Flexion Deformity Of Wrist Research Articles

Combined Wrist Extensor Tenodesis and Tendon Transfers for Severe Spastic Flexed Wrist Deformity: Surgical Technique and Case Series.

Spastic wrist flexion deformities both limit the functional use of the hand for grasp and pinch producing a stigmatizing appearance. Tendon transfers and total wrist arthrodesis are treatment options for this condition depending on the patient's characteristics, the latter the most commonly used in patients with severe wrist flexion deformities. Tendon transfers alone in this scenario have the tendency for recurrent deformity due to tenorrhaphy failure or soft tissue creep and resultant loss of tension. Total wrist arthrodesis is a more invasive procedure, which can have hardware or fusion problems and that is irreversible. We propose a novel technique that incorporates a distally based wrist extensor tendon slip and suture tape tenodesis to the distal radius. The rationale of this technique is to act as a protective, internal splint to prevent recurrent deformity after primary or revision tendon transfer for moderate to severe spastic flexed wrist deformities, avoiding the need to perform a total wrist arthrodesis.

Managing Severe Postburn Wrist Flexion Contracture by Proximal Row Carpectomy and Abdominal Interpolation Flap.

Introduction: Postburn upper extremity contractures can greatly diminish the quality of life. To successfully manage these contractures and achieve successful functional outcomes, an optimal surgical method should be planned to address all affected tissues on the extremities. Conventional soft tissue transfers after releasing the contracture, such as skin grafts or flaps, may be insufficient. In addition to capsulotomy, tendon release, and lengthening procedures, more aggressive modalities may be indicated. Methods: In this retrospective study, patients who developed wrist flexion deformities due to burn injuries and underwent proximal row carpectomy and abdominal interpolation flaps were included. Results: Between January 2019 and June 2020, 5 patients underwent surgery using this technique. All patients were male, 2 had thermal burns, 2 had electrical burns, and 1 had chemical burns. Preoperatively, all patients had severe flexion deformities ranging from 70° to 85°. There were no postoperative complications, and stable wrists with a good and functional alignment were achieved, although the preoperative and postoperative range of motion differences were limited, where a postoperative range of motions were ranging from 5 to 15 in terms of extension, 15 to 20 in terms of flexion. Preoperative QuickDash scores were between 79.5 and 95.5, postoperative scores ranged from 25 to 36.4. Conclusion Proximal row carpectomy shortens the length of the wrist, resurfaces the wrist joint, and provides a release in tendons and other soft tissues. Together with soft tissue transfer, this technique can be used for severe wrist flexion contractures.

Wrist shortening arthrodesis with volar plate in a dorsal position for spastic wrist contracture

Total wrist arthrodesis in severe wrist flexion deformities (greater than 60°) due to spasticity represents a valid therapeutic option. It aims to improve the hand’s appearance, hygiene, function and to prevent the deformity from getting worse. The objective of this study is to evaluate the clinical and anatomical results of wrist shortening arthrodesis using a classic volar plate in the dorsal position in functional surgery for central spastic hands. We conducted a single-center analysis of a series of patients who underwent this shortening arthrodesis. The review at a minimum 1-year follow-up included a clinical evaluation (House score, INOM score, patient satisfaction and complications), and anatomical evaluation (arthrodesis position, bone healing and carpometacarpal arthropathy). Twenty-eight patients with a mean age of 40.6 years (18–74) were included at a mean follow-up of 30.6 months (12–75). The fusion rate was 100%. No carpometacarpal arthropathy was noted. The mean position of the fused wrist was 11° extension and 15° ulnar tilt. There were two complications (7%): one postoperative hematoma and one case of discomfort due to impingement that required plate removal. The House score was significantly improved postoperatively (2.4 (0–5) versus 1.8 (0–4), p < 0.001), as was the INOM score (45 (12–64) versus 63 (36–84), p < 0.001). The patient satisfaction rate was 93%. The use of a simple and common material (volar plate in dorsal position) during this challenging surgery (spastic wrist contracture), provides good anatomical results and high patient satisfaction. Level of evidenceLevel 4, case series, therapeutic study.

Customized reconstruction of complex soft tissue defects in the upper extremities with variants of double skin paddle anterolateral thigh perforator flap

BackgroundComplex soft tissue defects in the upper extremities are challenging to reconstruct. The purpose of this study was to share our experience with using four variants of double skin paddle Anterolateral Thigh Perforator (ALT) flap to achieve the customized reconstruction of the complex defects. Patients and methodsFrom January 2007 to December 2019, 15 patients (14 male and 1 female) aged 15–61 years underwent double skin paddle ALT flap reconstruction of the upper extremities. 10 wounds were located in the wrist or hand, while four wounds were located in the forearm, and one wound in the elbow. All the wounds were large with non-adjacent defects and with or without a dead space. Four variants of double skin paddle anterolateral thigh perforator flaps were harvested according to the patient's needs. ResultsThe flaps received were consisted of 7 classic double skin paddle ALT flap, 4 vastus lateralis muscle-chimeric double skin paddle ALT flap, 2 microdissected thin double skin paddle ALT flap, and 2 flow-through double skin paddle ALT flap. The size of the skin flap ranged from 6 × 6 cm2 to 26 × 7 cm2, and the size of the muscle segment ranged from 5 × 2 × 1 cm3 to 16× 6 × 2 cm3. Flap necrosis related to the pedicle kinking was observed in one patient, while the rest of the flaps survived without complications. The follow-up period ranged from 7 to 54 months, with a median of 15.6 months. The mean value of the qDASH scores at the last follow-up was 27.12 ± 16.51 (range, 11.4–59.1). None of the patients showed wrist flexion deformity. Postoperatively, three patients developed finger joint stiffness, which correlated with the severity of the injury. ConclusionsVariants of double skin paddle ALT flaps provide versatile design and allow customized reconstruction of complex soft tissue defects in the upper extremities with limited donor site morbidity. We believe that the algorithm provided will help the surgeons with deciding among variants of double skin paddle ALT flap.

Wrist Arthrodesis in Athetoid Type Cerebral Palsy: A Case Study of 2 Patients

Wrist arthrodesis has been used successfully for the management of severe wrist flexion deformity when soft tissue procedures would not provide adequate correction. However, in athetoid type cerebral palsy which has a component of involuntary movement, the outcome of wrist arthrodesis has not been discussed much. We present our experience in 2 athetoid type cerebral palsy patients who underwent wrist arthrodesis due to severe involuntary movement of the wrist. One patient had a nonunion and both patients had unexpected aggravation of involuntary movement in the adjacent joints. Secure fixation using a pre-contoured plate is necessary and preparation for iliac bone grafting should be considered as proximal row carpectomy is usually not necessary in these patients. In addition, although single-event, multi-level surgery is advocated for patients with cerebral palsy, potential additional procedures for the adjacent joints should be discussed preoperatively because unexpected aggravation of involuntary movement of adjacent joints can occur after stabilization of the wrist.

Intermittent serial casting for wrist flexion deformity in children with spastic cerebral palsy: a randomized controlled trial.

To assess the efficacy of intermittent serial casting in conjunction with occupational therapy and botulinum neurotoxin A (BoNT-A) in children with cerebral palsy (CP) presenting spastic wrist flexion deformity. This was a controlled, prospective study in which 34 children (19 females, 15 males; mean [SD] 11y [4y 6mo]) were randomly allocated to casting or control groups in a ratio of 2:1. Both groups were subjected to BoNT-A treatment and occupational therapy. The casting group additionally received a series of progressive casts intermittently for three consecutive weekends. Outcome measures consisted of passive range of motion (PROM) as assessed by goniometer, muscle tone by Modified Ashworth scale (MAS), and spasticity by Tardieu Scale. Assessments were done at baseline, week 4, and week 12. Baseline characteristics of casting and control groups were comparable. PROM, MAS, and Tardieu angle of catch (XV3) of the casting and control groups significantly improved after treatment (p<0.001 for all). Nevertheless the mean change from baseline MAS at week 12, mean changes from baseline PROM, Tardieu XV3, and the spasticity grade (Y) at week 4 and week 12 of the casting group showed statistical superiority over those of the control group (p<0.05 for all). Children with CP presenting spastic wrist flexion deformity might gain additional benefits from supplementary intermittent serial casting as well as BoNT-A injections and occupational therapy. Serial casting could be considered as a complementary treatment to BoNT-A and occupational therapy in children with clinically significant PROM limitations.

A prospective study on transfer of pronator teres to extensor carpi radialis brevis for forearm and wrist deformity in children with cerebral palsy.

We prospectively evaluated the clinical and functional outcomes of pronator teres to extensor carpi radialis brevis transfer in children with cerebral palsy. Patients were followed-up at 6 months postoperatively, and functionally assessed using the House classification, Manual Ability Classification System (MACS) and Upper Extremity Functional Index (UEFI). Fifteen children with a mean age of 8.1 years underwent tendon transfers. All patients were of Gschwind and Tonkin Grade 2 for pronation deformity; eight patients were of Zancolli's classification Group 1 and seven, Group 2 for wrist flexion deformity. The average gain in active supination was 67°, and wrist extension 15°. An increase of 7.0 in the UEFI score was recorded, although no significant improvement in MACS and House classification was observed. We conclude that the pronator teres to extensor carpi radialis brevis transfer improves upper limb function through effective correction of forearm pronation and wrist flexion deformities.Level of evidence: II.

Surgery for the Pronated Forearm and Flexed Wrist in Children with Cerebral Palsy.

There is no consensus in the literature on how best to manage wrist flexion and forearm pronation deformities in children with cerebral palsy (CP). The aim of this research was to come up with a treatment algorithm for the surgical management of such cases. Children with CP who underwent upper limb surgery between 2009 and 2016 at a single centre and by a single lead surgeon were reviewed retrospectively. Movement analysis and Shriners Hospital Upper Extremity Evaluation (SHUEE) data collected pre- and post-operatively. Thirteen patients were recruited. Most patients underwent a flexor carpi ulnaris (FCU) to extensor carpi radialis brevis (ECRB) transfer, with or without pronator teres (PT) re-routing, and finger flexor or elbow flexor releases. Mean increase in active range of supination was 40.8° (p = 0.002) and wrist extension 28.9° (p = 0.004). The mean increase in dynamic positional analysis (part of the SHUEE) was 25.4% (of which 40.3% was due the increases in wrist function and 16.8% due to forearm function). The loss of wrist flexion was not significant (p = 0.125). The mean follow-up was 14months (range 9-21). To tackle both a pronation and flexion deformity, the authors favour performing a FCU to ECRB transfer in isolation if there is active supination to neutral; if active supination is short of neutral, then a FCU to ECRB with a PT release and possible re-routing performed. A treatment algorithm is proposed. IV.

Prevalence of limb deformities among children having cerebral palsy in Jalandhar District of Punjab

Introduction: Cerebral palsy (CP) is a nonprogressive disorder of the developing brain. The newborn child with CP usually has no deformities or musculoskeletal abnormalities at birth. However, the distribution and prevalence of deformities in CP is a less researched area. Most of the studies have dealt with the correction of deformities. The purpose of this study is to determine the prevalence of deformities in CP and explore the relationship between their impairments and function. Methodology: A database of 248 children with CP between the age group of 3 and 13 years in a survey conducted in Jalandhar District of Punjab constituted the population of this study. Each child was physically examined by the researcher to assess primary and secondary impairments using standard clinical tests, such as Gross Motor Function Measure (GMFM-88), Quality of Upper Extremity Skill Test (QUEST), Gross Motor Function Classification System (GMFCS), and passive range of motion. Cross tabulation with Chi-square and correlation was a tool of statistical analysis for categorical variables, whereas t-test was used for continuous variables. Results: Equinus deformity of the ankle was most common followed by knee flexion, forearm pronation, and wrist flexion deformities. Deformity score showed statistically significant negative correlation with GMFM score (r = −0.43, P Conclusions: Occurrence of deformities is the most common secondary impairment observed in children with CP. Deformities limit gross as well as the fine motor activities and hence the overall functional outcome in these children.

A prospective study on outcome of function after proximal row carpectomy

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Proximal row carpectomy (PRC) is a procedure with varied indications. The purpose of this study was to evaluate functional outcomes with PRC in wrist flexion deformities, neuromuscular disorders and also post-traumatic wrist arthritis.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; A prospective study was performed on all patients who underwent PRC between April 2015 and December 2017, in BIRRD (T) hospital, Tirupati, Andhra Pradesh with a minimum follow up of 6 months. Outcome was assessed in terms of range of motion (ROM), grip strength, quick disabilities of the arm, shoulder, and hand (QDASH) score and pain score. Data was analyzed using the Student t-test.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Thirty-two patients underwent PRC of which 12 are neuromuscular disorders, 10 are wrist flexion deformities, 10 are post-traumatic wrist arthritis. On the final follow-up, significant improvement in ROM was observed in wrist flexion deformities and neuromuscular disorders, whereas grip strength and QDASH scores showed a significant difference in post-traumatic wrist arthritis. Pain was studied only in post-traumatic wrist arthritis, all were very much pleased with pain reduction.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; PRC is fairly a reliable procedure for all the indications in our study. We consider that PRC is a promising procedure in correcting wrist flexion deformities. Though there has been significant improvement in all the parameters for all the cases, we consider this procedure is best suited for post-traumatic arthritis group.&lt;/p&gt;

Early Shortening of Wrist Flexor Muscles Coincides With Poor Recovery After Stroke

Background. The mechanism and time course of increased wrist joint stiffness poststroke and clinically observed wrist flexion deformity is still not well understood. The components contributing to increased joint stiffness are of neural reflexive and peripheral tissue origin and quantified by reflexive torque and muscle slack length and stiffness coefficient parameters. Objective. To investigate the time course of the components contributing to wrist joint stiffness during the first 26 weeks poststroke in a group of patients, stratified by prognosis and functional recovery of the upper extremity. Methods. A total of 36 stroke patients were measured on 8 occasions within the first 26 weeks poststroke using ramp-and-hold rotations applied to the wrist joint by a robot manipulator. Neural reflexive and peripheral tissue components were estimated using an electromyography-driven antagonistic wrist model. Outcome was compared between groups cross-sectionally at 26 weeks poststroke and development over time was analyzed longitudinally. Results. At 26 weeks poststroke, patients with poor recovery (Action Research Arm Test [ARAT] ≤9 points) showed a higher predicted reflexive torque of the flexors (P < .001) and reduced predicted slack length (P < .001) indicating shortened muscles contributing to higher peripheral tissue stiffness (P < .001), compared with patients with good recovery (ARAT ≥10 points). Significant differences in peripheral tissue stiffness between groups could be identified around weeks 4 and 5; for neural reflexive stiffness, this was the case around week 12. Conclusions. We found onset of peripheral tissue stiffness to precede neural reflexive stiffness. Temporal identification of components contributing to joint stiffness after stroke may prompt longitudinal interventional studies to further evaluate and eventually prevent these phenomena.

Spectrum of Joint Deformities in Children with Juvenile Idiopathic Arthritis.

To determine the frequency and types of joint deformities in children with juvenile idiopathic arthritis and their association with clinical parameters and rheumatoid factor. Cross-sectional study. Rheumatology Outpatient Clinic, the Children's Hospital and the Institute of Child Health, Lahore, from September 2014 to February 2015. All patients of both genders of less than 16 years of age, who fulfilled the International League of Association for Rheumatology (ILAR) criteria for Juvenile Idiopathic Arthritis (JIA), were enrolled in this study. Their demographic data, duration of disease at the time of presentation, types of JIA, various joint deformities and rheumatoid factor (RF) were documented. Statistical analysis of data was done on SPSS version 16. Chi-square test was applied to determine the association of clinical deformity with age of patients, disease duration at presentation, types of JIA and RF. Out of 70 patients enrolled during the study period, 51.4% were boys with mean age at presentation being 9.44 ±3.89 years (2-7 years) and median duration of disease being 24 months (interquartile range 42 months). Forty patients (57.1%) had joint deformities. Most common joints involved were hand (50%), wrist (50%), and knee (35.7%). The common types of joint deformities were boutonniere deformity (28.6%), ulnar deviation of wrist (28.6%), fixed flexion deformity of wrist (22.9%), and knee (31.4%). The most common type of JIA was polyarthritis RF negative with or without deformity. There was a strong association of deformities with older age of patients at presentation (p=0.036), longer duration of disease at presentation (p=0.028), polyarthritis (RF seronegative / seropositive) (p=0.013), and seropositivity (p=0.04). More than 50% patients with JIA have joint deformities. Joint deformities are more likely to be seen in children with long-standing disease, those with polyarthritis JIA and seropositive patients.

Flexion Deformities of the Wrist and Fingers in Spastic Cerebral Palsy: A Protocol of Management.

Background:Literature is confusing regarding grading and treatment of flexion deformities of wrist and fingers in spastic cerebral palsy (CP). The most established classification is that described by Zancolli; unfortunately, it has its shortcomings which we experienced in the beginning of our approach to manage this rather difficult deformity. We thus modified Zancolli's classification and developed a classification system and treatment protocol.Materials and Methods:Thirty patients with spastic CP were operated upon due to flexion deformity of the wrist and fingers and were included in this study. Age ranged from 4 to 14 years, average 7 years. There were twenty boys and ten girls.Results:The average followup was 18 months (range 9 months - 3 years). The power of wrist dorsiflexion, the “House's classification of upper extremity functional use” and the clinical assessment of hand function were used for evaluation; they improved in all patients and this improvement was statistically significant. In all patients, cosmetic appearance improved without any residual flexion deformity.Conclusion:This study introduces a new grading system for flexion deformity of wrist and fingers in spastic CP that correlates with severity of the condition and allows a treatment protocol to be established.

Effectiveness of intermittent serial casting on spastic wrist flexion deformity in children with cerebral palsy treated by botulinum toxin‐A

Effectiveness of intermittent serial casting on spastic wrist flexion deformity in children with cerebral palsy treated by botulinum toxin‐A

Effects of intermittent serial casting on spastic wrist flexion deformity in children with cerebral palsy treated by botulinum toxin-A

Effects of intermittent serial casting on spastic wrist flexion deformity in children with cerebral palsy treated by botulinum toxin-A

Wrist arthrodesis in adolescents with cerebral palsy.

Twenty adolescents with severe spastic deformities of the wrist (Zancolli type 3) and poor function on the House score were operated on between 2009 and 2014, and included in this retrospective cohort study. All were treated by wrist arthrodesis combining a proximal row carpectomy, curetting of the distal radius in order to imbed the capitate and a dorsal locking plate. The primary endpoint was improvement in the House score. Secondary endpoints included pre- and postoperative wrist flexion deformity, bone union, patient satisfaction regarding appearance and complications. The mean follow-up was 22 months. The mean age at the time of surgery was 16.2 years. Additional soft-tissue release was necessary in eight wrists. The mean House score improved significantly from 0.9 to 2.7. Average flexion deformity improved significantly from 66° to 10°. Bony union was achieved in all patients within 6 months. Four of the 20 patients required hardware removal because of fixed extension of the middle metacarpal. Wrist arthrodesis combining proximal row carpectomy with the use of a dorsal locking plate is a safe and reliable technique to improve function and appearance. IV.

Spastic wrist flexion in cerebral palsy. Pronator teres versus flexor carpi ulnaris transfer.

OBJECTIVE: Analize data on patients submitted to transfer of the pronator teres (PT) or the flexor carpi ulnaris (FCB) to the extensor carpi radialis longus/brevis (ECRL/B) in order to correct flexed wrist deformity in patients with cerebral palsy. METHOD: Patients were divided into two groups: PT group and FCU group to ECRL/B. The results were evaluated by goniometry and by the functional hand test (FHT). RESULTS: Goniometry showed a statistically significant difference in favor of FCU transfer. There was no statistically significant difference regarding FHT. CONCLUSION: Both transfers PT and FCU to ECRB are good options to correct wrist flexion deformity in cerebral palsy. Level of Evidence III, Non-randomized Controlled Cohort/Follow-Up Study.

Long-Term Outcome Following Carpal Wedge Osteotomy in the Arthrogrypotic Patient

Wrist flexion and ulnar deviation deformity is a common presentation in children with amyoplasia congenita. Multiple surgical procedures have been reported to correct the deformity to enhance functional independence and improve quality of life. We performed a retrospective review to detail our long-term results with carpal wedge osteotomy in these patients. Medical records of all patients with the amyoplasia form of arthrogryposis who underwent carpal wedge osteotomy between 1994 and 2008 were reviewed. Patients with a follow-up of two years or less were excluded. Preoperative and postoperative resting position and range of motion of the wrist were recorded. Interviews and questionnaires were completed to assess the mean overall satisfaction level of the parent or guardian with the outcome of surgery, function, and task completion with use of parent-guardian surveys, the Manual Ability Classification System, and the ABILHAND-Kids measure of manual ability. Seventy-five wrists in forty-six patients who met the inclusion criteria were reviewed. The average age of the patients at the time of surgery was 4.3 years (range, nine months to eighteen years; median, 2.7 years). The average duration of follow-up was 5.7 years (range, two to 10.3 years; median, 5.3 years). The average resting position of the wrist postoperatively (11° of flexion) was significantly different from that measured preoperatively (55° of flexion) (p < 0.001). The arc of wrist motion measured preoperatively (32°) did not differ significantly from that measured postoperatively (22°) (p = 0.4903). The location of the motion arc was significantly improved to a more functional position. The average active extension of the wrist changed from -37° of extension preoperatively to -11° of extension postoperatively (p < 0.001). Active wrist flexion also significantly changed from 69° preoperatively to 33° postoperatively (p < 0.001). Parent-guardian surveys indicated that the mean overall satisfaction score after surgery was 9.1 of 10 possible points and that the mean ranking for task completion in activities of daily living was 4 (easier following surgery). Long-term outcomes reveal that surgical correction of wrist flexion posture in children with amyoplasia congenita results in improvement that is sustained over time. The surveys and questionnaires completed by parents or guardians indicated that they were satisfied with the results of the operation.

Dorsal Carpal Wedge Osteotomy in the Arthrogrypotic Wrist

To assess the outcome of patients who underwent dorsal carpal wedge osteotomy (DCWO) for the treatment of wrist flexion deformities causing functional limitations resulting from arthrogryposis. We performed a retrospective chart review of consecutive patients treated with DCWO between 1996 and 2009 by a single surgeon. Follow-up of greater than 1 year (mean, 45 mo; range, 12-108 mo) was available in 12 patients (20 wrists). All 12 patients' parents reported subjective improvement in position and appearance, and in performing activities of daily living. Wrist extension was significantly increased (mean, 43°), wrist flexion was significantly decreased (mean, 34° from neutral), and there was no significant change in wrist motion arc. We saw significantly greater improvement in wrist extension in children operated on at 7 years of age or greater and in patients treated concomitantly with an extensor carpi ulnaris tendon transfer. Complications included 1 infection. The excessively flexed wrist in children with arthrogryposis can safely and effectively be improved with DCWO, which in turn facilitates independence in activities of daily living and school-related tasks as reported by parents. For patients older than 7 years of age at the time of surgery, and for patients treated with concomitant extensor carpi ulnaris transfer at the time of DCWO, we found greater recovery of wrist extension. Therapeutic IV.

Long-Term Results of Forearm Shortening and Volar Radiocarpal Capsulotomy for Wrist Flexion Deformity in Children With Amyoplasia

To perform a long-term review of results of forearm shortening osteotomies, tenotomy, and volar wrist capsulotomy for treatment of typical wrist flexion deformities in children with the amyoplasia form of arthrogryposis, a procedure originally reported and described as "most rewarding" by Lexington Shriners Hospital for Children in 1965. A retrospective review of operating room and clinic records was done. An attempt to contact all patients produced 1 current follow-up. Nine extremities in 6 patients had undergone the procedure. Of the 9 extremities, 3 subsequently underwent salvage procedures, 2 had salvage procedures recommended, and 1 had a distal forearm fracture angular malunion that compensated for the wrist flexion contracture. The charts for the patients with the 3 remaining extremities showed that at 3-year follow-up, the wrist flexion contractures had recurred. Long-term follow-up of the procedure shows that the initial improvement in wrist position is not maintained. This procedure is not recommended for correction of the wrist deformity in amyoplasia. Therapeutic IV.