axons that innervate the musculature, and the third root of the second thoracic ganglion usually contains five. The largest number of deep flexor axons (10) occurs in the third root of the third thoracic ganglion.Methylene blue staining and microelectrode recording methods show that each deep flexor muscle fiber is innervated by three motoneurons: the motor giant, a non‐giant excitor and an inhibitor. The motor giant elicits excitatory postsynaptic potentials (EPSPs) that rapidly antifacilitate, while the non‐giant excitor elicits EPSPs that do not antifacilitate. Both excitors produce spiking activity in the deep flexors. The inhibitory motor neuron reduces the amplitude and duration of the EPSP and prevents spiking activity. These results show that the thoracic deep flexor system is similar to the homologous system in the abdomen.

Treatment of compression neuropathy of the ulnar nerve at the elbow by epicondylectomy and neurolysis

Compression neuropathy of the ulnar nerve at the elbow is treated by neurolysis and excision of the medial humeral epicondyle without transposing the ulnar nerve anteriorly. Removal of the medial humeral epicondyle is not associated with loss of motion at the elbow or reduction in strength of finger or wrist flexion because of the multiple muscle origins, as well as the firm healing of the common flexor origin to the resected bone surface. Thirty cases were treated between 1965 and 1977. Treatment halted progression of the disease in all patients. Discomfort and pain subsided in every instance. All 12 of the grade I patients had return of normal nerve function. Four of the 12 grade II patients were left with some weakness. Four of the six grade III patients improved to grade II status. None required secondary procedures on the ulnar nerve.

THREE CASES OF COMPOUND POSTERIOR DISLOCATION OF THE ELBOW WITH RUPTURE OF THE BRACHIAL ARTERY

1. Rupture of the brachial artery or of one of its divisions in association with elbow injuries is probably more common than a survey of the literature would imply. Three cases of rupture of the brachial artery complicating compound dislocation of the elbow are reported. 2. These cases appear to have a consistent pattern of soft-tissue damage, with avulsion of the common flexor origin, and a varying degree of damage to the biceps and brachialis. The median nerve escaped injury. 3. The method of dealing with the divided vessels does not appear to be of importance in determining the outcome, simple ligation being as satisfactory as attempts at grafting or suture. 4. In no case was there any evidence of Volkmann's contracture. Provided rapid reduction of the dislocation is effected, together with ligation of the vessels, a satisfactory return of the circulation may be expected.