Flexor Carpi Radialis Tendon Research Articles

Trapezometacarpal ligamentoplasty: personal technique

We describe a new procedure of trapeziometacarpal ligamentoplasty. This ligamentoplasty is both passive and active. The operation is performed in three stages: (1) Transfert of part of the abductor pollicis longus in a posterior and distal direction; (2) Transfert of the radial part of the extensor carpi radialis longus into the proximal first metacarpal; (3) Forming a loop around the flexor carpi radialis tendon with a distally inserted slip of abductor pollicis longus.

Ligament reconstruction and tendon interposition arthroplasty of the trapeziometacarpal joint with the use of the entire flexor carpi radialis tendon

Objectives: We prospectively analyzed the short-term clinical outcomes of ligament reconstruction tendon interposition arthroplasty with the use of the entire flexor carpi radialis (FCR) tendon in osteoarthritis of the carpometacarpal joint of the thumb. Methods: The study included eight thumbs of seven patients (6 women, 1 men; mean age 57 years; range 51-71 years) who underwent arthroplasty for osteoarthritis at the base of the thumb. All the patients had pain and disability in daily activities, which did not respond satisfactorily to conservative treatment modalities. Clinical and radiologic evaluations were made at three and twelve months postoperatively. Results: All patients had complete relief of pain and returned to normal daily activities. At the end of 12 months, improvements achieved in grip, tip pinch and key pinch strengths were 46%, 54%, 30%, respectively. Mobility of the thumbs improved; six thumbs could reach the base of the little finger, and two thumbs the crease of the proximal interphalangeal joint. The mean web angle of the thumb which had been increased from 25° to 39° was well preserved postoperatively. Radiographically, all of the thumbs remained stable; no subluxation of the metacarpal base or definite loss of height of the arthroplasty space were observed. The strength of the wrist flexion was preserved postoperatively. Conclusion: Ligament reconstruction tendon interposition arthroplasty with the use of entire FCR tendon provides stable and functional restoration of the thumb.

Evidence for fusimotor drive in stroke patients based on muscle spindle thixotropy

To study fusimotor function in stroke patients, we compared the amplitude of stretch reflexes elicited in flexor carpi radialis (FCR) after contraction of FCR with the wrist held flexed (`hold-short') or extended (`hold-long'). Seven subjects with impaired hand function and spasticity due to stroke, and seven healthy subjects were investigated. Surface electrodes recorded electromyographic activity of wrist flexors and extensors while subjects performed isometric wrist flexions with the wrist alternately in 15° of flexion or extension. After contractions the wrist was moved passively to the mid-position, and stretch reflexes were elicited via controlled mechanical taps delivered over the FCR tendon. For both groups, the amplitude of the stretch reflex was greater after `hold-short' than `hold-long' contractions. This finding is consistent with the `after-effects' of intrafusal fibre activation, and suggests that fusimotor neurones are activated during voluntary contractions of the paretic limb, just as in the limb of a healthy subject.

A method of restoration of the abduction of the thumb in traumatic tetraplegic patients.

A method of restoring extension and abduction of the thumb in traumatic tetraplegia is described. This method includes tenodesis of the abductor pollicis longus, transfer of the distal stump of the extensor pollicis brevis tendon to the flexor carpi radialis tendon, and transfer of the distal stump of the extensor pollicis longus tendon to the brachioradialis tendon. I performed this procedure on 6 hands in 5 patients and monitored each patient for 6 to 12 months. A significant increase in radial abduction of the thumb (0.5 +/- 0.2 cm to 2.8 +/- 0.2 cm) occurred in all hands.

The detailed anatomy of the palmar cutaneous nerves and its clinical implications

The forearms and hands of 40 fresh-frozen cadavers were dissected under the microscope to study the palmar cutaneous branch of the median nerve (PCBm) and the palmar cutaneous branch of the ulnar nerve (PCBu). Branches of the PCBm innervating the scaphoid were typically found, but in no specimen did we find a 'typical' cutaneous branch of the ulnar nerve. According to our findings, standard incisions for open carpal tunnel release carry a significant risk of damaging branches of the PCBm or PCBu. The chance of injury to these sensory nerves can be minimized by using a short incision in the proximal palm or a twin incision approach, which we describe. Because the PCBm is closely associated with the ulnar side of the flexor carpi radialis (FCR) sheath, this sheath should be opened on the radial side during harvest of the FCR tendon for transfer. When transferring the palmaris longus tendon, it should be cut proximal to the distal wrist crease to avoid possible damage to the PCBm.

Scapholunate interosseous ligament sectioning adversely affects excursions of radial wrist extensor and flexor tendons

Excursions of tendons around the scaphoid were measured in 6 fresh cadaver forearms to evaluate the role of the scapholunate interosseous ligament (SLIL) in wrist joint motion. Excursions of the extensor carpi radialis longus (ECRL) and brevis (ECRB) tendons and the flexor carpi radialis (FCR) tendon were continuously recorded during wrist flexion, extension, and radial and ulnar deviation. Tendon excursions were measured in the intact wrists and after complete sectioning of the SLIL. Tendon excursions were altered significantly in the major ranges of wrist motion after SLIL sectioning. After ligament sectioning, excursions of the ECRL and ECRB tendons increased significantly in wrist flexion and extension. Excursions of the FCR tendon increased significantly during wrist extension and ulnar deviation. These findings support the concepts that integrity of the SLIL plays an important role in wrist function and that injury of the ligament may cause clinical problems.

Modified burton and pellegrini procedure for trapezium excision, ligament reconstruction and interposition arthroplasty of the tendon of flexor carpi radialis

Modified burton and pellegrini procedure for trapezium excision, ligament reconstruction and interposition arthroplasty of the tendon of flexor carpi radialis

Modified Burton and Pellegrini procedure for trapezium excision, ligament reconstruction and interposition arthroplasty of the tendon of flexor Carpi radialis

Relieve of pain and increased stability at the base of 1st metacarpal. Painful degenerative and inflammatory arthritis in trapeziometacarpal joint (TMCJ). Patients not willing to undergo lengthy intensive postoperative rehabilitation. Rheumatoid arthritis (relative). Supine. Hand table. General or regional anaesthesia. Modification of the Burton-Pelligrini operation by using half of the flexor carpi radialis for interposition between base of 1st metacarpal and scaphoid. Stabilization with a Kirschner wire. In the presence of scaphotrapezoid arthritis an arthrodesis of this joint is performed for better pain control. Immobilization in a below elbow cast for 6 weeks. Then active physiotherapy, night splint for another 6 weeks. Fracture while drilling the base of the 1st metacarpus, migration of Kirschner wires, injury to the radial artery and cutaneous nerves. Out of 15 patients 12 (14 thumbs) were followed for at least 6 months. In 11 patients the shape of the hand was normal and 10 patients were satisfied with the result of the operation. Complications included: twice postoperative migration of Kirschner wires, and once intraoperative tearing of the tendon which had to be sutured.

Bilateral osteoarthritis of the trapeziometacarpal joint treated by bilateral tendon interposition arthroplasty

Twenty-four flexor carpi radialis (FCR) tendon interposition arthroplasties of the trapezium for bilateral trapeziometacarpal osteoarthritis were reviewed. Pain was reduced in all cases. Function was improved in all right hands and in 92% of the left hands. FCR tendon interposition arthroplasty for bilateral trapeziometacarpal osteoarthritis yields satisfactory long-term results on both sides.

Radical forearm flap with vascularized tendons for hand reconstruction.

We treated six patients with soft-tissue defects involving the skin and extensor or flexor tendons using a cutaneotendinous radial forearm flap. There were five male patients and one female patient. Their ages at operation ranged from 22 to 65 years (mean 50 years). In one patient, the flexor pollicis longus tendon was reconstructed with a palmaris longus tendon graft. Four patients each had two extensor tendons reconstructed. This was performed either with the palmaris longus tendon folded in the center (n = 2) or with the palmaris longus and flexor carpi radialis tendons (n = 2). In the remaining patient, three extensor tendons were reconstructed with the palmaris longus and flexor carpi radialis tendons. All the flaps survived. Recovery of motor function has been satisfactory in all but one patient.

Local Full-Thickness Skin-Graft Coverage for the Radial Forearm Flap Donor Site

Closure of the radial forearm flap donor site has been achieved by triangulating the defect and using a full-thickness skin graft from the adjacent volar forearm. Coverage of the flexor carpi radialis tendon has been more robust, and the aesthetic results have been superior to split-thickness skin-graft coverage of the forearm flap donor site.

The isolated scapho-trapezio-trapezoid ligament injury: Diagnosis and surgical treatment in four cases

Isolated injuries of the scapho-trapezial ligament complex are not well recognized. The ligament complex comprises the stout scapho-trapezial ligament, the floor of the flexor carpi radialis (FCR) tendon sheath and the scapho-capitate ligament. Between August 1991 and May 1992, we diagnosed and treated four cases of partial chronic post-traumatic lesions of this ligament complex. There was chronic pain at the base of the thenar eminence and instability of the thumb-index-middle finger pinch. Standard X-rays were normal. The diagnosis of ligament rupture was confirmed by mid-carpal arthrography showing filling of the sheath of FCR tendon. Surgical exploration showed complete rupture of the tendon sheath of FCR in two cases, associated in the other two cases with complete rupture of the scapho-trapezial ligament. Direct repair of the ligamentous elements was performed in all cases. The tendon of FCR was sutured to the tubercle of scaphoid to protect and to reinforce the ligament repair. The patients have been followed-up for between 6 and 12 months. All four patients recovered normal pinch strength to the middle finger. One patient suffered from chronic pain at work.

A study of the orientation of the fibers of the flexor carpi radialis tendon: anatomy and clinical applications.

The authors report a series of 41 dissections of the forearm intended to study the orientation of the fibers of the flexor carpi radialis (FCR). This shows that there is a constant torsion of the fibers of the FCR by an average of 180 degrees. Half of this torsion occurs in the forearm and half in the sheath of the FCR at wrist level. Awareness of this torsion is particularly useful surgically when the tendon is employed in ligamentoplasty, particularly after trapeziectomy. Our study of the orientation of the fibers was aimed at the ability to perform subcutaneous splitting of the fibers for use of part of the tendon.

Interaction between short- and long-latency components of the human stretch reflex during sinusoidal stretching.

1. Using wrist muscles, the subdivision of the human stretch reflex into separate components was examined with small amplitude sinusoidal stretching of relatively high frequency (10-40 Hz). The reflex was evoked by angular rotation of the wrist (below 1 deg amplitude), applied via the hand during maintained voluntary contraction of the muscle studied; both flexors and extensors were tested. 2. The reflex response was recorded electromyographically rather than mechanically. For each condition, the surface EMG was rectified and averaged to give a cycle average showing the mean response evoked by a cycle of stretching. The cycle average was fitted with a sinusoid, the amplitude and phase of which were used to assess the reflex; their value reflects the combined action of its various sub-components. Fourier analysis gave similar results (the EMG was then rectified but not averaged). 3. The amplitude of the reflex response typically fell to a minimum in the region of 20-25 Hz. The phase lag of the response in relation to the stimulus increased approximately linearly with frequency, except in the region of the amplitude minimum. Here the lag tended to remain constant, or to decrease slightly; this created a discontinuity between the upper and lower limbs of the phase plot. 4. Such effects are attributed to an interaction between two components of the reflex that differ in latency by 20-25 ms. These would progressively change their relative phase as the frequency increased. At first they would come to interfere with each other, but then the more delayed reflex produced by a given cycle of stretching would begin to sum with the shorter latency reflex evoked by the next stretch. 5. At high and low frequencies the cycle averages were normally well fitted by a single sinusoid. Around 20-25 Hz, however, they typically showed appreciable harmonic distortion, with the second harmonic larger than the fundamental. The cycle average then showed two separate responses per cycle of stretching. These were considered to represent the uncancelled non-linear residua of separate components of the reflex response. Their relative timing shifted appropriately with change of frequency. 6. These 'double responses' are unlikely to be due to mechanical resonance. First, the relative sizes of the two components could be altered by the reflex action of cutaneous afferents. Second, the same pattern of behaviour was found when the mechanical stimuli were applied directly to the tendon of flexor carpi radialis while the hand remained fixed.(ABSTRACT TRUNCATED AT 400 WORDS)

An anomaly of the radial artery—relevance for the forearm flap

The radial artery runs between the Flexor Carpi Radialis tendon and the Brachioradialis tendon in the distal one-third of the forearm. Here it is covered only be the superficial fascia, subcutaneous tissue and skin, so that it is easy to palpate. However, the case reported here describes a rare anomaly of the radial artery which has relevance to use of the forearm flap.

Use of a Flexor Carpi Ulnaris Muscle Flap To Cover an Exposed Hemodialysis Access—A Case Report

Exposed vascular grafts rapidly become infected, and these infections are difficult to eradicate. Salvage of exposed vascular grafts can be achieved by muscle flap, since the potential increase in local blood supply can help to control the infection. The authors report a case in which an exposed hemodialysis graft was covered with a flap created from the flexor carpi ulnaris muscle. Because this muscle is a wrist flexor and adductor, its use in a flap may weaken the wrist. However, tenodesing the flexor carpi ulnaris tendon to the flexor carpi radialis tendon, as was done in this case, can help preserve the function of the flexor carpi uinaris muscle.

Proprioceptive guidance of human voluntary wrist movements studied using muscle vibration.

1. The alterations in voluntary wrist extension and flexion movement trajectories induced by application of vibration to the tendon of flexor carpi radialis throughout the course of the movement, together with the associated EMG patterns, have been studied in normal human subjects. Both extension and flexion movements were routinely of a target amplitude of 30 deg and made against a torque load of 0.32 N m. Flexor tendon vibration consistently produced undershooting of voluntary extension movements. In contrast, voluntary flexion movements were relatively unaffected. 2. The degree of vibration-induced undershooting of 1 s voluntary extension movements was graded according to the amplitude (0.75, 1.0 and 1.5 mm) of flexor tendon vibration. 3. As flexor vibration was initiated progressively later (at greater angular thresholds) during the course of 1 s voluntary extension movements, and the period of vibration was proportionately reduced, so the degree of vibration-induced undershooting showed a corresponding decline. 4. Varying the torque loads (0.32, 0.65 and 0.97 N m) against which 1 s extension movements were made, and thereby the strength of voluntary extensor contraction, produced no systematic changes in the degree of flexor vibration-induced undershooting. 5. Analysis of EMG patterns recorded from wrist flexor and extensor muscles indicated that vibration-induced undershooting of extension movements resulted largely from a reduction in activity in the prime-mover rather than increased antagonist activity. The earliest reductions in extensor EMG commenced some 40 ms after the onset of vibration, i.e. well before voluntary reaction time; these initial responses were considered to be 'automatic' in nature. 6. These results support the view that the central nervous system utilizes proprioceptive information in the continuous regulation of moderately slow voluntary wrist movements. Proprioceptive sensory input from the passively lengthening antagonist muscle, presumably arising mainly from muscle spindle I a afferents, appears to be particularly important and to act mainly in the reciprocal control of the prime-mover.

Observations on the reflex effects seen in Parkinson's disease on terminating a period of tendon vibration.

Vibration was applied to the tendon of flexor carpi radialis while recording the EMG of the wrist flexors in 29 Parkinsonian patients. Cessation of the vibration led to a small short-latency (approximately 25 ms) reduction in the level of activity which did not differ in magnitude from the normal. Moreover, there was no sign of any subsequent long-latency reduction of activity. Thus the maintained tonic activity of Parkinsonian muscles seems unlikely to be due to an enhancement of the tonic reflex actions of the Ia afferents, especially via the short-latency pathway. In addition, the findings argue against reduction of either Ia or Ib firing being responsible for the delayed excitatory "Westphal" (or "shortening") response that may occur in parkinsonism on allowing a muscle to shorten; this was never found on terminating vibration, even when present on muscle release.

Pattern of projections of group I afferents from forearm muscles to motoneurones supplying biceps and triceps muscles in man.

1) Two independent methods were used, in man, to assess the modifications of the excitability of biceps and triceps brachii motoneurone pools following the stimulation of group I afferents coming from muscles acting at the wrist: a) the modifications of the excitability of a motoneuronal population were studied using a reflex technique, b) the modifications of the excitability of an isolated motor unit were estimated using a post-stimulus time histogram (p.s.t.h.) method. 2) The activation of group I afferents contained in the median nerve, originating from wrist flexors and pronators, resulted in a strong, short-latency facilitation of the biceps brachii motoneurones. A similar effect was also evoked by stimulation of group I afferents in the radial nerve, distally to the branch supplying the brachio-radialis muscle. The latency of both median and radial-induced facilitations is compatible with a monosynaptic linkage. 3) The stimulation of group I afferents in the median or the radial nerves produced inhibition of triceps motoneurones, with a latency compatible with a disynaptic linkage. 4) The prolonged vibration of the tendon of the flexor carpi radialis (FCR) or of the extensor carpi radialis (ECR) raised the threshold for both the facilitation of biceps and the inhibition of triceps motoneurones. The same pattern of excitatory and inhibitory convergence could also be obtained when the electrical conditioning stimulus to the median or radial nerves was replaced by a tap applied to the tendons of FCR or ECR respectively. Both results suggest that the conditioning fibres were Ia fibres. 5) The pattern of distribution of Ia afferents from muscles acting at the wrist onto motoneurones of muscles acting at the elbow has been compared to that described in the cat and monkey. A comparison has also been made between Ia connections of muscles acting at different joints in the upper and lower limb in man. The differences are discussed in relation to the manipulating capacity of the hand.

The Problem of Trapeziometacarpal Degenerative Arthritis

Trapeziometacarpal arthritis commonly afflicts women older than 40 years of age. This may be due to the inherent shallowness of the saddle joint and the laxity of the volar ligaments. Compressive forces across this joint may be as high as 120 kg during strong grasp; hence, it is not surprising that it is frequently the site of osteoarthritis. Pain and swelling over the trapeziometacarpal joint are the earliest symptoms. As the disease progresses, subluxation of the metacarpal base and, later, collapse deformity of the thumb develop. Surgical treatment is indicated if all nonsurgical treatment fails. A bewildering array of surgical techniques is available to treat trapeziometacarpal arthritis, each having its proponents. Each of these procedures provides some degree of pain relief in a majority of patients. However, none of them fulfills the criteria of an ideal arthroplasty. Criteria for good results in the literature differ among authors. Quantitative analysis of objective measurements, e.g., grasp and pinch, although valuable in comparing the results of different techniques, vary so much among individuals that they provide inadequate information about the functional status of the hand. Range of motion of the operated thumb is frequently omitted, while compensatory motion at the distal joints is not given proper credit. No procedure can claim absolute superiority over another. In comparison with other techniques, interpositional arthroplasty, using the flexor carpi radialis tendon, is less complex and radical yielding satisfactory results when compared both objectively and subjectively.