Extensor Indicis Proprius Transfer Research Articles

Nerve compression after opponensplasty: a cadaveric study

Background: We describe the differences in thumb opposition between different opponensplasty tendon transfers and determine the immediate pressure on the median and ulnar nerves incurred by each transfer. Methods: Using fresh frozen cadavers (8 specimens), opponensplasties were performed using extensor indicis proprius (EIP), flexor digitorum superficialis (FDS) with flexor carpi ulnaris (FCU) pulley, palmaris longus (PL, Camitz procedure), and PL utilizing the thenar fascia as a pulley (PLwP). Each tendon transfer was tensioned, and the thumb flexion, abduction and pronation were measured. The pressure on the median and ulnar nerves were measured for each tendon transfer at varying tensions. Results: There were no differences seen in flexion or pronation between any of the four tendon transfers. FDS, PL and PLwP demonstrated more abduction than the EIP transfer, however differences were less than 10°. EIP and FDS transfers caused significantly more pressure on the median nerve than PL or PLwP at high tendon tensions. Both EIP and FDS tendon transfers caused significantly more pressure on the ulnar nerve than PL or PLwP, and the pressure increased as tension on the transfer increased. No pressure differences were seen between PL and PLwP. Conclusions: No significant differences were seen in thumb flexion or pronation between the four tendon transfers. Differences were seen for abduction with EIP showing the least amount of abduction. EIP and FDS caused more median nerve compression than PL transfers at high tension. Both EIP and FDS tendon transfers cause more ulnar nerve compression than PL transfers at all tensions. Level of Evidence Level: V

Extensor indicis proprius to extensor pollicis longus transfer in spontaneous rupture of extensor pollicis longus following non displaced fracture distal end radius

Exact incidence of extensor pollicis longus (EPL) ruptures following distal radius fracture is not known. Peculiarly it’s common in nondisplaced fracture of the distal radius with an incidence of EPL rupture of 0.2-5%. Cortical irregularities from distal radius fractures or osteophytes easily abrade the tendon, causing gradual attrition and ultimately rupture. Compromised blood supply is also related to EPL rupture which is supported by microcirculatory anatomic studies. We present a case of 49 year old female who presented with spontaneous rupture of the EPL following a nondisplaced fracture of the distal radius managed by extensor indicis proprius (EIP) transfer. EIP transfer gives promising outcome. Optimum tension of the tendon is crucial for good functional outcome. We recommend suturing the tendon with thumb in extension and wrist in neutral position for optimum tension of tendon to avoid extensor lag and to prevent loss of IP flexion.

Delayed reconstruction of a missed Extensor Pollicis Brevis and Abductor Pollicis Longus injury using tendon transfers and an onlay tendon graft: a case report

Delayed presentation of extensor tendon injury comes with unique challenges due to retraction of tendons, adhesions and problems of disuse of the muscles. We present a case report of tendon reconstruction eight months after a sharp injury to the Extensor Pollicis Brevis (EPB) and Abductor Pollicis Longus (APL) tendon in zone VIII. The EPB was reconstructed by using an Extensor Indicis Proprius (EIP) to EPB transfer. The APL was found slack due to a large section of pseudotendon. After tenolysis the proximal tendon stump of the EPB was sutured to the APL, thus combining the impaired EPB and APL muscles for APL function. The slack section of pseudotendon of the APL was plicated to restore tension and reinforced with an onlay tendon graft (left-over from the EIP transfer). Outcomes were excellent. This is the first publication to discuss delayed repair of a combined EPB and APL injury and gives insights into the anatomical and biomechanical balance of the thumb extensors. • Delayed reconstruction of tendons is challenging due to retraction of tendons, adhesions and problems of disuse of muscles. • This is the first case report published on delayed repair of a combined APL and EPB injury. • EIP to EPB transfer is a good option for EPB reconstruction. • EIP transfer for extensor tendon reconstruction in zone VII/VIII offers surplus tendon to be used as a separate tendon graft.

Primary repair of extensor pollicis longus rupture after volar locking plating for distal radial fracture

We presumed that primary repair would be possible if the extensor pollicis longus (EPL) rupture after volar locking plating (VLP) for distal radius fracture (DRF) was diagnosed earlier. Thus, five cases of EPL ruptures were resolved via primary repair rather than extensor indicis proprius (EIP) transfer, so we reported the clinical outcomes of at least 2 years follow-up since EPL repair. Of 588 consecutive patients with the fractures treated between January 2016 and December 2019, 501 who met out inclusion/exclusion criteria were initially investigated. We informed patients of: (1) the ordinary range of motion of thumb at full wrist flexion/extension; (2) the proper tone of thumb extension compared to the contralateral thumb; and (3) the degree of pain/discomfort during thumb exercise. After discharge, we called each patient monthly commencing at 8 weeks postoperatively to enquire if any of those had worsened, by telephone. Five patients had ruptured EPLs diagnosed at a mean of postoperative-12.8 weeks. Three came to outpatient department for suspected tendon rupture just after telephone survey with the authors. The other two visited after detecting insufficiency in the three items, during the period between telephone inquiries. In four, the torn EPL were encapsulated by tendon sheathes. Extension lag at interphalangeal joint was absent and other clinical outcomes associated with DRF were all satisfactory at final follow-up. Primary repair of EPL rupture (rather than EIP transfer) is possible if patients are properly followed up after VLP for DRF. Level of evidenceLevel IV, retrospective case series.

Extensor Pollicis Brevis Transfer to Extensor Pollicis Longus for Delay Spontaneous Ruptures: A Case Series and Functional Outcomes at One Year Follow Up

Introduction: When Extensor Pollicis Longus (EPL) spontaneously ruptures, two major risk factors are present: rheumatoid arthritis and distal radius fracture. The gold standard treatment is the transfer of Extensor Indicis Proprius (EIP) to restore the functionality of the thumb. Utilization of Extensor Pollicis Brevis (EPB) was used initially, in patients with rheumatoid arthritis. The aim of this study is to ascertain if the EPB transfer technique is the most competent and efficient surgical method for rupture of EPL, analyzing functional outcomes, complications and final patient`s satisfaction. Material & Methods: Eighteen patients (14 female and 4 men) with an average age of 43 years old were introduced in this study. All cases reported no history of trauma. From the derived clinical history, 8 cases suffered from rheumatoid arthritis, 4 patients reported initial corticosteroid injection in radial side of wrist, one case was revised surgery and in rest cases the etiology was unknown. Radiographic investigation was normal in all cases, while magnetic resonance studies detect EPL ruptures. All patients were operated in a mean time of 3, 4 weeks (ranging from 2 to 6 weeks) after the diagnosis and in all cases the tendon applied was the EPB. After surgery all patients followed the same rehabilitation program. Results: The mean follow-up was 20,5 months (range from 15 months to 36 months). None of patients missed the last re-examination. Results were evaluated according to complications, range of motion of the thumb (elevation deficit, opposition distance, difference flexion-extension deficit), Quick Dash Score, EQ-5D-5L, and satisfaction of the patients. No intra-or extra-operative complications or re-ruptures were noted. At the final follow up the mean range of elevation deficit was0,7(from 0,5 to 1,5), opposition distance was 0,8(range from 0,5 to 1,8) and difference flexion-extension deficit was 1,6˚ (from 0˚ to 5˚). The Quick Dash score was 1.38 (varied from 0.0- 6.8) and the EQ-5D-5L was 92. Finally, the majority of patients appeared to be very satisfied (66,7%) or satisfied (27,8%). Conclusion: Extensor Pollicis Longus tendon spontaneously ruptures due to specific factors. Restore of thumb functionality is achieved only with tendon transfer technique and the use of Extensor Indicis Proprius tendon has been described as the gold standard. Extensor Pollicis Brevis tendon transfer is an alternative technique with significant advantages which preserves good functionality of the thumb and excellent patient satisfaction.

Functional and Cosmetic Reconstruction of Floating Thumb: A Thumb-preserving Technique.

For the severely hypoplastic thumb, including floating thumb, it is difficult to acquire function while preserving the thumb. Pollicization using the index finger after removing the hypoplastic thumb is usually indicated for such cases. However, most parents of children undergoing surgery for deformed hands desire retaining the digit number, 1 thumb and 4 fingers. A floating thumb has a neurovascular band in its pedicle, and we can identify and divide the band with precision for preservation, although it seems impossible to retain it. For acquiring function while retaining the thumb, we developed carpometacarpal arthroplasty of the floating thumb. For the first stage, the fourth metatarsal head was transferred to the first metacarpal base, followed by third metatarsal half-slip transfer to the space of the excised fourth metatarsal head with the first web plasty using a dorsal sliding flap. Second stage surgery was performed ∼6 months after the first stage. For creating stable opponensplasty, the abductor digiti minimi tendon was anchored to the ulnar side of the metacarpophalangeal joint; for extension, extensor indicis proprius transfer to the hypoplastic extensor pollicis longus tendon was performed; for flexion, ring finger flexor digitorum superficialis transfer to the hypoplastic flexor pollicis longus tendon was performed. In general, the functional results were acceptable with a high degree of family satisfaction, although in some cases function was limited to simple object holding. We explain the surgical procedures to preserve the thumb while gaining function as well as appearance using high-quality illustrations, figures, and videos. This should be helpful for surgeons who want children with hypoplastic thumbs to have both 5 digits and reasonable functional ability.

Extensor indicis transfer improves function in patients after rupture of the extensor pollicis longus tendon

The primary aim was to determine the improvement in patient-reported functional outcomes (PROMs) following extensor indicis proprius (EIP) transfer for a closed rupture of the extensor pollicis longus (EPL) tendon. Secondary aims were to analyze the impact of this procedure on health-related quality of life (HRQoL) and satisfaction. Preoperative and one-year postoperative PROMs were collected prospectively at a single institution over a two-year period (2014-2016). The primary outcome measure was the QuickDASH score. Patients also completed satisfaction scores, and the EQ-5D-5L score was used to evaluate HRQoL. Paired data was available for 12 patients (92%) at mean 19 months following surgery. A statistically-significant improvement in mean QuickDASH score was observed from 29.7 (SD: 21.7) preoperatively to 15.2 (SD: 16.4) postoperatively (p?=?0.05). Nine patients reported an improvement, one patient reported no change, and the remaining two reported deterioration in QuickDASH score. Median EQ-5D-5L improved significantly from 0.82 (IQR: 0.71 – 1.0) to 0.93 (0.77 to 1.0) postoperatively (p?<?0.05). Eleven patients were satisfied and no complications were reported. This study has demonstrated an improvement in upper-limb specific function and HRQoL following EIP transfer for rupture of the EPL. This procedure was also associated with a low rate of complications and a high rate of patient satisfaction. Level of evidenceIII (cohort study).

Reconstruction of abduction of index finger by tendon transfer of extensor indicis proprius via the pulley around the first extensor compartment

Reconstruction of abduction of index finger by tendon transfer of extensor indicis proprius via the pulley around the first extensor compartment

Reconstruction strategies after rupture of the extensor pollicis longus tendon: A systematic review

Ruptures of the extensor pollicis longus (EPL) tendon result in a major loss of function. The most practiced reconstruction surgery appears to be extensor indicis proprius (EIP) transfer, which is contraindicated in certain cases. The objective of this review was to present the various reconstruction methods for the EPL tendon. A systematic review was conducted of the literature from 2010 to 2020 on strategies for reconstructing the EPL tendon. A search of the PubMed database was done using the following keywords: ‘extensor’, ‘pollicis’, ‘longus’, and ‘thumb’. Data analyzed were the type of study, the number of patients, surgery, follow-up, and results. Of the 142 articles selected from PubMed, only 18 (12.7%) were included in the analysis. Follow-up ranged from 6 months to 6 years, with an average of 28 months, and the total number of patients was 515. Numerous strategies exist for reconstruction following rupture of the EPL tendon. The preferred modality seems to be a transfer of the EIP tendon with intraoperative testing of applied tension with the interphalangeal joint in extension, hand flat, forearm in pronation, and neutral wrist position. When the EIP is not available, other transfers should be considered if the patient has significant tendon attrition, or a graft should be considered if an isolated defect is present.

Functional evaluation of early tendon transfer for thumb opposition in median nerve palsy

BackgroundThere is paucity of literature on early tendon transfer in surgical rehabilitation of hands with median nerve injuries. Since the single most important functional deficit in median nerve palsy is the loss of thumb opposition, we evaluated the results of early tendon transfer in restoration of thumb opposition. MethodsThis prospective study involved 10 cases of isolated median nerve paralysis (axonotmesis or neurotmesis) that underwent early tendon transfer for restoration of thumb opposition. A pre- and post-operative evaluation in terms of power and precision grip strength and range of opposition of thumb was done. Median nerve exploration was performed in 4 cases and was supplemented by a tendon transfer for thumb opposition. The extensor indicis proprius (EIP) opponensplasty was performed in nine out of ten cases. In one case where the patient had scarring over the EIP tendon, palmaris longus (PL) opponensplasty was performed. ResultsThe median age at injury was 29 years (range; 8 years–57 years). Minimum period of follow-up was 6 months. Six patients who underwent EIP transfer had excellent opposition while 3 had good opposition. The patient, in whom PL opponensplasty was done, had an excellent opposition. The median time for return to work was 2.75 months.There was significant improvement in the power grip and all three types of precision grip at 6 months follow-up. The percentage deficit in the affected hand compared to the normal hand was significantly reduced. There was no case of tendon pull out in our study, nor did any of our patients have an extensor lag following EIP transfer. ConclusionEarly tendon transfer has a unique role in the management of median nerve palsy hand and we suggest this procedure should be considered in both high and low lesions.

Extensor indicis proprius tendon transfer using shear wave elastography

The means for judging optimal tension during tendon transfers are approximate and not very quantifiable. The purpose of this study was to demonstrate the feasibility of quantitatively assessing muscular mechanical properties intraoperatively using ultrasound elastography (shear wave elastography [SWE]) during extensor indicis proprius (EIP) transfer. We report two cases of EIP transfer for post-traumatic rupture of the extensor pollicis longus muscle. Ultrasound acquisitions measured the elasticity modulus of the EIP muscle at different stages: rest, active extension, active extension against resistance, EIP section, distal passive traction of the tendon, after tendon transfer at rest and then during active extension. A preliminary analysis was conducted of the distribution of values for this modulus at the various transfer steps. Different shear wave velocity and elasticity modulus values were observed at the various transfer steps. The tension applied during the transfer seemed close to the resting tension if a traditional protocol were followed. The elasticity modulus varied by a factor of 37 between the active extension against resistance step (565.1 kPa) and after the tendon section (15.3 kPa). The elasticity modulus values were distributed in the same way for each patient. The therapeutic benefit of SWE elastography was studied for the first time in tendon transfers. Quantitative data on the elasticity modulus during this test may make it an effective means of improving intraoperative adjustments.

Salvage of an Extensive Degloving Injury of the Forearm-Hand with Orthotopic Free Tissue Transplantation.

LETTER TO THE EDITOR: Traumatic degloving injuries of the forearm and hand with extensive loss of substance, usually involve exposure of underlying structures (nerves, vessels, tendon, bone), requiring proper coverage for protection and facilitation of future reconstructions. Different techniques have been described. Dermal substitutes (Integra ®) are gaining popularity; regional flaps such as groin flap, radial or ulnar forearm flaps, ulnodorsal septocutaneous (Becker), or the posterior interosseous flap are reasonable options for small to medium-sized defects. Different free flaps have also been proposed, including the lateral arm flap, paraescapular flap, dorsalis pedis flap, temporal fascia free flap, medial sural artery perforator flap and anterolateral thigh (ALT) flap [1, 2]. However, in the presence of an extensive degloving injury of the forearm and hand, with associated tendinous or bone lesions, the ideal reconstructive procedure should use forearm/hand like tissue to optimize the aesthetic and functional results. A 41 year-old female, was victim of a car accident which resulted in a massive degloving injury with severe loss of substance of the forearm and dorsum of the left hand (Fig. 1a and b), associated fractures of the 4th and 5th proximal phalanges, carpal bone loss, as well as loss of the extensor tendons of the fourth and fifth fingers. She was initially submitted to K-wire fixation of proximal phalangeal fractures, extensor indicis proprius transfer for the 4th and 5th fingers and soft tissue repair. After 2 weeks, she underwent reconstruction with a free contralateral radial forearm flap designed to exactly match the recipient defect, incorporating the palmaris longus muscle (for additional tendon reconstruction); microsurgical anastomosis were performed to the radial artery and cephalic vein (Fig. 1c). Fig. 1 a Severe degloving injury of the forearm and hand (lateral view). b Dorsoulnar view: extensive tendon and bone exposure. c Harvesting of an extended contralateral flap. d Good aesthetic and functional result after 5 years The postoperative period was uneventful, with total flap viability, satisfactory healing of the donor area and good adaptation to the defect. The patient was discharged on the 68th postoperative day after completing a daily rehabilitation program. After 5 years, a good aesthetic and functional result was observed; she still retains some extension limitation of the ring finger in relation to the injury severity (Fig. 1d). Her DASH score-Disabilities of the Arm, Shoulder, and Hand Questionnaire is 59 (It ranges from 0- no disability, to 100- most severe disability). She is very satisfied with the functional results as she previously thought that her forearm would be amputated, and doesn’t complain about the receptor/donor site appearance and scarring. Microsurgical free tissue transfer has changed the reconstructive paradigm from simply “filling the defect” to reconstructive refinement to provide the best results [3, 4]. An orthotopic free tissue transplantation is a simple and versatile option for the reconstruction of an extensive loss of substance of the hand and forearm, due to the existing anatomical and functional similarity, comprising a thin flap with reduced adiposity and elastic/sliding properties. In addition to the consistent vascular anatomy and the possibility of including tendon/bone, the large anatomic boundaries of this flap can involve practically the entire volar surface and ulnodorsal forearm. It also enables two surgical teams to work simultaneously, which are basic prerequisites for the reconstruction of extensive degloving injuries.

Nerve Transfer for Restoring Upper Limb Function in Traumatic Cervical Spinal Cord Injury

Introduction: Cervical spinal cord injury (CSCI) is a devastating consequence of trauma that leads to disabling loss of upper limb function. Restoration of any upper limb function can improve quality of life, reduce long-term care needs, and is highly rated by affected individuals. Historically, the International Classification of Surgery of the Hand in Tetraplegia (ICHST) has guided the use of tendon transfers in CSCI but there is now renewed interest in the role of nerve transfer. Selective nerve fascicle transfer offers opportunities for greater functional gain with restoration of prehensile grip and maintenance of donor muscle function. We present an evidence-based surgical strategy for restoration of upper limb function using nerve transfer in CSCI. Objectives: Derivation of evidence-based surgical algorithm for restoration of upper limb function in CSCI. Methods: A nonsystematic review of all studies reporting nerve transfer in CSCI available through PubMed was performed. For each level of spinal cord injury, a reconstructive algorithm was constructed considering available donors. The following hierarchy of movement was prioritized: elbow extension, wrist extension, finger flexion, finger extension, and intrinsic function. Results: The reconstructive algorithm derived is summarized below. &gt;C5—Limited donors available. Suggest lateral branch of accessory nerve transfer to long thoracic nerve or phrenic nerve (in cases of phrenic nerve palsy). Achievable outcomes: respiratory independence for ventilator or cough assist. C5*†—Suggest: (1) Axillary nerve fascicle to teres minor transfer to medial or long head of triceps fascicles. (2) Proximal supinator nerve transfer to nerve to extensor carpi radialis brevis (ECRB) fascicles. (3) Finger extensor tenodesis. (4) Nerve to brachialis transfer to fascicles to anterior interosseous nerve (AIN) and pronator teres. Achievable outcomes: active elbow and wrist extension, passive finger extension, active pronation, and finger flexion. C6*†—Suggest: (1) Axillary nerve fascicle to teres minor transfer to medial or long head of triceps fascicles. (2) Nerve branches to supinator transfer to ECRB. (3) Finger extensor tenodesis. (4) Nerve to brachialis transfer to fascicles to AIN and pronator teres. Achievable outcomes: active elbow extension, stronger active wrist and passive finger extension, active pronation, and finger flexion. C7*†—Suggest: (1) Nerve to brachialis transfer to fascicles to AIN and pronator teres. (2) posterior interosseous nerve (PIN) branches to abductor pollicis longus (APL), extensor pollicis brevis (EPB) and extensor indicis proprius (EIP) transfer to deep branch ulnar nerve fascicles. Achievable outcomes: active pronation, finger flexion, and intrinsics. C8*—Suggest: (1) AIN branch to pronator quadratus transfer to deep branch ulnar nerve fascicles. (2) PIN branches to APL, EPB and EIP transfer to deep branch median nerve fascicles. Achievable outcomes: active intrinsics. Conclusion: Nerve transfer for CSCI is an emerging area of upper limb surgery that demonstrates very significant promise. A bespoke surgical strategy tailored to each patient’s level of CSCI and individual needs that is undertaken early during the rehabilitative course will revolutionize functional outcomes for this deserving patient group. *Brachioradialis to flexor pollicis longus (FPL) tendon transfer as necessary. †House intrinsic tenodesis and/or carpometacarpal joint (CMCJ) arthrodesis as necessary.

A New Method to Control Tendon Tension in the Transfer of Extensor Indicis Proprius to Extensor Pollicis Longus Rupture.

This study evaluated the outcomes of extensor indicis proprius (EIP) transfer based on varying degrees of thumb extension after EIP transfer and elongation of the EIP. A total of 24 cases with extensor pollicis longus (EPL) ruptures who underwent EIP to EPL transfer were analyzed prospectively. The EIP transfer was performed with neutral wrist positioning. In group I (12 cases), EIP and EPL were sutured on the thumb in neutral state at interphalangeal joint, and the mean EIP elongation of this group measured 0.2 cm (range, -0.5 to 0.5 cm). In group II (12 cases), EIP and EPL were sutured on the thumb in full extension state at interphalangeal joint, and the mean EIP elongation measured 0.7 cm (range, 0.5-1.5 cm). The mean follow-up period was 13.5 months. The 2 groups were compared based on thumb motion, grip strength, pinch power, and the Disabilities of the Arm, Shoulder, and Hand questionnaire score. Extension of the thumb at the interphalangeal joint was -5.2° in group I and 7.2° in group II, demonstrating statistically significant differences. No significant differences were found between the 2 groups in other parameters. In EIP transfer, thumb in extension after transfer and EIP elongation is recommended for restoring thumb extension at the interphalangeal joint.

Comparison of surgical treatments for triple extensor tendon ruptures in rheumatoid hands: A retrospective study of 48 cases

Objective. This retrospective study was designed to evaluate the outcomes of four different surgical reconstructions for extensor tendon ruptures in ulnar three fingers in 48 patients with rheumatoid arthritis.Methods. The following four techniques were performed; palmaris longus tendon grafting (PL group; n = 9), extensor indicis proprius (EIP) tendon transfers (EIP group; n = 8), end-to-side transfers with tension-reduced early mobilization (End-to-side group; n = 16), and a combination of end-to-side and EIP transfers (Combination group; n = 15). Loss of extension was evaluated to determine the mean postoperative range of motion of the metacarpophalangeal (MP) joint and clinical outcomes were categorized using modified Geldmacher criteria.Results. Combination group demonstrated the best mean MP joint extension (− 3°), followed by End-to-side group (− 12°), EIP group (− 16°), and PL group (− 21°). Combination group yielded the best clinical outcomes with all cases showing good results.Conclusions. The combination of end-to-side and EIP transfer was an effective surgical reconstruction procedure for triple fingers extension loss.

Late extensor pollicis longus rupture following plate fixation in Galeazzi fracture dislocation.

Late rupture of extensor pollicis longus (EPL) tendon after Galeazzi fracture dislocation fixation is an unknown entity though it is a well-established complication following distal radius fractures. We report the case of a 55-year old male who presented with late EPL tendon rupture 4 months following internal fixation of Galeazzi fracture dislocation with a Locking Compression Plate (LCP). He was managed with extensor indicis proprius (EIP) transfer to restore thumb extension. At 4 years followup, functional result of the transfer was good. We identify possible pitfalls with this particular patient and discuss how to avoid them in future.

Standard versus over-tensioning in the transfer of extensor indicis proprius to extensor pollicis longus for chronic rupture of the thumb extensor

The purpose of this study was to evaluate the functional outcomes of the over-tensioning technique compared with those of the standard tensioning technique in the transfer of extensor indicis proprius (EIP) to extensor pollicis longus (EPL) for the chronic rupture of the thumb extensor. Data were collected from patients who underwent tendon transfer using EIP between March 2003 and August 2011. 23 were treated with the standard tensioning technique and 25 patients (Group B) with the over-tensioning technique. While standard tension was maintained with the thumb in full extension and the wrist in 30° of flexion, over-tension was maintained with the thumb in full extension and the wrist in the neutral position. All patients were assessed for total range of motion, elevation and flexion deficit, the thumb grip and pinch strength, and the thumb and the index extension strength compared to the unaffected side, EIP-EPL evaluation as suggested by Lemmen et al. and Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH). Group A: total range of motion 115°, elevation deficit 2.0 cm, combined flexion deficit 1.0 cm, thumb extension strength 75%, thumb grip strength 91%, and pinch strength 87%. Functional outcomes were 13 excellent, 6 good, 3 fair, and 1 poor. Median DASH score was 21.3 points. Group B: total range of motion 125°, elevation deficit 1.0 cm, combined flexion deficit 1.5 cm, thumb extension strength 85%, thumb grip strength 88%, and pinch strength 83%. Functional outcomes were 16 excellent, 7 good, 2 fair, and 0 poor. Median DASH score was 19.8 points. There are significant differences in the range of motion, elevation deficit, and extension strength of thumb between the two groups (p=.001, p=.001, and p=.028, respectively). While the functional outcomes of both groups were favorably acceptable in a majority of the patients, there were significant differences in aspects of range of motion, elevation deficit, and strength of the thumb between both groups. Case-control study, Level III.

Emergent Tendon Transfer in Hand Trauma: A Case Report

In this report we describe our encounter of a case of hand trauma referred to our center presenting with incomplete left thumb amputation at metacarpal level with extensor pollicis longus (EPL) and flexor pollicis longus (FPL) tendon avulsion from the tenomuscular junction. After metacarpal bone fixation the ulnar digital artery was anastomosed and the digital nerves were coapted. Transfer of extensor indicis proprius (EIP) to EPL and side-to-side suturing of the FPL to the deep flexor tendon of the index finger were performed.

Extensor Pollicis Longus Rupture after Distal Radius Fracture

Purpose: To evaluate the cause and surgical outcome of extensor pollicis longus rupture after distal radius fractures. Materials and Methods: Nineteen cases in which the patients underwent surgical treatment for rupture of the extensor pollicis longus after distal radius fractures were followed for more than one year. Among the nineteen cases, fourteen extensor pollicis longus ruptures occurred after conservative treatment, four occurred after closed reduction with K-wire fixation, and one occurred after open reduction and internal fixation with a plate. All cases were treated by extensor indicis proprius transfer. Results: Extensor pollicis longus ruptures were caused by K-wire irritation in two, by a protruding screw tip in one, and by a callus in one. In the conservative treatment group, tendon ruptures were diagnosed at an average of 3.1 months (0.7∼17). Tendon ruptures were detected in the surgical treatment group at an average of 12.8 months (1∼48). All the patients showed favorable recovery of the extension capability of the thumb at the final follow-up. Conclusion: The main cause of extensor pollicis longus rupture after distal radius fracture was ischemic damage. Therefore, during the surgery, the length and direction of screws and K-wires should be fixed carefully to avoid such damage. Distal radius fracture also requires careful observation of the extensor pollicis longus during follow-up. Furthermore, extensor indicis proprius transfer is considered to be an effective method for extensor pollicis longus rupture.

Motor somatotopy of extensor indicis proprius and extensor pollicis longus

After tendon transfer of extensor indicis proprius (EIP) to extensor pollicis longus (EPL), rehabilitation is initiated to enhance motor cortex reorganization. However, patients have been described showing thumb extension immediately after the tendon transfer. At cortical level, no evidence supports either of these assumptions. We noninvasively investigated motor cortical source locations of EIP and EPL muscles. Magnetoencephalography was used to identify motor somatotopic map in healthy right-handed participants, who performed voluntary extension at index metacarpophalangeal joint and thumb interphalangeal joint. Motor cortical representation of EIP was more medial than cortical representation of EPL, with mean Euclidean distance of 15.4±2.7 mm. Motor somatotopic map of EIP/EPL that was obtained by magnetoencephalography supports 'functional somatotopy' representation of the finger in primary motor cortex.