Extensor Indicis Proprius Transfer Research Articles

Extensor Indicis Proprius Transfer for the Abducted Small Finger

Persistent abduction of the small finger has usually been treated by transfer of the extensor digiti minimi muscle. However, anatomic variations of the extensor system may limit the potential for a successful extensor digiti minimi transfer. Therefore, we evaluated the outcomes of an alternative reconstruction method for the abducted small finger using an extensor indicis proprius (EIP) transfer. We performed 8 EIP transfers in 8 patients with persistent, flexible abduction posturing of the small finger. The primary etiology of the deformity was incomplete motor reinnervation after surgeries for ulnar neuropathy in 6 patients, rupture of the third palmar interosseous musculotendinous unit in 1 patient, and intrinsic muscle fibrosis in 1 patient. The EIP was elongated by splitting the tendinous portion and was transferred to the distal and radial part of the extensor hood. Surgical outcomes were assessed by comparing preoperative and postoperative active adduction and abduction motion of the 2 ulnar digits. At the mean follow-up of 23 months, the average adduction angle improved from 19 degrees to 1 degrees postoperatively. In terms of active finger motion, 6 patients showed excellent results, 1 good, and 1 fair, without loss of flexion and extension. No patient had an extension lag or complained of functional deficits of the donor index finger. There was not adverse change to digital function or range of motion for the middle and ring fingers that are crossed by the EIP. Extensor indicis proprius transfer can be a reliable option for correction of abduction deformity of the small finger, maintaining active abduction and full flexion and extension. Therapeutic IV.

Paralysis of the first dorsal interosseous muscle after external fixation of a distal radial fracture treated by transfer of the extensor indicis proprius tendon

We describe a patient in whom the motor branch to the first dorsal interosseous muscle was injured by the pins of an fixator used to treat an unstable fracture of the distal radius. She was successfully treated by extensor indicis proprius transfer to the base of the proximal phalanx of the index finger.

Unusual complication of an opposition tendon transfer at the wrist: ulnar nerve compression syndrome

Restoration of thumb opposition by tendon transfer may be necessary in cases of severe thenar atrophy caused by long-standing carpal tunnel syndrome. Routing the extensor indicis proprius transfer subcutaneously around the ulna to reanimate thumb opposition is an accepted procedure and is considered safe. Ulnar nerve compression leading to palsy is possible, however, as shown in the patient presented. Neurolysis failed to improve the palsy. Rerouting of the transfer deep to the ulnar nerve was necessary to treat the iatrogenic condition. Possible nerve compression should be kept in mind when planning a tendon transfer around the ulnar side of the forearm or carpus and when following up with the patient. Early intervention is necessary to prevent permanent sequelae.

Transfer of Either Index Finger Extensor Tendon to the Extensor Pollicis Longus Tendon

Extensor pollicis longus (EPL) tendon ruptures have been treated succesfully with the transfer of the extensor indicis proprius (EIP) tendon. Situations exist in which, due to intraoperative observations, another tendon transfer may be considered preferable to the standard EIP transfer method. To determine whether transfer of the extensor digitorum communis II (EDC II) tendon from the index finger to the EPL tendon, leaving the EIP tendon to the index finger intact, would serve as an equally efficient transfer and not adversely affect the function of the hand. Two patients who had the EDC II tendon transferred to the ruptured EPL tendon, and two patients who had the EIP tendon transferred, were retrospectively reviewed. In each transfer type, one patient had suffered an EPL tendon rupture after a Colles' fracture, and the other had rheumatoid arthritis. The rupture occurred on the non-dominant side in one patient in each transfer type. Each patient was examined and subjected to range of motion and power testing at least one year following surgery. All four patients showed a minimal extension lag with the lift off test, but there was no noticeable difference in range of motion, pinch grip and hand grip strength between the transfer types. Both EDC II transfer patients demonstrated an 8° to 15° loss of thumb interphalangeal joint flexion compared with the unoperated side; EIP transfer patients demonstrated less than a 5° loss. Three patients demonstrated a minor extension lag in the index finger and middle finger. Extension power of the thumb and index finger in all patients varied with wrist flexion and extension and ranged from 50% to 150% of the unoperated side. These case reports suggest that either index finger tendon may be successfully transferred in EPL tendon ruptures.

A New Modification of Extensor Indicis Proprius Transfer to Extensor Pollicis Longus Using a Retinacular Pulley

A new modification of the extensor indicis proprius transfer to the extensor pollicis longus tendon through a fourth dorsal compartment retinacular pulley is described. This new modification has been assessed in cadavers biomechanically via computer simulation and in a limited number of patients with success. It affords the benefit over the standard subcutaneous extensor indicis proprius to the extensor pollicis longus tendon transfer of maintaining the adduction moment arm of the thumb. The moment arm mechanics of the pulley transfer resemble those of the intact extensor pollicis longus. Therefore this new modification offers better thumb function in both adduction and circumduction motions.

Effects of extensor pollicis longus transposition and extensor indicis proprius transfer to extensor pollicis longus on thumb mechanics

Purpose: The spatial relationship of the extensor pollicis longus (EPL) to the thumb carpometacarpal (CMC) joint may be altered by its transposition from the third dorsal wrist compartment and by subcutaneous extensor indicis proprius (EIP) to EPL tendon transfer. Changes in tendon position could alter thumb function. This study examined changes in the EPL adduction moment arm after EPL tendon transposition from its extensor compartment or EIP transfer. Methods: The EPL adduction moment arm at the thumb carpometacarpal joint was determined under 4 tendon conditions: (1) intact extensor pollicis longus, (2) transposed extensor pollicis longus, (3) extensor indicis proprius to extensor pollicis longus tendon transfer through an extensor retinacular pulley, and (4) extensor indicis proprius tendon transfer through a subcutaneous route. Each tendon condition was tested in 2 wrist positions: neutral and 40° of flexion. Results: The wrist neutral/flexion moment arms for the 4 tendon conditions, in millimeters, were 9.2/7.3, 3.6/1.2, 8.3/5.1, and 4.8/1.0. Conclusions: EPL transposition produces a significant decrease of its adduction moment arm at the thumb CMC joint, an effect exacerbated by wrist flexion. The moment arm mechanics of the pulley and subcutaneous EIP tendon transfer resemble those of the intact and transposed EPL, respectively. Diminution of the adduction moment arm could impair thumb function, especially adduction.

ISOLATED PARALYSIS OF THE EXTENSOR POLLICIS LONGUS MUSCLE: A FURTHER VARIATION OF POSTERIOR INTEROSSEOUS NERVE PALSY

A case of isolated extensor pollicis longus paralysis is reported representing a fourth, very localized, variation of posterior interosseous nerve palsy. Extensor indicis proprius transfer resulted in a return to function. As the posterior interosseous nerve supplies this and other muscles available for transfer, and the preoperative assessment of extensor indicis proprius function is difficult, the management of this localized nerve palsy presents a delimma to the surgeon.

Spontaneous rupture of extensor pollicis longus tendon in a kick boxer.

A 23 year old male kick boxer presented with a 24 hour history of pain and being unable to extend the interphalangeal joint of the left thumb. There was no...

Independent index extension after indicis proprius transfer: Excision of juncturae tendinum

Isolated extension of the index finger after extensor indicis proprius (EIP) transfer was studied. In cadavers, the extensor digitorum communis (EDC) muscle of the index finger received distinct innervation from the posterior interosseous nerve and was well separated, with its own innervation, from the other EDC muscle. Examination of von Schroeder's type I juncturae tendinum (JT) between the index and long finger showed two types: von Schroeder type IA (16 of 27 hands; 59%) was fascia only; von Schroeder type IB (11 of 27 hands; 41%) was thin filamentous bands. In clinical cases, 3 hands were type IA and 10 were type IB. Retained independent index finger extension was obtained in all patients with excision of the JT between the index and long finger following EIP transfer.

Anatomy of the extensor tendons to the index finger

An anatomic study was performed to better delineate the extensor tendons of the index finger. Seventy-two cadaver hands were dissected. Classically, a single slip of the extensor digitorum communis (EDC) and a single slip of the extensor indicis proprius (EIP) are said to run to the index finger. The EIP is said to be ulnar to the EDC at the level of the metacarpal head. In dissections in this study, the classic description was noted in 58 of the hands. Ten hands had a double slip of the EIP. Two hands had a double slip of the EDC running to the index. Two hands had a single slip of the EIP either volar or radial to the EDC at the level of the metacarpal head. Thirteen hands (19%) showed anatomic variants of the EIP and EDC tendons at the level of the metacarpal head, differing from the classic description. Additionally, two hands showed aberrant tendons. A knowledge of these variants when performing tendon repair or EIP transfer is necessary.

Extensor indicis proprius transfer for restoration of extensor pollicis longus function: results and new aspects

Extensor indicis proprius transfer for restoration of extensor pollicis longus function: results and new aspects

Delayed rupture of the thumb extensor tendon

Sir-In the article “Delayed rupture of the thumb extensor tendon, a 5-year study of 18 consecutive cases”, Hove (1994) reports nearly complete satisfaction after tendon transfer for extensor pollicis longus rupture, with which we concur. He concludes that all patients were able to raise their thumbs to the level of the palm. In a recent similar study (Noorda and Hage 1994). we found different results. On the basis of Geldmacher’s (1986) evaluation scheme for assessment of the results of extensor tendon reconstruction our patients scored less favourably, especially with regard to raising the thumb to the plane of the hand. The mean score for thumb elevation in our series was 1.6 out of 6 points, corresponding to a lag of 2.1-3 cm when compared with the opposite thumb. This accords with the findings of Magnussen et al. (1990). Unlike Hove and Magnussen et al. (1990) we found no flexion deficit. Hove further concludes that full index extension was achieved either when all fingers were extended simultaneously (dependent) or when the remaining fingers were flexed (independent). In a recent study (Noorda et al. 1994). we reviewed the long-term morbidity of the donor index finger following extensor indicis proprius transfer. An extension lag of the donor index was found in 71 percent. Hove admitted that, in spite of achieving full extension, a few patients had to use more force than on the contralateral side when extending the index finger independently. We observed a significantly reduced extension strength of the donor index finger in all patients, whether measured dependently or independently. In spite of these results we, like Hove and like Littler (1967), feel that the extensor lag is not caused by the removal of the force of the motor per se. The integrity of the dorsal hood and noninterference with intrinsic or extrinsic tendon amplitude is of utmost importance. For this reason, we gratefully acknowledge that an alternative method should be considered for patients in whom individual extension of the index finger is of importance.

Index finger extension and strength after extensor indicis proprius transfer

We reviewed the long-term morbidity of the donor index finger following extensor indicis proprius tendon transfer in 34 patients with an average follow-up period of 8 years. An extension lag of the donor index was found to present in 24 patients. In all patients a reduced extension strength of the donor index finger was noticed, either measured dependently (with concurrent long finger extension) or independently (without long finger extension). Despite these findings, 30 of the patients described no limitations in their daily life activities. In nearly all patients the dependent extension strength was superior to the independent extension strength. To prevent an extension lag, the surgeon should avoid surgical trauma to the dorsal aponeurosis (“hood”) by sectioning the index tendon proximal to the hood.

Delayed rupture of the thumb extensor tendon. A 5-year study of 18 consecutive cases.

18 consecutive cases of delayed rupture of the extensor pollicis longus tendon were recorded during 5 years; 4 were spontaneous, and 14 after distal radius fracture, most of which were undisplaced or only slightly displaced. 15 cases were operated upon with tendon transfers: 13 had extensor indicis proprius transfer, 1 transfer of the extensor carpi radialis longus, and 1 reoperated with the extensor communis to the little finger as a motor unit. Subjectively, nearly complete satisfaction was reported; all patients were able to elevate the thumb to the level of the palm and full independent index finger movements were noted. In this 5-year-period 4,400 patients with distal radius fractures were treated, giving an incidence of delayed tendon rupture after distal radius fracture of 0.3 percent.

Extensor tendon surgery in rheumatoid arthritis

Rheumatoid arthritis causes tendon ruptures through a combination of attrition over sharp bony surfaces and invasive tenosynovitis. Extensor tendon ruptures often can be prevented with the performance of an appropriately timed dorsal tenosynovectomy. A distal ulna resection is added when needed. Once ruptures occur, they need to be addressed expeditiously, because further ruptures are likely. Tendon reconstruction is performed using a variety of techniques—adjacent tendon suture, extensor indicis proprius transfer, or flexor digitorum sublimis transfer. The choice of technique depends on the digits and number of tendons involved.

けん移行によるピンチ機能再建術の検討

Four cases treated with tendon transfer for pinch reconstruct were studied. Three patients with loss of both thumb adduction and index abduction by either ulnar nerve injury (2 cases) or brachial plexus injury (1 case) received simultaneous reconstruction of index abduction by transfer of abductor pollicis longus (APL) after Neviaser's method and thumb adduction by extensor indicis proprius transfer (EIP transfer). Average side pinch strength improved from 1.9kg to 3.1kg after surgery. One patient who could not pinch at all after adductor release for burn contractures only received EIP transfer. However, he became able to pinch small objects, even though his pinch strength was 0kg. EMG recordings from APL of healthy volunteers demonstrated little APL activity during side pinch movement. However, high APL activity was seen during side pinch in cases who had received a Neviaser transfer. Functional side pinch was regained in cases who received simultaneous tendon transfer to reconstruct both index abduction and thumb adduction. Transferred APL started to abduct the thumb independently.

Sports-induced spontaneous rupture of the extensor pollicis longus tendon

Two cases of spontaneous extensor pollicis longus tendon rupture are presented. One occurred in a 17-year-old diver and the other in a 69-year-old physician tennis player. Neither patient experienced pain, and only the diver had premonitory wrist discomfort. The diver was treated by an extensor indicis proprius transfer. The physician denied any disability and elected to have no treatment.

Extensor indicis proprius transfer for rupture of the extensor pollicis longus tendon

We reviewed 21 patients with 22 ruptures of the extensor pollicis longus at a mean of 5.3 years after transfer of the extensor indicis proprius tendon. Of these, 19 with 21 transfers described the result as good, and two as fair. The mean deficit of extension between the operated and unoperated thumbs was 1.4 cm, and the mean flexion deficit 0.6 cm. Pressure gauge measurements showed that the strength of the transfer was 51% of that of the uninjured extensor. The two fair results had an extensor lag of over 1.5 cm. Independent extension of the index was maintained in all patients, none having a discernible lag, but the strength of index extension was reduced to 49% of that of the normal finger. There was no evidence of functional loss. Extensor indicis proprius transfer for rupture of the extensor pollicis longus tendon is a simple and reliable procedure with few complications. It gives satisfactory long-term extension of the thumb.